Healthreform Sbs Full

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Health Reform

This side-by-side compares the leading comprehensive reform proposals across a number of key characteristics and plan components. Included in this side-by-
side are proposals for moving toward universal coverage that have been put forward by the President and Members of Congress. In an effort to capture the most
important proposals, we have included those that have been formally introduced as legislation as well as those that have been offered as principles or in White
Paper form. This side-by-side will be regularly updated to reflect changes in the proposals and to incorporate major new proposals as they are announced.
The House Tri-Committee summary incorporates the major amendments to the legislation adopted by the three committees of jurisdiction during their mark-ups
of the bill. These amendments are identified using an abbreviation for the House panel that approved it — “E&C” for the Committee on Energy and Commerce;
“E&L” for the Committee on Education and Labor; and “W&M” for the Committee on Ways and Means.

House Tri-Committee
America’s Affordable Health
Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama
Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform

Date plan announced April – May 2009 June 9, 2009 June 19, 2009 February 26, 2009
Overall approach The Senate Finance Committee Require individuals to have health Require all individuals to have President Obama outlined eight
to expanding access released a series of papers laying insurance. Create state-based health insurance. Create a Health principles for health care reform
to coverage out options for health reform. While American Health Benefit Gateways Insurance Exchange through which in his FY 2010 Budget overview.
not a formal proposal, these papers through which individuals and small individuals and smaller employers The President has indicated that
offer a framework for achieving businesses can purchase health can purchase health coverage, with comprehensive health reform should:
health reform goals and present the coverage, with subsidies available to premium and cost-sharing credits • Reduce long-term growth of
range of options the Committee will individuals/families with incomes up available to individuals/families health care costs for businesses
consider as it works to draft health to 400% of the federal poverty level with incomes up to 400% of the and government.
reform legislation. (or $73,240 for a family of three in federal poverty level (or $73,240 for
• Protect families from bankruptcy or
Require all individuals to have 2009). Require employers to provide a family of three in 2009). Require
debt because of health care costs.
health insurance. Create a Health coverage to their employees or employers to provide coverage to
• Guarantee choice of doctors and
Insurance Exchange through which pay an annual fee, with exceptions employees or pay into a Health
health plans.
individuals and small businesses for small employers, and provide Insurance Exchange Trust Fund,
certain small employers a credit with exceptions for certain small • Invest in prevention and wellness.
can purchase health coverage, with
to offset the costs of providing employers, and provide certain • Improve patient safety and quality
subsidies available to individuals/
coverage. Impose new regulations small employers a credit to offset care.
families with incomes between 100
and 400% of the federal poverty on the individual and small group the costs of providing coverage. • Assure affordable, quality health
level. Impose new regulations on insurance markets. Expand Impose new regulations on plans coverage for all Americans.
the non-group and small group Medicaid to all individuals with participating in the Exchange and in • Maintain coverage when you
insurance markets. Expand incomes up to 150% of the federal the small group insurance market. change or lose your job.
Medicaid and CHIP and offer a poverty level. Expand Medicaid to 133% of the • End barriers to coverage for
temporary Medicare buy-in for the poverty level. people with pre-existing medical
pre-Medicare population. conditions.

Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009

House Tri-Committee

Individual mandate • Require all individuals to have • Require individuals to have • Require all individuals to have • The plan must put the country
insurance that meets minimum qualifying health coverage. “acceptable health coverage”. on a clear path to cover all
coverage standards. Enforced Enforced through a minimum Those without coverage pay Americans.
through an excise tax equal to a tax penalty of no more than a penalty of 2.5% of modified
percentage of the premium for $750 per year. Exemptions to the adjusted gross income up to
the lowest cost option available individual mandate will be granted the cost of the average national
through the Health Insurance to residents of states that do not premium for self-only or
Exchange in the area where the establish an American Health family coverage under a basic
individual resides. Exemptions will Benefit Gateway, members of plan in the Health Insurance
be granted for financial hardship; Indian tribes, those for whom Exchange. Exceptions granted for
if the lowest cost plan option affordable coverage is not dependents, religious objections,
exceeds 10% of an individual’s available, and those without and financial hardship.
income; and if the individual has coverage for fewer than 90 days.
income below 100% of the poverty
level.
Employer requirements • Proposed Option A: Require • Require employers to offer health • Require employers to offer Not specified.
employers with more than coverage to their employees and coverage to their employees and
$500,000 in total payroll per contribute at least 60% of the contribute at least 72.5% of the
year to offer coverage to their premium cost or pay $750 for premium cost for single coverage
employees and contribute at each uninsured full-time and 65% of the premium cost for
least 50% of the premium or pay employee and $375 for each family coverage of the lowest cost
an assessment. The employer uninsured part-time employee plan that meets the essential
assessment could be structured who is not offered coverage. For benefits package requirements or
in several ways: 1) a set fee per employers subject to the pay 8% of payroll into the Health
enrollee per month based on total assessment, the first 25 workers Insurance Exchange Trust Fund.
annual payroll; 2) a tiered penalty are exempted. [EL Committee amendment:
calculated as a percentage of • Exempt employers with 25 or Provide hardship exemptions
payroll; or 3) a larger penalty only fewer employees from the for employers that would be
on firms with annual payroll of requirement to provide coverage. negatively affected by job losses
more than $1,500,000. as a result of requirement.]
• Proposed Option B: No employer
“pay or play” requirement.

Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009 2

House Tri-Committee

Employer requirements • Eliminate or reduce the pay
(continued) or play assessment for small
employers with annual payroll of
less than $400,000:
– Annual payroll less than
$250,000: exempt
– Annual payroll between
$250,000 and $300,000: 2% of
payroll;
$300,000 and $350,000: 4% of
payroll;
$350,000 and $400,000: 6% of
payroll.
[EC Committee amendment:
Extend the reduction in the pay
or play assessment for small
employers with annual payroll of
less than $750,000 and replace
the above schedule with the
following:
– Annual payroll less than
$500,000: exempt
$500,000 and $585,000: 2% of
payroll;
$585,000 and $670,000: 4% of
payroll;
$670,000 and $750,000: 6% of
payroll.]
• Require employers that offer
coverage to automatically enroll
into the employer’s lowest cost
premium plan any individual who
does not elect coverage under the
employer plan or does not opt out
of such coverage.


House Tri-Committee

Expansion of public Medicaid • Expand Medicaid to all individuals • Expand Medicaid to all individuals • As a foundation for health
programs • Expand Medicaid to all individuals (children, pregnant women, (children, pregnant women, reform, the President signed
with incomes up to 115% FPL, parents, and adults without parents, and adults without the Children’s Health Insurance
with a possible increase in dependent children) with incomes dependent children) with incomes Program Reauthorization
eligibility for parents, pregnant up to 150% FPL. Individuals up to 133% FPL. Newly eligible, Act (CHIPRA), which provides
women, and children to a eligible for Medicaid will be non-traditional (childless adults) coverage to 11 million children.
higher level. Coverage could be covered through state Medicaid Medicaid beneficiaries may
provided through the current programs and will not be eligible enroll in coverage through the
program structure or by enrolling for credits to purchase coverage Exchange if they were enrolled
children, pregnant women, through American Health Benefit in qualified health coverage
parents, and childless adults in Gateways. during the six months before
the Health Insurance Exchange. • Grant individuals eligible for becoming Medicaid eligible.
Another alternative is to enroll the Children’s Health Insurance Provide Medicaid coverage for all
all populations except childless Program (CHIP) the option of newborns who lack acceptable
adults in Medicaid. Under this enrolling in CHIP or enrolling in coverage and provide optional
approach, childless adults would a qualified health plan through a Medicaid coverage to low-income
not be eligible for Medicaid but Gateway. HIV-infected individuals and for
would be given tax credits to family planning services to certain
purchase coverage through the low-income women. In addition,
Exchange or to buy-in to Medicaid. increase Medicaid payment
Children’s Health Insurance rates for primary care providers
Program to 100% of Medicare rates.
• After September 30, 2013, expand [EC Committee amendment:
CHIP eligibility to 275% FPL. Once Require states to submit a state
the Health Insurance Exchange is plan amendment specifying the
fully operational, CHIP enrollees payment rates to be paid under
would obtain coverage through the state’s Medicaid program.]
the Exchange and states would The coverage expansions (except
be required to continue to provide the optional expansions) and the
services not covered by plans in enhanced provider payments
the Exchange, including Early and will be fully financed with
Periodic Screening, Diagnosis, federal funds. [EC Committee
and Treatment (EPSDT) services. amendment: Replace full federal
financing for Medicaid coverage
Medicare expansions with 100% federal
• Until the Health Insurance financing through 2014 and 90%
Exchange is underway, allow federal financing beginning in year
individuals aged 55-64 without 2015.]
coverage to buy-in to Medicare at
full-cost.
• Phase-out or reduce the two-
year waiting period for Medicare
eligibility for people with
disabilities.


