SUMMARY OF PATIENT PROTECTION AND AFFORDABLE CARE ACT. Prepared by Health Policy Alternatives

Transcription

1 SUMMARY OF PATIENT PROTECTION AND AFFORDABLE CARE ACT Prepared by Health Policy Alternatives April 5, 2010

2 NOTE FOR READERS This summary of the Patient Protection and Affordable Care Act (PPACA, P.L ), as amended by the Health Care and Education Reconciliation Act of 2010 (HCERA, P.L ), was prepared by Health Policy Alternatives. Except for a few selected provisions, this edition of the summary does not include Title V, Health Care Workforce. A revised summary with a complete Title V will be available in the near future. The summary includes revenue provisions except those unrelated to health care. The organization of the summary follows PPACA, with entirely new sections added by Title X of that law or by HCERA placed at the end of the related material in the summary. Changes made to existing sections of PPACA by Title X of that law or by HCERA are incorporated in the description of the pertinent section. We wish to acknowledge helpful assistance from Julie James in preparing the summary. Health Policy Alternatives April 5, 2010

3 PATIENT PROTECTION AND AFFORDABLE CARE ACT Table of Contents TITLE I QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS.. 1 Subtitle A Immediate Improvements in Health Care Coverage for All Americans Sec Amendments to the Public Health Service Act PHS Act sec No lifetime or annual limits (as modified by sec and sec of HCERA). (p. 1) PHS Act sec Prohibition on rescissions (as modified by sec of HCERA). (p. 1) PHS Act sec Coverage of Preventive Health Services (as modified by sec ). (p. 2) PHS Act sec Extension of dependent coverage (as modified by sec of HCERA). (p. 2) PHS Act sec Development and utilization of uniform explanation of coverage documents and standardized definitions (as modified by sec ). (p. 3) PHS Act sec. 2715A. Provision of additional information (as modified by sec ). (p. 3) PHS Act sec Prohibition of discrimination based on salary (as modified by sec ). (p. 4) PHS Act sec Ensuring the Quality of Care (as modified by sec ). (p. 4) PHS Act sec Bringing down the cost of health care coverage (as modified by sec ). (p. 5) PHS Act sec Appeals process (as modified by sec ). (p. 6) PHS Act sec. 2719A. Patient Protections (as modified by sec ). (p. 6) Sec Health insurance consumer information....7 PHS Act sec Health Insurance Consumer Information. (p. 7) Sec Ensuring that consumers get value for their dollars... 8 PHS Act sec Ensuring that consumers get value for their dollars as modified by sec ). (p. 8) Sec Effective dates....9 Subtitle B Immediate Actions to Preserve and Expand Coverage. 9 Sec Immediate access to insurance for uninsured individuals with a preexisting condition... 9 Sec Reinsurance for early retirees Sec Immediate information that allows consumers to identify affordable coverage options.. 11 Sec Administrative simplification..12 Sec Effective date...15 Subtitle C Quality Health Insurance Coverage for All Americans. 15 PART I HEALTH INSURANCE MARKET REFORMS Sec Amendment to the Public Health Service Act. 15 Prepared by Health Policy Alternatives April 5, i -

4 PHS Act sec Fair health insurance premiums (as modified by sec ). (p. 15) PHS Act sec Guaranteed availability of coverage. (p. 15) PHS Act sec Guaranteed renewability of coverage. (p. 16) PHS Act sec Prohibition of preexisting condition exclusions or other discrimination based on health status (as modified by sec ). (p. 16) PHS Act sec Prohibiting discrimination against individual participants and beneficiaries based on health status. (p. 16) PHS Act sec Non-discrimination in health care. (p. 18) PHS Act sec Comprehensive health insurance coverage. (p. 18) PHS Act sec Prohibition on excessive waiting periods. (p. 19) PHS Act sec Coverage for individuals participating in approved clinical trials (as modified by sec ). (p. 19) PART II OTHER PROVISIONS Sec Preservation of right to maintain existing coverage Sec Rating reforms must apply uniformly to all health insurance issuers and group health plans Sec Effective dates Sec Study of large group market (as modified by sec ) Sec Effective dates Subtitle D Available Coverage Choices for All Americans PART I ESTABLISHMENT OF QUALIFIED HEALTH PLANS...21 Sec Qualified health plan defined. 21 Sec Essential health benefits requirements Sec Special rules. 24 Sec Related definitions PART II CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH BENEFIT EXCHANGES Sec Affordable choices of health benefit plans Sec Consumer choice Sec Financial integrity PART III STATE FLEXIBILITY RELATING TO EXCHANGES Sec State flexibility in operation and enforcement of Exchanges and related requirements Sec Federal program to assist establishment and operation of nonprofit, member-run health insurance issuers Sec Community health insurance option Sec Level playing field PART IV STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE PROGRAMS Sec State flexibility to establish basic health programs for low-income individuals not eligible for Medicaid Sec Waiver for State innovation...38 Sec Provisions relating to offering of plans in more than one State...39 Sec Multi-state plans (as modified by sec ) PART V REINSURANCE AND RISK ADJUSTMENT Sec Transitional reinsurance program for individual and small group markets in each State. 41 Prepared by Health Policy Alternatives April 5, ii -

