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HR 3200 IHRHCommentsClose CommentsPermalink

111th CONGRESSCommentsClose CommentsPermalink

1st SessionCommentsClose CommentsPermalink

H. R. 3200CommentsClose CommentsPermalink

To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.CommentsClose CommentsPermalink

IN THE HOUSE OF REPRESENTATIVESCommentsClose CommentsPermalink

July 14, 2009CommentsClose CommentsPermalink

Mr. DINGELL (for himself, Mr. RANGEL, Mr. WAXMAN, Mr. GEORGE MILLER of California, Mr. STARK, Mr. PALLONE, and Mr. ANDREWS) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Education and Labor, Oversight and Government Reform, and the Budget, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concernedCommentsClose CommentsPermalink

A BILLCommentsClose CommentsPermalink

To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.CommentsClose CommentsPermalink

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, CommentsClose CommentsPermalink

SECTION 1. SHORT TITLE; TABLE OF DIVISIONS, TITLES, AND SUBTITLES.

(a) Short Title- This Act may be cited as the ‘America’s Affordable Health Choices Act of 2009’. CommentsClose CommentsPermalink





(b) Table of Divisions, Titles, and Subtitles- This Act is divided into divisions, titles, and subtitles as follows: CommentsClose CommentsPermalink

DIVISION A--AFFORDABLE HEALTH CARE CHOICES

TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS CommentsClose CommentsPermalink





Subtitle A--General Standards CommentsClose CommentsPermalink





Subtitle B--Standards Guaranteeing Access to Affordable Coverage CommentsClose CommentsPermalink





Subtitle C--Standards Guaranteeing Access to Essential Benefits CommentsClose CommentsPermalink





Subtitle D--Additional Consumer Protections CommentsClose CommentsPermalink





Subtitle E--Governance CommentsClose CommentsPermalink





Subtitle F--Relation to Other Requirements; Miscellaneous CommentsClose CommentsPermalink





Subtitle G--Early Investments CommentsClose CommentsPermalink





TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS CommentsClose CommentsPermalink





Subtitle A--Health Insurance Exchange CommentsClose CommentsPermalink





Subtitle B--Public Health Insurance Option CommentsClose CommentsPermalink





Subtitle C--Individual Affordability Credits CommentsClose CommentsPermalink





Subtitle D--Health Insurance Cooperatives CommentsClose CommentsPermalink





TITLE III--SHARED RESPONSIBILITY CommentsClose CommentsPermalink





Subtitle A--Individual Responsibility Subtitle B--Employer Responsibility Subtitle A--Individual Responsibility CommentsClose CommentsPermalink





Subtitle B--Employer Responsibility CommentsClose CommentsPermalink





TITLE IV--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986 CommentsClose CommentsPermalink





Subtitle A--Shared Responsibility CommentsClose CommentsPermalink





Subtitle B--Credit for Small Business Employee Health Coverage Expenses CommentsClose CommentsPermalink





Subtitle C--Disclosures To Carry Out Health Insurance Exchange Subsidies CommentsClose CommentsPermalink





Subtitle D--Other Revenue Provisions CommentsClose CommentsPermalink

DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS

TITLE I--IMPROVING HEALTH CARE VALUE CommentsClose CommentsPermalink





Subtitle A--Provisions Related to Medicare Part A CommentsClose CommentsPermalink





Subtitle B--Provisions Related to Part BMedicare Part B CommentsClose CommentsPermalink





Subtitle C--Provisions Related to Medicare Parts A and B CommentsClose CommentsPermalink





Subtitle D--Medicare Advantage Reforms CommentsClose CommentsPermalink





Subtitle E--Improvements to Medicare Part D CommentsClose CommentsPermalink





Subtitle F--Medicare Rural Access Protections CommentsClose CommentsPermalink





TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS CommentsClose CommentsPermalink





Subtitle A--Improving and Simplifying Financial Assistance for Low Income Medicare Beneficiaries CommentsClose CommentsPermalink





Subtitle B--Reducing Health Disparities CommentsClose CommentsPermalink





Subtitle C--Miscellaneous Improvements CommentsClose CommentsPermalink





TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND COORDINATED CARE CommentsClose CommentsPermalink





TITLE IV--QUALITY CommentsClose CommentsPermalink





Subtitle A--Comparative Effectiveness Research CommentsClose CommentsPermalink





Subtitle B--Nursing Home Transparency Subtitle B--Nursing Home Transparency CommentsClose CommentsPermalink





Subtitle C--Quality Measurements CommentsClose CommentsPermalink





Subtitle D--Physician Payments Sunshine Provision CommentsClose CommentsPermalink





Subtitle E--Public Reporting on Health Care-Associated Infections CommentsClose CommentsPermalink





TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION CommentsClose CommentsPermalink





TITLE VI--PROGRAM INTEGRITY CommentsClose CommentsPermalink





Subtitle A--Increased Funding To Fight Waste, Fraud, and Abuse CommentsClose CommentsPermalink





Subtitle B--Enhanced Penalties for Fraud and Abuse CommentsClose CommentsPermalink





Subtitle C--Enhanced Program and Provider Protections CommentsClose CommentsPermalink





Subtitle D--Access to Information Needed To Prevent Fraud, Waste, and Abuse CommentsClose CommentsPermalink





TITLE VII--MEDICAID AND CHIP CommentsClose CommentsPermalink





Subtitle A--Medicaid and Health Reform CommentsClose CommentsPermalink





Subtitle B--Prevention Subtitle C--Access Subtitle D--Coverage Subtitle B--Prevention CommentsClose CommentsPermalink





Subtitle C--Access CommentsClose CommentsPermalink





Subtitle D--Coverage CommentsClose CommentsPermalink





Subtitle E--Financing CommentsClose CommentsPermalink





Subtitle F--Waste, Fraud, and Abuse CommentsClose CommentsPermalink





Subtitle G--Puerto Rico and the Territoriesayments to the Territories CommentsClose CommentsPermalink





Subtitle H--Miscellaneous CommentsClose CommentsPermalink





TITLE VIII--REVENUE-RELATED PROVISIONS CommentsClose CommentsPermalink





TITLE IX--MISCELLANEOUS PROVISIONS CommentsClose CommentsPermalink

DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT

TITLE I--COMMUNITY HEALTH CENTERS CommentsClose CommentsPermalink





TITLE II--WORKFORCE CommentsClose CommentsPermalink





Subtitle A--Primary Care Workforce CommentsClose CommentsPermalink





Subtitle B--Nursing Workforce CommentsClose CommentsPermalink





Subtitle C--Public Health Workforce CommentsClose CommentsPermalink





Subtitle D--Adapting Workforce to Evolving Health System Needs CommentsClose CommentsPermalink





TITLE III--PREVENTION AND WELLNESS CommentsClose CommentsPermalink





TITLE IV--QUALITY AND SURVEILLANCE CommentsClose CommentsPermalink





TITLE V--OTHER PROVISIONS CommentsClose CommentsPermalink





Subtitle A--Drug Discount for Rural and Other Hospitals CommentsClose CommentsPermalink





Subtitle B--School-Based Health Clinics Subtitle C--National Medical Device Registry Subtitle D--Grants for Comprehensive Programs To Provide Education to Nurses and Create a Pipeline to Nursing Subtitle B--Programs CommentsClose CommentsPermalink





Subtitle C--Food and Drug Administration CommentsClose CommentsPermalink





Subtitle D--Community Living Assistance Services and Supports CommentsClose CommentsPermalink





Subtitle E--States Failing To Adhere to Certain Employment ObligationMiscellaneous CommentsClose CommentsPermalink

DIVISION A--AFFORDABLE HEALTH CARE CHOICES CommentsClose CommentsPermalink

SEC. 100. PURPOSE; TABLE OF CONTENTS OF DIVISION; GENERAL DEFINITIONS.

(a) Purpose- CommentsClose CommentsPermalink





(1) IN GENERAL- The purpose of this division is to provide affordable, quality health care for all Americans and reduce the growth in health care spending. CommentsClose CommentsPermalink





(2) BUILDING ON CURRENT SYSTEM- This division achieves this purpose by building on what works in today’s health care system, while repairing the aspects that are broken. CommentsClose CommentsPermalink





(3) INSURANCE REFORMS- This division-- CommentsClose CommentsPermalink





(A) enacts strong insurance market reforms; CommentsClose CommentsPermalink





(B) creates a new Health Insurance Exchange, with a public health insurance option alongside private plans and cooperatives under subtitle D of title II; CommentsClose CommentsPermalink





(C) includes sliding scale affordability credits; and CommentsClose CommentsPermalink





(D) initiates shared responsibility among workers, employers, and the government; CommentsClose CommentsPermalink





so that all Americans have coverage of essential health benefits. CommentsClose CommentsPermalink





(4) HEALTH DELIVERY REFORM- This division institutes health delivery system reforms both to increase quality and to reduce growth in health spending so that health care becomes more affordable for businesses, families, and government. CommentsClose CommentsPermalink





(b) Table of Contents of Division- The table of contents of this division is as follows: CommentsClose CommentsPermalink





Sec. 100. Purpose; table of contents of division; general definitions. CommentsClose CommentsPermalink

TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS

Subtitle A--General Standards

Sec. 101. Requirements reforming health insurance marketplace. CommentsClose CommentsPermalink





Sec. 102. Protecting the choice to keep current coverage. CommentsClose CommentsPermalink

Subtitle B--Standards Guaranteeing Access to Affordable Coverage

Sec. 111. Prohibiting pre-existing condition exclusions. CommentsClose CommentsPermalink





Sec. 112. Guaranteed issue and renewal for insured plans. CommentsClose CommentsPermalink





Sec. 113. Insurance rating rules. CommentsClose CommentsPermalink





Sec. 114. Nondiscrimination in benefits; parity in mental health and substance abuse disorder benefits. CommentsClose CommentsPermalink





Sec. 115. Ensuring adequacy of provider networks. CommentsClose CommentsPermalink





Sec. 116. Ensuring value and lower premiums. CommentsClose CommentsPermalink

Subtitle C--Standards Guaranteeing Access to Essential Benefits

Sec. 121. Coverage of essential benefits package. CommentsClose CommentsPermalink





Sec. 122. Essential benefits package defined. CommentsClose CommentsPermalink





Sec. 123. Health Benefits Advisory Committee. CommentsClose CommentsPermalink





Sec. 124. Process for adoption of recommendations; adoption of benefit standards. CommentsClose CommentsPermalink





Sec. 125. Prohibition of discrimination in health care services based on religious or spiritual content. CommentsClose CommentsPermalink

Subtitle D--Additional Consumer Protections

Sec. 131. Requiring fair marketing practices by health insurers. CommentsClose CommentsPermalink





Sec. 132. Requiring fair grievance and appeals mechanisms. CommentsClose CommentsPermalink





Sec. 133. Requiring information transparency and plan disclosure. CommentsClose CommentsPermalink





Sec. 134. Application to qualified health benefits plans not offered through the Health Insurance Exchange. CommentsClose CommentsPermalink





Sec. 135. Timely payment of claims. CommentsClose CommentsPermalink





Sec. 136. Standardized rules for coordination and subrogation of benefits. CommentsClose CommentsPermalink





Sec. 137. Application of administrative simplification. CommentsClose CommentsPermalink





Sec. 138. Information on end-of-life planning. CommentsClose CommentsPermalink





Sec. 139. Utilization review activities. CommentsClose CommentsPermalink





Sec. 139A. Internal appeals procedures. CommentsClose CommentsPermalink





Sec. 139B. External appeals procedures. CommentsClose CommentsPermalink

Subtitle E--Governance

Sec. 141. Health Choices Administration; Health Choices Commissioner. CommentsClose CommentsPermalink





