Project Vote Smart

Legislation - Signed (Executive) - March 23, 2010

Legislation - Concurrence Vote Passed (House) - March 21, 2010 (Key vote)

Title: Health Care and Insurance Law Amendments ("Patient Protection and Affordable Care Act")

Vote Smart's Synopsis:

Vote to concur with Senate amendments and pass a bill that amends various statues related to health care and heath insurance coverage, including, but not limited to, the establishment of a Health Insurance Exchange Program, an individual mandate to purchase insurance, a prohibition on insurers denying or rescinding coverage based on a preexisting condition, a tax on "high cost employer-sponsored health care plans," various mechanisms aimed at reducing Medicare spending, and an expansion of Medicaid eligibility.

Highlight: Insurance Regulations -Prohibits health insurers from imposing any preexisting condition exclusions (Sec. 1201). -Prohibits health insurers from establishing rules for eligibility (including continued eligibility) based on any of the following factors (Sec. 1201):

-Health status; -Medical condition (including physical and mental illnesses); -Claims experience; -Receipt of health care; -Medical history; -Genetic information; -Evidence of insurability (including conditions relating to domestic violence); -Disability; and -Any other health status-related factor determined appropriate by the Secretary.

-Requires health insurers to base premium rates for plans in the individual or small group markets on the following (Sec. 1201):

-Whether the plan or coverage covers an individual or family; -Rating area; -Age, except that the rate shall not vary by more than 3 to 1 for adults; and -Tobacco use, except that the rate shall not vary by more than 1.5 to 1.

-Prohibits health insurers from establishing lifetime limits or annual limits on the dollar value of benefits for any participant or beneficiary, except that prior to 2014 insurers may establish "restricted annual limits" that the Secretary of Health and Human Services determines will not impede access to "needed services" and will have a "minimal impact" on premiums (Secs. 1001 & 10101). -Prohibits health insurers from rescinding coverage unless there is an occurrence of fraud in violation of the terms of the health plan or health insurance coverage (Sec. 1001). -Requires health insurers to provide coverage for the following preventive services at no cost to the patient (Sec. 1001):

-Services that have an "A" or "B" rating in the recommendations of the U.S. Preventive Services Task Force; -Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and -Preventive health care and screenings for women, infants, children and adolescents as provided for in guidelines supported by the Health Resources and Services Administration.

-Specifies that the recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention issued in or around November 2009 shall not apply for the purposes of federal law (Sec. 1001). -Requires health insurers that provide dependent coverage of children to continue to make such coverage available for an unmarried adult child until he or she turns 26 years old (Sec. 1001). -Prohibits a group health plan from discriminating in favor of the highest paid 25 percent of employees, shareholders owning more than 10 percent of the employer's stock value, or the five highest paid officers with regards to eligibility or benefits (Secs. 1001 & 10101). -Requires the Secretary to establish a temporary high risk health insurance pool program no later than 90 days after the date of enactment to provide coverage through 2013 to individuals that (Sec. 1101):

-Are a citizen or national of the United States or are lawfully present in the United States; -Have not been covered during the 6 month period prior to application; and -Have a preexisting condition that is consistent with the guidelines established by the Secretary.

-Establishes the following requirements for the high risk pool (Sec. 1101):

-It must provide coverage in which the insurer's share of the total allowed costs of benefits is not less than 65 percent; -It must provide coverage that has an out of pocket limit that does not exceed $5,000 annually for self-only coverage and $10,000 annually for family coverage, except that the Secretary may modify the limit to ensure that the insurer's share of total allowed costs of benefits is not less than 65 percent; -The premium rate must be established at a standard rate for a standard population and the rate must vary only as allowed elsewhere in this Act, except that it may vary on the basis of age by a factor of no more than 4 to 1; and -It must meet any other requirements determined "appropriate" by the Secretary.

-Requires the Secretary to establish a temporary reinsurance program to reimburse employment-based health plans covering early retirees (55 years of age or older but not eligible for Social Security) for claims that are between $15,000 and $90,000 through 2013, and specifies that the reimbursement shall be 80 percent of the costs that exceed $15,000 (Sec. 1102). -Requires participating employment-based plans to use amounts paid to them under the temporary reinsurance program to lower costs for the plan (Sec. 1102). -Specifies that nothing in this Act shall be construed to require an individual to terminate coverage under a group health plan or health insurance coverage in which the individual was enrolled on the date of enactment (Sec. 1251). -Defines "qualified health plan" as a plan that meets the following criteria (Secs. 1301-1302):

-Has in effect a Certification that it meets the criteria issued or recognized by each Exchange through which it is offered; -Provides the following levels of coverage, with some exceptions:
-"Bronze level," in which 60 percent of the costs are reimbursed; -"Silver level," in which 70 percent of the costs are reimbursed; -"Gold level," in which 80 percent of the costs are reimbursed; and -"Platinum level," in which 90 percent of the costs are reimbursed;
-Covers the following services:
-Ambulatory patient Services -Emergency services; -Hospitalization; -Maternity and newborn care; -Mental health and substance use disorder services; -Prescription drugs; -Rehabilitative and habilitative services and devices; -Laboratory services; -Preventive and wellness services and chronic disease management; and -Pediatric services, including oral and vision care;
-Limits cost sharing to the following amounts:
-Beginning in 2014, $5,000 for individual coverage and $10,000 for family coverage; and -Beginning after 2014, the 2014 amount for family or individual coverage increased by the product of that amount and the percentage (if any) by which the average premium for health insurance coverage in the U.S. for the preceding calendar year exceeds the average premium for 2013;
-For employment-based plans, limits the deductibles to the following amounts:
-Beginning in 2014, $2,000 for individual coverage and $4,000 for any other plan; -For individual coverage beginning after 2014, the 2014 amount increased by the product of that amount and the percentage (if any) by which the average premium for health insurance coverage in the U.S. for the preceding calendar year exceeds the average premium for 2013; and -For any other coverage beginning after 2014, twice the amount of the aforementioned amount;
-Is offered by a health insurer that offers at least one "silver level" and "gold level" plan in each Exchange; -Is offered by a health insurer that agrees to charge the same premium rate for each plan regardless of whether the plan is offered through and Exchange or directly; and -Is offered by a health insurer that complies with the regulations developed by the Secretary and the applicable Exchange.

-Relies on the same definition of "qualified health plan" for plans that are qualified to be offered as CO-OP plans or multi-state plans (Secs. 1301 & 10104). -Specifies that nothing in Title I of this act shall be construed to require a qualified health plan to provide coverage of any type of abortion, and allows health insurers that issue qualified health plans to determine whether or not the plans shall provide coverage of any kind of abortion services (Sec. 1303). Health Insurance Exchange -Requires the Secretary to disperse funds so that each state may establish no later than January 1, 2014 an Health Benefit Exchange, a governmental or non-profit agency that shall make qualified health plans available to qualified individuals (excluding undocumented immigrants and incarcerated individuals) and employers (those offering coverage to all full-time employees), with specific requirements, including, but not limited to, the following (Secs. 1311 & 1312):

-Establish a Small Business Health Options Program ("SHOP Exchange') to assist qualifying small employers with enrolling employees in a qualified health program; -Maintain a website through which prospective enrollees may compare health plans; -Assign ratings for every qualified health plan offered; and -Provide an electronic calculator for the purpose of determining the cost of coverage.

-Requires state Exchanges to establish Navigator Programs that provide grants to any entity that has existing relationships or the capacity to establish relationships with employers and employees, consumers, or self-employed individuals who are likely to be qualified to enroll in a qualified health plan, and requires every Navigator to perform various duties, including, but not limited to, the following (Sec. 1311):

-Conduct public education activities that raise awareness of the availability of qualified health plans; and -Distribute "fair and impartial information" about enrollment and the availability of premium tax credits and cost-sharing reductions.

-Specifies that qualified individuals are not required to participate in an Exchange (Sec. 1312). -Specifies that states have the right to require any benefits in addition to the essential health benefits established under this Act, and specifies that states shall also assume the costs for such benefits to any individual enrolled in a qualified health care plan (Sec. 1311). -Requires the Secretary to establish an Exchange within a state if that state fails to or has not taken necessary action to do so by January 1, 2014 (Sec. 1321). -Authorizes states to enact laws prohibiting abortion coverage in qualified health plans offered through an Exchange in the state, and specifies that states may also repeal such laws (Sec. 10104). -Appropriates $6 billion for the purpose of establishing a Consumer Operated and Oriented Plan (CO-OP), a program intended to encourage states to create qualified nonprofit health insurance issuers that will offer qualified health plans in the individual and small group markets, and authorizes the Secretary to award grants and loans to individuals applying to become a nonprofit health insurance issuer through CO-OP based on the following criteria (Sec. 1322):

-Recommendations of the 15-member CO-OP advisory board established by this Act, in which members are appointed by the Comptroller General in accordance with ethics and conflict-of-interest guidelines; -Whether applicants will offer qualified health plans on a statewide basis, will utilize integrated care models, and have significant private support; and -Whether there will be sufficient funding to meet the requirement to establish at least 1 qualified nonprofit health insurance issuer in each state.

-Requires that plans offered through the CO-OP program or any nationwide qualified health plan be subject to the same laws that apply to private health insurers (Sec. 1324). -Requires the Director of the Office of Personnel Management to enter into contracts with health insurers, without regard to competitive bidding statutes, to offer at least 2 multi-state qualified health plans (with at least one being a non-profit) through each Exchange (Sec. 10104). -Specifies that multi-state qualified health plans must meet the following requirements (Sec. 10104):

-Must offer benefits packages that are uniform in each state and consist of the essential benefits as defined in this Act; -Must meet all the requirements of a qualified health plan under this Act; -Must determine premiums on the basis of the rating requirements of Part A, Title XXVII of the Public Health Service Act; and -The insurer must offer the plan in all geographic regions and in all states that have adopted adjusted community rating before the date of enactment.

-Establishes a program that allows states to enter into a competitive process to negotiate contracts, premiums, cost sharing, and benefits with standard health plans for individuals who meet the following requirements (Sec. 1331):

-Must be ineligible to enroll in Medicaid; -Must be ineligible for minimum essential coverage (§ 5000A(f), Internal Revenue Code) or eligible for an employer-sponsored plan that is not "affordable" (§ 5000A(e)(2), Internal Revenue Code); -Household income is above 133 percent but not more than 200 percent of the federal poverty line (according to the size of that individual's family); and -Who is under age 65 at the beginning of the plan year.

-Requires the Secretary, in consultation with the National Association of Insurance Commissioners, to establish regulations for interstate health care compacts, under which qualified health plans offered in one state can be purchased in another state beginning in 2016, provided the insurers are licensed in each participating state and are subject to the market conduct, unfair trade practices, network adequacy, and consumer protection standards of the purchaser's state (Sec. 1333). -Establishes tax credits to assist individuals with the cost of health insurance premiums, and specifies that such assistance shall be equal to the lesser of (Sec. 1401):

-The monthly premiums for one or more qualified Exchange health plans offered in the individual market within a state which cover the taxpayer, the taxpayer's spouse, and any dependent(s); or -The excess (if any) of the adjusted monthly premium for the second lowest cost silver plan over an amount equal to 1/12 of the "applicable percentage," calculated by a formula established by this Act.

-Establishes the following cost sharing reductions for individuals enrolled in a plan providing silver level coverage through an Exchange and whose household income is greater than 100 percent but less than 400 percent of the federal poverty line (Sec. 1402):

-2/3 reduction if household income is between 100 and 200 percent of the federal poverty line; -1/2 reduction if household income is between 200 and 300 percent of the federal poverty line; and -1/3 reduction if household income is between 300 and 400 percent of the federal poverty line.

-Establishes a tax credit for small businesses that purchase health insurance for their employees of 50 percent (or 35 percent for a small employer eligible for tax exemption) of the lesser of (Sec. 1421):

-Total nonelective contributions the employer made on behalf of its employees for premiums for qualified health plans offered through an Exchange; or -Total nonelective contributions the employer would have made if each employee had enrolled in a qualified health plan with a premium equal to the average premium for the small group market in the rating area in which the employee enrolls for coverage.

