SEC. 101. REQUIREMENTS REFORMING HEALTH
The purpose of [HR3200} is to establish standards to ensure that
new health insurance coverage and employment-based health plans
that are offered meet
guaranteeing access to affordable coverage, essential benefits,
and other consumer protections.
SEC. 111. PROHIBITING PRE-EXISTING
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 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.
requirements of sections 2711 .....
availability and re-newability 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
offered in the
small group market,
such section 2712(b)(1) shall apply only if, before
discontinuation of coverage,
the issuer has
enrollee with notice of non-payment of premiums
and there is a
period during which the enrollees has an opportunity to correct
Rescissions of such coverage shall be prohibited except in cases of
fraud as defined in sections 2712(b)(2) of such Act.
SEC. 113. INSURANCE RATING RULES.
(a) In General-
rate charged for an insured qualified health benefits plan may not
vary except as follows:
AGE VARIATION PERMITTED-
.... so long as the
the highest such premium to the lowest such premium does not
exceed the ratio of 2 to 1.
BY AREA- By premium rating area (as permitted by State insurance
regulators or, in the case of Exchange-participating health
benefits plans ... )
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
SEC. 114. NONDISCRIMINATION IN
BENEFITS; PARITY IN MENTAL HEALTH AND SUBSTANCE ABUSE DISORDER BENEFITS.
(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 employer
health care markets.
Such study shall examine the following:
types of employers
by key characteristics, including size, that purchase insured
products versus those that self-insure.
differences between typical insured and self-insured health
and capital reserve levels of employers that self-insure by
self-insured employers not being able to pay obligations or
otherwise becoming financially insolvent.
(E) The extent
to which rating rules are likely to
large group market
to encourage small
and mid size employers to self-insure
REPORTS- Not later than 18 months after the date of the
enactment of this Act....
recommendations the Commissioner deems appropriate to ensure
that the law does
not provide incentives
for small and
mid-size employers to self-insure or create adverse selection in
the risk pools of large group insurers and self-insured
Benefits- A qualified health benefits plan shall comply with
standards established by the Commissioner to prohibit discrimination
benefits or benefit structures .....
(b) Parity in Mental
Health and Substance Abuse Disorder Benefits-
SEC. 115. ENSURING ADEQUACY OF
In General- A
qualified health benefits
plan that uses a provider network for items and services shall
standards respecting provider networks
as the Commissioner may establish
to assure the adequacy of such networks in
access to such items and services and transparency in the
cost-sharing differentials between in-network coverage and
SEC. 116. ENSURING VALUE AND LOWER
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
enrollees of payment sufficient to meet such loss ratio.
(b) Building on
Interim Rules- ...... for determining how to calculate the
medical loss ratio.
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.
SEC. 121. COVERAGE OF ESSENTIAL
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
Choice of Coverage-
NON-EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS
EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS-
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
such benefits are offered under a separate policy, contract,
or certificate of insurance.
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
SEC. 122. ESSENTIAL BENEFITS PACKAGE
(a) In this division, the term
‘essential benefits package’
benefits coverage, consistent with standards adopted ... to ensure the provision of quality health care and financial
payment for the items and services
accordance with generally accepted standards of medical or
other appropriate clinical or professional practice;
cost-sharing for such covered health care items and services
in accordance with such benefit standards ...
not impose any annual or lifetime limit on the coverage of
covered health care items and services;
complies with section 115(a) (relating to
as certified by Office of the Actuary of the Centers for
Medicare & Medicaid Services,
to the average
prevailing employer-sponsored coverage.
To Be Covered-
The items and services described in this subsection are the
hospital and outpatient clinic services, including emergency
services of physicians and other health professionals.
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
(5) Prescription drugs.
Rehabilitative and habilitative services.
and substance use disorder services.
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.
Well baby and
well child care
oral health, vision, and hearing services,
equipment, and supplies
at least for
children under 21 years of age.
Relating to Cost-sharing and Minimum Actuarial Value-
COST-SHARING FOR PREVENTIVE SERVICES- There shall be no
cost-sharing under the essential benefits package for preventive
items and services (as specified under the benefit standards),
including well baby and well child care.
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) 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 CO-PAYMENTS- In
establishing cost-sharing levels for basic, enhanced, and
premium plans under this subsection, the Secretary shall, to
the maximum extent possible, use only co-payments and not
GENERAL- The cost-sharing under the essential benefits
package shall be designed to provide a level of coverage
that is designed 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).
BENEFITS PACKAGE DESCRIBED- 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
GENERAL- There is
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
RECOMMENDATIONS ON BENEFIT STANDARDS-
The Health Benefits Advisory Committee shall recommend to
the Secretary of Health and Human Services .... benefit
standards .... and periodic updates to such standards. In
developing such recommendations, the Committee shall
account innovation in health care and consider how such
standards could reduce health disparities
The Health Benefits Advisory Committee shall
public input as a part of developing recommendations
under this subsection.
In this subtitle, the term ‘benefit standards’ means
(5) LEVELS OF
COST-SHARING FOR ENHANCED AND PREMIUM PLANS-
essential benefits package described in section
122, including categories of covered treatments, items
and services within benefit classes, and cost-sharing;
cost-sharing levels for enhanced plans and premium plans
(as provided under section 203(c) .... etc
The level of cost-sharing 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 ....
