HAPI (http://hapi.ucla.edu/) Apoya carreras como ciencias sociales y humanidades, Artes, arquitectura, lingüística, literatura, filosofía, música, danza, teatro, Antropología, arqueología, Comunicaciones, Psicología y Relaciones Internacionales. Es un recurso facil de utilizar ya que nos muestra un menu claro y también nos da la posibilidad de verlo en idioma español, ingles, portugues. Lo calificaria con 5 debido al buen diseño que tiene la pagina, para facilitarnos su consulta.

merhaba çok kıymetli ve sevgili arkadaşlar..

Meksika biber hapı hakkında yorum sayfasına hoşgeldiniz..

Bu Sayfada Biber hapı hakkındaki yorumları bulabilecek ve dilerseniz biber hapı hakkında yorumlarınızı bırakabileceksiniz..

Sizde Biber hapı hakkında yorum yapmak istiyorsanız aşağıdaki yorum yaz bölümünü kullanabilirsiniz yada yorumları okumak için aşağıya doğru ilerleyebilirsiniz..

iyi günler dilerim..

merhaba sevgili ve değerli arkadaşlar..

uzun bir süredir biber hapı acı biber hapı meksika biber hapı diye kullandığımız isimleri artık değiştirdik..

şimdiki hali ise şu şekildedir..

acı biber hapı meksika biber hapı sitesi biberhapı gibi olmuştur..

her ne kadar pek değişememiş gibi görünesede aslında bayağı bir değişiklik yapılmıştır yeni halinde..

iyi günler dileriz..

FX 15 tok tutucu ozelligi ile size dogal diyet yaptirir. Ozel bi program uygulamaniza gerek yok ama tatli – hamur isi gibi seylere dikkat edersek daha iyi olur. Cildi sikilastirici ozelligi ile gozler gorulur incelme saglar. Duzenli kullanima devam ederek ideal kilonuza gelebilirsiniz.

FX15'in bir ilac olmadigini tekrar belirtmek isteriz. Icerigindeki uzum ekstresi sindirimi duzenledigi icin mide rahatsizligi gibi bir sikayetiniz varsa daha da fayda saglayacaktir. Yuksek tansiyonu dusurucu ozelligi vardir.

FX15 hapi (biber hapi) zayiflama , kilo verme hapi ile alakali tum bilgiler ve yorumlar su linkte.

FX 15 tok tutucu ozelligi ile size dogal diyet yaptirir. Ozel bi program uygulamaniza gerek yok ama tatli – hamur isi gibi seylere dikkat edersek daha iyi olur. Cildi sikilastirici ozelligi ile gozler gorulur incelme saglar. Duzenli kullanima devam ederek ideal kilonuza gelebilirsiniz.

FX15'in bir ilac olmadigini tekrar belirtmek isteriz. Icerigindeki uzum ekstresi sindirimi duzenledigi icin mide rahatsizligi gibi bir sikayetiniz varsa daha da fayda saglayacaktir. Yuksek tansiyonu dusurucu ozelligi vardir.

FX15 hapi (biber hapi) zayiflama , kilo verme hapi ile alakali tum bilgiler ve yorumlar su linkte.

Selamlar Güzel Ülkemin Güzel İnsanları..

Biliyorsunuz ki Biber Hapı Bir Müddet önce Bakanlık onaylı olarak  satılmaya başladı..

Bizde Bu Başlığı daha önce açmış olduğumuz biber hapı kullanıcı yorumları sayfasının fazla yorumdan ötürü yoğunlaşmasına binaen açmış bulunmaktayız..

Biber Hapı ile ilgili kullanıcı yorumlarını okumak veya kullanıcı yorumlarınız ı bırakmak istiyorsanız aşağıdaki yorum yaz bölümünü kullanabilirsiniz..

Biber Hapı Kullanıcı Yorumları

And now, just in time for Halloween: Stupidest. Thing. Ever.

Here’s a closeup of the photographic “evidence” of a ghost.

Tell me how that isn’t just a perfectly normal picture of a guy walking into a room.