5 Sec Establishment of risk corridors for plans in individual and small group markets..43 Sec Risk adjustment...43 Implementation Funding (added by sec of HCERA)...44 Subtitle E Affordable Coverage Choices for All Americans PART I PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS...44 SUBPART A PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS. 44 Sec Refundable tax credit providing premium assistance for coverage under a qualified health plan 44 Sec Reduced cost-sharing for individuals enrolling in qualified health plans..46 SUBPART B ELIGIBILITY DETERMINATIONS Sec Procedures for determining eligibility for Exchange participation, premium tax credits and reduced cost-sharing, and individual responsibility exemptions Sec Advance determination and payment of premium tax credits and costsharing reductions Sec Streamlining of procedures for enrollment through an exchange and State Medicaid, CHIP, and health subsidy programs...49 Sec Disclosures to carry out eligibility requirements for certain programs...50 Sec Premium tax credit and cost-sharing reduction payments disregarded for Federal and Federally-assisted programs...50 Sec Study of geographic variation in application of FPL (added by sec ) PART II SMALL BUSINESS TAX CREDIT Sec Credit for employee health insurance expenses of small businesses Subtitle F Shared Responsibility for Health Care..52 PART I INDIVIDUAL RESPONSIBILITY.52 Sec Requirement to maintain minimum essential coverage Sec Reporting of health insurance coverage. 53 PART II EMPLOYER RESPONSIBILITIES...53 Sec Automatic enrollment for employees of large employers Sec Employer requirement to inform employees of coverage options..54 Sec Shared responsibility for employers 54 Sec Reporting of employer health insurance coverage...55 Sec Offering of Exchange-participating qualified health plans through cafeteria plans Subtitle G Miscellaneous Provisions Sec Definitions. 55 Sec Transparency in government. 55 Sec Prohibition against discrimination on assisted suicide..56 Sec Access to therapies. 56 Sec Freedom not to participate in Federal health insurance programs..56 Sec Equity for certain eligible survivors...56 Sec Nondiscrimination...56 Sec Protections for employees. 57 Prepared by Health Policy Alternatives April 5, iii -

6 Sec Oversight..57 Sec Rules of construction..57 Sec Health information technology enrollment standards and protocols..57 Sec Conforming amendments...58 Sec Conforming amendments (as modified by sec )...58 Sec Small Business Procurement (as added by sec )..58 Sec Sense of the Senate promoting fiscal responsibility..58 Sec Free Choice Vouchers Sec. 1004(d) of HCERA: Adult dependents TITLE II ROLE OF PUBLIC PROGRAMS...59 Subtitle A Improved Access to Medicaid.59 Sec Medicaid coverage for the lowest income populations..59 Sec Income eligibility for nonelderly determined using modified gross income...61 Sec Requirement to offer premium assistance for employer-sponsored insurance..62 Sec Medicaid coverage for former foster care children...62 Sec Payments to territories 63 Sec Special adjustment to FMAP determination for certain States recovering from a major disaster..63 Sec Medicaid Improvement Fund rescission.. 63 Subtitle B Enhanced Support for the Children s Health Insurance Program.. 63 Sec Additional federal financial participation for CHIP..63 Sec Technical corrections..64 Subtitle C Medicaid and CHIP Enrollment Simplification Sec Enrollment Simplification and coordination with State Health Insurance Exchanges. 64 Sec Permitting hospitals to make presumptive eligibility determinations for all Medicaid eligible populations Subtitle D Improvements to Medicaid Services.65 Sec Coverage for freestanding birth center services Sec Concurrent care for children..65 Sec State eligibility option for family planning services. 65 Sec Clarification of definition of medical assistance..66 Subtitle E New Options for States to Provide Long-Term Services and Supports...66 Sec Community First Choice Option Sec Removal of barriers to providing home and community-based services. 66 Sec Money Follows the Person Rebalancing Demonstration..67 Sec Protection for recipients of home and community-based services against spousal impoverishment Sec Funding to expand State Aging and Disability Resource Centers..67 Sec Sense of the Senate regarding long-term care..67 Prepared by Health Policy Alternatives April 5, iv -

