HUFFINGTON POST
08/14/2009 05:12 am ET | Updated May 25, 2011

House Health Care BIll (Pages 51-100)

House Health Care Bill (Pages 51-100)

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covered by this Act shall be provided without regard to personal characteristics extraneous to the provision of high quality health care or related services.

(b) IMPLEMENTATION.--To implement the requirement set forth in subsection (a), the Secretary of Health and Human Services shall, not later than 18 months after the date of the enactment of this Act, promulgate such regulations as are necessary or appropriate to insure that all health care and related services (including insurance coverage and public health activities) covered by this Act are provided (whether directly or through contractual, licensing, or other arrangements) without regard to personal characteristics extraneous to the provision of high quality health care or related services.

SEC. 153. WHISTLE BLOWER PROTECTION.

(a) RETALIATION PROHIBITED.--No employer may discharge any employee or otherwise discriminate against any employee with respect to his compensation, terms, conditions, or other privileges of employment because the employee (or any person acting pursuant to a request of the employee)--

(1) provided, caused to be provided, or is about to provide or cause to be provided to the employer, the Federal Government, or the attorney general of a State information relating to any violation of, or

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any act or omission the employee reasonably believes
to be a violation of any provision of this Act or any
order, rule, or regulation promulgated under this
Act;

(2) testified or is about to testify in a proceeding concerning such violation;

(3) assisted or participated or is about to assist or participate in such a proceeding; or

(4) objected to, or refused to participate in, any activity, policy, practice, or assigned task that the employee (or other such person) reasonably believed to be in violation of any provision of this Act or any order, rule, or regulation promulgated under this Act.

(b) ENFORCEMENT ACTION.--An employee covered
by this section who alleges discrimination by an employer in violation of subsection (a) may bring an action governed by the rules, procedures, legal burdens of proof, and remedies set forth in section 40(b) of the Consumer Product Safety Act (15 U.S.C. 2087(b)).

(c) EMPLOYER DEFINED.--As used in this section, the term ''employer'' means any person (including one or more individuals, partnerships, associations, corporations, trusts, professional membership organization including a
certification, disciplinary, or other professional body, unin-

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corporated organizations, nongovernmental organizations, or trustees) engaged in profit or nonprofit business or industry whose activities are governed by this Act, and any agent, contractor, subcontractor, grantee, or consultant of such person.

(d) RULE OF CONSTRUCTION.--The rule of construction set forth in section 20109(h) of title 49, United States Code, shall also apply to this section.

SEC. 154. CONSTRUCTION REGARDING COLLECTIVE BARGAINING.
Nothing in this division shall be construed to alter of supercede any statutory or other obligation to engage in collective bargaining over the terms and conditions of employment related to health care.

SEC. 155. SEVERABILITY.
If any provision of this Act, or any application of such provision to any person or circumstance, is held to be unconstitutional, the remainder of the provisions of this Act and the application of the provision to any other person or circumstance shall not be affected.

Subtitle G--Early Investments

SEC. 161. ENSURING VALUE AND LOWER PREMIUMS.

(a) GROUP HEALTH INSURANCE COVERAGE.--Title XXVII of the Public Health Service Act is amended by inserting after section 2713 the following new section:

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''SEC. 2714. ENSURING VALUE AND LOWER PREMIUMS."

(a) IN GENERAL.--Each health insurance issuer that offers health insurance coverage in the small or large group market shall provide that for any plan year in which the coverage has a medical loss ratio below a level specified by the Secretary, the issuer shall provide in a manner specified by the Secretary for rebates to enrollees of pay-ment sufficient to meet such loss ratio. Such methodology shall be set at the highest level medical loss ratio possible that is designed to ensure adequate participation by issuers, competition in the health insurance market, and value for consumers so that their premiums are used for services.

(b) UNIFORM DEFINITIONS.--The Secretary shall establish a uniform definition of medical loss ratio and methodology for determining how to calculate the medical loss ratio. Such methodology shall be designed to take into account the special circumstances of smaller plans, dif-ferent types of plans, and newer plans.''.

(b) INDIVIDUAL HEALTH INSURANCE COVERAGE.--
Such title is further amended by inserting after section 2753 the following new section:

''SEC. 2754. ENSURING VALUE AND LOWER PREMIUMS.
''The provisions of section 2714 shall apply to health insurance coverage offered in the individual market in the

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

(c) IMMEDIATE IMPLEMENTATION.--The amendments made by this section shall apply in the group and individual market for plan years beginning on or after
January 1, 2011.

SEC. 162. ENDING HEALTH INSURANCE RESCISSION ABUSE.

(a) CLARIFICATION REGARDING APPLICATION OF GUARANTEED RENEWABILITY OF INDIVIDUAL HEALTH INSURANCE COVERAGE.--Section 2742 of the Public Health Service Act (42 U.S.C. 300gg-42) is amended--

(1) in its heading, by inserting ''AND CONTINUATION IN FORCE, INCLUDING PROHIBITION OF RESCISSION,'' after ''GUARANTEED RENEWABILITY''; and

(2) in subsection (a), by inserting '', including without rescission,'' after ''continue in force''.

(b) SECRETARIAL GUIDANCE REGARDING RESCISSIONS.--Section 2742 of such Act (42 U.S.C. 300gg-42) is amended by adding at the end the following:

''(f) RESCISSION.--A health insurance issuer may rescind health insurance coverage only upon clear and convincing evidence of fraud described in subsection (b)(2). The Secretary, no later than July 1, 2010, shall issue

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guidance implementing this requirement, including procedures for independent, external third party review.''.

(c) OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD PARTY REVIEW IN CERTAIN CASES.--Subpart 1 of part B of title XXVII of such Act (42 U.S.C. 300gg-41 et seq.) is amended by adding at the end the following: ''SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD PARTY REVIEW IN CASES OF RESCISSION.

