‘‘(3) 
EMPLOYER
SHARED
RESPONSIBILITY 
CREDIT.—The Secretary may provide a credit to pri-
vate employers who provided health insurance bene-
fits greater than the 80th percentile of the national 
average in the 4 years prior to enactment of the 
Healthy Americans Act, if such employer can dem-
onstrate the benefits provided encouraged prevention 
and wellness activities as defined in this Act, and 
that the employer continues to provide wellness pro-
grams. 
‘‘(4) SPECIAL
RULE
FOR
SELF-INSURED
EM-
PLOYERS.—In the case of any employer who pro-
vided health care coverage for employees through 
self-insurance, ‘average HAPI plan premium amount 
for the first year this section applies’ shall be sub-
stituted for ‘designated employee health insurance 
premium amount of such employer’ in paragraphs 
(1)(A) and (2)(A)(ii). 
‘‘(5) REGULATIONS.—The Secretary may estab-
lish such rules and regulations as necessary to carry 
out the purposes of this subsection. 
‘‘(d) TRANSITION RATE FOR EMPLOYERS NOT PRE-
VIOUSLY PROVIDING HEALTH INSURANCE.—In the case 
of any employer who did not provide health insurance to 
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employees on the day before the date of enactment of the 
Healthy Americans Act— 
‘‘(1) the employer shared responsibility pay-
ment for the first year this section applies shall be 
an amount equal 1⁄3 of the amount otherwise re-
quired under this section (determined without regard 
to this subsection), and 
‘‘(2) the employer shared responsibility pay-
ment for the second year this section applies shall be 
an amount equal 2⁄3 of the amount otherwise re-
quired under this section (determined without regard 
to this subsection). 
‘‘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. 
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‘‘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, 
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. 
‘‘(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 
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(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 
amount’ means the national average yearly premium 
for HAPI plans with standard coverage (as deter-
mined under section 103(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-
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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 
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 
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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. 
‘‘(6) FULL-TIME EMPLOYEE.—The term ‘full- 
time employee’ means an employee (including a com-
mon law employee) who during an average workweek 
performs, or can reasonably be expected to perform, 
at least 40 hours of work. The Secretary may pre-
scribe alternative rules for determining full-time 
equivalent employees in occupations or industries not 
using a standard workweek. 
‘‘(7) HAPI PLAN.—The term ‘HAPI plan’ has 
the meaning given such term under section 3 of the 
Healthy Americans Act. 
‘‘(8) HAPI PLAN
PREMIUM
AMOUNT.—The 
term ‘HAPI plan premium amount’ means, with re-
spect to any individual, the monthly premium for the 
HAPI plan under which such individual is enrolled, 
determined after taking into account any subsidy 
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provided to such individual under section 131 of the 
Healthy Americans Act. 
‘‘(9) LARGE EMPLOYER.—The term ‘large em-
ployer’ means, with respect to any year, an employer 
who employs an average of over 200 full-time equiv-
alent employees during such year. 
‘‘(10) REVENUE
PER
EMPLOYEE.—The term 
‘revenue per employee’ means, with respect to any 
employer for any year, the gross receipts of the em-
ployer for such year divided by the number of full- 
time equivalent employees employed by such em-
ployer for such year. 
‘‘(11) SMALL EMPLOYER.—The term ‘small em-
ployer’ means, with respect to any year, an employer 
who employs an average of 200 or fewer full-time 
equivalent employees during such year. 
‘‘(12) WAGES.—The term ‘wages’ has the 
meaning given such term under section 3401(a). 
‘‘(b) SPECIAL RULES.— 
‘‘(1) SPECIAL RULE FOR SELF-EMPLOYED INDI-
VIDUALS.—For purposes of this chapter, a self-em-
ployed 
individual 
(as 
defined 
by 
section 
401(c)(1)(B)) shall be treated as both a full-time 
equivalent employee and as an employer. 
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‘‘(2) TREATMENT
OF
PAYMENTS.—For pur-
poses of this title, the payments required by sections 
3411 and 3421 shall be treated as a tax imposed by 
such sections, respectively. 
‘‘(3) OTHER SPECIAL RULES.—For purposes of 
this chapter, rules similar to rules under the fol-
lowing provisions shall apply: 
‘‘(A) Section 3122 (relating to Federal 
service). 
‘‘(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 
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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 
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’’. 
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(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)— 
(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. 
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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 
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-
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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 
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); 
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(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; 
(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 adults covered by a plan to partici-
pate in prevention, wellness and chronic disease 
management 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; 
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(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 website 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-
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. 
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(c) UNIFORM BILLING PRACTICES.— 
(1) IN GENERAL.—A health insurance issuer of-
fering a HAPI plan in a State shall not receive sub-
sidy payments from the applicable State HHA un-
less such issuer agrees 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; 
(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. 
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100 
(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-
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 enti-
ty selected by the State HHA, the chronic care man-
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101 
agement performance of the issuer as measured by 
the uniform clinical performance standards described 
in paragraph (3). The issuer shall make such per-
formance 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. 
(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-
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102 
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 
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; 
and 
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