House Tri-Committee

Expansion of public Public Health Insurance Option • Require Children’s Health
programs (continued) • Proposed Option A: Create a new Insurance Program (CHIP)
public plan to be offered through enrollees to obtain coverage
the Exchange that will be subject through the Health Insurance
to the same rating and risk Exchange (in the first year the
adjustment rules as the private Exchange is available) provided
plans. The public plan could the Health Choices Commissioner
be administered by the federal determines that the Exchange
government, by multiple third- has the capacity to cover these
party administrators, or by the children and that procedures
states. are in place to ensure the timely
• Proposed Option B: Do not create transition of CHIP enrollees
a public plan option. into the Exchange without an
interruption of coverage.
Premium subsidies • Provide refundable tax credits • Provide premium credits on a • Provide affordability premium • The plan must protect families’
to individuals to individuals and families with sliding scale basis to individuals credits to eligible individuals from bankruptcy or debt because
incomes between 100 and 400% and families with incomes up to and families with incomes up to of health care costs.
FPL to purchase insurance 400% FPL to purchase coverage 400% FPL to purchase insurance • The American Recovery and
through the Health Insurance through the Gateway. The through the Health Insurance Reinvestment Act makes coverage
Exchange. The level of the premium credits will be based Exchange. The premium credits more affordable for Americans
premium tax credit could be set on the average cost of the three will be based on the average cost who lose their jobs and their
as a percentage of income or as a lowest cost qualified health plans of the three lowest cost basic access to employer-based health
percentage of the premium, with in the area, but will be such that health plans in the area and will coverage by offering a subsidy of
additional limits on cost-sharing. individuals with incomes less be set on a sliding scale such 65 percent of the premium costs
than 400% FPL pay no more than that the premium contributions for COBRA coverage.
12.5% of income and individuals are limited to the following
with incomes less than 150% FPL percentages of income for
pay 1% of income, with additional specified income tiers:
limits on cost-sharing. 133-150% FPL: 1.5 - 3% of income
• Limit availability of premium 150-200% FPL: 3 - 5% of income
credits through the Gateway to 200-250% FPL: 5 - 7% of income
individuals who are not eligible 250-300% FPL: 7 - 9% of income
for employer-based coverage that
300-350% FPL: 9 - 10% of income
meets minimum qualifying criteria
and affordability standards, 350-400% FPL: 10 - 11% of income
Medicare, Medicaid, TRICARE,
or the Federal Employee Health
Benefits Program. Individuals
with access to employer-based
coverage are eligible for the
premium credits if the cost of the
employee premium exceeds 12.5%
of the individuals’ income.


