I 111TH CONGRESS 1ST SESSION H. R. 3200 To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes. INTHEHOUSEOFREPRESENTATIVES JULY 14, 2009 Mr.DINGELL (forhimself,Mr.RANGEL,Mr.WAXMAN,Mr.GEORGE MILLER ofCalifornia,Mr.STARK,Mr.PALLONE,andMr.ANDREWS)introduced thefollowingbill;whichwasreferredtotheCommitteeonEnergyand Commerce,andinadditiontotheCommitteesonWaysandMeans,Edu-cationandLabor,OversightandGovernmentReform,andtheBudget, foraperiodtobesubsequentlydeterminedbytheSpeaker,ineachcase forconsiderationofsuchprovisionsasfallwithinthejurisdictionofthe committee concerned ABILL Toprovideaffordable,qualityhealthcareforallAmericans andreducethegrowthinhealthcarespending,and for other purposes. BeitenactedbytheSenateandHouseofRepresenta- 1tives of the United States of America in Congress assembled,2SECTION1.SHORTTITLE;TABLEOFDIVISIONS,TITLES,3AND SUBTITLES.4(a)SHORT TITLE.ThisActmaybecitedasthe5Americas Affordable Health Choices Act of 2009.6VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS2 HR3200IH(b)TABLE OF DIVISIONS,TITLES,AND SUB- 1TITLES.ThisActisdividedintodivisions,titles,and2subtitles as follows:3DIVISIONAAFFORDABLEHEALTHCARECHOICES TITLEIPROTECTIONSANDSTANDARDSFORQUALIFIED HEALTHBENEFITSPLANS SubtitleAGeneralStandards SubtitleBStandardsGuaranteeingAccesstoAffordableCoverage SubtitleCStandardsGuaranteeingAccesstoEssentialBenefits SubtitleDAdditionalConsumerProtections SubtitleEGovernance SubtitleFRelationtoOtherRequirements;Miscellaneous SubtitleGEarlyInvestments TITLEIIHEALTHINSURANCEEXCHANGEANDRELATED PROVISIONS SubtitleAHealthInsuranceExchange SubtitleBPublicHealthInsuranceOption SubtitleCIndividualAffordabilityCredits TITLEIIISHAREDRESPONSIBILITY SubtitleAIndividualResponsibility SubtitleBEmployerResponsibility TITLEIVAMENDMENTSTOINTERNALREVENUECODEOF1986 SubtitleASharedResponsibility SubtitleBCreditforSmallBusinessEmployeeHealthCoverageExpenses SubtitleCDisclosuresToCarryOutHealthInsuranceExchangeSubsidies SubtitleDOtherRevenueProvisions DIVISIONBMEDICAREANDMEDICAIDIMPROVEMENTS TITLEIIMPROVINGHEALTHCAREVALUE SubtitleAProvisionsRelatedtoMedicarePartA SubtitleBProvisionsRelatedtoPartB SubtitleCProvisionsRelatedtoMedicarePartsAandB VerDate Nov 24 200802:21 Jul 15, 2009 Jkt 079200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6211 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS3 HR3200IHSubtitleDMedicareAdvantageReforms SubtitleEImprovementstoMedicarePartD SubtitleFMedicareRuralAccessProtections TITLEIIMEDICAREBENEFICIARYIMPROVEMENTS SubtitleAImprovingandSimplifyingFinancialAssistanceforLowIncome MedicareBeneficiaries SubtitleBReducingHealthDisparities SubtitleCMiscellaneousImprovements TITLEIIIPROMOTINGPRIMARYCARE,MENTALHEALTH SERVICES,ANDCOORDINATEDCARE TITLEIVQUALITY SubtitleAComparativeEffectivenessResearch SubtitleBNursingHomeTransparency SubtitleCQualityMeasurements SubtitleDPhysicianPaymentsSunshineProvision SubtitleEPublicReportingonHealthCare-AssociatedInfections TITLEVMEDICAREGRADUATEMEDICALEDUCATION TITLEVIPROGRAMINTEGRITY SubtitleAIncreasedFundingToFightWaste,Fraud,andAbuse SubtitleBEnhancedPenaltiesforFraudandAbuse SubtitleCEnhancedProgramandProviderProtections SubtitleDAccesstoInformationNeededToPreventFraud,Waste,and Abuse TITLEVIIMEDICAIDANDCHIP SubtitleAMedicaidandHealthReform SubtitleBPrevention SubtitleCAccess SubtitleDCoverage SubtitleEFinancing SubtitleFWaste,Fraud,andAbuse SubtitleGPuertoRicoandtheTerritories SubtitleHMiscellaneous VerDate Nov 24 200802:21 Jul 15, 2009 Jkt 079200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6211 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS4 HR3200IHTITLEVIIIREVENUE-RELATEDPROVISIONS TITLEIXMISCELLANEOUSPROVISIONS DIVISIONCPUBLICHEALTHANDWORKFORCEDEVELOPMENT TITLEICOMMUNITYHEALTHCENTERS TITLEIIWORKFORCE SubtitleAPrimaryCareWorkforce SubtitleBNursingWorkforce SubtitleCPublicHealthWorkforce SubtitleDAdaptingWorkforcetoEvolvingHealthSystemNeeds TITLEIIIPREVENTIONANDWELLNESS TITLEIVQUALITYANDSURVEILLANCE TITLEVOTHERPROVISIONS SubtitleADrugDiscountforRuralandOtherHospitals SubtitleBSchool-BasedHealthClinics SubtitleCNationalMedicalDeviceRegistry SubtitleDGrantsforComprehensiveProgramsToProvideEducationto NursesandCreateaPipelinetoNursing SubtitleEStatesFailingToAdheretoCertainEmploymentObligations DIVISION AAFFORDABLE1HEALTH CARE CHOICES2SEC.100.PURPOSE;TABLEOFCONTENTSOFDIVISION;3GENERAL DEFINITIONS.4(a) PURPOSE.5(1)IN GENERAL.Thepurposeofthisdivision6istoprovideaffordable,qualityhealthcareforall7Americansandreducethegrowthinhealthcare8spending.9(2)BUILDING ON CURRENT SYSTEM.Thisdi- 10visionachievesthispurposebybuildingonwhat11VerDate Nov 24 200802:21 Jul 15, 2009 Jkt 079200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS5 HR3200IHworksintodayshealthcaresystem,whilerepairing1the aspects that are broken.2(3) INSURANCE REFORMS.This division3(A)enactsstronginsurancemarketre- 4forms;5(B)createsanewHealthInsuranceEx- 6change,withapublichealthinsuranceoption7alongside private plans;8(C)includesslidingscaleaffordability9credits; and10(D)initiatessharedresponsibilityamong11workers, employers, and the government;12sothatallAmericanshavecoverageofessential13health benefits.14(4)HEALTH DELIVERY REFORM.Thisdivision15instituteshealthdeliverysystemreformsbothtoin- 16creasequalityandtoreducegrowthinhealthspend- 17ingsothathealthcarebecomesmoreaffordablefor18businesses, families, and government.19(b)TABLE OF CONTENTS OF DIVISION.Thetable20of contents of this division is as follows:21Sec. 100. Purpose; table of contents of division; general definitions. TITLEIPROTECTIONSANDSTANDARDSFORQUALIFIED HEALTHBENEFITSPLANS SubtitleAGeneralStandards Sec. 101. Requirements reforming health insurance marketplace. Sec. 102. Protecting the choice to keep current coverage. VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6211 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS6 HR3200IHSubtitleBStandardsGuaranteeingAccesstoAffordableCoverage Sec. 111. Prohibiting pre-existing condition exclusions. Sec. 112. Guaranteed issue and renewal for insured plans. Sec. 113. Insurance rating rules. Sec. 114. Nondiscriminationinbenefits;parityinmentalhealthandsubstance abuse disorder benefits. Sec. 115. Ensuring adequacy of provider networks. Sec. 116. Ensuring value and lower premiums. SubtitleCStandardsGuaranteeingAccesstoEssentialBenefits Sec. 121. Coverage of essential benefits package. Sec. 122. Essential benefits package defined. Sec. 123. Health Benefits Advisory Committee. Sec. 124. Processforadoptionofrecommendations;adoptionofbenefitstand-ards. SubtitleDAdditionalConsumerProtections Sec. 131. Requiring fair marketing practices by health insurers. Sec. 132. Requiring fair grievance and appeals mechanisms. Sec. 133. Requiring information transparency and plan disclosure. Sec. 134. Applicationtoqualifiedhealthbenefitsplansnotofferedthroughthe Health Insurance Exchange. Sec. 135. Timely payment of claims. Sec. 136. Standardized rules for coordination and subrogation of benefits. Sec. 137. Application of administrative simplification. SubtitleEGovernance Sec. 141. Health Choices Administration; Health Choices Commissioner. Sec. 142. Duties and authority of Commissioner. Sec. 143. Consultation and coordination. Sec. 144. Health Insurance Ombudsman. SubtitleFRelationtoOtherRequirements;Miscellaneous Sec. 151. Relation to other requirements. Sec. 152. Prohibiting discrimination in health care. Sec. 153. Whistleblower protection. Sec. 154. Construction regarding collective bargaining. Sec. 155. Severability. SubtitleGEarlyInvestments Sec. 161. Ensuring value and lower premiums. Sec. 162. Ending health insurance rescission abuse. Sec. 163. Administrative simplification. Sec. 164. Reinsurance program for retirees. TITLEIIHEALTHINSURANCEEXCHANGEANDRELATED PROVISIONS SubtitleAHealthInsuranceExchange Sec. 201. EstablishmentofHealthInsuranceExchange;outlineofduties;defi-nitions. VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6211 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS7 HR3200IHSec. 202. Exchange-eligible individuals and employers. Sec. 203. Benefits package levels. Sec. 204. ContractsfortheofferingofExchange-participatinghealthbenefits plans. Sec. 205. OutreachandenrollmentofExchange-eligibleindividualsandemploy-ers in Exchange-participating health benefits plan. Sec. 206. Other functions. Sec. 207. Health Insurance Exchange Trust Fund. Sec. 208. Optional operation of State-based health insurance exchanges. SubtitleBPublicHealthInsuranceOption Sec. 221. Establishmentandadministrationofapublichealthinsuranceoption as an Exchange-qualified health benefits plan. Sec. 222. Premiums and financing. Sec. 223. Payment rates for items and services. Sec. 224. Modernized payment initiatives and delivery system reform. Sec. 225. Provider participation. Sec. 226. Application of fraud and abuse provisions. SubtitleCIndividualAffordabilityCredits Sec. 241. Availability through Health Insurance Exchange. Sec. 242. Affordable credit eligible individual. Sec. 243. Affordable premium credit. Sec. 244. Affordability cost-sharing credit. Sec. 245. Income determinations. Sec. 246. No Federal payment for undocumented aliens. TITLEIIISHAREDRESPONSIBILITY SubtitleAIndividualResponsibility Sec. 301. Individual responsibility. SubtitleBEmployerResponsibility PART 1HEALTH COVERAGE PARTICIPATION REQUIREMENTS Sec. 311. Health coverage participation requirements. Sec. 312. Employerresponsibilitytocontributetowardsemployeeanddepend-ent coverage. Sec. 313. Employer contributions in lieu of coverage. Sec. 314. Authority related to improper steering. PART 2SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS Sec. 321. Satisfactionofhealthcoverageparticipationrequirementsunderthe Employee Retirement Income Security Act of 1974. Sec. 322. Satisfactionofhealthcoverageparticipationrequirementsunderthe Internal Revenue Code of 1986. Sec. 323. Satisfactionofhealthcoverageparticipationrequirementsunderthe Public Health Service Act. Sec. 324. Additionalrulesrelatingtohealthcoverageparticipationrequire-ments. TITLEIVAMENDMENTSTOINTERNALREVENUECODEOF1986 VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6211 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS8 HR3200IHSubtitleASharedResponsibility PART 1INDIVIDUAL RESPONSIBILITY Sec. 401. Tax on individuals without acceptable health care coverage. PART 2EMPLOYER RESPONSIBILITY Sec. 411. Election to satisfy health coverage participation requirements. Sec. 412. Responsibilities of nonelecting employers. SubtitleBCreditforSmallBusinessEmployeeHealthCoverageExpenses Sec. 421. Credit for small business employee health coverage expenses. SubtitleCDisclosuresToCarryOutHealthInsuranceExchangeSubsidies Sec. 431. Disclosures to carry out health insurance exchange subsidies. SubtitleDOtherRevenueProvisions PART 1GENERAL PROVISIONS Sec. 441. Surcharge on high income individuals. Sec. 