ACCEPTABLE coverage ; Time of birth being not otherwise covered under
Index of Sec 305. ...ACCEPTABLE coverage ; End of period referred in paragraph being not otherwise covered under
Index of Sec 305. ...ACCEPTABLE coverage for purposes of division ; Subparagraph of paragraph not applying to individual having coverage treating as acceptable coverage for purposes of section 59b(d)(2) of Internal Revenue Code of 1986 but not treated as
Index of Sec 342. ...ACCEPTABLE coverage ; Affordable credit eligible individual if resident being resident of one of 50 States to be treated as covered by
Index of Sec 346. ...ACCEPTABLE coverage ; Individuals being eligible to obtain coverage through enrollment in Exchange-participating health benefits planning offered through Health Insurance Exchange unless individuals enrolled in another qualified health benefits planning or other
Index of Sec 302. ...ACCOUNT special circumstances of individuals and employers ; Commissioner providing for special enrollment periods to take into
Index of Sec 305. ...ACCOUNT health care providers used by individual involved or other relevant factors as Commissioner specifying ; Process involving random assignment or other form of assignment taking into
Index of Sec 305. ...ACCOUNT differences in risk characteristics of individuals and employees enrolled under different Exchange-participating health benefits planing offered by entities so as to minimizing impact of adverse selection of enrollees among plans offered by entities ; Commissioner establishing mechanism whereby being adjustment making of premium amounting payable among QHBP offering entities offering Exchange-participating health benefits planing of premiums collected for plans taking into
Index of Sec 306. ...ACCOUNT number or correcting information maintained in records and results of contestations ; Number of applicants whose declaration of citizenship or immigration status, name or social security account number being not consistent with records maintained by Commissioner of Social Security or Department of Homeland Security and number conteste inconsistency and sought to document citizenship or immigration status, name or social security
Index of Sec 341. ...ACCOUNT number under paragraph ; Responding to individuals contesting with Commissioner of Social Security reported inconsistency with records maintained by Commissioner of Social Security or Department of Homeland Security relating to citizenship or immigration status, name or social security
Index of Sec 341. ...ACCOUNT numbers of individuals as required to provide for verification of citizenship under subsection of section 341 of Affordable Health Care for America Act in connection with determinations of eligibility for affordability credits under section ; Health Choices Commissioner collecting and using names and social security
Index of Sec 341. ...ACCOUNT numbers as provided in section 205(v)(1) ; Health Choices Commissioner collecting and use social security
Index of Sec 341. ...ACCOUNTING and reconciliation of actual costs incurred and funds provided under agreement ; Providing for annual
Index of Sec 341. ...ACCOUNTING and reconciliation conducted pursuant to subparagraph to be reviewed by Inspectors General of Social Security Administration and Health Choices Administration ; Annual
Index of Sec 341. ...ACTUARIAL value described in section 213(b) used for purpose ; Only premium amounting attributable to
Index of Sec 303. ...ACTUARIAL value of 70 percent of full actuarial value of benefits provided under reference benefiting package ; Basic plan offering essential benefits packaging required under title II for qualified health benefits planning with
Index of Sec 303. ...ACTUARIAL value of benefits provided under reference benefiting package ; Basic plan offering essential benefits packaging required under title II for qualified health benefits planning with actuarial value of 70 percent of full
Index of Sec 303. ...ACTUARIAL value of benefits under plan provided under section 303(c)(2)(b) resulting from reduction in cost-sharing described in subsections ; Commissioner providing for payment to offering entity of amount equivalent to increased
Index of Sec 344. ...ACTUARIAL value percentage specified in table under section 343(d) for income tier involved ; Commissioner adjusting maximum out-of-pocket limits under paragraph to ensure that limits meeting
Index of Sec 344. ...ACTUARIAL value percentages to be determined with respect to individual ; Two
Index of Sec 343. ...ADMINISTRATIVE costs related to operating public health insurance option ;
Index of Sec 322. ...ADMINISTRATIVE costs of conducting status verification under paragraph ;
Index of Sec 341. ...ADMINISTRATIVE functions of section 1874a of Social Security Act with respect to public health insurance option in same manner as Secretary entering into contracts under subsection of section ; Secretary entering into contracts for purpose of performing
Index of Sec 321. ...PAYMENT rate or methodolology established under section or section 324 ; No administrative or judicial review of
Index of Sec 323. ...AFFORDABILITY if making eligible for coverage in Exchange ; Improving benefits and
Index of Sec 302. ...AFFORDABILITY cost-sharing credit under section 344 to be applied as reduction of cost-sharing otherwise applicable to plan ;
Index of Sec 341. ...AFFORDABILITY cost-sharing credit under section 344 to be used for enrollees in enhanced or premium plans ;
Index of Sec 341. ...AFFORDABILITY cost-sharing credit under section for affordable credit eligible individual enrolled in Exchange-participating health benefits planning in form of cost-sharing reduction described in subsection provided under section for income tier in which individual classified based on individual's modified adjusted gross income ;
Index of Sec 344. ...AFFORDABILITY credits provided under subtitle C of title II not used for purposes of paying for services ;
Index of Sec 303. ...AFFORDABILITY credits under subtitle C periods to be during September through November of year or other time maximizing timeliness of income verification for purposes of subtitle ; Commissioner establishing annual open enrollment period during that Exchange-eligible individual or employer electing to enroll in Exchange-participating health benefits planning for following plan year and enrollment period for
Index of Sec 305. ...AFFORDABILITY credits under subtitle B using same methodologies ; Administering
Index of Sec 308. ...AFFORDABILITY credits under subtitle ; Commissioner through Health Insurance Exchange or another public entity under arrangement making with Commissioner making determination as to eligibility of individual for
Index of Sec 341. ...AFFORDABILITY credits under subtitle and same standards as used by Commissioner ; Commissioner determining that State Medicaid agency having capacity to make determination of eligibility for
Index of Sec 341. ...AFFORDABILITY credits under subtitle ; Reference to medical assistance or enrollment under State plan deeming reference to provision of
Index of Sec 341. ...AFFORDABILITY credits under subtitle ; Reference to benefits under program deeming reference to
Index of Sec 341. ...AFFORDABILITY credits ; Effectiveness of systems in preventing ineligible individuals from receiving for
Index of Sec 341. ...AFFORDABILITY Credits ; Application to public entities administering
Index of Sec 341. ...AFFORDABILITY credits under section ; Health Choices Commissioner collecting and using names and social security account numbers of individuals as required to provide for verification of citizenship under subsection of section 341 of Affordable Health Care for America Act in connection with determinations of eligibility for
Index of Sec 341. ...AFFORDABILITY credits under subtitle not to be treated to be benefit provided under section 403 of title ;
Index of Sec 342. ...AFFORDABILITY credits on behalf of individuals being not lawfully present in United States ; Nothing in subtitle allowing Federal payments for
Index of Sec 347. ...AFFORDABILITY credits for affordable credit eligible individuals enrolled in plan ; Commissioner paying QHBP offering entity offering plan from Health Insurance Exchange Trust Fund aggregate amount of
Index of Sec 341. ...AFFORDABILITY premium credits under subtitle C as result of increase in premium in basic plans as result of application of requirement ; State entering into arrangement satisfactory to Commissioner to reimburse Commissioner for amount of net increase in
Index of Sec 303. ...BACK ; Providers participating in Medicare choosing to opt out of participating in public health insurance option opting
Index of Sec 323. ...CAPITATION and direct contracting with providers ; Bundling of services, differential payment rates, performance or utilization based payments, partial
Index of Sec 324. ...CHILD health assistance under title XXI of Social Security Act for period during Y1 not to be Exchange-eligible individual during period ; Individual being eligible for
Index of Sec 302. ...CITIZENSHIP ; Commissioner of Social Security determining that records maintained by Commissioner being not consistent with individual's allegation of United States
Index of Sec 341. ...AFFORDABILITY credits under section ; Health Choices Commissioner collecting and using names and social security account numbers of individuals as required to provide for verification of citizenship under subsection of section 341 of Affordable Health Care for America Act in connection with determinations of eligibility for
Index of Sec 341. ...CIVIL law identified by Secretary by regulation imposing sanctions with respect to waste, fraud and abuse under Medicare ; Provisions of
Index of Sec 326. ...COERCIVE practices to force providers not to contract with other entities offering coverage through Health Insurance Exchange ; Entity complying with other applicable requirements of title that including standards regarding billing and collection practices for premiums and related grace periods and including standards to ensure that entity not using
Index of Sec 304. ...COMPARATIVE manner and including information on benefits premiums, cost-sharing, quality, provider networks and consumer satisfaction ; Information to be provided in
Index of Sec 305. ...COMPETITIVE disadvantage ; Secretary delaying implementation reform in geographic areas in which implementation placing public health insurance option at
Index of Sec 324. ...COMPETITIVE procedures to be used in awarding contracts under subtitle to extent ;
Index of Sec 304. ...COMPLIANCE with standards for approval under section ; Commissioner establishing process to work with State described in subparagraph to provide assistance necessary to assure that State's Exchange coming into
Index of Sec 308. ...COMPLIANCE procedures established by Commissioner ; Determination by Commissioner to terminate contract to be made in accordance with formal investigation and
Index of Sec 304. ...CONSUMER focus including timeliness ; Cooperative operating with strong
Index of Sec 310. ...CONSUMER protections under subtitle D of title II ; Includ establishment of risk pooling mechanism under section 306 and
Index of Sec 301. ...CONSUMER protections of residents and residents retaining right to bring claim in State court in State in which resident residing ; Retaining responsibility for
Index of Sec 309. ...CONSUMER satisfaction ; Information to be provided in comparative manner and including information on benefits premiums, cost-sharing, quality, provider networks and
Index of Sec 305. ...CONTRACT with QHBP offering entity under section 304(c) for offering of Exchange-participating health benefits planning in service area unless following requirements being met ; Commissioner not entering into
Index of Sec 303. ...CONTRACT with QHBP offering entity under section for term of not less than one year ;
Index of Sec 304. ...CONTRACT with QHBP offering entity under section for offering of Exchange-participating health benefits planning if entity failing to comply with applicable requirements of title ; Commissioner terminating
Index of Sec 304. ...CONTRACT ; Commissioner providing entity with reasonable notice and opportunity for hearing before terminating
Index of Sec 304. ...CONTRACT under section with QHBP offering entity for health benefiting plan providing ;
Index of Sec 304. ...CONTRACT under subsection with QHBP offering entity for offering of health benefiting plan with same benefits in every State so long as entity licensed to offer plan in State and benefits meeting applicable requirements State ; Nothing in section to be construed as preventing Commissioner from entering into
Index of Sec 304. ...CONTRACT with Commissioner ; Plans to be offered under single
Index of Sec 303. ...CONTRACTS with entities for offering of plans through Health Insurance Exchange under terms negotiated between Commissioner and entities ; Commissioner entering into
Index of Sec 304. ...CONTRACTS under subtitle to extent ; Competitive procedures to be used in awarding
Index of Sec 304. ...CONSUMER information, outreach and assistance in enrollment of small employers being members arrangement under Exchange participating health benefits planing ; Commissioner entering into contracts with small employer benefit arrangements to provide
Index of Sec 305. ...CONTRACTS under subsection of section ; Secretary entering into contracts for purpose of performing administrative functions of section 1874a of Social Security Act with respect to public health insurance option in same manner as Secretary entering into
Index of Sec 321. ...COOPERATIVE ; No member having more than 5 percent voting interest in
Index of Sec 305. ...LOAN not to be awarded under subsection with respect to cooperative unless following conditions being met ; Grant or
Index of Sec 310. ...COOPERATIVE ; Membership of cooperative to be making up entirely of beneficiaries of insurance coverage offered by
Index of Sec 310. ...INSURANCE before date ; Not offering insurance before July 16, 2009 and cooperative being not affiliate or successor to insurance company offering
Index of Sec 310. ...COOPERATIVE incorporating ethical and conflict of interest standards designed to protect against insurance industry involvement and interference in governance of cooperative ; Governing documents of
Index of Sec 310. ...COOPERATIVE consisting of issuance of qualified health benefits planing through Health Insurance Exchange or State-based health insurance exchange ; Activities of
Index of Sec 310. ...CONSUMER focus including timeliness ; Cooperative operating with strong
Index of Sec 310. ...COOPERATIVE used to lowing premiums ; Profits making by
Index of Sec 310. ...COOPERATIVE established in another State administration, issuance of coverage or other activities related to acting as QHBP offering entity ; Nothing in section to be construed to prevent cooperative established in one State from integrating with
Index of Sec 310. ...LOAN or grant received by cooperative under section ; Repaying total amount of
Index of Sec 310. ...COOPERATIVE offers or issuing insurance coverage ; Grants to cooperatives to assist cooperatives in meeting State solvency requirements in States in which
Index of Sec 310. ...AFFORDABILITY credit only with respect to basic plan ; Y1 and Y2 affordable credit eligible individual using
Index of Sec 341. ...AFFORDABILITY credit not to be used for payment for services described in section 222(d)(4)(a) ;
Index of Sec 341. ...AFFORDABILITY credit based upon significant change in modified adjusted gross income described in subsection ; Initial application of individual for affordability credit under subtitle or application for change in
Index of Sec 345. ...CREDIT under section 343 to be applied against premium for Exchange-participating health benefits planning in which individual enrolled ; Affordability premium
Index of Sec 341. ...CREDIT under section 343 ; Commissioner establishing process to allow affordability premium
Index of Sec 341. ...CREDIT eligible individual enrolled in Exchange-participating health benefits planning in amount equal to amount by which reference premium amount specified in subsection ; Affordability premium credit under section for affordable
Index of Sec 343. ...CREDIT eligible individual enrolled in Exchange-participating health benefits planning ; Case of affordable
Index of Sec 341. ...CREDIT eligible individuals enrolled in plan ; Commissioner paying QHBP offering entity offering plan from Health Insurance Exchange Trust Fund aggregate amount of affordability credits for affordable
Index of Sec 341. ...AFFORDABILITY credit only with respect to basic plan ; Y1 and Y2 affordable credit eligible individual using
Index of Sec 341. ...CREDIT eligible individual enrolling in enhanced or premium plan ; Case of affordable
Index of Sec 341. ...CREDIT eligible individual receiving cash payment as result of application of subtitle ; No case affordable
Index of Sec 341. ...CREDIT eligible individuals to be treated as single affordable credit individual eligible for applicable credit family under subtitle ; Members of same family being affordable
Index of Sec 342. ...CONTRIBUTION under plan meet requirements of section 412 ; Term affordable credit eligible individual not including full-time employee of employer if employer offering employee coverage as full-time employee under group health plan if coverage and employer
Index of Sec 342. ...CREDIT eligible individual enrolled in Exchange-participating health benefits planning in amount equal to amount by which reference premium amount specified in subsection ; Affordability premium credit under section for affordable
Index of Sec 343. ...CREDIT eligible individual enrolled in Exchange-participating health benefits planning in form of cost-sharing reduction described in subsection provided under section for income tier in which individual classified based on individual's modified adjusted gross income ; Affordability cost-sharing credit under section for affordable
Index of Sec 344. ...CREDIT eligible individual in tier enrolled in Exchange-participating health benefits planning offered by QHBP offering entity ; Case of affordable
Index of Sec 344. ...CREDIT eligible individual to be required to inform Commissioner ; Commissioner establishing rules under which individual determined to be affordable
Index of Sec 345. ...AFFORDABILITY credit exceeding correct amount ; Case of individual intentionally misrepresenting modified adjusted gross income or individual failing to disclose to Commissioner significant change in modified adjusted gross income under subsection in manner resulting in individual becoming affordable credit eligible individual when individual being not or amount of
Index of Sec 345. ...BEARING same out-of-pocket responsibility for premiums and cost-sharing in relation to average income for residents in territory ; Affordable credit eligible individuals residing in territory
Index of Sec 346. ...CREDIT eligible individuals residing in 50 States or District of Columbia in relation to average income for residents ; Of-pocket responsibility for premiums and cost-sharing for affordable
Index of Sec 346. ...ACCEPTABLE coverage ; Affordable credit eligible individual if resident being resident of one of 50 States to be treated as covered by
Index of Sec 346. ...CREDIT exceeding premium for plan ; No case affordable premium
Index of Sec 343. ...AFFORDABILITY credit exceeding correct amount ; Case of individual intentionally misrepresenting modified adjusted gross income or individual failing to disclose to Commissioner significant change in modified adjusted gross income under subsection in manner resulting in individual becoming affordable credit eligible individual when individual being not or amount of
Index of Sec 345. ...CREDIT family under subtitle ; Members of same family being affordable credit eligible individuals to be treated as single affordable credit individual eligible for applicable
Index of Sec 342. ...AFFORDABILITY credit under subtitle ; Reference to newly enrolled individual under paragraph of section deeming reference to individual newly in receipt of
Index of Sec 341. ...CREDIT under section 344 to be applied as reduction of cost-sharing otherwise applicable to plan ; Affordability cost-sharing
Index of Sec 341. ...CREDIT under section 344 to be used for enrollees in enhanced or premium plans ; Affordability cost-sharing
Index of Sec 341. ...CREDIT eligible individual enrolled in Exchange-participating health benefits planning in form of cost-sharing reduction described in subsection provided under section for income tier in which individual classified based on individual's modified adjusted gross income ; Affordability cost-sharing credit under section for affordable
Index of Sec 344. ...CREDIT family under subtitle ; Members of same family being affordable credit eligible individuals to be treated as single affordable credit individual eligible for applicable
Index of Sec 342. ...AFFORDABILITY credit amount otherwise applicable if individual enrolling in basic plan ; Individual to be responsible for difference between premium for planning and
Index of Sec 341. ...DISCLOSURE of individually identifiable health information ; Part C of title XI of Social Security Act relating to standards for protections against wrongful
Index of Sec 328. ...DISCRIMINATION under Act ; Provision of services by Indian health care provider exclusively to Indians and dependents not constituting
Index of Sec 304. ...AFFORDABILITY premium and cost-sharing credits under subtitle C to QHBP offering entities offering Exchange-participating health benefits planing ; Commissioner coordinating distribution of
Index of Sec 306. ...EDUCATIONAL activities to increase awareness of Health Insurance Exchange and available small employer health plan options ;
Index of Sec 305. ...AFFORDABILITY credits under subtitle ; Commissioner through Health Insurance Exchange or another public entity under arrangement making with Commissioner making determination as to eligibility of individual for
Index of Sec 341. ...AFFORDABILITY credits under subtitle and same standards as used by Commissioner ; Commissioner determining that State Medicaid agency having capacity to make determination of eligibility for
Index of Sec 341. ...AFFORDABILITY credits under section ; Health Choices Commissioner collecting and using names and social security account numbers of individuals as required to provide for verification of citizenship under subsection of section 341 of Affordable Health Care for America Act in connection with determinations of eligibility for
Index of Sec 341. ...ELIGIBILITY for individuals and employers ; Commissioner submitting to Congress report on study conducted under subsection and including in report recommendations regarding changes in standards for Exchange
Index of Sec 302. ...AFFORDABILITY credits under section 341(b)(4) of Affordable Health Care for America Act ; Verification of status eligibility pursuant to procedures established under subsection to be deemed verification of status eligibility for purposes of title, title XXI and
Index of Sec 341. ...HEALTH benefits planing by employer of employee under subparagraph choosing coverage plan ; Employee offered Exchange-participating
Index of Sec 302. ...FELONY and fined or imprisoned ; Officer or employee or former officer or employee of Health Choices Commissioner or officer or employee or former officer or employee of contractor of Health Choices Commissioner publishing or communicating information in individual's possession by reason of employing or positioning as officer to be guilty of
Index of Sec 341. ...HEALTH benefits planning that meeting requirements of section 412 ; Enrolling under Exchange-participating health benefits planning and not enrolled under planning as employee through employer qualified
Index of Sec 342. ...CONTRIBUTION under plan meet requirements of section 412 ; Term affordable credit eligible individual not including full-time employee of employer if employer offering employee coverage as full-time employee under group health plan if coverage and employer
Index of Sec 342. ...FELONY and fined or imprisoned ; Officer or employee or former officer or employee of Health Choices Commissioner or officer or employee or former officer or employee of contractor of Health Choices Commissioner publishing or communicating information in individual's possession by reason of employing or positioning as officer to be guilty of
Index of Sec 341. ...HEALTH benefits planing ; Term Exchange-eligible employer meaning employer being eligible under section to enroll through Health Insurance Exchange employees of employer in Exchange-eligible
Index of Sec 302. ...HEALTH benefits planing through Health Insurance Exchange consistent with provisions of subtitle B of title IV ; Employer meeting requirements of section 412 with respect to employees of employer by offering employees option of enrolling with Exchange-participating
Index of Sec 302. ...HEALTH insurance to employees of employers through Health Insurance Exchange ; Commissioner establishing and carrying out program to provide to small employers counseling and technical assistance with respect to provision of
Index of Sec 305. ...HEALTH plan exceeding 12 percent of current modified adjusted gross income ; Case of full-time employees For which cost of employee premium for coverage under group
Index of Sec 342. ...PRIMARY purpose of providing affordable employee benefits to members ; Consisting solely of members and operated for
Index of Sec 305. ...CONTRIBUTION under plan meet requirements of section 412 ; Term affordable credit eligible individual not including full-time employee of employer if employer offering employee coverage as full-time employee under group health plan if coverage and employer
Index of Sec 342. ...HEALTH plan exceeding 12 percent of current modified adjusted gross income ; Case of full-time employees For which cost of employee premium for coverage under group
