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Health Care Bill Released: What Does Congress Hope You're Missing (INTERACTIVE INVESTIGATION)

Huffington Post   First Posted: 08/14/09 06:12 AM ET Updated: 05/25/11 02:35 PM ET

Health Care

House Democrats have released their newest version of the health care reform bill, weighing in at a whopping 1,018 pages, and HuffPost's Eyes and Ears is calling on you to help read through the legislation.

The bill lays out a host of reforms that are already making headlines, including a measure that would prohibit insurance companies from denying coverage based on pre-existing medical conditions, and a cap on the amount that the insured would be required to pay for "out-of-pocket" health care expenses.

According to Reuters, a public-financed insurance option remains the cornerstone of the proposed reform, which Obama has championed. In order to pay for extended coverage and overhaul of the current health care system, a number of new taxes would be levied -- including a 5.4 percent tax hike on those earning over $1 million.

These are highlights of the proposed legislation, but the devil is in the details of any bill of this size. While politicians and pundits will continue to debate the larger ideological implications of a health care overhaul, Eyes and Ears will be digging into each line item of this legislation to understand the precise ramifications of the proposed plan. And as the bill gets passed through three committees on its way to the House floor, we will be tracking how the bill changes and which members of Congress are responsible for its inevitable departure from the version released today.

To this end, HuffPost is partnering with Insight to launch a beta test of their interactive research tool. In the past we have posted legislation and asked you, our readers, to email us about problematic line items and to investigate potential red flags; With Insight, you will now have the ability to highlight such controversial line items for the entire Huffington Post community to see and discuss.

Insight is a newly released application meant to give readers the ability to rate the accuracy and importance of widely cited quotes and ideas. This project will adapt Insight's interface for a slightly different purpose, allowing you to have a public dialogue on individual line items of legislation. So bear with us, as some aspects on the Insight interface will simply not apply to this project.

Using Insight, readers can create a public comment thread on individual sections of an online text. In this case, you can highlight any line item and make a comment that applies specifically to that section of the legislation. Other investigators will then have the option to click on the same portion of text and include their own comments or vote on a 1-5 scale on the section's accuracy, importance and to what extent you agree. For the purpose of this project, you can skip the accuracy section (the whole bill is accurate to the extent that it is currently being considered by Congress in the form you see below) and stick to the latter two metrics. To clarify, the importance metric will act as a public rating of how under-reported the particular aspect of the bill has been, which should take into consideration the quality of the comments under that highlighted section of the bill. If all of this is confusing you, take a look at this two-minute screen cast produced by the people at Insight. It will explain the basics.




To get you thinking, here are some examples of sections of the bill worth highlighting:


- An important regulation, expenditure or tax that has not been reported by the press
- A line item that you have inside information about that has not yet been made public (e.g. you know which Congressperson introduced the item)
- A line item that has been the subject of public scrutiny (you are encouraged to add quotes from an expert or politician where they apply)
- An item that you can definitively identify as the pet project of a specific special interest group (make sure to cite your source)


This distributive legislation investigation is just one aspect of HuffPost's Eyes and Ears health care investigation that will be keeping an eye on legislators and lobbyists as the battle over reform evolves.

This week, citizen journalists at the Huffington Post Health Care Investigative Unit will be also be mapping out connections between some of the most influential members of Congress and the funds that drive their campaigns. Meanwhile, reporters are in touch with congressional offices on a regular basis, keeping their latest stances on record.

If you are interested in joining the team, click here and check out Adam Clark Estes's latest update here.

To make the bill compatible with Insight, we split the full text into fifty page segments. The first fifty pages of the House bill are below and the second and third section have their own entries. We will release additional section of the bill in the days to come.


The text version below does not include the indenting and line numbers featured in the pdf version which you can download here. Creating an Insight account will make commenting easier, though it's not necessary. Also, be advised that because this program is geared toward highlighting quotations, it will prompt you to record "who said this" when you add your "insight." You can skip that step or simply credit "House Democrats."

UPDATE

Readers have asked for a simple breakdown of how to use Insight. To recap:

STEP ONE: Highlight text to add a comment or rate the text for its importance.

STEP TWO: Ask a question or add a comment (cite your facts when possible).

STEP THREE: Register for Insight when prompted (required to leave more than 10 "insights").

The Insight interface should appear at the bottom of your browser when this page loads. If it does not, let me know.

Thanks for participating in the inaugural application of this exciting new technology. Please email me with any questions or suggestions at matthew@huffingtonpost.com.

- Part 2: Pages 50-100
- Part 3: Pages 101-150
- Part 4: Pages 151-200
- Part 5: Pages 201-250
- Part 6: Pages 251-300
- Part 7: Pages 301-350
- Part 8: Pages 351-400
- Part 9: Pages 401-443
- Full text and page for comments on the latter half of the bill.

Additional sections to come.


.....................................................................