7 Subtitle F Medicaid Prescription Drug Coverage..67 Sec Prescription drug rebates...67 Sec Elimination of exclusion of coverage of certain drugs...68 Sec Providing adequate pharmacy reimbursement...68 Subtitle G Medicaid Disproportionate Share Hospital (DSH) Payments. 69 Sec Disproportionate share hospital payments..69 Subtitle H Improved Coordination for Dual Eligible Beneficiaries 69 Sec year period for demonstration projects. 69 Sec Providing Federal coverage and payment coordination for dual eligible beneficiaries Subtitle I Improving the Quality of Medicaid for Patients and Providers...70 Sec Adult health quality measures...70 Sec Payment Adjustment for Health Care-Acquired Conditions. 70 Sec State option to provide health homes for enrollees with chronic conditions..71 Sec Demonstration project to evaluate integrated care around a hospitalization..71 Sec Medicaid Global Payment System Demonstration Project...72 Sec Pediatric Accountable Care Organization Demonstration Project...72 Sec Medicaid emergency psychiatric demonstration project...72 Subtitle J Improvements to the Medicaid and CHIP Payment and Access Commission (MACPAC). 72 Sec MACPAC assessment of policies affecting all Medicaid beneficiaries. 72 Subtitle K Protections for American Indians and Alaska Natives.73 Sec Special rules relating to Indians...73 Sec Elimination of sunset for reimbursement for all Medicare Part B services furnished by certain Indian hospitals and clinics. 73 Sec (i) Amendments to Section 1115 Waivers...73 Sec Incentives for States to Offer Home and Community-Based Services as a Long-Term Care Alternative.74 Sec of HCERA. Payments to Primary Care Physicians.74 Subtitle L Maternal and Child Health Services.. 75 Sec Maternal, infant, and early childhood home visiting programs. 75 Sec Support, education, and research for postpartum depression. 75 Sec Personal responsibility education. 75 Sec Restoration of funding for abstinence education...75 Sec Inclusion of information about the importance of having a health care power of attorney in transition planning for children aging out of foster care and independent living programs. 76 Sec Definitions for pregnancy assistance fund 76 Sec Definitions for pregnancy assistance fund 76 Sec Permissible uses of Fund.76 Sec Appropriations 77 Prepared by Health Policy Alternatives April 5, v -

8 Sec Indian health care improvement.77 TITLE III IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE.77 Subtitle A Transforming the Health Care Delivery System...77 PART I LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE MEDICARE PROGRAM Sec Hospital Value-Based purchasing program. 77 Sec Improvements to the physician quality reporting system..79 Sec Improvements to the physician feedback program Sec Quality reporting for long-term care hospitals, inpatient rehabilitation hospitals, and hospice programs..80 Sec Quality reporting for PPS-exempt cancer hospitals...80 Sec Plans for a Value-Based purchasing program for skilled nursing facilities and home health agencies..80 Sec Value-based payment modifier under the physician fee schedule..81 Sec Payment adjustment for conditions acquired in hospitals.82 Sec Pilot testing pay-for-performance programs for certain Medicare providers 82 Sec Public reporting of performance information.82 PART II NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITY 83 Sec National strategy..83 Sec Interagency Working Group on Health Care Quality. 83 Sec Quality measure development..83 Sec Quality measurement..84 Sec Data collection; public reporting PART III ENCOURAGING DEVELOPMENT OF NEW PATIENT CARE MODELS..85 Sec Establishment of Center for Medicare and Medicaid Innovation within CMS 85 Sec Medicare shared savings program...85 Sec National pilot program on payment bundling..85 Sec Independence at home demonstration program Sec Hospital readmissions reduction program...87 Sec Community-Based Care Transitions Program Sec Extension of gainsharing demonstration. 89 Subtitle B Improving Medicare for Patients and Providers. 89 PART I ENSURING BENEFICIARY ACCESS TO PHYSICIAN CARE AND OTHER SERVICES. 89 Sec Increase in the physician payment update..89 Sec Extension of the work geographic index floor and revisions to the practice expense geographic adjustment under the Medicare physician fee schedule 89 Sec Extension of exceptions process for Medicare therapy caps...89 Sec Extension of payment for technical component of certain physician pathology services Sec Extension of ambulance add-ons. 89 Sec Extension of certain payment rules for long-term care hospital services and of moratorium on the establishment of certain hospitals and facilities...90 Sec Extension of physician fee schedule mental health add-on. 90 Prepared by Health Policy Alternatives April 5, vi -

9 Sec Permitting physician assistants to order post-hospital extended care services. 90 Sec Exemption of certain pharmacies from accreditation requirements Sec Part B special enrollment period for disabled TRICARE beneficiaries.. 91 Sec Payment for bone density tests. 91 Sec Revision to the Medicare Improvement Fund. 91 Sec Treatment of certain complex diagnostic laboratory tests Sec Improved access for certified nurse-midwife services...91 Sec GAO study and report on Medicare beneficiary access to high-quality dialysis services...91 PART II RURAL PROTECTIONS..91 Sec Extension of outpatient hold harmless provision Sec Extension of Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural.areas 92 Sec Extension of the Rural Community Hospital Demonstration Program. 92 Sec Extension of the Medicare-dependent hospital (MDH) program.92 Sec Temporary improvements to the Medicare inpatient hospital payment adjustment for low-volume hospitals Sec Improvements to the demonstration project on community health integration models in certain rural counties. 92 Sec MedPAC study on adequacy of Medicare payments for health care providers serving in rural areas 92 Sec Technical correction related to critical access hospital services. 92 Sec Extension of and revisions to Medicare rural hospital flexibility program. 92 PART III IMPROVING PAYMENT ACCURACY.93 Sec Payment adjustments for home health care...93 Sec Hospice reform 93 Sec Improvement to Medicare disproportionate share hospital (DSH) payments..94 Sec Misvalued codes under the physician fee schedule..94 Sec Modification of equipment utilization factor for advanced imaging services. 95 Sec Revision of payment for power-driven wheelchairs...95 Sec Hospital wage index improvement...96 Sec Treatment of certain cancer hospitals..96 Sec Payment for biosimilar biological products..96 Sec Medicare hospice concurrent care demonstration program. 96 Sec Application of budget neutrality on a national basis in the calculation of the Medicare hospital wage index floor Sec HHS study on urban Medicare-dependent hospitals. 97 Sec Protecting home health benefits...97 Sec Revision to skilled nursing facility prospective payment system...97 Subtitle C Provisions Relating to Part C..97 Sec Medicare Advantage payment..97 Sec Benefit protection and simplification. 98 Sec Application of coding intensity adjustment during MA payment transition...98 Prepared by Health Policy Alternatives April 5, vii -

