- Establish a temporary national high-risk pool
to provide health coverage to individuals with
pre-existing medical conditions. (Effective 90
days following enactment until January 1, 2014)
- Provide dependent coverage for adult children
up to age 26 for all individual and group
- Prohibit individual and group health plans
from placing lifetime limits on the dollar value
of coverage and prior to 2014, plans may only
impose annual limits on coverage as determined
by the Secretary. Prohibit insurers from
rescinding coverage except in cases of fraud and
prohibit pre-existing condition exclusions for
- Require qualified health plans to provide at a
minimum coverage without cost-sharing for
preventive services rated A or B by the U.S.
Preventive Services Task Force, recommended
immunizations, preventive care for infants,
children, and adolescents, and additional
preventive care and screenings for women.
- Provide tax credits to small employers with no
more than 25 employees and average annual wages
of less than $50,000 that purchase health
insurance for employees.
- Create a temporary reinsurance program for
employers providing health insurance coverage to
retirees over age 55 who are not eligible for
Medicare. (Effective 90 days following enactment
until January 1, 2014)
- Require health plans to report the proportion
of premium dollars spent on clinical services,
quality, and other costs and provide rebates to
consumers for the amount of the premium spent on
clinical services and quality that is less than
85% for plans in the large group market and 80%
for plans in the individual and small group
markets. (Requirement to report medical loss
ratio effective plan year 2010; requirement to
provide rebates effective January 1, 2011)
- Establish a process for reviewing increases in
health plan premiums and require plans to
justify increases. Require states to report on
trends in premium increases and recommend
whether certain plan should be excluded from the
Exchange based on unjustified premium increases.
- Provide a $250 rebate to Medicare
beneficiaries who reach the Part D coverage gap
in 2010 and gradually eliminate the Medicare
Part D coverage gap by 2020.
- Expand Medicare coverage to individuals who
have been exposed to environmental health
hazards from living in an area subject to an
emergency declaration made as of June 17, 2009
and have developed certain health conditions as
- Improve care coordination for dual eligibles
by creating a new office within the Centers for
Medicare and Medicaid services, the Federal
Coordinated Health Care Office.
- Reduce annual market basket updates for
inpatient hospital, home health, skilled nursing
facility, hospice and other Medicare providers,
and adjust for productivity.
- Ban new physician-owned hospitals in Medicare,
requiring hospitals to have a provider agreement
in effect by December 31; limit the growth of
certain grandfathered physician-owned hospitals.
- Creates a state option to cover childless
adults though a Medicaid State Plan Amendment.
- Creates a state option to provide Medicaid
coverage for family planning services to certain
low-income individuals through a Medicaid State
Plan Amendment up to the highest level of
eligibility for pregnant women.
- Creates a new option for states to provide
CHIP coverage to children of state employees
eligible for health benefits if certain
conditions are met.
- Increase the Medicaid drug rebate percentage
for brand name drugs to 23.1% (except the rebate
for clotting factors and drugs approved
exclusively for pediatric use increases to
17.1%); increase the Medicaid rebate for
non-innovator, multiple source drugs to 13% of
average manufacturer price; and extend the drug
rebate to Medicaid managed care plans.
- Provide funding for and expand the role of the
Medicaid and CHIP Payment and Access Commission
to include assessments of adult services
(including those dually eligible for Medicare
- Require the Secretary of HHS to issue
regulations to establish a process for public
notice and comment for section 1115 waivers in
Medicaid and CHIP.
- Authorize the Food and Drug Administration to
approve generic versions of biologic drugs and
grant biologics manufacturers 12 years of
exclusive use before generics can be developed.
- Support comparative effectiveness research by
establishing a non-profit Patient-Centered
Outcomes Research Institute.
- Establish a commissioned Regular Corps and a
Ready Reserve Corps for service in time of a
- Reauthorize and amend the Indian Health Care
- Establish the Workforce Advisory Committee to
develop a national workforce strategy.
- Increase workforce supply and support training
of health professionals through scholarships and
- Establish Teaching Health Centers to provide
Medicare payments for primary care residency
programs in federally qualified health centers.
- Impose additional requirements on non-profit
hospitals. Impose a tax of $50,000 per year for
failure to meet these requirements.
- Limit the deductibility of executive and
employee compensation to $500,000 per applicable
individual for health insurance providers.
- Impose a tax of 10% on the amount paid for
indoor tanning services.
- Exclude unprocessed fuels from the definition
of cellulosic biofuel for purposes of applying
the cellulosic biofuel producer credit.
- Clarify application of the economic substance
doctrine and increase penalties for
underpayments attributable to a transaction
lacking economic substance.
- Establish a national, voluntary insurance
program for purchasing community living
assistance services and supports (CLASS
- Award five-year demonstration grants to states
to develop, implement, and evaluate alternatives
to current tort litigations.
- Improve prevention by covering only proven
preventive services and eliminating cost-sharing
for preventive services in Medicare; increase
Medicare payments for certain preventive
services to 100% of actual charges or fee
schedule rates. For states that provide Medicaid
coverage for and remove cost-sharing for
preventive services recommended by the US
Preventive Services Task Force and recommended
immunizations, provide a one percentage point
increase in the FMAP for these services.
- Provide Medicare beneficiaries access to a
comprehensive health risk assessment and
creation of a personalized prevention plan and
provide incentives to Medicare and Medicaid
beneficiaries to complete behavior modification
- Provide grants for up to five years to small
employers that establish wellness programs.
- Establish the National Prevention, Health
Promotion and Public Health Council to develop a
national strategy to improve the nation’s
- Require chain restaurants and food sold from
vending machines to disclose the nutritional
content of each item.
- Require pharmaceutical manufacturers to
provide a 50% discount on brand-name
prescriptions filled in the Medicare Part D
coverage gap beginning in 2011 and begin
phasing-in federal subsidies for generic
prescriptions filled in the Medicare Part D
- Provide a 10% Medicare bonus payment to
primary care physicians and to general surgeons
practicing in health professional shortage
areas. (Effective 2011 through 2015)
- Restructure payments to Medicare Advantage
(MA) plans by setting payments to different
percentages of Medicare fee-for-service (FFS)
- Prohibit Medicare Advantage plans from
imposing higher cost-sharing requirements for
some Medicare covered benefits than is required
under the traditional fee-for-service program.
- Reduce annual market basket updates for
Medicare providers beginning in 2011.
- Provide Medicare payments to qualifying
hospitals in counties with the lowest quartile
Medicare spending for 2011 and 2012.
- Freeze the income threshold for income-related
Medicare Part B premiums for 2011 through 2019
at 2010 levels, and reduce the Medicare Part D
premium subsidy for those with incomes above
$85,000/individual and $170,000/couple.
- Create an Innovation Center within the Centers
for Medicare and Medicaid Services.
- Prohibit federal payments to states for
Medicaid services related to health care
- Create a new Medicaid state plan option to
permit Medicaid enrollees with at least two
chronic conditions, one condition and risk of
developing another, or at least one serious and
persistent mental health condition to designate
a provider as a health home. Provide states
taking up the option with 90% FMAP for two years
for health home related services including care
management, care coordination and health
- Create the State Balancing Incentive Program
in Medicaid to provide enhanced federal matching
payments to increase non-institutionally based
long-term care services.
- Establish the Community First Choice Option in
Medicaid to provide community-based attendant
support services to certain people with
- Develop a national quality improvement
strategy that includes priorities to improve the
delivery of health care services, patient health
outcomes, and population health.
- Establish the Community-based Collaborative
Care Network Program to support consortiums of
health care providers to coordinate and
integrate health care services, for low-income
uninsured and underinsured populations.
- Establish a new trauma center program to
strengthen emergency department and trauma
- Improve access to care by increasing funding
by $11 billion for community health centers and
the National Health Service Corps over five
years; establish new programs to support
school-based health centers and nurse-managed
- Exclude the costs for over-the-counter drugs
not prescribed by a doctor from being reimbursed
through an HRA or health FSA and from being
reimbursed on a tax-free basis through an HSA or
Archer Medical Savings Account.
- Increase the tax on distributions from a
health savings account or an Archer MSA that are
not used for qualified medical expenses to 20%
of the disbursed amount.
- Impose new annual fees on the pharmaceutical
- Make Part D cost-sharing for full-benefit dual
eligible beneficiaries receiving home and
community-based care services equal to the
cost-sharing for those who receive institutional
- Allow providers organized as accountable care
organizations (ACOs) that voluntarily meet
quality thresholds to share in the cost savings
they achieve for the Medicare program.
- Reduce Medicare payments that would otherwise
be made to hospitals by specified percentages to
account for excess (preventable) hospital
- Create the Medicare Independence at Home
- Establish a hospital value-based purchasing
program in Medicare and develop plans to
implement value-based purchasing programs for
skilled nursing facilities, home health
agencies, and ambulatory surgical centers.
- Provide bonus payments to high–quality
Medicare Advantage plans.
- Reduce rebates for Medicare Advantage plans.
- Create new demonstration projects in Medicaid
to pay bundled payments for episodes of care
that include hospitalizations (effective January
1, 2012 through December 31, 2016); to make
global capitated payments to safety net hospital
systems (effective fiscal years 2010 through
2012); to allow pediatric medical providers
organized as accountable care organizations to
share in cost-savings (effective January 1, 2012
through December 31, 2016); and to provide
Medicaid payments to institutions of mental
disease for adult enrollees who require
stabilization of an emergency condition
(effective October 1, 2011 through December 31,
- Require enhanced collection and reporting of
data on race, ethnicity, sex, primary language,
disability status, and for underserved rural and
- Create the Consumer Operated and Oriented Plan
(CO-OP) program to foster the creation of
non-profit, member-run health insurance
companies in all 50 states and the District of
Columbia to offer qualified health plans.
(Appropriate $6 billion to finance the program
and award loans and grants to establish CO-OPs
by July 1, 2013)
- Simplify health insurance administration by
adopting a single set of operating rules for
eligibility verification and claims status
(rules adopted July 1, 2011; effective January
1, 2013), electronic funds transfers and health
care payment and remittance (rules adopted July
1, 2012; effective January 1, 2014), and health
claims or equivalent encounter information,
enrollment and disenrollment in a health plan,
health plan premium payments, and referral
certification and authorization (rules adopted
July 1, 2014; effective January 1, 2016). Health
plans must document compliance with these
standards or face a penalty of no more than $1
per covered life. (Effective April 1, 2014)
- Begin phasing-in federal subsidies for
brand-name prescriptions filled in the Medicare
Part D coverage gap (to 25% in 2020, in addition
to the 50% manufacturer brand-name discount).
- Establish a national Medicare pilot program to
develop and evaluate paying a bundled payment
for acute, inpatient hospital services,
physician services, outpatient hospital
services, and post-acute care services for an
episode of care.
- Increase Medicaid payments for primary care
services provided by primary care doctors for
2013 and 2014 with 100% federal funding.
- Require disclosure of financial relationships
between health entities, including physicians,
hospitals, pharmacists, other providers, and
manufacturers and distributors of covered drugs,
devices, biologicals, and medical supplies.
- Increase the threshold for the itemized
deduction for unreimbursed medical expenses from
7.5% of adjusted gross income to 10% of adjusted
gross income for regular tax purposes; waive the
increase for individuals age 65 and older for
tax years 2013 through 2016.
- Increase the Medicare Part A (hospital
insurance) tax rate on wages by 0.9% (from 1.45%
to 2.35%) on earnings over $200,000 for
individual taxpayers and $250,000 for married
couples filing jointly and impose a 3.8%
assessment on unearned income for higher-income
- Limit the amount of contributions to a
flexible spending account for medical expenses
to $2,500 per year increased annually by the
cost of living adjustment.
- Impose an excise tax of 2.3% on the sale of
any taxable medical device.
- Eliminate the tax-deduction for employers who
receive Medicare Part D retiree drug subsidy
Individual and Employer Requirements
- Require U.S. citizens and legal residents to
have qualifying health coverage (phase-in tax
penalty for those without coverage).
