Text of Public Option in House Bill:

[yurbud]

http://docs.house.gov/rules/health/111_ahcaa.pdf


•HR 3962 IH
Subtitle B—Public Health
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Insurance Option
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SEC. 321. ESTABLISHMENT AND ADMINISTRATION OF A
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PUBLIC HEALTH INSURANCE OPTION AS AN
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EXCHANGE-QUALIFIED HEALTH BENEFITS
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PLAN.
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(a) ESTABLISHMENT.—For years beginning with Y1,
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the Secretary of Health and Human Services (in this sub-
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title referred to as the ‘‘Secretary’’) shall provide for the
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offering of an Exchange-participating health benefits plan
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(in this division referred to as the ‘‘public health insurance
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option’’) that ensures choice, competition, and stability of
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affordable, high quality coverage throughout the United
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States in accordance with this subtitle. In designing the
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option, the Secretary’s primary responsibility is to create
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a low-cost plan without compromising quality or access to
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care.
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(b) OFFERING AS AN EXCHANGE-PARTICIPATING
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HEALTHBENEFITSPLAN.—
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(1) EXCLUSIVETOTHEEXCHANGE.—The pub-
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lic health insurance option shall only be made avail-
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able through the Health Insurance Exchange.
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(2) ENSURINGALEVELPLAYINGFIELD.—Con-
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sistent with this subtitle, the public health insurance
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option shall comply with requirements that are ap-
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plicable under this title to an Exchange-participating
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health benefits plan, including requirements related
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to benefits, benefit levels, provider networks, notices,
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consumer protections, and cost-sharing.
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(3) PROVISIONOFBENEFITLEVELS.—The pub-
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lic health insurance option—
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(A) shall offer basic, enhanced, and pre-
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mium plans; and
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(B) may offer premium-plus plans.
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(c) ADMINISTRATIVECONTRACTING.—The Secretary
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may enter into contracts for the purpose of performing
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administrative functions (including functions described in
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subsection (a)(4) of section 1874A of the Social Security
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Act) with respect to the public health insurance option in
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the same manner as the Secretary may enter into con-
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tracts under subsection (a)(1) of such section. The Sec-
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retary has the same authority with respect to the public
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health insurance option as the Secretary has under sub-
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sections (a)(1) and (b) of section 1874A of the Social Se-
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curity Act with respect to title XVIII of such Act. Con-
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tracts under this subsection shall not involve the transfer
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of insurance risk to such entity.
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(d) OMBUDSMAN.—The Secretary shall establish an
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office of the ombudsman for the public health insurance
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option which shall have duties with respect to the public
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health insurance option similar to the duties of the Medi-
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care Beneficiary Ombudsman under section 1808(c)(2) of
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the Social Security Act.
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(e) DATACOLLECTION.—The Secretary shall collect
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such data as may be required to establish premiums and
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payment rates for the public health insurance option and
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for other purposes under this subtitle, including to im-
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prove quality and to reduce racial, ethnic, and other dis-
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parities in health and health care. Nothing in this subtitle
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may be construed as authorizing the Secretary (or any em-
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ployee or contractor) to create or maintain lists of non-
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medical personal property.
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(f) TREATMENTOFPUBLICHEALTHINSURANCEOP-
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TION.—With respect to the public health insurance option,
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the Secretary shall be treated as a QHBP offering entity
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offering an Exchange-participating health benefits plan.
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(g) ACCESSTOFEDERALCOURTS.—The provisions
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of Medicare (and related provisions of title II of the Social
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Security Act) relating to access of Medicare beneficiaries
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to Federal courts for the enforcement of rights under
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Medicare, including with respect to amounts in con-
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troversy, shall apply to the public health insurance option
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and individuals enrolled under such option under this title
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in the same manner as such provisions apply to Medicare
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and Medicare beneficiaries.
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SEC. 322. PREMIUMS AND FINANCING.
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(a) ESTABLISHMENTOFPREMIUMS.—
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(1) INGENERAL.—The Secretary shall establish
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geographically adjusted premium rates for the public
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health insurance option—
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(A) in a manner that complies with the
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premium rules established by the Commissioner
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under section 213 for Exchange-participating
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health benefits plans; and
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(B) at a level sufficient to fully finance the
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costs of—
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(i) health benefits provided by the
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public health insurance option; and
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(ii) administrative costs related to op-
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erating the public health insurance option.
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(2) CONTINGENCY MARGIN.—In establishing
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premium rates under paragraph (1), the Secretary
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shall include an appropriate amount for a contin-