Sec. 142. Duties and authority of Commissioner. CommentsClose CommentsPermalink





Sec. 143. Consultation and coordination. CommentsClose CommentsPermalink





Sec. 144. Health Insurance Ombudsman. CommentsClose CommentsPermalink

Subtitle F--Relation to Other Requirements; Miscellaneous

Sec. 151. Relation to other requirements. CommentsClose CommentsPermalink





Sec. 152. Prohibiting discrimination in health care. CommentsClose CommentsPermalink





Sec. 153. Whistleblower protection. CommentsClose CommentsPermalink





Sec. 154. Construction regarding collective bargaining. CommentsClose CommentsPermalink





Sec. 155. Severability. CommentsClose CommentsPermalink





Sec. 156. Application of State and Federal laws regarding abortion. CommentsClose CommentsPermalink





Sec. 157. Non-discrimination on abortion and respect for rights of conscience. CommentsClose CommentsPermalink

Subtitle G--Early Investments

Sec. 161. Ensuring value and lower premiums. CommentsClose CommentsPermalink





Sec. 162. Ending health insurance rescission abuse. CommentsClose CommentsPermalink





Sec. 163. Ending health insurance denials and delays of necessary treatment for children with deformities. CommentsClose CommentsPermalink





Sec. 164. Administrative simplification. CommentsClose CommentsPermalink





Sec. 1645. Expansion of electronic transactions in medicare. CommentsClose CommentsPermalink





Sec. 166. Reinsurance program for retirees. CommentsClose CommentsPermalink





Sec. 167. Limitations on preexisting condition exclusions in group health plans and health insurance coverage in the group and individual markets in advance of applicability of new prohibition of preexisting condition exclusions. CommentsClose CommentsPermalink

TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

Subtitle A--Health Insurance Exchange

Sec. 201. Establishment of Health Insurance Exchange; outline of duties; definitions. CommentsClose CommentsPermalink





Sec. 202. Exchange-eligible individuals and employers. CommentsClose CommentsPermalink





Sec. 203. Benefits package levels. CommentsClose CommentsPermalink





Sec. 204. Contracts for the offering of Exchange-participating health benefits plans. CommentsClose CommentsPermalink





Sec. 205. Outreach and enrollment of Exchange-eligible individuals and employers in Exchange-participating health benefits plans. CommentsClose CommentsPermalink





Sec. 206. Other functions. CommentsClose CommentsPermalink





Sec. 207. Health Insurance Exchange Trust Fund. CommentsClose CommentsPermalink





Sec. 208. Optional operation of State-based health insurance exchanges. CommentsClose CommentsPermalink





Sec. 209. Limitation on premium increases under Exchange-participating health benefits plans. CommentsClose CommentsPermalink

Subtitle B--Public Health Insurance Option

Sec. 221. Establishment and administration of a public health insurance option as an Exchange-qualified health benefits plan. CommentsClose CommentsPermalink





Sec. 222. Premiums and financing. CommentsClose CommentsPermalink





Sec. 223. PNegotiated payment rates for items and services. CommentsClose CommentsPermalink





Sec. 224. Modernized payment initiatives and delivery system reform. CommentsClose CommentsPermalink





Sec. 225. Provider participation. CommentsClose CommentsPermalink





Sec. 226. Application of fraud and abuse provisions. CommentsClose CommentsPermalink





Sec. 227. Application of HIPAA insurance requirements. CommentsClose CommentsPermalink





Sec. 228. Application of health information privacy, security, and electronic transaction requirements. CommentsClose CommentsPermalink





Sec. 229. Enrollment in public health insurance option is voluntary. CommentsClose CommentsPermalink

Subtitle C--Individual Affordability Credits

Sec. 241. Availability through Health Insurance Exchange. CommentsClose CommentsPermalink





Sec. 242. Affordable credit eligible individual. CommentsClose CommentsPermalink





Sec. 243. Affordable premium credit. CommentsClose CommentsPermalink





Sec. 244. Affordability cost-sharing credit. CommentsClose CommentsPermalink





Sec. 245. Income determinations. CommentsClose CommentsPermalink





Sec. 246. No Federal payment for undocumented aliens. CommentsClose CommentsPermalink

TITLE III--SHARED RESPONSIBILITY

Subtitle A--Individual Responsibility

Sec. 301. Individual responsibility. CommentsClose CommentsPermalink

Subtitle B--Employer Responsibility

Part 1--Health Coverage Participation Requirements

Sec. 311. Health coverage participation requirements. CommentsClose CommentsPermalink





Sec. 312. Employer responsibility to contribute towards employee and dependent coverage. CommentsClose CommentsPermalink





Sec. 313. Employer contributions in lieu of coverage. CommentsClose CommentsPermalink





Sec. 314. Authority related to improper steering. CommentsClose CommentsPermalink

Part 2--Satisfaction of Health Coverage Participation Requirements

Sec. 321. Satisfaction of health coverage participation requirements under the Employee Retirement Income Security Act of 1974. CommentsClose CommentsPermalink





Sec. 322. Satisfaction of health coverage participation requirements under the Internal Revenue Code of 1986. CommentsClose CommentsPermalink





Sec. 323. Satisfaction of health coverage participation requirements under the Public Health Service Act. CommentsClose CommentsPermalink





Sec. 324. Additional rules relating to health coverage participation requirements. CommentsClose CommentsPermalink

TITLE IV--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

Subtitle A--Shared Responsibility

Part 1--Individual Responsibility

Sec. 401. Tax on individuals without acceptable health care coverage. CommentsClose CommentsPermalink

Part 2--Employer Responsibility

Sec. 411. Election to satisfy health coverage participation requirements. CommentsClose CommentsPermalink





Sec. 412. Responsibilities of nonelecting employers. CommentsClose CommentsPermalink

Subtitle B--Credit for Small Business Employee Health Coverage Expenses

Sec. 421. Credit for small business employee health coverage expenses. CommentsClose CommentsPermalink

Subtitle C--Disclosures To Carry Out Health Insurance Exchange Subsidies

Sec. 431. Disclosures to carry out health insurance exchange subsidies. CommentsClose CommentsPermalink

Subtitle D--Other Revenue Provisions

Part 1--General Provisions

Sec. 441. Surcharge on high income individuals. CommentsClose CommentsPermalink





Sec. 442. Delay in application of worldwide allocation of interest. CommentsClose CommentsPermalink

Part 2--Prevention of Tax Avoidance

Sec. 451. Limitation on treaty benefits for certain deductible payments. CommentsClose CommentsPermalink





Sec. 452. Codification of economic substance doctrine. CommentsClose CommentsPermalink





Sec. 453. Penalties for underpayments. CommentsClose CommentsPermalink





(c) General Definitions- Except as otherwise provided, in this division: CommentsClose CommentsPermalink





(1) ACCEPTABLE COVERAGE- The term ‘acceptable coverage’ has the meaning given such term in section 202(d)(2). CommentsClose CommentsPermalink





(2) BASIC PLAN- The term ‘basic plan’ has the meaning given such term in section 203(c). CommentsClose CommentsPermalink





(3) COMMISSIONER- The term ‘Commissioner’ means the Health Choices Commissioner established under section 141. CommentsClose CommentsPermalink





(4) COST-SHARING- The term ‘cost-sharing’ includes deductibles, coinsurance, copayments, and similar charges but does not include premiums or any network payment differential for covered services or spending for non-covered services. CommentsClose CommentsPermalink





(5) DEPENDENT- The term ‘dependent’ has the meaning given such term by the Commissioner and includes a spouse. CommentsClose CommentsPermalink





(6) EMPLOYMENT-BASED HEALTH PLAN- The term ‘employment-based health plan’-- CommentsClose CommentsPermalink





(A) means a group health plan (as defined in section 733(a)(1) of the Employee Retirement Income Security Act of 1974); and CommentsClose CommentsPermalink





(B) includes such a plan that is the following: CommentsClose CommentsPermalink





(i) FEDERAL, STATE, AND TRIBAL GOVERNMENTAL PLANS- A governmental plan (as defined in section 3(32) of the Employee Retirement Income Security Act of 1974), including a health benefits plan offered under chapter 89 of title 5, United States Code. CommentsClose CommentsPermalink





(ii) CHURCH PLANS- A church plan (as defined in section 3(33) of the Employee Retirement Income Security Act of 1974). CommentsClose CommentsPermalink





(7) ENHANCED PLAN- The term ‘enhanced plan’ has the meaning given such term in section 203(c). CommentsClose CommentsPermalink





(8) ESSENTIAL BENEFITS PACKAGE- The term ‘essential benefits package’ is defined in section 122(a). CommentsClose CommentsPermalink





(9) FAMILY- The term ‘family’ means an individual and includes the individual’s dependents. CommentsClose CommentsPermalink





(10) FEDERAL POVERTY LEVEL; FPL- The terms ‘Federal poverty level’ and ‘FPL’ have the meaning given the term ‘poverty line’ in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section. CommentsClose CommentsPermalink





(11) HEALTH BENEFITS PLAN- The terms ‘health benefits plan’ means health insurance coverage and an employment-based health plan and includes the public health insurance option.(12) HEALTH INSURANCE COVERAGE; HEALTH INSURANCE and cooperatives under subtitle D of title II. CommentsClose CommentsPermalink





(12) HEALTH INSURANCE COVERAGE; HEALTH INSURANCE ISSUER- The terms ‘health insurance coverage’ and ‘health insurance issuer’ have the meanings given such terms in section 2791 of the Public Health Service Act. CommentsClose CommentsPermalink





(13) HEALTH INSURANCE EXCHANGE- The term ‘Health Insurance Exchange’ means the Health Insurance Exchange established under section 201. CommentsClose CommentsPermalink





(14) MEDICAID- The term ‘Medicaid’ means a State plan under title XIX of the Social Security Act (whether or not the plan is operating under a waiver under section 1115 of such Act). CommentsClose CommentsPermalink





(15) MEDICARE- The term ‘Medicare’ means the health insurance programs under title XVIII of the Social Security Act. CommentsClose CommentsPermalink





(16) PLAN SPONSOR- The term ‘plan sponsor’ has the meaning given such term in section 3(16)(B) of the Employee Retirement Income Security Act of 1974. CommentsClose CommentsPermalink





(17) PLAN YEAR- The term ‘plan year’ means-- CommentsClose CommentsPermalink





(A) with respect to an employment-based health plan, a plan year as specified under such plan; or CommentsClose CommentsPermalink





(B) with respect to a health benefits plan other than an employment-based health plan, a 12-month period as specified by the Commissioner. CommentsClose CommentsPermalink





(18) PREMIUM PLAN; PREMIUM-PLUS PLAN- The terms ‘premium plan’ and ‘premium-plus plan’ have the meanings given such terms in section 203(c). CommentsClose CommentsPermalink





(19) QHBP OFFERING ENTITY- The terms ‘QHBP offering entity’ means, with respect to a health benefits plan that is-- CommentsClose CommentsPermalink





(A) a group health plan (as defined, subject to subsection (d), in section 733(a)(1) of the Employee Retirement Income Security Act of 1974), the plan sponsor in relation to such group health plan, except that, in the case of a plan maintained jointly by 1 or more employers and 1 or more employee organizations and with respect to which an employer is the primary source of financing, such term means such employer; CommentsClose CommentsPermalink





(B) health insurance coverage, the health insurance issuer offering the coverage;(C) the public health, including a cooperative under subtitle D of title II; CommentsClose CommentsPermalink





(C) the public health insurance option, the Secretary of Health and Human Services; CommentsClose CommentsPermalink





(D) a non-Federal governmental plan (as defined in section 2791(d) of the Public Health Service Act), the State or political subdivision of a State (or agency or instrumentality of such State or subdivision) which establishes or maintains such plan; or CommentsClose CommentsPermalink





