,i #aacth ,,congress #ast ,session ,h4 ,r4 #bfa ,,in ,,the ,,house ,,of ,,representatives ,january #ae1 #bjac ,ms4 ,schakowsky 7for herself1 ,mr4 ,waxman1 ,mr4 ,pallone1 ,ms4 ,de,gette1 ,mr4 ,engel1 ,mr4 ,sarbanes1 ,ms4 ,chu1 ,mr4 ,clay1 ,mr4 ,cohen1 ,mr4 ,conyers1 ,mr4 ,cummings1 ,ms4 ,de,lauro1 ,mr4 ,deutch1 ,ms4 ,edwards1 ,mr4 ,ellison1 ,mr4 ,farr1 ,mr4 ,fattah1 ,mr4 ,grijalva1 ,ms4 ,hahn1 ,mr4 ,higgins1 ,mr4 ,holt1 ,mr4 ,honda1 ,mr4 ,johnson of ,georgia1 ,ms4 ,kaptur1 ,ms4 ,lee of ,california1 ,ms4 ,lofgren1 ,mr4 ,ben ,ray ,lujn of ,new ,mexico1 ,ms4 ,mc,collum1 ,mr4 ,mc,dermott1 ,mr4 ,mc,govern1 ,mr4 ,george ,miller of ,california1 ,ms4 ,moore1 ,mr4 ,nadler1 ,ms4 ,norton1 ,ms4 ,pingree of ,maine1 ,mr4 ,polis1 ,mr4 ,rangel1 ,ms4 ,roybal-,allard1 ,mr4 ,serrano1 ,ms4 ,shea-,porter1 ,ms4 ,slaughter1 ,mr4 ,tonko1 ,ms4 ,waters1 ,mr4 ,welch1 and ,mr4 ,yarmuth7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce ,a ,,bill ,to amend the ,patient ,protection and ,affordable ,care ,act to establish a public health insurance option4 #a4 ,short title ,this ,act may be cited as the ,public ,option ,deficit ,reduction ,act4 #b4 ,public health insurance option 7a7 ,in general ,part #c of subtitle ,d of title ,i of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh7 is amended by adding at the end the following new section3 #acbe4 ,public health insurance option 7a7 ,establishment and administration of a public health insurance option 7#a7 ,establishment ,for years beginning with #bjad1 the ,secretary of ,health and ,human ,services 7in this subtitle referred to as the ,secretary7 shall provide for the offering through ,exchanges established under this title of a health benefits plan 7in this ,act referred to as the public health insurance option7 that ensures choice1 competition1 and stability of affordable1 high-quality coverage throughout the ,united ,states in accordance with this section4 ,in designing the option1 the ,secretary's primary responsibility is to create a low-cost plan without compromising quality or access to care4 7#b7 ,offering through ,exchanges 7,a7 ,exclusive to ,exchanges ,the public health insurance option shall only be made available through ,exchanges established under this title4 7,b7 ,ensuring a level playing field ,consistent with this section1 the public health insurance option shall comply with requirements that are applicable under this title to health benefits plans offered through such ,exchanges1 including requirements related to benefits1 benefit levels1 provider networks1 notices1 consumer protections1 and cost sharing4 7,c7 ,provision of benefit levels ,the public health insurance option-- 7i7 shall offer bronze1 silver1 and gold plans2 and 7ii7 may offer platinum plans4 7#c7 ,administrative contracting ,the ,secretary may enter into contracts for the purpose of performing administrative functions 7including functions described in subsection 7a77#d7 of section #ahgd;,a of the ,social ,security ,act7 with respect to the public health insurance option in the same manner as the ,secretary may enter into contracts under subsection 7a77#a7 of such section4 ,the ,secretary has the same authority with respect to the public health insurance option as the ,secretary has under subsections 7a77#a7 and 7b7 of section #ahgd;,a of the ,social ,security ,act with respect to title ,,xviii of such ,act4 ,contracts under this subsection shall not involve the transfer of insurance risk to such entity4 7#d7 ,ombudsman ,the ,secretary shall establish an office of the ombudsman for the public health insurance option which shall have duties with respect to the public health insurance option similar to the duties of the ,medicare ,beneficiary ,ombudsman under section #ahjh7;c77#b7 of the ,social ,security ,act4 ,in addition1 such office shall work with ,states to ensure that information and notice is provided that the public health insurance option is one of the health plans available through an ,exchange4 7#e7 ,data collection ,the ,secretary shall collect such data as may be required to establish premiums and payment rates for the public health insurance option and for other purposes under this section1 including to improve quality and to reduce racial1 ethnic1 and other disparities in health and health care4 7#f7 ,access