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111TH CONGRESS

1st Session

HOUSE OF REPRESENTATIVES

REPT. 111-299

Part 1

DISSENTING VIEWS

[To accompany H.R. 3200]

do pass.

CONTENTS

Amendment

Purpose and Summary

Background and Need for Legislation

Legislative History

Committee Consideration

Committee Votes

Committee Oversight Findings and Recommendations

New Budget Authority, Entitlement Authority, and Tax Expenditures

Statement of General Performance Goals and Objectives

Constitutional Authority Statement

Earmarks and Tax and Tariff Benefits

Advisory Committee Statement

Applicability of Law to Legislative Branch

Federal Mandates Statement

Committee Cost Estimate

Congressional Budget Office Estimate

Section-by-Section Analysis of the Legislation

Additional Committee Action Relating to H.R. 3200

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Changes in Existing Law Made by the Bill, as Reported
Dissenting Views .....
Appendix A–Text of Motion to Instruct the Chairman on H.R. 3200

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AMENDMENT
The amendment is as follows:

Strike all after the enacting clause (other than sections 321 and
322, title IV of division A, subtitle A of title I of division B, and
title VIII of division B) and insert the following:

SECTION 1. SHORT TITLE; TABLE OF DIVISIONS, TITLES, AND SUBTITLES.

(a) SHORT TITLE.—This Act may be cited as the “America's Affordable Health
Choices Act of 2009”.

(b) TABLE OF DIVISIONS, TITLES, AND SUBTITLES.—This Act is divided into divi-
sions, titles, and subtitles as follows:

DIVISION A-AFFORDABLE HEALTH CARE CHOICES

TITLE I-PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS

Subtitle A—General Standards

Subtitle B—Standards Guaranteeing Access to Affordable Coverage

Subtitle C—Standards Guaranteeing Access to Essential Benefits

Subtitle D—Additional Consumer Protections

Subtitle E-Governance

Subtitle F-Relation to Other Requirements; Miscellaneous

Subtitle G-Early Investments

TITLE II-HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

Subtitle A-Health Insurance Exchange

Subtitle B—Public Health Insurance Option

Subtitle C-Individual Affordability Credits

Subtitle D_Health Insurance Cooperatives

TITLE III-SHARED RESPONSIBILITY

Subtitle A-Individual Responsibility

Subtitle B—Employer Responsibility

TITLE IV-AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

Subtitle A-Shared Responsibility

Subtitle B—Credit for Small Business Employee Health Coverage Expenses

Subtitle C—Disclosures To Carry Out Health Insurance Exchange Subsidies

Subtitle D-Other Revenue Provisions

DIVISION B-MEDICARE AND MEDICAID IMPROVEMENTS

TITLE I-IMPROVING HEALTH CARE VALUE

Subtitle A-Provisions Related to Medicare Part A

Subtitle B-Provisions Related to Medicare Part B

Subtitle C—Provisions Related to Medicare Parts A and B

Subtitle D_Medicare Advantage Reforms

Subtitle E-Improvements to Medicare Part D

Subtitle F-Medicare Rural Access Protections

TITLE II–MEDICARE BENEFICIARY IMPROVEMENTS

Subtitle A-Improving and Simplifying Financial Assistance for Low Income Medicare Beneficiaries

Subtitle B—Reducing Health Disparities

Subtitle C—Miscellaneous Improvements

TITLE III-PROMOTING PRİMARY CARE, MENTAL HEALTH SERVICES, AND COORDINATED CARE

TITLE IV-QUALITY

Subtitle A-Comparative Effectiveness Research

Subtitle B—Nursing Home Transparency

Subtitle C—Quality Measurements

Subtitle D-Physician Payments Sunshine Provision

Subtitle E-Public Reporting on Health Care-Associated Infections

TITLE V-MEDICARE GRADUATE MEDICAL EDUCATION

TITLE VI–PROGRAM INTEGRITY

Subtitle A-Increased Funding To Fight Waste, Fraud, and Abuse

Subtitle B—Enhanced Penalties for Fraud and Abuse

Subtitle C-Enhanced Program and Provider Protections

Subtitle D-Access to Information Needed To Prevent Fraud, Waste, and Abuse

TITLE VII–MEDICAID AND CHIP

Subtitle A-Medicaid and Health Reform

Subtitle B—Prevention

Subtitle C—Access

Subtitle D-Coverage

Subtitle E-Financing

Subtitle F-Waste, Fraud, and Abuse

Subtitle G-Payments to the Territories

Subtitle H-Miscellaneous

TITLE VIII–REVENUE-RELATED PROVISIONS

TITLE IX-MISCELLANEOUS PROVISIONS

DIVISION C—PUBLIC HEALTH AND WORKFORCE DEVELOPMENT

TITLE -COMMUNITY HEALTH CENTERS

TITLE II—WORKFORCE

Subtitle A-Primary Care Workforce

Subtitle B~Nursing Workforce

Subtitle C—Public Health Workforce

government;

so that all Americans have coverage of essential health benefits.