''(a) NOTICE AND REVIEW RIGHT.--If a health insurance issuer determines to rescind health insurance coverage for an individual in the individual market, before such rescission may take effect the issuer shall provide the individual with notice of such proposed rescission and an
opportunity for a review of such determination by an independent, external third party under procedures specified by the Secretary under section 2742(f).

''(b) INDEPENDENT DETERMINATION.--If the individual requests such review by an independent, external third party of a rescission of health insurance coverage, the coverage shall remain in effect until such third party determines that the coverage may be rescinded under the guidance issued by the Secretary under section 2742(f).''.

(d) EFFECTIVE DATE.--The amendments made by this section shall apply on and after October 1, 2010, with

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respect to health insurance coverage issued before, on, or after such date.

SEC. 163. ADMINISTRATIVE SIMPLIFICATION.

(a) STANDARDIZING ELECTRONIC ADMINISTRATIVE TRANSACTIONS.--

(1) IN GENERAL.--Part C of title XI of the Social Security Act (42 U.S.C. 1320d et seq.) is amended by inserting after section 1173 the following new section:

''SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE TRANSACTIONS.

''(a) STANDARDS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS.--

''(1) IN GENERAL.--The Secretary shall adopt and regularly update standards consistent with the goals described in paragraph (2).

''(2) GOALS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS.--The goals for standards under paragraph (1) are that such standards shall--
''(A) be unique with no conflicting or redundant standards;
''(B) be authoritative, permitting no additions or constraints for electronic transactions, including companion guides;


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''(C) be comprehensive, efficient and robust, requiring minimal augmentation by paper transactions or clarification by further communications;

''(D) enable the real-time (or near real time) determination of an individual's financial responsibility at the point of service and, to the extent possible, prior to service, including whether the individual is eligible for a specific service with a specific physician at a specific facility, which may include utilization of a machine-readable health plan beneficiary identification card;

''(E) enable, where feasible, near real-time adjudication of claims;

''(F) provide for timely acknowledgment, response, and status reporting applicable to any electronic transaction deemed appropriate by the Secretary;

''(G) describe all data elements (such as reason and remark codes) inunambiguous terms, notpermit optional fields, require that data elements be either required or conditioned upon set values in other fields, and prohibit ad-
ditional conditions; and

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''(H) harmonize all common data elements across administrative and clinical transaction standards.

''(3) TIME FOR ADOPTION.--Not later than 2 years after the date of implementation of the X12 Version 5010 transaction standards implemented under this part, the Secretary shall adopt standards under this section.

''(4) REQUIREMENTS FOR SPECIFIC STAND-ARDS.--The standards under this section shall be developed, adopted and enforced so as to--

''(A) clarify, refine, complete, and expand, as needed, the standards required under section 1173;

''(B) require paper versions of standard-ized transactions to comply with the same
standards as to data content such that a fully compliant, equivalent electronic transaction can be populated from the data from a paper
version;

''(C) enable electronic funds transfers, in order to allow automated reconciliation with the related health care payment and remittance ad-
vice;

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''(D) require timely and transparent claim and denial management processes, including tracking, adjudication, and appeal processing ;

''(E) require the use of a standard elec-tronic transaction with which health care pro-viders may quickly and efficiently enroll with a health plan to conduct the other electronic transactions provided for in this part; and

''(F) provide for other requirements relat-ing to administrative simplification as identified by the Secretary, in consultation with stake-
holders.

''(5) BUILDING ON EXISTING STANDARDS.--In developing the standards under this section, the Secretary shall build upon existing and planned stand-
ards.

''(6) IMPLEMENTATION AND ENFORCEMENT.-- Not later than 6 months after the date of the enactment of this section, the Secretary shall submit to the appropriate committees of Congress a plan for the implementation and enforcement, by not later than 5 years after such date of enactment, of the standards under this section. Such plan shall include--

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''(A) a process and timeframe with mile-stones for developing the complete set of stand-ards;

''(B) an expedited upgrade program for continually developing and approving additions and modifications to the standards as often as annually to improve their quality and extend their functionality to meet evolving require-ments in health care;

''(C) programs to provide incentives for, and ease the burden of, implementation for cer-tain health care providers, with special consid-eration given to such providers serving rural or underserved areas and ensure coordination with standards, implementation specifications, and certification criteria being adopted under the HITECH Act;

''(D) programs to provide incentives for, and ease the burden of, health care providers who volunteer to participate in the process of setting standards for electronic transactions;

''(E) an estimate of total funds needed to ensure timely completion of the implementation plan; and

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''(F) an enforcement process that includes timely investigation of complaints, random au-dits to ensure compliance, civil monetary and programmatic penalties for non-compliance con-sistent with existing laws and regulations, and a fair and reasonable appeals process building off of enforcement provisions under this part.

''(b) LIMITATIONS ON USE OF DATA.--Nothing in this section shall be construed to permit the use of infor-mation collected under this section in a manner that would adversely affect any individual.

''(c) PROTECTION OF DATA.--The Secretary shall en-sure (through the promulgation of regulations or other-wise) that all data collected pursuant to subsection (a) are--

''(1) used and disclosed in a manner that meets the HIPAA privacy and security law (as defined in section 3009(a)(2) of the Public Health Service Act), including any privacy or security standard adopted under section 3004 of such Act; and

''(2) protected from all inappropriate internal use by any entity that collects, stores, or receives the data, including use of such data in determinations of eligibility (or continued eligibility) in health plans,


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and from other inappropriate uses, as defined by the Secretary.''.

