The bill would provide a tax deduction and an income-related refundable tax credit for health insurance purchased by individuals (i.e., outside the group insurance market). The tax credit would be available only to individuals living in states operating a high-risk health insurance pool; and federal grant funding would be provided to states for such pools. Incentives would be given for employers to offer employees the option of a contribution toward other health insurance coverage in lieu of the employer plan. State insurance laws would be overridden to permit the sale of individual health insurance across state lines. Federal rules would be established and application of state laws preempted for insurance provided through association health plans and individual membership associations. Expansion of the State Children’s Health Insurance Program (CHIP) would be prohibited for those with incomes above 300% of the federal poverty level (FPL) and restricted for those between 200% and 300% of FPL. States would be required to offer group coverage and other private coverage options under Medicaid and CHIP. Federal limits on medical liability claims would be established. Medicare physician payment would be modified. The bill would be financed through reduced discretionary spending, repeal of stimulus bill provisions and other provisions.
Individual requirements (mandate)
No provision.
Employer requirements (mandate)
Employers would have to disclose on each employee’s W2 Form the employer’s contribution toward the employee’s health insurance benefit.
Employer health plans would be exempted from various existing federal requirements (but not those regarding pre-existing condition exclusions) if they offer employees the option of receiving a contribution toward other health insurance coverage in lieu of the employer plan. The Contribution would equal the employer’s share of premiums under the employer’s group coverage. The federal employees health benefits program would offer this option, and would also be required to equalize the employer contribution amount for each health plan offered to federal employees.
States could not impose restrictions on employee health plan autoenrollment under which employees are automatically enrolled the employer’s health plan with the lowest employee premium unless they choose otherwise. Notice and employee opt-out requirements are specified.
Public programs
States could not expand CHIP coverage to children in families with incomes above 300% of the federal poverty level (FPL), and could only expand CHIP between 200% and 300% of FPL once 90% of eligible children under 200% of FPL are enrolled in Medicaid or CHIP. Coverage in states with prior eligibility would be grandfathered. State application of income disregards in determining CHIP eligibility would be limited. All states would be required to indicate plans for achieving the 90% enrollment target.
States would have to provide a means for Medicaid and CHIP coverage of children under group health plans and would be given flexibility for covering enrollees through purchase of family coverage under group health plans. Such enrollment could not be made mandatory. No federal minimum benefit requirements or limits on beneficiary cost sharing would apply. States would be required to ensure coverage of well baby and well child care through supplemental benefits if not covered under the group plan.
States required to offer private plan coverage options under Medicaid and CHIP; cost sharing limitations would not apply to this coverage; states could supplement cost sharing.
Tax subsidies to individuals
A tax deduction would be provided for individual health insurance premiums, capped at the national average value of employer contributions for health insurance coverage (which are excluded from individual income taxes). Deduction would be “above the line” (i.e., allowed in computing adjusted gross income.)
An advanceable, refundable health insurance tax credit would be provided of up to $2,000 a year for an individual, $4,000 for a couple, plus $500 per dependent up to a maximum of 2 dependents. Credit amounts would be indexed to the consumer price index. The credit would be gradually reduced for those with incomes above 200% of the FPL, and is intended to be unavailable to those above 300% of FPL. The credit would not be available to individuals with subsidized employer group coverage. Also excluded would be those enrolled in Medicare, Medicaid, CHIP, or other federal health coverage, except that these individuals could elect the tax credit in lieu of these benefits.
Board-certified physicians could deduct from income taxes any bad debts related to provision of federally-required emergency care, up to Medicare rates.
Tax subsidies to small employers
A temporary (2 year) tax credit would be available to small employers (50 employees or fewer) of up to $1,500 for the costs of establishing employee health plan defined contribution options or an autoenrollment process.
Insurance reforms
State laws with respect to individual health insurance coverage would be preempted to permit sale of insurance across state lines. Insurers would identify a primary state, the insurance laws of which would apply; laws of secondary states in which coverage is sold related to the offer, sale, rating and renewal and issuance of coverage would be preempted. Secondary states could impose applicable premium taxes and require registry and, at times, require financial examination. Insurers could not reclassify individuals upon renewal, or increase premiums based on health status or claims experience; premium increases based on claims experience of a class of business, discounts for wellness activities, and retroactive rate adjustments for applicant misrepresentation would be permitted. Requirements would be imposed regarding disclosures and enrollee appeals. The primary state would have to use a risk-based capital formula for determining insurer capital and surplus requirements. The bill intends that after 2 years, individuals could only purchase insurance from another state if home-state premiums exceed the national average by 10 percent or more.