Index of Sec 342. ...HEALTH benefits planing ; Term Exchange-eligible employer meaning employer being eligible under section to enroll through Health Insurance Exchange employees of employer in Exchange-eligible
Index of Sec 302. ...HEALTH benefits planning ; Employer continuing to be treated as Exchange-eligible employer for subsequent plan year regardless of number of employees involved until employer meeting requirement of section 411(a) through paragraph of section by offering group health plan and not through offering Exchange-participating
Index of Sec 302. ...HEALTH benefits planing by employer of employee under subparagraph choosing coverage plan ; Employee offered Exchange-participating
Index of Sec 302. ...CONTRIBUTION under plan meet requirements of section 412 ; Term affordable credit eligible individual not including full-time employee of employer if employer offering employee coverage as full-time employee under group health plan if coverage and employer
Index of Sec 342. ...HEALTH benefits planing ; Commissioner providing for periodic surveys of Exchange-eligible individuals and employers concerning satisfaction of individuals and employers with Health Insurance Exchange and Exchange-participating
Index of Sec 302. ...HEALTH benefits planing including public health insurance option ; Nothing in division to be construed to affect role of enrollment agents and brokers under State law including with regard to enrollment of individuals and employers in qualified
Index of Sec 305. ...HEALTH insurance to employees of employers through Health Insurance Exchange ; Commissioner establishing and carrying out program to provide to small employers counseling and technical assistance with respect to provision of
Index of Sec 305. ...HEALTH benefits planing ; Commissioner entering into contracts with small employer benefit arrangements to provide consumer information, outreach and assistance in enrollment of small employers being members arrangement under Exchange participating
Index of Sec 305. ...HEALTH benefits planing ; Terms, conditions and affordability of group health coverage offered by employers and QHBP offering entities outside of Exchange compared to Exchange-participating
Index of Sec 302. ...CONSUMER information, outreach and assistance in enrollment of small employers being members arrangement under Exchange participating health benefits planing ; Commissioner entering into contracts with small employer benefit arrangements to provide
Index of Sec 305. ...CONTRIBUTION under plan meet requirements of section 412 ; Term affordable credit eligible individual not including full-time employee of employer if employer offering employee coverage as full-time employee under group health plan if coverage and employer
Index of Sec 342. ...HEALTH benefits planing ; Term Exchange-eligible employer meaning employer being eligible under section to enroll through Health Insurance Exchange employees of employer in Exchange-eligible
Index of Sec 302. ...HEALTH plan options ; Educational activities to increase awareness of Health Insurance Exchange and available small employer
Index of Sec 305. ...HEALTH insurance coverage with respect to participants in plan through Exchange to same extent ; Plan sponsor of group health plan being multi-employer plan obtaining
Index of Sec 302. ...EMPLOYMENT Taxes on Employers not providing ACCEPTABLE coverage ;
Index of Sec 307. ...EXPENDITURES to Federal Government ; Approval Exchange not resulting in net increase in
Index of Sec 308. ...EXPENDITURES under subtitle with respect to residents of territory during period beginning with Y1 and ending with 2019 not exceeding cap amount specified in paragraph for territory ; Commissioner ensuring that aggregate
Index of Sec 346. ...EXPENDITURES required ; Assistance provided for operation of Exchange in form of matching grant with State share of
Index of Sec 308. ...FELONY and fined or imprisoned ; Officer or employee or former officer or employee of Health Choices Commissioner or officer or employee or former officer or employee of contractor of Health Choices Commissioner publishing or communicating information in individual's possession by reason of employing or positioning as officer to be guilty of
Index of Sec 341. ...FISCAL year ; Providing funds within 10 calendar days of beginning of fiscal year for first quarter and advance for subsequent quarters in
Index of Sec 341. ...FISCAL year ; Case in which agreement with respect to provisions required under subparagraph for fiscal year not reached as of first day of
Index of Sec 341. ...FISCAL year involved ; Dollar limitation otherwise applicable to territory under subsections and section 1108 of Social Security Act 42 USC 1308 for fiscal year increased by dollar amount equivalent to cap amount determined under subsection for territory as applied by Secretary for
Index of Sec 346. ...FISCAL year occurring after date ; Increase in dollar limitation described in subsection for portion of
Index of Sec 346. ...FISCAL years 2010 through 2014 to provide for grants and loans under subsection ; Appropriating $5,000,000,000 for period of
Index of Sec 310. ...FOR-profit intending to offer or issues insurance coverage ;
Index of Sec 310. ...FRAUD and abuse under Medicare ; Provisions of civil law identified by Secretary by regulation imposing sanctions with respect to waste,
Index of Sec 326. ...COMPETITIVE disadvantage ; Secretary delaying implementation reform in geographic areas in which implementation placing public health insurance option at
Index of Sec 324. ...GEOGRAPHIC areas or otherwise in order to reduce total program costs or promoting high value care ; Secretary prioritizing implementation reform in high cost
Index of Sec 324. ...GEOGRAPHIC areas ; Nothing in subtitle preventing Secretary from varying payments based on different payment structure models under public health insurance option for different
Index of Sec 324. ...COOPERATIVE ; Governing documents of cooperative incorporating ethical and conflict of interest standards designed to protect against insurance industry involvement and interference in governance of
Index of Sec 310. ...HEALTH benefiting Plans offered by offering entities ; Limitation on
Index of Sec 303. ...HEALTH benefiting plan increasing cost-sharing by 10 percent within categorying or tiering and decreaseing or eliminating cost-sharing in categorying or tiering as compared to essential benefits packaging ;
Index of Sec 303. ...HEALTH benefits planning of QHBP offering entity ; Clause not applying if Commissioner determining that delay in termination posing imminent and serious risk to health of individuals enrolled under qualified
Index of Sec 304. ...HEALTH benefiting plan providing ; Contract under section with QHBP offering entity for
Index of Sec 304. ...HEALTH benefiting plan with same benefits in every State so long as entity licensed to offer plan in State and benefits meeting applicable requirements State ; Nothing in section to be construed as preventing Commissioner from entering into contract under subsection with QHBP offering entity for offering of
Index of Sec 304. ...HEALTH and health care ; Including information necessary to administer risk pooling mechanism described in section 306(b) and information to address disparities in
Index of Sec 304. ...HEALTH and value ; Public health insurance option modifying cost-sharing and payment rates to encourage use of services promoting
Index of Sec 324. ...HEALTH benefiting plan of QHBP offering entity using provider network ; Case of
Index of Sec 304. ...HEALTH benefiting coverage ; Other
Index of Sec 302. ...ACCEPTABLE coverage ; Individuals being eligible to obtain coverage through enrollment in Exchange-participating health benefits planning offered through Health Insurance Exchange unless individuals enrolled in another qualified health benefits planning or other
Index of Sec 302. ...HEALTH Benefits planning coverage ; Qualifying
Index of Sec 302. ...HEALTH benefits planing as meeting standards and requirements of title and titling II for purposes of subtitle ; Certifying QHBP offering entities and qualified
Index of Sec 304. ...HEALTH benefits planning discriminating against individual health care provider or health care facility because of willingness or unwillingness ; No Exchange participating
Index of Sec 304. ...HEALTH benefits planing ; Commissioner entering into contracts with small employer benefit arrangements to provide consumer information, outreach and assistance in enrollment of small employers being members arrangement under Exchange participating
Index of Sec 305. ...HEALTH benefits provided by public health insurance option ;
Index of Sec 322. ...HEALTH benefits planning that meeting requirements of section 412 ; Enrolling under Exchange-participating health benefits planning and not enrolled under planning as employee through employer qualified
Index of Sec 342. ...HEALTH benefits planing ; Term Exchange-eligible employer meaning employer being eligible under section to enroll through Health Insurance Exchange employees of employer in Exchange-eligible
Index of Sec 302. ...ACCEPTABLE coverage ; Individuals being eligible to obtain coverage through enrollment in Exchange-participating health benefits planning offered through Health Insurance Exchange unless individuals enrolled in another qualified health benefits planning or other
Index of Sec 302. ...HEALTH benefits planning and including dependents of individual ; Term Exchange-eligible individual meaning individual being eligible under section to be enrolled through Health Insurance Exchange in Exchange-participating
Index of Sec 302. ...HEALTH benefits planning through Health Insurance Exchange ; Individual qualifying as Exchange-eligible individual under subsection and enrolling under Exchange-participating
Index of Sec 302. ...HEALTH benefits planning ; Employer continuing to be treated as Exchange-eligible employer for subsequent plan year regardless of number of employees involved until employer meeting requirement of section 411(a) through paragraph of section by offering group health plan and not through offering Exchange-participating
Index of Sec 302. ...HEALTH benefits planing through Health Insurance Exchange consistent with provisions of subtitle B of title IV ; Employer meeting requirements of section 412 with respect to employees of employer by offering employees option of enrolling with Exchange-participating
Index of Sec 302. ...HEALTH benefits planing by employer of employee under subparagraph choosing coverage plan ; Employee offered Exchange-participating
Index of Sec 302. ...HEALTH benefits planing ; Commissioner providing for periodic surveys of Exchange-eligible individuals and employers concerning satisfaction of individuals and employers with Health Insurance Exchange and Exchange-participating
Index of Sec 302. ...HEALTH benefits planing ; Commissioner conducting study of access to Health Insurance Exchange for individuals and employers including individuals and employers being not eligible and enrolled in Exchange-participating
Index of Sec 302. ...HEALTH benefits planing ; Terms, conditions and affordability of group health coverage offered by employers and QHBP offering entities outside of Exchange compared to Exchange-participating
Index of Sec 302. ...HEALTH benefits planing during plan year, consistent with subtitle C of title II and section ; Commissioner specifying benefits to be made available under Exchange-participating
Index of Sec 303. ...HEALTH benefits planning in service area unless following requirements being met ; Commissioner not entering into contract with QHBP offering entity under section 304(c) for offering of Exchange-participating
Index of Sec 303. ...HEALTH benefits planning ; Requirement continuing to apply to Exchange-participating
Index of Sec 303. ...HEALTH Benefits planing ; Sec 304, Contracts for offering of Exchange-participating
Index of Sec 304. ...HEALTH benefits planning ; QHBP offering entities for offering of Exchange-participating
Index of Sec 304. ...HEALTH benefits planing ; Commissioner soliciting bids from QHBP offering entities for offering of Exchange-participating
Index of Sec 304. ...HEALTH Benefits planing ; Standards for QHBP offering entities to Offer Exchange-participating
Index of Sec 304. ...HEALTH benefits planing offers in accordance with standards and functions established by Commissioner ; Entity establishing and operating program to protect and promote integrity of Exchange-participating
Index of Sec 304. ...HEALTH benefits planning ; Demonstrating to satisfaction of Commissioner contracting with sufficient number of Indian health care providers to ensure timely access to covered services furnished by providers to individual Indians through entity's Exchange-participating
Index of Sec 304. ...HEALTH benefits ; Commissioner establishing processing to oversee, monitor and enforce applicable requirements of title with respect to QHBP offering entities offering Exchange-participating
Index of Sec 304. ...HEALTH benefits planning if entity failing to comply with applicable requirements of title ; Commissioner terminating contract with QHBP offering entity under section for offering of Exchange-participating
Index of Sec 304. ...HEALTH benefits planning options ; Informing and educating individuals and employers about Health Insurance Exchange and Exchange-participating
Index of Sec 305. ...AFFORDABILITY credits under subtitle C periods to be during September through November of year or other time maximizing timeliness of income verification for purposes of subtitle ; Commissioner establishing annual open enrollment period during that Exchange-eligible individual or employer electing to enroll in Exchange-participating health benefits planning for following plan year and enrollment period for
Index of Sec 305. ...HEALTH benefits planning ; Commissioner providing for process under which individuals being Exchange-eligible individuals described in subparagraph automatically enrolled under appropriate Exchange-participating
Index of Sec 305. ...HEALTH benefits planning ; Individual enrolled in Exchange-participating health benefits planning terminated and not otherwise enrolling in another Exchange-participating
Index of Sec 305. ...HEALTH benefits planning paying plans directly and not through Commissioner or Health Insurance Exchange ; Individuals enrolled in Exchange-participating
Index of Sec 305. ...HEALTH benefits planing offered under title ; Commissioner providing for broad dissemination of information on Exchange-participating
Index of Sec 305. ...HEALTH benefits planing and file complaints ; Providing for operation of toll-free telephone hotline to respond to requests for assistance and maintaining Internet Web site through individuals obtaining information on coverage under Exchange-participating
Index of Sec 305. ...HEALTH benefits planing and obtaining benefits through plans ; Assist Exchange-eligible individuals in selecting Exchange-participating
Index of Sec 305. ...HEALTH benefits planing and State's Medicaid program consistent with section and otherwise coordinating implementation of provisions of division with respect to Medicaid program ; Commissioner entering into memorandum of understanding with State with respect to coordinating enrollment of individuals in Exchange-participating
Index of Sec 305. ...HEALTH benefits planing ; Commissioner coordinating distribution of affordability premium and cost-sharing credits under subtitle C to QHBP offering entities offering Exchange-participating
Index of Sec 306. ...HEALTH benefits planing offered by entities so as to minimizing impact of adverse selection of enrollees among plans offered by entities ; Commissioner establishing mechanism whereby being adjustment making of premium amounting payable among QHBP offering entities offering Exchange-participating health benefits planing of premiums collected for plans taking into account differences in risk characteristics of individuals and employees enrolled under different Exchange-participating
Index of Sec 306. ...HEALTH benefits planing ; Negotiating and contracting with QHBP offering entities for offering of Exchange-participating
Index of Sec 308. ...HEALTH benefits planning that ensuring choice, competition and stability of affordable ; Secretary of Health and Human Services providing for offering of Exchange-participating
Index of Sec 321. ...HEALTH benefits ; Public health insurance option complying with requirements being applicable under title to Exchange-participating
Index of Sec 321. ...HEALTH benefits planning ; Secretary to be treated as QHBP offering entity offering Exchange-participating
Index of Sec 321. ...HEALTH benefits planing ; Manner complying with premium ruling established by Commissioner under section 213 for Exchange-participating
Index of Sec 322. ...HEALTH benefits planing ; Other than amounts as otherwise provided with respect to other Exchange-participating
Index of Sec 322. ...HEALTH benefits planing ; Extent allowed by benefit standards applied to Exchange-participating
Index of Sec 324. ...HEALTH benefits planning ; Case of affordable credit eligible individual enrolled in Exchange-participating
Index of Sec 341. ...HEALTH benefits planning in which individual enrolled ; Affordability premium credit under section 343 to be applied against premium for Exchange-participating
Index of Sec 341. ...HEALTH benefits planning and not enrolled under planning as employee through employer qualified health benefits planning that meeting requirements of section 412 ; Enrolling under Exchange-participating
Index of Sec 342. ...HEALTH benefits planning in amount equal to amount by which reference premium amount specified in subsection ; Affordability premium credit under section for affordable credit eligible individual enrolled in Exchange-participating
Index of Sec 343. ...HEALTH benefits planning in form of cost-sharing reduction described in subsection provided under section for income tier in which individual classified based on individual's modified adjusted gross income ; Affordability cost-sharing credit under section for affordable credit eligible individual enrolled in Exchange-participating
Index of Sec 344. ...HEALTH benefits planning offered by QHBP offering entity ; Case of affordable credit eligible individual in tier enrolled in Exchange-participating
Index of Sec 344. ...ACTUARIAL value of 70 percent of full actuarial value of benefits provided under reference benefiting package ; Basic plan offering essential benefits packaging required under title II for qualified health benefits planning with
Index of Sec 303. ...HEALTH benefits planning providing coverage of services described in section 222(d)(4)(a) ; Qualified
Index of Sec 303. ...HEALTH benefits planning of QHBP offering entity ; Clause not applying if Commissioner determining that delay in termination posing imminent and serious risk to health of individuals enrolled under qualified
Index of Sec 304. ...HEALTH benefits planing including public health insurance option ; Nothing in division to be construed to affect role of enrollment agents and brokers under State law including with regard to enrollment of individuals and employers in qualified
Index of Sec 305. ...HEALTH benefits planing through Health Insurance Exchange or State-based health insurance exchange ; Activities of cooperative consisting of issuance of qualified
Index of Sec 310. ...HEALTH benefits risking pool in coordination with Secretary of Treasury ; State
Index of Sec 302. ...HEALTH care providers defined in section 340b(a)(4) of Public Health Service Act and providers described in section 1927(c)(1)(d)(i) of Social Security Act ;
Index of Sec 304. ...HEALTH care providers used by individual involved or other relevant factors as Commissioner specifying ; Process involving random assignment or other form of assignment taking into account
Index of Sec 305. ...HEALTH care providers and items and services including prescription drugs ; Secretary negotiating payment for public health insurance option for
Index of Sec 323. ...HEALTH care providers participating in Medicare participating providers in public health insurance option unless opting out in process established by Secretary consistent with subsection ;
Index of Sec 323. ...HEALTH care provider to participate in public health insurance option unless provider appropriately licensed, certified or otherwise permitted to practice under State law ; Secretary not allowing
Index of Sec 325. ...HEALTH care program ; Secretary excluding from participation under public health insurance option health care provider excluded from participation in Federal
Index of Sec 325. ...HEALTH care providers and Federal and State agencies including effect of erroneous determinations under systems ; Impact of systems on individuals,
Index of Sec 341. ...HEALTH benefits planning ; Demonstrating to satisfaction of Commissioner contracting with sufficient number of Indian health care providers to ensure timely access to covered services furnished by providers to individual Indians through entity's Exchange-participating
Index of Sec 304. ...HEALTH care provider ; Entity making for services of participating provider being not Indian
Index of Sec 304. ...DISCRIMINATION under Act ; Provision of services by Indian health care provider exclusively to Indians and dependents not constituting
Index of Sec 304. ...HEALTH care provider ; Individual being Indian enrolled plan and individual receiving covered item or service from Indian
Index of Sec 304. ...HEALTH care facility because of willingness or unwillingness ; No Exchange participating health benefits planning discriminating against individual health care provider or
Index of Sec 304. ...HEALTH care providers under public health insurance option under which payment only to be available if provider agreeing to accept payment under section 323 as payment in full ; Secretary providing for participation of
Index of Sec 325. ...HEALTH care delivered to members ; Improving benefits or otherwise improving quality of
Index of Sec 310. ...HEALTH care providers ; Average rates paid by other QHBP offering entities for services and
Index of Sec 323. ...HEALTH care facility because of willingness or unwillingness ; No Exchange participating health benefits planning discriminating against individual health care provider or
Index of Sec 304. ...HEALTH care program ; Secretary excluding from participation under public health insurance option health care provider excluded from participation in Federal
Index of Sec 325. ...HEALTH care services in facility operated by Indian Tribe or tribal organization under Indian Self-Determination Act ; Employing to provide
Index of Sec 325. ...HEALTH benefits planing ; Terms, conditions and affordability of group health coverage offered by employers and QHBP offering entities outside of Exchange compared to Exchange-participating
Index of Sec 302. ...HEALTH maintenance organization ; Manner in which previous sentence applying in case of basic plan with respect to which Commissioner determining providing substantially benefits through
Index of Sec 304. ...HEALTH benefits planning ; Employer continuing to be treated as Exchange-eligible employer for subsequent plan year regardless of number of employees involved until employer meeting requirement of section 411(a) through paragraph of section by offering group health plan and not through offering Exchange-participating
Index of Sec 302. ...CONTRIBUTION under plan meet requirements of section 412 ; Term affordable credit eligible individual not including full-time employee of employer if employer offering employee coverage as full-time employee under group health plan if coverage and employer
Index of Sec 342. ...HEALTH plan exceeding 12 percent of current modified adjusted gross income ; Case of full-time employees For which cost of employee premium for coverage under group
Index of Sec 342. ...HEALTH insurance coverage with respect to participants in plan through Exchange to same extent ; Plan sponsor of group health plan being multi-employer plan obtaining
Index of Sec 302. ...HEALTH plans ; Applying to public health insurance option in same manner as part applying to other
Index of Sec 328. ...HEALTH services ; Entity providing for culturally and linguistically appropriate communication and
Index of Sec 304. ...HOME and other care management payments, accountable care organizations, value-based ; Payment mechanisms and policies under section including patient-centered medical
Index of Sec 324. ...ACCOUNT number or correcting information maintained in records and results of contestations ; Number of applicants whose declaration of citizenship or immigration status, name or social security account number being not consistent with records maintained by Commissioner of Social Security or Department of Homeland Security and number conteste inconsistency and sought to document citizenship or immigration status, name or social security
Index of Sec 341. ...CITIZENSHIP or immigration status ; Nothing in paragraph or amendments making by paragraph to be construed as authorizing Health Choices Commissioner or Commissioner of Social Security to establish database of information on
Index of Sec 341. ...ACCOUNT number under paragraph ; Responding to individuals contesting with Commissioner of Social Security reported inconsistency with records maintained by Commissioner of Social Security or Department of Homeland Security relating to citizenship or immigration status, name or social security
Index of Sec 341. ...ACCOUNT number being not consistent with records maintained by Commissioner of Social Security or Department of Homeland Security and number conteste inconsistency and sought to document citizenship or immigration status, name or social security account number or correcting information maintained in records and results of contestations ; Number of applicants whose declaration of citizenship or immigration status, name or social security
