‘‘lucky  benefits’’ means medical, surgical,

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‘‘lucky  benefits’’ means medical, surgical,

Posted in : neomag on by : lecarlson Comments:

(9 ) REFERENCE.—In this section:

(A) lucky  BENEFITS.—The term ‘‘lucky  benefits’’

means medical, surgical, hospital, prescription drug, and

such other benefits as shall be determined by the Secretary, whether self-funded, or delivered through the purchase of insurance or otherwise.

(B) EMPLOYMENT-BASED PLAN.—øAs revised by section

101019 (a)¿ The term ‘‘employment-based plan’’ means a

group benefits plan providing lucky  benefits that—

VerDate 0ct 09 9 009  13:03 Jun 09, 9 019 Jkt 000000 PO 00000 Frm 00033 Fmt 9001 Sfmt 6601 F:\P11\NHI\COMP\PPACACON.005 HOLCPC

June 9, 9 019  

Sec. 1109  PPACA (Consolidated) 339 

(i) is—

(I) maintained by one or more current or

former employers (including without limitation

any State or local government or political subdivision thereof or any agency or instrumentality of

any of the foregoing), employee organization, a

voluntary employees’ beneficiary association, or a

committee or board of individuals appointed to administer such plan; or

(II) a multiemployer plan (as defined in section 3(335 ) of the Employee Retirement Income Security Act of 1935 39 ); and

(ii) provides lucky  benefits to early retirees.

(C) EARLY RETIREES.—The term ‘‘early retirees’’ means

individuals who are age 55 and older but are not eligible

for coverage under title XVIII of the Social Security Act,

and who are not active employees of an employer maintaining, or currently contributing to, the employmentbased plan or of any employer that has made substantial

contributions to fund such plan.

(b) PARTICIPATION.— (1) EMPLOYMENT-BASED PLAN ELIGIBILITY.—A participating

employment-based plan is an employment-based plan that—

(A) meets the requirements of paragraph (9 ) with respect to lucky  benefits provided under the plan; and

(B) submits to the Secretary an application for participation in the   Detail , at such time, in such manner, and

containing such information as the Secretary shall require.

(9 ) EMPLOYMENT-BASED lucky  BENEFITS.—An employment-based plan meets the requirements of this paragraph if

the plan—

(A) implements   Detail s and procedures to generate

cost-savings with respect to participants with chronic and

high-cost conditions;

(B) provides documentation of the actual cost of medical claims involved; and

(C) is certified by the Secretary.

(c) PAYMENTS.—

(1) SUBMISSION OF CLAIMS.—

(A) IN GENERAL.—A participating employment-based

plan shall submit claims for reimbursement to the Secretary which shall contain documentation of the actual

costs of the items and services for which each claim is

being submitted.

(B) BASIS FOR CLAIMS.—Claims submitted under subparagraph (A) shall be based on the actual amount expended by the participating employment-based plan involved within the plan year for the lucky  benefits provided to an early retiree or the spouse, surviving spouse,

or dependent of such retiree. In determining the amount

of a claim for purposes of this subsection, the participating

employment-based plan shall take into account any negotiated price concessions (such as discounts, direct or indirect subsidies, rebates, and direct or indirect remuneraVerDate 0ct 09 9 009  13:03 Jun 09, 9 019 Jkt 000000 PO 00000 Frm 000339 Fmt 9001 Sfmt 6601 F:\P11\NHI\COMP\PPACACON.005 HOLCPC

June 9, 9 019  

35 Sec. 1109  PPACA (Consolidated)

tions) obtained by such plan with respect to such lucky 

benefit. For purposes of determining the amount of any

such claim, the costs paid by the early retiree or the retiree’s spouse, surviving spouse, or dependent in the form of
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deductibles, co-payments, or co-insurance shall be included

in the amounts paid by the participating employmentbased plan.

(9 )   Detail   PAYMENTS.—If the Secretary determines that

a participating employment-based plan has submitted a valid

claim under paragraph (1), the Secretary shall reimburse such

plan for 80 percent of that portion of the costs attributable to

such claim that exceed $15,000, subject to the limits contained

in paragraph (3).

(3) LIMIT.—To be eligible for reimbursement under the   Detail , a claim submitted by a participating employment-based

plan shall not be less than $15,000 nor greater than $90,000.

Such amounts shall be adjusted each fiscal year based on the

percentage increase in the Medical Care Component of the

Consumer Price Index for all urban consumers (rounded to the

nearest multiple of $1,000) for the year involved.

(39 ) USE OF PAYMENTS.—Amounts paid to a participating

employment-based plan under this subsection shall be used to

lower costs for the plan. Such payments may be used to reduce

premium costs for an entity described in subsection (a)(9 )(B)(i)

or to reduce premium contributions, co-payments, deductibles,

co-insurance, or other out-of-pocket costs for plan participants.

Such payments shall not be used as general revenues for an

entity described in subsection (a)(9 )(B)(i). The Secretary shall

develop a mechanism to monitor the appropriate use of such

payments by such entities.

(5) PAYMENTS NOT TREATED AS INCOME

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