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.
IN THE HOUSE OF REPRESENTATIVES
Mr. DINGELL (for himself, Mr. RANGEL, Mr. WAXMAN, Mr. GEORGE MILLER
of California, Mr. STARK, Mr. PALLONE, and Mr. ANDREWS) introduced
the following bill; which was referred to the Committee on July 14, 2009

A BILL

To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

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

    • (a) SHORT TITLE.--This Act may be cited as the ''America's Affordable Health Choices Act of 2009''.


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    • (b) TABLE OF DIVISIONS, TITLES, AND SUBTITLES.--This Act is divided into divisions, titles, and
      subtitles as follows:

DIVISION A--AFFORDABLE HEALTH CARE CHOICES

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

Subtitle A--General Standards
Subtitle B--Standards Guaranteeing Access to Affordable Coverage
Subtitle C--Standards Guaranteeing Access to Essential Benefits
Subtitle D--Additional Consumer Protections
Subtitle E--Governance
Subtitle F--Relation to Other Requirements; Miscellaneous
Subtitle G--Early Investments

TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

Subtitle A--Health Insurance Exchange
Subtitle B--Public Health Insurance Option
Subtitle C--Individual Affordability Credits

TITLE III--SHARED RESPONSIBILITY

Subtitle A--Individual Responsibility
Subtitle B--Employer Responsibility

TITLE IV--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

Subtitle A--Shared Responsibility
Subtitle B--Credit for Small Business Employee Health Coverage Expenses
Subtitle C--Disclosures to Carry Out Health Insurance Exchange Subsidies
Subtitle D--Other Revenue Provisions

DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS

TITLE I--IMPROVING HEALTH CARE VALUE

Subtitle A--Provisions Related to Medicare Part A
Subtitle B--Provisions Related to Part B
Subtitle C--Provisions Related to Medicare Parts A and B


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Subtitle D--Medicare Advantage Reforms
Subtitle E--Improvements to Medicare Part D
Subtitle F--Medicare Rural Access Protections

TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS

Subtitle A--Improving and Simplifying Financial Assistance for Low Income Medicare Beneficiaries
Subtitle B--Reducing Health Disparities
Subtitle C--Miscellaneous Improvements

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

TITLE IV--QUALITY

Subtitle A--Comparative Effectiveness Research
Subtitle B--Nursing Home Transparency
Subtitle C--Quality Measurements
Subtitle D--Physician Payments Sunshine Provision
Subtitle E--Public Reporting on Health Care-Associated Infections

TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION

TITLE VI--PROGRAM INTEGRITY

Subtitle A--Increased Funding to Fight Waste, Fraud, and Abuse
Subtitle B--Enhanced Penalties for Fraud and Abuse
Subtitle C--Enhanced Program and Provider Protections
Subtitle D--Access to Information Needed to Prevent Fraud, Waste, and Abuse

TITLE VII--MEDICAID AND CHIP

Subtitle A--Medicaid and Health Reform
Subtitle B--Prevention
Subtitle C--Access
Subtitle D--Coverage
Subtitle E--Financing
Subtitle F--Waste, Fraud, and Abuse
Subtitle G--Puerto Rico and the Territories
Subtitle H--Miscellaneous


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TITLE VIII--REVENUE-RELATED PROVISIONS

TITLE IX--MISCELLANEOUS PROVISIONS

DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT

TITLE I--COMMUNITY HEALTH CENTERS

TITLE II--WORKFORCE

Subtitle A--Primary Care Workforce
Subtitle B--Nursing Workforce
Subtitle C--Public Health Workforce
Subtitle D--Adapting Workforce to Evolving Health System Needs

TITLE III--PREVENTION AND WELLNESS

TITLE IV--QUALITY AND SURVEILLANCE

TITLE V--OTHER PROVISIONS

Subtitle A--Drug Discount for Rural and Other Hospitals
Subtitle B--School-Based Health Clinics
Subtitle C--National Medical Device Registry
Subtitle D--Grants for Comprehensive Programs to Provide Education to Nurses and Create a Pipeline to Nursing
Subtitle E--States Failing to Adhere to Certain Employment Obligations

DIVISION A--AFFORDABLE HEALTH CARE CHOICES

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

  • (a) PURPOSE.--
    • (1) IN GENERAL.--The purpose of this division is to provide affordable, quality health care for all Americans and reduce the growth in health care spending.
    • (2) BUILDING ON CURRENT SYSTEM.--This division achieves this purpose by building on what


      P. 5

      works in today's health care system, while repairing the aspects that are broken.

    • (3) INSURANCE REFORMS.--This division--
      • (A) enacts strong insurance market reforms;
      • (B) creates a new Health Insurance Exchange, with a public health insurance option alongside private plans;
      • (C) includes sliding scale affordability credits; and
      • (D) initiates shared responsibility among workers, employers, and the government; so that all Americans have coverage of essential health benefits.

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

  • (b) TABLE OF CONTENTS OF DIVISION.--The table of contents of this division is as follows:


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

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

Subtitle A--General Standards

Sec. 101. Requirements reforming health insurance marketplace.


