1397 
tioner who is a type of practitioner 
that does not typically participate in 
Medicare (as determined by the Sec-
retary) shall also be eligible for the 
increased payment rates under sub-
paragraph (A). 
(2) SUBSEQUENT
PERIODS.—Beginning 
with Y4 and for subsequent years, the 
Secretary shall continue to use an admin-
istrative process to set such rates in 
order to promote payment accuracy, to 
ensure adequate beneficiary access to 
providers, and to promote affordability 
and the efficient delivery of medical care 
consistent with section 221(a). Such rates 
shall not be set at levels expected to in-
crease overall medical costs under the 
option beyond what would be expected if 
the process under subsection (a)(2) and 
paragraph (1) of this subsection were 
continued. 
(3) ESTABLISHMENT OF A PROVIDER NET-
WORK.—Health 
care 
providers 
partici-
pating under Medicare are participating 
providers in the public health insurance 
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option unless they opt out in a process 
established by the Secretary. 
(c) ADMINISTRATIVE PROCESS FOR SETTING 
RATES.—Chapter 5 of title 5, United States 
Code shall apply to the process for the initial 
establishment of payment rates under this 
section but not to the specific methodology 
for establishing such rates or the calculation 
of such rates. 
(d) CONSTRUCTION.—Nothing in this sub-
title shall be construed as limiting the Sec-
retary’s authority to correct for payments 
that are excessive or deficient, taking into ac-
count the provisions of section 221(a) and the 
amounts paid for similar health care pro-
viders and services under other Exchange- 
participating health benefits plans. 
(e) CONSTRUCTION.—Nothing in this sub-
title shall be construed as affecting the au-
thority of the Secretary to establish payment 
rates, including payments to provide for the 
more efficient delivery of services, such as the 
initiatives provided for under section 224. 
(f) LIMITATIONS ON REVIEW.—There shall be 
no administrative or judicial review of a pay-
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ment rate or methodology established under 
this section or under section 224. 
SEC. 224. MODERNIZED PAYMENT INITIATIVES AND DELIV-
ERY SYSTEM REFORM. 
(a) IN GENERAL.—For plan years beginning 
with Y1, the Secretary may utilize innovative 
payment mechanisms and policies to deter-
mine payments for items and services under 
the public health insurance option. The pay-
ment mechanisms and policies under this sec-
tion may include patient-centered medical 
home and other care management payments, 
accountable care organizations, value-based 
purchasing, bundling of services, differential 
payment rates, performance or utilization 
based payments, partial capitation, and direct 
contracting with providers. 
(b) REQUIREMENTS
FOR INNOVATIVE PAY-
MENTS.—The Secretary shall design and imple-
ment the payment mechanisms and policies 
under this section in a manner that— 
(1) seeks to— 
(A) improve health outcomes; 
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(B) reduce health disparities (in-
cluding racial, ethnic, and other dis-
parities); 
(C) provide efficient and afford-
able care; 
(D) address geographic variation 
in the provision of health services; or 
(E) prevent or manage chronic ill-
ness; and 
(2) promotes care that is integrated, 
patient-centered, quality, and efficient. 
(c) ENCOURAGING THE USE OF HIGH VALUE 
SERVICES.—To the extent allowed by the ben-
efit standards applied to all Exchange-partici-
pating health benefits plans, the public health 
insurance option may modify cost sharing 
and payment rates to encourage the use of 
services that promote health and value. 
(d) NON-UNIFORMITY PERMITTED.—Nothing 
in this subtitle shall prevent the Secretary 
from varying payments based on different 
payment structure models (such as account-
able care organizations and medical homes) 
under the public health insurance option for 
different geographic areas. 
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SEC. 225. PROVIDER PARTICIPATION. 
(a) IN GENERAL.—The Secretary shall es-
tablish conditions of participation for health 
care providers under the public health insur-
ance option. 
(b) LICENSURE
OR
CERTIFICATION.—The 
Secretary shall not allow a health care pro-
vider to participate in the public health insur-
ance option unless such provider is appro-
priately licensed or certified under State law. 
(c) PAYMENT TERMS FOR PROVIDERS.— 
(1) PHYSICIANS.—The Secretary shall 
provide for the annual participation of 
physicians under the public health insur-
ance option, for which payment may be 
made for services furnished during the 
year, in one of 2 classes: 
(A) PREFERRED PHYSICIANS.—Those 
physicians who agree to accept the 
payment rate established under sec-
tion 223 (without regard to cost-shar-
ing) as the payment in full. 
(B) PARTICIPATING, NON-PREFERRED 
PHYSICIANS.—Those 
physicians 
who 
agree not to impose charges (in rela-
tion to the payment rate described in 
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section 223 for such physicians) that 
exceed the ratio permitted under sec-
tion 1848(g)(2)(C) of the Social Secu-
rity Act. 
(2) OTHER PROVIDERS.—The Secretary 
shall provide for the participation (on an 
annual or other basis specified by the 
Secretary) of health care providers (other 
than physicians) under the public health 
insurance option under which payment 
shall only be available if the provider 
agrees to accept the payment rate estab-
lished under section 223 (without regard 
to cost-sharing) as the payment in full. 
(d) EXCLUSION
OF CERTAIN PROVIDERS.— 
The Secretary shall exclude from participa-
tion under the public health insurance option 
a health care provider that is excluded from 
participation in a Federal health care pro-
gram (as defined in section 1128B(f) of the So-
cial Security Act). 
SEC. 226. APPLICATION OF FRAUD AND ABUSE PROVI-
SIONS. 