442. Delay in application of worldwide allocation of interest. PART 2PREVENTION OF TAX AVOIDANCE Sec. 451. Limitation on treaty benefits for certain deductible payments. Sec. 452. Codification of economic substance doctrine. Sec. 453. Penalties for underpayments. (c)GENERAL DEFINITIONS.Exceptasotherwise1provided, in this division:2(1)ACCEPTABLE COVERAGE.Thetermac- 3ceptablecoveragehasthemeaninggivensuchterm4in section 202(d)(2).5(2)BASIC PLAN.Thetermbasicplanhas6the meaning given such term in section 203(c).7(3)COMMISSIONER.ThetermCommis- 8sionermeanstheHealthChoicesCommissioneres- 9tablished under section 141.10(4)COST-SHARING.Thetermcost-sharing11includesdeductibles,coinsurance,copayments,and12VerDate Nov 24 200802:21 Jul 15, 2009 Jkt 079200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS9 HR3200IHsimilarchargesbutdoesnotincludepremiumsor1anynetworkpaymentdifferentialforcoveredserv- 2ices or spending for non-covered services.3(5)DEPENDENT.Thetermdependenthas4themeaninggivensuchtermbytheCommissioner5and includes a spouse.6(6)EMPLOYMENT-BASED HEALTH PLAN.The7term employment-based health plan8(A)meansagrouphealthplan(asdefined9insection733(a)(1)oftheEmployeeRetire- 10ment Income Security Act of 1974); and11(B)includessuchaplanthatisthefol- 12lowing:13(i)FEDERAL,STATE,AND TRIBAL14GOVERNMENTAL PLANS.Agovernmental15plan(asdefinedinsection3(32)ofthe16EmployeeRetirementIncomeSecurityAct17of1974),includingahealthbenefitsplan18offeredunderchapter89oftitle5,United19States Code.20(ii)CHURCH PLANS.Achurchplan21(asdefinedinsection3(33)oftheEm- 22ployeeRetirementIncomeSecurityActof231974).24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS10 HR3200IH(7)ENHANCED PLAN.Thetermenhanced1planhasthemeaninggivensuchterminsection2203(c).3(8)ESSENTIAL BENEFITS PACKAGE.Theterm4essentialbenefitspackageisdefinedinsection5122(a).6(9)FAMILY.Thetermfamilymeansanin- 7dividual and includes the individuals dependents.8(10)FEDERAL POVERTY LEVEL;FPL.The9termsFederalpovertylevelandFPLhavethe10meaninggiventhetermpovertylineinsection11673(2)oftheCommunityServicesBlockGrantAct12(42U.S.C.9902(2)),includinganyrevisionrequired13by such section.14(11)HEALTH BENEFITS PLAN.Theterms15healthbenefitsplanmeanshealthinsurancecov- 16erageandanemployment-basedhealthplanandin- 17cludes the public health insurance option.18(12)HEALTH INSURANCE COVERAGE;HEALTH19INSURANCE ISSUER.Thetermshealthinsurance20coverageandhealthinsuranceissuerhavethe21meaningsgivensuchtermsinsection2791ofthe22Public Health Service Act.23(13)HEALTH INSURANCE EXCHANGE.The24termHealthInsuranceExchangemeansthe25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS11 HR3200IHHealthInsuranceExchangeestablishedundersec- 1tion 201.2(14)MEDICAID.ThetermMedicaidmeans3aStateplanundertitleXIXoftheSocialSecurity4Act(whetherornottheplanisoperatingundera5waiver under section 1115 of such Act).6(15)MEDICARE.ThetermMedicaremeans7thehealthinsuranceprogramsundertitleXVIIIof8the Social Security Act.9(16)PLAN SPONSOR.Thetermplanspon- 10sorhasthemeaninggivensuchterminsection113(16)(B)oftheEmployeeRetirementIncomeSecu- 12rity Act of 1974.13(17)PLAN YEAR.Thetermplanyear14means15(A)withrespecttoanemployment-based16healthplan,aplanyearasspecifiedundersuch17plan; or18(B)withrespecttoahealthbenefitsplan19otherthananemployment-basedhealthplan,a2012-monthperiodasspecifiedbytheCommis- 21sioner.22(18)PREMIUM PLAN;PREMIUM-PLUS PLAN.23Thetermspremiumplanandpremium-plus24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS12 HR3200IHplanhavethemeaningsgivensuchtermsinsection1203(c).2(19)QHBPOFFERING ENTITY.Theterms3QHBPofferingentitymeans,withrespecttoa4health benefits plan that is5(A)agrouphealthplan(asdefined,sub- 6jecttosubsection(d),insection733(a)(1)of7theEmployeeRetirementIncomeSecurityAct8of1974),theplansponsorinrelationtosuch9grouphealthplan,exceptthat,inthecaseofa10planmaintainedjointlyby1ormoreemployers11and1ormoreemployeeorganizationsandwith12respecttowhichanemployeristheprimary13sourceoffinancing,suchtermmeanssuchem- 14ployer;15(B)healthinsurancecoverage,thehealth16insurance issuer offering the coverage;17(C)thepublichealthinsuranceoption,the18Secretary of Health and Human Services;19(D)anon-Federalgovernmentalplan(as20definedinsection2791(d)ofthePublicHealth21ServiceAct),theStateorpoliticalsubdivision22ofaState(oragencyorinstrumentalityofsuch23Stateorsubdivision)whichestablishesormain- 24tains such plan; or25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS13 HR3200IH(E)aFederalgovernmentalplan(asde- 1finedinsection2791(d)ofthePublicHealth2Service Act), the appropriate Federal official.3(20)QUALIFIED HEALTH BENEFITS PLAN.4Thetermqualifiedhealthbenefitsplanmeansa5healthbenefitsplanthatmeetstherequirementsfor6suchaplanundertitleIandincludesthepublic7health insurance option.8(21)PUBLIC HEALTH INSURANCE OPTION.9Thetermpublichealthinsuranceoptionmeans10thepublichealthinsuranceoptionasprovidedunder11subtitle B of title II.12(22)SERVICE AREA;PREMIUM RATING AREA.13Thetermsserviceareaandpremiumrating14areameanwithrespecttohealthinsurancecov- 15erage16(A)offeredotherthanthroughtheHealth17InsuranceExchange,suchanareaasestab- 18lishedbytheQHBPofferingentityofsuchcov- 19erageinaccordancewithapplicableStatelaw;20and21(B)offeredthroughtheHealthInsurance22Exchange,suchanareaasestablishedbysuch23entityinaccordancewithapplicableStatelaw24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS14 HR3200IHandapplicablerulesoftheCommissionerfor1Exchange-participating health benefits plans.2(23)STATE.ThetermStatemeansthe503States and the District of Columbia.4(24)STATE MEDICAID AGENCY.Theterm5StateMedicaidagencymeans,withrespecttoa6Medicaidplan,thesingleStateagencyresponsible7foradministeringsuchplanundertitleXIXofthe8Social Security Act.9(25)Y1,Y2,ETC.ThetermsY1,Y2,10Y3,Y4,Y5,andsimilarsubsequentlynum- 11beredterms,mean2013andsubsequentyears,re- 12spectively.13TITLEIPROTECTIONSAND14STANDARDSFORQUALIFIED15HEALTH BENEFITS PLANS16Subtitle AGeneral Standards17SEC.101.REQUIREMENTSREFORMINGHEALTHINSUR- 18ANCE MARKETPLACE.19(a)PURPOSE.Thepurposeofthistitleistoestab- 20lishstandardstoensurethatnewhealthinsurancecov- 21erage and employment-based health plans that are offered22meetstandardsguaranteeingaccesstoaffordablecov- 23erage,essentialbenefits,andotherconsumerprotections.24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS15 HR3200IH(b) REQUIREMENTS FOR QUALIFIED HEALTH BENE- 1FITS PLANS.OnorafterthefirstdayofY1,ahealth2benefitsplanshallnotbeaqualifiedhealthbenefitsplan3underthisdivisionunlesstheplanmeetstheapplicable4requirements of the following subtitles for the type of plan5and plan year involved:6(1)SubtitleB(relatingtoaffordablecoverage).7(2) Subtitle C (relating to essential benefits).8(3)SubtitleD(relatingtoconsumerprotec- 9tion).10(c) TERMINOLOGY.In this division:11(1)ENROLLMENT IN EMPLOYMENT-BASED12HEALTH PLANS.Anindividualshallbetreatedas13beingenrolledinanemployment-basedhealth14planiftheindividualisaparticipantorbeneficiary15(assuchtermsaredefinedinsection3(7)and3(8),16respectively,oftheEmployeeRetirementIncomeSe- 17curity Act of 1974) in such plan.18(2)INDIVIDUAL AND GROUP HEALTH INSUR- 19ANCE COVERAGE.Thetermsindividualhealthin- 20surancecoverageandgrouphealthinsurancecov- 21eragemeanhealthinsurancecoverageofferedin22theindividualmarketorlargeorsmallgroupmar- 23ket,respectively,asdefinedinsection2791ofthe24Public Health Service Act.25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS16 HR3200IHSEC.102.PROTECTINGTHECHOICETOKEEPCURRENT1COVERAGE.2(a)GRANDFATHERED HEALTH INSURANCE COV- 3ERAGE DEFINED.Subject to the succeeding provisions of4thissection,forpurposesofestablishingacceptablecov- 5erageunderthisdivision,thetermgrandfatheredhealth6insurancecoveragemeansindividualhealthinsurance7coveragethatisofferedandinforceandeffectbeforethe8first day of Y1 if the following conditions are met:9(1) LIMITATION ON NEW ENROLLMENT.10(A)IN GENERAL.Exceptasprovidedin11thisparagraph,theindividualhealthinsurance12issuerofferingsuchcoveragedoesnotenroll13anyindividualinsuchcoverageifthefirstef- 14fectivedateofcoverageisonorafterthefirst15day of Y1.16(B)DEPENDENT COVERAGE PER- 17MITTED.Subparagraph(A)shallnotaffect18thesubsequentenrollmentofadependentofan19individualwhoiscoveredasofsuchfirstday.20(2)LIMITATION ON CHANGES IN TERMS OR21CONDITIONS.Subjecttoparagraph(3)andexcept22asrequiredbylaw,theissuerdoesnotchangeany23ofitstermsorconditions,includingbenefitsand24cost-sharing,fromthoseineffectasofthedaybe- 25fore the first day of Y1.26VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS17 HR3200IH(3)RESTRICTIONS ON PREMIUM INCREASES.1Theissuercannotvarythepercentageincreasein2thepremiumforariskgroupofenrolleesinspecific3grandfatheredhealthinsurancecoveragewithout4changingthepremiumforallenrolleesinthesame5riskgroupatthesamerate,asspecifiedbythe6Commissioner.7(b)GRACE PERIOD FOR CURRENT EMPLOYMENT-8BASED HEALTH PLANS.9(1) GRACE PERIOD.10(A)IN GENERAL.TheCommissioner11shallestablishagraceperiodwhereby,forplan12yearsbeginningaftertheendofthe5-yearpe- 13riodbeginningwithY1,anemployment-based14healthplaninoperationasofthedaybefore15thefirstdayofY1mustmeetthesamerequire- 16mentsasapplytoaqualifiedhealthbenefits17planundersection101,includingtheessential18benefitpackagerequirementundersection121.19(B)EXCEPTION FOR LIMITED BENEFITS20PLANS.Subparagraph(A)shallnotapplyto21anemployment-basedhealthplaninwhichthe22coverageconsistsonlyofoneormoreofthefol- 23lowing:24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00017 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS18 HR3200IH(i)Anycoveragedescribedinsection13001(a)(1)(B)(ii)(IV)ofdivisionBofthe2AmericanRecoveryandReinvestmentAct3of 2009 (Public Law 1115).4(ii)Exceptedbenefits(asdefinedin5section733(c)oftheEmployeeRetirement6IncomeSecurityActof1974),including7coverageunderaspecifieddiseaseorill- 8nesspolicydescribedinparagraph(3)(A)9of such section.10(iii)Suchotherlimitedbenefitsasthe11Commissioner may specify.12Innocaseshallanemployment-basedhealth13planinwhichthecoverageconsistsonlyofone14ormoreofthecoverageorbenefitsdescribedin15clauses(i)through(iii)betreatedasacceptable16coverage under this division17(2)TRANSITIONAL TREATMENT AS ACCEPT- 18ABLE COVERAGE.Duringthegraceperiodspecified19inparagraph(1)(A),anemployment-basedhealth20planthatisdescribedinsuchparagraphshallbe21treated as acceptable coverage under this division.22(c) LIMITATION ON INDIVIDUAL HEALTH INSURANCE23COVERAGE.24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00018 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS19 HR3200IH(1)IN GENERAL.Individualhealthinsurance1coveragethatisnotgrandfatheredhealthinsurance2coverageundersubsection(a)mayonlybeoffered3onorafterthefirstdayofY1asanExchange-par- 4ticipating health benefits plan.5(2)SEPARATE,EXCEPTED COVERAGE PER- 