Subtitle B—Public Health
2 Insurance Option
3 SEC. 221. ESTABLISHMENT AND ADMINISTRATION OF A
4 PUBLIC HEALTH INSURANCE OPTION AS AN
5 EXCHANGE-QUALIFIED HEALTH BENEFITS
6 PLAN.
7 (a) ESTABLISHMENT.—For years beginning with Y1,
8 the Secretary of Health and Human Services (in this sub9
title referred to as the ‘‘Secretary’’) shall provide for the
10 offering of an Exchange-participating health benefits plan
11 (in this subdivision referred to as the ‘‘public health insur12
ance option’’) that ensures choice, competition, and sta13
bility of affordable, high quality coverage throughout the
14 United States in accordance with this subtitle. In design15
ing the option, the Secretary’s primary responsibility is
16 to create a low-cost plan without compromising quality or
17 access to care.
18 (b) OFFERING AS AN EXCHANGE-PARTICIPATING
19 HEALTH BENEFITS PLAN.—
20 (1) EXCLUSIVE TO THE EXCHANGE.—The pub21
lic health insurance option shall only be made avail22
able through the Health Insurance Exchange.
23 (2) ENSURING A LEVEL PLAYING FIELD.—Con24
sistent with this subtitle, the public health insurance
25 option shall comply with requirements that are ap117
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1 plicable under this title to an Exchange-participating
2 health benefits plan, including requirements related
3 to benefits, benefit levels, provider networks, notices,
4 consumer protections, and cost sharing.
5 (3) PROVISION OF BENEFIT LEVELS.—The pub6
lic health insurance option—
7 (A) shall offer basic, enhanced, and pre8
mium plans; and
9 (B) may offer premium-plus plans.
10 (c) ADMINISTRATIVE CONTRACTING.—The Secretary
11 may enter into contracts for the purpose of performing
12 administrative functions (including functions described in
13 subsection (a)(4) of section 1874A of the Social Security
14 Act) with respect to the public health insurance option in
15 the same manner as the Secretary may enter into con16
tracts under subsection (a)(1) of such section. The Sec17
retary has the same authority with respect to the public
18 health insurance option as the Secretary has under sub19
sections (a)(1) and (b) of section 1874A of the Social Se20
curity Act with respect to title XVIII of such Act. Con21
tracts under this subsection shall not involve the transfer
22 of insurance risk to such entity.
23 (d) OMBUDSMAN.—The Secretary shall establish an
24 office of the ombudsman for the public health insurance
25 option which shall have duties with respect to the public
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1 health insurance option similar to the duties of the Medi2
care Beneficiary Ombudsman under section 1808(c)(2) of
3 the Social Security Act.
4 (e) DATA COLLECTION.—The Secretary shall collect
5 such data as may be required to establish premiums and
6 payment rates for the public health insurance option and
7 for other purposes under this subtitle, including to im8
prove quality and to reduce racial, ethnic, and other dis9
parities in health and health care.
10 (f) TREATMENT OF PUBLIC HEALTH INSURANCE OP11
TION.—With respect to the public health insurance option,
12 the Secretary shall be treated as a QHBP offering entity
13 offering an Exchange-participating health benefits plan.
14 (g) ACCESS TO FEDERAL COURTS.—The provisions
15 of Medicare (and related provisions of title II of the Social
16 Security Act) relating to access of Medicare beneficiaries
17 to Federal courts for the enforcement of rights under
18 Medicare, including with respect to amounts in con19
troversy, shall apply to the public health insurance option
20 and individuals enrolled under such option under this title
21 in the same manner as such provisions apply to Medicare
22 and Medicare beneficiaries.
23 SEC. 222. PREMIUMS AND FINANCING.
24 (a) ESTABLISHMENT OF PREMIUMS.—
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1 (1) IN GENERAL.—The Secretary shall establish
2 geographically-adjusted premium rates for the public
3 health insurance option in a manner—
4 (A) that complies with the premium rules
5 established by the Commissioner under section
6 113 for Exchange-participating health benefit
7 plans; and
8 (B) at a level sufficient to fully finance the
9 costs of—
10 (i) health benefits provided by the
11 public health insurance option; and
12 (ii) administrative costs related to op13
erating the public health insurance option.
14 (2) CONTINGENCY MARGIN.—In establishing
15 premium rates under paragraph (1), the Secretary
16 shall include an appropriate amount for a contin17
gency margin.
18 (b) ACCOUNT.—
19 (1) ESTABLISHMENT.—There is established in
20 the Treasury of the United States an Account for
21 the receipts and disbursements attributable to the
22 operation of the public health insurance option, in23
cluding the start-up funding under paragraph (2).
24 Section 1854(g) of the Social Security Act shall
25 apply to receipts described in the previous sentence
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1 in the same manner as such section applies to pay2
ments or premiums described in such section.
3 (2) START-UP FUNDING.—
4 (A) IN GENERAL.—In order to provide for
5 the establishment of the public health insurance
6 option there is hereby appropriated to the Sec7
retary, out of any funds in the Treasury not
8 otherwise appropriated, $2,000,000,000. In
9 order to provide for initial claims reserves be10
fore the collection of premiums, there is hereby
11 appropriated to the Secretary, out of any funds
12 in the Treasury not otherwise appropriated,
13 such sums as necessary to cover 90 days worth
14 of claims reserves based on projected enroll15
ment.