The Secretary would be required to contract with states to develop websites providing standardized information for consumers on health insurance plans available for purchase and price and quality information on health care providers.
Insurers would have to disclose to employers and other group health plan sponsors, upon request, specified information on the plan’s claims experience.
Benefits
No funds authorized in the bill could be used to cover any part of the costs of a health plan that covers abortion except in specified limited circumstances. Federal agencies and states would be prohibited from discriminating against health care entities that do not provide, pay for, or refer for abortions.
Group health plans could vary premiums and cost sharing for participation in a standards-based wellness program by up to 50% of the value of the plan benefits.
Pooling Mechanism: State High Risk Pools
$300 million would be appropriated annually for block grants to states operating high risk pools under current law or for new pools, which would have to offer at least one option that is a high deductible plan in combination with a health savings account. Funds could also be used for reinsurance pools or other risk adjustment mechanisms for high risk populations. Bonus payments would be available to states that act to guarantee availability of insurance to certain individuals, reduce premium trends, expand the pool, or adopt model legislation.
Individual Membership Associations
State benefit mandates and certain other state laws would be preempted with respect to health insurance sold through individual membership associations (IMAs), directed by an association that has existed for at least 5 years and formed for purposes other than offering insurance. IMAs could only offer coverage to members, would have to offer it to all members, and could not condition membership on health status. IMA coverage would have to be provided through licensed health insurers; IMAs could not assume insurance risk.
Association Health Plans
Rules and procedures would be established for federal certification of Association Health Plans (AHPs) offered to employers, and certified AHPs would be exempted from most state health insurance laws, including benefit mandates. AHPs would be certified by the Secretary of Labor (consulting with the AHPs primary domicile state).
An AHP sponsor could be a bona fide trade or industry association, chamber of commerce, or similar organization operating for purposes other than obtaining or providing medical care. Membership could not be conditioned on health status and members must pay dues. Certification requirements specified related to sponsors, participation and coverage, premiums, and marketing. Premiums charged to participating small employers could not vary on the basis of health status, business or industry, but could vary based on claims experience and other methods that would be permitted under state laws regulating bona fide associations. AHPs offering self-insured plans would have to meet additional requirements, primarily related to financial reserves and solvency. Trusteeship by the Secretary of Labor would be established for any certified plans that become insolvent.
States could only impose premium taxes on AHPs that begin operating in the state after enactment. Rate could not exceed that imposed on other insurers, and would be reduced by amounts imposed on any insurers in connection with the AHP.
Other provisions
Federal rules would be established for medical liability claims, including a limit on compensation for noneconomic damages of $250,000 and restrictions on claims for punitive damages. No punitive damages would be permitted for products approved by the Food and Drug Administration and providers would not liable for claims related to use of FDA-approved products. Conflicting state laws would be preempted, but not those providing for greater protections for providers and health care organizations.
No award of nonecomonic damages would be permitted for treatment within guidelines that the Secretary is directed to issue; the guidelines would be developed by a physician consensus building organization under a contract agreement and would have to be approved by physician specialty organizations. Funding would be authorized for demonstration grants to states for establishing administrative health care tribunals to resolve liability disputes.
Authorization of funding for medical student loans for primary care would be extended, and unspecified funding authorized for loans to medical students in residency programs other than primary care. A new loan forgiveness program would be created providing up to $50,000 for medical students who practice primary care for at least five years.
The sustainable growth rate formula for Medicare physician payment would be revised and House rules would be amended to apply procedures relating to the Medicare funding warning.
Data from federally-funded comparative effectiveness research could not be used to deny coverage under federal health care programs, and such research account would be required to account for specified factors contributing to differences in treatment response and treatment preferences of patients.
The Secretary would be required to propose to the Congress a formalized process for developing performance based quality measures for Medicare physician services. Measures would have to be agreed to by the Physician Consortium for Performance Improvement and by each physician specialty organization.
Financing
Discretionary spending would be reduced; unused discretionary funds appropriated in the American Recovery and Reinvestment Act of 2009 would be rescinded and numerous provisions of that Act would be repealed, including increased Medicaid funding, premium assistance for COBRA benefits, and Medicare and Medicaid health information technology funding. Medicare and Medicaid disproportionate share hospital funding would be reduced if bill results in a decrease in the rate of uninsured of more than 8 percentage points). The bill also includes anti-fraud and abuse provisions.