-Defines an "eligible small employer" as an employer with not more than 25 full-time employees whose average annual wages are less than $50,000 (through 2013, and an increased amount allowing for cost of living adjustments in subsequent years) and who arrange to make nonelective contributions on behalf of each employee (Sec. 1421). Employer and Individual Mandates -Requires applicable individuals to maintain "minimum essential health care coverage" for themselves and any dependents beginning after January 1, 2014, meaning one of the following (Sec. 1501):

-Medicare and Medicaid; -Children's Health Insurance Program; -TRICARE; -Veteran's health care program; -Health care for Peace Corps volunteers; -Employer-sponsored plans; -Individual market plans; -Grandfathered health care plans, meaning coverage that is offered and effective before the date of enactment; or -Other health care plan recognized by the Secretary of Health and Human Services (including state high-risk pooling plans).

-Establishes a monthly penalty on individuals who can afford minimal health coverage but fail to provide it for themselves and any dependents, a penalty that must be reported on income tax returns, and resolves that such penalty shall be the greater of 1/12 of the following (Sec. 1501):

-A flat dollar amount, calculated by applying an "applicable dollar amount" multiplied by the number of people for whom the individual is liable, or 300 percent of such amount for the taxable year; or -A percentage of the individual's income: 0.5 percent for taxable years beginning in 2014, 1.0 percent for taxable years beginning in 2015, or 2.0 percent for taxable years beginning after 2015.

-Defines "applicable dollar amount" as $95 for 2014, $495 for 2015, and $750 thereafter, provided the amount is amended according to the cost of living adjustment beginning in 2017, unless the individual is under 18 years of age, then such amount shall be 1/2 of the amounts specified (Sec. 1501). -Exempts the following individuals from the penalty for failure to acquire coverage (Sec. 1501):

-Individuals with conflicts of "religious conscience"; -Individuals who are members of a health care sharing ministry; -Undocumented immigrants; -Incarcerated individuals; -Individuals for whom the cost of minimal health care coverage would exceed 8 percent of his or her income for 2013; -Individuals whose income is under 100 percent of the federal poverty line; -Members of Native American tribes; -Individual who has "suffered a hardship," as determined by the Secretary; and -Any other applicable individual who was not covered on the last day of the month for three consecutive months.

-Specifies that taxpayers cannot be criminally prosecuted, nor can a lien be placed on a taxpayer's property, for failure to pay penalties for lack of health care coverage (Sec. 1501). -Requires businesses that employ more than 200 full-time employees and offer more than 1 health benefits plan to automatically enroll employees into a plan, and requires the employer to notify employees that they may opt out of such plan and provide literature to employees on all health plan options, including the existence of a Health Care Exchange (Secs. 1511 - 1512). -Requires large employers (average of at least 50 full time employees, with exceptions for seasonal workers) with at least one full time employee receiving a premium assistance tax credit that fails to provide health care coverage to other employees to pay an assessable payment equal to the number of uncovered employees multiplied by 1/12 of $750 (adjusted for inflation beginning in 2015) for every month the employer failed to provide coverage (Sec. 1513). -Requires large employers that impose a waiting period of 60 days or more to enroll in the company's health benefits plan to pay an assessable payment of $600 (adjusted for inflation beginning in 2015) for every full-time employee affected by the waiting period (Sec. 1513). -Requires large employers that enroll employees in its health benefits plan and have at least 1 employee who is eligible for premium tax credits or cost-sharing reductions to pay an assessable payment of $3,000 for each individual for which this provision applies (Sec. 1513). -Establishes an excise tax of 40 percent on coverage providers that provide "high cost employer-sponsored health care plans," to be applied to the amount of the premium in excess of the following thresholds (Sec. 9001):

-$8,500 for single coverage, or $9,850 for employees of high-risk professions and single retired persons 55 and older (cost of living adjustment applied beginning in 2014); -$23,000 for family coverage, or $26,000 for employees of high-risk professions and retired persons 55 and older with family coverage (cost of living adjustment applied beginning in 2014); and -If the plan is offered in 1 of the 17 states that the Secretary of Health and Human Services determines had the highest average cost of health care in 2012, the threshold will be increased from 2012 through 2015.

-Exempts the following types of coverage from the aforementioned excise tax (Sec. 9001):

-Long-term care; -Accident or disability insurance -Coverage only for a specified disease or illness; and -Hospital or other fixed indemnity insurance.

-Defines "coverage provider" to include each of the following entities (Sec. 9001):

-Issuers of group health insurance plans; -Employers who make contributions to employees Health Savings or Medical Savings Accounts; -Self-employed individuals who are eligible to deduct the cost of their health insurance plan; and -Administrators of other health care plans.

-Defines a "high risk profession" as follows (Secs. 9001 & 10901):

-Individuals who install or repair electrical and telecommunications lines; -Law enforcement officers; -Fire fighters; -Emergency medical technicians, paramedics, first-responders, and others who provide out-of-hospital emergency medical care; and -Construction workers, longshore workers, miners, most agricultural workers, foresters, and fishermen.

-Increases a tax on payment distributions from HSAs to beneficiaries for non-qualified medical expenses from 10 percent to 20 percent, beginning in 2011 (Sec. 9004). -Increases a tax on payment distributions from Archer MSAs to beneficiaries for non-qualified medical expenses from 15 percent to 20 percent, beginning in 2011 (Sec. 9004). -Establishes a non-deductible flat fee to be collected annually after 2010 totaling $2 billion on medical device manufacturers and importers making more than $5 million during a calendar year, the amount of which shall be paid in proportion based on a percentage of the company's gross receipts over the aggregate of gross receipts from sales made by the medical device manufacturing sector in the same year (Sec. 9009). -Specifies that the flat fee imposed on medical device manufacturers and importers shall be increased after 2017, totaling $3 billion to be collected from that sector (Sec. 9009). -Increases the hospital insurance tax rate by 0.9 percent on individuals earning over $200,000 and on married couples filing jointly that earn over $250,000, beginning in 2013 (Secs. 9015 & 10906). -Establishes a 10 percent excise tax on voluntary indoor tanning services, to be collected at the point of service beginning after July 1, 2010, and specifies that phototherapy services performed by a licensed professional are exempt from such tax (Secs. 9017 & 10907). Medicare and Medicaid -Requires the Secretary of Health and Human Services to establish a modifier for Medicare rates of payments to physicians based on the quality of care compared to the cost during a performance period, and specifies that the modifier shall only apply to specific physicians, as determined by the Secretary, beginning in 2015, and shall apply to all physicians beginning in 2017 (Sec. 3007). -Establishes a 1 percent Medicare payment reduction, beginning in fiscal year 2014-2015, for hospitals that are in the top quarter, relative to the national average, of hospital acquired conditions that (Sec. 3008):

-Have high cost, high volume, or both; -Result in the assignment of a case to a diagnosis-related group that has a higher payment when the code is present as a secondary diagnosis; and -Could reasonably have been prevented through the application of evidence-based guidelines.

-Requires the Secretary of Health and Human Services to reduce Medicare rates of payment to hospitals by specific amounts based upon their rates of "excess readmission" for 3 conditions selected by the Secretary with readmission measures that are endorsed by the National Quality Forum beginning in fiscal year 2012-2013, and requires the Secretary expand the number of conditions beginning in fiscal year 2014-2015 (Sec. 3025). -Requires the Secretary to establish a Hospital Value-Based Purchasing Program in which incentive payments are made to hospitals, beginning with fiscal year 2012-2013, based on performance standards that are established by the Secretary for the following conditions or procedures (Sec. 3001):

-Acute myocardia infarction (AMI); -Heart failure; -Pneumonia; -Surgeries, as mentioned by the Surgical Care Improvement Project; and -Healthcare-associated infections, as measured by the prevention metrics and targets established by the Secretary's Action Plan to Prevent Healthcare-Associated Infections of the Department of Health and Human Services.

-Requires the Secretary to calculate Medicare Part C (Medicare Advantage Plan) rates of payment based on the weighted average of monthly bids for each plan in the area, and establishes a phase-in period beginning in 2011 and culminating in 2014 (Sec. 3201). -Establishes the following quality performance bonuses for Medicare Part C plans beginning in 2014 based on their rating according to a 5 star rating system established by the Secretary that measures clinical quality and enrollee satisfaction (Sec. 3201):

-For plans that achieve a 3 star rating, a monthly payment equal to 2 percent of the national monthly per capita cost for expenditures for individuals enrolled under the original Medicare fee-for-service program; and -For plans that achieve a 4 or 5 star rating, a monthly payment equal to 4 percent of the national monthly per capita cost for expenditures for individuals enrolled under the original Medicare fee-for-service program.

-Establishes "improved quality bonuses" for Medicare Part C plans that did not receive a quality performance bonus, beginning in 2014, that is equal to 1 percent of the national monthly per capita cost for expenditures for individuals enrolled under the original Medicare fee-for-service program, provided that the Secretary has determined that the plan is an "improved quality MA plan" (Sec. 3201). -Reduces the coverage gap under Medicare Part D that separates the limit on initial coverage and the coverage for catastrophic care ("donut hole") by $500 beginning January 1, 2010 (Sec. 3315). -Requires the Secretary to establish a program no later than July 1, 2010 in which the Secretary shall enter into agreements with drug manufacturers to provide individuals who are subject to the Medicare Part D coverage gap a 50 percent discount for specifics drugs and biologics (Sec. 3301). -Prohibits Medicare Part D cost-sharing for full-benefit dual eligible individuals that are receiving care under a home and community based waiver who would otherwise require the level of care provided in a hospital, nursing facility, or intermediate care facility for the mentally disabled (Sec. 3309). -Establishes the Independent Medicare Advisory Board, consisting of 15 voting members appointed by the President and confirmed by the Senate, to submit proposals for reducing Medicare spending on January 15 of each year in which the Chief Actuary of the Centers for Medicare and Medicaid Services determines Medicare costs are unsustainable, beginning in 2014, and specifies that such proposal must meet specific requirements, including, but not limited to, the following (Sec. 3403):

-The Chief Actuary has determined that such proposal will result in a net reduction in total Medicare spending equaled to an amount established by a specific formula; -Inclusion of recommendations to reduce Medicare payments under parts C and D, denying or removing high bids for prescription drug coverage from the calculation of the national monthly bid amount, and reductions in payments to Medicare Advantage plans that are related to administrative expenses and performance bonuses; and -Exclusion of any recommendation to ration health care, raise revenues or premiums, increase cost-sharing, restrict benefits, or modify eligibility criteria.

-Requires the Secretary to implement the recommendations of the Independent Medicare Advisory Board on August 15 of the year in which the proposal is submitted, unless Congress has either passed legislation that specifies that it supersedes the recommendations of the Board or has adopted a joint resolution that discontinues the Board (Sec. 3403). -Prohibits Congress from adopting legislation that supersedes the recommendations of the Independent Medicare Advisory Board if the legislation is expected to result in an increase in Medicare spending, or if the Chief Actuary has determined that such legislation will not result in a net reduction in total Medicare spending equaled to an amount established by a specific formula (Sec. 3403). -Expands Medicaid eligibility to include individuals under 65 years of age with incomes that do not exceed 133 percent of the federal poverty level, including adults without children or a disability, beginning January 1, 2014, and authorizes states to expand Medicaid coverage to include all individuals not eligible for Medicare and with incomes above 133 percent of the federal poverty level beginning April 1, 2010 (Secs. 2001 & 10201). -Specifies that the federal government will compensate the states for the costs of the aforementioned expansion in Medicaid eligibility as follows (Sec. 2001):

-For 2014 through 2016: all states are compensated for 100 percent of the costs; -For 2017: a 30.3 point Federal Medical Assistance Percentage (FMAP) increase for expansion states, and and a 34.3 point FMAP increase for non-expansion states.; -For 2018, a 31.3 point FMAP increase for expansion states, and a 33.3 point FMAP increase for non- expansion states; and -For 2019 and each year thereafter, a 32.3 point FMAP increase for all states.