II
111TH CONGRESS
1ST SESSION S. 391
To provide affordable, guaranteed private health coverage that will make
Americans healthier and can never be taken away.
IN THE SENATE OF THE UNITED STATES
FEBRUARY 5, 2009
Mr. WYDEN (for himself, Mr. BENNETT, Mr. INOUYE, Mr. SPECTER, Mr.
LIEBERMAN, Ms. LANDRIEU, Mr. CRAPO, Mr. NELSON of Florida, Ms.
STABENOW, Ms. CANTWELL, Mr. GRAHAM, Mr. ALEXANDER, and Mr.
MERKLEY) introduced the following bill; which was read twice and referred
to the Committee on Finance
A BILL
To provide affordable, guaranteed private health coverage
that will make Americans healthier and can never be
taken away.
Be it enacted by the Senate and House of Representa- 1
tives of the United States of America in Congress assembled, 2
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 3
(a) SHORT TITLE.—This Act may be cited as the 4
‘‘Healthy Americans Act’’. 5
(b) TABLE OF CONTENTS.— 6
Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Definitions.
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TITLE I—HEALTHY AMERICANS PRIVATE INSURANCE PLANS
Subtitle A—Guaranteed Private Coverage
Sec. 101. Guarantee of Healthy Americans Private Insurance coverage.
Sec. 102. Individual responsibility to enroll in a Healthy Americans Private Insurance
plan.
Sec. 103. Guaranteeing you can keep the coverage you have.
Sec. 104. Coordination of supplemental coverage under the Medicaid program
to HAPI plan coverage for nondisabled, nonelderly adult individuals.
Subtitle B—Standards for Healthy Americans Private Insurance Coverage
Sec. 111. Healthy Americans Private Insurance Plans.
Sec. 112. Specific coverage requirements.
Sec. 113. Updating Healthy Americans Private Insurance plan requirements.
Subtitle C—Eligibility for Premium and Personal Responsibility Contribution
Subsidies
Sec. 121. Eligibility for premium subsidies.
Sec. 122. Eligibility for personal responsibility contribution subsidies.
Sec. 123. Definitions and special rules.
Subtitle D—Wellness Programs
Sec. 131. Requirements for wellness programs.
TITLE II—HEALTHY START FOR CHILDREN
Subtitle A—Benefits and Eligibility
Sec. 201. General goal and authorization of appropriations for HAPI plan coverage
for children.
Sec. 202. Coordination of supplemental coverage under the Medicaid program
with HAPI plan coverage for children.
Subtitle B—Service Providers
Sec. 211. Inclusion of providers under HAPI plans.
Sec. 212. Use of, and grants for, school-based health centers.
TITLE III—BETTER HEALTH FOR OLDER AND DISABLED
AMERICANS
Subtitle A—Assurance of Supplemental Medicaid Coverage
Sec. 301. Coordination of supplemental coverage under the Medicaid program
for elderly and disabled individuals.
Subtitle B—Empowering Individuals and States To Improve Long-Term Care
Choices
Sec. 311. New, automatic Medicaid option for State Choices for Long-Term
Care Program.
Sec. 312. Simpler and more affordable long-term care insurance coverage.
TITLE IV—HEALTHIER MEDICARE
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Subtitle A—Authority To Adjust Amount of Part B Premium To Reward
Positive Health Behavior
Sec. 401. Authority to adjust amount of Medicare part B premium to reward
positive health behavior.
Subtitle B—Promoting Primary Care for Medicare Beneficiaries
Sec. 411. Primary care services management payment.
Subtitle C—Chronic Care Disease Management
Sec. 421. Chronic care disease management.
Sec. 422. Chronic Care Education Centers.
Subtitle D—Part D Improvements
Sec. 431. Process for individuals entering the Medicare coverage gap to switch
to a plan that provides coverage in the gap.
Subtitle E—Improving Quality in Hospitals for All Patients
Sec. 441. Improving quality in hospitals for all patients.
Subtitle F—End-of-Life Care Improvements
Sec. 451. Patient empowerment and following a patient’s health care wishes.
Sec. 452. Permitting hospice beneficiaries to receive curative care.
Sec. 453. Providing beneficiaries with information regarding end-of-life care
clearinghouse.
Sec. 454. Clearinghouse.
Subtitle G—Additional Provisions
Sec. 461. Additional cost information.
Sec. 462. Reducing Medicare paperwork and regulatory burdens.
TITLE V—STATE HEALTH HELP AGENCIES
Sec. 501. Establishment.
Sec. 502. Responsibilities and authorities.
Sec. 503. Appropriations for Transition to State Health Help Agencies.
TITLE VI—SHARED RESPONSIBILITIES
Subtitle A—Individual Responsibilities
Sec. 601. Individual responsibility to ensure HAPI plan coverage.
Subtitle B—Employer Responsibilities
Sec. 611. Health care responsibility payments.
Sec. 612. Distribution of individual responsibility payments to HHAs.
Subtitle C—Insurer Responsibilities
Sec. 621. Insurer responsibilities.
Subtitle D—State Responsibilities
Sec. 631. State responsibilities.
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Sec. 632. Empowering states to innovate through waivers.
Subtitle E—Federal Fallback Guarantee Responsibility
Sec. 641. Federal guarantee of access to coverage.
Subtitle F—Federal Financing Responsibilities
Sec. 651. Appropriation for subsidy payments.
Sec. 652. Recapture of Medicare and 90 percent of Medicaid Federal DSH
funds to strengthen Medicare and ensure continued support for
public health programs.
Subtitle G—Tax Treatment of Health Care Coverage Under Healthy Americans
Program; Termination of Coverage Under Other Governmental Programs
and Transition Rules for Medicaid and CHIP
PART I—TAX TREATMENT OF HEALTH CARE COVERAGE UNDER HEALTHY
AMERICANS PROGRAM
Sec. 661. Limited employee income and payroll tax exclusion for employer
shared responsibility payments, historic retiree health contributions,
and transitional coverage contributions.
Sec. 662. Exclusion for limited employer-provided health care fringe benefits.
Sec. 663. Limited employer deduction for employer shared responsibility payments,
historic retiree health contributions, and other health
care expenses.
Sec. 664. Health care standard deduction.
Sec. 665. Modification of other tax incentives to complement Healthy Americans
program.
PART II—CLARIFICATION OF ERISA TREATMENT; TERMINATION OF COVERAGE
UNDER OTHER GOVERNMENTAL PROGRAMS AND TRANSITION
RULES FOR MEDICAID AND CHIP
Sec. 671. Clarification of ERISA applicability to employer-sponsored HAPI
plans.
Sec. 672. Federal Employees Health Benefits Plan.
Sec. 673. Medicaid and CHIP.
TITLE VII—PURCHASING HEALTH SERVICES AND PRODUCTS
THAT ARE MOST EFFECTIVE
Subtitle A—Effective Health Services and Products
Sec. 701. One time disallowance of deduction for advertising and promotional
expenses for certain prescription pharmaceuticals.
Sec. 702. Enhanced new drug and device approval.
Sec. 703. Medical schools and finding what works in health care.
Sec. 704. Finding affordable health care providers nearby.
Subtitle B—Other Provisions to Improve Health Care Services and Quality
Sec. 711. Individual medical records.
Sec. 712. Bonus payment for medical malpractice reform.
Sec. 713. Prioritizing health care employment and training activities.
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TITLE VIII—CONTAINING MEDICAL COSTS AND GETTING MORE
VALUE FOR THE HEALTH CARE DOLLAR
Sec. 801. Cost-containment results of the Healthy Americans Act.
SEC. 2. FINDINGS. 1
Congress makes the following findings: 2
(1) Americans want affordable, guaranteed pri- 3
vate health coverage that makes them healthier and 4
can never be taken away. 5
(2) American health care provides primarily 6
‘‘sick care’’ and does not do enough to prevent 7
chronic illnesses like heart disease, stroke, and dia- 8
betes. This results in significantly higher health 9
costs for all Americans. 10
(3) Staying as healthy as possible often requires 11
an individual to change behavior and assume more 12
personal responsibility for his or her health. 13
(4) Personal responsibility for one’s health 14
should include purchasing one’s own private health 15
care coverage. 16
(5) To accompany this new focus on staying 17
healthy and personal responsibility, our government 18
must guarantee that all Americans receive private 19
affordable health coverage that can never be taken 20
away. 21
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(6) Financing this guarantee should be a 1
shared responsibility between individuals, the Gov- 2
ernment, and employers. 3
(7) The $2,200,000,000,000 spent annually on 4
American health care must be spent more effectively 5
in order to meet this guarantee. 6
(8) This guarantee must include easier access 7
to understandable information about the quality, 8
cost, and effectiveness of health care providers, prod- 9
ucts, and services. 10
(9) The fact that businesses in the United 11
States compete globally against businesses whose 12
governments pay for health care, coupled with the 13
aging of the American population and the explosive 14
growth of preventable health problems, makes the 15
status quo in American health care unacceptable. 16
SEC. 3. DEFINITIONS. 17
In this Act: 18
(1) ADULT INDIVIDUAL.—The term ‘‘adult indi- 19
vidual’’ means an individual who— 20
(A) is— 21
(i) age 19 or older; 22
(ii) a resident of a State; 23
(iii)(I) a United States citizen; or 24
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(II) an alien with permanent resi- 1
dence; 2
(iv) not a dependent child; and 3
(v) not an alien unlawfully present in 4
the United States; and 5
(B) in the case of an incarcerated indi- 6
vidual, such an individual who is incarcerated 7
for less than 1 month. 8
(2) ALIEN WITH PERMANENT RESIDENCE.— 9
The term ‘‘alien with permanent residence’’ has the 10
meaning given the term ‘‘qualified alien’’ in section 11
431 of the Personal Responsibility and Work Oppor- 12
tunity Reconciliation Act of 1996 (8 U.S.C. 1641). 13
(3) COVERED INDIVIDUAL.—The term ‘‘covered 14
individual’’ means an individual who is enrolled in a 15
HAPI plan. 16
(4) DEPENDENT CHILD.—The term ‘‘dependent 17
child’’ has the meaning given the term ‘‘qualifying 18
child’’ in section 152(c) of the Internal Revenue 19
Code of 1986. 20
(5) HAPI PLAN.—The term ‘‘HAPI plan’’ 21
means— 22
(A) a Healthy Americans Private Insur- 23
ance plan described under subtitle B of title I; 24
or 25
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(B) an employer-sponsored health coverage 1
plan described under section 103 offered by an 2
employer. 3
(6) HHA.—The term ‘‘HHA’’ means the 4
Health Help Agency of a State as described under 5
title V. 6
(7) HEALTH INSURANCE ISSUER.—The term 7
‘‘health insurance issuer’’ means an insurance com- 8
pany, insurance service, or insurance organization 9
(including a health maintenance organization, as de- 10
fined in paragraph (7)) which is licensed to engage 11
in the business of insurance in a State and which is 12
subject to State law which regulates insurance (with- 13
in the meaning of section 514(b)(2) of the Employee 14
Retirement Income Security Act of 1974). Such 15
term does not include a group health plan. 16
(8) HEALTH MAINTENANCE ORGANIZATION.— 17
The term ‘‘health maintenance organization’’ 18
means— 19
(A) a federally qualified health mainte- 20
nance organization (as defined in section 21
1301(a)), 22
(B) an organization recognized under State 23
law as a health maintenance organization, or 24
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(C) a similar organization regulated under 1
State law for solvency in the same manner and 2
to the same extent as such a health mainte- 3
nance organization. 4
(9) PERSONAL RESPONSIBILITY CONTRIBU- 5
TION.—The term ‘‘personal responsibility contribu- 6
tion’’ means a payment made by a covered individual 7
to a health care provider or a health insurance 8
issuer with respect to the provision of health care 9
services under a HAPI plan, not including any 10
health insurance premium payment. 11
(10) QUALIFIED COLLECTIVE BARGAINING 12
AGREEMENT.— 13
(A) IN GENERAL.—The term ‘‘qualified 14
collective bargaining agreement’’ means an 15
agreement between a qualified collective bar- 16
gaining employer and an employee organization 17
that represents the employees of such employer 18
that is in effect until the date that is the earlier 19
of— 20
(i) January 1 of the first year which 21
is more than 7 years after the date of en- 22
actment of this Act, or 23
(ii) the date the collective bargaining 24
agreement expires. 25
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(B) QUALIFIED COLLECTIVE BARGAINING 1
EMPLOYER.—The term ‘‘qualified collective bar- 2
gaining employer’’ means an employer who pro- 3
vides health insurance to employees under the 4
terms of a collective bargaining agreement 5
which is entered into before the date of the en- 6
actment of this Act. 7
(11) SECRETARY.—The term ‘‘Secretary’’ 8
means the Secretary of Health and Human Services. 9
(12) STATE.—The term ‘‘State’’ means each of 10
the several States of the United States, the District 11
of Columbia, the Commonwealth of Puerto Rico, the 12
Virgin Islands, American Samoa, Guam, the Com- 13
monwealth of the Northern Mariana Islands, and 14
other territories of the United States. 15
(13) STATE OF RESIDENCE.—The term ‘‘State 16
of residence’’, with respect to an individual, means 17
the State in which the individual has primary resi- 18
dence. 19
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TITLE I—HEALTHY AMERICANS 1
PRIVATE INSURANCE PLANS 2
Subtitle A—Guaranteed Private 3
Coverage 4
SEC. 101. GUARANTEE OF HEALTHY AMERICANS PRIVATE 5
INSURANCE COVERAGE. 6
Not later than the date that is 2 years after the date 7
of enactment of this Act, each adult individual shall have 8
the opportunity to purchase a Healthy Americans Private 9
Insurance plan that meets the requirements of subtitle B 10
(referred to in this Act as ‘‘HAPI plan’’), for such indi- 11
vidual and the dependent children of such individual. 12
SEC. 102. INDIVIDUAL RESPONSIBILITY TO ENROLL IN A 13
HEALTHY AMERICANS PRIVATE INSURANCE 14
PLAN. 15
(a) INDIVIDUAL RESPONSIBILITY.— 16
(1) ADULT INDIVIDUALS.—Each adult indi- 17
vidual shall have the responsibility to enroll in a 18
HAPI plan, unless the adult individual— 19
(A) provides evidence of receipt of coverage 20
under, or enrollment in a health plan offered 21
through— 22
(i) the Medicare program under title 23
XVIII of the Social Security Act; 24
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(ii) a health insurance plan offered by 1
the Department of Defense; 2
(iii) an employee benefit plan through 3
a former employer; 4
(iv) a qualified collective bargaining 5
agreement; 6
(v) the Department of Veterans Af- 7
fairs; or 8
(vi) the Indian Health Service; or 9
(B) is opposed to health plan coverage for 10
religious reasons, including an individual who 11
declines health plan coverage due to a reliance 12
on healing using spiritual means through prayer 13
alone. 14
(2) DEPENDENT CHILDREN.—Each adult indi- 15
vidual shall have the responsibility to enroll each de- 16
pendent child of the adult individual in a HAPI 17
plan, unless the adult individual— 18
(A) provides evidence that the dependent 19
child is enrolled in a health plan offered 20
through a program described in paragraph 21
(1)(A); or 22
(B) is described in paragraph (1)(B). 23
(3) VERIFICATION OF RELIGIOUS EXCEPTION.— 24
Each State shall develop guidelines for determining 25
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and verifying the individuals who qualify for the ex- 1
ception under paragraph (1)(B). 2
(b) PENALTY FOR FAILURE TO PURCHASE COV- 3
ERAGE.— 4
(1) PENALTY.— 5
(A) IN GENERAL.—In the case of an indi- 6
vidual described in subparagraph (B), such in- 7
dividual shall be subject to a late enrollment 8
penalty in an amount determined under sub- 9
paragraph (C). 10
(B) INDIVIDUALS SUBJECT TO PENALTY.— 11
An individual described in this subparagraph is 12
an adult individual for whom there is a contin- 13
uous period of 63 days or longer, beginning on 14
the applicable date (as defined in subparagraph 15
(E)) and ending on the date of enrollment in a 16
HAPI plan, during all of which the individual— 17
(i) was not covered under a HAPI 18
plan or a health plan offered through a 19
program described in paragraph (1)(A) of 20
subsection (a); and 21
(ii) was not described in paragraph 22
(1)(B) of such section. 23
(C) AMOUNT OF PENALTY.— 24
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(i) IN GENERAL.—The amount deter- 1
mined under this subparagraph for an in- 2
dividual is an amount equal to the sum 3
of— 4
(I) the number of uncovered 5
months multiplied by the weighted av- 6
erage of the monthly premium for 7
HAPI plans of the same class of cov- 8
erage as the individual’s in the appli- 9
cable coverage area (determined with- 10
out regard to any subsidy under sec- 11
tion 121); and 12
(II) 15 percent of the amount de- 13
termined under subclause (I). 14
(ii) UNCOVERED MONTH DEFINED.— 15
For purposes of this subsection, the term 16
‘‘uncovered month’’ means, with respect to 17
an individual, any month beginning on or 18
after the applicable date (as defined in 19
subparagraph (E)) unless the individual 20
can demonstrate that the individual— 21
(I) was covered under a HAPI 22
plan or a health plan offered through 23
a program described in paragraph 24
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(1)(A) of subsection (a) for any por- 1
tion of such month; or 2
(II) was described in paragraph 3
(1)(B) of such section for any portion 4
of such month. 5
A month shall not be treated as an uncov- 6
ered month if the individual has already 7
paid a late enrollment penalty under this 8
subsection for such month or if the indi- 9
vidual was incarcerated for the entire 10
month. 11
(D) PAYMENT.—Payment of any late en- 12
rollment penalty by an individual under this 13
subsection shall be made to the HHA of the in- 14
dividual’s State of residence under procedures 15
established by the State. 16
(E) APPLICABLE DATE.—In this para- 17
graph, the term ‘‘applicable date’’ means the 18
earlier of— 19
(i) the day after the end of the State’s 20
first open enrollment period for HAPI 21
plans (during which all adult individuals 22
are eligible to enroll); and 23
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(ii) the day after the end of the first 1
enrollment period for a fallback HAPI plan 2
in the State. 3
(2) WAIVER.—An HHA of a State may reduce 4
or waive the amount of any late enrollment penalty 5
applicable to an individual under this subsection if 6
payment of such penalty would constitute a hardship 7
(determined under procedures established by the 8
State). 9
(3) ENFORCEMENT.—Each State shall deter- 10
mine appropriate mechanisms, which may not in- 11
clude revocation or ineligibility for coverage under a 12
HAPI plan, to enforce the responsibility of each 13
adult individual to purchase HAPI plan coverage for 14
such individual and any dependent children of such 15
individual under subsection (a). 16
(c) OTHER INSURANCE COVERAGE.—Nothing in this 17
Act shall be construed to prohibit an individual from en- 18
rolling in a health insurance plan that is not a HAPI plan. 19
SEC. 103. GUARANTEEING YOU CAN KEEP THE COVERAGE 20
YOU HAVE. 21
(a) PLAN REQUIREMENTS.— 22
(1) IN GENERAL.—A health coverage plan de- 23
scribed in section 105(h)(6) of the Internal Revenue 24
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Code of 1986 (relating to self-insured plans) that is 1
offered by an employer shall be subject to— 2
(A) the requirements of subtitle B (except 3
for subsections (a), (d)(2), and (d)(4) of section 4
111); and 5
(B) a risk-adjustment mechanism used to 6
spread risk across all health plans. 7
(2) OTHER PLANS.—A health coverage plan 8
that is not described in section 105(h)(6) of the In- 9
ternal Revenue Code of 1986 that is offered by an 10
employer shall be subject to the requirements of sub- 11
title B (except for subsection (a) of section 111). 12
(b) DISTRIBUTION OF INFORMATION.—Employers 13
that offer an employer-sponsored health coverage plan 14
shall distribute to employees standardized, unbiased infor- 15
mation on HAPI plans and supplemental health insurance 16
options provided by the State HHA under section 502(b). 17
(c) PLANS OFFERED THROUGH EMPLOYERS.—An 18
employer-sponsored health coverage plan shall be offered 19
by an employer and not through the applicable State 20
HHA. 21
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SEC. 104. COORDINATION OF SUPPLEMENTAL COVERAGE 1
UNDER THE MEDICAID PROGRAM TO HAPI 2
PLAN COVERAGE FOR NONDISABLED, NON- 3
ELDERLY ADULT INDIVIDUALS. 4
(a) ASSURANCE OF SUPPLEMENTAL COVERAGE.— 5
Subject to section 631(d), the Secretary, States, and 6
health insurance issuers shall ensure that any nondisabled, 7
nonelderly adult individual eligible under title XIX of the 8
Social Security Act (including any nondisabled, nonelderly 9
adult individual eligible under a waiver under such title 10
or under section 1115 of such Act (42 U.S.C. 1315)) cov- 11
ered under a HAPI plan provided through the State HHA 12
receives medical assistance under State Medicaid plans in 13
a manner that— 14
(1) is provided in coordination with, and as a 15
supplement to, the coverage provided the non- 16
disabled, nonelderly adult individual under the 17
HAPI plan in which the individual is enrolled; 18
(2) does not supplant the nondisabled, non- 19
elderly adult individual’s coverage under a HAPI 20
plan; 21
(3) ensures that the nondisabled, nonelderly 22
adult individual receives all items or services that 23
are not available (or are otherwise limited) under the 24
HAPI plan in which they are enrolled but that is 25
provided under the State plan (or provided to a 26
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•S 391 IS
greater extent or in a less restrictive manner) under 1
title XIX of the Social Security Act (including any 2
waiver under such title or under section 1115 of 3
such Act (42 U.S.C. 1315)) of the State in which 4
the nondisabled, nonelderly adult individual resides; 5
and 6
(4) ensures that the family of the nondisabled, 7
nonelderly adult individual is not charged premiums, 8
deductibles, or other cost-sharing that is greater 9
than would have been charged under the State plan 10
under title XIX of the Social Security Act of the 11
State in which the nondisabled, nonelderly adult in- 12
dividual resides if such coverage was not provided as 13
a supplement to the coverage provided the child 14
under the HAPI plan in which the nondisabled, non- 15
elderly adult individual is enrolled. 16
(b) GUIDANCE TO STATES AND HEALTH INSURANCE 17
ISSUERS.—The Secretary shall issue regulations and guid- 18
ance to States and health insurance issuers implementing 19
this section not later than 6 months prior to the date on 20
which coverage under a HAPI plan first begins. 21
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Subtitle B—Standards for Healthy 1
Americans Private Insurance 2
Coverage 3
SEC. 111. HEALTHY AMERICANS PRIVATE INSURANCE 4
PLANS. 5
(a) OPTIONS.—A State HHA— 6
(1) shall require that at least 2 HAPI plans 7
that comply with the requirements of subsection (b), 8
be offered through the HHA to each individual in 9
the State; 10
(2) may require the offering of 1 or more HAPI 11
plans that include coverage for benefits, items, or 12
services required by the State in addition to the 13
standardized benefits, items, or services required 14
under subsection (b) for HAPI plans if— 15
(A) such additional benefits, items, and 16
services build upon the standardized benefits 17
package; 18
(B) a list of such additional benefits, 19
items, or services, and the prices applicable to 20
such additional benefits, items, and services, is 21
displayed in a manner that is separate from the 22
description of the standardized benefits, items, 23
or services required under the plan under this 24
section (and consistent with the manner in 25
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•S 391 IS
which such items are displayed by medigap poli- 1
cies) and that enables a consumer to identify 2
such additional benefits, items, and services and 3
the cost associated with such; and 4
(C) no premium subsidies are available 5
under subtitle C for any portion of the pre- 6
miums for a HAPI plan that are attributable to 7
such additional benefits, items, or services; and 8
(3) may permit the offering of 1 or more actu- 9
arially equivalent HAPI plans through the HHA as 10
provided for in subsection (c). 11
(b) STANDARDIZED COVERAGE REQUIREMENTS FOR 12
HAPI PLANS.— 13
(1) IN GENERAL.—Each HAPI plan offered 14
through an HHA shall— 15
(A) provide benefits for health care items 16
and services that are actuarially equivalent or 17
greater in value than the benefits offered as of 18
January 1, 2009, under the Blue Cross/Blue 19
Shield Standard Plan provided under the Fed- 20
eral Employees Health Benefit Program under 21
chapter 89 of title 5, United States Code, in- 22
cluding coverage of an initial primary care as- 23
sessment and annual physical examinations; 24
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•S 391 IS
(B) provide benefits for wellness programs 1
and incentives to promote the use of such pro- 2
grams; 3
(C) provide coverage for catastrophic med- 4
ical events that result in out-of-pocket costs for 5
an individual or family if lifetime limits are ex- 6
hausted; 7
(D) designate a health care provider, such 8
as a primary care physician, nurse practitioner, 9
or other qualified health provider, to monitor 10
the health and health care of a covered individ- 11
uals (such provider shall be known as the 12
‘‘health home’’ of the covered individual); 13
(E) ensure that, as part of the first visit 14
with a primary care physician or the health 15
home of a covered individual, such provider and 16
individual determine a care plan to maximize 17
the health of the individual through wellness 18
and activities prevention; 19
(F) provide benefits for comprehensive dis- 20
ease prevention, early detection, disease man- 21
agement, and chronic condition management 22
that meets minimum standards developed by 23
the Secretary; 24
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•S 391 IS
(G) provide for the application of personal 1
responsibility contribution requirements with re- 2
spect to covered benefits in a manner that may 3
be similar to the cost sharing requirements ap- 4
plied as of January 1, 2009, under the Blue 5
Cross/Blue Shield Standard Plan provided 6
under the Federal Employees Health Benefit 7
Program under chapter 89 of title 5, United 8
States Code, except that no contributions shall 9
be required for— 10
(i) preventive items or services; and 11
(ii) early detection, disease manage- 12
ment, or chronic pain treatment items or 13
services; and 14
(H) comply with the requirements of sec- 15
tion 112. 16
(2) DETERMINATION OF BENEFITS BY SEC- 17
RETARY.—Not later than 1 year after the date of 18
enactment of this Act, the Secretary shall promul- 19
gate guidelines concerning the benefits, items, and 20
services that are covered under paragraph (1). 21
(3) COVERAGE FOR FAMILY PLANNING.— 22
(A) IN GENERAL.—Except as provided in 23
subparagraph (B), a health insurance issuer 24
shall make available supplemental coverage for 25
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•S 391 IS
abortion services that may be purchased in con- 1
junction with enrollment in a HAPI plan or an 2
actuarially equivalent healthy American plan. 3
(B) RELIGIOUS AND MORAL EXCEPTION.— 4
Nothing in this paragraph shall be construed to 5
require a health insurance issuer affiliated with 6
a religious institution to provide the coverage 7
described in subparagraph (A). 8
(4) RULE OF CONSTRUCTION.—Nothing in this 9
subsection shall be construed to prohibit a HAPI 10
plan from providing coverage for benefits, items, and 11
services in addition to the coverage required under 12
this subsection. No premium subsidies shall be avail- 13
able under subtitle C for any portion of the pre- 14
miums for a HAPI plan that are attributable to 15
such additional benefits, items, or services. 16
(c) ACTUARIALLY EQUIVALENT HEALTHY AMERICAN 17
PLANS.—Each actuarially equivalent healthy American 18
plan offered through an HHA shall— 19
(1) cover all treatments, items, services, and 20
providers at least to the same extent as those cov- 21
ered under a HAPI plan that— 22
(A) shall include coverage for— 23
(i) preventive items or services (in- 24
cluding well baby care and well child care 25
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•S 391 IS
and appropriate immunizations) and dis- 1
ease management services; 2
(ii) inpatient and outpatient hospital 3
services; 4
(iii) physicians’ surgical and medical 5
services; and 6
(iv) laboratory and x-ray services; and 7
(B) may include additional supplemental 8
benefits to the extent approved by the State 9
and provided for in advance in the plan con- 10
tract; and 11
(2) ensure that no personal responsibility con- 12
tribution requirements are applied for benefits, 13
items, or services and chronic disease management 14
prevention. 15
(d) PREMIUMS AND RATING REQUIREMENTS.— 16
(1) CLASSES OF COVERAGE.—With respect to a 17
HAPI plan, a health insurance issuer shall provide 18
for the following classes of coverage: 19
(A) Coverage of an individual. 20
(B) Coverage of a married couple or do- 21
mestic partnership (as determined by a State) 22
without dependent children. 23
(C) Coverage of an adult individual with 1 24
or more dependent children. 25
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•S 391 IS
(D) Coverage of a married couple or do- 1
mestic partnership (as determined by a State) 2
with 1 or more dependent children. 3
(2) DETERMINATIONS OF PREMIUMS.—With re- 4
spect to each class of coverage described in para- 5
graph (1), a health insurance issuer shall determine 6
the premium amount for a HAPI plan using ad- 7
justed community rating principals (including a risk- 8
adjustment mechanism), as described in paragraphs 9
(3) and (4) established by the State. States may 10
permit premium variations based only on geography, 11
tobacco use, and family size. A State may determine 12
to have no variation. 13
(3) REWARDS.—A State shall permit a health 14
insurance issuer to provide premium discounts and 15
other incentives to enrollees based on the participa- 16
tion of such enrollees in wellness, chronic disease 17
management, and other programs designed to im- 18
prove the health of the enrollees. 19
(4) LIMITATION.—A health insurance issuer 20
shall not consider age, gender, industry, health sta- 21
tus, or claims experience in determining premiums 22
under this subsection. 23
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•S 391 IS
(e) APPLICATION OF STATE MANDATE LAWS.—State 1
benefit mandate laws that would otherwise be applicable 2
to HAPI plans shall be preempted. 3
(f) DEFINITION OF PREVENTIVE ITEMS OR SERV- 4
ICES.—In this section, the term ‘‘preventive items or serv- 5
ices’’ means clinical activities that help prevent or detect 6
disease, illness, or disability and may include— 7
(1) immunizations and preventive physical ex- 8
aminations; 9
(2) screening tests for blood pressure, high cho- 10
lesterol, diabetes, cancer, and mental illness; and 11
(3) other services that the Secretary determines 12
to be reasonable and necessary for the prevention or 13
early detection of a disease, illness, or disability. 14
SEC. 112. SPECIFIC COVERAGE REQUIREMENTS. 15
(a) IN GENERAL.—Each HAPI plan offered through 16
a HHA shall— 17
(1) provide for increased portability through 18
limitations on the application of preexisting condi- 19
tion exclusions, consistent with that provided for 20
under section 2701 of the Public Health Service Act 21
(42 U.S.C. 300gg), as such section existed on the 22
day before the date of enactment of this Act, except 23
that the State shall develop procedures to ensure 24
that preexisting exclusion limitations do not apply to 25
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•S 391 IS
new enrollees who had no applicable creditable cov- 1
erage immediately prior to the first enrollment pe- 2
riod; 3
(2) provide for the guaranteed availability of 4
coverage to prospective enrollees in a manner similar 5
to that provided for under section 2711 of the Pub- 6
lic Health Service Act (42 U.S.C. 300gg–11), as 7
such section existed on the day before the date of 8
enactment of this Act; 9
(3) provide for the guaranteed renewability of 10
coverage in a manner similar to that provided for 11
under section 2712 of the Public Health Service Act 12
(42 U.S.C. 300gg–12), as such section existed on 13
the day before the date of enactment of this Act, ex- 14
cept that the prohibition on market reentry provided 15
