,i  #aac? ,,congress  #a/ ,session  ,h4 
,r4 #bfa  ,,9 ,,! ,,h\se ,,(            
,,repres5tatives  ,janu>y #ae1 #bjac    
,ms4 ,s*ak[sky 7= h]self1 ,mr4 ,waxman1 
,mr4 ,pallone1 ,ms4 ,de,gette1 ,mr4     
,engel1 ,mr4 ,s>banes1 ,ms4 ,*u1 ,mr4   
,clay1 ,mr4 ,coh51 ,mr4 ,cony]s1 ,mr4   
,cumm+s1 ,ms4 ,de,lauro1 ,mr4 ,deut*1   
,ms4 ,edw>ds1 ,mr4 ,ellison1 ,mr4 ,f>r1 
,mr4 ,fattah1 ,mr4 ,grijalva1 ,ms4      
,hahn1 ,mr4 ,higg9s1 ,mr4 ,holt1 ,mr4   
,honda1 ,mr4 ,johnson ( ,georgia1 ,ms4  
,kaptur1 ,ms4 ,lee ( ,cali=nia1 ,ms4    
,l(gr51 ,mr4 ,b5 ,ray ,lujn ( ,new      
,mexico1 ,ms4 ,mc,collum1 ,mr4          
,mc,dermott1 ,mr4 ,mc,govern1 ,mr4      
,george ,mill] ( ,cali=nia1 ,ms4 ,moore1
 ,mr4 ,nadl]1 ,ms4 ,norton1 ,ms4 ,p+ree 
( ,ma9e1 ,mr4 ,polis1 ,mr4 ,rangel1 ,ms4
 ,roybal-,all>d1 ,mr4 ,s]rano1 ,ms4     
,%ea-,port]1 ,ms4 ,slaught]1 ,mr4       
,tonko1 ,ms4 ,wat]s1 ,mr4 ,wel*1 & ,mr4 
,y>mu?7 introduc$ ! foll[+ bill2 :i* 0  
ref]r$ to ! ,committee on ,en]gy &      
,comm]ce  ,a ,,bill  ,to am5d ! ,pati5t 

,protection & ,af=dable ,c>e ,act to    
e/abli% a public heal? insurance option4
  #a4 ,%ort title ,?is ,act may be cit$ 
z ! ,public ,option ,deficit ,r$uction  
,act4  #b4 ,public heal? insurance      
option  7a7 ,9 g5]al ,"p #c ( subtitle  
,d ( title ,i ( ! ,pati5t ,protection & 
,af=dable ,c>e ,act 7,public ,law       
#aaa-adh7 is am5d$ by add+ at ! end !   
foll[+ new section3  #acbe4 ,public     
heal? insurance option  7a7 ,e/abli%m5t 
& adm9i/ration ( a public heal?         
insurance option  7#a7 ,e/abli%m5t ,=   
ye>s beg9n+ ) #bjad1 ! ,secret>y (      
,heal? & ,human ,s]vices 79 ?is subtitle
 ref]r$ to z ! ,secret>y7 %all provide =
 ! (f]+ ?r\gh ,ex*anges e/abli%$ "u ?is 
title ( a heal? b5efits plan 79 ?is ,act
 ref]r$ to z ! public heal? insurance   
option7 t ensures *oice1 competition1 & 
/ability ( af=dable1 high-quality       
cov]age ?r\gh\t ! ,unit$ ,/ates 9       
accordance ) ?is section4 ,9 design+ !  
option1 ! ,secret>y's prim>y            
responsibility is to create a l[-co/    

plan )\t compromis+ quality or access to
 c>e4  7#b7 ,(f]+ ?r\gh ,ex*anges  7,a7 
,exclusive to ,ex*anges ,! public heal? 
insurance option %all only be made      
available ?r\gh ,ex*anges e/abli%$ "u   
?is title4  7,b7 ,ensur+ a level play+  
field ,consi/5t ) ?is section1 ! public 
heal? insurance option %all comply )    
requirem5ts t are applicable "u ?is     
title to heal? b5efits plans (f]$ ?r\gh 
su* ,ex*anges1 includ+ requirem5ts      
relat$ to b5efits1 b5efit levels1       
provid] networks1 notices1 consum]      
protections1 & co/ %>+4  7,c7 ,provision
 ( b5efit levels ,! public heal?        
insurance option--  7i7 %all (f] bronze1
 silv]1 & gold plans2 &  7ii7 may (f]   
plat9um plans4  7#c7 ,adm9i/rative      
contract+ ,! ,secret>y may ent] into    
contracts = ! purpose ( p]=m+           
adm9i/rative functions 7includ+         
functions describ$ 9 subsection 7a77#d7 
( section #ahgd;,a ( ! ,social ,security
 ,act7 ) respect to ! public heal?      
insurance option 9 ! same mann] z !     