(2) DEFINITIONS.--Section 1171 of such Act (42 U.S.C. 1320d) is amended--

(A) in paragraph (7), by striking ''with reference to'' and all that follows and inserting ''with reference to a transaction or data element of health information in section 1173 means implementation specifications, certifi-cation criteria, operating rules, messaging formats, codes, and code sets adopted or estab-lished by the Secretary for the electronic exchange and use of information''; and

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

''(9) OPERATING RULES.--The term 'operating rules' means business rules for using and processing transactions. Operating rules should address the fol-
lowing:

''(A) Requirements for data content using available and established national standards.

''(B) Infrastructure requirements that es-tablish best practices for streamlining data flow to yield timely execution of transactions.

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''(C) Policies defining the transaction re- lated rights and responsibilities for entities that are transmitting or receiving data.''.

(3) CONFORMING AMENDMENT.--Section 1179(a) of such Act (42 U.S.C. 1320d-8(a)) is amended, in the matter before paragraph (1)--

(A) by inserting ''on behalf of an indi-vidual'' after ''1978)''; and

(B) by inserting ''on behalf of an indi-vidual'' after ''for a financial institution'' and

(b) STANDARDS FOR CLAIMS ATTACHMENTS AND COORDINATION OF BENEFITS.--

(1) STANDARD FOR HEALTH CLAIMS ATTACH-MENTS.--Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall promulgate a final rule to es-tablish a standard for health claims attachment transaction described in section 1173(a)(2)(B) of the Social Security Act (42 U.S.C. 1320d-2(a)(2)(B)) and coordination of benefits.

(2) REVISION IN PROCESSING PAYMENT TRANS-ACTIONS BY FINANCIAL INSTITUTIONS.--

(A) IN GENERAL.--Section 1179 of the Social Security Act (42 U.S.C. 1320d-8) is
amended, in the matter before paragraph (1)--

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(i) by striking ''or is engaged'' and inserting ''and is engaged''; and

(ii) by inserting ''(other than as a business associate for a covered entity)'' after ''for a financial institution''.

(B) EFFECTIVE DATE.--The amendments made by paragraph (1) shall apply to trans-actions occurring on or after such date (not later than 6 months after the date of the enact-ment of this Act) as the Secretary of Health and Human Services shall specify.

SEC. 164. REINSURANCE PROGRAM FOR RETIREES.

(a) ESTABLISHMENT.--

(1) IN GENERAL.--Not later than 90 days after the date of the enactment of this Act, the Secretary of Health and Human Services shall establish a temporary reinsurance program (in this section referred to as the ''reinsurance program'') to provide reimbursement to assist participating employment-based plans with the cost of providing health benefits to retirees and to eligible spouses, surviving spouses and dependents of such retirees.

(2) DEFINITIONS.--For purposes of this sec-
tion:

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(A) The term ''eligible employment-based plan'' means a group health benefits plan
that--

(i) is maintained by one or more em-ployers, former employers or employee associations, or a voluntary employees' beneficiary association, or a committee or board of individuals appointed to administer such plan, and

(ii) provides health benefits to retirees.

(B) The term ''health benefits'' means medical, surgical, hospital, prescription drug,
and such other benefits as shall be determined by the Secretary, whether self-funded or delivered through the purchase of insurance or oth-
erwise.

(C) The term ''participating employment-based plan'' means an eligible employment-based plan that is participating in the reinsurance program.

(D) The term ''retiree'' means, with respect to a participating employment-benefit
plan, an individual who--

(i) is 55 years of age or older;

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(ii) is not eligible for coverage under title XVIII of the Social Security Act; and

(iii) is not an active employee of an employer maintaining the plan or of any
employer that makes or has made substantial contributions to fund such plan.

(E) The term ''Secretary'' means Secretary of Health and Human Services.

(b) PARTICIPATION.--To be eligible to participate in the reinsurance program, an eligible employment-based plan shall submit to the Secretary an application for participation in the program, at such time, in such manner, and containing such information as the Secretary shall require.

(c) PAYMENT.--

(1) SUBMISSION OF CLAIMS.--

(A) IN GENERAL.--Under the reinsurance program, a participating employment-based plan shall submit claims for reimbursement to the Secretary which shall contain documentation of the actual costs of the items and services for which each claim is being submitted.

(B) BASIS FOR CLAIMS.--Each claim submitted under subparagraph (A) shall be based on the actual amount expended by the partici-

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pating employment-based plan involved within the plan year for the appropriate employment based health benefits provided to a retiree or to the spouse, surviving spouse, or dependent of a retiree. In determining the amount of any claim for purposes of this subsection, the participating employment-based plan shall take into account any negotiated price concessions (such as discounts, direct or indirect subsidies, rebates, and direct or indirect remunerations) obtained by such plan with respect to such health benefits. For purposes of calculating the amount of any claim, the costs paid by the retiree or by the spouse, surviving spouse, or dependent of the retiree in the form of deductibles, co-payments, and co-insurance shall be included along with the amounts paid by the participating employment-based plan.

(2) PROGRAM PAYMENTS AND LIMIT.--If the Secretary determines that a participating employment-based plan has submitted a valid claim under paragraph (1), the Secretary shall reimburse such plan for 80 percent of that portion of the costs attributable to such claim that exceeds $15,000, but is less than $90,000. Such amounts shall be adjusted

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each year based on the percentage increase in the medical care component of the Consumer Price Index (rounded to the nearest multiple of $1,000) for the year involved.

(3) USE OF PAYMENTS.--Amounts paid to a participating employment-based plan under this subsection shall be used to lower the costs borne directly by the participants and beneficiaries for health benefits provided under such plan in the form of premiums, co-payments, deductibles, co-insurance, or other out-of-pocket costs. Such payments shall not be used to reduce the costs of an employer maintaining the participating employment-based plan. The Secretary shall develop a mechanism to monitor the appropriate use of such payments by such plans.