for under such section shall be deemed to be 2 years; 16
(4) prohibit discrimination against individual 17
enrollees and prospective enrollees based on health 18
status in a manner similar to that provided for 19
under section 2702 of the Public Health Service Act 20
(42 U.S.C. 300gg–1), as such section existed on the 21
day before the date of enactment of this Act; 22
(5) provide coverage protections for enrollees 23
who are mothers and newborns in a manner similar 24
to that provided for under section 2704 of the Pub- 25
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29
•S 391 IS
lic Health Service Act (42 U.S.C. 300gg–3), as such 1
section existed on the day before the date of enact- 2
ment of this Act; 3
(6) provide for full parity in the application of 4
certain limits to mental health benefits in a manner 5
similar to that provided for under section 2705 of 6
the Public Health Service Act (42 U.S.C. 300gg–4), 7
as such section existed on the day before the date 8
of enactment of this Act; 9
(7) provide coverage for reconstructive surgery 10
following a mastectomy in a manner similar to that 11
provided for under section 2706 of the Public 12
Health Service Act (42 U.S.C. 300gg–5), as such 13
section existed on the day before the date of enact- 14
ment of this Act; and 15
(8) prohibit discrimination on the basis of ge- 16
netic information, as provided for under the amend- 17
ments made by the Genetic Information Non- 18
discrimination Act of 2008 (Public Law 110–233). 19
(b) GUIDELINES.—Not later than 1 year after the 20
date of enactment of this Act, the Secretary shall develop 21
guidelines for the application of the requirements of this 22
section. 23
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•S 391 IS
SEC. 113. UPDATING HEALTHY AMERICANS PRIVATE IN- 1
SURANCE PLAN REQUIREMENTS. 2
(a) IN GENERAL.—The Secretary shall establish the 3
Healthy America Advisory Committee (referred to in this 4
section as the ‘‘Advisory Committee’’) to provide annual 5
recommendations to the Secretary and Congress con- 6
cerning modifications to the benefits, items, and services 7
required under section 111(a)(1). 8
(b) COMPOSITION.— 9
(1) IN GENERAL.—The Advisory Committee 10
shall be composed of 15 members to be appointed by 11
the Comptroller General, of which— 12
(A) at least 1 such member shall be a 13
health economist; 14
(B) at least 1 such member shall be an 15
ethicist; 16
(C) at least 1 such member shall be a rep- 17
resentative of health care providers, including 18
nurses and other nonphysician providers; 19
(D) at least 1 such member shall be a rep- 20
resentative of health insurance issuers; 21
(E) at least 1 such member shall be a 22
health care consumer; 23
(F) at least 1 such member shall be a rep- 24
resentative of the United States Preventive 25
Services Task Force; and 26
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•S 391 IS
(G) at least 1 such member shall be an ac- 1
tuary. 2
(2) GEOGRAPHIC BALANCE.—The Comptroller 3
General shall ensure the geographic diversity of the 4
members appointed under paragraph (1). 5
(c) TERMS, VACANCIES.—Members of the Advisory 6
Committee shall be appointed for a term of 3 years and 7
may be reappointed for 1 additional term. In appointing 8
members, the Comptroller General shall stagger the terms 9
of the initial members so that the terms of one-third of 10
the members expire each year. Vacancies in the member- 11
ship of the Advisory Committee shall not affect the Com- 12
mittee’s ability to carry out its functions. The Comptroller 13
General shall appoint an individual to fill the remaining 14
term of a vacant member within 2 months of being noti- 15
fied of such vacancy. 16
(d) COMPENSATION AND EXPENSES.—Each member 17
of the Advisory Committee who is not otherwise employed 18
by the United States Government shall receive compensa- 19
tion at a rate equal to the daily rate prescribed for GS– 20
18 under the General Schedule under section 5332 of title 21
5, United States Code, for each day, including travel time, 22
such member is engaged in the actual performance of du- 23
ties as a member of the Committee. A member of the Advi- 24
sory Committee who is an officer or employee of the 25
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•S 391 IS
United States Government shall serve without additional 1
compensation. All members of the Advisory Committee 2
shall be reimbursed for travel, subsistence, and other nec- 3
essary expenses incurred by them in the performance of 4
their duties. 5
(e) ACTION BY SECRETARY.—Not later than Decem- 6
ber 31 of the second full calendar year following the date 7
of enactment of this Act, and each December 31 there- 8
after, the Advisory Committee shall provide to Congress 9
and the Secretary a report that— 10
(1) describes any recommendations for modi- 11
fications to the benefits, items, and services that are 12
required to be covered under a HAPI plan; and 13
(2) includes any recommendations to modify 14
HAPI plans to improve the quality of life for United 15
States citizens and to ensure that benefits in such 16
plans are medically- and cost-effective. 17
(f) APPLICATION OF FACA.—The Federal Advisory 18
Committee Act (5 U.S.C. App.) shall apply to the Advisory 19
Committee, except that section 14 of such Act shall not 20
apply. 21
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•S 391 IS
Subtitle C—Eligibility for Premium 1
and Personal Responsibility 2
Contribution Subsidies 3
SEC. 121. ELIGIBILITY FOR PREMIUM SUBSIDIES. 4
(a) INDIVIDUALS AND FAMILIES AT OR BELOW THE 5
POVERTY LINE.—For any calendar year, in the case of 6
a covered individual who is determined to have a modified 7
adjusted gross income that is at or below 100 percent of 8
the poverty line, as applicable to a family of the size in- 9
volved, the covered individual is entitled under this section 10
to an income-related premium subsidy equal to the basic 11
premium subsidy amount. 12
(b) PARTIAL SUBSIDY FOR OTHER INDIVIDUALS AND 13
FAMILIES.— 14
(1) IN GENERAL.—For any calendar year, in 15
the case of a covered individual who is determined 16
to have a modified adjusted gross income that is 17
greater than 100 percent of the poverty line, as ap- 18
plicable to a family of the size involved, but below 19
the applicable percentage of the poverty line, as ap- 20
plicable to a family of the size involved, the covered 21
individual is entitled under this section to an in- 22
come-related premium subsidy equal to the basic 23
premium subsidy amount reduced by the amount de- 24
termined under paragraph (2). 25
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•S 391 IS
(2) AMOUNT OF REDUCTION.—The amount of 1
the reduction determined under this paragraph is 2
the amount that bears the same ratio to the basic 3
premium subsidy amount as— 4
(A) the excess of— 5
(i) such individual’s modified adjusted 6
gross income, over 7
(ii) an amount equal to 100 percent of 8
the poverty line as applicable to a family of 9
the size involved, bears to 10
(B) the excess of— 11
(i) an amount equal to the applicable 12
percentage of the poverty line as applicable 13
to a family of the size involved, over 14
(ii) an amount equal to 100 percent of 15
the poverty line as applicable to a family of 16
the size involved. 17
(3) APPLICABLE PERCENTAGE.—For purposes 18
of this subsection, the applicable percentage is 400 19
percent. 20
(c) BASIC PREMIUM SUBSIDY AMOUNT.—For pur- 21
poses of this section, the term ‘‘basic premium subsidy 22
amount’’ means, with respect to any individual, the lesser 23
of— 24
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•S 391 IS
(1) the annual premium for the HAPI plan 1
under which the individual is a covered individual; or 2
(2) the weighted average of the premium for 3
HAPI plans of the same class of coverage (as de- 4
scribed in section 111(d)(1)) as the individual’s in 5
the applicable coverage area. 6
(d) CHANGE IN STATUS NOTIFICATION.— 7
(1) IN GENERAL.—If an individual’s modified 8
adjusted income changes such that the individual be- 9
comes eligible or ineligible for a subsidy under this 10
section, the individual shall report that change to 11
the HHA of the individual’s State of residence not 12
more than 60 days after the change takes effect. If 13
an individual reports the change within 60 days 14
under the preceding sentence, the individual’s HAPI 15
plan coverage shall be deemed credible coverage for 16
the purposes of maintaining coverage for preexisting 17
conditions. 18
(2) ADJUSTMENT.—The HHA shall adjust the 19
premium subsidy of such individual to take effect on 20
the first month after the date of the notification 21
under paragraph (1) for which the next premium 22
payment would be due from the individual. 23
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•S 391 IS
(e) CATASTROPHIC EVENT.—A State may develop 1
mechanisms to ensure that covered individuals do not have 2
a break in coverage due to a catastrophic financial event. 3
SEC. 122. ELIGIBILITY FOR PERSONAL RESPONSIBILITY 4
CONTRIBUTION SUBSIDIES. 5
(a) FULL SUBSIDY.—To meet the eligibility require- 6
ments under subtitle B for an HHA, for any taxable year, 7
in the case of a covered individual who is determined to 8
have a modified adjusted gross income that is below 100 9
percent of the poverty line as applicable to a family of 10
the size involved, an HHA shall provide to such an indi- 11
vidual a subsidy equal to the full amount of any personal 12
responsibility contributions applicable to such individual. 13
(b) PARTIAL SUBSIDY.—To meet the eligibility re- 14
quirements under subtitle B for an HHA, for any taxable 15
year, in the case of a covered individual who is determined 16
to have a modified adjusted gross income that is at or 17
above 100 percent of the poverty line as applicable to a 18
family of the size involved, an HHA may provide to such 19
an individual a subsidy equal to the part of the amount 20
of any personal responsibility contributions applicable to 21
such individual. 22
SEC. 123. DEFINITIONS AND SPECIAL RULES. 23
(a) DETERMINATION OF MODIFIED ADJUSTED 24
GROSS INCOME.— 25
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•S 391 IS
(1) IN GENERAL.—In this subtitle, the term 1
‘‘modified adjusted gross income’’ means adjusted 2
gross income (as defined in section 62 of the Inter- 3
nal Revenue Code of 1986)— 4
(A) determined without regard to sections 5
86, 135, 137, 199, 221, 222, 911, 931, and 6
933 of such Code; and 7
(B) increased by— 8
(i) the amount of interest received or 9
accrued during the taxable year which is 10
exempt from tax under such Code; and 11
(ii) the amount of any social security 12
benefits (as defined in section 86(d) of 13
such Code) received or accrued during the 14
taxable year. 15
(2) TAXABLE YEAR TO BE USED TO DETER- 16
MINE MODIFIED ADJUSTED GROSS INCOME.—In ap- 17
plying this subtitle to determine an individual’s an- 18
nual premiums, the covered individual’s modified ad- 19
justed gross income shall be such income determined 20
using the individual’s most recent income tax return 21
or other information furnished to the Secretary by 22
such individual, as the Secretary may require. 23
(b) POVERTY LINE.—In this subtitle, the term ‘‘pov- 24
erty line’’ has the meaning given such term in section 25
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•S 391 IS
673(2) of the Community Health Services Block Grant 1
Act (42 U.S.C. 9902(2)), including any revision required 2
by such section. 3
(c) OTHER PROCEDURES TO DETERMINE SUB- 4
SIDIES.—The Secretary shall promulgate regulations to be 5
used by HHAs to calculate the premium subsidies under 6
section 121 and personal responsibility subsidies under 7
section 122 for individuals whose modified adjusted gross 8
income described in subsection (a)(2) is significantly lower 9
than the modified adjusted gross income of the year in- 10
volved. 11
(d) SPECIAL RULE FOR UNLAWFULLY PRESENT 12
ALIENS.—A health insurance issuer shall remit to the 13
Federal Government any funding, including any subsidy 14
payments, received by such issuer from the Federal Gov- 15
ernment on behalf of any adult alien who is unlawfully 16
present in the United States. 17
(e) SPECIAL RULE FOR ALIENS.—The Secretary of 18
Homeland Security may not extend or renew an alien’s 19
eligibility for status in the United States or adjust the sta- 20
tus of an alien in the United States if the alien owes— 21
(1) a premium payment for a HAPI plan that 22
is past due; or 23
(2) a penalty incurred for failing to pay such a 24
premium. 25
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•S 391 IS
(f) NO DISCHARGE IN BANKRUPTCY.—In the case of 1
any bankruptcy filed by or on behalf of any person after 2
the date that is 2 years after the date of enactment of 3
this Act, under title 11, United States Code, any penalty 4
imposed with respect to such person for failure to pay a 5
HAPI plan premium shall not be subject to discharge 6
under such title. 7
Subtitle D—Wellness Programs 8
SEC. 131. REQUIREMENTS FOR WELLNESS PROGRAMS. 9
(a) DEFINITION.—In this Act, the term ‘‘wellness 10
program’’ means a program that consists of a combination 11
of activities that are designed to increase awareness, as- 12
sess risks, educate, and promote voluntary behavior 13
change to improve the health of an individual, modify his 14
or her consumer health behavior, enhance his or her per- 15
sonal well-being and productivity, and prevent illness and 16
injury. 17
(b) DISCOUNTS.— 18
(1) ELIGIBILITY.—With respect to a HAPI 19
plan that is offered in a State that permits premium 20
discounts for enrollees who participate in a wellness 21
program, to be eligible to receive such a discount, 22
the administrator of the wellness program, on behalf 23
of the enrollee, shall certify in writing to the plan 24
that— 25
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•S 391 IS
(A)(i) the enrollee is participating in an 1
approved wellness program; or 2
(ii) the dependent child of the enrollee is 3
participating in an approved wellness program; 4
and 5
(B) the wellness program meets the re- 6
quirements of this subsection. 7
(2) REQUIREMENTS.—A wellness program 8
meets the requirements of this paragraph if such 9
program— 10
(A) is reasonably designed (as determined 11
by the HAPI plan) to promote good health and 12
prevent disease for program participants; 13
(B) has been approved by the HAPI plan 14
for purposes of applying participation discounts; 15
(C) is offered to all enrollees in a HAPI 16
plan regardless of health status; 17
(D) permits any enrollee for whom it is un- 18
reasonably difficult to meet the initial program 19
standard for participation due to a medical con- 20
dition (or for whom it is medically inadvisable 21
to attempt) an opportunity to meet a reason- 22
able alternative participation standard— 23
(i)(I) that is developed prior to enroll- 24
ment of the enrollee; or 25
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•S 391 IS
(II) that is developed in consultation 1
with the enrollee after enrollment of the 2
enrollee, after a determination has been 3
made that the enrollee cannot safely meet 4
the program participation standard; and 5
(ii) the availability of which is dis- 6
closed in the original documents relating to 7
participation in the program; 8
(E) applies procedures for determining 9
whether an enrollee is participating in a mean- 10
ingful manner in the program, including proce- 11
dures to determine if such participation is re- 12
sulting in lifestyle changes that are indicative of 13
an improved health outcome or outcomes; and 14
(F) meets any other requirements imposed 15
by the HAPI plan. 16
(3) RELATION TO HEALTH STATUS.—Participa- 17
tion in a wellness program may not be used by a 18
HAPI plan to make rate or discount determinations 19
with respect to the health status of an enrollee. 20
(4) AVAILABILITY OF DISCOUNTS.— 21
(A) OFFERING OF ENROLLMENT.—A 22
HAPI plan shall provide enrollees with the op- 23
portunity to participate in a wellness program 24
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•S 391 IS
(for purposes of qualifying for premium dis- 1
counts) at least once each year. 2
(B) DETERMINATIONS.—Determinations 3
with respect to the successful participation by 4
an enrollee in a wellness program for purposes 5
of qualifying for discounts shall be made by the 6
HAPI plan based on a retrospective review of 7
the scope of activities of the enrollee under the 8
program. The HAPI plan may require a min- 9
imum level of successful participation in such a 10
program prior to applying any premium dis- 11
count. 12
(C) PARTICIPATION IN MULTIPLE PRO- 13
GRAMS.—An enrollee may participate in mul- 14
tiple wellness programs to reach the maximum 15
premium discount permitted by the HAPI plan 16
under applicable State law. 17
(5) PERSONAL RESPONSIBILITY CONTRIBUTION 18
DISCOUNT.—A HAPI plan may elect to provide dis- 19
counts in the amount of the personal responsibility 20
contribution that is required of an enrollee if the en- 21
rollee participates in an approved wellness program. 22
(c) EMPLOYER INCENTIVE FOR WELLNESS PRO- 23
GRAMS.—For provisions relating to employers deducting 24
the costs of offering wellness programs or worksite health 25
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•S 391 IS
centers see section 162(l) of the Internal Revenue Code 1
of 1986. 2
TITLE II—HEALTHY START FOR 3
CHILDREN 4
Subtitle A—Benefits and Eligibility 5
SEC. 201. GENERAL GOAL AND AUTHORIZATION OF APPRO- 6
PRIATIONS FOR HAPI PLAN COVERAGE FOR 7
CHILDREN. 8
(a) GENERAL GOAL.—It is the general goal of this 9
Act to provide essential, good quality, affordable, and pre- 10
vention-oriented health care coverage for all children in 11
the United States. 12
(b) AUTHORIZATION OF APPROPRIATIONS.—There is 13
authorized to be appropriated, such sums as may be nec- 14
essary for each fiscal year to enable the Secretary to pro- 15
vide assistance to States to enable such States to ensure 16
that each child who is a member of a family with a modi- 17
fied adjusted gross income that is below 300 percent of 18
the poverty line as applicable to a family of the size in- 19
volved, who is not otherwise eligible for coverage as a de- 20
pendent under a HAPI plan maintained by his or her par- 21
ents, is covered under a HAPI plan provided through the 22
State HHA. 23
(c) POLICIES AND PROCEDURES.—The Secretary 24
shall develop policies and procedures to be applied by the 25
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•S 391 IS
States to identify children described in subsection (a) and 1
to provide such children with coverage under a HAPI plan. 2
States shall determine, in consultation with health insur- 3
ance issuers, a separate class of coverage to assure afford- 4
able child coverage. 5
(d) DEFINITION.—In this title, the term ‘‘child’’ 6
means an individual who is under the age of 19 years or, 7
in the case of an individual in foster care, under the age 8
of 21 years. 9
SEC. 202. COORDINATION OF SUPPLEMENTAL COVERAGE 10
UNDER THE MEDICAID PROGRAM WITH HAPI 11
PLAN COVERAGE FOR CHILDREN. 12
(a) ASSURANCE OF SUPPLEMENTAL COVERAGE.— 13
Subject to section 631(d), the Secretary, States, and 14
health insurance issuers shall ensure that any child eligible 15
under title XIX of the Social Security Act (including any 16
child eligible under a waiver under such title or under sec- 17
tion 1115 of such Act (42 U.S.C. 1315)) covered under 18
a HAPI plan provided through the State HHA receives 19
medical assistance under State Medicaid plans in a man- 20
ner that— 21
(1) is provided in coordination with, and as a 22
supplement to, the coverage provided the child under 23
the HAPI plan in which the child is enrolled; 24
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•S 391 IS
(2) does not supplant the child’s coverage under 1
a HAPI plan; 2
(3) ensures that the child receives all items or 3
services that are not available (or are otherwise lim- 4
ited) under the HAPI plan in which they are en- 5
rolled but that is provided under the State plan (or 6
provided to a greater extent or in a less restrictive 7
manner) under title XIX of the Social Security Act 8
(including any waiver under such title or under sec- 9
tion 1115 of such Act (42 U.S.C. 1315)) of the 10
State in which the child resides; and 11
(4) ensures that the family of the child is not 12
charged premiums, deductibles, or other cost-sharing 13
that is greater than would have been charged under 14
the State plan under title XIX of the Social Security 15
Act of the State in which the child resides if such 16
coverage was not provided as a supplement to the 17
coverage provided the child under the HAPI plan in 18
which the child is enrolled. 19
(b) GUIDANCE TO STATES AND HEALTH INSURANCE 20
ISSUERS.—The Secretary shall issue regulations and guid- 21
ance to States and health insurance issuers implementing 22
this section not later than 6 months prior to the date on 23
which coverage under a HAPI plan first begins. 24
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•S 391 IS
(c) RULE OF CONSTRUCTION.—Nothing in this sec- 1
tion shall be construed as affecting a State’s requirement 2
to provide items and services described in section 3
1905(a)(4)(B) (relating to early and periodic screening, 4
diagnostic, and treatment services defined in section 5
1905(r) and provided in accordance with the requirements 6
of section 1902(a)(43)). 7
(d) CHILD.—In this section, the term ‘‘child’’ has the 8
meaning given that term under section 201(d), and in- 9
cludes any individual who would be considered a child 10
under the Medicaid program of the State in which the in- 11
dividual resides. 12
Subtitle B—Service Providers 13
SEC. 211. INCLUSION OF PROVIDERS UNDER HAPI PLANS. 14
(a) IN GENERAL.—To ensure that children have ac- 15
cess to health care in their communities, and that such 16
care is provided to such children for no cost or on a reim- 17
bursable basis, a HAPI plan shall ensure that health care 18
items and services may be obtained by such children from, 19
at a minimum, the providers described in subsection (b) 20
if available in the area involved. 21
(b) PROVIDERS DESCRIBED.—The providers de- 22
scribed in this subsection include the following: 23
(1) A school-based health center (in accordance 24
with section 212). 25
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•S 391 IS
(2) A health center funded under section 330 of 1
the Public Health Service Act (42 U.S.C. 254b). 2
(3) A federally qualified health center. 3
(4) A rural health clinic under title XVIII of 4
the Social Security Act (42 U.S.C. 1395 et seq.). 5
(5) An Indian health service facility. 6
SEC. 212. USE OF, AND GRANTS FOR, SCHOOL-BASED 7
HEALTH CENTERS. 8
(a) DEFINITION.—In this section, the term ‘‘school- 9
based health center’’ means a health center that— 10
(1) is located within an elementary or secondary 11
school facility; 12
(2) is operated in collaboration with the school 13
in which such center is located; 14
(3) is administered by a community-based orga- 15
nization including a hospital, public health depart- 16
ment, community health center, or nonprofit health 17
care agency; 18
(4) at a minimum, provides to school-aged chil- 19
dren— 20
(A) primary health care services, including 21
comprehensive health assessments, and diag- 22
nosis and treatment of minor, acute, and chron- 23
ic medical conditions and Healthy Start bene- 24
fits; 25
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•S 391 IS
(B) mental health services, including crisis 1
intervention, counseling, and emergency psy- 2
chiatric care at the school or by referral; 3
(C) the availability of services at the school 4
when the school is open and 24-hour coverage 5
through an on-call system with other providers 6
to ensure access when the school or health cen- 7
ter is closed; 8
(D) services through the use of a qualified 9
and appropriately credentialed individual, in- 10
cluding a nurse practitioner or physician assist- 11
ant, a mental health professional, a physician, 12
and a health assistant; and 13
(E) by not later than January 1, 2012, an 14
electronic medical record relating to the indi- 15
vidual; and 16
(5) may provide optional preventive dental serv- 17
ices, consistent with State licensure law, through the 18
use of dental hygienists or dental assistants that 19
provide preventive services such as basic oral exams, 20
cleanings, and sealants. 21
(b) ACCESS TO SCHOOL-BASED HEALTH CEN- 22
TERS.— 23
(1) IN GENERAL.—A school-based health center 24
may provide services to students in more than 1 25
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•S 391 IS
school if the school district or other supervising 1
State entity determined that capacity and geo- 2
graphic location make such provision of services ap- 3
propriate. 4
(2) ENROLLMENT.—Upon the enrollment of a 5
student in a school with a school-based health cen- 6
ter, the center will provide the student with the op- 7
portunity to enroll, after parental consent (subject to 8
State and local law), to receive health care from the 9
center. 10
(3) REIMBURSEMENT FOR SERVICES.— 11
(A) IN GENERAL.—A school-based health 12
center may seek reimbursement from a third 13
party payer if available, including a HAPI plan, 14
if a child receives health care items or services 15
through the center. 16
(B) USE OF FUNDS.—Amounts received 17
from a third party payer under subparagraph 18
(A) shall be allocated to the school-based health 19
center that provided the care for which the re- 20
imbursement was provided for use by that cen- 21
ter for providing additional health care items 22
and services. 23
(c) DEVELOPMENTAL GRANTS.— 24
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•S 391 IS
(1) IN GENERAL.—The Secretary shall award 1
grants to local school districts and communities for 2
the establishment and operation of school-based 3
health centers. 4
(2) ELIGIBILITY.—To be eligible for a grant 5
under paragraph (1), a local school district or local 6
community shall submit to the Secretary an applica- 7
tion at such time, in such manner, and containing 8
such information as the Secretary may require. 9
(3) SELECTION CRITERIA.—In awarding grants 10
under this subsection, the Secretary shall give pri- 11
ority to— 12
(A) an applicant that will use amounts 13
under the grant to establish a school-based 14
health center in a medically underserved area, 15
or an area for which there are extended dis- 16
tances between the school involved and appro- 17
priate providers of care for school-aged children 18
in the geographic area involved; 19
(B) an applicant that will use amounts 20
under the grant to establish a school-based 21
health center in a school that serves students 22
with the highest incidence of unmet medical 23
and psycho-social needs; and 24
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•S 391 IS
(C) an applicant that can demonstrate that 1
State, local, or community partners, or any 2
combination of such entities, have provided at 3
least 50 percent of the funding for the school- 4
based health center involved to ensure the ongo- 5
ing operation of the center. 6
(4) USE OF FUNDS.—A grantee shall use 7
amounts received under a grant under this sub- 8
section to establish and operate a school-based 9
health center (including purchasing and maintaining 10
electronic medical records). Not less than 50 percent 11
of the amounts received under the grant shall be 12
used for the ongoing operations of the center (in- 13
cluding such purchases and maintenance). 14
(d) COVERAGE BY FEDERAL TORT CLAIMS ACT.— 15
In providing health care items and services to students 16
through a school-based health care center, a health care 17
provider shall be deemed to be an employee of the govern- 18
ment for purposes of the application of chapter 171 of 19
title 28, United States Code (the Federal Tort Claims Act) 20
if such provider was acting within the scope of his or her 21
license. 22
(e) AUTHORIZATION OF APPROPRIATIONS.—There is 23
authorized to be appropriated, such sums as may be nec- 24
essary for each fiscal year to carry out this section. 25
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•S 391 IS
TITLE III—BETTER HEALTH FOR 1
OLDER AND DISABLED AMER- 2
ICANS 3
Subtitle A—Assurance of 4
Supplemental Medicaid Coverage 5
SEC. 301. COORDINATION OF SUPPLEMENTAL COVERAGE 6
UNDER THE MEDICAID PROGRAM FOR EL- 7
DERLY AND DISABLED INDIVIDUALS. 8
(a) ASSURANCE OF SUPPLEMENTAL COVERAGE.— 9
Subject to section 631(d), the Secretary, States, and 10
health insurance issuers shall ensure that any elderly or 11
disabled individual eligible under title XIX of the Social 12
Security Act (including any such individual eligible pursu- 13
ant to a waiver under such title or under section 1115 14
of such Act (42 U.S.C. 1315)) covered under a HAPI plan 15
provided through the State HHA receives medical assist- 16
ance under State Medicaid plans in a manner that— 17
(1) is provided in coordination with, and as a 18
supplement to, the coverage provided the individual 19
under the HAPI plans in which the individual is en- 20
rolled; 21
(2) does not supplant the individual’s coverage 22
under a HAPI plan; 23
(3) ensures that the elderly or disabled indi- 24
vidual receives all items or services, including insti- 25
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•S 391 IS
tutional care or home and community-based services 1
that are not available (or are otherwise limited) 2
under the HAPI plan in which they are enrolled but 3
that is provided (or provided to a greater extent or 4
in a less restrictive manner) under the State plan 5
under title XIX of the Social Security Act (including 6
through any waiver under such title or under section 7
1115 of such Act (42 U.S.C. 1315)) of the State in 8
which the individual resides; 9
(4) ensures that the elderly or disabled indi- 10
vidual is not charged premiums, deductibles and 11
other cost-sharing that is greater than would have 12
been charged under the State plan under title XIX 13
of the Social Security Act (including any waiver 14
under such title or under section 1115 of such Act 15
(42 U.S.C. 1315)) of the State in which the indi- 16
vidual resides if such coverage was not provided as 17
a supplement to the coverage provided the individual 18
under the HAPI plan in which the individual is en- 19
rolled. 20
(b) GUIDANCE TO STATES AND HEALTH INSURANCE 21
ISSUERS.—The Secretary shall issue regulations and guid- 22
ance to States and health insurance issuers implementing 23
this section that takes into account the special health care 24
needs of elderly and disabled individuals who are eligible 25
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•S 391 IS
for medical assistance under State Medicaid programs, 1
particularly with respect to institutionalized care or home 2
and community-based services, not later than 6 months 3
prior to the date on which coverage under a HAPI plan 4
first begins. 5
(c) DEFINITIONS.—In this section— 6
(1) the term ‘‘institutionalized care’’ means the 7
health care provided under the Medicaid plan of the 8
State of residence of an elderly or disabled individual 9
who is a patient in a hospital, nursing facility, inter- 10
mediate care facility for the mentally retarded, or an 11
institution for mental diseases (as such terms are 12
defined for purposes of such plan); and 13
(2) the term ‘‘home and community-based serv- 14
ices’’ means any services which may be offered 15
under the Medicaid plan of the State of residence of 16
an elderly or disabled individual under a home and 17
community-based waiver authorized for a State 18
under section 1115 of the Social Security Act (42 19
U.S.C. 1315) or under subsection (c), (d), or (i) of 20
section 1915 of such Act (42 U.S.C. 1396n). 21
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•S 391 IS
Subtitle B—Empowering Individ- 1
uals and States To Improve 2
Long-Term Care Choices 3
SEC. 311. NEW, AUTOMATIC MEDICAID OPTION FOR STATE 4
CHOICES FOR LONG-TERM CARE PROGRAM. 5
(a) IN GENERAL.—Title XIX of the Social Security 6
Act (42 U.S.C. 1396 et seq.) is amended by adding at 7
the end the following new section: 8
‘‘STATE CHOICES FOR LONG-TERM CARE PROGRAM 9
‘‘SEC. 1942. (a) IN GENERAL.—Notwithstanding any 10
other provision of this title, the Secretary shall permit a 11
State to establish and operate under the State plan under 12
this title (including such a plan operating under a state- 13
wide waiver under section 1115) a State Choices for Long- 14
Term Care Program in accordance with this section. 15