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gency margin (which shall be not less than 90 days
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of estimated claims). Before setting such appropriate
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amount for years starting with Y3, the Secretary
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shall solicit a recommendation on such amount from
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the American Academy of Actuaries.
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(b) ACCOUNT.—
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(1) ESTABLISHMENT.—There is established in
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the Treasury of the United States an Account for
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the receipts and disbursements attributable to the
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operation of the public health insurance option, in-
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cluding the start-up funding under paragraph (2).
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Section 1854(g) of the Social Security Act shall
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apply to receipts described in the previous sentence
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in the same manner as such section applies to pay-
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ments or premiums described in such section.
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(2) START-UPFUNDING.—
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(A) INGENERAL.—In order to provide for
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the establishment of the public health insurance
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option, there is hereby appropriated to the Sec-
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retary, out of any funds in the Treasury not
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otherwise appropriated, $2,000,000,000. In
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order to provide for initial claims reserves be-
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fore the collection of premiums, there are here-
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by appropriated to the Secretary, out of any
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funds in the Treasury not otherwise appro-
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priated, such sums as necessary to cover 90
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days worth of claims reserves based on pro-
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jected enrollment.
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(B) AMORTIZATION OF START-UP FUND-
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ING.—The Secretary shall provide for the re-
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payment of the startup funding provided under
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subparagraph (A) to the Treasury in an amor-
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tized manner over the 10-year period beginning
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with Y1.
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(C) LIMITATIONONFUNDING.—Nothing in
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this section shall be construed as authorizing
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any additional appropriations to the Account,
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other than such amounts as are otherwise pro-
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vided with respect to other Exchange-partici-
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pating health benefits plans.
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(3) NOBAILOUTS.—In no case shall the public
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health insurance option receive any Federal funds
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for purposes of insolvency in any manner similar to
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the manner in which entities receive Federal funding
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under the Troubled Assets Relief Program of the
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Secretary of the Treasury.
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SEC. 323. PAYMENT RATES FOR ITEMS AND SERVICES.
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(a) NEGOTIATIONOFPAYMENTRATES.—
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(1) IN GENERAL.—The Secretary shall nego-
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tiate payment for the public health insurance option
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for health care providers and items and services, in-
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cluding prescription drugs, consistent with this sec-
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tion and section 324.
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(2) MANNEROFNEGOTIATION.—The Secretary
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shall negotiate such rates in a manner that results
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in payment rates that are not lower, in the aggre-
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gate, than rates under title XVIII of the Social Se-
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curity Act, and not higher, in the aggregate, than
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the average rates paid by other QHBP offering enti-
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ties for services and health care providers.
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(3) INNOVATIVEPAYMENTMETHODS.—Nothing
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in this subsection shall be construed as preventing
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the use of innovative payment methods such as those
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described in section 324 in connection with the nego-
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tiation of payment rates under this subsection.
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(b) ESTABLISHMENTOFAPROVIDERNETWORK.—
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(1) INGENERAL.—Health care providers (in-
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cluding physicians and hospitals) participating in
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Medicare are participating providers in the public
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health insurance option unless they opt out in a
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process established by the Secretary consistent with
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this subsection.
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(2) REQUIREMENTS FOROPT-OUTPROCESS.—
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Under the process established under paragraph
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(1)—
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(A) providers described in such paragraph
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shall be provided at least a 1-year period prior
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to the first day of Y1 to opt out of participating
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in the public health insurance option;
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(B) no provider shall be subject to a pen-
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alty for not participating in the public health
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insurance option;
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(C) the Secretary shall include information
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on how providers participating in Medicare who
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chose to opt out of participating in the public
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health insurance option may opt back in; and
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(D) there shall be an annual enrollment
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period in which providers may decide whether
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to participate in the public health insurance op-
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tion.
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(3) RULEMAKING.—Not later than 18 months
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before the first day of Y1, the Secretary shall pro-
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mulgate rules (pursuant to notice and comment) for
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the process described in paragraph (1).
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(c) LIMITATIONSONREVIEW.—There shall be no ad-
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ministrative or judicial review of a payment rate or meth-
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odology established under this section or under section 20