111TH CONGRESS
1ST SESSION
H. R. ll
To provide affordable, quality health care for all Americans and reduce
the growth in health care spending, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
Mr. DINGELL (for himself, Mr. RANGEL, Mr. WAXMAN, Mr. GEORGE MILLER
of California, Mr. STARK, Mr. PALLONE, and Mr. ANDREWS) introduced
the following bill; which was referred to the Committee on
lllllllllllllll
A BILL
To provide affordable, quality health care for all Americans
and reduce the growth in health care spending, and
for other purposes.
1 Be it enacted by the Senate and House of Representa-
2 tives of the United States of America in Congress assembled,
3 SECTION 1. SHORT TITLE; TABLE OF DIVISIONS, TITLES,
4 AND SUBTITLES.
5 (a) SHORT TITLE.—This Act may be cited as the
6 ‘‘America’s Affordable Health Choices Act of 2009’’.
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1 (b) TABLE OF DIVISIONS, TITLES, AND SUB-
2 TITLES.—This Act is divided into divisions, titles, and
3 subtitles as follows:
DIVISION A—AFFORDABLE HEALTH CARE CHOICES
TITLE I—PROTECTIONS AND STANDARDS FOR QUALIFIED
HEALTH BENEFITS PLANS
Subtitle A—General Standards
Subtitle B—Standards Guaranteeing Access to Affordable Coverage
Subtitle C—Standards Guaranteeing Access to Essential Benefits
Subtitle D—Additional Consumer Protections
Subtitle E—Governance
Subtitle F—Relation to Other Requirements; Miscellaneous
Subtitle G—Early Investments
TITLE II—HEALTH INSURANCE EXCHANGE AND RELATED
PROVISIONS
Subtitle A—Health Insurance Exchange
Subtitle B—Public Health Insurance Option
Subtitle C—Individual Affordability Credits
TITLE III—SHARED RESPONSIBILITY
Subtitle A—Individual Responsibility
Subtitle B—Employer Responsibility
TITLE IV—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986
Subtitle A—Shared Responsibility
Subtitle B—Credit for Small Business Employee Health Coverage Expenses
Subtitle C—Disclosures to Carry Out Health Insurance Exchange Subsidies
Subtitle D—Other Revenue Provisions
DIVISION B—MEDICARE AND MEDICAID IMPROVEMENTS
TITLE I—IMPROVING HEALTH CARE VALUE
Subtitle A—Provisions Related to Medicare Part A
Subtitle B—Provisions Related to Part B
Subtitle C—Provisions Related to Medicare Parts A and B
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Subtitle D—Medicare Advantage Reforms
Subtitle E—Improvements to Medicare Part D
Subtitle F—Medicare Rural Access Protections
TITLE II—MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A—Improving and Simplifying Financial Assistance for Low Income
Medicare Beneficiaries
Subtitle B—Reducing Health Disparities
Subtitle C—Miscellaneous Improvements
TITLE III—PROMOTING PRIMARY CARE, MENTAL HEALTH
SERVICES, AND COORDINATED CARE
TITLE IV—QUALITY
Subtitle A—Comparative Effectiveness Research
Subtitle B—Nursing Home Transparency
Subtitle C—Quality Measurements
Subtitle D—Physician Payments Sunshine Provision
Subtitle E—Public Reporting on Health Care-Associated Infections
TITLE V—MEDICARE GRADUATE MEDICAL EDUCATION
TITLE VI—PROGRAM INTEGRITY
Subtitle A—Increased Funding to Fight Waste, Fraud, and Abuse
Subtitle B—Enhanced Penalties for Fraud and Abuse
Subtitle C—Enhanced Program and Provider Protections
Subtitle D—Access to Information Needed to Prevent Fraud, Waste, and
Abuse
TITLE VII—MEDICAID AND CHIP
Subtitle A—Medicaid and Health Reform
Subtitle B—Prevention
Subtitle C—Access
Subtitle D—Coverage
Subtitle E—Financing