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Subtitle B--Standards Guaranteeing Access to Affordable Coverage

Sec. 111. Prohibiting pre-existing condition exclusions.
Sec. 112. Guaranteed issue and renewal for insured plans.
Sec. 113. Insurance rating rules.
Sec. 114. Nondiscrimination in benefits; parity in mental health and substance abuse disorder
benefits.
Sec. 115. Ensuring adequacy of provider networks.
Sec. 116. Ensuring value and lower premiums.

Subtitle C--Standards Guaranteeing Access to Essential Benefits

Sec. 121. Coverage of essential benefits package.
Sec. 122. Essential benefits package defined.
Sec. 123. Health Benefits Advisory Committee.
Sec. 124. Process for adoption of recommendations; adoption of benefit standards.

Subtitle D--Additional Consumer Protections

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. Application to qualified health benefits plans not offered through the 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.

Subtitle E--Governance

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.

Subtitle F--Relation to Other Requirements; 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.

Subtitle G--Early Investments

Sec. 161. Ensuring value and lower premiums.
Sec. 162. Ending health insurance rescission abuse.
Sec. 163. Administrative simplification.
Sec. 164. Reinsurance program for retirees.

TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

Subtitle A--Health Insurance Exchange

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


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Sec. 202. Exchange-eligible individuals and employers.
Sec. 203. Benefits package levels.
Sec. 204. Contracts for the offering of Exchange-participating health benefits plans.
Sec. 205. Outreach and enrollment of Exchange-eligible individuals and employers 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.

Subtitle B--Public Health Insurance Option

Sec. 221. Establishment and administration of a public health insurance option 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.

Subtitle C--Individual Affordability Credits

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.

TITLE III--SHARED RESPONSIBILITY

Subtitle A--Individual Responsibility


Sec. 301. Individual responsibility.

Subtitle B--Employer Responsibility

PART 1--HEALTH COVERAGE PARTICIPATION REQUIREMENTS

Sec. 311. Health coverage participation requirements.
Sec. 312. Employer responsibility to contribute towards employee and dependent coverage.
Sec. 313. Employer contributions in lieu of coverage.
Sec. 314. Authority related to improper steering.

PART 2--SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS

Sec. 321. Satisfaction of health coverage participation requirements under the Employee
Retirement Income Security Act of 1974.
Sec. 322. Satisfaction of health coverage participation requirements under the Internal Revenue Code of 1986.
Sec. 323. Satisfaction of health coverage participation requirements under the Public Health Service Act.
Sec. 324. Additional rules relating to health coverage participation requirements.

TITLE IV--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986


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Subtitle A--Shared Responsibility

PART 1--INDIVIDUAL RESPONSIBILITY

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

PART 2--EMPLOYER RESPONSIBILITY

Sec. 411. Election to satisfy health coverage participation requirements.
Sec. 412. Responsibilities of nonelecting employers.

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

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

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

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

Subtitle D--Other Revenue Provisions
PART 1--GENERAL PROVISIONS

Sec. 441. Surcharge on high income individuals.
Sec. 442. Delay in application of worldwide allocation of interest.

PART 2--PREVENTION 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.--Except as otherwise provided, in this division:
(1) ACCEPTABLE COVERAGE.--The term ''acceptable coverage'' has the meaning given such term in section 202(d)(2).
(2) BASIC PLAN.--The term ''basic plan'' has the meaning given such term in section 203(c).
(3) COMMISSIONER.--The term ''Commissioner'' means the Health Choices Commissioner established under section 141.
(4) COST-SHARING.--The term ''cost-sharing'' includes deductibles, coinsurance, copayments, and


P. 9

similar charges but does not include premiums or any network payment differential for covered services or spending for non-covered services.

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

(6) EMPLOYMENT-BASED HEALTH PLAN.--The term ''employment-based health plan''--

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

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

(i) FEDERAL, STATE, AND TRIBAL GOVERNMENTAL PLANS.--A governmental plan (as defined in section 3(32) of the Employee Retirement Income Security Act of 1974), including a health benefits plan offered under chapter 89 of title 5, United States Code.
(ii) CHURCH PLANS.--A church plan (as defined in section 3(33) of the Employee Retirement Income Security Act of 1974).


P. 10

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

(8) ESSENTIAL BENEFITS PACKAGE.--The term ''essential benefits package'' is defined in section 122(a).

(9) FAMILY.--The term ''family'' means an individual and includes the individual's dependents.

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

(11) HEALTH BENEFITS PLAN.--The terms ''health benefits plan'' means health insurance coverage and an employment-based health plan and includes the public health insurance option.

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

(13) HEALTH INSURANCE EXCHANGE.--The term ''Health Insurance Exchange'' means the


P. 11

Health Insurance Exchange established under section 201.

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

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

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

(17) PLAN YEAR.--The term ''plan year'' means--

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

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

(18) PREMIUM PLAN; PREMIUM-PLUS PLAN.--The terms ''premium plan'' and ''premium-plus


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plan'' have the meanings given such terms in section 203(c).

(19) QHBP OFFERING ENTITY.--The terms ''QHBP offering entity'' means, with respect to a
health benefits plan that is--

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

(B) health insurance coverage, the health insurance issuer offering the coverage;

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

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

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

(20) QUALIFIED HEALTH BENEFITS PLAN.--The term ''qualified health benefits plan'' means a
health benefits plan that meets the requirements for such a plan under title I and includes the public health insurance option.