10 Sec Simplification of annual beneficiary election periods 99 Sec Extension for specialized MA plans for special needs individuals..99 Sec Extension of reasonable cost contracts...99 Sec Technical correction to MA private fee-for-service plans Sec Making senior housing facility demonstration permanent..100 Sec Authority to deny plan bids..100 Sec Development of new standards for certain Medigap plans Sec of HCERA. Savings from limits on MA plan administrative costs Subtitle D Medicare Part D Improvements for Prescription Drug Plans and MA PD Plans 100 Sec Medicare coverage gap discount program 100 Sec Improvement in determination of Medicare part D low-income benchmark premium.102 Sec Voluntary de minimis policy for subsidy eligible individuals under prescription drug plans and MA PD plans 102 Sec Special rule for widows and widowers regarding eligibility for low-income assistance.102 Sec Improved information for subsidy eligible individuals reassigned to prescription drug plans and MA PD plans Sec Funding outreach and assistance for low-income programs. 102 Sec Improving formulary requirements for prescription drug plans and MA PD plans with respect to certain categories or classes of drugs Sec Reducing part D premium subsidy for high-income beneficiaries.103 Sec Elimination of cost sharing for certain dual eligible individuals..103 Sec Reducing wasteful dispensing of outpatient prescription drugs in long-term care facilities under prescription drug plans and MA PD plans..103 Sec Improved Medicare prescription drug plan and MA PD plan complaint system Sec Uniform exceptions and appeals process for prescription drug plans and MA PD plans Sec Office of the Inspector General studies and reports Sec Including costs incurred by AIDS drug assistance programs and Indian Health Service in providing prescription drugs toward the annual out-of-pocket threshold under part D Sec Immediate reduction in coverage gap in Sec Improvement in part D medication therapy management (MTM) Programs 105 Subtitle E Ensuring Medicare Sustainability Sec Revision of certain market basket updates and incorporation of productivity improvements into market basket updates that do not already incorporate such improvements..105 Sec Temporary adjustment to the calculation of part B premiums Sec Independent Medicare Advisory Board. 107 Sec of HCERA. Payment for qualifying hospitals.109 Subtitle F Health Care Quality Improvements..109 Sec Health care delivery system research; Quality improvement technical assistance..109 Prepared by Health Policy Alternatives April 5, viii -

11 Sec Establishing community health teams to support the patient-centered medical home Sec Medication management services in treatment of chronic disease Sec Design and implementation of regionalized systems for emergency care..110 Sec Trauma care centers and service availability Sec Program to facilitate shared decisionmaking Sec Presentation of prescription drug benefit and risk information..111 Sec Demonstration program to integrate quality improvement and patient safety training into clinical education of health professionals Sec Improving women s health Sec Patient navigator program Sec Authorization of appropriations Sec Community-based collaborative care networks.111 Sec Minority health.111 Subtitle G Protecting and Improving Guaranteed Medicare Benefits Sec Protecting and improving guaranteed Medicare benefits Sec No cuts in guaranteed benefits Sec Medicare coverage for individuals exposed to environmental health hazards 112 TITLE IV PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH.112 Subtitle A Modernizing Disease Prevention and Public Health Systems.112 Sec National Prevention, Health Promotion and Public Health Council Sec Prevention and Public Health Fund Sec Clinical and community preventive services 113 Sec Education and outreach campaign regarding preventive benefits Subtitle B Increasing Access to Clinical Preventive Services. 114 Sec School-based health centers Sec Oral healthcare prevention activities..114 Sec Medicare coverage of annual wellness visit providing a personalized prevention plan..114 Sec Removal of barriers to preventive services in Medicare. 115 Sec Evidence-based coverage of preventive services in Medicare..115 Sec Improving access to preventive services for eligible adults in Medicaid..115 Sec Coverage of comprehensive tobacco cessation services for pregnant women in Medicaid..115 Sec Incentives for prevention of chronic diseases in Medicaid. 116 Subtitle C Creating Healthier Communities..116 Sec Community transformation grants..116 Sec Healthy aging, living well; evaluation of community-based prevention and wellness programs for Medicare beneficiaries..117 Sec Removing barriers and improving access to wellness for individuals with disabilities Sec Immunizations Sec Nutrition labeling of standard menu items at chain restaurants Prepared by Health Policy Alternatives April 5, ix -

