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 serv-
ices. 
‘‘(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) CHILDREN’S 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 2007. 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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