to ,federal courts ,the provisions of ,medicare 7and related provisions of title ,,ii of the ,social ,security ,act7 relating to access of ,medicare beneficiaries to ,federal courts for the enforcement of rights under ,medicare1 including with respect to amounts in controversy1 shall apply to the public health insurance option and individuals enrolled under such option under this title in the same manner as such provisions apply to ,medicare and ,medicare beneficiaries4 7b7 ,premiums and financing 7#a7 ,establishment of premiums 7,a7 ,in general ,the ,secretary shall establish geographically adjusted premium rates for the public health insurance option-- 7i7 in a manner that complies with the premium rules under paragraph 7#c72 and 7ii7 at a level sufficient to fully finance the costs of-- 7,i7 health benefits provided by the public health insurance option2 and 7,,ii7 administrative costs related to operating the public health insurance option4 7,b7 ,contingency margin ,in establishing premium rates under subparagraph 7,a71 the ,secretary shall include an appropriate amount for a contingency margin4 7#b7 ,account 7,a7 ,establishment ,there is established in the ,treasury of the ,united ,states an account for the receipts and disbursements attributable to the operation of the public health insurance option1 including the start-up funding under subparagraph 7,b74 ,section #ahed7;g7 of the ,social ,security ,act shall apply to receipts described in the previous sentence in the same manner as such section applies to payments or premiums described in such section4 7,b7 ,start-up funding 7i7 ,in general ,in order to provide for the establishment of the public health insurance option there is hereby appropriated to the ,secretary1 out of any funds in the ,treasury not otherwise appropriated1 #b1jjj1jjj1jjj4 ,in order to provide for initial claims reserves before the collection of premiums1 there is hereby appropriated to the ,secretary1 out of any funds in the ,treasury not otherwise appropriated1 such sums as necessary to cover #ij days worth of claims reserves based on projected enrollment4 7ii7 ,amortization of start-up funding ,the ,secretary shall provide for the repayment of the startup funding provided under clause 7i7 to the ,treasury in an amortized manner over the #aj-year period beginning with #bjad4 7iii7 ,limitation on funding ,nothing in this subsection shall be construed as authorizing any additional appropriations to the account1 other than such amounts as are otherwise provided with respect to other health benefits plans participating under the ,exchange involved4 7#c7 ,insurance rating rules ,the premium rate charged for the public health insurance option may not vary except as provided under section #bgja of the ,public ,health ,service ,act4 7c7 ,payment rates for items and services 7#a7 ,rates established by ,secretary 7,a7 ,in general ,the ,secretary shall establish payment rates for the public health insurance option for services and health care providers consistent with this subsection and may change such payment rates in accordance with subsection 7d74 7,b7 ,initial payment rules 7i7 ,in general ,during #bjad1 #bjae1 and #bjaf1 the ,secretary shall set the payment rates under this subsection for services and providers described in subparagraph 7,a7 equal to the payment rates for equivalent services and providers under parts ,a and ,b of ,medicare1 subject to clause 7ii71 paragraphs 7#b77;,a7 and 7#d71 and subsection 7d74 7ii7 ,exceptions 7,i7 ,practitioners' services ,payment rates for practitioners' services otherwise established under the fee schedule under section #ahdh of the ,social ,security ,act shall be applied without regard to the provisions under subsection 7f7 of such section and the update under subsection 7d77#d7 under such section for a year as applied under this paragraph shall be not less than #a percent4 7,,ii7 ,adjustments ,the ,secretary may determine the extent to which ,medicare adjustments applicable to base payment rates under parts ,a and ,b of ,medicare for graduate medical education and disproportionate share hospitals shall apply under this section4 7,c7 ,for new services ,the ,secretary shall modify payment rates described in subparagraph 7,b7 in order to accommodate payments for