Subtitle F—Waste, Fraud, and Abuse
Subtitle G—Puerto Rico and the Territories
Subtitle H—Miscellaneous

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TITLE VIII—REVENUE-RELATED PROVISIONS
TITLE IX—MISCELLANEOUS PROVISIONS
DIVISION C—PUBLIC HEALTH AND WORKFORCE DEVELOPMENT
TITLE I—COMMUNITY HEALTH CENTERS
TITLE II—WORKFORCE
Subtitle A—Primary Care Workforce
Subtitle B—Nursing Workforce
Subtitle C—Public Health Workforce
Subtitle D—Adapting Workforce to Evolving Health System Needs
TITLE III—PREVENTION AND WELLNESS
TITLE IV—QUALITY AND SURVEILLANCE
TITLE V—OTHER PROVISIONS
Subtitle A—Drug Discount for Rural and Other Hospitals
Subtitle B—School-Based Health Clinics
Subtitle C—National Medical Device Registry
Subtitle D—Grants for Comprehensive Programs to Provide Education to
Nurses and Create a Pipeline to Nursing
Subtitle E—States Failing to Adhere to Certain Employment Obligations
1 DIVISION A—AFFORDABLE
2 HEALTH CARE CHOICES
3 SEC. 100. PURPOSE; TABLE OF CONTENTS OF DIVISION;
4 GENERAL DEFINITIONS.
5 (a) PURPOSE.—
6 (1) IN GENERAL.—The purpose of this division
7 is to provide affordable, quality health care for all
8 Americans and reduce the growth in health care
9 spending.
10 (2) BUILDING ON CURRENT SYSTEM.—This di-
11 vision achieves this purpose by building on what
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1 works in today’s health care system, while repairing
2 the aspects that are broken.
3 (3) INSURANCE REFORMS.—This division—
4 (A) enacts strong insurance market re-
5 forms;
6 (B) creates a new Health Insurance Ex-
7 change, with a public health insurance option
8 alongside private plans;
9 (C) includes sliding scale affordability
10 credits; and
11 (D) initiates shared responsibility among
12 workers, employers, and the government;
13 so that all Americans have coverage of essential
14 health benefits.
15 (4) HEALTH DELIVERY REFORM.—This division
16 institutes health delivery system reforms both to in-
17 crease quality and to reduce growth in health spend-
18 ing so that health care becomes more affordable for
19 businesses, families, and government.
20 (b) TABLE OF CONTENTS OF DIVISION.—The table
21 of contents of this division is as follows:
Sec. 100. Purpose; table of contents of division; general definitions.
TITLE I—PROTECTIONS AND STANDARDS FOR QUALIFIED
HEALTH BENEFITS PLANS
Subtitle A—General Standards
Sec. 101. Requirements reforming health insurance marketplace.
Sec. 102. Protecting the choice to keep current coverage.
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Subtitle B—Standards Guaranteeing Access to Affordable Coverage
Sec. 111. Prohibiting pre-existing condition exclusions.
Sec. 112. Guaranteed issue and renewal for insured plans.
Sec. 113. Insurance rating rules.
Sec. 114. Nondiscrimination in benefits; parity in mental health and substance
abuse disorder benefits.
Sec. 115. Ensuring adequacy of provider networks.
Sec. 116. Ensuring value and lower premiums.
Subtitle C—Standards Guaranteeing Access to Essential Benefits
Sec. 121. Coverage of essential benefits package.
Sec. 122. Essential benefits package defined.
Sec. 123. Health Benefits Advisory Committee.
Sec. 124. Process for adoption of recommendations; adoption of benefit standards.
Subtitle D—Additional Consumer Protections
Sec. 131. Requiring fair marketing practices by health insurers.
Sec. 132. Requiring fair grievance and appeals mechanisms.