‘‘(b) PROGRAM REQUIREMENTS.—A program estab- 16
lished under the authority of this section shall satisfy the 17
following requirements: 18
‘‘(1) INDIVIDUALIZED BENEFIT PACKAGE.— 19
Each individual enrolled in the program shall be pro- 20
vided with long-term care coverage consisting of 21
medical assistance for long-term care services that 22
are provided according to the specific needs of the 23
individual and that best reflect the individual’s needs 24
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•S 391 IS
and preferences, based on a clinical assessment of 1
the individual. 2
‘‘(2) PERSONAL CASE MANAGERS.—Each indi- 3
vidual enrolled in the program shall be provided with 4
a personal case manager who shall assist the indi- 5
vidual in— 6
‘‘(A) determining the individual’s needs 7
and preferences for the long-term care services 8
that are contained within the individual’s ben- 9
efit package, including the selection of the serv- 10
ice providers for such services; 11
‘‘(B) identifying community resources that 12
are available to provide support for the indi- 13
vidual; and 14
‘‘(C) addressing issues related to ensuring 15
the safety and quality of the long-term care 16
services provided to the individual. 17
‘‘(3) INFORMED CHOICE.—The program shall 18
have procedures to ensure that each individual that 19
is likely to satisfy the eligibility criteria established 20
for the program under paragraph (6) who is dis- 21
charged from a hospital or who resides in a nursing 22
facility, intermediate care facility for the mentally 23
retarded, or institution for mental diseases and who 24
requires long-term care services is informed of the 25
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•S 391 IS
options available to the individual under the pro- 1
gram for obtaining such services. 2
‘‘(4) SELF-DIRECTED OPTION.—The program 3
shall provide an individual enrolled in the program 4
with the option to elect to plan and purchase the 5
long-term care services that are contained in the in- 6
dividual’s benefit package under the direction and 7
control of the individual (or the individual’s author- 8
ized representative), subject to an individualized 9
budget developed for, and with the involvement of, 10
the individual (or the individual’s authorized rep- 11
resentative). 12
‘‘(5) EQUAL ACCESS TO INSTITUTIONAL CARE 13
AND HOME AND COMMUNITY-BASED SERVICES.—The 14
program shall provide an individual enrolled in the 15
program who, because of the individual’s mental or 16
physical condition, requires a level of care for long 17
term care services that is above a level of care for 18
such services that can appropriately be provided 19
solely through home and community-based providers 20
(as defined by the State and approved by the Sec- 21
retary), with equal access to long-term care services 22
provided through institutional facilities and long- 23
term care services provided through home and com- 24
munity-based providers. 25
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•S 391 IS
‘‘(6) ELIGIBILITY; PRIORITIZATION OF NEED.— 1
The program shall apply eligibility criteria for indi- 2
viduals desiring to enroll in the program that is es- 3
tablished by the State and approved by the Sec- 4
retary. The eligibility criteria established by the 5
State shall— 6
‘‘(A) require that an individual enrolled in 7
the program— 8
‘‘(i) be eligible for medical assistance 9
under the State plan (or under a statewide 10
waiver of such plan) for nursing facility 11
services, services in an intermediate care 12
facility for the mentally retarded, services 13
in an institution for mental diseases, or 14
services provided under a home and com- 15
munity-based waiver approved for the 16
State; and 17
‘‘(ii) satisfy such other criteria as the 18
State shall establish; and 19
‘‘(B) be based on a strategy for prioritizing 20
and allocating expenditures so that those indi- 21
viduals with the highest level of need for long- 22
term care services are assured of receiving such 23
services through an institutional facility or 24
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•S 391 IS
through a home and community-based provider, 1
based on the individual’s needs and preferences. 2
‘‘(c) ADDITIONAL REQUIREMENTS.—A State may not 3
establish and operate a program under this section unless 4
it satisfies the following requirements: 5
‘‘(1) AGREEMENT TO LIMIT FEDERAL EXPENDI- 6
TURES.— 7
‘‘(A) IN GENERAL.—The State agrees to 8
an aggregate limit for a 5-year period for Fed- 9
eral payments under section 1903(a) for ex- 10
penditures for medical assistance for long-term 11
care services under the State plan and adminis- 12
trative expenditures related to the provision of 13
such assistance. 14
‘‘(B) CALCULATION OF AGGREGATE 15
LIMIT.—The 5-year aggregate limit applicable 16
to a State under subparagraph (A) shall be de- 17
termined by the State and the Secretary based 18
on the following: 19
‘‘(i) HISTORICAL AND PROJECTED 20
CASELOADS.—The historical and projected 21
State caseloads (determined for a 5-year 22
period, respectively) of individuals receiving 23
nursing facility services, services in an in- 24
termediate care facility for the mentally re- 25
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•S 391 IS
tarded, services in an institution for men- 1
tal diseases, or services provided under a 2
home and community-based waiver ap- 3
proved for the State under the State plan, 4
based on data from the Secretary, the Bu- 5
reau of the Census, the Commissioner of 6
Social Security, and such other sources as 7
the Secretary may approve. 8
‘‘(ii) HISTORICAL AND PROJECTED 9
EXPENDITURES.—The historical and pro- 10
jected expenditures (determined for a 5- 11
year period, respectively) for the services 12
identified in clause (i). Projected expendi- 13
tures shall be determined without regard to 14
the program established under this section 15
and shall take into account the percentage 16
change (if any) in the medical care compo- 17
nent of the consumer price index for all 18
urban consumers (U.S. city average) for 19
each year of the period. 20
‘‘(C) RULE OF CONSTRUCTION.—Nothing 21
in this paragraph shall be construed as affect- 22
ing the requirement for a State to incur State 23
expenditures for medical assistance for long- 24
term care services in order to be paid the Fed- 25
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eral medical assistance percentage determined 1
for the State for such expenditures (not to ex- 2
ceed the aggregate 5-year limit on Federal pay- 3
ments for such expenditures applicable under 4
subparagraph (A)). 5
‘‘(2) PLAN FOR CAPACITY BUILDING AND 6
SKILLS ENHANCEMENT.—The State establishes a 7
plan for building the capacity of the long-term care 8
services system within the State, particularly with 9
respect to the delivery of home and community- 10
based services, and for enhancing the skill levels of 11
the caregivers for individuals eligible for medical as- 12
sistance for such services under the State plan. 13
‘‘(3) DEDICATION OF PROGRAM SAVINGS FOR 14
PREVENTION OR EARLY INTERVENTION SERVICES.— 15
The State agrees that for each fiscal year in which 16
the program is operated, the State will expend an 17
amount equal to the State share of the expenditures 18
that the State would have made under the State 19
plan for providing medical assistance for long-term 20
care services for individuals enrolled in the program 21
but for the operation of such program, for the provi- 22
sion of prevention or early intervention services for 23
nonenrolled individuals residing in the State who re- 24
quire a level of long-term care services that is below 25
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the level that individuals enrolled in the program re- 1
quire (regardless of whether such nonenrolled indi- 2
viduals are eligible for medical assistance under the 3
State plan). 4
‘‘(d) OPTION TO OPERATE PROGRAM THROUGH A 5
MANAGED CARE PLAN.—A State may operate a program 6
under this section through an arrangement on a capitated 7
basis with a medicaid managed care organization (as de- 8
fined in section 1903(m)(1)(A)). 9
‘‘(e) INDEPENDENT EVALUATION AND REPORT.— 10
‘‘(1) IN GENERAL.—The Secretary shall con- 11
tract with a nongovernmental organization or aca- 12
demic institution to conduct an ongoing independent 13
evaluation of the program that assesses— 14
‘‘(A) the quality of the long-term care serv- 15
ices provided under the program; 16
‘‘(B) the cost-effectiveness of such services; 17
‘‘(C) consumer satisfaction; and 18
‘‘(D) the consistency and accuracy with 19
which the prioritization of need criteria required 20
under subsection (b)(6)(B) is applied. 21
‘‘(2) BIENNIAL REPORTS.—The organization or 22
institution conducting the evaluation required under 23
this subsection shall submit biennial reports to the 24
Secretary regarding the results of the evaluation. 25
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‘‘(f) DEFINITION OF LONG-TERM CARE SERVICES.— 1
For purposes of this section, the term ‘long-term care 2
services’ has the meaning given such term by a State es- 3
tablishing and operating a program under this section, 4
subject to approval by the Secretary.’’. 5
(b) EFFECTIVE DATE.—The amendment made by 6
subsection (a) takes effect on the date of enactment of 7
this Act. 8
SEC. 312. SIMPLER AND MORE AFFORDABLE LONG-TERM 9
CARE INSURANCE COVERAGE. 10
(a) QUALIFIED LONG-TERM CARE INSURANCE CON- 11
TRACT MUST SATISFY QUALIFIED LONG-TERM CARE 12
PLAN REQUIREMENTS.—Section 7702B(b)(1)(A) of the 13
Internal Revenue Code of 1986 (defining qualified long- 14
term care insurance contract) is amended by inserting 15
‘‘through a qualified long-term care plan’’ after ‘‘qualified 16
long-term care services’’. 17
(b) QUALIFIED LONG-TERM CARE PLAN.—Section 18
7702B of such Code is amended by adding at the end the 19
following new subsection: 20
‘‘(h) QUALIFIED LONG-TERM CARE PLAN.—For pur- 21
poses of this section— 22
‘‘(1) IN GENERAL.—The term ‘qualified long- 23
term care plan’ means an insurance plan that meets 24
the standards and requirements set forth in para- 25
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graph (2) (including the 2011 NAIC Model Regula- 1
tion or 2011 Federal Regulation (as the case may 2
be)) on or after the date specified in paragraph (5). 3
‘‘(2) DEVELOPMENT OF STANDARDS AND RE- 4
QUIREMENTS FOR QUALIFIED LONG-TERM CARE 5
PLANS.— 6
‘‘(A) IN GENERAL.—If, within 9 months 7
after the date of the enactment of this sub- 8
section, the National Association of Insurance 9
Commissioners (in this subsection referred to as 10
the ‘Association’) adopts a model regulation (in 11
this section referred to as the ‘2011 NAIC 12
Model Regulation’) to incorporate— 13
‘‘(i) limitations on the groups or pack- 14
ages of benefits that may be offered under 15
a long-term care insurance policy con- 16
sistent with paragraphs (3) and (4), 17
‘‘(ii) uniform language and definitions 18
to be used with respect to such benefits, 19
‘‘(iii) uniform format to be used in the 20
policy with respect to such benefits, and 21
‘‘(iv) other standards required by the 22
Secretary of Health and Human Services, 23
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paragraph (1) shall be applied in each State, ef- 1
fective for policies issued to policyholders on 2
and after the date specified in paragraph (5). 3
‘‘(B) SECRETARIAL RESPONSIBILITY.—If 4
the Association does not adopt the 2011 NAIC 5
Model Regulation within the 9-month period 6
specified in subparagraph (A), the Secretary 7
shall promulgate, not later than 9 months after 8
the end of such period, a regulation (in this sec- 9
tion referred to as the ‘2011 Federal Regula- 10
tion’) and paragraph (1) shall be applied in 11
each State, effective for policies issued to pol- 12
icyholders on and after the date specified in 13
paragraph (5). 14
‘‘(C) CONSULTATION.—In promulgating 15
standards and requirements under this para- 16
graph, the Association or Secretary shall con- 17
sult with a working group composed of rep- 18
resentatives of issuers of long-term care insur- 19
ance policies, consumer groups, long-term care 20
insurance beneficiaries, and other qualified indi- 21
viduals. Such representatives shall be selected 22
in a manner so as to insure balanced represen- 23
tation among the interested groups. 24
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‘‘(3) LIMITATIONS OF GROUPS OR PACKAGES OF 1
BENEFITS.—The benefits under the 2011 NAIC 2
Model Regulation or 2011 Federal Regulation shall 3
provide— 4
‘‘(A) for such groups or packages of bene- 5
fits as may be appropriate taking into account 6
the considerations specified in paragraph (4) 7
and the requirements of the succeeding sub- 8
paragraphs, 9
‘‘(B) for identification of a core group of 10
basic benefits common to all policies, and 11
‘‘(C) that the total number of different 12
benefit packages (counting the core group of 13
basic benefits described in subparagraph (B) 14
and each other combination of benefits that 15
may be offered as a separate benefit package) 16
that may be established in all the States and by 17
all issuers shall not exceed 10. 18
‘‘(4) SPECIFIC CONSIDERATIONS.—The benefits 19
under paragraph (3) shall, to the extent possible— 20
‘‘(A) provide for benefits that offer con- 21
sumers the ability to purchase the benefits that 22
are available in the market as of November 5, 23
2010, and 24
‘‘(B) balance the objectives of— 25
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‘‘(i) simplifying the market to facili- 1
tate comparisons among policies, 2
‘‘(ii) avoiding adverse selection, 3
‘‘(iii) providing consumer choice, 4
‘‘(iv) providing market stability, and 5
‘‘(v) promoting competition. 6
‘‘(5) EFFECTIVE DATE.— 7
‘‘(A) IN GENERAL.—Subject to subpara- 8
graph (B), the date specified in this paragraph 9
shall be the date the State adopts the 2011 10
NAIC Model Regulation or 2011 Federal Regu- 11
lation or 1 year after the date the Association 12
or the Secretary first adopts such standards, 13
whichever is earlier. 14
‘‘(B) REQUIRED STATE LEGISLATION.—In 15
the case of a State which the Secretary identi- 16
fies, in consultation with the Association, as— 17
‘‘(i) requiring State legislation (other 18
than legislation appropriating funds) in 19
order for long-term care insurance policies 20
to meet the 2011 NAIC Model Regulation 21
or 2011 Federal Regulation, but 22
‘‘(ii) having a legislature which is not 23
scheduled to meet in 2011 in a legislative 24
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session in which such legislation may be 1
considered, 2
the date specified in this paragraph is the first 3
day of the first calendar quarter beginning after 4
the close of the first legislative session of the 5
State legislature that begins on or after Janu- 6
ary 1, 2012. For purposes of the preceding sen- 7
tence, in the case of a State that has a 2-year 8
legislative session, each year of such session 9
shall be deemed to be a separate regular session 10
of the State legislature.’’. 11
(c) ADDITIONAL CONSUMER PROTECTIONS.— 12
(1) IN GENERAL.—Section 7702B(g)(1) of such 13
Code (relating to consumer protection provisions) is 14
amended— 15
(A) by striking subparagraph (A) and in- 16
serting the following new paragraph: 17
‘‘(1) the requirements of the 1993 NAIC model 18
regulation and model Act described in paragraph (2) 19
and the 2000 NAIC model regulation and model Act 20
described in paragraph (5),’’, 21
(B) by striking ‘‘and’’ at the end of sub- 22
paragraph (B), 23
(C) by striking the period at the end of 24
subparagraph (C) and inserting ‘‘, and’’, and 25
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(D) by adding at the end the following new 1
subparagraph: 2
‘‘(D) the requirements relating to manda- 3
tory offer and information under paragraph 4
(6).’’. 5
(2) NAIC MODEL REGULATION AND ACT.—Sec- 6
tion 7702B(g) of such Code is amended— 7
(A) by inserting ‘‘1993 NAIC’’ after ‘‘RE- 8
QUIREMENTS OF’’ in the heading for paragraph 9
(2), 10
(B) by redesignating paragraph (5) as 11
paragraph (7), and 12
(C) by inserting after paragraph (4) the 13
following new paragraph: 14
‘‘(5) REQUIREMENTS OF 2000 NAIC MODEL REG- 15
ULATION AND ACT.— 16
‘‘(A) IN GENERAL.—The requirements of 17
this paragraph are met with respect to any con- 18
tract if such contract meets— 19
‘‘(i) MODEL REGULATION.—The fol- 20
lowing requirements of the model regula- 21
tion: 22
‘‘(I) Section 6A (other than para- 23
graph (5) thereof) and the require- 24
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ments of section 6B of the model Act 1
relating to such section 6A. 2
‘‘(II) Section 6B (other than 3
paragraph (7) thereof). 4
‘‘(III) Sections 6C, 6D, 6E, and 5
7. 6
‘‘(IV) Section 8 (other than sec- 7
tions 8F, 8G, 8H, and 8I thereof). 8
‘‘(V) Sections 9, 11, 12, 14, 15, 9
and 22. 10
‘‘(VI) Section 23, including inac- 11
curate completion of medical histories 12
(other than paragraphs (1), (6), and 13
(9) of section 23C). 14
‘‘(VII) Sections 24 and 25. 15
‘‘(VIII) The provisions of section 16
26 relating to contingent nonforfeiture 17
benefits, if the policyholder declines 18
the offer of a nonforfeiture provision 19
described in paragraph (4). 20
‘‘(IX) Sections 29 and 30. 21
‘‘(ii) MODEL ACT.—The following re- 22
quirements of the model Act: 23
‘‘(I) Sections 6C and 6D. 24
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‘‘(II) The provisions of section 8 1
relating to contingent nonforfeiture 2
benefits. 3
‘‘(III) Sections 6F, 6G, 6H, 6J, 4
6K, and 7. 5
‘‘(B) DEFINITIONS.—For purposes of this 6
paragraph— 7
‘‘(i) MODEL PROVISIONS.—The terms 8
‘model regulation’ and ‘model Act’ mean 9
the long-term care insurance model regula- 10
tion, and the long-term care insurance 11
model Act, respectively, promulgated by 12
the National Association of Insurance 13
Commissioners (as adopted as of October 14
2000). 15
‘‘(ii) COORDINATION.—Any provision 16
of the model regulation or model Act listed 17
under clause (i) or (ii) of subparagraph 18
(A) shall be treated as including any other 19
provision of such regulation or Act nec- 20
essary to implement the provision. 21
‘‘(iii) DETERMINATION.—For pur- 22
poses of this section and section 4980C, 23
the determination of whether any require- 24
ment of a model regulation or the model 25
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Act has been met shall be made by the 1
Secretary.’’. 2
(d) MANDATORY OFFER AND INFORMATION.—Sec- 3
tion 7702B(g) of such Code, as amended by subsection 4
(c), is amended by inserting after paragraph (5) the fol- 5
lowing new paragraph: 6
‘‘(6) MANDATORY OFFER AND INFORMATION.— 7
The requirements of this paragraph are met if— 8
‘‘(A) MANDATORY OFFER.—Any person 9
who sells a long-term care insurance policy to 10
an individual shall make available for sale to 11
the individual a long-term care insurance policy 12
with only the core group of basic benefits (de- 13
scribed in subsection (h)(3)(B)). 14
‘‘(B) INFORMATION.—Any person who sells 15
a long-term care insurance policy to an indi- 16
vidual shall provide the individual, before the 17
sale of the policy, an outline of coverage which 18
describes the benefits under the policy. Such 19
outline shall be on a standard form approved by 20
the State regulatory program or the Secretary 21
(as the case may be) consistent with the 2011 22
NAIC Model Regulation or 2011 Federal Regu- 23
lation.’’. 24
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(e) STATE REGULATION OF OUT-OF-STATE CON- 1
TRACTS.—Section 7702B of such Code, as amended by 2
subsection (b), is amended by adding at the end the fol- 3
lowing new subsection: 4
‘‘(i) STATE REGULATION OF OUT-OF-STATE CON- 5
TRACTS.—Nothing in this section shall be construed so as 6
to affect the right of any State to regulate long-term care 7
insurance policies which, under the provisions of this sec- 8
tion, are considered to be issued in another State.’’. 9
(f) EFFECTIVE DATE.—The amendments made by 10
this section shall apply to contracts issued after December 11
31, 2010. 12
TITLE IV—HEALTHIER 13
MEDICARE 14
Subtitle A—Authority To Adjust 15
Amount of Part B Premium To 16
Reward Positive Health Behav- 17
ior 18
SEC. 401. AUTHORITY TO ADJUST AMOUNT OF MEDICARE 19
PART B PREMIUM TO REWARD POSITIVE 20
HEALTH BEHAVIOR. 21
Section 1839 of the Social Security Act (42 U.S.C. 22
1395r) is amended— 23
(1) in subsection (a)(2), by striking ‘‘and (i)’’ 24
and inserting ‘‘(i), and (j)’’; and 25
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(2) by adding at the end the following new sub- 1
section: 2
‘‘(j)(1) With respect to the monthly premium amount 3
for months after December 2010, the Secretary may ad- 4
just (under procedures established by the Secretary) the 5
amount of such premium for an individual based on 6
whether or not the individual participates in certain 7
healthy behaviors, such as weight management, exercise, 8
nutrition counseling, refraining from tobacco use, desig- 9
nating a health home, and other behaviors determined ap- 10
propriate by the Secretary. 11
‘‘(2) In making the adjustments under paragraph (1) 12
for a month, the Secretary shall ensure that the total 13
amount of premiums to be paid under this part for the 14
month is equal to the total amount of premiums that 15
would have been paid under this part for the month if 16
no such adjustments had been made, as estimated by the 17
Secretary.’’. 18
Subtitle B—Promoting Primary 19
Care for Medicare Beneficiaries 20
SEC. 411. PRIMARY CARE SERVICES MANAGEMENT PAY- 21
MENT. 22
Title XVIII of the Social Security Act (42 U.S.C. 23
1395 et seq.) is amended by inserting after section 1807 24
the following new section: 25
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‘‘SEC. 1807A. PRIMARY CARE MANAGEMENT PAYMENT FOR 1
COORDINATING CARE. 2
‘‘(a) PAYMENT.— 3
‘‘(1) IN GENERAL.—Not later than January 1, 4
2010, the Secretary, subject to paragraph (2), shall 5
establish procedures for providing primary care and 6
participating providers with a management fee (as 7
determined appropriate by the Secretary, in con- 8
sultation with the Medicare Payment Advisory Com- 9
mission established under section 1805) that reflects 10
the amount of time spent with a Medicare bene- 11
ficiary, and the family of such beneficiary, providing 12
chronic care disease management services or other 13
services in assisting in coordinating care. 14
‘‘(2) REQUIREMENT FOR DESIGNATION AS 15
HEALTH HOME.—The management fee under para- 16
graph (1) shall not be provided to a primary care 17
provider with respect to a Medicare beneficiary un- 18
less the provider has been designated (under proce- 19
dures established by the Secretary) as the health 20
home by the beneficiary. 21
‘‘(b) DEFINITIONS.—In this section: 22
‘‘(1) HEALTH HOME.—The term ‘health home’ 23
means a health care provider that a Medicare bene- 24
ficiary has designated to monitor the health and 25
health care of the beneficiary. 26
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‘‘(2) MEDICARE BENEFICIARY.—The term 1
‘Medicare beneficiary’ means an individual who is 2
entitled to, or enrolled for, benefits under part A, 3
enrolled under part B, or both. 4
‘‘(3) PRIMARY CARE PROVIDER.— 5
‘‘(A) IN GENERAL.—The term ‘primary 6
care provider’ means a primary care physician 7
(as defined in subparagraph (B)), a nurse prac- 8
titioner (as defined in section 1861aa(5)(A)), or 9
a physician assistant (as so defined). 10
‘‘(B) PRIMARY CARE PHYSICIAN.—In sub- 11
paragraph (A), the term ‘primary care physi- 12
cian’ means a physician, such as a family prac- 13
titioner or internist, who is chosen by an indi- 14
vidual to provide continuous medical care, who 15
is able to give a wide range of care, including 16
prevention and treatment, and who can refer 17
the individual to a specialist.’’. 18
Subtitle C—Chronic Care Disease 19
Management 20
SEC. 421. CHRONIC CARE DISEASE MANAGEMENT. 21
Title XVIII of the Social Security Act (42 U.S.C. 22
1395 et seq.), as amended by section 411, is amended by 23
inserting after section 1807A the following new section: 24
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‘‘SEC. 1807B. CHRONIC CARE DISEASE MANAGEMENT PRO- 1
GRAM. 2
‘‘(a) ESTABLISHMENT.— 3
‘‘(1) IN GENERAL.—Not later than January 1, 4
2010, the Secretary shall develop and implement a 5
chronic care disease management program (in this 6
section referred to as the ‘program’). The program 7
shall be designed to provide chronic care disease 8
management to all Medicare beneficiaries with re- 9
spect to at least the 5 most prevalent diseases within 10
the population of such beneficiaries (as determined 11
by the Secretary). 12
‘‘(2) DEVELOPMENT.—In developing and imple- 13
menting the program under paragraph (1), the Sec- 14
retary shall— 15
‘‘(A) take into consideration— 16
‘‘(i) the results of chronic care im- 17
provement programs conducted under sec- 18
tion 1807, including the independent eval- 19
uations of such programs conducted under 20
section 1807(b)(5) and any outcomes re- 21
ports submitted under section 22
1807(e)(4)(A); and 23
‘‘(ii) the results of the payments to 24
primary care providers under section 25
1807A; and 26
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‘‘(B) consult individuals with expertise in 1
chronic care disease management. 2
‘‘(b) IDENTIFICATION AND ENROLLMENT.—The Sec- 3
retary shall establish procedures for identifying and enroll- 4
ing Medicare beneficiaries who may benefit from participa- 5
tion in the program. 6
‘‘(c) CHRONIC CARE DISEASE MANAGEMENT PAY- 7
MENT FOR NON-PRIMARY CARE PHYSICIANS.— 8
‘‘(1) IN GENERAL.—Under the program, a non- 9
primary care physician shall receive a chronic care 10
disease management payment if the physician serves 11
the Medicare beneficiary by assuring the beneficiary 12
receives appropriate and comprehensive care, includ- 13
ing referral of the individual to specialists, and as- 14
suring the beneficiary receives preventive services. 15
‘‘(2) AMOUNT OF PAYMENT.—The amount of 16
the management payment under the program shall 17
be an amount determined appropriate by the Sec- 18
retary, in consultation with the Medicare Payment 19
Advisory Commission established under section 20
1805. Such amount shall reflect the amount of time 21
spent with a Medicare beneficiary, and the family of 22
such beneficiary, providing chronic care disease man- 23
agement services. 24
‘‘(d) DEFINITIONS.—In this section: 25
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‘‘(1) MEDICARE BENEFICIARY.—The term 1
‘Medicare beneficiary’ means an individual who is 2
entitled to, or enrolled for, benefits under part A, 3
enrolled under part B, or both. 4
‘‘(2) NON-PRIMARY CARE PHYSICIAN.—The 5
term ‘non-primary care physician’ means a physician 6
who— 7
‘‘(A) is not a primary care physician (as 8
defined in section 1807A(b)(3)(B)); and 9
‘‘(B) provides chronic care disease manage- 10
ment services to a Medicare beneficiary under 11
the program.’’. 12
SEC. 422. CHRONIC CARE EDUCATION CENTERS. 13
(a) ESTABLISHMENT.—The Secretary shall establish 14
Chronic Care Education Centers. 15
(b) PURPOSE.—The Chronic Care Education Centers 16
established under subsection (a) shall serve as clearing- 17
houses for information on health care providers who have 18
expertise in the management of chronic disease. 19
(c) USE OF CERTAIN INFORMATION.—In developing 20
the information described in subsection (b), the Secretary 21
shall utilize— 22
(1) information on the performance of providers 23
in chronic disease demonstration projects and pay 24
for performance efforts; and 25
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(2) additional information determined appro- 1
priate by the Secretary. 2
Subtitle D—Part D Improvements 3
SEC. 431. PROCESS FOR INDIVIDUALS ENTERING THE 4
MEDICARE COVERAGE GAP TO SWITCH TO A 5
PLAN THAT PROVIDES COVERAGE IN THE 6
GAP. 7
(a) PROCESS.—Notwithstanding any other provision 8
of law, by not later than 30 days after the date of enact- 9
ment of this Act, the Secretary shall establish a process 10
under which an applicable individual may terminate enroll- 11
ment in the prescription drug plan or the MA–PD plan 12
in which they are enrolled and enroll in any prescription 13
drug plan or MA–PD plan— 14
(1) that provides some coverage of covered part 15
D drugs (as defined in subsection (e) of section 16
1860D–2 of the Social Security Act (42 U.S.C. 17
1395w–102)) after the individual has reached the 18
initial coverage limit under the plan but has not 19
reached the annual out-of-pocket threshold under 20
subsection (b)(4)(B) of such section; and 21
(2) subject to subsection (b), that serves the 22
area in which the individual resides. 23
(b) SPECIAL RULE PERMITTING APPLICABLE INDI- 24
VIDUALS TO ENROLL IN A PRESCRIPTION DRUG PLAN 25
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OUTSIDE OF THE REGION IN WHICH THE INDIVIDUAL 1
RESIDES.—In the case of an applicable individual who re- 2
sides in a PDP region under section 1860D–11(a)(2) of 3
the Social Security Act (42 U.S.C. 1395w–111(a)(2)) in 4
which there is no prescription drug plan available that pro- 5
vides some coverage of brand name covered part D drugs 6
(as so defined) after the individual has reached the initial 7
coverage limit under the plan but before the individual has 8
reached such annual out-of-pocket threshold, the Sec- 9
retary shall ensure that the process established under sub- 10
section (a) permits the individual to enroll in a prescrip- 11
tion drug plan that provides such coverage but is in an- 12
other PDP region. The Secretary shall determine the PDP 13
region in which the individual may enroll in such a pre- 14
scription drug plan. 15
(c) NOTIFICATION OF APPLICABLE INDIVIDUALS.— 16
Under the process established under subsection (a), the 17
Secretary shall notify, or require sponsors of prescription 18
drug plans and organizations offering MA–PD plans to 19
notify, applicable individuals of the option to change plans 20
under such process. Such notice shall be provided to an 21
applicable individual within 30 days of meeting the defini- 22
tion of such an individual. 23
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(d) PROCESS IN EFFECT THROUGH 2014.—The 1
process established under subsection (a) shall remain in 2
effect through December 31, 2014. 3
(e) DEFINITIONS.—In this section: 4
(1) APPLICABLE INDIVIDUAL.—The term ‘‘ap- 5
plicable individual’’ means a part D eligible indi- 6
vidual (as defined in section 1860D–1(a)(3)(A) of 7
the Social Security Act (42 U.S.C. 1395w– 8
101(a)(3)(A)) who, with respect to a year— 9
(A) is enrolled in a prescription drug plan 10
or an MA–PD plan that does not provide any 11
coverage of covered part D drugs (as so de- 12
fined) after the individual has reached the ini- 13
tial coverage limit under the plan but has not 14
reached such annual out-of-pocket threshold; 15
and 16
(B) has reached such initial coverage limit 17
or is within $750 of reaching such limit. 18
(2) PRESCRIPTION DRUG PLAN; MA–PD PLAN.— 19
The terms ‘‘prescription drug plan’’ and ‘‘MA–PD 20
plan’’ have the meanings given those terms in sec- 21
tion 1860D–41(a)(14) of the Social Security Act (42 22
U.S.C. 1395w–151(a)(14)) and section 1860D– 23
1(a)(3)(C) of such Act (42 U.S.C. 1395w– 24
101(a)(3)(C)), respectively. 25
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Subtitle E—Improving Quality in 1
Hospitals for All Patients 2
SEC. 441. IMPROVING QUALITY IN HOSPITALS FOR ALL PA- 3
TIENTS. 4
(a) IMPROVING HEALTHCARE QUALITY FOR ALL PA- 5
TIENTS.— 6
(1) IN GENERAL.—Section 1866(a)(1) of the 7
Social Security Act (42 U.S.C. 1395cc(a)(1)) is 8
amended— 9
(A) in subparagraph (U), by striking 10
‘‘and’’ at the end; 11
(B) in subparagraph (V), by striking the 12
period at the end and inserting ‘‘, and’’; and 13
(C) by inserting after subparagraph (V) 14
the following new subparagraph: 15
‘‘(W) in the case of hospitals, to demonstrate to 16
accrediting bodies measurable improvement in qual- 17
ity control with respect to all patients and to have 18
in place quality control programs that are directed 19
at care for all patients and that include— 20
‘‘(i) rapid response teams that can assist 21
patients with unstable vital signs; 22
‘‘(ii) heart attack treatments with proven 23
reliability; 24
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‘‘(iii) procedures that reduce medication 1
errors; 2
‘‘(iv) aggressive infection prevention, with 3
special focus on surgeries and infections with 4
the highest death rates; 5
