Version	Word Count	Changes From Previous Version	Percent Change
Introduced in House	348,220	n/a	n/a
Engrossed in House	353,828	277	3%
Placed on Calendar Senate	351,993	8 Show Changes Hide Changes	0%
Engrossed Amendment Senate	12,420	909	99%
Enrolled Bill	11,849	11	1%

Display Version Introduced in House Engrossed in House Placed on Calendar Senate Engrossed Amendment Senate Enrolled Bill

Most commented sections:

• Paragraph 52 (6 comments)
• Paragraph 1,948 (5 comments)
• Paragraph 375 (3 comments)

HR 3962 EHPCSCommentsClose CommentsPermalink

111th CONGRESSCommentsClose CommentsPermalink

1st SessionCommentsClose CommentsPermalink

H. R. 3962CommentsClose CommentsPermalink

AN ACTCommentsClose 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 ‘Affordable Health Care for America Act’.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--IMMEDIATE REFORMSCommentsClose CommentsPermalink





TITLE II--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANSCommentsClose CommentsPermalink





Subtitle A--General StandardsCommentsClose CommentsPermalink





Subtitle B--Standards Guaranteeing Access to Affordable CoverageCommentsClose CommentsPermalink





Subtitle C--Standards Guaranteeing Access to Essential BenefitsCommentsClose CommentsPermalink





Subtitle D--Additional Consumer ProtectionsCommentsClose CommentsPermalink





Subtitle E--GovernanceCommentsClose CommentsPermalink





Subtitle F--Relation to Other Requirements; MiscellaneousCommentsClose CommentsPermalink





TITLE III--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONSCommentsClose CommentsPermalink





Subtitle A--Health Insurance ExchangeCommentsClose CommentsPermalink





Subtitle B--Public Health Insurance OptionCommentsClose CommentsPermalink





Subtitle C--Individual Affordability CreditsCommentsClose CommentsPermalink





TITLE IV--SHARED RESPONSIBILITYCommentsClose CommentsPermalink





Subtitle A--Individual ResponsibilityCommentsClose CommentsPermalink





Subtitle B--Employer ResponsibilityCommentsClose CommentsPermalink





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





Subtitle A--Shared ResponsibilityCommentsClose CommentsPermalink





Subtitle B--Credit for Small Business Employee Health Coverage ExpensesCommentsClose CommentsPermalink





Subtitle C--Disclosures To Carry Out Health Insurance Exchange SubsidiesCommentsClose CommentsPermalink





Subtitle D--Other Revenue ProvisionsCommentsClose CommentsPermalink

DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS

TITLE I--IMPROVING HEALTH CARE VALUECommentsClose CommentsPermalink





Subtitle A--Provisions related to Medicare part ACommentsClose CommentsPermalink





Subtitle B--Provisions Related to Part BCommentsClose CommentsPermalink





Subtitle C--Provisions Related to Medicare Parts A and BCommentsClose CommentsPermalink





Subtitle D--Medicare Advantage ReformsCommentsClose CommentsPermalink





Subtitle E--Improvements to Medicare Part DCommentsClose CommentsPermalink





Subtitle F--Medicare Rural Access ProtectionsCommentsClose CommentsPermalink





TITLE II--MEDICARE BENEFICIARY IMPROVEMENTSCommentsClose CommentsPermalink





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





Subtitle B--Reducing Health DisparitiesCommentsClose CommentsPermalink





Subtitle C--Miscellaneous ImprovementsCommentsClose CommentsPermalink





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





TITLE IV--QUALITYCommentsClose CommentsPermalink





Subtitle A--Comparative Effectiveness ResearchCommentsClose CommentsPermalink





Subtitle B--Nursing Home TransparencyCommentsClose CommentsPermalink





Subtitle C--Quality MeasurementsCommentsClose CommentsPermalink





Subtitle D--Physician Payments Sunshine ProvisionCommentsClose CommentsPermalink





Subtitle E--Public Reporting on Health Care-Associated InfectionsCommentsClose CommentsPermalink





TITLE V--MEDICARE GRADUATE MEDICAL EDUCATIONCommentsClose CommentsPermalink





TITLE VI--PROGRAM INTEGRITYCommentsClose CommentsPermalink





Subtitle A--Increased funding to fight waste, fraud, and abuseCommentsClose CommentsPermalink





Subtitle B--Enhanced penalties for fraud and abuseCommentsClose CommentsPermalink





Subtitle C--Enhanced Program and Provider ProtectionsCommentsClose CommentsPermalink





Subtitle D--Access to Information Needed to Prevent Fraud, Waste, and AbuseCommentsClose CommentsPermalink





TITLE VII--MEDICAID AND CHIPCommentsClose CommentsPermalink





Subtitle A--Medicaid and Health ReformCommentsClose CommentsPermalink





Subtitle B--PreventionCommentsClose CommentsPermalink





Subtitle C--AccessCommentsClose CommentsPermalink





Subtitle D--CoverageCommentsClose CommentsPermalink





Subtitle E--FinancingCommentsClose CommentsPermalink





Subtitle F--Waste, Fraud, and AbuseCommentsClose CommentsPermalink





Subtitle G--Puerto Rico and the TerritoriesCommentsClose CommentsPermalink





Subtitle H--MiscellaneousCommentsClose CommentsPermalink





TITLE VIII--REVENUE-RELATED PROVISIONSCommentsClose CommentsPermalink





TITLE IX--MISCELLANEOUS PROVISIONSCommentsClose CommentsPermalink

DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT

TITLE I--COMMUNITY HEALTH CENTERSCommentsClose CommentsPermalink





TITLE II--WORKFORCECommentsClose CommentsPermalink





Subtitle A--Primary Care WorkforceCommentsClose CommentsPermalink





Subtitle B--Nursing WorkforceCommentsClose CommentsPermalink





Subtitle C--Public Health WorkforceCommentsClose CommentsPermalink





Subtitle D--Adapting Workforce to Evolving Health System NeedsCommentsClose CommentsPermalink





TITLE III--PREVENTION AND WELLNESSCommentsClose CommentsPermalink





TITLE IV--QUALITY AND SURVEILLANCECommentsClose CommentsPermalink





TITLE V--OTHER PROVISIONSCommentsClose CommentsPermalink





Subtitle A--Drug Discount for Rural and Other Hospitals; 340B Program IntegrityCommentsClose CommentsPermalink





Subtitle B--ProgramsCommentsClose CommentsPermalink





Subtitle C--Food and Drug AdministrationCommentsClose CommentsPermalink





Subtitle D--Community Living Assistance Services and SupportsCommentsClose CommentsPermalink





Subtitle E--MiscellaneousCommentsClose CommentsPermalink

DIVISION D--INDIAN HEALTH CARE IMPROVEMENT

TITLE I--AMENDMENTS TO INDIAN LAWSCommentsClose CommentsPermalink





TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL SECURITY ACTCommentsClose CommentsPermalink

DIVISION A--AFFORDABLE HEALTH CARE CHOICESCommentsClose 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;CommentsClose CommentsPermalink





(C) includes sliding scale affordability credits; andCommentsClose 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--IMMEDIATE REFORMS

Sec. 101. National high-risk pool program.CommentsClose CommentsPermalink





Sec. 102. Ensuring value and lower premiums.CommentsClose CommentsPermalink





Sec. 103. Ending health insurance rescission abuse.CommentsClose CommentsPermalink





Sec. 104. Sunshine on price gouging by health insurance issuers.CommentsClose CommentsPermalink





Sec. 105. Requiring the option of extension of dependent coverage for uninsured young adults.CommentsClose CommentsPermalink





Sec. 106. Limitations on preexisting condition exclusions in group health plans in advance of applicability of new prohibition of preexisting condition exclusions.CommentsClose CommentsPermalink





Sec. 107. Prohibiting acts of domestic violence from being treated as preexisting conditions.CommentsClose CommentsPermalink





Sec. 108. Ending health insurance denials and delays of necessary treatment for children with deformities.CommentsClose CommentsPermalink





Sec. 109. Elimination of lifetime limits.CommentsClose CommentsPermalink





Sec. 110. Prohibition against postretirement reductions of retiree health benefits by group health plans.CommentsClose CommentsPermalink





Sec. 111. Reinsurance program for retirees.CommentsClose CommentsPermalink





Sec. 112. Wellness program grants.CommentsClose CommentsPermalink





Sec. 113. Extension of COBRA continuation coverage.CommentsClose CommentsPermalink





Sec. 114. State Health Access Program grants.CommentsClose CommentsPermalink





Sec. 115. Administrative simplification.CommentsClose CommentsPermalink

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

Subtitle A--General Standards

Sec. 201. Requirements reforming health insurance marketplace.CommentsClose CommentsPermalink





Sec. 202. Protecting the choice to keep current coverage.CommentsClose CommentsPermalink

Subtitle B--Standards Guaranteeing Access to Affordable Coverage

Sec. 211. Prohibiting preexisting condition exclusions.CommentsClose CommentsPermalink





Sec. 212. Guaranteed issue and renewal for insured plans and prohibiting rescissions.CommentsClose CommentsPermalink





Sec. 213. Insurance rating rules.CommentsClose CommentsPermalink





Sec. 214. Nondiscrimination in benefits; parity in mental health and substance abuse disorder benefits.CommentsClose CommentsPermalink





Sec. 215. Ensuring adequacy of provider networks.CommentsClose CommentsPermalink





Sec. 216. Requiring the option of extension of dependent coverage for uninsured young adults.CommentsClose CommentsPermalink





Sec. 217. Consistency of costs and coverage under qualified health benefits plans during plan year.CommentsClose CommentsPermalink

Subtitle C--Standards Guaranteeing Access to Essential Benefits

Sec. 221. Coverage of essential benefits package.CommentsClose CommentsPermalink





Sec. 222. Essential benefits package defined.CommentsClose CommentsPermalink





Sec. 223. Health Benefits Advisory Committee.CommentsClose CommentsPermalink





Sec. 224. Process for adoption of recommendations; adoption of benefit standards.CommentsClose CommentsPermalink

Subtitle D--Additional Consumer Protections

Sec. 231. Requiring fair marketing practices by health insurers.CommentsClose CommentsPermalink





Sec. 232. Requiring fair grievance and appeals mechanisms.CommentsClose CommentsPermalink





Sec. 233. Requiring information transparency and plan disclosure.CommentsClose CommentsPermalink





Sec. 234. Application to qualified health benefits plans not offered through the Health Insurance Exchange.CommentsClose CommentsPermalink





Sec. 235. Timely payment of claims.CommentsClose CommentsPermalink





Sec. 236. Standardized rules for coordination and subrogation of benefits.CommentsClose CommentsPermalink





Sec. 237. Application of administrative simplification.CommentsClose CommentsPermalink





Sec. 238. State prohibitions on discrimination against health care providers.CommentsClose CommentsPermalink





Sec. 239. Protection of physician prescriber information.CommentsClose CommentsPermalink





Sec. 240. Dissemination of advance care planning information.CommentsClose CommentsPermalink

Subtitle E--Governance

Sec. 241. Health Choices Administration; Health Choices Commissioner.CommentsClose CommentsPermalink





Sec. 242. Duties and authority of Commissioner.CommentsClose CommentsPermalink





Sec. 243. Consultation and coordination.CommentsClose CommentsPermalink





Sec. 244. Health Insurance Ombudsman.CommentsClose CommentsPermalink

Subtitle F--Relation to Other Requirements; Miscellaneous

Sec. 251. Relation to other requirements.CommentsClose CommentsPermalink





Sec. 252. Prohibiting discrimination in health care.CommentsClose CommentsPermalink





Sec. 253. Whistleblower protection.CommentsClose CommentsPermalink





Sec. 254. Construction regarding collective bargaining.CommentsClose CommentsPermalink





Sec. 255. Severability.CommentsClose CommentsPermalink





Sec. 256. Treatment of Hawaii Prepaid Health Care Act.CommentsClose CommentsPermalink





Sec. 257. Actions by State attorneys general.CommentsClose CommentsPermalink





Sec. 258. Application of State and Federal laws regarding abortion.CommentsClose CommentsPermalink





Sec. 259. Nondiscrimination on abortion and respect for rights of conscience.CommentsClose CommentsPermalink





Sec. 260. Authority of Federal Trade Commission.CommentsClose CommentsPermalink





Sec. 261. Construction regarding standard of care.CommentsClose CommentsPermalink





Sec. 262. Restoring application of antitrust laws to health sector insurers.CommentsClose CommentsPermalink





Sec. 263. Study and report on methods to increase EHR use by small health care providers.CommentsClose CommentsPermalink





Sec. 264. Performance assessment and accountability: application of GPRA.CommentsClose CommentsPermalink





