Subtitle B—Public Health Insurance Option

[LSK]

http://budget.house.gov/doc-library/FY2010/03.15.2010_reconciliation2010.PDF

http://budget.house.gov

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•J. 55–345
Subtitle B—Public Health 1
Insurance Option 2
SEC. 221. ESTABLISHMENT AND ADMINISTRATION OF A 3
PUBLIC HEALTH INSURANCE OPTION AS AN 4
EXCHANGE-QUALIFIED HEALTH BENEFITS 5
PLAN. 6
(a) ESTABLISHMENT.—For years beginning with Y1, 7
the Secretary of Health and Human Services (in this sub- 8
title referred to as the ‘‘Secretary’’) shall provide for the 9
offering of an Exchange-participating health benefits plan 10
(in this subdivision referred to as the ‘‘public health insur- 11
ance option’’) that ensures choice, competition, and sta- 12
bility of affordable, high quality coverage throughout the 13
United States in accordance with this subtitle. In design- 14
ing the option, the Secretary’s primary responsibility is 15
to create a low-cost plan without compromising quality or 16
access to care. 17
(b) OFFERING AS AN EXCHANGE-PARTICIPATING 18
HEALTH BENEFITS PLAN.— 19
(1) EXCLUSIVE TO THE EXCHANGE.—The pub- 20
lic health insurance option shall only be made avail- 21
able through the Health Insurance Exchange. 22
(2) ENSURING A LEVEL PLAYING FIELD.—Con- 23
sistent with this subtitle, the public health insurance 24
option shall comply with requirements that are ap- 25
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plicable under this title to an Exchange-participating 1
health benefits plan, including requirements related 2
to benefits, benefit levels, provider networks, notices, 3
consumer protections, and cost sharing. 4
(3) PROVISION OF BENEFIT LEVELS.—The pub- 5
lic health insurance option— 6
(A) shall offer basic, enhanced, and pre- 7
mium plans; and 8
(B) may offer premium-plus plans. 9
(c) ADMINISTRATIVE CONTRACTING.—The Secretary 10
may enter into contracts for the purpose of performing 11
administrative functions (including functions described in 12
subsection (a)(4) of section 1874A of the Social Security 13
Act) with respect to the public health insurance option in 14
the same manner as the Secretary may enter into con- 15
tracts under subsection (a)(1) of such section. The Sec- 16
retary has the same authority with respect to the public 17
health insurance option as the Secretary has under sub- 18
sections (a)(1) and (b) of section 1874A of the Social Se- 19
curity Act with respect to title XVIII of such Act. Con- 20
tracts under this subsection shall not involve the transfer 21
of insurance risk to such entity. 22
(d) OMBUDSMAN.—The Secretary shall establish an 23
office of the ombudsman for the public health insurance 24
option which shall have duties with respect to the public 25
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health insurance option similar to the duties of the Medi- 1
care Beneficiary Ombudsman under section 1808(c)(2) of 2
the Social Security Act. 3
(e) DATA COLLECTION.—The Secretary shall collect 4
such data as may be required to establish premiums and 5
payment rates for the public health insurance option and 6
for other purposes under this subtitle, including to im- 7
prove quality and to reduce racial, ethnic, and other dis- 8
parities in health and health care. 9
(f) TREATMENT OF PUBLIC HEALTH INSURANCE OP- 10
TION.—With respect to the public health insurance option, 11
the Secretary shall be treated as a QHBP offering entity 12
offering an Exchange-participating health benefits plan. 13
(g) ACCESS TO FEDERAL COURTS.—The provisions 14
of Medicare (and related provisions of title II of the Social 15
Security Act) relating to access of Medicare beneficiaries 16
to Federal courts for the enforcement of rights under 17
Medicare, including with respect to amounts in con- 18
troversy, shall apply to the public health insurance option 19
and individuals enrolled under such option under this title 20
in the same manner as such provisions apply to Medicare 21
and Medicare beneficiaries. 22
SEC. 222. PREMIUMS AND FINANCING. 23
(a) ESTABLISHMENT OF PREMIUMS.— 24
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(1) IN GENERAL.—The Secretary shall establish 1
geographically-adjusted premium rates for the public 2
health insurance option in a manner— 3
(A) that complies with the premium rules 4
established by the Commissioner under section 5
113 for Exchange-participating health benefit 6
plans; and 7
(B) at a level sufficient to fully finance the 8
costs of— 9
(i) health benefits provided by the 10
public health insurance option; and 11
(ii) administrative costs related to op- 12
erating the public health insurance option. 13
(2) CONTINGENCY MARGIN.—In establishing 14
premium rates under paragraph (1), the Secretary 15
shall include an appropriate amount for a contin- 16
gency margin. 17
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(b) ACCOUNT.— 18
(1) ESTABLISHMENT.—There is established in 19
the Treasury of the United States an Account for 20
the receipts and disbursements attributable to the 21
operation of the public health insurance option, in- 22
cluding the start-up funding under paragraph (2). 23
Section 1854(g) of the Social Security Act shall 24
apply to receipts described in the previous sentence 25
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in the same manner as such section applies to pay- 1
ments or premiums described in such section. 2
(2) START-UP FUNDING.— 3
(A) IN GENERAL.—In order to provide for 4
the establishment of the public health insurance 5
option there is hereby appropriated to the Sec- 6
retary, out of any funds in the Treasury not 7
otherwise appropriated, $2,000,000,000. In 8