6MITTED.Exceptedbenefits(asdefinedinsection72791(c)ofthePublicHealthServiceAct)arenot8includedwithinthedefinitionofhealthinsurance9coverage.Nothinginparagraph(1)shallpreventthe10offering,otherthanthroughtheHealthInsurance11Exchange,ofexceptedbenefitssolongasitisof- 12feredandpricedseparatelyfromhealthinsurance13coverage.14SubtitleBStandardsGuaran- 15teeingAccesstoAffordableCov- 16erage17SEC.111.PROHIBITINGPRE-EXISTINGCONDITIONEXCLU- 18SIONS.19Aqualifiedhealthbenefitsplanmaynotimposeany20pre-existingconditionexclusion(asdefinedinsection212701(b)(1)(A) of the Public Health Service Act) or other- 22wiseimposeanylimitorconditiononthecoverageunder23theplanwithrespecttoanindividualordependentbased24onanyhealthstatus-relatedfactors(asdefinedinsection25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00019 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS20 HR3200IH2791(d)(9)ofthePublicHealthServiceAct)inrelation1to the individual or dependent.2SEC.112.GUARANTEEDISSUEANDRENEWALFORIN- 3SURED PLANS.4Therequirementsofsections2711(otherthansub- 5sections (c) and (e)) and 2712 (other than paragraphs (3),6and (6) of subsection (b) and subsection (e)) of the Public7Health Service Act, relating to guaranteed availability and8renewabilityofhealthinsurancecoverage,shallapplyto9individualsandemployersinallindividualandgroup10healthinsurancecoverage,whetherofferedtoindividuals11oremployersthroughtheHealthInsuranceExchange,12throughanyemployment-basedhealthplan,orotherwise,13inthesamemannerassuchsectionsapplytoemployers14andhealthinsurancecoverageofferedinthesmallgroup15market,exceptthatsuchsection2712(b)(1)shallapply16onlyif,beforenonrenewalordiscontinuationofcoverage,17theissuerhasprovidedtheenrolleewithnoticeofnon-18paymentofpremiumsandthereisagraceperiodduring19whichtheenrolleeshasanopportunitytocorrectsuch20nonpayment. Rescissions of such coverage shall be prohib- 21itedexceptincasesoffraudasdefinedinsections222712(b)(2) of such Act.23VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00020 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS21 HR3200IHSEC. 113. INSURANCE RATING RULES.1(a) IN GENERAL.The premium rate charged for an2insured qualified health benefits plan may not vary except3as follows:4(1)LIMITED AGE VARIATION PERMITTED.By5age(withinsuchagecategoriesastheCommissioner6shallspecify)solongastheratioofthehighestsuch7premiumtothelowestsuchpremiumdoesnotex- 8ceed the ratio of 2 to 1.9(2)BY AREA.Bypremiumratingarea(as10permittedbyStateinsuranceregulatorsor,inthe11caseofExchange-participatinghealthbenefitsplans,12asspecifiedbytheCommissionerinconsultation13with such regulators).14(3)BY FAMILY ENROLLMENT.Byfamilyen- 15rollment(suchasvariationswithincategoriesand16compositionsoffamilies)solongastheratioofthe17premiumforfamilyenrollment(orenrollments)to18thepremiumforindividualenrollmentisuniform,as19specifiedunderStatelawandconsistentwithrules20of the Commissioner.21(b) STUDY AND REPORTS.22(1)STUDY.TheCommissioner,incoordina- 23tionwiththeSecretaryofHealthandHumanServ- 24icesandtheSecretaryofLabor,shallconducta25studyofthelargegroupinsuredandself-insured26VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00021 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS22 HR3200IHemployerhealthcaremarkets.Suchstudyshallex- 1amine the following:2(A)Thetypesofemployersbykeycharac- 3teristics,includingsize,thatpurchaseinsured4products versus those that self-insure.5(B)Thesimilaritiesanddifferencesbe- 6tweentypicalinsuredandself-insuredhealth7plans.8(C)Thefinancialsolvencyandcapitalre- 9servelevelsofemployersthatself-insurebyem- 10ployer size.11(D)Theriskofself-insuredemployersnot12beingabletopayobligationsorotherwisebe- 13coming financially insolvent.14(E)Theextenttowhichratingrulesare15likelytocauseadverseselectioninthelarge16groupmarketortoencouragesmallandmid17size employers to self-insure18(2)REPORTS.Notlaterthan18monthsafter19thedateoftheenactmentofthisAct,theCommis- 20sionershallsubmittoCongressandtheapplicable21agenciesareportonthestudyconductedunder22paragraph(1).Suchreportshallincludeanyrec- 23ommendationstheCommissionerdeemsappropriate24toensurethatthelawdoesnotprovideincentives25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00022 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS23 HR3200IHforsmallandmid-sizeemployerstoself-insureor1createadverseselectionintheriskpoolsoflarge2groupinsurersandself-insuredemployers.Notlater3than18monthsafterthefirstdayofY1,theCom- 4missionershallsubmittoCongressandtheapplica- 5bleagenciesanupdatedreportonsuchstudy,in- 6cluding updates on such recommendations.7SEC.114.NONDISCRIMINATIONINBENEFITS;PARITYIN8MENTALHEALTHANDSUBSTANCEABUSE9DISORDER BENEFITS.10(a)NONDISCRIMINATION IN BENEFITS.Aqualified11healthbenefitsplanshallcomplywithstandardsestab- 12lishedbytheCommissionertoprohibitdiscriminationin13healthbenefitsorbenefitstructuresforqualifyinghealth14benefitsplans,buildingfromsections702ofEmployee15RetirementIncomeSecurityActof1974,2702ofthe16PublicHealthServiceAct,andsection9802oftheInter- 17nal Revenue Code of 1986.18(b)PARITY IN MENTAL HEALTH AND SUBSTANCE19ABUSE DISORDER BENEFITS.Totheextentsuchprovi- 20sionsarenotsupercededbyorinconsistentwithsubtitle21C,theprovisionsofsection2705(otherthansubsections22(a)(1),(a)(2),and(c))ofsection2705ofthePublic23HealthServiceActshallapplytoaqualifiedhealthbene- 24fitsplan,regardlessofwhetheritisofferedintheindi- 25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00023 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS24 HR3200IHvidual or group market, in the same manner as such provi- 1sionsapplytohealthinsurancecoverageofferedinthe2large group market.3SEC.115.ENSURINGADEQUACYOFPROVIDERNETWORKS.4(a)IN GENERAL.Aqualifiedhealthbenefitsplan5thatusesaprovidernetworkforitemsandservicesshall6meetsuchstandardsrespectingprovidernetworksasthe7Commissionermayestablishtoassuretheadequacyof8suchnetworksinensuringenrolleeaccesstosuchitems9and services and transparency in the cost-sharing differen- 10tials between in-network coverage and out-of-network cov- 11erage.12(b)PROVIDER NETWORK DEFINED.Inthisdivi- 13sion,thetermprovidernetworkmeanstheproviders14withrespecttowhichcoveredbenefits,treatments,and15services are available under a health benefits plan.16SEC. 116. ENSURING VALUE AND LOWER PREMIUMS.17(a)IN GENERAL.Aqualifiedhealthbenefitsplan18shallmeetamedicallossratioasdefinedbytheCommis- 19sioner.Foranyplanyearinwhichthequalifiedhealth20benefits plan does not meet such medical loss ratio, QHBP21offeringentityshallprovideinamannerspecifiedbythe22Commissionerforrebatestoenrolleesofpaymentsuffi- 23cient to meet such loss ratio.24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00024 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS25 HR3200IH(b)BUILDING ON INTERIM RULES.Inimple- 1mentingsubsection(a),theCommissionershallbuildon2the definition and methodology developed by the Secretary3ofHealthandHumanServicesundertheamendments4madebysection161fordetermininghowtocalculatethe5medicallossratio.Suchmethodologyshallbesetatthe6highestlevelmedicallossratiopossiblethatisdesigned7toensureadequateparticipationbyQHBPofferingenti- 8ties,competitioninthehealthinsurancemarketinand9out of the Health Insurance Exchange, and value for con- 10sumers so that their premiums are used for services.11SubtitleCStandardsGuaran- 12teeingAccesstoEssentialBene- 13fits14SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE.15(a)IN GENERAL.Aqualifiedhealthbenefitsplan16shallprovidecoveragethatatleastmeetsthebenefit17standards adopted under section 124 for the essential ben- 18efitspackagedescribedinsection122fortheplanyear19involved.20(b) CHOICE OF COVERAGE.21(1)NON-EXCHANGE-PARTICIPATING HEALTH22BENEFITS PLANS.Inthecaseofaqualifiedhealth23benefitsplanthatisnotanExchange-participating24healthbenefitsplan,suchplanmayoffersuchcov- 25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00025 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS26 HR3200IHerageinadditiontotheessentialbenefitspackageas1the QHBP offering entity may specify.2(2)EXCHANGE-PARTICIPATING HEALTH BENE- 3FITS PLANS.InthecaseofanExchange-partici- 4patinghealthbenefitsplan,suchplanisrequired5undersection203toprovidespecifiedlevelsofbene- 6fitsand,inthecaseofaplanofferingapremium-7plus level of benefits, provide additional benefits.8(3)CONTINUATION OF OFFERING OF SEPARATE9EXCEPTED BENEFITS COVERAGE.Nothinginthis10divisionshallbeconstruedasaffectingtheoffering11ofhealthbenefitsintheformofexceptedbenefits12(describedinsection102(b)(1)(B)(ii))ifsuchbene- 13fitsareofferedunderaseparatepolicy,contract,or14certificate of insurance.15(c)NO RESTRICTIONS ON COVERAGE UNRELATED16TO CLINICAL APPROPRIATENESS.A qualified health ben- 17efits plan may not impose any restriction (other than cost-18sharing)unrelatedtoclinicalappropriatenessonthecov- 19erage of the health care items and services.20SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.21(a)IN GENERAL.Inthisdivision,thetermessen- 22tialbenefitspackagemeanshealthbenefitscoverage,23consistentwithstandardsadoptedundersection124to24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00026 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS27 HR3200IHensuretheprovisionofqualityhealthcareandfinancial1security, that2(1)providespaymentfortheitemsandservices3describedinsubsection(b)inaccordancewithgen- 4erallyacceptedstandardsofmedicalorotherappro- 5priate clinical or professional practice;6(2)limitscost-sharingforsuchcoveredhealth7careitemsandservicesinaccordancewithsuchben- 8efit standards, consistent with subsection (c);9(3)doesnotimposeanyannualorlifetimelimit10onthecoverageofcoveredhealthcareitemsand11services;12(4)complieswithsection115(a)(relatingto13network adequacy); and14(5)isequivalent,ascertifiedbyOfficeofthe15ActuaryoftheCentersforMedicare&Medicaid16Services,totheaverageprevailingemployer-spon- 17sored coverage.18(b)MINIMUM SERVICES TO BE COVERED.The19items and services described in this subsection are the fol- 20lowing:21(1) Hospitalization.22(2)Outpatienthospitalandoutpatientclinic23services, including emergency department services.24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00027 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS28 HR3200IH(3) Professional services of physicians and other1health professionals.2(4)Suchservices,equipment,andsuppliesinci- 3denttotheservicesofaphysiciansorahealthpro- 4fessionalsdeliveryofcareininstitutionalsettings,5physicianoffices,patientshomesorplaceofresi- 6dence, or other settings, as appropriate.7(5) Prescription drugs.8(6) Rehabilitative and habilitative services.9(7)Mentalhealthandsubstanceusedisorder10services.11(8)Preventiveservices,includingthoseservices12recommendedwithagradeofAorBbytheTask13ForceonClinicalPreventiveServicesandthosevac- 14cinesrecommendedforusebytheDirectorofthe15Centers for Disease Control and Prevention.16(9) Maternity