House Tri-Committee

Premium subsidies [EC Committee amendment:
to individuals (continued) Replaces the above subsidy
schedule with the following:
133-150% FPL: 1.5 - 3% of income
150-200% FPL: 3 – 5.5% of income
200-250% FPL: 5.5 - 8% of income
250-300% FPL: 8 - 10% of income
300-350% FPL: 10 - 11% of income
350-400% FPL: 11 - 12% of income]
Increase the affordability credits
annually by the estimated savings
achieved through adopting a
formulary in the public health
insurance option, pharmacy
benefit manager transparency
requirements, developing
accountable care organization
pilot programs in Medicaid, and
administrative simplification.]
Increase the affordability credits
annually by the estimated
savings achieved through limiting
increases in premiums for plans
in the Exchange to no more than
150% of the annual increase in
medical inflation and by requiring
the Secretary to negotiate
directly with prescription drug
manufacturers to lower the prices
for Medicare Part D plans.]


House Tri-Committee

Premium subsidies • Provide affordability cost-sharing
to individuals (continued) credits to eligible individuals and
families with incomes up to 400%
FPL. The cost-sharing credits
reduce the cost-sharing amounts
and annual cost-sharing limits
and have the effect of increasing
the actuarial value of the basic
benefit plan to the following
percentages of the full value of the
plan for the specified income tier:
133-150% FPL: 97%
150-200% FPL: 93%
200-250% FPL: 85%
250-300% FPL: 78%
300-350% FPL: 72%
350-400% FPL: 70%
• Limit availability of premium and
cost-sharing credits to US citizens
and lawfully residing immigrants
who meet the income limits
and are not enrolled in qualified
or grandfathered employer or
individual coverage, Medicare,
Medicaid (except those eligible
to enroll in the Exchange),
TRICARE, or VA coverage (with
some exceptions). Individuals
with access to employer-based
coverage are eligible for the
premium and cost-sharing
credits if the cost of the employee
premium exceeds 11% of
the individuals’ income [EC
Committee amendment: To be
eligible for the premium and cost-
sharing credits, the cost of the
employee premium must exceed
12% of individuals’ income.].


House Tri-Committee

Premium subsidies • Provide certain small employers • Provide qualifying small • Provide small employers with Not specified.
to employers that purchase insurance for their employers with a health options fewer than 25 employees and
employees with a tax credit. The program credit. To qualify for the average wages of less than
full credit of 50% of the average credit, employers must have fewer $40,000 with a health coverage
total premium cost paid by the than 50 full-time employees, pay tax credit. The full credit of 50% of
employer would be available an average wage of less than premium costs paid by employers
to employers with 10 or fewer $50,000, and must pay at least is available to employers with 10
employees and whose employees 60% of employee health expenses. or fewer employees and average
have average annual wages of less The credit is equal to $1,000 annual wages of $20,000 or less.
than $20,000. The tax credit would for each employee with single The credit phases-out as firm size
be phased out as firm size and coverage and $2,000 for each and average wage increases and
earnings increase. The tax credit employee with family coverage, is not permitted for employees
would not be payable in advance adjusted for firm size (phasing earning more than $80,000 per
or refundable. out as firm size increases) and year.
number of months of coverage • Create a temporary reinsurance
provided. Bonus payments are program for employers providing
given for each additional 10% health insurance coverage to
of employee health expenses retirees ages 55 to 64. Program
above 60% paid by the employer. will reimburse employers for 80%
Employers may not receive of retiree claims between $15,000
the credit for more than three and $90,000. Payments from the
consecutive years. Self-employed reinsurance program will be used
individuals who do not receive to lower the costs for enrollees in
premium credits for purchasing the employer plan. Appropriate
coverage through the Gateway are $10 billion over ten years for the
eligible for the credit. reinsurance program.
• Create a temporary reinsurance
program for employers providing
health insurance coverage to
retirees ages 55 to 64. Program
will reimburse employers for
80% of retiree claims between
$15,000 and $90,000. Program
will end when the state Gateway
is established. Payments from the
reinsurance program will be used
to lower the costs for enrollees in
the employer plan.