‘‘(v) procedures that reduce the threat of 6
pneumonia, with special focus on the incidence 7
of ventilator-related illness; and 8
‘‘(vi) such other elements as the Secretary 9
determines appropriate.’’. 10
(2) EFFECTIVE DATE.—The amendments made 11
by paragraph (1) shall apply to hospitals as of the 12
date that is 2 years after the date of enactment of 13
this Act. 14
(b) PANEL OF INDEPENDENT EXPERTS.—Beginning 15
not later than the date that is 2 years after the date of 16
enactment of this Act, in order to ensure that hospitals 17
practice state-of-the-art quality control, the Secretary 18
shall convene a panel of independent experts to update the 19
measures of quality control and the types of quality con- 20
trol programs, including the elements of such programs, 21
required under section 1866(a)(1)(W) of the Social Secu- 22
rity Act, as added by subsection (a), not less frequently 23
than on an annual basis. 24
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Subtitle F—End-of-Life Care 1
Improvements 2
SEC. 451. PATIENT EMPOWERMENT AND FOLLOWING A PA- 3
TIENT’S HEALTH CARE WISHES. 4
(a) IN GENERAL.—Section 1866(a)(1) of the Social 5
Security Act (42 U.S.C. 1395cc(a)(1)), as amended by 6
section 441(a), is amended— 7
(1) in subparagraph (V), by striking ‘‘and’’ at 8
the end; 9
(2) in subparagraph (W), by striking the period 10
at the end and inserting ‘‘, and’’; and 11
(3) by inserting after subparagraph (W) the fol- 12
lowing new subparagraph: 13
‘‘(X) to provide each patient with a document 14
designed to promote patient autonomy by docu- 15
menting the patient’s treatment preferences (and co- 16
ordinating these preferences with physician orders) 17
that at a minimum— 18
‘‘(i) transfers with the patient from one 19
setting to another; 20
‘‘(ii) provides a summary of treatment 21
preferences in multiple scenarios by the patient 22
or the patient’s guardian and a physician or 23
other practitioner’s order for care; 24
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‘‘(iii) is easy to read in an emergency situ- 1
ation; 2
‘‘(iv) reduces repetitive activities in com- 3
plying with the Patient Self Determination Act; 4
‘‘(v) ensures that the use of the document 5
is voluntary by the patient or the patient’s 6
guardian; 7
‘‘(vi) is easily accessible in a patient’s med- 8
ical chart; and 9
‘‘(vii) does not supplant State health care 10
proxy, living wills, or other end-of-life care 11
forms.’’. 12
(b) EFFECTIVE DATE.—The amendments made by 13
subsection (a) shall apply to entities as of the date that 14
is 2 years after the date of enactment of this Act. 15
SEC. 452. PERMITTING HOSPICE BENEFICIARIES TO RE- 16
CEIVE CURATIVE CARE. 17
(a) IN GENERAL.—Section 1812 of the Social Secu- 18
rity Act (42 U.S.C. 1395d) is amended— 19
(1) in subsection (a)(4), by striking ‘‘in lieu of 20
certain other benefits,’’; and 21
(2) in subsection (d)— 22
(A) in paragraph (1), by striking ‘‘instead 23
of certain other benefits under this title’’; and 24
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(B) in paragraph (2)(A), by striking ‘‘to 1
be—’’ and all that follows before the period and 2
inserting ‘‘to be equivalent to (or duplicative of) 3
hospice care’’. 4
(b) CONFORMING AMENDMENT.—Section 1862(a)(1) 5
of the Social Security Act (42 U.S.C. 1395y(a)(1)) is 6
amended by striking subparagraph (C). 7
(c) EFFECTIVE DATE.—The amendment made by 8
this section shall apply to services furnished on or after 9
the date of enactment of this Act. 10
SEC. 453. PROVIDING BENEFICIARIES WITH INFORMATION 11
REGARDING END-OF-LIFE CARE CLEARING- 12
HOUSE. 13
Section 1804 of the Social Security Act (42 U.S.C. 14
1395b–2) is amended— 15
(1) in the heading, by inserting ‘‘; END-OF-LIFE 16
CARE INFORMATION’’ after ‘‘INFORMATION’’; and 17
(2) by adding at the end the following new sub- 18
section: 19
‘‘(d) Not later than 1 year after the date of enact- 20
ment of the Healthy Americans Act, the Secretary shall 21
establish procedures to ensure that each individual, at the 22
time the individual applies for benefits under part A or 23
enrolls under part B, is provided with contact information 24
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for the clearinghouse described in section 454 of such 1
Act.’’. 2
SEC. 454. CLEARINGHOUSE. 3
(a) IN GENERAL.—Not later than 1 year after the 4
date of enactment of this Act, the Secretary shall provide 5
for the establishment of a national, toll-free, information 6
clearinghouse that the public may access to find out about 7
State-specific information regarding advance directive and 8
end-of-life care decisions. If the Secretary determines that 9
such a clearinghouse exists and is administered by a not- 10
for-profit organization and meets standards developed by 11
the Secretary to assure the easy access of the public to 12
State-specific information and forms concerning advance 13
directives and end-of-life care decisions through the Inter- 14
net and a national toll free information line, the Secretary 15
shall support such clearinghouse. 16
(b) AUTHORIZATION OF APPROPRIATIONS.—There 17
are authorized to be appropriated $1,000,000 for fiscal 18
year 2009 and each subsequent fiscal year to carry out 19
this section. 20
Subtitle G—Additional Provisions 21
SEC. 461. ADDITIONAL COST INFORMATION. 22
(a) IN GENERAL.—Section 1857(e) of the Social Se- 23
curity Act (42 U.S.C. 1395w–27(e)) is amended by adding 24
at the end the following new paragraph: 25
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‘‘(4) ADDITIONAL COST INFORMATION.—A con- 1
tract under this section shall require a Medicare Ad- 2
vantage Organization to aggregate claims informa- 3
tion into episodes of care and to provide such infor- 4
mation to the Secretary so that costs for specific 5
hospitals and physicians may be measured and com- 6
pared. The Secretary shall make such information 7
public on an annual basis.’’. 8
(b) EFFECTIVE DATE.—The amendment made by 9
subsection (a) shall apply to contracts entered into on or 10
after the date of enactment of this Act. 11
SEC. 462. REDUCING MEDICARE PAPERWORK AND REGU- 12
LATORY BURDENS. 13
Not later than 18 months after the date of enactment 14
of this Act, the Secretary shall provide to Congress a plan 15
for reducing regulations and paperwork in the Medicare 16
program under title XVIII of the Social Security Act (42 17
U.S.C. 1395 et seq.). Such plan shall focus initially on 18
regulations that do not directly enhance the quality of pa- 19
tient care provided under such program. 20
TITLE V—STATE HEALTH HELP 21
AGENCIES 22
SEC. 501. ESTABLISHMENT. 23
As a condition of receiving payment under section 24
503, a State shall, not later than the date that is 2 years 25
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after the date of enactment of this Act, establish or des- 1
ignate a State agency, to be known as the State ‘‘Health 2
Help Agency’’ (referred to in this Act as a ‘‘HHA’’) to— 3
(1) carry out the administration of HAPI plans 4
to individuals in such State; and 5
(2) carry out the functions described in section 6
502. 7
SEC. 502. RESPONSIBILITIES AND AUTHORITIES. 8
(a) PROMOTION OF PREVENTION AND WELLNESS.— 9
Each HHA shall promote prevention and wellness for all 10
State residents, including through the implementation of 11
programs that— 12
(1) educate residents about responsibility for in- 13
dividual health and the health of children; 14
(2) upon request, distribute information to cov- 15
ered individuals regarding the availability of wellness 16
programs; 17
(3) make available to the public, with respect to 18
each health insurance issuer and each HAPI plan, 19
the number of covered individuals who have des- 20
ignated a health home described in section 111(b); 21
and 22
(4) promote the use and understanding of 23
health information technology. 24
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(b) ENROLLMENT OVERSIGHT.—Each HHA shall 1
oversee enrollment in HAPI plans by— 2
(1) providing standardized, unbiased informa- 3
tion on HAPI plans and supplemental health insur- 4
ance options; 5
(2) not less than once per year, administering 6
open enrollment periods for individuals; 7
(3) allowing a covered individual to make en- 8
rollment changes during a 30-day period following 9
marriage, divorce, birth, adoption or placement for 10
adoption, and other circumstances; 11
(4) establish procedures for health insurance 12
issuers to report to the HHA of each State in which 13
the issuer offers a HAPI plan, the health insurance 14
status of State residents in order for the HHA to 15
report annual on the number of uninsured and other 16
relevant data; 17
(5) establish procedures for default enrollment 18
of uninsured individuals into low-cost HAPI plans 19
for individuals or families who do not enroll, are not 20
covered under a health plan offered through a pro- 21
gram described in paragraphs (1)(A) of section 22
102(a), and are not described in paragraph (1)(B) 23
of such section; 24
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(6) establish procedures for hospitals and other 1
providers to report to the HHA if an individual 2
seeks care and is uninsured or does not know his or 3
her health insurance status; 4
(7) ensure that the enrollment of all individuals 5
into HAPI plans, including those individuals assisted 6
by an employer, insurance agent, or other person, is 7
administered by the HHA; 8
(8) develop standardized language for HAPI 9
plan terms and conditions and require participating 10
health insurance issuers to use such language in 11
plan information documents; 12
(9) provide prospective enrollees with a com- 13
parative document that describes all the HAPI plans 14
in which the individual may enroll; and 15
(10) to assist consumers in choosing a HAPI 16
plan, publish information that includes loss ratios, 17
outcome data regarding wellness programs, disease 18
detection and chronic care management programs 19
categorized by health insurance issuer, and other 20
data as the HHA determines appropriate. 21
(c) DETERMINATION AND ADMINISTRATION OF 22
HAPI PLAN SUBSIDIES.—Each HHA shall oversee the 23
determination and administration of HAPI plan subsidies 24
by— 25
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(1) informing State residents about how subsidy 1
eligibility determinations are made; 2
(2) obtaining necessary information about in- 3
come from individuals and Federal and State agen- 4
cies; 5
(3) making eligibility determinations on an indi- 6
vidual basis and informing individuals of such deter- 7
minations; 8
(4) establishing a process by which an indi- 9
vidual may appeal an eligibility determination; 10
(5) collecting from health insurance issuers an 11
administrative fee for joining the HHA system and 12
offering a HAPI plan in a State; 13
(6) collecting premium payments made by, or 14
on behalf of, covered individuals, and remitting such 15
payments to the HAPI plans; and 16
(7) collecting Federal premium subsidies for 17
covered individuals and remitting such subsidies to 18
HAPI plans. 19
(d) PREMIUM RATING RULES.—Each HHA shall en- 20
sure that the premium payments for each HAPI plan are 21
determined in accordance with the rating rules described 22
in section 111(d). 23
(e) EMPOWERMENT OF INDIVIDUALS TO MAKE 24
HEALTH CARE DECISIONS.—Each HHA shall, upon en- 25
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rollment of an individual in a HAPI plan, provide such 1
individual with information regarding— 2
(1) the right of individuals to refuse treatment 3
and to make end-of-life care decisions; 4
(2) State laws relating to end-of-life care, in- 5
cluding applicable State law with respect to health 6
care proxies, advanced directives, living wills, and 7
other documentation by which individuals may make 8
their care decisions known; 9
(3) contact information for any State end-of-life 10
care advocates; and 11
(4) applicable State forms on health proxies, 12
advanced directives, living wills, and other such doc- 13
umentation. 14
(f) DETERMINATION OF PLAN COVERAGE AREAS.— 15
Each HHA shall establish, and may revise, HAPI plan 16
coverage areas for the State in which the HHA is located. 17
The service area of a HAPI plan shall consist of an entire 18
coverage area established under the preceding sentence. 19
(g) COOPERATION AMONG STATES.—States that 20
share 1 or more metropolitan statistical area may enter 21
into agreements to share administrative responsibilities 22
described under this section. 23
(h) TRANSITION FROM MEDICAID AND CHIP; CO- 24
ORDINATION OF SUPPLEMENTAL MEDICAL ASSISTANCE 25
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FOR ELDERLY AND DISABLED MEDICAID ELIGIBLES.— 1
Each HHA shall work with the Secretary to ensure that 2
the requirements of section 301 of this Act, section 1943 3
of the Social Security Act (as added by section 673(a) of 4
this Act), and subsections (a) and (b) of section 1942 of 5
the Social Security Act (as added by section 311 of this 6
Act) are met. 7
SEC. 503. APPROPRIATIONS FOR TRANSITION TO STATE 8
HEALTH HELP AGENCIES. 9
(a) APPROPRIATION.—There is authorized to be ap- 10
propriated and there is appropriated, for each of the 2 11
full fiscal years immediately following the date of enact- 12
ment of this Act, such sums as may be necessary for the 13
purpose of enabling each State to carry out the purposes 14
of this title. The sums made available under this section 15
shall be used for making payments to States that have 16
submitted, and had approved by the Secretary, an HHA 17
plan under this section. 18
(b) SUBMISSION OF STATE HHA PLAN.—Each HHA 19
plan submitted by a State shall provide for— 20
(1) the establishment of an HHA within such 21
State by the date that is 2 years after the date of 22
enactment of this Act; 23
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(2) the administration by with State of such 1
HHA in accordance with the requirements described 2
under this Act; and 3
(3) the compliance by the State of the require- 4
ments described under section 631. 5
(c) PAYMENT TO STATES.—From the sums appro- 6
priated under subsection (a), the Secretary shall pay to 7
each State that has an HHA plan approved under this 8
section, an amount necessary for the State to implement 9
such plan for the applicable fiscal year. 10
TITLE VI—SHARED 11
RESPONSIBILITIES 12
Subtitle A—Individual 13
Responsibilities 14
SEC. 601. INDIVIDUAL RESPONSIBILITY TO ENSURE HAPI 15
PLAN COVERAGE. 16
(a) OPEN SEASON.—An adult individual, on behalf 17
of such individual and the dependent children of such indi- 18
vidual, shall— 19
(1) enroll in a HAPI plan through the HHA of 20
the individual’s State of residence during an open 21
enrollment period; and 22
(2) submit necessary documentation to the ap- 23
plicable HHA so that such HHA may determine in- 24
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dividual eligibility for premium and personal respon- 1
sibility contribution subsidies. 2
An adult individual may carry out the activities described 3
under paragraphs (1) and (2) on behalf of the spouse of 4
such adult individual. 5
(b) DURING PLAN YEAR.—A covered individual 6
shall— 7
(1) submit any required monthly premium pay- 8
ments; 9
(2) submit any personal responsibility contribu- 10
tions as required; and 11
(3) inform such HHA of any changes in the 12
family status or residence of such individual. 13
Subtitle B—Employer 14
Responsibilities 15
SEC. 611. HEALTH CARE RESPONSIBILITY PAYMENTS. 16
(a) PAYMENT REQUIREMENTS.— 17
(1) IN GENERAL.—Subtitle C of the Internal 18
Revenue Code of 1986 is amended by inserting after 19
chapter 24 the following new chapter: 20
‘‘CHAPTER 24A—HEALTH CARE 21
RESPONSIBILITY PAYMENTS 22
‘‘SUBCHAPTER A—EMPLOYER SHARED RESPONSIBILITY PAYMENTS
‘‘SUBCHAPTER B—INDIVIDUAL SHARED RESPONSIBILITY PAYMENTS
‘‘SUBCHAPTER C—GENERAL PROVISIONS
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‘‘Subchapter A—Employer Shared 1
Responsibility Payments 2
‘‘Sec. 3411. Payment requirement.
‘‘Sec. 3412. Instrumentalities of the United States.
‘‘SEC. 3411. PAYMENT REQUIREMENT. 3
‘‘(a) EMPLOYER SHARED RESPONSIBILITY PAY- 4
MENTS.—Every employer shall pay an employer shared re- 5
sponsibility payment for each calendar year in an amount 6
equal to the product of— 7
‘‘(1) the number of full-time equivalent employ- 8
ees employed by the employer during the preceding 9
calendar year, multiplied by 10
‘‘(2) the applicable percentage of the average 11
HAPI plan premium amount for such calendar year. 12
‘‘(b) APPLICABLE PERCENTAGE.—For purposes of 13
subsection (a)(2)— 14
‘‘(1) IN GENERAL.—The applicable percentage 15
shall be determined as follows: 16
‘‘Revenue per employee national percentile of the
taxpayer for the preceding calendar year:
Large
employer:
Small
employer:
0–20th percentile ……………………………………………….. 17% 2%
21st–40th percentile …………………………………………… 19% 4%
41st–60th percentile …………………………………………… 21% 6%
61st–80th percentile …………………………………………… 23% 8%
81st–99th percentile …………………………………………… 25% 10%.
‘‘(2) APPLICABLE PERCENTAGE FOR CERTAIN 17
NON-REVENUE PRODUCING ENTITIES.—In the case 18
of an employer which is a nonprofit entity, a State 19
or local government, or any other type of entity for 20
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which the Secretary determines that calculating rev- 1
enue per employee is not appropriate, the applicable 2
percentage shall be— 3
‘‘(A) in the case of a large employer, 17 4
percent, and 5
‘‘(B) in the case of a small employer, 2 6
percent. 7
‘‘(3) ADDITIONAL RATE FOR CERTAIN SMALL 8
EMPLOYERS.— 9
‘‘(A) IN GENERAL.—In the case of a small 10
employer, the applicable percentage determined 11
under paragraph (1) shall be increased by 0.1 12
percent for each full-time equivalent employee 13
employed by the employer during the preceding 14
calendar year in excess of 50. 15
‘‘(B) MAXIMUM ADDITIONAL RATE.—The 16
increase in the applicable percentage deter- 17
mined under this paragraph shall not exceed 15 18
percent. 19
‘‘(4) REVENUE PER EMPLOYEE NATIONAL PER- 20
CENTILE RANK.—At the beginning of each calendar 21
year, the Secretary, in consultation with the Sec- 22
retary of Labor, shall publish a table, based on sam- 23
pling of employers, to be used in determining the na- 24
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tional percentile for revenue per employee amounts 1
for the preceding calendar year. 2
‘‘(c) TRANSITION RATES.— 3
‘‘(1) TRANSITION RATE FOR EMPLOYERS PRE- 4
VIOUSLY PROVIDING HEALTH INSURANCE.— 5
‘‘(A) IN GENERAL.—In the case of the first 6
and second calendar years to which this section 7
applies, in the case of any employer who pro- 8
vided health insurance coverage for employees 9
on the day before the date of enactment of the 10
Healthy Americans Act, the employer shared 11
responsibility payment shall be, in lieu of the 12
amount determined under subsection (a), an 13
amount equal to— 14
‘‘(i) 100 percent of the designated em- 15
ployee health insurance premium amount 16
of such employer, minus 17
‘‘(ii) the employee salary investment 18
amount. 19
‘‘(B) EMPLOYEE SALARY INVESTMENT 20
AMOUNT.—For purposes of this paragraph— 21
‘‘(i) IN GENERAL.—The term ‘em- 22
ployee salary investment amount’ means 23
the lesser of— 24
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‘‘(I) the excess of the amount of 1
average yearly wages paid to all em- 2
ployees for such year over the amount 3
of average yearly wages paid to such 4
employee for the year before the first 5
year this section applies, or 6
‘‘(II) the designated employee 7
health insurance premium amount of 8
such employer. 9
‘‘(ii) NONDISCRIMINATION RULES.— 10
No amount paid by an employer shall be 11
treated as an employee salary investment 12
amount unless such amount is distributed 13
to all employees on a basis that is propor- 14
tional to the designated employee health 15
insurance premium amount paid with re- 16
spect to such employee before such dis- 17
tribution. 18
‘‘(iii) NOTICE REQUIREMENT.—No 19
amount paid by an employer shall be treat- 20
ed as an employee salary investment 21
amount unless the employer gives each em- 22
ployee notice of the amount of the des- 23
ignated employee health insurance pre- 24
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mium amount paid by the employer with 1
respect to the employee. 2
‘‘(C) EMPLOYER SHARED RESPONSIBILITY 3
CREDIT.—The Secretary may provide a credit 4
to private employers who provided health insur- 5
ance benefits greater than the 80th percentile 6
of the national average in the 2 years prior to 7
enactment of this Act, can demonstrate the 8
benefits provided encouraged prevention and 9
wellness activities as defined in this Act, and 10
continue to provide wellness programs. 11
‘‘(D) SPECIAL RULE FOR SELF-INSURED 12
EMPLOYERS.—In the case of any employer who 13
provided health care coverage for employees 14
through self-insurance, ‘average HAPI plan 15
premium amount for the first year this section 16
applies’ shall be substituted for ‘designated em- 17
ployee health insurance premium amount of 18
such employer’ in subparagraphs (A)(i) and 19
(B)(i)(II). 20
‘‘(E) REGULATIONS.—The Secretary may 21
establish such rules and regulations as nec- 22
essary to carry out the purposes of this para- 23
graph. 24
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‘‘(2) TRANSITION RATE FOR OTHER EMPLOY- 1
ERS.—In the case of any employer who did not pro- 2
vide health insurance to employees on the day before 3
the date of enactment of the Healthy Americans 4
Act— 5
‘‘(A) the employer shared responsibility 6
payment for the first year this section applies 7
shall be an amount equal 1⁄3 of the amount oth- 8
erwise required under this section (determined 9
without regard to this subsection), and 10
‘‘(B) the employer shared responsibility 11
payment for the second year this section applies 12
shall be an amount equal 2⁄3 of the amount oth- 13
erwise required under this section (determined 14
without regard to this subsection). 15
‘‘SEC. 3412. INSTRUMENTALITIES OF THE UNITED STATES. 16
‘‘Notwithstanding any other provision of law (wheth- 17
er enacted before or after the enactment of this section) 18
which grants to any instrumentality of the United States 19
an exemption from taxation, such instrumentality shall 20
not be exempt from the payment required by section 3411 21
unless such provision of law grants a specific exemption, 22
by reference to section 3111 from the payment required 23
by such section. 24
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‘‘Subchapter B—Individual Shared 1
Responsibility Payments 2
‘‘Sec. 3421. Amount of payment.
‘‘Sec. 3422. Deduction of tax from wages.
‘‘SEC. 3421. AMOUNT OF PAYMENT. 3
‘‘(a) IN GENERAL.—Every individual shall pay an in- 4
dividual shared responsibility payment in an amount equal 5
to the HAPI plan premium amount of such individual. 6
‘‘(b) EXCEPTION.—This section shall not apply to 7
any individual— 8
‘‘(1) who is covered under a HAPI plan of an- 9
other individual, or 10
‘‘(2) who provides such documentation as re- 11
quired by the Secretary demonstrating that such in- 12
dividual has paid such HAPI plan premium amount, 13
but only for the period with respect to which such 14
amount is shown to be paid. 15
‘‘SEC. 3422. DEDUCTION OF INDIVIDUAL SHARED RESPON- 16
SIBILITY PAYMENT FROM WAGES. 17
‘‘(a) IN GENERAL.—The individual shared responsi- 18
bility payment imposed by section 3421 shall be collected 19
by the employer by deducting the amount of the payment 20
from the wages as and when paid. The preceding sentence 21
shall not apply to any employer who employs an average 22
of less than 10 full-time equivalent employees during such 23
year. 24
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‘‘(b) NONDEDUCTIBILITY BY EMPLOYER.—The indi- 1
vidual shared responsibility payment deducted and with- 2
held by the employer under subsection (a) shall not be al- 3
lowed as a deduction to the employer in computing taxable 4
income under subtitle A. 5
‘‘(c) INDEMNIFICATION OF EMPLOYER; SPECIAL 6
RULE FOR TIPS.—Rules similar to the rules of subsections 7
(b) and (c) of section 3102 shall apply for purposes of 8
this section. 9
‘‘Subchapter C—General Provisions 10
‘‘Sec. 3431. Definitions and special rules.
‘‘Sec. 3432. Labor contracts.
‘‘SEC. 3431. DEFINITIONS AND SPECIAL RULES. 11
‘‘(a) DEFINITIONS.—For purposes of this chapter— 12
‘‘(1) AVERAGE HAPI PLAN PREMIUM 13
AMOUNT.—The term ‘average HAPI plan premium 14
amount’ means the national average yearly premium 15
for HAPI plans with standard coverage (as deter- 16
mined under section 111(b) of the Healthy Ameri- 17
cans Act), determined without regard to differing 18
classes of coverage. 19
‘‘(2) DESIGNATED EMPLOYEE HEALTH INSUR- 20
ANCE PREMIUM AMOUNT.—The term ‘designated 21
employee health insurance premium amount’ means 22
the greater of— 23
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‘‘(A) the yearly premium paid by an em- 1
ployer for health insurance coverage for employ- 2
ees for the most recent calendar year ending be- 3
fore the date of enactment of the Healthy 4
Americans Act, or 5
‘‘(B) the yearly premium paid by an em- 6
ployer for health insurance coverage for employ- 7
ees for the year before the first year this section 8
applies. 9
‘‘(3) EMPLOYER.— 10
‘‘(A) IN GENERAL.—The term ‘employer’ 11
has the meaning given such term under section 12
3401(d). 13
‘‘(B) AGGREGATION RULES.—For purposes 14
of this chapter, all persons treated as a single 15
employer under subsection (a) or (b) of section 16
52 shall be treated as 1 person. 17
‘‘(4) EMPLOYMENT.—The term ‘employment’ 18
has the meaning given such term under section 19
3121(b). 20
‘‘(5) FULL-TIME EQUIVALENT EMPLOYEE.— 21
The term ‘full-time equivalent employee’ means the 22
equivalent number of full-time employees of an em- 23
ployer determined for any year under the following 24
formula: 25
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‘‘(A) The sum of the number of full-time 1
employees employed by the employer for more 2
than 3 months during such year, plus 3
‘‘(B) The quotient of— 4
‘‘(i) the sum of the average weekly 5
hours worked during such year for each 6
employee of the employer (including com- 7
mon law employees) who— 8
‘‘(I) was employed by such em- 9
ployer during such year for more than 10
3 months, and 11
‘‘(II) is not a full-time employee, 12
divided by 13
‘‘(ii) 40. 14
‘‘(6) FULL-TIME EMPLOYEE.—The term ‘full- 15
time employee’ means an employee (including a com- 16
mon law employee) who during an average workweek 17
performs, or can reasonably be expected to perform, 18
at least 40 hours of work. The Secretary may pre- 19
scribe alternative rules for determining full-time 20
equivalent employees in occupations or industries not 21
using a standard workweek. 22
‘‘(7) HAPI PLAN.—The term ‘HAPI plan’ has 23
the meaning given such term under section 3 of the 24
Healthy Americans Act. 25
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‘‘(8) HAPI PLAN PREMIUM AMOUNT.—The 1
term ‘HAPI plan premium amount’ means, with re- 2
spect to any individual, the monthly premium for the 3
HAPI plan under which such individual is enrolled, 4
determined after taking into account any subsidy 5
provided to such individual under section 131 of the 6
Healthy Americans Act. 7
‘‘(9) LARGE EMPLOYER.—The term ‘large em- 8
ployer’ means, with respect to any year, an employer 9
who employs an average of over 200 full-time equiv- 10
alent employees during such year. 11
‘‘(10) REVENUE PER EMPLOYEE.—The term 12
‘revenue per employee’ means, with respect to any 13
employer for any year, the gross receipts of the em- 14
ployer for such year divided by the number of full- 15
time equivalent employees employed by such em- 16
ployer for such year. 17
‘‘(11) SMALL EMPLOYER.—The term ‘small em- 18
ployer’ means, with respect to any year, an employer 19
who employs an average of 200 or fewer full-time 20
equivalent employees during such year. 21
‘‘(12) WAGES.—The term ‘wages’ has the 22
meaning given such term under section 3401(a). 23
‘‘(b) SPECIAL RULES.— 24
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‘‘(1) SPECIAL RULE FOR SELF-EMPLOYED INDI- 1
VIDUALS.—For purposes of this chapter, a self-em- 2
ployed individual (as defined by section 3
401(c)(1)(B)) shall be treated as both a full-time 4
equivalent employee and as an employer. 5
‘‘(2) TREATMENT OF PAYMENTS.—For pur- 6
poses of this title, the payments required by sections 7
3411 and 3421 shall be treated as a tax imposed by 8
such sections, respectively. 9
‘‘(3) OTHER SPECIAL RULES.—For purposes of 10
this chapter, rules similar to rules under the fol- 11
lowing provisions shall apply: 12
‘‘(A) Section 3122 (relating to Federal 13
service). 14
‘‘(B) Section 3123 (relating to deductions 15
as constructive payments). 16
‘‘(C) Section 3125 (relating to returns in 17
the case of governmental employees in States, 18
Guam, American Samoa, and the District of 19
Columbia). 20
‘‘(D) Section 3126 (relating to return and 21
payment by government employer). 22
‘‘(E) Section 3127 (relating to exemption 23
for employers and their employees where both 24
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are members of religious faiths opposed to par- 1
ticipation in social security act programs). 2
‘‘SEC. 3432. LABOR CONTRACTS. 3
‘‘(a) IN GENERAL.—This chapter shall not apply with 4
respect to any qualified collective bargaining employee of 5
any qualified collective bargaining employer before the 6
earlier of— 7
‘‘(1) January 1 of the first year which is more 8
than 7 years after the date of the enactment of this 9
chapter, or 10
‘‘(2) the date the collective bargaining agree- 11
ment expires. 12
‘‘(b) DEFINITIONS.—For purposes of this section— 13
‘‘(1) QUALIFIED COLLECTIVE BARGAINING EM- 14
PLOYER.—The term ‘qualified collective bargaining 15
employer’ means an employer who provides health 16
insurance to employees under the terms of a collec- 17
tive bargaining agreement which is entered into be- 18
fore the date of the enactment of this chapter. 19
‘‘(2) QUALIFIED COLLECTIVE BARGAINING EM- 20
PLOYEE.—The term ‘qualified collective bargaining 21
employee’ means an employee of a qualified collec- 22
tive bargaining employer who is covered by a collec- 23
tive bargaining agreement governing the employee’s 24
health insurance.’’. 25
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(2) CONFORMING AMENDMENT.—The table of 1
chapters of the Internal Revenue Code of 1986 is 2
amended by inserting after the item relating to 3
chapter 24 the following new item: 4
‘‘CHAPTER 24A—HEALTH CARE RESPONSIBILITY PAYMENTS’’.
(b) COLLECTION OF INDIVIDUAL SHARED RESPONSI- 5
BILITY PAYMENTS THROUGH ESTIMATED TAXES.—Sec- 6
tion 6654 of the Internal Revenue Code of 1986 (relating 7
to failure by individual to pay estimated tax) is amended— 8
(1) in subsection (a), by striking ‘‘and the tax 9
under chapter 2’’ and inserting ‘‘, the tax under 10
chapter 2, and the individual shared responsibility 11
payment required under subchapter B of chapter 12
24A’’, and 13
(2) in subsection (f)— 14
(A) by striking ‘‘minus’’ at the end of 15
paragraph (2) and inserting ‘‘plus’’, 16
(B) by redesignating paragraph (3) as 17
paragraph (5), and 18
(C) by inserting after paragraph (2) the 19
following new paragraphs: 20
‘‘(3) the individual shared responsibility pay- 21
ment required under subchapter B of chapter 24A, 22
minus 23
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‘‘(4) the amount withheld as an individual 1
shared responsibility payment under section 3422, 2
minus’’. 3
(c) EFFECTIVE DATE.—The amendments made by 4
this section shall apply to calendar years beginning at 5
least 2 years after the date of the enactment of this Act. 6
SEC. 612. DISTRIBUTION OF INDIVIDUAL RESPONSIBILITY 7
PAYMENTS TO HHAS. 8
(a) IN GENERAL.—The Secretary of the Treasury 9
shall pay to the HHA in each State an amount equal to 10
the amount of individual shared responsibility payments 11
received under section 3421 of the Internal Revenue Code 12
of 1986 with respect to each individual residing in such 13
State. 14
(b) TREATMENT OF PAYMENTS.—Any amount paid 15
to a State under subsection (a) shall be treated as an 16
amount paid by the individual as a premium for the HAPI 17
plan in which such individual is enrolled. 18
Subtitle C—Insurer 19
Responsibilities 20
SEC. 621. INSURER RESPONSIBILITIES. 21
(a) IN GENERAL.—To offer a HAPI plan through an 22
HHA, a State shall require that a health insurance issuer 23
meet the requirements of this section. 24
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(b) REQUIREMENTS.—A health insurance issuer of- 1