(4) APPEALS AND PROGRAM PROTECTIONS.--
The Secretary shall establish--

(A) an appeals process to permit participating employment-based plans to appeal a determination of the Secretary with respect to claims submitted under this section; and

(B) procedures to protect against fraud, waste, and abuse under the program.

(5) AUDITS.--The Secretary shall conduct annual audits of claims data submitted by partici-

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pating employment-based plans under this section to ensure that they are in compliance with the requirements of this section.

(d) RETIREE RESERVE TRUST FUND.--

(1) ESTABLISHMENT.--

(A) IN GENERAL.--There is established in the Treasury of the United States a trust fund to be known as the ''Retiree Reserve Trust Fund'' (referred to in this section as the ''Trust Fund''), that shall consist of such amounts as may be appropriated or credited to the Trust Fund as provided for in this subsection to enable the Secretary to carry out the reinsurance program. Such amounts shall remain available until expended.

(B) FUNDING.--There are hereby appropriated to the Trust Fund, out of any moneys in the Treasury not otherwise appropriated, an amount requested by the Secretary as necessary to carry out this section, except that the total of all such amounts requested shall not exceed $10,000,000,000.

(C) APPROPRIATIONS FROM THE TRUST
FUND.--

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(i) IN GENERAL.--Amounts in the Trust Fund are appropriated to provide funding to carry out the reinsurance program and shall be used to carry out such program.

(ii) BUDGETARY IMPLICATIONS.-- Amounts appropriated under clause (i), and outlays flowing from such appropriations, shall not be taken into account for
purposes of any budget enforcement procedures including allocations under section 302(a) and (b) of the Balanced Budget and Emergency Deficit Control Act and budget resolutions for fiscal years during which appropriations are made from the Trust Fund.
(iii) LIMITATION TO AVAILABLE FUNDS.--The Secretary has the authority to stop taking applications for participa-tion in the program or take such other steps in reducing expenditures under the reinsurance program in order to ensure that expenditures under the reinsurance program do not exceed the funds available
under this subsection.

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TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

Subtitle A--Health Insurance Exchange

SEC. 201. ESTABLISHMENT OF HEALTH INSURANCE EXCHANGE; OUTLINE OF DUTIES; DEFINITIONS.

(a) ESTABLISHMENT.--There is established within the Health Choices Administration and under the direction of the Commissioner a Health Insurance Exchange in order to facilitate access of individuals and employers, through a transparent process, to a variety of choices of affordable, quality health insurance coverage, including a public health insurance option.

(b) OUTLINE OF DUTIES OF COMMISSIONER.--In accordance with this subtitle and in coordination with appropriate Federal and State officials as provided under section 143(b), the Commissioner shall--

(1) under section 204 establish standards for, accept bids from, and negotiate and enter into contracts with, QHBP offering entities for the offering
of health benefits plans through the Health Insurance Exchange, with different levels of benefits required under section 203, and including with respect to oversight and enforcement;

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(2) under section 205 facilitate outreach and enrollment in such plans of Exchange-eligible individuals and employers described in section 202; and

(3) conduct such activities related to the Health Insurance Exchange as required, including establishment of a risk pooling mechanism under section 206 and consumer protections under subtitle D of title I.

(c) EXCHANGE-PARTICIPATING HEALTH BENEFITS PLAN DEFINED.--In this division, the term ''Exchange-participating health benefits plan'' means a qualified
health benefits plan that is offered through the Health Insurance Exchange.

SEC. 202. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS.

(a) ACCESS TO COVERAGE.--In accordance with this section, all individuals are eligible to obtain coverage through enrollment in an Exchange-participating health
benefits plan offered through the Health Insurance Exchange unless such individuals are enrolled in another qualified health benefits plan or other acceptable coverage.

(b) DEFINITIONS.--In this division:

(1) EXCHANGE-ELIGIBLE INDIVIDUAL.--The term ''Exchange-eligible individual'' means an individual who is eligible under this section to be enrolled through the Health Insurance Exchange in an


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Exchange-participating health benefits plan and, with respect to family coverage, includes dependents of such individual.

(2) EXCHANGE-ELIGIBLE EMPLOYER.--The term ''Exchange-eligible employer'' means an employer that is eligible under this section to enroll through the Health Insurance Exchange employees of the employer (and their dependents) in Exchange-eligible health benefits plans.

(3) EMPLOYMENT-RELATED DEFINITIONS.-- The terms ''employer'', ''employee'', ''full-time employee'', and ''part-time employee'' have the meanings given such terms by the Commissioner for purposes of this division.

(c) TRANSITION.--Individuals and employers shall only be eligible to enroll or participate in the Health Insurance Exchange in accordance with the following transition schedule:

(1) FIRST YEAR.--In Y1 (as defined in section 100(c))--

(A) individuals described in subsection (d)(1), including individuals described in paragraphs (3) and (4) of subsection (d); and

(B) smallest employers described in sub-
section (e)(1).

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(2) SECOND YEAR.--In Y2--

(A) individuals and employers described in paragraph (1); and

(B) smaller employers described in sub-section (e)(2).

(3) THIRD AND SUBSEQUENT YEARS.--In Y3 and subsequent years--

(A) individuals and employers described in paragraph (2); and

(B) larger employers as permitted by the Commissioner under subsection (e)(3).
(d) INDIVIDUALS.--

(1) INDIVIDUAL DESCRIBED.--Subject to the succeeding provisions of this subsection, an individual described in this paragraph is an individual who--

(A) is not enrolled in coverage described in subparagraphs (C) through (F) of paragraph

(2); and

(B) is not enrolled in coverage as a full-time employee (or as a dependent of such an employee) under a group health plan if the coverage and an employer contribution under the plan meet the requirements of section 312.