Sec. 265. Limitation on abortion funding.CommentsClose CommentsPermalink

TITLE III--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

Subtitle A--Health Insurance Exchange

Sec. 301. Establishment of Health Insurance Exchange; outline of duties; definitions.CommentsClose CommentsPermalink





Sec. 302. Exchange-eligible individuals and employers.CommentsClose CommentsPermalink





Sec. 303. Benefits package levels.CommentsClose CommentsPermalink





Sec. 304. Contracts for the offering of Exchange-participating health benefits plans.CommentsClose CommentsPermalink





Sec. 305. Outreach and enrollment of Exchange-eligible individuals and employers in Exchange-participating health benefits plan.CommentsClose CommentsPermalink





Sec. 306. Other functions.CommentsClose CommentsPermalink





Sec. 307. Health Insurance Exchange Trust Fund.CommentsClose CommentsPermalink





Sec. 308. Optional operation of State-based health insurance exchanges.CommentsClose CommentsPermalink





Sec. 309. Interstate health insurance compacts.CommentsClose CommentsPermalink





Sec. 310. Health insurance cooperatives.CommentsClose CommentsPermalink





Sec. 311. Retention of DOD and VA authority.CommentsClose CommentsPermalink

Subtitle B--Public Health Insurance Option

Sec. 321. Establishment and administration of a public health insurance option as an Exchange-qualified health benefits plan.CommentsClose CommentsPermalink





Sec. 322. Premiums and financing.CommentsClose CommentsPermalink





Sec. 323. Payment rates for items and services.CommentsClose CommentsPermalink





Sec. 324. Modernized payment initiatives and delivery system reform.CommentsClose CommentsPermalink





Sec. 325. Provider participation.CommentsClose CommentsPermalink





Sec. 326. Application of fraud and abuse provisions.CommentsClose CommentsPermalink





Sec. 327. Application of HIPAA insurance requirements.CommentsClose CommentsPermalink





Sec. 328. Application of health information privacy, security, and electronic transaction requirements.CommentsClose CommentsPermalink





Sec. 329. Enrollment in public health insurance option is voluntary.CommentsClose CommentsPermalink





Sec. 330. Enrollment in public health insurance option by Members of Congress.CommentsClose CommentsPermalink





Sec. 331. Reimbursement of Secretary of Veterans Affairs.CommentsClose CommentsPermalink

Subtitle C--Individual Affordability Credits

Sec. 341. Availability through Health Insurance Exchange.CommentsClose CommentsPermalink





Sec. 342. Affordable credit eligible individual.CommentsClose CommentsPermalink





Sec. 343. Affordability premium credit.CommentsClose CommentsPermalink





Sec. 344. Affordability cost-sharing credit.CommentsClose CommentsPermalink





Sec. 345. Income determinations.CommentsClose CommentsPermalink





Sec. 346. Special rules for application to territories.CommentsClose CommentsPermalink





Sec. 347. No Federal payment for undocumented aliens.CommentsClose CommentsPermalink

TITLE IV--SHARED RESPONSIBILITY

Subtitle A--Individual Responsibility

Sec. 401. Individual responsibility.CommentsClose CommentsPermalink

Subtitle B--Employer Responsibility

Part 1--Health Coverage Participation Requirements

Sec. 411. Health coverage participation requirements.CommentsClose CommentsPermalink





Sec. 412. Employer responsibility to contribute toward employee and dependent coverage.CommentsClose CommentsPermalink





Sec. 413. Employer contributions in lieu of coverage.CommentsClose CommentsPermalink





Sec. 414. Authority related to improper steering.CommentsClose CommentsPermalink





Sec. 415. Impact study on employer responsibility requirements.CommentsClose CommentsPermalink





Sec. 416. Study on employer hardship exemption.CommentsClose CommentsPermalink

Part 2--Satisfaction of Health Coverage Participation Requirements

Sec. 421. Satisfaction of health coverage participation requirements under the Employee Retirement Income Security Act of 1974.CommentsClose CommentsPermalink





Sec. 422. Satisfaction of health coverage participation requirements under the Internal Revenue Code of 1986.CommentsClose CommentsPermalink





Sec. 423. Satisfaction of health coverage participation requirements under the Public Health Service Act.CommentsClose CommentsPermalink





Sec. 424. Additional rules relating to health coverage participation requirements.CommentsClose CommentsPermalink

TITLE V--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

Subtitle A--Provisions Relating to Health Care Reform

Part 1--Shared Responsibility

subpart a--individual responsibility

Sec. 501. Tax on individuals without acceptable health care coverage.CommentsClose CommentsPermalink

subpart b--employer responsibility

Sec. 511. Election to satisfy health coverage participation requirements.CommentsClose CommentsPermalink





Sec. 512. Health care contributions of nonelecting employers.CommentsClose CommentsPermalink

Part 2--Credit for Small Business Employee Health Coverage Expenses

Sec. 521. Credit for small business employee health coverage expenses.CommentsClose CommentsPermalink

Part 3--Limitations on Health Care Related Expenditures

Sec. 531. Distributions for medicine qualified only if for prescribed drug or insulin.CommentsClose CommentsPermalink





Sec. 532. Limitation on health flexible spending arrangements under cafeteria plans.CommentsClose CommentsPermalink





Sec. 533. Increase in penalty for nonqualified distributions from health savings accounts.CommentsClose CommentsPermalink





Sec. 534. Denial of deduction for federal subsidies for prescription drug plans which have been excluded from gross income.CommentsClose CommentsPermalink

Part 4--Other Provisions to Carry Out Health Insurance Reform

Sec. 541. Disclosures to carry out health insurance exchange subsidies.CommentsClose CommentsPermalink





Sec. 542. Offering of exchange-participating health benefits plans through cafeteria plans.CommentsClose CommentsPermalink





Sec. 543. Exclusion from gross income of payments made under reinsurance program for retirees.CommentsClose CommentsPermalink





Sec. 544. CLASS program treated in same manner as long-term care insurance.CommentsClose CommentsPermalink





Sec. 545. Exclusion from gross income for medical care provided for Indians.CommentsClose CommentsPermalink

Subtitle B--Other Revenue Provisions

Part 1--General Provisions

Sec. 551. Surcharge on high income individuals.CommentsClose CommentsPermalink





Sec. 552. Excise tax on medical devices.CommentsClose CommentsPermalink





Sec. 553. Expansion of information reporting requirements.CommentsClose CommentsPermalink





Sec. 554. Repeal of worldwide allocation of interest.CommentsClose CommentsPermalink





Sec. 555. Exclusion of unprocessed fuels from the cellulosic biofuel producer credit.CommentsClose CommentsPermalink

Part 2--Prevention of Tax Avoidance

Sec. 561. Limitation on treaty benefits for certain deductible payments.CommentsClose CommentsPermalink





Sec. 562. Codification of economic substance doctrine; penalties.CommentsClose CommentsPermalink





Sec. 563. Certain large or publicly traded persons made subject to a more likely than not standard for avoiding penalties on underpayments.CommentsClose CommentsPermalink

Part 3--Parity in Health Benefits

Sec. 571. Certain health related benefits applicable to spouses and dependents extended to eligible beneficiaries.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 302(d)(2).CommentsClose CommentsPermalink





(2) BASIC PLAN- The term ‘basic plan’ has the meaning given such term in section 303(c).CommentsClose CommentsPermalink





(3) COMMISSIONER- The term ‘Commissioner’ means the Health Choices Commissioner established under section 241.CommentsClose CommentsPermalink





(4) COST-SHARING- The term ‘cost-sharing’ includes deductibles, coinsurance, copayments, and similar charges, but does not include premiums, balance billing amounts for non-network providers, 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);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); andCommentsClose CommentsPermalink





(C) excludes coverage described in section 302(d)(2)(E) (relating to TRICARE).CommentsClose CommentsPermalink





(7) ENHANCED PLAN- The term ‘enhanced plan’ has the meaning given such term in section 303(c).CommentsClose CommentsPermalink





(8) ESSENTIAL BENEFITS PACKAGE- The term ‘essential benefits package’ is defined in section 222(a).CommentsClose CommentsPermalink





(9) EXCHANGE-PARTICIPATING HEALTH BENEFITS PLAN- The term ‘Exchange-participating health benefits plan’ means a qualified health benefits plan that is offered through the Health Insurance Exchange and may be purchased directly from the entity offering the plan or through enrollment agents and brokers.CommentsClose CommentsPermalink





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





(11) 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





(12) HEALTH BENEFITS PLAN- The term ‘health benefits plan’ means health insurance coverage and an employment-based health plan and includes the public health insurance option.CommentsClose CommentsPermalink





(13) HEALTH INSURANCE COVERAGE- The term ‘health insurance coverage’ has the meaning given such term in section 2791 of the Public Health Service Act, but does not include coverage in relation to its provision of excepted benefits--CommentsClose CommentsPermalink





(A) described in paragraph (1) of subsection (c) of such section; orCommentsClose CommentsPermalink





(B) described in paragraph (2), (3), or (4) of such subsection if the benefits are provided under a separate policy, certificate, or contract of insurance.CommentsClose CommentsPermalink





(14) HEALTH INSURANCE ISSUER- The term ‘health insurance issuer’ has the meaning given such term in section 2791(b)(2) of the Public Health Service Act.CommentsClose CommentsPermalink





(15) HEALTH INSURANCE EXCHANGE- The term ‘Health Insurance Exchange’ means the Health Insurance Exchange established under section 301.CommentsClose CommentsPermalink





(16) INDIAN- The term ‘Indian’ has the meaning given such term in section 4 of the Indian Health Care Improvement Act (24 U.S.C. 1603).CommentsClose CommentsPermalink





(17) INDIAN HEALTH CARE PROVIDER- The term ‘Indian health care provider’ means a health care program operated by the Indian Health Service, an Indian tribe, tribal organization, or urban Indian organization as such terms are defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603).CommentsClose CommentsPermalink





(18) 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





(19) MEDICAID ELIGIBLE INDIVIDUAL- The term ‘Medicaid eligible individual’ means an individual who is eligible for medical assistance under Medicaid.CommentsClose CommentsPermalink





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





(21) 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





(22) 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; orCommentsClose 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





(23) PREMIUM PLAN; PREMIUM-PLUS PLAN- The terms ‘premium plan’ and ‘premium-plus plan’ have the meanings given such terms in section 303(c).CommentsClose CommentsPermalink





(24) 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;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; orCommentsClose CommentsPermalink





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





(25) QUALIFIED HEALTH BENEFITS PLAN- The term ‘qualified health benefits plan’ means a health benefits plan that--CommentsClose CommentsPermalink





(A) meets the requirements for such a plan under title II and includes the public health insurance option; andCommentsClose CommentsPermalink





(B) is offered by a QHBP offering entity that meets the applicable requirements of such title with respect to such plan.CommentsClose CommentsPermalink





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





(27) 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; andCommentsClose 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





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





(A) for purposes of title I, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands; andCommentsClose CommentsPermalink





(B) for purposes of titles II and III, as elected under and subject to section 346, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.CommentsClose CommentsPermalink





(29) 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





(30) 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--IMMEDIATE REFORMSCommentsClose CommentsPermalink

SEC. 101. NATIONAL HIGH-RISK POOL PROGRAM.

