I 111th CONGRESS 1st Session H. R. 3962 IN THE HOUSE OF REPRESENTATIVES October 29, 2009 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 Energy and Commerce, and in addition to the Committees on Education and Labor, Ways and Means, Oversight and Government Reform, the Budget, Rules, Natural Resources, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.
1.
Short title; table of divisions, titles, and subtitles
(a)
Short title
This Act may be cited as the Affordable Health Care for America Act. (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—Immediate Reforms Title II—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 Title III—Health Insurance Exchange and Related Provisions Subtitle A—Health Insurance Exchange Subtitle B—Public Health Insurance Option Subtitle C—Individual Affordability Credits Title IV—Shared responsibility Subtitle A—Individual Responsibility Subtitle B—Employer Responsibility Title V—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 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 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; 340B Program Integrity Subtitle B—Programs Subtitle C—Food and Drug Administration Subtitle D—Community Living Assistance Services and Supports Subtitle E—Miscellaneous Division D—Indian Health Care Improvement Title I—Amendments to Indian Laws Title II—Improvement of Indian Health Care Provided Under the Social Security Act
A
Affordable Health Care Choices
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 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—Immediate Reforms Sec. 101. National high-risk pool program. Sec. 102. Ensuring value and lower premiums. Sec. 103. Ending health insurance rescission abuse. Sec. 104. Sunshine on price gouging by health insurance issuers. Sec. 105. Requiring the option of extension of dependent coverage for uninsured young adults. Sec. 106. Limitations on preexisting condition exclusions in group health plans in advance of applicability of new prohibition of preexisting condition exclusions. Sec. 107. Prohibiting acts of domestic violence from being treated as preexisting conditions. Sec. 108. Ending health insurance denials and delays of necessary treatment for children with deformities. Sec. 109. Elimination of lifetime limits. Sec. 110. Prohibition against postretirement reductions of retiree health benefits by group health plans. Sec. 111. Reinsurance program for retirees. Sec. 112. Wellness program grants. Sec. 113. Extension of COBRA continuation coverage. Sec. 114. State Health Access Program grants. Sec. 115. Administrative simplification. Title II—Protections and Standards for Qualified Health Benefits Plans Subtitle A—General Standards Sec. 201. Requirements reforming health insurance marketplace. Sec. 202. Protecting the choice to keep current coverage. Subtitle B—Standards Guaranteeing Access to Affordable Coverage Sec. 211. Prohibiting preexisting condition exclusions. Sec. 212. Guaranteed issue and renewal for insured plans and prohibiting rescissions. Sec. 213. Insurance rating rules. Sec. 214. Nondiscrimination in benefits; parity in mental health and substance abuse disorder benefits. Sec. 215. Ensuring adequacy of provider networks. Sec. 216. Requiring the option of extension of dependent coverage for uninsured young adults. Sec. 217. Consistency of costs and coverage under qualified health benefits plans during plan year. Subtitle C—Standards Guaranteeing Access to Essential Benefits Sec. 221. Coverage of essential benefits package. Sec. 222. Essential benefits package defined. Sec. 223. Health Benefits Advisory Committee. Sec. 224. Process for adoption of recommendations; adoption of benefit standards. Subtitle D—Additional Consumer Protections Sec. 231. Requiring fair marketing practices by health insurers. Sec. 232. Requiring fair grievance and appeals mechanisms. Sec. 233. Requiring information transparency and plan disclosure. Sec. 234. Application to qualified health benefits plans not offered through the Health Insurance Exchange. Sec. 235. Timely payment of claims. Sec. 236. Standardized rules for coordination and subrogation of benefits. Sec. 237. Application of administrative simplification. Sec. 238. State prohibitions on discrimination against health care providers. Sec. 239. Protection of physician prescriber information. Sec. 240. Dissemination of advance care planning information. Subtitle E—Governance Sec. 241. Health Choices Administration; Health Choices Commissioner. Sec. 242. Duties and authority of Commissioner. Sec. 243. Consultation and coordination. Sec. 244. Health Insurance Ombudsman. Subtitle F—Relation to other requirements; Miscellaneous Sec. 251. Relation to other requirements. Sec. 252. Prohibiting discrimination in health care. Sec. 253. Whistleblower protection. Sec. 254. Construction regarding collective bargaining. Sec. 255. Severability. Sec. 256. Treatment of Hawaii Prepaid Health Care Act. Sec. 257. Actions by State attorneys general. Sec. 258. Application of State and Federal laws regarding abortion. Sec. 259. Nondiscrimination on abortion and respect for rights of conscience. Sec. 260. Authority of Federal Trade Commission. Sec. 261. Construction regarding standard of care. Sec. 262. Restoring application of antitrust laws to health sector insurers. Sec. 263. Study and report on methods to increase EHR use by small health care providers. Title III—Health Insurance Exchange and Related Provisions Subtitle A—Health Insurance Exchange Sec. 301. Establishment of Health Insurance Exchange; outline of duties; definitions. Sec. 302. Exchange-eligible individuals and employers. Sec. 303. Benefits package levels. Sec. 304. Contracts for the offering of Exchange-participating health benefits plans. Sec. 305. Outreach and enrollment of Exchange-eligible individuals and employers in Exchange-participating health benefits plan. Sec. 306. Other functions. Sec. 307. Health Insurance Exchange Trust Fund. Sec. 308. Optional operation of State-based health insurance exchanges. Sec. 309. Interstate health insurance compacts. Sec. 310. Health insurance cooperatives. Sec. 311. Retention of DOD and VA authority. Subtitle B—Public Health Insurance Option Sec. 321. Establishment and administration of a public health insurance option as an Exchange-qualified health benefits plan. Sec. 322. Premiums and financing. Sec. 323. Payment rates for items and services. Sec. 324. Modernized payment initiatives and delivery system reform. Sec. 325. Provider participation. Sec. 326. Application of fraud and abuse provisions. Sec. 327. Application of HIPAA insurance requirements. Sec. 328. Application of health information privacy, security, and electronic transaction requirements. Sec. 329. Enrollment in public health insurance option is voluntary. Sec. 330. Enrollment in public health insurance option by Members of Congress. Sec. 331. Reimbursement of Secretary of Veterans Affairs. Subtitle C—Individual Affordability Credits Sec. 341. Availability through Health Insurance Exchange. Sec. 342. Affordable credit eligible individual. Sec. 343. Affordability premium credit. Sec. 344. Affordability cost-sharing credit. Sec. 345. Income determinations. Sec. 346. Special rules for application to territories. Sec. 347. No Federal payment for undocumented aliens. Title IV—Shared responsibility Subtitle A—Individual responsibility Sec. 401. Individual responsibility. Subtitle B—Employer Responsibility Part 1—Health coverage participation requirements Sec. 411. Health coverage participation requirements. Sec. 412. Employer responsibility to contribute toward employee and dependent coverage. Sec. 413. Employer contributions in lieu of coverage. Sec. 414. Authority related to improper steering. Sec. 415. Impact study on employer responsibility requirements. Sec. 416. Study on employer hardship exemption. Part 2—Satisfaction of Health Coverage Participation Requirements Sec. 421. Satisfaction of health coverage participation requirements under the Employee Retirement Income Security Act of 1974. Sec. 422. Satisfaction of health coverage participation requirements under the Internal Revenue Code of 1986. Sec. 423. Satisfaction of health coverage participation requirements under the Public Health Service Act. Sec. 424. Additional rules relating to health coverage participation requirements. Title V—Amendments to Internal Revenue Code of 1986 Subtitle A—Provisions relating to health care reform Part 1—Shared responsibility Subpart A—Individual responsibility Sec. 501. Tax on individuals without acceptable health care coverage. Subpart B—Employer Responsibility Sec. 511. Election to satisfy health coverage participation requirements. Sec. 512. Health care contributions of nonelecting employers. Part 2—Credit for small business employee health coverage expenses Sec. 521. Credit for small business employee health coverage expenses. Part 3—Limitations on health care related expenditures Sec. 531. Distributions for medicine qualified only if for prescribed drug or insulin. Sec. 532. Limitation on health flexible spending arrangements under cafeteria plans. Sec. 533. Increase in penalty for nonqualified distributions from health savings accounts. Sec. 534. Denial of deduction for federal subsidies for prescription drug plans which have been excluded from gross income. Part 4—Other provisions to carry out health insurance reform Sec. 541. Disclosures to carry out health insurance exchange subsidies. Sec. 542. Offering of exchange-participating health benefits plans through cafeteria plans. Sec. 543. Exclusion from gross income of payments made under reinsurance program for retirees. Sec. 544. CLASS program treated in same manner as long-term care insurance. Sec. 545. Exclusion from gross income for medical care provided for Indians. Subtitle B—Other revenue provisions Part 1—General provisions Sec. 551. Surcharge on high income individuals. Sec. 552. Excise tax on medical devices. Sec. 553. Expansion of information reporting requirements. Sec. 554. Delay in application of worldwide allocation of interest. Part 2—Prevention of tax avoidance Sec. 561. Limitation on treaty benefits for certain deductible payments. Sec. 562. Codification of economic substance doctrine; penalties. Sec. 563. Certain large or publicly traded persons made subject to a more likely than not standard for avoiding penalties on underpayments. Part 3—Parity in health benefits Sec. 571. Certain health related benefits applicable to spouses and dependents extended to eligible beneficiaries. (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 302(d)(2). (2)
Basic plan
The term basic plan has the meaning given such term in section 303(c). (3)
Commissioner
The term Commissioner means the Health Choices Commissioner established under section 241. (4)
Cost-sharing
The term cost-sharing includes deductibles, coinsurance, copayments, and similar charges, but does not include premiums, balance billing amounts for non-network providers, 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); (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); and (C)excludes coverage described in section 302(d)(2)(E) (relating to TRICARE). (7)
Enhanced plan
The term enhanced plan has the meaning given such term in section 303(c). (8)
Essential benefits package
The term essential benefits package is defined in section 222(a). (9)
Exchange-participating health benefits plan
The term Exchange-participating health benefits plan means a qualified health benefits plan that is offered through the Health Insurance Exchange and may be purchased directly from the entity offering the plan or through enrollment agents and brokers. (10)
Family
The term family means an individual and includes the individual’s dependents. (11)
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. (12)
Health benefits plan
The term health benefits plan means health insurance coverage and an employment-based health plan and includes the public health insurance option. (13)
Health insurance coverage
The term health insurance coverage has the meaning given such term in section 2791 of the Public Health Service Act, but does not include coverage in relation to its provision of excepted benefits— (A)described in paragraph (1) of subsection (c) of such section; or (B)described in paragraph (2), (3), or (4) of such subsection if the benefits are provided under a separate policy, certificate, or contract of insurance. (14)
Health insurance issuer
The term health insurance issuer has the meaning given such term in section 2791(b)(2) of the Public Health Service Act. (15)
Health Insurance Exchange
The term Health Insurance Exchange means the Health Insurance Exchange established under section 301. (16)
Indian
The term Indian has the meaning given such term in section 4 of the Indian Health Care Improvement Act (24 U.S.C. 1603). (17)
Indian health care provider
The term Indian health care provider means a health care program operated by the Indian Health Service, an Indian tribe, tribal organization, or urban Indian organization as such terms are defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603). (18)
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). (19)
Medicaid eligible individual
The term Medicaid eligible individual means an individual who is eligible for medical assistance under Medicaid. (20)
Medicare
The term Medicare means the health insurance programs under title XVIII of the Social Security Act. (21)
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. (22)
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. (23)
Premium plan; premium-plus plan
The terms premium plan and premium-plus plan have the meanings given such terms in section 303(c). (24)
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 (E)a Federal governmental plan (as defined in section 2791(d) of the Public Health Service Act), the appropriate Federal official. (25)
Qualified health benefits plan
The term qualified health benefits plan means a health benefits plan that— (A)meets the requirements for such a plan under title II and includes the public health insurance option; and (B)is offered by a QHBP offering entity that meets the applicable requirements of such title with respect to such plan. (26)
Public health insurance option
The term public health insurance option means the public health insurance option as provided under subtitle B of title III. (27)
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 and applicable rules of the Commissioner for Exchange-participating health benefits plans. (28)
State
The term State means the 50 States and the District of Columbia and includes— (A)for purposes of title I, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands; and (B)for purposes of titles II and III, as elected under and subject to section 346, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. (29)
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. (30)
Y1, Y2, etc
The terms Y1, Y2, Y3, Y4, Y5, and similar subsequently numbered terms, mean 2013 and subsequent years, respectively.