The level of cost-sharing for premium plans shall be
designed so 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
SEC. 131. REQUIRING FAIR MARKETING
PRACTICES BY HEALTH INSURERS.
shall establish uniform marketing standards that all insured QHBP
offering entities shall meet.
SEC. 132. REQUIRING
AND APPEALS MECHANISMS.
(a) A QHBP
shall provide for
timely grievance and appeals mechanisms that the Commissioner
(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 .... and shall update
such process in accordance with any standards that the Commissioner
(1) 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.
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
binding on the plan and the entity.
Nothing in this section shall be construed as affecting the
availability of judicial review under State law for adverse
SEC. 133. REQUIRING INFORMATION
TRANSPARENCY AND PLAN DISCLOSURE.
GENERAL- A qualified health benefits plan shall comply with
standards established by the Commissioner for the
timely disclosure 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.
Commissioner shall require that such
In this subsection,
‘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.
Commissioner shall develop and issue guidance on best
practices of plain language writing.
Reimbursement- A qualified health benefits plan shall comply
with standards established by the Commissioner to
transparency to each health care provider relating to
reimbursement arrangements between such plan and such provider.
Advance Notice of
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. 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. 137. APPLICATION OF
A QHBP offering
entity is required to
standards for electronic financial and administrative
under section 1173A of the Social Security Act, added by section
SEC. 144. HEALTH
within the Health Choices Administration a
Benefits Plan Ombudsman
who shall have
and experience in the fields of health care and education of
(and assistance to) individuals.
The Qualified Health Benefits Plan Ombudsman shall, in a
linguistically appropriate manner--
complaints, grievances, and requests for information
submitted by individuals;
assistance with respect to complaints, grievances,
referred to in paragraph (1), including--
helping individuals determine the relevant information
seek an appeal of a decision or determination;
assistance to such individuals with any
problems arising from dis-enrollment from such a plan;
assistance to such individuals in choosing a qualified
health benefits plan in which to enroll;
to such individuals in presenting information under subtitle
C (relating to affordability credits); and
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.
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.
to Other Requirements; Miscellaneous
SEC. 152. PROHIBITING DISCRIMINATION
IN HEALTH CARE.
(a) In General-
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) covered by this Act
shall be provided
without regard to personal characteristics extraneous to the
provision of high quality health care or related services.
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. WHISTLEBLOWER PROTECTION.
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)--
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 any act or omission
reasonably believes to be a violation of any provision of
this Act or any order, rule, or regulation promulgated under
is about to testify in a proceeding concerning such
participated or is about to assist or participate in such a
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.
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)).
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,
unincorporated 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.
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
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.
provision of this Act, or any application of such provision to
any person or circumstance, is held to be unconstitutional,
remainder of the provisions of this Act and the application of
the provision to any other person or circumstance shall not
Subtitle G--Early Investments
SEC. 161. ENSURING VALUE AND LOWER
- (a) Group
Health Insurance Coverage- Title XXVII of the Public Health
Service Act is amended by
after section 2713
the following new
‘SEC. 2714. ENSURING VALUE AND LOWER
Each health insurance issuer that
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
enrollees of payment sufficient to meet such loss ratio.
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.
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, different types of plans, and newer plans.’.
Health Insurance Coverage- Such title is
after section 2753 the
following new section:
ENSURING VALUE AND LOWER
provisions of section 2714 shall
apply to health
insurance coverage offered in the individual market in the same
manner as such provisions apply to health insurance coverage
offered in the small or large group market.’
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
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’;
(2) in subsection (a), by inserting ‘, including without
rescission,’ after ‘continue in force’.
Guidance Regarding Rescissions- Section 2742 of such Act (42 U.S.C.
300gg-42) is amended by adding at the end the following:
Rescission- A health insurance issuer may rescind health insurance
coverage only upon clear and convincing evidence of fraud described
(b)(2). The Secretary,
no later than July 1,
2010, shall issue guidance implementing this requirement, including
procedures for independent, external third party review.’
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.
Notice and Review
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
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).’
The amendments made by this section shall apply on and after
October 1, 2010,
with respect to
health insurance coverage issued before, on, or after such
SEC. 163. ADMINISTRATIVE
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
inserting after section 1173 the following new section:
Temporary End of
marked up text --
will continue Monday, August 10th
‘SEC. 1173A. STANDARDIZE ELECTRONIC
- ‘(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) GOALS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS-
The goals for standards under paragraph (1) are that such
- ‘(A) be
unique with no conflicting or redundant standards;
authoritative, permitting no additions or constraints for
electronic transactions, including companion guides;
be comprehensive, efficient and robust, requiring minimal
augmentation by paper transactions or clarification by
‘(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
‘(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
‘(G) describe all data elements (such as reason
and remark codes) in unambiguous terms, not permit optional
fields, require that data elements be either required or
conditioned upon set values in other fields, and prohibit
additional conditions; and
‘(H) harmonize all common data
elements across administrative and clinical transaction