care.17(10)Wellbabyandwellchildcareandoral18health,vision,andhearingservices,equipment,and19suppliesatleastforchildrenunder21yearsofage.20(c)REQUIREMENTS RELATING TO COST-SHARING21AND MINIMUM ACTUARIAL VALUE.22(1)NO COST-SHARING FOR PREVENTIVE SERV- 23ICES.Thereshallbenocost-sharingunderthees- 24sentialbenefitspackageforpreventiveitemsand25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00028 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS29 HR3200IHservices(asspecifiedunderthebenefitstandards),1including well baby and well child care.2(2) ANNUAL LIMITATION.3(A)ANNUAL LIMITATION.Thecost-shar- 4ingincurredundertheessentialbenefitspack- 5agewithrespecttoanindividual(orfamily)for6ayeardoesnotexceedtheapplicablelevelspec- 7ified in subparagraph (B).8(B)APPLICABLE LEVEL.Theapplicable9levelspecifiedinthissubparagraphforY1is10$5,000foranindividualand$10,000fora11family.Suchlevelsshallbeincreased(rounded12tothenearest$100)foreachsubsequentyear13bytheannualpercentageincreaseintheCon- 14sumerPriceIndex(UnitedStatescityaverage)15applicable to such year.16(C) USE OF COPAYMENTS.In establishing17cost-sharinglevelsforbasic,enhanced,andpre- 18miumplansunderthissubsection,theSec- 19retaryshall,tothemaximumextentpossible,20use only copayments and not coinsurance.21(3) MINIMUM ACTUARIAL VALUE.22(A)IN GENERAL.Thecost-sharingunder23theessentialbenefitspackageshallbedesigned24toprovidealevelofcoveragethatisdesigned25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00029 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS30 HR3200IHtoprovidebenefitsthatareactuariallyequiva- 1lenttoapproximately70percentofthefullac- 2tuarialvalueofthebenefitsprovidedunderthe3referencebenefitspackagedescribedinsub- 4paragraph (B).5(B)REFERENCE BENEFITS PACKAGE DE- 6SCRIBED.Thereferencebenefitspackagede- 7scribedinthissubparagraphistheessential8benefitspackageiftherewerenocost-sharing9imposed.10SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE.11(a) ESTABLISHMENT.12(1)IN GENERAL.Thereisestablishedapri- 13vate-publicadvisorycommitteewhichshallbea14panelofmedicalandotherexpertstobeknownas15theHealthBenefitsAdvisoryCommitteetorec- 16ommendcoveredbenefitsandessential,enhanced,17and premium plans.18(2)CHAIR.TheSurgeonGeneralshallbea19memberandthechairoftheHealthBenefitsAdvi- 20sory Committee.21(3)MEMBERSHIP.TheHealthBenefitsAdvi- 22soryCommitteeshallbecomposedofthefollowing23members, in addition to the Surgeon General:24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00030 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS31 HR3200IH(A)9memberswhoarenotFederalem- 1ployeesorofficersandwhoareappointedby2the President.3(B)9memberswhoarenotFederalem- 4ployeesorofficersandwhoareappointedby5theComptrollerGeneraloftheUnitedStatesin6amannersimilartothemannerinwhichthe7ComptrollerGeneralappointsmemberstothe8MedicarePaymentAdvisoryCommissionunder9section 1805(c) of the Social Security Act.10(C)Suchevennumberofmembers(notto11exceed8)whoareFederalemployeesandoffi- 12cers, as the President may appoint.13Suchinitialappointmentsshallbemadenotlater14than60daysafterthedateoftheenactmentofthis15Act.16(4) TERMS.Each member of the Health Bene- 17fitsAdvisoryCommitteeshallservea3-yeartermon18theCommittee,exceptthatthetermsoftheinitial19membersshallbeadjustedinordertoprovidefora20staggeredtermofappointmentforallsuchmem- 21bers.22(5)PARTICIPATION.Themembershipofthe23HealthBenefitsAdvisoryCommitteeshallatleast24reflectproviders,consumerrepresentatives,employ- 25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00031 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS32 HR3200IHers,labor,healthinsuranceissuers,expertsinhealth1carefinancinganddelivery,expertsinracialand2ethnicdisparities,expertsincareforthosewithdis- 3abilities,representativesofrelevantgovernmental4agencies.andatleastonepracticingphysicianor5otherhealthprofessionalandanexpertonchildrens6healthandshallrepresentabalanceamongvarious7sectorsofthehealthcaresystemsothatnosingle8sectorundulyinfluencestherecommendationsof9such Committee.10(b) DUTIES.11(1)RECOMMENDATIONS ON BENEFIT STAND- 12ARDS.TheHealthBenefitsAdvisoryCommittee13shallrecommendtotheSecretaryofHealthand14HumanServices(inthissubtitlereferredtoasthe15Secretary)benefitstandards(asdefinedinpara- 16graph(4)),andperiodicupdatestosuchstandards.17Indevelopingsuchrecommendations,theCommittee18shalltakeintoaccountinnovationinhealthcareand19consider how such standards could reduce health dis- 20parities.21(2)DEADLINE.TheHealthBenefitsAdvisory22Committeeshallrecommendinitialbenefitstandards23totheSecretarynotlaterthan1yearafterthedate24of the enactment of this Act.25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00032 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS33 HR3200IH(3)PUBLIC INPUT.TheHealthBenefitsAdvi- 1soryCommitteeshallallowforpublicinputasapart2ofdevelopingrecommendationsunderthissub- 3section.4(4)BENEFIT STANDARDS DEFINED.Inthis5subtitle,thetermbenefitstandardsmeansstand- 6ards respecting7(A)theessentialbenefitspackagede- 8scribedinsection122,includingcategoriesof9coveredtreatments,itemsandserviceswithin10benefit classes, and cost-sharing; and11(B)thecost-sharinglevelsforenhanced12plansandpremiumplans(asprovidedunder13section 203(c)) consistent with paragraph (5).14(5)LEVELS OF COST-SHARING FOR ENHANCED15AND PREMIUM PLANS.16(A)ENHANCED PLAN.Thelevelofcost-17sharingforenhancedplansshallbedesignedso18thatsuchplanshavebenefitsthatareactuari- 19allyequivalenttoapproximately85percentof20theactuarialvalueofthebenefitsprovided21underthereferencebenefitspackagedescribed22in section 122(c)(3)(B).23(B)PREMIUM PLAN.Thelevelofcost-24sharingforpremiumplansshallbedesignedso25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00033 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS34 HR3200IHthatsuchplanshavebenefitsthatareactuari- 1allyequivalenttoapproximately95percentof2theactuarialvalueofthebenefitsprovided3underthereferencebenefitspackagedescribed4in section 122(c)(3)(B).5(c) OPERATIONS.6(1)PER DIEM PAY.Eachmemberofthe7HealthBenefitsAdvisoryCommitteeshallreceive8travelexpenses,includingperdieminaccordance9withapplicableprovisionsundersubchapterIof10chapter57oftitle5,UnitedStatesCode,andshall11otherwise serve without additional pay.12(2)MEMBERS NOT TREATED AS FEDERAL EM- 13PLOYEES.MembersoftheHealthBenefitsAdvi- 14soryCommitteeshallnotbeconsideredemployeesof15theFederalgovernmentsolelybyreasonofanyserv- 16ice on the Committee.17(3)APPLICATION OF FACA.TheFederalAdvi- 18soryCommitteeAct(5U.S.C.App.),otherthansec- 19tion14,shallapplytotheHealthBenefitsAdvisory20Committee.21(d)PUBLICATION.TheSecretaryshallprovidefor22publication in the Federal Register and the posting on the23Internet website of the Department of Health and Human24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00034 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS35 HR3200IHServices of all recommendations made by the Health Ben- 1efits Advisory Committee under this section.2SEC.124.PROCESSFORADOPTIONOFRECOMMENDA- 3TIONS; ADOPTION OF BENEFIT STANDARDS.4(a)PROCESS FOR ADOPTION OF RECOMMENDA- 5TIONS.6(1)REVIEW OF RECOMMENDED STANDARDS.7Notlaterthan45daysafterthedateofreceiptof8benefitstandardsrecommendedundersection1239(includingsuchstandardsasmodifiedunderpara- 10graph(2)(B)),theSecretaryshallreviewsuch11standardsandshalldeterminewhethertopropose12adoption of such standards as a package.13(2)DETERMINATION TO ADOPT STANDARDS.14If the Secretary determines15(A)toproposeadoptionofbenefitstand- 16ardssorecommendedasapackage,theSec- 17retaryshall,byregulationundersection553of18title5,UnitedStatesCode,proposeadoption19such standards; or20(B)nottoproposeadoptionofsuchstand- 21ardsasapackage,theSecretaryshallnotify22theHealthBenefitsAdvisoryCommitteein23writingofsuchdeterminationandthereasons24fornotproposingtheadoptionofsuchrec- 25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00035 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS36 HR3200IHommendationandprovidetheCommitteewitha1furtheropportunitytomodifyitspreviousrec- 2ommendationsandsubmitnewrecommenda- 3tions to the Secretary on a timely basis.4(3)CONTINGENCY.If,becauseoftheapplica- 5tionofparagraph(2)(B),theSecretarywouldother- 6wisebeunabletoproposeinitialadoptionofsuch7recommendedstandardsbythedeadlinespecifiedin8subsection(b)(1),theSecretaryshall,byregulation9undersection553oftitle5,UnitedStatesCode,10proposeadoptionofinitialbenefitstandardsbysuch11deadline.12(4)PUBLICATION.TheSecretaryshallprovide13forpublicationintheFederalRegisterofalldeter- 14minationsmadebytheSecretaryunderthissub- 15section.16(b) ADOPTION OF STANDARDS.17(1)INITIAL STANDARDS.Notlaterthan1818monthsafterthedateoftheenactmentofthisAct,19theSecretaryshall,throughtherulemakingprocess20consistentwithsubsection(a),adoptaninitialsetof21benefit standards.22(2)PERIODIC UPDATING STANDARDS.Under23subsection(a),theSecretaryshallprovideforthe24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00036 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS37 HR3200IHperiodicupdatingofthebenefitstandardspreviously1adopted under this section.2(3)REQUIREMENT.TheSecretarymaynot3adoptanybenefitstandardsforanessentialbenefits4packageorforlevelofcost-sharingthatareincon- 5sistentwiththerequirementsforsuchapackageor6level under sections 122 and 123(b)(5).7Subtitle DAdditional Consumer8Protections9SEC.131.REQUIRINGFAIRMARKETINGPRACTICESBY10HEALTH INSURERS.11TheCommissionershallestablishuniformmarketing12standardsthatallinsuredQHBPofferingentitiesshall13meet.14SEC.132.REQUIRINGFAIRGRIEVANCEANDAPPEALS15MECHANISMS.16(a) IN GENERAL.A QHBP offering entity shall pro- 17vide for timely grievance and appeals mechanisms that the18Commissioner shall establish.19(b)INTERNAL CLAIMS AND APPEALS PROCESS.20Under a qualified health benefits plan the QHBP offering21entity shall provide an internal claims and appeals process22thatinitiallyincorporatestheclaimsandappealsproce- 23dures(includingurgentclaims)setforthatsection242560.5031oftitle29,CodeofFederalRegulations,as25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00037 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS38 HR3200IHpublishedonNovember21,2000(65Fed.Reg.70246)1andshallupdatesuchprocessinaccordancewithany2standards that the Commissioner may establish.3(c) EXTERNAL REVIEW PROCESS.4(1)IN GENERAL.TheCommissionershalles- 5tablishanexternalreviewprocess(includingproce- 6duresforexpeditedreviewsofurgentclaims)that7providesforanimpartial,independent,anddenovo8review of denied claims under this division.9(2)REQUIRING FAIR GRIEVANCE AND APPEALS10MECHANISMS.Adeterminationmade,withrespect11toaqualifiedhealthbenefitsplanofferedbya12QHBPofferingentity,undertheexternalreview13processestablishedunderthissubsectionshallbe14binding on the plan and the entity.15(d) CONSTRUCTION.Nothing in this section shall be16construedasaffectingtheavailabilityofjudicialreview17under State law for adverse decisions under subsection (b)18or (c), subject to section 151.19SEC.133.REQUIRINGINFORMATIONTRANSPARENCYAND20PLAN DISCLOSURE.21(a) ACCURATE AND TIMELY DISCLOSURE.22(1)IN GENERAL.Aqualifiedhealthbenefits23planshallcomplywithstandardsestablishedbythe24Commissionerfortheaccurateandtimelydisclosure25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00038 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS39 HR3200IHofplandocuments,plantermsandconditions,1claimspaymentpoliciesandpractices,periodicfi- 2nancialdisclosure,dataonenrollment,dataon3disenrollment,dataonthenumberofclaimsdenials,4dataonratingpractices,informationoncost-sharing5andpaymentswithrespecttoanyout-of-network6coverage,andotherinformationasdeterminedap- 7propriatebytheCommissioner.TheCommissioner8shallrequirethatsuchdisclosurebeprovidedin9plain language.10(2)PLAIN LANGUAGE.Inthissubsection,the11termplainlanguagemeanslanguagethatthein- 12tendedaudience,includingindividualswithlimited13Englishproficiency,canreadilyunderstandanduse14becausethatlanguageisclean,concise,well-orga- 15nized,andfollowsotherbestpracticesofplainlan- 16guage writing.17(3)GUIDANCE.TheCommissionershallde- 18velopandissueguidanceonbestpracticesofplain19language writing.20(b)CONTRACTING REIMBURSEMENT.Aqualified21healthbenefitsplanshallcomplywithstandardsestab- 22lished by the Commissioner to ensure transparency to each23healthcareproviderrelatingtoreimbursementarrange- 24ments between such plan and such provider.25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00039 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS40 HR3200IH(c)ADVANCE NOTICE OF PLAN CHANGES.A1changeinaqualifiedhealthbenefitsplanshallnotbe2madewithoutsuchreasonableandtimelyadvancenotice3to enrollees of such change.4SEC.134.APPLICATIONTOQUALIFIEDHEALTHBENEFITS5PLANSNOTOFFEREDTHROUGHTHE6HEALTH INSURANCE EXCHANGE.7Therequirementsofthepreviousprovisionsofthis8subtitleshallapplytoqualifiedhealthbenefitsplansthat9arenotbeingofferedthroughtheHealthInsuranceEx- 10changeonlytotheextentspecifiedbytheCommissioner.11SEC. 135. TIMELY PAYMENT OF CLAIMS.12AQHBPofferingentityshallcomplywiththere- 13quirementsofsection1857(f)oftheSocialSecurityAct14withrespecttoaqualifiedhealthbenefitsplanitoffers15inthesamemanneranMedicareAdvantageorganization16is required to comply with such requirements with respect17toaMedicareAdvantageplanitoffersunderpartCof18Medicare.19SEC.136.STANDARDIZEDRULESFORCOORDINATIONAND20SUBROGATION OF BENEFITS.21TheCommissionershallestablishstandardsforthe22coordinationandsubrogationofbenefitsandreimburse- 23mentofpaymentsincasesinvolvingindividualsandmul- 24tiple plan coverage.25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00040 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS41 HR3200IHSEC.137.APPLICATIONOFADMINISTRATIVESIMPLIFICA- 1TION.2AQHBPofferingentityisrequiredtocomplywith3standardsforelectronicfinancialandadministrative4transactionsundersection1173AoftheSocialSecurity5Act, added by section 163(a).6Subtitle EGovernance7SEC.141.HEALTHCHOICESADMINISTRATION;HEALTH8CHOICES COMMISSIONER.9(a) IN GENERAL.There is hereby established, as an10independent agency in the executive branch of the Govern- 11ment,aHealthChoicesAdministration(inthisdivision12referred to as the Administration).13(b) COMMISSIONER.14(1)IN GENERAL.TheAdministrationshallbe15headedbyaHealthChoicesCommissioner(inthis16divisionreferredtoastheCommissioner)who17shallbeappointedbythePresident,byandwiththe18advice and consent of the Senate.19(2)COMPENSATION;ETC.Theprovisionsof20paragraphs(2),(5),and(7)ofsubsection(a)(relat- 21ingtocompensation,terms,generalpowers,rule- 22making,anddelegation)ofsection702oftheSocial23SecurityAct(42U.S.C.902)shallapplytothe24CommissionerandtheAdministrationinthesame25mannerassuchprovisionsapplytotheCommis- 26VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00041 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS42 HR3200IHsionerofSocialSecurityandtheSocialSecurityAd- 1ministration.2SEC. 142. DUTIES AND AUTHORITY OF COMMISSIONER.3(a)DUTIES.TheCommissionerisresponsiblefor4carryingoutthefollowingfunctionsunderthisdivision:5(1)QUALIFIED PLAN STANDARDS.Theestab- 6lishmentofqualifiedhealthbenefitsplanstandards7underthistitle,includingtheenforcementofsuch8standardsincoordinationwithStateinsuranceregu- 9latorsandtheSecretariesofLaborandtheTreas- 10ury.11(2)HEALTH INSURANCE EXCHANGE.Thees- 12tablishmentandoperationofaHealthInsurance13Exchange under subtitle A of title II.14(3)INDIVIDUAL AFFORDABILITY CREDITS.15Theadministrationofindividualaffordabilitycredits16undersubtitleCoftitleII,includingdetermination17of eligibility for such credits.18(4)ADDITIONAL FUNCTIONS.Suchadditional19functions as may be specified in this division.20(b) PROMOTING ACCOUNTABILITY.21(1)IN GENERAL.TheCommissionershallun- 22dertakeactivitiesinaccordancewiththissubtitleto23promoteaccountabilityofQHBPofferingentitiesin24meetingFederalhealthinsurancerequirements,re- 25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00042 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS43 HR3200IHgardlessofwhethersuchaccountabilityiswithre- 1specttoqualifiedhealthbenefitsplansoffered2throughtheHealthInsuranceExchangeoroutside3of such Exchange.4(2)COMPLIANCE EXAMINATION AND AUDITS.5(A)IN GENERAL.Thecommissioner6shall,incoordinationwithStates,conductau- 7ditsofqualifiedhealthbenefitsplancompliance8withFederalrequirements.Suchauditsmayin- 9cluderandomcomplianceauditsandtargeted10auditsinresponsetocomplaintsorothersus- 11pected non-compliance.12(B)RECOUPMENT OF COSTS IN CONNEC- 13TION WITH EXAMINATION AND AUDITS.The14Commissionerisauthorizedtorecoupfrom15qualifiedhealthbenefitsplansreimbursement16forthecostsofsuchexaminationsandauditof17such QHBP offering entities.18(c)DATA COLLECTION.TheCommissionershall19collectdataforpurposesofcarryingouttheCommis- 20sionersduties,includingforpurposesofpromotingqual- 21ityandvalue,protectingconsumers,andaddressingdis- 22parities in health and health care and may share such data23with the Secretary of Health and Human Services.24(d) SANCTIONS AUTHORITY.25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00043 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS44 HR3200IH(1)IN GENERAL.InthecasethattheCom- 1missionerdeterminesthataQHBPofferingentity2violatesarequirementofthistitle,theCommis- 3sionermay,incoordinationwithStateinsurance4regulatorsandtheSecretaryofLabor,provide,in5additiontoanyotherremediesauthorizedbylaw,6foranyoftheremediesdescribedinparagraph(2).7(2)REMEDIES.Theremediesdescribedinthis8paragraph, with respect to a qualified health benefits9plan offered by a QHBP offering entity, are10(A)civilmoneypenaltiesofnotmorethan11theamountthatwouldbeapplicableunder12similarcircumstancesforsimilarviolations13undersection1857(g)oftheSocialSecurity14Act;15(B)suspensionofenrollmentofindividuals16undersuchplanafterthedatetheCommis- 17sionernotifiestheentityofadetermination18underparagraph(1)anduntiltheCommis- 19sionerissatisfiedthatthebasisforsuchdeter- 20minationhasbeencorrectedandisnotlikelyto21recur;22(C)inthecaseofanExchange-partici- 23patinghealthbenefitsplan,suspensionofpay- 24menttotheentityundertheHealthInsurance25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00044 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS45 HR3200IHExchangeforindividualsenrolledinsuchplan1afterthedatetheCommissionernotifiestheen- 2tityofadeterminationunderparagraph(1)3anduntiltheSecretaryissatisfiedthatthe4basisforsuchdeterminationhasbeencorrected5and is not likely to recur; or6(D)workingwithStateinsuranceregu- 7latorstoterminateplansforrepeatedfailureby8theofferingentitytomeettherequirementsof9this title.10(e)STANDARD DEFINITIONS OF INSURANCE AND11MEDICAL TERMS.TheCommissionershallprovidefor12thedevelopmentofstandardsforthedefinitionsofterms13used in health insurance coverage, including insurance-re- 14lated terms.15(f) EFFICIENCY IN ADMINISTRATION.The Commis- 16sioner shall issue regulations for the effective and efficient17administrationoftheHealthInsuranceExchangeandaf- 18fordability credits under subtitle C, including, with respect19tothedeterminationofeligibilityforaffordabilitycredits,20the use of personnel who are employed in accordance with21therequirementsoftitle5,UnitedStatesCode,tocarry22outthedutiesoftheCommissioneror,inthecaseofsec- 23tions208and241(b)(2),theuseofStatepersonnelwho24areemployedinaccordancewithstandardsprescribedby25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00045 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS46 HR3200IHtheOfficeofPersonnelManagementpursuanttosection1208oftheIntergovernmentalPersonnelActof1970(422U.S.C. 4728).3SEC. 143. CONSULTATION AND COORDINATION.4(a)CONSULTATION.IncarryingouttheCommis- 5sionersdutiesunderthisdivision,theCommissioner,as6appropriate,shallconsultwithatleastwiththefollowing:7(1)TheNationalAssociationofInsurance8Commissioners,Stateattorneysgeneral,andState9insuranceregulators,includingconcerningthe10standardsforinsuredqualifiedhealthbenefitsplans11underthistitleandenforcementofsuchstandards.12(2)AppropriateStateagencies,specificallycon- 13cerningtheadministrationofindividualaffordability14creditsundersubtitleCoftitleIIandtheoffering15ofExchange-participatinghealthbenefitsplans,to16MedicaideligibleindividualsundersubtitleAofsuch17title.18(3) Other appropriate Federal agencies.19(4) Indian tribes and tribal organizations.20(5)TheNationalAssociationofInsurance21Commissionersforpurposesofusingmodelguide- 22linesestablishedbysuchassociationforpurposesof23subtitles B and D.24(b) COORDINATION.25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00046 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS47 HR3200IH(1)IN GENERAL.Incarryingoutthefunc- 1tionsoftheCommissioner,includingwithrespectto2theenforcementoftheprovisionsofthisdivision,3theCommissionershallworkincoordinationwith4existingFederalandStateentitiestothemaximum5extentfeasibleconsistentwiththisdivisionandina6mannerthatpreventsconflictsofinterestinduties7and ensures effective enforcement.8(2)UNIFORM STANDARDS.TheCommissioner,9incoordinationwithsuchentities,shallseekto10achieveuniformstandardsthatadequatelyprotect11consumersinamannerthatdoesnotunreasonably12affect employers and insurers.13SEC. 144. HEALTH INSURANCE OMBUDSMAN.14(a)IN GENERAL.TheCommissionershallappoint15withintheHealthChoicesAdministrationaQualified16HealthBenefitsPlanOmbudsmanwhoshallhaveexper- 17tiseandexperienceinthefieldsofhealthcareandedu- 18cation of (and assistance to) individuals.19(b)DUTIES.TheQualifiedHealthBenefitsPlan20Ombudsmanshall,inalinguisticallyappropriateman- 21ner22(1)receivecomplaints,grievances,andrequests23for information submitted by individuals;24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00047 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS48 HR3200IH(2)provideassistancewithrespecttocom- 1plaints,grievances,andrequestsreferredtoinpara- 2graph (1), including3(A)helpingindividualsdeterminetherel- 4evantinformationneededtoseekanappealof5a decision or determination;6(B)assistancetosuchindividualswithany7problemsarisingfromdisenrollmentfromsuch8a plan;9(C)assistancetosuchindividualsinchoos- 10ingaqualifiedhealthbenefitsplaninwhichto11enroll; and12(D)assistancetosuchindividualsinpre- 13sentinginformationundersubtitleC(relating14to affordability credits); and15(3)submitannualreportstoCongressandthe16CommissionerthatdescribetheactivitiesoftheOm- 17budsmanandthatincludesuchrecommendationsfor18improvement in the administration of this division as19theOmbudsmandeterminesappropriate.TheOm- 20budsmanshallnotserveasanadvocateforanyin- 21creasesinpaymentsornewcoverageofservices,but22mayidentifyissuesandproblemsinpaymentorcov- 23erage policies.24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00048 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS49 HR3200IHSubtitle FRelation to Other1Requirements; Miscellaneous2SEC. 151. RELATION TO OTHER REQUIREMENTS.3(a)COVERAGE NOT OFFERED THROUGH EX- 4CHANGE.5(1)IN GENERAL.Inthecaseofhealthinsur- 6ancecoveragenotofferedthroughtheHealthInsur- 7anceExchange(whetherornotofferedinconnection8withanemployment-basedhealthplan),andinthe9caseofemployment-basedhealthplans,therequire- 10mentsofthistitledonotsupercedeanyrequire- 11mentsapplicableundertitlesXXIIandXXVIIof12thePublicHealthServiceAct,parts6and7ofsub- 13titleBoftitleIoftheEmployeeRetirementIncome14SecurityActof1974,orStatelaw,exceptinsofaras15suchrequirementspreventtheapplicationofare- 16quirementofthisdivision,asdeterminedbythe17Commissioner.18(2)CONSTRUCTION.Nothinginparagraph(1)19shall be construed as affecting the application of sec- 20tion514oftheEmployeeRetirementIncomeSecu- 21rity Act of 1974.22(b) COVERAGE OFFERED THROUGH EXCHANGE.23VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00049 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS50 HR3200IH(1)IN GENERAL.Inthecaseofhealthinsur- 1ancecoverageofferedthroughtheHealthInsurance2Exchange3(A)therequirementsofthistitledonot4supercedeanyrequirements(includingrequire- 5mentsrelatingtogeneticinformationnon- 6discriminationandmentalhealth)applicable7undertitleXXVIIofthePublicHealthService8ActorunderStatelaw,exceptinsofarassuch9requirementspreventtheapplicationofare- 10quirementofthisdivision,asdeterminedbythe11Commissioner; and12(B)individualrightsandremediesunder13State laws shall apply.14(2)CONSTRUCTION.Inthecaseofcoverage15describedinparagraph(1),nothinginsuchpara- 16graphshallbeconstruedaspreventingtheapplica- 17tionofrightsandremediesunderStatelawswith18respecttoanyrequirementreferredtoinparagraph19(1)(A).20SEC. 152. PROHIBITING DISCRIMINATION IN HEALTH CARE.21(a) IN GENERAL.Except as otherwise explicitly per- 22mittedbythisActandbysubsequentregulationscon- 23sistentwiththisAct,allhealthcareandrelatedservices24(including insurance coverage and public health activities)25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00050 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS51 HR3200IHcoveredbythisActshallbeprovidedwithoutregardto1personalcharacteristicsextraneoustotheprovisionof2high quality health care or related services.3(b)IMPLEMENTATION.Toimplementtherequire- 4mentsetforthinsubsection(a),theSecretaryofHealth5and Human Services shall, not later than 18 months after6thedateoftheenactmentofthisAct,promulgatesuch7regulationsasarenecessaryorappropriatetoinsurethat8allhealthcareandrelatedservices(includinginsurance9coverageandpublichealthactivities)coveredbythisAct10areprovided(whetherdirectlyorthroughcontractual,li- 11censing,orotherarrangements)withoutregardtoper- 12sonalcharacteristicsextraneoustotheprovisionofhigh13quality health care or related services.14SEC. 153. WHISTLEBLOWER PROTECTION.15(a)RETALIATION PROHIBITED.Noemployermay16dischargeanyemployeeorotherwisediscriminateagainst17anyemployeewithrespecttohiscompensation,terms,18conditions,orotherprivilegesofemploymentbecausethe19employee(oranypersonactingpursuanttoarequestof20the employee)21(1)provided,causedtobeprovided,orisabout22toprovideorcausetobeprovidedtotheemployer,23theFederalGovernment,ortheattorneygeneralof24aStateinformationrelatingtoanyviolationof,or25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00051 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS52 HR3200IHanyactoromissiontheemployeereasonablybelieves1tobeaviolationofanyprovisionofthisActorany2order,rule,orregulationpromulgatedunderthis3Act;4(2)testifiedorisabouttotestifyinapro- 5ceeding concerning such violation;6(3)assistedorparticipatedorisabouttoassist7or participate in such a proceeding; or8(4)objectedto,orrefusedtoparticipatein,any9activity,policy,practice,orassignedtaskthatthe10employee(orothersuchperson)reasonablybelieved11tobeinviolationofanyprovisionofthisActorany12order,rule,orregulationpromulgatedunderthis13Act.14(b)ENFORCEMENT ACTION.Anemployeecovered15bythissectionwhoallegesdiscriminationbyanemployer16in violation of subsection (a) may bring an action governed17bytherules,procedures,legalburdensofproof,andrem- 18ediessetforthinsection40(b)oftheConsumerProduct19Safety Act (15 U.S.C. 2087(b)).20(c)EMPLOYER DEFINED.Asusedinthissection,21thetermemployermeansanyperson(includingoneor22moreindividuals,partnerships,associations,corporations,23trusts,professionalmembershiporganizationincludinga24certification, disciplinary, or other professional body, unin- 25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00052 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS53 HR3200IHcorporatedorganizations,nongovernmentalorganizations,1ortrustees)engagedinprofitornonprofitbusinessorin- 2dustrywhoseactivitiesaregovernedbythisAct,andany3agent, contractor, subcontractor, grantee, or consultant of4such person.5(d) RULE OF CONSTRUCTION.The rule of construc- 6tionsetforthinsection20109(h)oftitle49,United7States Code, shall also apply to this section.8SEC.154.CONSTRUCTIONREGARDINGCOLLECTIVEBAR- 9GAINING.10Nothinginthisdivisionshallbeconstruedtoalter11ofsupercedeanystatutoryorotherobligationtoengage12incollectivebargainingoverthetermsandconditionsof13employment related to health care.14SEC. 155. SEVERABILITY.15If any provision of this Act, or any application of such16provisiontoanypersonorcircumstance,isheldtobeun- 17constitutional,theremainderoftheprovisionsofthisAct18andtheapplicationoftheprovisiontoanyotherperson19or circumstance shall not be affected.20Subtitle GEarly Investments21SEC. 161. ENSURING VALUE AND LOWER PREMIUMS.22(a)GROUP HEALTH INSURANCE COVERAGE.Title23XXVIIofthePublicHealthServiceActisamendedby24inserting after section 2713 the following new section:25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00053 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS54 HR3200IHSEC. 2714. ENSURING VALUE AND LOWER PREMIUMS.1(a)IN GENERAL.Eachhealthinsuranceissuer2that offers health insurance coverage in the small or large3group market shall provide that for any plan year in which4the coverage has a medical loss ratio below a level specified5bytheSecretary,theissuershallprovideinamanner6specifiedbytheSecretaryforrebatestoenrolleesofpay- 7ment sufficient to meet such loss ratio. Such methodology8shallbesetatthehighestlevelmedicallossratiopossible9thatisdesignedtoensureadequateparticipationby10issuers,competitioninthehealthinsurancemarket,and11valueforconsumerssothattheirpremiumsareusedfor12services.13(b)UNIFORM DEFINITIONS.TheSecretaryshall14establishauniformdefinitionofmedicallossratioand15methodologyfordetermininghowtocalculatethemedical16loss ratio. Such methodology shall be designed to take into17accountthespecialcircumstancesofsmallerplans,dif- 18ferent types of plans, and newer plans..19(b)INDIVIDUAL HEALTH INSURANCE COVERAGE.20Suchtitleisfurtheramendedbyinsertingaftersection212753 the following new section:22SEC. 2754. ENSURING VALUE AND LOWER PREMIUMS.23Theprovisionsofsection2714shallapplytohealth24insurance coverage offered in the individual market in the25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00054 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS55 HR3200IHsame manner as such provisions apply to health insurance1coverage offered in the small or large group market..2(c)IMMEDIATE IMPLEMENTATION.Theamend- 3mentsmadebythissectionshallapplyinthegroupand4individualmarketforplanyearsbeginningonorafter5January 1, 2011.6SEC. 162. ENDING HEALTH INSURANCE RESCISSION ABUSE.7(a)CLARIFICATION REGARDING APPLICATION OF8GUARANTEED RENEWABILITY OF INDIVIDUAL HEALTH9INSURANCE COVERAGE.Section2742ofthePublic10HealthServiceAct(42U.S.C.300gg42)isamended11(1)initsheading,byinsertingAND CON- 12TINUATION IN FORCE,INCLUDING PROHIBI- 13TION OF RESCISSION,afterGUARANTEED RE- 14NEWABILITY; and15(2)insubsection(a),byinserting,including16without rescission, after continue in force.17(b)SECRETARIAL GUIDANCE REGARDING RESCIS- 18SIONS.Section2742ofsuchAct(42U.S.C.300gg42)19is amended by adding at the end the following:20(f) RESCISSION.A health insurance issuer may re- 21scindhealthinsurancecoverageonlyuponclearandcon- 22vincingevidenceoffrauddescribedinsubsection(b)(2).23TheSecretary,nolaterthanJuly1,2010,shallissue24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00055 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS56 HR3200IHguidanceimplementingthisrequirement,includingproce- 1dures for independent, external third party review..2(c)OPPORTUNITY FOR INDEPENDENT,EXTERNAL3THIRD PARTY REVIEW IN CERTAIN CASES.Subpart14ofpartBoftitleXXVIIofsuchAct(42U.S.C.300gg541 et seq.) is amended by adding at the end the following:6SEC.2746.OPPORTUNITYFORINDEPENDENT,EXTERNAL7THIRDPARTYREVIEWINCASESOFRESCIS- 8SION.9(a)NOTICE AND REVIEW RIGHT.Ifahealthin- 10surance issuer determines to rescind health insurance cov- 11erageforanindividualintheindividualmarket,before12such rescission may take effect the issuer shall provide the13individualwithnoticeofsuchproposedrescissionandan14opportunity for a review of such determination by an inde- 15pendent,externalthirdpartyunderproceduresspecified16by the Secretary under section 2742(f).17(b)INDEPENDENT DETERMINATION.Iftheindi- 18vidualrequestssuchreviewbyanindependent,external19thirdpartyofarescissionofhealthinsurancecoverage,20thecoverageshallremainineffectuntilsuchthirdparty21determinesthatthecoveragemayberescindedunderthe22guidanceissuedbytheSecretaryundersection2742(f)..23(d)EFFECTIVE DATE.Theamendmentsmadeby24this section shall apply on and after October 1, 2010, with25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00056 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS57 HR3200IHrespecttohealthinsurancecoverageissuedbefore,on,or1after such date.2SEC. 163. ADMINISTRATIVE SIMPLIFICATION.3(a)STANDARDIZING ELECTRONIC ADMINISTRATIVE4TRANSACTIONS.5(1)IN GENERAL.PartCoftitleXIoftheSo- 