<enum>I</enum><header>Immediate Reforms</header> <section id="HA69182C7988F4092BC3EE94C83422701" commented="no"><enum>101.</enum><header>National high-risk pool program</header> <subsection id="HBB643789A2D14D368A4EB697D87619E5" commented="no"><enum>(a)</enum><header>In general</header><text>The Secretary of Health and Human Services (in this section referred to as the <quote>Secretary</quote>) shall establish a temporary national high-risk pool program (in this section referred to as the <quote>program</quote>) to provide health benefits to eligible individuals during the period beginning on January 1, 2010, and, subject to subsection (h)(3)(B), ending on the date on which the Health Insurance Exchange is established.</text></subsection> <subsection id="H7B0AB2F921CD4D11A028941A33A2F954" commented="no"><enum>(b)</enum><header>Administration</header><text>The Secretary may carry out this section directly or, pursuant to agreements, grants, or contracts with States, through State high-risk pool programs provided that the requirements of this section are met.</text></subsection> <subsection id="H491883495B514CB19AE990007BA4E2E2" commented="no"><enum>(c)</enum><header>Eligibility</header><text>For purposes of this section, the term <quote>eligible individual</quote> means an individual—</text> <paragraph id="HE6BE5B90419B49F391D0EF0C22B8B076" commented="no"><enum>(1)</enum><text>who—</text> <subparagraph id="HF81641E830384B17B26FC6460830A6A3" commented="no"><enum>(A)</enum><text>is not eligible for—</text> <clause id="H72DB8DB98D624434BBEBEE4C85179F41" commented="no"><enum>(i)</enum><text>benefits under title XVIII, XIX, or XXI of the Social Security Act; or</text></clause> <clause id="H982911C90F0949D08B4F546512A3099F" commented="no"><enum>(ii)</enum><text>coverage under an employment-based health plan (not including coverage under a COBRA continuation provision, as defined in section 107(d)(1)); and</text></clause></subparagraph> <subparagraph id="HA64D88258039434797D24EE76ED84CF5" commented="no"><enum>(B)</enum><text>who—</text> <clause id="HA716E01E05CF480C886BBD5514FB6436" commented="no"><enum>(i)</enum><text>is an eligible individual under section 2741(b) of the Public Health Service Act; or</text></clause> <clause id="H3FAD95D0AF514117BF73FBC7687B8879" commented="no"><enum>(ii)</enum><text>is medically eligible for the program by virtue of being an individual described in subsection (d) at any time during the 6-month period ending on the date the individual applies for high-risk pool coverage under this section;</text></clause></subparagraph></paragraph> <paragraph id="H46770EA48D5B46CEAC4368FF38DE2EE3" commented="no"><enum>(2)</enum><text>who is the spouse or dependent of an individual who is described in paragraph (1); or</text></paragraph> <paragraph id="HE749444114094804B922B4E36101A6A5" commented="no"><enum>(3)</enum><text>who has not had health insurance coverage or coverage under an employment-based health plan for at least the 6-month period immediately preceding the date of the individual’s application for high-risk pool coverage under this section.</text></paragraph><continuation-text continuation-text-level="subsection" commented="no">For purposes of paragraph (1)(A)(ii), a person who is in a waiting period as defined in section 2701(b)(4) of the Public Health Service Act shall not be considered to be eligible for coverage under an employment-based health plan.</continuation-text></subsection> <subsection id="H0D64172EF76C4E11A09F7A9B8DE24C8B" commented="no"><enum>(d)</enum><header>Medically eligible requirements</header><text>For purposes of subsection (c)(1)(B)(ii), an individual described in this subsection is an individual—</text> <paragraph id="H9874A4BD39E9401E869B75E87F63DA94" commented="no"><enum>(1)</enum><text display-inline="yes-display-inline">who, during the 6-month period ending on the date the individual applies for high-risk pool coverage under this section applied for individual health insurance coverage and—</text> <subparagraph id="HB32C6CDD2A4F4648B2516EE8B4780312" commented="no"><enum>(A)</enum><text>was denied such coverage because of a preexisting condition or health status; or</text></subparagraph> <subparagraph id="H02075DEB134245CB882257346AEDB998" commented="no"><enum>(B)</enum><text>was offered such coverage—</text> <clause id="HEA4EAF3599D3432D8FACDE30E50C877A" commented="no"><enum>(i)</enum><text>under terms that limit the coverage for such a preexisting condition; or</text></clause> <clause id="H227C34A063694F29BE51EAF3A4EA1334" commented="no"><enum>(ii)</enum><text display-inline="yes-display-inline">at a premium rate that is above the premium rate for high risk pool coverage under this section; or</text></clause></subparagraph></paragraph> <paragraph id="HC768A97A38EB4F0F9476CD1AD0EE05F6" commented="no"><enum>(2)</enum><text display-inline="yes-display-inline">who has an eligible medical condition as defined by the Secretary. </text></paragraph><continuation-text continuation-text-level="subsection" commented="no">In making a determination under paragraph (1) of whether an individual was offered individual coverage at a premium rate above the premium rate for high risk pool coverage, the Secretary shall make adjustments to offset differences in premium rating that are attributable solely to differences in age rating. </continuation-text></subsection> <subsection id="H346D23447075428BA6CAA19D1B1FB643" commented="no"><enum>(e)</enum><header>Enrollment</header><text>To enroll in coverage in the program, an individual shall—</text> <paragraph id="H6BFCE6DAD0894CCAA3E17D7BE61BD477" commented="no"><enum>(1)</enum><text>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; </text></paragraph> <paragraph id="HA01941CD8CC64B42BF5568AB5D3181EC" commented="no"><enum>(2)</enum><text>attest that the individual is an eligible individual and is a resident of one of the 50 States or the District of Columbia; and</text></paragraph> <paragraph id="HB2BAC3284EA7415798786C50596A7F89" commented="no"><enum>(3)</enum><text>if the individual had other prior health insurance coverage or coverage under an employment-based health plan during the previous 6 months, provide information as to the nature and source of such coverage and reasons for its discontinuance.</text></paragraph></subsection> <subsection id="H3E63DD7676EB4D10963EA5D62B8056D4" commented="no"><enum>(f)</enum><header>Protection against dumping risks by insurers</header> <paragraph id="H4D24FEB7A3CF45DCACE2B0E278D72B81" commented="no"><enum>(1)</enum><header>In general</header><text>The Secretary shall establish criteria for determining whether health insurance issuers and employment-based health plans have discouraged an individual from remaining enrolled in prior coverage based on that individual’s health status.</text></paragraph> <paragraph id="H7A53D2D921434B7BA9F94CA981ACF638" commented="no"><enum>(2)</enum><header>Sanctions</header><text display-inline="yes-display-inline">An issuer or employment-based health plan shall be responsible for reimbursing the program for the medical expenses incurred by the program for an individual who, based on criteria established by the Secretary, the Secretary finds was encouraged by the issuer to disenroll from health benefits coverage prior to enrolling in the program. The criteria shall include at least the following circumstances:</text> <subparagraph id="H6CFEA8DCFE394AB1A8E23A72EC31E02E" commented="no"><enum>(A)</enum><text>In the case of prior coverage obtained through an employer, the provision by the employer, group health plan, or the issuer of money or other financial consideration for disenrolling from the coverage.</text></subparagraph> <subparagraph id="H88285615CCEA47C49552CDF165894D33" commented="no"><enum>(B)</enum><text>In the case of prior coverage obtained directly from an issuer or under an employment-based health plan—</text> <clause id="HE48ED297E9FB4964ABDD4A4EDC97AAC1" commented="no"><enum>(i)</enum><text display-inline="yes-display-inline">the provision by the issuer or plan of money or other financial consideration for disenrolling from the coverage; or</text></clause> <clause id="HF06139C3A71542DE8C182574BE6E29EB" commented="no"><enum>(ii)</enum><text display-inline="yes-display-inline">in the case of an individual whose premium for the prior coverage exceeded the premium required by the program (adjusted based on the age factors applied to the prior coverage)—</text> <subclause id="HBE3F39CD26354083976FB94B31B104E8" commented="no"><enum>(I)</enum><text display-inline="yes-display-inline">the prior coverage is a policy that is no longer being actively marketed (as defined by the Secretary) by the issuer; or</text></subclause> <subclause id="H4EEA659749344CDEB666FC21EA502B27" commented="no"><enum>(II)</enum><text display-inline="yes-display-inline">the prior coverage is a policy for which duration of coverage form issue or health status are factors that can be considered in determining premiums at renewal.</text></subclause></clause></subparagraph></paragraph> <paragraph id="H2F46FB75293844F0A77900064DA1EE9E" commented="no"><enum>(3)</enum><header>Construction</header><text>Nothing in this subsection shall be construed as constituting exclusive remedies for violations of criteria established under paragraph (1) or as preventing States from applying or enforcing such paragraph or other provisions under law with respect to health insurance issuers.</text></paragraph></subsection> <subsection id="H6F009B0C94704115841871381B91D5E2" commented="no"><enum>(g)</enum><header>Covered benefits, cost-sharing, premiums, and consumer protections</header> <paragraph id="H681B5B9C9DB542A6B254BE49D9CBA979" commented="no"><enum>(1)</enum><header>Premium</header><text>The monthly premium charged to eligible individuals for coverage under the program—</text> <subparagraph id="H10CEB0ED3E134916AE201FB20B626777" commented="no"><enum>(A)</enum><text>may vary by age so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 2 to 1;</text></subparagraph> <subparagraph id="H888F27C86AE5438A9B84E28E09EF04A9" commented="no"><enum>(B)</enum><text>shall be set at a level that does not exceed 125 percent of the prevailing standard rate for comparable coverage in the individual market; and</text></subparagraph> <subparagraph id="H1E09302790274A6EBC60E992FB15B9F6" commented="no"><enum>(C)</enum><text>shall be adjusted for geographic variation in costs.</text></subparagraph><continuation-text continuation-text-level="paragraph" commented="no">Health insurance issuers shall provide such information as the Secretary may require to determine prevailing standard rates under this paragraph. The Secretary shall establish standard rates in consultation with the National Association of Insurance Commissioners.</continuation-text></paragraph> <paragraph id="HC97B31185B1C48669DFA85CCA4FC2E4B" commented="no"><enum>(2)</enum><header>Covered benefits</header><text>Covered benefits under the program shall be determined by the Secretary and shall be consistent with the basic categories in the essential benefits package described in section 222. Under such benefits package—</text> <subparagraph id="HA09F171EB08D419BB09EA8B887A3CC13" commented="no"><enum>(A)</enum><text>the annual deductible for such benefits may not be higher than $1,500 for an individual or such higher amount for a family as determined by the Secretary;</text></subparagraph> <subparagraph id="HD4F3A335692B4702B5AA56848D405286" commented="no"><enum>(B)</enum><text>there may not be annual or lifetime limits; and</text></subparagraph> <subparagraph id="HA49F10182BA6474DA6043F56C2ECB82A" commented="no"><enum>(C)</enum><text>the maximum cost-sharing with respect to an individual (or family) for a year shall not exceed $5,000 for an individual (or $10,000 for a family).</text></subparagraph></paragraph> <paragraph id="H15F1A0D16E734C0D91DD30E2C53367E3" commented="no"><enum>(3)</enum><header>No preexisting condition exclusion periods</header><text>No preexisting condition exclusion period shall be imposed on coverage under the program.</text></paragraph> <paragraph id="HBA7D0C4DA0974DC79B305B7BED6525E4" commented="no"><enum>(4)</enum><header>Appeals</header><text>The Secretary shall establish an appeals process for individuals to appeal a determination of the Secretary—</text> <subparagraph id="HFC393EC87BC843A7B2261D4B98EAEB85" commented="no"><enum>(A)</enum><text>with respect to claims submitted under this section; and</text></subparagraph> <subparagraph id="HFB91B8C7ED8345198E846B0502587E42" commented="no"><enum>(B)</enum><text>with respect to eligibility determinations made by the Secretary under this section.</text></subparagraph></paragraph> <paragraph id="H0AF3F0E02BBA46ED993628A1FF64A47A" commented="no"><enum>(5)</enum><header>State contribution, maintenance of effort</header><text>As a condition of providing health benefits under this section to eligible individual residing in a State—</text> <subparagraph id="H986071EC8E844B87867D12D9A405F3A8" commented="no"><enum>(A)</enum><text>in the case of a State in which a qualified high-risk pool (as defined under section 2744(c)(2) of the Public Health Service Act) was in effect as of July 1, 2009, the Secretary shall require the State make a maintenance of effort payment each year that the high-risk pool is in effect equal to an amount not less than the amount of all sources of funding for high-risk pool coverage made by that State in the year ending July 1, 2009; and</text></subparagraph> <subparagraph id="HD6AD084ED9FB49198D6648A9B22C21E9" commented="no"><enum>(B)</enum><text>in the case of a State which required health insurance issuers to contribute to a State high-risk pool or similar arrangement for the assessment against such issuers for pool losses, the State shall maintain such a contribution arrangement among such issuers.</text></subparagraph></paragraph> <paragraph id="HE470EBB61CF345458665DE809CEE7050" commented="no"><enum>(6)</enum><header>Limiting program expenditures</header><text>The Secretary shall, with respect to the program—</text> <subparagraph id="H33E2C5FE683A41D599A2455175F62FBC" commented="no"><enum>(A)</enum><text>establish procedures to protect against fraud, waste, and abuse under the program; and</text></subparagraph> <subparagraph id="H5A4DAECDA8B44616883BB7CE1576B072" commented="no"><enum>(B)</enum><text>provide for other program integrity methods.</text></subparagraph></paragraph> <paragraph id="H2B42DCDAFEAF4966AEFDD318C8C819CA" commented="no"><enum>(7)</enum><header>Treatment as creditable coverage</header><text>Coverage under the program shall be treated, for purposes of applying the definition of <quote>creditable coverage</quote> under the provisions of title XXVII of the Public Health Service Act, part 6 of subtitle B of title I of Employee Retirement Income Security Act of 1974, and chapter 100 of the Internal Revenue Code of 1986 (and any other provision of law that references such provisions) in the same manner as if it were coverage under a State health benefits risk pool described in section 2701(c)(1)(G) of the Public Health Service Act.</text></paragraph></subsection> <subsection id="H8BC2ECA9674945A09D46129BE040E052" display-inline="no-display-inline" commented="no"><enum>(h)</enum><header>Funding; Termination of Authority</header> <paragraph id="H3460766D0F874745A01A2DC1BD692707" commented="no"><enum>(1)</enum><header>In general</header><text>There is appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, $5,000,000,000 to pay claims against (and administrative costs of) the high-risk pool under this section in excess of the premiums collected with respect to eligible individuals enrolled in the high-risk pool. Such funds shall be available without fiscal year limitation. </text></paragraph> <paragraph id="HEFA5989898EB4DF2A251B8C4737E03CD" commented="no"><enum>(2)</enum><header>Insufficient funds</header><text>If the Secretary estimates for any fiscal year that the aggregate amounts available for payment of expenses of the high-risk pool will be less than the amount of the expenses, the Secretary shall make such adjustments as are necessary to eliminate such deficit, including reducing benefits, increasing premiums, or establishing waiting lists. </text></paragraph> <paragraph id="H4D050E53DDA34804B0CEDBC614C99146" commented="no"><enum>(3)</enum><header>Termination of authority</header> <subparagraph id="H651F104416B84891A9DFF12866500A91" commented="no"><enum>(A)</enum><header>In general</header><text display-inline="yes-display-inline">Except as provided in subparagraph (B), coverage of eligible individuals under a high-risk pool shall terminate as of the date on which the Health Insurance Exchange is established.