Sec. 133. Requiring information transparency and plan disclosure.
Sec. 134. Application to qualified health benefits plans not offered through the
Health Insurance Exchange.
Sec. 135. Timely payment of claims.
Sec. 136. Standardized rules for coordination and subrogation of benefits.
Sec. 137. Application of administrative simplification.
Subtitle E—Governance
Sec. 141. Health Choices Administration; Health Choices Commissioner.
Sec. 142. Duties and authority of Commissioner.
Sec. 143. Consultation and coordination.
Sec. 144. Health Insurance Ombudsman.
Subtitle F—Relation to Other Requirements; Miscellaneous
Sec. 151. Relation to other requirements.
Sec. 152. Prohibiting discrimination in health care.
Sec. 153. Whistleblower protection.
Sec. 154. Construction regarding collective bargaining.
Sec. 155. Severability.
Subtitle G—Early Investments
Sec. 161. Ensuring value and lower premiums.
Sec. 162. Ending health insurance rescission abuse.
Sec. 163. Administrative simplification.
Sec. 164. Reinsurance program for retirees.
TITLE II—HEALTH INSURANCE EXCHANGE AND RELATED
PROVISIONS
Subtitle A—Health Insurance Exchange
Sec. 201. Establishment of Health Insurance Exchange; outline of duties; definitions.
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Sec. 202. Exchange-eligible individuals and employers.
Sec. 203. Benefits package levels.
Sec. 204. Contracts for the offering of Exchange-participating health benefits
plans.
Sec. 205. Outreach and enrollment of Exchange-eligible individuals and employers in Exchange-participating health benefits plan.
Sec. 206. Other functions.
Sec. 207. Health Insurance Exchange Trust Fund.
Sec. 208. Optional operation of State-based health insurance exchanges.
Subtitle B—Public Health Insurance Option
Sec. 221. Establishment and administration of a public health insurance option
as an Exchange-qualified health benefits plan.
Sec. 222. Premiums and financing.
Sec. 223. Payment rates for items and services.
Sec. 224. Modernized payment initiatives and delivery system reform.
Sec. 225. Provider participation.
Sec. 226. Application of fraud and abuse provisions.
Subtitle C—Individual Affordability Credits
Sec. 241. Availability through Health Insurance Exchange.
Sec. 242. Affordable credit eligible individual.
Sec. 243. Affordable premium credit.
Sec. 244. Affordability cost-sharing credit.
Sec. 245. Income determinations.
Sec. 246. No Federal payment for undocumented aliens.
TITLE III—SHARED RESPONSIBILITY
Subtitle A—Individual Responsibility
Sec. 301. Individual responsibility.
Subtitle B—Employer Responsibility
PART 1—HEALTH COVERAGE PARTICIPATION REQUIREMENTS
Sec. 311. Health coverage participation requirements.
Sec. 312. Employer responsibility to contribute towards employee and dependent coverage.
Sec. 313. Employer contributions in lieu of coverage.
Sec. 314. Authority related to improper steering.
PART 2—SATISFACTION OF HEALTH COVERAGE PARTICIPATION
REQUIREMENTS
Sec. 321. Satisfaction of health coverage participation requirements under the
Employee Retirement Income Security Act of 1974.
Sec. 322. Satisfaction of health coverage participation requirements under the
Internal Revenue Code of 1986.
Sec. 323. Satisfaction of health coverage participation requirements under the
Public Health Service Act.
Sec. 324. Additional rules relating to health coverage participation requirements.
TITLE IV—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986
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Subtitle A—Shared Responsibility
PART 1—INDIVIDUAL RESPONSIBILITY
Sec. 401. Tax on individuals without acceptable health care coverage.
PART 2—EMPLOYER RESPONSIBILITY
Sec. 411. Election to satisfy health coverage participation requirements.
Sec. 412. Responsibilities of nonelecting employers.