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For purposes of subparagraph (B), in the case of an individual who is self-employed, who has at least 1employee, and who meets the requirements of section 312, such individual shall be deemed a full-time employee described in such subparagraph.

(2) ACCEPTABLE COVERAGE.--For purposes of this division, the term ''acceptable coverage'' means any of the following:

(A) QUALIFIED HEALTH BENEFITS PLAN COVERAGE.--Coverage under a qualified health benefits plan.

(B) GRANDFATHERED HEALTH INSURANCE COVERAGE; COVERAGE UNDER CURRENT GROUP HEALTH PLAN.--Coverage under a grand-fathered health insurance coverage (as defined in subsection (a) of section 102) or under a current group health plan (described in sub-section (b) of such section).

(C) MEDICARE.--Coverage under part A of title XVIII of the Social Security Act.

(D) MEDICAID.--Coverage for medical assistance under title XIX of the Social Security Act, excluding such coverage that is only available because of the application of subsection (u), (z), or (aa) of section 1902 of such Act

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(E) MEMBERS OF THE ARMED FORCES AND DEPENDENTS (INCLUDING TRICARE).-- Coverage under chapter 55 of title 10, United States Code, including similar coverage furnished under section 1781 of title 38 of such Code.

(F) VA.--Coverage under the veteran's health care program under chapter 17 of title
38, United States Code, but only if the coverage for the individual involved is determined by the Commissioner in coordination with the Secretary of Treasury to be not less than a level specified by the Commissioner and Secretary of Veteran's Affairs, in coordination with the Secretary of Treasury, based on the individual's
priority for services as provided under section 1705(a) of such title.

(G) OTHER COVERAGE.--Such other health benefits coverage, such as a State health benefits risk pool, as the Commissioner, in coordination with the Secretary of the Treasury, recognizes for purposes of this paragraph. The Commissioner shall make determinations under this paragraph in coordination with the Secretary of the Treasury.

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(3) TREATMENT OF CERTAIN NON-TRADITIONAL MEDICAID ELIGIBLE INDIVIDUALS.--An individual who is a non-traditional Medicaid eligible individual (as defined in section 205(e)(4)(C)) in a State may be an Exchange-eligible individual if the individual was enrolled in a qualified health benefits plan, grandfathered health insurance coverage, or current group health plan during the 6 months before the individual became a non-traditional Medicaid eligible individual. During the period in which such an individual has chosen to enroll in an Exchange-participating health benefits plan, the individual is not also eligible for medical assistance under Medicaid.

(4) CONTINUING ELIGIBILITY PERMITTED.--

(A) IN GENERAL.--Except as provided in subparagraph (B), once an individual qualifies as an Exchange-eligible individual under this subsection (including as an employee or dependent of an employee of an Exchange-eligible employer) and enrolls under an Exchange-participating health benefits plan through the Health
Insurance Exchange, the individual shall continue to be treated as an Exchange-eligible individual until the individual is no longer enrolled

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with an Exchange-participating health benefits plan.

(B) EXCEPTIONS.--

(i) IN GENERAL.--Subparagraph (A) shall not apply to an individual once the individual becomes eligible for coverage--

(I) under part A of the Medicare program;

(II) under the Medicaid program as a Medicaid eligible individual, except as permitted under paragraph

(3) or clause (ii); or

(III) in such other circumstances as the Commissioner may provide.

(ii) TRANSITION PERIOD.--In the case described in clause (i)(II), the Commissioner shall permit the individual to continue treatment under subparagraph (A) until such limited time as the Commis-sioner determines it is administratively fea-
sible, consistent with minimizing disruption in the individual's access to health care.

(e) EMPLOYERS.--


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(1) SMALLEST EMPLOYER.--Subject to paragraph (4), smallest employers described in this paragraph are employers with 10 or fewer employees.

(2) SMALLER EMPLOYERS.--Subject to paragraph (4), smaller employers described in this paragraph are employers that are not smallest employers described in paragraph (1) and have 20 or fewer employees.

(3) LARGER EMPLOYERS.--

(A) IN GENERAL.--Beginning with Y3, the Commissioner may permit employers not described in paragraph (1) or (2) to be Exchange-eligible employers.

(B) PHASE-IN.--In applying subparagraph (A), the Commissioner may phase-in the application of such subparagraph based on the number of full-time employees of an employer and such other considerations as the Commissioner deems appropriate.

(4) CONTINUING ELIGIBILITY.--Once an employer is permitted to be an Exchange-eligible employer under this subsection and enrolls employees through the Health Insurance Exchange, the employer shall continue to be treated as an Exchange-eligible employer for each subsequent plan year re-

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gardless of the number of employees involved unless and until the employer meets the requirement of section 311(a) through paragraph (1) of such section by offering a group health plan and not through offering Exchange-participating health benefits plan.

(5) EMPLOYER PARTICIPATION AND CONTRIBU-
TIONS.--

(A) SATISFACTION OF EMPLOYER RESPON-SIBILITY.--For any year in which an employer is an Exchange-eligible employer, such employer may meet the requirements of section 312 with respect to employees of such employer by offering such employees the option of enrolling with Exchange-participating health benefits plans through the Health Insurance Exchange consistent with the provisions of subtitle B of title III.
(B) EMPLOYEE CHOICE.--Any employee
offered Exchange-participating health benefits plans by the employer of such employee under subparagraph (A) may choose coverage under any such plan. That choice includes, with respect to family coverage, coverage of the dependents of such employee.

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(6) AFFILIATED GROUPS.--Any employer which is part of a group of employers who are treated as a single employer under subsection (b), (c), (m), or
(o) of section 414 of the Internal Revenue Code of 1986 shall be treated, for purposes of this subtitle, as a single employer.