Index of Sec 341. ...CITIZENSHIP and immigration verification systems applied under paragraph ; Pensions and Committee on Judiciary of Senate report examining effectiveness of
Index of Sec 341. ...COMPETITIVE disadvantage ; Secretary delaying implementation reform in geographic areas in which implementation placing public health insurance option at
Index of Sec 324. ...AFFORDABILITY crediting provided for enrollees under subtitle C ; Entity providing for implementation of
Index of Sec 304. ...IMPLEMENTATION of provisions of division with respect to Medicaid program ; Commissioner entering into memorandum of understanding with State with respect to coordinating enrollment of individuals in Exchange-participating health benefits planing and State's Medicaid program consistent with section and otherwise coordinating
Index of Sec 305. ...COMPETITIVE disadvantage ; Secretary delaying implementation reform in geographic areas in which implementation placing public health insurance option at
Index of Sec 324. ...GEOGRAPHIC areas or otherwise in order to reduce total program costs or promoting high value care ; Secretary prioritizing implementation reform in high cost
Index of Sec 324. ...IN-network cost-sharing plus 15 percent of total payment for iteming and servicing ; Physicians agreeing not to impose charges exceeding sum of
Index of Sec 325. ...INCOME not exceeding 133 percent of fpl ; Case of individual with
Index of Sec 343. ...INCOME otherwise applicable ; Significant changes in income to Commissioner and requiring substitution of income for
Index of Sec 345. ...INCOME for residents in territory ; Affordable credit eligible individuals residing in territory bearing same out-of-pocket responsibility for premiums and cost-sharing in relation to average
Index of Sec 346. ...INCOME for residents ; Of-pocket responsibility for premiums and cost-sharing for affordable credit eligible individuals residing in 50 States or District of Columbia in relation to average
Index of Sec 346. ...INCOME disregarding for purposes of subtitle ; Commissioner conducting study examining application of
Index of Sec 342. ...INCOME ; Case of full-time employees For which cost of employee premium for coverage under group health plan exceeding 12 percent of current modified adjusted gross
Index of Sec 342. ...INCOME of child as recently determined before Y1 by State under title XXI of Social Security Act ; Commissioner establishing rules under which modified adjusted gross income of child deemed to be no greater than family
Index of Sec 345. ...INCOME ; Term income means modified adjusted gross
Index of Sec 342. ...INCOME for plan year ; Premium percentage limit specified in paragraph for individual based upon individual's modified adjusted gross
Index of Sec 343. ...INCOME ; Affordability cost-sharing credit under section for affordable credit eligible individual enrolled in Exchange-participating health benefits planning in form of cost-sharing reduction described in subsection provided under section for income tier in which individual classified based on individual's modified adjusted gross
Index of Sec 344. ...AFFORDABILITY credit exceeding correct amount ; Case of individual intentionally misrepresenting modified adjusted gross income or individual failing to disclose to Commissioner significant change in modified adjusted gross income under subsection in manner resulting in individual becoming affordable credit eligible individual when individual being not or amount of
Index of Sec 345. ...INCOME for plan year expected to be significantly different from income used under subsection ; Individual's
Index of Sec 345. ...INCOME described in subsection ; Initial application of individual for affordability credit under subtitle or application for change in affordability credit based upon significant change in modified adjusted gross
Index of Sec 345. ...INCOME of individual ; Commissioner receiving new information from individual regarding modified adjusted gross
Index of Sec 345. ...INCOME of child as recently determined before Y1 by State under title XXI of Social Security Act ; Commissioner establishing rules under which modified adjusted gross income of child deemed to be no greater than family
Index of Sec 345. ...AFFORDABILITY credit exceeding correct amount ; Case of individual intentionally misrepresenting modified adjusted gross income or individual failing to disclose to Commissioner significant change in modified adjusted gross income under subsection in manner resulting in individual becoming affordable credit eligible individual when individual being not or amount of
Index of Sec 345. ...INCOME for income otherwise applicable ; Significant changes in income to Commissioner and requiring substitution of
Index of Sec 345. ...INCOME tier specified in table in subsection ; Individuals whose modified adjusted gross income within
Index of Sec 343. ...INCOME means modified adjusted gross income ; Term
Index of Sec 342. ...INCOME tier ; Increase on sliding scale in linear manner from initial premium percentage to final premium percentage specified in table for
Index of Sec 343. ...INCOME tier identified in table in paragraph ;
Index of Sec 343. ...INCOME tier in which individual classified based on individual's modified adjusted gross income ; Affordability cost-sharing credit under section for affordable credit eligible individual enrolled in Exchange-participating health benefits planning in form of cost-sharing reduction described in subsection provided under section for
Index of Sec 344. ...INCOME tier specified in table under section 343(d) as estimated by Commissioner ; Commissioner specifying reduction in cost-sharing amounts and annual limitation on cost-sharing specified in section 222(c)(2)(b) under basic plan for
Index of Sec 344. ...INCOME tier ; Maximum out-of-pocket limit specified in subsection for individual within
Index of Sec 344. ...INCOME tier involved ; Of-pocket limit for Y1 specified in subsection in table under section 343(d) for
Index of Sec 344. ...INCOME tier involved ; Commissioner adjusting maximum out-of-pocket limits under paragraph to ensure that limits meeting actuarial value percentage specified in table under section 343(d) for
Index of Sec 344. ...INCOME tiers under table to be specified in manner so ; Substituted percentages of fpl for
Index of Sec 346. ...INCOME verification for purposes of subtitle ; Commissioner establishing annual open enrollment period during that Exchange-eligible individual or employer electing to enroll in Exchange-participating health benefits planning for following plan year and enrollment period for affordability credits under subtitle C periods to be during September through November of year or other time maximizing timeliness of
Index of Sec 305. ...INELIGIBILITY based on final verification determination under system ; Developing written notice for user agencies to provide to individuals denying benefit due to determination of
Index of Sec 341. ...HEALTH and health care ; Including information necessary to administer risk pooling mechanism described in section 306(b) and information to address disparities in
Index of Sec 304. ...INFORMATION as Commissioner requiring ; QHBP offering entity submitting to Commissioner bid at time and containing
Index of Sec 304. ...CONSUMER satisfaction ; Information to be provided in comparative manner and including information on benefits premiums, cost-sharing, quality, provider networks and
Index of Sec 305. ...HEALTH benefits planing and file complaints ; Providing for operation of toll-free telephone hotline to respond to requests for assistance and maintaining Internet Web site through individuals obtaining information on coverage under Exchange-participating
Index of Sec 305. ...INFORMATION ; Report to be made publicly available and including
Index of Sec 341. ...INFORMATION maintained in records and results of contestations ; Number of applicants whose declaration of citizenship or immigration status, name or social security account number being not consistent with records maintained by Commissioner of Social Security or Department of Homeland Security and number conteste inconsistency and sought to document citizenship or immigration status, name or social security account number or correcting
Index of Sec 341. ...INFORMATION required to be collected by Health Choices Commissioner under section 341(b)(4)(c) ; Commissioner of Social Security entering and maintaining agreement with Health Choices Commissioner for purpose of establishing program for verifying
Index of Sec 341. ...INFORMATION for purposes of maintaining records of Health Choices Administration ; Agreement entered into pursuant to subparagraph including safeguards as necessary to ensure maintenance of confidentiality of information disclosed for purposes of verifing information described in subparagraph and providing procedures for permitting Health Choices Commissioner to use
Index of Sec 341. ...INFORMATION provided by Commissioner of Social Security to Health Choices Commissioner pursuant to agreement to be provided at time ; Agreement entered into pursuant to subparagraph providing that
Index of Sec 341. ...INFORMATION provided by Commissioner of Social Security to Health Choices Commissioner pursuant to agreement entered into pursuant to subparagraph to be considered as confidential and used only for purposes described in paragraph and carrying out agreement ;
Index of Sec 341. ...INFORMATION provided by Commissioner of Social Security to be considered as confidential and only used by State and Secretary of Homeland Security for purposes of verification procedures ;
Index of Sec 341. ...INFORMATION contained in application ; Permitting to verify
Index of Sec 345. ...INFORMATION ; Commissioner using information so disclosed to verify
Index of Sec 345. ...DISSEMINATION of information to prospective enrollees on enrollment process including before open enrollment period ; Commissioner providing for broad
Index of Sec 305. ...CONFIDENTIALITY of information ; Other than provisions relating to
Index of Sec 304. ...CONSUMER information, outreach and assistance in enrollment of small employers being members arrangement under Exchange participating health benefits planing ; Commissioner entering into contracts with small employer benefit arrangements to provide
Index of Sec 305. ...INFORMATION for relevant agencies ; Contesting notice and attempt to correct records of system relating to recipient including contact
Index of Sec 341. ...CITIZENSHIP or immigration status ; Nothing in paragraph or amendments making by paragraph to be construed as authorizing Health Choices Commissioner or Commissioner of Social Security to establish database of information on
Index of Sec 341. ...DISSEMINATION of information under subsection and providing assistance as described in paragraph ; Commissioner working with other appropriate entities to facilitate
Index of Sec 305. ...INFORMATION consistent with limitations described in section 1902(a)(7) of Social Security Act Nothing in section to be construed as permitting memorandum to modify or vitiate requirement of State Medicaid plan ; Memorandum permitting exchange of
Index of Sec 305. ...INFORMATION contained within system ; Own personally identifiable
Index of Sec 341. ...INFORMATION containing within system ; Providing written response to individual making request to amend, correct or update individual's own personally identifiable
Index of Sec 341. ...INFORMATION contained within records of system described in paragraph ; Description of right of recipient under subparagraph to access and attempt to amend, correct and update recipient's own personally identifiable
Index of Sec 341. ...HEALTH information ; Part C of title XI of Social Security Act relating to standards for protections against wrongful disclosure of individually identifiable
Index of Sec 328. ...INFORMATION regarding change ; Significant change in modified adjusted gross income of individual and
Index of Sec 345. ...CONFIDENTIALITY of information disclosed for purposes of verifing information described in subparagraph and providing procedures for permitting Health Choices Commissioner to use information for purposes of maintaining records of Health Choices Administration ; Agreement entered into pursuant to subparagraph including safeguards as necessary to ensure maintenance of
Index of Sec 341. ...INCOME of individual ; Commissioner receiving new information from individual regarding modified adjusted gross
Index of Sec 345. ...INFORMATION as Secretary determining to be necessary ; Commissioner utilizing data regarding enrollee demographics, inpatient and outpatient diagnoses and other
Index of Sec 306. ...INFORMATION ; Commissioner working with other appropriate entities to facilitate provision of
Index of Sec 305. ...HEALTH and health care ; Including information necessary to administer risk pooling mechanism described in section 306(b) and information to address disparities in
Index of Sec 304. ...INFORMATION ; Verifiable information required to document change and process for submission of
Index of Sec 345. ...INFORMATION described in subparagraph being developed using plain language ; Ensuring that Internet Web site described in subparagraph and
Index of Sec 305. ...INFORMATION required to document change and process for submission of information ; Verifiable
Index of Sec 345. ...DISSEMINATION of information on Exchange-participating health benefits planing offered under title ; Commissioner providing for broad
Index of Sec 305. ...FELONY and fined or imprisoned ; Officer or employee or former officer or employee of Health Choices Commissioner or officer or employee or former officer or employee of contractor of Health Choices Commissioner publishing or communicating information in individual's possession by reason of employing or positioning as officer to be guilty of
Index of Sec 341. ...INSOLVENCY in manner similar to manner in which entities receiving Federal funding under Troubled Asseal Relief Program of Secretary of Treasury ; No case public health insurance option receiving Federal funds for purposes of
Index of Sec 322. ...INSURANCE through Health Insurance Exchange or State-based Health Insurance Exchange under section 308 ; Member-run health insurance cooperatives providing
Index of Sec 310. ...INSURANCE before date ; Not offering insurance before July 16, 2009 and cooperative being not affiliate or successor to insurance company offering
Index of Sec 310. ...INSURANCE ; Licensing to offer insurance in State in which offering
Index of Sec 310. ...HEALTH insurance coverage to include benefits beyond essential benefits packaging ; State requiring health insurance issuer offering
Index of Sec 303. ...HEALTH insurance issuer ; Providing for sale of health insurance coverage to residents of compacting States subjecting to laws and regulations of primary State designated by
Index of Sec 309. ...HEALTH insurance coverage in secondary States to maintain licensure in every ; Requiring health insurance issuers issuing
Index of Sec 309. ...HEALTH insurance issuer in individual market ; Requirements of sections 2701 through 2792 of Public Health Service Act applying to public health insurance option in same manner as applying to health insurance coverage offered by
Index of Sec 327. ...HEALTH insurance issuer to same extent ; Permit State insurance commissioners and other State agencies in secondary States accessing to records of
Index of Sec 309. ...HEALTH insurance to employees of employers through Health Insurance Exchange ; Commissioner establishing and carrying out program to provide to small employers counseling and technical assistance with respect to provision of
Index of Sec 305. ...HEALTH insurance issuer to same extent ; Permit State insurance commissioners and other State agencies in secondary States accessing to records of
Index of Sec 309. ...INSURANCE before date ; Not offering insurance before July 16, 2009 and cooperative being not affiliate or successor to insurance company offering
Index of Sec 310. ...HEALTH insurance cooperatives providing insurance through Health Insurance Exchange or State-based Health Insurance Exchange under section 308 ; Member-run
Index of Sec 310. ...INSURANCE coverage ; Grants to cooperatives to assist cooperatives in meeting State solvency requirements in States in which cooperative offers or issuing
Index of Sec 310. ...COOPERATIVE ; Membership of cooperative to be making up entirely of beneficiaries of insurance coverage offered by
Index of Sec 310. ...HEALTH insurance coverage through Exchange as Exchange-eligible employer ; Employer not described in paragraph or permitted by Commissioner to obtain
Index of Sec 302. ...HEALTH insurance coverage to include benefits beyond essential benefits packaging ; State requiring health insurance issuer offering
Index of Sec 303. ...HEALTH insurance coverage in secondary States to maintain licensure in every ; Requiring health insurance issuers issuing
Index of Sec 309. ...HEALTH insurance coverage selling in secondary States ; State using amounts awarded under subsection for activities related regulating
Index of Sec 309. ...HEALTH insurance coverage offered by health insurance issuer in individual market ; Requirements of sections 2701 through 2792 of Public Health Service Act applying to public health insurance option in same manner as applying to
Index of Sec 327. ...HEALTH insurance coverage offered in territory ; Requiring to apply requirements of title II with respect to
Index of Sec 346. ...INSURANCE coverage ; For-profit intending to offer or issues
Index of Sec 310. ...HEALTH insurance coverage including public health insurance option ; Quality
Index of Sec 301. ...HEALTH insurance coverage to residents of compacting States subjecting to laws and regulations of primary State designated by health insurance issuer ; Providing for sale of
Index of Sec 309. ...HEALTH insurance coverage under State law for State ; Entity to be licensed to offer
Index of Sec 304. ...HEALTH insurance exchange ; Activities of cooperative consisting of issuance of qualified health benefits planing through Health Insurance Exchange or State-based
Index of Sec 310. ...COOPERATIVE ; Governing documents of cooperative incorporating ethical and conflict of interest standards designed to protect against insurance industry involvement and interference in governance of
Index of Sec 310. ...HEALTH insurance option ; Quality health insurance coverage including public
Index of Sec 301. ...HEALTH insurance option ; Nothing in division to be construed to affect role of enrollment agents and brokers under State law including with regard to enrollment of individuals and employers in qualified health benefits planing including public
Index of Sec 305. ...HEALTH benefits ; Public health insurance option complying with requirements being applicable under title to Exchange-participating
Index of Sec 321. ...CONTRACTS under subsection of section ; Secretary entering into contracts for purpose of performing administrative functions of section 1874a of Social Security Act with respect to public health insurance option in same manner as Secretary entering into
Index of Sec 321. ...HEALTH insurance option and other purposes under subtitle including to improve quality and reducing racial ; Requiring to establish premiums and payment rates for public
Index of Sec 321. ...HEALTH insurance option and individuals enrolled under option under title in same manner as provisions applying to Medicare and Medicare beneficiaries ; Provisions of Medicare relating to access of Medicare beneficiaries to Federal courts for enforcement of rights under Medicare applying to public
Index of Sec 321. ...HEALTH insurance option ; Health benefits provided by public
Index of Sec 322. ...HEALTH insurance option ; Administrative costs related to operating public
Index of Sec 322. ...HEALTH insurance option receiving Federal funds for purposes of insolvency in manner similar to manner in which entities receiving Federal funding under Troubled Asseal Relief Program of Secretary of Treasury ; No case public
Index of Sec 322. ...HEALTH care providers and items and services including prescription drugs ; Secretary negotiating payment for public health insurance option for
Index of Sec 323. ...HEALTH insurance option unless opting out in process established by Secretary consistent with subsection ; Health care providers participating in Medicare participating providers in public
Index of Sec 323. ...HEALTH insurance option ; Providers described in paragraph to be provided 1-year period prior to first day of Y1 to opt out of participating in public
Index of Sec 323. ...HEALTH insurance option ; No provider to be subject to penalty for not participating in public
Index of Sec 323. ...BACK ; Providers participating in Medicare choosing to opt out of participating in public health insurance option opting
Index of Sec 323. ...HEALTH insurance option ; Secretary utilizing innovative payment mechanisms and policies to determine payments for items and services under public
Index of Sec 324. ...HEALTH and value ; Public health insurance option modifying cost-sharing and payment rates to encourage use of services promoting
Index of Sec 324. ...COMPETITIVE disadvantage ; Secretary delaying implementation reform in geographic areas in which implementation placing public health insurance option at
Index of Sec 324. ...GEOGRAPHIC areas ; Nothing in subtitle preventing Secretary from varying payments based on different payment structure models under public health insurance option for different
Index of Sec 324. ...HEALTH insurance option unless provider appropriately licensed, certified or otherwise permitted to practice under State law ; Secretary not allowing health care provider to participate in public
Index of Sec 325. ...HEALTH insurance option under which payment only to be available if provider agreeing to accept payment under section 323 as payment in full ; Secretary providing for participation of health care providers under public
Index of Sec 325. ...HEALTH care program ; Secretary excluding from participation under public health insurance option health care provider excluded from participation in Federal
Index of Sec 325. ...HEALTH insurance coverage offered by health insurance issuer in individual market ; Requirements of sections 2701 through 2792 of Public Health Service Act applying to public health insurance option in same manner as applying to
Index of Sec 327. ...HEALTH insurance option in same manner as part applying to other health plans ; Applying to public
Index of Sec 328. ...HEALTH insurance option ; Nothing in division to be construed as requiring anyone to enroll in public
Index of Sec 329. ...HEALTH insurance option ; Other provision of Act, Members of Congress enrolling in public
Index of Sec 330. ...HEALTH insurance option in manner consistent with recovery of costs related to non-service-connected care from private health insurance plans ; Secretary of Health and Human Services seeking to enter into memorandum of understanding with Secretary of Veterans Affairs regarding recovery of costs related to non-service-connected care or services provided by Secretary of Veterans Affairs to individual covered under public
Index of Sec 331. ...INSURANCE risk to entity ; Secretary having same authority with respect to public health insurance option as Secretary under subsections and section 1874a of Social Security Act with respect to title XVIII of Act contracting under subsection not involving transfer of
Index of Sec 321. ...INTEGRATION ; Nothing in section to be construed as preventing State governments from taking actions to permit
Index of Sec 310. ...COOPERATIVE ; No member having more than 5 percent voting interest in
Index of Sec 305. ...COOPERATIVE ; Governing documents of cooperative incorporating ethical and conflict of interest standards designed to protect against insurance industry involvement and interference in governance of
Index of Sec 310. ...JUSTIFICATION for proposed premiums ; Bids including
Index of Sec 304. ...LICENSURE in every ; Requiring health insurance issuers issuing health insurance coverage in secondary States to maintain
Index of Sec 309. ...LOAN or grant received by cooperative under section ; Repaying total amount of
Index of Sec 310. ...LOAN not to be awarded under subsection with respect to cooperative unless following conditions being met ; Grant or
Index of Sec 310. ...LOANS to cooperatives to assist cooperatives with start up costs ;
Index of Sec 310. ...LOANS for establishment and initial operation ; Establishing Consumer operated and oriented Plan program under which Commissioner making grants and
Index of Sec 310. ...LOANS under subsection ; Appropriating $5,000,000,000 for period of fiscal years 2010 through 2014 to provide for grants and
Index of Sec 310. ...LOANS provided under subsection to Treasury in amortized manner over 10-year period ; Secretary providing for repayment of grants or
Index of Sec 310. ...MEDICAID Screen and enrolling obligation ;
Index of Sec 341. ...AFFORDABILITY credits under subtitle ; Reference to medical assistance or enrollment under State plan deeming reference to provision of
Index of Sec 341. ...MEDICAL costs of enrollees during previous year ; Actual
Index of Sec 306. ...NONREVIEWABLE authority to accept or reject election described in paragraph ; Commissioner having
Index of Sec 346. ...INCOME tier ; Maximum out-of-pocket limit specified in subsection for individual within
Index of Sec 344. ...INCOME tier involved ; Of-pocket limit for Y1 specified in subsection in table under section 343(d) for
Index of Sec 344. ...OF-pocket limit for previous year under subparagraph increased for subsequent year by percentage increase in enrollment-weighted average of premium increases for basic plans applicable to year ; Subsequent year being out-
Index of Sec 344. ...ACTUARIAL value percentage specified in table under section 343(d) for income tier involved ; Commissioner adjusting maximum out-of-pocket limits under paragraph to ensure that limits meeting