House Tri-Committee

Tax changes related • Considers several health • Impose a minimum tax on • Impose a tax on individuals Not specified.
to health insurance insurance-related tax changes individuals without qualifying without acceptable health care
affecting the tax preference for health care coverage of no more coverage of 2.5% of modified
employer-sponsored insurance, than $750 per year. adjusted gross income.
health savings accounts,
flexible spending accounts, and
deductions for medical expenses.
Creation of insurance • Create one national or multiple • Create state-based American • Create a National Health Insurance • The plan should provide portability
pooling mechanisms regional Health Insurance Health Benefit Gateways, Exchange, through which individuals of coverage and should offer
Exchanges through which administered by a governmental and employers (phasing-in eligibility Americans a choice of health
individuals and small employers agency or non-profit organization, for employers starting with smallest plans.
can purchase qualified insurance. through which individuals and employers) can purchase qualified
• Require all state-licensed insurers small employers can purchase insurance, including from private
in the non-group and small group qualified coverage. States may health plans and the public health
markets to participate in the form regional Gateways or allow insurance option.
Health Insurance Exchange(s). more than one Gateway to operate • Restrict access to coverage
• Require guarantee issue and in a state as long as each Gateway through the Exchange to
renewability and allow rating serves a distinct geographic area. individuals who are not enrolled
variation based only on age, • Restrict access to coverage in qualified or grandfathered
tobacco use, family composition, through the Gateways to employer or individual coverage,
and geography (not health status) individuals who are not Medicare, Medicaid (with some
in the Exchange(s). incarcerated and who are not exceptions), TRICARE, or VA
• Require the Exchange(s) to eligible for employer-sponsored coverage (with some exceptions).
develop a standardized format coverage that meets minimum [EC Committee amendment:
for presenting insurance qualifying criteria and affordability Permit members of the armed
options, create a web portal to standards, Medicare, Medicaid, forces and those with coverage
help consumers find insurance, TRICARE, or the Federal Employee through TRICARE or the VA to
maintain a call center for Health Benefits Program. enroll in a health benefits plan
customer service, and establish offered through the Exchange.]
procedures for enrolling • Create a new public health
individuals and businesses and insurance option to be offered
for determining eligibility for tax through the Health Insurance
credits. Exchange that must meet the same
requirements as private plans
regarding benefit levels, provider
networks, consumer protections,
and cost-sharing. Require the
public plan to offer basic, enhanced,
and premium plans, and permit it to
offer premium plus plans. Finance
the costs of the public plan through
revenues from premiums.


House Tri-Committee

Creation of insurance • Create a community health For the first three years, set
pooling mechanisms insurance option to be offered provider payment rates in the
(continued) through state Gateways that public plan at Medicare rates
complies with the requirements and allow bonus payments of
of being a qualified health plan. 5% for providers that participate
Require that the costs of the in both Medicare and the public
community health insurance plan plan and for pediatricians
be financed through revenues and other providers that don’t
from premiums, require the typically participate in Medicare.
plan to negotiate payment rates In subsequent years, permit the
with providers, and contract Secretary to establish a process
with qualified nonprofit entities for setting rates. [EC Committee
to administer the plan. Permit amendment: Require the public
the plan to develop innovative health insurance option to
payment policies to promote negotiate rates with providers so
quality, efficiency, and savings to that the rates are not lower than
consumers. Require each State to Medicare rates and not higher
establish a State Advisory Council than the average rates paid by
to provide recommendations on other qualified health benefit
policies and procedures for the plan offering entities.] Health
community health insurance care providers participating
option. in Medicare are considered
• Create three benefit tiers of participating providers in the
plans to be offered through the public plan unless they opt out.
Gateways based on the percentage Permit the public plan to develop
of allowed benefit costs covered by innovative payment mechanisms,
the plan: including medical home and other
– Tier 1: includes the essential care management payments,
health benefits and covers 76% value-based purchasing, bundling
of the benefit costs of the plan; of services, differential payment
– Tier 2: includes the essential rates, performance based
health benefits and covers 84% payments, or partial capitation
of the benefit costs of the plan; and modify cost sharing and
payment rates to encourage use
– Tier 3: includes the essential
of high-value services. [EC
health benefits and covers 93%
Committee amendment: Clarify
of the benefit costs of the plan.
that the public health insurance
option must meet the same
requirements as other plans
relating to guarantee issue and
renewability, insurance rating
rules, network adequacy, and
transparency of information.]