,secret>y may ent] into contracts "u    
subsection 7a77#a7 ( su* section4 ,!    
,secret>y has ! same au?ority ) respect 
to ! public heal? insurance option z !  
,secret>y has "u subsections 7a77#a7 &  
7b7 ( section #ahgd;,a ( ! ,social      
,security ,act ) respect to title       
,,xviii ( su* ,act4 ,contracts "u ?is   
subsection %all n involve ! transf] (   
insurance risk to su* entity4  7#d7     
,ombudsman ,! ,secret>y %all e/abli% an 
(fice ( ! ombudsman = ! public heal?    
insurance option :i* %all h duties )    
respect to ! public heal? insurance     
option simil> to ! duties ( ! ,m$ic>e   
,b5efici>y ,ombudsman "u section        
#ahjh7;c77#b7 ( ! ,social ,security     
,act4 ,9 addition1 su* (fice %all "w )  
,/ates to ensure t in=mation & notice is
 provid$ t ! public heal? insurance     
option is "o ( ! heal? plans available  
?r\gh an ,ex*ange4  7#e7 ,data          
collection ,! ,secret>y %all collect su*
 data z may be requir$ to e/abli%       
premiums & paym5t rates = ! public heal?

 insurance option & = o!r purposes "u   
?is section1 includ+ to improve quality 
& to r$uce racial1 e?nic1 & o!r         
disp>ities 9 heal? & heal? c>e4  7#f7   
,access to ,f$]al c\rts ,! provisions ( 
,m$ic>e 7& relat$ provisions ( title    
,,ii ( ! ,social ,security ,act7 relat+ 
to access ( ,m$ic>e b5efici>ies to      
,f$]al c\rts = ! en=cem5t ( rights "u   
,m$ic>e1 includ+ ) respect to am\nts 9  
controv]sy1 %all apply to ! public heal?
 insurance option & individuals enroll$ 
"u su* option "u ?is title 9 ! same     
mann] z su* provisions apply to ,m$ic>e 
& ,m$ic>e b5efici>ies4  7b7 ,premiums & 
f9anc+  7#a7 ,e/abli%m5t ( premiums     
7,a7 ,9 g5]al ,! ,secret>y %all e/abli% 
geographically adju/$ premium rates = ! 
public heal? insurance option--  7i7 9 a
 mann] t complies ) ! premium rules "u  
p>agraph 7#c72 &  7ii7 at a level       
suffici5t to fully f9ance ! co/s (--    
7,i7 heal? b5efits provid$ by ! public  
heal? insurance option2 &  7,,ii7       
adm9i/rative co/s relat$ to op]at+ !    

public heal? insurance option4  7,b7    
,cont+5cy m>g9 ,9 e/abli%+ premium rates
 "u subp>agraph 7,a71 ! ,secret>y %all  
include an appropriate am\nt = a        
cont+5cy m>g94  7#b7 ,acc\nt  7,a7      
,e/abli%m5t ,!re is e/abli%$ 9 !        
,treasury ( ! ,unit$ ,/ates an acc\nt = 
! receipts & disbursem5ts attributable  
to ! op]ation ( ! public heal? insurance
 option1 includ+ ! />t-up fund+ "u      
subp>agraph 7,b74 ,section #ahed7;g7 ( !
 ,social ,security ,act %all apply to   
receipts describ$ 9 ! previ\s s5t5ce 9 !
 same mann] z su* section applies to    
paym5ts or premiums describ$ 9 su*      
section4  7,b7 ,/>t-up fund+  7i7 ,9    
g5]al ,9 ord] to provide = ! e/abli%m5t 
( ! public heal? insurance option !re is
 h]eby appropriat$ to ! ,secret>y1 out (
 any funds 9 ! ,treasury n o!rwise      
appropriat$1 #b1jjj1jjj1jjj4 ,9 ord] to 
provide = initial claims res]ves be=e ! 
collection ( premiums1 !re is h]eby     
appropriat$ to ! ,secret>y1 out ( any   
funds 9 ! ,treasury n o!rwise           