(a) In General- The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall establish a temporary national high-risk pool program (in this section referred to as the ‘program’) to provide health benefits to eligible individuals during the period beginning on January 1, 2010, and, subject to subsection (h)(3)(B), ending on the date on which the Health Insurance Exchange is established.CommentsClose CommentsPermalink





(b) Administration- The Secretary may carry out this section directly or, pursuant to agreements, grants, or contracts with States, through State high-risk pool programs provided that the requirements of this section are met. For a State without a high-risk pool program, the Secretary may work with the State to coordinate with other forms of coverage expansions, such as State public-private partnerships.CommentsClose CommentsPermalink





(c) Eligibility- For purposes of this section, the term ‘eligible individual’ means an individual who meets the requirements of subsection (i)(1)--CommentsClose CommentsPermalink





(1) who--CommentsClose CommentsPermalink





(A) is not eligible for--CommentsClose CommentsPermalink





(i) benefits under title XVIII, XIX, or XXI of the Social Security Act; orCommentsClose CommentsPermalink





(ii) coverage under an employment-based health plan (not including coverage under a COBRA continuation provision, as defined in section 107(d)(1)); andCommentsClose CommentsPermalink





(B) who--CommentsClose CommentsPermalink





(i) is an eligible individual under section 2741(b) of the Public Health Service Act; orCommentsClose CommentsPermalink





(ii) is medically eligible for the program by virtue of being an individual described in subsection (d) at any time during the 6-month period ending on the date the individual applies for high-risk pool coverage under this section;CommentsClose CommentsPermalink





(2) who is the spouse or dependent of an individual who is described in paragraph (1);CommentsClose CommentsPermalink





(3) who has not had health insurance coverage or coverage under an employment-based health plan for at least the 6-month period immediately preceding the date of the individual’s application for high-risk pool coverage under this section; orCommentsClose CommentsPermalink





(4) who on or after October 29, 2009, had employment-based retiree health coverage (as defined in subsection (i)) and the annual increase in premiums for such individual under such coverage (for any coverage period beginning on or after such date) exceeds such excessive percentage as the Secretary shall specify.CommentsClose CommentsPermalink





For purposes of paragraph (1)(A)(ii), a person who is in a waiting period as defined in section 2701(b)(4) of the Public Health Service Act shall not be considered to be eligible for coverage under an employment-based health plan.CommentsClose CommentsPermalink





(d) Medically Eligible Requirements- For purposes of subsection (c)(1)(B)(ii), an individual described in this subsection is an individual--CommentsClose CommentsPermalink





(1) who, during the 6-month period ending on the date the individual applies for high-risk pool coverage under this section applied for individual health insurance coverage and--CommentsClose CommentsPermalink





(A) was denied such coverage because of a preexisting condition or health status; orCommentsClose CommentsPermalink





(B) was offered such coverage--CommentsClose CommentsPermalink





(i) under terms that limit the coverage for such a preexisting condition; orCommentsClose CommentsPermalink





(ii) at a premium rate that is above the premium rate for high risk pool coverage under this section; orCommentsClose CommentsPermalink





(2) who has an eligible medical condition as defined by the Secretary.CommentsClose CommentsPermalink





In making a determination under paragraph (1) of whether an individual was offered individual coverage at a premium rate above the premium rate for high risk pool coverage, the Secretary shall make adjustments to offset differences in premium rating that are attributable solely to differences in age rating.CommentsClose CommentsPermalink





(e) Enrollment- To enroll in coverage in the program, an individual shall--CommentsClose CommentsPermalink





(1) 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





(2) attest, consistent with subsection (i)(2), that the individual is an eligible individual and is a resident of one of the 50 States or the District of Columbia; andCommentsClose CommentsPermalink





(3) if the individual had other prior health insurance coverage or coverage under an employment-based health plan during the previous 6 months, provide information as to the nature and source of such coverage and reasons for its discontinuance.CommentsClose CommentsPermalink





(f) Protection Against Dumping Risks by Insurers-CommentsClose CommentsPermalink





(1) IN GENERAL- The Secretary shall establish criteria for determining whether health insurance issuers and employment-based health plans have discouraged an individual from remaining enrolled in prior coverage based on that individual’s health status.CommentsClose CommentsPermalink





(2) SANCTIONS- An issuer or employment-based health plan shall be responsible for reimbursing the program for the medical expenses incurred by the program for an individual who, based on criteria established by the Secretary, the Secretary finds was encouraged by the issuer to disenroll from health benefits coverage prior to enrolling in the program. The criteria shall include at least the following circumstances:CommentsClose CommentsPermalink





(A) In the case of prior coverage obtained through an employer, the provision by the employer, group health plan, or the issuer of money or other financial consideration for disenrolling from the coverage.CommentsClose CommentsPermalink





(B) In the case of prior coverage obtained directly from an issuer or under an employment-based health plan--CommentsClose CommentsPermalink





(i) the provision by the issuer or plan of money or other financial consideration for disenrolling from the coverage; orCommentsClose CommentsPermalink





(ii) in the case of an individual whose premium for the prior coverage exceeded the premium required by the program (adjusted based on the age factors applied to the prior coverage)--CommentsClose CommentsPermalink





(I) the prior coverage is a policy that is no longer being actively marketed (as defined by the Secretary) by the issuer; orCommentsClose CommentsPermalink





(II) the prior coverage is a policy for which duration of coverage form issue or health status are factors that can be considered in determining premiums at renewal.CommentsClose CommentsPermalink





(3) CONSTRUCTION- Nothing in this subsection shall be construed as constituting exclusive remedies for violations of criteria established under paragraph (1) or as preventing States from applying or enforcing such paragraph or other provisions under law with respect to health insurance issuers.CommentsClose CommentsPermalink





(g) Covered Benefits, Cost-sharing, Premiums, and Consumer Protections-CommentsClose CommentsPermalink





(1) PREMIUM- The monthly premium charged to eligible individuals for coverage under the program--CommentsClose CommentsPermalink





(A) may vary by age 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





(B) shall be set at a level that does not exceed 125 percent of the prevailing standard rate for comparable coverage in the individual market; andCommentsClose CommentsPermalink





(C) shall be adjusted for geographic variation in costs.CommentsClose CommentsPermalink





Health insurance issuers shall provide such information as the Secretary may require to determine prevailing standard rates under this paragraph. The Secretary shall establish standard rates in consultation with the National Association of Insurance Commissioners.CommentsClose CommentsPermalink





(2) COVERED BENEFITS- Covered benefits under the program shall be determined by the Secretary and shall be consistent with the basic categories in the essential benefits package described in section 222. Under such benefits package--CommentsClose CommentsPermalink





(A) the annual deductible for such benefits may not be higher than $1,500 for an individual or such higher amount for a family as determined by the Secretary;CommentsClose CommentsPermalink





(B) there may not be annual or lifetime limits; andCommentsClose CommentsPermalink





(C) the maximum cost-sharing with respect to an individual (or family) for a year shall not exceed $5,000 for an individual (or $10,000 for a family).CommentsClose CommentsPermalink





(3) NO PREEXISTING CONDITION EXCLUSION PERIODS- No preexisting condition exclusion period shall be imposed on coverage under the program.CommentsClose CommentsPermalink





(4) APPEALS- The Secretary shall establish an appeals process for individuals to appeal a determination of the Secretary--CommentsClose CommentsPermalink





(A) with respect to claims submitted under this section; andCommentsClose CommentsPermalink





(B) with respect to eligibility determinations made by the Secretary under this section.CommentsClose CommentsPermalink





(5) STATE CONTRIBUTION, MAINTENANCE OF EFFORT- As a condition of providing health benefits under this section to eligible individual residing in a State--CommentsClose CommentsPermalink





(A) in the case of a State in which a qualified high-risk pool (as defined under section 2744(c)(2) of the Public Health Service Act) was in effect as of July 1, 2009, the Secretary shall require the State make a maintenance of effort payment each year that the high-risk pool is in effect equal to an amount not less than the amount of all sources of funding for high-risk pool coverage made by that State in the year ending July 1, 2009; andCommentsClose CommentsPermalink





(B) in the case of a State which required health insurance issuers to contribute to a State high-risk pool or similar arrangement for the assessment against such issuers for pool losses, the State shall maintain such a contribution arrangement among such issuers.CommentsClose CommentsPermalink





(6) LIMITING PROGRAM EXPENDITURES- The Secretary shall, with respect to the program--CommentsClose CommentsPermalink





(A) establish procedures to protect against fraud, waste, and abuse under the program; andCommentsClose CommentsPermalink





(B) provide for other program integrity methods.CommentsClose CommentsPermalink





(7) TREATMENT AS CREDITABLE COVERAGE- Coverage under the program shall be treated, for purposes of applying the definition of ‘creditable coverage’ under the provisions of title XXVII of the Public Health Service Act, part 6 of subtitle B of title I of Employee Retirement Income Security Act of 1974, and chapter 100 of the Internal Revenue Code of 1986 (and any other provision of law that references such provisions) in the same manner as if it were coverage under a State health benefits risk pool described in section 2701(c)(1)(G) of the Public Health Service Act.CommentsClose CommentsPermalink





(h) Funding; Termination of Authority-CommentsClose CommentsPermalink





(1) IN GENERAL- There is appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, $5,000,000,000 to pay claims against (and administrative costs of) the high-risk pool under this section in excess of the premiums collected with respect to eligible individuals enrolled in the high-risk pool. Such funds shall be available without fiscal year limitation.CommentsClose CommentsPermalink





(2) INSUFFICIENT FUNDS- If the Secretary estimates for any fiscal year that the aggregate amounts available for payment of expenses of the high-risk pool will be less than the amount of the expenses, the Secretary shall make such adjustments as are necessary to eliminate such deficit, including reducing benefits, increasing premiums, or establishing waiting lists.CommentsClose CommentsPermalink





(3) TERMINATION OF AUTHORITY-CommentsClose CommentsPermalink





(A) IN GENERAL- Except as provided in subparagraph (B), coverage of eligible individuals under a high-risk pool shall terminate as of the date on which the Health Insurance Exchange is established.CommentsClose CommentsPermalink





(B) TRANSITION TO EXCHANGE- The Secretary shall develop procedures to provide for the transition of eligible individuals who are enrolled in health insurance coverage offered through a high-risk pool established under this section to be enrolled in acceptable coverage. Such procedures shall ensure that there is no lapse in coverage with respect to the individual and may extend coverage offered through such a high-risk pool beyond 2012 if the Secretary determines necessary to avoid such a lapse.CommentsClose CommentsPermalink





(i) Application and Verification of Requirement of Citizenship or Lawful Presence in the United States-CommentsClose CommentsPermalink





(1) REQUIREMENT- No individual shall be an eligible individual under this section unless the individual is a citizen or national of the United States or is lawfully present in a State in the United States (other than as a nonimmigrant described in a subparagraph (excluding subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of the Immigration and Nationality Act).CommentsClose CommentsPermalink





(2) APPLICATION OF VERIFICATION PROCESS FOR AFFORDABILITY CREDITS- The provisions of paragraphs (4) (other than subparagraphs (F) and (H)(i)) and (5)(A) of section 341(b), and of subsections (v) (other than paragraph (3)) and (x) of section 205 of the Social Security Act, shall apply to the verification of eligibility of an eligible individual by the Secretary (or by a State agency approved by the Secretary) for benefits under this section in the same manner as such provisions apply to the verification of eligibility of an affordable credit eligible individual for affordability credits by the Commissioner under section 341(b). The agreement referred to in section 205(v)(2)(A) of the Social Security Act (as applied under this paragraph) shall also provide for funding, to be payable from the amount made available under subsection (h)(1), to the Commissioner of Social Security in such amount as is agreed to by such Commissioner and the Secretary.CommentsClose CommentsPermalink





(j) Employment-based Retiree Health Coverage- In this section, the term ‘employment-based retiree health coverage’ means health insurance or other coverage of health care costs (whether provided by voluntary insurance coverage or pursuant to statutory or contractual obligation) for individuals (or for such individuals and their spouses and dependents) under a group health plan based on their status as retired participants in such plan.CommentsClose CommentsPermalink

SEC. 102. 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 (but not less than 85 percent), the issuer shall provide in a manner specified by the Secretary for rebates to enrollees of the amount by which the issuer’s medical loss ratio is less than the level so specified.CommentsClose CommentsPermalink





‘(b) Implementation- The Secretary shall establish a uniform definition of medical loss ratio and methodology for determining how to calculate it based on the average medical loss ratio in a health insurance issuer’s book of business for the small and large group market. Such methodology shall be designed to take into account the special circumstances of smaller plans, different types of plans, and newer plans. In determining the medical loss ratio, the Secretary shall exclude State taxes and licensing or regulatory fees. Such methodology shall be designed and exceptions shall be established to ensure adequate participation by health insurance issuers, competition in the health insurance market, and value for consumers so that their premiums are used for services.CommentsClose CommentsPermalink





‘(c) Sunset- Subsections (a) and (b) shall not apply to health insurance coverage on and after the first date that health insurance coverage is offered through the Health Insurance Exchange.’.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 except to the extent the Secretary determines that the application of such section may destabilize the existing individual 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, 2010, or as soon as practicable after such date.CommentsClose CommentsPermalink

SEC. 103. ENDING HEALTH INSURANCE RESCISSION ABUSE.

(a) Clarification Regarding Application of Guaranteed Renewability of Individual and Group Health Insurance Coverage- Sections 2712 and 2742 of the Public Health Service Act (42 U.S.C. 300gg-12, 300gg-42) are each amended--CommentsClose CommentsPermalink





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





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





(b) Secretarial Guidance Regarding Rescissions-CommentsClose CommentsPermalink





(1) GROUP HEALTH INSURANCE MARKET- Section 2712 of such Act (42 U.S.C. 300gg-12) is amended by adding at the end the following:CommentsClose CommentsPermalink





‘(f) Rescission- A health insurance issuer may rescind group health insurance coverage only upon clear and convincing evidence of fraud described in subsection (b)(2), under procedures that provide for independent, external third-party review.’.CommentsClose CommentsPermalink





(2) INDIVIDUAL HEALTH MARKET- 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 individual health insurance coverage only upon clear and convincing evidence of fraud described in subsection (b)(2), under procedures that provide for independent, external third-party review.’.CommentsClose CommentsPermalink





(3) GUIDANCE- The Secretary of Health and Human Services, no later than 90 days after the date of the enactment of this Act, shall issue guidance implementing the amendments made by paragraphs (1) and (2), including procedures for independent, external third-party review.CommentsClose CommentsPermalink





(c) Opportunity for Independent, External Third-party Review in Certain Cases-CommentsClose CommentsPermalink





(1) INDIVIDUAL MARKET- 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





(2) APPLICATION TO GROUP HEALTH INSURANCE- Such title is further amended by adding after section 2702 the following new section:CommentsClose CommentsPermalink

‘SEC. 2703. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD-PARTY REVIEW IN CASES OF RESCISSION.