House Tri-Committee

Creation of insurance • Require guarantee issue and [EC Committee amendment:
pooling mechanisms renewability of health insurance Require the public health
(continued) policies in the individual and small insurance option to adopt a
group markets; prohibit pre- prescription drug formulary.]
existing condition exclusions; and • Create four benefit categories of
allow rating variation based only plans to be offered through the
on family structure, geography, Exchange:
the actuarial value of the health – Basic plan includes essential
plan benefit, tobacco use, and age benefits package and covers
(with only 2 to 1 variation). 70% of the benefit costs of the
• Require plans participating in plan;
the Gateway to provide coverage – Enhanced plan includes
for at least the essential health essential benefits package,
care benefits, meet network reduced cost sharing compared
adequacy requirements, and to the basic plan, and covers
make information regarding plan 85% of benefit costs of the plan;
benefits service area, premium – Premium plan includes essential
and cost sharing, and grievance benefits package with reduced
and appeal procedures available cost sharing compared to the
to consumers. enhanced plan and covers 95%
• Require states to adjust payments of the benefit costs of the plan;
to health plans based on the – Premium plus plan is a premium
actuarial risk of plan enrollees plan that provides additional
using methods established by the benefits, such as oral health and
Secretary. vision care.
• Require the Gateway to certify • Require guarantee issue and
participating health plans, provide renewability; allow rating variation
consumers with information based only on age (limited to 2 to
allowing them to choose among 1 ratio), premium rating area, and
plans (including through a family enrollment; and limit the
centralized website), contract with medical loss ratio to a specified
navigators to conduct outreach percentage.
and enrollment assistance, create
a single point of entry for enrolling
in coverage through the Gateway
or through Medicaid, CHIP or
other federal programs, and assist
consumers with the purchase
of long-term care services and
supports.


House Tri-Committee

Creation of insurance • Following initial federal support, • Require plans participating
pooling mechanisms the Gateway will be funded by in the Exchange to be state
(continued) a surcharge of no more than licensed, report data as required,
4% of premiums collected by implement affordability credits,
participating health plans. meet network adequacy
standards, provide culturally and
linguistically appropriate services,
contract with essential community
providers, and participate in risk
pooling. Require participating
plans to offer one basic plan for
each service area and permit
them to offer additional plans.
Require plans to provide
information related to end-of-life
planning to individuals and provide
the option to establish advance
directives and physician’s order
for life sustaining treatment.]
• Require risk adjustment of
participating Exchange plans.
• Provide information to consumers
to enable them to choose among
plans in the Exchange, including
establishing a telephone hotline
and maintaining a website and
provide information on open
enrollment periods and how to
enroll.
• [EC Committee amendment:
Prohibit plans participating in the
Exchange from discriminating
against any provider because of
a willingness or unwillingness to
provide abortions.] .
• [EC Committee amendment:
Facilitate the establishment of
non-for-profit, member-run
health insurance cooperatives
to provide insurance through the
Exchange.]