(E) a Federal governmental plan (as defined in section 2791(d) of the Public Health Service Act), the appropriate Federal official. CommentsClose CommentsPermalink





(20) QUALIFIED HEALTH BENEFITS PLAN- The term ‘qualified health benefits plan’ means a health benefits plan that meets the requirements for such a plan under title I and includes the public health insurance option.(21) PUBLIC HEALTH INSURANCE and cooperatives under subtitle D of title II. CommentsClose CommentsPermalink





(21) PUBLIC HEALTH INSURANCE OPTION- The term ‘public health insurance option’ means the public health insurance option as provided under subtitle B of title II. CommentsClose CommentsPermalink





(22) SERVICE AREA; PREMIUM RATING AREA- The terms ‘service area’ and ‘premium rating area’ mean with respect to health insurance coverage-- CommentsClose CommentsPermalink





(A) offered other than through the Health Insurance Exchange, such an area as established by the QHBP offering entity of such coverage in accordance with applicable State law; and CommentsClose CommentsPermalink





(B) offered through the Health Insurance Exchange, such an area as established by such entity in accordance with applicable State law and applicable rules of the Commissioner for Exchange-participating health benefits plans. CommentsClose CommentsPermalink





(23) STATE- The term ‘State’ means the 50 States and the District of Columbia. CommentsClose CommentsPermalink





(24) STATE MEDICAID AGENCY- The term ‘State Medicaid agency’ means, with respect to a Medicaid plan, the single State agency responsible for administering such plan under title XIX of the Social Security Act. CommentsClose CommentsPermalink





(25) Y1, Y2, ETC.- The terms ‘Y1’ , ‘Y2’, ‘Y3’, ‘Y4’, ‘Y5’, and similar subsequently numbered terms, mean 2013 and subsequent years, respectively. CommentsClose CommentsPermalink

TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS CommentsClose CommentsPermalink

Subtitle A--General Standards CommentsClose CommentsPermalink

SEC. 101. REQUIREMENTS REFORMING HEALTH INSURANCE MARKETPLACE.

(a) Purpose- The purpose of this title is to establish standards to ensure that new health insurance coverage and employment-based health plans that are offered meet standards guaranteeing access to affordable coverage, essential benefits, and other consumer protections. CommentsClose CommentsPermalink





(b) Requirements for Qualified Health Benefits Plans- On or after the first day of Y1, a health benefits plan shall not be a qualified health benefits plan under this division unless the plan meets the applicable requirements of the following subtitles for the type of plan and plan year involved: CommentsClose CommentsPermalink





(1) Subtitle B (relating to affordable coverage). CommentsClose CommentsPermalink





(2) Subtitle C (relating to essential benefits). CommentsClose CommentsPermalink





(3) Subtitle D (relating to consumer protection). CommentsClose CommentsPermalink





(c) Terminology- In this division: CommentsClose CommentsPermalink





(1) ENROLLMENT IN EMPLOYMENT-BASED HEALTH PLANS- An individual shall be treated as being ‘enrolled’ in an employment-based health plan if the individual is a participant or beneficiary (as such terms are defined in section 3(7) and 3(8), respectively, of the Employee Retirement Income Security Act of 1974) in such plan. CommentsClose CommentsPermalink





(2) INDIVIDUAL AND GROUP HEALTH INSURANCE COVERAGE- The terms ‘individual health insurance coverage’ and ‘group health insurance coverage’ mean health insurance coverage offered in the individual market or large or small group market, respectively, as defined in section 2791 of the Public Health Service Act. CommentsClose CommentsPermalink

SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE.

(a) Grandfathered Health Insurance Coverage Defined- Subject to the succeeding provisions of this section, for purposes of establishing acceptable coverage under this division, the term ‘grandfathered health insurance coverage’ means individual health insurance coverage that is offered and in force and effect before the first day of Y1 if the following conditions are met: CommentsClose CommentsPermalink





(1) LIMITATION ON NEW ENROLLMENT- CommentsClose CommentsPermalink





(A) IN GENERAL- Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1. CommentsClose CommentsPermalink





(B) DEPENDENT COVERAGE PERMITTED- Subparagraph (A) shall not affect the subsequent enrollment of a dependent of an individual who is covered as of such first day. CommentsClose CommentsPermalink





(2) LIMITATION ON CHANGES IN TERMS OR CONDITIONS- Subject to paragraph (3) and except as required by law, the issuer does not change any of its terms or conditions, including benefits and cost-sharing, from those in effect as of the day before the first day of Y1. CommentsClose CommentsPermalink





(3) RESTRICTIONS ON PREMIUM INCREASES- The issuer cannot vary the percentage increase in the premium for a risk group of enrollees in specific grandfathered health insurance coverage without changing the premium for all enrollees in the same risk group at the same rate, as specified by the Commissioner. CommentsClose CommentsPermalink





(b) Grace Period for Current Employment-based Health Plans- CommentsClose CommentsPermalink





(1) GRACE PERIOD- CommentsClose CommentsPermalink





(A) IN GENERAL- The Commissioner shall establish a grace period whereby, for plan years beginning after the end of the 5-year period beginning with Y1, an employment-based health plan in operation as of the day before the first day of Y1 must meet the same requirements as apply to a qualified health benefits plan under section 101, including the essential benefit package requirement under section 121. CommentsClose CommentsPermalink





(B) EXCEPTION FOR LIMITED BENEFITS PLANS- Subparagraph (A) shall not apply to an employment-based health plan in which the coverage consists only of one or more of the following: CommentsClose CommentsPermalink





(i) Any coverage described in section 3001(a)(1)(B)(ii)(IV) of division B of the American Recovery and Reinvestment Act of 2009 (Public LawL 111-5). CommentsClose CommentsPermalink





(ii) Excepted benefits (as defined in section 733(c) of the Employee Retirement Income Security Act of 1974), including coverage under a specified disease or illness policy described in paragraph (3)(A) of such section. CommentsClose CommentsPermalink





(iii) Such other limited benefits as the Commissioner may specify. CommentsClose CommentsPermalink





In no case shall an employment-based health plan in which the coverage consists only of one or more of the coverage or benefits described in clauses (i) through (iii) be treated as acceptable coverage under this division CommentsClose CommentsPermalink





(2) TRANSITIONAL TREATMENT AS ACCEPTABLE COVERAGE- During the grace period specified in paragraph (1)(A), an employment-based health plan that is described in such paragraph shall be treated as acceptable coverage under this division. CommentsClose CommentsPermalink





(c) Limitation on Individual Health Insurance Coverage- CommentsClose CommentsPermalink





(1) IN GENERAL- Individual health insurance coverage that is not grandfathered health insurance coverage under subsection (a) may only be offered on or after the first day of Y1 as an Exchange-participating health benefits plan. CommentsClose CommentsPermalink





(2) SEPARATE, EXCEPTED COVERAGE PERMITTED- Excepted benefits (as defined in section 2791(c) of the Public Health Service Act) are not included within the definition of health insurance coverage. Nothing in paragraph (1) shall prevent the offering, other than through the Health Insurance Exchange, of excepted benefits so long as it is offered and priced separately from health insurance coverage. CommentsClose CommentsPermalink





(3) STAND-ALONE DENTAL AND VISION COVERAGE PERMITTED- Nothing in this division shall be construed-- CommentsClose CommentsPermalink





(A) to prevent the offering of a stand-alone plans that offer coverage of excepted benefits described in section 2791(c)(2)(A) of the Public Health Service Act (relating to limited scope dental or vision benefits)for individuals and families from a State licensed dental and vision carrier; or CommentsClose CommentsPermalink





(B) as applying requirements for a qualified health benefits plan to such stand-alone plans that is offered and priced separately from a qualified health benefits plan. CommentsClose CommentsPermalink

Subtitle B--Standards Guaranteeing Access to Affordable Coverage CommentsClose CommentsPermalink

SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS.

A qualified health benefits plan may not impose any pre-existing condition exclusion (as defined in section 2701(b)(1)(A) of the Public Health Service Act) or otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent based on any health status-related factors (as defined in section 2791(d)(9) of the Public Health Service Act) in relation to the individual or dependent. CommentsClose CommentsPermalink

SEC. 112. GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS.

The requirements of sections 2711 (other than subsections (c) and (e)) and 2712 (other than paragraphs (3), and (6) of subsection (b) and subsection (e)) of the Public Health Service Act, relating to guaranteed availability and renewability of health insurance coverage, shall apply to individuals and employers in all individual and group health insurance coverage, whether offered to individuals or employers through the Health Insurance Exchange, through any employment-based health plan, or otherwise, and shall apply to the public health insurance option, in the same manner as such sections apply to employers and health insurance coverage offered in the small group market, except that such section 2712(b)(1) shall apply only if, before nonrenewal or discontinuation of coverage, the issuer has provided the enrollee with notice of non-payment of premiums and there is a grace period during which the enrollees has an opportunity to correct such nonpayment. Rescissions of such coverage shall be prohibited except in cases of fraud as defined in sections 2712(b)(2) of such Act. CommentsClose CommentsPermalink

SEC. 113. INSURANCE RATING RULES.

(a) In General- The premium rate charged for an insured qualified health benefits plan and for coverage under the public health insurance option may not vary except as follows: CommentsClose CommentsPermalink





(1) LIMITED AGE VARIATION PERMITTED- By age (within such age categories as the Commissioner shall specify) so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 2 to 1. CommentsClose CommentsPermalink





(2) BY AREA- By premium rating area (as permitted by State insurance regulators or, in the case of Exchange-participating health benefits plans, as specified by the Commissioner in consultation with such regulators). CommentsClose CommentsPermalink





(3) BY FAMILY ENROLLMENT- By family enrollment (such as variations within categories and compositions of families) so long as the ratio of the premium for family enrollment (or enrollments) to the premium for individual enrollment is uniform, as specified under State law and consistent with rules of the Commissioner. CommentsClose CommentsPermalink





(b) Actuarial Value of Optional Service Coverage- CommentsClose CommentsPermalink





(1) IN GENERAL- The Commissioner shall estimate the basic per enrollee, per month cost, determined on an average actuarial basis, for including coverage under a basic plan of the services described in section 122(d)(4)(A). CommentsClose CommentsPermalink





(2) CONSIDERATIONS- In making such estimate the Commissioner-- CommentsClose CommentsPermalink





(A) may take into account the impact on overall costs of the inclusion of such coverage, but may not take into account any cost reduction estimated to result from such services, including prenatal care, delivery, or postnatal care; CommentsClose CommentsPermalink





(B) shall estimate such costs as if such coverage were included for the entire population covered; and CommentsClose CommentsPermalink





(C) may not estimate such a cost at less than $1 per enrollee, per month. CommentsClose CommentsPermalink





(c) Study and Reports- CommentsClose CommentsPermalink





(1) STUDY- The Commissioner, in coordination with the Secretary of Health and Human Services and the Secretary of Labor, shall conduct a study of the large group insured and self-insured employer health care markets. Such study shall examine the following: CommentsClose CommentsPermalink





(A) The types of employers by key characteristics, including size, that purchase insured products versus those that self-insure. CommentsClose CommentsPermalink





(B) The similarities and differences between typical insured and self-insured health plans. CommentsClose CommentsPermalink





(C) The financial solvency and capital reserve levels of employers that self-insure by employer size. CommentsClose CommentsPermalink





(D) The risk of self-insured employers not being able to pay obligations or otherwise becoming financially insolvent. CommentsClose CommentsPermalink





(E) The extent to which rating rules are likely to cause adverse selection in the large group market or to encourage small and mid size employers to self-insure CommentsClose CommentsPermalink





(2) REPORTS- Not later than 18 months after the date of the enactment of this Act, the Commissioner shall submit to Congress and the applicable agencies a report on the study conducted under paragraph (1). Such report shall include any recommendations the Commissioner deems appropriate to ensure that the law does not provide incentives for small and mid-size employers to self-insure or create adverse selection in the risk pools of large group insurers and self-insured employers. Not later than 18 months after the first day of Y1, the Commissioner shall submit to Congress and the applicable agencies an updated report on such study, including updates on such recommendations. CommentsClose CommentsPermalink

SEC. 114. NONDISCRIMINATION IN BENEFITS; PARITY IN MENTAL HEALTH AND SUBSTANCE ABUSE DISORDER BENEFITS.