‘The provisions of section 2746 shall apply to group health insurance coverage in the same manner as such provisions apply to individual health insurance coverage, except that any reference to section 2742(f) is deemed a reference to section 2712(f).’.CommentsClose CommentsPermalink





(d) Effective Date- The amendments made by this section shall take effect on the date of the enactment of this Act and shall apply to rescissions occurring on and after July 1, 2010, with respect to health insurance coverage issued before, on, or after such date.CommentsClose CommentsPermalink

SEC. 104. SUNSHINE ON PRICE GOUGING BY HEALTH INSURANCE ISSUERS.

(a) Initial Premium Review Process-CommentsClose CommentsPermalink





(1) IN GENERAL- The Secretary of Health and Human Services, in conjunction with States, shall establish a process for the annual review, beginning with 2010 and subject to subsection (c)(3)(A), of increases in premiums for health insurance coverage.CommentsClose CommentsPermalink





(2) JUSTIFICATION AND DISCLOSURE- Such process shall require health insurance issuers to submit a justification for any premium increase prior to implementation of the increase. Such issuers shall prominently post such information on their websites. The Secretary shall ensure the public disclosure of information on such increases and justifications for all health insurance issuers.CommentsClose CommentsPermalink





(b) Continuing Premium Review Process-CommentsClose CommentsPermalink





(1) INFORMING COMMISSIONER OF PREMIUM INCREASE PATTERNS- As a condition of receiving a grant under subsection (c)(1), a State, through its Commissioner of Insurance, shall--CommentsClose CommentsPermalink





(A) provide the Health Choices Commissioner with information about trends in premium increases in health insurance coverage in premium rating areas in the State; andCommentsClose CommentsPermalink





(B) make recommendations, as appropriate, to such Commissioner about whether particular health insurance issuers should be excluded from participation in the Health Insurance Exchange based on a pattern of excessive or unjustified premium increases.CommentsClose CommentsPermalink





(2) COMMISSIONER AUTHORITY REGARDING EXCHANGE PARTICIPATION- In making determinations concerning entering into contracts with QHBP offering entities for the offering of Exchange-participating health plans under section 304, the Commissioner shall take into account the information and recommendations provided under paragraph (1).CommentsClose CommentsPermalink





(3) MONITORING BY COMMISSIONER OF PREMIUM INCREASES-CommentsClose CommentsPermalink





(A) IN GENERAL- Beginning in 2014, the Commissioner, in conjunction with the States and in place of the monitoring by the Secretary under subsection (a)(1) and consistent with the provisions of subsection (a)(2), shall monitor premium increases of health insurance coverage offered inside the Health Insurance Exchange under section 304 and outside of the Exchange.CommentsClose CommentsPermalink





(B) CONSIDERATION IN OPENING EXCHANGE- In determining under section 302(e)(4) whether to make additional larger employers eligible to participate in the Health Insurance Exchange, the Commissioner shall take into account any excess of premium growth outside the Exchange as compared to the rate of such growth inside the Exchange, including information reported by the States.CommentsClose CommentsPermalink





(c) Grants in Support of Process-CommentsClose CommentsPermalink





(1) PREMIUM REVIEW GRANTS DURING 2010 THROUGH 2014- The Secretary shall carry out a program of grants to States during the 5-year period beginning with 2010 to assist them in carrying out subsection (a), including--CommentsClose CommentsPermalink





(A) in reviewing and, if appropriate under State law, approving premium increases for health insurance coverage; andCommentsClose CommentsPermalink





(B) in providing information and recommendations to the Commissioner under subsection (b)(1).CommentsClose CommentsPermalink





(2) FUNDING-CommentsClose CommentsPermalink





(A) IN GENERAL- Out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary $1,000,000,000, to be available for expenditure for grants under paragraph (1) and subparagraph (B).CommentsClose CommentsPermalink





(B) FURTHER AVAILABILITY FOR INSURANCE REFORM AND CONSUMER PROTECTION GRANTS- If the amounts appropriated under subparagraph (A) are not fully obligated under grants under paragraph (1) by the end of 2014, any remaining funds shall remain available to the Secretary for grants to States for planning and implementing the insurance reforms and consumer protections under title II.CommentsClose CommentsPermalink





(C) ALLOCATION- The Secretary shall establish a formula for determining the amount of any grant to a State under this subsection. Under such formula--CommentsClose CommentsPermalink





(i) the Secretary shall consider the number of plans of health insurance coverage offered in each State and the population of the State; andCommentsClose CommentsPermalink





(ii) no State qualifying for a grant under paragraph (1) shall receive less than $1,000,000, or more than $5,000,000 for a grant year.CommentsClose CommentsPermalink

SEC. 105. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE FOR UNINSURED YOUNG ADULTS.

(a) Under Group Health Plans-CommentsClose CommentsPermalink





(1) PHSA- Title XXVII of the Public Health Service Act is amended by inserting after section 2702 the following new section:CommentsClose CommentsPermalink

‘SEC. 2703. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE FOR UNINSURED YOUNG ADULTS.

‘(a) In General- A group health plan and a health insurance issuer offering health insurance coverage in connection with a group health plan that provides coverage for dependent children shall make available such coverage, at the option of the participant involved, for one or more qualified children (as defined in subsection (b)) of the participant.CommentsClose CommentsPermalink





‘(b) Qualified Child Defined- In this section, the term ‘qualified child’ means, with respect to a participant in a group health plan or group health insurance coverage, an individual who (but for age) would be treated as a dependent child of the participant under such plan or coverage and who--CommentsClose CommentsPermalink





‘(1) is under 27 years of age; andCommentsClose CommentsPermalink





‘(2) is not enrolled as a participant, beneficiary, or enrollee (other than under this section, section 2746, or section 704 of the Employee Retirement Income Security Act of 1974) under any health insurance coverage or group health plan.CommentsClose CommentsPermalink





‘(c) Premiums- Nothing in this section shall be construed as preventing a group health plan or health insurance issuer with respect to group health insurance coverage from increasing the premiums otherwise required for coverage provided under this section consistent with standards established by the Secretary based upon family size.’.CommentsClose CommentsPermalink





(2) EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974-CommentsClose CommentsPermalink





(A) IN GENERAL- Part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by inserting after section 703 the following new section:CommentsClose CommentsPermalink

‘SEC. 704. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE FOR UNINSURED YOUNG ADULTS.

‘(a) In General- A group health plan and a health insurance issuer offering health insurance coverage in connection with a group health plan that provides coverage for dependent children shall make available such coverage, at the option of the participant involved, for one or more qualified children (as defined in subsection (b)) of the participant.CommentsClose CommentsPermalink





‘(b) Qualified Child Defined- In this section, the term ‘qualified child’ means, with respect to a participant in a group health plan or group health insurance coverage, an individual who (but for age) would be treated as a dependent child of the participant under such plan or coverage and who--CommentsClose CommentsPermalink





‘(1) is under 27 years of age; andCommentsClose CommentsPermalink





‘(2) is not enrolled as a participant, beneficiary, or enrollee (other than under this section) under any health insurance coverage or group health plan.CommentsClose CommentsPermalink





‘(c) Premiums- Nothing in this section shall be construed as preventing a group health plan or health insurance issuer with respect to group health insurance coverage from increasing the premiums otherwise required for coverage provided under this section consistent with standards established by the Secretary based upon family size.’.CommentsClose CommentsPermalink





(B) CLERICAL AMENDMENT- The table of contents of such Act is amended by inserting after the item relating to section 703 the following new item:CommentsClose CommentsPermalink





‘Sec. 704. Requiring the option of extension of dependent coverage for uninsured young adults.’.CommentsClose CommentsPermalink





(3) IRC-CommentsClose CommentsPermalink





(A) IN GENERAL- Subchapter A of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new section:CommentsClose CommentsPermalink

‘SEC. 9804. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE FOR UNINSURED YOUNG ADULTS.

‘(a) In General- A group health plan that provides coverage for dependent children shall make available such coverage, at the option of the participant involved, for one or more qualified children (as defined in subsection (b)) of the participant.CommentsClose CommentsPermalink





‘(b) Qualified Child Defined- In this section, the term ‘qualified child’ means, with respect to a participant in a group health plan, an individual who (but for age) would be treated as a dependent child of the participant under such plan and who--CommentsClose CommentsPermalink





‘(1) is under 27 years of age; andCommentsClose CommentsPermalink





‘(2) is not enrolled as a participant, beneficiary, or enrollee (other than under this section, section 704 of the Employee Retirement Income Security Act of 1974, or section 2704 or 2746 of the Public Health Service Act) under any health insurance coverage or group health plan.CommentsClose CommentsPermalink





‘(c) Premiums- Nothing in this section shall be construed as preventing a group health plan from increasing the premiums otherwise required for coverage provided under this section consistent with standards established by the Secretary based upon family size.’.CommentsClose CommentsPermalink





(B) CLERICAL AMENDMENT- The table of sections of such chapter is amended by inserting after the item relating to section 9803 the following:CommentsClose CommentsPermalink





‘Sec. 9804. Requiring the option of extension of dependent coverage for uninsured young adults.’.CommentsClose CommentsPermalink





(b) Individual Health Insurance Coverage- Title XXVII of the Public Health Service Act is amended by inserting after section 2745 the following new section:CommentsClose CommentsPermalink

‘SEC. 2746. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE FOR UNINSURED YOUNG ADULTS.

‘The provisions of section 2703 shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as they apply to health insurance coverage offered by a health insurance issuer in connection with a group health plan in the small or large group market.’.CommentsClose CommentsPermalink





(c) Effective Dates-CommentsClose CommentsPermalink





(1) GROUP HEALTH PLANS- The amendments made by subsection (a) shall apply to group health plans for plan years beginning on or after January 1, 2010.CommentsClose CommentsPermalink





(2) INDIVIDUAL HEALTH INSURANCE COVERAGE- Section 2746 of the Public Health Service Act, as inserted by subsection (b), shall apply with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after January 1, 2010.CommentsClose CommentsPermalink

SEC. 106. LIMITATIONS ON PREEXISTING CONDITION EXCLUSIONS IN GROUP HEALTH PLANS IN ADVANCE OF APPLICABILITY OF NEW PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS.

(a) Amendments to the Employee Retirement Income Security Act of 1974-CommentsClose CommentsPermalink





(1) REDUCTION IN LOOK-BACK PERIOD- Section 701(a)(1) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1181(a)(1)) is amended by striking ‘6-month period’ and inserting ‘30-day period’.CommentsClose CommentsPermalink





(2) REDUCTION IN PERMITTED PREEXISTING CONDITION LIMITATION PERIOD- Section 701(a)(2) of such Act (29 U.S.C. 1181(a)(2)) is amended by striking ‘12 months’ and inserting ‘3 months’, and by striking ‘18 months’ and inserting ‘9 months’.CommentsClose CommentsPermalink





(3) SUNSET OF INTERIM LIMITATION- Section 701 of such Act (29 U.S.C. 1181) is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink





‘(h) Termination- This section shall cease to apply to any group health plan as of the date that such plan becomes subject to the requirements of section 211 of the (relating to prohibiting preexisting condition exclusions).’.CommentsClose CommentsPermalink





(b) Amendments to the Internal Revenue Code of 1986-CommentsClose CommentsPermalink





(1) REDUCTION IN LOOK-BACK PERIOD- Section 9801(a)(1) of the Internal Revenue Code of 1986 is amended by striking ‘6-month period’ and inserting ‘30-day period’.CommentsClose CommentsPermalink





(2) REDUCTION IN PERMITTED PREEXISTING CONDITION LIMITATION PERIOD- Section 9801(a)(2) of such Code is amended by striking ‘12 months’ and inserting ‘3 months’, and by striking ‘18 months’ and inserting ‘9 months’.CommentsClose CommentsPermalink





(3) SUNSET OF INTERIM LIMITATION- Section 9801 of such Code is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink





‘(g) Termination- This section shall cease to apply to any group health plan as of the date that such plan becomes subject to the requirements of section 211 of the Affordable Health Care for America Act (relating to prohibiting preexisting condition exclusions).’.CommentsClose CommentsPermalink