16 (B) AMORTIZATION OF START-UP FUND17
ING.—The Secretary shall provide for the re18
payment of the startup funding provided under
19 subparagraph (A) to the Treasury in an amor20
tized manner over the 10-year period beginning
21 with Y1.
22 (C) LIMITATION ON FUNDING.—Nothing in
23 this section shall be construed as authorizing
24 any additional appropriations to the Account,
25 other than such amounts as are otherwise pro121
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1 vided with respect to other Exchange-partici2
pating health benefits plans.
3 SEC. 223. PAYMENT RATES FOR ITEMS AND SERVICES.
4 (a) RATES ESTABLISHED BY SECRETARY.—
5 (1) IN GENERAL.—The Secretary shall establish
6 payment rates for the public health insurance option
7 for services and health care providers consistent with
8 this section and may change such payment rates in
9 accordance with section 224.
10 (2) INITIAL PAYMENT RULES.—
11 (A) IN GENERAL.—Except as provided in
12 subparagraph (B) and subsection (b)(1), during
13 Y1, Y2, and Y3, the Secretary shall base the
14 payment rates under this section for services
15 and providers described in paragraph (1) on the
16 payment rates for similar services and providers
17 under parts A and B of Medicare.
18 (B) EXCEPTIONS.—
19 (i) PRACTITIONERS’ SERVICES.—Pay20
ment rates for practitioners’ services other21
wise established under the fee schedule
22 under section 1848 of the Social Security
23 Act shall be applied without regard to the
24 provisions under subsection (f) of such sec25
tion and the update under subsection
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1 (d)(4) under such section for a year as ap2
plied under this paragraph shall be not less
3 than 1 percent.
4 (ii) ADJUSTMENTS.—The Secretary
5 may determine the extent to which Medi6
care adjustments applicable to base pay7
ment rates under parts A and B of Medi8
care shall apply under this subtitle.
9 (3) FOR NEW SERVICES.—The Secretary shall
10 modify payment rates described in paragraph (2) in
11 order to accommodate payments for services, such as
12 well-child visits, that are not otherwise covered
13 under Medicare.
14 (4) PRESCRIPTION DRUGS.—Payment rates
15 under this section for prescription drugs that are not
16 paid for under part A or part B of Medicare shall
17 be at rates negotiated by the Secretary.
18 (b) INCENTIVES FOR PARTICIPATING PROVIDERS.—
19 (1) INITIAL INCENTIVE PERIOD.—
20 (A) IN GENERAL.—The Secretary shall
21 provide, in the case of services described in sub22
paragraph (B) furnished during Y1, Y2, and
23 Y3, for payment rates that are 5 percent great24
er than the rates established under subsection
25 (a).
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1 (B) SERVICES DESCRIBED.—The services
2 described in this subparagraph are items and
3 professional services, under the public health in4
surance option by a physician or other health
5 care practitioner who participates in both Medi6
care and the public health insurance option.
7 (C) SPECIAL RULES.—A pediatrician and
8 any other health care practitioner who is a type
9 of practitioner that does not typically partici10
pate in Medicare (as determined by the Sec11
retary) shall also be eligible for the increased
12 payment rates under subparagraph (A).
13 (2) SUBSEQUENT PERIODS.— Beginning with
14 Y4 and for subsequent years, the Secretary shall
15 continue to use an administrative process to set such
16 rates in order to promote payment accuracy, to en17
sure adequate beneficiary access to providers, and to
18 promote affordability and the efficient delivery of
19 medical care consistent with section 221(a). Such
20 rates shall not be set at levels expected to increase
21 overall medical costs under the option beyond what
22 would be expected if the process under subsection
23 (a)(2) and paragraph (1) of this subsection were
24 continued.
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1 (3) ESTABLISHMENT OF A PROVIDER NET2
WORK.—Health care providers participating under
3 Medicare are participating providers in the public
4 health insurance option unless they opt out in a
5 process established by the Secretary.
6 (c) ADMINISTRATIVE PROCESS FOR SETTING
7 RATES.—Chapter 5 of title 5, United States Code shall
8 apply to the process for the initial establishment of pay9
ment rates under this section but not to the specific meth10
odology for establishing such rates or the calculation of
11 such rates.
12 (d) CONSTRUCTION.—Nothing in this subtitle shall
13 be construed as limiting the Secretary’s authority to cor14
rect for payments that are excessive or deficient, taking
15 into account the provisions of section 221(a) and the
16 amounts paid for similar health care providers and serv17
ices under other Exchange-participating health benefits
18 plans.
19 (e) CONSTRUCTION.—Nothing in this subtitle shall be
20 construed as affecting the authority of the Secretary to
21 establish payment rates, including payments to provide for
22 the more efficient delivery of services, such as the initia23
tives provided for under section 224.
24 (f) LIMITATIONS ON REVIEW.—There shall be no ad25
ministrative or judicial review of a payment rate or meth125
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1 odology established under this section or under section
2 224.
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