12 Sec Demonstration project concerning individualized wellness plan Sec Reasonable break time for nursing mothers. 118 Subtitle D Support for Prevention and Public Health Innovation Sec Research on optimizing the delivery of public health services..118 Sec Understanding health disparities: data collection and analysis. 118 Sec CDC and employer-based wellness programs. 119 Sec Epidemiology-Laboratory Capacity Grants Sec Advancing research and treatment for pain care management 119 Sec Funding for Childhood Obesity Demonstration Project..120 Subtitle E Miscellaneous Provisions..120 Sec Sense of the Senate concerning CBO scoring.120 Sec Effectiveness of Federal health and wellness initiatives.120 Sec Amendment relating to waiving coinsurance for preventive services.120 Sec Better diabetes care 120 Sec Grants for small businesses to provide comprehensive workplace wellness programs 121 Sec Cures Acceleration Network..121 Sec Centers of Excellence for Depression.121 Sec Programs relating to congenital heart disease Sec Automated Defibrillation in Adam s Memory Act 121 Sec Young women s breast health awareness and support of young women diagnosed with breast cancer 121 TITLE V HEALTH CARE WORKFORCE Subtitle A Purpose and Definitions.121 Sec Interagency Task Force to Assess and Improve Access to Health Care in the State of Alaska (added by Sec.10501).121 Subtitle D Enhancing Health Care Workforce Education and Training. 121 Sec Demonstration Grants for Family Nurse Practitioner Training Programs. (added by Sec 10501) Subtitle F Strengthening Primary Care and Other Workforce Improvements Sec Expanding access to primary care services and general surgery services Sec Medicare Federally qualified health center improvements. 122 Sec Distribution of additional residency positions Sec Counting resident time in nonprovider settings Sec Rules for counting resident time for didactic and scholarly activities and other activities Sec Preservation of resident cap positions from closed hospitals Subtitle G Improving Access to Health Care Services Sec State Grants to Health Care Providers Who Provide Services to a High Percentage or Medically Underinsured Populations or Other Special Populations. (added by Sec ). 123 Sec Amendments to the Public Health Service Act..124 Amends Sec. 399V-3 of the PHS Act. National Diabetes Prevention Prepared by Health Policy Alternatives April 5, x -

13 Program. Amends Sec. 749B of the PHS Act. Rural Physician Training Grants. (p. 124) Amends Sec. 768 to the PHS Act. Preventive Medicine and Public Health Training Grant Program. (p. 124) Amends Sec. 770(a) of the PHS Act. (p. 124) Sec Infrastructure to Expand Access to Care 124 Sec Community Health Centers and the National Health Service Corps Fund (as amended by Sec of HCERA) Sec of PPACA. Demonstration project to provide access to affordable care..124 TITLE VI TRANSPARENCY AND PROGRAM INTEGRITY..125 Subtitle A Physician Ownership and Other Transparency Sec Limitation on Medicare exception to the prohibition on certain physician referrals for hospitals..125 Sec Transparency reports and reporting of physician ownership or investment interests..126 Sec Disclosure requirements for in-office ancillary services exception to the prohibition on physician self-referral for certain imaging services..126 Sec Prescription drug sample transparency. 126 Sec Pharmacy benefit managers transparency requirements Subtitle B Nursing Home Transparency and Improvement PART I IMPROVING TRANSPARENCY OF INFORMATION Sec Required disclosure of ownership and additional disclosable parties information..127 Sec Accountability requirements for skilled nursing facilities and nursing facilities Sec Nursing home compare Medicare website Sec Reporting of expenditures Sec Standardized complaint form..127 Sec Ensuring staffing accountability..128 Sec GAO study and report on Five-Star Quality Rating System..128 PART II TARGETING ENFORCEMENT Sec Civil money penalties Sec National independent monitor demonstration project..128 Sec Notification of facility closure Sec National demonstration projects on culture change and use of information technology in nursing homes..128 PART III IMPROVING STAFF TRAINING.128 Sec Dementia and abuse prevention training..128 Subtitle C Nationwide Program for National and State Background Checks on Direct Patient Access Employees of Long-term Care Facilities and Providers Sec Nationwide program for National and State background checks on direct patient access employees of long-term care facilities and providers Subtitle D Patient-Centered Outcomes Research Sec Patient-Centered Outcomes Research..129 Prepared by Health Policy Alternatives April 5, xi -

14 Sec Federal coordinating council for comparative effectiveness research..130 Subtitle E Medicare, Medicaid, and CHIP Program Integrity Provisions..130 Sec Provider screening and other enrollment requirements under Medicare, Medicaid, and CHIP Sec Enhanced Medicare and Medicaid program integrity provisions Sec Elimination of duplication between the Healthcare Integrity and Protection Data Bank and the National Practitioner Data Bank. 133 Sec Maximum period for submission of Medicare claims reduced to not more than 12 months Sec Physicians who order items or services required to be Medicare enrolled physicians or eligible professionals. 133 Sec Requirement for physicians to provide documentation on referrals to programs at high risk of waste and abuse 133 Sec Face to face encounter with patient required before physicians may certify eligibility for home health services or durable medical equipment under Medicare Sec Enhanced penalties..134 Sec Medicare self-referral disclosure protocol. 134 Sec Adjustments to the Medicare durable medical equipment, prosthetics, orthotics, and supplies competitive acquisition program Sec Expansion of the Recovery Audit Contractor (RAC) program Subtitle F Additional Medicaid Program Integrity Provisions..135 Sec Termination of provider participation under Medicaid if terminated under Medicare or other State plan Sec Medicaid exclusion from participation relating to certain ownership, control, and management affiliations. 135 Sec Billing agents, clearinghouses, or other alternate payees required to register under Medicaid Sec Requirement to report expanded set of data elements under MMIS to detect fraud and abuse Sec Prohibition on payments to institutions or entities located outside of the United States Sec Overpayments Sec Mandatory State use of national correct coding initiative Sec General effective date..136 Subtitle G Additional Program Integrity Provisions Sec Prohibition on false statements and representations..136 Sec Clarifying definition Sec Development of model uniform report form..136 Sec Applicability of State law to combat fraud and abuse.136 Sec Enabling the Department of Labor to issue administrative summary cease and desist orders and summary seizures orders against plans that are in financially hazardous condition Sec MEWA plan registration with Department of Labor. 137 Sec Permitting evidentiary privilege and confidential communications Prepared by Health Policy Alternatives April 5, xii -