(c) Amendments to Public Health Service Act-CommentsClose CommentsPermalink





(1) REDUCTION IN LOOK-BACK PERIOD- Section 2701(a)(1) of the Public Health Service Act (42 U.S.C. 300gg(a)(1)) is amended by striking ‘6-month period’ and inserting ‘30-day period’.CommentsClose CommentsPermalink





(2) REDUCTION IN PERMITTED PREEXISTING CONDITION LIMITATION PERIOD- Section 2701(a)(2) of such Act (42 U.S.C. 300gg(a)(2)) is amended by striking ‘12 months’ and inserting ‘3 months’, and by striking ‘18 months’ and inserting ‘9 months’.CommentsClose CommentsPermalink





(3) SUNSET OF INTERIM LIMITATION- Section 2701 of such Act (42 U.S.C. 300gg) is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink





‘(h) Termination- This section shall cease to apply to any group health plan as of the date that such plan becomes subject to the requirements of section 211 of the (relating to prohibiting preexisting condition exclusions).’.CommentsClose CommentsPermalink





(4) MISCELLANEOUS TECHNICAL AMENDMENT- Section 2702(a)(2) of such Act (42 U.S.C. 300gg-1) is amended by striking ‘701’ and inserting ‘2701’.CommentsClose CommentsPermalink





(d) Effective Date-CommentsClose CommentsPermalink





(1) IN GENERAL- Except as provided in paragraph (2), the amendments made by this section shall apply with respect to group health plans for plan years beginning on or after January 1, 2010.CommentsClose CommentsPermalink





(2) SPECIAL RULE FOR COLLECTIVE BARGAINING AGREEMENTS- In the case of a group health plan maintained pursuant to 1 or more collective bargaining agreements between employee representatives and 1 or more employers ratified before the date of the enactment of this Act, the amendments made by this section shall not apply to plan years beginning before the earlier of--CommentsClose CommentsPermalink





(A) the date on which the last of the collective bargaining agreements relating to the plan terminates (determined without regard to any extension thereof agreed to after the date of the enactment of this Act);CommentsClose CommentsPermalink





(B) 3 years after the date of the enactment of this Act.CommentsClose CommentsPermalink

SEC. 107. PROHIBITING ACTS OF DOMESTIC VIOLENCE FROM BEING TREATED AS PREEXISTING CONDITIONS.

(a) ERISA- Section 701(d)(3) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. ) is amended--CommentsClose CommentsPermalink





(1) in the heading, by inserting ‘OR DOMESTIC VIOLENCE’ after ‘PREGNANCY’; andCommentsClose CommentsPermalink





(2) by inserting ‘or domestic violence’ after ‘relating to pregnancy’.CommentsClose CommentsPermalink





(b) PHSA-CommentsClose CommentsPermalink





(1) GROUP MARKET- Section 2701(d)(3) of the Public Health Service Act (42 U.S.C. 300gg(d)(3)) is amended--CommentsClose CommentsPermalink





(A) in the heading, by inserting ‘OR DOMESTIC VIOLENCE’ after ‘PREGNANCY’; andCommentsClose CommentsPermalink





(B) by inserting ‘or domestic violence’ after ‘relating to pregnancy’.CommentsClose CommentsPermalink





(2) INDIVIDUAL MARKET- Title XXVII of such Act is amended by inserting after section 2753 the following new section:CommentsClose CommentsPermalink

‘SEC. 2754. PROHIBITION ON DOMESTIC VIOLENCE AS PREEXISTING CONDITION.

‘A health insurance issuer offering health insurance coverage in the individual market may not, on the basis of domestic violence, impose any preexisting condition exclusion (as defined in section 2701(b)(1)(A)) with respect to such coverage.’.CommentsClose CommentsPermalink





(c) IRC- Section 9801(d)(3) of the Internal Revenue Code of 1986 is amended--CommentsClose CommentsPermalink





(1) in the heading, by inserting ‘OR DOMESTIC VIOLENCE’ after ‘PREGNANCY’; andCommentsClose CommentsPermalink





(2) by inserting ‘or domestic violence’ after ‘relating to pregnancy’.CommentsClose CommentsPermalink





(d) Effective Dates-CommentsClose CommentsPermalink





(1) Except as otherwise provided in this subsection, the amendments made by this section shall apply with respect to group health plans (and health insurance issuers offering group health insurance coverage) for plan years beginning on or after January 1, 2010.CommentsClose CommentsPermalink





(2) The amendment made by subsection (b)(2) shall apply with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after such date.CommentsClose CommentsPermalink

SEC. 108. ENDING HEALTH INSURANCE DENIALS AND DELAYS OF NECESSARY TREATMENT FOR CHILDREN WITH DEFORMITIES.

(a) Amendments to the Employee Retirement Income Security Act of 1974-CommentsClose CommentsPermalink





(1) IN GENERAL- Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by adding at the end the following new section:CommentsClose CommentsPermalink

‘SEC. 715. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD’S CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

‘(a) Requirements for Treatment for Children With Deformities-CommentsClose CommentsPermalink





‘(1) IN GENERAL- A group health plan, and a health insurance issuer offering group health insurance coverage, that provides coverage for surgical benefits shall provide coverage for outpatient and inpatient diagnosis and treatment of a minor child’s congenital or developmental deformity, disease, or injury. A minor child shall include any individual who is 21 years of age or younger.CommentsClose CommentsPermalink





‘(2) TREATMENT DEFINED-CommentsClose CommentsPermalink





‘(A) IN GENERAL- In this section, the term ‘treatment’ includes reconstructive surgical procedures (procedures that are generally performed to improve function, but may also be performed to approximate a normal appearance) that are performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, including--CommentsClose CommentsPermalink





‘(i) procedures that do not materially affect the function of the body part being treated; andCommentsClose CommentsPermalink





‘(ii) procedures for secondary conditions and follow-up treatment.CommentsClose CommentsPermalink





‘(B) EXCEPTION- Such term does not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem.CommentsClose CommentsPermalink





‘(b) Notice- A group health plan under this part shall comply with the notice requirement under section 713(b) (other than paragraph (3)) with respect to the requirements of this section.’.CommentsClose CommentsPermalink





(2) CONFORMING AMENDMENT-CommentsClose CommentsPermalink





(A) Subsection (c) of section 731 of such Act is amended by striking ‘section 711’ and inserting ‘sections 711 and 715’.CommentsClose CommentsPermalink





(B) The table of contents in section 1 of such Act is amended by inserting after the item relating to section 714 the following new item:CommentsClose CommentsPermalink





‘Sec. 715. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.’.CommentsClose CommentsPermalink





(b) Amendments to the Internal Revenue Code of 1986-CommentsClose CommentsPermalink





(1) IN GENERAL- Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new section:CommentsClose CommentsPermalink

‘SEC. 9814. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD’S CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

‘(a) Requirements for Treatment for Children With Deformities- A group health plan that provides coverage for surgical benefits shall provide coverage for outpatient and inpatient diagnosis and treatment of a minor child’s congenital or developmental deformity, disease, or injury. A minor child shall include any individual who is 21 years of age or younger.CommentsClose CommentsPermalink





‘(b) Treatment Defined-CommentsClose CommentsPermalink





‘(1) IN GENERAL- In this section, the term ‘treatment’ includes reconstructive surgical procedures (procedures that are generally performed to improve function, but may also be performed to approximate a normal appearance) that are performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, including--CommentsClose CommentsPermalink





‘(A) procedures that do not materially affect the function of the body part being treated, andCommentsClose CommentsPermalink





‘(B) procedures for secondary conditions and follow-up treatment.CommentsClose CommentsPermalink





‘(2) EXCEPTION- Such term does not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem.’.CommentsClose CommentsPermalink





(2) CLERICAL AMENDMENT- The table of sections for subchapter B of chapter 100 of such Code is amended by adding at the end the following new item:CommentsClose CommentsPermalink





‘Sec. 9814. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.’.CommentsClose CommentsPermalink





(c) Amendments to the Public Health Service Act-CommentsClose CommentsPermalink





(1) IN GENERAL- Subpart 2 of part A of title XXVII of the Public Health Service Act is amended by adding at the end the following new section:CommentsClose CommentsPermalink

‘SEC. 2708. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD’S CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

‘(a) Requirements for Treatment for Children With Deformities-CommentsClose CommentsPermalink





‘(1) IN GENERAL- A group health plan, and a health insurance issuer offering group health insurance coverage, that provides coverage for surgical benefits shall provide coverage for outpatient and inpatient diagnosis and treatment of a minor child’s congenital or developmental deformity, disease, or injury. A minor child shall include any individual who is 21 years of age or younger.CommentsClose CommentsPermalink





‘(2) TREATMENT DEFINED-CommentsClose CommentsPermalink





‘(A) IN GENERAL- In this section, the term ‘treatment’ includes reconstructive surgical procedures (procedures that are generally performed to improve function, but may also be performed to approximate a normal appearance) that are performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, including--CommentsClose CommentsPermalink





‘(i) procedures that do not materially affect the function of the body part being treated; andCommentsClose CommentsPermalink





‘(ii) procedures for secondary conditions and follow-up treatment.CommentsClose CommentsPermalink





‘(B) EXCEPTION- Such term does not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem.CommentsClose CommentsPermalink





‘(b) Notice- A group health plan under this part shall comply with the notice requirement under section 715(b) of the Employee Retirement Income Security Act of 1974 with respect to the requirements of this section as if such section applied to such plan.’.CommentsClose CommentsPermalink





(2) INDIVIDUAL HEALTH INSURANCE- Subpart 2 of part B of title XXVII of the Public Health Service Act, as amended by section 161(b), is further amended by adding at the end the following new section:CommentsClose CommentsPermalink

‘SEC. 2755. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD’S CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

‘The provisions of section 2708 shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as such provisions apply to health insurance coverage offered by a health insurance issuer in connection with a group health plan in the small or large group market.’.CommentsClose CommentsPermalink





(3) CONFORMING AMENDMENTS-CommentsClose CommentsPermalink





(A) Section 2723(c) of such Act (42 U.S.C. 300gg-23(c)) is amended by striking ‘section 2704’ and inserting ‘sections 2704 and 2708’.CommentsClose CommentsPermalink





(B) Section 2762(b)(2) of such Act (42 U.S.C. 300gg-62(b)(2)) is amended by striking ‘section 2751’ and inserting ‘sections 2751 and 2755’.CommentsClose CommentsPermalink





(d) Effective Dates-CommentsClose CommentsPermalink





(1) The amendments made by this section shall apply with respect to group health plans (and health insurance issuers offering group health insurance coverage) for plan years beginning on or after January 1, 2010.CommentsClose CommentsPermalink





(2) The amendment made by subsection (c)(2) shall apply with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after such date.CommentsClose CommentsPermalink





(e) Coordination- Section 104(1) of the Health Insurance Portability and Accountability Act of 1996 is amended by striking ‘(and the amendments made by this subtitle and section 401)’ and inserting ‘, part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974, parts A and C of title XXVII of the Public Health Service Act, and chapter 100 of the Internal Revenue Code of 1986’.CommentsClose CommentsPermalink

SEC. 109. ELIMINATION OF LIFETIME LIMITS.

