Insurance reforms. Prohibits insurance rating based on health status or pre-existing conditions, and limits age rating to 2:1. Prohibits annual or lifetime limits on medical spending. Grandfathers current individual policies. Applies these reforms to the entire market (inside and outside the Exchange), although employers have a five-year grace period to come into compliance. Establishes important consumer protections, including internal and external appeal requirements, provider network adequacy requirements, and greater transparency by insurance companies.
Exchange. Creates a new marketplace called the national “Health Insurance Exchange”, with an option for
states that agree to meet federal standards to run their own exchange. U.S. Territories will also have the
option of operating an exchange if they meet all of the insurance reforms and requirements as established
by this Act.
Eligibility. People are eligible to enter the Exchange and purchase health insurance on their own as long as
they are not enrolled in employer sponsored insurance, Medicare or Medicaid. The Exchange is also open
to businesses, starting with small firms and growing over time. Firms with twenty-five or fewer employees
are permitted to buy in the Exchange in 2013, firms with fifty or fewer employees in 2014, and firms with
at least one hundred employees in 2015 with discretion to the Commissioner to open the Exchange to
larger businesses in that year and the future.
Benefits. Outlines broad categories of covered services in the law, and creates a Health Benefits Advisory
Commission, with physicians and other expert members, to help the Secretary of HHS define the essential
benefit package. Cost-sharing varies by four tiers ranging in actuarial value (AV) from 70 percent to 95
percent (“basic,” “standard,” “premium,” and “premium plus”). In other words, in a 70 percent plan, the
plan pays 70 percent of the costs and an individual would pay the other 30 percent of expenses on
average. The fourth tier plan (“premium plus”) will offer additional benefits such as adult dental or vision,
gym memberships, or private hospital rooms. All plans will limit annual out-of-pocket expenses for
enrollees at a maximum of $5,000 for an individual and $10,000 for a family, with lower levels for lower-
and middle-income families.
Public health insurance option. The bill establishes a public health insurance option available within the
Exchange to ensure choice, competition and accountability. Like other private plans, the public option
must survive on its premiums. The Secretary of Health and Human Services will administer the public
option and negotiate rates for providers that participate in the public option. The public health insurance
option is provided startup administrative funding, but it is required to amortize these costs into future
premiums to ensure it operates on a level playing field with private insurers.
New health insurance options. The legislation authorizes start-up loans to assist states with the creation
of health insurance co-operatives as an additional option. It also permits states to enter into agreements
to allow for the sale of health insurance across state lines when the state legislatures agree to such
compacts. Grants are also awarded to help states with this endeavor.
Repealing the antitrust exemption for insurers. The bill promotes competition among health insurers and
medical malpractice insurers by removing the antitrust exemption so that it no longer shields these
insurers from liability for fixing prices, dividing up territories, or monopolizing their market.
Help for early retirees (temporary reinsurance program). Creates a $10 billion fund to finance a
temporary reinsurance program to help offset the costs of expensive health claims for employers that
provide health benefits for retirees age 55-64.
Limitation on post-retirement reductions of retiree healthcare benefits. Prohibits employers from
reducing retirees‘ health benefits after those retirees have retired, unless the reduction is also made to
benefits for active participants.
Employers. Employers must either provide health insurance to their employees or make a contribution to help fund
affordable health insurance. Employers that choose to offer coverage contribute at least 72.5 percent of premium
for workers, 65 percent for families. However, if the coverage is unaffordable for low-wage workers, that worker
can choose subsidized coverage in the Exchange and the employer makes a contribution to the Exchange.
Employers who do not offer qualified coverage contribute 8 percent of their payroll to help cover expenses of
employees who seek coverage through the Exchange.
Small business protections. Small businesses with annual payrolls below $500,000 are exempt from requirements
to offer or contribute to coverage, including the 8 percent payroll contribution for failure to provide health benefits
to their workers. As a result of this exemption, 86 percent of America’s businesses are exempt from any requirement
to provide coverage to their employees. The 8 percent requirement is phased in for small businesses with an annual
payroll between $500,000 and $750,000. There is also a tax credit program to help low-wage small businesses offer
coverage to their employees.
Small business tax credits. Small business tax credits are available for businesses with 10 or fewer employees and
$20,000 or less in average wages. The credits phase-out if the employer has 25 or more employees or if average
wages are $40,000 or more. The credits are available on rolling basis for the first two years that an employer offers
Individuals. Individuals are required to obtain health insurance coverage or pay a fee equal to lower of 2.5 percent
of their adjusted income above the filing threshold or the average premium on the Exchange. Individuals and
families below the income tax filing are exempt. (NOTE: In 2009, the threshold for taxpayers under age 65 is $9,350
for singles and $18,700 for couples). Individuals may apply for a hardship waiver if coverage is unaffordable and
selected exemptions from the mandate are provided in the statute. Those with coverage through the VA or who are
eligible for government-sponsored healthcare because they are a member of a tribe are considered to have fulfilled
the requirement to obtain coverage.
Government responsibility. It is the responsibility of the federal government to ensure that essential health
coverage is affordable and available to all Americans by establishing consumer protections and insurance reforms,
affordability credits and overseeing a fair marketplace for people to choose among options.
Affordability credits. Provides financial assistance for premiums and cost sharing for individuals and
families with incomes up to 400 percent of the federal poverty level (FPL). Affordability credits are offered
on a sliding scale such that premiums range from 1.5 percent of income at the lowest tier to 12 percent at
400 percent FPL. Provides additional assistance for households with incomes up to 400 percent FPL by
limiting cost-sharing to 3 percent of plan costs at the lowest tier rising to 30 percent of plan costs at 350-
400 percent of FPL. Specific out-of-pocket maximums are added to protect individuals at each income tier.
Income Premium Limit as Percent
Percent of Plan Costs Paid
Annual Out-of-Pocket Cap
Under 133 – 150% FPL 1.5 – 3% 3% $500/$1000
150 – 200% FPL 3 – 5.5% 7% $1,000/$2,000
200 – 250% FPL 5.5 – 8% 15% $2,000/$4,000
250 – 300% FPL 8 – 10% 22% $4,000/$8,000
300 – 350% FPL 10 – 11% 28% $4,500/$9,000
350 – 400% FPL 11 – 12% 30% $5,000/$10,000
Eligibility. Affordability credits are available to American citizens and legal residents whose employers do
not offer coverage or whose share of employer-sponsored health insurance costs more than 12 percent of
their family income. Those eligible for other government health care programs, such as Medicare or
Medicaid, cannot receive affordability credits. Establishes a mechanism by which the Commissioner must
verify that individuals are citizens or legal immigrants in order to receive affordability credits.
Caps out-of-pocket spending and limits. Helps prevent medical bankruptcy by limiting out-of pocket costs
to no more than $5,000 for individuals and $10,000 for families; these levels are indexed to inflation.
Those receiving affordability credits have lower out-of-pocket caps.
Medicaid and CHIP. Expands Medicaid coverage to everyone within income at or below 150 percent FPL
($33,100 per year for a family of 4) who is not eligible for Medicare. Eliminates assets tests for eligibility
groups other than for long-term care. Requires States that now cover those above 150 percent FPL to
maintain eligibility. States receive full federal funding for costs of expansion populations in 2013 and
2014. Thereafter, States pay 9 percent and the federal government pays 91 percent. CHIP-eligible
children move to the Exchange or Medicaid in 2014.
Revenue. The bill would impose a surcharge on taxpayers with adjusted gross income in excess of $1
million (married filing a joint return) and $500,000 (single) at a rate of 5.4 percent. The bill also: delays
implementation of worldwide interest allocation until 2020; limits eligibility for reduced treaty withholding
rates; codifies economic substance doctrine; information reporting for payments made to corporations;
eliminates nontaxable reimbursements of over the counter medications from HSAs, HRAs, and health
FSAs; limits contributions to health FSAs to $2,500; increases the penalty for non-health related
distributions from HSAs (from 10 percent to 20 percent); eliminates the tax deduction for employers who
receive a government subsidy for providing retiree prescription drug coverage; impose an excise tax of 2.5
percent on medical devices used in the United States; and ensures tax parity for employer-provided
coverage for domestic partners and other non-dependents. The bill also clarifies that an employee’s share
of premiums for employer-provided coverage offered through the Exchange may be paid on a pre-tax basis
through a cafeteria plan, but Exchange coverage that is not employer-offered is not eligible to be offered
through a cafeteria plan.
The Affordable Health Care for America Act proposes major improvements and investments in the Medicare
program. It closes the donut hole while providing discounted drugs to beneficiaries; protects the doctor-
patient relationship for Medicare patients by promoting primary care, care coordination and other payment
reforms; and promotes wellness by eliminating cost-sharing for preventive services and increasing access to
vaccines. In addition, Affordable Health Care for America Act strengthens Medicare by extending solvency of
the Trust Fund for five years through its provisions that attack waste, fraud and abuse and reform the
payment and delivery systems.
Hospitals. Substantial delivery and payment system reforms, including productivity adjustments and
reductions in market basket updates for most providers, per recommendations from MedPAC, OIG, GAO
Skilled nursing facilities. Follows recommendations from MedPAC and others to encourage payment
accuracy that more accurately reflects the costs of services provided. Nursing home transparency
provisions provide regulators and families additional information on nursing home ownership and control
and more information on nursing home staffing and quality through Nursing Home Compare. Tougher
penalties on nursing homes that fail to provide adequate care to their residents and improved training for
nursing home staff to increase quality of care. See Medicaid section for additional nursing facility-related
Medicare DSH payments. Directs the Secretary of HHS to study Medicare DSH payments and report to
Congress with recommendations on how best to ensure that DSH is properly targeted to adequately
reflect the higher costs of care associated with treating low-income patients. Reduces Medicare DSH
payments starting in 2017 if the uninsured rate drops by a certain number of percentage points between
2012 and 2014.
Graduate medical education. Provides incentives for the training of primary care physicians. Encourages
medical residency training in non-hospital settings so that the future physicians of America will be able to
provide coordinated care across the spectrum of provider settings.
Hospice moratorium. Extends a one year moratorium on regulatory changes that would phase out the
budget neutrality adjustment factor for Hospice providers to ensure that hospices continue to receive the
same reimbursement rate for wages for fiscal year 2010.
Reducing potentially preventable hospital readmissions. Changes payment incentives to hospitals and
post-acute care providers to discourage preventable hospital readmissions.
Post-acute care bundling. Promotes bundled payments that encourage providers to coordinate a patient’s
care across the entire spectrum, from the doctor’s office, to the hospital, through a rehabilitative or
nursing facility stay, and back to home.
Center for Medicare & Medicaid Innovation. Establishes a Center for Medicare & Medicaid Innovation to
empower CMS to pursue additional payment and delivery system reforms.
Healthcare-associated infections. Requires hospitals and ambulatory surgical centers to report public
health information on healthcare-associated infections to the Centers for Disease Control and Prevention.
IOM study of the appropriateness of Medicare payment rates based on geography. Within one year of
enactment, the Institute of Medicine is required to report to CMS on the validity of the geographic
adjusters that apply to Medicare physician and hospital payments and include any recommendations for
improvements. CMS is instructed to respond to such recommendations and may spend up to $4 billion
per year, for two years, to increase payment rates as appropriate.
IOM study of the extent of geographic variation in health spending. Instructs the IOM to study the extent
and cause of geographic variation in spending on health care (including all payers). The study will focus on
major contributors to that variation such as input prices, health status, socioeconomic factors, and access
to services. The IOM will make recommendations for addressing such variation in Medicare, which will
take into account the need to maintain beneficiary access to services. CMS will implement changes to
Medicare payment systems unless Congress votes to disapprove the planned changes.
Home health study. Requires MedPAC to undertake a study to examine the significant variation in
Medicare margins among home health agencies. Factors considered will include patient characteristics
(including health and socioeconomic factors), agency characteristics, and the types of services provided by
Productivity adjustments. Expands productivity adjustments to Medicare providers who receive CPI updates in
addition to those that receive market basket updates. These providers are: ambulatory surgical centers,
ambulances, clinical laboratories, and durable medical equipment not competitively bid.
Hospital outpatient department updates. Expands productivity adjustments to hospital outpatient departments.
Accountable Care Organization program. Establishes a new program that allows providers to share in Medicare
savings they help create through care coordination and quality improvement initiatives. Ensures that doctors can
join with hospitals and others when forming these organizations.
Telehealth. Expands Medicare’s telehealth benefit to beneficiaries who are receiving care at freestanding dialysis
centers. Also establishes a Telehealth Advisory Committee to provide HHS with additional expertise on the
Quality measures. Creates a timely process to allow for a multi-stakeholder group to provide the Secretary with
input into the selection of quality measures and provides for consultation by the Secretary of a consensus-based
entity in the use of quality measures.
Demonstration program on shared decision making. Uses decision aids and other technologies to help patients and
consumers improve their understanding of the risks and benefits of treatment options and make informed decisions
about medical care.
Medical home pilot program. Creates a pilot program to reward providers who agree to provide services necessary
to make their practice a “medical home” by ensuring full access to patients and providing for coordinated and
Cost sharing for preventive services. Eliminates deductibles and co-payments for all preventive services covered by
the Medicare program.
Improved access to vaccines. Makes it easier for Medicare beneficiaries to get access to needed vaccinations by
covering all vaccines under Part B of the program rather than Part D.
Extend Qualified Individuals (QI) program. Extends the QI program two years to help low-income beneficiaries pay
their Part B premiums.
Extends months of coverage of immunosuppressive drugs for kidney transplant patients. Lifts the current 36-
month limitation on Medicare coverage of immunosuppressive drugs for kidney transplant patients who would
otherwise lose this coverage on or after January 1, 2012.
Part B premium clarification. Allows capital gains from the sale of a primary residence to count as a life-changing
event for purposes of using a more recent tax year for determination of the Part B income-related premium so that
the use of a nest egg doesn’t increase the Part B premium owed.
Durable medical equipment in Medicare. Provides protections for beneficiaries receiving oxygen therapy in the
event an oxygen supplier goes out of business. Exempts certain pharmacies from the surety bond requirement and
the need to be accredited to sell diabetic testing supplies and certain other items.
Payment for imaging services. Instructs CMS to pay more accurately for imaging services in Medicare. Excludes low-
tech imaging devices (such as ultrasound, mammograms, EKGs, and x-rays) from the adjustment in payment.
Medicare Advantage payment. Beginning in 2011, reduces MA payments over three years to achieve
parity with 100 percent FFS rates; provides targeted bonuses to high-quality plans in high-enrollment areas
where reductions likely to be most disruptive.
Medicare Advantage reforms. Changes the annual enrollment period for beneficiaries to enroll in
Medicare Advantage to November 1 – December 15.
Medicare Advantage administrative costs and consumer protections. Beginning in 2014, requires MA
plans to maintain medical loss ratios of at least 85 percent, ensuring that payments to plans are
predominantly spent on providing healthcare, not overhead and profit. Limits Medicare Advantage cost-
sharing to no greater than cost-sharing in traditional Medicare.
Medicare drug benefit. Eliminates Part D donut hole over time and provides 50 percent discount in donut
hole for Part D enrollees. Restores manufacturer rebate for Part D drugs used by dual eligibles, as well as
low-income subsidy eligibles after 2015. Funds raised by this provision are used to close the Part D donut
Medicare low-income subsidy. Increases eligibility limits by raising assets test and clarifying what counts
toward the asset test. Eliminates cost-sharing for certain non-institutionalized dual eligibles.
Encourage accurate dispensing of drugs. Requires that Part D and MA-PD plans develop methods to
reduce waste of drugs in the long-term care setting.
Increase use of generics. Increases generic drug utilization by eliminating current requirements that
prevent Part D and MA-PD plans from creating incentives for seniors to use lower-cost generic drugs.
Follow-on biologics. Creates an FDA licensure pathway for “biosimilar” generic biological
products, allowing these products to come to market and compete with brand name biologics. The
biosimilar product must have no clinically meaningful differences in safety, purity or potency from the
reference product, and may not be licensed until at least 12 years after the date that the brand-name
product was licensed.
Physician Payment Sunshine. Requires manufacturers or distributors to electronically report to the HHS
OIG any payments or other transfers of value above a $5 de minimis made to a “covered
recipient” (physician, physician group practice, other prescribers, pharmacy or pharmacist, health
insurance issuer, group health plan, pharmacy benefit manager, hospital, medical school, sponsor of a
continuing medical education program, patient advocacy or disease specific group, organization of health
care professionals, biomedical researcher, group purchasing organization.) Requires hospitals,
manufacturers and group purchasing organizations to report the nature of ownership arrangements by
physicians. Failure to report is subject to civil monetary penalties from $1000 to $10,000 (max $150,000
per year) per payment, transfer of value, or investment interest not disclosed; penalties for knowing
failure to report range from $10,000 to $100,000 per payment, not to exceed $1,000,000 in one year or
.1% of revenues for that year.
Comparative Effectiveness Research (CER). Creates a new Center at the Agency for Healthcare Research
and Quality, supported by a combination of public and private funding that will conduct, support and
synthesize CER. An independent stakeholder Commission makes recommendations to the Center on
research priorities, study methods, and ways to disseminate research. The Commission has its own source
of funding and is responsible for evaluating the processes of the Center and is authorized to make reports
directly to Congress. A majority of the Commission members would be required to be physicians, other
health care practitioners, consumers or patients. The blended bill contains improved protections to
ensure that subpopulations are appropriately accounted for in research study design and dissemination.
The bill contains protections to prevent the Center and Commission from mandating payment, coverage or
reimbursement policies. In addition, the bill contains protections to ensure that research findings are not
construed to mandate coverage, reimbursement or other policies to any public or private payer, and clarify
that federal officers and employees will not interfere in the practice of medicine.
Increases funding by $100 million annually for the Healthcare Fraud and Abuse Control Fund to fight Medicare
and Medicaid fraud; improves provider and payment screening to prevent fraud and abuse before it occurs;
creates enhanced oversight for Medicare and Medicaid programs at risk of fraud and abuse; creates new
penalties for providers and suppliers that defraud federal health care programs; partners with the private
sector to reduce waste and abuse by requiring that all Medicare and Medicaid providers establish compliance
programs to reduce waste, fraud, and abuse.
Creates a grant program to help small and mid-sized employers begin or strengthen workplace wellness
programs. These grants will assist in improving the health of our nation’s workforce and will reduce employer
health care costs. Participating employers must offer the programs to all employees and cannot mandate
participation nor use participation as a condition to receive any financial incentive.
(provisions relating to Health Care Reform are above)
Preventive services. Requires State Medicaid programs to cover recommended preventive services
without cost-sharing. States will receive their regular federal matching rate for the cost of these services.
Payments for primary care services. Requires that physicians and other practitioners are paid for primary
care services they provide to Medicaid patients at 100 percent of Medicare rates beginning in 2012. The
federal government will pay 100 percent of the increased costs in 2012 through 2014, 90 percent
Additional federal funds to states with high unemployment. Assists States in maintaining access to
Medicaid services during the recession by extending the current Recovery Act increase in federal Medicaid
payments to states with high unemployment rates.
Coverage for HIV-positive individuals. Allows State Medicaid programs to cover low-income individuals
who are HIV positive through December 31, 2013, after which coverage will be available through the
Health Insurance Exchange or, for those with incomes at or below 133 percent of poverty, Medicaid.
States would receive the enhanced federal matching rate for these costs.
Nurse home visitation. Allows State Medicaid programs to cover nurse home visitation services for first-
time pregnant women and mothers with children under 2. The federal government would match these
costs at the state’s regular rate.
Increasing prescription drug rebates. Increases the minimum percentage rebate on brand-name drugs to
23.1 percent of average manufacturer price; extends rebates to new formulations of brand-name drugs;
and extends rebate requirement to drugs prescribed by Medicaid managed care organizations.
Reductions in Medicaid DSH payments. Directs the Secretary of HHS to reduce Medicaid DSH payments
to States by a total of $10 billion ($1.5 billion in FY 2017, $2.5 billion in FY 2018, and $6.0 billion in FY 2019)
using a methodology that imposes the largest reductions on states with the lowest percentages of
uninsured individuals or the least effective targeting of funds on DSH hospitals.
Payments to pharmacists. Increases the ceiling on payments for generic drugs to 130 percent of the
weighted average of monthly average manufacturer prices.
Medical home pilot program. Establishes a 5-year pilot program to evaluate medical home models for
beneficiaries including medically fragile children. A total of $1.235 billion is made available for increased
federal matching for administrative costs.
Managed care organizations. Requires that Medicaid MCOs meet a medical loss ratio standard set by the
Secretary of HHS at not less than 85 percent.
Territories. Raises federal payment ceilings and matching rates for Puerto Rico, Virgin Islands, Guam,
Northern Mariana Islands, and American Samoa by a total of $10.35 billion from FY 2011 through 2019.
Supplemental payments to certain nursing facilities. Directs the Secretary to make supplemental
payments to nursing facilities with high percentages of Medicare and Medicaid residents that are
efficiently and transparently operated and that provide quality care. Provides a total of $6 billion over the
period 2010 through 2013 ($1.5 billion each year) for this purpose. Directs the Medicaid and CHIP
Payment and Access Commission (“MACPAC”) to study the adequacy of Medicaid payments to nursing
facilities and to provide recommendations to the Congress by December 31, 2011.
Prohibitions on Medicaid and CHIP payment for undocumented Immigrants. Provides that the Medicaid
title does not change current prohibitions against Federal Medicaid or CHIP payments for persons not
lawfully present in the U.S.
Funding for public health and workforce development. Provides funds for years FY 2015 through FY
Community health centers. Provides significant increases in funding for community health centers.
Primary care residencies in community health centers. Establishes a new grant program to support the
development and operation of primary care residency programs in community-based settings such as
community health centers.
Health workforce. Provides new and increased investments in training programs designed to
increase the number of primary care physicians, nurses, and public health professionals.
Treatment of teaching as obligated service. Provides discretionary authority to the Secretary to allow up
to 20 percent of teaching time to count toward meeting obligated service requirements under the National
Health Service Corps program. Provides increases in support for Corps scholarship and loan repayment
Data collection and analysis on health disparities. Directs a new Assistant Secretary for Health
Information to set standards for the collection of data on a broad set of population and subpopulation
categories and to facilitate and coordinate analyses of health disparities within HHS and in collaboration
with other departments.
Community preventive services grants. Establishes new grants program for states to provide prevention
and wellness services to communities, with a special emphasis on health disparities.
Research and requirements for healthy behaviors and community wellness. Provides for the research
and inclusion of proven healthy behaviors in the essential benefits package and in community wellness
School-Based health clinics. Establishes a new grants program to support school-based health clinics that
provide health services to children and adolescents.
Public health infrastructure. Provides new investments in state, local, and tribal health departments to
build their capacity to address public health epidemics such as tobacco use and obesity, and to be
prepared for public health emergencies such as the H1N1 flu epidemic or breakouts of foodborne diseases.
National medical device registry. Establishes a national directory for class III medical devices and class II
devices that are permanently implantable, life-supporting, or life-sustaining. Device information in the
registry would be linked with patient safety and outcomes data from various public and private databases
to facilitate analyses of post-market device safety and effectiveness.
Expanded Participation in 340B Program. Extends the section 340B outpatient drug discounts to certain
rural and other hospitals, including Critical Access Hospitals.
IHS reauthorization. A new division is added to provide for the reauthorization of the Indian Health Care
Improvement Act (IHCIA). IHCIA provides the main legal authority for the provision of health care to
American Indians and Alaskan Natives. The main provisions of this new division address: improvements in
workforce development and recruitment; facilities construction, maintenance and improvements, access
to and financing of health services; provision of health services for urban Indians; organization
improvements within the Indian Health Service (IHS); and the provision of behavioral health services.
PREPARED BY THE HOUSE COMMITTEES ON WAYS AND MEANS, ENERGY AND COMMERCE, AND EDUCATION AND LABOR
OCTOBER 29, 2009