(a) In General- The Office shall establish and administer the Consumer Choice Health Plan (referred to in this Act as the ‘Plan’) to provide for health insurance coverage that is made available to all eligible individuals (as described in subsection (d)(1)) in the United States and its territories.
(1) ELIGIBILITY- An individual who is eligible to purchase coverage from a health insurance plan through the National Health Insurance Exchange shall be eligible to enroll in the Plan.
(2) ENROLLMENT PROCESS- An individual may enroll in the Plan only in such manner and form as may be prescribed by applicable regulations, and only during an enrollment period as prescribed by the Director.
(3) EMPLOYER ENROLLMENT- An employer shall be eligible to purchase health insurance coverage for their employees and the employees’ dependents to the extent provided for all health benefits plans under the National Health Insurance Exchange.
(4) SATISFACTION OF INDIVIDUAL MANDATE REQUIREMENT- An individual’s enrollment with the Plan shall be treated as satisfying any requirement under Federal law for such individual to demonstrate enrollment in health insurance or benefits coverage.
(1) NETWORK REQUIREMENT-
(A) MEDICARE- A participating provider who is voluntarily providing health care services under the Medicare program established under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) shall be required to provide services to any individual enrolled in the Plan.
(B) MEDICAID AND CHIP- A provider of health care services under the Medicaid program established under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), or the CHIP program established under title XXI of such Act (42 U.S.C. 1397aa et seq.), shall be required to provide services to any individual enrolled in the Plan.
(2) EXCEPTION- Paragraph (1) shall not be construed as requiring a provider to accept new patients due to bona fide capacity limitations of the provider.
(3) OPT-OUT PROVISION-
(A) MEDICARE- A participating provider as described under paragraph (1)(A) shall be required to provide services to any individual enrolled in the Plan for the 3-year period following the establishment of the Plan. Upon the expiration of the 3-year period, a participating provider in the Plan may elect to become a non-participating provider without affecting their status as a participating provider under the Medicare program.
(B) MEDICAID AND CHIP- A provider as described under paragraph (1)(B) shall be required to provide services to any individual enrolled in the Plan for the 3-year period following the establishment of the Plan. Upon the expiration of the 3-year period, a provider in the Plan may elect to cease provision of services under the Plan without affecting their status as a provider under the Medicaid program or the CHIP program.
(4) PAYMENT RATES-
(A) INITIAL PAYMENT RATES-
(i) IN GENERAL- During the 2-year period following the establishment of the Plan, providers shall be reimbursed at such payment rates as are applicable under the Medicare program.
(ii) ADJUSTMENT- The Director may reimburse providers at rates lower or higher than applicable under the Medicare program if the Director determines that the adjusted rates are appropriate and ensure that enrollees in the Plan are provided with adequate access to health care services.
(B) SUBSEQUENT PAYMENT RATES- Subject to subparagraph (C), upon the expiration of the 2-year period following the establishment of the Plan, the Director shall develop payment rates for reimbursement of providers in order to maintain an adequate provider network necessary to assure that enrollees in the Plan have adequate access to health care. In determining such payment rates, the Director shall consider--
(i) competitive provider payment rates in both the public and private sectors;
(ii) best practices among providers;
(iii) integrated models of care delivery (including medical home and chronic care coordination models);
(iv) geographic variation in health care costs;
(v) evidence-based practices;
(vi) quality improvement;
(vii) use of health information technology; and
(viii) any additional measures, as determined by the Director.
(C) PAYMENT RATE CONSULTATION- The Director shall determine payment rates under subparagraph (B) in consultation with providers participating under the Plan, the Director of the Office of Personnel Management, the Medicare Payment Advisory Commission, and the Medicaid and CHIP Payment and Access Commission.
(5) ADOPTION OF MEDICARE REFORMS- The Plan may adopt Medicare system delivery reforms that provide patients with a coordinated system of care and make changes to the provider payment structure.
(f) Subsidies- The Plan shall be eligible to accept subsidies, including subsidies for the enrollment of individuals under the Plan, in the same manner and to the same extent as other health insurance plans offered through the National Health Insurance Exchange.
(1) TRANSITIONAL FUNDING-
(A) IN GENERAL- In order to provide for adequate funding of the Plan in advance of receipt of payments as described in paragraph (2), beginning July 1, 2010, there are transferred to the Plan from the general fund of the Treasury such amounts as may be necessary for operation of the Plan until the end of the 3-year period following the establishment of the Plan.
(B) RETURN OF FUNDS- Upon the expiration of the 3-year period following the establishment of the Plan, the Director shall enter into a repayment schedule with the Secretary of the Treasury to provide for repayment of funds provided under subparagraph (A). Any expenditures made by the Plan pursuant to a repayment schedule established under this subparagraph shall not constitute administrative expenses as described in paragraph (2)(B).
(2) SELF-FINANCING-
(A) IN GENERAL- The Plan shall be financially self-sustaining insofar as funds used for operation of the Plan (including benefits, administration, and marketing) shall be derived from--
(i) insurance premium payments and subsidies for individuals enrolled in the Plan; and
(ii) payments made to the Plan by employers that do not offer health insurance coverage to their employees.
(B) LIMITATION ON ADMINISTRATIVE EXPENSES- Not more than 5 percent of the amounts provided under subparagraph (A) may be used for the annual administrative costs of the Plan.
(3) CONTINGENCY RESERVE-
(A) IN GENERAL- The Director shall establish and fund a contingency reserve for the Plan in a form similar to the contingency reserve provided for health benefits plans under the Federal Employees Health Benefits Program under chapter 89 of title 5, United States Code.
(B) REVENUE- Any revenue generated through the contingency reserve established in subparagraph (A) shall be transferred to the Plan for the purpose of reducing enrollee premiums, reducing enrollee cost-sharing, increasing enrollee benefits, or any combination thereof.
(4) GAO FINANCIAL AUDIT AND REPORT- Beginning not later than October 1, 2011, the Comptroller General shall conduct an annual audit of the financial statements and records of the Plan, in accordance with generally accepted government auditing standards, and submit an annual report on such audit to the Congress.
(5) SUPERMAJORITY REQUIREMENT FOR SUPPLEMENTAL FUNDING- Upon certification by the Comptroller General that the financial audit described in paragraph (4) indicates that the Plan is insolvent, supplemental funding may be appropriated for the Plan if such measure receives not less than a three-fifths vote of approval of the total number of Members of the House of Representatives and the Senate.
(1) IN GENERAL- Beginning with the first year of operation of the Plan through the National Health Insurance Exchange, the Director shall provide standards and undertake activities for promoting transparency in costs, benefits, and other factors for health insurance coverage provided under the Plan.
(2) STANDARD DEFINITIONS OF INSURANCE AND MEDICAL TERMS-
(A) IN GENERAL- The Director shall provide for the development of standards for the definitions of terms used in health insurance coverage under the Plan, including insurance-related terms (including the insurance-related terms described in subparagraph (B)) and medical terms (including the medical terms described in subparagraph (C)).
(B) INSURANCE-RELATED TERMS- The insurance-related terms described in this subparagraph are premium, deductible, co-insurance, co-payment, out-of-pocket limit, preferred provider, non-preferred provider, out-of-network co-payments, UCR (usual, customary and reasonable) fees, excluded services, grievance and appeals, and such other terms as the Director determines are important to define so that consumers may compare health insurance coverage and understand the terms of their coverage.
(C) MEDICAL TERMS- The medical terms described in this subparagraph are hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage, durable medical equipment, home health care, skilled nursing care, rehabilitation services, hospice services, emergency medical transportation, and such other terms as the Director determines are important to define so that consumers may compare the medical benefits offered by health insurance plans and understand the extent of those medical benefits (or exceptions to those benefits).
(3) DISCLOSURE-
(A) IN GENERAL- In carrying out this subsection, the Director shall disclose to Plan enrollees, potential enrollees, in-network health care providers, and others (through a publically available Internet website and other appropriate means) relevant information regarding each policy of health insurance coverage marketed or in force (in such standardized manner as determined by the Director), including--
(i) full policy contract language; and
(ii) a summary of the information described in paragraph (4).
(B) PERSONALIZED STATEMENT- The Director shall disclose to enrollees (in such standardized manner as determined by the Director) an annual personalized statement that summarizes use of health care services and payment of claims with respect to an enrollee (and covered dependents) under health insurance coverage provided through the Plan in the preceding year.
(4) REQUIRED INFORMATION- The information described in this paragraph includes, but is not limited to, the following:
(A) Data on the price of each new policy of health insurance coverage and renewal rating practices.
(B) Claims payment policies and practices, including how many and how quickly claims were paid.
(C) Provider fee schedules and usual, customary, and reasonable fees (for both in-network and out-of-network providers).
(D) Provider participation and provider directories.
(E) Loss ratios, including detailed information about amount and type of non-claims expenses.
(F) Covered benefits, cost-sharing, and amount of payment provided toward each type of service identified as a covered benefit, including preventive care services recommended by the United States Preventive Services Task Force.
(G) Civil or criminal actions successfully concluded against the Plan by any governmental entity.
(H) Benefit exclusions and limits.
(5) DEVELOPMENT OF PATIENT CLAIMS SCENARIOS-
(A) IN GENERAL- In order to improve the ability of individuals and employers to compare the coverage and relative value provided under the Plan, the Director shall develop and make publically available a series of patient claims scenarios under which benefits (including out-of-pocket costs) under the Plan are simulated for certain common or expensive conditions or courses of treatment (including maternity care, breast cancer, heart disease, diabetes management, and well-child visits).
(B) CONSULTATION- The Director shall develop the patient claims scenarios described in subparagraph (A)--
(i) in consultation with the Secretary of Health and Human Services, the National Institutes of Health, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, health professional societies, patient advocates, and other entities as deemed necessary by the Director; and
(ii) based upon recognized clinical practice guidelines.
(6) MANNER OF DISCLOSURE- The Director shall disclose the information under this subsection--
(A) with all marketing materials;
(B) on the website for the Plan; and
(C) at other times upon request.