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S 1679 PCSCommentsClose CommentsPermalink

To make quality, affordable health care available to all Americans, reduce costs, improve health care quality, enhance disease prevention, and strengthen the health care workforce.CommentsClose CommentsPermalink

September 17, 2009CommentsClose CommentsPermalink

Mr. HARKIN, from the Committee on Health, Education, Labor, and Pensions reported the following original bill; which was read twice and placed on the calendarCommentsClose CommentsPermalink

To make quality, affordable health care available to all Americans, reduce costs, improve health care quality, enhance disease prevention, and strengthen the health care workforce.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 CONTENTS.

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





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





Sec. 1. Short title; table of contents.CommentsClose CommentsPermalink

TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS

Subtitle A--Effective Coverage for All Americans

PART I--Provisions Applicable to the Individual and Group Markets

Sec. 101. Amendment to the Public Health Service Act.CommentsClose CommentsPermalink

‘PART A--Individual and Group Market Reforms

‘subpart 1--general reform

‘Sec. 2705. Prohibition of preexisting condition exclusions or other discrimination based on health status.CommentsClose CommentsPermalink

‘Sec. 2701. Fair insurance coverage.CommentsClose CommentsPermalink

‘Sec. 2702. Guaranteed availability of coverage.CommentsClose CommentsPermalink

‘Sec. 2703. Guaranteed renewability of coverage.CommentsClose CommentsPermalink

‘Sec. 2704. Increasing the Transparency of Health Care Costs and Regulatory Fees.CommentsClose CommentsPermalink

‘Sec. 2706. Prohibiting discrimination against individual participants and beneficiaries based on health status.CommentsClose CommentsPermalink

‘Sec. 2707. Ensuring the quality of care.CommentsClose CommentsPermalink

‘Sec. 2708. Coverage of preventive health services.CommentsClose CommentsPermalink

‘Sec. 2709. Coverage of Preventive Women’s Health Services.CommentsClose CommentsPermalink

‘Sec. 2710. Extension of dependent coverage.CommentsClose CommentsPermalink

‘Sec. 2711. No lifetime or annual limits.CommentsClose CommentsPermalink

‘Sec. 2712. Notification by plans not providing minimum qualifying coverage.CommentsClose CommentsPermalink

‘Sec. 2713. Non-discrimination in health care.CommentsClose CommentsPermalink

PART II--Provision Applicable to the Group Market

Sec. 121. Amendment to the Public Health Service Act.CommentsClose CommentsPermalink

‘Sec. 2720A. Prohibition of discrimination based on salary.CommentsClose CommentsPermalink

PART III--Other Provisions

Sec. 131. No changes to existing coverage.CommentsClose CommentsPermalink





Sec. 132. Applicability.CommentsClose CommentsPermalink





Sec. 133. Conforming amendments.CommentsClose CommentsPermalink





Sec. 134. Savings.CommentsClose CommentsPermalink





Sec. 135. Effective dates.CommentsClose CommentsPermalink

Subtitle B--Available Coverage for All Americans

Sec. 141. Building on the success of the Federal Employees Health Benefits Program and the health benefits program of most large employers so all Americans have affordable health benefit choices.CommentsClose CommentsPermalink





Sec. 142. Affordable health choices for all Americans.CommentsClose CommentsPermalink

‘TITLE XXXI--AFFORDABLE HEALTH CHOICES FOR ALL AMERICANS

‘Subtitle A--Affordable Choices

‘Sec. 3101. Affordable choices of health benefit plans.CommentsClose CommentsPermalink

‘Sec. 3102. Financial integrity.CommentsClose CommentsPermalink

‘Sec. 3103. Program design.CommentsClose CommentsPermalink

‘Sec. 3104. Allowing State flexibility.CommentsClose CommentsPermalink

‘Sec. 3105. Navigators.CommentsClose CommentsPermalink

‘Sec. 3106. Community health insurance option.CommentsClose CommentsPermalink

‘Sec. 3107. Application of same laws to private plans and the community health insurance option.CommentsClose CommentsPermalink

‘Sec. 3108. Participation of professionals on certain health-related commissions.CommentsClose CommentsPermalink

‘Sec. 3109. Health insurance consumer assistance grants.CommentsClose CommentsPermalink

Sec. 143. Freedom not to participate in Federal health insurance programs.CommentsClose CommentsPermalink

Subtitle C--Affordable Coverage for All Americans

Sec. 151. Support for affordable health coverage.CommentsClose CommentsPermalink

‘Subtitle B--Making Coverage Affordable

‘Sec. 3111. Support for affordable health coverage.CommentsClose CommentsPermalink

‘Sec. 3112. Small business health options program credit.CommentsClose CommentsPermalink

Sec. 152. Program integrity.CommentsClose CommentsPermalink

Subtitle D--Shared Responsibility for Health Care

Sec. 161. Individual responsibility.CommentsClose CommentsPermalink





Sec. 162. Notification on the availability of affordable health choices.CommentsClose CommentsPermalink





Sec. 163. Shared responsibility of employers.CommentsClose CommentsPermalink

‘Sec. 3115. Shared responsibility of employers.CommentsClose CommentsPermalink

‘Sec. 3116. Definitions.CommentsClose CommentsPermalink

Subtitle E--Improving Access to Health Care Services

Sec. 171. Spending for Federally Qualified Health Centers (FQHCs).CommentsClose CommentsPermalink





Sec. 172. Other provisions.CommentsClose CommentsPermalink





Sec. 173. Negotiated rulemaking for development of methodology and criteria for designating medically underserved populations and health professions shortage areas.CommentsClose CommentsPermalink





Sec. 174. Equity for certain eligible survivors.CommentsClose CommentsPermalink





Sec. 175. Reauthorization of the Wakefield Emergency Medical Services for Children Program.CommentsClose CommentsPermalink





Sec. 176. Co-locating primary and specialty care in community-based mental health settings.CommentsClose CommentsPermalink

Subtitle F--Making Health Care More Affordable for Retirees

Sec. 181. Reinsurance for retirees.CommentsClose CommentsPermalink

Subtitle G--Improving the Use of Health Information Technology for Enrollment; Miscellaneous Provisions

Sec. 185. Health information technology enrollment standards and protocols.CommentsClose CommentsPermalink





Sec. 186. Rule of construction regarding Hawaii’s Prepaid Health Care Act.CommentsClose CommentsPermalink





Sec. 187. Key National indicators.CommentsClose CommentsPermalink





Sec. 188. Study and report on rates of preventable diseases in new Medicare enrollees.CommentsClose CommentsPermalink





Sec. 189. Transparency in government.CommentsClose CommentsPermalink





Sec. 189A. Preserving the solvency of Medicare and Social Security.CommentsClose CommentsPermalink





Sec. 189B. Prohibition against discrimination on assisted suicide.CommentsClose CommentsPermalink





Sec. 189C. Access to therapies.CommentsClose CommentsPermalink





Sec. 189D. Freedom not to participate in Federal health insurance programs.CommentsClose CommentsPermalink

Subtitle H--CLASS Act

Sec. 190. Short title of subtitle.CommentsClose CommentsPermalink





Sec. 191. Establishment of national voluntary insurance program for purchasing community living assistance services and support.CommentsClose CommentsPermalink

‘TITLE XXXII--COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS

‘Sec. 3201. Purpose.CommentsClose CommentsPermalink

‘Sec. 3202. Definitions.CommentsClose CommentsPermalink

‘Sec. 3203. CLASS Independence Benefit Plan.CommentsClose CommentsPermalink

‘Sec. 3204. Enrollment and disenrollment requirements.CommentsClose CommentsPermalink

‘Sec. 3205. Benefits.CommentsClose CommentsPermalink

‘Sec. 3206. CLASS Independence Fund.CommentsClose CommentsPermalink

‘Sec. 3207. CLASS Independence Advisory Council.CommentsClose CommentsPermalink

‘Sec. 3208. Regulations; annual report.CommentsClose CommentsPermalink

‘Sec. 3209. Inspector General’s report.CommentsClose CommentsPermalink

‘Sec. 3210. Tax treatment of program.CommentsClose CommentsPermalink

TITLE II--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE

Subtitle A--National Strategy to Improve Health Care Quality

Sec. 201. National strategy.CommentsClose CommentsPermalink





Sec. 202. Interagency Working Group on Health Care Quality.CommentsClose CommentsPermalink





Sec. 203. Quality measure development.CommentsClose CommentsPermalink





Sec. 204. Quality measure endorsement; public reporting; data collection.CommentsClose CommentsPermalink





Sec. 205. Collection and analysis of data for quality and resource use measures.CommentsClose CommentsPermalink

Subtitle B--Health Care Quality Improvements

Sec. 211. Health care delivery system research; Quality improvement technical assistance.CommentsClose CommentsPermalink





Sec. 212. Grants to establish community health teams to support the patient-centered medical home.CommentsClose CommentsPermalink





Sec. 213. Grants to implement medication management services in treatment of chronic disease.CommentsClose CommentsPermalink





Sec. 214. Design and implementation of regionalized systems for emergency care.CommentsClose CommentsPermalink





Sec. 215. Trauma care centers and service availability.CommentsClose CommentsPermalink





Sec. 216. Reducing and reporting hospital readmissions.CommentsClose CommentsPermalink





Sec. 217. Program to facilitate shared decisionmaking.CommentsClose CommentsPermalink





Sec. 218. Presentation of prescription drug benefit and risk information.CommentsClose CommentsPermalink





Sec. 219. Center for health outcomes research and evaluation.CommentsClose CommentsPermalink





Sec. 220. Demonstration program to integrate quality improvement and patient safety training into clinical education of health professionals.CommentsClose CommentsPermalink





Sec. 221. Office of women’s health.CommentsClose CommentsPermalink





Sec. 222. Administrative simplification.CommentsClose CommentsPermalink





Sec. 223. Patient navigator program.CommentsClose CommentsPermalink





Sec. 224. Authorization of appropriations.CommentsClose CommentsPermalink

Subtitle C--Civil and Criminal Penalties for Acts Involving Federal Health Care Programs; Exception to Limitation on Certain Physician Referrals

Sec. 231. Safe harbors to antikickback civil penalties and criminal penalties for provision of health information technology and training services.CommentsClose CommentsPermalink





Sec. 232. Exception to limitation on certain physician referrals (under Stark) for provision of health information technology and training services to health care professionals.CommentsClose CommentsPermalink





Sec. 233. Rules of construction regarding use of consortia.CommentsClose CommentsPermalink

TITLE III--IMPROVING THE HEALTH OF THE AMERICAN PEOPLE

Subtitle A--Modernizing Disease Prevention and Public Health Systems

Sec. 301. National Prevention, Health Promotion and Public Health Council.CommentsClose CommentsPermalink





Sec. 302. Prevention and Public Health Fund.CommentsClose CommentsPermalink





Sec. 303. Clinical and Community Preventive Services.CommentsClose CommentsPermalink





Sec. 304. Education and outreach campaign regarding preventive benefits.CommentsClose CommentsPermalink

Subtitle B--Increasing Access to Clinical Preventive Services

Sec. 311. Right choices program.CommentsClose CommentsPermalink





Sec. 312. School-based health clinics.CommentsClose CommentsPermalink





Sec. 313. Oral healthcare prevention activities.CommentsClose CommentsPermalink





Sec. 314. Oral health improvement.CommentsClose CommentsPermalink

Subtitle C--Creating Healthier Communities

Sec. 321. Community transformation grants.CommentsClose CommentsPermalink





Sec. 322. Healthy aging, living well.CommentsClose CommentsPermalink





Sec. 323. Wellness for individuals with disabilities.CommentsClose CommentsPermalink





Sec. 324. Immunizations.CommentsClose CommentsPermalink





Sec. 325. Nutrition labeling of standard menu items at chain restaurants and of articles of food sold from vending machines.CommentsClose CommentsPermalink





Sec. 326. Encouraging employer-sponsored wellness programs.CommentsClose CommentsPermalink





Sec. 327. Demonstration project concerning individualized wellness plan.CommentsClose CommentsPermalink





Sec. 328. Reasonable break time for nursing mothers.CommentsClose CommentsPermalink

Subtitle D--Support for Prevention and Public Health Innovation

Sec. 331. Research on optimizing the delivery of public health services.CommentsClose CommentsPermalink





Sec. 332. Understanding health disparities: data collection and analysis.CommentsClose CommentsPermalink