appropriat$1 su* sums z necess>y to cov]
 #ij days wor? ( claims res]ves bas$ on 
project$ enrollm5t4  7ii7 ,amortization 
( />t-up fund+ ,! ,secret>y %all provide
 = ! repaym5t ( ! />tup fund+ provid$ "u
 clause 7i7 to ! ,treasury 9 an amortiz$
 mann] ov] ! #aj-ye> p]iod beg9n+ )     
#bjad4  7iii7 ,limitation on fund+ ,no?+
 9 ?is subsection %all be con/ru$ z     
au?oriz+ any additional appropriations  
to ! acc\nt1 o!r ?an su* am\nts z are   
o!rwise provid$ ) respect to o!r heal?  
b5efits plans p>ticipat+ "u ! ,ex*ange  
involv$4  7#c7 ,insurance rat+ rules ,! 
premium rate *>g$ = ! public heal?      
insurance option may n v>y except z     
provid$ "u section #bgja ( ! ,public    
,heal? ,s]vice ,act4  7c7 ,paym5t rates 
= items & s]vices  7#a7 ,rates e/abli%$ 
by ,secret>y  7,a7 ,9 g5]al ,! ,secret>y
 %all e/abli% paym5t rates = ! public   
heal? insurance option = s]vices & heal?
 c>e provid]s consi/5t ) ?is subsection 
& may *ange su* paym5t rates 9          
accordance ) subsection 7d74  7,b7      

,initial paym5t rules  7i7 ,9 g5]al     
,dur+ #bjad1 #bjae1 & #bjaf1 ! ,secret>y
 %all set ! paym5t rates "u ?is         
subsection = s]vices & provid]s describ$
 9 subp>agraph 7,a7 equal to ! paym5t   
rates = equival5t s]vices & provid]s "u 
p>ts ,a & ,b ( ,m$ic>e1 subject to      
clause 7ii71 p>agraphs 7#b77;,a7 & 7#d71
 & subsection 7d74  7ii7 ,exceptions    
7,i7 ,practition]s' s]vices ,paym5t     
rates = practition]s' s]vices o!rwise   
e/abli%$ "u ! fee s*$ule "u section     
#ahdh ( ! ,social ,security ,act %all be
 appli$ )\t reg>d to ! provisions "u    
subsection 7f7 ( su* section & ! update 
"u subsection 7d77#d7 "u su* section = a
 ye> z appli$ "u ?is p>agraph %all be n 
less ?an #a p]c5t4  7,,ii7 ,adju/m5ts ,!
 ,secret>y may det]m9e ! ext5t to :i*   
,m$ic>e adju/m5ts applicable to base    
paym5t rates "u p>ts ,a & ,b ( ,m$ic>e =
 graduate m$ical education &            
disproportionate %>e hospitals %all     
apply "u ?is section4  7,c7 ,= new      
s]vices ,! ,secret>y %all modify paym5t 

rates describ$ 9 subp>agraph 7,b7 9 ord]
 to accommodate paym5ts = s]vices1 su* z
 well-*ild visits1 t are n o!rwise cov]$
 "u ,m$ic>e4  7,d7 ,prescription drugs  
,paym5t rates "u ?is subsection =       
prescription drugs t are n paid = "u "p 
,a or "p ,b ( ,m$ic>e %all be at rates  
negotiat$ by ! ,secret>y4  7#b7         
,inc5tives = p>ticipat+ provid]s  7,a7  
,initial inc5tive p]iod  7i7 ,9 g5]al ,!
 ,secret>y %all provide1 9 ! case (     
s]vices describ$ 9 clause 7ii7 furni%$  
dur+ #bjad1 #bjae1 & #bjaf1 = paym5t    
rates t are #e p]c5t great] ?an ! rates 
e/abli%$ "u p>agraph 7#a74  7ii7        
,s]vices describ$ ,! s]vices describ$ 9 
?is clause are items & pr(essional      
s]vices1 "u ! public heal? insurance    
option by a physician or o!r heal? c>e  
practition] :o p>ticipates 9 bo? ,m$ic>e
 & ! public heal? insurance option4     
7iii7 ,special rules ,a p$iatrician &   
any o!r heal? c>e practition] :o is a   
type ( practition] t does n typically   
p>ticipate 9 ,m$ic>e 7z det]m9$ by !    