House Tri-Committee

Creation of insurance • Allow states to operate state-
pooling mechanisms based exchanges if they
(continued) demonstrate the capacity to
meet the requirements for
administering the Exchange.
Benefit design • Create four benefit categories • Create the essential health care • Create an essential benefits Not specified.
(lowest, low, medium, and high). benefits package that provides a package that provides a
Require all plans to provide a comprehensive array of services comprehensive set of services,
comprehensive set of services and and prohibits inclusion of lifetime covers 70% of the actuarial value
prohibit inclusion of lifetime limits or annual limits on the dollar of the covered benefits, limits
on coverage or annual limits on value of the benefits. The essential annual cost-sharing to $5,000/
benefits. health benefits must be included individual and $10,000/family,
• All policies (except certain in all qualified health plans and and does not impose annual or
grandfathered employer- must be equal to the scope of lifetime limits on coverage. The
sponsored plans) must comply benefits provided by a typical Health Benefits Advisory Council,
with one of the four benefit employer plan. Create a chaired by the Surgeon General,
categories, including those offered temporary, independent will make recommendations on
through the Exchange and those commission to advise the specific services to be covered by
offered outside of the Exchange. Secretary in the development of the essential benefits package as
the essential health benefit well as cost-sharing levels. [EL
package. Committee amendment: Require
• Specify the criteria for minimum early and periodic screening,
qualifying coverage for purposes diagnostic, and treatment
of meeting the individual mandate (EPSDT) services for children
for coverage, and an affordability under age 21 be included in the
standard such that coverage is essential benefits package.] [EC
deemed unaffordable if the Committee amendment: Prohibit
premium exceeds 12.5% of an abortion coverage from being
individual’s adjusted gross income. required as part of the essential
benefits package; require
segregation of public subsidy
funds from private premiums
payments for plans that choose
to cover abortion services beyond
Hyde—which allows coverage for
abortion services to save the life
of the woman and in cases of rape
or incest; and require there be no
effect on state or federal laws on
abortions.]


House Tri-Committee

Benefit design • All qualified health benefits plans,
(continued) including those offered through
the Exchange and those offered
outside of the Exchange (except
certain grandfathered individual
and employer-sponsored plans)
must provide at least the essential
benefits package.
Changes to private • Require guarantee issue and • Impose the same insurance • Prohibit coverage purchased • The plan must end barriers to
insurance renewability and allow rating market regulations relating through the individual market coverage for people with pre-
variation based only on age, to guarantee issue, premium from qualifying as acceptable existing medical conditions.
tobacco use, family composition, rating, and prohibitions on pre- coverage for purposes of the
and geography (not health status) existing condition exclusions in individual mandate unless it
in the non-group, micro-group the individual and small group is grandfathered coverage.
(2-10 employees), and small group markets and in the American Individuals can purchase a
markets. Require risk adjustment Health Benefit Gateways (see qualifying health benefit plan
in all markets. creation of insurance pooling through the Health Insurance
• Require all state-licensed insurers mechanism). Exchange.
in the non-group and small group • Require health insurers to report • Impose the same insurance
markets to participate in the their medical loss ratio. market regulations relating to
Health Insurance Exchange. • Require health insurers to provide guarantee issue, premium rating,
• Require all insurers to issue financial incentives to providers and prohibitions on pre-existing
policies in each of the four new to better coordinate care through condition exclusions in the insured
benefit categories. case management and chronic group market and in the Exchange
• Allow states the option of merging disease management, promote (see creation of insurance pooling
the non-group and small group wellness and health improvement mechanism).
markets. activities, improve patient safety, • Limit health plans’ medical loss
and reduce medical errors. ratio to a percentage specified
• Provide dependent coverage by the Secretary to be enforced
for children up to age 26 for all through a rebate back to
individual and group policies. consumers.
• Require insurers and group plans • Improve consumer protections by
to notify enrollees if coverage does establishing uniform marketing
not meet minimum qualifying standards, requiring fair grievance
coverage standards for purposes and appeals mechanisms,
of satisfying the individual and prohibiting insurers from
mandate for coverage. rescinding health insurance
• Permit licensed health insurers coverage except in cases of fraud.
to sell health insurance policies • Adopt standards for financial
outside of the Gateway. States and administrative transactions
will regulate these outside-the- to promote administrative
Gateway plans. simplification.