fering a HAPI plan in a State shall— 2
(1) implement and emphasize prevention, early 3
detection and chronic disease management; 4
(2) ensure that a wellness program as described 5
in section 131 is available to all covered individuals 6
so long as such a wellness program meets the re- 7
quirements of the health insurance issuers and other 8
relevant requirements; 9
(3) demonstrate how the provider reimburse- 10
ment methodology used by such an issuer has been 11
adjusted to reward providers for achieving quality 12
and cost efficiency in prevention, early detection of 13
disease, and chronic care management; 14
(4) ensure enrollees have the opportunity to 15
designate a health home as described in section 16
111(b) and make public how many enrollees per pol- 17
icy have designated a health home; 18
(5) upon enrollment, make available to each 19
covered individual an initial physical and a care 20
plan; 21
(6) create and implement an electronic medical 22
record for each covered individual, unless the indi- 23
vidual submits a notification to the issuer that the 24
individual declines to have such a record; 25
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(7) contribute to the financing of the HHAs by 1
incorporating into the administration component of 2
premiums an additional amount to reimburse HHAs 3
for administrative costs; 4
(8) comply with loss ratios as established by the 5
Secretary under subsection (e); 6
(9) use standardized common claims forms and 7
uniform billing practices as provided for under sub- 8
section (c); 9
(10) require that hospitals, as a condition of re- 10
ceiving payment, send bills that are in an amount 11
more than $5,000 to the covered individual (without 12
regard to whether the covered individual is respon- 13
sible for full or partial payment of the bill) and pro- 14
vide the individual the contact information of a per- 15
son who can discuss the bill with the individual; 16
(11) provide incentives such as premium dis- 17
counts— 18
(A) for parents, if a covered child partici- 19
pates in wellness activities and the health of 20
such child improves; and 21
(B) for adults covered by a plan to partici- 22
pate in prevention, wellness and chronic disease 23
management programs; 24
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(12) report to the HHA of the State in which 1
the issuer offers HAPI plans, outcome data regard- 2
ing wellness program, disease detection and chronic 3
care management, and loss ratio information, so 4
that the HHAs may make such data available to the 5
public in a consumer-friendly format; 6
(13) work with the Agency for Healthcare Re- 7
search and Quality, medical experts, and patient 8
groups to make information on high quality afford- 9
able health providers available to all Americans with- 10
in 2 years of the date of enactment of this Act 11
through a website searchable by zip code; 12
(14) provide to the HHA of each State in which 13
the issuer offers a HAPI plan, detailed information 14
on the HAPI plans offered by such issuer, using 15
standardized language as required by the HHA, so 16
that the HHA may compile a document that com- 17
pares the HAPI plans for use by prospective enroll- 18
ees; and 19
(15) paying to the HHA of each State in which 20
the issuer seeks to offer a HAPI plan the amount 21
of the administrative fee assessed by the HHA 22
under section 502(c)(5) to enter the HHA system of 23
that State. 24
(c) UNIFORM BILLING PRACTICES.— 25
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(1) IN GENERAL.—A health insurance issuer of- 1
fering a HAPI plan in a State shall not receive sub- 2
sidy payments from the applicable State HHA un- 3
less such issuer agrees to use standardized common 4
claim forms prescribed by the applicable State HHA. 5
(2) EXCEPTION.—Paragraph (1) shall not 6
apply to any State worker’s compensation system. 7
(d) CHRONIC CARE PROGRAMS OFFERED BY 8
ISSUERS.— 9
(1) IN GENERAL.—A health insurance issuer of- 10
fering a HAPI plan in a State shall provide a chron- 11
ic care program to provide early identification and 12
management of chronic diseases. 13
(2) DETERMINATION OF CHRONIC CARE PRO- 14
GRAM.—Each State HHA shall determine what con- 15
stitutes a chronic care program under this sub- 16
section and whether to collect and report financial 17
information related to chronic care programs. 18
(3) UNIFORM CLINICAL PERFORMANCE STAND- 19
ARDS.—Each chronic care program offered by a 20
health insurance issuer shall use a uniform set of 21
clinical performance standards prescribed by the 22
HHA of the State in which the issuer offers a HAPI 23
plan (in consultation with the State Medicare quality 24
improvement organizations and patient and physi- 25
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cian organizations) which should include encourage- 1
ment that the issuers not require personal responsi- 2
bility contributions for clinically needed services to 3
treat or manage a covered individual’s chronic dis- 4
ease, particularly if the individual is taking an active 5
management role in working with their provider to 6
manage any such disease. 7
(4) REPORTING BY ISSUERS.—Five years after 8
the date of enactment of this Act and on an annual 9
basis thereafter, each health insurance issuer shall 10
report to the applicable State Insurance Commis- 11
sioner, State Secretary of Health or other state enti- 12
ty selected by the State HHA, the chronic care man- 13
agement performance of the issuer as measured by 14
the uniform clinical performance standards described 15
in paragraph (3). The issuer shall make such per- 16
formance public in a manner accessible to the public. 17
(e) PRIVATE INSURANCE COMPANY LOSS RATIO.— 18
(1) IN GENERAL.—The Secretary, in consulta- 19
tion with consumer and patient organizations, the 20
National Association of Insurance Commissioners, 21
and health insurance issuers (including health main- 22
tenance organizations) shall establish a loss ratio for 23
issuers of HAPI plans. 24
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(2) DETERMINATION OF LOSS RATIO.—In de- 1
termining the loss ratio, administrative costs shall be 2
defined as expenses consisting of all actual, allow- 3
able, allocable, and reasonable expenses incurred in 4
the adjudication of subscriber benefit claims or in- 5
curred in the health insurance issuer’s overall oper- 6
ation of the business. 7
(3) ADMINISTRATIVE EXPENSES.—Unless oth- 8
erwise determined by an agreement between a State 9
HHA and a health insurance issuer, the administra- 10
tive expenses of an issuer shall— 11
(A) include all taxes (excluding premium 12
taxes) reinsurance premiums, medical and den- 13
tal consultants used in the adjudication process, 14
concurrent or managed care review when not 15
billed by a health care provider and other forms 16
of utilization review, the cost of maintaining eli- 17
gibility files, legal expenses incurred in the liti- 18
gation of benefit payments, and bank charges 19
for letters of credit; and 20
(B) not include the cost of personnel, 21
equipment, and facilities directly used in the de- 22
livery of health care services (benefit costs), 23
payments to HHAs for establishment and ad- 24
ministration of HHAs, and the cost of over- 25
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seeing chronic disease management programs 1
and wellness programs. 2
Subtitle D—State Responsibilities 3
SEC. 631. STATE RESPONSIBILITIES. 4
(a) GENERAL REQUIREMENTS.—As a condition of re- 5
ceiving payment under section 503, each State shall— 6
(1) designate or create a Health Help Agency 7
as described in title V; 8
(2) ensure that the HAPI plans offered in the 9
State— 10
(A) are sold only through the State HHA 11
(except for employer-sponsored health coverage 12
plans described under section 103 offered by 13
employers); and 14
(B) comply with the requirements of this 15
Act; 16
(3) ensure that health insurance issuers offer- 17
ing a HAPI plan in such State comply with the re- 18
quirements described in section 621; 19
(4) make risk-adjusted payments to all health 20
insurance issuers and employers offering a HAPI 21
plan in such State to account for the specific popu- 22
lation covered by the plan, in accordance with guide- 23
lines established by the Secretary; 24
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(5) ensure that HAPI plans offer premium dis- 1
counts and incentives for participation in wellness 2
programs; 3
(6) implement mechanisms to collect premium 4
payments not otherwise collected under chapter 24A 5
of the Internal Revenue Code of 1986 (as added by 6
this Act); 7
(7) continue to apply State law with respect 8
to— 9
(A) solvency and financial standards for 10
health insurance issuers; 11
(B) fair marketing practices for health in- 12
surance issuers; 13
(C) grievances and appeals for covered in- 14
dividuals; and 15
(D) patient protection; 16
(8) eliminate fictitious group prohibitions; and 17
(9) comply with subsections (b), (c), and (d). 18
(b) ENSURING MAXIMUM ENROLLMENT.—Each 19
State shall— 20
(1) collect and exchange data with Federal and 21
other public agencies as necessary to maintain a 22
database containing information on the health insur- 23
ance enrollment status of all State residents; 24
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(2) implement methods to check enrollment sta- 1
tus and enroll individuals in HAPI plans, such as 2
through the Department of Motor Vehicles of the 3
State, the enrollment of children in elementary and 4
secondary schools, the voter registration authority of 5
the State, and other checkpoints determined appro- 6
priate by the State; 7
(3) implement mechanisms, which may not in- 8
clude revocation or ineligibility for coverage under a 9
HAPI plan, to enforce the responsibility of each 10
adult individual to purchase HAPI plan coverage for 11
such individual and any dependent children of such 12
individual; and 13
(4) implement a mechanism to automatically 14
enroll individuals in a HAPI plan who present in 15
emergency departments without health insurance. 16
(c) MAINTENANCE OF EFFORT.—Each State shall 17
submit an annual report to the Secretary that dem- 18
onstrates that, for each State fiscal year that begins on 19
or after January 1 of the first calendar year in which 20
HAPI coverage begins under this Act, State expenditures 21
for health services (as defined by the Secretary) are not 22
less than the amount equal to— 23
(1) in the case of the first State fiscal year for 24
which such a report is submitted, 100 percent of the 25
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total amount of the State share of expenditures for 1
such services under all public health programs oper- 2
ated in the State that are funded in whole or in part 3
with State expenditures (including the Medicaid pro- 4
gram) for the most recent State fiscal year ending 5
before January 1 of the first calendar year in which 6
HAPI coverage begins under this Act; and 7
(2) in the case of any subsequent State fiscal 8
year for which such a report is submitted, the 9
amount applicable under this subsection for the pre- 10
ceding State fiscal year increased by the percentage 11
change, if any, in the consumer price index for all 12
urban consumers over the previous Federal fiscal 13
year. 14
(d) MAINTENANCE OF ELIGIBILITY AND BENEFITS 15
UNDER STATE MEDICAID PROGRAMS.—A State shall en- 16
sure that eligibility and benefits under the State plan 17
under title XIX of the Social Security Act (including eligi- 18
bility or benefits provided through any waiver under such 19
title or under section 1115 of such Act (42 U.S.C. 1315) 20
and premiums, deductibles, co-payments, or other cost- 21
sharing imposed for benefits under such plan or waiver), 22
are no more restrictive than the eligibility or benefits, re- 23
spectively, under such plan or waiver as in effect on the 24
date of enactment of the Healthy Americans Act. 25
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SEC. 632. EMPOWERING STATES TO INNOVATE THROUGH 1
WAIVERS. 2
(a) IN GENERAL.—A State that meets the require- 3
ments of subsection (b) shall be eligible for a waiver of 4
applicable Federal health-related program requirements. 5
(b) ELIGIBILITY REQUIREMENTS.—A State shall be 6
eligible to receive a waiver under this section if— 7
(1) the State approves a plan to provide health 8
care coverage to its residents that is at least as com- 9
prehensive as the coverage required under a HAPI 10
plan; and 11
(2) the State submits to the Secretary an appli- 12
cation at such time, in such manner, and containing 13
such information as the Secretary may require, in- 14
cluding a comprehensive description of the State leg- 15
islation or plan for implementing the State-based 16
health plan. 17
(c) DETERMINATIONS BY SECRETARY.— 18
(1) IN GENERAL.—Not later than 180 days 19
after the receipt of an application from a State 20
under subsection (b)(2), the Secretary shall make a 21
determination with respect to the granting of a waiv- 22
er under this section to such State. 23
(2) GRANTING OF WAIVER.—If the Secretary 24
determines that a waiver should be granted under 25
this section, the Secretary shall notify the State in- 26
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volved of such determination and the terms and ef- 1
fectiveness of such waiver. 2
(3) REFUSAL TO GRANT WAIVER.—If the Sec- 3
retary refuses to grant a waiver under this section, 4
the Secretary shall— 5
(A) notify the State involved of such deter- 6
mination, and the reasons therefore; and 7
(B) notify the appropriate committees of 8
Congress of such determination and the reasons 9
therefore. 10
(d) SCOPE OF WAIVERS.—The Secretary shall deter- 11
mine the scope of a waiver granted to a State under this 12
section, including which Federal laws and requirements 13
will not apply to the State under the waiver. 14
Subtitle E—Federal Fallback 15
Guarantee Responsibility 16
SEC. 641. FEDERAL GUARANTEE OF ACCESS TO COVERAGE. 17
(a) FEDERAL GUARANTEE.— 18
(1) IN GENERAL.—If a State does not establish 19
an HHA in compliance with title V by the date that 20
is 2 years after the date of enactment of this Act, 21
the Secretary shall ensure that each individual has 22
available, consistent with paragraph (2), a choice of 23
enrollment in at least 2 HAPI plans in the coverage 24
area in which the individual resides. In any such 25
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case in which such plans are not available, the indi- 1
vidual shall be given the opportunity to enroll in a 2
fallback HAPI plan. 3
(2) REQUIREMENT FOR DIFFERENT PLAN 4
SPONSORS.—The requirement in paragraph (1) is 5
not satisfied with respect to a coverage area if only 6
1 entity offers all the HAPI plans in the area. 7
(b) CONTRACTS.— 8
(1) IN GENERAL.—The Secretary shall enter 9
into contracts under this subsection with entities for 10
the offering of fallback HAPI plans in coverage 11
areas in which the guarantee under subsection (a) is 12
not met. 13
(2) COMPETITIVE PROCEDURES.—Competitive 14
procedures (as defined in section 4(5) of the Office 15
of Federal Procurement Policy Act (41 U.S.C. 16
403(5))) shall be used to enter into a contract under 17
this subsection. 18
(c) FALLBACK HAPI PLAN.—For purposes of this 19
section, the term ‘‘fallback HAPI plan’’ means a HAPI 20
plan that— 21
(1) meets the requirements described in section 22
111(b) and does not provide actuarially equivalent 23
coverage described in section 111(c); and 24
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(2) meets such other requirements as the Sec- 1
retary may specify. 2
Subtitle F—Federal Financing 3
Responsibilities 4
SEC. 651. APPROPRIATION FOR SUBSIDY PAYMENTS. 5
There is authorized to be appropriated and there is 6
appropriated for each fiscal year such sums as may be 7
necessary to fund the insurance premium subsidies under 8
section 121. 9
SEC. 652. RECAPTURE OF MEDICARE AND 90 PERCENT OF 10
MEDICAID FEDERAL DSH FUNDS TO 11
STRENGTHEN MEDICARE AND ENSURE CON- 12
TINUED SUPPORT FOR PUBLIC HEALTH PRO- 13
GRAMS. 14
(a) RECAPTURE OF MEDICARE DSH FUNDS.— 15
(1) IN GENERAL.—Section 1886(d)(5)(F)(i) of 16
the Social Security Act (42 U.S.C. 17
1395ww(d)(5)(F)(i)) is amended by inserting ‘‘and 18
before January 1 of the first calendar year in which 19
coverage under a HAPI plan begins under the 20
Healthy Americans Act,’’ after ‘‘May 1, 1986,’’. 21
(2) SAVINGS TO PART A TRUST FUND.—The 22
savings to the Federal Hospital Insurance Trust 23
Fund by reason of the amendment made by para- 24
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graph (1) shall be used to strengthen the financial 1
solvency of such Trust Fund. 2
(b) RECAPTURE OF 90 PERCENT OF MEDICAID DSH 3
FUNDS.— 4
(1) HEALTHY AMERICANS PUBLIC HEALTH 5
TRUST FUND.—Subchapter A of chapter 98 of the 6
Internal Revenue Code of 1986 (relating to trust 7
fund code) is amended by adding at the end the fol- 8
lowing new section: 9
‘‘SEC. 9511. HEALTHY AMERICANS PUBLIC HEALTH TRUST 10
FUND. 11
‘‘(a) CREATION OF TRUST FUND.—There is estab- 12
lished in the Treasury of the United States a trust fund 13
to be known as the ‘Healthy Americans Public Health 14
Trust Fund’, consisting of any amount appropriated or 15
credited to the Trust Fund as provided in this section or 16
section 9602(b). 17
‘‘(b) TRANSFER TO TRUST FUND OF 90 PERCENT 18
OF MEDICAID DSH FUNDS.—There are hereby appro- 19
priated to the Healthy Americans Public Health Trust 20
Fund the following amounts: 21
‘‘(1) In the case of the second, third, and 22
fourth quarters of the first fiscal year in which cov- 23
erage under a HAPI plan begins under the Healthy 24
Americans Act, an amount equal to 90 percent of 25
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the amount that would otherwise have been appro- 1
priated for the purpose of making payments to 2
States under section 1903(a) of the Social Security 3
Act for the Federal share of disproportionate share 4
hospital payments made under section 1923 of such 5
Act for such quarters of that fiscal year but for sub- 6
sections (c)(2) and (d)(2)(D) of section 1943 of the 7
such Act, as determined by the Secretary of Health 8
and Human Services. 9
‘‘(2) In the case of each succeeding fiscal year, 10
an amount equal to 90 percent of the amount that 11
would otherwise have been appropriated for the pur- 12
pose of making payments to States under section 13
1903(a) of the Social Security Act for the Federal 14
share of disproportionate share hospital payments 15
made under section 1923 of such Act for that fiscal 16
year but for subsections (c)(1) and (d)(2)(D) of sec- 17
tion 1943 of such Act, as determined by the Sec- 18
retary of Health and Human Services, taking into 19
account the percentage change, if any, in the con- 20
sumer price index for all urban consumers (U.S. city 21
average) for the preceding fiscal year. 22
‘‘(c) EXPENDITURES FROM TRUST FUND.—With re- 23
spect to each fiscal year for which transfers are made 24
under subsection (b), amounts in the Healthy Americans 25
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Public Health Trust Fund shall be available for that fiscal 1
year for the following purposes: 2
‘‘(1) PROVIDING PREMIUM AND PERSONAL RE- 3
SPONSIBILITY CONTRIBUTION SUBSIDIES.—For 4
making appropriations authorized under section 651 5
of the Healthy Americans Act for providing pre- 6
mium and personal responsibility contribution sub- 7
sidies in accordance with section 122 of such Act. 8
‘‘(2) MAKING BONUS PAYMENTS TO STATES 9
FOR IMPLEMENTING MEDICAL MALPRACTICE RE- 10
FORM.—For making appropriations for bonus pay- 11
ments to States in accordance with section 802 of 12
such Act for implementing a State medical mal- 13
practice reform law that complies with subsection 14
(b) of such section. 15
‘‘(3) REDUCING THE FEDERAL BUDGET DEF- 16
ICIT.—The Secretary shall transfer any amounts in 17
the Trust Fund that are not expended as of Sep- 18
tember 30 of a fiscal year for a purpose described 19
in paragraph (1), (2), or (3) to the general revenues 20
account of the Treasury.’’. 21
(2) CLERICAL AMENDMENT.—The table of sec- 22
tions for such subchapter is amended by adding at 23
the end the following new item: 24
‘‘Sec. 9511. Healthy Americans Public Health Trust Fund.’’.
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Subtitle G—Tax Treatment of 1
Health Care Coverage Under 2
Healthy Americans Program; 3
Termination of Coverage Under 4
Other Governmental Programs 5
and Transition Rules for Med- 6
icaid and CHIP 7
PART I—TAX TREATMENT OF HEALTH CARE COV- 8
ERAGE UNDER HEALTHY AMERICANS PRO- 9
GRAM 10
SEC. 661. LIMITED EMPLOYEE INCOME AND PAYROLL TAX 11
EXCLUSION FOR EMPLOYER SHARED RE- 12
SPONSIBILITY PAYMENTS, HISTORIC RE- 13
TIREE HEALTH CONTRIBUTIONS, AND TRAN- 14
SITIONAL COVERAGE CONTRIBUTIONS. 15
(a) INCOME TAX EXCLUSION.— 16
(1) IN GENERAL.—Subsection (a) of section 17
106 of the Internal Revenue Code of 1986 (relating 18
to contributions by employer to accident and health 19
plans) is amended to read as follows: 20
‘‘(a) GENERAL RULE.—Gross income of an individual 21
does not include— 22
‘‘(1) if such individual is an employee, shared 23
responsibility payments made by an employer under 24
section 3411, 25
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‘‘(2) if such individual is a former employee be- 1
fore the first calendar year beginning 2 years after 2
the date of the enactment of the Healthy Americans 3
Act, employer-provided coverage under an accident 4
or health plan, 5
‘‘(3) if such individual is a qualified collective 6
bargaining employee under an accident or health 7
plan in effect on January 1 of the first calendar year 8
beginning 2 years after the date of the enactment of 9
the Healthy Americans Act, employer-provided cov- 10
erage under such plan during any transition period 11
described in section 3432, and 12
‘‘(4) employer-provided coverage for qualified 13
long-term care services (as defined in section 14
7702B(c)).’’. 15
(2) CONFORMING AMENDMENTS.—Section 106 16
of such Code is amended— 17
(A) by adding at the end of subsection (b) 18
the following new paragraph: 19
‘‘(8) TERMINATION.—This subsection shall not 20
apply to contributions made in any calendar year be- 21
ginning at least 2 years after the date of the enact- 22
ment of the Healthy Americans Act.’’, 23
(B) by inserting ‘‘and before the first cal- 24
endar year beginning 2 years after the date of 25
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the enactment of the Healthy Americans Act,’’ 1
after ‘‘January 1, 1997,’’ in subsection (c)(1), 2
and 3
(C) by striking ‘‘shall be treated as em- 4
ployer-provided coverage for medical expenses 5
under an accident or health plan’’ in subsection 6
(d)(1) and inserting ‘‘shall not be included in 7
such employee’s gross income’’. 8
(b) PAYROLL TAXES.— 9
(1) IN GENERAL.—Section 3121(a) (defining 10
wages) is amended by adding at the end the fol- 11
lowing new sentence: ‘‘In the case of any calendar 12
year beginning at least 2 years after the date of the 13
enactment of the Healthy Americans Act, para- 14
graphs (2) and (3) shall apply to payments on ac- 15
count of sickness only if such payments are de- 16
scribed in section 106(a).’’. 17
(2) RAILROAD RETIREMENT.—Section 18
3231(e)(1) (defining wages) is amended by adding 19
at the end the following new sentence: ‘‘In the case 20
of any calendar year beginning at least 2 years after 21
the date of the enactment of the Healthy Americans 22
Act, this paragraph shall apply to payments on ac- 23
count of sickness only if such payments are de- 24
scribed in section 106(a).’’. 25
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(3) UNEMPLOYMENT.—Section 3306(b) (defin- 1
ing wages) is amended by adding at the end the fol- 2
lowing new sentence: ‘‘In the case of any calendar 3
year beginning at least 2 years after the date of the 4
enactment of the Healthy Americans Act, para- 5
graphs (2) and (4) shall apply to payments on ac- 6
count of sickness only if such payments are de- 7
scribed in section 106(a).’’. 8
(c) EFFECTIVE DATE.—The amendments made by 9
this section shall apply to calendar years beginning at 10
least 2 years after the date of the enactment of the 11
Healthy Americans Act. 12
SEC. 662. EXCLUSION FOR LIMITED EMPLOYER-PROVIDED 13
HEALTH CARE FRINGE BENEFITS. 14
(a) IN GENERAL.—Section 132(a) of the Internal 15
Revenue Code of 1986 (relating to certain fringe benefits) 16
is amended by striking ‘‘or’’ at the end of paragraph (7), 17
by striking the period at the end of paragraph (8) and 18
inserting ‘‘, or’’, and by adding at the end the following 19
new paragraph: 20
‘‘(9) qualified health care fringe.’’. 21
(b) QUALIFIED HEALTH CARE FRINGE.— 22
(1) IN GENERAL.—Section 132 of the Internal 23
Revenue Code of 1986 is amended by redesignating 24
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subsection (o) as subsection (p) and by inserting 1
after subsection (n) the following new subsection: 2
‘‘(o) QUALIFIED HEALTH CARE FRINGE.—For pur- 3
poses of this section, the term ‘qualified health care fringe’ 4
means— 5
‘‘(1) any wellness program described in section 6
131 of the Healthy Americans Act, and 7
‘‘(2) any on-site first aid coverage for employ- 8
ees.’’. 9
(2) NONDISCRIMINATORY TREATMENT.—Sec- 10
tion 132(j)(1) of such Code (relating to exclusions 11
under subsection (a)(1) and (2) apply to highly com- 12
pensated employees only if no discrimination) is 13
amended— 14
(A) by striking ‘‘Paragraphs (1) and (2) of 15
subsection (a)’’ and inserting ‘‘Paragraphs (1), 16
(2), and (9) of subsection (a)’’, and 17
(B) by striking ‘‘SUBSECTION (a)(1) AND 18
(2)’’ in the heading and inserting ‘‘SUB- 19
SECTIONS (a)(1), (2), AND (9)’’. 20
(c) EFFECTIVE DATE.—The amendments made by 21
this section shall apply to calendar years beginning at 22
least 2 years after the date of the enactment of the 23
Healthy Americans Act. 24
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SEC. 663. LIMITED EMPLOYER DEDUCTION FOR EMPLOYER 1
SHARED RESPONSIBILITY PAYMENTS, HIS- 2
TORIC RETIREE HEALTH CONTRIBUTIONS, 3
AND OTHER HEALTH CARE EXPENSES. 4
(a) IN GENERAL.—Subsection (l) of section 162 of 5
the Internal Revenue Code of 1986 (relating to trade or 6
business expenses) is amended to read as follows: 7
‘‘(l) LIMITATION ON DEDUCTIBLE EMPLOYER 8
HEALTH CARE EXPENDITURES.—No deduction shall be 9
allowed under this chapter for any employer contribution 10
to an accident or health plan other than— 11
‘‘(1) any shared responsibility payment made 12
under section 3411, 13
‘‘(2) any accident or health plan coverage for 14
individuals who are former employees before the first 15
calendar year beginning 2 years after the date of the 16
enactment of the Healthy Americans Act, 17
‘‘(3) any accident or health plan in effect on 18
January 1 of the first calendar year beginning 2 19
years after the date of the enactment of the Healthy 20
Americans Act with respect to coverage for qualified 21
collective bargaining employees during a transition 22
period described in section 3432, 23
‘‘(4) any accident or health plan which qualifies 24
as a wellness program described in section 131 of 25
such Act, 26
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‘‘(5) any accident or health plan which con- 1
stitutes on-site first aid coverage for employees, and 2
‘‘(6) any accident or health plan which is a 3
qualified long-term care insurance contract.’’. 4
(b) CONFORMING AMENDMENT.—Section 162 of the 5
Internal Revenue Code of 1986 is amended by striking 6
subsection (n). 7
(c) EFFECTIVE DATE.—The amendments made by 8
this section shall apply to calendar years beginning at 9
least 2 years after the date of the enactment of the 10
Healthy Americans Act. 11
SEC. 664. HEALTH CARE STANDARD DEDUCTION. 12
(a) IN GENERAL.—Section 62(a) of the Internal Rev- 13
enue Code of 1986 (defining adjusted gross income) is 14
amended by inserting after paragraph (21) the following 15
new paragraph: 16
‘‘(22) INDIVIDUAL SHARED RESPONSIBILITY 17
PAYMENTS.— 18
‘‘(A) IN GENERAL.—In the case of a tax- 19
payer with gross income for the taxable year ex- 20
ceeding 100 percent of the poverty line (ad- 21
justed for the size of the family involved) for 22
the calendar year in which such taxable year 23
begins and who is enrolled in a HAPI plan 24
under the Healthy Americans Act, the deduc- 25
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tion allowable under section 213 by reason of 1
subsection (d)(1)(D) thereof (determined with- 2
out regard to any income limitation under sub- 3
section (a) thereof) in an amount equal to the 4
applicable fraction times, in the case of— 5
‘‘(i) coverage of an individual, $6,025, 6
‘‘(ii) coverage of a married couple or 7
domestic partnership (as determined by a 8
State) without dependent children, 9
$12,050, 10
‘‘(iii) coverage of an unmarried indi- 11
vidual with 1 or more dependent children, 12
$8,610, plus $2,000 for each dependent 13
child, and 14
‘‘(iv) coverage of a married couple or 15
domestic partnership (as determined by a 16
State) with 1 or more dependent children, 17
$15,210, plus $2,000 for each dependent 18
child. 19
‘‘(B) APPLICABLE FRACTION.—For pur- 20
poses of subparagraph (A), the applicable frac- 21
tion is the fraction (not to exceed 1)— 22
‘‘(i) the numerator of which is the 23
gross income of the taxpayer for the tax- 24
able year expressed as a percentage of the 25
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poverty line (adjusted for the size of the 1
family involved) minus such poverty line 2
for the calendar year in which such taxable 3
year begins, and 4
‘‘(ii) the denominator of which is 400 5
percent of the poverty line (adjusted for 6
the size of the family involved) minus such 7
poverty line. 8
‘‘(C) PHASEOUT OF DEDUCTION 9
AMOUNT.— 10
‘‘(i) IN GENERAL.—The amount oth- 11
erwise determined under subparagraph (A) 12
for any taxable year shall be reduced by 13
the amount determined under clause (ii). 14
‘‘(ii) AMOUNT OF REDUCTION.—The 15
amount determined under this clause shall 16
be the amount which bears the same ratio 17
to the amount determined under subpara- 18
graph (A) as— 19
‘‘(I) the excess of the taxpayer’s 20
modified adjusted gross income for 21
such taxable year, over $62,500 22
($125,000 in the case of a joint re- 23
turn), bears to 24
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‘‘(II) $62,500 ($125,000 in the 1
case of a joint return). 2
Any amount determined under this clause 3
which is not a multiple of $1,000 shall be 4
rounded to the next lowest $1,000. 5
‘‘(D) INFLATION ADJUSTMENT.—In the 6
case of any taxable year beginning in a calendar 7
year after 2011, each dollar amount contained 8
in subparagraph (A) and subparagraph 9
(C)(ii)(I) shall be increased by an amount equal 10
to such dollar amount, multiplied by the cost- 11
of-living adjustment determined under section 12
1(f)(3) for the calendar year in which the tax- 13
able year begins, determined by substituting 14
‘calendar year 2010’ for ‘calendar year 1992’ in 15
subparagraph (B) thereof. Any increase deter- 16
mined under the preceding sentence shall be 17
rounded to the nearest multiple of $50 ($1,000 18
in the case of the dollar amount contained in 19
subparagraph (C)(ii)(I)). 20
‘‘(E) DETERMINATION OF MODIFIED AD- 21
JUSTED GROSS INCOME.— 22
‘‘(i) IN GENERAL.—For purposes of 23
this paragraph, the term ‘modified ad- 24
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justed gross income’ means adjusted gross 1
income— 2
‘‘(ii) determined without regard to 3
this section and sections 86, 135, 137, 4
199, 221, 222, 911, 931, and 933, and 5
‘‘(iii) increased by— 6
‘‘(I) the amount of interest re- 7
ceived or accrued during the taxable 8
year which is exempt from tax under 9
this title, and 10
‘‘(II) the amount of any social se- 11
curity benefits (as defined in section 12
86(d)) received or accrued during the 13
taxable year. 14
‘‘(F) POVERTY LINE.—For purposes of 15
this paragraph, the term ‘poverty line’ has the 16
meaning given such term in section 673(2) of 17
the Community Health Services Block Grant 18
Act (42 U.S.C. 9902(2)), including any revision 19
required by such section.’’. 20
(b) CONFORMING AMENDMENT.—Section 21
213(d)(1)(D) of the Internal Revenue Code of 1986 is 22
amended by inserting ‘‘amounts paid under section 3421 23
and’’ after ‘‘including’’. 24
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(c) EFFECTIVE DATE.—The amendments made by 1
this section shall apply to payments made in calendar 2
years beginning at least 2 years after the date of the en- 3