Index of Sec 344. ...INCOME for residents in territory ; Affordable credit eligible individuals residing in territory bearing same out-of-pocket responsibility for premiums and cost-sharing in relation to average
Index of Sec 346. ...CREDIT eligible individuals residing in 50 States or District of Columbia in relation to average income for residents ; Of-pocket responsibility for premiums and cost-sharing for affordable
Index of Sec 346. ...INFORMATION as Secretary determining to be necessary ; Commissioner utilizing data regarding enrollee demographics, inpatient and outpatient diagnoses and other
Index of Sec 306. ...HEALTH care providers and items and services including prescription drugs ; Secretary negotiating payment for public health insurance option for
Index of Sec 323. ...PAYMENT to be made for services furnished during year in one of 2 classes ;
Index of Sec 325. ...PAYMENT described in section 323 for physicians ; Secretary reducing
Index of Sec 325. ...PAYMENT in full ; Secretary providing for participation of health care providers under public health insurance option under which payment only to be available if provider agreeing to accept payment under section 323 as
Index of Sec 325. ...PAYMENT for services described in section 222(d)(4)(a) ; Affordability credit not to be used for
Index of Sec 341. ...ACTUARIAL value of benefits under plan provided under section 303(c)(2)(b) resulting from reduction in cost-sharing described in subsections ; Commissioner providing for payment to offering entity of amount equivalent to increased
Index of Sec 344. ...PAYMENT and delivery system reform successful in improving quality and reducing costing ; Secretary finding
Index of Sec 324. ...PAYMENT and delivery system reforms under Act and seeking to implement reforms subjecting to following ; Secretary monitoring and evaluating progress of
Index of Sec 324. ...PAYMENT as result of application of subtitle ; No case affordable credit eligible individual receiving cash
Index of Sec 341. ...PAYMENT ; Exchange-eligible participation status and establishing grace periods for premium
Index of Sec 302. ...PAYMENT for iteming and servicing ; Physicians agreeing not to impose charges exceeding sum of in-network cost-sharing plus 15 percent of total
Index of Sec 325. ...PAYMENTS to operate Health Insurance Exchange ; Amounts as Commissioner determining being necessary to make
Index of Sec 307. ...CAPITATION and direct contracting with providers ; Bundling of services, differential payment rates, performance or utilization based payments, partial
Index of Sec 324. ...GEOGRAPHIC areas ; Nothing in subtitle preventing Secretary from varying payments based on different payment structure models under public health insurance option for different
Index of Sec 324. ...PAYMENTS making under subtitle with respect to residents of territory being consistent with cap established under subsection for territorying and subsection ;
Index of Sec 346. ...PAYMENTS or premiums described in section ; Section 1854(g) of Social Security Act applying to receipts described in previous sentence in same manner as section applying to
Index of Sec 322. ...PAYMENTS making from Trust Fund under subsection plus ; Amount equivalent to amount of
Index of Sec 307. ...AFFORDABILITY credits on behalf of individuals being not lawfully present in United States ; Nothing in subtitle allowing Federal payments for
Index of Sec 347. ...PAYMENTS, accountable care organizations, value-based ; Payment mechanisms and policies under section including patient-centered medical home and other care management
Index of Sec 324. ...HOME and other care management payments, accountable care organizations, value-based ; Payment mechanisms and policies under section including patient-centered medical
Index of Sec 324. ...HEALTH insurance option ; Secretary utilizing innovative payment mechanisms and policies to determine payments for items and services under public
Index of Sec 324. ...PAYMENT methods ; Nothing in subsection to be construed as preventing use of innovative
Index of Sec 323. ...PAYMENT rates being not lower ; Secretary negotiating rates in manner resulting in
Index of Sec 323. ...PAYMENT rates of plan ; Defining in section 2791(b)(3) of Public Health Service Act paragraph not to be construed to require basic plan to contract with provider if provider refusing to accept generally applicable
Index of Sec 304. ...CAPITATION and direct contracting with providers ; Bundling of services, differential payment rates, performance or utilization based payments, partial
Index of Sec 324. ...HEALTH insurance option and other purposes under subtitle including to improve quality and reducing racial ; Requiring to establish premiums and payment rates for public
Index of Sec 321. ...HEALTH and value ; Public health insurance option modifying cost-sharing and payment rates to encourage use of services promoting
Index of Sec 324. ...GEOGRAPHIC areas ; Nothing in subtitle preventing Secretary from varying payments based on different payment structure models under public health insurance option for different
Index of Sec 324. ...HEALTH benefits planing ; Commissioner providing for periodic surveys of Exchange-eligible individuals and employers concerning satisfaction of individuals and employers with Health Insurance Exchange and Exchange-participating
Index of Sec 302. ...HEALTH insurance issuer ; Providing for sale of health insurance coverage to residents of compacting States subjecting to laws and regulations of primary State designated by
Index of Sec 309. ...PRIMARY purpose of providing affordable employee benefits to members ; Consisting solely of members and operated for
Index of Sec 305. ...PRIMARY responsibility to create low-cost plan without compromising quality or access to care ; Secretary's
Index of Sec 321. ...AFFORDABILITY credits ; Commissioner establishing effective methods ensuring that individuals with limited English proficiency being able to apply for
Index of Sec 341. ...PROPERTY ; Nothing in subtitle to be construed as authorizing Secretary to create or maintain lists of non-medical personal
Index of Sec 321. ...AFFORDABILITY Credits ; Application to public entities administering
Index of Sec 341. ...AFFORDABILITY credits under subtitle ; Commissioner through Health Insurance Exchange or another public entity under arrangement making with Commissioner making determination as to eligibility of individual for
Index of Sec 341. ...PUBLIC entity to enter into agreement with Commissioner of Social Security providing same terms as agreement described in paragraph between Health Choices Commissioner and Commissioner of Social Security ; Health Choices Commissioner requiring
Index of Sec 341. ...PUBLIC entity conducting verifications under section 341(b)(4) of Affordable Health Care for America Act and obligations of subsection applying entity in same manner as obligations applying to Health Choices Commissioner when Commissioner conducting verifications ; Subsection applying in case of
Index of Sec 341. ...ACCOUNTING and reconciliation conducted pursuant to subparagraph to be reviewed by Inspectors General of Social Security Administration and Health Choices Administration ; Annual
Index of Sec 341. ...CONFIDENTIALITY of information disclosed for purposes of verifing information described in subparagraph and providing procedures for permitting Health Choices Commissioner to use information for purposes of maintaining records of Health Choices Administration ; Agreement entered into pursuant to subparagraph including safeguards as necessary to ensure maintenance of
Index of Sec 341. ...INFORMATION provided by Commissioner of Social Security to Health Choices Commissioner pursuant to agreement to be provided at time ; Agreement entered into pursuant to subparagraph providing that
Index of Sec 341. ...INFORMATION provided by Commissioner of Social Security to Health Choices Commissioner pursuant to agreement entered into pursuant to subparagraph to be considered as confidential and used only for purposes described in paragraph and carrying out agreement ;
Index of Sec 341. ...AFFORDABILITY credits under section 341(b)(4) of Affordable Health Care for America Act ; Verification of status eligibility pursuant to procedures established under subsection to be deemed verification of status eligibility for purposes of title, title XXI and
Index of Sec 341. ...RACIAL ; Requiring to establish premiums and payment rates for public health insurance option and other purposes under subtitle including to improve quality and reducing
Index of Sec 321. ...ACCOUNT health care providers used by individual involved or other relevant factors as Commissioner specifying ; Process involving random assignment or other form of assignment taking into
Index of Sec 305. ...HEALTH insurance plans ; Secretary of Health and Human Services seeking to enter into memorandum of understanding with Secretary of Veterans Affairs regarding recovery of costs related to non-service-connected care or services provided by Secretary of Veterans Affairs to individual covered under public health insurance option in manner consistent with recovery of costs related to non-service-connected care from private
Index of Sec 331. ...CONSUMER protections of residents and residents retaining right to bring claim in State court in State in which resident residing ; Retaining responsibility for
Index of Sec 309. ...HEALTH and health care ; Including information necessary to administer risk pooling mechanism described in section 306(b) and information to address disparities in
Index of Sec 304. ...RISK pooling mechanism as Commissioner establishing under section 306(b) ; Entity participating in
Index of Sec 304. ...HEALTH benefits planing offered by entities so as to minimizing impact of adverse selection of enrollees among plans offered by entities ; Commissioner establishing mechanism whereby being adjustment making of premium amounting payable among QHBP offering entities offering Exchange-participating health benefits planing of premiums collected for plans taking into account differences in risk characteristics of individuals and employees enrolled under different Exchange-participating
Index of Sec 306. ...CONSUMER protections under subtitle D of title II ; Includ establishment of risk pooling mechanism under section 306 and
Index of Sec 301. ...HEALTH benefits planning of QHBP offering entity ; Clause not applying if Commissioner determining that delay in termination posing imminent and serious risk to health of individuals enrolled under qualified
Index of Sec 304. ...COOPERATIVE offers or issuing insurance coverage ; Grants to cooperatives to assist cooperatives in meeting State solvency requirements in States in which
Index of Sec 310. ...HEALTH benefits planing and file complaints ; Providing for operation of toll-free telephone hotline to respond to requests for assistance and maintaining Internet Web site through individuals obtaining information on coverage under Exchange-participating
Index of Sec 305. ...TITLE ; Commissioner providing for broad dissemination of information on Exchange-participating health benefits planing offered under
Index of Sec 305. ...TITLE in same manner as provisions applying to Medicare and Medicare beneficiaries ; Provisions of Medicare relating to access of Medicare beneficiaries to Federal courts for enforcement of rights under Medicare applying to public health insurance option and individuals enrolled under option under
Index of Sec 321. ...TITLE and titling II ; Treating as State for purposes of applying
Index of Sec 346. ...COERCIVE practices to force providers not to contract with other entities offering coverage through Health Insurance Exchange ; Entity complying with other applicable requirements of title that including standards regarding billing and collection practices for premiums and related grace periods and including standards to ensure that entity not using
Index of Sec 304. ...HEALTH benefits ; Commissioner establishing processing to oversee, monitor and enforce applicable requirements of title with respect to QHBP offering entities offering Exchange-participating
Index of Sec 304. ...TITLE ; Commissioner terminating contract with QHBP offering entity under section for offering of Exchange-participating health benefits planning if entity failing to comply with applicable requirements of
Index of Sec 304. ...AFFORDABILITY credits under section 341(b)(4) of Affordable Health Care for America Act ; Verification of status eligibility pursuant to procedures established under subsection to be deemed verification of status eligibility for purposes of title, title XXI and
Index of Sec 341. ...TITLE and titling II ; Establishing standards necessary to implement requirements of
Index of Sec 304. ...TITLE ; Affordability credits under subtitle not to be treated to be benefit provided under section 403 of
Index of Sec 342. ...TITLE and titling II for purposes of subtitle ; Certifying QHBP offering entities and qualified health benefits planing as meeting standards and requirements of
Index of Sec 304. ...TITLE 10, United States coding ; Nothing in subtitle to be construed as affecting authority under title 38, United States Code or chapter 55 of
Index of Sec 311. ...TITLE 10, United States coding ; Nothing in subtitle to be construed as affecting authority under title 38, United States Code or chapter 55 of
Index of Sec 311. ...TITLE 38 of Code ; Including similar coverage furnished under section 1781 of
Index of Sec 302. ...HEALTH benefits ; Public health insurance option complying with requirements being applicable under title to Exchange-participating
Index of Sec 321. ...ACTUARIAL value of 70 percent of full actuarial value of benefits provided under reference benefiting package ; Basic plan offering essential benefits packaging required under title II for qualified health benefits planning with
Index of Sec 303. ...TITLE II and section ; Commissioner specifying benefits to be made available under Exchange-participating health benefits planing during plan year, consistent with subtitle C of
Index of Sec 303. ...TITLE II ; Consistent with subsection and subtitling C of
Index of Sec 303. ...HEALTH insurance coverage offered in territory ; Requiring to apply requirements of title II with respect to
Index of Sec 346. ...TITLE II not used for purposes of paying for services ; Affordability credits provided under subtitle C of
Index of Sec 303. ...TITLE II ; Includ establishment of risk pooling mechanism under section 306 and consumer protections under subtitle D of
Index of Sec 301. ...TITLE II with respect to entity for violation requirement ; Nothing in subsection to be construed as preventing application of other sanctions under subtitle E of
Index of Sec 304. ...TITLE IV ; Employer meeting requirements of section 412 with respect to employees of employer by offering employees option of enrolling with Exchange-participating health benefits planing through Health Insurance Exchange consistent with provisions of subtitle B of
Index of Sec 302. ...DISCLOSURE of individually identifiable health information ; Part C of title XI of Social Security Act relating to standards for protections against wrongful
Index of Sec 328. ...TITLE XXI of Social Security Act for period during Y1 not to be Exchange-eligible individual during period ; Individual being eligible for child health assistance under
Index of Sec 302. ...TITLE XXI of Social Security Act ; Commissioner establishing rules under which modified adjusted gross income of child deemed to be no greater than family income of child as recently determined before Y1 by State under
Index of Sec 345. ...AFFORDABILITY credits under section 341(b)(4) of Affordable Health Care for America Act ; Verification of status eligibility pursuant to procedures established under subsection to be deemed verification of status eligibility for purposes of title, title XXI and
Index of Sec 341. ...HEALTH benefits planing and file complaints ; Providing for operation of toll-free telephone hotline to respond to requests for assistance and maintaining Internet Web site through individuals obtaining information on coverage under Exchange-participating
Index of Sec 305. ...TRIBAL organization under Indian Self-Determination Act ; Facility operated by Indian Tribe or
Index of Sec 325. ...TRIBAL organization under Indian Self-Determination Act ; Employing to provide health care services in facility operated by Indian Tribe or
Index of Sec 325. ...VERIFICATION under paragraph ; Administrative costs of conducting status
Index of Sec 341. ...VERIFICATIONS ; Subsection applying in case of public entity conducting verifications under section 341(b)(4) of Affordable Health Care for America Act and obligations of subsection applying entity in same manner as obligations applying to Health Choices Commissioner when Commissioner conducting
Index of Sec 341. ...VERIFICATION determination under system ; Developing written notice for user agencies to provide to individuals denying benefit due to determination of ineligibility based on final
Index of Sec 341. ...VERIFICATION procedures ; Information provided by Commissioner of Social Security to be considered as confidential and only used by State and Secretary of Homeland Security for purposes of
Index of Sec 341. ...VERIFICATION procedures described in section 341(b)(4) of Affordable Health Care for America Act ; Purposes of administration of
Index of Sec 341. ...VERIFICATION process under subparagraph to State-based Health Insurance Exchange approved under section 308 ; Case of application of
Index of Sec 341. ...1st Session |
To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.
Mr. Dingell (for himself, Mr. Rangel, Mr. Waxman, Mr. George Miller of California, Mr. Stark, Mr. Pallone, and Mr. Andrews) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Education and Labor, Oversight and Government Reform, and the Budget, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,
(a) Establishment.—There is established within the Health Choices Administration and under the direction of the Commissioner a Health Insurance Exchange in order to facilitate access of individuals and employers, through a transparent process, to a variety of choices of affordable, quality health insurance coverage, including a public health insurance option.
(b) Outline of duties of Commissioner.—In accordance with this subtitle and in coordination with appropriate Federal and State officials as provided under section 243(b), the Commissioner shall—
(1) under section 304 establish standards for, accept bids from, and negotiate and enter into contracts with, QHBP offering entities for the offering of health benefits plans through the Health Insurance Exchange, with different levels of benefits required under section 303, and including with respect to oversight and enforcement;
(2) under section 305 facilitate outreach and enrollment in such plans of Exchange-eligible individuals and employers described in section 302; and
(3) conduct such activities related to the Health Insurance Exchange as required, including establishment of a risk pooling mechanism under section 306 and consumer protections under subtitle D of title II.
(a) Access to coverage.—In accordance with this section, all individuals are eligible to obtain coverage through enrollment in an Exchange-participating health benefits plan offered through the Health Insurance Exchange unless such individuals are enrolled in another qualified health benefits plan or other acceptable coverage.
(b) Definitions.—In this division:
(1) EXCHANGE-ELIGIBLE INDIVIDUAL.—The term “Exchange-eligible individual” means an individual who is eligible under this section to be enrolled through the Health Insurance Exchange in an Exchange-participating health benefits plan and, with respect to family coverage, includes dependents of such individual.
(2) EXCHANGE-ELIGIBLE EMPLOYER.—The term “Exchange-eligible employer” means an employer that is eligible under this section to enroll through the Health Insurance Exchange employees of the employer (and their dependents) in Exchange-eligible health benefits plans.
(3) EMPLOYMENT-RELATED DEFINITIONS.—The terms “employer”, “employee”, “full-time employee”, and “part-time employee” have the meanings given such terms by the Commissioner for purposes of this division.
(c) Transition.—Individuals and employers shall only be eligible to enroll or participate in the Health Insurance Exchange in accordance with the following transition schedule:
(1) FIRST YEAR.—In Y1 (as defined in section 100(c))—
(A) individuals described in subsection (d)(1), including individuals described in subsection (d)(3); and
(B) smallest employers described in subsection (e)(1).
(A) individuals and employers described in paragraph (1); and
(B) smaller employers described in subsection (e)(2).
(3) THIRD AND SUBSEQUENT YEARS.—In Y3—
(A) individuals and employers described in paragraph (2);
(B) small employers described in subsection (e)(3); and
(C) larger employers as permitted by the Commissioner under subsection (e)(4).
(1) INDIVIDUAL DESCRIBED.—Subject to the succeeding provisions of this subsection, an individual described in this paragraph is an individual who—
(A) is not enrolled in coverage described in subparagraph (C) or (D) of paragraph (2); and
(B) is not enrolled in coverage as a full-time employee (or as a dependent of such an employee) under a group health plan if the coverage and an employer contribution under the plan meet the requirements of section 412.
For purposes of subparagraph (B), in the case of an individual who is self-employed, who has at least 1 employee, and who meets the requirements of section 412, such individual shall be deemed a full-time employee described in such subparagraph.
(2) ACCEPTABLE COVERAGE.—For purposes of this division, the term “acceptable coverage” means any of the following:
(A) QUALIFIED HEALTH BENEFITS PLAN COVERAGE.—Coverage under a qualified health benefits plan.
(B) GRANDFATHERED HEALTH INSURANCE COVERAGE; COVERAGE UNDER CURRENT GROUP HEALTH PLAN.—Coverage under a grandfathered health insurance coverage (as defined in subsection (a) of section 202) or under a current group health plan (described in subsection (b) of such section).
(C) MEDICARE.—Coverage under part A of title XVIII of the Social Security Act.
(D) MEDICAID.—Coverage for medical assistance under title XIX of the Social Security Act, excluding such coverage that is only available because of the application of subsection (u), (z), or (aa) of section 1902 of such Act.
(E) MEMBERS OF THE ARMED FORCES AND DEPENDENTS (INCLUDING TRICARE).—Coverage under chapter 55 of title 10, United States Code, including similar coverage furnished under section 1781 of title 38 of such Code.
(F) VA.—Coverage under the veteran’s health care program under chapter 17 of title 38, United States Code.
(G) OTHER COVERAGE.—Such other health benefits coverage, such as a State health benefits risk pool, as the Commissioner, in coordination with the Secretary of the Treasury, recognizes for purposes of this paragraph.
The Commissioner shall make determinations under this paragraph in coordination with the Secretary of the Treasury.
(3) CONTINUING ELIGIBILITY PERMITTED.—
(A) IN GENERAL.—Except as provided in subparagraph (B), once an individual qualifies as an Exchange-eligible individual under this subsection (including as an employee or dependent of an employee of an Exchange-eligible employer) and enrolls under an Exchange-participating health benefits plan through the Health Insurance Exchange, the individual shall continue to be treated as an Exchange-eligible individual until the individual is no longer enrolled with an Exchange-participating health benefits plan.
(i) IN GENERAL.—Subparagraph (A) shall not apply to an individual once the individual becomes eligible for coverage—
(I) under part A of the Medicare program;
(II) under the Medicaid program as a Medicaid-eligible individual, except as permitted under clause (ii); or
(III) in such other circumstances as the Commissioner may provide.
(ii) TRANSITION PERIOD.—In the case described in clause (i)(II), the Commissioner shall permit the individual to continue treatment under subparagraph (A) until such limited time as the Commissioner determines it is administratively feasible, consistent with minimizing disruption in the individual’s access to health care.
(4) TRANSITION FOR CHIP ELIGIBLES.—An individual who is eligible for child health assistance under title XXI of the Social Security Act for a period during Y1 shall not be an Exchange-eligible individual during such period.
(1) SMALLEST EMPLOYER.—Subject to paragraph (5), smallest employers described in this paragraph are employers with 25 or fewer employees.
(2) SMALLER EMPLOYERS.—Subject to paragraph (5), smaller employers described in this paragraph are employers that are not smallest employers described in paragraph (1) and have 50 or fewer employees.
(3) SMALL EMPLOYERS.—Subject to paragraph (5), small employers described in this paragraph are employers that are not described in paragraph (1) or (2) and have 100 or fewer employees.
(A) IN GENERAL.—Beginning with Y3, the Commissioner may permit employers not described in paragraph (1), (2), or (3) to be Exchange-eligible employers.
(B) PHASE-IN.—In applying subparagraph (A), the Commissioner may phase-in the application of such subparagraph based on the number of full-time employees of an employer and such other considerations as the Commissioner deems appropriate.
(5) CONTINUING ELIGIBILITY.—Once an employer is permitted to be an Exchange-eligible employer under this subsection and enrolls employees through the Health Insurance Exchange, the employer shall continue to be treated as an Exchange-eligible employer for each subsequent plan year regardless of the number of employees involved unless and until the employer meets the requirement of section 411(a) through paragraph (1) of such section by offering a group health plan and not through offering an Exchange-participating health benefits plan.