Sec. 333. Health impact assessments.CommentsClose CommentsPermalink





Sec. 334. CDC and employer-based wellness programs.CommentsClose CommentsPermalink





Sec. 335. Epidemiology-Laboratory Capacity Grants.CommentsClose CommentsPermalink





Sec. 336. Federal messaging on health promotion and disease prevention.CommentsClose CommentsPermalink

Subtitle E--Advancing Research and Treatment for Pain Care Management

Sec. 341. Institute of Medicine Conference on Pain.CommentsClose CommentsPermalink





Sec. 342. Pain research at National Institutes of Health.CommentsClose CommentsPermalink





Sec. 343. Pain care education and training.CommentsClose CommentsPermalink





Sec. 344. Public awareness campaign on pain management.CommentsClose CommentsPermalink

Subtitle F--Coordinated Environmental Public Health Network

Sec. 351. Amendment to the Public Health Service Act.CommentsClose CommentsPermalink

Subtitle G--Miscellaneous Provisions

Sec. 361. Sense of the Senate concerning CBO scoring.CommentsClose CommentsPermalink





Sec. 362. Effectiveness of Federal health and wellness initiatives.CommentsClose CommentsPermalink

TITLE IV--HEALTH CARE WORKFORCE

Subtitle A--Purpose and Definitions

Sec. 401. Purpose.CommentsClose CommentsPermalink





Sec. 402. Definitions.CommentsClose CommentsPermalink

Subtitle B--Innovations in the Health Care Workforce

Sec. 411. National health care workforce commission.CommentsClose CommentsPermalink





Sec. 412. State health care workforce development grants.CommentsClose CommentsPermalink





Sec. 413. Health care workforce program assessment.CommentsClose CommentsPermalink

Subtitle C--Increasing the Supply of the Health Care Workforce

Sec. 421. Federally supported student loan funds.CommentsClose CommentsPermalink





Sec. 422. Nursing student loan program.CommentsClose CommentsPermalink





Sec. 423. Health care workforce loan repayment programs.CommentsClose CommentsPermalink





Sec. 424. Public health workforce recruitment and retention programs.CommentsClose CommentsPermalink





Sec. 425. Allied health workforce recruitment and retention programs.CommentsClose CommentsPermalink





Sec. 426. Grants for State and local programs.CommentsClose CommentsPermalink





Sec. 427. Funding for National Health Service Corps.CommentsClose CommentsPermalink





Sec. 428. Nurse-managed health clinics.CommentsClose CommentsPermalink





Sec. 429. Elimination of cap on commissioned corps.CommentsClose CommentsPermalink





Sec. 430. Establishing a Ready Reserve Corps.CommentsClose CommentsPermalink

Subtitle D--Enhancing Health Care Workforce Education and Training

Sec. 431. Training in family medicine, general internal medicine, general pediatrics, and physician assistantship.CommentsClose CommentsPermalink





Sec. 432. Training opportunities for direct care workers.CommentsClose CommentsPermalink





Sec. 433. Training in general, pediatric, and public health dentistry.CommentsClose CommentsPermalink





Sec. 434. Alternative dental health care providers demonstration project.CommentsClose CommentsPermalink





Sec. 435. Geriatric education and training; career awards; comprehensive geriatric education.CommentsClose CommentsPermalink





Sec. 436. Mental and behavioral health education and training grants.CommentsClose CommentsPermalink





Sec. 437. Cultural competency, prevention and public health and individuals with disabilities training.CommentsClose CommentsPermalink





Sec. 438. Advanced nursing education grants.CommentsClose CommentsPermalink





Sec. 439. Nurse education, practice, and retention grants.CommentsClose CommentsPermalink





Sec. 440. Loan repayment and scholarship program.CommentsClose CommentsPermalink





Sec. 441. Nurse faculty loan program.CommentsClose CommentsPermalink





Sec. 442. Authorization of appropriations for parts B through D of title VIII.CommentsClose CommentsPermalink





Sec. 443. Grants to promote the community health workforce.CommentsClose CommentsPermalink





Sec. 444. Youth public health program.CommentsClose CommentsPermalink





Sec. 445. Fellowship training in public health.CommentsClose CommentsPermalink





Sec. 446. United States Public Health Sciences Track.CommentsClose CommentsPermalink

Subtitle E--Supporting the Existing Health Care Workforce

Sec. 451. Centers of excellence.CommentsClose CommentsPermalink





Sec. 452. Health care professionals training for diversity.CommentsClose CommentsPermalink





Sec. 453. Interdisciplinary, community-based linkages.CommentsClose CommentsPermalink





Sec. 454. Workforce diversity grants.CommentsClose CommentsPermalink





Sec. 455. Primary care extension program.CommentsClose CommentsPermalink





Sec. 456. Definition of economic hardship.CommentsClose CommentsPermalink

Subtitle F--General Provisions

Sec. 461. Reports.CommentsClose CommentsPermalink

TITLE V--PREVENTING FRAUD AND ABUSE

Subtitle A--Establishment of New Health and Human Services and Department of Justice Health Care Fraud Positions

Sec. 501. Health and Human Services Senior Advisor.CommentsClose CommentsPermalink





Sec. 502. Department of Justice Position.CommentsClose CommentsPermalink





Sec. 503. Reports to Congress.CommentsClose CommentsPermalink





Sec. 504. Fraud, waste, and abuse commission.CommentsClose CommentsPermalink

Subtitle B--Health Care Program Integrity Coordinating Council

Sec. 511. Establishment.CommentsClose CommentsPermalink

Subtitle C--False Statements and Representations

Sec. 521. Prohibition on false statements and representations.CommentsClose CommentsPermalink

Subtitle D--Federal Health Care Offense

Sec. 531. Clarifying definition.CommentsClose CommentsPermalink

Subtitle E--Uniformity in Fraud and Abuse Reporting

Sec. 541. Development of model uniform report form.CommentsClose CommentsPermalink

Subtitle F--Applicability of State Law to Combat Fraud and Abuse

Sec. 551. Applicability of State law to combat fraud and abuse.CommentsClose CommentsPermalink

Subtitle G--Enabling the Department of Labor to Issue Administrative Summary Cease and Desist Orders and Summary Seizures Orders Against Plans That Are in Financially Hazardous Condition

Sec. 561. Enabling the Department of Labor to issue administrative summary cease and desist orders and summary seizures orders against plans that are in financially hazardous condition.CommentsClose CommentsPermalink

Subtitle H--Requiring Multiple Employer Welfare Arrangement (MEWA) Plans to File a Registration Form With the Department of Labor Prior to Enrolling Anyone in the Plan

Sec. 571. MEWA plan registration with Department of Labor.CommentsClose CommentsPermalink

Subtitle I--Permitting Evidentiary Privilege and Confidential Communications

Sec. 581. Permitting evidentiary privilege and confidential communications.CommentsClose CommentsPermalink

TITLE VI--IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES

Subtitle A--Biologics Price Competition and Innovation

Sec. 601. Short title.CommentsClose CommentsPermalink





Sec. 602. Approval pathway for biosimilar biological products.CommentsClose CommentsPermalink





Sec. 603. Savings.CommentsClose CommentsPermalink

Subtitle B--More Affordable Medicines for Children and Underserved Communities

Sec. 611. Expanded participation in 340B program.CommentsClose CommentsPermalink





Sec. 612. Improvements to 340B program integrity.CommentsClose CommentsPermalink





Sec. 613. GAO study to make recommendations on improving the 340B program.CommentsClose CommentsPermalink

TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANSCommentsClose CommentsPermalink

Subtitle A--Effective Coverage for All AmericansCommentsClose CommentsPermalink

PART I--PROVISIONS APPLICABLE TO THE INDIVIDUAL AND GROUP MARKETS

SEC. 101. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT.

Part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended--CommentsClose CommentsPermalink





(1) by striking the part heading and heading for subpart 1 and inserting the following:CommentsClose CommentsPermalink

‘PART A--INDIVIDUAL AND GROUP MARKET REFORMS

‘Subpart 1--General Reform’;

(2) in section 2701 (42 U.S.C. 300gg)--CommentsClose CommentsPermalink





(A) by striking the section heading and subsection (a) and inserting the following:CommentsClose CommentsPermalink

‘SEC. 2705. PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS OR OTHER DISCRIMINATION BASED ON HEALTH STATUS.

‘(a) In General- A group health plan and a health insurance issuer offering group or individual health insurance coverage may not impose any preexisting condition exclusion with respect to such plan or coverage.’; andCommentsClose CommentsPermalink





(B) by transferring the remainder of section so as to appear after the section 2704 as added by paragraph (5);CommentsClose CommentsPermalink





(3) in section 2702 (42 U.S.C. 300gg-1)--CommentsClose CommentsPermalink





(A) by striking the section heading and all that follows through subsection (a)--CommentsClose CommentsPermalink





(B) in subsection (b)--CommentsClose CommentsPermalink





(i) by striking ‘health insurance issuer offering health insurance coverage in connection with a group health plan’ each place that such appears and inserting ‘health insurance issuer offering group or individual health insurance coverage’; andCommentsClose CommentsPermalink





(ii) in paragraph (2)(A)--CommentsClose CommentsPermalink





(I) by inserting ‘or individual’ after ‘employer’; andCommentsClose CommentsPermalink





(II) by inserting ‘or individual health coverage, as the case may be’ before the semicolon;CommentsClose CommentsPermalink





(C) by redesignating subsections (b) through (f) as subsections (e) through (i), respectively; andCommentsClose CommentsPermalink





(D) by transferring the remainder of such section to appear at the end of section 2706 (as added by paragraph (5));CommentsClose CommentsPermalink





(4) by redesignating existing sections 2704 through 2707 and sections 2711 through 2713 as sections 2717 through 2720 and sections 2714 through 2716, respectively; andCommentsClose CommentsPermalink





(5) by inserting after the subpart heading (as added by paragraph (1)) the following:CommentsClose CommentsPermalink

‘SEC. 2701. FAIR INSURANCE COVERAGE.

‘(a) In General- With respect to the premium rate charged by a health insurance issuer for health insurance coverage offered in the individual or small group market--CommentsClose CommentsPermalink





‘(1) such rate shall vary with respect to the particular plan or coverage involved only by--CommentsClose CommentsPermalink





‘(A) family structure;CommentsClose CommentsPermalink





‘(B) community rating area;CommentsClose CommentsPermalink





‘(C) the actuarial value of the benefit;CommentsClose CommentsPermalink





‘(D) age, except that such rate shall not vary by more than 2 to 1;CommentsClose CommentsPermalink





‘(E) tobacco use, except that such rate shall not vary by more than 1.5 to 1; andCommentsClose CommentsPermalink





‘(F) adherence to or participation in a reasonably designed program of health promotion and disease prevention, if such a program is offered by the employer that is the sponsor of the coverage involved; andCommentsClose CommentsPermalink





‘(2) such rate shall not vary with respect to the particular plan or coverage involved by health status-related factors, gender, class of business, claims experience, industry, or any other factor not described in paragraph (1), except that group health plans and health insurance issuers offering group health insurance coverage may establish premium discounts or rebates for modifying otherwise applicable copayments or deductibles in return for adherence to or participation in reasonably designed programs of health promotion or disease prevention.CommentsClose CommentsPermalink





‘(b) Community Rating Area- Taking into account the applicable recommendations of the National Association of Insurance Commissioners, the Secretary shall by regulation establish a minimum size for community rating areas for purposes of this section, which, for areas contained in a Metropolitan Statistical Area, shall not be smaller than such area.CommentsClose CommentsPermalink

‘SEC. 2702. GUARANTEED AVAILABILITY OF COVERAGE.

‘(a) Issuance of Coverage in the Individual and Group Market- Subject to subsections (b) through (e), each health insurance issuer that offers health insurance coverage in the individual or group market in a State must accept every employer and individual in the State that applies for such coverage.CommentsClose CommentsPermalink





‘(b) Enrollment-CommentsClose CommentsPermalink





‘(1) RESTRICTION- A health insurance issuer described in subsection (a) may restrict enrollment in coverage described in such subsection to open or special enrollment periods.CommentsClose CommentsPermalink





‘(2) ESTABLISHMENT- A health insurance issuer described in subsection (a) shall, in accordance with the regulations promulgated under paragraph (3), establish special enrollment periods for qualifying events (under section 603 of the Employee Retirement Income Security Act of 1974).CommentsClose CommentsPermalink





‘(3) REGULATIONS- Not later than 1 year after the date of enactment of this section, the Secretary shall promulgate regulations with respect to enrollment periods under paragraphs (1) and (2).CommentsClose CommentsPermalink

‘SEC. 2703. GUARANTEED RENEWABILITY OF COVERAGE.

‘(a) In General- Except as provided in this section, if a health insurance issuer offers health insurance coverage in the individual or group market, the issuer must renew or continue in force such coverage at the option of the plan sponsor or the individual, as applicable.CommentsClose CommentsPermalink





‘(b) Prohibition on Rescissions- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not rescind such coverage once the plan involved has been issued, except that this subsection shall not apply to a covered individual who has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the coverage. Coverage may not be cancelled except with prior notice to the enrollee, and only as permitted under section 2702(c) or 2742(b).CommentsClose CommentsPermalink

‘SEC. 2704. INCREASING THE TRANSPARENCY OF HEALTH CARE COSTS AND REGULATORY FEES.

‘(a) Clear Accounting for Costs- A health insurance issuer offering group or individual health insurance coverage shall publicly report (in a manner to be established by the Secretary through regulation) the percentage of total premium revenue that such coverage expends--CommentsClose CommentsPermalink





‘(1) on reimbursement for clinical services provided to enrollees under such plan or coverage;CommentsClose CommentsPermalink





‘(2) for activities that improve health care quality;CommentsClose CommentsPermalink





‘(3) on taxes, license, or regulatory fee costs, and the cost of any surcharge imposed by the Gateway under title XXXI; andCommentsClose CommentsPermalink





‘(4) on all other non-claims costs, including an explanation of the nature of such costs and an itemized list of costs associated with compliance with the Affordable Health Choices Act.CommentsClose CommentsPermalink





‘(b) Definition- In this section, the term ‘activities to improve health care quality’ means activities described in section 2707.CommentsClose CommentsPermalink





‘(c) Processes and Methods- The Secretary shall develop a methodology for calculating the percentages described in subsection (a). Such methodology may provide for a requirement that a report described in subsection (a) include an actuarial certification of the information included in such report.CommentsClose CommentsPermalink

‘SEC. 2706. PROHIBITING DISCRIMINATION AGAINST INDIVIDUAL PARTICIPANTS AND BENEFICIARIES BASED ON HEALTH STATUS.

‘(a) In General- A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan or coverage based on any of the following health status-related factors in relation to the individual or a dependent of the individual:CommentsClose CommentsPermalink





‘(1) Health status.CommentsClose CommentsPermalink





‘(2) Medical condition (including both physical and mental illnesses).CommentsClose CommentsPermalink





‘(3) Claims experience.CommentsClose CommentsPermalink





‘(4) Receipt of health care.CommentsClose CommentsPermalink





‘(5) Medical history.CommentsClose CommentsPermalink





‘(6) Genetic information.CommentsClose CommentsPermalink





‘(7) Evidence of insurability (including conditions arising out of acts of domestic violence).CommentsClose CommentsPermalink





‘(8) Disability.CommentsClose CommentsPermalink





‘(9) Any other health status-related factor determined appropriate by the Secretary.CommentsClose CommentsPermalink





‘(b) Programs of Health Promotion or Disease Prevention-CommentsClose CommentsPermalink





‘(1) GENERAL PROVISIONS-CommentsClose CommentsPermalink





‘(A) GENERAL RULE- For purposes of paragraph (2)(B), a program of health promotion or disease prevention (referred to in this subsection as a ‘wellness program’) shall be a program offered by an employer that is designed to promote health or prevent disease that meets the applicable requirements of this subsection.CommentsClose CommentsPermalink





‘(B) NO CONDITIONS BASED ON HEALTH STATUS FACTOR- If none of the conditions for obtaining a premium discount or rebate or other reward for participation in a wellness program is based on an individual satisfying a standard that is related to a health status factor, such wellness program shall not violate this section if participation in the program is made available to all similarly situated individuals and the requirements of paragraph (2) are complied with.CommentsClose CommentsPermalink





‘(C) CONDITIONS BASED ON HEALTH STATUS FACTOR- If any of the conditions for obtaining a premium discount or rebate or other reward for participation in a wellness program is based on an individual satisfying a standard that is related to a health status factor, such wellness program shall not violate this section if the requirements of paragraph (3) are complied with.CommentsClose CommentsPermalink





‘(2) WELLNESS PROGRAMS NOT SUBJECT TO REQUIREMENTS- If none of the conditions for obtaining a premium discount or rebate or other reward under a wellness program as described in paragraph (1)(B) are based on an individual satisfying a standard that is related to a health status factor (or if such a wellness program does not provide such a reward), the wellness program shall not violate this section if participation in the program is made available to all similarly situated individuals. The following programs shall not have to comply with the requirements of paragraph (3) if participation in the program is made available to all similarly situated individuals:CommentsClose CommentsPermalink





‘(A) A program that reimburses all or part of the cost for memberships in a fitness center.CommentsClose CommentsPermalink





‘(B) A diagnostic testing program that provides a reward for participation and does not base any part of the reward on outcomes.CommentsClose CommentsPermalink





‘(C) A program that encourages preventive care related to a health condition through the waiver of the copayment or deductible requirement under an individual or group health plan for the costs of certain items or services related to a health condition (such as prenatal care or well-baby visits).CommentsClose CommentsPermalink





‘(D) A program that reimburses individuals for the costs of smoking cessation programs without regard to whether the individual quits smoking.CommentsClose CommentsPermalink





‘(E) A program that provides a reward to individuals for attending a periodic health education seminar.CommentsClose CommentsPermalink





‘(3) WELLNESS PROGRAMS SUBJECT TO REQUIREMENTS- If any of the conditions for obtaining a premium discount, rebate, or reward under a wellness program as described in paragraph (1)(C) is based on an individual satisfying a standard that is related to a health status factor, the wellness program shall not violate this section if the following requirements are complied with:CommentsClose CommentsPermalink





‘(A) The reward for the wellness program, together with the reward for other wellness programs with respect to the plan that requires satisfaction of a standard related to a health status factor, shall not exceed 30 percent of the cost of employee-only coverage under the plan. If, in addition to employees or individuals, any class of dependents (such as spouses or spouses and dependent children) may participate fully in the wellness program, such reward shall not exceed 30 percent of the cost of the coverage in which an employee or individual and any dependents are enrolled. For purposes of this paragraph, the cost of coverage shall be determined based on the total amount of employer and employee contributions for the benefit package under which the employee is (or the employee and any dependents are) receiving coverage. A reward may be in the form of a discount or rebate of a premium or contribution, a waiver of all or part of a cost-sharing mechanism (such as deductibles, copayments, or coinsurance), the absence of a surcharge, or the value of a benefit that would otherwise not be provided under the plan. The Secretaries of Labor, Health and Human Services, and the Treasury may increase the reward available under this subparagraph to up to 50 percent of the cost of coverage if the Secretaries determine that such an increase is appropriate.CommentsClose CommentsPermalink





‘(B) The wellness program shall be reasonably designed to promote health or prevent disease. A program complies with the preceding sentence if the program has a reasonable chance of improving the health of, or preventing disease in, participating individuals and it is not overly burdensome, is not a subterfuge for discriminating based on a health status factor, and is not highly suspect in the method chosen to promote health or prevent disease. The plan or issuer shall evaluate the program’s reasonableness at least once per year.CommentsClose CommentsPermalink





‘(C) The plan shall give individuals eligible for the program the opportunity to qualify for the reward under the program at least once each year.CommentsClose CommentsPermalink





‘(D) The full reward under the wellness program shall be made available to all similarly situated individuals. For such purpose, among other things:CommentsClose CommentsPermalink





‘(i) The reward is not available to all similarly situated individuals for a period unless the wellness program allows--CommentsClose CommentsPermalink





‘(I) for a reasonable alternative standard (or waiver of the otherwise applicable standard) for obtaining the reward for any individual for whom, for that period, it is unreasonably difficult due to a medical condition to satisfy the otherwise applicable standard; andCommentsClose CommentsPermalink





‘(II) for a reasonable alternative standard (or waiver of the otherwise applicable standard) for obtaining the reward for any individual for whom, for that period, it is medically inadvisable to attempt to satisfy the otherwise applicable standard.CommentsClose CommentsPermalink





‘(ii) If reasonable under the circumstances, the plan or issuer may seek verification, such as a statement from an individual’s physician, that a health status factor makes it unreasonably difficult or medically inadvisable for the individual to satisfy or attempt to satisfy the otherwise applicable standard.CommentsClose CommentsPermalink





‘(E) The plan or issuer involved shall disclose in all plan materials describing the terms of the wellness program the availability of a reasonable alternative standard (or the possibility of waiver of the otherwise applicable standard) required under subparagraph (D). If plan materials disclose that such a program is available, without describing its terms, the disclosure under this subparagraph shall not be required.CommentsClose CommentsPermalink





‘(c) Existing Programs- Nothing in this section shall prohibit a program of health promotion or disease prevention that was established prior to the date of enactment of this section and applied with all applicable regulations, and that is operating on such date, from continuing to be carried out for as long as such regulations remain in effect.CommentsClose CommentsPermalink





‘(d) Regulations- Nothing in this section shall be construed as prohibiting the Secretaries of Labor, Health and Human Services, or the Treasury from promulgating regulations in connection with this section.CommentsClose CommentsPermalink

‘SEC. 2707. ENSURING THE QUALITY OF CARE.

‘(a) In General- Except as provided in subsection (c), a group health plan and a health insurance issuer offering group or individual health insurance coverage shall develop and implement a reimbursement structure for making payments to health care providers that provides incentives for--CommentsClose CommentsPermalink





‘(1) the provision of high quality health care under the plan or coverage in a manner that includes--CommentsClose CommentsPermalink





‘(A) the implementation of case management, care coordination, chronic disease management, and medication and care compliance activities that includes the use of the medical home model as defined in section 212 of the Affordable Health Choices Act for treatment or services under the plan or coverage;CommentsClose CommentsPermalink





‘(B) the implementation of activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post-discharge reinforcement by an appropriate health care professional;CommentsClose CommentsPermalink





‘(C) the implementation of activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage;CommentsClose CommentsPermalink





‘(D) the implementation of wellness and health promotion activities;CommentsClose CommentsPermalink





‘(E) child health measures under section 1139A of the Social Security Act; andCommentsClose CommentsPermalink





‘(F) culturally and linguistically appropriate care, as defined by the Secretary; andCommentsClose CommentsPermalink





‘(2) payment policies that substantially reflects the payment policy of the Medicare program under title XVIII of the Social Security Act and the Children’s Health Insurance Program under title XXI of such Act with respect to any generally implemented incentive policy to promote high quality health care, except that in order that no plan or issuer be forced to deny patients medical care needed to prevent their deaths or preserve or restore their health, no plan or issuer shall be prohibited from providing payment for a treatment or diagnostic procedure it chooses to cover, unless such treatment or procedure has been determined to be unsafe or dangerous or capable of neither preventing the patient’s death nor preserving or restoring the patient’s health.CommentsClose CommentsPermalink





‘(b) Wellness and Prevention Programs- For purposes of subsection (a)(1)(D), wellness and health promotion activities may include personalized wellness and prevention services, which are coordinated, maintained or delivered by a health care provider, a wellness and prevention plan manager, or a health, wellness or prevention services organization that conducts health risk assessments or offer ongoing face-to-face, telephonic or web-based intervention efforts for each of the program’s participants, and which may include the following wellness and prevention efforts:CommentsClose CommentsPermalink





‘(1) Smoking cessation.CommentsClose CommentsPermalink





‘(2) Weight management.CommentsClose CommentsPermalink





‘(3) Stress management.CommentsClose CommentsPermalink





‘(4) Physical fitness.CommentsClose CommentsPermalink





‘(5) Nutrition.CommentsClose CommentsPermalink





‘(6) Heart disease prevention.CommentsClose CommentsPermalink





‘(7) Healthy lifestyle support.CommentsClose CommentsPermalink





‘(8) Diabetes prevention.CommentsClose CommentsPermalink





‘(c) Exceptions- In promulgating regulations under subsection (d), the Secretary may provide for exceptions to the requirements of subsection (a) for insurers that substantially meet the goals of this section.CommentsClose CommentsPermalink





‘(d) Regulations- Not later than 180 days after the date of enactment of the Affordable Health Choices Act, the Secretary shall promulgate regulations--CommentsClose CommentsPermalink





‘(1) that define the term ‘generally implemented’ for purposes of subsection (a)(2);CommentsClose CommentsPermalink





‘(2) that require the expiration of a minimum period of time between the date on which a policy is generally implemented for purposes of subsection (a)(2) and the date on which such policy shall apply with respect to health insurance coverage offered in the individual or group market; andCommentsClose CommentsPermalink





‘(3) that provide criteria for determining whether a payment policy is described in subsection (a).CommentsClose CommentsPermalink





‘(e) Study and Report- Not later than 180 days after the date of enactment of the Affordable Health Choices Act, the Government Accountability Office shall conduct a study and submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives a report regarding the impact the activities under this section have had on the quality and cost of health care.CommentsClose CommentsPermalink

‘SEC. 2708. COVERAGE OF PREVENTIVE HEALTH SERVICES.

‘(a) In General- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide coverage for and shall not impose any cost sharing requirements (other than minimal cost sharing in accordance with guidelines developed by the Secretary) for--CommentsClose CommentsPermalink





‘(1) evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force;CommentsClose CommentsPermalink





‘(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; andCommentsClose CommentsPermalink





‘(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.CommentsClose CommentsPermalink





‘(b) Interval-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall establish a minimum interval between the date on which a recommendation described in subsection (a)(1) or (a)(2) or a guideline under subsection (a)(3) is issued and the plan year with respect to which the requirement described in subsection (a) is effective with respect to the service described in such recommendation or guideline.CommentsClose CommentsPermalink





‘(2) MINIMUM- The interval described in paragraph (1) shall not be less than 1 year.CommentsClose CommentsPermalink

‘SEC. 2709. COVERAGE OF PREVENTIVE WOMEN’S HEALTH SERVICES.

‘A group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide coverage for, and shall not impose any cost sharing requirements (other than minimal cost sharing in accordance with guidelines developed by the Secretary) for, with respect to women (including pregnant women and individuals of child bearing age), such additional preventive care and screenings not covered under section 2708 as provided for in guidelines supported by the Health Resources and Services Administration.CommentsClose CommentsPermalink

‘SEC. 2710. EXTENSION OF DEPENDENT COVERAGE.

‘(a) In General- A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child until the child turns 26 years of age. Nothing in this section shall require a health plan or a health insurance issuer described in the preceding sentence to make coverage available for a child of a child receiving dependent coverage.CommentsClose CommentsPermalink





‘(b) Regulations- The Secretary shall promulgate regulations to define the dependents to which coverage shall be made available under subsection (a).CommentsClose CommentsPermalink

‘SEC. 2711. NO LIFETIME OR ANNUAL LIMITS.

‘(a) In General- A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish lifetime or annual limits on the dollar value of benefits for any participant or beneficiary.CommentsClose CommentsPermalink





‘(b) Preventing Fraud and Abuse- This section shall not apply until the date on which the Secretary certifies that enacting this section will not result in undue proliferation of fraud and abuse, especially with regard to durable medical equipment.CommentsClose CommentsPermalink

‘SEC. 2712. NOTIFICATION BY PLANS NOT PROVIDING MINIMUM QUALIFYING COVERAGE.

‘(a) In General- Not later than 1 year after the date on which the Secretary establishes criteria with respect to minimum qualifying coverage under section 3103, a group health plan and a health insurance issuer offering group or individual health insurance coverage that fails to provide such minimum qualifying coverage shall notify, in such manner as may be required by the Secretary, enrollees and prospective enrollees in such plan or coverage of such failure prior to enrollment or re-enrollment.CommentsClose CommentsPermalink





‘(b) Modifications- If the Secretary modifies the criteria with respect to minimum qualifying coverage under section 3103, a group health plan or health insurance issuer that fails to provide such modified minimum qualifying coverage shall provide the notice required under subsection (a) within 60 days of the date of such modification.CommentsClose CommentsPermalink

‘SEC. 2713. NON-DISCRIMINATION IN HEALTH CARE.

‘A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.’.CommentsClose CommentsPermalink

PART II--PROVISION APPLICABLE TO THE GROUP MARKET

SEC. 121. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT.

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

‘SEC. 2720A. PROHIBITION OF DISCRIMINATION BASED ON SALARY.

‘(a) In General- A group health plan and a health insurance issuer offering group health insurance coverage may not establish rules relating to the health insurance coverage eligibility (including continued eligibility) of any full-time employee under the terms of the plan that are based on the total hourly or annual salary of the employee.CommentsClose CommentsPermalink





‘(b) Limitation- Subsection (a) shall not be construed to prohibit a group health plan or health insurance issuer from establishing contribution requirements for enrollment in the plan or coverage that provide for the payment by employees with lower hourly or annual compensation of a lower dollar or percentage contribution than the payment required of a similarly situated employees with a higher hourly or annual compensation.’.CommentsClose CommentsPermalink

PART III--OTHER PROVISIONS

SEC. 131. NO CHANGES TO EXISTING COVERAGE.

(a) Option to Retain Current Insurance Coverage-CommentsClose CommentsPermalink





(1) IN GENERAL- Nothing in this Act (or an amendment made by this Act) shall be construed to require that an individual terminate coverage under a group health plan or health insurance coverage in which such individual was enrolled prior to the date of enactment of this title.CommentsClose CommentsPermalink





(2) CONTINUATION OF COVERAGE- With respect to a group health plan or health insurance coverage in which an individual was enrolled prior to the date of enactment of this title, this subtitle (and the amendments made by this subtitle) shall not apply to such plan or coverage, regardless of whether the individual renews such coverage after such date of enactment.CommentsClose CommentsPermalink





(b) Allowance for Family Members to Join Current Coverage- With respect to a group health plan or health insurance coverage in which an individual was enrolled prior to the date of enactment of this title and which is renewed after such date, family members of such individual shall be permitted to enroll in such plan or coverage if such enrollment is permitted under the terms of the plan in effect as of such date of enactment.CommentsClose CommentsPermalink





(c) Allowance for New Employees to Join Current Plan- A group health plan that provides coverage on the date of enactment of this Act may provide for the enrolling of new employees (and their families) in such plan, and this subtitle (and the amendments made by this subtitle) shall not apply with respect to such plan and such new employees (and their families).CommentsClose CommentsPermalink





(d) No Additional Benefit- Subsections (b) and (c) shall only apply to individuals described in such subsections and the family members of such individuals (as provided for in such subsections).CommentsClose CommentsPermalink





(e) Limitation- Subsections (a) through (d) shall not apply to any group health plan or health insurance coverage that has been modified to a significant extent with respect to covered benefits or cost sharing requirements after the date of enactment of this Act. The Secretary shall by regulation establish criteria to determine whether a plan or health insurance coverage has been modified to a significant extent under the preceding sentence, except that any coverage amendment made pursuant to an agreement between an employer or an individual and a health insurance issuer relating to the coverage which amends the coverage solely to conform to any requirement added by this Act (or amendments to this Act) shall not be treated as a significant modification.CommentsClose CommentsPermalink





(f) Effect on Collective Bargaining Agreements- In the case of health insurance coverage maintained pursuant to one or more collective bargaining agreements between employee representatives and one or more employers that was ratified before the date of enactment of this title, the provisions of this subtitle (and the amendments made by this subtitle) shall not apply until the date on which the last of the collective bargaining agreements relating to the coverage terminates. Any coverage amendment made pursuant to a collective bargaining agreement relating to the coverage which amends the coverage solely to conform to any requirement added by this subtitle (or amendments) shall not be treated as a termination of such collective bargaining agreement.CommentsClose CommentsPermalink





(g) Risk Adjustment- The provisions of section 3101(c)(6) of the Public Health Service Act (as added by section 142) shall not apply to a group health plan or health insurance coverage to which this section applies.CommentsClose CommentsPermalink

SEC. 132. APPLICABILITY.

Section 2721 of the Public Health Service Act (42 U.S.C. 300gg-21) is amended--CommentsClose CommentsPermalink





(1) by striking subsection (a);CommentsClose CommentsPermalink





(2) in subsection (b)--CommentsClose CommentsPermalink





(A) in paragraph (1), by striking ‘1 through 3’ and inserting ‘1 and 2’; andCommentsClose CommentsPermalink





(B) in paragraph (2)--CommentsClose CommentsPermalink





(i) in subparagraph (A), by striking ‘subparagraph (D)’ and inserting ‘subparagraph (D) or (E)’;CommentsClose CommentsPermalink





(ii) by striking ‘1 through 3’ and inserting ‘1 and 2’; andCommentsClose CommentsPermalink





(iii) by adding at the end the following:CommentsClose CommentsPermalink





‘(E) ELECTION NOT APPLICABLE- The election described in subparagraph (A) shall not be available with respect to the provisions of subpart 1.’;CommentsClose CommentsPermalink





(3) in subsection (c), by striking ‘1 through 3 shall not apply to any group’ and inserting ‘1 and 2 shall not apply to any individual coverage or any group’; andCommentsClose CommentsPermalink





(4) in subsection (d)--CommentsClose CommentsPermalink





(A) in paragraph (1), by striking ‘1 through 3 shall not apply to any group’ and inserting ‘1 and 2 shall not apply to any individual coverage or any group’;CommentsClose CommentsPermalink





(B) in paragraph (2)--CommentsClose CommentsPermalink





(i) in the matter preceding subparagraph (A), by striking ‘1 through 3 shall not apply to any group’ and inserting ‘1 and 2 shall not apply to any individual coverage or any group’; andCommentsClose CommentsPermalink





(ii) in subparagraph (C), by inserting ‘or, with respect to individual coverage, under any health insurance coverage maintained by the same health insurance issuer’; andCommentsClose CommentsPermalink





(C) in paragraph (3), by striking ‘any group’ and inserting ‘any individual coverage or any group’.CommentsClose CommentsPermalink

SEC. 133. CONFORMING AMENDMENTS.

(a) Public Health Service Act- Title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended--CommentsClose CommentsPermalink





(1) in section 2705 (42 U.S.C. 300gg), as so redesignated by section 101(2)--CommentsClose CommentsPermalink





(A) in subsection (c)--CommentsClose CommentsPermalink





(i) in paragraph (2), by striking ‘group health plan’ each place that such appears and inserting ‘group or individual health plan’; andCommentsClose CommentsPermalink





(ii) in paragraph (3)--CommentsClose CommentsPermalink





(I) by striking ‘group health insurance’ each place that such appears and inserting ‘group or individual health insurance’; andCommentsClose CommentsPermalink





(II) in subparagraph (D), by striking ‘small or large’ and inserting ‘individual or group’;CommentsClose CommentsPermalink





(B) in subsection (d), by striking ‘group health insurance’ each place that such appears and inserting ‘group or individual health insurance’; andCommentsClose CommentsPermalink





(C) in subsection (e)(1)(A), by striking ‘group health insurance’ and inserting ‘group or individual health insurance’;CommentsClose CommentsPermalink





(2) by striking the heading for subpart 2 of part A;CommentsClose CommentsPermalink





(3) in section 2717 (42 U.S.C. 300gg-4), as so redesignated--CommentsClose CommentsPermalink





(A) in subsection (a), by striking ‘health insurance issuer offering group health insurance coverage’ and inserting ‘health insurance issuer offering group or individual health insurance coverage’;CommentsClose CommentsPermalink





(B) in subsection (b)--CommentsClose CommentsPermalink





(i) by striking ‘health insurance issuer offering group health insurance coverage in connection with a group health plan’ in the matter preceding paragraph (1) and inserting ‘health insurance issuer offering group or individual health insurance coverage’; andCommentsClose CommentsPermalink





(ii) in paragraph (1), by striking ‘plan’ and inserting ‘plan or coverage’;CommentsClose CommentsPermalink





(C) in subsection (c)--CommentsClose CommentsPermalink





(i) in paragraph (2), by striking ‘group health insurance coverage offered by a health insurance issuer’ and inserting ‘health insurance issuer offering group or individual health insurance coverage’; andCommentsClose CommentsPermalink





(ii) in paragraph (3), by striking ‘issuer’ and inserting ‘health insurance issuer’; andCommentsClose CommentsPermalink





(D) in subsection (e), by striking ‘health insurance issuer offering group health insurance coverage’ and inserting ‘health insurance issuer offering group or individual health insurance coverage’;CommentsClose CommentsPermalink





(4) in section 2718 (42 U.S.C. 300gg-5), as so redesignated--CommentsClose CommentsPermalink





(A) in subsection (a), by striking ‘(or health insurance coverage offered in connection with such a plan)’ each place that such appears and inserting ‘or a health insurance issuer offering group or individual health insurance coverage’;CommentsClose CommentsPermalink





(B) in subsection (b), by striking ‘(or health insurance coverage offered in connection with such a plan)’ each place that such appears and inserting ‘or a health insurance issuer offering group or individual health insurance coverage’; andCommentsClose CommentsPermalink





(C) in subsection (c)--CommentsClose CommentsPermalink





(i) in paragraph (1), by striking ‘(and group health insurance coverage offered in connection with a group health plan)’ and inserting ‘and a health insurance issuer offering group or individual health insurance coverage’;CommentsClose CommentsPermalink





(ii) in paragraph (2), by striking ‘(or health insurance coverage offered in connection with such a plan)’ each place that such appears and inserting ‘or a health insurance issuer offering group or individual health insurance coverage’;CommentsClose CommentsPermalink





(5) in section 2719 (42 U.S.C. 300gg-6), as so redesignated, by striking ‘health insurance issuers providing health insurance coverage in connection with group health plans’ and inserting ‘and health insurance issuers offering group or individual health insurance coverage’;CommentsClose CommentsPermalink





(6) in section 2720 (42 U.S.C. 300gg-7), as so redesignated--CommentsClose CommentsPermalink





(A) in subsection (a), by striking ‘health insurance coverage offered in connection with such plan’ and inserting ‘individual health insurance coverage’;CommentsClose CommentsPermalink





(B) in subsection (b)--CommentsClose CommentsPermalink





(i) in paragraph (1), by striking ‘or a health insurance issuer that provides health insurance coverage in connection with a group health plan’ and inserting ‘or a health insurance issuer that offers group or individual health insurance coverage’;CommentsClose CommentsPermalink





(ii) in paragraph (2), by striking ‘health insurance coverage offered in connection with the plan’ and inserting ‘individual health insurance coverage’; andCommentsClose CommentsPermalink





(iii) in paragraph (3), by striking ‘health insurance coverage offered by an issuer in connection with such plan’ and inserting ‘individual health insurance coverage’;CommentsClose CommentsPermalink





(C) in subsection (c), by striking ‘health insurance issuer providing health insurance coverage in connection with a group health plan’ and inserting ‘health insurance issuer that offers group or individual health insurance coverage’; andCommentsClose CommentsPermalink





(D) in subsection (e)(1), by striking ‘health insurance coverage offered in connection with such a plan’ and inserting ‘individual health insurance coverage’;CommentsClose CommentsPermalink





(7) by striking the heading for subpart 3;CommentsClose CommentsPermalink





(8) in section 2714 (42 U.S.C. 300gg-11), as so redesignated--CommentsClose CommentsPermalink





(A) by striking the section heading and all that follows through subsection (b);CommentsClose CommentsPermalink





(B) in subsection (c)--CommentsClose CommentsPermalink





(i) in paragraph (1)--CommentsClose CommentsPermalink





(I) in the matter preceding subparagraph (A), by striking ‘small group’ and inserting ‘group and individual’; andCommentsClose CommentsPermalink





(II) in subparagraph (B)--CommentsClose CommentsPermalink

(aa) in the matter preceding clause (i), by inserting ‘and individuals’ after ‘employers’;CommentsClose CommentsPermalink

(bb) in clause (i), by inserting ‘or any additional individuals’ after ‘additional groups’; andCommentsClose CommentsPermalink

(cc) in clause (ii), by striking ‘without regard to the claims experience of those employers and their employees (and their dependents) or any health status-related factor relating to such’ and inserting ‘and individuals without regard to the claims experience of those individuals, employers and their employees (and their dependents) or any health status-related factor relating to such individuals’; andCommentsClose CommentsPermalink

(ii) in paragraph (2), by striking ‘small group’ and inserting ‘group or individual’;CommentsClose CommentsPermalink





(C) in subsection (d)--CommentsClose CommentsPermalink





(i) by striking ‘small group’ each place that such appears and inserting ‘group or individual’; andCommentsClose CommentsPermalink





(ii) in paragraph (1)(B)--CommentsClose CommentsPermalink





(I) by striking ‘all employers’ and inserting ‘all employers and individuals’;CommentsClose CommentsPermalink





(II) by striking ‘those employers’ and inserting ‘those individuals, employers’; andCommentsClose CommentsPermalink





(III) by striking ‘such employees’ and inserting ‘such individuals, employees’;CommentsClose CommentsPermalink





(D) by striking subsection (e);CommentsClose CommentsPermalink





(E) by striking subsection (f); andCommentsClose CommentsPermalink





(F) by transferring the remainder of such section to appear at the end of section 2702 (as added by section 101(5));CommentsClose CommentsPermalink





(9) in section 2715 (42 U.S.C. 300gg-12), as so redesignated--CommentsClose CommentsPermalink





(A) by striking the section heading and all that follows through subsection (a);CommentsClose CommentsPermalink





(B) in subsection (b)--CommentsClose CommentsPermalink





(i) in the matter preceding paragraph (1), by striking ‘group health plan in the small or large group market’ and inserting ‘health insurance coverage offered in the group or individual market’;CommentsClose CommentsPermalink





(ii) in paragraph (1), by inserting ‘, or individual, as applicable,’ after ‘plan sponsor’;CommentsClose CommentsPermalink





(iii) in paragraph (2), by inserting ‘, or individual, as applicable,’ after ‘plan sponsor’; andCommentsClose CommentsPermalink





(iv) by striking paragraph (3) and inserting the following:CommentsClose CommentsPermalink





‘(3) VIOLATION OF PARTICIPATION OR CONTRIBUTION RATES- In the case of a group health plan, the plan sponsor has failed to comply with a material plan provision relating to employer contribution or group participation rules, pursuant to applicable State law.’;CommentsClose CommentsPermalink





(C) in subsection (c)--CommentsClose CommentsPermalink





(i) in paragraph (1)--CommentsClose CommentsPermalink





(I) in the matter preceding subparagraph (A), by striking ‘group health insurance coverage offered in the small or large group market’ and inserting ‘group or individual health insurance coverage’;CommentsClose CommentsPermalink





(II) in subparagraph (A), by inserting ‘or individual, as applicable,’ after ‘plan sponsor’;CommentsClose CommentsPermalink





(III) in subparagraph (B)--CommentsClose CommentsPermalink

(aa) by inserting ‘or individual, as applicable,’ after ‘plan sponsor’; andCommentsClose CommentsPermalink

(bb) by inserting ‘or individual health insurance coverage’; andCommentsClose CommentsPermalink

(IV) in subparagraph (C), by inserting ‘or individuals, as applicable,’ after ‘those sponsors’; andCommentsClose CommentsPermalink





(ii) in paragraph (2)(A)--CommentsClose CommentsPermalink





(I) in the matter preceding clause (i), by striking ‘small group market or the large group market, or both markets,’ and inserting ‘individual or group market, or all markets,’; andCommentsClose CommentsPermalink





(II) in clause (i), by inserting ‘or individual, as applicable,’ after ‘plan sponsor’; andCommentsClose CommentsPermalink





(D) by transferring the remainder of such section to appear at the end of section 2703 (as added by section 101(5));CommentsClose CommentsPermalink





(10) in section 2716 (42 U.S.C. 300gg-13), as so redesignated--CommentsClose CommentsPermalink





(A) in subsection (a)--CommentsClose CommentsPermalink





(i) in the matter preceding paragraph (1), by striking ‘small employer’ and inserting ‘small employer or an individual’;CommentsClose CommentsPermalink





(ii) in paragraph (1), by inserting ‘, or individual, as applicable,’ after ‘employer’ each place that such appears; andCommentsClose CommentsPermalink





(iii) in paragraph (2), by striking ‘small employer’ and inserting ‘employer, or individual, as applicable,’;CommentsClose CommentsPermalink





(B) in subsection (b)--CommentsClose CommentsPermalink





(i) in paragraph (1)--CommentsClose CommentsPermalink





(I) in the matter preceding subparagraph (A), by striking ‘small employer’ and inserting ‘employer, or individual, as applicable,’;CommentsClose CommentsPermalink





(II) in subparagraph (A), by adding ‘and’ at the end;CommentsClose CommentsPermalink





(III) by striking subparagraphs (B) and (C); andCommentsClose CommentsPermalink





(IV) in subparagraph (D)--CommentsClose CommentsPermalink

(aa) by inserting ‘, or individual, as applicable,’ after ‘employer’; andCommentsClose CommentsPermalink

(bb) by redesignating such subparagraph as subparagraph (B);CommentsClose CommentsPermalink

(ii) in paragraph (2)--CommentsClose CommentsPermalink





(I) by striking ‘small employers’ each place that such appears and inserting ‘employers, or individuals, as applicable,’; andCommentsClose CommentsPermalink





(II) by striking ‘small employer’ and inserting ‘employer, or individual, as applicable,’; andCommentsClose CommentsPermalink





(C) by redesignating such section as section 2712 and transferring such section to appear after section 2711 (as added by section 101(5));CommentsClose CommentsPermalink





(11) by redesignating subpart 4 as subpart 2;CommentsClose CommentsPermalink





(12) in section 2721 (42 U.S.C. 300gg-21)--CommentsClose CommentsPermalink





(A) by striking subsection (a);CommentsClose CommentsPermalink





(B) by striking ‘subparts 1 through 3’ each place that such appears and inserting ‘subpart 1’; andCommentsClose CommentsPermalink





(C) by redesignating subsections (b) through (e) as subsections (a) through (d), respectively;CommentsClose CommentsPermalink





(13) in section 2722 (42 U.S.C. 300gg-22)--CommentsClose CommentsPermalink





(A) in subsection (a)--CommentsClose CommentsPermalink





(i) in paragraph (1), by striking ‘small or large group markets’ and inserting ‘individual or group market’; andCommentsClose CommentsPermalink





(ii) in paragraph (2), by inserting ‘or individual health insurance coverage’ after ‘group health plans’; andCommentsClose CommentsPermalink





(B) in subsection (b)(1)(B), by inserting ‘individual health insurance coverage or’ after ‘respect to’; andCommentsClose CommentsPermalink





(14) in section 2723(a)(1) (42 U.S.C. 300gg-23), by inserting ‘individual or’ before ‘group health insurance’.CommentsClose CommentsPermalink





(b) Applicability- Notwithstanding any other provision of the Affordable Health Choices Act, nothing in such Act (or an amendment made by such Act) shall be construed to--CommentsClose CommentsPermalink





(1) authorize the Secretary of Health and Human Services to promulgate regulations that prohibit a group health plan or health insurance issuer from carrying out utilization management techniques that are commonly used as of the date of enactment of this section; orCommentsClose CommentsPermalink





(2) restrict the application of the amendments made by this subtitle.CommentsClose CommentsPermalink





(c) Technical Amendment to the Employee Retirement Income Security Act of 1974- Subpart B of part 7 of subtitle A of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1181 et. seq.) is amended, by adding at the end the following:CommentsClose CommentsPermalink

‘SEC. 715. ADDITIONAL MARKET REFORMS.

‘(a) General Rule- Except as provided in subsection (b)--CommentsClose CommentsPermalink





‘(1) the provisions of subpart 1 of part A of title XXVII of the Public Health Service Act (as amended by the Affordable Health Choices Act) shall apply to group health plans, and health insurance issuers providing health insurance coverage in connection with group health plans, as if included in this subpart; andCommentsClose CommentsPermalink





‘(2) to the extent that any provision of this part conflicts with a provision of such subpart 1 with respect to group health plans, or health insurance issuers providing health insurance coverage in connection with group health plans, the provisions of such subpart 1 shall apply.CommentsClose CommentsPermalink





‘(b) Exception- Notwithstanding subsection (a), the provisions of sections 2701, 2702, and 2704 of title XXVII of the Public Health Service Act (as amended by the Affordable Health Choices Act) shall not apply with respect to self-insured group health plans, and the provisions of this part shall continue to apply to such plans as if such sections of the Public Health Service Act (as so amended) had not been enacted.’.CommentsClose CommentsPermalink





(d) Technical Amendment to the Internal Revenue Code of 1986- Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following:CommentsClose CommentsPermalink

‘SEC. 9815. ADDITIONAL MARKET REFORMS.

‘(a) General Rule- Except as provided in subsection (b)--CommentsClose CommentsPermalink





‘(1) the provisions of subpart 1 of part A of title XXVII of the Public Health Service Act (as amended by the Affordable Health Choices Act) shall apply to group health plans, and health insurance issuers providing health insurance coverage in connection with group health plans, as if included in this subchapter; andCommentsClose CommentsPermalink





‘(2) to the extent that any provision of this subchapter conflicts with a provision of such subpart 1 with respect to group health plans, or health insurance issuers providing health insurance coverage in connection with group health plans, the provisions of such subpart 1 shall apply.CommentsClose CommentsPermalink





‘(b) Exception- Notwithstanding subsection (a), the provisions of sections 2701, 2702, and 2704 of title XXVII of the Public Health Service Act (as amended by the Affordable Health Choices Act) shall not apply with respect to self-insured group health plans, and the provisions of this subchapter shall continue to apply to such plans as if such sections of the Public Health Service Act (as so amended) had not been enacted.’.CommentsClose CommentsPermalink

SEC. 134. SAVINGS.

(a) Determination- The Secretary of the Treasury, in consultation with the Secretary of Health and Human Services, shall for each fiscal year determine the amount of savings to the Federal Government as a result of the enactment of this subtitle.CommentsClose CommentsPermalink





(b) Use- Notwithstanding any other provision of this subtitle (or an amendment made by this subtitle), the savings to the Federal Government generated as a result of the enactment of this subtitle shall be used for deficit reduction.CommentsClose CommentsPermalink

SEC. 135. EFFECTIVE DATES.

(a) Applicability- Except as otherwise provided in subsection (b), this subtitle (and the amendments made by this subtitle) shall become effective for plan years beginning on or after the date that is 1 year after the date of enactment of this Act.CommentsClose CommentsPermalink





(b) Delayed Applicability- Sections 2701, 2702, 2705, and 2706 of the Public Health Service Act (as added by section 101) shall become effective with respect to group health plans or health insurance coverage offered in a State on the date on which such State becomes a participating or establishing State under section 3104 of the Public Health Service Act (as added by section 142).CommentsClose CommentsPermalink

Subtitle B--Available Coverage for All AmericansCommentsClose CommentsPermalink

SEC. 141. BUILDING ON THE SUCCESS OF THE FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM AND THE HEALTH BENEFITS PROGRAM OF MOST LARGE EMPLOYERS SO ALL AMERICANS HAVE AFFORDABLE HEALTH BENEFIT CHOICES.

(a) Findings- The Senate finds that--CommentsClose CommentsPermalink





(1) the Federal employees health benefits program under chapter 89 of title 5, United States Code, allows Members of Congress, and section 514 of the Employee Retirement Income Security Act of 1974 allows large employers, to have affordable choices among competing health benefit plans;CommentsClose CommentsPermalink





(2) the Federal employees health benefits program ensures that the health benefit plans available to Members of Congress meet minimum standards of quality and effectiveness;CommentsClose CommentsPermalink





(3) millions of Americans have no meaningful choice in health benefits, because health benefit plans are either unavailable or unaffordable; andCommentsClose CommentsPermalink





(4) all Americans should have the same kinds of meaningful choices of health benefit plans that Members of Congress, as Federal employees, enjoy through the Federal employees health benefits program.CommentsClose CommentsPermalink





(b) Sense of the Senate- It is the sense of the Senate that Congress should establish a means for all Americans to enjoy affordable choices in health benefit plans, in the same manner that Members of Congress have such choices through the Federal employees health benefits program.CommentsClose CommentsPermalink

SEC. 142. AFFORDABLE HEALTH CHOICES FOR ALL AMERICANS.

(a) Purpose- It is the purpose of this section to facilitate the establishment of Affordable Health Benefit Gateways in each State, with appropriate flexibility for States in establishing and administering the Gateways.CommentsClose CommentsPermalink





(b) American Health Benefit Gateways- The Public Health Service Act ( 42 U.S.C. 201 et seq.) is amended by adding at the end the following:CommentsClose CommentsPermalink

‘TITLE XXXI--AFFORDABLE HEALTH CHOICES FOR ALL AMERICANSCommentsClose CommentsPermalink

‘Subtitle A--Affordable ChoicesCommentsClose CommentsPermalink

‘SEC. 3101. AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS.

‘(a) Assistance to States to Establish American Health Benefit Gateways-CommentsClose CommentsPermalink





‘(1) PLANNING AND ESTABLISHMENT GRANTS- Not later than 60 days after the date of enactment of this section (or as soon as practicable thereafter), the Secretary shall make awards, from amounts appropriated under paragraph (5), to States in the amount specified in paragraph (2) for the uses described in paragraph (3).CommentsClose CommentsPermalink





‘(2) AMOUNT SPECIFIED-CommentsClose CommentsPermalink





‘(A) TOTAL DETERMINED- For each fiscal year, the Secretary shall determine the total amount that the Secretary will make available for grants under this subsection.CommentsClose CommentsPermalink





‘(B) STATE AMOUNT- For each State that is awarded a grant under paragraph (1), the amount of such grants shall be based on a formula established by the Secretary under which each State shall receive an award in an amount that is based on the following two components:CommentsClose CommentsPermalink





‘(i) A minimum amount for each State.CommentsClose CommentsPermalink





‘(ii) An additional amount based on population.CommentsClose CommentsPermalink





The Secretary shall ensure that the aggregate amount awarded to all States under clause (i) is not less than 60 percent of the aggregate amount awarded to all States under this subparagraph.CommentsClose CommentsPermalink





‘(3) USE OF FUNDS- A State shall use amounts awarded under this subsection for activities (including planning activities) related to establishing an American Health Benefit Gateway, as described in subsection (b).CommentsClose CommentsPermalink





‘(4) RENEWABILITY OF GRANT-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary may renew a grant awarded under paragraph (1) if the State recipient of such grant--CommentsClose CommentsPermalink





‘(i) is making progress, as determined by the Secretary, toward--CommentsClose CommentsPermalink





‘(I) establishing a Gateway; andCommentsClose CommentsPermalink





‘(II) implementing the reforms described in subtitle A of title I of the Affordable Health Choices Act; andCommentsClose CommentsPermalink





‘(ii) is meeting such other benchmarks as the Secretary may establish.CommentsClose CommentsPermalink





‘(B) LIMITATION- If a State is an establishing State or a participating State (as defined in section 3104), such State shall not be eligible for a grant renewal under subparagraph (A) as of the second fiscal year following the date on which such State was deemed to be an establishing State or a participating State.CommentsClose CommentsPermalink





‘(5) AUTHORIZATION OF APPROPRIATIONS- There are authorized to be appropriated such sums as may be necessary to carry out this subsection in each of fiscal years 2009 through 2014.CommentsClose CommentsPermalink





‘(b) American Health Benefit Gateways- An American Health Benefit Gateway (referred to in this title as a ‘Gateway’) means a mechanism that--CommentsClose CommentsPermalink





‘(1) facilitates the purchase of health insurance coverage and related insurance products through the Gateway at an affordable price by qualified individuals and qualified employers and reduces the cost of health care; andCommentsClose CommentsPermalink





‘(2) meets the requirements of subsection (c).CommentsClose CommentsPermalink





‘(c) Requirements-CommentsClose CommentsPermalink





‘(1) ESTABLISHMENT- A Gateway shall be a governmental agency or nonprofit entity that is established by--CommentsClose CommentsPermalink





‘(A) a State, in the case of an establishing State (as described in section 3104); orCommentsClose CommentsPermalink





‘(B) the Secretary, in the case of a participating State (as described in section 3104).CommentsClose CommentsPermalink





‘(2) OFFERING OF COVERAGE-CommentsClose CommentsPermalink





‘(A) IN GENERAL- A Gateway shall make available qualified health plans to qualified individuals and qualified employers.CommentsClose CommentsPermalink





‘(B) INCLUSION- In making available coverage pursuant to subparagraph (A), a Gateway shall include a community health insurance option (as described in section 3106).CommentsClose CommentsPermalink





‘(C) LIMITATION- A Gateway may not make available any health plan or other health insurance coverage that is not a qualified health plan.CommentsClose CommentsPermalink





‘(D) ALLOWANCE TO OFFER- A Gateway may make available a qualified health plan notwithstanding any provision of law that may require benefits other than the essential health benefits specified under section 3103(a).CommentsClose CommentsPermalink





‘(E) STATES MAY REQUIRE ADDITIONAL BENEFITS- Subject to the requirements of subparagraph (F), a State may require that a qualified health plan offered in such State offer benefits in addition to the essential health benefits described in section 3103(a).CommentsClose CommentsPermalink





‘(F) ADDITIONAL BENEFITS-CommentsClose CommentsPermalink





‘(i) NO ADDITIONAL FEDERAL COST- A requirement by a State under subparagraph (E) that a qualified health plan cover benefits in addition to the essential health benefits required shall not affect the amount of a credit provided under section 3111 with respect to such plan.CommentsClose CommentsPermalink





‘(ii) STATE MUST ASSUME COST- A State shall make payments to or on behalf of an eligible individual to defray the cost of any additional benefits described in subparagraph (E).CommentsClose CommentsPermalink





‘(3) FUNCTIONS- A Gateway shall, at a minimum--CommentsClose CommentsPermalink





‘(A) establish procedures for the certification, recertification, and decertification, consistent with guidelines developed by the Secretary under subsection (m), of health plans as qualified health plans;CommentsClose CommentsPermalink





‘(B) develop and make available tools to allow consumers to receive accurate and culturally and linguistically appropriate information on--CommentsClose CommentsPermalink





‘(i) expected premiums and out of pocket expenses (taking into account any credits for which such individual is eligible under section 3111);CommentsClose CommentsPermalink





‘(ii) the availability of in-network and out-of-network providers;CommentsClose CommentsPermalink





‘(iii) the costs of any surcharge assessed under paragraph (4);CommentsClose CommentsPermalink





‘(iv) data, by plan, that reflects the frequency with which preventive services rated ‘A’ or ‘B’ by the U.S. Preventive Services Task Force or recommended by the Advisory Committee on Immunization Practices are utilized by enrollees, a comparison of such data to the average frequency with which such preventive services are utilized by enrollees across all qualified health plans, and whether such preventive services are utilized by enrollees as frequently as recommended;CommentsClose CommentsPermalink





‘(v) medical loss ratios, as reported under section 2704(a);CommentsClose CommentsPermalink





‘(vi) any quality measures for health plan performance endorsed under section 399JJ; andCommentsClose CommentsPermalink





‘(vii) such other matters relating to consumer costs and expected experience under the plan as a Gateway may determine necessary;CommentsClose CommentsPermalink





‘(C) utilize the administrative simplification measures and standards developed under section 222 of the Affordable Health Choices Act;CommentsClose CommentsPermalink





‘(D) enter into agreements, to the extent determined appropriate by the Gateway, with navigators, as described in section 3105;CommentsClose CommentsPermalink





‘(E) facilitate the purchase of coverage for long-term services and supports;CommentsClose CommentsPermalink





‘(F) collect, analyze, and respond to complaints and concerns from enrollees regarding coverage provided through the Gateway;CommentsClose CommentsPermalink





‘(G) provide for the operation of a toll-free telephone hotline to respond to requests for assistance; andCommentsClose CommentsPermalink





‘(H) maintain an Internet website through which enrollees and prospective enrollees of qualified health plans may obtain standardized comparative information on such plans.CommentsClose CommentsPermalink





‘(4) SURCHARGES-CommentsClose CommentsPermalink





‘(A) IN GENERAL- A Gateway may assess a surcharge on all health insurance issuers offering qualified health plans through the Gateway to pay for the administrative and operational expenses of the Gateway.CommentsClose CommentsPermalink





‘(B) LIMITATION- A surcharge described in subparagraph (A) may not exceed 4 percent of the premiums collected by a qualified health plan.CommentsClose CommentsPermalink





‘(C) FURTHER LIMITATION- No funds collected through a Gateway surcharge for administrative and operational expenses may be used for staff retreats, promotional giveaways, excessive executive compensation, or promotion of Federal or State legislative and regulatory modifications.CommentsClose CommentsPermalink





‘(5) RISK ADJUSTMENT PAYMENT-CommentsClose CommentsPermalink





‘(A) ESTABLISHING AND PARTICIPATING STATES-CommentsClose CommentsPermalink





‘(i) LOW ACTUARIAL RISK PLANS- Using the criteria and methods developed under subparagraph (B), each establishing State or participating State (as defined in section 3104) shall assess a charge on health plans and health insurance issuers (with respect to health insurance coverage) described in subparagraph (C) if the actuarial risk of the enrollees of such plans or coverage for a year is less than the average actuarial risk of all enrollees in all plans or coverage in such State for such year that are not self-insured group health plans (which are subject to the provisions of the Employee Retirement Income Security Act of 1974).CommentsClose CommentsPermalink





‘(ii) HIGH ACTUARIAL RISK PLANS- Using the criteria and methods developed under subparagraph (B), each establishing State or participating State (as defined in section 3104) shall provide a payment to health plans and health insurance issuers (with respect to health insurance coverage) described in subparagraph (C) if the actuarial risk of the enrollees of such plans or coverage for a year is greater than the average actuarial risk of all enrollees in all plans and coverage in such State for such year that are not self-insured group health plans (which are subject to the provisions of the Employee Retirement Income Security Act of 1974).CommentsClose CommentsPermalink





‘(B) CRITERIA AND METHODS- The Secretary, in consultation with States, shall establish criteria and methods to be used in carrying out the risk adjustment activities under this paragraph. The Secretary may utilize criteria and methods similar to the criteria and methods utilized under part C or D of title XVIII of the Social Security Act.CommentsClose CommentsPermalink





‘(C) SCOPE- A health plan or a health insurance issuer is described in this subparagraph if such health plan or health insurance issuer provides coverage for an individual or for an employer group the size of which does not exceed--CommentsClose CommentsPermalink





‘(i) in the case of an employer with its primary place of business located in an establishing State, the criteria relating to the size of employers established by such State as described in section 3116(a)(2)(A)(ii)(I); orCommentsClose CommentsPermalink





‘(ii) in the case of an employer with its primary place of business located in a participating State, the criteria relating to the size of employers established by the Secretary as described in section 3116(a)(2)(A)(ii)(II).CommentsClose CommentsPermalink





‘(6) FACILITATING ENROLLMENT-CommentsClose CommentsPermalink





‘(A) IN GENERAL- A Gateway shall (through, to the extent practicable, the use of information technology) implement policies and procedures to--CommentsClose CommentsPermalink





‘(i) facilitate the identification of individuals who lack qualifying coverage; andCommentsClose CommentsPermalink





‘(ii) assist such individuals in enrolling in--CommentsClose CommentsPermalink





‘(I) a qualified health plan that is affordable and available to such individual, if such individual is a qualified individual;CommentsClose CommentsPermalink





‘(II) the medicaid program under title XIX of the Social Security Act, if such individual is eligible for such program;CommentsClose CommentsPermalink





‘(III) the CHIP program under title XXI of the Social Security Act, if such individual is eligible for such program; orCommentsClose CommentsPermalink





‘(IV) other Federal programs in which such individual is eligible to participate.CommentsClose CommentsPermalink





‘(B) CHOICE FOR INDIVIDUALS ELIGIBLE FOR CHIP- A qualified individual who is eligible for the Children’s Health Insurance Program under title XXI of the Social Security Act may elect to enroll in such program or in a qualified health plan. Where such individual is a minor child, such election shall be made by the parent or guardian of such child.CommentsClose CommentsPermalink





‘(C) OVERSIGHT- The Secretary shall oversee the implementation of subparagraph (A)(ii) to ensure that individuals are assisted to enroll in the program most appropriate under such subparagraph for each such individual.CommentsClose CommentsPermalink





‘(D) ACCESSIBILITY OF MATERIALS- Any materials used by a Gateway to carry out this paragraph shall be provided in a form and manner calculated to be understood by individuals who may apply to be enrollees in a qualified health plan, taking into account potential language barriers and disabilities of individuals.CommentsClose CommentsPermalink





‘(7) CONSULTATION- A Gateway shall consult with stakeholders relevant to carrying out the activities under this subsection, including--CommentsClose CommentsPermalink





‘(A) educated health care consumers who are enrollees in qualified health plans;CommentsClose CommentsPermalink





‘(B) individuals and entities with experience in facilitating enrollment in qualified health plans;CommentsClose CommentsPermalink





‘(C) representatives of small businesses and self-employed individuals;CommentsClose CommentsPermalink





‘(D) State Medicaid offices; andCommentsClose CommentsPermalink





‘(E) advocates for enrolling hard to reach populations.CommentsClose CommentsPermalink





‘(8) STANDARDS AND PROTOCOLS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary, in consultation with the Office of the National Coordinator for Health Information Technology, shall develop interoperable, secure, scalable, and reusable standards and protocols that facilitate enrollment of individuals in Federal and State health and human services programs.CommentsClose CommentsPermalink





‘(B) COORDINATION- The Secretary shall facilitate enrollment of individuals in programs described in subparagraph (A) through methods which shall include--CommentsClose CommentsPermalink





‘(i) electronic matching against existing Federal and State data to serve as evidence of eligibility and digital documentation in lieu of paper-based documentation;CommentsClose CommentsPermalink





‘(ii) capability for individuals to apply, recertify, and manage eligibility information online, including conducting real-time queries against databases for existing eligibility prior to submitting applications; andCommentsClose CommentsPermalink





‘(iii) other functionalities necessary to provide eligible individuals with a streamlined enrollment process.CommentsClose CommentsPermalink





‘(C) ASSISTANCE- The Secretary shall award grants to enhance community-based enrollment to--CommentsClose CommentsPermalink





‘(i) States to assist such States in--CommentsClose CommentsPermalink





‘(I) contracting with qualified technology vendors to develop or acquire electronic enrollment software systems;CommentsClose CommentsPermalink





‘(II) contracting with community and consumer focused nonprofit organizations with experience working with consumers, including the uninsured and the underinsured, to establish Statewide helplines for enrollment assistance and referrals; andCommentsClose CommentsPermalink





‘(III) establishing public education campaigns through grants to qualifying organizations for the design and implementation of public education campaigns targeting uninsured and traditionally underserved communities; andCommentsClose CommentsPermalink





‘(ii) community-based organizations for infrastructure and training to establish electronic assistance programs.CommentsClose CommentsPermalink





‘(9) NOTIFICATION- With respect to the standards and protocols developed under paragraph (8), the Secretary--CommentsClose CommentsPermalink





‘(A) shall notify States of such standards and protocols; andCommentsClose CommentsPermalink





‘(B) may require, as a condition of receiving Federal funds, that States or other entities incorporate such standards and protocols into such investments.CommentsClose CommentsPermalink





‘(10) PUBLICATION OF COSTS- A Gateway shall publish the average costs of income or other taxes, licensing or regulatory fees, and any surcharges imposed by the Gateway, and the administrative costs of such Gateway, on an Internet website to educate consumers on such costs. Such information shall also include monies lost to waste, fraud, and abuse.CommentsClose CommentsPermalink





‘(d) Certification- A Gateway may certify a health plan as a qualified health plan if--CommentsClose CommentsPermalink





‘(1) such health plan meets the requirements of subsection (m);CommentsClose CommentsPermalink





‘(2) the Gateway determines that making available such health plan through such Gateway is in the interests of qualified individuals and qualified employers in the States or States in which such Gateway operates, except that the Gateway may not exclude a health plan--CommentsClose CommentsPermalink





‘(A) on the basis that such plan is a fee-for-service plan;CommentsClose CommentsPermalink





‘(B) through the imposition of premium price controls; orCommentsClose CommentsPermalink





‘(C) on the basis that the plan provides treatments necessary to prevent patients’ deaths in circumstances the Gateway determines are inappropriate or to costly; andCommentsClose CommentsPermalink





‘(3) the Gateway determines that the plan has not established a pattern or practice under which benefits covered by the plan are denied to covered individuals on the basis of the individuals’ age or expected length of life or of the individuals’ present or predicted disability, degree of medical dependency, or quality of life.CommentsClose CommentsPermalink





‘(e) Guidance- The Secretary shall develop guidance that may be used by a Gateway to carry out the activities described in this section.CommentsClose CommentsPermalink





‘(f) Flexibility-CommentsClose CommentsPermalink





‘(1) REGIONAL OR OTHER INTERSTATE GATEWAYS- A Gateway may operate in more than one State, provided that each State in which such Gateway operates permits such operation.CommentsClose CommentsPermalink





‘(2) SUBSIDIARY GATEWAYS- A State may establish one or more subsidiary Gateway, provided that--CommentsClose CommentsPermalink





‘(A) each such Gateway serves a geographically distinct area; andCommentsClose CommentsPermalink





‘(B) the area served by each such Gateway is at least as large as a community rating area described in section 2701.CommentsClose CommentsPermalink





‘(g) No Limitation on Contracting Based on Abortion- No individual health care provider or health care facility may be excluded from contracting with a health insurance issuer participating in the Gateway on the basis that the provider or facility performs abortions or the provider or facility refuses to perform abortions, except in an emergency, if performing abortions is contrary to the religious or moral beliefs of the provider or facility.CommentsClose CommentsPermalink





‘(h) Portals to State Gateway- The Secretary shall establish a mechanism, including an Internet website, through which a resident of any State may identify any Gateway operating in such State.CommentsClose CommentsPermalink





‘(i) Choice-CommentsClose CommentsPermalink





‘(1) QUALIFIED INDIVIDUALS- A qualified individual may enroll in any qualified health plan available to such individual.CommentsClose CommentsPermalink





‘(2) QUALIFIED EMPLOYERS-CommentsClose CommentsPermalink





‘(A) EMPLOYER MAY SPECIFY TIER- A qualified employer may provide support for coverage of employees under a qualified health plan by selecting any tier of cost sharing described in section 3111(a)(1).CommentsClose CommentsPermalink





‘(B) EMPLOYEE MAY CHOOSE PLANS WITHIN A TIER- Each employee of a qualified employer may choose to enroll in a qualified health plan that offers coverage at the tier of cost sharing selected by an employer, as described in subparagraph (A).CommentsClose CommentsPermalink





‘(3) SELF-EMPLOYED INDIVIDUALS-CommentsClose CommentsPermalink





‘(A) DEEMING- An individual who is self-employed (as defined in section 401(c)(1) of the Internal Revenue Code of 1986) shall be deemed to be a qualified employer unless such individual notifies the applicable Gateway that such individual elects to be considered a qualified individual.CommentsClose CommentsPermalink





‘(B) ELIGIBILITY- In the case of a self-employed individual making the election described in subparagraph (A)--CommentsClose CommentsPermalink





‘(i) the income of such individual for purposes of section 3111 shall be deemed to be the total business income of such individual;CommentsClose CommentsPermalink





‘(ii) premium payments made by such individual to a qualified health plan shall not be treated as employer-provided coverage under section 106(a) of the Internal Revenue Code of 1986; andCommentsClose CommentsPermalink





‘(iii) the individual shall not be eligible for a credit under section 3112.CommentsClose CommentsPermalink





‘(j) Payment of Premiums by Qualified Individuals- A qualified individual enrolled in any qualified health plan may pay any applicable premium owed by such individual to the health insurance issuer issuing such qualified health plan.CommentsClose CommentsPermalink





‘(k) Single Risk Pool-CommentsClose CommentsPermalink





‘(1) INDIVIDUAL MARKET- A health insurance issuer shall consider all enrollees in an individual plan, including individuals who do not purchase such a plan through the Gateway, to be members of a single risk pool.CommentsClose CommentsPermalink





‘(2) GROUP HEALTH INSURANCE POLICIES- A health insurance issuer shall consider all enrollees in a small group health plan, other than a self-insured group health plan, including individuals who do not purchase such a plan through the Gateway, to be members of a single risk pool.CommentsClose CommentsPermalink





‘(l) Empowering Consumer Choice-CommentsClose CommentsPermalink





‘(1) CONTINUED OPERATION OF MARKET OUTSIDE GATEWAYS- Nothing in this title shall be construed to prohibit a health insurance issuer from offering a health insurance policy or providing coverage under such policy to a qualified individual where such policy is not a qualified health plan. Nothing in this title shall be construed to prohibit a qualified individual from enrolling in a health insurance plan where such plan is not a qualified health plan.CommentsClose CommentsPermalink