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

(22) SERVICE AREA; PREMIUM RATING AREA.--The terms ''service area'' and ''premium rating area'' mean with respect to health insurance coverage--

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

(B) offered through the Health Insurance Exchange, such an area as established by such entity in accordance with applicable State law


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and applicable rules of the Commissioner for Exchange-participating health benefits plans.

(23) STATE.--The term ''State'' means the 50 States and the District of Columbia.

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

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

TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS
Subtitle A--General Standards

SEC. 101. REQUIREMENTS REFORMING HEALTH INSURANCE MARKETPLACE.

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


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(b) REQUIREMENTS FOR QUALIFIED HEALTH BENEFITS PLANS.--On or after the first day of Y1, a health benefits plan shall not be a qualified health benefits plan under this division unless the plan meets the applicable requirements of the following subtitles for the type of plan and plan year involved:

(1) Subtitle B (relating to affordable coverage).
(2) Subtitle C (relating to essential benefits).
(3) Subtitle D (relating to consumer protection).

(c) TERMINOLOGY.--In this division:

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

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


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

(a) GRANDFATHERED HEALTH INSURANCE COVERAGE DEFINED.--Subject to the succeeding provisions of this section, for purposes of establishing acceptable coverage under this division, the term ''grandfathered health insurance coverage'' means individual health insurance coverage that is offered and in force and effect before the first day of Y1 if the following conditions are met:

(1) LIMITATION ON NEW ENROLLMENT.--

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

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

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


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

(b) GRACE PERIOD FOR CURRENT EMPLOYMENT-BASED HEALTH PLANS.--

(1) GRACE PERIOD.--

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

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


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

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

(iii) Such other limited benefits as the Commissioner may specify. In no case shall an employment-based health plan in which the coverage consists only of one or more of the coverage or benefits described in clauses (i) through (iii) be treated as acceptable coverage under this division

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

(c) LIMITATION ON INDIVIDUAL HEALTH INSURANCE COVERAGE.--


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

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

Subtitle B--Standards Guaranteeing Access to Affordable Coverage

SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS.

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


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2791(d)(9) of the Public Health Service Act) in relation to the individual or dependent.

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

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


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SEC. 113. INSURANCE RATING RULES.

(a) IN GENERAL.--The premium rate charged for an insured qualified health benefits plan may not vary except as follows:

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

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

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

(b) STUDY AND REPORTS.--

(1) STUDY.--The Commissioner, in coordination with the Secretary of Health and Human Services and the Secretary of Labor, shall conduct a study of the large group insured and self-insured


P. 22

employer health care markets. Such study shall examine the following:

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

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

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

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

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

(2) REPORTS.--Not later than 18 months after the date of the enactment of this Act, the Commissioner shall submit to Congress and the applicable agencies a report on the study conducted under paragraph (1). Such report shall include any recommendations the Commissioner deems appropriate to ensure that the law does not provide incentives


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for small and mid-size employers to self-insure or create adverse selection in the risk pools of large group insurers and self-insured employers. Not later than 18 months after the first day of Y1, the Commissioner shall submit to Congress and the applicable agencies an updated report on such study, including updates on such recommendations.

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

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

(b) PARITY IN MENTAL HEALTH AND SUBSTANCE ABUSE DISORDER BENEFITS.--To the extent such provisions are not superceded by or inconsistent with subtitle C, the provisions of section 2705 (other than subsections (a)(1), (a)(2), and (c)) of section 2705 of the Public Health Service Act shall apply to a qualified health benefits plan, regardless of whether it is offered in the


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individual or group market, in the same manner as such provisions apply to health insurance coverage offered in the large group market.

SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS.

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

(b) PROVIDER NETWORK DEFINED.--In this division, the term ''provider network'' means the providers with respect to which covered benefits, treatments, and services are available under a health benefits plan.

SEC. 116. ENSURING VALUE AND LOWER PREMIUMS.

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


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

Subtitle C--Standards Guaranteeing Access to Essential Benefits

SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE.

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

(b) CHOICE OF COVERAGE.--

(1) NON-EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS.--In the case of a qualified health benefits plan that is not an Exchange-participating health benefits plan, such plan may offer such


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coverage in addition to the essential benefits package as the QHBP offering entity may specify.

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

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

(c) NO RESTRICTIONS ON COVERAGE UNRELATED TO CLINICAL APPROPRIATENESS.--A qualified health benefits plan may not impose any restriction (other than cost-sharing) unrelated to clinical appropriateness on the coverage of the health care items and services.

SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.

(a) INGENERAL.--In this division, the term ''essential benefits package'' means health benefits coverage, consistent with standards adopted under section 124 to


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ensure the provision of quality health care and financial security, that--
(1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice;
(2) limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c);
(3) does not impose any annual or lifetime limit on the coverage of covered health care items and services;
(4) complies with section 115(a) (relating to network adequacy); and
(5) is equivalent, as certified by Office of the Actuary of the Centers for Medicare & Medicaid
Services, to the average prevailing employer-sponsored coverage.
(b) MINIMUM SERVICES TO BE COVERED.--The items and services described in this subsection are the following:
(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic and outpatient clinic services, including emergency department services.