order to provide for initial claims reserves be- 9
fore the collection of premiums, there is hereby 10
appropriated to the Secretary, out of any funds 11
in the Treasury not otherwise appropriated, 12
such sums as necessary to cover 90 days worth 13
of claims reserves based on projected enroll- 14
ment. 15
(B) AMORTIZATION OF START-UP FUND- 16
ING.—The Secretary shall provide for the re- 17
payment of the startup funding provided under 18
subparagraph (A) to the Treasury in an amor- 19
tized manner over the 10-year period beginning 20
with Y1. 21
(C) LIMITATION ON FUNDING.—Nothing in 22
this section shall be construed as authorizing 23
any additional appropriations to the Account, 24
other than such amounts as are otherwise pro- 25
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vided with respect to other Exchange-partici- 1
pating health benefits plans. 2
SEC. 223. PAYMENT RATES FOR ITEMS AND SERVICES. 3
(a) RATES ESTABLISHED BY SECRETARY.— 4
(1) IN GENERAL.—The Secretary shall establish 5
payment rates for the public health insurance option 6
for services and health care providers consistent with 7
this section and may change such payment rates in 8
accordance with section 224. 9
(2) INITIAL PAYMENT RULES.— 10
(A) IN GENERAL.—Except as provided in 11
subparagraph (B) and subsection (b)(1), during 12
Y1, Y2, and Y3, the Secretary shall base the 13
payment rates under this section for services 14
and providers described in paragraph (1) on the 15
payment rates for similar services and providers 16
under parts A and B of Medicare. 17
(B) EXCEPTIONS.— 18
(i) PRACTITIONERS’ SERVICES.—Pay- 19
ment rates for practitioners’ services other- 20
wise established under the fee schedule 21
under section 1848 of the Social Security 22
Act shall be applied without regard to the 23
provisions under subsection (f) of such sec- 24
tion and the update under subsection 25
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(d)(4) under such section for a year as ap- 1
plied under this paragraph shall be not less 2
than 1 percent. 3
(ii) ADJUSTMENTS.—The Secretary 4
may determine the extent to which Medi- 5
care adjustments applicable to base pay- 6
ment rates under parts A and B of Medi- 7
care shall apply under this subtitle. 8
(3) FOR NEW SERVICES.—The Secretary shall 9
modify payment rates described in paragraph (2) in 10
order to accommodate payments for services, such as 11
well-child visits, that are not otherwise covered 12
under Medicare. 13
(4) PRESCRIPTION DRUGS.—Payment rates 14
under this section for prescription drugs that are not 15
paid for under part A or part B of Medicare shall 16
be at rates negotiated by the Secretary. 17
(b) INCENTIVES FOR PARTICIPATING PROVIDERS.— 18
(1) INITIAL INCENTIVE PERIOD.— 19
(A) IN GENERAL.—The Secretary shall 20
provide, in the case of services described in sub- 21
paragraph (B) furnished during Y1, Y2, and 22
Y3, for payment rates that are 5 percent great- 23
er than the rates established under subsection 24
(a). 25
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(B) SERVICES DESCRIBED.—The services 1
described in this subparagraph are items and 2
professional services, under the public health in- 3
surance option by a physician or other health 4
care practitioner who participates in both Medi- 5
care and the public health insurance option. 6
(C) SPECIAL RULES.—A pediatrician and 7
any other health care practitioner who is a type 8
of practitioner that does not typically partici- 9
pate in Medicare (as determined by the Sec- 10
retary) shall also be eligible for the increased 11
payment rates under subparagraph (A). 12
(2) SUBSEQUENT PERIODS.— Beginning with 13
Y4 and for subsequent years, the Secretary shall 14
continue to use an administrative process to set such 15
rates in order to promote payment accuracy, to en- 16
sure adequate beneficiary access to providers, and to 17
promote affordability and the efficient delivery of 18
medical care consistent with section 221(a). Such 19
rates shall not be set at levels expected to increase 20
overall medical costs under the option beyond what 21
would be expected if the process under subsection 22
(a)(2) and paragraph (1) of this subsection were 23
continued. 24
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(3) ESTABLISHMENT OF A PROVIDER NET- 1
WORK.—Health care providers participating under 2
Medicare are participating providers in the public 3
health insurance option unless they opt out in a 4
process established by the Secretary. 5
(c) ADMINISTRATIVE PROCESS FOR SETTING 6
RATES.—Chapter 5 of title 5, United States Code shall 7
apply to the process for the initial establishment of pay- 8
ment rates under this section but not to the specific meth- 9
odology for establishing such rates or the calculation of 10
such rates. 11
(d) CONSTRUCTION.—Nothing in this subtitle shall 12
be construed as limiting the Secretary’s authority to cor- 13
rect for payments that are excessive or deficient, taking 14
into account the provisions of section 221(a) and the 15
amounts paid for similar health care providers and serv- 16
ices under other Exchange-participating health benefits 17
plans. 18
(e) CONSTRUCTION.—Nothing in this subtitle shall be 19
construed as affecting the authority of the Secretary to 20
establish payment rates, including payments to provide for 21
the more efficient delivery of services, such as the initia- 22
tives provided for under section 224. 23
(f) LIMITATIONS ON REVIEW.—There shall be no ad- 24
ministrative or judicial review of a payment rate or meth- 25
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odology established under this section or under section 1
224. 2

[kirby]

1. FYI, Y1 == 2013 n/t