(a) Nondiscrimination in Benefits- A qualified health benefits plan (including the public health insurance option) shall comply with standards established by the Commissioner to prohibit discrimination in health benefits or benefit structures for qualifying health benefits plans, building from sections 702 of Employee Retirement Income Security Act of 1974, 2702 of the Public Health Service Act, and section 9802 of the Internal Revenue Code of 1986. CommentsClose CommentsPermalink





(b) Parity in Mental Health and Substance Abuse Disorder Benefits- To the extent such provisions are not superceded by or inconsistent with subtitle C, the provisions of section 2705 (other than subsections (a)(1), (a)(2), and (c)) of section 2705 of the Public Health Service Act shall apply to a qualified health benefits plan, regardless of whether it is offered in the individual or group market, in the same manner as such provisions apply to health insurance coverage offered in the large group market. CommentsClose CommentsPermalink

SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS.

(a) In General- A qualified health benefits plan that(including the public health insurance option) that uses a provider network for items and services shall meet such standards respecting provider networks as the Commissioner may establish to assure the adequacy of such networks in ensuring enrollee access to such items and services and transparency in the cost-sharing differentials between in-network coverage and out-of-network coverage. CommentsClose CommentsPermalink





(b) Provider Network Defined- In this division, the term ‘provider network’ means the providers with respect to which covered benefits, treatments, and services are available under a health benefits plan. CommentsClose CommentsPermalink

SEC. 116. ENSURING VALUE AND LOWER PREMIUMS.

(a) In General- A qualified health benefits plan shall meet a medical loss ratio as defined by the Commissioner. For any plan year in which the qualified health benefits plan does not meet such medical loss ratio, QHBP offering entity shall provide in a manner specified by the Commissioner for rebates to enrollees of payment sufficient to meet such loss ratio. CommentsClose CommentsPermalink





(b) Building on Interim Rules- In implementing subsection (a), the Commissioner shall build on the definition and methodology developed by the Secretary of Health and Human Services under the amendments made by section 161 for determining how to calculate the medical loss ratio. Such methodology shall be set at the highest level medical loss ratio possible that is designed to ensure adequate participation by QHBP offering entities, competition in the health insurance market in and out of the Health Insurance Exchange, and value for consumers so that their premiums are used for services. CommentsClose CommentsPermalink

Subtitle C--Standards Guaranteeing Access to Essential Benefits CommentsClose CommentsPermalink

SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE.

(a) In General- A qualified health benefits plan shall provide coverage that at least meets the benefit standards adopted under section 124 for the essential benefits package described in section 122 for the plan year involved. CommentsClose CommentsPermalink





(b) Choice of Coverage- CommentsClose CommentsPermalink





(1) NON-EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS- In the case of a qualified health benefits plan that is not an Exchange-participating health benefits plan, such plan may offer such coverage in addition to the essential benefits package as the QHBP offering entity may specify. CommentsClose CommentsPermalink





(2) EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS- In the case of an Exchange-participating health benefits plan, such plan is required under section 203 to provide specified levels of benefits and, in the case of a plan offering a premium-plus level of benefits, provide additional benefits. CommentsClose CommentsPermalink





(3) CONTINUATION OF OFFERING OF SEPARATE EXCEPTED BENEFITS COVERAGE- Nothing in this division shall be construed as affecting the offering of health benefits in the form of excepted benefits (described in section 102(b)(1)(B)(ii)) if such benefits are offered under a separate policy, contract, or certificate of insurance. CommentsClose CommentsPermalink





(c) No Restrictions on Coverage Unrelated to Clinical Appropriateness- A qualified health benefits plan may not impose any restriction (other than cost-sharing) unrelated to clinical appropriateness on the coverage of the health care items and services. CommentsClose CommentsPermalink

SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.

(a) In General- In this division, the term ‘essential benefits package’ means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security, that-- CommentsClose CommentsPermalink





(1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice; CommentsClose CommentsPermalink





(2) limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c); CommentsClose CommentsPermalink





(3) does not impose any annual or lifetime limit on the coverage of covered health care items and services; CommentsClose CommentsPermalink





(4) complies with section 115(a) (relating to network adequacy); and CommentsClose CommentsPermalink





(5) is equivalent, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage. CommentsClose CommentsPermalink





(b) Minimum Services Tto Be Covered- TSubject to subsection (d), the items and services described in this subsection are the following: CommentsClose CommentsPermalink





(1) Hospitalization. CommentsClose CommentsPermalink





(2) Outpatient hospital and outpatient clinic services, including emergency department services. CommentsClose CommentsPermalink





(3) Professional services of physicians and other health professionals. CommentsClose CommentsPermalink





(4) Such services, equipment, and supplies incident to the services of a physician’s or a health professional’s delivery of care in institutional settings, physician offices, patients’ homes or place of residence, or other settings, as appropriate. CommentsClose CommentsPermalink





(5) Prescription drugs. CommentsClose CommentsPermalink





(6) Rehabilitative and habilitative services. CommentsClose CommentsPermalink





(7) Mental health and substance use disorder services, including behavioral health treatments. CommentsClose CommentsPermalink





(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention. CommentsClose CommentsPermalink





(9) Maternity care. CommentsClose CommentsPermalink





(10) Well baby and well child care; treatment of a congenital or developmental deformity, disease, or injury; and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age. CommentsClose CommentsPermalink





(c) Requirements Relating to Cost-sharing and Minimum Actuarial Value- CommentsClose CommentsPermalink





(1) NO COST-SHARING FOR PREVENTIVE SERVICES- There shall be no cost-sharing under the essential benefits package for preventive items and services (as specified under the benefit standards), including well baby and well child care. CommentsClose CommentsPermalink





(2) ANNUAL LIMITATION- CommentsClose CommentsPermalink





(A) ANNUAL LIMITATION- The cost-sharing incurred under the essential benefits package with respect to an individual (or family) for a year does not exceed the applicable level specified in subparagraph (B). CommentsClose CommentsPermalink





(B) APPLICABLE LEVEL- The applicable level specified in this subparagraph for Y1 is $5,000 for an individual and $10,000 for a family. Such levels shall be increased (rounded to the nearest $100) for each subsequent year by the annual percentage increase in the Consumer Price Index (United States city average) applicable to such year. CommentsClose CommentsPermalink





(C) USE OF COPAYMENTS- In establishing cost-sharing levels for basic, enhanced, and premium plans under this subsection, the Secretary shall, to the maximum extent possible, use only copayments and not coinsurance. CommentsClose CommentsPermalink





(3) MINIMUM ACTUARIAL VALUE- CommentsClose CommentsPermalink





(A) IN GENERAL- The cost-sharing under the essential benefits package shall be designed to provide a level of coverage that is designed to provide benefits that are actuarially equivalent to approximately 70 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph (B). CommentsClose CommentsPermalink





(B) REFERENCE BENEFITS PACKAGE DESCRIBED- The reference benefits package described in this subparagraph is the essential benefits package if there were no cost-sharing imposed. CommentsClose CommentsPermalink





(d) Abortion Coverage Prohibited as Part of Minimum Benefits Package- CommentsClose CommentsPermalink





(1) PROHIBITION OF REQUIRED COVERAGE- The Health Benefits Advisory Committee may not recommend under section 123(b) and the Secretary may not adopt in standards under section 124(b), the services described in paragraph (4)(A) or (4)(B) as part of the essential benefits package and the Commissioner may not require such services for qualified health benefits plans to participate in the Health Insurance Exchange. CommentsClose CommentsPermalink





(2) VOLUNTARY CHOICE OF COVERAGE BY PLAN- In the case of a qualified health benefits plan, the plan is not required (or prohibited) under this Act from providing coverage of services described in paragraph (4)(A) or (4)(B) and the QHBP offering entity shall determine whether such coverage is provided. CommentsClose CommentsPermalink





(3) COVERAGE UNDER PUBLIC HEALTH INSURANCE OPTION- The public health insurance option shall provide coverage for services described in paragraph (4)(B). Nothing in this Act shall be construed as preventing the public health insurance option from providing for or prohibiting coverage of services described in paragraph (4)(A). CommentsClose CommentsPermalink





(4) ABORTION SERVICES- CommentsClose CommentsPermalink





(A) ABORTIONS FOR WHICH PUBLIC FUNDING IS PROHIBITED- The services described in this subparagraph are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is not permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved. CommentsClose CommentsPermalink





(B) ABORTIONS FOR WHICH PUBLIC FUNDING IS ALLOWED- The services described in this subparagraph are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved. CommentsClose CommentsPermalink





(e) Stand-alone Coverage- CommentsClose CommentsPermalink





(1) NO APPLICATION TO ADULT COVERAGE- Nothing in this subtitle shall be construed as requiring an individual who is 21 years of age or older to be provided stand-alone dental-only or vision-only coverage. CommentsClose CommentsPermalink





(2) TREATMENT OF COMBINED COVERAGE- The combination of stand-alone coverage described in paragraph (1) and a qualified health benefits plan without coverage of such oral and vision services shall be treated as satisfying the essential benefits package under this division. CommentsClose CommentsPermalink

SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE.

(a) Establishment- CommentsClose CommentsPermalink





(1) IN GENERAL- There is established a private-public advisory committee which shall be a panel of medical and other experts to be known as the Health Benefits Advisory Committee to recommend covered benefits and essential, enhanced, and premium plans. CommentsClose CommentsPermalink





(2) CHAIR- The Surgeon General shall be a member and the chair of the Health Benefits Advisory Committee. CommentsClose CommentsPermalink





(3) MEMBERSHIP- The Health Benefits Advisory Committee shall be composed of the following members, in addition to the Surgeon General: CommentsClose CommentsPermalink





(A) 9 members who are not Federal employees or officers and who are appointed by the President. CommentsClose CommentsPermalink





(B) 9 members who are not Federal employees or officers and who are appointed by the Comptroller General of the United States in a manner similar to the manner in which the Comptroller General appoints members to the Medicare Payment Advisory Commission under section 1805(c) of the Social Security Act. CommentsClose CommentsPermalink





(C) Such even number of members (not to exceed 8) who are Federal employees and officers, as the President may appoint. CommentsClose CommentsPermalink





Such initial appointments shall be made not later than 60 days after the date of the enactment of this Act. CommentsClose CommentsPermalink





(4) TERMS- Each member of the Health Benefits Advisory Committee shall serve a 3-year term on the Committee, except that the terms of the initial members shall be adjusted in order to provide for a staggered term of appointment for all such members. CommentsClose CommentsPermalink





(5) PARTICIPATION- The membership of the Health Benefits Advisory Committee shall at least reflect providers, consumer representatives, employers, labor, health insurance issuers, experts in health care financing and delivery, experts in racial and ethnic disparities, experts in care for those with disabilities, representatives of relevant governmental agencies. and at least one practicing physician or other health professional and an expert on children’s health and shall represent a balance among various sectors of the health care system so that no single sector unduly influences the recommendations of such Committee. Not less than 25 percent of the members of the Committee shall be practicing health care practitioners who, as of the date of their appointment, practice in a rural area and who have practiced in a rural area for at least the 5-year period preceding such date. CommentsClose CommentsPermalink