15 Subtitle H Elder Justice Act..137 Sec Short title of subtitle..137 Sec Definitions Sec Elder Justice..137 Subtitle I Sense of the Senate Regarding Medical Malpractice Sec Sense of the Senate regarding medical malpractice Sec GAO Study on Causes of Action..137 Sec Health care fraud enforcement.138 Sec State demonstration programs to evaluate alternatives to current medical tort litigation.138 Sec Extension of medical malpractice coverage to free clinics..138 Sec Labeling changes 139 Sec of HCERA. Community mental health centers.139 Sec of HCERA. Medicare prepayment medical review limitations.139 TITLE VII IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES Subtitle A Biologics Price Competition and Innovation 139 Sec Short title. 139 Sec Approval pathway for biosimilar biological products Sec Savings Subtitle B More Affordable Medicines for Children and Underserved Communities Sec Expanded participation in 340B program..141 Sec Improvements to 340B program integrity..142 Sec GAO study to make recommendations on improving the 340B program TITLE VIII CLASS ACT. 142 Sec Short title of title. 142 Sec Establishment of national voluntary insurance program for purchasing community living assistance services and support. 143 TITLE IX REVENUE PROVISIONS 146 Subtitle A Revenue Offset Provisions 146 Sec Excise tax on high cost employer-sponsored health coverage. 146 Sec Inclusion of cost of employer-sponsored health coverage on W Sec Distributions for medicine qualified only if for prescribed drug or insulin..148 Sec Increase in additional tax on distributions from HSAs and Archer MSAs not used for qualified medical expenses Sec Limitation on health flexible spending arrangements under cafeteria plans Sec Expansion of information reporting requirements Sec Additional requirements for charitable hospitals..148 Sec Imposition of annual fee on branded prescription pharmaceutical manufacturers and importers..149 Prepared by Health Policy Alternatives April 5, xiii -

16 Sec Imposition of annual fee on medical device manufacturers and importers. 149 Sec Imposition of annual fee on health insurance providers. 150 Sec Study and report of effect on veterans health care.150 Sec Elimination of deduction for expenses allocable to Medicare Part D subsidy Sec Modification of itemized deduction for medical expenses..150 Sec Limitation on excessive remuneration paid by certain health insurance providers Sec Additional hospital insurance tax on high-income taxpayers. 151 Sec Modification of section 833 treatment of certain health organizations..151 Sec Excise tax on elective cosmetic medical procedures..151 Subtitle B Other Provisions Sec Exclusion of health benefits provided by Indian tribal governments..152 Sec Establishment of simple cafeteria plans for small businesses..152 Sec Qualifying therapeutic discovery project credit 152 NOTE: The following revenue measures are not directly related to health care, and not summarized: Sec of HCERA: Elimination of unintended application of cellulosic biofuel producer credit. Sec of HCERA: Codification of economic substance doctrine and imposition of penalties. Sec of HCERA: Time for payment of corporate estimated taxes. Prepared by Health Policy Alternatives April 5, xiv -

17 SUMMARY OF PATIENT PROTECTION AND AFFORDABLE CARE ACT TITLE I QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS Subtitle A Immediate Improvements in Health Care Coverage for All Americans Sec Amendments to the Public Health Service Act (PHS)(as modified by sec and sec of HCERA). Redesignates certain existing sections of title XXVII of the PHS Act and inserts new provisions. New or revised PHS Act sections are identified below. Note. See below sec of the Act (sec of the PHS Act) for the prohibition on preexisting condition exclusions with respect to enrollees in group or individual health insurance who are under 19 years of age. This provision is effective for plan years beginning on or after the date that is 6 months after enactment. Applies also for those under 19 to grandfathered group health plans for plan years beginning on or after 9/23/2010. PHS Act sec No lifetime or annual limits (as modified by sec and sec of HCERA). Amends the PHS Act to prohibit a group health plan and an issuer offering group or individual health insurance coverage from establishing lifetime limits on the dollar value of benefits for any participant or beneficiary; or impose annual limits on the dollar value of benefits for any participant or beneficiary. Provides that prior to 1/1/2014, a group health plan or issuer offering group or individual coverage may only establish a restricted annual limit on the dollar value of benefits with respect to the scope of the essential benefit package (see 1302 below for a definition). In defining the term restricted annual limit, requires the Secretary to ensure that access to needed services is made available with minimal impact on premiums. Clarifies that this provision does not prevent a group health plan or health insurance issuer from placing annual or lifetime per beneficiary limits on specific covered benefits that are not essential health benefits to the extent that such limits are otherwise permitted under federal or state law. Effective for plan years beginning on or after 9/23/2010. Applies also to grandfathered health plans for the first plan year on or after 9/23/2010. PHS Act sec Prohibition on rescissions (as modified by sec of HCERA). Prohibits a group health plan and a health insurance issuer offering group or individual coverage from rescinding such plan or coverage with respect to an enrollee once the enrollee is covered, except in the case of a covered individual who has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage. Provides that the coverage may not be cancelled without giving prior notice to the enrollee. Prepared by Health Policy Alternatives April 5,