Provisions of law (other than criminal law 
provisions) identified by the Secretary by reg-
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ulation, in consultation with the Inspector 
General of the Department of Health and 
Human Services, that impose sanctions with 
respect to waste, fraud, and abuse under 
Medicare, such as the False Claims Act (31 
U.S.C. 3729 et seq.), shall also apply to the 
public health insurance option. 
Subtitle C—Individual 
Affordability Credits 
SEC. 241. AVAILABILITY THROUGH HEALTH INSURANCE EX-
CHANGE. 
(a) IN
GENERAL.—Subject to the suc-
ceeding provisions of this subtitle, in the case 
of an affordable credit eligible individual en-
rolled in an Exchange-participating health 
benefits plan— 
(1) the individual shall be eligible for, 
in accordance with this subtitle, afford-
ability credits consisting of— 
(A) 
an 
affordability 
premium 
credit under section 243 to be applied 
against the premium for the Ex-
change-participating health benefits 
plan in which the individual is en-
rolled; and 
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(B) an affordability cost-sharing 
credit under section 244 to be applied 
as a reduction of the cost-sharing oth-
erwise applicable to such plan; and 
(2) the Commissioner shall pay the 
QHBP offering entity that offers such 
plan from the Health Insurance Exchange 
Trust Fund the aggregate amount of af-
fordability credits for all affordable cred-
it eligible individuals enrolled in such 
plan. 
(b) APPLICATION.— 
(1) IN GENERAL.—An Exchange eligible 
individual may apply to the Commis-
sioner through the Health Insurance Ex-
change or through another entity under 
an arrangement made with the Commis-
sioner, in a form and manner specified by 
the Commissioner. The Commissioner 
through the Health Insurance Exchange 
or through another public entity under 
an arrangement made with the Commis-
sioner shall make a determination as to 
eligibility of an individual for afford-
ability credits under this subtitle. The 
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Commissioner shall establish a process 
whereby, on the basis of information oth-
erwise available, individuals may be 
deemed to be affordable credit eligible in-
dividuals. In carrying this subtitle, the 
Commissioner shall establish effective 
methods that ensure that individuals 
with limited English proficiency are able 
to apply for affordability credits. 
(2) USE OF STATE MEDICAID AGENCIES.— 
If the Commissioner determines that a 
State Medicaid agency has the capacity 
to make a determination of eligibility for 
affordability credits under this subtitle 
and under the same standards as used by 
the Commissioner, under the Medicaid 
memorandum of understanding (as de-
fined in section 205(c)(4))— 
(A) the State Medicaid agency is 
authorized to conduct such deter-
minations for any Exchange-eligible 
individual who requests such a deter-
mination; and 
(B) the Commissioner shall reim-
burse the State Medicaid agency for 
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the costs of conducting such deter-
minations. 
(3) MEDICAID SCREEN AND ENROLL OBLI-
GATION.—In the case of an application 
made under paragraph (1), there shall be 
a determination of whether the indi-
vidual is a Medicaid-eligible individual. If 
the individual is determined to be so eli-
gible, the Commissioner, through the 
Medicaid memorandum of understanding, 
shall provide for the enrollment of the in-
dividual under the State Medicaid plan in 
accordance with the Medicaid memo-
randum of understanding. In the case of 
such an enrollment, the State shall pro-
vide for the same periodic redetermina-
tion of eligibility under Medicaid as 
would otherwise apply if the individual 
had directly applied for medical assist-
ance to the State Medicaid agency. 
(c) USE OF AFFORDABILITY CREDITS.— 
(1) IN GENERAL.—In Y1 and Y2 an af-
fordable credit eligible individual may 
use an affordability credit only with re-
spect to a basic plan. 
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(2) FLEXIBILITY
IN
PLAN
ENROLLMENT 
AUTHORIZED.—Beginning 
with 
Y3, 
the 
Commissioner shall establish a process to 
allow an affordability credit to be used 
for enrollees in enhanced or premium 
plans. In the case of an affordable credit 
eligible individual who enrolls in an en-
hanced or premium plan, the individual 
shall be responsible for any difference be-
tween the premium for such plan and the 
affordability credit amount otherwise ap-
plicable if the individual had enrolled in 
a basic plan. 
(d) ACCESS TO DATA.—In carrying out this 
subtitle, the Commissioner shall request from 
the Secretary of the Treasury consistent with 
section 6103 of the Internal Revenue Code of 
1986 such information as may be required to 
carry out this subtitle. 
(e) NO CASH REBATES.—In no case shall an 
affordable credit eligible individual receive 
any cash payment as a result of the applica-
tion of this subtitle. 
SEC. 242. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL. 
(a) DEFINITION.— 
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(1) IN GENERAL.—For purposes of this 
division, the term ‘‘affordable credit eligi-
ble individual’’ means, subject to sub-
section (b), an individual who is lawfully 
present in a State in the United States 
(other than as a nonimmigrant described 
in a subparagraph (excluding subpara-
graphs (K), (T), (U), and (V)) of section 
101(a)(15) of the Immigration and Nation-
ality Act)— 
(A) who is enrolled under an Ex-
change-participating health benefits 
plan and is not enrolled under such 
plan as an employee (or dependent of 
an employee) through an employer 
qualified health benefits plan that 
meets the requirements of section 
312; 
(B) with family income below 400 
percent of the Federal poverty level 
for a family of the size involved; and 
(C) who is not a Medicaid eligible 
individual, other than an individual 
described in section 202(d)(3) or an 
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