Senator Maria Cantwell (D-WA) has introduced 19 amendments to Senator Max Baucus’s health reform package, titled America’s Healthy Future Act of 2009.

Keep reading to see them all…

Cantwell Amendment #C1 to America’s Healthy Future Act of 2009

Short Title: Incentives for States to Offer Home and Community Based Services (HCBS) as a Long-Term Care Alternative to Nursing Homes for the Medicaid Population.

Description of Amendment: This amendment provides a modest, targeted, 5-year-limited increase in federal matching payments (FMAP) for Medicaid covered home and community based services (HBCS). This FMAP increase will be available only to those states willing to undertake certain structural reforms in their Medicaid long-term care programs that have been proven to increase nursing home diversions and access to HCBS. The targeted FMAP increase is offered on a scale based upon the percentage of a state’s long-term care that is offered through HCBS, with lower FMAP increases going to states that will need to make fewer reforms.

This amendment also includes provisions which make it easier for states to provide HCBS under existing Medicaid waiver and option authorities. States will be able to offer HCBS through state plan amendments for targeted populations, including HCBS populations up to 300 percent of the maximum Supplemental Security Income payment.

This amendment reflects S. 1256, the Home and Community Balanced Incentives Act of 2009.

Offset: A 1.45% surtax on short-term capital gains.

Cantwell Amendment #C-2 to America’s Healthy Future Act of 2009

Short Title: Pharmacy Benefit Manager (PBM) Transparency for Health Plans Operating in the Health Insurance Exchanges

Description of Amendment: The amendment requires pharmaceutical benefit managers (PBM) to share basic information with the commissioners of the exchanges and with any plans the PBMs contracts with in the exchanges. This information will be considered confidential and must be protected by the commissioners and the plans. The PBM will be required to confidentially disclose information on: (1) the percent of all prescriptions that are provided through retail pharmacies compared to mail order pharmacies, and the generic dispensing and substitution rates in each location; 2) the aggregate amount and types of rebates, discounts and price concessions that the PBM negotiates on behalf of the plan and the aggregate amount of these that are passed through to the plan sponsor; 3) the average aggregate difference between the amount the plan pays the PBM and the amount that the PBM pays the retail and mail order pharmacy. There are no mandates that these rebates are passed through, only that they be reported to plans.

Offset: This amendment is not expected to require an offset, however, a sufficient offset to ensure that it is revenue neutral will be provided, if needed.

Cantwell Amendment #C-3 to America’s Healthy Future Act of 2009.

Title: Increase authorized funding to allow for full national implementation of Aging and Disability Resource Centers (ADRC).

Description: The amendment modifies the Aging and Disability Resource Center (ADRC) section in the Chairman’s Mark to increase the total ADRC authorization to a total of $727 million for the years 2010 through 2020 years. This funding expands the Mark’s current proposal to allow for full national implementation of the ADRC pilot project.

ADRCs are a model tested and proven by demonstration projects under the Administration on Aging (AoA) and the Centers for Medicare and Medicaid (CMS). The amendment modifies the Mark to reflect current policy and ensure that the Secretary of Health and Human Services has the authority and resources to make grants to the states for ADRCs through the Administration on Aging, which administers the program. Demonstrations have achieved savings by diverting Medicaid eligible clients who qualify for institutional care to the Medicaid home and community based service (HCBS) waivers.

Offset: The amendment authorizes funding and therefore does not require an offset.

Cantwell Amendment #C-4 to America’s Healthy Future Act of 2009.

Title: Provide mandatory funding to allow for full national implementation of Aging and Disability Resource Centers (ADRC).


Description: The amendment modifies the Aging and Disability Resource Center (ADRC) section in the Chairman’s Mark to provide mandatory funding for ADRCs. The funding totals $727 million for the years 2010 through 2020 years. This funding expands the Mark’s current proposal to allow for full national implementation of the ADRC pilot project.

ADRCs are model tested and proven demonstration projects under the Administration on Aging (AoA) and the Centers for Medicare and Medicaid (CMS). The amendment modifies the Mark to reflect current policy and ensure that the Secretary of Health and Human Services has the authority and resources to make grants to the states for ADRCs through the Administration on Aging, which administers the program. Demonstrations have achieved savings by diverting Medicaid eligible clients who qualify for institutional care to the Medicaid home and community based service (HCBS) waivers.

The amendment reflects Subtitle A of S. 1217, Project 2020: Building on the Promise of Home and Community-Based Services Act of 2009.

Offset: The needed, the necessary offsets will be provided to ensure budget neutrality.

Cantwell Amendment #C-5 to America’s Healthy Future Act of 2009

Title: Authorize funding for national implementation of evidence-based wellness and disease prevention programs for older Americans to reduce the necessity of institutional care.

Description: The amendment would authorize $1.14 billion over 10 years to allow full implementation of demonstration projects currently authorized under the Older Americans Act. Wellness promotion and disease prevention programs are cost-effective, non-clinical programs. Currently, 26 Centers for Disease Control and Prevention approved pilot projects are operating across the nation. States that have piloted these programs see documented savings by helping participants avoid hospitalizations and unnecessary physician visits. Workforce training is provided to ensure the various evidence-based programs have sufficient staff. Under this amendment, all states would be eligible to receive funding for programs of this type.

The amendment reflects Subtitle B of S. 1217, Project 2020: Building on the Promise of Home and Community-Based Services Act of 2009.

Offset: The amendment authorizes funding and therefore does not require an offset.

Cantwell Amendment #C-6 to America’s Healthy Future Act of 2009

Title: Provide for mandatory funding for national implementation of evidence-based wellness and disease prevention programs for older Americans to reduce the necessity of institutional care.

Description: The amendment would provide $1.14 billion over 10 years in mandatory funding to allow full implementation of demonstration projects currently authorized under the Older Americans Act. Wellness promotion and disease prevention programs are cost-effective, non-clinical programs. Currently, 26 Centers for Disease Control and Prevention approved pilot projects are operating across the nation. States that have piloted these programs see documented savings by helping participants avoid hospitalizations and unnecessary physician visits. Workforce training is provided to ensure the various evidence-based programs have sufficient staff. Under this amendment, all states would be eligible to receive funding for programs of this type.

The amendment reflects Subtitle B of S. 1217, Project 2020: Building on the Promise of Home and Community-Based Services Act of 2009.

Offset: The needed, the necessary offsets will be provided to ensure budget neutrality.

Cantwell Amendment #C-7 to America’s Healthy Future Act of 2009

Title: National implementation of current Administration on Aging (AoA) and Centers for Medicare and Medicaid Services (CMS) nursing home diversion projects.

Description: The amendment authorizes $11.49 billion over 10 years to nationally implement current non-Medicaid nursing home diversion projects which prevent institutionalization and asset spend down to Medicaid eligibility. These programs prevent impoverishment and provide for a consumer-directed option allowing consumers to purchase services and supports that help them to remain independent. Such services including homemaker support, assistive technology, and minor adaptive and rehabilitative home repairs.

The amendment reflects Subtitle C of S. 1217, Project 2020: Building on the Promise of Home and Community-Based Services Act of 2009.

Offset: The amendment authorizes funding and therefore does not require an offset.

Cantwell Amendment #C-8 to America’s Healthy Future Act of 2009

Title: National implementation of current Administration on Aging (AoA) and Centers for Medicare and Medicaid Services (CMS) nursing home diversion projects.

Description: The amendment provides for $11.49 billion over 10 years in mandatory funding to nationally implement current non-Medicaid nursing home diversion projects which prevent institutionalization and asset spend down to Medicaid eligibility. These programs prevent impoverishment and provide for a consumer-directed option allowing consumers to purchase services and supports that help them to remain independent. Such services including homemaker support, assistive technology, and minor adaptive and rehabilitative home repairs.

The amendment reflects Subtitle C of S. 1217, Project 2020: Building on the Promise of Home and Community-Based Services Act of 2009.

Offset: The needed, the necessary offsets will be provided to ensure budget neutrality.

Cantwell Amendment #C-9 to America’s Healthy Future Act of 2009

Short Title: Provide for coverage in a direct primary care medical home plan, provided that plan is coupled with a quality wrap-around insurance program to cover non-primary care services.

Description: Direct primary care medical homes (DPM) practices offer patients comprehensive primary care coverage outside of traditional insurance and include preventive and primary care as well as chronic disease management. Care is coordinated with specialists and hospitals. Beneficiaries in a DPM program pay a flat monthly fee in lieu of a premium to cover primary care and preventive services. Specifies that enrollees in a DPM must also obtain wrap-around insurance to cover non-DPM provided services.

Offset: This amendment requires no funding and therefore does not require an offset.

Cantwell Amendment #C-10 to America’s Healthy Future Act of 2009.

Title: Allow states with “mature co-ops” to apply for federal start-up funding currently authorized in the Mark.

Description: The amendment would allow states with “mature co-ops,” to be defined by the amendment, to apply for federal start-up funding available through the new co-op program, and use such to expand access to care and make health care more affordable in the most efficient and effective way for that state. Such funds may be used in partnership with the mature co-ops at the discretion of the states.

Offset: No new funding is required for this amendment.

Cantwell Amendment #C-11 to America’s Healthy Future Act of 2009.

Title: Requires national plans to abide by all state insurance regulations.

Description: Any national insurance plans that wish to sell health care coverage across state lines would be required to abide by all existing state laws and regulations governing the health insurance market in the state in which the coverage is sold.

Offset: The amendment requires no new funding.

Cantwell Amendment #C-12 to America’s Healthy Future Act of 2009.

Title: To allow manufacturers to provide assistance to individuals enrolled in a Medicare Part D plan.

Description: The Amendment allows manufacturers to provide assistance to individuals enrolled in a Medicare Part D plan with substantial out-of-pocket costs through the use of coupons, co-payment cards, and other non-cash instruments. This manufacturer cost sharing assistance will count toward “true out-of-pocket” (TrOOP) expenses, so the assistance afforded by this program will not impede the beneficiary from reaching the annual out-of-pocket threshold. Manufacturer cost sharing assistance is only available for categories or classes of drugs that were found to result in lower spending per enrollee in the Medicare Replacement Drug Demonstration that was authorized by section 641 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (P.L. 108-173), or other products that the Secretary determines will result in lower Medicare expenditures or improve access to treatment. The Amendment will create an exception to the anti-kickback statute for manufacturer cost sharing assistance provided under the amendment and exempt the assistance from inclusion in the determination of “best price” under the Medicaid statute.

Offset: This amendment requires no new funding.

Cantwell Amendment #C-13 to the American’s Health Future Act of 2009

Short Title: Clarify the definition of full-time employee for purposes of determining the employer assessment.

Description of Amendment: This amendment would clarify that full-time employees are those working at least 390 hours per calendar quarter. In addition, for the purposes of determining the employer assessment, fees would be assessed quarterly at $100 multiplied by all full-time employees of the employer during such quarter (capped as under the mark at $400 per year).

Offset: Assumed in Chairman’s Mark.


Cantwell Amendment #C-14 to the American’s Health Future Act of 2009

Short Title: Reduce the amount of the “Free-Rider” Penalty by Employer Contributions into a Health Reimbursement Arrangement

Short Description: The amendment would allow an employer who is otherwise required to pay a fee for employees receiving premium credits to reduce the amount of that payment by any amounts contributed by the employer to an individually controlled HRA.

Offset: Cost should be negligible; but an appropriate offset will be provided if needed.

Cantwell Amendment #D-15 to America’s Healthy Future Act of 2009.

Title: Basic Health Plan

Description: The Secretary of Health and Human Services shall establish a basic health plan that will provide affordable coverage to individuals below 200 of the federal poverty level. Individuals below 200 percent of the federal poverty level will not be eligible to receive tax credits to purchase coverage through the health insurance exchanges, and will instead be able to access affordable coverage this basic health plan.

Offset: An appropriate offset will be provided if necessary.

Cantwell Amendment #D-1 to America’s Healthy Future Act of 2009

Short Title: Incentivize Value in the Medicare Fee-For-Service Physician Payment Formula

Description of Amendment: The Secretary of Health and Human Services shall apply a separate payment modifier to the physician payment formula, independent of the Geographic Adjustment Factor. This separate payment modifier will, in a budget neutral manner, pay physicians or groups of physicians differentially based upon the relative quality of care they achieve for Medicare beneficiaries relative to cost. Quality shall be based upon a composite of appropriate measures of quality that reflect the health outcomes and health status of Medicare beneficiaries served by physicians or groups of physicians. Costs shall be based upon a composite of appropriate measures of cost that take into account justifiable differences in input practice costs, as well as the demographic characteristics and baseline health status of the Medicare beneficiaries served by physicians or groups of physicians.