(4) HEALTH DELIVERY REFORM.—This division institutes health delivery sys-

tem reforms both to increase quality and to reduce growth in health spending

so that health care becomes more affordable for businesses, families, and gov-

ernment.

(b) TABLE OF CONTENTS OF DIVISION.—The table of contents of this division is as

follows:

Sec. 100. Purpose; table of contents of division; general definitions.

TITLE I-PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS

Subtitle A—General Standards

Sec. 101. Requirements reforming health insurance marketplace.

Sec. 102. Protecting the choice to keep current coverage.

Subtitle B—Standards Guaranteeing Access to Affordable Coverage

Sec. 111. Prohibiting preexisting condition exclusions.

Sec. 112. Guaranteed issue and renewal for insured plans.

Sec. 113. Insurance rating rules.

Sec. 114. Nondiscrimination in benefits; parity in mental health and substance abuse disorder benefits.

Sec. 115. Ensuring adequacy of provider networks.

Sec. 116. Ensuring value and lower premiums.

Subtitle C—Standards Guaranteeing Access to Essential Benefits

Sec. 121. Coverage of essential benefits package.

Sec. 122. Essential benefits package defined.

Sec. 123. Health Benefits Advisory Committee.

Sec. 124. Process for adoption of recommendations; adoption of benefit standards.

Sec. 125. Prohibition of discrimination in health care services based on religious or spiritual content.

Subtitle D—Additional Consumer Protections

Sec. 131. Requiring fair marketing practices by health insurers.

Sec. 132. Requiring fair grievance and appeals mechanisms.

Sec. 133. Requiring information transparency and plan disclosure.

Sec. 134. Application to qualified health benefits plans not offered through the Health Insurance Exchange.

Sec. 135. Timely payment of claims.

Sec. 136. Standardized rules for coordination and subrogation of benefits.

Sec. 137. Application of administrative simplification.

Sec. 138. Information on end-of-life planning.

Sec. 139. Utilization review activities.

Sec. 139A. Internal appeals procedures.

Sec. 139B. External appeals procedures.

Subtitle E-Governance

Sec. 141. Health Choices Administration; Health Choices Commissioner.

Sec. 142. Duties and authority of Commissioner.

Sec. 143. Consultation and coordination.

Sec. 144. Health Insurance Ombudsman.

Subtitle F-Relation to Other Requirements; Miscellaneous

Sec. 151. Relation to other requirements.

Sec. 152. Prohibiting discrimination in health care.

Sec. 153. Whistleblower protection.

Sec. 154. Construction regarding collective bargaining.

Sec. 155. Severability.

Sec. 156. Application of State and Federal laws regarding abortion.

Sec. 157. Non-discrimination on abortion and respect for rights of conscience.

Subtitle G-Early Investments

Sec. 161. Ensuring value and lower premiums.

Sec. 162. Ending health insurance rescission abuse.

Sec. 163. Ending health insurance denials and delays of necessary treatment for children with deformities.

Sec. 164. Administrative simplification.

Sec. 165. Expansion of electronic transactions in medicare.

Sec. 166. Reinsurance program for retirees.

Sec. 167. Limitations on preexisting condition exclusions in group health plans and health insurance coverage

in the group and individual markets in advance of applicability of new prohibition of preexisting con-

dition exclusions.

TITLE II—HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

Subtitle A-Health Insurance Exchange

Sec. 201. Establishment of Health Insurance Exchange; outline of duties; definitions.

Sec. 202. Exchange-eligible individuals and employers.

Sec. 203. Benefits package levels.

Sec. 204. Contracts for the offering of Exchange-participating health benefits plans.

Sec. 205. Outreach and enrollment of Exchange-eligible individuals and employers in Exchange-participating

health benefits plans.

Sec. 206. Other functions.

Sec. 207. Health Insurance Exchange Trust Fund.

Sec. 208. Optional operation of State-based health insurance exchanges.

Sec. 209. Limitation on premium increases under Exchange-participating health benefits plans.

Subtitle B—Public Health Insurance Option

Sec. 221. Establishment and administration of a public health insurance option as an Exchange-qualified

health benefits plan.

Sec. 222. Premiums and financing.

Sec. 223. Negotiated payment rates for items and services.

Sec. 224. Modernized payment initiatives and delivery system reform.

Sec. 225. Provider participation.

Sec. 226. Application of fraud and abuse provisions.

Sec. 227. Application of HIPAA insurance requirements.

Sec. 228. Application of health information privacy, security, and electronic transaction requirements.

Sec. 229. Enrollment in public health insurance option is voluntary.

Subtitle C—Individual Affordability Credits

Sec. 241. Availability through Health Insurance Exchange.

Sec. 242. Affordable credit eligible individual.

Sec. 243. Affordable premium credit.

Sec. 244. Affordability cost-sharing credit.

Sec. 245. Income determinations.

Sec. 246. No Federal payment for undocumented aliens.

Subtitle D—Health Insurance Cooperatives

Sec. 251. Establishment.

Sec. 252. Start-up and solvency grants and loans.

Sec. 253. Definitions.