actment of this Act. 4
SEC. 665. MODIFICATION OF OTHER TAX INCENTIVES TO 5
COMPLEMENT HEALTHY AMERICANS PRO- 6
GRAM. 7
(a) TERMINATION OF CREDIT FOR HEALTH INSUR- 8
ANCE COSTS OF ELIGIBLE INDIVIDUALS.—Section 35 of 9
the Internal Revenue Code of 1986 (relating to health in- 10
surance costs of eligible individuals) is amended by adding 11
at the end the following new subsection: 12
‘‘(h) TERMINATION.—This section shall not apply to 13
payments made in any calendar year beginning at least 14
2 years after the date of the enactment of the Healthy 15
Americans Act.’’. 16
(b) TERMINATION OF HEALTH CARE EXPENSE RE- 17
IMBURSEMENT UNDER CAFETERIA PLANS.— 18
(1) IN GENERAL.—Section 125 of the Internal 19
Revenue Code of 1986 (relating to cafeteria plans) 20
is amended by redesignating subsection (i) as sub- 21
section (j) and by inserting after subsection (h) the 22
following new subsection: 23
‘‘(i) TERMINATION.—This section shall not apply to 24
health benefits coverage in any calendar year beginning 25
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at least 2 years after the date of the enactment of the 1
Healthy Americans Act.’’. 2
(2) LONG-TERM CARE ALLOWED UNDER CAFE- 3
TERIA PLANS.— 4
(A) IN GENERAL.—Section 125(f) of such 5
Code (defining qualified benefits) is amended by 6
striking the last sentence. 7
(B) EFFECTIVE DATE.—The amendment 8
made by this paragraph shall apply to contracts 9
issued with respect to any calendar year begin- 10
ning at least 2 years after the date of the en- 11
actment of this Act. 12
(c) TERMINATION OF ARCHER MSA CONTRIBU- 13
TIONS.—Section 220 of the Internal Revenue Code of 14
1986 (relating to Archer MSAs) is amended— 15
(1) by inserting ‘‘and made before the first cal- 16
endar year beginning 2 years after the date of the 17
enactment of the Healthy Americans Act’’ after ‘‘in 18
cash’’ in subsection (d)(1)(A)(i), and 19
(2) by adding at the end the following new sub- 20
section: 21
‘‘(k) TERMINATION.—This section shall not apply to 22
contributions made in any calendar year beginning at least 23
2 years after the date of the enactment of the Healthy 24
Americans Act.’’. 25
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(d) HEALTH SAVINGS ACCOUNTS ALLOWED IN CON- 1
JUNCTION WITH HIGH DEDUCTIBLE HAPI PLANS.— 2
(1) IN GENERAL.—Section 223 of the Internal 3
Revenue Code of 1986 (relating to health savings ac- 4
counts) is amended— 5
(A) by inserting ‘‘qualified’’ before ‘‘high 6
deductible health plan’’ each place it appears in 7
the text (other than subsection (c)(2)(A)), 8
(B) by striking ‘‘The term ‘high deductible 9
health plan’ means a health plan’’ in subsection 10
(c)(2)(A) and inserting ‘‘The term ‘qualified 11
high deductible health plan’ means a HAPI 12
plan under the Healthy Americans Act’’, 13
(C) by striking subparagraphs (B) and (C) 14
of subsection (c)(2) and by redesignating sub- 15
paragraph (D) of subsection (c)(2) as subpara- 16
graph (B), and 17
(D) by striking ‘‘HIGH’’ in the heading for 18
paragraph (2) of subsection (c) and inserting 19
‘‘QUALIFIED HIGH’’. 20
(2) EFFECTIVE DATE.—The amendments made 21
by this subsection shall apply to payments made in 22
calendar years beginning at least 2 years after the 23
date of the enactment of this Act. 24
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PART II—CLARIFICATION OF ERISA TREATMENT; 1
TERMINATION OF COVERAGE UNDER OTHER 2
GOVERNMENTAL PROGRAMS AND TRANSI- 3
TION RULES FOR MEDICAID AND CHIP 4
SEC. 671. CLARIFICATION OF ERISA APPLICABILITY TO EM- 5
PLOYER-SPONSORED HAPI PLANS. 6
(a) ERISA.—Section 3(1) of Employee Retirement 7
Income Security Act of 1974 (29 U.S.C. 1002(1)) is 8
amended by adding at the end the following new sentence: 9
‘‘Such terms include the provision of medical, surgical, or 10
hospital care or benefits through a HAPI plan described 11
under section 103 of the Healthy Americans Act.’’. 12
(b) INTERNAL REVENUE CODE OF 1986.—Section 13
5000 of the Internal Revenue Code of 1986 (relating to 14
certain group health plans) is amended by adding at the 15
end the following new subsection: 16
‘‘(e) HAPI PLANS.—For purposes of this section, the 17
terms ‘group health plan’ and ‘large group health plan’ 18
include any HAPI plan described under section 103 of the 19
Healthy Americans Act.’’. 20
(c) PUBLIC HEALTH SERVICE ACT.—Section 21
2791(b)(5) of the Public Health Service Act (42 U.S.C. 22
300gg–91(b)(5)) is amended by adding at the end the fol- 23
lowing new sentence: ‘‘Such term includes health insur- 24
ance coverage offered to individuals through a HAPI plan 25
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described under section 103 of the Healthy Americans 1
Act.’’. 2
SEC. 672. FEDERAL EMPLOYEES HEALTH BENEFITS PLAN. 3
(a) IN GENERAL.—Chapter 89 of title 5, United 4
States Code, is amended by adding at the end the fol- 5
lowing new section: 6
‘‘§ 8915. Termination 7
‘‘No contract shall be entered into under this chapter 8
or chapters 89A and 89B with respect to any coverage 9
period occurring in any calendar year beginning at least 10
2 years after the date of the enactment of the Healthy 11
Americans Act.’’. 12
(b) CONFORMING AMENDMENT.—The table of sec- 13
tions for such chapter 89 is amended by adding at the 14
end the following new item: 15
‘‘8915. Termination.’’.
SEC. 673. MEDICAID AND CHIP. 16
(a) IN GENERAL.—Title XIX of the Social Security 17
Act, as amended by section 311, is amended by adding 18
at the end the following new section: 19
‘‘TRANSITION TO COVERAGE UNDER HAPI PLANS; RE- 20
QUIREMENT TO PROVIDE SUPPLEMENTAL COV- 21
ERAGE; TERMINATION OF UNNECESSARY PROVISIONS 22
‘‘SEC. 1943. (a) TRANSITION AND SUPPLEMENTAL 23
COVERAGE REQUIREMENTS.—The Secretary shall provide 24
technical assistance to States and health insurance issuers 25
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of HAPI plans to ensure that individuals receiving medical 1
assistance under State Medicaid plans under this title or 2
child health assistance under child health plans under title 3
XXI are— 4
‘‘(1) informed of— 5
‘‘(A) the guarantee of private coverage for 6
essential services for all Americans established 7
by the Healthy Americans Act; and 8
‘‘(B) each individual’s personal responsi- 9
bility— 10
‘‘(i) for health care prevention; 11
‘‘(ii) to enroll (or to be enrolled on 12
their behalf) in a HAPI plan through the 13
applicable State HHA during an open en- 14
rollment period; and 15
‘‘(iii) to submit necessary documenta- 16
tion to their State HHA so that the HHA 17
may determine the individual’s eligibility 18
for premium and personal responsibility 19
contribution subsidies; 20
‘‘(2) provided with appropriate assistance in 21
transitioning from receiving medical assistance 22
under State Medicaid plans or child health assist- 23
ance under child health plans for their primary 24
health coverage to obtaining such coverage through 25
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enrollment in HAPI plans in a manner that ensures 1
continuation of coverage for such individuals; 2
‘‘(3) notwithstanding any other provision of this 3
title, after December 31 of the last calendar year 4
ending before the first calendar year in which cov- 5
erage under a HAPI plan begins in accordance with 6
the Healthy Americans Act, provided with medical 7
assistance that consists of supplemental coverage 8
that meets the requirements of sections 202 and 301 9
of such Act; and 10
‘‘(4) if the State elects to establish a State 11
Choices for Long-Term Care Program under section 12
1942 and the individual is likely to be eligible for the 13
program, informed of the coverage available under 14
the program and how to enroll. 15
‘‘(b) MAINTENANCE OF MEDICARE COST-SHAR- 16
ING.—For each month beginning after the last month of 17
the last calendar year ending before the first calendar year 18
in which coverage under a HAPI plan begins in accord- 19
ance with the Healthy Americans Act— 20
‘‘(1) a State shall continue to provide medical 21
assistance for medicare cost-sharing to individuals 22
described in section 1902(a)(10)(E) as if the 23
Healthy Americans Act had not been enacted; and 24
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‘‘(2) the Secretary shall continue to reimburse 1
the State for the provision of such medical assist- 2
ance. 3
‘‘(c) CONTINUED SUPPORT FOR DSH EXPENDI- 4
TURES.— 5
‘‘(1) IN GENERAL.—Notwithstanding any other 6
provision of this title, with respect to each fiscal year 7
that begins after the first calendar year in which 8
coverage under a HAPI plan begins in accordance 9
with the Healthy Americans Act, the DSH allotment 10
for each State otherwise applicable under section 11
1923(f) for that fiscal year shall be reduced by 90 12
percent and no payment shall be made under section 13
1903(a) to a State with respect to any payment ad- 14
justment made under section 1923 for hospitals in 15
the State for quarters in the fiscal year in excess of 16
the reduced DSH allotment for the State applicable 17
for such year. 18
‘‘(2) SPECIAL RULE FOR LAST 3 QUARTERS OF 19
FIRST FISCAL YEAR IN WHICH COVERAGE UNDER A 20
HAPI PLAN BEGINS.—With respect to the first fiscal 21
year in which coverage under a HAPI plan begins 22
in accordance with the Healthy Americans Act, the 23
Secretary shall reduce the DSH allotment for each 24
State that is otherwise applicable under section 25
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1923(f) for that fiscal year so that each such DSH 1
allotment reflects a 90 percent reduction in the allot- 2
ment for the second, third, and fourth quarters of 3
that fiscal year. 4
‘‘(d) TERMINATION OF ALL FEDERAL PAYMENTS 5
UNDER THIS TITLE OTHER THAN FOR MEDICARE COST- 6
SHARING, SUPPLEMENTAL MEDICAL ASSISTANCE, OR A 7
STATE CHOICES FOR LONG-TERM CARE PROGRAM.—Not- 8
withstanding any other provision of this title: 9
‘‘(1) no individual other than an individual to 10
which section 202, 301, or 311 of the Healthy 11
Americans Act applies is entitled to medical assist- 12
ance under a State plan approved under this title for 13
any item or service furnished after December 31 of 14
the last calendar year ending before the first cal- 15
endar year in which coverage under a HAPI plan be- 16
gins in accordance with such Act; and 17
‘‘(2) no payment shall be made to a State 18
under section 1903(a) for any item or service fur- 19
nished after that date or for any other sums ex- 20
pended by a State for which a payment would have 21
been made under such section, other than for the 22
Federal medical assistance percentage of the total 23
amount expended by a State for each fiscal year 24
quarter beginning after that date for providing— 25
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‘‘(A) medical assistance for the mainte- 1
nance of medicare cost-sharing in accordance 2
with subsection (b); 3
‘‘(B) medical assistance for individuals who 4
are eligible for supplemental medical assistance 5
under this title after such date in accordance 6
with section 202 or 301 of the Healthy Ameri- 7
cans Act; 8
‘‘(C) payments for expenditures for estab- 9
lishing and operating a State Choices for Long- 10
Term Care Program under section 1942 (sub- 11
ject to the aggregate 5-year limit established 12
under subsection (c)(1) of such section); and 13
‘‘(D) payment adjustments under section 14
1923 for hospitals in the State that do not ex- 15
ceed the reduced DSH allotment for the State 16
determined under subsection (c).’’. 17
(b) APPLICATION TO CHIP.— 18
(1) APPLICATION OF TRANSITION REQUIRE- 19
MENTS.—Section 2107(e)(1) of the Social Security 20
Act (42 U.S.C. 1397gg(e)(1)) is amended by adding 21
at the end the following: 22
‘‘(E) Section 1943(a) (relating to transi- 23
tion to coverage under HAPI plans and, in the 24
case of paragraph (3) of such section, the re- 25
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quirement to provide supplemental medical as- 1
sistance for targeted low-income children who 2
are provided child health assistance as optional 3
targeted low-income children under title 4
XIX).’’. 5
(2) TERMINATION.—Title XXI of the Social Se- 6
curity Act is amended by adding at the end the fol- 7
lowing new section: 8
‘‘TERMINATION 9
‘‘SEC. 2111. Notwithstanding any other provision of 10
this title, no payment shall be made to a State under sec- 11
tion 2105(a) with respect to child health assistance for 12
any item or service furnished after December 31 of the 13
last calendar year ending before the first calendar year 14
in which coverage under a HAPI plan begins in accord- 15
ance with the Healthy Americans Act.’’. 16
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TITLE VII—PURCHASING 1
HEALTH SERVICES AND 2
PRODUCTS THAT ARE MOST 3
EFFECTIVE 4
Subtitle A—Effective Health 5
Services and Products 6
SEC. 701. ONE TIME DISALLOWANCE OF DEDUCTION FOR 7
ADVERTISING AND PROMOTIONAL EXPENSES 8
FOR CERTAIN PRESCRIPTION PHARMA- 9
CEUTICALS. 10
(a) IN GENERAL.—Part IX of subchapter B of chap- 11
ter 1 of subtitle A of the Internal Revenue Code of 1986 12
(relating to items not deductible) is amended by adding 13
at the end the following new section: 14
‘‘SEC. 280I. ONE TIME DISALLOWANCE OF DEDUCTION FOR 15
CERTAIN PRESCRIPTION PHARMACEUTICALS 16
ADVERTISING AND PROMOTIONAL EX- 17
PENSES. 18
‘‘(a) IN GENERAL.—No deduction shall be allowed 19
under this chapter for expenses relating to advertising or 20
promoting the sale and use of prescription pharma- 21
ceuticals other than drugs for rare diseases or conditions 22
(within the meaning of section 45C) for any taxable year 23
which includes any portion of— 24
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‘‘(1) the 3-year period which begins on the date 1
of a new drug application approval with respect to 2
such a pharmaceutical, unless the manufacturer of 3
such pharmaceutical demonstrates to the satisfaction 4
of the Secretary that such pharmaceutical is subject 5
to a comparison effectiveness study, including over- 6
the-counter medication (if appropriate), or 7
‘‘(2) the 1-year period which ends with the 8
availability of a generic drug substitute, unless such 9
advertising or promotion includes a statement that 10
a lower cost alternative may soon be available and 11
includes the chemical name of such alternative. 12
‘‘(b) ADVERTISING OR PROMOTING.—For purposes of 13
this section, the term ‘advertising or promoting’ includes 14
direct-to-consumer advertising and any activity designed 15
to promote the use of a prescription pharmaceutical di- 16
rected to providers or others who may make decisions 17
about the use of prescription pharmaceuticals (including 18
the provision of product samples, free trials, and starter 19
kits).’’. 20
(b) CONFORMING AMENDMENT.—The table of sec- 21
tions for such part IX is amended by adding after the 22
item relating to section 280H the following new item: 23
‘‘Sec. 280I. One time disallowance of deduction for certain prescription pharmaceuticals
advertising and promotional expenses.’’.
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(c) EFFECTIVE DATE.—The amendments made by 1
this section shall apply to taxable years beginning with 2
or within calendar years beginning at least 2 years after 3
the date of the enactment of this Act. 4
SEC. 702. ENHANCED NEW DRUG AND DEVICE APPROVAL. 5
(a) IN GENERAL.— 6
(1) NEW DRUGS.—Section 505 of the Federal 7
Food, Drug, and Cosmetic Act (21 U.S.C. 355) is 8
amended by adding at the end the following: 9
‘‘(v)(1) The sponsor of a new drug application under 10
subsection (b) may include as part of such application a 11
full report of an investigation which has been made to 12
show, with respect to the new drug that is the subject of 13
the application— 14
‘‘(A) the population for whom the drug is ap- 15
propriate; and 16
‘‘(B) the effectiveness of the drug when com- 17
pared to the effectiveness of drugs on the market as 18
of the date that the application is submitted. 19
‘‘(2) If a sponsor of a new drug application under 20
subsection (b) includes in such application the report de- 21
scribed under paragraph (1) then, notwithstanding any 22
other provision of law, the Secretary shall apply section 23
505A(b) to the drug that is the subject of such application 24
in the same manner as the Secretary applies such section 25
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to a new drug in the pediatric population that is the sub- 1
ject of a study described in such section. 2
‘‘(3) If a sponsor of a new drug application under 3
subsection (b) does not include in such application the re- 4
port described under paragraph (1) then, notwithstanding 5
any other provision of law, the Secretary shall require 6
that— 7
‘‘(A) all promotional material with respect to 8
such drug include the following disclosure: ‘This 9
drug has not been proven to be more effective than 10
other drugs on the market for any condition or ill- 11
ness mentioned in this advertisement.’; and 12
‘‘(B) such disclosure— 13
‘‘(i) appears at the beginning and end of 14
any audio and visual promotional material; 15
‘‘(ii) constitutes not less than 20 percent of 16
the time of any audio and visual promotional 17
material; and 18
‘‘(iii)(I) in any promotional material, in- 19
cludes a clear and conspicuous printed state- 20
ment that is larger than other print used in 21
such promotional material; and 22
‘‘(II) in any audio and visual promotional 23
material, includes such statement in audio as 24
well as visual format.’’. 25
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(2) NEW DEVICES.—Section 515(c) of the Fed- 1
eral Food, Drug, and Cosmetic Act (21 U.S.C. 2
360e) is amended by adding at the end the fol- 3
lowing: 4
‘‘(5)(A) A person that files a report seeking pre- 5
market approval under this subsection may include as part 6
of such report a full description of an investigation which 7
has been made to show, with respect to the device that 8
is the subject of the report— 9
‘‘(i) the population for whom the device is ap- 10
propriate; and 11
‘‘(ii) the effectiveness of the device when com- 12
pared to the effectiveness of devices on the market 13
as of the date that the report is submitted. 14
‘‘(B) If a person that files a report seeking premarket 15
approval under this subsection includes in such report the 16
description referred to under subparagraph (A), then the 17
Secretary shall certify to the Director of the United States 18
Patent and Trademark Office that such person included 19
such description in such report so that the Director may 20
extend the patent with respect to such device under section 21
702(b) of the Healthy Americans Act. 22
‘‘(C) If a person that files a report seeking premarket 23
approval under this subsection does not include in such 24
report the description referred to under subparagraph (A) 25
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then, notwithstanding any other provision of law, the Sec- 1
retary shall require that— 2
‘‘(i) all promotional material with respect to 3
such device include the following disclosure: ‘This 4
device has not been proven to be more effective than 5
other devices on the market for any condition or ill- 6
ness mentioned in this advertisement.’; and 7
‘‘(ii) such disclosure— 8
‘‘(I) appears at the beginning and end of 9
any audio and visual promotional material; 10
‘‘(II) constitutes not less than 20 percent 11
of the time of any audio and visual promotional 12
material; and 13
‘‘(III)(aa) in any promotional material, in- 14
cludes a clear and conspicuous printed state- 15
ment that is larger than other print used in 16
such promotional material; and 17
‘‘(bb) in any audio and visual promotional 18
material, includes such statement in audio as 19
well as visual format.’’. 20
(b) EXTENSION OF DEVICE PATENTS.—If the Direc- 21
tor of the United States Patent and Trademark Office re- 22
ceives a certification from the Secretary pursuant to sec- 23
tion 515(c)(5) of the Federal Food, Drug, and Cosmetic 24
Act (as added under subsection (a)), the Director shall 25
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extend, for a period of 2 years, the patent in effect with 1
respect to such device under title 35 of the United States 2
Code. 3
(c) EFFECTIVE DATE.—This section shall apply to 4
new drug applications filed under section 505(b) of the 5
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(b)) 6
and to applications for premarket approval of devices 7
under section 515 of such Act (21 U.S.C. 350e) 180 days 8
after the date of enactment of this Act. 9
SEC. 703. MEDICAL SCHOOLS AND FINDING WHAT WORKS 10
IN HEALTH CARE. 11
Part B of title IX of the Public Health Service Act 12
(42 U.S.C. 299b et seq.) is amended by adding at the end 13
the following: 14
‘‘SEC. 918. MEDICAL SCHOOLS AND FINDING WHAT WORKS 15
IN HEALTH CARE. 16
‘‘(a) ESTABLISHMENT OF WEBSITE.—Not later than 17
1 year after the date of enactment of the Healthy Ameri- 18
cans Act, the Agency shall establish an Internet website— 19
‘‘(1) on which researchers at medical schools 20
and other institutions may post the results of their 21
research concerning evidence-informed best practices 22
for improving the quality and efficiency of care; and 23
‘‘(2) that— 24
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‘‘(A) includes a description on how to im- 1
plement such best practices; and 2
‘‘(B) clearly identifies the funding source 3
for the research. 4
‘‘(b) PILOT PROGRAM.— 5
‘‘(1) ESTABLISHMENT.—Using the information 6
about evidence-informed best practices from the 7
website under subsection (a) and other sources, the 8
Agency, through the National Research Training 9
Program and in consultation with medical schools, 10
shall develop a pilot program to establish methods 11
by which medical school curricula and training may 12
be updated regularly to reflect best practices to im- 13
prove quality and efficiency in medical practice. 14
‘‘(2) APPLICATION TO PARTICIPATE.—To par- 15
ticipate in the pilot program, an entity shall— 16
‘‘(A) be an accredited medical school; and 17
‘‘(B) submit an application at such time, 18
in such manner, and containing such informa- 19
tion as the Secretary may require. 20
‘‘(3) PARTICIPANTS.—The Secretary shall en- 21
sure that not less than 28 medical schools shall be 22
included in the pilot program. 23
‘‘(4) DURATION; PUBLICATION OF RESULTS.— 24
The Agency shall— 25
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‘‘(A) operate the pilot program for 3 years; 1
‘‘(B) not later than 180 days after the 2
date of the completion of the pilot program, 3
publish and make public the results of the pilot 4
program; and 5
‘‘(C) include, as part of the published re- 6
sults under subparagraph (B), recommenda- 7
tions on how to assure that all medical school 8
curricula is updated on a regular basis to re- 9
flect best practices to improve quality and effi- 10
ciency in medical practice.’’. 11
SEC. 704. FINDING AFFORDABLE HEALTH CARE PRO- 12
VIDERS NEARBY. 13
(a) IN GENERAL.—Not later than 2 years after the 14
date of enactment of this Act, the Secretary, in consulta- 15
tion with each HHA and health insurance issuers that 16
offer a HAPI plan, shall establish an Internet website to 17
assist covered individuals with locating health care pro- 18
viders in their State of residence who provide affordable, 19
high-quality health care services. 20
(b) QUALITY OF CARE STANDARD.—To develop the 21
information displayed on the website with respect to the 22
quality of care of a health care provider, the Secretary 23
shall— 24
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(1) on the date of establishment of the website, 1
use information on the performance of providers in 2
quality initiatives under the Medicare program, in- 3
cluding demonstration projects, reporting initiatives, 4
and pay for performance efforts; and 5
(2) not later than 3 years after the date of es- 6
tablishment of the website, in addition to the infor- 7
mation used under paragraph (1), use quality of 8
care standards developed in consultation with, and 9
similar to standards used by, Medicare quality im- 10
provement organizations of each State. 11
(c) AFFORDABILITY STANDARD.—Not later than 2 12
years after the date of enactment of this Act, the Sec- 13
retary shall, in consultation with health insurance issuers 14
that offer a HAPI plan, develop guidelines by which each 15
health care provider reports to the Secretary with respect 16
to the affordability of services by such provider. The Sec- 17
retary shall ensure that such guidelines— 18
(1) on the date of establishment of such guide- 19
lines, provide for the reporting of affordability of 20
primary care services; and 21
(2) by a date that is no later than 3 years after 22
the date of enactment of this Act, provide for the re- 23
porting of other services. 24
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Subtitle B—Other Provisions to Im- 1
prove Health Care Services and 2
Quality 3
SEC. 711. INDIVIDUAL MEDICAL RECORDS. 4
The Secretary shall establish procedures to ensure 5
that an individual’s medical record is considered the prop- 6
erty of such individual. 7
SEC. 712. BONUS PAYMENT FOR MEDICAL MALPRACTICE 8
REFORM. 9
(a) IN GENERAL.—Effective 3 years after the date 10
of enactment of this Act, a State shall be eligible for bonus 11
payments under this Act if the State has enacted and is 12
implementing a State medical malpractice reform law that 13
complies with subsection (b). 14
(b) REQUIREMENTS FOR STATE REFORM LAW.—A 15
State medical malpractice reform law complies with this 16
subsection if such law— 17
(1) requires that an individual who files a med- 18
ical malpractice action in State court have the facts 19
of such individual’s case reviewed prior to such filing 20
by a panel that consists of— 21
(A) not less than 1 qualified medical ex- 22
pert, chosen in consultation with the State 23
Medicare quality improvement organizations or 24
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physician speciality society, whose expertise is 1
appropriate for case; 2
(B) not less than 1 legal expert; and 3
(C) not less than 1 community representa- 4
tive to verify that there is reasonable cause to 5
believe that a malpractice claim exists; 6
(2) permits an individual to engage in voluntary 7
non-binding mediation with respect to the mal- 8
practice claim involved prior to filing an action in 9
State court; 10
(3) imposes sanctions against plaintiffs and at- 11
torneys who file frivolous medical malpractice claims 12
in State courts; 13
(4) prohibits attorneys who file 3 frivolous med- 14
ical malpractice actions in State courts from filing 15
any another medical malpractice action in such 16
courts for a period of 10 years; and 17
(5) provides for the application of a presump- 18
tion of reasonableness with respect to a medical mal- 19
practice action if the defendant establishes that the 20
defendant provided the items or services involved in 21
accordance with accepted clinical practice guidelines 22
established by the specialty of which the defendant 23
is board certified or listed in the National Guideline 24
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•S 391 IS
Clearinghouse, unless such presumption is rebutted 1
by a preponderance of the evidence. 2
(c) USE OF BONUS PAYMENTS.—A State shall use 3
bonus payments received under this section to carry out 4
activities related to disease and illness prevention and for 5
the provision of enhanced health care services for children. 6
(d) PROCEDURES.—The Secretary, in consultation 7
with the Attorney General, shall by regulation establish 8
guidelines for the implementation of this section. 9
SEC. 713. PRIORITIZING HEALTH CARE EMPLOYMENT AND 10
TRAINING ACTIVITIES. 11
(a) DEFINITIONS.—In this section: 12
(1) EMPLOYMENT AND TRAINING ACTIVITY.— 13
The term ‘‘employment and training activity’’ 14
means— 15
(A) a workforce investment activity; 16
(B) a program or activity described in sub- 17
section (b)(1)(B) of section 121 of such Act (29 18
U.S.C. 2841), and a program described in sub- 19
section (b)(2)(B) of such section if the entity 20
carrying out the program is a one-stop partner 21
for the one-stop delivery system involved, other 22
than the provision of housing, health insurance, 23
or another supportive service that is wholly un- 24
related to employment, service, or training as- 25
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•S 391 IS
sistance (as determined by the Secretary of 1
Labor); and 2
(C) any other activity described in title I 3
or V of that Act (29 U.S.C. 2801 et seq., 9271 4
et seq.), other than the provision of housing, 5
health insurance, or another supportive service 6
that is wholly unrelated to employment, service, 7
or training assistance (as so determined). 8
(2) HEALTH CARE PROVIDERS.—The term 9
‘‘health care providers’’ includes nurses and other 10
nonphysician providers. 11
(3) ONE-STOP PARTNER; WORKFORCE INVEST- 12
MENT ACTIVITY.—The terms ‘‘one-stop partner’’ and 13
‘‘workforce investment activity’’ have the meanings 14
given the terms in section 101 of that Act (29 15
U.S.C. 2801). 16
(4) STIMULUS OR AUTHORIZATION FUNDS.— 17
The term ‘‘stimulus or authorization funds’’ 18
means— 19
(A) appropriations made available for fis- 20
cal year 2009, in an Act enacted after January 21
1, 2009, for a program that provides an em- 22
ployment and training activity; or 23
(B) appropriations made available for a 24
program that provides an employment and 25
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•S 391 IS
training activity, if Congress has passed legisla- 1
tion after January 1, 2009, that 2
(i) becomes law; and 3
(ii)(I) authorizes appropriations for 4
such program; or 5
(II) extends the authorization of ap- 6
propriations for, or duration of, such pro- 7
gram. 8
(b) PRIORITY.—In using stimulus or authorization 9
funds to provide services for individuals, the Secretary of 10
Labor, or any other Federal officer to whom such funds 11
are made available, shall give priority to individuals who 12
seek employment in or training for positions as health care 13
providers. 14
(c) CONSTRUCTION.—No provision of law shall be 15
considered to supersede or modify this section unless the 16
provision refers specifically to this section. 17
TITLE VIII—CONTAINING MED- 18
ICAL COSTS AND GETTING 19
MORE VALUE FOR THE 20
HEALTH CARE DOLLAR 21
SEC. 801. COST-CONTAINMENT RESULTS OF THE HEALTHY 22
AMERICANS ACT. 23
Congress finds that the Healthy Americans Act will 24
result in the following: 25
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•S 391 IS
(1) Private insurance companies will be forced 1
to hold down costs and will slow the rate of growth 2
because they are required to offer standardized 3
Healthy American Private Insurance plans. 4
(2) Administrative savings will be derived from 5
reducing employers’ and insurers’ administrative 6
costs relating to health care. 7
(3) Private insurance companies will implement 8
uniform billing and common claims forms. 9
(4) Congress will reclaim Medicare and Med- 10
icaid disproportionate share hospital (DSH) pay- 11
ments because previously uninsured persons will go 12
to providers on an outpatient basis instead of an 13
emergency department. 14
(5) State and local governments will save 15
money on programs they operated for the uninsured 16
before enactment of this Act. 17
(6) The Federal Government will save money 18
on Federal tax subsidies that reward inefficient care 19
and are regressive. 20
(7) The Federal Government and the private 21
sector will save money if the Food and Drug Admin- 22
istration determines whether products provide new 23
value. 24
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(8) Reducing medical errors will save the gov- 1
ernment and the private sector money. 2
(9) Requiring hospitals to send large bills to pa- 3
tients for their review will reduce errors in medical 4
billing and force major providers to be more cost 5
conscious. 6
(10) Requiring insurers to reimburse for quality 7
and cost effective services will hold down private sec- 8
tor costs. 9
(11) Reduction of Medicare’s restriction on bar- 10
gaining power for prescription drugs will reduce 11
costs for sole source drugs and other medications. 12
(12) Establishment of electronic medical 13
records by insurers will create savings. 14
(13) Publication of cost and quality data will 15
enable people to look up by zip code affordable high- 16
quality providers. 17
Æ
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biber hapı meksika biber hapı ve acı biber hapı zayıflama kapsüllerinde büyük indirim..