The Secretary would be required to specify, during fee schedule rulemaking applicable for 2011, how the measurement of quality and cost would be structured, as well as specifying the prospective performance period. During the performance period, which will begin in 2012, the Secretary will provide information to physicians about the value of care they provide. Performance would be assessed and the Secretary will implement payment consequences beginning in 2013.

The payment modifier shall be applied in a way that promotes systems-based care. The Secretary shall coordinate these value-based purchasing reforms with other HHS initiatives that are intended to incentivize more integrated and coordinated delivery of efficient and high-quality care.
The Secretary would be required to ensure that: (1) the VBP report to Congress includes a plan for moving the physician payment system to a value-driven model; (2) the plan is phased-in, in accordance with the schedule described in the plan, ensuring implementation as quickly as practicable, but no later than within five years of the initial implementation of this section. By this time, all physicians or groups of physicians must be participating in a payment system that holds them accountable for the value of care they deliver to Medicare beneficiaries.
Offset: This amendment is budget neutral.

Cantwell Amendment #D-2 to America’s Healthy Future Act of 2009

Short Title: Physician Workforce Enhancement

Description of Amendment: Directs the Secretary of the Department of Health and Human Services to establish the loan program through the Administrator of the Centers for Medicare & Medicaid Services. Hospitals committed to starting new osteopathic or allopathic residency training programs in one of eight medical specialties or a combination of specialties (family medicine, internal medicine, emergency medicine, obstetrics/gynecology, general surgery, preventive medicine, pediatrics, or behavioral and mental health) could secure start-up funding to offset the initial costs of starting such programs.

Provides financial incentives to facilitate the creation of new residency training programs in geographic areas that lack an adequate supply of physicians. Acquired funding could be used to offset the costs of residency salaries and benefits, faculty salaries, and other costs directly attributable to the residency program.

Directs the Secretary to establish the program no later than January 1, 2010. Requires hospitals securing a loan under the program to repay the total sum, without interest, to the Treasury within 24 months. The program would be terminated December 31, 2019.

This amendment reflects Title I, Physician Workforce Enhancement, of the S.1262, the Medical Efficiency and Delivery Improvement of Care Act (MEDIC) of 2009.

Offset: The amendment specifies loan re-payment schedule making it budget neutral.

Cantwell Amendment #F1 to the America’s Healthy Future Act of 2009

Title: Equalize the tax treatment of Health Reimbursement Arrangements (HRA) established by all governmental employers.

Description: Under current law, distributions from an HRA are excluded from gross income if they are used for qualified medical expenses. When a participant dies, the HRA can still be used to pay for qualified medical expenses of the participant’s surviving spouse or qualified dependents and these amounts will not be included in the spouse/dependent’s income.

IRS Revenue Ruling 2006-36, which took effect this year (2009), prohibits an HRA from providing excludable medical reimbursements to nondependent beneficiaries when no surviving spouse or qualified dependents remain after a participant’s death.

The elimination of medical reimbursements to non-dependent heirs is a concern for employees contemplating continued participation in their HRA plan. The fear of potentially losing accumulated assets within this key retiree medical savings tool, due to an untimely death, strongly discourages individual HRA savings for future health care expenses.

Congress partially addressed these concerns in the Worker, Retiree, and Employer Recovery Act of 2008 for participants in plans provided by certain governmental employers. The criteria laid out in the law, which covers plans established in connection with a public retirement system that has been authorized by a state legislature, however, leaves out plans provided to governmental employees using VEBAs and plans that are established by local government employers.

The amendment would correct this disparity by including plans established by or on behalf of a state or a political subdivision thereof and qualified VEBAs in the special rule under IRC Section 105(j).

The amendment will include offsets sufficient to ensure that the amendment is revenue neutral.

Cantwell Amendment #F2 to the America’s Healthy Future Act of 2009

Title: Clarify that tax-exempt bonds can be used for fixed-wing air ambulances.

Description: Under current law, tax-exempt bonds can not be issued for the purchase of any “airplane, skybox or other privacy luxury box, health club facility, facility primarily used for gambling, or store the principal business of which is the sale of alcoholic beverages for consumption off premises.” Unfortunately, these rules have been interpreted to also exclude the purchase of new, fixed-wing planes to provide air ambulance services.

The amendment would modify section 147(e) by clarifying that this restriction does not apply to apply to any fixed-wing aircraft equipped for, and exclusively dedicated to providing, acute care emergency medical services.

The amendment will include offsets sufficient to ensure that the amendment is revenue neutral.

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