(b) Duties- CommentsClose CommentsPermalink





(1) RECOMMENDATIONS ON BENEFIT STANDARDS- The Health Benefits Advisory Committee shall recommend to the Secretary of Health and Human Services (in this subtitle referred to as the ‘Secretary’) benefit standards (as defined in paragraph (4)), and periodic updates to such standards. In developing such recommendations, the Committee shall take into account innovation in health care and consider how such standards could reduce health disparities. CommentsClose CommentsPermalink





(2) DEADLINE- The Health Benefits Advisory Committee shall recommend initial benefit standards to the Secretary not later than 1 year after the date of the enactment of this Act. CommentsClose CommentsPermalink





(3) PUBLIC INPUT- The Health Benefits Advisory Committee shall allow for public input as a part of developing recommendations under this subsection. CommentsClose CommentsPermalink





(4) BENEFIT STANDARDS DEFINED- In this subtitle, the term ‘benefit standards’ means standards respecting-- CommentsClose CommentsPermalink





(A) the essential benefits package described in section 122, including categories of covered treatments, items and services within benefit classes, and cost-sharing consistent with subsection (d) of such section; and CommentsClose CommentsPermalink





(B) the cost-sharing levels for enhanced plans and premium plans (as provided under section 203(c)) consistent with paragraph (5). CommentsClose CommentsPermalink





(5) LEVELS OF COST-SHARING FOR ENHANCED AND PREMIUM PLANS- CommentsClose CommentsPermalink





(A) ENHANCED PLAN- The level of cost-sharing for enhanced plans shall be designed so that such plans have benefits that are actuarially equivalent to approximately 85 percent of the actuarial value of the benefits provided under the reference benefits package described in section 122(c)(3)(B). CommentsClose CommentsPermalink





(B) PREMIUM PLAN- The level of cost-sharing for premium plans shall be designed so that such plans have benefits that are actuarially equivalent to approximately 95 percent of the actuarial value of the benefits provided under the reference benefits package described in section 122(c)(3)(B). CommentsClose CommentsPermalink





(c) Operations- CommentsClose CommentsPermalink





(1) PER DIEM PAY- Each member of the Health Benefits Advisory Committee shall receive travel expenses, including per diem in accordance with applicable provisions under subchapter I of chapter 57 of title 5, United States Code, and shall otherwise serve without additional pay. CommentsClose CommentsPermalink





(2) MEMBERS NOT TREATED AS FEDERAL EMPLOYEES- Members of the Health Benefits Advisory Committee shall not be considered employees of the Federal government solely by reason of any service on the Committee. CommentsClose CommentsPermalink





(3) APPLICATION OF FACA- The Federal Advisory Committee Act (5 U.S.C. App.), other than section 14, shall apply to the Health Benefits Advisory Committee. CommentsClose CommentsPermalink





(d) Publication- The Secretary shall provide for publication in the Federal Register and the posting on the Internet website of the Department of Health and Human Services of all recommendations made by the Health Benefits Advisory Committee under this section. CommentsClose CommentsPermalink

SEC. 124. PROCESS FOR ADOPTION OF RECOMMENDATIONS; ADOPTION OF BENEFIT STANDARDS.

(a) Process for Adoption of Recommendations- CommentsClose CommentsPermalink





(1) REVIEW OF RECOMMENDED STANDARDS- Not later than 45 days after the date of receipt of benefit standards recommended under section 123 (including such standards as modified under paragraph (2)(B)), the Secretary shall review such standards and shall determine whether to propose adoption of such standards as a package. CommentsClose CommentsPermalink





(2) DETERMINATION TO ADOPT STANDARDS- If the Secretary determines-- CommentsClose CommentsPermalink





(A) to propose adoption of benefit standards so recommended as a package, the Secretary shall, by regulation undersection 553 of title 5, United States Code, propose adoption such standards; or CommentsClose CommentsPermalink





(B) not to propose adoption of such standards as a package, the Secretary shall notify the Health Benefits Advisory Committee in writing of such determination and the reasons for not proposing the adoption of such recommendation and provide the Committee with a further opportunity to modify its previous recommendations and submit new recommendations to the Secretary on a timely basis. CommentsClose CommentsPermalink





(3) CONTINGENCY- If, because of the application of paragraph (2)(B), the Secretary would otherwise be unable to propose initial adoption of such recommended standards by the deadline specified in subsection (b)(1), the Secretary shall, by regulation undersection 553 of title 5, United States Code, propose adoption of initial benefit standards by such deadline. CommentsClose CommentsPermalink





(4) PUBLICATION- The Secretary shall provide for publication in the Federal Register of all determinations made by the Secretary under this subsection. CommentsClose CommentsPermalink





(b) Adoption of Standards- CommentsClose CommentsPermalink





(1) INITIAL STANDARDS- Not later than 18 months after the date of the enactment of this Act, the Secretary shall, through the rulemaking process consistent with subsection (a), adopt an initial set of benefit standards. CommentsClose CommentsPermalink





(2) PERIODIC UPDATING STANDARDS- Under subsection (a), the Secretary shall provide for the periodic updating of the benefit standards previously adopted under this section. CommentsClose CommentsPermalink





(3) REQUIREMENT- The Secretary may not adopt any benefit standards for an essential benefits package or for level of cost-sharing that are inconsistent with the requirements for such a package or level under sections 122 (including subsection (d)) and 123(b)(5). CommentsClose CommentsPermalink

Subtitle D--Additional Consumer Protections CommentsClose CommentsPermalink

SEC. 131. REQUIRING FAIR MARKETING PRACTICES BY HEALTH INSURERS.

The Commissioner shall establish uniform marketing standards that all insured QHBP offering entities shall meet. CommentsClose CommentsPermalink

SEC. 132. REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS.

(a) In General- A QHBP offering entity shall provide for timely grievance and appeals mechanisms that the Commissioner shall establish.

(b) Internal Claims and Appeals Process- Under a qualified health benefits plan the QHBP offering entity shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70246) and shall update such process in accordance with any standards that the Commissioner may establish.

(c) External Review Process-

(1) IN GENERAL- The Commissioner shall establish an external review process (including procedures for expedited reviews of urgent claims) that provides for an impartial, independent, and de novo review of denied claims under this division.

(2) REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS- A determination made, with respect to a qualified health benefits plan offered by a QHBP offering entity, under the external review process established under this subsection shall be binding on the plan and the entity.

(d) Construction- Nothing in this section shall be construed as affecting the availability of judicial review under State law for adverse decisions under subsection (b) or (c), subject to section 151as the Commissioner shall establish consistent with sections 139 through 139B. CommentsClose CommentsPermalink

SEC. 133. REQUIRING INFORMATION TRANSPARENCY AND PLAN DISCLOSURE.

(a) Accurate and Timely Disclosure- CommentsClose CommentsPermalink





(1) IN GENERAL- A qualified health benefits plan (including the public health insurance option) shall comply with standards established by the Commissioner for the accurate and timely disclosure of plan documents, plan terms and conditions, claims payment policies and practices, periodic financial disclosure, data on enrollment, data on disenrollment, data on the number of claims denials, data on rating practices, information on cost-sharing and payments with respect to any out-of-network coverage, and other information as determined appropriate by the Commissioner. The Commissioner shall require that such disclosure be provided in plain language. CommentsClose CommentsPermalink





(2) PLAIN LANGUAGE- In this subsection, the term ‘plain language’ means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is clean, concise, well-organized, and follows other best practices of plain language writing. CommentsClose CommentsPermalink





(3) GUIDANCE- The Commissioner shall develop and issue guidance on best practices of plain language writing. CommentsClose CommentsPermalink





(b) Contracting Reimbursement- A qualified health benefits plan shall comply with standards established by the Commissioner to ensure(including the public health insurance option) shall comply with standards established by the Commissioner to ensure transparency to each health care provider relating to reimbursement arrangements between such plan and such provider. CommentsClose CommentsPermalink





(c) Advance Notice of Plan Changes- A change in a qualified health benefits plan shall not be made without such reasonable and timely advance notice to enrollees of such change(including the public health insurance option) shall not be made without such reasonable and timely advance notice to enrollees of such change. CommentsClose CommentsPermalink





(d) Pharmacy Benefit Managers Transparency Requirements- CommentsClose CommentsPermalink





(1) IN GENERAL- Notwithstanding any other provision of law, a qualified health benefits plan shall enter into a contract with a pharmacy benefit managers (in this subsection referred to as a ‘PBM’) to manage the prescription drug coverage provided under such plan, or to control the costs of such prescription drug coverage, only if as a condition of such contract the PBM is required to provide at least annually to the Commissioner and to the QHBP offering entity offering such plan the following information: CommentsClose CommentsPermalink





(A) Information on the volume of prescriptions under the contract that are filled via mail order and at retail pharmacies. CommentsClose CommentsPermalink





(B) An estimate of aggregate average payments under the contract, per prescription (weighted by prescription volume), made to mail order and retail pharmacists, and the average amount, per prescription, that the PBM was paid by the plan for prescriptions filled at mail order and retail pharmacists. CommentsClose CommentsPermalink





(C) An estimate of the aggregate average payment per prescription (weighted by prescription volume) under the contract received from pharmaceutical manufacturers, including all rebates, discounts, prices concessions, or administrative, and other payments from pharmaceutical manufacturers, and a description of the types of payments, and the amount of these payments that were shared with the plan, and a description of the percentage of prescriptions for which the PBM received such payments. CommentsClose CommentsPermalink





(D) Information on the overall percentage of generic drugs dispensed under the contract at retail and mail order pharmacies, and the percentage of cases in which a generic drug is dispensed when available. CommentsClose CommentsPermalink





(E) Information on the percentage and number of cases under the contract in which individuals were switched from a prescribed drug that was less expensive to a drug that was more expensive, the rationale for these switches, and a description of the PBM policies governing such switches. CommentsClose CommentsPermalink





(2) CONFIDENTIALITY OF INFORMATION- Notwithstanding any other provision of law, information disclosed by a PBM to the Commissioner or a QHBP offering entity under this subsection is confidential and shall not be disclosed by the Commissioner or the QHBP offering entity in a form which discloses the identity of a specific PBM or prices charged by such PBM or a specific retailer, manufacturer, or wholesaler, except-- CommentsClose CommentsPermalink





(A) as the Commissioner determines to be necessary to carry out this subsection; CommentsClose CommentsPermalink





(B) to permit the Comptroller General to review the information provided; CommentsClose CommentsPermalink





(C) to permit the Director of the Congressional Budget Office to review the information provided; and CommentsClose CommentsPermalink





(D) to permit the Commissioner to disclose industry-wide aggregate or average information to be used in assessing the overall impact of PBMs on prescription drug prices and spending. CommentsClose CommentsPermalink

SEC. 134. APPLICATION TO QUALIFIED HEALTH BENEFITS PLANS NOT OFFERED THROUGH THE HEALTH INSURANCE EXCHANGE.

The requirements of the previous provisions of this subtitle shall apply to qualified health benefits plans that are not being offered through the Health Insurance Exchange only to the extent specified by the Commissioner. CommentsClose CommentsPermalink

SEC. 135. TIMELY PAYMENT OF CLAIMS.

A QHBP offering entity shall comply with the requirements of section 1857(f) of the Social Security Act with respect to a qualified health benefits plan it offers in the same manner an Medicare Advantage organization is required to comply with such requirements with respect to a Medicare Advantage plan it offers under part C of Medicare. CommentsClose CommentsPermalink

SEC. 136. STANDARDIZED RULES FOR COORDINATION AND SUBROGATION OF BENEFITS.