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(3) Professional services of physicians and other health professionals.
(4) Such services, equipment, and supplies incident to the services of a physician's or a health professional's delivery of care in institutional settings, physician offices, patients' homes or place of residence, or other settings, as appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services.
(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention.
(9) Maternity care.
(10) Well baby and well child care and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age.
(c) REQUIREMENTS RELATING TO COST-SHARING AND MINIMUM ACTUARIAL VALUE.--
(1) NO COST-SHARING FOR PREVENTIVE SERVICES.--There shall be no cost-sharing under the essential benefits package for preventive items and

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services (as specified under the benefit standards), including well baby and well child care.
(2) ANNUAL LIMITATION.--
(A) ANNUAL LIMITATION.--The cost-sharing incurred under the essential benefits package with respect to an individual (or family) for a year does not exceed the applicable level specified in subparagraph (B).
(B) APPLICABLE LEVEL.--The applicable level specified in this subparagraph for Y1 is $5,000 for an individual and $10,000 for a family. Such levels shall be increased (rounded to the nearest $100) for each subsequent year by the annual percentage increase in the Consumer Price Index (United States city average) applicable to such year.
(C) USE OF COPAYMENTS.--In establishing cost-sharing levels for basic, enhanced, and premium plans under this subsection, the Secretary shall, to the maximum extent possible, use only copayments and not coinsurance.
(3) MINIMUM ACTUARIAL VALUE.--
(A) IN GENERAL.--The cost-sharing under the essential benefits package shall be designed to provide a level of coverage that is designed

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to provide benefits that are actuarially equivalent to approximately 70 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph (B).
(B) REFERENCE BENEFITS PACKAGE DE-
SCRIBED.--The reference benefits package described in this subparagraph is the essential benefits package if there were no cost-sharing imposed.

SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE.

(a) ESTABLISHMENT.--
(1) IN GENERAL.--There is established a private-public advisory committee which shall be a panel of medical and other experts to be known as the Health Benefits Advisory Committee to recommend covered benefits and essential, enhanced, and premium plans.
(2) CHAIR.--The Surgeon General shall be a member and the chair of the Health Benefits Advisory Committee.
(3) MEMBERSHIP.--The Health Benefits Advisory Committee shall be composed of the following members, in addition to the Surgeon General:

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(A) 9 members who are not Federal employees or officers and who are appointed by
the President.
(B) 9 members who are not Federal employees or officers and who are appointed by the Comptroller General of the United States in a manner similar to the manner in which the Comptroller General appoints members to the Medicare Payment Advisory Commission under section 1805(c) of the Social Security Act.
(C) Such even number of members (not to exceed 8) who are Federal employees and officers, as the President may appoint. Such initial appointments shall be made not later than 60 days after the date of the enactment of this Act.
(4) TERMS.--Each member of the Health Benefits Advisory Committee shall serve a 3-year term on the Committee, except that the terms of the initial members shall be adjusted in order to provide for a staggered term of appointment for all such members.
(5) PARTICIPATION.--The membership of the Health Benefits Advisory Committee shall at least reflect providers, consumer representatives, employ-

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ers, labor, health insurance issuers, experts in health care financing and delivery, experts in racial and ethnic disparities, experts in care for those with disabilities, representatives of relevant governmental agencies. and at least one practicing physician or other health professional and an expert on children's health and shall represent a balance among various sectors of the health care system so that no single sector unduly influences the recommendations of such Committee.
(b) DUTIES.--
(1) RECOMMENDATIONS ON BENEFIT STANDARDS.--The Health Benefits Advisory Committee shall recommend to the Secretary of Health and Human Services (in this subtitle referred to as the ''Secretary'') benefit standards (as defined in paragraph (4)), and periodic updates to such standards. In developing such recommendations, the Committee shall take into account innovation in health care and consider how such standards could reduce health disparities.
(2) DEADLINE.--The Health Benefits Advisory Committee shall recommend initial benefit standards to the Secretary not later than 1 year after the date of the enactment of this Act.