(a) Amendments to the Employee Retirement Income Security Act of 1974-CommentsClose CommentsPermalink





(1) IN GENERAL- Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.), as amended by section 108, is amended by adding at the end the following:CommentsClose CommentsPermalink

‘SEC. 716. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

‘(a) In General- A group health plan and a health insurance issuer providing health insurance coverage in connection with a group health plan, may not impose an aggregate dollar lifetime limit with respect to benefits payable under the plan or coverage.CommentsClose CommentsPermalink





‘(b) Definition- In this section, the term ‘aggregate dollar lifetime limit’ means, with respect to benefits under a group health plan or health insurance coverage offered in connection with a group health plan, a dollar limitation on the total amount that may be paid with respect to such benefits under the plan or health insurance coverage with respect to an individual or other coverage unit on a lifetime basis.’.CommentsClose CommentsPermalink





(2) CLERICAL AMENDMENT- The table of contents in section 1 of such Act, is amended by inserting after the item relating to section 715 the following new item:CommentsClose CommentsPermalink





‘Sec. 716. Elimination of lifetime aggregate limits.’.CommentsClose CommentsPermalink





(b) Amendments to the Internal Revenue Code of 1986-CommentsClose CommentsPermalink





(1) IN GENERAL- Subchapter B of chapter 100 of the Internal Revenue Code of 1986, as amended by section 108(b), is amended by adding at the end the following new section:CommentsClose CommentsPermalink

‘SEC. 9815. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

‘(a) In General- A group health plan may not impose an aggregate dollar lifetime limit with respect to benefits payable under the plan.CommentsClose CommentsPermalink





‘(b) Definition- In this section, the term ‘aggregate dollar lifetime limit’ means, with respect to benefits under a group health plan a dollar limitation on the total amount that may be paid with respect to such benefits under the plan with respect to an individual or other coverage unit on a lifetime basis.’.CommentsClose CommentsPermalink





(2) CLERICAL AMENDMENT- The table of sections for subchapter B of chapter 100 of such Code, as amended by section 108(b), is amended by adding at the end the following new item:CommentsClose CommentsPermalink





‘Sec. 9854. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.’.CommentsClose CommentsPermalink





(c) Amendment to the Public Health Service Act Relating to the Group Market-CommentsClose CommentsPermalink





(1) IN GENERAL- Subpart 2 of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-4 et seq.) as amended by section 108(c)(1), is amended by adding at the end the following:CommentsClose CommentsPermalink

‘SEC. 2709. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

‘(a) In General- A group health plan and a health insurance issuer providing health insurance coverage in connection with a group health plan, may not impose an aggregate dollar lifetime limit with respect to benefits payable under the plan or coverage.CommentsClose CommentsPermalink





‘(b) Definition- In this section, the term ‘aggregate dollar lifetime limit’ means, with respect to benefits under a group health plan or health insurance coverage, a dollar limitation on the total amount that may be paid with respect to such benefits under the plan or health insurance coverage with respect to an individual or other coverage unit on a lifetime basis.’.CommentsClose CommentsPermalink





(2) INDIVIDUAL MARKET- Subpart 2 of part B of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-51 et seq.), as amended by section 108(c)(2), is amended by adding at the end the following:CommentsClose CommentsPermalink

‘SEC. 2756. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

‘The provisions of section 2709 shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as they apply to health insurance coverage offered by a health insurance issuer in connection with a group health plan in the small or large group market.’.CommentsClose CommentsPermalink





(d) Effective Dates-CommentsClose CommentsPermalink





(1) The amendments made by this section shall apply with respect to group health plans (and health insurance issuers offering group health insurance coverage) for plan years beginning on or after January 1, 2010.CommentsClose CommentsPermalink





(2) The amendment made by subsection (c)(2) shall apply with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after such date.CommentsClose CommentsPermalink

SEC. 110. PROHIBITION AGAINST POSTRETIREMENT REDUCTIONS OF RETIREE HEALTH BENEFITS BY GROUP HEALTH PLANS.

(a) In General- Part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974, as amended by sections 108 and 109, is amended by inserting after section 716 the following new section:CommentsClose CommentsPermalink

‘SEC. 717. PROTECTION AGAINST POSTRETIREMENT REDUCTION OF RETIREE HEALTH BENEFITS.

‘(a) In General- Every group health plan shall contain a provision which expressly bars the plan, or any fiduciary of the plan, from reducing the benefits provided under the plan to a retired participant, or beneficiary of such participant, if such reduction affects the benefits provided to the participant or beneficiary as of the date the participant retired for purposes of the plan and such reduction occurs after the participant’s retirement unless such reduction is also made with respect to active participants. Nothing in this section shall prohibit a plan from enforcing a total aggregate cap on amounts paid for retiree health coverage that is part of the plan at the time of retirement.CommentsClose CommentsPermalink





‘(b) No Reduction- Notwithstanding that a group health plan may contain a provision reserving the general power to amend or terminate the plan or a provision specifically authorizing the plan to make post-retirement reductions in retiree health benefits, it shall be prohibited for any group health plan, whether through amendment or otherwise, to reduce the benefits provided to a retired participant or the participant’s beneficiary under the terms of the plan if such reduction of benefits occurs after the date the participant retired for purposes of the plan and reduces benefits that were provided to the participant, or the participant’s beneficiary, as of the date the participant retired unless such reduction is also made with respect to active participants.CommentsClose CommentsPermalink





‘(c) Reduction Described- For purposes of this section, a reduction in benefits--CommentsClose CommentsPermalink





‘(1) with respect to premiums occurs under a group health plan when a participant’s (or beneficiary’s) share of the total premium (or, in the case of a self-insured plan, the costs of coverage) of the plan substantially increases; orCommentsClose CommentsPermalink





‘(2) with respect to other cost-sharing and benefits under a group health plan occurs when there is a substantial decrease in the actuarial value of the benefit package under the plan.CommentsClose CommentsPermalink





For purposes of this section, the term ‘substantial’ means an increase in the total premium share or a decrease in the actuarial value of the benefit package that is greater than 5 percent.’CommentsClose CommentsPermalink





(b) Conforming Amendment- The table of contents in section 1 of such Act, as amended by sections 108 and 109, is amended by inserting after the item relating to section 716 the following new item:CommentsClose CommentsPermalink





‘Sec. 717. Protection against postretirement reduction of retiree health benefits.’.CommentsClose CommentsPermalink





(c) Waiver- An employer may, in a form and manner which shall be prescribed by the Secretary of Labor, apply for a waiver from this provision if the employer can reasonably demonstrate that meeting the requirements of this section would impose an undue hardship on the employer.CommentsClose CommentsPermalink





(d) Effective Date- The amendments made by this section shall take effect on the date of the enactment of this Act.CommentsClose CommentsPermalink

SEC. 111. 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 plan or employment-based health plan that--CommentsClose CommentsPermalink





(i) is --CommentsClose CommentsPermalink





(I) maintained by one or more employers (including without limitation any State or political subdivision thereof, or any agency or instrumentality of any of the foregoing), former employers or employee organizations or associations, or a voluntary employees’ beneficiary association, or a committee or board of individuals appointed to administer such plan; orCommentsClose CommentsPermalink





(II) a multiemployer plan (as defined in section 3(37) of the Employee Retirement Income Security Act of 1974); andCommentsClose 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; andCommentsClose 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, copayments, and coinsurance 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 only be used to reduce the costs of health care provided by the plan by reducing premium costs for the employer or employee association maintaining the plan, and reducing premium contributions, deductibles, copayments, coinsurance, or other out-of-pocket costs for plan participants and beneficiaries. Where the benefits are provided by an employer to members of a represented bargaining unit, the allocation of payments among these purposes shall be subject to collective bargaining. Amounts paid to the plan under this subsection shall not be used as general revenues by the employer or employee association maintaining the plan or for any other purposes. 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; andCommentsClose 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) 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

SEC. 112. WELLNESS PROGRAM GRANTS.

(a) Allowance of Grant-CommentsClose CommentsPermalink





(1) IN GENERAL- For purposes of this section, the Secretaries of Health and Human Services and Labor shall jointly award wellness grants as determined under this section. Wellness program grants shall be awarded to small employers (as defined by the Secretary) for any plan year in an amount equal to 50 percent of the costs paid or incurred by such employers in connection with a qualified wellness program during the plan year. For purposes of the preceding sentence, in the case of any qualified wellness program offered as part of an employment-based health plan, only costs attributable to the qualified wellness program and not to the health plan, or health insurance coverage offered in connection with such a plan, may be taken into account.CommentsClose CommentsPermalink





(2) LIMITATIONS-CommentsClose CommentsPermalink





(A) PERIOD- A wellness grant awarded to an employer under this section shall be for up to 3 years.CommentsClose CommentsPermalink





(B) AMOUNT- The amount of the grant under paragraph (1) for an employer shall not exceed--CommentsClose CommentsPermalink





(i) the product of $150 and the number of employees of the employer for any plan year; andCommentsClose CommentsPermalink





(ii) $50,000 for the entire period of the grant.CommentsClose CommentsPermalink





(b) Qualified Wellness Program- For purposes of this section:CommentsClose CommentsPermalink





(1) QUALIFIED WELLNESS PROGRAM- The term ‘qualified wellness program’ means a program that--CommentsClose CommentsPermalink





(A) includes any 3 wellness components described in subsection (c); andCommentsClose CommentsPermalink





(B) is to be certified jointly by the Secretary of Health and Human Services and the Secretary of Labor, in coordination with the Director of the Centers for Disease Control and Prevention, as a qualified wellness program under this section.CommentsClose CommentsPermalink





(2) PROGRAMS MUST BE CONSISTENT WITH RESEARCH AND BEST PRACTICES-CommentsClose CommentsPermalink





(A) IN GENERAL- The Secretary of Health and Human Services and the Secretary of Labor shall not certify a program as a qualified wellness program unless the program--CommentsClose CommentsPermalink





(i) is consistent with evidence-based research and best practices, as identified by persons with expertise in employer health promotion and wellness programs;CommentsClose CommentsPermalink





(ii) includes multiple, evidence-based strategies which are based on the existing and emerging research and careful scientific reviews, including the Guide to Community Preventative Services, the Guide to Clinical Preventative Services, and the National Registry for Effective Programs; andCommentsClose CommentsPermalink





(iii) includes strategies which focus on prevention and support for employee populations at risk of poor health outcomes.CommentsClose CommentsPermalink





(B) PERIODIC UPDATING AND REVIEW- The Secretaries of Health and Human Services and Labor, in consultation with other appropriate agencies shall jointly establish procedures for periodic review, evaluation, and update of the programs under this subsection.CommentsClose CommentsPermalink





(3) HEALTH LITERACY AND ACCESSIBILITY- The Secretaries of Health and Human Services and Labor shall jointly, as part of the certification process--CommentsClose CommentsPermalink





(A) ensure that employers make the programs culturally competent, physically and programmatically accessible (including for individuals with disabilities), and appropriate to the health literacy needs of the employees covered by the programs;CommentsClose CommentsPermalink





(B) require a health literacy component to provide special assistance and materials to employees with low literacy skills, limited English and from underserved populations; andCommentsClose CommentsPermalink





(C) require the Secretaries to compile and disseminate to employer health plans information on model health literacy curricula, instructional programs, and effective intervention strategies.CommentsClose CommentsPermalink





(c) Wellness Program Components- For purposes of this section, the wellness program components described in this subsection are the following:CommentsClose CommentsPermalink





(1) HEALTH AWARENESS COMPONENT- A health awareness component which provides for the following:CommentsClose CommentsPermalink





(A) HEALTH EDUCATION- The dissemination of health information which addresses the specific needs and health risks of employees.CommentsClose CommentsPermalink





(B) HEALTH SCREENINGS- The opportunity for periodic screenings for health problems and referrals for appropriate follow-up measures.CommentsClose CommentsPermalink





(2) EMPLOYEE ENGAGEMENT COMPONENT- An employee engagement component which provides for the active engagement of employees in worksite wellness programs through worksite assessments and program planning, onsite delivery, evaluation, and improvement efforts.CommentsClose CommentsPermalink





(3) BEHAVIORAL CHANGE COMPONENT- A behavioral change component which encourages healthy living through counseling, seminars, on-line programs, self-help materials, or other programs which provide technical assistance and problem solving skills. Such component may include programs relating to--CommentsClose CommentsPermalink





(A) tobacco use;CommentsClose CommentsPermalink





(B) obesity;CommentsClose CommentsPermalink





(C) stress management;CommentsClose CommentsPermalink





(D) physical fitness;CommentsClose CommentsPermalink





(E) nutrition;CommentsClose CommentsPermalink





(F) substance abuse;CommentsClose CommentsPermalink





(G) depression; andCommentsClose CommentsPermalink





(H) mental health promotion.CommentsClose CommentsPermalink





(4) SUPPORTIVE ENVIRONMENT COMPONENT- A supportive environment component which includes the following:CommentsClose CommentsPermalink





(A) ON-SITE POLICIES- Policies and services at the worksite which promote a healthy lifestyle, including policies relating to--CommentsClose CommentsPermalink





(i) tobacco use at the worksite;CommentsClose CommentsPermalink





(ii) the nutrition of food available at the worksite through cafeterias and vending options;CommentsClose CommentsPermalink





(iii) minimizing stress and promoting positive mental health in the workplace; andCommentsClose CommentsPermalink





(iv) the encouragement of physical activity before, during, and after work hours.CommentsClose CommentsPermalink





(d) Participation Requirement- No grant shall be allowed under subsection (a) unless the Secretaries of Health and Human Services and Labor, in consultation with other appropriate agencies, jointly certify, as a part of any certification described in subsection (b), that each wellness program component of the qualified wellness program--CommentsClose CommentsPermalink





(1) shall be available to all employees of the employer;CommentsClose CommentsPermalink





(2) shall not mandate participation by employees; andCommentsClose CommentsPermalink





(3) may provide a financial reward for participation of an individual in such program so long as such reward is not tied to the premium or cost-sharing of the individual under the health benefits plan.CommentsClose CommentsPermalink





(e) Privacy Protections- Data gathered for purposes of the employer wellness program may be used solely for the purposes of administering the program. The Secretaries of Health and Human Services and Labor shall develop standards to ensure such data remain confidential and are not used for purposes beyond those for administering the program.CommentsClose CommentsPermalink





(f) Certain Costs Not Included- For purposes of this section, costs paid or incurred by an employer for food or health insurance shall not be taken into account under subsection (a).CommentsClose CommentsPermalink





(g) Outreach- The Secretaries of Health and Human Services and Labor, in conjunction with other appropriate agencies and members of the business community, shall jointly institute an outreach program to inform businesses about the availability of the wellness program grant as well as to educate businesses on how to develop programs according to recognized and promising practices and on how to measure the success of implemented programs.CommentsClose CommentsPermalink





(h) Effective Date- This section shall take effect on July 1, 2010.CommentsClose CommentsPermalink





(i) Authorization of Appropriations- There are authorized to be appropriated such sums as are necessary to carry out this section.CommentsClose CommentsPermalink

SEC. 113. EXTENSION OF COBRA CONTINUATION COVERAGE.