The Commissioner shall establish standards for the coordination and subrogation of benefits and reimbursement of payments in cases involving individuals and multiple plan coverage. CommentsClose CommentsPermalink

SEC. 137. APPLICATION OF ADMINISTRATIVE SIMPLIFICATION.

A QHBP offering entity is required to comply with standards for electronic financial and administrative transactions under section 1173A of the Social Security Act, and the operating rules under section 1173B of such Act, as added by section 163(a). CommentsClose CommentsPermalink

Subtitle E--Governance CommentsClose CommentsPermalink

SEC. 141. HEALTH CHOICES ADMINISTRATION; HEALTH CHOICES COMMISSIONER.

(a) In General- There is hereby established, as an independent agency in the executive branch of the Government, a Health Choices Administration (in this division referred to as the ‘Administration’). CommentsClose CommentsPermalink





(b) Commissioner- CommentsClose CommentsPermalink





(1) IN GENERAL- The Administration shall be headed by a Health Choices Commissioner (in this division referred to as the ‘Commissioner’) who shall be appointed by the President, by and with the advice and consent of the Senate. CommentsClose CommentsPermalink





(2) COMPENSATION; ETC- The provisions of paragraphs (2), (5), and (7) of subsection (a) (relating to compensation, terms, general powers, rulemaking, and delegation) of section 702 of the Social Security Act (42 U.S.C. 902) shall apply to the Commissioner and the Administration in the same manner as such provisions apply to the Commissioner of Social Security and the Social Security Administration. CommentsClose CommentsPermalink

SEC. 142. DUTIES AND AUTHORITY OF COMMISSIONER.

(a) Duties- The Commissioner is responsible for carrying out the following functions under this division: CommentsClose CommentsPermalink





(1) QUALIFIED PLAN STANDARDS- The establishment of qualified health benefits plan standards under this title, including the enforcement of such standards in coordination with State insurance regulators and the Secretaries of Labor and the Treasury. CommentsClose CommentsPermalink





(2) HEALTH INSURANCE EXCHANGE- The establishment and operation of a Health Insurance Exchange under subtitle A of title II. CommentsClose CommentsPermalink





(3) INDIVIDUAL AFFORDABILITY CREDITS- The administration of individual affordability credits under subtitle C of title II, including determination of eligibility for such credits. CommentsClose CommentsPermalink





(4) ADDITIONAL FUNCTIONS- Such additional functions as may be specified in this division. CommentsClose CommentsPermalink





(b) Promoting Accountability- CommentsClose CommentsPermalink





(1) IN GENERAL- The Commissioner shall undertake activities in accordance with this subtitle to promote accountability of QHBP offering entities in meeting Federal health insurance requirements, regardless of whether such accountability is with respect to qualified health benefits plans offered through the Health Insurance Exchange or outside of such Exchange. CommentsClose CommentsPermalink





(2) COMPLIANCE EXAMINATION AND AUDITS- CommentsClose CommentsPermalink





(A) IN GENERAL- The commissioner shall, in coordination with States, conduct audits of qualified health benefits plan compliance with Federal requirements. Such audits may include random compliance audits and targeted audits in response to complaints or other suspected non-compliance. CommentsClose CommentsPermalink





(B) RECOUPMENT OF COSTS IN CONNECTION WITH EXAMINATION AND AUDITS- The Commissioner is authorized to recoup from qualified health benefits plans reimbursement for the costs of such examinations and audit of such QHBP offering entities. CommentsClose CommentsPermalink





(c) Data Collection- The Commissioner shall collect data for purposes of carrying out the Commissioner’s duties, including for purposes of promoting quality and value, protecting consumers, and addressing disparities in health and health care and may share such data with the Secretary of Health and Human Services. CommentsClose CommentsPermalink





(d) Sanctions Authority- CommentsClose CommentsPermalink





(1) IN GENERAL- In the case that the Commissioner determines that a QHBP offering entity violates a requirement of this title, the Commissioner may, in coordination with State insurance regulators and the Secretary of Labor, provide, in addition to any other remedies authorized by law, for any of the remedies described in paragraph (2). CommentsClose CommentsPermalink





(2) REMEDIES- The remedies described in this paragraph, with respect to a qualified health benefits plan offered by a QHBP offering entity, are-- CommentsClose CommentsPermalink





(A) civil money penalties of not more than the amount that would be applicable under similar circumstances for similar violations under section 1857(g) of the Social Security Act; CommentsClose CommentsPermalink





(B) suspension of enrollment of individuals under such plan after the date the Commissioner notifies the entity of a determination under paragraph (1) and until the Commissioner is satisfied that the basis for such determination has been corrected and is not likely to recur; CommentsClose CommentsPermalink





(C) in the case of an Exchange-participating health benefits plan, suspension of payment to the entity under the Health Insurance Exchange for individuals enrolled in such plan after the date the Commissioner notifies the entity of a determination under paragraph (1) and until the Secretary is satisfied that the basis for such determination has been corrected and is not likely to recur; or CommentsClose CommentsPermalink





(D) working with State insurance regulators to terminate plans for repeated failure by the offering entity to meet the requirements of this title. CommentsClose CommentsPermalink





(e) Standard Definitions of Insurance and Medical Terms- The Commissioner shall provide for the development of standards for the definitions of terms used in health insurance coverage, including insurance-related terms. CommentsClose CommentsPermalink





(f) Efficiency in Administration- The Commissioner shall issue regulations for the effective and efficient administration of the Health Insurance Exchange and affordability credits under subtitle C, including, with respect to the determination of eligibility for affordability credits, the use of personnel who are employed in accordance with the requirements of title 5, United States Code, to carry out the duties of the Commissioner or, in the case of sections 208 and 241(b)(2), the use of State personnel who are employed in accordance with standards prescribed by the Office of Personnel Management pursuant to section 208 of the Intergovernmental Personnel Act of 1970 (42 U.S.C. 4728). CommentsClose CommentsPermalink

SEC. 143. CONSULTATION AND COORDINATION.

(a) Consultation- In carrying out the Commissioner’s duties under this division, the Commissioner, as appropriate, shall consult with at least with the following: CommentsClose CommentsPermalink





(1) The National Association of Insurance Commissioners, State attorneys general, and State insurance regulators, including concerning the standards for insured qualified health benefits plans under this title and enforcement of such standards. CommentsClose CommentsPermalink





(2) Appropriate State agencies, specifically concerning the administration of individual affordability credits under subtitle C of title II and the offering of Exchange-participating health benefits plans, to Medicaid eligible individuals under subtitle A of such title. CommentsClose CommentsPermalink





(3) Other appropriate Federal agencies. CommentsClose CommentsPermalink





(4) Indian tribes and tribal organizations. CommentsClose CommentsPermalink





(5) The National Association of Insurance Commissioners for purposes of using model guidelines established by such association for purposes of subtitles B and D. CommentsClose CommentsPermalink





(b) Coordination- CommentsClose CommentsPermalink





(1) IN GENERAL- In carrying out the functions of the Commissioner, including with respect to the enforcement of the provisions of this division, the Commissioner shall work in coordination with existing Federal and State entities to the maximum extent feasible consistent with this division and in a manner that prevents conflicts of interest in duties and ensures effective enforcement. CommentsClose CommentsPermalink





(2) UNIFORM STANDARDS- The Commissioner, in coordination with such entities, shall seek to achieve uniform standards that adequately protect consumers in a manner that does not unreasonably affect employers and insurers. CommentsClose CommentsPermalink

SEC. 144. HEALTH INSURANCE OMBUDSMAN.

(a) In General- The Commissioner shall appoint within the Health Choices Administration a Qualified Health Benefits Plan Ombudsman who shall have expertise and experience in the fields of health care and education of (and assistance to) individuals. CommentsClose CommentsPermalink





(b) Duties- The Qualified Health Benefits Plan Ombudsman shall, in a linguistically appropriate manner-- CommentsClose CommentsPermalink





(1) receive complaints, grievances, and requests for information submitted by individuals; CommentsClose CommentsPermalink





(2) provide assistance with respect to complaints, grievances, and requests referred to in paragraph (1), including-- CommentsClose CommentsPermalink





(A) helping individuals determine the relevant information needed to seek an appeal of a decision or determination; CommentsClose CommentsPermalink





(B) assistance to such individuals with any problems arising from disenrollment from such a plan; CommentsClose CommentsPermalink





(C) assistance to such individuals in choosing a qualified health benefits plan in which to enroll; and CommentsClose CommentsPermalink





(D) assistance to such individuals in presenting information under subtitle C (relating to affordability credits); and CommentsClose CommentsPermalink





(3) submit annual reports to Congress and the Commissioner that describe the activities of the Ombudsman and that include such recommendations for improvement in the administration of this division as the Ombudsman determines appropriate. The Ombudsman shall not serve as an advocate for any increases in payments or new coverage of services, but may identify issues and problems in payment or coverage policies. CommentsClose CommentsPermalink

Subtitle F--Relation to Other Requirements; Miscellaneous CommentsClose CommentsPermalink

SEC. 151. RELATION TO OTHER REQUIREMENTS.

(a) Coverage Not Offered Through Exchange- CommentsClose CommentsPermalink





(1) IN GENERAL- In the case of health insurance coverage not offered through the Health Insurance Exchange (whether or not offered in connection with an employment-based health plan), and in the case of employment-based health plans, the requirements of this title do not supercede any requirements applicable under titles XXII and XXVII of the Public Health Service Act, parts 6 and 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974, or State law, except insofar as such requirements prevent the application of a requirement of this division, as determined by the Commissioner. CommentsClose CommentsPermalink





(2) CONSTRUCTION- Nothing in paragraph (1) shall be construed as affecting the application of section 514 of the Employee Retirement Income Security Act of 1974. CommentsClose CommentsPermalink





(b) Coverage Offered Through Exchange- CommentsClose CommentsPermalink





(1) IN GENERAL- In the case of health insurance coverage offered through the Health Insurance Exchange-- CommentsClose CommentsPermalink





(A) the requirements of this title do not supercede any requirements (including requirements relating to genetic information nondiscrimination and mental health) applicable under title XXVII of the Public Health Service Act or under State law, except insofar as such requirements prevent the application of a requirement of this division, as determined by the Commissioner; and CommentsClose CommentsPermalink





(B) individual rights and remedies under State laws shall apply. CommentsClose CommentsPermalink





(2) CONSTRUCTION- In the case of coverage described in paragraph (1), nothing in such paragraph shall be construed as preventing the application of rights and remedies under State laws with respect to any requirement referred to in paragraph (1)(A). CommentsClose CommentsPermalink

SEC. 152. PROHIBITING DISCRIMINATION IN HEALTH CARE.

(a) In General- Except as otherwise explicitly permitted by this Act and by subsequent regulations consistent with this Act, all health care and related services (including insurance coverage and public health activities) covered by this Act shall be provided without regard to personal characteristics extraneous to the provision of high quality health care or related services. CommentsClose CommentsPermalink





(b) Implementation- To implement the requirement set forth in subsection (a), the Secretary of Health and Human Services shall, not later than 18 months after the date of the enactment of this Act, promulgate such regulations as are necessary or appropriate to insure that all health care and related services (including insurance coverage and public health activities) covered by this Act are provided (whether directly or through contractual, licensing, or other arrangements) without regard to personal characteristics extraneous to the provision of high quality health care or related services. CommentsClose CommentsPermalink

SEC. 153. WHISTLEBLOWER PROTECTION.