18 Effective for plan years beginning on or after 9/23/2010. Applies also to grandfathered health plans for the first plan year on or after 9/23/2010. PHS Act sec Coverage of Preventive Health Services (as modified by sec ). Requires that at a minimum, a group health plan and an issuer offering group or individual coverage provide coverage for and not impose any cost sharing requirements for: (1) evidence-based items or services that have in effect a rating of A or B in the current recommendations of the U.S. Preventive Services Task Force (USPSTF); (2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; (3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; 4) with respect to women, such additional preventive care and screening services not described in paragraph (1) above as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for this purpose; and (5) for purposes of this Act and for purposes of any other provisions of law, the current recommendations of the USPTF regarding breast cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around November Clarifies that this provision is not meant to prohibit a plan or issuer from providing coverage for services in addition to those recommended by the USPSTF or from denying coverage for services that are not recommended by the Task Force. Interval. Requires the Secretary to establish a minimum interval between the date on which a recommendation or a guideline is issued and the plan year with respect to which the requirement is effective. Provides that the interval be no less than 1 year. Value-based insurance design. Authorizes the Secretary to develop guidelines to permit a group health plan and an issuer offering group or individual coverage to utilize valuebased insurance designs. Effective for plan years beginning on or after 9/23/2010. PHS Act sec Extension of dependent coverage (as modified by sec of HCERA). Requires a group health plan and an issuer offering group or individual coverage that provides coverage of dependent children to continue to make such coverage available for an adult child until the child turns 26 years of age. Clarifies that this provision does not require a plan or issuer to make coverage available for a child of a child receiving dependent coverage. ( 1251 below limits coverage of dependent children to those adult children without an employer offer of coverage for plan years beginning before 1/1/2014.) Requires the Secretary to issue regulations to define dependents for this purpose. Clarifies that this provision does not change dependent as used in the Internal Revenue Code (IRC) with respect to the tax treatment of the cost of coverage. Effective for plan years beginning on or after 9/23/2010. Applies also to grandfathered health plans for the first plan year on or after 9/23/2010. Prepared by Health Policy Alternatives April 5,

19 PHS Act sec Development and utilization of uniform explanation of coverage documents and standardized definitions (as modified by sec ). Requires the Secretary, within 12 months of enactment, to develop standards for use by a group health plan and an issuer offering group or individual health insurance coverage, in compiling and providing to applicants, enrollees and policyholders, a summary of benefits and coverage explanation that accurately describes the benefits and coverage under the applicable plan or coverage. Requires the Secretary to consult with the National Association of Insurance Commissioners (NAIC) and a working group composed of specified stakeholders. Requires that the standards for the summary of benefits and coverage meet specified requirements relating to appearance, language and contents. Requires the Secretary to periodically review and update, as appropriate, the standards developed under this section. Requirement to provide. Within 24 months after enactment, requires issuers (including a group health plan that is not self-insured) offering coverage within the U.S. or, in the case of a self-insured group health plan, the plan sponsor or designated administrator of the plan, to provide (prior to any enrollment restriction), a summary of benefits and coverage explanation pursuant to the above standards to applicants, enrollees and policyholders or certificate policyholders at the time of application; an enrollee prior to the time of enrollment or reenrollment, as applicable; and a policyholder or certificate holder at the time of issuance of the policy or delivery of the certificate. Compliance. Deems an entity specified above to be in compliance if the summary of benefits and coverage is provided in paper or electronic form. Notice of modifications. Provides that if a group health plan or issuer makes any material modification in any terms of the plan or coverage (see 102 of ERISA) that is not reflected in the most recently provided summary of benefits and coverage, the plan or issuer must provide notice of such modification to enrollees not later than 60 days before the effective date of the modification. Preemption. Provides that these standards preempt any related state standards that require a summary of benefits and coverage that provides less information to consumers than that required under this section, as determined by the Secretary. Failure to provide. Provides that a covered entity (issuer, group health plan, etc.) that willfully fails to provide the information required is subject to a fine of not more than $1,000 for each such failure. Provides that such failure with respect to each enrollee constitutes a separate offense. Development of standard definitions. Requires the Secretary, by regulation, to provide for the development of standards for the definitions of terms used in health insurance coverage, including specified insurance-related terms and medical terms. Effective 9/23/2010. PHS Act sec. 2715A. Provision of additional information (as modified by sec ). Requires that plans not sold through the state Exchanges only be required to submit certain information required under the transparency in coverage provisions (e.g., claims payment, periodic financial disclosure and other disclosures as specified in Prepared by Health Policy Alternatives April 5,