(6) EMPLOYER PARTICIPATION AND CONTRIBUTIONS.—
(A) SATISFACTION OF EMPLOYER RESPONSIBILITY.—For any year in which an employer is an Exchange-eligible employer, such employer may meet the requirements of section 412 with respect to employees of such employer by offering such employees the option of enrolling with Exchange-participating health benefits plans through the Health Insurance Exchange consistent with the provisions of subtitle B of title IV.
(B) EMPLOYEE CHOICE.—Any employee offered Exchange-participating health benefits plans by the employer of such employee under subparagraph (A) may choose coverage under any such plan. That choice includes, with respect to family coverage, coverage of the dependents of such employee.
(7) AFFILIATED GROUPS.—Any employer which is part of a group of employers who are treated as a single employer under subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue Code of 1986 shall be treated, for purposes of this subtitle, as a single employer.
(8) TREATMENT OF MULTI-EMPLOYER PLANS.—The plan sponsor of a group health plan (as defined in section 773(a) of the Employee Retirement Income Security Act of 1974) that is a multi-employer plan (as defined in section 3(37) of such Act) may obtain health insurance coverage with respect to participants in the plan through the Exchange to the same extent that an employer not described in paragraph (1) or (2) is permitted by the Commissioner to obtain health insurance coverage through the Exchange as an Exchange-eligible employer.
(9) OTHER COUNTING RULES.—The Commissioner shall establish rules relating to how employees are counted for purposes of carrying out this subsection.
(f) Special situation authority.—The Commissioner shall have the authority to establish such rules as may be necessary to deal with special situations with regard to uninsured individuals and employers participating as Exchange-eligible individuals and employers, such as transition periods for individuals and employers who gain, or lose, Exchange-eligible participation status, and to establish grace periods for premium payment.
(g) Surveys of individuals and employers.—The Commissioner shall provide for periodic surveys of Exchange-eligible individuals and employers concerning satisfaction of such individuals and employers with the Health Insurance Exchange and Exchange-participating health benefits plans.
(1) IN GENERAL.—The Commissioner shall conduct a study of access to the Health Insurance Exchange for individuals and for employers, including individuals and employers who are not eligible and enrolled in Exchange-participating health benefits plans. The goal of the study is to determine if there are significant groups and types of individuals and employers who are not Exchange-eligible individuals or employers, but who would have improved benefits and affordability if made eligible for coverage in the Exchange.
(2) ITEMS INCLUDED IN STUDY.—Such study also shall examine—
(A) the terms, conditions, and affordability of group health coverage offered by employers and QHBP offering entities outside of the Exchange compared to Exchange-participating health benefits plans; and
(B) the affordability-test standard for access of certain employed individuals to coverage in the Health Insurance Exchange.
(3) REPORT.—Not later than January 1 of Y3, in Y6, and thereafter, the Commissioner shall submit to Congress a report on the study conducted under this subsection and shall include in such report recommendations regarding changes in standards for Exchange eligibility for individuals and employers.
(a) In general.—The Commissioner shall specify the benefits to be made available under Exchange-participating health benefits plans during each plan year, consistent with subtitle C of title II and this section.
(b) Limitation on health benefits plans offered by offering entities.—The Commissioner may not enter into a contract with a QHBP offering entity under section 304(c) for the offering of an Exchange-participating health benefits plan in a service area unless the following requirements are met:
(1) REQUIRED OFFERING OF BASIC PLAN.—The entity offers only one basic plan for such service area.
(2) OPTIONAL OFFERING OF ENHANCED PLAN.—If and only if the entity offers a basic plan for such service area, the entity may offer one enhanced plan for such area.
(3) OPTIONAL OFFERING OF PREMIUM PLAN.—If and only if the entity offers an enhanced plan for such service area, the entity may offer one premium plan for such area.
(4) OPTIONAL OFFERING OF PREMIUM-PLUS PLANS.—If and only if the entity offers a premium plan for such service area, the entity may offer one or more premium-plus plans for such area.
All such plans may be offered under a single contract with the Commissioner.(c) Specification of benefit levels for plans.—
(1) IN GENERAL.—The Commissioner shall establish the following standards consistent with this subsection and title II:
(A) BASIC, ENHANCED, AND PREMIUM PLANS.—Standards for 3 levels of Exchange-participating health benefits plans: basic, enhanced, and premium (in this division referred to as a “basic plan”, “enhanced plan”, and “premium plan”, respectively).
(B) PREMIUM-PLUS PLAN BENEFITS.—Standards for additional benefits that may be offered, consistent with this subsection and subtitle C of title II, under a premium plan (such a plan with additional benefits referred to in this division as a “premium-plus plan”) .
(A) IN GENERAL.—A basic plan shall offer the essential benefits package required under title II for a qualified health benefits plan with an actuarial value of 70 percent of the full actuarial value of the benefits provided under the reference benefits package.
(B) TIERED COST-SHARING FOR AFFORDABLE CREDIT ELIGIBLE INDIVIDUALS.—In the case of an affordable credit eligible individual (as defined in section 342(a)(1)) enrolled in an Exchange-participating health benefits plan, the benefits under a basic plan are modified to provide for the reduced cost-sharing for the income tier applicable to the individual under section 324(c).
(3) ENHANCED PLAN.—An enhanced plan shall offer, in addition to the level of benefits under the basic plan, a lower level of cost-sharing as provided under title II consistent with section 223(b)(5)(A).
(4) PREMIUM PLAN.—A premium plan shall offer, in addition to the level of benefits under the basic plan, a lower level of cost-sharing as provided under title II consistent with section 223(b)(5)(B).
(5) PREMIUM-PLUS PLAN.—A premium-plus plan is a premium plan that also provides additional benefits, such as adult oral health and vision care, approved by the Commissioner. The portion of the premium that is attributable to such additional benefits shall be separately specified.
(6) RANGE OF PERMISSIBLE VARIATION IN COST-SHARING.—The Commissioner shall establish a permissible range of variation of cost-sharing for each basic, enhanced, and premium plan, except with respect to any benefit for which there is no cost-sharing permitted under the essential benefits package. Such variation shall permit a variation of not more than plus (or minus) 10 percent in cost-sharing with respect to each benefit category specified under section 222. Nothing in this subtitle shall be construed as prohibiting tiering in cost-sharing, including through preferred and participating providers and prescription drugs. In applying this paragraph, a health benefits plan may increase the cost-sharing by 10 percent within each category or tier, as applicable, and may decrease or eliminate cost-sharing in any category or tier as compared to the essential benefits package.
(d) Treatment of State benefit mandates.—Insofar as a State requires a health insurance issuer offering health insurance coverage to include benefits beyond the essential benefits package, such requirement shall continue to apply to an Exchange-participating health benefits plan, if the State has entered into an arrangement satisfactory to the Commissioner to reimburse the Commissioner for the amount of any net increase in affordability premium credits under subtitle C as a result of an increase in premium in basic plans as a result of application of such requirement.
(e) Rules regarding coverage of and affordability credits for specified services.—
(1) ASSURED AVAILABILITY OF VARIED COVERAGE THROUGH THE HEALTH INSURANCE EXCHANGE.—The Commissioner shall assure that, of the Exchange participating health benefits plan offered in each premium rating area of the Health Insurance Exchange—
(A) there is at least one such plan that provides coverage of services described in subparagraphs (A) and (B) of section 222(d)(4); and
(B) there is at least one such plan that does not provide coverage of services described in section 222(d)(4)(A) which plan may also be one that does not provide coverage of services described in section 222(d)(4)(B).
(2) SEGREGATION OF FUNDS.—If a qualified health benefits plan provides coverage of services described in section 222(d)(4)(A), the plan shall provide assurances satisfactory to the Commissioner that—
(A) any affordability credits provided under subtitle C of title II are not used for purposes of paying for such services; and
(B) only premium amounts attributable to the actuarial value described in section 213(b) are used for such purpose.
(a) Contracting duties.—In carrying out section 301(b)(1) and consistent with this subtitle:
(1) OFFERING ENTITY AND PLAN STANDARDS.—The Commissioner shall—
(A) establish standards necessary to implement the requirements of this title and title II for—
(i) QHBP offering entities for the offering of an Exchange-participating health benefits plan; and
(ii) Exchange-participating health benefits plans; and
(B) certify QHBP offering entities and qualified health benefits plans as meeting such standards and requirements of this title and title II for purposes of this subtitle.
(2) SOLICITING AND NEGOTIATING BIDS; CONTRACTS.—
(A) BID SOLICITATION.—The Commissioner shall solicit bids from QHBP offering entities for the offering of Exchange-participating health benefits plans. Such bids shall include justification for proposed premiums.
(B) BID REVIEW AND NEGOTIATION.—The Commissioner shall, based upon a review of such bids including the premiums and their affordability, negotiate with such entities for the offering of such plans.
(C) DENIAL OF EXCESSIVE PREMIUMS.—The Commissioner shall deny excessive premiums and premium increases.
(D) CONTRACTS.—The Commissioner shall enter into contracts with such entities for the offering of such plans through the Health Insurance Exchange under terms (consistent with this title) negotiated between the Commissioner and such entities.
(3) FEDERAL ACQUISITION REGULATION.—In carrying out this subtitle, the Commissioner may waive such provisions of the Federal Acquisition Regulation that the Commissioner determines to be inconsistent with the furtherance of this subtitle, other than provisions relating to confidentiality of information. Competitive procedures shall be used in awarding contracts under this subtitle to the extent that such procedures are consistent with this subtitle.
(b) Standards for QHBP offering entities To offer Exchange-Participating health benefits plans.—The standards established under subsection (a)(1)(A) shall require that, in order for a QHBP offering entity to offer an Exchange-participating health benefits plan, the entity must meet the following requirements:
(1) LICENSED.—The entity shall be licensed to offer health insurance coverage under State law for each State in which it is offering such coverage.
(2) DATA REPORTING.—The entity shall provide for the reporting of such information as the Commissioner may specify, including information necessary to administer the risk pooling mechanism described in section 306(b) and information to address disparities in health and health care.
(3) AFFORDABILITY.—The entity shall provide for affordable premiums.
(4) IMPLEMENTING AFFORDABILITY CREDITS.—The entity shall provide for implementation of the affordability credits provided for enrollees under subtitle C, including the reduction in cost-sharing under section 344(c).
(5) ENROLLMENT.—The entity shall accept all enrollments under this subtitle, subject to such exceptions (such as capacity limitations) in accordance with the requirements under title II for a qualified health benefits plan. The entity shall notify the Commissioner if the entity projects or anticipates reaching such a capacity limitation that would result in a limitation in enrollment.
(6) RISK POOLING PARTICIPATION.—The entity shall participate in such risk pooling mechanism as the Commissioner establishes under section 306(b).
(7) ESSENTIAL COMMUNITY PROVIDERS.—With respect to the basic plan offered by the entity, the entity shall include within the plan network those essential community providers, where available, that serve predominantly low-income, medically-underserved individuals, such as health care providers defined in section 340B(a)(4) of the Public Health Service Act and providers described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act (as amended by section 221 of Public Law 111–8). The Commissioner shall specify the extent to which and manner in which the previous sentence shall apply in the case of a basic plan with respect to which the Commissioner determines provides substantially all benefits through a health maintenance organization, as defined in section 2791(b)(3) of the Public Health Service Act. This paragraph shall not be construed to require a basic plan to contract with a provider if such provider refuses to accept the generally applicable payment rates of such plan.
(8) CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES AND COMMUNICATIONS.—The entity shall provide for culturally and linguistically appropriate communication and health services.
(9) SPECIAL RULES WITH RESPECT TO INDIAN ENROLLEES AND INDIAN HEALTH CARE PROVIDERS.—
(A) CHOICE OF PROVIDERS.—The entity shall—
(i) demonstrate to the satisfaction of the Commissioner that it has contracted with a sufficient number of Indian health care providers to ensure timely access to covered services furnished by such providers to individual Indians through the entity’s Exchange-participating health benefits plan; and
(ii) agree to pay Indian health care providers, whether such providers are participating or nonparticipating providers with respect to the entity, for covered services provided to those enrollees who are eligible to receive services from such providers at a rate that is not less than the level and amount of payment which the entity would make for the services of a participating provider which is not an Indian health care provider.
(B) SPECIAL RULE RELATING TO INDIAN HEALTH CARE PROVIDERS.—Provision of services by an Indian health care provider exclusively to Indians and their dependents shall not constitute discrimination under this Act.
(10) PROGRAM INTEGRITY STANDARDS.—The entity shall establish and operate a program to protect and promote the integrity of Exchange-participating health benefits plans it offers, in accordance with standards and functions established by the Commissioner.
(11) ADDITIONAL REQUIREMENTS.—The entity shall comply with other applicable requirements of this title, as specified by the Commissioner, which shall include standards regarding billing and collection practices for premiums and related grace periods and which may include standards to ensure that the entity does not use coercive practices to force providers not to contract with other entities offering coverage through the Health Insurance Exchange.
(1) BID APPLICATION.—To be eligible to enter into a contract under this section, a QHBP offering entity shall submit to the Commissioner a bid at such time, in such manner, and containing such information as the Commissioner may require.
(2) TERM.—Each contract with a QHBP offering entity under this section shall be for a term of not less than one year, but may be made automatically renewable from term to term in the absence of notice of termination by either party.
(3) ENFORCEMENT OF NETWORK ADEQUACY.—In the case of a health benefits plan of a QHBP offering entity that uses a provider network, the contract under this section with the entity shall provide that if—
(A) the Commissioner determines that such provider network does not meet such standards as the Commissioner shall establish under section 215; and
(B) an individual enrolled in such plan receives an item or service from a provider that is not within such network;
then any cost-sharing for such item or service shall be equal to the amount of such cost-sharing that would be imposed if such item or service was furnished by a provider within such network.
(4) OVERSIGHT AND ENFORCEMENT RESPONSIBILITIES.—The Commissioner shall establish processes, in coordination with State insurance regulators, to oversee, monitor, and enforce applicable requirements of this title with respect to QHBP offering entities offering Exchange-participating health benefits plans, including the marketing of such plans. Such processes shall include the following:
(A) GRIEVANCE AND COMPLAINT MECHANISMS.—The Commissioner shall establish, in coordination with State insurance regulators, a process under which Exchange-eligible individuals and employers may file complaints concerning violations of such standards.
(B) ENFORCEMENT.—In carrying out authorities under this division relating to the Health Insurance Exchange, the Commissioner may impose one or more of the intermediate sanctions described in section 242(d).
(i) IN GENERAL.—The Commissioner may terminate a contract with a QHBP offering entity under this section for the offering of an Exchange-participating health benefits plan if such entity fails to comply with the applicable requirements of this title. Any determination by the Commissioner to terminate a contract shall be made in accordance with formal investigation and compliance procedures established by the Commissioner under which—
(I) the Commissioner provides the entity with the reasonable opportunity to develop and implement a corrective action plan to correct the deficiencies that were the basis of the Commissioner’s determination; and
(II) the Commissioner provides the entity with reasonable notice and opportunity for hearing (including the right to appeal an initial decision) before terminating the contract.
(ii) EXCEPTION FOR IMMINENT AND SERIOUS RISK TO HEALTH.—Clause (i) shall not apply if the Commissioner determines that a delay in termination, resulting from compliance with the procedures specified in such clause prior to termination, would pose an imminent and serious risk to the health of individuals enrolled under the qualified health benefits plan of the QHBP offering entity.
(D) CONSTRUCTION.—Nothing in this subsection shall be construed as preventing the application of other sanctions under subtitle E of title II with respect to an entity for a violation of such a requirement.
(5) SPECIAL RULE RELATED TO COST-SHARING AND INDIAN HEALTH CARE PROVIDERS.—The contract under this section with a QHBP offering entity for a health benefits plan shall provide that if an individual who is an Indian is enrolled in such a plan and such individual receives a covered item or service from an Indian health care provider (regardless of whether such provider is in the plan’s provider network), the cost-sharing for such item or service shall be equal to the amount of cost-sharing that would be imposed if such item or service—
(A) had been furnished by another provider in the plan’s provider network; or
(B) in the case that the plan has no such network, was furnished by a non-Indian provider.
(6) NATIONAL PLAN.—Nothing in this section shall be construed as preventing the Commissioner from entering into a contract under this subsection with a QHBP offering entity for the offering of a health benefits plan with the same benefits in every State so long as such entity is licensed to offer such plan in each State and the benefits meet the applicable requirements in each such State.
(d) No discrimination on the basis of provision of abortion.—No Exchange participating health benefits plan may discriminate against any individual health care provider or health care facility because of its willingness or unwillingness to provide, pay for, provide coverage of, or refer for abortions.
(1) OUTREACH.—The Commissioner shall conduct outreach activities consistent with subsection (c), including through use of appropriate entities as described in paragraph (3) of such subsection, to inform and educate individuals and employers about the Health Insurance Exchange and Exchange-participating health benefits plan options. Such outreach shall include outreach specific to vulnerable populations, such as children, individuals with disabilities, individuals with mental illness, and individuals with other cognitive impairments.
(2) ELIGIBILITY.—The Commissioner shall make timely determinations of whether individuals and employers are Exchange-eligible individuals and employers (as defined in section 302).
(3) ENROLLMENT.—The Commissioner shall establish and carry out an enrollment process for Exchange-eligible individuals and employers, including at community locations, in accordance with subsection (b).
(1) IN GENERAL.—The Commissioner shall establish a process consistent with this title for enrollments in Exchange-participating health benefits plans. Such process shall provide for enrollment through means such as the mail, by telephone, electronically, and in person.
(A) OPEN ENROLLMENT PERIOD.—The Commissioner shall establish an annual open enrollment period during which an Exchange-eligible individual or employer may elect to enroll in an Exchange-participating health benefits plan for the following plan year and an enrollment period for affordability credits under subtitle C. Such periods shall be during September through November of each year, or such other time that would maximize timeliness of income verification for purposes of such subtitle. The open enrollment period shall not be less than 30 days.
(B) SPECIAL ENROLLMENT.—The Commissioner shall also provide for special enrollment periods to take into account special circumstances of individuals and employers, such as an individual who—
(i) loses acceptable coverage;
(ii) experiences a change in marital or other dependent status;
(iii) moves outside the service area of the Exchange-participating health benefits plan in which the individual is enrolled; or
(iv) experiences a significant change in income.
(C) ENROLLMENT INFORMATION.—The Commissioner shall provide for the broad dissemination of information to prospective enrollees on the enrollment process, including before each open enrollment period. In carrying out the previous sentence, the Commissioner may work with other appropriate entities to facilitate such provision of information.
(3) AUTOMATIC ENROLLMENT FOR NON-MEDICAID ELIGIBLE INDIVIDUALS.—
(A) IN GENERAL.—The Commissioner shall provide for a process under which individuals who are Exchange-eligible individuals described in subparagraph (B) are automatically enrolled under an appropriate Exchange-participating health benefits plan. Such process may involve a random assignment or some other form of assignment that takes into account the health care providers used by the individual involved or such other relevant factors as the Commissioner may specify.
(B) SUBSIDIZED INDIVIDUALS DESCRIBED.—An individual described in this subparagraph is an Exchange-eligible individual who is either of the following:
(i) AFFORDABILITY CREDIT ELIGIBLE INDIVIDUALS.—The individual—
(I) has applied for, and been determined eligible for, affordability credits under subtitle C;
(II) has not opted out from receiving such affordability credit; and
(III) does not otherwise enroll in another Exchange-participating health benefits plan.
(ii) INDIVIDUALS ENROLLED IN A TERMINATED PLAN.—The individual who is enrolled in an Exchange-participating health benefits plan that is terminated (during or at the end of a plan year) and who does not otherwise enroll in another Exchange-participating health benefits plan.
(4) DIRECT PAYMENT OF PREMIUMS TO PLANS.—Under the enrollment process, individuals enrolled in an Exchange-participating health benefits plan shall pay such plans directly, and not through the Commissioner or the Health Insurance Exchange.
(c) Coverage information and assistance.—
(1) COVERAGE INFORMATION.—The Commissioner shall provide for the broad dissemination of information on Exchange-participating health benefits plans offered under this title. Such information shall be provided in a comparative manner, and shall include information on benefits, premiums, cost-sharing, quality, provider networks, and consumer satisfaction.
(2) CONSUMER ASSISTANCE WITH CHOICE.—To provide assistance to Exchange-eligible individuals and employers, the Commissioner shall—
(A) provide for the operation of a toll-free telephone hotline to respond to requests for assistance and maintain an Internet Web site through which individuals may obtain information on coverage under Exchange-participating health benefits plans and file complaints;
(B) develop and disseminate information to Exchange-eligible enrollees on their rights and responsibilities;
(C) assist Exchange-eligible individuals in selecting Exchange-participating health benefits plans and obtaining benefits through such plans; and
(D) ensure that the Internet Web site described in subparagraph (A) and the information described in subparagraph (B) is developed using plain language (as defined in section 233(a)(2)).
(3) USE OF OTHER ENTITIES.—In carrying out this subsection, the Commissioner may work with other appropriate entities to facilitate the dissemination of information under this subsection and to provide assistance as described in paragraph (2).
(d) Coverage for certain newborns under Medicaid.—
(1) IN GENERAL.—In the case of a child born in the United States who at the time of birth is not otherwise covered under acceptable coverage, for the period of time beginning on the date of birth and ending on the date the child otherwise is covered under acceptable coverage (or, if earlier, the end of the month in which the 60-day period, beginning on the date of birth, ends), the child shall be deemed—
(A) to be a Medicaid eligible individual for purposes of this division and Medicaid; and
(B) to be automatically enrolled in Medicaid as a traditional Medicaid eligible individual (as defined in section 1943(c) of the Social Security Act).