(a) Retaliation Prohibited- No employer may discharge any employee or otherwise discriminate against any employee with respect to his compensation, terms, conditions, or other privileges of employment because the employee (or any person acting pursuant to a request of the employee)-- CommentsClose CommentsPermalink





(1) provided, caused to be provided, or is about to provide or cause to be provided to the employer, the Federal Government, or the attorney general of a State information relating to any violation of, or any act or omission the employee reasonably believes to be a violation of any provision of this Act or any order, rule, or regulation promulgated under this Act; CommentsClose CommentsPermalink





(2) testified or is about to testify in a proceeding concerning such violation; CommentsClose CommentsPermalink





(3) assisted or participated or is about to assist or participate in such a proceeding; or CommentsClose CommentsPermalink





(4) objected to, or refused to participate in, any activity, policy, practice, or assigned task that the employee (or other such person) reasonably believed to be in violation of any provision of this Act or any order, rule, or regulation promulgated under this Act. CommentsClose CommentsPermalink





(b) Enforcement Action- An employee covered by this section who alleges discrimination by an employer in violation of subsection (a) may bring an action governed by the rules, procedures, legal burdens of proof, and remedies set forth in section 40(b) of the Consumer Product Safety Act (15 U.S.C. 2087(b)). CommentsClose CommentsPermalink





(c) Employer Defined- As used in this section, the term ‘employer’ means any person (including one or more individuals, partnerships, associations, corporations, trusts, professional membership organization including a certification, disciplinary, or other professional body, unincorporated organizations, nongovernmental organizations, or trustees) engaged in profit or nonprofit business or industry whose activities are governed by this Act, and any agent, contractor, subcontractor, grantee, or consultant of such person. CommentsClose CommentsPermalink





(d) Rule of Construction- The rule of construction set forth insection 20109(h) of title 49, United States Code, shall also apply to this section. CommentsClose CommentsPermalink

SEC. 154. CONSTRUCTION REGARDING COLLECTIVE BARGAINING.

Nothing in this division shall be construed to alter of supercede any statutory or other obligation to engage in collective bargaining over the terms and conditions of employment related to health care. CommentsClose CommentsPermalink

SEC. 155. SEVERABILITY.

If any provision of this Act, or any application of such provision to any person or circumstance, is held to be unconstitutional, the remainder of the provisions of this Act and the application of the provision to any other person or circumstance shall not be affected. CommentsClose CommentsPermalink

Subtitle G--Early Investments CommentsClose CommentsPermalink

SEC. 161. ENSURING VALUE AND LOWER PREMIUMS.

(a) Group Health Insurance Coverage- Title XXVII of the Public Health Service Act is amended by inserting after section 2713 the following new section: CommentsClose CommentsPermalink

‘SEC. 2714. ENSURING VALUE AND LOWER PREMIUMS.

‘(a) In General- Each health insurance issuer that offers health insurance coverage in the small or large group market shall provide that for any plan year in which the coverage has a medical loss ratio below a level specified by the Secretary, the issuer shall provide in a manner specified by the Secretary for rebates to enrollees of payment sufficient to meet such loss ratio. Such methodology shall be set at the highest level medical loss ratio possible that is designed to ensure adequate participation by issuers, competition in the health insurance market, and value for consumers so that their premiums are used for services. CommentsClose CommentsPermalink





‘(b) Uniform Definitions- The Secretary shall establish a uniform definition of medical loss ratio and methodology for determining how to calculate the medical loss ratio. Such methodology shall be designed to take into account the special circumstances of smaller plans, different types of plans, and newer plans.’. CommentsClose CommentsPermalink





(b) Individual Health Insurance Coverage- Such title is further amended by inserting after section 2753 the following new section: CommentsClose CommentsPermalink

‘SEC. 2754. ENSURING VALUE AND LOWER PREMIUMS.

‘The provisions of section 2714 shall apply to health insurance coverage offered in the individual market in the same manner as such provisions apply to health insurance coverage offered in the small or large group market.’. CommentsClose CommentsPermalink





(c) Immediate Implementation- The amendments made by this section shall apply in the group and individual market for plan years beginning on or after January 1, 2011. CommentsClose CommentsPermalink

SEC. 162. ENDING HEALTH INSURANCE RESCISSION ABUSE.

(a) Clarification Regarding Application of Guaranteed Renewability of Individual Health Insurance Coverage- Section 2742 of the Public Health Service Act (42 U.S.C. 300gg-42) is amended-- CommentsClose CommentsPermalink





(1) in its heading, by inserting ‘and continuation in force, including prohibition of rescission,’ after ‘guaranteed renewability’; and CommentsClose CommentsPermalink





(2) in subsection (a), by inserting ‘, including without rescission,’ after ‘continue in force’. CommentsClose CommentsPermalink





(b) Secretarial Guidance Regarding Rescissions- Section 2742 of such Act (42 U.S.C. 300gg-42) is amended by adding at the end the following: CommentsClose CommentsPermalink





‘(f) Rescission- A health insurance issuer may rescind health insurance coverage only upon clear and convincing evidence of fraud described in subsection (b)(2). The Secretary, no later than July 1, 2010, shall issue guidance implementing this requirement, including procedures for independent, external third party review.’. CommentsClose CommentsPermalink





(c) Opportunity for Independent, External Third Party Review in Certain Cases- Subpart 1 of part B of title XXVII of such Act (42 U.S.C. 300gg-41 et seq.) is amended by adding at the end the following: CommentsClose CommentsPermalink

‘SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD PARTY REVIEW IN CASES OF RESCISSION.

‘(a) Notice and Review Right- If a health insurance issuer determines to rescind health insurance coverage for an individual in the individual market, before such rescission may take effect the issuer shall provide the individual with notice of such proposed rescission and an opportunity for a review of such determination by an independent, external third party under procedures specified by the Secretary under section 2742(f). CommentsClose CommentsPermalink





‘(b) Independent Determination- If the individual requests such review by an independent, external third party of a rescission of health insurance coverage, the coverage shall remain in effect until such third party determines that the coverage may be rescinded under the guidance issued by the Secretary under section 2742(f).’. CommentsClose CommentsPermalink





(d) Effective Date- The amendments made by this section shall apply on and after October 1, 2010, with respect to health insurance coverage issued before, on, or after such date. CommentsClose CommentsPermalink

SEC. 163. ENDING HEALTH INSURANCE DENIALS AND DELAYS OF NECESSARY TREATMENT FOR CHILDREN WITH DEFORMITIES.

SEC. 164. ADMINISTRATIVE SIMPLIFICATION.

(a) Standardizing Electronic Administrative Transactions- CommentsClose CommentsPermalink





(1) IN GENERAL- Part C of title XI of the Social Security Act (42 U.S.C. 1320d et seq.) is amended by inserting after section 1173 the following new sections: CommentsClose CommentsPermalink

‘SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE TRANSACTIONS.

‘(a) Standards for Financial and Administrative Transactions- CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall adopt and regularly update standards consistent with the goals described in paragraph (2). CommentsClose CommentsPermalink





‘(2) GOALS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS- The goals for standards under paragraph (1) are that such standards shall-- CommentsClose CommentsPermalink





‘(A) be unique with no conflicting or redundant standards; CommentsClose CommentsPermalink





‘(B) be authoritative, permitting no additions or constraints for electronic transactions, including companion guides; CommentsClose CommentsPermalink





‘(C) be comprehensive, efficient and robust, requiring minimal augmentation by paper transactions or clarification by further communications; CommentsClose CommentsPermalink





‘(D) enable the real-time (or near real-time) determination of an individual’s financial responsibility at the point of service and, to the extent possible, prior to service, including whether the individual is eligible for a specific service with a specific physician at a specific facility, which may include utilization of a machine-readable health plan beneficiary identification card; CommentsClose CommentsPermalink





‘(E) enable, where feasible, near real-time adjudication of claims; CommentsClose CommentsPermalink





‘(F) provide for timely acknowledgment, response, and status reporting applicable to any electronic transaction deemed appropriate by the Secretary; CommentsClose CommentsPermalink





‘(G) describe all data elements (such as reason and remark codes) in unambiguous terms, not permit optional fields, require that data elements be either required or conditioned upon set values in other fields, and prohibit additional conditions; and CommentsClose CommentsPermalink





‘(H) harmonize all common data elements across administrative and clinical transaction standards. CommentsClose CommentsPermalink





‘(3) TIME FOR ADOPTION- Not later than 2 years after the date of implementation of the X12 Version 5010 transaction standards implemented under this part, the Secretary shall adopt standards under this section. CommentsClose CommentsPermalink





‘(4) REQUIREMENTS FOR SPECIFIC STANDARDS- The standards under this section shall be developed, adopted, and enforced so as to-- CommentsClose CommentsPermalink





‘(A) clarify, refine, complete, and expand, as needed, the standards required under section 1173; CommentsClose CommentsPermalink





‘(B) require paper versions of standardized transactions to comply with the same standards as to data content such that a fully compliant, equivalent electronic transaction can be populated from the data from a paper version; CommentsClose CommentsPermalink





‘(C) enable electronic funds transfers, in order to allow automated reconciliation with the related health care payment and remittance advice; CommentsClose CommentsPermalink





‘(D) require timely and transparent claim and denial management processes, including tracking, adjudication, and appeal processing; CommentsClose CommentsPermalink





‘(E) require the use of a standard electronic transaction with which health care providers may quickly and efficiently enroll with a health plan to conduct the other electronic transactions provided for in this part; and CommentsClose CommentsPermalink





‘(F) provide for other requirements relating to administrative simplification as identified by the Secretary, in consultation with stakeholders. CommentsClose CommentsPermalink





‘(5) BUILDING ON EXISTING STANDARDS- In developing the standards under this section, the Secretary shall build upon existing and planned standards. CommentsClose CommentsPermalink





‘(6) IMPLEMENTATION AND ENFORCEMENT- Not later than 6 months after the date of the enactment of this section, the Secretary shall submit to the appropriate committees of Congress a plan for the implementation and enforcement, by not later than 5 years after such date of enactment, of the standards under this section. Such plan shall include-- CommentsClose CommentsPermalink





‘(A) a process and timeframe with milestones for developing the complete set of standards; CommentsClose CommentsPermalink





‘(B) an expedited upgrade program for continually developing and approving additions and modifications to the standards as often as annually to improve their quality and extend their functionality to meet evolving requirements in health care; CommentsClose CommentsPermalink





‘(C) programs to provide incentives for, and ease the burden of, implementation for certain health care providers, with special consideration given to such providers serving rural or underserved areas and ensure coordination with standards, implementation specifications, and certification criteria being adopted under the HITECH Act; CommentsClose CommentsPermalink





‘(D) programs to provide incentives for, and ease the burden of, health care providers who volunteer to participate in the process of setting standards for electronic transactions; CommentsClose CommentsPermalink





‘(E) an estimate of total funds needed to ensure timely completion of the implementation plan; and CommentsClose CommentsPermalink





‘(F) an enforcement process that includes timely investigation of complaints, random audits to ensure compliance, civil monetary and programmatic penalties for non-compliance consistent with existing laws and regulations, and a fair and reasonable appeals process building off of enforcement provisions under this part. CommentsClose CommentsPermalink





‘(b) Limitations on Use of Data- Nothing in this section shall be construed to permit the use of information collected under this section in a manner that would adversely affect any individual. CommentsClose CommentsPermalink





‘(c) Protection of Data- The Secretary shall ensure (through the promulgation of regulations or otherwise) that all data collected pursuant to subsection (a) are-- CommentsClose CommentsPermalink





‘(1) used and disclosed in a manner that meets the HIPAA privacy and security law (as defined in section 3009(a)(2) of the Public Health Service Act), including any privacy or security standard adopted under section 3004 of such Act; and CommentsClose CommentsPermalink





‘(2) protected from all inappropriate internal use by any entity that collects, stores, or receives the data, including use of such data in determinations of eligibility (or continued eligibility) in health plans, and from other inappropriate uses, as defined by the Secretary. CommentsClose CommentsPermalink

‘SEC. 1173B. OPERATING RULES.