services1 such as well-child visits1 that are not otherwise covered under ,medicare4 7,d7 ,prescription drugs ,payment rates under this subsection for prescription drugs that are not paid for under part ,a or part ,b of ,medicare shall be at rates negotiated by the ,secretary4 7#b7 ,incentives for participating providers 7,a7 ,initial incentive period 7i7 ,in general ,the ,secretary shall provide1 in the case of services described in clause 7ii7 furnished during #bjad1 #bjae1 and #bjaf1 for payment rates that are #e percent greater than the rates established under paragraph 7#a74 7ii7 ,services described ,the services described in this clause are items and professional services1 under the public health insurance option by a physician or other health care practitioner who participates in both ,medicare and the public health insurance option4 7iii7 ,special rules ,a pediatrician and any other health care practitioner who is a type of practitioner that does not typically participate in ,medicare 7as determined by the ,secretary7 shall also be eligible for the increased payment rates under clause 7i74 7,b7 ,subsequent periods ,beginning with #bjag and for subsequent years1 the ,secretary shall continue to use an administrative process to set such rates in order to promote payment accuracy1 to ensure adequate beneficiary access to providers1 and to promote affordability and the efficient delivery of medical care consistent with subsection 7a77#a74 ,such rates shall not be set at levels expected to increase average medical costs per enrollee covered under the public health insurance option beyond what would be expected if the process under paragraph 7#a77;,b7 and subparagraph 7,a7 were continued1 as certified by the ,office of the ,actuary of the ,centers for ,medicare ,medicaid ,services4 7,c7 ,establishment of a provider network ,health care providers participating under ,medicare are participating providers in the public health insurance option unless they opt out in a process established by the ,secretary4 7#c7 ,administrative process for setting rates ,chapter #e of title #e1 ,united ,states ,code shall apply to the process for the initial establishment of payment rates under this subsection but not to the specific methodology for establishing such rates or the calculation of such rates4 7#d7 ,construction ,nothing in this section shall be construed as limiting the ,secretary's authority to correct for payments that are excessive or deficient1 taking into account the provisions of subsection 7a77#a7 and any appropriate adjustments based on the demographic characteristics of enrollees covered under the public health insurance option1 but in no case shall the correction of payments under this paragraph result in a level of expenditures per enrollee that exceeds the level of expenditures that would have occurred under paragraphs 7#a77;,b7 and 7#b77;,a71 as certified by the ,office of the ,actuary of the ,centers for ,medicare ,medicaid ,services4 7#e7 ,construction ,nothing in this section shall be construed as affecting the authority of the ,secretary to establish payment rates1 including payments to provide for the more efficient delivery of services1 such as the initiatives provided for under subsection 7d74 7#f7 ,limitations on review ,there shall be no administrative or judicial review of a payment rate or methodology established under this subsection or under subsection 7d74 7d7 ,modernized payment initiatives and delivery system reform 7#a7 ,in general ,for plan years beginning with #bjad1 the ,secretary may utilize innovative payment mechanisms and policies to determine payments for items and services under the public health insurance option4 ,the payment mechanisms and policies under this subsection may include patient-centered medical home and other care management payments1 accountable care organizations1 value-based purchasing1 bundling of services1 differential payment rates1 performance or utilization based payments1 partial capitation1 and direct contracting with providers4 ,payment rates under such payment mechanisms and policies shall not be set at levels expected to increase average medical costs per enrollee covered under the public health insurance option beyond what would be expected if the process under paragraphs 