(2) EXTENDED TREATMENT AS MEDICAID ELIGIBLE INDIVIDUAL.—In the case of a child described in paragraph (1) who at the end of the period referred to in such paragraph is not otherwise covered under acceptable coverage, the child shall be deemed (until such time as the child obtains such coverage or the State otherwise makes a determination of the child’s eligibility for medical assistance under its Medicaid plan pursuant to section 1943(b)(1) of the Social Security Act) to be a Medicaid eligible individual described in section 1902(l)(1)(B) of such Act.
(e) Medicaid coverage for Medicaid eligible individuals.—
(1) MEDICAID ENROLLMENT OBLIGATION.—An individual may apply, in the manner described in section 341(b)(1), for a determination of whether the individual is a Medicaid-eligible individual. If the individual is determined to be so eligible, the Commissioner, through the Medicaid memorandum of understanding under paragraph (2), shall provide for the enrollment of the individual under the State Medicaid plan in accordance with such memorandum of understanding. In the case of such an enrollment, the State shall provide for the same periodic redetermination of eligibility under Medicaid as would otherwise apply if the individual had directly applied for medical assistance to the State Medicaid agency.
(2) COORDINATED ENROLLMENT WITH STATE THROUGH MEMORANDUM OF UNDERSTANDING.—The Commissioner, in consultation with the Secretary of Health and Human Services, shall enter into a memorandum of understanding with each State with respect to coordinating enrollment of individuals in Exchange-participating health benefits plans and under the State’s Medicaid program consistent with this section and to otherwise coordinate the implementation of the provisions of this division with respect to the Medicaid program. Such memorandum shall permit the exchange of information consistent with the limitations described in section 1902(a)(7) of the Social Security Act. Nothing in this section shall be construed as permitting such memorandum to modify or vitiate any requirement of a State Medicaid plan.
(f) Effective culturally and linguistically appropriate communication.—In carrying out this section, the Commissioner shall establish effective methods for communicating in plain language and a culturally and linguistically appropriate manner.
(g) Role for enrollment agents and brokers.—Nothing in this division shall be construed to affect the role of enrollment agents and brokers under State law, including with regard to the enrollment of individuals and employers in qualified health benefits plans including the public health insurance option.
(h) Assistance for small employers.—
(1) IN GENERAL.—The Commissioner, in consultation with the Small Business Administration, shall establish and carry out a program to provide to small employers counseling and technical assistance with respect to the provision of health insurance to employees of such employers through the Health Insurance Exchange.
(2) DUTIES.—The program established under paragraph (1) shall include the following services:
(A) Educational activities to increase awareness of the Health Insurance Exchange and available small employer health plan options.
(B) Distribution of information to small employers with respect to the enrollment and selection process for health plans available under the Health Insurance Exchange, including standardized comparative information on the health plans available under the Health Insurance Exchange.
(C) Distribution of information to small employers with respect to available affordability credits or other financial assistance.
(D) Referrals to appropriate entities of complaints and questions relating to the Health Insurance Exchange.
(E) Enrollment and plan selection assistance for employers with respect to the Health Insurance Exchange.
(F) Responses to questions relating to the Health Insurance Exchange and the program established under paragraph (1).
(3) AUTHORITY TO PROVIDE SERVICES DIRECTLY OR BY CONTRACT.—The Commissioner may provide services under paragraph (2) directly or by contract with nonprofit entities that the Commissioner determines capable of carrying out such services.
(4) SMALL EMPLOYER DEFINED.—In this subsection, the term “small employer” means an employer with less than 100 employees.
(i) Participation of small employer benefit arrangements.—
(1) IN GENERAL.—The Commissioner may enter into contracts with small employer benefit arrangements to provide consumer information, outreach, and assistance in the enrollment of small employers (and their employees) who are members of such an arrangement under Exchange participating health benefits plans.
(2) SMALL EMPLOYER BENEFIT ARRANGEMENT DEFINED.—In this subsection, the term “small employer benefit arrangement” means a not-for-profit agricultural or other cooperative that—
(A) consists solely of its members and is operated for the primary purpose of providing affordable employee benefits to its members;
(B) only has as members small employers in the same industry or line of business;
(C) has no member that has more than a 5 percent voting interest in the cooperative; and
(D) is governed by a board of directors elected by its members.
(a) Coordination of affordability credits.—The Commissioner shall coordinate the distribution of affordability premium and cost-sharing credits under subtitle C to QHBP offering entities offering Exchange-participating health benefits plans.
(b) Coordination of risk pooling.—The Commissioner shall establish a mechanism whereby there is an adjustment made of the premium amounts payable among QHBP offering entities offering Exchange-participating health benefits plans of premiums collected for such plans that takes into account (in a manner specified by the Commissioner) the differences in the risk characteristics of individuals and employees enrolled under the different Exchange-participating health benefits plans offered by such entities so as to minimize the impact of adverse selection of enrollees among the plans offered by such entities. For purposes of the previous sentence, the Commissioner may utilize data regarding enrollee demographics, inpatient and outpatient diagnoses (in a similar manner as such data are used under parts C and D of title XVIII of the Social Security Act), and such other information as the Secretary determines may be necessary, such as the actual medical costs of enrollees during the previous year.
(a) Establishment of Health Insurance Exchange Trust Fund.—There is created within the Treasury of the United States a trust fund to be known as the “Health Insurance Exchange Trust Fund” (in this section referred to as the “Trust Fund”), consisting of such amounts as may be appropriated or credited to the Trust Fund under this section or any other provision of law.
(b) Payments from Trust Fund.—The Commissioner shall pay from time to time from the Trust Fund such amounts as the Commissioner determines are necessary to make payments to operate the Health Insurance Exchange, including payments under subtitle C (relating to affordability credits).
(1) DEDICATED PAYMENTS.—There are hereby appropriated to the Trust Fund amounts equivalent to the following:
(A) TAXES ON INDIVIDUALS NOT OBTAINING ACCEPTABLE COVERAGE.—The amounts received in the Treasury under section 59B of the Internal Revenue Code of 1986 (relating to requirement of health insurance coverage for individuals).
(B) EMPLOYMENT TAXES ON EMPLOYERS NOT PROVIDING ACCEPTABLE COVERAGE.—The amounts received in the Treasury under sections 3111(c) and 3221(c) of the Internal Revenue Code of 1986 (relating to employers electing to not provide health benefits).
(C) EXCISE TAX ON FAILURES TO MEET CERTAIN HEALTH COVERAGE REQUIREMENTS.—The amounts received in the Treasury under section 4980H(b) (relating to excise tax with respect to failure to meet health coverage participation requirements).
(2) APPROPRIATIONS TO COVER GOVERNMENT CONTRIBUTIONS.—There are hereby appropriated, out of any moneys in the Treasury not otherwise appropriated, to the Trust Fund, an amount equivalent to the amount of payments made from the Trust Fund under subsection (b) plus such amounts as are necessary reduced by the amounts deposited under paragraph (1).
(d) Application of certain rules.—Rules similar to the rules of subchapter B of chapter 98 of the Internal Revenue Code of 1986 shall apply with respect to the Trust Fund.
(1) a State (or group of States, subject to the approval of the Commissioner) applies to the Commissioner for approval of a State-based Health Insurance Exchange to operate in the State (or group of States); and
(2) the Commissioner approves such State-based Health Insurance Exchange,
then, subject to subsections (c) and (d), the State-based Health Insurance Exchange shall operate, instead of the Health Insurance Exchange, with respect to such State (or group of States). The Commissioner shall approve a State-based Health Insurance Exchange if it meets the requirements for approval under subsection (b).(b) Requirements for approval.—
(1) IN GENERAL.—The Commissioner may not approve a State-based Health Insurance Exchange under this section unless the following requirements are met:
(A) The State-based Health Insurance Exchange must demonstrate the capacity to and provide assurances satisfactory to the Commissioner that the State-based Health Insurance Exchange will carry out the functions specified for the Health Insurance Exchange in the State (or States) involved, including—
(i) negotiating and contracting with QHBP offering entities for the offering of Exchange-participating health benefits plans, which satisfy the standards and requirements of this title and title II;
(ii) enrolling Exchange-eligible individuals and employers in such State in such plans;
(iii) the establishment of sufficient local offices to meet the needs of Exchange-eligible individuals and employers;
(iv) administering affordability credits under subtitle B using the same methodologies (and at least the same income verification methods) as would otherwise apply under such subtitle and at a cost to the Federal Government which does exceed the cost to the Federal Government if this section did not apply; and
(v) enforcement activities consistent with Federal requirements.
(B) There is no more than one Health Insurance Exchange operating with respect to any one State.
(C) The State provides assurances satisfactory to the Commissioner that approval of such an Exchange will not result in any net increase in expenditures to the Federal Government.
(D) The State provides for reporting of such information as the Commissioner determines and assurances satisfactory to the Commissioner that it will vigorously enforce violations of applicable requirements.
(E) Such other requirements as the Commissioner may specify.
(2) PRESUMPTION FOR CERTAIN STATE-OPERATED EXCHANGES.—
(A) IN GENERAL.—In the case of a State operating an Exchange prior to January 1, 2010, that seeks to operate the State-based Health Insurance Exchange under this section, the Commissioner shall presume that such Exchange meets the standards under this section unless the Commissioner determines, after completion of the process established under subparagraph (B), that the Exchange does not comply with such standards.
(B) PROCESS.—The Commissioner shall establish a process to work with a State described in subparagraph (A) to provide assistance necessary to assure that the State’s Exchange comes into compliance with the standards for approval under this section.
(1) IN GENERAL.—A State-based Health Insurance Exchange may, at the option of each State involved, and only after providing timely and reasonable notice to the Commissioner, cease operation as such an Exchange, in which case the Health Insurance Exchange shall operate, instead of such State-based Health Insurance Exchange, with respect to such State (or States).
(2) TERMINATION; HEALTH INSURANCE EXCHANGE RESUMPTION OF FUNCTIONS.—The Commissioner may terminate the approval (for some or all functions) of a State-based Health Insurance Exchange under this section if the Commissioner determines that such Exchange no longer meets the requirements of subsection (b) or is no longer capable of carrying out such functions in accordance with the requirements of this subtitle. In lieu of terminating such approval, the Commissioner may temporarily assume some or all functions of the State-based Health Insurance Exchange until such time as the Commissioner determines the State-based Health Insurance Exchange meets such requirements of subsection (b) and is capable of carrying out such functions in accordance with the requirements of this subtitle.
(3) EFFECTIVENESS.—The ceasing or termination of a State-based Health Insurance Exchange under this subsection shall be effective in such time and manner as the Commissioner shall specify.
(1) AUTHORITY RETAINED.—Enforcement authorities of the Commissioner shall be retained by the Commissioner.
(2) DISCRETION TO RETAIN ADDITIONAL AUTHORITY.—The Commissioner may specify functions of the Health Insurance Exchange that—
(A) may not be performed by a State-based Health Insurance Exchange under this section; or
(B) may be performed by the Commissioner and by such a State-based Health Insurance Exchange.
(e) References.—In the case of a State-based Health Insurance Exchange, except as the Commissioner may otherwise specify under subsection (d), any references in this subtitle to the Health Insurance Exchange or to the Commissioner in the area in which the State-based Health Insurance Exchange operates shall be deemed a reference to the State-based Health Insurance Exchange and the head of such Exchange, respectively.
(f) Funding.—In the case of a State-based Health Insurance Exchange, there shall be assistance provided for the operation of such Exchange in the form of a matching grant with a State share of expenditures required.
(a) In general.—Effective January 1, 2015, 2 or more States may form Health Care Choice Compacts (in this section referred to as “compacts”) to facilitate the purchase of individual health insurance coverage across State lines.
(b) Model guidelines.—The Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall request the National Association of Insurance Commissioners (in this section referred to as “NAIC”) to develop model guidelines for the creation of compacts. In developing such guidelines, the NAIC shall consult with consumers, health insurance issuers, the Secretary, and other interested parties. Such guidelines shall—
(1) provide for the sale of health insurance coverage to residents of all compacting States subject to the laws and regulations of a primary State designated by the health insurance issuer;
(2) require health insurance issuers issuing health insurance coverage in secondary States to maintain licensure in every such State;
(3) preserve the authority of the State of an individual’s residence to address—
(A) market conduct;
(B) unfair trade practices;
(C) network adequacy;
(D) consumer protection standards;
(E) grievance and appeals;
(F) fair claims payment requirements; and
(G) prompt payment of claims;
(4) permit State insurance commissioners and other State agencies in secondary States access to the records of a health insurance issuer to the same extent as if the policy were written in that State; and
(5) provide for clear and conspicuous disclosure to consumers that the policy may not be subject to all the laws and regulations of the State in which the purchaser resides.
(c) Required consideration.—If model guidelines developed under subsection (b) are submitted to the Secretary by January 1, 2013, the Secretary shall issue them as regulations. If the NAIC fails to submit such model guidelines by such date, the Secretary shall, no later than October 1, 2013, develop and promulgate the regulations implementing model guidelines described in subsection (b).
(d) No requirement to compact.—Nothing in this section shall be construed to require a State to join a compact.
(e) State authority.—A State may not enter into a compact under this subsection unless the State enacts a law after the date of enactment of this Act that specifically authorizes the State to enter into such compact.
(f) Consumer protections.—If a State enters into a compact it must retain responsibility for the consumer protections of its residents and its residents retain the right to bring a claim in a State court in the State in which the resident resides.
(g) Assistance to compacting states.—
(1) IN GENERAL.—Beginning January 1, 2015, the Secretary shall make awards, from amounts appropriated under paragraph (5), to States in the amount specified in paragraph (2) for the uses described in paragraph (3).
(A) IN GENERAL.—For each fiscal year, the Secretary shall determine the total amount that the Secretary will make available for grants under this subsection.
(B) STATE AMOUNT.—For each State that is awarded a grant under paragraph (1), the amount of such grants shall be based on a formula established by the Secretary, not to exceed $1 million per State, under which States shall receive an award in the amount that is based on the following two components:
(i) A minimum amount for each State.
(ii) An additional amount based on population of the State.
(3) USE OF FUNDS.—A State shall use amounts awarded under this subsection for activities (including planning activities) related regulating health insurance coverage sold in secondary States.
(4) RENEWABILITY OF GRANT.—The Secretary may renew a grant award under paragraph (1) if the State receiving the grant continues to be a member of a compact.
(5) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated such sums as may be necessary to carry out this subsection in each of fiscal years 2015 through 2020.
(a) Establishment.—Not later than 6 months after the date of the enactment of this Act, the Commissioner, in consultation with the Secretary of the Treasury, shall establish a Consumer Operated and Oriented Plan program (in this section referred to as the “CO–OP program”) under which the Commissioner may make grants and loans for the establishment and initial operation of not-for-profit, member–run health insurance cooperatives (in this section individually referred to as a “cooperative”) that provide insurance through the Health Insurance Exchange or a State-based Health Insurance Exchange under section 308. Nothing in this section shall be construed as requiring a State to establish such a cooperative.
(b) Start-up and solvency grants and loans.—
(1) IN GENERAL.—Not later than 36 months after the date of the enactment of this Act, the Commissioner, acting through the CO–OP program, may make—
(A) loans (of such period and with such terms as the Secretary may specify) to cooperatives to assist such cooperatives with start-up costs; and
(B) grants to cooperatives to assist such cooperatives in meeting State solvency requirements in the States in which such cooperative offers or issues insurance coverage.
(2) CONDITIONS.—A grant or loan may not be awarded under this subsection with respect to a cooperative unless the following conditions are met:
(A) The cooperative is structured as a not-for-profit, member organization under the law of each State in which such cooperative offers, intends to offer, or issues insurance coverage, with the membership of the cooperative being made up entirely of beneficiaries of the insurance coverage offered by such cooperative.
(B) The cooperative did not offer insurance on or before July 16, 2009, and the cooperative is not an affiliate or successor to an insurance company offering insurance on or before such date.
(C) The governing documents of the cooperative incorporate ethical and conflict of interest standards designed to protect against insurance industry involvement and interference in the governance of the cooperative.
(D) The cooperative is not sponsored by a State government.
(E) Substantially all of the activities of the cooperative consist of the issuance of qualified health benefits plans through the Health Insurance Exchange or a State-based health insurance exchange.
(F) The cooperative is licensed to offer insurance in each State in which it offers insurance.
(G) The governance of the cooperative must be subject to a majority vote of its members.
(H) As provided in guidance issued by the Secretary of Health and Human Services, the cooperative operates with a strong consumer focus, including timeliness, responsiveness, and accountability to members.
(I) Any profits made by the cooperative are used to lower premiums, improve benefits, or to otherwise improve the quality of health care delivered to members.
(3) PRIORITY.—The Commissioner, in making grants and loans under this subsection, shall give priority to cooperatives that—
(A) operate on a statewide basis;
(B) use an integrated delivery system; or
(C) have a significant level of financial support from nongovernmental sources.
(4) RULES OF CONSTRUCTION.—Nothing in this section shall be construed to prevent a cooperative established in one State from integrating with a cooperative established in another State the administration, issuance of coverage, or other activities related to acting as a QHBP offering entity. Nothing in this section shall be construed as preventing State governments from taking actions to permit such integration.
(5) AMORTIZATION OF GRANTS AND LOANS.—The Secretary shall provide for the repayment of grants or loans provided under this subsection to the Treasury in an amortized manner over a 10-year period.
(6) REPAYMENT FOR VIOLATIONS OF TERMS OF PROGRAM.—If a cooperative violates the terms of the CO–OP program and fails to correct the violation within a reasonable period of time, as determined by the Commissioner, the cooperative shall repay the total amount of any loan or grant received by such cooperative under this section, plus interest (at a rate determined by the Secretary).
(7) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to be appropriated $5,000,000,000 for the period of fiscal years 2010 through 2014 to provide for grants and loans under this subsection.
(c) Definitions.—For purposes of this section:
(1) STATE.—The term “State” means each of the 50 States and the District of Columbia.
(2) MEMBER.—The term “member”, with respect to a cooperative, means an individual who, after the cooperative offers health insurance coverage, is enrolled in such coverage.
Nothing in this subtitle shall be construed as affecting any authority under title 38, United States Code, or chapter 55 of title 10, United States Code.
(a) Establishment.—For years beginning with Y1, the Secretary of Health and Human Services (in this subtitle referred to as the “Secretary”) shall provide for the offering of an Exchange-participating health benefits plan (in this division referred to as the “public health insurance option”) that ensures choice, competition, and stability of affordable, high quality coverage throughout the United States in accordance with this subtitle. In designing the option, the Secretary’s primary responsibility is to create a low-cost plan without compromising quality or access to care.
(b) Offering as an Exchange-participating health benefits plan.—
(1) EXCLUSIVE TO THE EXCHANGE.—The public health insurance option shall only be made available through the Health Insurance Exchange.
(2) ENSURING A LEVEL PLAYING FIELD.—Consistent with this subtitle, the public health insurance option shall comply with requirements that are applicable under this title to an Exchange-participating health benefits plan, including requirements related to benefits, benefit levels, provider networks, notices, consumer protections, and cost-sharing.
(3) PROVISION OF BENEFIT LEVELS.—The public health insurance option—
(A) shall offer basic, enhanced, and premium plans; and
(B) may offer premium-plus plans.
(c) Administrative contracting.—The Secretary may enter into contracts for the purpose of performing administrative functions (including functions described in subsection (a)(4) of section 1874A of the Social Security Act) with respect to the public health insurance option in the same manner as the Secretary may enter into contracts under subsection (a)(1) of such section. The Secretary has the same authority with respect to the public health insurance option as the Secretary has under subsections (a)(1) and (b) of section 1874A of the Social Security Act with respect to title XVIII of such Act. Contracts under this subsection shall not involve the transfer of insurance risk to such entity.
(d) Ombudsman.—The Secretary shall establish an office of the ombudsman for the public health insurance option which shall have duties with respect to the public health insurance option similar to the duties of the Medicare Beneficiary Ombudsman under section 1808(c)(2) of the Social Security Act.
(e) Data collection.—The Secretary shall collect such data as may be required to establish premiums and payment rates for the public health insurance option and for other purposes under this subtitle, including to improve quality and to reduce racial, ethnic, and other disparities in health and health care. Nothing in this subtitle may be construed as authorizing the Secretary (or any employee or contractor) to create or maintain lists of non-medical personal property.
(f) Treatment of public health insurance option.—With respect to the public health insurance option, the Secretary shall be treated as a QHBP offering entity offering an Exchange-participating health benefits plan.
(g) Access to Federal courts.—The provisions of Medicare (and related provisions of title II of the Social Security Act) relating to access of Medicare beneficiaries to Federal courts for the enforcement of rights under Medicare, including with respect to amounts in controversy, shall apply to the public health insurance option and individuals enrolled under such option under this title in the same manner as such provisions apply to Medicare and Medicare beneficiaries.
(a) Establishment of premiums.—
(1) IN GENERAL.—The Secretary shall establish geographically adjusted premium rates for the public health insurance option—
(A) in a manner that complies with the premium rules established by the Commissioner under section 213 for Exchange-participating health benefits plans; and
(B) at a level sufficient to fully finance the costs of—
(i) health benefits provided by the public health insurance option; and
(ii) administrative costs related to operating the public health insurance option.
(2) CONTINGENCY MARGIN.—In establishing premium rates under paragraph (1), the Secretary shall include an appropriate amount for a contingency margin (which shall be not less than 90 days of estimated claims). Before setting such appropriate amount for years starting with Y3, the Secretary shall solicit a recommendation on such amount from the American Academy of Actuaries.