20 1311(e) below) to the Secretary and the state insurance commissioner, and make such information available to the public. Effective 9/23/2010. PHS Act sec Prohibition of discrimination based on salary (as modified by sec ). Requires group health plans (other than self-insured plans) to satisfy the requirements of 105(h)(2) of the IRC relating to prohibition on discrimination in favor of highly compensated individuals. Provides that rules similar to the rules contained in paragraphs (3), (4) and (8) of 105(h) apply. (Note that 105(h) currently applies non-discrimination rules to self-insured group health plans and paragraphs (3), (4), and (8) require that these plans must benefit at least 70 percent of employees who are not highly compensated and that the benefits available to the highly compensated individuals are also provided for all other participants.) Effective 9/23/2010. PHS Act sec Ensuring the Quality of Care (as modified by sec ). Requires the Secretary, within 2 years of enactment, and in consultation with experts in health care quality and stakeholders, to develop reporting requirements for use by a group health plan, and a health insurance issuer offering group or individual coverage, with respect to the plan or coverage benefits and health care provider reimbursement structures that: (1) improve health outcomes through implementation of activities such as quality reporting, effective case management, care coordination, etc.; (2) implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional; (3) implement activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage; and (4) implement wellness and health promotion activities. Provides examples of wellness and prevention programs. Reporting requirements. Requires a group health plan and an issuer offering group or individual coverage to annually submit to the Secretary, and to enrollees, a report on whether the benefits under the plan or coverage satisfy the above quality elements. Requires the report to be made available during each enrollment period. Permits the Secretary to develop and impose appropriate penalties for non-compliance with the reporting requirements. Permits exceptions. Regulations, study and report. Requires the Secretary to issue regulations within 2 years of enactment that provide criteria for determining whether a reimbursement structure meets the above requirements. Within 180 days after the regulations are issued, requires the Government Accountability Office (GAO) to review them and report to the Senate HELP and House Energy and Commerce Committees regarding the impact the activities under this section has had on the quality and cost of health care. Protection of second amendment gun rights. Prohibits a wellness and health promotion activity implemented under the above provisions from requiring disclosure or collection of any information relating to the presence or storage of a lawfully possessed firearm or Prepared by Health Policy Alternatives April 5,

21 ammunition in the residence or on the property of an individual; or the lawful use, possession, or storage of a firearm or ammunition by an individual. Prohibits the Secretary from using any authorities under the bill for the collection of any information relating to records of lawful ownership or possession of a firearm or ammunition; the lawful use of a firearm or ammunition; or lawful storage of a firearm or ammunition. Prohibits the Secretary from maintaining records relating to individual ownership or possession. Prohibits a premium rate from being increased, denying coverage and reducing a discount, rebate, or reward offered for participation in a wellness program on the basis of, or on reliance upon, the lawful ownership or possession of a firearm or ammunition; or the lawful use or storage of a firearm or ammunition. Prohibits a requirement on any individual to disclose any information under any data collection activity authorized under the bill relating to the lawful ownership or possession of a firearm or ammunition; or the lawful use, possession, or storage of a firearm or ammunition. Effective 9/23/2010. PHS Act sec Bringing down the cost of health care coverage (as modified by sec ). Requires an issuer offering group or individual coverage (including a grandfathered plan) to submit to the Secretary annually for each plan year a report concerning the ratio of the incurred loss (or incurred claims) plus the loss adjustment expense (or change in contract reserves) to earned premiums. Requires the report to include the percentage of total premium revenue, after accounting for collections or receipts for risk adjustment and risk corridors and payments of reinsurance, that such coverage expends on: reimbursement for clinical services provided under the coverage; activities that improve health care quality; and all other non-claims costs, including an explanation of the nature of such costs, and excluding federal and state taxes and licensing or regulatory fees. Requires the Secretary to make reports received available to the public on the Department of Health and Human Services (HHS) website. Ensuring that consumers receive value for their premium payments. By 1/1/2011, an issuer offering group or individual health insurance coverage (including a grandfathered plan) is required to provide an annual rebate to each enrollee, on a pro rata basis, if the ratio of the amount of premium revenue expended by the issuer on clinical services and quality improvement to the premium revenue (excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance) is less than 85% for large group coverage (or higher percentage if required under state law) or 80% in the small group and individual markets (or higher percentage if required under state law). Permits the Secretary to make an exception for individual coverage if the 80% minimum loss ratio would destabilize the market in a state. Requires the issuer to rebate to enrollees the amount by which the issuer s medical loss ratio is less than the required minimum. Beginning 1/1/2014, requires the calculation of the rebate for a year to be based on the costs and revenues for the previous 3 years for the plan. In setting minimum loss ratio percentages, requires a state to seek to ensure adequate participation by issuers, competition in the market and value for consumers so that premiums are used for clinical services and quality improvements. Requires the Secretary to issue regulations and authorizes the Secretary to provide for appropriate penalties. Prepared by Health Policy Alternatives April 5,