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(3) PUBLIC INPUT.--The Health Benefits Advisory Committee shall allow for public input as a part of developing recommendations under this subsection.
(4) BENEFIT STANDARDS DEFINED.--In this subtitle, the term ''benefit standards'' means standards respecting--
(A) the essential benefits package described in section 122, including categories of covered treatments, items and services within benefit classes, and cost-sharing; and
(B) the cost-sharing levels for enhanced plans and premium plans (as provided under section 203(c)) consistent with paragraph (5).
(5) LEVELS OF COST-SHARING FOR ENHANCED AND PREMIUM PLANS.--
(A) ENHANCED PLAN.--The level of costsharing for enhanced plans shall be designed so that such plans have benefits that are actuarially equivalent to approximately 85 percent of the actuarial value of the benefits provided under the reference benefits package described in section 122(c)(3)(B).
(B) PREMIUM PLAN.--The level of costsharing for premium plans shall be designed so

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that such plans have benefits that are actuarially equivalent to approximately 95 percent of the actuarial value of the benefits provided under the reference benefits package described in section 122(c)(3)(B).
(c) OPERATIONS.--
(1) PER DIEM PAY.--Each member of the Health Benefits Advisory Committee shall receive travel expenses, including per diem in accordance with applicable provisions under subchapter I of chapter 57 of title 5, United States Code, and shall otherwise serve without additional pay.
(2) MEMBERS NOT TREATED AS FEDERAL EMPLOYEES.--Members of the Health Benefits Advisory Committee shall not be considered employees of the Federal government solely by reason of any service on the Committee.
(3) APPLICATION OF FACA.--The Federal Advisory Committee Act (5 U.S.C. App.), other than section 14, shall apply to the Health Benefits Advisory Committee.
(d) PUBLICATION.--The Secretary shall provide for publication in the Federal Register and the posting on the Internet website of the Department of Health and Human

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Services of all recommendations made by the Health Benefits Advisory Committee under this section.

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

(a) PROCESS FOR ADOPTION OF RECOMMENDATIONS.--
(1) REVIEW OF RECOMMENDED STANDARDS.-- Not later than 45 days after the date of receipt of benefit standards recommended under section 123 (including such standards as modified under paragraph (2)(B)), the Secretary shall review such standards and shall determine whether to propose adoption of such standards as a package.
(2) DETERMINATION TO ADOPT STANDARDS.-- If the Secretary determines--
(A) to propose adoption of benefit standards so recommended as a package, the Secretary shall, by regulation under section 553 of title 5, United States Code, propose adoption such standards; or
(B) not to propose adoption of such standards as a package, the Secretary shall notify the Health Benefits Advisory Committee in writing of such determination and the reasons for not proposing the adoption of such rec-

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ommendation and provide the Committee with a further opportunity to modify its previous recommendations and submit new recommendations to the Secretary on a timely basis.
(3) CONTINGENCY.--If, because of the application of paragraph (2)(B), the Secretary would otherwise be unable to propose initial adoption of such recommended standards by the deadline specified in subsection (b)(1), the Secretary shall, by regulation under section 553 of title 5, United States Code, propose adoption of initial benefit standards by such deadline.
(4) PUBLICATION.--The Secretary shall provide for publication in the Federal Register of all determinations made by the Secretary under this subsection.
(b) ADOPTION OF STANDARDS.--
(1) INITIAL STANDARDS.--Not later than 18 months after the date of the enactment of this Act, the Secretary shall, through the rulemaking process consistent with subsection (a), adopt an initial set of benefit standards.
(2) PERIODIC UPDATING STANDARDS.--Under subsection (a), the Secretary shall provide for the

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periodic updating of the benefit standards previously adopted under this section.
(3) REQUIREMENT.--The Secretary may not adopt any benefit standards for an essential benefits package or for level of cost-sharing that are inconsistent with the requirements for such a package or level under sections 122 and 123(b)(5).
Subtitle D--Additional Consumer Protections

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

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

SEC. 132. REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS.

(a) INGENERAL.--A QHBP offering entity shall provide for timely grievance and appeals mechanisms that the Commissioner shall establish.
(b) INTERNAL CLAIMS AND APPEALS PROCESS.-- Under a qualified health benefits plan the QHBP offering entity shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section
2560.503-1 of title 29, Code of Federal Regulations, as

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published on November 21, 2000 (65 Fed. Reg. 70246) and shall update such process in accordance with any standards that the Commissioner may establish.
(c) EXTERNAL REVIEW PROCESS.--
(1) IN GENERAL.--The Commissioner shall establish an external review process (including procedures for expedited reviews of urgent claims) that provides for an impartial, independent, and de novo review of denied claims under this division.
(2) REQUIRING FAIR GRIEVANCE AND APPEALS
MECHANISMS.--A determination made, with respect to a qualified health benefits plan offered by a QHBP offering entity, under the external review process established under this subsection shall be binding on the plan and the entity.
(d) CONSTRUCTION.--Nothing in this section shall be construed as affecting the availability of judicial review under State law for adverse decisions under subsection (b)
or (c), subject to section 151.

SEC. 133. REQUIRING INFORMATION TRANSPARENCY AND PLAN DISCLOSURE.

(a) ACCURATE AND TIMELY DISCLOSURE.--
(1) IN GENERAL.--A qualified health benefits plan shall comply with standards established by the Commissioner for the accurate and timely disclosure

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of plan documents, plan terms and conditions, claims payment policies and practices, periodic financial disclosure, data on enrollment, data on disenrollment, data on the number of claims denials, data on rating practices, information on cost-sharing and payments with respect to any out-of-network coverage, and other information as determined appropriate by the Commissioner. The Commissioner shall require that such disclosure be provided in plain language.
(2) PLAIN LANGUAGE.--In this subsection, the term ''plain language'' means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is clean, concise, well-organized, and follows other best practices of plain language writing.
(3) GUIDANCE.--The Commissioner shall develop and issue guidance on best practices of plain language writing.
(b) CONTRACTING REIMBURSEMENT.--A qualified health benefits plan shall comply with standards established by the Commissioner to ensure transparency to each health care provider relating to reimbursement arrangements between such plan and such provider.