(a) Extension of Current Periods of Continuation Coverage-CommentsClose CommentsPermalink





(1) IN GENERAL- In the case of any individual who is, under a COBRA continuation coverage provision, covered under COBRA continuation coverage on or after the date of the enactment of this Act, the required period of any such coverage which has not subsequently terminated under the terms of such provision for any reason other than the expiration of a period of a specified number of months shall, notwithstanding such provision and subject to subsection (b), extend to the earlier of the date on which such individual becomes eligible for acceptable coverage or the date on which such individual becomes eligible for health insurance coverage through the Health Insurance Exchange (or a State-based Health Insurance Exchange operating in a State or group of States).CommentsClose CommentsPermalink





(2) NOTICE- As soon as practicable after the date of the enactment of this Act, the Secretary of Labor, in consultation with the Secretary of the Treasury and the Secretary of Health and Human Services, shall, in consultation with administrators of the group health plans (or other entities) that provide or administer the COBRA continuation coverage involved, provide rules setting forth the form and manner in which prompt notice to individuals of the continued availability of COBRA continuation coverage to such individuals under paragraph (1).CommentsClose CommentsPermalink





(b) Continued Effect of Other Terminating Events- Notwithstanding subsection (a), any required period of COBRA continuation coverage which is extended under such subsection shall terminate upon the occurrence, prior to the date of termination otherwise provided in such subsection, of any terminating event specified in the applicable continuation coverage provision other than the expiration of a period of a specified number of months.CommentsClose CommentsPermalink





(c) Access to State Health Benefits Risk Pools- This section shall supersede any provision of the law of a State or political subdivision thereof to the extent that such provision has the effect of limiting or precluding access by a qualified beneficiary whose COBRA continuation coverage has been extended under this section to a State health benefits risk pool recognized by the Commissioner for purposes of this section solely by reason of the extension of such coverage beyond the date on which such coverage otherwise would have expired.CommentsClose CommentsPermalink





(d) Definitions- For purposes of this section--CommentsClose CommentsPermalink





(1) COBRA CONTINUATION COVERAGE- The term ‘COBRA continuation coverage’ means continuation coverage provided pursuant to part 6 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (other than under section 609), title XXII of the Public Health Service Act, section 4980B of the Internal Revenue Code of 1986 (other than subsection (f)(1) of such section insofar as it relates to pediatric vaccines), or section 8905a of title 5, United States Code, or under a State program that provides comparable continuation coverage. Such term does not include coverage under a health flexible spending arrangement under a cafeteria plan within the meaning of section 125 of the Internal Revenue Code of 1986.CommentsClose CommentsPermalink





(2) COBRA CONTINUATION PROVISION- The term ‘COBRA continuation provision’ means the provisions of law described in paragraph (1).CommentsClose CommentsPermalink

SEC. 114. STATE HEALTH ACCESS PROGRAM GRANTS.

(a) In General- The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall provide grants to States (as defined for purposes of title XIX of the Social Security Act) to establish programs to expand access to affordable health care coverage for the uninsured populations in that State in a manner consistent with reforms to take effect under this division in Y1.CommentsClose CommentsPermalink





(b) Types of Programs- The types of programs for which grants are available under subsection (a) include the following:CommentsClose CommentsPermalink





(1) STATE INSURANCE EXCHANGES- State insurance exchanges that develop new, less expensive, portable benefit packages for small employers and part-time and seasonal workers.CommentsClose CommentsPermalink





(2) COMMUNITY COVERAGE PROGRAM- Community coverage with shared responsibility between employers, governmental or nonprofit entity, and the individual.CommentsClose CommentsPermalink





(3) REINSURANCE PLAN PROGRAM- Reinsurance plans that subsidize a certain share of carrier losses within a certain risk corridor health insurance premium assistance.CommentsClose CommentsPermalink





(4) TRANSPARENT MARKETPLACE PROGRAM- Transparent marketplace that provides an organized structure for the sale of insurance products such as a Web exchange or portal.CommentsClose CommentsPermalink





(5) AUTOMATED ENROLLMENT PROGRAM- Statewide or automated enrollment systems for public assistance programs.CommentsClose CommentsPermalink





(6) INNOVATIVE STRATEGIES- Innovative strategies to insure low-income childless adults.CommentsClose CommentsPermalink





(7) PURCHASING COLLABORATIVES- Not-for-profit business/consumer collaborative that provides direct contract health care service purchasing options for group plan sponsors.CommentsClose CommentsPermalink





(c) Eligibility and Administration-CommentsClose CommentsPermalink





(1) IMPLEMENTATION OF KEY STATUTORY OR REGULATORY CHANGES- In order to be awarded a grant under this section for a program, a State shall demonstrate that--CommentsClose CommentsPermalink





(A) it has achieved the key State and local statutory or regulatory changes required to begin implementing the new program within 1 year after the initiation of funding under the grant; andCommentsClose CommentsPermalink





(B) it will be able to sustain the program without Federal funding after the end of the period of the grant.CommentsClose CommentsPermalink





(2) INELIGIBILITY- A State that has already developed a comprehensive health insurance access program is not eligible for a grant under this section.CommentsClose CommentsPermalink





(3) APPLICATION REQUIRED- No State shall receive a grant under this section unless the State has approved by the Secretary such an application, in such form and manner as the Secretary specifies.CommentsClose CommentsPermalink





(4) ADMINISTRATION BASED ON CURRENT PROGRAM- The program under this section is intended to build on the State Health Access Program funded under the Omnibus Appropriations Act, 2009 (Public Law 111-8).CommentsClose CommentsPermalink





(d) Funding Limitations-CommentsClose CommentsPermalink





(1) IN GENERAL- A grant under this section shall--CommentsClose CommentsPermalink





(A) only be available for expenditures before Y1; andCommentsClose CommentsPermalink





(B) only be used to supplement, and not supplant, funds otherwise provided.CommentsClose CommentsPermalink





(2) MATCHING FUND REQUIREMENT-CommentsClose CommentsPermalink





(A) IN GENERAL- Subject to subparagraph (B), no grant may be awarded to a State unless the State demonstrates the seriousness of its effort by matching at least 20 percent of the grant amount through non-Federal resources, which may be a combination of State, local, private dollars from insurers, providers, and other private organizations.CommentsClose CommentsPermalink





(B) WAIVER- The Secretary may waive the requirement of subparagraph (A) if the State demonstrates to the Secretary financial hardship in complying with such requirement.CommentsClose CommentsPermalink





(e) Study- The Secretary shall review, study, and benchmark the progress and results of the programs funded under this section.CommentsClose CommentsPermalink





(f) Report- Each State receiving a grant under this section shall submit to the Secretary a report on best practices and lessons learned through the grant to inform the health reform coverage expansions under this division beginning in Y1.CommentsClose CommentsPermalink





(g) Funding- There are authorized to be appropriated such sums as may be necessary to carry out this section.CommentsClose CommentsPermalink

SEC. 115. 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, to the extent practicable--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, on a specific date or range of dates, include utilization of a machine-readable health plan beneficiary identification card or similar mechanism;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 except where required by (or to implement) State or Federal law or to protect against fraud and abuse; andCommentsClose 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 the enactment of this section, the Secretary shall adopt standards under this section by interim, final rule.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 uniform claim edits, uniform reason and remark denial codes, 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; andCommentsClose 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 adopting the standards under this section, the Secretary shall consider 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) a proposal for accommodating necessary changes between version changes and a process for upgrading standards as often as annually by interim, final rulemaking;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; andCommentsClose CommentsPermalink





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





The Secretary may promulgate an annual audit and certification process to ensure that all health plans and clearinghouses are both syntactically and functionally compliant with all the standard transactions mandated pursuant to the administrative simplification provisions of this part and the Health Insurance Portability and Accountability Act of 1996.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 violate State or Federal law.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 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.CommentsClose CommentsPermalink

‘SEC. 1173B. INTERIM COMPANION GUIDES, INCLUDING OPERATING RULES.

‘(a) In General- The Secretary shall adopt a single, binding, comprehensive companion guide, that includes operating rules for each X12 Version 5010 transaction described in section 1173(a)(2), to be effective until the new version of these transactions which comply with section 1173A are adopted and implemented.CommentsClose CommentsPermalink





‘(b) Companion Guide and Operating Rules Development- In adopting such interim companion guide and rules, the Secretary shall comply with section 1172, except that a nonprofit entity that meets the following criteria shall also be consulted:CommentsClose CommentsPermalink





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





‘(2) The entity uses a multistakeholder process that creates consensus-based companion guides, including operating rules using a voting process that ensures 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 or State agencies.CommentsClose CommentsPermalink





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





‘(4) The entity coordinates 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 the standards issued under Health Insurance Portability and Accountability Act of 1996 and this part, and in developing the companion guide and operating rules does not change the definition, data condition or use of a data element or segment in a standard, add any elements or segments to the maximum defined data set, use any codes or data elements that are either marked ‘not used’ in the standard’s implementation specifications or are not in the standard’s implementation specifications, or change the meaning or intent of the standard’s implementation specifications.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 comment on updates of the companion guide, including the operating rules.CommentsClose CommentsPermalink





‘(c) Implementation- The Secretary shall adopt a single, binding companion guide, including operating rules under this section, for each transaction, to become effective with the X12 Version 5010 transaction implementation, or as soon thereafter as feasible. The companion guide, including 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 companion guide, including operating rules for the remainder of the transactions described in section 1173(a)(2) 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 (1), by inserting ‘, and associated operational guidelines and instructions, as determined appropriate by the Secretary’ after ‘medical procedure codes’; andCommentsClose CommentsPermalink





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





‘(10) OPERATING RULES- The term ‘operating rules’ means business rules for using and processing transactions, such as service level requirements, which do not impact the implementation specifications or other data content requirements.’.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)’; andCommentsClose 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 an interim, 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’; andCommentsClose CommentsPermalink





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





(B) COMPLIANCE DATE- The amendments made by subparagraph (A) shall apply to transactions occurring on or after such date (not later than January 1, 2014) as the Secretary of Health and Human Services shall specify.CommentsClose CommentsPermalink





(c) Standards for First Report of Injury- Not later than January 1, 2014, the Secretary of Health and Human Services shall promulgate an interim final rule to establish a standard for the first report of injury transaction described in section 1173(a)(2)(G) of the Social Security Act (42 U.S.C. 1320d-2(a)(2)(G)).CommentsClose CommentsPermalink





(d) Unique Health Plan Identifier- Not later October 1, 2012, the Secretary of Health and Human Services shall promulgate an interim 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, health care providers, and other interested parties.CommentsClose CommentsPermalink





(e) Expansion of Electronic Transactions in Medicare- Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended--CommentsClose CommentsPermalink





(1) in paragraph (23), by striking ‘or’ at the end;CommentsClose CommentsPermalink





(2) in paragraph (24), by striking the period and inserting ‘; or’; andCommentsClose CommentsPermalink





(3) by inserting after paragraph (24) the following new paragraph:CommentsClose CommentsPermalink





‘(25) subject to subsection (h), not later than January 1, 2015, for which the payment is other than by electronic funds transfer (EFT) so long as the Secretary has adopted and implemented a standard for electronic funds transfer under section 1173A.’.CommentsClose CommentsPermalink





(f) Expansion of Penalties- Section 1176 of such Act (42 U.S.C. 1320d-5) is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink





‘(c) Expansion of Penalty Authority- The Secretary may, in addition to the penalties provided under subsections (a) and (b), provide for the imposition of penalties for violations of this part that are comparable--CommentsClose CommentsPermalink





‘(1) in the case of health plans, to the sanctions the Secretary is authorized to impose under part C or D of title XVIII in the case of a plan that violates a provision of such part; orCommentsClose CommentsPermalink





‘(2) in the case of a health care provider, to the sanctions the Secretary is authorized to impose under part A, B, or D of title XVIII in the case of a health care provider that violations a provision of such part with respect to that provider.’.CommentsClose CommentsPermalink

TITLE II--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANSCommentsClose CommentsPermalink

Subtitle A--General StandardsCommentsClose CommentsPermalink

SEC. 201. 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





(d) Treatment of Qualified Direct Primary Care Medical Home Plans- The Commissioner may permit a qualified health benefits plan to provide coverage through a qualified direct primary care medical home plan so long as the qualified health benefits plan meets all requirements that are otherwise applicable and the services covered by the medical home plan are coordinated with the QHBP offering entity.CommentsClose CommentsPermalink

SEC. 202. 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 201, including the essential benefit package requirement under section 221.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 Law 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 (which may be a high deducible health plan, as defined in section 223(c)(2) of the Internal Revenue Code of 1986) 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- Nothing in--CommentsClose CommentsPermalink





(A) paragraph (1) shall prevent the offering of excepted benefits described in section 2791(c) of the Public Health Service Act so long as such benefits are offered outside the Health Insurance Exchange and are priced separately from health insurance coverage; andCommentsClose CommentsPermalink





(B) this division shall be construed--CommentsClose CommentsPermalink





(i) to prevent the offering of a stand-alone plan that offers 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; orCommentsClose CommentsPermalink





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

Subtitle B--Standards Guaranteeing Access to Affordable CoverageCommentsClose CommentsPermalink

SEC. 211. PROHIBITING PREEXISTING CONDITION EXCLUSIONS.