7#a77;,b7 and 7#b77;,a7 of subsection 7c7 were continued1 as certified by the ,office of the ,actuary of the ,centers for ,medicare ,medicaid ,services4 7#b7 ,requirements for innovative payments ,the ,secretary shall design and implement the payment mechanisms and policies under this subsection in a manner that-- 7,a7 seeks to-- 7i7 improve health outcomes2 7ii7 reduce health disparities 7including racial1 ethnic1 and other disparities72 7iii7 provide efficient and affordable care2 7iv7 address geographic variation in the provision of health services2 or 7v7 prevent or manage chronic illness2 and 7,b7 promotes care that is integrated1 patient-centered1 high-quality1 and efficient4 7#c7 ,encouraging the use of high value services ,to the extent allowed by the benefit standards applied to all health benefits plans participating under the ,exchange involved1 the public health insurance option may modify cost sharing and payment rates to encourage the use of services that promote health and value4 7#d7 ,non-uniformity permitted ,nothing in this subtitle shall prevent the ,secretary from varying payments based on different payment structure models 7such as accountable care organizations and medical homes7 under the public health insurance option for different geographic areas4 7e7 ,provider participation 7#a7 ,in general ,the ,secretary shall establish conditions of participation for health care providers under the public health insurance option4 7#b7 ,licensure or certification ,the ,secretary shall not allow a health care provider to participate in the public health insurance option unless such provider is appropriately licensed or certified under ,state law4 7#c7 ,payment terms for providers 7,a7 ,physicians ,the ,secretary shall provide for the annual participation of physicians under the public health insurance option1 for which payment may be made for services furnished during the year1 in one of #b classes3 7i7 ,preferred physicians ,those physicians who agree to accept the payment rate established under this section 7without regard to cost-sharing7 as the payment in full4 7ii7 ,participating1 non-preferred physicians ,those physicians who agree not to impose charges 7in relation to the payment rate described in subsection 7c7 for such physicians7 that exceed the ratio permitted under section #ahdh7;g77#b77;,c7 of the ,social ,security ,act4 7,b7 ,other providers ,the ,secretary shall provide for the participation 7on an annual or other basis specified by the ,secretary7 of health care providers 7other than physicians7 under the public health insurance option under which payment shall only be available if the provider agrees to accept the payment rate established under subsection 7c7 7without regard to cost-sharing7 as the payment in full4 7#d7 ,exclusion of certain providers ,the ,secretary shall exclude from participation under the public health insurance option a health care provider that is excluded from participation in a ,federal health care program 7as defined in section #aabh;,b7f7 of the ,social ,security ,act74 7f7 ,application of fraud and abuse provisions ,provisions of law 7other than criminal law provisions7 identified by the ,secretary by regulation1 in consultation with the ,inspector ,general of the ,department of ,health and ,human ,services1 that impose sanctions with respect to waste1 fraud1 and abuse under ,medicare1 such as the ,false ,claims ,act 7#ca ,u4,s4,c4 #cgbi et seq471 shall also apply to the public health insurance option4 7g7 ,medicare defined ,for purposes of this section1 the term ,medicare means the health insurance programs under title ,,xviii of the ,social ,security ,act4 4 7b7 ,conforming amendments 7#a7 ,treatment as qualified health plan ,section #acja7;a77#b7 of the ,patient ,protection and ,affordable ,care ,act1 as amended by section #ajajd7;a7 of such ,act1 is amended-- 7,a7 in the heading1 by inserting 1 the public health insurance option1 before and2 and 7,b7 by inserting the public health insurance option under section #acbe1 before and a multi-,state plan4 7#b7 ,level playing field ,section #acbd7;a7 of such ,act1 as amended by section #ajajd7n7 of such ,act1 is amended by inserting the public health insurance option under section #acbe1 before or a multi-,state qualified health plan4