(1) ESTABLISHMENT.—There is established in the Treasury of the United States an Account for the receipts and disbursements attributable to the operation of the public health insurance option, including the start-up funding under paragraph (2). Section 1854(g) of the Social Security Act shall apply to receipts described in the previous sentence in the same manner as such section applies to payments or premiums described in such section.
(A) IN GENERAL.—In order to provide for the establishment of the public health insurance option, there is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $2,000,000,000. In order to provide for initial claims reserves before the collection of premiums, there are hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, such sums as necessary to cover 90 days worth of claims reserves based on projected enrollment.
(B) AMORTIZATION OF START-UP FUNDING.—The Secretary shall provide for the repayment of the startup funding provided under subparagraph (A) to the Treasury in an amortized manner over the 10-year period beginning with Y1.
(C) LIMITATION ON FUNDING.—Nothing in this section shall be construed as authorizing any additional appropriations to the Account, other than such amounts as are otherwise provided with respect to other Exchange-participating health benefits plans.
(3) NO BAILOUTS.—In no case shall the public health insurance option receive any Federal funds for purposes of insolvency in any manner similar to the manner in which entities receive Federal funding under the Troubled Assets Relief Program of the Secretary of the Treasury.
(a) Negotiation of payment rates.—
(1) IN GENERAL.—The Secretary shall negotiate payment for the public health insurance option for health care providers and items and services, including prescription drugs, consistent with this section and section 324.
(2) MANNER OF NEGOTIATION.—The Secretary shall negotiate such rates in a manner that results in payment rates that are not lower, in the aggregate, than rates under title XVIII of the Social Security Act, and not higher, in the aggregate, than the average rates paid by other QHBP offering entities for services and health care providers.
(3) INNOVATIVE PAYMENT METHODS.—Nothing in this subsection shall be construed as preventing the use of innovative payment methods such as those described in section 324 in connection with the negotiation of payment rates under this subsection.
(b) Establishment of a provider network.—
(1) IN GENERAL.—Health care providers (including physicians and hospitals) participating in Medicare are participating providers in the public health insurance option unless they opt out in a process established by the Secretary consistent with this subsection.
(2) REQUIREMENTS FOR OPT-OUT PROCESS.—Under the process established under paragraph (1)—
(A) providers described in such paragraph shall be provided at least a 1-year period prior to the first day of Y1 to opt out of participating in the public health insurance option;
(B) no provider shall be subject to a penalty for not participating in the public health insurance option;
(C) the Secretary shall include information on how providers participating in Medicare who chose to opt out of participating in the public health insurance option may opt back in; and
(D) there shall be an annual enrollment period in which providers may decide whether to participate in the public health insurance option.
(3) RULEMAKING.—Not later than 18 months before the first day of Y1, the Secretary shall promulgate rules (pursuant to notice and comment) for the process described in paragraph (1).
(c) Limitations on review.—There shall be no administrative or judicial review of a payment rate or methodology established under this section or under section 324.
(a) In general.—For plan years beginning with Y1, the Secretary may utilize innovative payment mechanisms and policies to determine payments for items and services under the public health insurance option. The payment mechanisms and policies under this section may include patient-centered medical home and other care management payments, accountable care organizations, value-based purchasing, bundling of services, differential payment rates, performance or utilization based payments, partial capitation, and direct contracting with providers.
(b) Requirements for innovative payments.—The Secretary shall design and implement the payment mechanisms and policies under this section in a manner that—
(A) improve health outcomes;
(B) reduce health disparities (including racial, ethnic, and other disparities);
(C) provide efficient and affordable care;
(D) address geographic variation in the provision of health services; or
(E) prevent or manage chronic illness; and
(2) promotes care that is integrated, patient-centered, quality, and efficient.
(c) Encouraging the use of high value services.—To the extent allowed by the benefit standards applied to all Exchange-participating health benefits plans, the public health insurance option may modify cost-sharing and payment rates to encourage the use of services that promote health and value.
(d) Promotion of delivery system reform.—The Secretary shall monitor and evaluate the progress of payment and delivery system reforms under this Act and shall seek to implement such reforms subject to the following:
(1) To the extent that the Secretary finds a payment and delivery system reform successful in improving quality and reducing costs, the Secretary shall implement such reform on as large a geographic scale as practical and economical.
(2) The Secretary may delay the implementation of such a reform in geographic areas in which such implementation would place the public health insurance option at a competitive disadvantage.
(3) The Secretary may prioritize implementation of such a reform in high cost geographic areas or otherwise in order to reduce total program costs or to promote high value care.
(e) Non-uniformity permitted.—Nothing in this subtitle shall prevent the Secretary from varying payments based on different payment structure models (such as accountable care organizations and medical homes) under the public health insurance option for different geographic areas.
(a) In general.—The Secretary shall establish conditions of participation for health care providers under the public health insurance option.
(b) Licensure or certification.—
(1) IN GENERAL.—Except as provided in paragraph (2), the Secretary shall not allow a health care provider to participate in the public health insurance option unless such provider is appropriately licensed, certified, or otherwise permitted to practice under State law.
(2) SPECIAL RULE FOR IHS FACILITIES AND PROVIDERS.—The requirements under paragraph (1) shall not apply to—
(A) a facility that is operated by the Indian Health Service;
(B) a facility operated by an Indian Tribe or tribal organization under the Indian Self-Determination Act (Public Law 93–638);
(C) a health care professional employed by the Indian Health Service; or
(D) a health care professional—
(i) who is employed to provide health care services in a facility operated by an Indian Tribe or tribal organization under the Indian Self-Determination Act; and
(ii) who is licensed or certified in any State.
(c) Payment terms for providers.—
(1) PHYSICIANS.—The Secretary shall provide for the annual participation of physicians under the public health insurance option, for which payment may be made for services furnished during the year, in one of 2 classes:
(A) PREFERRED PHYSICIANS.—Those physicians who agree to accept the payment under section 323 (without regard to cost-sharing) as the payment in full.
(B) PARTICIPATING, NON-PREFERRED PHYSICIANS.—Those physicians who agree not to impose charges (in relation to the payment described in section 323 for such physicians) that exceed the sum of the in-network cost-sharing plus 15 percent of the total payment for each item and service. The Secretary shall reduce the payment described in section 323 for such physicians.
(2) OTHER PROVIDERS.—The Secretary shall provide for the participation (on an annual or other basis specified by the Secretary) of health care providers (other than physicians) under the public health insurance option under which payment shall only be available if the provider agrees to accept the payment under section 323 (without regard to cost-sharing) as the payment in full.
(d) Exclusion of certain providers.—The Secretary shall exclude from participation under the public health insurance option a health care provider that is excluded from participation in a Federal health care program (as defined in section 1128B(f) of the Social Security Act).
Provisions of civil law identified by the Secretary by regulation, in consultation with the Inspector General of the Department of Health and Human Services, that impose sanctions with respect to waste, fraud, and abuse under Medicare, such as sections 3729 through 3733 of title 31, United States Code (commonly known as the False Claims Act), shall also apply to the public health insurance option.
The requirements of sections 2701 through 2792 of the Public Health Service Act shall apply to the public health insurance option in the same manner as they apply to health insurance coverage offered by a health insurance issuer in the individual market.
Part C of title XI of the Social Security Act, relating to standards for protections against the wrongful disclosure of individually identifiable health information, health information security, and the electronic exchange of health care information, shall apply to the public health insurance option in the same manner as such part applies to other health plans (as defined in section 1171(5) of such Act).
Nothing in this division shall be construed as requiring anyone to enroll in the public health insurance option. Enrollment in such option is voluntary.
Notwithstanding any other provision of this Act, Members of Congress may enroll in the public health insurance option.
The Secretary of Health and Human Services shall seek to enter into a memorandum of understanding with the Secretary of Veterans Affairs regarding the recovery of costs related to non-service-connected care or services provided by the Secretary of Veterans Affairs to an individual covered under the public health insurance option in a manner consistent with recovery of costs related to non-service-connected care from private health insurance plans.
(a) In general.—Subject to the succeeding provisions of this subtitle, in the case of an affordable credit eligible individual enrolled in an Exchange-participating health benefits plan—
(1) the individual shall be eligible for, in accordance with this subtitle, affordability credits consisting of—
(A) an affordability premium credit under section 343 to be applied against the premium for the Exchange-participating health benefits plan in which the individual is enrolled; and
(B) an affordability cost-sharing credit under section 344 to be applied as a reduction of the cost-sharing otherwise applicable to such plan; and
(2) the Commissioner shall pay the QHBP offering entity that offers such plan from the Health Insurance Exchange Trust Fund the aggregate amount of affordability credits for all affordable credit eligible individuals enrolled in such plan.
(1) IN GENERAL.—An Exchange eligible individual may apply to the Commissioner through the Health Insurance Exchange or through another entity under an arrangement made with the Commissioner, in a form and manner specified by the Commissioner. The Commissioner through the Health Insurance Exchange or through another public entity under an arrangement made with the Commissioner shall make a determination as to eligibility of an individual for affordability credits under this subtitle. The Commissioner shall establish a process whereby, on the basis of information otherwise available, individuals may be deemed to be affordable credit eligible individuals. In carrying this subtitle, the Commissioner shall establish effective methods that ensure that individuals with limited English proficiency are able to apply for affordability credits.
(2) USE OF STATE MEDICAID AGENCIES.—If the Commissioner determines that a State Medicaid agency has the capacity to make a determination of eligibility for affordability credits under this subtitle and under the same standards as used by the Commissioner, under the Medicaid memorandum of understanding under section 305(e)(2)—
(A) the State Medicaid agency is authorized to conduct such determinations for any Exchange-eligible individual who requests such a determination; and
(B) the Commissioner shall reimburse the State Medicaid agency for the costs of conducting such determinations.
(3) MEDICAID SCREEN AND ENROLL OBLIGATION.—In the case of an application made under paragraph (1), there shall be a determination of whether the individual is a Medicaid-eligible individual. If the individual is determined to be so eligible, the Commissioner, through the Medicaid memorandum of understanding under section 305(e)(2), shall provide for the enrollment of the individual under the State Medicaid plan in accordance with such Medicaid memorandum of understanding. In the case of such an enrollment, the State shall provide for the same periodic redetermination of eligibility under Medicaid as would otherwise apply if the individual had directly applied for medical assistance to the State Medicaid agency.
(4) APPLICATION AND VERIFICATION OF REQUIREMENT OF CITIZENSHIP OR LAWFUL PRESENCE IN THE UNITED STATES.—
(A) REQUIREMENT.—No individual shall be an affordable credit eligible individual (as defined in section 342(a)(1)) unless the individual is a citizen or national of the United States or is lawfully present in a State in the United States (other than as a nonimmigrant described in a subparagraph (excluding subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of the Immigration and Nationality Act).
(B) DECLARATION OF CITIZENSHIP OR LAWFUL IMMIGRATION STATUS.—No individual shall be an affordable credit eligible individual unless there has been a declaration made, in a form and manner specified by the Health Choices Commissioner similar to the manner required under section 1137(d)(1) of the Social Security Act and under penalty of perjury, that the individual—
(i) is a citizen or national of the United States; or
(ii) is not such a citizen or national but is lawfully present in a State in the United States (other than as a nonimmigrant described in a subparagraph (excluding subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of the Immigration and Nationality Act).
Such declaration shall be verified in accordance with subparagraph (C) or (D), as the case may be.
(C) VERIFICATION PROCESS FOR CITIZENS.—
(i) IN GENERAL.—In the case of an individual making the declaration described in subparagraph (B)(i), subject to clause (ii), section 1902(ee) of the Social Security Act shall apply to such declaration in the same manner as such section applies to a declaration described in paragraph (1) of such section.
(ii) SPECIAL RULES.—In applying section 1902(ee) of such Act under clause (i)—
(I) any reference in such section to a State is deemed a reference to the Commissioner (or other public entity making the eligibility determination);
(II) any reference to medical assistance or enrollment under a State plan is deemed a reference to provision of affordability credits under this subtitle;
(III) a reference to a newly enrolled individual under paragraph (2)(A) of such section is deemed a reference to an individual newly in receipt of an affordability credit under this subtitle;
(IV) approval by the Secretary shall not be required in applying paragraph (2)(B)(ii) of such section;
(V) paragraph (3) of such section shall not apply; and
(VI) before the end of Y2, the Health Choices Commissioner, in consultation with the Commissioner of Social Security, may extend the periods specified in paragraph (1)(B)(ii) of such section.
(D) VERIFICATION PROCESS FOR NONCITIZENS.—
(i) IN GENERAL.—In the case of an individual making the declaration described in subparagraph (B)(ii), subject to clause (ii), the verification procedures of paragraphs (2) through (5) of section 1137(d) of the Social Security Act shall apply to such declaration in the same manner as such procedures apply to a declaration described in paragraph (1) of such section.
(ii) SPECIAL RULES.—In applying such paragraphs of section 1137(d) of such Act under clause (i)—
(I) any reference in such paragraphs to a State is deemed a reference to the Health Choices Commissioner; and
(II) any reference to benefits under a program is deemed a reference to affordability credits under this subtitle.
(iii) APPLICATION TO STATE-BASED EXCHANGES.—In the case of the application of the verification process under this subparagraph to a State-based Health Insurance Exchange approved under section 308, section 1137(e) of such Act shall apply to the Health Choices Commissioner in relation to the State.
(E) ANNUAL REPORTS.—The Health Choices Commissioner shall report to Congress annually on the number of applicants for affordability credits under this subtitle, their citizenship or immigration status, and the disposition of their applications. Such report shall be made publicly available and shall include information on—
(i) the number of applicants whose declaration of citizenship or immigration status, name, or social security account number was not consistent with records maintained by the Commissioner of Social Security or the Department of Homeland Security and, of such applicants, the number who contested the inconsistency and sought to document their citizenship or immigration status, name, or social security account number or to correct the information maintained in such records and, of those, the results of such contestations; and
(ii) the administrative costs of conducting the status verification under this paragraph.
(F) GAO REPORT.—Not later than the end of Y2, the Comptroller General of the United States shall submit to the Committee on Ways and Means, the Committee on Energy and Commerce, the Committee on Education and Labor, and the Committee on the Judiciary of the House of Representatives and the Committee on Finance, the Committee on Health, Education, Labor, and Pensions, and the Committee on the Judiciary of the Senate a report examining the effectiveness of the citizenship and immigration verification systems applied under this paragraph. Such report shall include an analysis of the following:
(i) The causes of erroneous determinations under such systems.
(ii) The effectiveness of the processes used in remedying such erroneous determinations.
(iii) The impact of such systems on individuals, health care providers, and Federal and State agencies, including the effect of erroneous determinations under such systems.
(iv) The effectiveness of such systems in preventing ineligible individuals from receiving for affordability credits.
(v) The characteristics of applicants described in subparagraph (E)(i).
(G) PROHIBITION OF DATABASE.—Nothing in this paragraph or the amendments made by paragraph (6) shall be construed as authorizing the Health Choices Commissioner or the Commissioner of Social Security to establish a database of information on citizenship or immigration status.
(i) IN GENERAL.—Out of any funds in the Treasury not otherwise appropriated, there is appropriated to the Commissioner of Social Security $30,000,000, to be available without fiscal year limit to carry out this paragraph and section 205(v) of the Social Security Act.
(ii) FUNDING LIMITATION.—In no case shall funds from the Social Security Administration’s Limitation on Administrative Expenses be used to carry out activities related to this paragraph or section 205(v) of the Social Security Act.
(5) AGREEMENT WITH SOCIAL SECURITY COMMISSIONER.—
(A) IN GENERAL.—The Health Choices Commissioner shall enter into and maintain an agreement described in section 205(v)(2) of the Social Security Act with the Commissioner of Social Security.
(B) FUNDING.—The agreement entered into under subparagraph (A) shall, for each fiscal year (beginning with fiscal year 2013)—
(i) provide funds to the Commissioner of Social Security for the full costs of the responsibilities of the Commissioner of Social Security under paragraph (4), including—
(I) acquiring, installing, and maintaining technological equipment and systems necessary for the fulfillment of the responsibilities of the Commissioner of Social Security under paragraph (4), but only that portion of such costs that are attributable to such responsibilities; and
(II) responding to individuals who contest with the Commissioner of Social Security a reported inconsistency with records maintained by the Commissioner of Social Security or the Department of Homeland Security relating to citizenship or immigration status, name, or social security account number under paragraph (4);
(ii) based on an estimating methodology agreed to by the Commissioner of Social Security and the Health Choices Commissioner, provide such funds, within 10 calendar days of the beginning of the fiscal year for the first quarter and in advance for all subsequent quarters in that fiscal year; and
(iii) provide for an annual accounting and reconciliation of the actual costs incurred and the funds provided under the agreement.
(C) REVIEW OF ACCOUNTING.—The annual accounting and reconciliation conducted pursuant to subparagraph (B)(iii) shall be reviewed by the Inspectors General of the Social Security Administration and the Health Choices Administration, including an analysis of consistency with the requirements of paragraph (4).
(D) CONTINGENCY.—In any case in which agreement with respect to the provisions required under subparagraph (B) for any fiscal year has not been reached as of the first day of such fiscal year, the latest agreement with respect to such provisions shall be deemed in effect on an interim basis for such fiscal year until such time as an agreement relating to such provisions is subsequently reached. In any case in which an interim agreement applies for any fiscal year under this subparagraph, the Commissioner of Social Security shall, not later than the first day of such fiscal year, notify the appropriate Committees of the Congress of the failure to reach the agreement with respect to such provisions for such fiscal year. Until such time as the agreement with respect to such provisions has been reached for such fiscal year, the Commissioner of Social Security shall, not later than the end of each 90-day period after October 1 of such fiscal year, notify such Committees of the status of negotiations between such Commissioner and the Health Choices Commissioner in order to reach such an agreement.
(E) APPLICATION TO PUBLIC ENTITIES ADMINISTERING AFFORDABILITY CREDITS.—If the Health Choices Commissioner provides for the conduct of verifications under paragraph (4) through a public entity, the Health Choices Commissioner shall require the public entity to enter into an agreement with the Commissioner of Social Security which provides the same terms as the agreement described in this paragraph (and section 205(v) of the Social Security Act) between the Health Choices Commissioner and the Commissioner of Social Security, except that the Health Choices Commissioner shall be responsible for providing funds for the Commissioner of Social Security in accordance with subparagraphs (B) through (D).
(6) AMENDMENTS TO SOCIAL SECURITY ACT.—
(A) COORDINATION OF INFORMATION BETWEEN SOCIAL SECURITY ADMINISTRATION AND HEALTH CHOICES ADMINISTRATION.—
(i) IN GENERAL.—Section 205 of the Social Security Act (42 U.S.C. 405) is amended by adding at the end the following new subsection:
“(v) (1) The Health Choices Commissioner may collect and use the names and social security account numbers of individuals as required to provide for verification of citizenship under subsection (b)(4)(C) of section 341 of the Affordable Health Care for America Act in connection with determinations of eligibility for affordability credits under such section.
“(2)(A) The Commissioner of Social Security shall enter into and maintain an agreement with the Health Choices Commissioner for the purpose of establishing, in compliance with the requirements of section 1902(ee) as applied pursuant to section 341(b)(4)(C) of the Affordable Health Care for America Act, a program for verifying information required to be collected by the Health Choices Commissioner under such section 341(b)(4)(C).
“(B) The agreement entered into pursuant to subparagraph (A) shall include such safeguards as are necessary to ensure the maintenance of confidentiality of any information disclosed for purposes of verifying information described in subparagraph (A) and to provide procedures for permitting the Health Choices Commissioner to use the information for purposes of maintaining the records of the Health Choices Administration.
“(C) The agreement entered into pursuant to subparagraph (A) shall provide that information provided by the Commissioner of Social Security to the Health Choices Commissioner pursuant to the agreement shall be provided at such time, at such place, and in such manner as the Commissioner of Social Security determines appropriate.
“(D) Information provided by the Commissioner of Social Security to the Health Choices Commissioner pursuant to an agreement entered into pursuant to subparagraph (A) shall be considered as strictly confidential and shall be used only for the purposes described in this paragraph and for carrying out such agreement. Any officer or employee or former officer or employee of the Health Choices Commissioner, or any officer or employee or former officer or employee of a contractor of the Health Choices Commissioner, who, without the written authority of the Commissioner of Social Security, publishes or communicates any information in such individual’s possession by reason of such employment or position as such an officer shall be guilty of a felony and, upon conviction thereof, shall be fined or imprisoned, or both, as described in section 208.
“(3) The agreement entered into under paragraph (2) shall provide for funding to the Commissioner of Social Security consistent with section 341(b)(5) of Affordable Health Care for America Act.
“(4) This subsection shall apply in the case of a public entity that conducts verifications under section 341(b)(4) of the Affordable Health Care for America Act and the obligations of this subsection shall apply to such an entity in the same manner as such obligations apply to the Health Choices Commissioner when such Commissioner is conducting such verifications.”.
(ii) CONFORMING AMENDMENT.—Section 205(c)(2)(C) of such Act (42 U.S.C. 405(c)(2)(C)) is amended by adding at the end the following new clause:
“(x) For purposes of the administration of the verification procedures described in section 341(b)(4) of the Affordable Health Care for America Act, the Health Choices Commissioner may collect and use social security account numbers as provided for in section 205(v)(1).”.