6cialSecurityAct(42U.S.C.1320detseq.)is7amendedbyinsertingaftersection1173thefol- 8lowing new section:9SEC.1173A.STANDARDIZEELECTRONICADMINISTRATIVE10TRANSACTIONS.11(a)STANDARDS FOR FINANCIAL AND ADMINISTRA- 12TIVE TRANSACTIONS.13(1)IN GENERAL.TheSecretaryshalladopt14andregularlyupdatestandardsconsistentwiththe15goals described in paragraph (2).16(2)GOALS FOR FINANCIAL AND ADMINISTRA- 17TIVE TRANSACTIONS.Thegoalsforstandards18underparagraph(1)arethatsuchstandardsshall19(A)beuniquewithnoconflictingorre- 20dundant standards;21(B)beauthoritative,permittingnoaddi- 22tionsorconstraintsforelectronictransactions,23including companion guides;24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00057 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS58 HR3200IH(C)becomprehensive,efficientandro- 1bust,requiringminimalaugmentationbypaper2transactionsorclarificationbyfurthercommu- 3nications;4(D)enablethereal-time(ornearreal-5time)determinationofanindividualsfinancial6responsibilityatthepointofserviceand,tothe7extentpossible,priortoservice,including8whethertheindividualiseligibleforaspecific9servicewithaspecificphysicianataspecificfa- 10cility,whichmayincludeutilizationofama- 11chine-readablehealthplanbeneficiaryidenti- 12fication card;13(E)enable,wherefeasible,nearreal-time14adjudication of claims;15(F)providefortimelyacknowledgment,16response,andstatusreportingapplicabletoany17electronictransactiondeemedappropriateby18the Secretary;19(G)describealldataelements(suchas20reasonandremarkcodes)inunambiguous21terms,notpermitoptionalfields,requirethat22dataelementsbeeitherrequiredorconditioned23uponsetvaluesinotherfields,andprohibitad- 24ditional conditions; and25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00058 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS59 HR3200IH(H)harmonizeallcommondataelements1acrossadministrativeandclinicaltransaction2standards.3(3)TIME FOR ADOPTION.Notlaterthan24yearsafterthedateofimplementationoftheX125Version5010transactionstandardsimplemented6underthispart,theSecretaryshalladoptstandards7under this section.8(4)REQUIREMENTS FOR SPECIFIC STAND- 9ARDS.Thestandardsunderthissectionshallbe10developed, adopted and enforced so as to11(A)clarify,refine,complete,andexpand,12asneeded,thestandardsrequiredundersection131173;14(B)requirepaperversionsofstandard- 15izedtransactionstocomplywiththesame16standardsastodatacontentsuchthatafully17compliant,equivalentelectronictransactioncan18bepopulatedfromthedatafromapaper19version;20(C)enableelectronicfundstransfers,in21ordertoallowautomatedreconciliationwiththe22relatedhealthcarepaymentandremittancead- 23vice;24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00059 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS60 HR3200IH(D)requiretimelyandtransparentclaim1anddenialmanagementprocesses,including2tracking, adjudication, and appeal processing;3(E)requiretheuseofastandardelec- 4tronictransactionwithwhichhealthcarepro- 5vidersmayquicklyandefficientlyenrollwitha6healthplantoconducttheotherelectronic7transactions provided for in this part; and8(F)provideforotherrequirementsrelat- 9ingtoadministrativesimplificationasidentified10bytheSecretary,inconsultationwithstake- 11holders.12(5)BUILDING ON EXISTING STANDARDS.In13developingthestandardsunderthissection,theSec- 14retaryshallbuilduponexistingandplannedstand- 15ards.16(6)IMPLEMENTATION AND ENFORCEMENT.17Notlaterthan6monthsafterthedateoftheenact- 18mentofthissection,theSecretaryshallsubmitto19theappropriatecommitteesofCongressaplanfor20theimplementationandenforcement,bynotlater21than5yearsaftersuchdateofenactment,ofthe22standardsunderthissection.Suchplanshallin- 23clude24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00060 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS61 HR3200IH(A)aprocessandtimeframewithmile- 1stonesfordevelopingthecompletesetofstand- 2ards;3(B)anexpeditedupgradeprogramfor4continuallydevelopingandapprovingadditions5andmodificationstothestandardsasoftenas6annuallytoimprovetheirqualityandextend7theirfunctionalitytomeetevolvingrequire- 8ments in health care;9(C)programstoprovideincentivesfor,10andeasetheburdenof,implementationforcer- 11tainhealthcareproviders,withspecialconsid- 12erationgiventosuchprovidersservingruralor13underservedareasandensurecoordinationwith14standards,implementationspecifications,and15certificationcriteriabeingadoptedunderthe16HITECH Act;17(D)programstoprovideincentivesfor,18andeasetheburdenof,healthcareproviders19whovolunteertoparticipateintheprocessof20setting standards for electronic transactions;21(E)anestimateoftotalfundsneededto22ensuretimelycompletionoftheimplementation23plan; and24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00061 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS62 HR3200IH(F)anenforcementprocessthatincludes1timelyinvestigationofcomplaints,randomau- 2ditstoensurecompliance,civilmonetaryand3programmaticpenaltiesfornon-compliancecon- 4sistentwithexistinglawsandregulations,and5afairandreasonableappealsprocessbuilding6off of enforcement provisions under this part.7(b)LIMITATIONS ON USE OF DATA.Nothingin8thissectionshallbeconstruedtopermittheuseofinfor- 9mation collected under this section in a manner that would10adversely affect any individual.11(c) PROTECTION OF DATA.The Secretary shall en- 12sure(throughthepromulgationofregulationsorother- 13wise)thatalldatacollectedpursuanttosubsection(a)14are15(1)usedanddisclosedinamannerthatmeets16theHIPAAprivacyandsecuritylaw(asdefinedin17section3009(a)(2)ofthePublicHealthService18Act),includinganyprivacyorsecuritystandard19adopted under section 3004 of such Act; and20(2)protectedfromallinappropriateinternal21usebyanyentitythatcollects,stores,orreceivesthe22data,includinguseofsuchdataindeterminationsof23eligibility(orcontinuedeligibility)inhealthplans,24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00062 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS63 HR3200IHandfromotherinappropriateuses,asdefinedbythe1Secretary..2(2)DEFINITIONS.Section1171ofsuchAct3(42 U.S.C. 1320d) is amended4(A)inparagraph(7),bystrikingwith5referencetoandallthatfollowsandinserting6withreferencetoatransactionordataele- 7mentofhealthinformationinsection11738meansimplementationspecifications,certifi- 9cationcriteria,operatingrules,messagingfor- 10mats,codes,andcodesetsadoptedorestab- 11lishedbytheSecretaryfortheelectronicex- 12change and use of information; and13(B)byaddingattheendthefollowingnew14paragraph:15(9)OPERATING RULES.Thetermoperating16rulesmeansbusinessrulesforusingandprocessing17transactions.Operatingrulesshouldaddressthefol- 18lowing:19(A)Requirementsfordatacontentusing20available and established national standards.21(B)Infrastructurerequirementsthates- 22tablishbestpracticesforstreamliningdataflow23to yield timely execution of transactions.24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00063 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS64 HR3200IH(C)Policiesdefiningthetransactionre- 1latedrightsandresponsibilitiesforentitiesthat2are transmitting or receiving data..3(3)CONFORMING AMENDMENT.Section41179(a)ofsuchAct(42U.S.C.1320d8(a))is5amended, in the matter before paragraph (1)6(A)byinsertingonbehalfofanindi- 7vidual after 1978); and8(B)byinsertingonbehalfofanindi- 9vidual after for a financial institution.10(b)STANDARDS FOR CLAIMS ATTACHMENTS AND11COORDINATION OF BENEFITS .12(1)STANDARD FOR HEALTH CLAIMS ATTACH- 13MENTS.Notlaterthan1yearafterthedateofthe14enactmentofthisAct,theSecretaryofHealthand15HumanServicesshallpromulgateafinalruletoes- 16tablishastandardforhealthclaimsattachment17transaction described in section 1173(a)(2)(B) of the18SocialSecurityAct(42U.S.C.1320d2(a)(2)(B))19and coordination of benefits.20(2)REVISION IN PROCESSING PAYMENT TRANS- 21ACTIONS BY FINANCIAL INSTITUTIONS.22(A)IN GENERAL.Section1179oftheSo- 23cialSecurityAct(42U.S.C.1320d8)is24amended,inthematterbeforeparagraph(1)25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00064 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS65 HR3200IH(i)bystrikingorisengagedandin- 1serting and is engaged; and2(ii)byinserting(otherthanasa3businessassociateforacoveredentity)4after for a financial institution.5(B)EFFECTIVE DATE.Theamendments6madebyparagraph(1)shallapplytotrans- 7actionsoccurringonoraftersuchdate(not8laterthan6monthsafterthedateoftheenact- 9mentofthisAct)astheSecretaryofHealth10and Human Services shall specify.11SEC. 164. REINSURANCE PROGRAM FOR RETIREES.12(a) ESTABLISHMENT.13(1)IN GENERAL.Notlaterthan90daysafter14thedateoftheenactmentofthisAct,theSecretary15ofHealthandHumanServicesshallestablishatem- 16poraryreinsuranceprogram(inthissectionreferred17toasthereinsuranceprogram)toprovidereim- 18bursementtoassistparticipatingemployment-based19planswiththecostofprovidinghealthbenefitsto20retireesandtoeligiblespouses,survivingspouses21and dependents of such retirees.22(2)DEFINITIONS.Forpurposesofthissec- 23tion:24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00065 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS66 HR3200IH(A)Thetermeligibleemployment-based1planmeansagrouphealthbenefitsplan2that3(i)ismaintainedbyoneormoreem- 4ployers,formeremployersoremployeeas- 5sociations,oravoluntaryemployeesbene- 6ficiary association, or a committee or board7ofindividualsappointedtoadministersuch8plan, and9(ii)provideshealthbenefitstoretir- 10ees.11(B)Thetermhealthbenefitsmeans12medical,surgical,hospital,prescriptiondrug,13andsuchotherbenefitsasshallbedetermined14bytheSecretary,whetherself-fundedordeliv- 15eredthroughthepurchaseofinsuranceoroth- 16erwise.17(C)Thetermparticipatingemployment-18basedplanmeansaneligibleemployment-19basedplanthatisparticipatinginthereinsur- 20ance program.21(D)Thetermretireemeans,withre- 22specttoaparticipatingemployment-benefit23plan, an individual who24(i) is 55 years of age or older;25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00066 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS67 HR3200IH(ii)isnoteligibleforcoverageunder1titleXVIIIoftheSocialSecurityAct;and2(iii)isnotanactiveemployeeofan3employermaintainingtheplanorofany4employerthatmakesorhasmadesubstan- 5tial contributions to fund such plan.6(E)ThetermSecretarymeansSec- 7retary of Health and Human Services.8(b)PARTICIPATION.Tobeeligibletoparticipatein9thereinsuranceprogram,aneligibleemployment-based10planshallsubmittotheSecretaryanapplicationforpar- 11ticipationintheprogram,atsuchtime,insuchmanner,12and containing such information as the Secretary shall re- 13quire.14(c) PAYMENT.15(1) SUBMISSION OF CLAIMS.16(A)IN GENERAL.Underthereinsurance17program,aparticipatingemployment-based18planshallsubmitclaimsforreimbursementto19theSecretarywhichshallcontaindocumenta- 20tionoftheactualcostsoftheitemsandserv- 21ices for which each claim is being submitted.22(B)BASIS FOR CLAIMS.Eachclaimsub- 23mittedundersubparagraph(A)shallbebased24ontheactualamountexpendedbythepartici- 