-Defines "expansion state" as a state that on the date of enactment offers health coverage, including inpatient hospital services, to parents and nonpregnant, childless adults with incomes that are at least 100 percent of the federal poverty line and not dependent on access to employer-based coverage (Secs. 2001 & 10201). -Specifies that aforementioned federal Medicaid compensation guidelines do not apply to the state of Nebraska, which instead will be compensated for 100 percent of the costs beginning in 2014 and each subsequent year thereafter (Sec. 10201). -Prohibits States from adopting eligibility standards, methodologies, or procedures for Medicaid that are a more restrictive than than the eligibility standards, methodologies, or procedures that are effective on the date of enactment until December 31, 2013, and extends this requirement for children until September 20, 2019 (Sec. 2001). -Authorizes states to establish a Community First Choice Option beginning October 1, 2010 in which the states can provide home and community-based attendant services to disabled individuals that are eligible for Medicaid and would otherwise require the level of care provided by a hospital, nursing facility, intermediate care facility for the developmentally disabled, or institution for mental diseases (Sec. 2401). -Extends the current reauthorization of the Children's Health Insurance Program (CHIP) through September 31, 2015, and increases the FMAP for states to fund CHIP by 23 points for the period of October 1, 2015 through September 30, 2019, provided that it does not exceed 100 percent (Secs. 2101 & 10203). -Prohibits States from adopting eligibility standards, methodologies, or procedures for CHIP that are a more restrictive than than the eligibility standards, methodologies, or procedures that are effective on the date of enactment, and repeals this prohibition on September 30, 2019 (Sec. 2101). Public Health and Workforce Development -Establishes the National Prevention, Health Promotion and Public Health Council within the Department of Health and Human Services, and requires the Council to perform the following duties (Sec. 4001):

-Serve as a coordinating organization among all federal agencies with respect to prevention, wellness, and health promotion practices, the public health system, and integrative health care; -Develop a national strategy to improve the health of Americans and reduce incidents of preventable illnesses; -Provide the President and Congress with recommendations on the most pressing health issues, including any policy changes that may achieve national health and wellness goals; -Propose innovative approaches and policies for prevention, integrative wellness and public health for individuals and on community-levels; -Establish a process for continual public input at the regional, state, and local level; -Develop and make public the Council's national health strategy and recommendations; and -Perform other activities as required by the President.

-Establishes a Prevention and Public Health Fund to provide for the expansion and sustained investment in public health and preventative programs and to lessen growth in private and public sector health care costs, and appropriates to the Fund the following amounts (Sec. 4002):

-$500 million for fiscal year 2009-2010; -$750 million for fiscal year 2010-2011; -$1 billion for fiscal year 2011-2012; -$1.25 billion for fiscal year 2012-2013; -$1.5 billion for fiscal year 2013-2014; and -$2 billion for fiscal year 2014-2015 and each subsequent year thereafter.

-Appropriates $50 million for each fiscal year from 2009-2010 to 2012-2013 for the establishment of a grant program for school-based health centers, with preference given to health centers that serve a large child population eligible for assistance under the state Medicaid plan, and requires such health centers to provide the following core services (Sec. 4101):

-Health assessments, diagnosis, and treatment of minor, acute, and chronic medical conditions; and -Mental health and substance use disorder assessments, crisis intervention, counseling, treatment, and referral to a continuum of services including emergency psychiatric care, community support programs, inpatient care, and outpatient programs.

-Requires chain restaurants with more than 20 locations to display calorie content information next to food items on menus, including drive-through menu boards and self-service food and beverage bars, and to have that calorie information reflect servings as usually prepared and offered for sale (Sec. 4205). -Appropriates $25 million for the Childhood Obesity Demonstration Project for fiscal years 2009-2010 through 2013-2014 (Sec. 4306). -Establishes the National Health Care Workforce Commission to coordinate with various departments to determine if the demand for health care workers is being met (Sec. 5101). -Increases the maximum amount available for nursing student loans from $2,500 to $3,300 for any student and $4,000 to $5,200 for a student's last two academic years, and increases from $13,000 to $17,000 the limit for the aggregate of loans for all years for students during fiscal years 2009-2010 and 2010-2011 and an increased amount in subsequent years when the cost of attendance rises (Sec. 5202). -Establishes a pediatric specialty loan repayment program that covers the principal interest of undergraduate, graduate and medical degree loans up to $35,000 a year for not more then 3 years, provided that the recipient agrees to provide pediatric medical subspecialty, pediatric surgical specialty, or child and adolescent mental and behavioral health care in an area with a shortage (Sec. 5203). -Authorizes appropriations of the following amounts to the National Health Service Corps (Sec. 5207):

-$320.46 million for fiscal year 2009-2010; -$414.10 million for fiscal year 2010-2011; -$535.09 million for fiscal year 2011-2012; -$691.43 million for fiscal year 2012-2013; -$893.46 million for fiscal year 2013-2014; -$1.15 billion for fiscal year 2014-2015; and -For subsequent years, the amount of the previous fiscal year plus an adjustment for increases in health professions education costs and changes in the number of individuals residing in health profession shortage areas.

-Authorizes the appropriation of $50 million a year for fiscal year 2009-2010 for nurse-managed health clinics, and "such sums as may be necessary" for fiscal years 2010-2011 through 2013-2014 (Sec. 5208). -Authorizes the appropriation of $125 million for fiscal year 2009-2010 and "such sums as may be necessary" for fiscal years 2010-2011 through 2013-2014 to make grants available to accredited public or nonprofit private hospitals, schools of medicine or osteopathic medicine, or academically affiliated physician assistant training programs for support and development of primary care training programs (Sec. 5301). -Authorizes the appropriation of $10 million for fiscal years 2009-2010 through 2012-2013 for grants to accredited institutes of higher learning that have established a public-private educational partnership with a nursing home or skilled nursing facility, or similar entities that provide training for direct-care workers in long-term care facilities (Sec. 5302). -Authorizes the Secretary of Health and Human Services to award grants to higher education institutions that recruit and provide clinical experience to students in mental health and behavioral health education, and authorizes the appropriations of the following funds for fiscal years 2009-2010 through 2012-2013 to carry this out (Sec. 5306):

-$8 million for social work training; -$12 million for graduate psychology training; -$10 million for professional child and adolescent mental health training; and -$5 million for paraprofessional child and adolescent work.

-Authorizes the appropriation of $338 million for the purpose of expanding eligibility for loan repayment and scholarship programs to nursing school faculty (Secs. 5310 & 5312). -Authorizes the establishment of a Unites States Public Health Sciences Track, which shall be authorized to award advanced degrees through existing accredited academic institutions and shall emphasize team-based service, public health, epidemiology, and emergency preparedness and response (Sec. 5315). -Specifies that students admitted to the Track shall receive tuition (or tuition remission) and a stipend for each school year for up to four years, in exchange for the following (Sec. 5315):

-Maintain Track enrollment until the course of study is completed; -Maintain "an acceptable level" of academic standing (as determined by the Surgeon General); -Complete a residency or internship if pursuing a degree from a school of medicine or osteopathic medicine, dental, public health, or nursing school or a physician assistant, pharmacy, or behavioral and mental health professional program; and -Serve in the Commissioned Corps for two years for each year of enrollment, unless serving in a capacity which qualifies for a reduction.

-Authorizes the Secretary of Health and Human Services to award grants to teaching health centers to establish new accredited or expanded primary care residency programs, and authorizes a total of $125 million in appropriations for fiscal years 2009-2010 through 2011-2012 to carry this out (Sec. 5508). -Appropriates the following funds for federally qualified health centers (Sec. 5601):

-$2.99 billion for fiscal year 2009-2010; -$3.86 billion for fiscal year 2010-2011; -$4.99 billion for fiscal year 2011-2012; -$6.45 billion for fiscal year 2012-2013; -$7.33 billion for fiscal year 2013-2014; -$8.33 billion for fiscal year 2014-2015; and -For subsequent fiscal years, the amount of the previous fiscal year plus an adjustment for increases in costs incurred per patient served and increases in total number of patients.

-Establishes an approval pathway to license biological products that are biosimilar or interchangeable with products that are already licensed, and prohibits the licensing of biosimilar products until 12 years after the licensing of the already-licensed product (Sec. 7002).

Legislation - Bill Passed (Senate) - Dec. 24, 2009 (Key vote)

Title: Health Care and Insurance Law Amendments ("Patient Protection and Affordable Care Act")

Vote Smart's Synopsis:

Vote to pass a bill that amends various statues related to health care and heath insurance coverage, including, but not limited to, the establishment of a Health Insurance Exchange Program, an individual mandate to purchase insurance, a prohibition on insurers denying or rescinding coverage based on a preexisting condition, a tax on "high cost employer-sponsored health care plans," various mechanisms aimed at reducing Medicare spending, and an expansion of Medicaid eligibility.

Highlight: Insurance Regulations -Prohibits health insurers from imposing any preexisting condition exclusions (Sec. 1201). -Prohibits health insurers from establishing rules for eligibility (including continued eligibility) based on any of the following factors (Sec. 1201):

-Health status; -Medical condition (including physical and mental illnesses); -Claims experience; -Receipt of health care; -Medical history; -Genetic information; -Evidence of insurability (including conditions relating to domestic violence); -Disability; and -Any other health status-related factor determined appropriate by the Secretary.

-Requires health insurers to base premium rates for plans in the individual or small group markets on the following (Sec. 1201):

-Whether the plan or coverage covers an individual or family; -Rating area; -Age, except that the rate shall not vary by more than 3 to 1 for adults; and -Tobacco use, except that the rate shall not vary by more than 1.5 to 1.

-Prohibits health insurers from establishing lifetime limits or annual limits on the dollar value of benefits for any participant or beneficiary, except that prior to 2014 insurers may establish "restricted annual limits" that the Secretary of Health and Human Services determines will not impede access to "needed services" and will have a "minimal impact" on premiums (Secs. 1001 & 10101). -Prohibits health insurers from rescinding coverage unless there is an occurrence of fraud in violation of the terms of the health plan or health insurance coverage (Sec. 1001). -Requires health insurers to provide coverage for the following preventive services at no cost to the patient (Sec. 1001):

-Services that have an "A" or "B" rating in the recommendations of the U.S. Preventive Services Task Force; -Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and -Preventive health care and screenings for women, infants, children and adolescents as provided for in guidelines supported by the Health Resources and Services Administration.

-Specifies that the recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention issued in or around November 2009 shall not apply for the purposes of federal law (Sec. 1001). -Requires health insurers that provide dependent coverage of children to continue to make such coverage available for an unmarried adult child until he or she turns 26 years old (Sec. 1001). -Prohibits a group health plan from discriminating in favor of the highest paid 25 percent of employees, shareholders owning more than 10 percent of the employer's stock value, or the five highest paid officers with regards to eligibility or benefits (Secs. 1001 & 10101). -Requires the Secretary to establish a temporary high risk health insurance pool program no later than 90 days after the date of enactment to provide coverage through 2013 to individuals that (Sec. 1101):

-Are a citizen or national of the United States or are lawfully present in the United States; -Have not been covered during the 6 month period prior to application; and -Have a preexisting condition that is consistent with the guidelines established by the Secretary.

-Establishes the following requirements for the high risk pool (Sec. 1101):

-It must provide coverage in which the insurer's share of the total allowed costs of benefits is not less than 65 percent; -It must provide coverage that has an out of pocket limit that does not exceed $5,000 annually for self-only coverage and $10,000 annually for family coverage, except that the Secretary may modify the limit to ensure that the insurer's share of total allowed costs of benefits is not less than 65 percent; -The premium rate must be established at a standard rate for a standard population and the rate must vary only as allowed elsewhere in this Act, except that it may vary on the basis of age by a factor of no more than 4 to 1; and -It must meet any other requirements determined "appropriate" by the Secretary.