,secret>y7 %all also be eligible = !    
increas$ paym5t rates "u clause 7i74    
7,b7 ,subsequ5t p]iods ,beg9n+ ) #bjag &
 = subsequ5t ye>s1 ! ,secret>y %all     
cont9ue to use an adm9i/rative process  
to set su* rates 9 ord] to promote      
paym5t accuracy1 to ensure adequate     
b5efici>y access to provid]s1 & to      
promote af=dability & ! effici5t deliv]y
 ( m$ical c>e consi/5t ) subsection     
7a77#a74 ,su* rates %all n be set at    
levels expect$ to increase av]age m$ical
 co/s p] enrollee cov]$ "u ! public     
heal? insurance option beyond :at w\ld  
be expect$ if ! process "u p>agraph     
7#a77;,b7 & subp>agraph 7,a7 7 cont9u$1 
z c]tifi$ by ! ,(fice ( ! ,actu>y ( !   
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices4    
7,c7 ,e/abli%m5t ( a provid] network    
,heal? c>e provid]s p>ticipat+ "u       
,m$ic>e are p>ticipat+ provid]s 9 !     
public heal? insurance option unless !y 
opt out 9 a process e/abli%$ by !       
,secret>y4  7#c7 ,adm9i/rative process =
 sett+ rates ,*apt] #e ( title #e1      

,unit$ ,/ates ,code %all apply to !     
process = ! initial e/abli%m5t ( paym5t 
rates "u ?is subsection b n to !        
specific me?odology = e/abli%+ su* rates
 or ! calculation ( su* rates4  7#d7    
,con/ruction ,no?+ 9 ?is section %all be
 con/ru$ z limit+ ! ,secret>y's au?ority
 to correct = paym5ts t are excessive or
 defici5t1 tak+ into acc\nt ! provisions
 ( subsection 7a77#a7 & any appropriate 
adju/m5ts bas$ on ! demographic         
*>act]i/ics ( enrollees cov]$ "u !      
public heal? insurance option1 b 9 no   
case %all ! correction ( paym5ts "u ?is 
p>agraph result 9 a level ( exp5ditures 
p] enrollee t exce$s ! level (          
exp5ditures t w\ld h occurr$ "u         
p>agraphs 7#a77;,b7 & 7#b77;,a71 z      
c]tifi$ by ! ,(fice ( ! ,actu>y ( !     
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices4    
7#e7 ,con/ruction ,no?+ 9 ?is section   
%all be con/ru$ z affect+ ! au?ority ( !
 ,secret>y to e/abli% paym5t rates1     
includ+ paym5ts to provide = ! m        
effici5t deliv]y ( s]vices1 su* z !     

initiatives provid$ = "u subsection 7d74
  7#f7 ,limitations on review ,!re %all 
be no adm9i/rative or judicial review ( 
a paym5t rate or me?odology e/abli%$ "u 
?is subsection or "u subsection 7d74    
7d7 ,mod]niz$ paym5t initiatives &      
deliv]y sy/em re=m  7#a7 ,9 g5]al ,=    
plan ye>s beg9n+ ) #bjad1 ! ,secret>y   
may utilize innovative paym5t me*anisms 
& policies to det]m9e paym5ts = items & 
s]vices "u ! public heal? insurance     
option4 ,! paym5t me*anisms & policies  
"u ?is subsection may include           
pati5t-c5t]$ m$ical home & o!r c>e      
managem5t paym5ts1 acc\ntable c>e       
organizations1 value-bas$ pur*as+1      
bundl+ ( s]vices1 diff]5tial paym5t     
rates1 p]=mance or utilization bas$     
paym5ts1 p>tial capitation1 & direct    
contract+ ) provid]s4 ,paym5t rates "u  
su* paym5t me*anisms & policies %all n  
be set at levels expect$ to increase    
av]age m$ical co/s p] enrollee cov]$ "u 
! public heal? insurance option beyond  
:at w\ld be expect$ if ! process "u     

p>agraphs 7#a77;,b7 & 7#b77;,a7 (       
subsection 7c7 7 cont9u$1 z c]tifi$ by !
 ,(fice ( ! ,actu>y ( ! ,c5t]s = ,m$ic>e
  ,m$icaid ,s]vices4  7#b7 ,requirem5ts 
= innovative paym5ts ,! ,secret>y %all  
design & implem5t ! paym5t me*anisms &  
policies "u ?is subsection 9 a mann] t--
  7,a7 seeks to--  7i7 improve heal?    
outcomes2  7ii7 r$uce heal? disp>ities  
7includ+ racial1 e?nic1 & o!r           
disp>ities72  7iii7 provide effici5t &  
af=dable c>e2  7iv7 address geographic  
v>iation 9 ! provision ( heal? s]vices2 
or  7v7 prev5t or manage *ronic illness2
 &  7,b7 promotes c>e t is integrat$1   
pati5t-c5t]$1 high-quality1 & effici5t4 
7#c7 ,enc\rag+ ! use ( high value       
s]vices ,to ! ext5t all[$ by ! b5efit   
/&>ds appli$ to all heal? b5efits plans 
p>ticipat+ "u ! ,ex*ange involv$1 !     
public heal? insurance option may modify
 co/ %>+ & paym5t rates to enc\rage !   
use ( s]vices t promote heal? & value4  
7#d7 ,non-uni=mity p]mitt$ ,no?+ 9 ?is  
subtitle %all prev5t ! ,secret>y f v>y+ 