Subtitle B—Credit for Small Business Employee Health Coverage Expenses
Sec. 421. Credit for small business employee health coverage expenses.
Subtitle C—Disclosures to Carry Out Health Insurance Exchange Subsidies
Sec. 431. Disclosures to carry out health insurance exchange subsidies.
Subtitle D—Other Revenue Provisions
PART 1—GENERAL PROVISIONS
Sec. 441. Surcharge on high income individuals.
Sec. 442. Delay in application of worldwide allocation of interest.
PART 2—PREVENTION OF TAX AVOIDANCE
Sec. 451. Limitation on treaty benefits for certain deductible payments.
Sec. 452. Codification of economic substance doctrine.
Sec. 453. Penalties for underpayments.
1 (c) GENERAL DEFINITIONS.—Except as otherwise
2 provided, in this division:
3 (1) ACCEPTABLE COVERAGE.—The term ‘‘ac-
4 ceptable coverage’’ has the meaning given such term
5 in section 202(d)(2).
6 (2) BASIC PLAN.—The term ‘‘basic plan’’ has
7 the meaning given such term in section 203(c).
8 (3) COMMISSIONER.—The term ‘‘Commis-
9 sioner’’ means the Health Choices Commissioner es-
10 tablished under section 141.
11 (4) COST-SHARING.—The term ‘‘cost-sharing’’
12 includes deductibles, coinsurance, copayments, and
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1 similar charges but does not include premiums or
2 any network payment differential for covered serv-
3 ices or spending for non-covered services.
4 (5) DEPENDENT.—The term ‘‘dependent’’ has
5 the meaning given such term by the Commissioner
6 and includes a spouse.
7 (6) EMPLOYMENT-BASED HEALTH PLAN.—The
8 term ‘‘employment-based health plan’’—
9 (A) means a group health plan (as defined
10 in section 733(a)(1) of the Employee Retire-
11 ment Income Security Act of 1974); and
12 (B) includes such a plan that is the fol-
13 lowing:
14 (i) FEDERAL, STATE, AND TRIBAL
15 GOVERNMENTAL PLANS.—A governmental
16 plan (as defined in section 3(32) of the
17 Employee Retirement Income Security Act
18 of 1974), including a health benefits plan
19 offered under chapter 89 of title 5, United
20 States Code.
21 (ii) CHURCH PLANS.—A church plan
22 (as defined in section 3(33) of the Em-
23 ployee Retirement Income Security Act of
24 1974).
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1 (7) ENHANCED PLAN.—The term ‘‘enhanced
2 plan’’ has the meaning given such term in section
3 203(c).
4 (8) ESSENTIAL BENEFITS PACKAGE.—The term
5 ‘‘essential benefits package’’ is defined in section
6 122(a).
7 (9) FAMILY.—The term ‘‘family’’ means an in-
8 dividual and includes the individual’s dependents.
9 (10) FEDERAL POVERTY LEVEL; FPL.—The
10 terms ‘‘Federal poverty level’’ and ‘‘FPL’’ have the
11 meaning given the term ‘‘poverty line’’ in section
12 673(2) of the Community Services Block Grant Act
13 (42 U.S.C. 9902(2)), including any revision required
14 by such section.
15 (11) HEALTH BENEFITS PLAN.—The terms
16 ‘‘health benefits plan’’ means health insurance cov-
17 erage and an employment-based health plan and in-
18 cludes the public health insurance option.
19 (12) HEALTH INSURANCE COVERAGE; HEALTH
20 INSURANCE ISSUER.—The terms ‘‘health insurance
21 coverage’’ and ‘‘health insurance issuer’’ have the
22 meanings given such terms in section 2791 of the
23 Public Health Service Act.
24 (13) HEALTH INSURANCE EXCHANGE.—The
25 term ‘‘Health Insurance Exchange’’ means the
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1 Health Insurance Exchange established under sec-
2 tion 201.