‘(2) CONTINUED OPERATION OF STATE BENEFIT REQUIREMENTS- Nothing in this title shall be construed to terminate, abridge, or limit the operation of any requirement under State law with respect to any policy or plan that is not a qualified health plan to offer benefits required under State law.CommentsClose CommentsPermalink





‘(3) VOLUNTARY NATURE OF A GATEWAY-CommentsClose CommentsPermalink





‘(A) CHOICE TO ENROLL OR NOT TO ENROLL- Nothing in this title shall be construed to restrict the choice of a qualified individual to enroll or not to enroll in a qualified health plan or to participate in a Gateway.CommentsClose CommentsPermalink





‘(B) PROHIBITION AGAINST COMPELLED ENROLLMENT- Nothing in this title shall be construed to compel an individual to enroll in a qualified health plan or to participate in a Gateway.CommentsClose CommentsPermalink





‘(m) Criteria for Certification-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall, by regulation, establish criteria for certification of health plans as qualified health plans. Such criteria shall require that, to be certified, a plan--CommentsClose CommentsPermalink





‘(A) not employ marketing practices that have the effect of discouraging the enrollment in such plan by individuals with significant health needs;CommentsClose CommentsPermalink





‘(B) employ methods to ensure that insurance products are simple, comparable, and structured for ease of consumer choice;CommentsClose CommentsPermalink





‘(C) ensure a wide choice of providers (in a manner consistent with applicable network adequacy provisions under section 2702(c));CommentsClose CommentsPermalink





‘(D) include within health insurance plan networks those essential community providers, where available, that serve predominately low-income, medically-underserved individuals, such as health care providers defined in section 340B(a)(4) of the Public Health Service Act and providers described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act as set forth by section 221 of Public Law 111-8;CommentsClose CommentsPermalink





‘(E) make available to individuals enrolled in, or seeking to enroll in, such plan a detailed description of--CommentsClose CommentsPermalink





‘(i) benefits offered, including maximums, limitations (including differential cost-sharing for out of network services), exclusions and other benefit limitations;CommentsClose CommentsPermalink





‘(ii) the service area;CommentsClose CommentsPermalink





‘(iii) required premiums;CommentsClose CommentsPermalink





‘(iv) cost-sharing requirements;CommentsClose CommentsPermalink





‘(v) the manner in which enrollees access providers; andCommentsClose CommentsPermalink





‘(vi) the grievance and appeals procedures;CommentsClose CommentsPermalink





‘(F) provide coverage for at least the essential health care benefits established under section 3103(a);CommentsClose CommentsPermalink





‘(G)(i) is accredited by the National Committee for Quality Assurance or by any other entity recognized by the Secretary for the accreditation of health insurance issuers or plans; orCommentsClose CommentsPermalink





‘(ii) receives such accreditation within a period established by a Gateway for such accreditation that is applicable to all qualified health plans;CommentsClose CommentsPermalink





‘(H) implement a quality improvement strategy described in subsection (n)(1);CommentsClose CommentsPermalink





‘(I) have adequate procedures in place for appeals of coverage determinations;CommentsClose CommentsPermalink





‘(J) may not establish a benefit design that is likely to substantially discourage enrollment by certain qualified individuals in such plan; andCommentsClose CommentsPermalink





‘(K) report to the applicable Gateway data on any quality measures for health plan performance endorsed under section 399JJ.CommentsClose CommentsPermalink





‘(2) REQUEST TO NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS- The Secretary shall request the National Association of Insurance Commissioners to develop and submit to the Secretary model criteria for the certification of qualified health plans, that address the elements described in subparagraphs (A) through (K) of paragraph (1). In developing such criteria, the National Association of Insurance Commissioners shall consult with appropriate Federal agencies, consumer representatives, insurance carriers, and other stakeholders.CommentsClose CommentsPermalink





‘(3) REQUIRED CONSIDERATION- If the model criteria described in paragraph (2) are submitted to the Secretary by the date that is 9 months after the date on which a request is made under such paragraph, the Secretary shall consider such model criteria in promulgating the regulations under paragraph (1).CommentsClose CommentsPermalink





‘(4) RULE OF CONSTRUCTION- Nothing in paragraph (1)(D) shall be construed to require a qualified health plan to contract with a provider described in such paragraph if such provider refuses to accept the generally applicable payment rates of such plan.CommentsClose CommentsPermalink





‘(n) Rewarding Quality Through Market-Based Incentives-CommentsClose CommentsPermalink





‘(1) STRATEGY DESCRIBED- A strategy described in this paragraph is a payment structure that provides increased reimbursement or other incentives for--CommentsClose CommentsPermalink





‘(A) improving health outcomes through the implementation of activities that shall include quality reporting, effective case management, care coordination, chronic disease management, medication and care compliance initiatives, including through the use of the medical home model as defined in section 212 of the Affordable Health Choices Act, for treatment or services under the plan or coverage;CommentsClose CommentsPermalink





‘(B) the implementation of activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional;CommentsClose CommentsPermalink





‘(C) the implementation of activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage; andCommentsClose CommentsPermalink





‘(D) the implementation of wellness and health promotion activities.CommentsClose CommentsPermalink





‘(2) GUIDELINES- The Secretary, in consultation with experts in health care quality and stakeholders, shall develop guidelines concerning the matters described in paragraph (1).CommentsClose CommentsPermalink





‘(3) REQUIREMENTS- The guidelines developed under paragraph (2) shall require the periodic reporting to the applicable Gateway of the activities that a qualified health plan has conducted to implement a strategy described in paragraph (1).CommentsClose CommentsPermalink





‘(o) No Interference With State Regulatory Authority- Nothing in this title shall be construed to preempt any State law that does not prevent the application of the provisions of this title.CommentsClose CommentsPermalink





‘(p) Quality Improvement-CommentsClose CommentsPermalink





‘(1) ENHANCING PATIENT SAFETY- Beginning on January 1, 2012 a qualified health plan may contract with--CommentsClose CommentsPermalink





‘(A) a hospital with greater than 50 beds only if such hospital--CommentsClose CommentsPermalink





‘(i) utilizes a patient safety evaluation system as described in part C of title IX; andCommentsClose CommentsPermalink





‘(ii) implements a mechanism to ensure that each patient receives a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional; orCommentsClose CommentsPermalink





‘(B) a health care provider if such provider implements such mechanisms to improve health care quality as the Secretary may by regulation require.CommentsClose CommentsPermalink





‘(2) EXCEPTIONS- The Secretary may establish reasonable exceptions to the requirements described in paragraph (1).CommentsClose CommentsPermalink





‘(3) ADJUSTMENT- The Secretary may by regulation adjust the number of beds described in paragraph (1)(A).CommentsClose CommentsPermalink





‘(q) Continued Applicability of Mental Health Parity- Section 2716 shall apply to qualified health plans in the same manner and to the same extent as such section applies to health insurance issuers and group health plans.CommentsClose CommentsPermalink





‘(r) Promotion of Informed Choice of Health Insurance Coverage-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall develop standards for use by health insurance issuers offering health insurance coverage through the Gateway in the individual or group market in compiling and providing to enrollees a summary of benefits explanation that accurately represents the benefits and coverage provided by the issuer under each of its applicable health insurance products. In developing such standards, the Secretary shall consult with the National Association of Insurance Commissioners, a working group composed of representatives of health insurance-related consumer advocacy organizations, health insurance issuers, health care professionals, patient advocates including those representing individuals with limited English proficiency, and other qualified individuals.CommentsClose CommentsPermalink





‘(2) REQUIREMENTS- The standards for the summary of benefits explanation developed under paragraph (1) shall provide for the following:CommentsClose CommentsPermalink





‘(A) APPEARANCE- The standards shall ensure that the summary is presented in a uniform format.CommentsClose CommentsPermalink





‘(B) LANGUAGE- The standards shall ensure that the language used in the summary is presented in a manner determined to be understandable by the average health plan enrollee.CommentsClose CommentsPermalink





‘(C) CONTENTS- The standards shall ensure that the summary includes the following:CommentsClose CommentsPermalink





‘(i) Information determined to be essential to a consumer’s understanding of the applicable health insurance plan benefits.CommentsClose CommentsPermalink





‘(ii) Uniform definitions of standard insurance terms including premium, deductible, co-insurance, co-payment, out-of-pocket limit, preferred provider, non-preferred provider, out-of-network co-payments, usual, customary and reasonable fees, excluded services, grievance and appeals, prior authorization, precertification, and such other terms as determined by the Secretary so that consumers may compare health insurance coverage and understand the terms of coverage.CommentsClose CommentsPermalink





‘(iii) Uniform definitions of medical terms including hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage, durable medical equipment, home health care, skilled nursing care, rehabilitation services, hospice services, emergency medical transportation, and such other terms as determined by the Secretary so that consumers may compare the medical benefits and understand the extent of those medical benefits (or exceptions to those benefits).CommentsClose CommentsPermalink





‘(iv) A statement of whether the plan meets minimum qualifying coverage (when effective under section 3103.)CommentsClose CommentsPermalink





‘(v) Examples to illustrate common benefits scenarios, including scenarios that illustrate the health care needs of pregnancy and of at least several serious or chronic medical conditions.CommentsClose CommentsPermalink





‘(vi) Illustrations that enhance consumer understanding of the explanation.CommentsClose CommentsPermalink





‘(3) REQUIREMENT TO PROVIDE- Not later than 12 months after the Secretary develops standards under paragraph (1), each health insurance issuer offering health insurance coverage through the Gateway shall, prior to any enrollment restriction, provide annually to enrollees and potential enrollees a summary of benefits explanation pursuant to the standards developed by the Secretary under paragraph (1)CommentsClose CommentsPermalink





‘(4) PREEMPTION- The standards developed under paragraph (1) shall preempt any related State standards that require summary of benefits health plan explanations that provide less information to consumers, as determined by the Secretary.CommentsClose CommentsPermalink





‘(5) FAILURE TO PROVIDE- A health insurance issuer that willfully fails to provide the information required under this subsection shall be subject to a fine of not more than $1,000 for each such failure. Such failure with respect to each enrollee shall constitute a separate offense for purposes of this paragraph.CommentsClose CommentsPermalink





‘(6) APPLICATION- The provisions of this subsection shall apply to health insurance coverage offered through the Gateway. The Secretary shall evaluate the impact on consumers of expanding the application of the provisions of this subsection to additional health insurance issuers.CommentsClose CommentsPermalink





‘(s) Disclosure of Information-CommentsClose CommentsPermalink





‘(1) IN GENERAL- In connection with the offering of any health insurance coverage in the individual or group market through a Gateway, a health insurance issuer--CommentsClose CommentsPermalink





‘(A) shall disclose to such individual or employer as part of its solicitation and sales materials, the information described in paragraph (2);CommentsClose CommentsPermalink





‘(B) shall disclose to such individual or employer enrolled in such plan any change and an explanation of such change with respect to the information described in paragraph (2) with reasonable and timely advance notice with respect to such change;CommentsClose CommentsPermalink





‘(C) upon the request of such individual or employer, shall provide the information described in paragraph (2); andCommentsClose CommentsPermalink





‘(D) shall disclose such information as the Secretary may require in order to ensure compliance with consumer protection provisions under this title.CommentsClose CommentsPermalink





‘(2) INFORMATION DESCRIBED-CommentsClose CommentsPermalink





‘(A) IN GENERAL- Subject to subparagraph (C), with respect to a health insurance issuer offering health insurance coverage in the individual or group market through a Gateway, information disclosed under this paragraph shall include--CommentsClose CommentsPermalink





‘(i) the provisions of such coverage concerning the issuer’s right to change premium rates, co-payments, in- and out-of-provider networks, or any other information as determined by the Secretary; andCommentsClose CommentsPermalink





‘(ii) the benefits and premiums available under all health insurance coverage for which an individual or employers is qualified.CommentsClose CommentsPermalink





‘(B) FORM OF INFORMATION- Information shall be provided under this paragraph in a manner determined to be understandable by the average employer or individual and shall be sufficient to reasonably inform such employer or individual of their rights and obligations under the health insurance coverage involved.CommentsClose CommentsPermalink





‘(C) EXCEPTION- Information described under this paragraph shall not include information that is proprietary or trade secret information.CommentsClose CommentsPermalink