(7) OTHER COUNTING RULES.--The Commissioner shall establish rules relating to how employees are counted for purposes of carrying out this subsection.

(f) SPECIAL SITUATION AUTHORITY.--The Commissioner shall have the authority to establish such rules as may be necessary to deal with special situations with regard to uninsured individuals and employers participating as Exchange-eligible individuals and employers, such as transition periods for individuals and employers who gain, or lose, Exchange-eligible participation status, and to establish grace periods for premium payment.

(g) SURVEYS OF INDIVIDUALS AND EMPLOYERS.-- The Commissioner shall provide for periodic surveys of Exchange-eligible individuals and employers concerning satisfaction of such individuals and employers with the Health Insurance Exchange and Exchange-participating health benefits plans.

(h) EXCHANGE ACCESS STUDY.--

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(1) IN GENERAL.--The Commissioner shall conduct a study of access to the Health Insurance Exchange for individuals and for employers, including individuals and employers who are not eligible and enrolled in Exchange-participating health benefits plans. The goal of the study is to determine if there are significant groups and types of individuals and employers who are not Exchange eligible individuals or employers, but who would have improved benefits and affordability if made eligible for coverage in the Exchange.

(2) ITEMS INCLUDED IN STUDY.--Such study also shall examine--

(A) the terms, conditions, and affordability of group health coverage offered by employers and QHBP offering entities outside of the Exchange compared to Exchange-participating health benefits plans; and

(B) the affordability-test standard for access of certain employed individuals to coverage in the Health Insurance Exchange.

(3) REPORT.--Not later than January 1 of Y3, in Y6, and thereafter, the Commissioner shall submit to Congress on the study conducted under this subsection and shall include in such report rec-

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ommendations regarding changes in standards for Exchange eligibility for for individuals and employers.

SEC. 203. BENEFITS PACKAGE LEVELS.

(a) IN GENERAL.--The Commissioner shall specify the benefits to be made available under Exchange-participating health benefits plans during each plan year, consistent with subtitle C of title I and this section.

(b) LIMITATION ON HEALTH BENEFITS PLANS OFFERED BY OFFERING ENTITIES.--The Commissioner may not enter into a contract with a QHBP offering entity under section 204(c) for the offering of an Exchange-participating health benefits plan in a service area unless the following requirements are met:

(1) REQUIRED OFFERING OF BASIC PLAN.--The entity offers only one basic plan for such service area.

(2) OPTIONAL OFFERING OF ENHANCED PLAN.--If and only if the entity offers a basic plan for such service area, the entity may offer one enhanced plan for such area.

(3) OPTIONAL OFFERING OF PREMIUM PLAN.-- If and only if the entity offers an enhanced plan for such service area, the entity may offer one premium plan for such area.

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(4) OPTIONAL OFFERING OF PREMIUM-PLUS PLANS.--If and only if the entity offers a premium plan for such service area, the entity may offer one or more premium-plus plans for such area. All such plans may be offered under a single contract with the Commissioner.

(c) SPECIFICATION OF BENEFIT LEVELS FOR PLANS.--

(1) IN GENERAL.--The Commissioner shall establish the following standards consistent with this subsection and title I:

(A) BASIC, ENHANCED, AND PREMIUM PLANS.--Standards for 3 levels of Exchange- participating health benefits plans: basic, enhanced, and premium (in this division referred to as a ''basic plan'', ''enhanced plan'', and
''premium plan'', respectively).

(B) PREMIUM-PLUS PLAN BENEFITS.-- Standards for additional benefits that may be offered, consistent with this subsection and subtitle C of title I, under a premium plan (such a plan with additional benefits referred to in this division as a ''premium-plus plan'') .

(2) BASIC PLAN.--

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(A) IN GENERAL.--A basic plan shall offer the essential benefits package required under title I for a qualified health benefits plan.

(B) TIERED COST-SHARING FOR AFFORDABLE CREDIT ELIGIBLE INDIVIDUALS.--In the case of an affordable credit eligible individual
(as defined in section 242(a)(1)) enrolled in an Exchange-participating health benefits plan, the benefits under a basic plan are modified to provide for the reduced cost-sharing for the income tier applicable to the individual under section
244(c).

(3) ENHANCED PLAN.--A enhanced plan shall offer, in addition to the level of benefits under the basic plan, a lower level of cost-sharing as provided
under title I consistent with section 123(b)(5)(A).

(4) PREMIUM PLAN.--A premium plan shall offer, in addition to the level of benefits under the basic plan, a lower level of cost-sharing as provided under title I consistent with section 123(b)(5)(B).

(5) PREMIUM-PLUS PLAN.--A premium-plus plan is a premium plan that also provides additional benefits, such as adult oral health and vision care, approved by the Commissioner. The portion of the

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premium that is attributable to such additional benefits shall be separately specified.

(6) RANGE OF PERMISSIBLE VARIATION IN COST-SHARING.--The Commissioner shall establish a permissible range of variation of cost-sharing for
each basic, enhanced, and premium plan, except with respect to any benefit for which there is no cost-sharing permitted under the essential benefits package. Such variation shall permit a variation of not more than plus (or minus) 10 percent in cost-sharing with respect to each benefit category specified under section 122.

(d) TREATMENT OF STATE BENEFIT MANDATES.-- Insofar as a State requires a health insurance issuer offering health insurance coverage to include benefits beyond the essential benefits package, such requirement shall continue to apply to an Exchange-participating health benefits plan, if the State has entered into an arrangement satisfactory to the Commissioner to reimburse the Commissioner for the amount of any net increase in affordability premium credits under subtitle C as a result of an increase in premium in basic plans as a result of application of such requirement.

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SEC. 204. CONTRACTS FOR THE OFFERING OF EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS.