25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00067 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS68 HR3200IHpatingemployment-basedplaninvolvedwithin1theplanyearfortheappropriateemployment2basedhealthbenefitsprovidedtoaretireeorto3thespouse,survivingspouse,ordependentofa4retiree.Indeterminingtheamountofanyclaim5forpurposesofthissubsection,thepartici- 6patingemployment-basedplanshalltakeinto7accountanynegotiatedpriceconcessions(such8asdiscounts,directorindirectsubsidies,re- 9bates,anddirectorindirectremunerations)ob- 10tainedbysuchplanwithrespecttosuchhealth11benefits.Forpurposesofcalculatingthe12amountofanyclaim,thecostspaidbythere- 13tireeorbythespouse,survivingspouse,orde- 14pendentoftheretireeintheformof15deductibles,co-payments,andco-insuranceshall16beincludedalongwiththeamountspaidbythe17participating employment-based plan.18(2)PROGRAM PAYMENTS AND LIMIT.Ifthe19Secretarydeterminesthataparticipatingemploy- 20ment-basedplanhassubmittedavalidclaimunder21paragraph(1),theSecretaryshallreimbursesuch22planfor80percentofthatportionofthecostsat- 23tributabletosuchclaimthatexceeds$15,000,butis24lessthan$90,000.Suchamountsshallbeadjusted25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00068 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS69 HR3200IHeachyearbasedonthepercentageincreaseinthe1medicalcarecomponentoftheConsumerPrice2Index(roundedtothenearestmultipleof$1,000)3for the year involved.4(3)USE OF PAYMENTS.Amountspaidtoa5participatingemployment-basedplanunderthissub- 6sectionshallbeusedtolowerthecostsbornedi- 7rectly by the participants and beneficiaries for health8benefitsprovidedundersuchplanintheformof9premiums, co-payments, deductibles, co-insurance, or10otherout-of-pocketcosts.Suchpaymentsshallnot11beusedtoreducethecostsofanemployermaintain- 12ingtheparticipatingemployment-basedplan.The13Secretaryshalldevelopamechanismtomonitorthe14appropriate use of such payments by such plans.15(4)APPEALS AND PROGRAM PROTECTIONS.16The Secretary shall establish17(A)anappealsprocesstopermitpartici- 18patingemployment-basedplanstoappealade- 19terminationoftheSecretarywithrespectto20claims submitted under this section; and21(B)procedurestoprotectagainstfraud,22waste, and abuse under the program.23(5)AUDITS.TheSecretaryshallconductan- 24nualauditsofclaimsdatasubmittedbypartici- 25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00069 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS70 HR3200IHpatingemployment-basedplansunderthissectionto1ensurethattheyareincompliancewiththerequire- 2ments of this section.3(d) RETIREE RESERVE TRUST FUND.4(1) ESTABLISHMENT.5(A)IN GENERAL.Thereisestablishedin6theTreasuryoftheUnitedStatesatrustfund7tobeknownastheRetireeReserveTrust8Fund(referredtointhissectionastheTrust9Fund),thatshallconsistofsuchamountsas10maybeappropriatedorcreditedtotheTrust11Fundasprovidedforinthissubsectiontoen- 12abletheSecretarytocarryoutthereinsurance13program.Suchamountsshallremainavailable14until expended.15(B)FUNDING.Thereareherebyappro- 16priatedtotheTrustFund,outofanymoneys17intheTreasurynototherwiseappropriated,an18amountrequestedbytheSecretaryasnecessary19tocarryoutthissection,exceptthatthetotal20ofallsuchamountsrequestedshallnotexceed21$10,000,000,000.22(C)APPROPRIATIONS FROM THE TRUST23FUND.24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00070 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS71 HR3200IH(i)IN GENERAL.Amountsinthe1TrustFundareappropriatedtoprovide2fundingtocarryoutthereinsurancepro- 3gramandshallbeusedtocarryoutsuch4program.5(ii)BUDGETARY IMPLICATIONS.6Amountsappropriatedunderclause(i),7andoutlaysflowingfromsuchappropria- 8tions,shallnotbetakenintoaccountfor9purposesofanybudgetenforcementproce- 10duresincludingallocationsundersection11302(a)and(b)oftheBalancedBudget12andEmergencyDeficitControlActand13budgetresolutionsforfiscalyearsduring14whichappropriationsaremadefromthe15Trust Fund.16(iii)LIMITATION TO AVAILABLE17FUNDS.TheSecretaryhastheauthority18tostoptakingapplicationsforparticipa- 19tionintheprogramortakesuchother20stepsinreducingexpendituresunderthe21reinsuranceprograminordertoensure22thatexpendituresunderthereinsurance23programdonotexceedthefundsavailable24under this subsection.25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00071 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS72 HR3200IHTITLEIIHEALTHINSURANCE1EXCHANGEANDRELATED2PROVISIONS3Subtitle AHealth Insurance4Exchange5SEC.201.ESTABLISHMENTOFHEALTHINSURANCEEX- 6CHANGE;OUTLINEOFDUTIES;DEFINITIONS.7(a)ESTABLISHMENT.Thereisestablishedwithin8theHealthChoicesAdministrationandunderthedirec- 9tionoftheCommissioneraHealthInsuranceExchange10inordertofacilitateaccessofindividualsandemployers,11throughatransparentprocess,toavarietyofchoicesof12affordable,qualityhealthinsurancecoverage,includinga13public health insurance option.14(b) OUTLINE OF DUTIES OF COMMISSIONER.In ac- 15cordance with this subtitle and in coordination with appro- 16priateFederalandStateofficialsasprovidedundersec- 17tion 143(b), the Commissioner shall18(1)undersection204establishstandardsfor,19acceptbidsfrom,andnegotiateandenterintocon- 20tractswith,QHBPofferingentitiesfortheoffering21ofhealthbenefitsplansthroughtheHealthInsur- 22anceExchange,withdifferentlevelsofbenefitsre- 23quiredundersection203,andincludingwithrespect24to oversight and enforcement;25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00072 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS73 HR3200IH(2)undersection205facilitateoutreachand1enrollmentinsuchplansofExchange-eligibleindi- 2vidualsandemployersdescribedinsection202;and3(3)conductsuchactivitiesrelatedtotheHealth4InsuranceExchangeasrequired,includingestablish- 5mentofariskpoolingmechanismundersection2066andconsumerprotectionsundersubtitleDoftitleI.7(c)EXCHANGE-PARTICIPATING HEALTH BENEFITS8PLAN DEFINED.Inthisdivision,thetermExchange-9participatinghealthbenefitsplanmeansaqualified10health benefits plan that is offered through the Health In- 11surance Exchange.12SEC.202.EXCHANGE-ELIGIBLEINDIVIDUALSANDEMPLOY- 13ERS.14(a)ACCESS TO COVERAGE.Inaccordancewiththis15section,allindividualsareeligibletoobtaincoverage16throughenrollmentinanExchange-participatinghealth17benefitsplanofferedthroughtheHealthInsuranceEx- 18changeunlesssuchindividualsareenrolledinanother19qualified health benefits plan or other acceptable coverage.20(b) DEFINITIONS.In this division:21(1)EXCHANGE-ELIGIBLE INDIVIDUAL.The22termExchange-eligibleindividualmeansanindi- 23vidualwhoiseligibleunderthissectiontobeen- 24rolledthroughtheHealthInsuranceExchangeinan25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00073 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS74 HR3200IHExchange-participatinghealthbenefitsplanand,1withrespecttofamilycoverage,includesdependents2of such individual.3(2)EXCHANGE-ELIGIBLE EMPLOYER.The4termExchange-eligibleemployermeansanem- 5ployerthatiseligibleunderthissectiontoenroll6throughtheHealthInsuranceExchangeemployees7oftheemployer(andtheirdependents)inExchange-8eligible health benefits plans.9(3)EMPLOYMENT-RELATED DEFINITIONS.10Thetermsemployer,employee,full-timeem- 11ployee,andpart-timeemployeehavethemean- 12ingsgivensuchtermsbytheCommissionerforpur- 13poses of this division.14(c)TRANSITION.Individualsandemployersshall15only be eligible to enroll or participate in the Health Insur- 16ance Exchange in accordance with the following transition17schedule:18(1)FIRST YEAR.InY1(asdefinedinsection19100(c))20(A)individualsdescribedinsubsection21(d)(1),includingindividualsdescribedinpara- 22graphs (3) and (4) of subsection (d); and23(B)smallestemployersdescribedinsub- 24section (e)(1).25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00074 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS75 HR3200IH(2) SECOND YEAR.In Y21(A)individualsandemployersdescribedin2paragraph (1); and3(B)smalleremployersdescribedinsub- 4section (e)(2).5(3)THIRD AND SUBSEQUENT YEARS.InY36and subsequent years7(A)individualsandemployersdescribedin8paragraph (2); and9(B)largeremployersaspermittedbythe10Commissioner under subsection (e)(3).11(d) INDIVIDUALS.12(1)INDIVIDUAL DESCRIBED.Subjecttothe13succeedingprovisionsofthissubsection,anindi- 14vidualdescribedinthisparagraphisanindividual15who16(A)isnotenrolledincoveragedescribedin17subparagraphs(C)through(F)ofparagraph18(2); and19(B)isnotenrolledincoverageasafull-20timeemployee(orasadependentofsuchan21employee)underagrouphealthplanifthecov- 22erageandanemployercontributionunderthe23plan meet the requirements of section 312.24VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00075 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS76 HR3200IHForpurposesofsubparagraph(B),inthecaseofan1individualwhoisself-employed,whohasatleast12employee, and who meets the requirements of section3312,suchindividualshallbedeemedafull-timeem- 4ployee described in such subparagraph.5(2)ACCEPTABLE COVERAGE.Forpurposesof6thisdivision,thetermacceptablecoveragemeans7any of the following:8(A)QUALIFIED HEALTH BENEFITS PLAN9COVERAGE.Coverageunderaqualifiedhealth10benefits plan.11(B) GRANDFATHERED HEALTH INSURANCE12COVERAGE;COVERAGE UNDER CURRENT GROUP13HEALTH PLAN.Coverageunderagrand- 14fatheredhealthinsurancecoverage(asdefined15insubsection(a)ofsection102)orundera16currentgrouphealthplan(describedinsub- 17section (b) of such section).18(C)MEDICARE.CoverageunderpartAof19title XVIII of the Social Security Act.20(D)MEDICAID.Coverageformedicalas- 21sistanceundertitleXIXoftheSocialSecurity22Act,excludingsuchcoveragethatisonlyavail- 23ablebecauseoftheapplicationofsubsection24(u), (z), or (aa) of section 1902 of such Act.25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00076 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ8SOYB1PROD with BILLS77 HR3200IH(E)MEMBERS OF THE ARMED FORCES1AND DEPENDENTS (INCLUDING TRICARE).2Coverageunderchapter55oftitle10,United3StatesCode,includingsimilarcoveragefur- 4nishedundersection1781oftitle38ofsuch5Code.6(F)VA.Coverageundertheveterans7healthcareprogramunderchapter17oftitle838,UnitedStatesCode,butonlyifthecov- 9eragefortheindividualinvolvedisdetermined10bytheCommissionerincoordinationwiththe11Secretary of Treasury to be not less than a level12specifiedbytheCommissionerandSecretaryof13VeteransAffairs,incoordinationwiththeSec- 14retaryofTreasury,basedontheindividuals15priorityforservicesasprovidedundersection161705(a) of such title.17(G) OTHER COVERAGE.Such other health18benefitscoverage,suchasaStatehealthbene- 19fitsriskpool,astheCommissioner,incoordina- 20tionwiththeSecretaryoftheTreasury,recog- 21nizes for purposes of this paragraph.22TheCommissionershallmakedeterminationsunder23thisparagraphincoordinationwiththeSecretaryof24the Treasury.25VerDate Nov 24 200823:22 Jul 14, 2009 Jkt 079200 PO 00000 Frm 00077 Fmt 6652 Sfmt 6201 E:\BILLS\H3200.IH H3200jlentini on DSKJ