</text></subparagraph> <subparagraph id="HA683A9537ED743DCBC4DAB7B0F711EAD" commented="no"><enum>(B)</enum><header>Transition to exchange</header><text>The Secretary shall develop procedures to provide for the transition of eligible individuals who are enrolled in health insurance coverage offered through a high-risk pool established under this section to be enrolled in acceptable coverage. Such procedures shall ensure that there is no lapse in coverage with respect to the individual and may extend coverage offered through such a high-risk pool beyond 2012 if the Secretary determines necessary to avoid such a lapse.</text></subparagraph></paragraph></subsection></section> <section id="H8E38FAB8EBC64A0C9547166F1BA4B8A9"><enum>102.</enum><header>Ensuring value and lower premiums</header> <subsection id="HB04FCD47C6424848BE3996FB52FE05C4"><enum>(a)</enum><header>Group health insurance coverage</header><text display-inline="yes-display-inline">Title XXVII of the Public Health Service Act is amended by inserting after section 2713 the following new section:</text> <quoted-block style="OLC" id="H8076B44FDFDB47D2AEBC47E9EB6C7646" display-inline="no-display-inline"> <section id="HD4CC3ABC6037415F841AD0EECE351030"><enum>2714.</enum><header>Ensuring value and lower premiums</header> <subsection id="H36F90B95A45D43629BB7A538E6DC0115"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">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 (but not less than 85 percent), the issuer shall provide in a manner specified by the Secretary for rebates to enrollees of the amount by which the issuer’s medical loss ratio is less than the level so specified.</text></subsection> <subsection id="H6D6E1F7F6E2B4027AB822DEB3D6F4B1B"><enum>(b)</enum><header>Implementation</header><text display-inline="yes-display-inline">The Secretary shall establish a uniform definition of medical loss ratio and methodology for determining how to calculate it based on the average medical loss ratio in a health insurance issuer’s book of business for the small and large group market. Such methodology shall be designed to take into account the special circumstances of smaller plans, different types of plans, and newer plans. In determining the medical loss ratio, the Secretary shall exclude State taxes and licensing or regulatory fees. Such methodology shall be designed and exceptions shall be established to ensure adequate participation by health insurance issuers, competition in the health insurance market, and value for consumers so that their premiums are used for services.</text></subsection> <subsection id="HE03078D89DB04D4DBAA4BCD99D24F6F4"><enum>(c)</enum><header>Sunset</header><text>Subsections (a) and (b) shall not apply to health insurance coverage on and after the first date that health insurance coverage is offered through the Health Insurance Exchange. </text></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></subsection> <subsection id="H986CA8022E6C4F318801AE8472A981B6"><enum>(b)</enum><header>Individual health insurance coverage</header><text>Such title is further amended by inserting after section 2753 the following new section:</text> <quoted-block style="OLC" id="H2A2DB9331CEA4E3F8ED62F8FB3B6B784" display-inline="no-display-inline"> <section id="HC58FC630838B4E8E82E2F6D9425CF7FB"><enum>2754.</enum><header>Ensuring value and lower premiums</header><text display-inline="no-display-inline">The 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 except to the extent the Secretary determines that the application of such section may destabilize the existing individual market.</text></section><after-quoted-block>.</after-quoted-block></quoted-block></subsection> <subsection id="H93FE74F043C54051AF2ACC75700ED7A6"><enum>(c)</enum><header>Immediate implementation</header><text>The amendments made by this section shall apply in the group and individual market for plan years beginning on or after January 1, 2010, or as soon as practicable after such date.</text></subsection></section> <section id="HE140C9DF7ED34A95BEB419E137F87B64"><enum>103.</enum><header>Ending health insurance rescission abuse</header> <subsection id="HD66BF17804B349D58C2226D8160C9275"><enum>(a)</enum><header>Clarification regarding application of guaranteed renewability of individual and group health insurance coverage</header><text display-inline="yes-display-inline">Sections 2712 and 2742 of the Public Health Service Act (42 U.S.C. 300gg–12, 300gg–42) are each amended—</text> <paragraph id="H1FA779C153EC4D80865CD5801C993913"><enum>(1)</enum><text>in its heading, by inserting <quote><header-in-text level="section" style="OLC">and continuation in force, including prohibition of rescission,</header-in-text></quote> after <quote><header-in-text level="section" style="OLC">guaranteed renewability</header-in-text></quote>; and</text></paragraph> <paragraph id="HFC7CD99E62E54ED5AC39BF57A1C33755"><enum>(2)</enum><text>in subsection (a), by inserting <quote>, including without rescission,</quote> after <quote>continue in force</quote>.</text></paragraph></subsection> <subsection id="H52961D55A7D74662B768321AE170BAE0"><enum>(b)</enum><header>Secretarial guidance regarding rescissions</header> <paragraph id="H5C40B7F4262E4BB28B778DB39E04BF0F"><enum>(1)</enum><header>Group health insurance market</header><text>Section 2712 of such Act (42 U.S.C. 300gg–12) is amended by adding at the end the following:</text> <quoted-block style="OLC" id="HA82A982AF4C14ABB9C04A1439AEBCD3D" display-inline="no-display-inline"> <subsection id="H69999E9BE47A44C98001CB2F21072A96"><enum>(f)</enum><header>Rescission</header><text display-inline="yes-display-inline">A health insurance issuer may rescind group health insurance coverage only upon clear and convincing evidence of fraud described in subsection (b)(2), under procedures that provide for independent, external third-party review. </text></subsection><after-quoted-block>.</after-quoted-block></quoted-block></paragraph> <paragraph id="H677AB79236B34BF590874C0679F3321B"><enum>(2)</enum><header>Individual health market</header><text>Section 2742 of such Act (42 U.S.C. 300gg–42) is amended by adding at the end the following:</text> <quoted-block style="OLC" display-inline="no-display-inline" id="HCF165A52927249B396D31B098709A388"> <subsection id="H62C52552BF9B4EC085A8CEAFB9BE22BA"><enum>(f)</enum><header>Rescission</header><text display-inline="yes-display-inline">A health insurance issuer may rescind individual health insurance coverage only upon clear and convincing evidence of fraud described in subsection (b)(2), under procedures that provide for independent, external third-party review. </text></subsection><after-quoted-block>.</after-quoted-block></quoted-block></paragraph> <paragraph id="H11BB897370564F12BDDE4DE3515BDC56"><enum>(3)</enum><header>Guidance</header><text display-inline="yes-display-inline">The Secretary of Health and Human Services, no later than 90 days after the date of the enactment of this Act, shall issue guidance implementing the amendments made by paragraphs (1) and (2), including procedures for independent, external third-party review. </text></paragraph></subsection> <subsection id="HDB41871940454B31B684037D8931AC9D"><enum>(c)</enum><header>Opportunity for independent, external third-party review in certain cases</header> <paragraph id="H749CE252B6804B3FA640FC85CA602FA7"><enum>(1)</enum><header>Individual market</header><text>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:</text> <quoted-block style="OLC" display-inline="no-display-inline" id="H4340C58167BE49A2A4F5F2BD04C2D681"> <section id="H84E6FB2830D146FC8C1CBA016836A9AD"><enum>2746.</enum><header>Opportunity for independent, external third-party review in cases of rescission</header> <subsection id="H0D631879808145438D57DA5FBD5D4C26"><enum>(a)</enum><header>Notice and review right</header><text display-inline="yes-display-inline">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).</text></subsection> <subsection id="HC90881B74F754973BCEDFF2CFD272ECA"><enum>(b)</enum><header>Independent determination</header><text>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).</text></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></paragraph> <paragraph id="HFDCB51BDB38848B8895FFDEBE63E5ED6"><enum>(2)</enum><header>Application to group health insurance</header><text>Such title is further amended by adding after section 2702 the following new section:</text> <quoted-block style="OLC" id="H327E1B5319264A00BB8CC01546446BD5" display-inline="no-display-inline"> <section id="H0D18F572DA934F11BD31A369CCE56576"><enum>2703.</enum><header>Opportunity for independent, external third-party review in cases of rescission</header><text display-inline="no-display-inline">The provisions of section 2746 shall apply to group health insurance coverage in the same manner as such provisions apply to individual health insurance coverage, except that any reference to section 2742(f) is deemed a reference to section 2712(f).</text></section><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection> <subsection id="H08C607692E6742E4B558DD78FC3BF022"><enum>(d)</enum><header>Effective Date</header><text>The amendments made by this section shall take effect on the date of the enactment of this Act and shall apply to rescissions occurring on and after July 1, 2010, with respect to health insurance coverage issued before, on, or after such date.</text></subsection></section> <section id="H8F060837462C475494D7EE5E04387D9A"><enum>104.</enum><header>Sunshine on price gouging by health insurance issuers</header><text display-inline="no-display-inline">The Secretary of Health and Human Services, in conjunction with States, shall establish a process for the annual review of increases in premiums for health insurance coverage. Such process shall require health insurance issuers to submit a justification for any premium increases prior to implementation of the increase. </text></section> <section id="H2F2BB9B8717C4213AB76AF0BF91E270C" section-type="subsequent-section" commented="no"><enum>105.</enum><header>Requiring the option of extension of dependent coverage for uninsured young adults</header> <subsection id="HF5BDD0A000B34391B26062DCE405FB7B" commented="no"><enum>(a)</enum><header>Under group health plans</header> <paragraph id="HE00AC96C4B1D41D6B9984A94688EF739" commented="no"><enum>(1)</enum><header>PHSA</header><text>Title XXVII of the Public Health Service Act is amended by inserting after section 2702 the following new section:</text> <quoted-block display-inline="no-display-inline" id="H01810095A2284CFAB0E25FC6D71E54C6" style="OLC"> <section id="HD2FFE29284584245B21E0EF32588460E" commented="no"><enum>2703.</enum><header>Requiring the option of extension of dependent coverage for uninsured young adults</header> <subsection id="H261BCC1CEF8F447DAEDFA986C25C6F18" commented="no"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">A group health plan and a health insurance issuer offering health insurance coverage in connection with a group health plan that provides coverage for dependent children shall make available such coverage, at the option of the participant involved, for one or more qualified children (as defined in subsection (b)) of the participant.</text></subsection> <subsection id="HCE225D35C59D4C50BA00226CB7B4F268" commented="no"><enum>(b)</enum><header>Qualified child defined</header><text>In this section, the term <term>qualified child</term> means, with respect to a participant in a group health plan or group health insurance coverage, an individual who (but for age) would be treated as a dependent child of the participant under such plan or coverage and who—</text> <paragraph id="H204B05F7A1A84D439D7D92D845E3D4BF" commented="no"><enum>(1)</enum><text>is under 27 years of age; and</text></paragraph> <paragraph id="H5FE69BD9A31C4441B25B1540352EA9EF" commented="no"><enum>(2)</enum><text>is not enrolled as a participant, beneficiary, or enrollee (other than under this section, section 2746, or section 704 of the Employee Retirement Income Security Act of 1974) under any health insurance coverage or group health plan.</text></paragraph></subsection> <subsection id="H688E4F9E3B0C4B1DA3A631C857D8ACF9" commented="no"><enum>(c)</enum><header>Premiums</header><text>Nothing in this section shall be construed as preventing a group health plan or health insurance issuer with respect to group health insurance coverage from increasing the premiums otherwise required for coverage provided under this section consistent with standards established by the Secretary based upon family size.</text></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></paragraph> <paragraph id="H82AE5624CD864CFD833A75E530AB93F2" commented="no"><enum>(2)</enum><header>Employee retirement income security act of 1974</header> <subparagraph id="H2F50F924D3704596A99E81A5C330F0DA" commented="no"><enum>(A)</enum><header>In general</header><text>Part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by inserting after section 703 the following new section:</text> <quoted-block style="OLC" id="HD0892CEB2C5642A29B76850E6CB87D27" display-inline="no-display-inline"> <section id="H19AFC37D69E846669517D115F30255E8" commented="no"><enum>704.</enum><header>Requiring the option of extension of dependent coverage for uninsured young adults</header> <subsection id="H244D871943A64E899F2B9C0F239443B1" commented="no"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">A group health plan and a health insurance issuer offering health insurance coverage in connection with a group health plan that provides coverage for dependent children shall make available such coverage, at the option of the participant involved, for one or more qualified children (as defined in subsection (b)) of the participant.</text></subsection> <subsection id="H72E1CC45DE6944A2A048B68415329B52" commented="no"><enum>(b)</enum><header>Qualified child defined</header><text>In this section, the term <term>qualified child</term> means, with respect to a participant in a group health plan or group health insurance coverage, an individual who (but for age) would be treated as a dependent child of the participant under such plan or coverage and who—</text> <paragraph id="HBD2C9A00904B414096AF1A98FC2102EB" commented="no"><enum>(1)</enum><text>is under 27 years of age; and</text></paragraph> <paragraph id="HDD059DCA8BF94DF4A4A7D238E4D3BA7E" commented="no"><enum>(2)</enum><text>is not enrolled as a participant, beneficiary, or enrollee (other than under this section) under any health insurance coverage or group health plan.</text></paragraph></subsection> <subsection id="HF8B024B923F147ECB3B0771DA7A6AB68" commented="no"><enum>(c)</enum><header>Premiums</header><text>Nothing in this section shall be construed as preventing a group health plan or health insurance issuer with respect to group health insurance coverage from increasing the premiums otherwise required for coverage provided under this section consistent with standards established by the Secretary based upon family size.</text></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph> <subparagraph id="H64371CE8B4AC4DB68F86E55121AE02C7" commented="no"><enum>(B)</enum><header>Clerical amendment</header><text>The table of contents of such Act is amended by inserting after the item relating to section 703 the following new item:</text> <quoted-block style="OLC" id="H15BC731FFA304EF79BF634174A55EAE1" display-inline="no-display-inline"> <toc regeneration="no-regeneration"> <toc-entry level="section">Sec. 704. Requiring the option of extension of dependent coverage for uninsured young adults.</toc-entry></toc><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph></paragraph> <paragraph id="HAFA3A43E5BE74A0FBAF7F0F78F863F91" commented="no"><enum>(3)</enum><header>IRC</header> <subparagraph id="H58903B5CF3574B3A8C0ECFE518A60414" commented="no"><enum>(A)</enum><header>In general</header><text>Subchapter A of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new section:</text> <quoted-block style="OLC" id="H874B6F2F5A2D45F797EC270B1FE53D57" display-inline="no-display-inline"> <section id="H32B2A60A104841F2AC7C7D9F3D801C34" commented="no"><enum>9804.