-Requires the Secretary to establish a temporary reinsurance program to reimburse employment-based health plans covering early retirees (55 years of age or older but not eligible for Social Security) for claims that are between $15,000 and $90,000 through 2013, and specifies that the reimbursement shall be 80 percent of the costs that exceed $15,000 (Sec. 1102). -Requires participating employment-based plans to use amounts paid to them under the temporary reinsurance program to lower costs for the plan (Sec. 1102). -Specifies that nothing in this Act shall be construed to require an individual to terminate coverage under a group health plan or health insurance coverage in which the individual was enrolled on the date of enactment (Sec. 1251). -Defines "qualified health plan" as a plan that meets the following criteria (Secs. 1301-1302):

-Has in effect a Certification that it meets the criteria issued or recognized by each Exchange through which it is offered; -Provides the following levels of coverage, with some exceptions:
-"Bronze level," in which 60 percent of the costs are reimbursed; -"Silver level," in which 70 percent of the costs are reimbursed; -"Gold level," in which 80 percent of the costs are reimbursed; and -"Platinum level," in which 90 percent of the costs are reimbursed;
-Covers the following services:
-Ambulatory patient Services -Emergency services; -Hospitalization; -Maternity and newborn care; -Mental health and substance use disorder services; -Prescription drugs; -Rehabilitative and habilitative services and devices; -Laboratory services; -Preventive and wellness services and chronic disease management; and -Pediatric services, including oral and vision care;
-Limits cost sharing to the following amounts:
-Beginning in 2014, $5,000 for individual coverage and $10,000 for family coverage; and -Beginning after 2014, the 2014 amount for family or individual coverage increased by the product of that amount and the percentage (if any) by which the average premium for health insurance coverage in the U.S. for the preceding calendar year exceeds the average premium for 2013;
-For employment-based plans, limits the deductibles to the following amounts:
-Beginning in 2014, $2,000 for individual coverage and $4,000 for any other plan; -For individual coverage beginning after 2014, the 2014 amount increased by the product of that amount and the percentage (if any) by which the average premium for health insurance coverage in the U.S. for the preceding calendar year exceeds the average premium for 2013; and -For any other coverage beginning after 2014, twice the amount of the aforementioned amount;
-Is offered by a health insurer that offers at least one "silver level" and "gold level" plan in each Exchange; -Is offered by a health insurer that agrees to charge the same premium rate for each plan regardless of whether the plan is offered through and Exchange or directly; and -Is offered by a health insurer that complies with the regulations developed by the Secretary and the applicable Exchange.

-Relies on the same definition of "qualified health plan" for plans that are qualified to be offered as CO-OP plans or multi-state plans (Secs. 1301 & 10104). -Specifies that nothing in Title I of this act shall be construed to require a qualified health plan to provide coverage of any type of abortion, and allows health insurers that issue qualified health plans to determine whether or not the plans shall provide coverage of any kind of abortion services (Sec. 1303). Health Insurance Exchange -Requires the Secretary to disperse funds so that each state may establish no later than January 1, 2014 an Health Benefit Exchange, a governmental or non-profit agency that shall make qualified health plans available to qualified individuals (excluding undocumented immigrants and incarcerated individuals) and employers (those offering coverage to all full-time employees), with specific requirements, including, but not limited to, the following (Secs. 1311 & 1312):

-Establish a Small Business Health Options Program ("SHOP Exchange') to assist qualifying small employers with enrolling employees in a qualified health program; -Maintain a website through which prospective enrollees may compare health plans; -Assign ratings for every qualified health plan offered; and -Provide an electronic calculator for the purpose of determining the cost of coverage.

-Requires state Exchanges to establish Navigator Programs that provide grants to any entity that has existing relationships or the capacity to establish relationships with employers and employees, consumers, or self-employed individuals who are likely to be qualified to enroll in a qualified health plan, and requires every Navigator to perform various duties, including, but not limited to, the following (Sec. 1311):

-Conduct public education activities that raise awareness of the availability of qualified health plans; and -Distribute "fair and impartial information" about enrollment and the availability of premium tax credits and cost-sharing reductions.

-Specifies that qualified individuals are not required to participate in an Exchange (Sec. 1312). -Specifies that states have the right to require any benefits in addition to the essential health benefits established under this Act, and specifies that states shall also assume the costs for such benefits to any individual enrolled in a qualified health care plan (Sec. 1311). -Requires the Secretary to establish an Exchange within a state if that state fails to or has not taken necessary action to do so by January 1, 2014 (Sec. 1321). -Authorizes states to enact laws prohibiting abortion coverage in qualified health plans offered through an Exchange in the state, and specifies that states may also repeal such laws (Sec. 10104). -Appropriates $6 billion for the purpose of establishing a Consumer Operated and Oriented Plan (CO-OP), a program intended to encourage states to create qualified nonprofit health insurance issuers that will offer qualified health plans in the individual and small group markets, and authorizes the Secretary to award grants and loans to individuals applying to become a nonprofit health insurance issuer through CO-OP based on the following criteria (Sec. 1322):

-Recommendations of the 15-member CO-OP advisory board established by this Act, in which members are appointed by the Comptroller General in accordance with ethics and conflict-of-interest guidelines; -Whether applicants will offer qualified health plans on a statewide basis, will utilize integrated care models, and have significant private support; and -Whether there will be sufficient funding to meet the requirement to establish at least 1 qualified nonprofit health insurance issuer in each state.

-Requires that plans offered through the CO-OP program or any nationwide qualified health plan be subject to the same laws that apply to private health insurers (Sec. 1324). -Requires the Director of the Office of Personnel Management to enter into contracts with health insurers, without regard to competitive bidding statutes, to offer at least 2 multi-state qualified health plans (with at least one being a non-profit) through each Exchange (Sec. 10104). -Specifies that multi-state qualified health plans must meet the following requirements (Sec. 10104):

-Must offer benefits packages that are uniform in each state and consist of the essential benefits as defined in this Act; -Must meet all the requirements of a qualified health plan under this Act; -Must determine premiums on the basis of the rating requirements of Part A, Title XXVII of the Public Health Service Act; and -The insurer must offer the plan in all geographic regions and in all states that have adopted adjusted community rating before the date of enactment.

-Establishes a program that allows states to enter into a competitive process to negotiate contracts, premiums, cost sharing, and benefits with standard health plans for individuals who meet the following requirements (Sec. 1331):

-Must be ineligible to enroll in Medicaid; -Must be ineligible for minimum essential coverage (§ 5000A(f), Internal Revenue Code) or eligible for an employer-sponsored plan that is not "affordable" (§ 5000A(e)(2), Internal Revenue Code); -Household income is above 133 percent but not more than 200 percent of the federal poverty line (according to the size of that individual's family); and -Who is under age 65 at the beginning of the plan year.

-Requires the Secretary, in consultation with the National Association of Insurance Commissioners, to establish regulations for interstate health care compacts, under which qualified health plans offered in one state can be purchased in another state beginning in 2016, provided the insurers are licensed in each participating state and are subject to the market conduct, unfair trade practices, network adequacy, and consumer protection standards of the purchaser's state (Sec. 1333). -Establishes tax credits to assist individuals with the cost of health insurance premiums, and specifies that such assistance shall be equal to the lesser of (Sec. 1401):

-The monthly premiums for one or more qualified Exchange health plans offered in the individual market within a state which cover the taxpayer, the taxpayer's spouse, and any dependent(s); or -The excess (if any) of the adjusted monthly premium for the second lowest cost silver plan over an amount equal to 1/12 of the "applicable percentage," calculated by a formula established by this Act.

-Establishes the following cost sharing reductions for individuals enrolled in a plan providing silver level coverage through an Exchange and whose household income is greater than 100 percent but less than 400 percent of the federal poverty line (Sec. 1402):

-2/3 reduction if household income is between 100 and 200 percent of the federal poverty line; -1/2 reduction if household income is between 200 and 300 percent of the federal poverty line; and -1/3 reduction if household income is between 300 and 400 percent of the federal poverty line.

-Establishes a tax credit for small businesses that purchase health insurance for their employees of 50 percent (or 35 percent for a small employer eligible for tax exemption) of the lesser of (Sec. 1421):

-Total nonelective contributions the employer made on behalf of its employees for premiums for qualified health plans offered through an Exchange; or -Total nonelective contributions the employer would have made if each employee had enrolled in a qualified health plan with a premium equal to the average premium for the small group market in the rating area in which the employee enrolls for coverage.

-Defines an "eligible small employer" as an employer with not more than 25 full-time employees whose average annual wages are less than $50,000 (through 2013, and an increased amount allowing for cost of living adjustments in subsequent years) and who arrange to make nonelective contributions on behalf of each employee (Sec. 1421). Employer and Individual Mandates -Requires applicable individuals to maintain "minimum essential health care coverage" for themselves and any dependents beginning after January 1, 2014, meaning one of the following (Sec. 1501):

-Medicare and Medicaid; -Children's Health Insurance Program; -TRICARE; -Veteran's health care program; -Health care for Peace Corps volunteers; -Employer-sponsored plans; -Individual market plans; -Grandfathered health care plans, meaning coverage that is offered and effective before the date of enactment; or -Other health care plan recognized by the Secretary of Health and Human Services (including state high-risk pooling plans).

-Establishes a monthly penalty on individuals who can afford minimal health coverage but fail to provide it for themselves and any dependents, a penalty that must be reported on income tax returns, and resolves that such penalty shall be the greater of 1/12 of the following (Sec. 1501):

-A flat dollar amount, calculated by applying an "applicable dollar amount" multiplied by the number of people for whom the individual is liable, or 300 percent of such amount for the taxable year; or -A percentage of the individual's income: 0.5 percent for taxable years beginning in 2014, 1.0 percent for taxable years beginning in 2015, or 2.0 percent for taxable years beginning after 2015.

-Defines "applicable dollar amount" as $95 for 2014, $495 for 2015, and $750 thereafter, provided the amount is amended according to the cost of living adjustment beginning in 2017, unless the individual is under 18 years of age, then such amount shall be 1/2 of the amounts specified (Sec. 1501). -Exempts the following individuals from the penalty for failure to acquire coverage (Sec. 1501):

-Individuals with conflicts of "religious conscience"; -Individuals who are members of a health care sharing ministry; -Undocumented immigrants; -Incarcerated individuals; -Individuals for whom the cost of minimal health care coverage would exceed 8 percent of his or her income for 2013; -Individuals whose income is under 100 percent of the federal poverty line; -Members of Native American tribes; -Individual who has "suffered a hardship," as determined by the Secretary; and -Any other applicable individual who was not covered on the last day of the month for three consecutive months.

-Specifies that taxpayers cannot be criminally prosecuted, nor can a lien be placed on a taxpayer's property, for failure to pay penalties for lack of health care coverage (Sec. 1501). -Requires businesses that employ more than 200 full-time employees and offer more than 1 health benefits plan to automatically enroll employees into a plan, and requires the employer to notify employees that they may opt out of such plan and provide literature to employees on all health plan options, including the existence of a Health Care Exchange (Secs. 1511 - 1512). -Requires large employers (average of at least 50 full time employees, with exceptions for seasonal workers) with at least one full time employee receiving a premium assistance tax credit that fails to provide health care coverage to other employees to pay an assessable payment equal to the number of uncovered employees multiplied by 1/12 of $750 (adjusted for inflation beginning in 2015) for every month the employer failed to provide coverage (Sec. 1513). -Requires large employers that impose a waiting period of 60 days or more to enroll in the company's health benefits plan to pay an assessable payment of $600 (adjusted for inflation beginning in 2015) for every full-time employee affected by the waiting period (Sec. 1513). -Requires large employers that enroll employees in its health benefits plan and have at least 1 employee who is eligible for premium tax credits or cost-sharing reductions to pay an assessable payment of $3,000 for each individual for which this provision applies (Sec. 1513). -Establishes an excise tax of 40 percent on coverage providers that provide "high cost employer-sponsored health care plans," to be applied to the amount of the premium in excess of the following thresholds (Sec. 9001):

-$8,500 for single coverage, or $9,850 for employees of high-risk professions and single retired persons 55 and older (cost of living adjustment applied beginning in 2014); -$23,000 for family coverage, or $26,000 for employees of high-risk professions and retired persons 55 and older with family coverage (cost of living adjustment applied beginning in 2014); and -If the plan is offered in 1 of the 17 states that the Secretary of Health and Human Services determines had the highest average cost of health care in 2012, the threshold will be increased from 2012 through 2015.

-Exempts the following types of coverage from the aforementioned excise tax (Sec. 9001):

-Long-term care; -Accident or disability insurance -Coverage only for a specified disease or illness; and -Hospital or other fixed indemnity insurance.

-Defines "coverage provider" to include each of the following entities (Sec. 9001):

-Issuers of group health insurance plans; -Employers who make contributions to employees Health Savings or Medical Savings Accounts; -Self-employed individuals who are eligible to deduct the cost of their health insurance plan; and -Administrators of other health care plans.