House Tri-Committee

Changes to private • Create the Health Choices
insurance (continued) Administration to establish
the qualifying health benefits
standards, establish the
Exchange, administer the
affordability credits, and
enforce the requirements for
qualified health benefit plan
offering entities, including those
participating in the Exchange or
outside the Exchange.
State role • Allow states the option of merging • Establish American Health • Require states to enroll newly Not specified.
the non-group and small group Benefit Gateways meeting eligible Medicaid beneficiaries
insurance markets. federal standards and adopt into the state Medicaid
• Require state insurance individual and small group market programs and to implement the
commissioners to provide regulation changes. specified changes with respect
oversight of health plans with • Implement Medicaid eligibility to provider payment rates,
regard to consumer protections, expansions and adopt federal benefit enhancements, quality
rate reviews, solvency, reserve standards and protocols for improvement, and program
fund requirements, and premium facilitating enrollment of integrity.
taxes and to define rating areas. individuals in federal and state • Require states to maintain
health and human services Medicaid and CHIP eligibility
programs. standards, methodologies, or
• Create temporary “RightChoices” procedures that were in place as
programs to provide uninsured of June 16, 2009 as a condition of
individuals with immediate access receiving federal Medicaid or CHIP
to preventive care and treatment matching payments.
for identified chronic conditions. • Require states to enter into a
States will receive federal grants Memorandum of Understanding
to finance these programs. with the Health Insurance
Exchange to coordinate
enrollment of individuals in
Exchange-participating health
plans and under the state’s
Medicaid program.
• May require states to determine
eligibility for affordability credits
through the Health Insurance
Exchange.


House Tri-Committee

Cost containment • Encourage adoption and use of • Establish a Health Care Program • Simplify health insurance • The plan should reduce high
health information technology Integrity Coordinating Council administration by adopting administrative costs, unnecessary
by expanding eligibility for and two new federal department standards for financial and tests and services, waste, and
the Medicare HIT incentives positions to oversee policy, administrative transactions, other inefficiencies that consume
in the American Recovery and program development, and including timely and transparent money with no added benefit.
Reinvestment Act to include oversight of health care fraud, claims and denial management
additional providers. waste, and abuse in public and processes and use of standard
• Eliminate fraud, waste, and abuse private coverage. electronic transactions.
in public programs through more • Simplify health insurance • [EC Committee amendment:
intensive screening of providers, administration by adopting Limit annual increases in the
the development of the “One PI standards for financial and premiums charged under any
database” to capture and share administrative transactions, health plans participating in the
data across federal and state including timely and transparent Exchange to no more than 150%
programs, increased penalties claims and denial management of the annual percentage increase
for submitting false claims and processes and use of standard in medical inflation. Provide
violating EMTALA, and increase electronic transactions. exceptions if this limit would
funding for anti-fraud activities. threaten a health plan’s financial
• Restructure payments to Medicare viability.]
Advantage plans to promote • Modify provider payments under
efficiency and quality. Medicare including:
• Require drug or device – Modify market basket updates
manufacturers to disclose to account for productivity
payments and incentives given improvements for inpatient
to providers and any investment hospital, home health, skilled
interest held by a physician. nursing facility, and other
• Improve transparency of Medicare providers; and
information about skilled nursing – Reduce payments for
facilities. potentially preventable hospital
• Allow providers organized as readmissions.
accountable care organizations • Restructure payments to Medicare
that voluntarily meet quality Advantage plans, phasing to 100%
thresholds to share in the cost- of fee-for-services payments, with
savings they achieve for the bonus payments for quality.
Medicare program. • Increase the Medicaid drug
rebate percentage and extend
the prescription drug rebate to
Medicaid managed care plans.
Require drug manufacturers to
provide drug rebates for dual
eligibles enrolled in Part D plans.


House Tri-Committee

Cost containment • [EC Committee amendment:
(continued) Require the Secretary to negotiate
directly with pharmaceutical
manufacturers to lower drug
prices for Medicare Part D plans
and Medicare Advantage Part D
plans.]
• Reduce Medicaid DSH payments
by $6 billion in 2019, imposing the
largest percentage reductions in
state DSH allotments in states
with the lowest uninsured rates
and those that do not target DSH
payments.
• Require hospitals and ambulatory
surgical centers to report on
health care-associated infections
to the Centers for Disease Control
and Prevention and refuse
Medicaid payments for certain
health care-associated conditions.
• Reduce waste, fraud, and abuse
in public programs by allowing
provider screening, enhanced
oversight periods, and enrollment
moratoria in areas identified as
being at elevated risk of fraud
in all public programs, and by
requiring Medicare and Medicaid
program providers and suppliers
to establish compliance programs.


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