TITLE III—SHARED RESPONSIBILITY

Subtitle A—Individual Responsibility

Sec. 301. Individual responsibility.

Subtitle B—Employer Responsibility

PART 1–HEALTH COVERAGE PARTICIPATION REQUIREMENTS

Sec. 311. Health coverage participation requirements.

Sec. 312. Employer responsibility to contribute towards employee and dependent coverage.

Sec. 313. Employer contributions in lieu of coverage.

Sec. 314. Authority related to improper steering.

PART 24SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS

Sec. 321. Satisfaction of health coverage participation requirements under the Employee Retirement Income Se-

curity Act of 1974.

Sec. 322. Satisfaction of health coverage participation requirements under the Internal Revenue Code of 1986.

Sec. 323. Satisfaction of health coverage participation requirements under the Public Health Service Act.

Sec. 324. Additional rules relating to health coverage participation requirements.

TITLE IV-AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

Subtitle A—Shared Responsibility

PART 1-INDIVIDUAL RESPONSIBILITY

Sec. 401. Tax on individuals without acceptable health care coverage.

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PART 2-EMPLOYER RESPONSIBILITY

Sec. 411. Election to satisfy health coverage participation requirements.
Sec. 412. Responsibilities of nonelecting employers.

Subtitle B-Credit for Small Business Employee Health Coverage Expenses
Sec. 421. Credit for small business employee health coverage expenses.

Subtitle C—Disclosures To Carry Out Health Insurance Exchange Subsidies

Sec. 431. Disclosures to carry out health insurance exchange subsidies.

Subtitle D-Other Revenue Provisions

PART 1–GENERAL PROVISIONS

Sec. 441. Surcharge on high income individuals.
Sec. 442. Delay in application of worldwide allocation of interest.

PART 2—PREVENTION OF TAX AVOIDANCE
Sec. 451. Limitation on treaty benefits for certain deductible payments.
Sec. 452. Codification of economic substance doctrine.
Sec. 453. Penalties for underpayments..,
(c) GENERAL DEFINITIONS.—Except as otherwise provided, in this division:

(1) ACCEPTABLE COVERAGE. — The term “acceptable coverage” has the meaning

given such term in section 202(d)(2).

(2) BASIC PLAN.—The term “basic plan” has the meaning given such term in

section 203(c).

(3) COMMISSIONER.—The term "Commissioner" means the Health Choices

Commissioner established under section 141.

(4) COST-SHARING.–The term “cost-sharing" includes deductibles, coinsurance,
copayments, and similar charges but does not include premiums or any network
payment differential for covered services or spending for non-covered services.

(5) DEPENDENT.—The term “dependent” has the meaning given such term by
the Commissioner and includes a spouse.

(6) EMPLOYMENT-BASED HEALTH PLAN.—The term "employment-based health

plan”

(A) means a group health plan (as defined in section 733(a)(1) of the Em-

ployee Retirement Income Security Act of 1974); and
(B) includes such a plan that is the following:

(i) FEDERAL, STATE, AND TRIBAL GOVERNMENTAL PLANS.—A govern-

mental plan (as defined in section 3(32) of the Employee Retirement In-

come Security Act of 1974), including a health benefits plan offered

under chapter 89 of title 5, United States Code.

(ii) CHURCH PLANS.-A church plan (as defined in section 3(33) of the

Employee Retirement Income Security Act of 1974).

(7) ENHANCED PLAN.—The term “enhanced plan” has the meaning given such

term in section 203(c).

(8) ESSENTIAL BENEFITS PACKAGE.—The term “essential benefits package” is

defined in section 122(a).

(9) FAMILY.—The term “family” means an individual and includes the individ-
ual's dependents.

(10) FEDERAL POVERTY LEVEL; FPL.–The terms "Federal poverty level” and

"FPL” have the meaning given the term “poverty line” in section 673(2) of the

Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision

required by such section.

(11) HEALTH BENEFITS PLAN.—The terms "health benefits plan” means health

insurance coverage and an employment-based health plan and includes the pub-
lic health insurance option and cooperatives under subtitle D of title II.

(12) HEALTH INSURANCE COVERAGE; HEALTH INSURANCE ISSUER.—The terms
"health insurance coverage” and “health insurance issuer” have the meanings
given such terms in section 2791 of the Public Health Service Act.

(13) HEALTH INSURANCE EXCHANGE.—The term "Health Insurance Exchange"
means the Health Insurance Exchange established under section 201.

(14) MEDICAID.—The term “Medicaid” means a State plan under title XIX of
the Social Security Act (whether or not the plan is operating under a waiver
under section 1115 of such Act).

(15) MEDICARE.—The term "Medicare” means the health insurance programs

under title XVIII of the Social Security Act.

(16) PLAN SPONSOR.—The term “plan sponsor" has the meaning given such

term in section 3(16)(B) of the Employee Retirement Income Security Act of

1974.

(17) PLAN YEAR.—The term “plan year” means-

(A) with respect to an employment-based health plan, a plan year as

specified under such plan; or

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