-Defines a "high risk profession" as follows (Secs. 9001 & 10901):

-Individuals who install or repair electrical and telecommunications lines; -Law enforcement officers; -Fire fighters; -Emergency medical technicians, paramedics, first-responders, and others who provide out-of-hospital emergency medical care; and -Construction workers, longshore workers, miners, most agricultural workers, foresters, and fishermen.

-Increases a tax on payment distributions from HSAs to beneficiaries for non-qualified medical expenses from 10 percent to 20 percent, beginning in 2011 (Sec. 9004). -Increases a tax on payment distributions from Archer MSAs to beneficiaries for non-qualified medical expenses from 15 percent to 20 percent, beginning in 2011 (Sec. 9004). -Establishes a non-deductible flat fee to be collected annually after 2010 totaling $2 billion on medical device manufacturers and importers making more than $5 million during a calendar year, the amount of which shall be paid in proportion based on a percentage of the company's gross receipts over the aggregate of gross receipts from sales made by the medical device manufacturing sector in the same year (Sec. 9009). -Specifies that the flat fee imposed on medical device manufacturers and importers shall be increased after 2017, totaling $3 billion to be collected from that sector (Sec. 9009). -Increases the hospital insurance tax rate by 0.9 percent on individuals earning over $200,000 and on married couples filing jointly that earn over $250,000, beginning in 2013 (Secs. 9015 & 10906). -Establishes a 10 percent excise tax on voluntary indoor tanning services, to be collected at the point of service beginning after July 1, 2010, and specifies that phototherapy services performed by a licensed professional are exempt from such tax (Secs. 9017 & 10907). Medicare and Medicaid -Requires the Secretary of Health and Human Services to establish a modifier for Medicare rates of payments to physicians based on the quality of care compared to the cost during a performance period, and specifies that the modifier shall only apply to specific physicians, as determined by the Secretary, beginning in 2015, and shall apply to all physicians beginning in 2017 (Sec. 3007). -Establishes a 1 percent Medicare payment reduction, beginning in fiscal year 2014-2015, for hospitals that are in the top quarter, relative to the national average, of hospital acquired conditions that (Sec. 3008):

-Have high cost, high volume, or both; -Result in the assignment of a case to a diagnosis-related group that has a higher payment when the code is present as a secondary diagnosis; and -Could reasonably have been prevented through the application of evidence-based guidelines.

-Requires the Secretary of Health and Human Services to reduce Medicare rates of payment to hospitals by specific amounts based upon their rates of "excess readmission" for 3 conditions selected by the Secretary with readmission measures that are endorsed by the National Quality Forum beginning in fiscal year 2012-2013, and requires the Secretary expand the number of conditions beginning in fiscal year 2014-2015 (Sec. 3025). -Requires the Secretary to establish a Hospital Value-Based Purchasing Program in which incentive payments are made to hospitals, beginning with fiscal year 2012-2013, based on performance standards that are established by the Secretary for the following conditions or procedures (Sec. 3001):

-Acute myocardia infarction (AMI); -Heart failure; -Pneumonia; -Surgeries, as mentioned by the Surgical Care Improvement Project; and -Healthcare-associated infections, as measured by the prevention metrics and targets established by the Secretary's Action Plan to Prevent Healthcare-Associated Infections of the Department of Health and Human Services.

-Requires the Secretary to calculate Medicare Part C (Medicare Advantage Plan) rates of payment based on the weighted average of monthly bids for each plan in the area, and establishes a phase-in period beginning in 2011 and culminating in 2014 (Sec. 3201). -Establishes the following quality performance bonuses for Medicare Part C plans beginning in 2014 based on their rating according to a 5 star rating system established by the Secretary that measures clinical quality and enrollee satisfaction (Sec. 3201):

-For plans that achieve a 3 star rating, a monthly payment equal to 2 percent of the national monthly per capita cost for expenditures for individuals enrolled under the original Medicare fee-for-service program; and -For plans that achieve a 4 or 5 star rating, a monthly payment equal to 4 percent of the national monthly per capita cost for expenditures for individuals enrolled under the original Medicare fee-for-service program.

-Establishes "improved quality bonuses" for Medicare Part C plans that did not receive a quality performance bonus, beginning in 2014, that is equal to 1 percent of the national monthly per capita cost for expenditures for individuals enrolled under the original Medicare fee-for-service program, provided that the Secretary has determined that the plan is an "improved quality MA plan" (Sec. 3201). -Reduces the coverage gap under Medicare Part D that separates the limit on initial coverage and the coverage for catastrophic care ("donut hole") by $500 beginning January 1, 2010 (Sec. 3315). -Requires the Secretary to establish a program no later than July 1, 2010 in which the Secretary shall enter into agreements with drug manufacturers to provide individuals who are subject to the Medicare Part D coverage gap a 50 percent discount for specifics drugs and biologics (Sec. 3301). -Prohibits Medicare Part D cost-sharing for full-benefit dual eligible individuals that are receiving care under a home and community based waiver who would otherwise require the level of care provided in a hospital, nursing facility, or intermediate care facility for the mentally disabled (Sec. 3309). -Establishes the Independent Medicare Advisory Board, consisting of 15 voting members appointed by the President and confirmed by the Senate, to submit proposals for reducing Medicare spending on January 15 of each year in which the Chief Actuary of the Centers for Medicare and Medicaid Services determines Medicare costs are unsustainable, beginning in 2014, and specifies that such proposal must meet specific requirements, including, but not limited to, the following (Sec. 3403):

-The Chief Actuary has determined that such proposal will result in a net reduction in total Medicare spending equaled to an amount established by a specific formula; -Inclusion of recommendations to reduce Medicare payments under parts C and D, denying or removing high bids for prescription drug coverage from the calculation of the national monthly bid amount, and reductions in payments to Medicare Advantage plans that are related to administrative expenses and performance bonuses; and -Exclusion of any recommendation to ration health care, raise revenues or premiums, increase cost-sharing, restrict benefits, or modify eligibility criteria.

-Requires the Secretary to implement the recommendations of the Independent Medicare Advisory Board on August 15 of the year in which the proposal is submitted, unless Congress has either passed legislation that specifies that it supersedes the recommendations of the Board or has adopted a joint resolution that discontinues the Board (Sec. 3403). -Prohibits Congress from adopting legislation that supersedes the recommendations of the Independent Medicare Advisory Board if the legislation is expected to result in an increase in Medicare spending, or if the Chief Actuary has determined that such legislation will not result in a net reduction in total Medicare spending equaled to an amount established by a specific formula (Sec. 3403). -Expands Medicaid eligibility to include individuals under 65 years of age with incomes that do not exceed 133 percent of the federal poverty level, including adults without children or a disability, beginning January 1, 2014, and authorizes states to expand Medicaid coverage to include all individuals not eligible for Medicare and with incomes above 133 percent of the federal poverty level beginning April 1, 2010 (Secs. 2001 & 10201). -Specifies that the federal government will compensate the states for the costs of the aforementioned expansion in Medicaid eligibility as follows (Sec. 2001):

-For 2014 through 2016: all states are compensated for 100 percent of the costs; -For 2017: a 30.3 point Federal Medical Assistance Percentage (FMAP) increase for expansion states, and and a 34.3 point FMAP increase for non-expansion states.; -For 2018, a 31.3 point FMAP increase for expansion states, and a 33.3 point FMAP increase for non- expansion states; and -For 2019 and each year thereafter, a 32.3 point FMAP increase for all states.

-Defines "expansion state" as a state that on the date of enactment offers health coverage, including inpatient hospital services, to parents and nonpregnant, childless adults with incomes that are at least 100 percent of the federal poverty line and not dependent on access to employer-based coverage (Secs. 2001 & 10201). -Specifies that aforementioned federal Medicaid compensation guidelines do not apply to the state of Nebraska, which instead will be compensated for 100 percent of the costs beginning in 2014 and each subsequent year thereafter (Sec. 10201). -Prohibits States from adopting eligibility standards, methodologies, or procedures for Medicaid that are a more restrictive than than the eligibility standards, methodologies, or procedures that are effective on the date of enactment until December 31, 2013, and extends this requirement for children until September 20, 2019 (Sec. 2001). -Authorizes states to establish a Community First Choice Option beginning October 1, 2010 in which the states can provide home and community-based attendant services to disabled individuals that are eligible for Medicaid and would otherwise require the level of care provided by a hospital, nursing facility, intermediate care facility for the developmentally disabled, or institution for mental diseases (Sec. 2401). -Extends the current reauthorization of the Children's Health Insurance Program (CHIP) through September 31, 2015, and increases the FMAP for states to fund CHIP by 23 points for the period of October 1, 2015 through September 30, 2019, provided that it does not exceed 100 percent (Secs. 2101 & 10203). -Prohibits States from adopting eligibility standards, methodologies, or procedures for CHIP that are a more restrictive than than the eligibility standards, methodologies, or procedures that are effective on the date of enactment, and repeals this prohibition on September 30, 2019 (Sec. 2101). Public Health and Workforce Development -Establishes the National Prevention, Health Promotion and Public Health Council within the Department of Health and Human Services, and requires the Council to perform the following duties (Sec. 4001):

-Serve as a coordinating organization among all federal agencies with respect to prevention, wellness, and health promotion practices, the public health system, and integrative health care; -Develop a national strategy to improve the health of Americans and reduce incidents of preventable illnesses; -Provide the President and Congress with recommendations on the most pressing health issues, including any policy changes that may achieve national health and wellness goals; -Propose innovative approaches and policies for prevention, integrative wellness and public health for individuals and on community-levels; -Establish a process for continual public input at the regional, state, and local level; -Develop and make public the Council's national health strategy and recommendations; and -Perform other activities as required by the President.

-Establishes a Prevention and Public Health Fund to provide for the expansion and sustained investment in public health and preventative programs and to lessen growth in private and public sector health care costs, and appropriates to the Fund the following amounts (Sec. 4002):

-$500 million for fiscal year 2009-2010; -$750 million for fiscal year 2010-2011; -$1 billion for fiscal year 2011-2012; -$1.25 billion for fiscal year 2012-2013; -$1.5 billion for fiscal year 2013-2014; and -$2 billion for fiscal year 2014-2015 and each subsequent year thereafter.

-Appropriates $50 million for each fiscal year from 2009-2010 to 2012-2013 for the establishment of a grant program for school-based health centers, with preference given to health centers that serve a large child population eligible for assistance under the state Medicaid plan, and requires such health centers to provide the following core services (Sec. 4101):

-Health assessments, diagnosis, and treatment of minor, acute, and chronic medical conditions; and -Mental health and substance use disorder assessments, crisis intervention, counseling, treatment, and referral to a continuum of services including emergency psychiatric care, community support programs, inpatient care, and outpatient programs.

-Requires chain restaurants with more than 20 locations to display calorie content information next to food items on menus, including drive-through menu boards and self-service food and beverage bars, and to have that calorie information reflect servings as usually prepared and offered for sale (Sec. 4205). -Appropriates $25 million for the Childhood Obesity Demonstration Project for fiscal years 2009-2010 through 2013-2014 (Sec. 4306). -Establishes the National Health Care Workforce Commission to coordinate with various departments to determine if the demand for health care workers is being met (Sec. 5101). -Increases the maximum amount available for nursing student loans from $2,500 to $3,300 for any student and $4,000 to $5,200 for a student's last two academic years, and increases from $13,000 to $17,000 the limit for the aggregate of loans for all years for students during fiscal years 2009-2010 and 2010-2011 and an increased amount in subsequent years when the cost of attendance rises (Sec. 5202). -Establishes a pediatric specialty loan repayment program that covers the principal interest of undergraduate, graduate and medical degree loans up to $35,000 a year for not more then 3 years, provided that the recipient agrees to provide pediatric medical subspecialty, pediatric surgical specialty, or child and adolescent mental and behavioral health care in an area with a shortage (Sec. 5203). -Authorizes appropriations of the following amounts to the National Health Service Corps (Sec. 5207):

-$320.46 million for fiscal year 2009-2010; -$414.10 million for fiscal year 2010-2011; -$535.09 million for fiscal year 2011-2012; -$691.43 million for fiscal year 2012-2013; -$893.46 million for fiscal year 2013-2014; -$1.15 billion for fiscal year 2014-2015; and -For subsequent years, the amount of the previous fiscal year plus an adjustment for increases in health professions education costs and changes in the number of individuals residing in health profession shortage areas.