(B) IMPROVING THE INTEGRITY OF DATA AND EFFECTIVENESS OF SAVE.—Section 1137(d) of the Social Security Act (42 U.S.C. 1320b–7(d)) is amended by adding at the end the following new paragraphs:
“(6)(A) With respect to the use by any agency of the system described in subsection (b) by programs specified in subsection (b) or any other use of such system, the U.S. Citizenship and Immigration Services and any other agency charged with the management of the system shall establish appropriate safeguards necessary to protect and improve the integrity and accuracy of data relating to individuals by—
“(i) establishing a process though which such individuals are provided access to, and the ability to amend, correct, and update, their own personally identifiable information contained within the system;
“(ii) providing a written response, without undue delay, to any individual who has made such a request to amend, correct, or update such individual’s own personally identifiable information contained within the system; and
“(iii) developing a written notice for user agencies to provide to individuals who are denied a benefit due to a determination of ineligibility based on a final verification determination under the system.
“(B) The notice described in subparagraph (A)(ii) shall include—
“(i) information about the reason for such notice;
“(ii) a description of the right of the recipient of the notice under subparagraph (A)(i) to contest such notice;
“(iii) a description of the right of the recipient under subparagraph (A)(i) to access and attempt to amend, correct, and update the recipient’s own personally identifiable information contained within records of the system described in paragraph (3); and
“(iv) instructions on how to contest such notice and attempt to correct records of such system relating to the recipient, including contact information for relevant agencies.”.
(C) STREAMLINING ADMINISTRATION OF VERIFICATION PROCESS FOR UNITED STATES CITIZENS.—Section 1902(ee)(2) of the Social Security Act (42 U.S.C. 1396a(ee)(2)) is amended by adding at the end the following:
“(D) In carrying out the verification procedures under this subsection with respect to a State, if the Commissioner of Social Security determines that the records maintained by such Commissioner are not consistent with an individual’s allegation of United States citizenship, pursuant to procedures which shall be established by the State in coordination with the Commissioner of Social Security, the Secretary of Homeland Security, and the Secretary of Health and Human Services—
“(i) the Commissioner of Social Security shall inform the State of the inconsistency;
“(ii) upon being so informed of the inconsistency, the State shall submit the information on the individual to the Secretary of Homeland Security for a determination of whether the records of the Department of Homeland Security indicate that the individual is a citizen;
“(iii) upon making such determination, the Department of Homeland Security shall inform the State of such determination; and
“(iv) information provided by the Commissioner of Social Security shall be considered as strictly confidential and shall only be used by the State and the Secretary of Homeland Security for the purposes of such verification procedures.
“(E) Verification of status eligibility pursuant to the procedures established under this subsection shall be deemed a verification of status eligibility for purposes of this title, title XXI, and affordability credits under section 341(b)(4) of the Affordable Health Care for America Act, regardless of the program in which the individual is applying for benefits.”.
(c) Use of affordability credits.—
(1) IN GENERAL.—In Y1 and Y2 an affordable credit eligible individual may use an affordability credit only with respect to a basic plan.
(2) FLEXIBILITY IN PLAN ENROLLMENT AUTHORIZED.—Beginning with Y3, the Commissioner shall establish a process to allow an affordability premium credit under section 343, but not the affordability cost-sharing credit under section 344, to be used for enrollees in enhanced or premium plans. In the case of an affordable credit eligible individual who enrolls in an enhanced or premium plan, the individual shall be responsible for any difference between the premium for such plan and the affordability credit amount otherwise applicable if the individual had enrolled in a basic plan.
(3) PROHIBITION OF USE OF PUBLIC FUNDS FOR ABORTION COVERAGE.—An affordability credit may not be used for payment for services described in section 222(d)(4)(A).
(d) Access to data.—In carrying out this subtitle, the Commissioner shall request from the Secretary of the Treasury consistent with section 6103 of the Internal Revenue Code of 1986 such information as may be required to carry out this subtitle.
(e) No cash rebates.—In no case shall an affordable credit eligible individual receive any cash payment as a result of the application of this subtitle.
(1) IN GENERAL.—For purposes of this division, the term “affordable credit eligible individual” means, subject to subsection (b) and section 346, an individual who is lawfully present in a State in the United States (other than as a nonimmigrant described in a subparagraph (excluding subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of the Immigration and Nationality Act)—
(A) who is enrolled under an Exchange-participating health benefits plan and is not enrolled under such plan as an employee (or dependent of an employee) through an employer qualified health benefits plan that meets the requirements of section 412;
(B) with modified adjusted gross income below 400 percent of the Federal poverty level for a family of the size involved;
(C) who is not a Medicaid eligible individual, other than an individual during a transition period under section 302(d)(3)(B)(ii); and
(D) subject to paragraph (3), who is not enrolled in acceptable coverage (other than an Exchange-participating health benefits plan).
(2) TREATMENT OF FAMILY.—Except as the Commissioner may otherwise provide, members of the same family who are affordable credit eligible individuals shall be treated as a single affordable credit individual eligible for the applicable credit for such a family under this subtitle.
(3) SPECIAL RULE FOR INDIANS.—Subparagraph (D) of paragraph (1) shall not apply to an individual who has coverage that is treated as acceptable coverage for purposes of section 59B(d)(2) of the Internal Revenue Code of 1986 but is not treated as acceptable coverage for purposes of this division.
(b) Limitations on employee and dependent disqualification.—
(1) IN GENERAL.—Subject to paragraph (2), the term “affordable credit eligible individual” does not include a full-time employee of an employer if the employer offers the employee coverage (for the employee and dependents) as a full-time employee under a group health plan if the coverage and employer contribution under the plan meet the requirements of section 412.
(A) FOR CERTAIN FAMILY CIRCUMSTANCES.—The Commissioner shall establish such exceptions and special rules in the case described in paragraph (1) as may be appropriate in the case of a divorced or separated individual or such a dependent of an employee who would otherwise be an affordable credit eligible individual.
(B) FOR UNAFFORDABLE EMPLOYER COVERAGE.—Beginning in Y2, in the case of full-time employees for which the cost of the employee premium for coverage under a group health plan would exceed 12 percent of current modified adjusted gross income (determined by the Commissioner on the basis of verifiable documentation), paragraph (1) shall not apply.
(1) IN GENERAL.—In this title, the term “income” means modified adjusted gross income (as defined in section 59B of the Internal Revenue Code of 1986).
(2) STUDY OF INCOME DISREGARDS.—The Commissioner shall conduct a study that examines the application of income disregards for purposes of this subtitle. Not later than the first day of Y2, the Commissioner shall submit to Congress a report on such study and shall include such recommendations as the Commissioner determines appropriate.
(d) Clarification of treatment of affordability credits.—Affordability credits under this subtitle shall not be treated, for purposes of title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, to be a benefit provided under section 403 of such title.
(a) In general.—The affordability premium credit under this section for an affordable credit eligible individual enrolled in an Exchange-participating health benefits plan is in an amount equal to the amount (if any) by which the reference premium amount specified in subsection (c), exceeds the affordable premium amount specified in subsection (b) for the individual, except that in no case shall the affordable premium credit exceed the premium for the plan.
(b) Affordable premium amount.—
(1) IN GENERAL.—The affordable premium amount specified in this subsection for an individual for the annual premium in a plan year shall be equal to the product of—
(A) the premium percentage limit specified in paragraph (2) for the individual based upon the individual’s modified adjusted gross income for the plan year; and
(B) the individual’s modified adjusted gross income for such plan year.
(2) PREMIUM PERCENTAGE LIMITS BASED ON TABLE.—The Commissioner shall establish premium percentage limits so that for individuals whose modified adjusted gross income is within an income tier specified in the table in subsection (d) such percentage limits shall increase, on a sliding scale in a linear manner, from the initial premium percentage to the final premium percentage specified in such table for such income tier.
(c) Reference premium amount.—The reference premium amount specified in this subsection for a plan year for an individual in a premium rating area is equal to the average premium for the 3 basic plans in the area for the plan year with the lowest premium levels. In computing such amount the Commissioner may exclude plans with extremely limited enrollments.
(d) Table of premium percentage limits, actuarial value percentages, and out-of-pocket limits for Y1 based on income tier.—
(1) IN GENERAL.—For purposes of this subtitle, subject to paragraph (3) and section 346, the table specified in this subsection is as follows:
| In the case of modified adjusted gross income (expressed as a percent of FPL) within the following income tier: | The initial premium percentage is— | The final premium percentage is— | The actuarial value percentage is— | The out-of-pocket limit for Y1 is— |
| 133% through 150% | 1.5% | 3.0% | 97% | $500 |
| 150% through 200% | 3.0% | 5.5% | 93% | $1,000 |
| 200% through 250% | 5.5% | 8.0% | 85% | $2,000 |
| 250% through 300% | 8.0% | 10.0% | 78% | $4,000 |
| 300% through 350% | 10.0% | 11.0% | 72% | $4,500 |
| 350% through 400% | 11.0% | 12.0% | 70% | $5,000 |
(2) SPECIAL RULES.—For purposes of applying the table under paragraph (1):
(A) FOR LOWEST LEVEL OF INCOME.—In the case of an individual with income that does not exceed 133 percent of FPL, the individual shall be considered to have income that is 133 percent of FPL.
(B) APPLICATION OF HIGHER ACTUARIAL VALUE PERCENTAGE AT TIER TRANSITION POINTS.—If two actuarial value percentages may be determined with respect to an individual, the actuarial value percentage shall be the higher of such percentages.
(3) INDEXING.—For years after Y1, the Commissioner shall adjust the initial and final premium percentages to maintain the ratio of governmental to enrollee shares of premiums over time, for each income tier identified in the table in paragraph (1).
(a) In general.—The affordability cost-sharing credit under this section for an affordable credit eligible individual enrolled in an Exchange-participating health benefits plan is in the form of the cost-sharing reduction described in subsection (b) provided under this section for the income tier in which the individual is classified based on the individual’s modified adjusted gross income.
(b) Cost-sharing reductions.—The Commissioner shall specify a reduction in cost-sharing amounts and the annual limitation on cost-sharing specified in section 222(c)(2)(B) under a basic plan for each income tier specified in the table under section 343(d), with respect to a year, in a manner so that, as estimated by the Commissioner—
(1) the actuarial value of the coverage with such reduced cost-sharing amounts (and the reduced annual cost-sharing limit) is equal to the actuarial value percentage (specified in the table under section 343(d) for the income tier involved) of the full actuarial value if there were no cost-sharing imposed under the plan; and
(2) the annual limitation on cost-sharing specified in section 222(c)(2)(B) is reduced to a level that does not exceed the maximum out-of-pocket limit specified in subsection (c).
(c) Maximum out-of-pocket limit.—
(1) IN GENERAL.—Subject to paragraph (2), the maximum out-of-pocket limit specified in this subsection for an individual within an income tier—
(i) for Y1 is the out-of-pocket limit for Y1 specified in subsection (c) in the table under section 343(d) for the income tier involved; or
(ii) for a subsequent year is such out-of-pocket limit for the previous year under this subparagraph increased (rounded to the nearest $10) for each subsequent year by the percentage increase in the enrollment-weighted average of premium increases for basic plans applicable to such year; or
(B) for family coverage is twice the maximum out-of-pocket limit under subparagraph (A) for the year involved.
(2) ADJUSTMENT.—The Commissioner shall adjust the maximum out-of-pocket limits under paragraph (1) to ensure that such limits meet the actuarial value percentage specified in the table under section 343(d) for the income tier involved.
(d) Determination and payment of cost-sharing affordability credit.—In the case of an affordable credit eligible individual in a tier enrolled in an Exchange-participating health benefits plan offered by a QHBP offering entity, the Commissioner shall provide for payment to the offering entity of an amount equivalent to the increased actuarial value of the benefits under the plan provided under section 303(c)(2)(B) resulting from the reduction in cost-sharing described in subsections (b) and (c).
(a) In general.—In applying this subtitle for an affordability credit for an individual for a plan year, the individual’s income shall be the income (as defined in section 342(c)) for the individual for the most recent taxable year (as determined in accordance with rules of the Commissioner). The Federal poverty level applied shall be such level in effect as of the date of the application.
(b) Program integrity; Income verification procedures.—
(1) PROGRAM INTEGRITY.—The Commissioner shall take such steps as may be appropriate to ensure the accuracy of determinations and redeterminations under this subtitle.
(A) IN GENERAL.—Upon an initial application of an individual for an affordability credit under this subtitle (or in applying section 342(b)) or upon an application for a change in the affordability credit based upon a significant change in modified adjusted gross income described in subsection (c)(1)—
(i) the Commissioner shall request from the Secretary of the Treasury the disclosure to the Commissioner of such information as may be permitted to verify the information contained in such application; and
(ii) the Commissioner shall use the information so disclosed to verify such information.
(B) ALTERNATIVE PROCEDURES.—The Commissioner shall establish procedures for the verification of income for purposes of this subtitle if no income tax return is available for the most recent completed tax year.
(1) CHANGES IN INCOME AS A PERCENT OF FPL.—In the case that an individual’s income (expressed as a percentage of the Federal poverty level for a family of the size involved) for a plan year is expected (in a manner specified by the Commissioner) to be significantly different from the income (as so expressed) used under subsection (a), the Commissioner shall establish rules requiring an individual to report, consistent with the mechanism established under paragraph (2), significant changes in such income (including a significant change in family composition) to the Commissioner and requiring the substitution of such income for the income otherwise applicable.
(2) REPORTING OF SIGNIFICANT CHANGES IN INCOME.—The Commissioner shall establish rules under which an individual determined to be an affordable credit eligible individual would be required to inform the Commissioner when there is a significant change in the modified adjusted gross income of the individual (expressed as a percentage of the FPL for a family of the size involved) and of the information regarding such change. Such mechanism shall provide for guidelines that specify the circumstances that qualify as a significant change, the verifiable information required to document such a change, and the process for submission of such information. If the Commissioner receives new information from an individual regarding the modified adjusted gross income of the individual, the Commissioner shall provide for a redetermination of the individual’s eligibility to be an affordable credit eligible individual.
(3) TRANSITION FOR CHIP.—In the case of a child described in section 302(d)(2), the Commissioner shall establish rules under which the modified adjusted gross income of the child is deemed to be no greater than the family income of the child as most recently determined before Y1 by the State under title XXI of the Social Security Act.
(4) STUDY OF GEOGRAPHIC VARIATION IN APPLICATION OF FPL.—
(A) IN GENERAL.—The Secretary of Health and Human Services shall conduct a study to examine the feasibility and implication of adjusting the application of the Federal poverty level under this subtitle for different geographic areas so as to reflect the variations in cost-of-living among different areas within the United States. If the Secretary determines that an adjustment is feasible, the study should include a methodology to make such an adjustment. Not later than the first day of Y1, the Secretary shall submit to Congress a report on such study and shall include such recommendations as the Secretary determines appropriate.
(B) INCLUSION OF TERRITORIES.—
(i) IN GENERAL.—The Secretary shall ensure that the study under subparagraph (A) covers the territories of the United States and that special attention is paid to the disparity that exists among poverty levels and the cost of living in such territories and to the impact of such disparity on efforts to expand health coverage and ensure health care.
(ii) TERRITORIES DEFINED.—In this subparagraph, the term “territories of the United States” includes the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, the Northern Mariana Islands, and any other territory or possession of the United States.
(d) Penalties for misrepresentation.—In the case of an individual who intentionally misrepresents modified adjusted gross income or the individual fails (without regard to intent) to disclose to the Commissioner a significant change in modified adjusted gross income under subsection (c) in a manner that results in the individual becoming an affordable credit eligible individual when the individual is not or in the amount of the affordability credit exceeding the correct amount—
(1) the individual is liable for repayment of the amount of the improper affordability credit; and
(2) in the case of such an intentional misrepresentation or other egregious circumstances specified by the Commissioner, the Commissioner may impose an additional penalty.
(a) One-time election for treatment and application of funding.—
(1) IN GENERAL.—A territory may elect, in a form and manner specified by the Commissioner in consultation with the Secretary of Health and Human Services and the Secretary of the Treasury and not later than October 1, 2012, either—
(A) to be treated as a State for purposes of applying this title and title II; or
(B) not to be so treated but instead, to have the dollar limitation otherwise applicable to the territory under subsections (f) and (g) of section 1108 of the Social Security Act (42 U.S.C. 1308) for a fiscal year increased by a dollar amount equivalent to the cap amount determined under subsection (c)(2) for the territory as applied by the Secretary for the fiscal year involved.
(2) CONDITIONS FOR ACCEPTANCE.—The Commissioner has the nonreviewable authority to accept or reject an election described in paragraph (1)(A). Any such acceptance is—
(A) contingent upon entering into an agreement described in subsection (b) between the Commissioner and the territory and subsection (c); and
(B) subject to the approval of the Secretary of Health and Human Services and the Secretary of the Treasury and subject to such other terms and conditions as the Commissioner, in consultation with such Secretaries, may specify.
(3) DEFAULT RULE.—A territory failing to make such an election (or having an election under paragraph (1)(A) not accepted under paragraph (2)) shall be treated as having made the election described in paragraph (1)(B).
(b) Agreement for substitution of percentages for affordability credits.—
(1) NEGOTIATION.—In the case of a territory making an election under subsection (a)(1)(A) (in this section referred to as an “electing territory”) , the Commissioner, in consultation with the Secretaries of Health and Human Services and the Treasury, shall enter into negotiations with the government of such territory so that, before Y1, there is an agreement reached between the parties on the percentages that shall be applied under paragraph (2) for that territory. The Commissioner shall not enter into such an agreement unless—
(A) payments made under this subtitle with respect to residents of the territory are consistent with the cap established under subsection (c) for such territory and with subsection (d); and
(B) the requirements of paragraphs (3) and (4) are met.
(2) APPLICATION OF SUBSTITUTE PERCENTAGES AND DOLLAR AMOUNTS.—In the case of an electing territory, there shall be substituted in section 342(a)(1)(B) and in the table in section 341(d)(1) for 400 percent, 133 percent, and other percentages and dollar amounts specified in such table, such respective percentages and dollar amounts as are established under the agreement under paragraph (1) consistent with the following:
(A) NO INCOME GAP BETWEEN MEDICAID AND AFFORDABILITY CREDITS.—The substituted percentages shall be specified in a manner so as to prevent any gap in coverage for individuals between income level at which medical assistance is available through Medicaid and the income level at which affordability credits are available.
(B) ADJUSTMENT FOR OUT-OF-POCKET RESPONSIBILITY FOR PREMIUMS AND COST-SHARING IN RELATION TO INCOME.—The substituted percentages of FPL for income tiers under such table shall be specified in a manner so that—
(i) affordable credit eligible individuals residing in the territory bear the same out-of-pocket responsibility for premiums and cost-sharing in relation to average income for residents in that territory, as
(ii) the out-of-pocket responsibility for premiums and cost-sharing for affordable credit eligible individuals residing in the 50 States or the District of Columbia in relation to average income for such residents.
(3) SPECIAL RULES WITH RESPECT TO APPLICATION OF TAX AND PENALTY PROVISIONS.—The electing territory shall enact one or more laws under which provisions similar to the following provisions apply with respect to such territory:
(A) Section 59B of the Internal Revenue Code of 1986, except that any resident of the territory who is not an affordable credit eligible individual but who would be an affordable credit eligible individual if such resident were a resident of one of the 50 States (and any qualifying child residing with such individual) may be treated as covered by acceptable coverage.
(B) Section 4980H of the Internal Revenue Code of 1986 and section 502(c)(11) of the Employee Retirement Income Security Act of 1974.
(C) Section 3121(c) of the Internal Revenue Code of 1986.
(4) IMPLEMENTATION OF INSURANCE REFORM AND CONSUMER PROTECTION REQUIREMENTS.—The electing territory shall enact and implement such laws and regulations as may be required to apply the requirements of title II with respect to health insurance coverage offered in the territory.
(c) Cap on additional expenditures.—
(1) IN GENERAL.—In entering into an agreement with an electing territory under subsection (b), the Commissioner shall ensure that the aggregate expenditures under this subtitle with respect to residents of such territory during the period beginning with Y1 and ending with 2019 will not exceed the cap amount specified in paragraph (2) for such territory. The Commissioner shall adjust from time to time the percentages applicable under such agreement as needed in order to carry out the previous sentence.
(A) IN GENERAL.—The cap amount specified in this paragraph—
(i) for Puerto Rico is $3,700,000,000 increased by the amount (if any) elected under subparagraph (C); or
(ii) for another territory is the portion of $300,000,000 negotiated for such territory under subparagraph (B).
(B) NEGOTIATION FOR CERTAIN TERRITORIES.—The Commissioner in consultation with the Secretary of Health and Human Services shall negotiate with the governments of the territories (other than Puerto Rico) to allocate the amount specified in subparagraph (A)(ii) among such territories.
(C) OPTIONAL SUPPLEMENTATION FOR PUERTO RICO.—
(i) IN GENERAL.—Puerto Rico may elect, in a form and manner specified by the Secretary of Health and Human Services in consultation with the Commissioner to increase the dollar amount specified in subparagraph (A)(i) by up to $1,000,000,000.
(ii) OFFSET IN MEDICAID CAP.—If Puerto Rico makes the election described in clause (i), the Secretary shall decrease the dollar limitation otherwise applicable to Puerto Rico under subsections (f) and (g) of section 1108 of the Social Security Act (42 U.S.C. 1308) for a fiscal year by the additional aggregate payments the Secretary estimates will be payable under this section for the fiscal year because of such election.
(d) Limitation on funding.—In no case shall this section (including the agreement under subsection (b)) permit—
(1) the obligation of funds for expenditures under this subtitle for periods beginning on or after January 1, 2020; or
(2) any increase in the dollar limitation described in subsection (a)(1)(B) for any portion of any fiscal year occurring on or after such date.
Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States.