Arkadaşlar bir önceki yazımda reklam demişken devam etmek istedim bu konuda..

Biliyorsunuz ki Biber Hapı Artık Türkiye Geneli Bilinen ve Kullanılan Bir Zayıflama Ürünüdür..

Bu nedenledir ki insanların Hüsn-ü Teveccühleri doğrultusunda bende Biber Hapı satış yapan sitelerdeki avantajları sizlere duyurmak istedim..

Burada ticari bir amacım yoktur tamamen bilgilendirme amaçlı yazıyorum bu özgün yazılar..

Yine bin önceki yazımda reklamını yapmış olduğum internet sitesi olan biber hapı burada adlı biber hapı satış sitesi yeni bir kampanya başlatmış..

Kampanya Özeti Şu Şekildedir.. (İki Türlü Kampanya Bulunmaktadır.)

1. 2 Tane Biber Hapı veya üzeri Biber Hapı Alan Kullanıcılara 1 Adet Zayıflatıcı Termal Kemer Hediye..
2. Toplu Biber Hapı Alımlarında Ekstra Biber Hapı Hediyesi.(10 Adet Biber Hapı Alana 1 Adet Biber Hapı Bedava)

Biber Hapı Burada Satış Sitesine Gitmek için Tıklayın

Evet Kampanya Yapan Sitelerden Bir Tanesi Biber Hapı Burada idi. Diğer Bir Kampanya Yapan Biber Hapı Satış Sitesi ise Orjinal Biber Hapı Adlı internet sitesidir ki bu siteninde kampanyaları azımsanmayacak kadar güzeldir..

Öncelikle Orjinal Biber Hapı Satış Sitesinde’de iki türlü kampanya olduğunu belitmek isterim..

Biber Hapı Burada‘daki kampanya ile benzerlik göstersede aslında tamamen farklı bir satış kampanyasıdır..

1. 2 Tane Biber Hapı veya üzeri Biber Hapı Alan Kullanıcılara 1 Adet Zayıflatıcı Termal Kemer Hediye..
2. Bu Sitede Toplu Biber Hapı Alımlarında Ayak Kokusu Giderici Bitkisel ürün olan Fx7 Ayak Kokusu Giderici Hediyedir..

Orjinal Biber Hapı Satış Sitesine Gitmek için Tıklayın

Biber Hapı Yorumları

Merhaba arkadaşlar burada zaman zaman Biber Hapı kapsülü satış siteleri veya Biber Hapı bilgilendirme sitelerinin reklamını yapacağım..

Bugünlük ilk olması hasebiyle Biber Hapı Burada Adlı Biber Hapı Satış Sitesinin reklamını yapacağım..

Biber Hapı Burada Sitesi’nde Ürünler Sağlam Ürünler Olup Bizzat Kendim Denemiş ve Kullanmışım..

Ürünlerde Herhangi Bir Sorun Olmadı Şimdiye Kadar. Kullanan Arkadaşlarımda Herhangi bir şikayette bulunmadı..

Biber Hapı Burada Internet Sitesi: http://www.biberhapiburada.com

Biber Hapı Burada Sipariş Sayfası:http://www.biberhapiburada.com/siparis.html

Biber Hapı Burada Adlı Biber Hapı Satış Sitesi Ekran Görüntüsü Yandaki Gibidir.

Güzel ülkemin güzel insanları merhaba hepinize..

bir çok kişinin merak ettiği bir konu hakkında durmak istiyorum bugün.

Ramazan ayının gelmesi hasebiyle bir çok arkadaş ramazanda biber hapı kullanılır mı diye sorup duruyordu. Tek tek cevap veriliyordu ama istedim ki internette arama yapan herkes bundan istifade etsin..

Evet arkadaşlar Ramazan’da biber hapı kullanılabilir. Kullanımı ise normal günlük kullanım gibidir. yalnız bu sefer sahurda değilde iftardan sonra yenilmelidir.

Akşam ezanı okundu diyelim iftarınızı açtınız sonrasında 20-30 dakika beklersiniz ve biber hapı zayıflama kapsülünü bol suyla birlikte içersiniz..

Zannediyorum Ramazan’da biber hapı Kullanımı Hakkında kimsenin bir şüphesi kalmadı..

Soru ve cevaplarınız için lütfen yorum bırakınız..

Arkadaşlar Biliyorum ki bu sayfaya gelme nedeniniz Zayıflatma özelliği olan Biber Hapı Hakkında Yapılan Yorumları Okumak veya Biber Hapı Hakkında Olumlu veya Olumsuz Bir Yorum Yapmaktır..

Sizde Biliyorsunuz ki biber hapı piyasaya çıktığı ilk günden bu yana türkiye genelinde halkın hüsn-ü kabülünü görmüş bir bitkisel zayıflama ürünüdür.

Elbetteki Biber Hapı Kullanan İnsanların Hepsi Olumlu Sonuç Yazacak Diye bir Şey yoktur.

Kimi Arkadaşlar Olumsuz Yorum Yazacak Kimi Arkadaşlar ise Olumlu Yorum Yazacaktır..

Biber Hapı Hakkında Yapılan Yorumlar Aşağıdaki gibidir.

Sizde Biber Hapı Hakında Yorum Yapmak için aşağıya doğru ilerleyiniz.

Biber Hapı, Acı Biber Hapı, Meksika Biber Hapı,

Yukarıda bahsedilen değişik isimlerdeki zayıflama ürünleri aynı ürünlermidir  yoksa her biri farklı bir ürün müdür? gibi sorular gelebiliyor insanların kafasına ve tereddütte kalıyorlar kimi zaman. Belki çok uygun bir fiyata bir yerden Biber Hapı bulmuşken kendisi Acı Biber Hapı aradığından dolayı uygun olan Biber Hapı kapsülünü kaçırmış oluyor ki buda kullanıcının cebine zarar olmaktadır. bende böyle bir şeyi aziz ve necip milletim yaşamasın diye bu şekilde bir konu açma gereksinimi duydum.

Kardeşlerim,

Yukarıda ismi geçen Biber Hapı, Meksika Biber Hapı ve Acı Biber Hapı Aslında aynı ürünlerdir.

Bu şekilde farklı isimler altında satılmasının sebebi ise kullanıcıların hüsn-ü zanlarından dolayıdır.

Yani Biber Hapı Farklı Bir Ürün, Acı Biber Hapı Bambaşka Bir Ürün yada Meksika Biber Hapı daha değişik bir ürün değildir.

Bu ürünlerin hepsi tek başlık altında Biber Hapı olarak toplanmakta ve Biber Hapı olarak satılmaktadır..

buda bu şekilde ufak bir bilgi olarak bulunsun istedim..

Merhabalar Sevgili arkadaşlar..

Malumunuz 11 Ayın Sultanı olan Müslümanların İbadet Ayı Ramazan Ayı geldi-çattı.

Doğal olarak türkiye geneli 99% nüfusun müslüman olduğu bir ülke olduğundan dolayı aziz halkımız oruç tutacaktır.

Ramazan Ayında Kullanıcılar Hem Zayıflamak istediklerinden hemde oruç  tutacaklarından dolayıdır ki Biber Hapı konusunda tereddütte kalacaklardır..

Bende Burada Biber Hapı Kullanacak Olan kişilere Ramazan Ayında neler yapmaları gerektiği konusunda bilgi vereceğim..

Evet arkadaşlar Ramazan Ayında normal günlük yaşamın tersi bir hayata girdiğimizden dolayı aslında sahurlar bizim akşam yemeklerimi ve iftarlar ise kahvaltımız olmaktadır.  Gün içerisinde insanlar zaten yorgun ve argın olduklarından dolayı en çok enerji akşam vakitlerinde olmaktadır. Bu nedenledir ki Biber Hapı Kullanacak olan kullanıcılar Biber Hapı‘nı İftar’dan sonra kullanmalıdırlar. Yine Aynı şekilde İftar Açtıktan 20 dakika sonra Biber Hapı‘nı bol su ile birlikte tüketmeniz gerekmektedir.

Umarım Ramazan Ayında Biber Hapı kullanımı ile ilgili yardımcı olmuşumdur.

Sizinde aklınızda varsa sorular burada sorup cevaplarını konusunda da elimden geldiğince yardımcı olmaya çalışırım

İyi Günler (Meksika Biber Hapı Kullanıcısı)

Biber Hapı Memnuniyet Araştırması

Türkiye’nin her tarafında büyük beğeni toplayan Biber Hapı zayıflama kapsülü hakkında biraz araştırma yaptım da öncelikli olarak hangi ilde daha fazla kullanılıyor diye ve elde ettiğim sonuçlar doğrultusunda Biber Hapı‘nın En Çok Ankara‘da kullanıldığı Sonrasında Samsun ve onu takip eden İzmir ile devam etmektedir..

Ankara‘daki Biber Hapı Kullanıcıları Burada Yorumlarını Yaparlarsa Kullanıcıların Memnuniyet oranlarını da bu şekilde anlayabiliriz..

Teşekkürler..

Biber Hapı Dünyasından Merhaba arkadaşlar..

geçtiğimiz günlerde meksika Biber Hapı ile ilgili google istatistiklerine baktımda geçen aya göre bayağı bir düşüş göstermişti.. Bunun nedenleri araştırırken önüme bir kaç seçenek geldi ve düşünmeye başladım..

Havaların Sıcak Olması ve Milletin Tatile Gidiyor olması..

Türkiye’deki Herkesin Biber Hapı Kullanıyor Olması ve Ihtiyaçlarının kalmaması

Biber Hapı‘ndan Başka Bir Ürünün Piyasaya Çıkmış Olması

Bunlar Arasında kalıp durdum sürekli.. Ama bu seçeneklerde ilk seçenek daha mantıklı gibime geldi. Nedeni ise eğer türkiye’deki kilo problemi olan tüm insanlar Biber Hapı kullanıyor ise etkisini gördüklerinden dolayı bir daha ihtiyaç duymamalarıdır. yok eğer Biber Hapı‘ndan başka bir ürün piyasaya çıkmış ise hangi ürün olduğunu bilmememdir ki bir sonuç vereyim sizlere..

Dediğim gibi sevgili dostlar bu ay google’daki Biber Hapı istatistikleri hiçte iç açıcı değildi.

İyi Günler..

evet arkadaslar yarisma basladi hayirli olsun bunlarda kurallar : fx15 biber hapı 100 kontör mp3 indir milenyum: -Hertürlü domain-blogla katılım serbesttir free farketmeksizin, yalnız alt sayfalar hariç domainadı.com/x.html gibi. Not:Yarışma kelmesi domainin içinde geçmesi gerekmektedir.Mesela yarışmamızın ismi “r10 seo x milenyum” domain isminizde muhakkak r10seoxmilenyum olmalıdır. -Kodlar her sayfanızda header kısmında ve tüm alt sayfalarda olacaktır. -Yarışmacılar bu yarışmaya katıldığı sitelerle başka bir seo yarışmasına katılamazlar. fx15 biber hapı 100 kontör mp3 indir milenyum -Sitelerinizden link satışı yapabilirsiniz fakat yarışma şartlarında bahsi geçen kelimelerle ilgili satış yapamazsınız.(yarışmaya katılan bir blog’a satıyorsanız sorun yok) -Yarışmaya katılan site adresi google aramasında birden çok gösterilirse tek olarak sayılacaktır.Alt sayfası derecelendirmeye alınmayacaktır.(yarışmacı birden fazla siteyle katılıyorsa ve derecedeyse ödülü alır) -Eski ve/ya yeni siteler gözetmeksiniz tüm siteler bu yarışmaya dahil olablirler. fx15 biber hapı 100 kontör mp3 indir milenyum -Ve son olarak yarışmaya istediğiniz kadar alan adıyla katılabilirsiniz. fx15 biber hapı 100 kontör mp3 indir milenyum Yarışma durumuna göre kurallarda ekleme-çıkarma yapılabilir.Kuralları ihlal edenler yarışmayı dikkatlice takip etmelidir.İhlal söz konusu ise 5 (beş) günlük süreçte zaman verilir,aksi takdirde yarışmacı diskalifiyedir. Yarışmaya katılacak arkadaşlar,kodları olduğu gibi ekleyecek,kodlarda oynama-değişiklik yapmayacak,no-follow vermeyecek ve tüm sayfalara ekleyeceklerini taahhüt eder. fx15 biber hapı 100 kontör mp3 indir milenyum Herkese bol şanslar.