(a) CONTRACTING DUTIES.--In carrying out section 201(b)(1) and consistent with this subtitle:

(1) OFFERING ENTITY AND PLAN STANDARDS.--The Commissioner shall--

(A) establish standards necessary to implement the requirements of this title and title I for--

(i) QHBP offering entities for the offering of an Exchange-participating health benefits plan; and

(ii) for Exchange-participating health benefits plans; and

(B) certify QHBP offering entities and qualified health benefits plans as meeting such standards and requirements of this title and title I for purposes of this subtitle.

(2) SOLICITING AND NEGOTIATING BIDS; CONTRACTS.--The Commissioner shall--

(A) solicit bids from QHBP offering entities for the offering of Exchange-participating
health benefits plans;

(B) based upon a review of such bids, negotiate with such entities for the offering of such plans; and

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(C) enter into contracts with such entities for the offering of such plans through the
Health Insurance Exchange under terms (consistent with this title) negotiated between the Commissioner and such entities.

(3) FAR NOT APPLICABLE.--The provisions of the Federal Acquisition Regulation shall not apply to contracts between the Commissioner and QHBP offering entities for the offering of Exchange-participating health benefits plans under this title.

(b) STANDARDS FOR QHBP OFFERING ENTITIES TO OFFER EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS.--The standards established under subsection (a)(1)(A) shall require that, in order for a QHBP offering entity to offer an Exchange-participating health benefits plan, the entity must meet the following requirements:

(1) LICENSED.--The entity shall be licensed to offer health insurance coverage under State law for each State in which it is offering such coverage.

(2) DATA REPORTING.--The entity shall provide for the reporting of such information as the Commissioner may specify, including information necessary to administer the risk pooling mechanism described in section 206(b) and information to address disparities in health and health care.


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(3) IMPLEMENTING AFFORDABILITY CREDITS.--The entity shall provide for implementation of the affordability credits provided for enrollees under subtitle C, including the reduction in cost-sharing under section 244(c).

(4) ENROLLMENT.--The entity shall accept all enrollments under this subtitle, subject to such exceptions (such as capacity limitations) in accordance with the requirements under title I for a qualified health benefits plan. The entity shall notify the Commissioner if the entity projects or anticipates reaching such a capacity limitation that would result in a limitation in enrollment.

(5) RISKPOOLINGPARTICIPATION.--The entity shall participate in such risk pooling mechanism as the Commissioner establishes under section 206(b).

(6) ESSENTIALCOMMUNITYPROVIDERS.--With respect to the basic plan offered by the entity, the entity shall contract for outpatient services with covered entities (as defined in section 340B(a)(4) of the Public Health Service Act, as in effect as of July 1, 2009). The Commissioner shall specify the extent to which and manner in which the previous sentence shall apply in the case of a basic plan with respect to which the Commissioner determines provides sub-

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stantially all benefits through a health maintenance organization, as defined in section 2791(b)(3) of the Public Health Service Act.

(7) CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES AND COMMUNICATIONS.--The entity shall provide for culturally and linguistically ap-
propriate communication and health services.

(8) ADDITIONAL REQUIREMENTS.--The entity shall comply with other applicable requirements of this title, as specified by the Commissioner, which shall include standards regarding billing and collec-tion practices for premiums and related grace periods and which may include standards to ensure that the entity does not use coercive practices to force providers not to contract with other entities offering coverage through the Health Insurance Exchange.

(c) CONTRACTS.--

(1) BID APPLICATION.--To be eligible to enter into a contract under this section, a QHBP offering entity shall submit to the Commissioner a bid at such time, in such manner, and containing such in-formation as the Commissioner may require.

(2) TERM.--Each contract with a QHBP offering entity under this section shall be for a term of not less than one year, but may be made automati-

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cally renewable from term to term in the absence of
notice of termination by either party.

(3) ENFORCEMENT OF NETWORK ADEQUACY.-- In the case of a health benefits plan of a QHBP offering entity that uses a provider network, the contract under this section with the entity shall provide that if--

(A) the Commissioner determines that such provider network does not meet such
standards as the Commissioner shall establish under section 115; and

(B) an individual enrolled in such plan receives an item or service from a provider that is not within such network; then any cost-sharing for such item or service shall
be equal to the amount of such cost-sharing that would be imposed if such item or service was furnished by a provider within such network.

(4) OVERSIGHT AND ENFORCEMENT RESPONSIBILITIES.--The Commissioner shall establish processes, in coordination with State insurance regulators, to oversee, monitor, and enforce applicable requirements of this title with respect to QHBP offering entities offering Exchange-participating health benefits plans and such plans, including the mar-

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keting of such plans. Such processes shall include the following:

(A) GRIEVANCE AND COMPLAINT MECHANISMS.--The Commissioner shall establish, in coordination with State insurance regulators, a process under which Exchange-eligible individuals and employers may file complaints concerning violations of such standards.

(B) ENFORCEMENT.--In carrying out authorities under this division relating to the
Health Insurance Exchange, the Commissioner may impose one or more of the intermediate sanctions described in section 142(c).

(C) TERMINATION.--

(i) IN GENERAL.--The Commissioner may terminate a contract with a QHBP offering entity under this section for the offering of an Exchange-participating health
benefits plan if such entity fails to comply with the applicable requirements of this
title. Any determination by the Commissioner to terminate a contract shall be made in accordance with formal investigation and compliance procedures established by the Commissioner under which--

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(I) the Commissioner provides the entity with the reasonable opportunity to develop and implement a corrective action plan to correct the deficiencies that were the basis of the Commissioner's determination; and

(II) the Commissioner provides the entity with reasonable notice and opportunity for hearing (including the right to appeal an initial decision) be-fore terminating the contract.