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(c) ADVANCE NOTICE OF PLAN CHANGES.--A change in a qualified health benefits plan shall not be made without such reasonable and timely advance notice to enrollees of such change.

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

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

SEC. 135. TIMELY PAYMENT OF CLAIMS.

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

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

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

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SEC. 137. APPLICATION OF ADMINISTRATIVE SIMPLIFICTION.

A QHBP offering entity is required to comply with standards for electronic financial and administrative transactions under section 1173A of the Social Security
Act, added by section 163(a).
Subtitle E--Governance

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

(a) IN GENERAL.--There is hereby established, as an independent agency in the executive branch of the Government, a Health Choices Administration (in this division referred to as the ''Administration'').
(b) COMMISSIONER.--
(1) IN GENERAL.--The Administration shall be headed by a Health Choices Commissioner (in this division referred to as the ''Commissioner'') who shall be appointed by the President, by and with the advice and consent of the Senate.
(2) COMPENSATION; ETC.--The provisions of paragraphs (2), (5) and (7) of subsection (a) (relating to compensation, terms, general powers, rulemaking, and delegation) of section 702 of the Social Security Act (42 U.S.C. 902) shall apply to the Commissioner and the Administration in the same manner as such provisions apply to the Commis-

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sioner of Social Security and the Social Security Administration.

SEC. 142. DUTIES AND AUTHORITY OF COMMISSIONER.

(a) DUTIES.--The Commissioner is responsible for carrying out the following functions under this division:
(1) QUALIFIED PLAN STANDARDS.--The establishment of qualified health benefits plan standards under this title, including the enforcement of such standards in coordination with State insurance regulators and the Secretaries of Labor and the Treasury.
(2) HEALTH INSURANCE EXCHANGE.--The establishment and operation of a Health Insurance Exchange under subtitle A of title II.
(3) INDIVIDUAL AFFORDABILITY CREDITS.-- The administration of individual affordability credits under subtitle C of title II, including determination of eligibility for such credits.
(4) ADDITIONAL FUNCTIONS.--Such additional functions as may be specified in this division.
(b) PROMOTING ACCOUNTABILITY.--
(1) IN GENERAL.--The Commissioner shall undertake activities in accordance with this subtitle to promote accountability of QHBP offering entities in meeting Federal health insurance requirements, re-

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gardless of whether such accountability is with respect to qualified health benefits plans offered through the Health Insurance Exchange or outside of such Exchange.
(2) COMPLIANCE EXAMINATION AND AUDITS.--
(A) IN GENERAL.--The commissioner shall, in coordination with States, conduct audits of qualified health benefits plan compliance with Federal requirements. Such audits may include random compliance audits and targeted audits in response to complaints or other suspected non-compliance.
(B) RECOUPMENT OF COSTS IN CONNECTION WITH EXAMINATION AND AUDITS.--The Commissioner is authorized to recoup from qualified health benefits plans reimbursement
for the costs of such examinations and audit of such QHBP offering entities.
(c) DATA COLLECTION.--The Commissioner shall collect data for purposes of carrying out the Commissioner's duties, including for purposes of promoting quality and value, protecting consumers, and addressing disparities in health and health care and may share such data with the Secretary of Health and Human Services.
(d) SANCTIONS AUTHORITY.--

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(1) IN GENERAL.--In the case that the Commissioner determines that a QHBP offering entity violates a requirement of this title, the Commissioner may, in coordination with State insurance regulators and the Secretary of Labor, provide, in addition to any other remedies authorized by law, for any of the remedies described in paragraph (2).
(2) REMEDIES.--The remedies described in this paragraph, with respect to a qualified health benefits plan offered by a QHBP offering entity, are--
(A) civil money penalties of not more than the amount that would be applicable under similar circumstances for similar violationsunder section 1857(g) of the Social Security Act;
(B) suspension of enrollment of individuals under such plan after the date the Commissioner notifies the entity of a determination under paragraph (1) and until the Commissioner is satisfied that the basis for such determination has been corrected and is not likely to recur;
(C) in the case of an Exchange-participating health benefits plan, suspension of payment to the entity under the Health Insurance

P. 45

Exchange for individuals enrolled in such plan after the date the Commissioner notifies the entity of a determination under paragraph (1) and until the Secretary is satisfied that the basis for such determination has been corrected and is not likely to recur; or
(D) working with State insurance regulators to terminate plans for repeated failure by the offering entity to meet the requirements of this title.
(e) STANDARD DEFINITIONS OF INSURANCE AND MEDICAL TERMS.--The Commissioner shall provide for the development of standards for the definitions of terms used in health insurance coverage, including insurance-related terms.
(f) EFFICIENCY IN ADMINISTRATION.--The Commissioner shall issue regulations for the effective and efficient administration of the Health Insurance Exchange and affordability credits under subtitle C, including, with respect to the determination of eligibility for affordability credits, the use of personnel who are employed in accordance with the requirements of title 5, United States Code, to carry out the duties of the Commissioner or, in the case of sections 208 and 241(b)(2), the use of State personnel who are employed in accordance with standards prescribed by

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the Office of Personnel Management pursuant to section 208 of the Intergovernmental Personnel Act of 1970 (42 U.S.C. 4728).