</enum><header>Requiring the option of extension of dependent coverage for uninsured young adults</header> <subsection id="H8280536DD3FE4BE7BEB9F1A272D14907" commented="no"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">A group health plan that provides coverage for dependent children shall make available such coverage, at the option of the participant involved, for one or more qualified children (as defined in subsection (b)) of the participant.</text></subsection> <subsection id="H048852D8360247809387CF71F5FF15AD" commented="no"><enum>(b)</enum><header>Qualified child defined</header><text>In this section, the term <term>qualified child</term> means, with respect to a participant in a group health plan, an individual who (but for age) would be treated as a dependent child of the participant under such plan and who—</text> <paragraph id="H5F497617208D4CA39310B74C0A6B9A38" commented="no"><enum>(1)</enum><text>is under 27 years of age; and</text></paragraph> <paragraph id="H7B871450B01C49C2B28FBB4D1BCE2337" commented="no"><enum>(2)</enum><text>is not enrolled as a participant, beneficiary, or enrollee (other than under this section, section 704 of the Employee Retirement Income Security Act of 1974, or section 2704 or 2746 of the Public Health Service Act) under any health insurance coverage or group health plan.</text></paragraph></subsection> <subsection id="HC599C3399BE146DE840586EC1C519849" commented="no"><enum>(c)</enum><header>Premiums</header><text>Nothing in this section shall be construed as preventing a group health plan from increasing the premiums otherwise required for coverage provided under this section consistent with standards established by the Secretary based upon family size.</text></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph> <subparagraph id="H7A5212BD46BA4DC8A0BD6EF8044498DE" commented="no"><enum>(B)</enum><header>Clerical amendment</header><text>The table of sections of such chapter is amended by inserting after the item relating to section 9803 the following:</text> <quoted-block style="OLC" id="H33F3F7106A5D4C54A3134C284F47E1A3" display-inline="no-display-inline"> <toc regeneration="no-regeneration"> <toc-entry level="section">Sec. 9804. Requiring the option of extension of dependent coverage for uninsured young adults.</toc-entry></toc><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph></paragraph></subsection> <subsection id="H6BE00D604F624DFA9BCC014C665469B7" commented="no"><enum>(b)</enum><header>Individual health insurance coverage</header><text>Title XXVII of the Public Health Service Act is amended by inserting after section 2745 the following new section:</text> <quoted-block display-inline="no-display-inline" id="H8C62CF88DF1947848C514F3EB064B599" style="OLC"> <section id="HE2194399F0B04B8BB1FCAB0C7E3E8CBE" commented="no"><enum>2746.</enum><header>Requiring the option of extension of dependent coverage for uninsured young adults</header><text display-inline="no-display-inline">The provisions of section 2703 shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as they apply to health insurance coverage offered by a health insurance issuer in connection with a group health plan in the small or large group market.</text></section><after-quoted-block>.</after-quoted-block></quoted-block></subsection> <subsection id="H4B0118766B5D4A84A18091672EA5CBE3" commented="no"><enum>(c)</enum><header>Effective dates</header> <paragraph id="H44E4CA4863A24631B5CCB54BEE774118" commented="no"><enum>(1)</enum><header>Group health plans</header><text display-inline="yes-display-inline">The amendments made by subsection (a) shall apply to group health plans for plan years beginning on or after January 1, 2010.</text></paragraph> <paragraph id="HA7E65F121B2848EFAB07B3D5009B4566" commented="no"><enum>(2)</enum><header>Individual health insurance coverage</header><text display-inline="yes-display-inline">Section 2746 of the Public Health Service Act, as inserted by subsection (b), shall apply with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after January 1, 2010.</text></paragraph></subsection></section> <section display-inline="no-display-inline" id="H73BF1F182D5D4F578A37AF638F670E26" section-type="subsequent-section" commented="no"><enum>106.</enum><header>Limitations on preexisting condition exclusions in group health plans in advance of applicability of new prohibition of preexisting condition exclusions</header> <subsection id="H12148C6259314CB7A605C0749D8323C5" commented="no"><enum>(a)</enum><header>Amendments to the Employee Retirement Income Security Act of 1974</header> <paragraph id="H8B30A17D5B654CBAB04D664E21F125A4" commented="no"><enum>(1)</enum><header>Reduction in look-back period</header><text>Section 701(a)(1) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1181(a)(1)) is amended by striking <quote>6-month period</quote> and inserting <quote>30-day period</quote>.</text></paragraph> <paragraph id="H64330C2DCC7646A1806D00EA4169516E" commented="no"><enum>(2)</enum><header>Reduction in permitted preexisting condition limitation period</header><text>Section 701(a)(2) of such Act (29 U.S.C. 1181(a)(2)) is amended by striking <quote>12 months</quote> and inserting <quote>3 months</quote>, and by striking <quote>18 months</quote> and inserting <quote>9 months</quote>.</text></paragraph> <paragraph id="H393E7446E13F4C388BE842E632E6AC48" commented="no"><enum>(3)</enum><header>Sunset of interim limitation</header><text display-inline="yes-display-inline">Section 701 of such Act (29 U.S.C. 1181) is amended by adding at the end the following new subsection:</text> <quoted-block style="OLC" id="H13759A1E69F3494D860F55EE10C926F6" display-inline="no-display-inline"> <subsection id="H6E34FD88F65F464E85B41FA6681A9D75" commented="no"><enum>(h)</enum><header>Termination</header><text display-inline="yes-display-inline">This section shall cease to apply to any group health plan as of the date that such plan becomes subject to the requirements of section 211 of the (relating to prohibiting preexisting condition exclusions).</text></subsection><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection> <subsection id="H53FA45FAEDC84E88B841D93F8657AF82" commented="no"><enum>(b)</enum><header>Amendments to the Internal Revenue Code of 1986</header> <paragraph id="H8235743EBF2043E4A7B73D900EFDE229" commented="no"><enum>(1)</enum><header>Reduction in look-back period</header><text>Section 9801(a)(1) of the Internal Revenue Code of 1986 is amended by striking <quote>6-month period</quote> and inserting <quote>30-day period</quote>.</text></paragraph> <paragraph id="H4815C65A1E134980AA1069F6F8837313" commented="no"><enum>(2)</enum><header>Reduction in permitted preexisting condition limitation period</header><text>Section 9801(a)(2) of such Code is amended by striking <quote>12 months</quote> and inserting <quote>3 months</quote>, and by striking <quote>18 months</quote> and inserting <quote>9 months</quote>.</text></paragraph> <paragraph id="H2B592FDC40F0453B9B265FA099E3B45D" commented="no"><enum>(3)</enum><header>Sunset of interim limitation</header><text display-inline="yes-display-inline">Section 9801 of such Code is amended by adding at the end the following new subsection:</text> <quoted-block style="OLC" display-inline="no-display-inline" id="H53E513E4036C4260AF81A1D9D5B02956"> <subsection id="H5F5868DAFA1F42E99104F5BE064076D6" commented="no"><enum>(g)</enum><header>Termination</header><text display-inline="yes-display-inline">This section shall cease to apply to any group health plan as of the date that such plan becomes subject to the requirements of section 211 of the (relating to prohibiting preexisting condition exclusions).</text></subsection><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection> <subsection id="HD6B122BCB65C49A298849003AE9A96DF" commented="no"><enum>(c)</enum><header>Amendments to Public Health Service Act</header> <paragraph id="HB57104EBFC864379A2F740A852B8E21B" commented="no"><enum>(1)</enum><header>Reduction in look-back period</header><text>Section 2701(a)(1) of the Public Health Service Act (42 U.S.C. 300gg(a)(1)) is amended by striking <quote>6-month period</quote> and inserting <quote>30-day period</quote>.</text></paragraph> <paragraph id="H9E241C8EA99744B1B93940E78406113A" commented="no"><enum>(2)</enum><header>Reduction in permitted preexisting condition limitation period</header><text>Section 2701(a)(2) of such Act (42 U.S.C. 300gg(a)(2)) is amended by striking <quote>12 months</quote> and inserting <quote>3 months</quote>, and by striking <quote>18 months</quote> and inserting <quote>9 months</quote>.</text></paragraph> <paragraph id="HD532DFF2AB844F1CADCB85C8080E0229" commented="no"><enum>(3)</enum><header>Sunset of interim limitation</header><text display-inline="yes-display-inline">Section 2701 of such Act (42 U.S.C. 300gg) is amended by adding at the end the following new subsection:</text> <quoted-block style="OLC" display-inline="no-display-inline" id="HA284583A5A5547CF9B12A4EADB10A513"> <subsection id="HDCDAE2DFE89549EFBDFCEC924966E9B7" commented="no"><enum>(h)</enum><header>Termination</header><text display-inline="yes-display-inline">This section shall cease to apply to any group health plan as of the date that such plan becomes subject to the requirements of section 211 of the (relating to prohibiting preexisting condition exclusions).</text></subsection><after-quoted-block>.</after-quoted-block></quoted-block></paragraph> <paragraph id="HB9E3FEA738944FEA93E5238AB9856711" commented="no"><enum>(4)</enum><header>Miscellaneous technical amendment</header><text>Section 2702(a)(2) of such Act (42 U.S.C. 300gg–1) is amended by striking <quote>701</quote> and inserting <quote>2701</quote>. </text></paragraph></subsection> <subsection id="H4EB0BC94EB43481497717B9D3F225A92" commented="no"><enum>(d)</enum><header>Effective date</header> <paragraph id="H6B075A2C11014A17A95964DA96366FB3"><enum>(1)</enum><header>In general</header><text>Except as provided in paragraph (2), the amendments made by this section shall apply with respect to group health plans for plan years beginning on or after January 1, 2010.</text></paragraph> <paragraph id="H12F2126954764AB6937639F1410D3AF4"><enum>(2)</enum><header>Special rule for collective bargaining agreements</header><text>In the case of a group health plan maintained pursuant to 1 or more collective bargaining agreements between employee representatives and 1 or more employers ratified before the date of the enactment of this Act, the amendments made by this section shall not apply to plan years beginning before the earlier of—</text> <subparagraph id="H1967E9FB64D14FB89A9390DC10F144F9"><enum>(A)</enum><text>the date on which the last of the collective bargaining agreements relating to the plan terminates (determined without regard to any extension thereof agreed to after the date of the enactment of this Act);</text></subparagraph> <subparagraph id="H6ECA1ED04DC74CD6BE6024E00B521C50"><enum>(B)</enum><text>3 years after the date of the enactment of this Act.</text></subparagraph></paragraph></subsection></section> <section id="H3E6DB2000A834B61B912AB2550CF7693"><enum>107.</enum><header>Prohibiting acts of domestic violence from being treated as preexisting conditions</header> <subsection id="H0E6150740BEE4F2B91E2DC55A5C317A1"><enum>(a)</enum><header>ERISA</header><text display-inline="yes-display-inline">Section 701(d)(3) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. ) is amended—</text> <paragraph id="H26D00C4636F04263969351A88E8EC123"><enum>(1)</enum><text>in the heading, by inserting <quote><header-in-text level="paragraph" style="OLC">or domestic violence</header-in-text></quote> after <quote><header-in-text level="paragraph" style="OLC">pregnancy</header-in-text></quote>; and</text></paragraph> <paragraph id="H8E401CDE95E64094B85F65F8D9F8897A"><enum>(2)</enum><text>by inserting <quote>or domestic violence</quote> after <quote>relating to pregnancy</quote>.</text></paragraph></subsection> <subsection id="H1F191480335C4CFB96F6DBF41BB9376C"><enum>(b)</enum><header>PHSA</header> <paragraph id="HF9C178B1C68C48DFB35CC0D46B023946"><enum>(1)</enum><header>Group market</header><text display-inline="yes-display-inline">Section 2701(d)(3) of the Public Health Service Act (42 U.S.C. 300gg(d)(3)) is amended—</text> <subparagraph id="H2D0AD99754954229AFFC3708E1E6F99C" display-inline="no-display-inline"><enum>(A)</enum><text>in the heading, by inserting <quote><header-in-text level="paragraph" style="OLC">or domestic violence</header-in-text></quote> after <quote><header-in-text level="paragraph" style="OLC">pregnancy</header-in-text></quote>; and</text></subparagraph> <subparagraph id="H6BD3D7FC90B54C3FA368A6D4A64A069A"><enum>(B)</enum><text>by inserting <quote>or domestic violence</quote> after <quote>relating to pregnancy</quote>.</text></subparagraph></paragraph> <paragraph id="HBD62F7F61F4D434F903AB78ACC5C503A"><enum>(2)</enum><header>Individual market</header><text>Title XXVII of such Act is amended by inserting after section 2753 the following new section:</text> <quoted-block style="OLC" id="H07E408CACD7B4F5D9C1B599EF9AA88E9" display-inline="no-display-inline"> <section id="H4E1CCB358DC3488DACAAA70D508EF127"><enum>2754.</enum><header>Prohibition on domestic violence as preexisting condition</header><text display-inline="no-display-inline">A health insurance issuer offering health insurance coverage in the individual market may not, on the basis of domestic violence, impose any preexisting condition exclusion (as defined in section 2701(b)(1)(A)) with respect to such coverage.</text></section><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection> <subsection id="HFA245EB50F4447EB96E5FF551282B775"><enum>(c)</enum><header>IRC</header><text>Section 9801(d)(3) of the Internal Revenue Code of 1986 is amended—</text> <paragraph id="H0D6DFEC134C5492B874C6CF8695F3724"><enum>(1)</enum><text>in the heading, by inserting <quote><header-in-text level="paragraph" style="OLC">or domestic violence</header-in-text></quote> after <quote><header-in-text level="paragraph" style="OLC">pregnancy</header-in-text></quote>; and</text></paragraph> <paragraph id="HFB2D4602BF7442BCA3EBC072FC4E4037"><enum>(2)</enum><text>by inserting <quote>or domestic violence</quote> after <quote>relating to pregnancy</quote>.</text></paragraph></subsection> <subsection id="HB07F703D3AC146159D34E6BA6BE33849" commented="no"><enum>(d)</enum><header>Effective dates</header> <paragraph id="HBB18328B49BF4C8D89EA808BADF3742A" commented="no" display-inline="no-display-inline"><enum>(1)</enum><text display-inline="yes-display-inline">Except as otherwise provided in this subsection, the amendments made by this section shall apply with respect to group health plans (and health insurance issuers offering group health insurance coverage) for plan years beginning on or after January 1, 2010.</text></paragraph> <paragraph id="H395179CD8FBB475186B234F3B16EB408" commented="no"><enum>(2)</enum><text>The amendment made by subsection (b)(2) shall apply with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after such date.</text></paragraph></subsection></section> <section id="HAE121774DC124329BECC27B953793120" commented="no" display-inline="no-display-inline" section-type="subsequent-section"><enum>108.</enum><header>Ending health insurance denials and delays of necessary treatment for children with deformities</header> <subsection id="HB3225FBD0A04476F8828AF9F453C23A7" commented="no"><enum>(a)</enum><header>Amendments to the Employee Retirement Income Security Act of 1974</header> <paragraph id="H1653B7680D4E41CCA3087B578F3341FF" commented="no"><enum>(1)</enum><header>In general</header><text>Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by adding at the end the following new section:</text> <quoted-block style="OLC" id="HC3D4A36136D2499499C3B0E2828D59A1" display-inline="no-display-inline"> <section id="H413A774013F94A9C84593561CA9ABC60" commented="no"><enum>715.