-Authorizes the appropriation of $50 million a year for fiscal year 2009-2010 for nurse-managed health clinics, and "such sums as may be necessary" for fiscal years 2010-2011 through 2013-2014 (Sec. 5208). -Authorizes the appropriation of $125 million for fiscal year 2009-2010 and "such sums as may be necessary" for fiscal years 2010-2011 through 2013-2014 to make grants available to accredited public or nonprofit private hospitals, schools of medicine or osteopathic medicine, or academically affiliated physician assistant training programs for support and development of primary care training programs (Sec. 5301). -Authorizes the appropriation of $10 million for fiscal years 2009-2010 through 2012-2013 for grants to accredited institutes of higher learning that have established a public-private educational partnership with a nursing home or skilled nursing facility, or similar entities that provide training for direct-care workers in long-term care facilities (Sec. 5302). -Authorizes the Secretary of Health and Human Services to award grants to higher education institutions that recruit and provide clinical experience to students in mental health and behavioral health education, and authorizes the appropriations of the following funds for fiscal years 2009-2010 through 2012-2013 to carry this out (Sec. 5306):

-$8 million for social work training; -$12 million for graduate psychology training; -$10 million for professional child and adolescent mental health training; and -$5 million for paraprofessional child and adolescent work.

-Authorizes the appropriation of $338 million for the purpose of expanding eligibility for loan repayment and scholarship programs to nursing school faculty (Secs. 5310 & 5312). -Authorizes the establishment of a Unites States Public Health Sciences Track, which shall be authorized to award advanced degrees through existing accredited academic institutions and shall emphasize team-based service, public health, epidemiology, and emergency preparedness and response (Sec. 5315). -Specifies that students admitted to the Track shall receive tuition (or tuition remission) and a stipend for each school year for up to four years, in exchange for the following (Sec. 5315):

-Maintain Track enrollment until the course of study is completed; -Maintain "an acceptable level" of academic standing (as determined by the Surgeon General); -Complete a residency or internship if pursuing a degree from a school of medicine or osteopathic medicine, dental, public health, or nursing school or a physician assistant, pharmacy, or behavioral and mental health professional program; and -Serve in the Commissioned Corps for two years for each year of enrollment, unless serving in a capacity which qualifies for a reduction.

-Authorizes the Secretary of Health and Human Services to award grants to teaching health centers to establish new accredited or expanded primary care residency programs, and authorizes a total of $125 million in appropriations for fiscal years 2009-2010 through 2011-2012 to carry this out (Sec. 5508). -Appropriates the following funds for federally qualified health centers (Sec. 5601):

-$2.99 billion for fiscal year 2009-2010; -$3.86 billion for fiscal year 2010-2011; -$4.99 billion for fiscal year 2011-2012; -$6.45 billion for fiscal year 2012-2013; -$7.33 billion for fiscal year 2013-2014; -$8.33 billion for fiscal year 2014-2015; and -For subsequent fiscal years, the amount of the previous fiscal year plus an adjustment for increases in costs incurred per patient served and increases in total number of patients.

-Establishes an approval pathway to license biological products that are biosimilar or interchangeable with products that are already licensed, and prohibits the licensing of biosimilar products until 12 years after the licensing of the already-licensed product (Sec. 7002).

Note:

NOTE: THIS BILL WAS AMENDED BY STRIKING THE ENTIRETY OF THE ORIGINAL TEXT OF THE BILL AND REPLACING IT WITH THE TEXT OF THE AMENDMENT. THE DEGREE TO WHICH THE NEW BILL TEXT DIFFERS FROM THE PREVIOUS VERSION OF THE TEXT CAN VARY GREATLY; IT MAY ADDRESS AN ENTIRELY DIFFERENT SUBJECT.

Legislation - Cloture Invoked (Senate) - Dec. 23, 2009 (Key vote)

Title: Health Care and Insurance Law Amendments ("Patient Protection and Affordable Care Act")

Vote Smart's Synopsis:

Vote on a motion to invoke cloture on a bill that amends various statues related to health care and heath insurance coverage, including, but not limited to, the establishment of a Health Insurance Exchange Program, an individual mandate to purchase insurance, a prohibition on insurers denying or rescinding coverage based on a preexisting condition, a tax on "high cost employer-sponsored health care plans," various mechanisms aimed at reducing Medicare spending, and an expansion of Medicaid eligibility.

Highlight: Insurance Regulations -Prohibits health insurers from imposing any preexisting condition exclusions (Sec. 1201). -Prohibits health insurers from establishing rules for eligibility (including continued eligibility) based on any of the following factors (Sec. 1201):

-Health status; -Medical condition (including physical and mental illnesses); -Claims experience; -Receipt of health care; -Medical history; -Genetic information; -Evidence of insurability (including conditions relating to domestic violence); -Disability; and -Any other health status-related factor determined appropriate by the Secretary.

-Requires health insurers to base premium rates for plans in the individual or small group markets on the following (Sec. 1201):

-Whether the plan or coverage covers an individual or family; -Rating area; -Age, except that the rate shall not vary by more than 3 to 1 for adults; and -Tobacco use, except that the rate shall not vary by more than 1.5 to 1.

-Prohibits health insurers from establishing lifetime limits or annual limits on the dollar value of benefits for any participant or beneficiary, except that prior to 2014 insurers may establish "restricted annual limits" that the Secretary of Health and Human Services determines will not impede access to "needed services" and will have a "minimal impact" on premiums (Secs. 1001 & 10101). -Prohibits health insurers from rescinding coverage unless there is an occurrence of fraud in violation of the terms of the health plan or health insurance coverage (Sec. 1001). -Requires health insurers to provide coverage for the following preventive services at no cost to the patient (Sec. 1001):

-Services that have an "A" or "B" rating in the recommendations of the U.S. Preventive Services Task Force; -Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and -Preventive health care and screenings for women, infants, children and adolescents as provided for in guidelines supported by the Health Resources and Services Administration.

-Specifies that the recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention issued in or around November 2009 shall not apply for the purposes of federal law (Sec. 1001). -Requires health insurers that provide dependent coverage of children to continue to make such coverage available for an unmarried adult child until he or she turns 26 years old (Sec. 1001). -Prohibits a group health plan from discriminating in favor of the highest paid 25 percent of employees, shareholders owning more than 10 percent of the employer's stock value, or the five highest paid officers with regards to eligibility or benefits (Secs. 1001 & 10101). -Requires the Secretary to establish a temporary high risk health insurance pool program no later than 90 days after the date of enactment to provide coverage through 2013 to individuals that (Sec. 1101):

-Are a citizen or national of the United States or are lawfully present in the United States; -Have not been covered during the 6 month period prior to application; and -Have a preexisting condition that is consistent with the guidelines established by the Secretary.

-Establishes the following requirements for the high risk pool (Sec. 1101):

-It must provide coverage in which the insurer's share of the total allowed costs of benefits is not less than 65 percent; -It must provide coverage that has an out of pocket limit that does not exceed $5,000 annually for self-only coverage and $10,000 annually for family coverage, except that the Secretary may modify the limit to ensure that the insurer's share of total allowed costs of benefits is not less than 65 percent; -The premium rate must be established at a standard rate for a standard population and the rate must vary only as allowed elsewhere in this Act, except that it may vary on the basis of age by a factor of no more than 4 to 1; and -It must meet any other requirements determined "appropriate" by the Secretary.

-Requires the Secretary to establish a temporary reinsurance program to reimburse employment-based health plans covering early retirees (55 years of age or older but not eligible for Social Security) for claims that are between $15,000 and $90,000 through 2013, and specifies that the reimbursement shall be 80 percent of the costs that exceed $15,000 (Sec. 1102). -Requires participating employment-based plans to use amounts paid to them under the temporary reinsurance program to lower costs for the plan (Sec. 1102). -Specifies that nothing in this Act shall be construed to require an individual to terminate coverage under a group health plan or health insurance coverage in which the individual was enrolled on the date of enactment (Sec. 1251). -Defines "qualified health plan" as a plan that meets the following criteria (Secs. 1301-1302):

-Has in effect a Certification that it meets the criteria issued or recognized by each Exchange through which it is offered; -Provides the following levels of coverage, with some exceptions:
-"Bronze level," in which 60 percent of the costs are reimbursed; -"Silver level," in which 70 percent of the costs are reimbursed; -"Gold level," in which 80 percent of the costs are reimbursed; and -"Platinum level," in which 90 percent of the costs are reimbursed;
-Covers the following services:
-Ambulatory patient Services -Emergency services; -Hospitalization; -Maternity and newborn care; -Mental health and substance use disorder services; -Prescription drugs; -Rehabilitative and habilitative services and devices; -Laboratory services; -Preventive and wellness services and chronic disease management; and -Pediatric services, including oral and vision care;
-Limits cost sharing to the following amounts:
-Beginning in 2014, $5,000 for individual coverage and $10,000 for family coverage; and -Beginning after 2014, the 2014 amount for family or individual coverage increased by the product of that amount and the percentage (if any) by which the average premium for health insurance coverage in the U.S. for the preceding calendar year exceeds the average premium for 2013;
-For employment-based plans, limits the deductibles to the following amounts:
-Beginning in 2014, $2,000 for individual coverage and $4,000 for any other plan; -For individual coverage beginning after 2014, the 2014 amount increased by the product of that amount and the percentage (if any) by which the average premium for health insurance coverage in the U.S. for the preceding calendar year exceeds the average premium for 2013; and -For any other coverage beginning after 2014, twice the amount of the aforementioned amount;
-Is offered by a health insurer that offers at least one "silver level" and "gold level" plan in each Exchange; -Is offered by a health insurer that agrees to charge the same premium rate for each plan regardless of whether the plan is offered through and Exchange or directly; and -Is offered by a health insurer that complies with the regulations developed by the Secretary and the applicable Exchange.

-Relies on the same definition of "qualified health plan" for plans that are qualified to be offered as CO-OP plans or multi-state plans (Secs. 1301 & 10104). -Specifies that nothing in Title I of this act shall be construed to require a qualified health plan to provide coverage of any type of abortion, and allows health insurers that issue qualified health plans to determine whether or not the plans shall provide coverage of any kind of abortion services (Sec. 1303). Health Insurance Exchange -Requires the Secretary to disperse funds so that each state may establish no later than January 1, 2014 an Health Benefit Exchange, a governmental or non-profit agency that shall make qualified health plans available to qualified individuals (excluding undocumented immigrants and incarcerated individuals) and employers (those offering coverage to all full-time employees), with specific requirements, including, but not limited to, the following (Secs. 1311 & 1312):

-Establish a Small Business Health Options Program ("SHOP Exchange') to assist qualifying small employers with enrolling employees in a qualified health program; -Maintain a website through which prospective enrollees may compare health plans; -Assign ratings for every qualified health plan offered; and -Provide an electronic calculator for the purpose of determining the cost of coverage.

-Requires state Exchanges to establish Navigator Programs that provide grants to any entity that has existing relationships or the capacity to establish relationships with employers and employees, consumers, or self-employed individuals who are likely to be qualified to enroll in a qualified health plan, and requires every Navigator to perform various duties, including, but not limited to, the following (Sec. 1311):

-Conduct public education activities that raise awareness of the availability of qualified health plans; and -Distribute "fair and impartial information" about enrollment and the availability of premium tax credits and cost-sharing reductions.

-Specifies that qualified individuals are not required to participate in an Exchange (Sec. 1312). -Specifies that states have the right to require any benefits in addition to the essential health benefits established under this Act, and specifies that states shall also assume the costs for such benefits to any individual enrolled in a qualified health care plan (Sec. 1311). -Requires the Secretary to establish an Exchange within a state if that state fails to or has not taken necessary action to do so by January 1, 2014 (Sec. 1321). -Authorizes states to enact laws prohibiting abortion coverage in qualified health plans offered through an Exchange in the state, and specifies that states may also repeal such laws (Sec. 10104). -Appropriates $6 billion for the purpose of establishing a Consumer Operated and Oriented Plan (CO-OP), a program intended to encourage states to create qualified nonprofit health insurance issuers that will offer qualified health plans in the individual and small group markets, and authorizes the Secretary to award grants and loans to individuals applying to become a nonprofit health insurance issuer through CO-OP based on the following criteria (Sec. 1322):

-Recommendations of the 15-member CO-OP advisory board established by this Act, in which members are appointed by the Comptroller General in accordance with ethics and conflict-of-interest guidelines; -Whether applicants will offer qualified health plans on a statewide basis, will utilize integrated care models, and have significant private support; and -Whether there will be sufficient funding to meet the requirement to establish at least 1 qualified nonprofit health insurance issuer in each state.

-Requires that plans offered through the CO-OP program or any nationwide qualified health plan be subject to the same laws that apply to private health insurers (Sec. 1324). -Requires the Director of the Office of Personnel Management to enter into contracts with health insurers, without regard to competitive bidding statutes, to offer at least 2 multi-state qualified health plans (with at least one being a non-profit) through each Exchange (Sec. 10104). -Specifies that multi-state qualified health plans must meet the following requirements (Sec. 10104):

-Must offer benefits packages that are uniform in each state and consist of the essential benefits as defined in this Act; -Must meet all the requirements of a qualified health plan under this Act; -Must determine premiums on the basis of the rating requirements of Part A, Title XXVII of the Public Health Service Act; and -The insurer must offer the plan in all geographic regions and in all states that have adopted adjusted community rating before the date of enactment.

-Establishes a program that allows states to enter into a competitive process to negotiate contracts, premiums, cost sharing, and benefits with standard health plans for individuals who meet the following requirements (Sec. 1331):

-Must be ineligible to enroll in Medicaid; -Must be ineligible for minimum essential coverage (§ 5000A(f), Internal Revenue Code) or eligible for an employer-sponsored plan that is not "affordable" (§ 5000A(e)(2), Internal Revenue Code); -Household income is above 133 percent but not more than 200 percent of the federal poverty line (according to the size of that individual's family); and -Who is under age 65 at the beginning of the plan year.

-Requires the Secretary, in consultation with the National Association of Insurance Commissioners, to establish regulations for interstate health care compacts, under which qualified health plans offered in one state can be purchased in another state beginning in 2016, provided the insurers are licensed in each participating state and are subject to the market conduct, unfair trade practices, network adequacy, and consumer protection standards of the purchaser's state (Sec. 1333). -Establishes tax credits to assist individuals with the cost of health insurance premiums, and specifies that such assistance shall be equal to the lesser of (Sec. 1401):

-The monthly premiums for one or more qualified Exchange health plans offered in the individual market within a state which cover the taxpayer, the taxpayer's spouse, and any dependent(s); or -The excess (if any) of the adjusted monthly premium for the second lowest cost silver plan over an amount equal to 1/12 of the "applicable percentage," calculated by a formula established by this Act.

-Establishes the following cost sharing reductions for individuals enrolled in a plan providing silver level coverage through an Exchange and whose household income is greater than 100 percent but less than 400 percent of the federal poverty line (Sec. 1402):

-2/3 reduction if household income is between 100 and 200 percent of the federal poverty line; -1/2 reduction if household income is between 200 and 300 percent of the federal poverty line; and -1/3 reduction if household income is between 300 and 400 percent of the federal poverty line.

-Establishes a tax credit for small businesses that purchase health insurance for their employees of 50 percent (or 35 percent for a small employer eligible for tax exemption) of the lesser of (Sec. 1421):

-Total nonelective contributions the employer made on behalf of its employees for premiums for qualified health plans offered through an Exchange; or -Total nonelective contributions the employer would have made if each employee had enrolled in a qualified health plan with a premium equal to the average premium for the small group market in the rating area in which the employee enrolls for coverage.

-Defines an "eligible small employer" as an employer with not more than 25 full-time employees whose average annual wages are less than $50,000 (through 2013, and an increased amount allowing for cost of living adjustments in subsequent years) and who arrange to make nonelective contributions on behalf of each employee (Sec. 1421). Employer and Individual Mandates -Requires applicable individuals to maintain "minimum essential health care coverage" for themselves and any dependents beginning after January 1, 2014, meaning one of the following (Sec. 1501):

-Medicare and Medicaid; -Children's Health Insurance Program; -TRICARE; -Veteran's health care program; -Health care for Peace Corps volunteers; -Employer-sponsored plans; -Individual market plans; -Grandfathered health care plans, meaning coverage that is offered and effective before the date of enactment; or -Other health care plan recognized by the Secretary of Health and Human Services (including state high-risk pooling plans).

-Establishes a monthly penalty on individuals who can afford minimal health coverage but fail to provide it for themselves and any dependents, a penalty that must be reported on income tax returns, and resolves that such penalty shall be the greater of 1/12 of the following (Sec. 1501):

-A flat dollar amount, calculated by applying an "applicable dollar amount" multiplied by the number of people for whom the individual is liable, or 300 percent of such amount for the taxable year; or -A percentage of the individual's income: 0.5 percent for taxable years beginning in 2014, 1.0 percent for taxable years beginning in 2015, or 2.0 percent for taxable years beginning after 2015.

-Defines "applicable dollar amount" as $95 for 2014, $495 for 2015, and $750 thereafter, provided the amount is amended according to the cost of living adjustment beginning in 2017, unless the individual is under 18 years of age, then such amount shall be 1/2 of the amounts specified (Sec. 1501). -Exempts the following individuals from the penalty for failure to acquire coverage (Sec. 1501):

-Individuals with conflicts of "religious conscience"; -Individuals who are members of a health care sharing ministry; -Undocumented immigrants; -Incarcerated individuals; -Individuals for whom the cost of minimal health care coverage would exceed 8 percent of his or her income for 2013; -Individuals whose income is under 100 percent of the federal poverty line; -Members of Native American tribes; -Individual who has "suffered a hardship," as determined by the Secretary; and -Any other applicable individual who was not covered on the last day of the month for three consecutive months.

-Specifies that taxpayers cannot be criminally prosecuted, nor can a lien be placed on a taxpayer's property, for failure to pay penalties for lack of health care coverage (Sec. 1501). -Requires businesses that employ more than 200 full-time employees and offer more than 1 health benefits plan to automatically enroll employees into a plan, and requires the employer to notify employees that they may opt out of such plan and provide literature to employees on all health plan options, including the existence of a Health Care Exchange (Secs. 1511 - 1512). -Requires large employers (average of at least 50 full time employees, with exceptions for seasonal workers) with at least one full time employee receiving a premium assistance tax credit that fails to provide health care coverage to other employees to pay an assessable payment equal to the number of uncovered employees multiplied by 1/12 of $750 (adjusted for inflation beginning in 2015) for every month the employer failed to provide coverage (Sec. 1513). -Requires large employers that impose a waiting period of 60 days or more to enroll in the company's health benefits plan to pay an assessable payment of $600 (adjusted for inflation beginning in 2015) for every full-time employee affected by the waiting period (Sec. 1513). -Requires large employers that enroll employees in its health benefits plan and have at least 1 employee who is eligible for premium tax credits or cost-sharing reductions to pay an assessable payment of $3,000 for each individual for which this provision applies (Sec. 1513). -Establishes an excise tax of 40 percent on coverage providers that provide "high cost employer-sponsored health care plans," to be applied to the amount of the premium in excess of the following thresholds (Sec. 9001):

-$8,500 for single coverage, or $9,850 for employees of high-risk professions and single retired persons 55 and older (cost of living adjustment applied beginning in 2014); -$23,000 for family coverage, or $26,000 for employees of high-risk professions and retired persons 55 and older with family coverage (cost of living adjustment applied beginning in 2014); and -If the plan is offered in 1 of the 17 states that the Secretary of Health and Human Services determines had the highest average cost of health care in 2012, the threshold will be increased from 2012 through 2015.

-Exempts the following types of coverage from the aforementioned excise tax (Sec. 9001):

-Long-term care; -Accident or disability insurance -Coverage only for a specified disease or illness; and -Hospital or other fixed indemnity insurance.

-Defines "coverage provider" to include each of the following entities (Sec. 9001):

-Issuers of group health insurance plans; -Employers who make contributions to employees Health Savings or Medical Savings Accounts; -Self-employed individuals who are eligible to deduct the cost of their health insurance plan; and -Administrators of other health care plans.

-Defines a "high risk profession" as follows (Secs. 9001 & 10901):

-Individuals who install or repair electrical and telecommunications lines; -Law enforcement officers; -Fire fighters; -Emergency medical technicians, paramedics, first-responders, and others who provide out-of-hospital emergency medical care; and -Construction workers, longshore workers, miners, most agricultural workers, foresters, and fishermen.

-Increases a tax on payment distributions from HSAs to beneficiaries for non-qualified medical expenses from 10 percent to 20 percent, beginning in 2011 (Sec. 9004). -Increases a tax on payment distributions from Archer MSAs to beneficiaries for non-qualified medical expenses from 15 percent to 20 percent, beginning in 2011 (Sec. 9004). -Establishes a non-deductible flat fee to be collected annually after 2010 totaling $2 billion on medical device manufacturers and importers making more than $5 million during a calendar year, the amount of which shall be paid in proportion based on a percentage of the company's gross receipts over the aggregate of gross receipts from sales made by the medical device manufacturing sector in the same year (Sec. 9009). -Specifies that the flat fee imposed on medical device manufacturers and importers shall be increased after 2017, totaling $3 billion to be collected from that sector (Sec. 9009). -Increases the hospital insurance tax rate by 0.9 percent on individuals earning over $200,000 and on married couples filing jointly that earn over $250,000, beginning in 2013 (Secs. 9015 & 10906). -Establishes a 10 percent excise tax on voluntary indoor tanning services, to be collected at the point of service beginning after July 1, 2010, and specifies that phototherapy services performed by a licensed professional are exempt from such tax (Secs. 9017 & 10907). Medicare and Medicaid -Requires the Secretary of Health and Human Services to establish a modifier for Medicare rates of payments to physicians based on the quality of care compared to the cost during a performance period, and specifies that the modifier shall only apply to specific physicians, as determined by the Secretary, beginning in 2015, and shall apply to all physicians beginning in 2017 (Sec. 3007). -Establishes a 1 percent Medicare payment reduction, beginning in fiscal year 2014-2015, for hospitals that are in the top quarter, relative to the national average, of hospital acquired conditions that (Sec. 3008):

-Have high cost, high volume, or both; -Result in the assignment of a case to a diagnosis-related group that has a higher payment when the code is present as a secondary diagnosis; and -Could reasonably have been prevented through the application of evidence-based guidelines.

-Requires the Secretary of Health and Human Services to reduce Medicare rates of payment to hospitals by specific amounts based upon their rates of "excess readmission" for 3 conditions selected by the Secretary with readmission measures that are endorsed by the National Quality Forum beginning in fiscal year 2012-2013, and requires the Secretary expand the number of conditions beginning in fiscal year 2014-2015 (Sec. 3025). -Requires the Secretary to establish a Hospital Value-Based Purchasing Program in which incentive payments are made to hospitals, beginning with fiscal year 2012-2013, based on performance standards that are established by the Secretary for the following conditions or procedures (Sec. 3001):

-Acute myocardia infarction (AMI); -Heart failure; -Pneumonia; -Surgeries, as mentioned by the Surgical Care Improvement Project; and -Healthcare-associated infections, as measured by the prevention metrics and targets established by the Secretary's Action Plan to Prevent Healthcare-Associated Infections of the Department of Health and Human Services.

-Requires the Secretary to calculate Medicare Part C (Medicare Advantage Plan) rates of payment based on the weighted average of monthly bids for each plan in the area, and establishes a phase-in period beginning in 2011 and culminating in 2014 (Sec. 3201). -Establishes the following quality performance bonuses for Medicare Part C plans beginning in 2014 based on their rating according to a 5 star rating system established by the Secretary that measures clinical quality and enrollee satisfaction (Sec. 3201):

-For plans that achieve a 3 star rating, a monthly payment equal to 2 percent of the national monthly per capita cost for expenditures for individuals enrolled under the original Medicare fee-for-service program; and -For plans that achieve a 4 or 5 star rating, a monthly payment equal to 4 percent of the national monthly per capita cost for expenditures for individuals enrolled under the original Medicare fee-for-service program.

-Establishes "improved quality bonuses" for Medicare Part C plans that did not receive a quality performance bonus, beginning in 2014, that is equal to 1 percent of the national monthly per capita cost for expenditures for individuals enrolled under the original Medicare fee-for-service program, provided that the Secretary has determined that the plan is an "improved quality MA plan" (Sec. 3201). -Reduces the coverage gap under Medicare Part D that separates the limit on initial coverage and the coverage for catastrophic care ("donut hole") by $500 beginning January 1, 2010 (Sec. 3315). -Requires the Secretary to establish a program no later than July 1, 2010 in which the Secretary shall enter into agreements with drug manufacturers to provide individuals who are subject to the Medicare Part D coverage gap a 50 percent discount for specifics drugs and biologics (Sec. 3301). -Prohibits Medicare Part D cost-sharing for full-benefit dual eligible individuals that are receiving care under a home and community based waiver who would otherwise require the level of care provided in a hospital, nursing facility, or intermediate care facility for the mentally disabled (Sec. 3309). -Establishes the Independent Medicare Advisory Board, consisting of 15 voting members appointed by the President and confirmed by the Senate, to submit proposals for reducing Medicare spending on January 15 of each year in which the Chief Actuary of the Centers for Medicare and Medicaid Services determines Medicare costs are unsustainable, beginning in 2014, and specifies that such proposal must meet specific requirements, including, but not limited to, the following (Sec. 3403):

-The Chief Actuary has determined that such proposal will result in a net reduction in total Medicare spending equaled to an amount established by a specific formula; -Inclusion of recommendations to reduce Medicare payments under parts C and D, denying or removing high bids for prescription drug coverage from the calculation of the national monthly bid amount, and reductions in payments to Medicare Advantage plans that are related to administrative expenses and performance bonuses; and -Exclusion of any recommendation to ration health care, raise revenues or premiums, increase cost-sharing, restrict benefits, or modify eligibility criteria.

-Requires the Secretary to implement the recommendations of the Independent Medicare Advisory Board on August 15 of the year in which the proposal is submitted, unless Congress has either passed legislation that specifies that it supersedes the recommendations of the Board or has adopted a joint resolution that discontinues the Board (Sec. 3403). -Prohibits Congress from adopting legislation that supersedes the recommendations of the Independent Medicare Advisory Board if the legislation is expected to result in an increase in Medicare spending, or if the Chief Actuary has determined that such legislation will not result in a net reduction in total Medicare spending equaled to an amount established by a specific formula (Sec. 3403). -Expands Medicaid eligibility to include individuals under 65 years of age with incomes that do not exceed 133 percent of the federal poverty level, including adults without children or a disability, beginning January 1, 2014, and authorizes states to expand Medicaid coverage to include all individuals not eligible for Medicare and with incomes above 133 percent of the federal poverty level beginning April 1, 2010 (Secs. 2001 & 10201). -Specifies that the federal government will compensate the states for the costs of the aforementioned expansion in Medicaid eligibility as follows (Sec. 2001):

-For 2014 through 2016: all states are compensated for 100 percent of the costs; -For 2017: a 30.3 point Federal Medical Assistance Percentage (FMAP) increase for expansion states, and and a 34.3 point FMAP increase for non-expansion states.; -For 2018, a 31.3 point FMAP increase for expansion states, and a 33.3 point FMAP increase for non- expansion states; and -For 2019 and each year thereafter, a 32.3 point FMAP increase for all states.

-Defines "expansion state" as a state that on the date of enactment offers health coverage, including inpatient hospital services, to parents and nonpregnant, childless adults with incomes that are at least 100 percent of the federal poverty line and not dependent on access to employer-based coverage (Secs. 2001 & 10201). -Specifies that aforementioned federal Medicaid compensation guidelines do not apply to the state of Nebraska, which instead will be compensated for 100 percent of the costs beginning in 2014 and each subsequent year thereafter (Sec. 10201). -Prohibits States from adopting eligibility standards, methodologies, or procedures for Medicaid that are a more restrictive than than the eligibility standards, methodologies, or procedures that are effective on the date of enactment until December 31, 2013, and extends this requirement for children until September 20, 2019 (Sec. 2001). -Authorizes states to establish a Community First Choice Option beginning October 1, 2010 in which the states can provide home and community-based attendant services to disabled individuals that are eligible for Medicaid and would otherwise require the level of care provided by a hospital, nursing facility, intermediate care facility for the developmentally disabled, or institution for mental diseases (Sec. 2401). -Extends the current reauthorization of the Children's Health Insurance Program (CHIP) through September 31, 2015, and increases the FMAP for states to fund CHIP by 23 points for the period of October 1, 2015 through September 30, 2019, provided that it does not exceed 100 percent (Secs. 2101 & 10203). -Prohibits States from adopting eligibility standards, methodologies, or procedures for CHIP that are a more restrictive than than the eligibility standards, methodologies, or procedures that are effective on the date of enactment, and repeals this prohibition on September 30, 2019 (Sec. 2101). Public Health and Workforce Development -Establishes the National Prevention, Health Promotion and Public Health Council within the Department of Health and Human Services, and requires the Council to perform the following duties (Sec. 4001):

-Serve as a coordinating organization among all federal agencies with respect to prevention, wellness, and health promotion practices, the public health system, and integrative health care; -Develop a national strategy to improve the health of Americans and reduce incidents of preventable illnesses; -Provide the President and Congress with recommendations on the most pressing health issues, including any policy changes that may achieve national health and wellness goals; -Propose innovative approaches and policies for prevention, integrative wellness and public health for individuals and on community-levels; -Establish a process for continual public input at the regional, state, and local level; -Develop and make public the Council's national health strategy and recommendations; and -Perform other activities as required by the President.

-Establishes a Prevention and Public Health Fund to provide for the expansion and sustained investment in public health and preventative programs and to lessen growth in private and public sector health care costs, and appropriates to the Fund the following amounts (Sec. 4002):

-$500 million for fiscal year 2009-2010; -$750 million for fiscal year 2010-2011; -$1 billion for fiscal year 2011-2012; -$1.25 billion for fiscal year 2012-2013; -$1.5 billion for fiscal year 2013-2014; and -$2 billion for fiscal year 2014-2015 and each subsequent year thereafter.

-Appropriates $50 million for each fiscal year from 2009-2010 to 2012-2013 for the establishment of a grant program for school-based health centers, with preference given to health centers that serve a large child population eligible for assistance under the state Medicaid plan, and requires such health centers to provide the following core services (Sec. 4101):

-Health assessments, diagnosis, and treatment of minor, acute, and chronic medical conditions; and -Mental health and substance use disorder assessments, crisis intervention, counseling, treatment, and referral to a continuum of services including emergency psychiatric care, community support programs, inpatient care, and outpatient programs.

-Requires chain restaurants with more than 20 locations to display calorie content information next to food items on menus, including drive-through menu boards and self-service food and beverage bars, and to have that calorie information reflect servings as usually prepared and offered for sale (Sec. 4205). -Appropriates $25 million for the Childhood Obesity Demonstration Project for fiscal years 2009-2010 through 2013-2014 (Sec. 4306). -Establishes the National Health Care Workforce Commission to coordinate with various departments to determine if the demand for health care workers is being met (Sec. 5101). -Increases the maximum amount available for nursing student loans from $2,500 to $3,300 for any student and $4,000 to $5,200 for a student's last two academic years, and increases from $13,000 to $17,000 the limit for the aggregate of loans for all years for students during fiscal years 2009-2010 and 2010-2011 and an increased amount in subsequent years when the cost of attendance rises (Sec. 5202). -Establishes a pediatric specialty loan repayment program that covers the principal interest of undergraduate, graduate and medical degree loans up to $35,000 a year for not more then 3 years, provided that the recipient agrees to provide pediatric medical subspecialty, pediatric surgical specialty, or child and adolescent mental and behavioral health care in an area with a shortage (Sec. 5203). -Authorizes appropriations of the following amounts to the National Health Service Corps (Sec. 5207):

-$320.46 million for fiscal year 2009-2010; -$414.10 million for fiscal year 2010-2011; -$535.09 million for fiscal year 2011-2012; -$691.43 million for fiscal year 2012-2013; -$893.46 million for fiscal year 2013-2014; -$1.15 billion for fiscal year 2014-2015; and -For subsequent years, the amount of the previous fiscal year plus an adjustment for increases in health professions education costs and changes in the number of individuals residing in health profession shortage areas.

-Authorizes the appropriation of $50 million a year for fiscal year 2009-2010 for nurse-managed health clinics, and "such sums as may be necessary" for fiscal years 2010-2011 through 2013-2014 (Sec. 5208). -Authorizes the appropriation of $125 million for fiscal year 2009-2010 and "such sums as may be necessary" for fiscal years 2010-2011 through 2013-2014 to make grants available to accredited public or nonprofit private hospitals, schools of medicine or osteopathic medicine, or academically affiliated physician assistant training programs for support and development of primary care training programs (Sec. 5301). -Authorizes the appropriation of $10 million for fiscal years 2009-2010 through 2012-2013 for grants to accredited institutes of higher learning that have established a public-private educational partnership with a nursing home or skilled nursing facility, or similar entities that provide training for direct-care workers in long-term care facilities (Sec. 5302). -Authorizes the Secretary of Health and Human Services to award grants to higher education institutions that recruit and provide clinical experience to students in mental health and behavioral health education, and authorizes the appropriations of the following funds for fiscal years 2009-2010 through 2012-2013 to carry this out (Sec. 5306):

-$8 million for social work training; -$12 million for graduate psychology training; -$10 million for professional child and adolescent mental health training; and -$5 million for paraprofessional child and adolescent work.

-Authorizes the appropriation of $338 million for the purpose of expanding eligibility for loan repayment and scholarship programs to nursing school faculty (Secs. 5310 & 5312). -Authorizes the establishment of a Unites States Public Health Sciences Track, which shall be authorized to award advanced degrees through existing accredited academic institutions and shall emphasize team-based service, public health, epidemiology, and emergency preparedness and response (Sec. 5315). -Specifies that students admitted to the Track shall receive tuition (or tuition remission) and a stipend for each school year for up to four years, in exchange for the following (Sec. 5315):

-Maintain Track enrollment until the course of study is completed; -Maintain "an acceptable level" of academic standing (as determined by the Surgeon General); -Complete a residency or internship if pursuing a degree from a school of medicine or osteopathic medicine, dental, public health, or nursing school or a physician assistant, pharmacy, or behavioral and mental health professional program; and -Serve in the Commissioned Corps for two years for each year of enrollment, unless serving in a capacity which qualifies for a reduction.

-Authorizes the Secretary of Health and Human Services to award grants to teaching health centers to establish new accredited or expanded primary care residency programs, and authorizes a total of $125 million in appropriations for fiscal years 2009-2010 through 2011-2012 to carry this out (Sec. 5508). -Appropriates the following funds for federally qualified health centers (Sec. 5601):

-$2.99 billion for fiscal year 2009-2010; -$3.86 billion for fiscal year 2010-2011; -$4.99 billion for fiscal year 2011-2012; -$6.45 billion for fiscal year 2012-2013; -$7.33 billion for fiscal year 2013-2014; -$8.33 billion for fiscal year 2014-2015; and -For subsequent fiscal years, the amount of the previous fiscal year plus an adjustment for increases in costs incurred per patient served and increases in total number of patients.

-Establishes an approval pathway to license biological products that are biosimilar or interchangeable with products that are already licensed, and prohibits the licensing of biosimilar products until 12 years after the licensing of the already-licensed product (Sec. 7002).

Note:

NOTE: INVOKING CLOTURE REQUIRES A 3/5 MAJORITY OF THE SENATE. IT IS NOT A VOTE ON THE PASSAGE OF THE PIECE OF LEGISLATION, BUT LIMITS FURTHER DEBATE TO 30 HOURS. CLOTURE IS TYPICALLY USED TO END A FILIBUSTER. A FAILED CLOTURE VOTE OFTEN PREVENTS THE LEGISLATION FROM EVER COMING TO A VOTE.

Legislation - Bill Passed (House) - Oct. 8, 2009

Legislation - Introduced (House) - Sept. 17, 2009

Title: Health Care and Insurance Law Amendments ("Patient Protection and Affordable Care Act")