SEC. 143. CONSULTATION AND COORDINATION.

(a) CONSULTATION.--In carrying out the Commissioner's duties under this division, the Commissioner, as appropriate, shall consult with at least with the following:
(1) The National Association of Insurance Commissioners, State attorneys general, and State insurance regulators, including concerning the standards for insured qualified health benefits plans under this title and enforcement of such standards.
(2) Appropriate State agencies, specifically concerning the administration of individual affordability credits under subtitle C of title II and the offering of Exchange-participating health benefits plans, to Medicaid eligible individuals under subtitle A of such title.
(3) Other appropriate Federal agencies.
(4) Indian tribes and tribal organizations.
(5) The National Association of Insurance Commissioners for purposes of using model guidelines established by such association for purposes of subtitles B and D.
(b) COORDINATION.--

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(1) IN GENERAL.--In carrying out the functions of the Commissioner, including with respect to
the enforcement of the provisions of this division, the Commissioner shall work in coordination with existing Federal and State entities to the maximum extent feasible consistent with this division and in a manner that prevents conflicts of interest in duties and ensures effective enforcement.
(2) UNIFORM STANDARDS.--The Commissioner, in coordination with such entities, shall seek to achieve uniform standards that adequately protect consumers in a manner that does not unreasonably affect employers and insurers.

SEC. 144. HEALTH INSURANCE OMBUDSMAN.

(a) INGENERAL.--The Commissioner shall appoint within the Health Choices Administration a Qualified Health Benefits Plan Ombudsman who shall have expertise and experience in the fields of health care and education of (and assistance to) individuals.
(b) DUTIES.--The Qualified Health Benefits Plan
Ombudsman shall, in a linguistically appropriate manner--
(1) receive complaints, grievances, and requests for information submitted by individuals;


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(2) provide assistance with respect to complaints, grievances, and requests referred to in paragraph (1), including--
(A) helping individuals determine the relevant information needed to seek an appeal of a decision or determination;
(B) assistance to such individuals with any problems arising from disenrollment from such a plan;
(C) assistance to such individuals in choosing a qualified health benefits plan in which to enroll; and
(D) assistance to such individuals in presenting information under subtitle C (relating to affordability credits); and
(3) submit annual reports to Congress and the Commissioner that describe the activities of the Ombudsman and that include such recommendations for improvement in the administration of this division as the Ombudsman determines appropriate. The Ombudsman shall not serve as an advocate for any increases in payments or
(3) submit annual reports to Congress and the Commissioner that describe the activities of the Ombudsman and that include such recommendations for improvement in the administration of this division as the Ombudsman determines appropriate. The Ombudsman shall not serve as an advocate for any increases in payments or new coverage of services, but may identify issues and problems in payment or coverage policies.


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Subtitle F--Relation to Other Requirements; Miscellaneous

SEC. 151. RELATION TO OTHER REQUIREMENTS.

(a) COVERAGE NOT OFFERED THROUGH EXCHANGE.--
(1) IN GENERAL.--In the case of health insurance coverage not offered through the Health Insurance Exchange (whether or not offered in connection with an employment-based health plan), and in the case of employment-based health plans, the requirements of this title do not supercede any requirements applicable under titles XXII and XXVII of
the Public Health Service Act, parts 6 and 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974, or State law, except insofar as such requirements prevent the application of a requirement of this division, as determined by the
Commissioner.
(2) CONSTRUCTION.--Nothing in paragraph (1) shall be construed as affecting the application of section 514 of the Employee Retirement Income Security Act of 1974.
(b) COVERAGE OFFERED THROUGH EXCHANGE.--

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(1) INGENERAL.--In the case of health insurance coverage offered through the Health Insurance
Exchange--
(A) the requirements of this title do not supercede any requirements (including requirements relating to genetic information nondiscrimination and mental health) applicable under title XXVII of the Public Health Service Act or under State law, except insofar as such requirements prevent the application of a requirement of this division, as determined by the Commissioner; and
(B) individual rights and remedies under State laws shall apply.
(2) CONSTRUCTION.--In the case of coverage described in paragraph (1), nothing in such paragraph shall be construed as preventing the application of rights and remedies under State laws with respect to any requirement referred to in paragraph
(1)(A).

SEC. 152. PROHIBITING DISCRIMINATION IN HEALTH CARE.

(a) INGENERAL.--Except as otherwise explicitly permitted by this Act and by subsequent regulations consistent with this Act, all health care and related services (including insurance coverage and public health activities)...


Continued on Part 2: Pages 50-100


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