3 (14) MEDICAID.—The term ‘‘Medicaid’’ means
4 a State plan under title XIX of the Social Security
5 Act (whether or not the plan is operating under a
6 waiver under section 1115 of such Act).
7 (15) MEDICARE.—The term ‘‘Medicare’’ means
8 the health insurance programs under title XVIII of
9 the Social Security Act.
10 (16) PLAN SPONSOR.—The term ‘‘plan spon-
11 sor’’ has the meaning given such term in section
12 3(16)(B) of the Employee Retirement Income Secu-
13 rity Act of 1974.
14 (17) PLAN YEAR.—The term ‘‘plan year’’
15 means—
16 (A) with respect to an employment-based
17 health plan, a plan year as specified under such
18 plan; or
19 (B) with respect to a health benefits plan
20 other than an employment-based health plan, a
21 12-month period as specified by the Commis-
22 sioner.
23 (18) PREMIUM PLAN; PREMIUM-PLUS PLAN.—
24 The terms ‘‘premium plan’’ and ‘‘premium-plus
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1 plan’’ have the meanings given such terms in section
2 203(c).
3 (19) QHBP OFFERING ENTITY.—The terms
4 ‘‘QHBP offering entity’’ means, with respect to a
5 health benefits plan that is—
6 (A) a group health plan (as defined, sub-
7 ject to subsection (d), in section 733(a)(1) of
8 the Employee Retirement Income Security Act
9 of 1974), the plan sponsor in relation to such
10 group health plan, except that, in the case of a
11 plan maintained jointly by 1 or more employers
12 and 1 or more employee organizations and with
13 respect to which an employer is the primary
14 source of financing, such term means such em-
15 ployer;
16 (B) health insurance coverage, the health
17 insurance issuer offering the coverage;
18 (C) the public health insurance option, the
19 Secretary of Health and Human Services;
20 (D) a non-Federal governmental plan (as
21 defined in section 2791(d) of the Public Health
22 Service Act), the State or political subdivision
23 of a State (or agency or instrumentality of such
24 State or subdivision) which establishes or main-
25 tains such plan; or
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1 (E) a Federal governmental plan (as de-
2 fined in section 2791(d) of the Public Health
3 Service Act), the appropriate Federal official.
4 (20) QUALIFIED HEALTH BENEFITS PLAN.—
5 The term ‘‘qualified health benefits plan’’ means a
6 health benefits plan that meets the requirements for
7 such a plan under title I and includes the public
8 health insurance option.
9 (21) PUBLIC HEALTH INSURANCE OPTION.—
10 The term ‘‘public health insurance option’’ means
11 the public health insurance option as provided under
12 subtitle B of title II.
13 (22) SERVICE AREA; PREMIUM RATING AREA.—
14 The terms ‘‘service area’’ and ‘‘premium rating
15 area’’ mean with respect to health insurance cov-
16 erage—
17 (A) offered other than through the Health
18 Insurance Exchange, such an area as estab-
19 lished by the QHBP offering entity of such cov-
20 erage in accordance with applicable State law;
21 and
22 (B) offered through the Health Insurance
23 Exchange, such an area as established by such
24 entity in accordance with applicable State law
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1 and applicable rules of the Commissioner for
2 Exchange-participating health benefits plans.
3 (23) STATE.—The term ‘‘State’’ means the 50
4 States and the District of Columbia.
5 (24) STATE MEDICAID AGENCY.—The term
6 ‘‘State Medicaid agency’’ means, with respect to a
7 Medicaid plan, the single State agency responsible
8 for administering such plan under title XIX of the
9 Social Security Act.
10 (25) Y1, Y2, ETC..—The terms ‘‘Y1’’ , ‘‘Y2’’,
11 ‘‘Y3’’, ‘‘Y4’’, ‘‘Y5’’, and similar subsequently num-
12 bered terms, mean 2013 and subsequent years, re-
13 spectively.

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