‘(a) In General- The Secretary shall adopt operating rules for each transaction described in section 1173(a)(2) of the Social Security Act (42 U.S.C. 1320d-2(a)) CommentsClose CommentsPermalink





‘(b) Operating Rules Development- In adopting such rules, the Secretary shall take into account the development of operating rules that have been developed by a nonprofit entity that meets the following criteria: CommentsClose CommentsPermalink





‘(1) The entity focuses its mission on administrative simplification. CommentsClose CommentsPermalink





‘(2) The entity demonstrates a established multi-stakeholder process that creates consensus based operating rules using a voting policy with balanced representation by the critical stakeholders (including health plans and health care providers) so that no one group dominates the entity and shall include others such as standards development organizations, and relevant Federal agencies. CommentsClose CommentsPermalink





‘(3) The entity has in place a public set of guiding principles that ensure the operating rules and process are open and transparent. CommentsClose CommentsPermalink





‘(4) The entity shall coordinate its activities with the HIT Policy Committee and the HIT Standards Committee (established under title XXX of the Public Health Service Act) and complements the efforts of the Office of the National Healthcare Coordinator and its related health information exchange goals. CommentsClose CommentsPermalink





‘(5) The entity incorporates national standards, including the transaction standards issued under Health Insurance Portability and Accountability Act of 1996. CommentsClose CommentsPermalink





‘(6) The entity uses existing market research and proven best practices. CommentsClose CommentsPermalink





‘(7) The entity has a set of measures that allow for the evaluation of their market impact and public reporting of aggregate stakeholder impact. CommentsClose CommentsPermalink





‘(8) The entity supports nondiscrimination and conflict of interest policies that demonstrate a commitment to open, fair, and nondiscriminatory practices. CommentsClose CommentsPermalink





‘(9) The entity allows for public reviews and updates of the operating rules. CommentsClose CommentsPermalink





‘(c) Implementation- The Secretary shall adopt operating rules under this section, by regulation or otherwise, only after taking into account the rules developed by the entity under subsection (b) and having ensured consultation with providers. The first set of operating rules for the transactions for eligibility for health plan and health claims status under this section shall be adopted not later than October 1, 2011, in a manner such that such set of rules is effective beginning not later than January 1, 2013. The second set of operating rules for the remainder of the transactions described in section 1173(a)(2) of the Social Security Act (42 U.S.C. 1320d-2(a)) shall be adopted not later than October 1, 2012, in a manner such that such set of rules is effective beginning not later than January 1, 2014.’. CommentsClose CommentsPermalink





(2) DEFINITIONS- Section 1171 of such Act (42 U.S.C. 1320d) is amended-- CommentsClose CommentsPermalink





(A) in paragraph (7), by striking ‘with reference to’ and all that follows and inserting ‘with reference to a transaction or data element of health information in section 1173 means implementation specifications, certification criteria, operating rules, messaging formats, codes, and code sets adopted or established by the Secretary for the electronic exchange and use of information.’; and CommentsClose CommentsPermalink





(B) by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(9) OPERATING RULES- The term ‘operating rules’ means business rules for using and processing transactions. Operating rules should address the following: CommentsClose CommentsPermalink





‘(A) Requirements for data content using available and established national standards. CommentsClose CommentsPermalink





‘(B) Infrastructure requirements that establish best practices for streamlining data flow to yield timely execution of transactions. CommentsClose CommentsPermalink





‘(C) Policies defining the transaction related rights and responsibilities for entities that are transmitting or receiving data.’. CommentsClose CommentsPermalink





(3) CONFORMING AMENDMENT- Section 1179(a) of such Act (42 U.S.C. 1320d-8(a)) is amended, in the matter before paragraph (1)-- CommentsClose CommentsPermalink





(A) by inserting ‘on behalf of an individual’ after ‘1978)’; and CommentsClose CommentsPermalink





(B) by inserting ‘on behalf of an individual’ after ‘for a financial institution.’’. CommentsClose CommentsPermalink





(b) Standards for Claims Attachments and Coordination of Benefits - CommentsClose CommentsPermalink





(1) STANDARD FOR HEALTH CLAIMS ATTACHMENTS- Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall promulgate a final rule to establish a standard for health claims attachment transaction described in section 1173(a)(2)(B) of the Social Security Act (42 U.S.C. 1320d-2(a)(2)(B)) and coordination of benefits. CommentsClose CommentsPermalink





(2) REVISION IN PROCESSING PAYMENT TRANSACTIONS BY FINANCIAL INSTITUTIONS- CommentsClose CommentsPermalink





(A) IN GENERAL- Section 1179 of the Social Security Act (42 U.S.C. 1320d-8) is amended, in the matter before paragraph (1)-- CommentsClose CommentsPermalink





(i) by striking ‘or is engaged’ and inserting ‘and is engaged’; and CommentsClose CommentsPermalink





(ii) by inserting ‘(other than as a business associate for a covered entity)’ after ‘for a financial institution’. CommentsClose CommentsPermalink





(B) EFFECTIVE DATE- The amendments made by paragraph (1) shall apply to transactions occurring on or after such date (not later than 6 months after the date of the enactment of this Act) as the Secretary of Health and Human Services shall specify. CommentsClose CommentsPermalink





(c) Unique Health Plan Identifier- Not later than 2 years after the date of the enactment of this Act, the Secretary of Health and Human Services shall promulgate a final rule to establish a unique health plan identifier described in section 1173(b) of the Social Security Act (42 U.S.C. 1320d-2(b)) based on the input of the National Committee of Vital and Health Statistics and consultation with health plans. The Secretary may do so on an interim final basis and effective not later than October 1, 2012. CommentsClose CommentsPermalink

SEC. 1645. EXPANSION OF ELECTRONIC TRANSACTIONS IN MEDICARE.

SEC. 166. REINSURANCE PROGRAM FOR RETIREES.

(a) Establishment- CommentsClose CommentsPermalink





(1) IN GENERAL- Not later than 90 days after the date of the enactment of this Act, the Secretary of Health and Human Services shall establish a temporary reinsurance program (in this section referred to as the ‘reinsurance program’) to provide reimbursement to assist participating employment-based plans with the cost of providing health benefits to retirees and to eligible spouses, surviving spouses and dependents of such retirees. CommentsClose CommentsPermalink





(2) DEFINITIONS- For purposes of this section: CommentsClose CommentsPermalink





(A) The term ‘eligible employment-based plan’ means a group health benefits plan that-- CommentsClose CommentsPermalink





(i) is maintained by one or more employers, former employers or employee associations, or a voluntary employees’ beneficiary association, or a committee or board of individuals appointed to administer such plan, and CommentsClose CommentsPermalink





(ii) provides health benefits to retirees. CommentsClose CommentsPermalink





(B) The term ‘health 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. CommentsClose CommentsPermalink





(C) The term ‘participating employment-based plan’ means an eligible employment-based plan that is participating in the reinsurance program. CommentsClose CommentsPermalink





(D) The term ‘retiree’ means, with respect to a participating employment-benefit plan, an individual who-- CommentsClose CommentsPermalink





(i) is 55 years of age or older; CommentsClose CommentsPermalink





(ii) is not eligible for coverage under title XVIII of the Social Security Act; and CommentsClose CommentsPermalink





(iii) is not an active employee of an employer maintaining the plan or of any employer that makes or has made substantial contributions to fund such plan. CommentsClose CommentsPermalink





(E) The term ‘Secretary’ means Secretary of Health and Human Services. CommentsClose CommentsPermalink





(b) Participation- To be eligible to participate in the reinsurance program, an eligible employment-based plan shall submit to the Secretary an application for participation in the program, at such time, in such manner, and containing such information as the Secretary shall require. CommentsClose CommentsPermalink





(c) Payment- CommentsClose CommentsPermalink





(1) SUBMISSION OF CLAIMS- CommentsClose CommentsPermalink





(A) IN GENERAL- Under the reinsurance program, 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. CommentsClose CommentsPermalink





(B) BASIS FOR CLAIMS- Each claim 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 appropriate employment based health benefits provided to a retiree or to the spouse, surviving spouse, or dependent of a retiree. In determining the amount of any 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 remunerations) obtained by such plan with respect to such health benefits. For purposes of calculating the amount of any claim, the costs paid by the retiree or by the spouse, surviving spouse, or dependent of the retiree in the form of deductibles, co-payments, and co-insurance shall be included along with the amounts paid by the participating employment-based plan. CommentsClose CommentsPermalink





(2) PROGRAM PAYMENTS AND LIMIT- 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 exceeds $15,000, but is less than $90,000. Such amounts shall be adjusted each year based on the percentage increase in the medical care component of the Consumer Price Index (rounded to the nearest multiple of $1,000) for the year involved. CommentsClose CommentsPermalink





(3) USE OF PAYMENTS- Amounts paid to a participating employment-based plan under this subsection shall be used to lower the costs borne directly by the participants and beneficiaries for health benefits provided under such plan in the form of premiums, co-payments, deductibles, co-insurance, or other out-of-pocket costs. Such payments shall not be used to reduce the costs of an employer maintaining the participating employment-based plan. The Secretary shall develop a mechanism to monitor the appropriate use of such payments by such plans. CommentsClose CommentsPermalink





(4) APPEALS AND PROGRAM PROTECTIONS- The Secretary shall establish-- CommentsClose CommentsPermalink





(A) an appeals process to permit participating employment-based plans to appeal a determination of the Secretary with respect to claims submitted under this section; and CommentsClose CommentsPermalink





(B) procedures to protect against fraud, waste, and abuse under the program. CommentsClose CommentsPermalink





(5) AUDITS- The Secretary shall conduct annual audits of claims data submitted by participating employment-based plans under this section to ensure that they are in compliance with the requirements of this section. CommentsClose CommentsPermalink





(d) Retiree Reserve Trust Fund- CommentsClose CommentsPermalink





(1) ESTABLISHMENT- CommentsClose CommentsPermalink





(A) IN GENERAL- There is established in the Treasury of the United States a trust fund to be known as the ‘Retiree Reserve Trust Fund’ (referred to in this section as the ‘Trust Fund’), that shall consist of such amounts as may be appropriated or credited to the Trust Fund as provided for in this subsection to enable the Secretary to carry out the reinsurance program. Such amounts shall remain available until expended. CommentsClose CommentsPermalink





(B) FUNDING- There are hereby appropriated to the Trust Fund, out of any moneys in the Treasury not otherwise appropriated, an amount requested by the Secretary as necessary to carry out this section, except that the total of all such amounts requested shall not exceed $10,000,000,000. CommentsClose CommentsPermalink





(C) APPROPRIATIONS FROM THE TRUST FUND- CommentsClose CommentsPermalink





(i) IN GENERAL- Amounts in the Trust Fund are appropriated to provide funding to carry out the reinsurance program and shall be used to carry out such program. CommentsClose CommentsPermalink





(ii) BUDGETARY IMPLICATIONS- Amounts appropriated under clause (i), and outlays flowing from such appropriations, shall not be taken into account for purposes of any budget enforcement procedures including allocations under section 302(a) and (b) of the Balanced Budget and Emergency Deficit Control Act and budget resolutions for fiscal years during which appropriations are made from the Trust Fund. CommentsClose CommentsPermalink





(iii) LIMITATION TO AVAILABLE FUNDS- The Secretary has the authority to stop taking applications for participation in the program or take such other steps in reducing expenditures under the reinsurance program in order to ensure that expenditures under the reinsurance program do not exceed the funds available under this subsection. CommentsClose CommentsPermalink

TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS