Select Provisions in Health Care Reform

Insurance Reform:

No lifetime and annual limits: (Sec. 1001 as modified by Sec. 10101) Prohibits a health plan from establishing lifetime limits or annual limits on the dollar value of benefits for any participant or beneficiary after January 1, 2014. Permits a restricted annual limit for plan years beginning prior to January 1, 2014. Declares that a health plan shall not be prevented from placing annual or lifetime per-beneficiary limits on covered benefits to the extent that such limits are otherwise permitted.

Prohibition on rescissions: Prohibits a health plan from rescinding coverage of an enrollee except in the case of fraud or intentional misrepresentation of material fact.

Dependent coverage: Requires a health plan that provides dependent coverage of children to make such coverage available for an unmarried, adult child until the child turns 26 years of age. (Sec. 1004) Makes this subtitle effective for plan years beginning six months after enactment of this Act, with certain exceptions.

Limits on Preexisting condition exclusions: (Sec. 1201 as modified by Sec. 10103) Prohibits pre-existing condition exclusions. Prohibits discrimination on the basis of any health status-related factor. Allows premium rates to vary only by individual or family coverage, rating area, age, or tobacco use.

- High Risk Pools: (Sec. 1101) Requires the Secretary to establish a temporary high-risk health insurance pool program to provide health insurance coverage to eligible individuals with a pre-existing condition. Terminates such coverage on January 1, 2014, and provides for a transition to an American Health Benefit Exchange.

Guaranteed Issue/Renewability: Requires health plans in a state to: 1) accept every employer and individual in the state that applies for coverage; and 2) renew or continue coverage at the option of the plan sponsor or the individual, as applicable. Prohibits a health plan from establishing individual eligility rules based on health status-related factors, including medical condition, claims experience, receipt of health care, medical history, genetic information, and evidence of insurability.

Prohibition on excessive waiting periods: Prohibits a health plan from: 1) applying any waiting period for coverage that exceeds 90 days; or 2) discriminating against individual participation in clinical trials with respect to treatment of cancer or any other life-threatening disease or condition.

Essential Health Benefits: (Sec. 1302 as modified by Sec. 10104) Defines "qualified health plan" to require that such a plan provides "essential health benefits" and limit cost sharing. Directs the Secretary to: 1) define essential health benefits and include emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care; 2) ensure that the scope of the essential health benefits is equal to the scope of benefits provided under a typical employer plan; and 3) provide notice and an opportunity for public commend in defining the essential health benefits. Package to be updated annually.

Medicaid

Concurrent Care for Children (Sec. 2302) Allows payment for services provided to children, as defined by the state, who are eligible for Medicaid and have voluntarily elected to receive hospice services, without foregoing coverage of and payment for other services that are related to the treatment of the child's condition for which a diagnosis of terminal illness has been made.

Pediatric Accountable Care Organization Demonstration Project (Sec. 2706) Directs the Secretary to establish the Pediatric Accountable Care Organization Demonstration Project to authorize a participating state to allow pediatric medical providers meeting specified requirements to be recognized as an accountable care organization for the purpose of receiving specified incentive payments. Participating States, in consultation with the Secretary, would be required to establish an annual minimum level of savings in expenditures for items and services covered under Medicaid and CHIP that would need to be achieved by an ACO in order for the ACO to receive an incentive payment. ACOs that meet the performance guidelines established by the Secretary and achieve savings greater than the annual minimal savings level established by the state would receive an incentive payment.

Quality

National Quality Strategy (Sec. 3011 as modified by Sec. 10302) Directs the Secretary, through a transparent collaborative process, to establish a National Strategy for Quality Improvement in health care services, patient health outcomes, and population health, taking into consideration certain limitations on the use of comparative effectiveness data. In developing these priorities, the Secretary would ensure that they will: 1) have the greatest potential for improving health outcomes, efficiency, and patient-centeredness of health care; 2) identify areas in the delivery of health care services that have the potential for rapid improvement in the quality and efficiency of patient care; 3) address gaps in quality, efficiency, and health outcomes measures and data aggregation techniques; 4) improve Federal payment policy to emphasize quality and efficiency; 5) enhance the use of health care data to improve quality, efficiency, transparency, and outcomes; 6) address the health care provided to patients with high-cost chronic diseases; 7) improve strategies and best practices to improve patient safety and reduce medical errors, preventable admissions and readmissions, and health care-associated infections; 8) reduce health disparities across health disparity populations and geographic areas; and 9) address other areas as determined appropriate by the Secretary. The Secretary would update the national strategy not less than annually and the first report would be due to Congress not later than January 1, 2011. (Sec.3012) Directs the President to convene an Interagency Working Group on Health Care Quality.

Chronic Disease

Pain Care Management (Sec. 4305) Requires the Secretary to: 1) enter into an agreement with the Institute of Medicine to convene a Conference on Pain, the purposes of which shall include to increase the recognition of pain as a significant public health problem in the United States; and 2) establish the Interagency Pain Research Coordinating Committee. (Language from H.R.756/ S.660 - Rep. Capps (D-CA) and Sen. Hatch (R-UT) sponsors)

Comparative Effectiveness

Patient-Centered Outcomes (Sec. 6301 as modified by Sec. 10602) Amends SSA title XI to establish the Patient-Centered Outcomes Research Institute to identify priorities for, and establish, update, and carry out a national comparative outcomes research project agenda. Provides for a peer review process for primary research. Prohibits the Institute from allowing the subsequent use of data from original research in work-for-hire contracts with individuals, entities, or instrumentalities that have a financial interest in the results, unless approved by the Institute under a data use agreement. Amends the Public Health Service Act to direct the Office of Communication and Knowledge Transfer at AHRQ to disseminate broadly the research findings published by the Institute and other government-funded research relevant to comparative clinical effective research. Prohibits the Secretary from using evidence and findings from Institute research to make a determination regarding Medicare coverage unless such use is through an iterative and transparent process which includes public comment and considers the effect on subpopulations. (Sec. 6302) Terminates the Federal Coordinating Council for Comparative Effectiveness Research upon enactment of this Act.

Drug Development

Therapeutic Discovery Project Credit (Sec. 9023) Allows a 50% tax credit for investment in any qualifying therapeutic discovery project, defined as a project that is designed to: 1) treat or prevent diseases by conducting pre-clinical activities, clinical trials, and clinical studies, or carrying out research projects to approve new drugs or other biologic products; 2) diagnose diseases or conditions to determine molecular factors related to diseases or conditions; or 3) develop a product, process, or technology to further the delivery or administration of therapeutics. Companies must apply to the Secretary to obtain certification for qualifying investments. The Secretary, in determining qualifying projects, will consider only those projects that show reasonable potential to: 1) result in new therapies to treat areas of unmet medical need or to prevent, detect, or treat chronic or acute disease and conditions; 2) reduce long-term health care costs in the United States; or 3) significantly advance the goal of curing cancer within a 30-year period. Qualified therapeutic discovery project expenditures do not qualify for the research credit, orphan drug credit, or bonus depreciation. Directs the Secretary of the Treasury to award grants for 50% of the investment in 2009/2010 in such a project, in lieu of the tax credit. The provision allocates $1 billion during the 2-year period 2009-2010 for the program. The credit is available only to companies having 250 or fewer employees. (Championed by Senator Memendez (D-NJ)).

Cures Acceleration Network (Sec. 10409) Cures Acceleration Network Act of 2009 - Amends the Public Health Service Act to require the Secretary, acting through the Director of the National Institutes of Health (NIH), to implement the Cures Acceleration Network under which grants and contracts will be awarded to accelerate the development of high need cures. Defines "high need cure" as a drug, biological product, or device: 1) that is a priority to diagnose, mitigate, prevent, or treat harm from any disease or condition; and 2) for which the incentives of the commercial market are unlikely to result in its adequate or timely development. Establishes a Cures Acceleration Network Review Board. (Language from Sen. Spector's (D-PA) bill, S.914)