- Assess employers with more than 50 employees
that do not offer coverage and have at least one
full-time employee who receives a premium tax
credit a fee of $2,000 per full-time employee,
excluding the first 30 employees from the
assessment. Employers with more than 50
employees that offer coverage but have at least
one full-time employee receiving a premium tax
credit, will pay the lesser of $3,000 for each
employee receiving a premium credit or $2,000
for each full-time employee. Require employers
with more than 200 employees to automatically
enroll employees into health insurance plans
offered by the employer. Employees may opt out
- Create state-based American Health Benefit
Exchanges and Small Business Health Options
Program (SHOP) Exchanges, administered by a
governmental agency or non-profit organization,
through which individuals and small businesses
with up to 100 employees can purchase qualified
- Require guarantee issue and renewability and
allow rating variation based only on age
(limited to 3 to 1 ratio), premium rating area,
family composition, and tobacco use (limited to
1.5. to 1 ratio) in the individual and the small
group market and the Exchanges.
- Reduce the out-of-pocket limits for those with
incomes up to 400% FPL to the following levels:
- 100-200% FPL: one-third of the HSA limits
($1,983/individual and $3,967/family);
- 200-300% FPL: one-half of the HSA limits
($2,975/individual and $5,950/family);
- 300-400% FPL: two-thirds of the HSA limits
($3,987/individual and $7,973/family).
- Limit deductibles for health plans in the
small group market to $2,000 for individuals and
$4,000 for families unless contributions are
offered that offset deductible amounts above
- Limit any waiting periods for coverage to 90
- Create an essential health benefits package
that provides a comprehensive set of services,
covers at least 60% of the actuarial value of
the covered benefits, limits annual cost-sharing
to the current law HSA limits ($5,950/individual
and $11,900/family in 2010), and is not more
extensive than the typical employer plan.
- Require the Office of Personnel Management to
contract with insurers to offer at least two
multi-state plans in each Exchange. At least one
plan must be offered by a non-profit entity and
at least one plan must not provide coverage for
abortions beyond those permitted by federal law.
- Permit states the option to create a Basic
Health Plan for uninsured individuals with
incomes between 133-200% FPL who would otherwise
be eligible to receive premium subsidies in the
- Allow states the option of merging the
individual and small group markets. (Effective
January 1, 2014)
- Create a temporary reinsurance program to
collect payments from health insurers in the
individual and group markets to provide payments
to plans in the individual market that cover
- Require qualified health plans to meet new
operating standards and reporting requirements.
- Provide refundable and advanceable premium
credits and cost sharing subsidies to eligible
individuals and families with incomes between
133-400% FPL to purchase insurance through the
- Reduce the out-of-pocket amount that qualifies
an enrollee for catastrophic coverage in
Medicare Part D (effective through 2019);
- Establish an Independent Payment Advisory
Board comprised of 15 members to submit
legislative proposals containing recommendations
to reduce the per capita rate of growth in
Medicare spending if spending exceeds a target
growth rate. (Issue recommendations beginning
- Reduce Medicare Disproportionate Share
Hospital (DSH) payments initially by 75% and
subsequently increase payments based on the
percent of the population uninsured and the
amount of uncompensated care provided.
- Require Medicare Advantage plans to have
medical loss ratios no lower than 85%.
- Expand Medicaid to all non-Medicare eligible
individuals under age 65 (children, pregnant
women, parents, and adults without dependent
children) with incomes up to 133% FPL based on
modified adjusted gross income (MAGI) and
provides enhanced federal matching for new
- Reduce states’ Medicaid Disproportionate
Share Hospital (DSH) allotments.
- Increase spending caps for the territories.
- Permit employers to offer employees rewards of
up to 30%, increasing to 50% if appropriate, of
the cost of coverage for participating in a
wellness program and meeting certain
health-related standards. Establish 10-state
pilot programs to permit participating states to
apply similar rewards for participating in
wellness programs in the individual market.
- Impose fees on the health insurance sector.
2015 and later
- Permit states to form health care choice
compacts and allow insurers to sell policies in
any state participating in the compact.
(Compacts may not take effect before January 1,
- Reduce Medicare payments to certain hospitals
for hospital-acquired conditions by 1%.
(Effective fiscal year 2015)
- Impose an excise tax on insurers of
employer-sponsored health plans with aggregate
values that exceed $10,200 for individual
coverage and $27,500 for family coverage.
(Effective January 1, 2018)