(ii) EXCEPTION FOR IMMINENT AND SERIOUS RISK TO HEALTH.--Clause (i) shall not apply if the Commissioner determines that a delay in termination, resulting from compliance with the procedures specified in such clause prior to termination, would pose an imminent and serious risk to the health of individuals enrolled under the qualified health benefits plan of the QHBP offering entity.

(D) CONSTRUCTION.--Nothing in this subsection shall be construed as preventing the application of other sanctions under subtitle E of

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title I with respect to an entity for a violation of such a requirement.

SEC. 205. OUTREACH AND ENROLLMENT OF EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS IN EXCHANGE-PARTICIPATING HEALTH BENEFITS PLAN.

(a) IN GENERAL.--

(1) OUTREACH.--The Commissioner shall conduct outreach activities consistent with subsection (c), including through use of appropriate entities as described in paragraph (4) of such subsection, to inform and educate individuals and employers about the Health Insurance Exchange and Exchange-participating health benefits plan options. Such outreach shall include outreach specific to vulnerable
populations, such as children, individuals with disabilities, individuals with mental illness, and individuals with other cognitive impairments.

(2) ELIGIBILITY.--The Commissioner shall make timely determinations of whether individuals and employers are Exchange-eligible individuals and employers (as defined in section 202).

(3) ENROLLMENT.--The Commissioner shall es-
tablish and carry out an enrollment process for Ex-
change-eligible individuals and employers, including

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at community locations, in accordance with subsection (b).

(b) ENROLLMENT PROCESS.--

(1) IN GENERAL.--The Commissioner shall establish a process consistent with this title for enrollments in Exchange-participating health benefits plans. Such process shall provide for enrollment through means such as the mail, by telephone, electronically, and in person.

(2) ENROLLMENT PERIODS.--

(A) OPEN ENROLLMENT PERIOD.--The Commissioner shall establish an annual open enrollment period during which an Exchange-eligible individual or employer may elect to enroll in an Exchange-participating health benefits plan for the following plan year and an enrollment period for affordability credits under sub-
title C. Such periods shall be during September through November of each year, or such other time that would maximize timeliness of income verification for purposes of such subtitle. The open enrollment period shall not be less than 30 days.

(B) SPECIAL ENROLLMENT.--The Commissioner shall also provide for special enroll-

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ment periods to take into account special circumstances of individuals and employers, such as an individual who--

(i) loses acceptable coverage;

(ii) experiences a change in marital or other dependent status;

(iii) moves outside the service area of the Exchange-participating health benefits plan in which the individual is enrolled; or

(iv) experiences a significant change in income.

(C) ENROLLMENT INFORMATION.--The Commissioner shall provide for the broad dissemination of information to prospective enrollees on the enrollment process, including before each open enrollment period. In carrying out the previous sentence, the Commissioner may work with other appropriate entities to facilitate
such provision of information.

(3) AUTOMATIC ENROLLMENT FOR NON-MEDICAID ELIGIBLE INDIVIDUALS.--

(A) IN GENERAL.--The Commissioner shall provide for a process under which individuals who are Exchange-eligible individuals described in subparagraph (B) are automatically

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enrolled under an appropriate Exchange-participating health benefits plan. Such process may involve a random assignment or some other form of assignment that takes into account the health care providers used by the individual involved or such other relevant factors as the Commissioner may specify.

(B) SUBSIDIZED INDIVIDUALS DESCRIBED.--An individual described in this subparagraph is an Exchange-eligible individual who is either of the following:

(i) AFFORDABILITY CREDIT ELIGIBLE INDIVIDUALS.--The individual--

(I) has applied for, and been determined eligible for, affordability credits under subtitle C;

(II) has not opted out from receiving such affordability credit; and

(III) does not otherwise enroll in another Exchange-participating health benefits plan.

(ii) INDIVIDUALS ENROLLED IN A TERMINATED PLAN.--The individual is enrolled in an Exchange-participating health benefits plan that is terminated (during or

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at the end of a plan year) and who does not otherwise enroll in another Exchange-participating health benefits plan.

(4) DIRECT PAYMENT OF PREMIUMS TO PLANS.--Under the enrollment process, individuals enrolled in an Exchange-partcipating health benefits plan shall pay such plans directly, and not through the Commissioner or the Health Insurance Ex-
change.

(c) COVERAGE INFORMATION AND ASSISTANCE.--

(1) COVERAGE INFORMATION.--The Commis-sioner shall provide for the broad dissemination of information on Exchange-participating health benefits plans offered under this title. Such information shall be provided in a comparative manner, and shall include information on benefits, premiums, cost-sharing, quality, provider networks, and consumer satisfaction.

(2) CONSUMER ASSISTANCE WITH CHOICE.--To provide assistance to Exchange-eligible individuals and employers, the Commissioner shall--

(A) provide for the operation of a toll-free telephone hotline to respond to requests for assistance and maintain an Internet website through which individuals may obtain informa-


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tion on coverage under Exchange-participating health benefits plans and file complaints;

(B) develop and disseminate information to Exchange-eligible enrollees on their rights and responsibilities;

(C) assist Exchange-eligible individuals in selecting Exchange-participating health benefits plans and obtaining benefits through such plans; and

(D) ensure that the Internet website described in subparagraph (A) and the information described in subparagraph (B) is developed using plain language (as defined in section 133(a)(2)).

(3) USE OF OTHER ENTITIES.--In carrying out this subsection, the Commissioner may work with other appropriate entities to facilitate the dissemination of information under this subsection and to provide assistance as described in paragraph (2).

(d) SPECIAL DUTIES RELATED TO MEDICAID AND CHIP.--

(1) COVERAGE FOR CERTAIN NEWBORNS.--

(A) IN GENERAL.--In the case of a child born in the United States who at the time of
birth is not otherwise covered under acceptable

Continued On Section 3 (Pages 101-150)