A qualified health benefits plan may not impose any preexisting 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 of the following: health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, disability, or source of injury (including conditions arising out of acts of domestic violence) or any similar factors.CommentsClose CommentsPermalink

SEC. 212. GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS AND PROHIBITING RESCISSIONS.

The requirements of sections 2711 (other than subsections (e) and (f)) 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, 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 nonpayment of premiums and there is a grace period during which the enrollee has an opportunity to correct such nonpayment. Rescissions of such coverage shall be prohibited except in cases of fraud as defined in section 2712(b)(2) of such Act.CommentsClose CommentsPermalink

SEC. 213. INSURANCE RATING RULES.

(a) In General- The premium rate charged for a qualified health benefits plan that is health insurance coverage 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) 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 midsize 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 midsize 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. 214. NONDISCRIMINATION IN BENEFITS; PARITY IN MENTAL HEALTH AND SUBSTANCE ABUSE DISORDER BENEFITS.

(a) Nondiscrimination in Benefits- A qualified health benefits plan shall comply with standards established by the Commissioner to prohibit discrimination in health benefits or benefit structures for qualifying health benefits plans, building from section 702 of the Employee Retirement Income Security Act of 1974, section 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 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. 215. ENSURING ADEQUACY OF PROVIDER NETWORKS.

(a) In General- A qualified health benefits plan 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 among providers participating in the network and policies for accessing out-of-network providers.CommentsClose CommentsPermalink





(b) Internet Access to Information- A qualified health benefits plan that uses a provider network shall provide a current listing of all providers in its network on its Website and such data shall be available on the Health Insurance Exchange Website as a part of the basic information on that plan. The Commissioner shall also establish an on-line system whereby an individual may select by name any medical provider (as defined by the Commissioner) and be informed of the plan or plans with which that provider is contracting.CommentsClose CommentsPermalink





(c) 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. 216. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE FOR UNINSURED YOUNG ADULTS.

(a) In General- A qualified health benefits plan shall make available, at the option of the principal enrollee under the plan, coverage for one or more qualified children (as defined in subsection (b)) of the enrollee.CommentsClose CommentsPermalink





(b) Qualified Child Defined- In this section, the term ‘qualified child’ means, with respect to a principal enrollee in a qualified health benefits plan, an individual who (but for age) would be treated as a dependent child of the enrollee under such plan and who--CommentsClose CommentsPermalink





(1) is under 27 years of age; andCommentsClose CommentsPermalink





(2) is not enrolled in a health benefits plan other than under this section.CommentsClose CommentsPermalink





(c) Premiums- Nothing in this section shall be construed as preventing a qualified health benefits plan from increasing the premiums otherwise required for coverage provided under this section consistent with standards established by the Commissioner based upon family size under section 213(a)(3).CommentsClose CommentsPermalink

SEC. 217. CONSISTENCY OF COSTS AND COVERAGE UNDER QUALIFIED HEALTH BENEFITS PLANS DURING PLAN YEAR.

In the case of health insurance coverage offered under a qualified health benefits plan, if the coverage decreases or the cost-sharing increases, the issuer of the coverage shall notify enrollees of the change at least 90 days before the change takes effect (or such shorter period of time in cases where the change is necessary to ensure the health and safety of enrollees).CommentsClose CommentsPermalink

Subtitle C--Standards Guaranteeing Access to Essential BenefitsCommentsClose CommentsPermalink

SEC. 221. 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 224 for the essential benefits package described in section 222 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 outside of the Health Insurance Exchange and under State law of health benefits in the form of excepted benefits (described in section 202(b)(1)(B)(ii)) if such benefits are offered under a separate policy, contract, or certificate of insurance.CommentsClose CommentsPermalink





(c) Clinical Appropriateness- Nothing in this Act shall be construed to prohibit a group health plan or health insurance issuer from using medical management practices so long as such management practices are based on valid medical evidence and are relevant to the patient whose medical treatment is under review.CommentsClose CommentsPermalink





(d) Provision of Benefits- Nothing in this division shall be construed as prohibiting a qualified health benefits plan from subcontracting with stand-alone health insurance issuers or insurers for the provision of dental, vision, mental health, and other benefits and services.CommentsClose CommentsPermalink

SEC. 222. 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 224, 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 215(a) (relating to network adequacy); andCommentsClose CommentsPermalink





(5) is equivalent in its scope of benefits, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage in Y1.CommentsClose CommentsPermalink





In order to carry out paragraph (5), the Secretary of Labor shall conduct a survey of employer-sponsored coverage to determine the benefits typically covered by employers, including multiemployer plans, and provide a report on such survey to the Health Benefits Advisory Committee and to the Secretary of Health and Human Services.CommentsClose CommentsPermalink





(b) Minimum Services To Be Covered- Subject 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 and oral health, vision, and hearing services, equipment, and supplies for children under 21 years of age.CommentsClose CommentsPermalink





(11) Durable medical equipment, prosthetics, orthotics and related supplies.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--CommentsClose CommentsPermalink





(A) preventive items and 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; orCommentsClose CommentsPermalink





(B) 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 not to exceed $5,000 for an individual and not to exceed $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 enrollment-weighted average of premium increases for basic plans applicable to such year, except that Secretary shall adjust such increase to ensure that the applicable level specified in this subparagraph meets the minimum actuarial value required under paragraph (3).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) Assessment and Counseling for Domestic Violence- The Secretary shall support the need for an assessment and brief counseling for domestic violence as part of a behavioral health assessment or primary care visit and determine the appropriate coverage for such assessment and counseling.CommentsClose CommentsPermalink





(e) 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 223(b), and the Secretary may not adopt in standards under section 224(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) 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





(f) Report Regarding Inclusion of Oral Health Care in Essential Benefits Package- Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall submit to Congress a report containing the results of a study determining the need and cost of providing accessible and affordable oral health care to adults as part of the essential benefits package.CommentsClose CommentsPermalink

SEC. 223. 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) Nine members who are not Federal employees or officers and who are appointed by the President.CommentsClose CommentsPermalink





(B) Nine 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, patient representatives, employers (including small employers), labor, health insurance issuers, experts in health care financing and delivery, experts in oral health care, experts in racial and ethnic disparities, experts on health care needs and disparities of individuals with disabilities, representatives of relevant governmental agencies, and at least one practicing physician or other health professional and an expert in child and adolescent 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.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 (5)), 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) STATE INPUT- The Health Benefits Advisory Committee shall examine the health coverage laws and benefits of each State in developing recommendations under this subsection and may incorporate such coverage and benefits as the Committee determines to be appropriate and consistent with this Act. The Health Benefits Advisory Committee shall also seek input from the States and consider recommendations on how to ensure quality of health coverage in all States.CommentsClose CommentsPermalink





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





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





(A) the essential benefits package described in section 222, including categories of covered treatments, items and services within benefit classes, and cost-sharing; andCommentsClose CommentsPermalink





(B) the cost-sharing levels for enhanced plans and premium plans (as provided under section 303(c)) consistent with paragraph (5).CommentsClose CommentsPermalink





(6) 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 222(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 222(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, except such members shall be considered to be within the meaning of section 202(a) of title 18, United States Code, for the purposes of disclosure and management of conflicts of interest.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. 224. 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 223 (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 under section 553 of title 5, United States Code, propose adoption of such standards; orCommentsClose 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 under section 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 222 and 223(b)(5).CommentsClose CommentsPermalink

Subtitle D--Additional Consumer ProtectionsCommentsClose CommentsPermalink

SEC. 231. REQUIRING FAIR MARKETING PRACTICES BY HEALTH INSURERS.

The Commissioner shall establish uniform marketing standards that all QHBP offering entities shall meet with respect to qualified health benefits plans that are health insurance coverage.CommentsClose CommentsPermalink

SEC. 232. REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS.

(a) In General- A QHBP offering entity shall provide for timely grievance and appeals mechanisms with respect to qualified health benefits plans that the Commissioner shall establish consistent with this section. The Commissioner shall establish time limits for each of such mechanisms and implement them in a manner that is protective to the needs of patients.CommentsClose CommentsPermalink





(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.CommentsClose CommentsPermalink





(c) External Review Process-CommentsClose CommentsPermalink





(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.CommentsClose CommentsPermalink





(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.CommentsClose CommentsPermalink





(d) Time Limits- The Commissioner shall establish time limits for each of these processes and implement them in a manner that is protective to the patient.CommentsClose CommentsPermalink





(e) 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 251.CommentsClose CommentsPermalink

SEC. 233. REQUIRING INFORMATION TRANSPARENCY AND PLAN DISCLOSURE.

(a) Accurate and Timely Disclosure-CommentsClose CommentsPermalink





(1) FOR EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS- A QHBP offering entity offering an Exchange-participating health benefits plan shall comply with standards established by the Commissioner for the accurate and timely disclosure to the Commissioner and the public 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.CommentsClose CommentsPermalink





(2) EMPLOYMENT-BASED HEALTH PLANS- The Secretary of Labor shall update and harmonize the Secretary’s rules concerning the accurate and timely disclosure to participants by group health plans of plan disclosure, plan terms and conditions, and periodic financial disclosure with the standards established by the Commissioner under paragraph (1).CommentsClose CommentsPermalink





(3) USE OF PLAIN LANGUAGE-CommentsClose CommentsPermalink





(A) IN GENERAL- The disclosures under paragraphs (1) and (2) shall be provided in plain language.CommentsClose CommentsPermalink





(B) DEFINITION- In this paragraph, 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 concise, well-organized, and follows other best practices of plain language writing.CommentsClose CommentsPermalink





(C) GUIDANCE- The Commissioner and the Secretary of Labor shall jointly develop and issue guidance on best practices of plain language writing.CommentsClose CommentsPermalink





(4) INFORMATION ON RIGHTS- The information disclosed under this subsection shall include information on enrollee and participant rights under this division.CommentsClose CommentsPermalink





(5) COST-SHARING TRANSPARENCY- A qualified health benefits plan shall allow individuals to learn the amount of cost-sharing (including deductibles, copayments, and coinsurance) under the individual’s plan or coverage that the individual would be responsible for paying with respect to the furnishing of a specific item or service by a participating provider in a timely manner upon request. At a minimum, this information shall be made available to such individual via an Internet Website and other means for individuals without access to the Internet.CommentsClose CommentsPermalink





(b) Contracting Reimbursement- A qualified health benefits plan 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) Pharmacy Benefit Managers Transparency Requirements-CommentsClose CommentsPermalink





(1) IN GENERAL- If a QHBP offering entity contracts with a pharmacy benefit manager or other entity (in this subsection referred to as a ‘PBM’) to manage prescription drug coverage or otherwise control prescription drug costs under a qualified health benefits plan, the PBM shall provide at least annually to the Commissioner and to the QHBP offering entity offering such plan the following information, in a form and manner to be determined by the Commissioner:CommentsClose CommentsPermalink





(A) Information on the number and total cost 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 pharmacies, 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 because of PBM policies or at the direct or indirect control of the PBM from a prescribed drug that had a lower cost for the QHBP offering entity to a drug that had a higher cost for the QHBP offering entity, the rationale for these switches, and a description of the PBM policies governing such switches.CommentsClose CommentsPermalink





(2) CONFIDENTIALITY OF INFORMATION- 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 only by the Commissioner--CommentsClose CommentsPermalink





(A) to permit State or Federal law enforcement authorities to use the information provided for program compliance purposes and for the purpose of combating waste, fraud, and abuse;CommentsClose CommentsPermalink





(B) to permit the Comptroller General, the Medicare Payment Advisory Commission, or the Secretary of Health and Human Services to review the information provided; andComments