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