</enum><header>Standards relating to benefits for minor child’s congenital or developmental deformity or disorder</header> <subsection id="H1618D5D7C0EE4835AE84953E994B3C36" commented="no"><enum>(a)</enum><header>Requirements for treatment for children with deformities</header> <paragraph id="H7C665E7CD0E64DAF93F8C231A238ED86" commented="no"><enum>(1)</enum><header>In general</header><text>A group health plan, and a health insurance issuer offering group health insurance coverage, that provides coverage for surgical benefits shall provide coverage for outpatient and inpatient diagnosis and treatment of a minor child’s congenital or developmental deformity, disease, or injury. A minor child shall include any individual who is 21 years of age or younger.</text></paragraph> <paragraph id="HDCBF0672D6BB49A7B5F53D863E11363E" commented="no"><enum>(2)</enum><header>Treatment defined</header> <subparagraph id="H80988239ADFE42E9BCACCE4045142AC1" commented="no"><enum>(A)</enum><header>In general</header><text>In this section, the term <quote>treatment</quote> includes reconstructive surgical procedures (procedures that are generally performed to improve function, but may also be performed to approximate a normal appearance) that are performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, including—</text> <clause id="HA66A8334C53D4733952A62FF149F2833" commented="no"><enum>(i)</enum><text>procedures that do not materially affect the function of the body part being treated; and</text></clause> <clause id="H938B9FA6AB1941D3AEFC10F2502F5FC1" commented="no"><enum>(ii)</enum><text>procedures for secondary conditions and follow-up treatment.</text></clause></subparagraph> <subparagraph id="H814A0815DE5A4512BF06B8ABC0AD9D41" commented="no"><enum>(B)</enum><header>Exception</header><text>Such term does not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem.</text></subparagraph></paragraph></subsection> <subsection id="H36C205D74D6D44FB88C74AA28C52E75A" commented="no"><enum>(b)</enum><header>Notice</header><text display-inline="yes-display-inline">A group health plan under this part shall comply with the notice requirement under section 713(b) (other than paragraph (3)) with respect to the requirements of this section.</text></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></paragraph> <paragraph id="H4355B36CC10142699FD8DF586718F658" commented="no"><enum>(2)</enum><header>Conforming amendment</header> <subparagraph id="HDBC7A79486414C04A0E4E653A34524AA" commented="no"><enum>(A)</enum><text>Subsection (c) of section 731 of such Act is amended by striking <quote>section 711</quote> and inserting <quote>sections 711 and 715</quote>.</text></subparagraph> <subparagraph id="H4FA1FB5F62594D93B0327E8ECA5439F4" commented="no"><enum>(B)</enum><text>The table of contents in section 1 of such Act is amended by inserting after the item relating to section 714 the following new item:</text> <quoted-block style="OLC" id="HC3F43D50018F46EB9047D6FA2541C3E2" display-inline="no-display-inline"> <toc container-level="quoted-block-container" quoted-block="no-quoted-block" lowest-level="section" idref="HC3D4A36136D2499499C3B0E2828D59A1" regeneration="yes-regeneration" lowest-bolded-level="division-lowest-bolded"> <toc-entry idref="H413A774013F94A9C84593561CA9ABC60" level="section">Sec. 715. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.</toc-entry></toc><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph></paragraph></subsection> <subsection id="H6A68CA1438814A2E948B792D436B3A5A" commented="no"><enum>(b)</enum><header>Amendments to the Internal Revenue Code of 1986</header> <paragraph id="H505EA88DD5694DCF8413D01A160C45D2" commented="no"><enum>(1)</enum><header>In general</header><text>Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new section:</text> <quoted-block style="OLC" id="H60D53B0644A548D589B0F75CCC628E3F" display-inline="no-display-inline"> <section id="HDF67114C494B4DD584C39F134857FC03" commented="no"><enum>9814.</enum><header>Standards relating to benefits for minor child’s congenital or developmental deformity or disorder</header> <subsection id="H17D79EB8113B4FC5BEDD6D771262E212" commented="no"><enum>(a)</enum><header>Requirements for treatment for children with deformities</header><text>A group health plan that provides coverage for surgical benefits shall provide coverage for outpatient and inpatient diagnosis and treatment of a minor child’s congenital or developmental deformity, disease, or injury. A minor child shall include any individual who is 21 years of age or younger.</text></subsection> <subsection id="HF52C6AF3B65D4768B566DA9E0934F441" commented="no"><enum>(b)</enum><header>Treatment defined</header> <paragraph id="HB4054D7A0753429F9555DDB061271F1E" commented="no"><enum>(1)</enum><header>In general</header><text>In this section, the term <quote>treatment</quote> includes reconstructive surgical procedures (procedures that are generally performed to improve function, but may also be performed to approximate a normal appearance) that are performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, including—</text> <subparagraph id="H212DFF5FB39C4A7181650F1A0673FC9D" commented="no"><enum>(A)</enum><text>procedures that do not materially affect the function of the body part being treated, and</text></subparagraph> <subparagraph id="HDD7481ABE1F24776994B9395B6EE4F66" commented="no"><enum>(B)</enum><text>procedures for secondary conditions and follow-up treatment.</text></subparagraph></paragraph> <paragraph id="H24EF72B0BB0C48B1A426C9DE64E82358" commented="no"><enum>(2)</enum><header>Exception</header><text>Such term does not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem.</text></paragraph></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></paragraph> <paragraph id="H11782E9CEA8A49D5A7BCD820297FEC95" commented="no"><enum>(2)</enum><header>Clerical amendment</header><text display-inline="yes-display-inline">The table of sections for subchapter B of chapter 100 of such Code is amended by adding at the end the following new item:</text> <quoted-block style="OLC" id="HC067A01B9E5B4BE1A6118D23ADE3F242" display-inline="no-display-inline"> <toc container-level="quoted-block-container" quoted-block="no-quoted-block" lowest-level="section" idref="H60D53B0644A548D589B0F75CCC628E3F" regeneration="yes-regeneration" lowest-bolded-level="division-lowest-bolded"> <toc-entry idref="HDF67114C494B4DD584C39F134857FC03" level="section">Sec. 9814. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.</toc-entry></toc><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection> <subsection id="H24D9ECD49C0A423DB85B65771A1A4EC3" commented="no"><enum>(c)</enum><header>Amendments to the Public Health Service Act</header> <paragraph id="HC027068F10F94F798BE6C03AD53FE29D" commented="no"><enum>(1)</enum><header>In general</header><text>Subpart 2 of part A of title XXVII of the Public Health Service Act is amended by adding at the end the following new section:</text> <quoted-block id="H5C9C0CCC4A0741C986D87CEA75FF9F26" style="OLC"> <section id="HD97F3B241D574C0C885937A815C02398" commented="no"><enum>2708.</enum><header>Standards relating to benefits for minor child’s congenital or developmental deformity or disorder</header> <subsection id="H8D2913BDDF874D3A9DE466190364152C" commented="no"><enum>(a)</enum><header>Requirements for treatment for children with deformities</header> <paragraph id="H7626F386AA484C57A2430954F4E455F6" commented="no"><enum>(1)</enum><header>In general</header><text>A group health plan, and a health insurance issuer offering group health insurance coverage, that provides coverage for surgical benefits shall provide coverage for outpatient and inpatient diagnosis and treatment of a minor child’s congenital or developmental deformity, disease, or injury. A minor child shall include any individual who is 21 years of age or younger.</text></paragraph> <paragraph id="H0BFE7293A0F648FEA04282BD395B1A51" commented="no"><enum>(2)</enum><header>Treatment defined</header> <subparagraph id="H1CD4781BE8B045D8B5A8D69842DA64BF" commented="no"><enum>(A)</enum><header>In general</header><text>In this section, the term <quote>treatment</quote> includes reconstructive surgical procedures (procedures that are generally performed to improve function, but may also be performed to approximate a normal appearance) that are performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, including—</text> <clause id="H1018AF6E673149D99A8977C59B2F7A78" commented="no"><enum>(i)</enum><text>procedures that do not materially affect the function of the body part being treated; and</text></clause> <clause id="HF883109344B3430AA6C6BFF8F72381CD" commented="no"><enum>(ii)</enum><text>procedures for secondary conditions and follow-up treatment.</text></clause></subparagraph> <subparagraph id="H9B1BEC627A0B4AFA9D0089F8EEF46D6E" commented="no"><enum>(B)</enum><header>Exception</header><text>Such term does not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem.</text></subparagraph></paragraph></subsection> <subsection id="HDFFB44D5AD484A77BDA20A2F2D703AFC" commented="no"><enum>(b)</enum><header>Notice</header><text display-inline="yes-display-inline">A group health plan under this part shall comply with the notice requirement under section 715(b) of the Employee Retirement Income Security Act of 1974 with respect to the requirements of this section as if such section applied to such plan. </text></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></paragraph> <paragraph id="HB41F57A53CA04197BC8FD09862F86066" commented="no"><enum>(2)</enum><header>Individual health insurance</header><text>Subpart 2 of part B of title XXVII of the Public Health Service Act, as amended by section 161(b), is further amended by adding at the end the following new section:</text> <quoted-block style="OLC" id="H18C21CF8B1094F4A9586AB7FE71B78DD" display-inline="no-display-inline"> <section id="H739A2B012CF04CB7959D35DDD9480F2D" commented="no"><enum>2755.</enum><header>Standards relating to benefits for minor child’s congenital or developmental deformity or disorder</header><text display-inline="no-display-inline">The provisions of section 2708 shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as such provisions apply to health insurance coverage offered by a health insurance issuer in connection with a group health plan in the small or large group market. </text></section><after-quoted-block>.</after-quoted-block></quoted-block></paragraph> <paragraph id="H3144A52C76DF42B2893E7DDD8BCEE265" commented="no"><enum>(3)</enum><header>Conforming amendments</header> <subparagraph id="H59428EB504DA47FE845C2A0A0DA12EA1" commented="no"><enum>(A)</enum><text>Section 2723(c) of such Act (42 U.S.C. 300gg–23(c)) is amended by striking <quote>section 2704</quote> and inserting <quote>sections 2704 and 2708</quote>.</text></subparagraph> <subparagraph id="HBF2BD0D36A364045A874F27FCE716AD2" commented="no"><enum>(B)</enum><text>Section 2762(b)(2) of such Act (42 U.S.C. 300gg–62(b)(2)) is amended by striking <quote>section 2751</quote> and inserting <quote>sections 2751 and 2755</quote>.</text></subparagraph></paragraph></subsection> <subsection id="H7744D87888A243CBAAA1B5E0E8C04551" commented="no"><enum>(d)</enum><header>Effective dates</header> <paragraph id="H71048C46D03C44DFA6CDD7A86E797B40" commented="no" display-inline="no-display-inline"><enum>(1)</enum><text display-inline="yes-display-inline">The amendments made by this section shall apply with respect to group health plans (and health insurance issuers offering group health insurance coverage) for plan years beginning on or after January 1, 2010.</text></paragraph> <paragraph id="HEB7153467D7E467C847D6C5148D28C6F" commented="no"><enum>(2)</enum><text>The amendment made by subsection (c)(2) shall apply with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after such date.</text></paragraph></subsection> <subsection id="H81A02C01097E40EE80D8076FA6EB8D40" commented="no"><enum>(e)</enum><header>Coordination</header><text display-inline="yes-display-inline">Section 104(1) of the Health Insurance Portability and Accountability Act of 1996 is amended by striking <quote>(and the amendments made by this subtitle and section 401)</quote> and inserting <quote>, part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974, parts A and C of title XXVII of the Public Health Service Act, and chapter 100 of the Internal Revenue Code of 1986</quote>.</text></subsection></section> <section id="HA589B94690284417A035CF50479C2F92"><enum>109.</enum><header>Elimination of lifetime limits</header> <subsection id="H6B6BB9A52244423E8D6DE02FA9FCB03C"><enum>(a)</enum><header>Amendments to the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of 1974</act-name></header> <paragraph id="H91C44E192D7E44558C54E44B3300772D"><enum>(1)</enum><header>In General</header><text>Subpart B of part 7 of subtitle B of title I of the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of 1974</act-name> (29 U.S.C. 1185 et seq.), as amended by section 108, is amended by adding at the end the following:</text> <quoted-block act-name="Employee Retirement Income Security Act of 1974" id="H2E881972ECD64E89870BDFE1F67EC1EC" style="OLC"> <section id="HEDA157C19A284E89BE6CAC94CE0D8F20"><enum>716.</enum><header>Elimination of lifetime aggregate limits</header> <subsection id="H7F5BFB95878F448DB8E093140F206301"><enum>(a)</enum><header>In general</header><text>A group health plan and a health insurance issuer providing health insurance coverage in connection with a group health plan, may not impose an aggregate dollar lifetime limit with respect to benefits payable under the plan or coverage.</text></subsection> <subsection id="HD7D5AEF432C940B0B36BF3CB40EAB50E"><enum>(b)</enum><header>Definition</header><text>In this section, the term <term>aggregate dollar lifetime limit</term> means, with respect to benefits under a group health plan or health insurance coverage offered in connection with a group health plan, a dollar limitation on the total amount that may be paid with respect to such benefits under the plan or health insurance coverage with respect to an individual or other coverage unit on a lifetime basis.</text></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></paragraph> <paragraph id="H403697FCEF5D44D6997721B20582E764"><enum>(2)</enum><header>Clerical Amendment</header><text>The table of contents in section 1 of such Act, is amended by inserting after the item relating to section 715 the following new item:</text> <quoted-block id="HFED76D7517BF476EA580A7A09DCDDE33" style="OLC"> <toc regeneration="no-regeneration"> <toc-entry level="section">Sec. 716. Elimination of lifetime aggregate limits.</toc-entry></toc><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection> <subsection id="H46102FEB27FB40F8AF2D30594419E849" commented="no"><enum>(b)</enum><header>Amendments to the Internal Revenue Code of 1986</header> <paragraph id="H4CA34891C5F14CD392C5FBFDFB373264" commented="no"><enum>(1)</enum><header>In general</header><text>Subchapter B of chapter 100 of the Internal Revenue Code of 1986, as amended by section 108(b), is amended by adding at the end the following new section:</text> <quoted-block style="OLC" id="H961959B294BC472FA3EF83BC7AB283D9" display-inline="no-display-inline"> <section id="H5D2F8CB783CB4550B4408B587FDBF130" commented="no"><enum>9815.</enum><header>Elimination of lifetime aggregate limits</header> <subsection id="H82EB00A4AB614FC8B82A132B457616FF"><enum>(a)</enum><header>In general</header><text>A group health plan may not impose an aggregate dollar lifetime limit with respect to benefits payable under the plan.</text></subsection> <subsection id="HAF5DC54292DC4BF9A4175DF2BA3B7A22"><enum>(b)</enum><header>Definition</header><text>In this section, the term <term>aggregate dollar lifetime limit</term> means, with respect to benefits under a group health plan a dollar limitation on the total amount that may be paid with respect to such benefits under the plan with respect to an individual or other coverage unit on a lifetime basis.</text></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></paragraph> <paragraph id="HA6387DF41BBB4231A3466958672EADBA" commented="no"><enum>(2)</enum><header>Clerical amendment</header><text display-inline="yes-display-inline">The table of sections for subchapter B of chapter 100 of such Code, as amended by section 108(b), is amended by adding at the end the following new item:</text> <quoted-block style="OLC" id="HA8CBE97659934BCD966141ED2DCD9350" display-inline="no-display-inline"> <toc container-level="quoted-block-container" quoted-block="no-quoted-block" lowest-level="section" idref="H961959B294BC472FA3EF83BC7AB283D9" regeneration="yes-regeneration" lowest-bolded-level="division-lowest-bolded"> <toc-entry idref="H5D2F8CB783CB4550B4408B587FDBF130" level="section">Sec. 9854. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.</toc-entry></toc><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection> <subsection id="HB0F4C1FC9D87445F8121DD791ED9F9DE"><enum>(c)</enum><header>Amendment to the <act-name parsable-cite="PHSA">Public Health Service Act</act-name> relating to the group market</header> <paragraph id="H6221049703CF49EA992EE71B967DF16C"><enum>(1)</enum><header>In General</header><text>Subpart 2 of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–4 et seq.) as amended by section 108(c)(1), is amended by adding at the end the following:</text> <quoted-block act-name="Public Health Service Act" id="H26F98741071C4ADFB4ECC00DB753D7B2" style="OLC"> <section id="HF99CB1532CA04623AAFBB738B2F9305D"><enum>2709.</enum><header>Elimination of lifetime aggregate limits</header> <subsection id="H63A832301D0040A1820AB28E2F166874"><enum>(a)</enum><header>In General</header><text>A group health plan and a health insurance issuer providing health insurance coverage in connection with a group health plan, may not impose an aggregate dollar lifetime limit with respect to benefits payable under the plan or coverage.</text></subsection> <subsection id="HD6AD8D70495B473894159A94F23D958F"><enum>(b)</enum><header>Definition</header><text>In this section, the term <term>aggregate dollar lifetime limit</term> means, with respect to benefits under a group health plan or health insurance coverage, a dollar limitation on the total amount that may be paid with respect to such benefits under the plan or health insurance coverage with respect to an individual or other coverage unit on a lifetime basis.</text></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></paragraph> <paragraph id="H356CA504917A42E7BF8D3D836DFC2DCA"><enum>(2)</enum><header>Individual market</header><text>Subpart 2 of part B of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–51 et seq.), as amended by section 108(c)(2), is amended by adding at the end the following:</text> <quoted-block display-inline="no-display-inline" id="HBBCB690E1E4547059D02459FE011F2CD" style="OLC"> <section id="HAF7B244B93B34F9583362BB6CE56B58D"><enum>2756.</enum><header>Elimination of annual or lifetime aggregate limits</header><text display-inline="no-display-inline">The provisions of section 2709 shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as they apply to health insurance coverage offered by a health insurance issuer in connection with a group health plan in the small or large group market.</text></section><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection> <subsection id="HA8F741CFA6CC4888A6BDF935BA9A7F6B" commented="no"><enum>(d)</enum><header>Effective dates</header> <paragraph id="H3A5CD4CDD2DC47118A01C24353470CE2" commented="no" display-inline="no-display-inline"><enum>(1)</enum><text display-inline="yes-display-inline">The amendments made by this section shall apply with respect to group health plans (and health insurance issuers offering group health insurance coverage) for plan years beginning on or after January 1, 2010.</text></paragraph> <paragraph id="H98391AE803164C93A506936227A222C2" commented="no"><enum>(2)</enum><text>The amendment made by subsection (c)(2) shall apply with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after such date.</text></paragraph></subsection></section> <section id="H027B6058A40E4720BB0588B5D3FDDA05" commented="no"><enum>110.</enum><header>Prohibition against postretirement reductions of retiree health benefits by group health plans</header> <subsection id="H06237F761D5C4C8E9DCC9BA3A8642CED" commented="no"><enum>(a)</enum><header>In general</header><text>Part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974, as amended by sections 108 and 109, is amended by inserting after section 716 the following new section:</text> <quoted-block id="H72C88E84D7B6474FBE6DBD3707B68D05" style="OLC"> <section id="H7C5A95B35EB4418CBAD955D8FEFB9100" commented="no"><enum>717.</enum><header>Protection against postretirement reduction of retiree health benefits</header> <subsection id="HA8DB6730311E46D2B95712F339129CB6" commented="no"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">Every group health plan shall contain a provision which expressly bars the plan, or any fiduciary of the plan, from reducing the benefits provided under the plan to a retired participant, or beneficiary of such participant, if such reduction affects the benefits provided to the participant or beneficiary as of the date the participant retired for purposes of the plan and such reduction occurs after the participant’s retirement unless such reduction is also made with respect to active participants. Nothing in this section shall prohibit a plan from enforcing a total aggregate cap on amounts paid for retiree health coverage that is part of the plan at the time of retirement. </text></subsection> <subsection id="HAB2A7E5DBDF140EF8B7DDB9A1FC89E42" commented="no"><enum>(b)</enum><header>No reduction</header><text>Notwithstanding that a group health plan may contain a provision reserving the general power to amend or terminate the plan or a provision specifically authorizing the plan to make post-retirement reductions in retiree health benefits, it shall be prohibited for any group health plan, whether through amendment or otherwise, to reduce the benefits provided to a retired participant or the participant’s beneficiary under the terms of the plan if such reduction of benefits occurs after the date the participant retired for purposes of the plan and reduces benefits that were provided to the participant, or the participant’s beneficiary, as of the date the participant retired unless such reduction is also made with respect to active participants.</text></subsection> <subsection id="H018073C7B95D45F99ADAE7D1FB01D6E2" commented="no"><enum>(c)</enum><header>Reduction described</header><text> For purposes of this section, a reduction in benefits—</text> <paragraph id="H302397A8D3F3481AAA5A5FE5BDA3EFDF" commented="no"><enum>(1)</enum><text display-inline="yes-display-inline">with respect to premiums occurs under a group health plan when a participant’s (or beneficiary’s) share of the total premium (or, in the case of a self-insured plan, the costs of coverage) of the plan substantially increases; or</text></paragraph> <paragraph id="HD26D579DCBB645CC82EEF172CD7CFC1B" commented="no"><enum>(2)</enum><text>with respect to other cost-sharing and benefits under a group health plan occurs when there is a substantial decrease in the actuarial value of the benefit package under the plan. </text></paragraph><continuation-text continuation-text-level="subsection" commented="no">For purposes of this section, the term <quote>substantial</quote> means an increase in the total premium share or a decrease in the actuarial value of the benefit package that is greater than 5 percent.</continuation-text></subsection></section><after-quoted-block/></quoted-block></subsection> <subsection id="H8DEF376F91A5481D9B326F44C378B77A" commented="no"><enum>(b)</enum><header>Conforming amendment</header><text>The table of contents in section 1 of such Act, as amended by sections 108 and 109, is amended by inserting after the item relating to section 716 the following new item:</text> <quoted-block style="OLC" id="H41C0C3C7F07C4A03AF8F4128DE2E5921" display-inline="no-display-inline"> <toc regeneration="no-regeneration"> <toc-entry level="section">Sec. 717. Protection against postretirement reduction of retiree health benefits.</toc-entry></toc><after-quoted-block>.</after-quoted-block></quoted-block></subsection> <subsection id="HD8FF79F4E6E84265B6A30861D1C4F331" commented="no"><enum>(c)</enum><header>Waiver</header><text display-inline="yes-display-inline">An employer may, in a form and manner which shall be prescribed by the Secretary of Labor, apply for a waiver from this provision if the employer can reasonably demonstrate that meeting the requirements of this section would impose an undue hardship on the employer.</text></subsection> <subsection id="H06A56861695C4368A6170E2149C3DBDE" commented="no"><enum>(d)</enum><header>Effective date</header><text>The amendments made by this section shall take effect on the date of the enactment of this Act.</text></subsection></section> <section id="H83EE2937DC0C40A6ADE0B21CED36774D"><enum>111.</enum><header>Reinsurance program for retirees</header> <subsection id="H076127586DE546CC837BB119FCC0211D"><enum>(a)</enum><header>Establishment</header> <paragraph id="HFE0E411BDF2C4F8987CE250AC3871379"><enum>(1)</enum><header>In general</header><text>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 <quote>reinsurance program</quote>) 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.</text></paragraph> <paragraph id="HC61E328546594B55BD2E56A5A3CDA3BC"><enum>(2)</enum><header>Definitions</header><text>For purposes of this section:</text> <subparagraph id="H9B38216D62AE4A04A70BD291BA3BE3CD"><enum>(A)</enum><text>The term <term>eligible employment-based plan</term> means a group health plan or employment-based health plan that—</text> <clause id="HE5427B4AA6D0418D8066811C5E08E1A2"><enum>(i)</enum><text>is —</text> <subclause id="HF25FB43E780C4B389DC5C01FFA84D6E2"><enum>(I)</enum><text display-inline="yes-display-inline">maintained by one or more employers (including without limitation any State or political subdivision thereof, or any agency or instrumentality of any of the foregoing), former employers or employee organizations or associations, or a voluntary employees’ beneficiary association, or a committee or board of individuals appointed to administer such plan; or</text></subclause> <subclause id="H6F87B249EE314C629E626F876B2CAFF1"><enum>(II)</enum><text display-inline="yes-display-inline">a multiemployer plan (as defined in section 3(37) of the Employee Retirement Income Security Act of 1974); and</text></subclause></clause> <clause id="H55400E67232E4E43A492A5D1EED878DE"><enum>(ii)</enum><text>provides health benefits to retirees.</text></clause></subparagraph> <subparagraph id="H22A05C673CAC4EC4A952B1E3FF270DEB"><enum>(B)</enum><text>The term <term>health benefits</term> 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 otherwise.</text></subparagraph> <subparagraph id="HB4DB0FA0FA8C47929827D3C32BC193AD"><enum>(C)</enum><text>The term <term>participating employment-based plan</term> means an eligible employment-based plan that is participating in the reinsurance program.</text></subparagraph> <subparagraph id="HCA0CD9475C184D9A960A67880E4788F2"><enum>(D)</enum><text>The term <term>retiree</term> means, with respect to a participating employment-benefit plan, an individual who—</text> <clause id="HB340600C19A4444AB37DCF4322854CBA"><enum>(i)</enum><text>is 55 years of age or older;</text></clause> <clause id="H4A6FA9CDD5C948F7AADAF0A37ECC40DA"><enum>(ii)</enum><text>is not eligible for coverage under title XVIII of the Social Security Act; and</text></clause> <clause id="H0D2922E7876C4E2485E012F8E6D482EC"><enum>(iii)</enum><text>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.</text></clause></subparagraph> <subparagraph id="H0D71B39588A14EC3A1EAFE3C433C6DEB"><enum>(E)</enum><text>The term <term>Secretary</term> means Secretary of Health and Human Services. </text></subparagraph></paragraph></subsection> <subsection id="H876C6717D2004D3FA4606236EECD7982"><enum>(b)</enum><header>Participation</header><text display-inline="yes-display-inline">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.</text></subsection> <subsection id="H5A7F2FC7829A43EFAFF5A1588BB95679"><enum>(c)</enum><header>Payment</header> <paragraph id="HC71BFC880AF2442384FC215AA9369B32"><enum>(1)</enum><header>Submission of claims</header> <subparagraph id="HEF6A296C4ACD4517936F62150B9B5D5D"><enum>(A)</enum><header>In general</header><text>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.</text></subparagraph> <subparagraph id="HBCE551B1BE894247B672B7C5D114EE63"><enum>(B)</enum><header>Basis for claims</header><text display-inline="yes-display-inline">Each claim submitted under subparagraph (A) shall be based on the actual amount expended by the participating 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, copayments, and coinsurance shall be included along with the amounts paid by the participating employment-based plan.</text></subparagraph></paragraph> <paragraph id="HAA951212E60E45FA9EDF7918F21B9CEC"><enum>(2)</enum><header>Program payments and limit</header><text>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 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.</text></paragraph> <paragraph id="HA2CFB9775CBB4101B4DB0DAB4A260B3D"><enum>(3)</enum><header>Use of payments</header><text>Amounts paid to a participating employment-based plan under this subsection shall only be used to reduce the costs of health care provided by the plan by reducing premium costs for the employer or employee association maintaining the plan, and reducing premium contributions, deductibles, copayments, coinsurance, or other out-of-pocket costs for plan participants and beneficiaries. Where the benefits are provided by an employer to members of a represented bargaining unit, the allocation of payments among these purposes shall be subject to collective bargaining. Amounts paid to the plan under this subsection shall not be used as general revenues by the employer or employee association maintaining the plan or for any other purposes. The Secretary shall develop a mechanism to monitor the appropriate use of such payments by such plans.</text></paragraph> <paragraph id="H1B9037F948264775A2D506DBCE968D6E"><enum>(4)</enum><header>Appeals and program protections</header><text>The Secretary shall establish—</text> <subparagraph id="HBF622269E7044C4D8D1ECB2F416CFF97"><enum>(A)</enum><text>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</text></subparagraph> <subparagraph id="H92B6D90D950744C09157FAF2F7D3D0A2"><enum>(B)</enum><text>procedures to protect against fraud, waste, and abuse under the program.</text></subparagraph></paragraph> <paragraph id="H93E2CA1094354F5DAA06E661F00FEA8C"><enum>(5)</enum><header>Audits</header><text>The Secretary shall conduct annual audits of claims data submitted by participating employment-based plans under this section to ensure that they are in compliance with the requirements of this section.</text></paragraph></subsection> <subsection id="HD13E36D901534D93B0592D74D2B84DAF"><enum>(d)</enum><header>Retiree Reserve Trust Fund</header> <paragraph id="H90E973560573476F914D9E4462F6F33E"><enum>(1)</enum><header>Establishment</header> <subparagraph id="HE8F724B6868442A8AD07EA90864BA77D"><enum>(A)</enum><header>In general</header><text>There is established in the Treasury of the United States a trust fund to be known as the <quote>Retiree Reserve Trust Fund</quote> (referred to in this section as the <quote>Trust Fund</quote>), 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.</text></subparagraph> <subparagraph id="H02849C2F235B451BA8392713CE4B3754"><enum>(B)</enum><header>Funding</header><text>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.</text></subparagraph> <subparagraph id="HFF0679D678394AEBAF6346F780E60446"><enum>(C)</enum><header>Appropriations from the Trust Fund</header> <clause id="HB77FB271D5E54F95BC9F141FE3AB1E96"><enum>(i)</enum><header>In general</header><text>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. </text></clause> <clause id="HB44A7F0C53EA4487A99245EC121E8ED6"><enum>(ii)</enum><header>Limitation to available funds</header><text>The Secretary has the authority to stop taking applications for participation 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.</text></clause></subparagraph></paragraph></subsection></section> <section id="HC85E6E2229754F04809448E4A0CB969F" display-inline="no-display-inline" section-type="subsequent-section" commented="no"><enum>112.