paym5ts bas$ on diff]5t paym5t /ructure 
models 7su* z acc\ntable c>e            
organizations & m$ical homes7 "u !      
public heal? insurance option = diff]5t 
geographic areas4  7e7 ,provid]         
p>ticipation  7#a7 ,9 g5]al ,! ,secret>y
 %all e/abli% conditions ( p>ticipation 
= heal? c>e provid]s "u ! public heal?  
insurance option4  7#b7 ,lic5sure or    
c]tification ,! ,secret>y %all n all[ a 
heal? c>e provid] to p>ticipate 9 !     
public heal? insurance option unless su*
 provid] is appropriately lic5s$ or     
c]tifi$ "u ,/ate law4  7#c7 ,paym5t t]ms
 = provid]s  7,a7 ,physicians ,!        
,secret>y %all provide = ! annual       
p>ticipation ( physicians "u ! public   
heal? insurance option1 = :i* paym5t may
 be made = s]vices furni%$ dur+ ! ye>1 9
 "o ( #b classes3  7i7 ,pref]r$         
physicians ,^? physicians :o agree to   
accept ! paym5t rate e/abli%$ "u ?is    
section 7)\t reg>d to co/-%>+7 z !      
paym5t 9 full4  7ii7 ,p>ticipat+1       
non-pref]r$ physicians ,^? physicians :o

 agree n to impose *>ges 79 relation to 
! paym5t rate describ$ 9 subsection 7c7 
= su* physicians7 t exce$ ! ratio       
p]mitt$ "u section #ahdh7;g77#b77;,c7 ( 
! ,social ,security ,act4  7,b7 ,o!r    
provid]s ,! ,secret>y %all provide = !  
p>ticipation 7on an annual or o!r basis 
specifi$ by ! ,secret>y7 ( heal? c>e    
provid]s 7o!r ?an physicians7 "u !      
public heal? insurance option "u :i*    
paym5t %all only be available if !      
provid] agrees to accept ! paym5t rate  
e/abli%$ "u subsection 7c7 7)\t reg>d to
 co/-%>+7 z ! paym5t 9 full4  7#d7      
,exclusion ( c]ta9 provid]s ,! ,secret>y
 %all exclude f p>ticipation "u ! public
 heal? insurance option a heal? c>e     
provid] t is exclud$ f p>ticipation 9 a 
,f$]al heal? c>e program 7z def9$ 9     
section #aabh;,b7f7 ( ! ,social         
,security ,act74  7f7 ,application (    
fraud & abuse provisions ,provisions (  
law 7o!r ?an crim9al law provisions7    
id5tifi$ by ! ,secret>y by regulation1 9
 consultation ) ! ,inspector ,g5]al ( ! 

,dep>tm5t ( ,heal? & ,human ,s]vices1 t 
impose sanctions ) respect to wa/e1     
fraud1 & abuse "u ,m$ic>e1 su* z !      
,false ,claims ,act 7#ca ,u4,s4,c4 #cgbi
 et seq471 %all also apply to ! public  
heal? insurance option4  7g7 ,m$ic>e    
def9$ ,= purposes ( ?is section1 ! t]m  
,m$ic>e means ! heal? insurance programs
 "u title ,,xviii ( ! ,social ,security 
,act4  4  7b7 ,con=m+ am5dm5ts  7#a7    
,treatm5t z qualifi$ heal? plan ,section
 #acja7;a77#b7 ( ! ,pati5t ,protection &
 ,af=dable ,c>e ,act1 z am5d$ by section
 #ajajd7;a7 ( su* ,act1 is am5d$--  7,a7
 9 ! head+1 by ins]t+ 1 ! public heal?  
insurance option1 be=e &2 &  7,b7 by    
ins]t+ ! public heal? insurance option  
"u section #acbe1 be=e & a multi-,/ate  
plan4  7#b7 ,level play+ field ,section 
#acbd7;a7 ( su* ,act1 z am5d$ by section
 #ajajd7n7 ( su* ,act1 is am5d$ by      
ins]t+ ! public heal? insurance option  
"u section #acbe1 be=e or a multi-,/ate 
qualifi$ heal? plan4