To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,
SHORT TITLE.—This Act may be cited as the ‘‘America’s Affordable Health Choices Act of 2009’’.
IN GENERAL.—The purpose of this division is to provide affordable, quality health care for all Americans and reduce the growth in health care spending.
BUILDING ON CURRENT SYSTEM.—This division achieves this purpose by building on what works in today’s health care system, while repairing the aspects that are broken.
INSURANCE REFORMS.—This division enacts strong insurance market reforms; creates a new Health Insurance Exchange, with a public health insurance option alongside private plans; includes sliding scale affordability credits; and initiates shared responsibility among workers, employers, and the government; so that all Americans have coverage of essential health benefits.
((“alongside private plans” means this most certainly is not a government takeover of health insurance. “sliding scale affordability“ means that lower income individuals on the government option will pay less, unlike private insurance plans.))
Subtitle A—General Standards
IN GENERAL.—The premium rate charged for an insured qualified health benefits plan may not vary except as follows:
LIMITED AGE VARIATION PERMITTED.—By age (within such age categories as the Commissioner shall specify) so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 2 to 1.
BY AREA.—By premium rating area (as permitted by State insurance regulators or, in the case of Exchange-participating health benefits plans, as specified by the Commissioner in consultation with such regulators).
BY FAMILY ENROLLMENT.—By family enrollment (such as variations within categories and compositions of families) so long as the ratio of the premium for family enrollment (or enrollments) to the premium for individual enrollment is uniform, as specified under State law and consistent with rules of the Commissioner.
((At this stage the bill puts a great many stipulations unto the Commissioner while retaining the existing powers of State law and insurance regulators.))
SEC. 142. DUTIES AND AUTHORITY OF COMMISSIONER.
DUTIES.—The Commissioner is responsible for carrying out the following functions under this division:
QUALIFIED PLAN STANDARDS.—The establishment of qualified health benefits plan standards under this title, including the enforcement of such standards in coordination with State insurance regulators and the Secretaries of Labor and the Treasury.
HEALTH INSURANCE EXCHANGE.—The establishment and operation of a Health Insurance Exchange under subtitle A of title II.
INDIVIDUAL AFFORDABILITY CREDITS.— The administration of individual affordability credits under subtitle C of title II, including determination of eligibility for such credits.
IN GENERAL.—The Commissioner shall undertake activities in accordance with this subtitle to promote accountability of QHBP offering entities in meeting Federal health insurance requirements, regardless of whether such accountability is with respect to qualified health benefits plans offered through the Health Insurance Exchange or outside of such Exchange.
COMPLIANCE EXAMINATION AND AUDITS.—
IN GENERAL.—The Commissioner shall, in coordination with States, conduct audits of qualified health benefits plan compliance with Federal requirements. Such audits may include random compliance audits and targeted audits in response to complaints or other suspected non-compliance.
RECOUPMENT OF COSTS IN CONNECTION WITH EXAMINATION AND AUDITS.—The Commissioner is authorized to recoup from qualified health benefits plans reimbursement for the costs of such examinations and audit of such QHBP offering entities.
DATA COLLECTION.—The Commissioner shall collect data for purposes of carrying out the Commissioner’s duties, including for purposes of promoting quality and value, protecting consumers, and addressing disparities in health and health care and may share such data with the Secretary of Health and Human Services
IN GENERAL.—In the case that the Commissioner determines that a QHBP offering entity violates a requirement of this title, the Commissioner may, in coordination with State insurance regulators and the Secretary of Labor, provide, in addition to any other remedies authorized by law, for any of the remedies described in paragraph
REMEDIES.—The remedies described in this paragraph, with respect to a qualified health benefits plan offered by a QHBP offering entity, are— (A) civil money penalties of not more than the amount that would be applicable under similar circumstances for similar violations under section 1857(g) of the Social Security Act; suspension of enrollment of individuals under such plan after the date the Commissioner notifies the entity of a determination under paragraph (1) and until the Commissioner is satisfied that the basis for such determination has been corrected and is not likely to recur;SEC. 2714.
ENSURING VALUE AND LOWER PREMIUMS.
IN GENERAL.—Each health insurance issuer that offers health insurance coverage in the small or large group market shall provide that for any plan year in which the coverage has a medical loss ratio below a level specified by the Secretary, the issuer shall provide in a manner specified by the Secretary for rebates to enrollees of payment sufficient to meet such loss ratio. Such methodology shall be set at the highest level medical loss ratio possible that is designed to ensure adequate participation by issuers, competition in the health insurance market, and value for consumers so that their premiums are used for services.
(“ensure adequate participation by issuers” is the key concept to understand.)
UNIFORM DEFINITIONS.—The Secretary shall establish a uniform definition of medical loss ratio and methodology for determining how to calculate the medical loss ratio. Such methodology shall be designed to take into account the special circumstances of smaller plans, different types of plans, and newer plans.The provisions of section 2714 shall apply to health insurance coverage offered in the individual market in the same manner as such provisions apply to health insurance coverage offered in the small or large group market.
IMMEDIATE IMPLEMENTATION.—The amendments made by this section shall apply in the group and individual market for plan years beginning on or after January 1, 2011.SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE
TRANSACTIONS.STANDARDS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS.—
IN GENERAL.—The Secretary shall adopt and regularly update standards consistent with the goals described in paragraph (2).
(2) GOALS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS.—The goals for standards under paragraph (1) are that such standards shall be unique with no conflicting or redundant standards; be authoritative, permitting no additions or constraints for electronic transactions, including companion guides; be comprehensive, efficient and robust, requiring minimal augmentation by paper transactions or clarification by further communications; enable the real-time (or near real-time) determination of an individual’s financial responsibility at the point of service and, to the extent possible, prior to service, including whether the individual is eligible for a specific service with a specific physician at a specific facility, which may include utilization of a machine-readable health plan beneficiary identification card; enable, where feasible, near real-time adjudication of claims; provide for timely acknowledgment, response, and status reporting applicable to any electronic transaction deemed appropriate by the Secretary; describe all data elements (such as reason and remark codes) in unambiguous terms, not permit optional fields, require that data elements be either required or conditioned upon set values in other fields, and prohibit additional conditions; and harmonize all common data elements across administrative and clinical transaction standards.
TIME FOR ADOPTION.—Not later than years after the date of implementation of the X12 Version 5010 transaction standards implemented under this part, the Secretary shall adopt standards under this section.
REQUIREMENTS FOR SPECIFIC STANDARDS.—The standards under this section shall be developed, adopted and enforced so as to— (A) clarify, refine, complete, and expand, as needed, the standards required under section 1173; (B) require paper versions of standardized transactions to comply with the same standards as to data content such that a fully compliant, equivalent electronic transaction can be populated from the data from a paper version; (C) enable electronic funds transfers, in order to allow automated reconciliation with the related health care payment and remittance advice; (D) require timely and transparent claim and denial management processes, including tracking, adjudication, and appeal processing; (E) require the use of a standard electronic transaction with which health care providers may quickly and efficiently enroll with a health plan to conduct the other electronic transactions provided for in this part; and (F) provide for other requirements relating to administrative simplification as identified by the Secretary, in consultation with stake holders.
BUILDING ON EXISTING STANDARDS.—In developing the standards under this section, the Secretary shall build upon existing and planned standards.
IMPLEMENTATION AND ENFORCEMENT.—Not later than 6 months after the date of the enactment of this section, the Secretary shall submit to the appropriate committees of Congress a plan for the implementation and enforcement, by not later than 5 years after such date of enactment, of the standards under this section.