</enum><header>Wellness program grants</header> <subsection id="HD7487994EDEF465F9B70AD62FF529CE4" commented="no"><enum>(a)</enum><header>Allowance of grant</header> <paragraph id="HACBA3ECD80A54B3DA3DEFA3939966CAF" commented="no"><enum>(1)</enum><header>In general</header><text>For purposes of this section, the Secretaries of Health and Human Services and Labor shall jointly award wellness grants as determined under this section. Wellness program grants shall be awarded to small employers (as defined by the Secretary) for any plan year in an amount equal to 50 percent of the costs paid or incurred by such employers in connection with a qualified wellness program during the plan year. For purposes of the preceding sentence, in the case of any qualified wellness program offered as part of an employment-based health plan, only costs attributable to the qualified wellness program and not to the health plan, or health insurance coverage offered in connection with such a plan, may be taken into account.</text></paragraph> <paragraph id="H0A7350B181914BAFAB032166EED8DBBD" commented="no"><enum>(2)</enum><header>Limitations</header> <subparagraph id="H644DBB2F0EDA40E5B5EEE113376109F7" commented="no"><enum>(A)</enum><header>Period</header><text display-inline="yes-display-inline">A wellness grant awarded to an employer under this section shall be for up to 3 years.</text></subparagraph> <subparagraph id="HDBF654B9056F4326A409D0738A3AE544" commented="no"><enum>(B)</enum><header>Amount</header><text>The amount of the grant under paragraph (1) for an employer shall not exceed—</text> <clause id="H0EA78CBD9C004F7E83C8F2C6D8BE7CE5" commented="no"><enum>(i)</enum><text>the product of $150 and the number of employees of the employer for any plan year; and</text></clause> <clause id="HFA3B4AAC339E494D9B8351CCC8D67611" commented="no"><enum>(ii)</enum><text>$50,000 for the entire period of the grant.</text></clause></subparagraph></paragraph></subsection> <subsection id="H98610E2478A14BC59B7CAA50FBC4E675" commented="no"><enum>(b)</enum><header>Qualified wellness program</header><text>For purposes of this section:</text> <paragraph id="H58070C94EF374DDC888F9079F6178F32" commented="no"><enum>(1)</enum><header>Qualified wellness program</header><text>The term <quote>qualified wellness program</quote> means a program that —</text> <subparagraph id="H3B31172412D34CE0A885B0B3A62D12F9" commented="no"><enum>(A)</enum><text>includes any 3 wellness components described in subsection (c); and</text></subparagraph> <subparagraph id="HC8CFD4DFF39E4F698EB00319B7C97D04" commented="no"><enum>(B)</enum><text>is to be certified jointly by the Secretary of Health and Human Services and the Secretary of Labor, in coordination with the Director of the Centers for Disease Control and Prevention, as a qualified wellness program under this section.</text></subparagraph></paragraph> <paragraph id="HD546109AC281490DB9ECDD1644176480" commented="no"><enum>(2)</enum><header>Programs must be consistent with research and best practices</header> <subparagraph id="HFDAB71C9570D4935B920732FE2F367BB" commented="no"><enum>(A)</enum><header>In general</header><text>The Secretary of Health and Human Services and the Secretary of Labor shall not certify a program as a qualified wellness program unless the program—</text> <clause id="HDDF689480552480F9A181C4C4D957E7C" commented="no"><enum>(i)</enum><text>is consistent with evidence-based research and best practices, as identified by persons with expertise in employer health promotion and wellness programs;</text></clause> <clause id="HF5A5B12B0A134A35880B046000F6BE5C" commented="no"><enum>(ii)</enum><text>includes multiple, evidence-based strategies which are based on the existing and emerging research and careful scientific reviews, including the Guide to Community Preventative Services, the Guide to Clinical Preventative Services, and the National Registry for Effective Programs, and</text></clause> <clause id="H85EF0BE9BA8B4B58BD7BBE8F9ACCB221" commented="no"><enum>(iii)</enum><text>includes strategies which focus on prevention and support for employee populations at risk of poor health outcomes.</text></clause></subparagraph> <subparagraph id="H1AF7009B66B44FF5800F423DF54DEBD4" commented="no"><enum>(B)</enum><header>Periodic updating and review</header><text>The Secretaries of Health and Human Services and Labor, in consultation with other appropriate agencies shall jointly establish procedures for periodic review, evaluation, and update of the programs under this subsection.</text></subparagraph></paragraph> <paragraph id="H6C091F06B35E40A8B401A9EE76B4EED2" commented="no"><enum>(3)</enum><header>Health literacy and accessibility</header><text>The Secretaries of Health and Human Services and Labor shall jointly, as part of the certification process—</text> <subparagraph id="H16DACF77BD064DAEA8DDB851E2503DAE" commented="no"><enum>(A)</enum><text>ensure that employers make the programs culturally competent, physically and programmatically accessible (including for individuals with disabilities), and appropriate to the health literacy needs of the employees covered by the programs;</text></subparagraph> <subparagraph id="H3C7FF90B90834DDAAA7C062CAC060DE7" commented="no"><enum>(B)</enum><text>require a health literacy component to provide special assistance and materials to employees with low literacy skills, limited English and from underserved populations; and</text></subparagraph> <subparagraph id="H1086EA11F74C4B18A9A86603E188DBCB" commented="no"><enum>(C)</enum><text>require the Secretaries to compile and disseminate to employer health plans information on model health literacy curricula, instructional programs, and effective intervention strategies.</text></subparagraph></paragraph></subsection> <subsection id="H69A75B1B653546309A77F340B7460FE4" commented="no"><enum>(c)</enum><header>Wellness program components</header><text>For purposes of this section, the wellness program components described in this subsection are the following:</text> <paragraph id="HB43CB94AF5524E83A1B2953F99D45040" commented="no"><enum>(1)</enum><header>Health awareness component</header><text>A health awareness component which provides for the following:</text> <subparagraph id="H39CA390BF8E44A059DF18309FD3E628C" commented="no"><enum>(A)</enum><header>Health education</header><text>The dissemination of health information which addresses the specific needs and health risks of employees.</text></subparagraph> <subparagraph id="HFBD3D19AF625447692938A1BE3568E2E" commented="no"><enum>(B)</enum><header>Health screenings</header><text>The opportunity for periodic screenings for health problems and referrals for appropriate follow-up measures.</text></subparagraph></paragraph> <paragraph id="H2648F2E8AB6840F692C85B9B53244B18" commented="no"><enum>(2)</enum><header>Employee engagement component</header><text>An employee engagement component which provides for the active engagement of employees in worksite wellness programs through worksite assessments and program planning, onsite delivery, evaluation, and improvement efforts.</text></paragraph> <paragraph id="H7FF2C3801F7C4BB48DDFB34DDB2DA7D0" commented="no"><enum>(3)</enum><header>Behavioral change component</header><text display-inline="yes-display-inline">A behavioral change component which encourages healthy living through counseling, seminars, on-line programs, self-help materials, or other programs which provide technical assistance and problem solving skills. Such component may include programs relating to—</text> <subparagraph id="H9FC12E81543A469FB59F9CC97A15893D" commented="no"><enum>(A)</enum><text>tobacco use;</text></subparagraph> <subparagraph id="H2BDC117C524645F99A197FE3538AC2CF" commented="no"><enum>(B)</enum><text>obesity;</text></subparagraph> <subparagraph id="HEA8F8D5084A146E4B763C7661D8091CD" display-inline="no-display-inline" commented="no"><enum>(C)</enum><text>stress management;</text></subparagraph> <subparagraph id="H3ED818B180C74040881AFD4954A8DD98" commented="no"><enum>(D)</enum><text>physical fitness;</text></subparagraph> <subparagraph id="HA21B8D9515024B239D4CA9D7F64C6A7A" commented="no"><enum>(E)</enum><text>nutrition;</text></subparagraph> <subparagraph id="H2F73BF4362CD482F94BAD60D235ABC9D" commented="no"><enum>(F)</enum><text>substance abuse;</text></subparagraph> <subparagraph id="H66961D5B20D1474EB20D1C5DD5C79A38" commented="no"><enum>(G)</enum><text>depression; and</text></subparagraph> <subparagraph id="H447735BEFD4E4754BCA3C24D7DD32D8E" commented="no"><enum>(H)</enum><text>mental health promotion.</text></subparagraph></paragraph> <paragraph id="HF037F9EBCCAF4A9185D4CEC4BED05741" commented="no"><enum>(4)</enum><header>Supportive environment component</header><text>A supportive environment component which includes the following:</text> <subparagraph id="HD8C8B325AB6D487998A09823C68F7F17" commented="no"><enum>(A)</enum><header>On-site policies</header><text display-inline="yes-display-inline">Policies and services at the worksite which promote a healthy lifestyle, including policies relating to—</text> <clause id="H086125CA33064D589F53389D110502B8" commented="no"><enum>(i)</enum><text>tobacco use at the worksite;</text></clause> <clause id="H02281BCD55CB4875A1C4A18CFC0BCA98" commented="no"><enum>(ii)</enum><text>the nutrition of food available at the worksite through cafeterias and vending options;</text></clause> <clause id="H9285C9742BBF451C8AC3B978B895000D" commented="no"><enum>(iii)</enum><text>minimizing stress and promoting positive mental health in the workplace; and</text></clause> <clause id="H4925710A489143AE894C4915B5BFBD64" commented="no"><enum>(iv)</enum><text>the encouragement of physical activity before, during, and after work hours.</text></clause></subparagraph></paragraph></subsection> <subsection id="H356FA9F01EB34FE68B2D6E29402CC1F0" commented="no"><enum>(d)</enum><header>Participation requirement</header><text>No grant shall be allowed under subsection (a) unless the Secretaries of Health and Human Services and Labor, in consultation with other appropriate agencies, jointly certify, as a part of any certification described in subsection (b), that each wellness program component of the qualified wellness program—</text> <paragraph id="HCCCDDEC672A044AF8A8A8E7CBB2CCE30" commented="no"><enum>(1)</enum><text>shall be available to all employees of the employer;</text></paragraph> <paragraph id="HB7BD0F17B32843E4A8059B5932C7F258" commented="no"><enum>(2)</enum><text>shall not mandate participation by employees; and</text></paragraph> <paragraph id="HFD3726C35EC04ADDBF14E0A95ED90564" commented="no"><enum>(3)</enum><text>may provide a financial reward for participation of an individual in such program so long as such reward is not tied to the premium or cost-sharing of the individual under the health benefits plan.</text></paragraph></subsection> <subsection id="H7C0951EA1D644914B37ED7F4428E98A2" commented="no"><enum>(e)</enum><header>Privacy protections</header><text display-inline="yes-display-inline">Data gathered for purposes of the employer wellness program may be used solely for the purposes of administering the program. The Secretaries of Health and Human Services and Labor shall develop standards to ensure such data remain confidential and are not used for purposes beyond those for administering the program.</text></subsection> <subsection id="H9447D3668C8B4976880D37CBEFBF3079" commented="no"><enum>(f)</enum><header>Certain costs not included</header><text>For purposes of this section, costs paid or incurred by an employer for food or health insurance shall not be taken into account under subsection (a).</text></subsection> <subsection id="H6694C80567F643279544C5A354135FF4" commented="no"><enum>(g)</enum><header>Outreach</header><text display-inline="yes-display-inline">The Secretaries of Health and Human Services and Labor, in conjunction with other appropriate agencies and members of the business community, shall jointly institute an outreach program to inform businesses about the availability of the wellness program grant as well as to educate businesses on how to develop programs according to recognized and promising practices and on how to measure the success of implemented programs.</text></subsection> <subsection id="H6A5C42E4CCD446E599F920FAE18F39E3" commented="no"><enum>(h)</enum><header>Effective date</header><text>This section shall take effect on July 1, 2010.</text></subsection> <subsection id="H3122AEDB89554EA1AA8C030823BD3609" commented="no"><enum>(i)</enum><header>Authorization of appropriations</header><text>There are authorized to be appropriated such sums as are necessary to carry out this section.</text></subsection></section> <section id="H5A6B634F52D64760B843F70E70C781DC" commented="no" display-inline="no-display-inline" section-type="subsequent-section"><enum>113.</enum><header>Extension of COBRA continuation coverage</header> <subsection id="HCF52F6CA4DD9446C9E452F6E3F14AFB7" commented="no"><enum>(a)</enum><header>Extension of current periods of continuation coverage</header> <paragraph id="H7689340EC49240179D36CB5B7C45549C" commented="no"><enum>(1)</enum><header>In general</header><text>In the case of any individual who is, under a COBRA continuation coverage provision, covered under COBRA continuation coverage on or after the date of the enactment of this Act, the required period of any such coverage which has not subsequently terminated under the terms of such provision for any reason other than the expiration of a period of a specified number of months shall, notwithstanding such provision and subject to subsection (b), extend to the earlier of the date on which such individual becomes eligible for acceptable coverage or the date on which such individual becomes eligible for health insurance coverage through the Health Insurance Exchange (or a State-based Health Insurance Exchange operating in a State or group of States).</text></paragraph> <paragraph id="H609455C4D7BA4CE1A28E867422F1A098" commented="no"><enum>(2)</enum><header>Notice</header><text display-inline="yes-display-inline">As soon as practicable after the date of the enactment of this Act, the Secretary of Labor, in consultation with the Secretary of the Treasury and the Secretary of Health and Human Services, shall, in consultation with administrators of the group health plans (or other entities) that provide or administer the COBRA continuation coverage involved, provide rules setting forth the form and manner in which prompt notice to individuals of the continued availability of COBRA continuation coverage to such individuals under paragraph (1).</text></paragraph></subsection> <subsection id="H203D5A7FF69742BE8CD79A68BF22FD9B" commented="no"><enum>(b)</enum><header>Continued effect of other terminating events</header><text display-inline="yes-display-inline">Notwithstanding subsection (a), any required period of COBRA continuation coverage which is extended under such subsection shall terminate upon the occurrence, prior to the date of termination otherwise provided in such subsection, of any terminating event specified in the applicable continuation coverage provision other than the expiration of a period of a specified number of months.</text></subsection> <subsection id="H3E13B61BB5FF41668BBFD7561FB82707" commented="no"><enum>(c)</enum><header>Access to State health benefits risk pools</header><text>This section shall supersede any provision of the law of a State or political subdivision thereof to the extent that such provision has the effect of limiting or precluding access by a qualified beneficiary whose COBRA continuation coverage has been extended under this section to a State health benefits risk pool recognized by the Commissioner for purposes of this section solely by reason of the extension of such coverage beyond the date on which such coverage otherwise would have expired. </text></subsection> <subsection id="H050AC4DB38C341DD93A38B30839D954D" commented="no"><enum>(d)</enum><header>Definitions</header><text>For purposes of this section—</text> <paragraph id="HE71605EE74E644FD8503EFBD2599F145" commented="no"><enum>(1)</enum><header>COBRA continuation coverage</header><text display-inline="yes-display-inline">The term <quote>COBRA continuation coverage</quote> means continuation coverage provided pursuant to part 6 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (other than under section 609), title XXII of the Public Health Service Act, section 4980B of the Internal Revenue Code of 1986 (other than subsection (f)(1) of such section insofar as it relates to pediatric vaccines), or section 905a of title 5, United States Code, or under a State program that provides comparable continuation coverage. Such term does not include coverage under a health flexible spending arrangement under a cafeteria plan within the meaning of section 125 of the Internal Revenue Code of 1986.</text></paragraph> <paragraph id="H88090FBB000547619867BD225A143F97" commented="no"><enum>(2)</enum><header>COBRA continuation provision</header><text display-inline="yes-display-inline">The term <quote>COBRA continuation provision</quote> means the provisions of law described in paragraph (1).</text></paragraph></subsection></section> <section id="H89995C2679F24B22A476A051B903C165" commented="no"><enum>114.</enum><header>State Health Access Program grants</header> <subsection id="HB9A8B6B06D63480DAE4B3C7BFB9305BF" commented="no"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">The Secretary of Health and Human Services (in this section referred to as the <quote>Secretary</quote>) shall provide grants to States (as defined for purposes of title XIX of the Social Security Act) to establish programs to expand access to affordable health care coverage for the uninsured populations in that State in a manner consistent with reforms to take effect under this division in Y1.</text></subsection> <subsection id="H3B65F9F737A54D8C8AFD80BE4742636E" commented="no"><enum>(b)</enum><header>Types of programs</header><text>The types of programs for which grants are available under subsection (a) include the following:</text> <paragraph id="H1A83DAB2E158457D9CDA2D947E6FE8E8" commented="no"><enum>(1)</enum><header>State insurance exchanges</header><text>State insurance exchanges that develop new, less expensive, portable benefit packages for small employers and part-time and seasonal workers.</text></paragraph> <paragraph id="HA92400BA8DA542F3AC3B0683F483F713" commented="no"><enum>(2)</enum><header>Community coverage program</header><text>Community coverage with shared responsibility between employers, governmental or nonprofit entity, and the individual.</text></paragraph> <paragraph id="H824059EC0C0C4FD1AEEABBF8F40FDDA0" commented="no"><enum>(3)</enum><header>Reinsurance plan program</header><text>Reinsurance plans that subsidize a certain share of carrier losses within a certain risk corridor health insurance premium assistance.</text></paragraph> <paragraph id="H653C2F46B9B54D5BB11732E15632A28E" commented="no"><enum>(4)</enum><header>Transparent marketplace program</header><text>Transparent marketplace that provides an organized structure for the sale of insurance products such as a Web exchange or portal.</text></paragraph> <paragraph id="H787F7EF1B3B845E5BAAB25D84EE50884" commented="no"><enum>(5)</enum><header>Automated enrollment program</header><text>Statewide or automated enrollment systems for public assistance programs.</text></paragraph> <paragraph id="H3222C08FF3C04E60A608ED96D8B61DC1" commented="no"><enum>(6)</enum><header>Innovative strategies</header><text>Innovative strategies to insure low-income childless adults.</text></paragraph> <paragraph id="HCD5FCF33139C4B94921EF622282E3164" commented="no"><enum>(7)</enum><header>Purchasing collaboratives</header><text display-inline="yes-display-inline">Business/consumer collaborative that provides direct contract health care service purchasing options for group plan sponsors.</text></paragraph></subsection> <subsection id="H935190B2BF3B43ADB6B11C1B8E90884E" commented="no"><enum>(c)</enum><header>Eligibility and administration</header><text><?xm-replace_text ?></text> <paragraph id="HDAF48D258F244B8EB2DBCE84AE48779D" commented="no"><enum>(1)</enum><header>Implementation of key statutory or regulatory changes</header><text>In order to be awarded a grant under this section for a program, a State shall demonstrate that—</text> <subparagraph id="HA7B6521B84CD4B7490C1F72930777DF0" commented="no"><enum>(A)</enum><text>it has achieved the key State and local statutory or regulatory changes required to begin implementing the new program within 1 year after the initiation of funding under the grant; and</text></subparagraph> <subparagraph id="H80ABAF1C68B1456390C6BEFDD0C2BA69" commented="no"><enum>(B)</enum><text display-inline="yes-display-inline">it will be able to sustain the program without Federal funding after the end of the period of the grant.</text></subparagraph></paragraph> <paragraph id="H0FB904AFACEA4311BC8D39F107DB2C2E" commented="no"><enum>(2)</enum><header>Ineligibility</header><text>A State that has already developed a comprehensive health insurance access program is not eligible for a grant under this section.</text></paragraph> <paragraph id="HF4B674D49CB44C13985F4DFBA7EFC691" commented="no"><enum>(3)</enum><header>Application required</header><text>No State shall receive a grant under this section unless the State has approved by the Secretary such an application, in such form and manner as the Secretary specifies.</text></paragraph> <paragraph id="H46571E6827C14A6FACF6D55A968B5C5E" commented="no"><enum>(4)</enum><header>Administration based on current program</header><text display-inline="yes-display-inline">The program under this section is intended to build on the State Health Access Program funded under the Omnibus Appropriations Act, 2009 (Public Law 111–8).</text></paragraph></subsection> <subsection id="H490186F6CC1A4004B99E23B11A452924" commented="no"><enum>(d)</enum><header>Funding limitations</header> <paragraph id="H964F80BFC3F342ABB978076B0A5EA6DC" commented="no"><enum>(1)</enum><header>In general</header><text>A grant under this section shall—</text> <subparagraph id="HDF110546B553428E9D65B927993BB67D" commented="no"><enum>(A)</enum><text>only be available for expenditures before Y1; and</text></subparagraph> <subparagraph id="HF80F23349D05418485A2C9E2E74DDD8E" commented="no"><enum>(B)</enum><text>only be used to supplement, and not supplant, funds otherwise provided.</text></subparagraph></paragraph> <paragraph id="HBD82011775F840C09C6B40C9CB724258" commented="no"><enum>(2)</enum><header>Matching fund requirement</header> <subparagraph id="H9429DEF5ADC94F55AAAFB302E1F8D8EF" commented="no"><enum>(A)</enum><header>In general</header><text>Subject to subparagraph (B), no grant may be awarded to a State unless the State demonstrates the seriousness of its effort by matching at least 20 percent of the grant amount through non-Federal resources, which may be a combination of State, local, private dollars from insurers, providers, and other private organizations.</text></subparagraph> <subparagraph id="H65477BE985D14C9BB23FC7BDDC9F7B7B" commented="no"><enum>(B)</enum><header>Waiver</header><text>The Secretary may waive the requirement of subparagraph (A) if the State demonstrates to the Secretary financial hardship in complying with such requirement.</text></subparagraph></paragraph></subsection> <subsection id="HFD813A956897441EA21DF65C07F489BC" commented="no"><enum>(e)</enum><header>Study</header><text>The Secretary shall review, study, and benchmark the progress and results of the programs funded under this section.</text></subsection> <subsection id="H8D10E212D06A4A1EA4D5AFCDC131E6AA" commented="no"><enum>(f)</enum><header>Report</header><text>Each State receiving a grant under this section shall submit to the Secretary a report on best practices and lessons learned through the grant to inform the health reform coverage expansions under this division beginning in Y1.</text></subsection> <subsection id="H35941DF5598A4226B1FA2465697B136A" commented="no"><enum>(g)</enum><header>Funding</header><text>There are authorized to be appropriated such sums as may be necessary to carry out this section.</text></subsection></section> <section id="H055118CCFF89445F9BEBBB4F23F09D0D"><enum>115.</enum><header>Administrative simplification</header> <subsection id="H2C94A8B36FFD4926B9BD60C3A55F3E59"><enum>(a)</enum><header>Standardizing electronic administrative transactions</header> <paragraph id="H2F3EB0C709A7499A988EA9F74539DC67"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">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 sections:</text> <quoted-block id="H7B75EB32AE984A01BD9B2AB2EBD305A3" style="OLC"> <section id="HAABB57E5EF8A49A1B8E4C0B880C7A7E5"><enum>1173A.</enum><header>Standardize electronic administrative transactions</header> <subsection id="H2E3B1D87BD114D138F798E7242BD99B0"><enum>(a)</enum><header>Standards for financial and administrative transactions</header> <paragraph id="HF99CCED5B1C545B78ACB781A9F49B04C"><enum>(1)</enum><header>In general</header><text>The Secretary shall adopt and regularly update standards consistent with the goals described in paragraph (2).</text></paragraph> <paragraph id="H50B971308A4B47BFBF81C25E1BB76452"><enum>(2)</enum><header>Goals for financial and administrative transactions</header><text>The goals for standards under paragraph (1) are that such standards shall, to the extent practicable—</text> <subparagraph id="HA95256370C274C78A7B715FCC5445818"><enum>(A)</enum><text>be unique with no conflicting or redundant standards;</text></subparagraph> <subparagraph id="H166D91E928C044ED8FEEF10AEC2083E4"><enum>(B)</enum><text>be authoritative, permitting no additions or constraints for electronic transactions, including companion guides;</text></subparagraph> <subparagraph id="H1CECDF4E00FC4FBDA80E8FA8770AAE1A"><enum>(C)</enum><text>be comprehensive, efficient and robust, requiring minimal augmentation by paper transactions or clarification by further communications;</text></subparagraph> <subparagraph id="H88BBE365C79A48DEA6DD8105E1B13848"><enum>(D)</enum><text>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, on a specific date or range of dates, include utilization of a machine-readable health plan beneficiary identification card or similar mechanism;</text></subparagraph> <subparagraph id="H08C58E004BE74EFDAB8F9E187494ADA2"><enum>(E)</enum><text>enable, where feasible, near real-time adjudication of claims;</text></subparagraph> <subparagraph id="H410684D96A72432E987CBE9241A7D587"><enum>(F)</enum><text>provide for timely acknowledgment, response, and status reporting applicable to any electronic transaction deemed appropriate by the Secretary;</text></subparagraph> <subparagraph id="H00E9597A8C3E49B6B65D7CD5EE611956"><enum>(G)</enum><text>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 except where required by (or to implement) State or Federal law or to protect against fraud and abuse; and</text></subparagraph> <subparagraph id="HAA4FA7A2539F4EA6A15D4639AD1CB5CE"><enum>(H)</enum><text>harmonize all common data elements across administrative and clinical transaction standards.</text></subparagraph></paragraph> <paragraph id="H67F334D9F6F94823983F0A5F0A430837"><enum>(3)</enum><header>Time for adoption</header><text display-inline="yes-display-inline">Not later than 2 years after the date of the enactment of this section, the Secretary shall adopt standards under this section by interim, final rule.</text></paragraph> <paragraph id="H9CFA5E218EF841718D3E605164943D13"><enum>(4)</enum><header>Requirements for specific standards</header><text>The standards under this section shall be developed, adopted, and enforced so as to—</text> <subparagraph id="HD60D66A08B174EEC8C2346BD2F15D34B"><enum>(A)</enum><text>clarify, refine, complete, and expand, as needed, the standards required under section 1173;</text></subparagraph> <subparagraph id="H7484BA57E0F44F29A53FE267A2AED5FC"><enum>(B)</enum><text>require paper versions of standardized 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;</text></subparagraph> <subparagraph id="H4D0FDB3D282B46DDA9C454D012DA4297"><enum>(C)</enum><text>enable electronic funds transfers, in order to allow automated reconciliation with the related health care payment and remittance advice;</text></subparagraph> <subparagraph id="H11C894A8520049E2B3546296FDA68A95"><enum>(D)</enum><text>require timely and transparent claim and denial management processes, including uniform claim edits, uniform reason and remark denial codes, tracking, adjudication, and appeal processing;</text></subparagraph> <subparagraph id="H8D3B8A4CE34A4993944BDE2193EA1D08"><enum>(E)</enum><text>require the use of a standard electronic transaction with which health care providers may quickly and efficiently enroll with a health plan to conduct the other electronic transactions provided for in this part; and</text></subparagraph> <subparagraph id="HB26E4BE80DB144C59108C6978F6B7F59"><enum>(F)</enum><text>provide for other requirements relating to administrative simplification as identified by the Secretary, in consultation with stakeholders.</text></subparagraph></paragraph> <paragraph id="H4CA4370C8F6C487AA304CCF95A02B69E"><enum>(5)</enum><header>Building on existing standards</header><text>In adopting the standards under this section, the Secretary shall consider existing and planned standards.</text></paragraph> <paragraph id="H99FF8C1B761940878D7F94CB04ECC422"><enum>(6)</enum><header>Implementation and enforcement</header><text>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—</text> <subparagraph id="HE114FD42D2BC4F40B1427C9C257A3EF0"><enum>(A)</enum><text>a process and timeframe with milestones for developing the complete set of standards;</text></subparagraph> <subparagraph id="H243EB9A0F0F44672B72B774F0C35A319"><enum>(B)</enum><text>a proposal for accommodating necessary changes between version changes and a process for upgrading standards as often as annually by interim, final rulemaking;</text></subparagraph> <subparagraph id="HC4D3D32D859345BBA05ED1AE36DE4133"><enum>(C)</enum><text>programs to provide incentives for, and ease the burden of, implementation for certain health care providers, with special consideration 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;</text></subparagraph> <subparagraph id="HA80DBEECDB8C4D08AFB3E4980BA31CE8"><enum>(D)</enum><text>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;</text></subparagraph> <subparagraph id="H508AA275443F4F30A8C261B9B7A06DFD"><enum>(E)</enum><text>an estimate of total funds needed to ensure timely completion of the implementation plan; and</text></subparagraph> <subparagraph id="HD36AEB23818343E8A66AA09C7B86F9F7"><enum>(F)</enum><text>an enforcement process that includes timely investigation of complaints, random audits to ensure compliance, civil monetary and programmatic penalties for noncompliance consistent with existing laws and regulations, and a fair and reasonable appeals process building off of enforcement provisions under this part, and concurrent State enforcement jurisdiction.</text></subparagraph><continuation-text continuation-text-level="paragraph">The Secretary may promulgate an annual audit and certification process to ensure that all health plans and clearinghouses are both syntactically and functionally compliant with all the standard transactions mandated pursuant to the administrative simplification provisions of this part and the Health Insurance Portability and Accountability Act of 1996.</continuation-text></paragraph></subsection> <subsection id="H9A5010CC16A349D8AB20C9BCFCE1A052"><enum>(b)</enum><header>Limitations on use of data</header><text>Nothing in this section shall be construed to permit the use of information collected under this section in a manner that would violate State or Federal law.</text></subsection> <subsection id="H4BC71CD0CC1D4EA598902B3B881A26D9"><enum>(c)</enum><header>Protection of data</header><text>The Secretary shall ensure (through the promulgation of regulations or otherwise) that all data collected pursuant to subsection (a) are 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.</text></subsection></section> <section id="HF807EB44028C4A29B36C9E2B7F6C1D61"><enum>1173B.</enum><header>Interim companion guides, including operating rules</header> <subsection id="H8161BD5829494DA69C45C3DB0C8B2E23"><enum>(a)</enum><header>In general</header><text>The Secretary shall adopt a single, binding, comprehensive companion guide, that includes operating rules for each X12 Version 5010 transaction described in section 1173(a)(2), to be effective until the new version of these transactions which comply with section 1173A are adopted and implemented.</text></subsection> <subsection id="H1636CA87A9784223A8C8B5DA1ADD4DFB"><enum>(b)</enum><header>Companion guide and operating rules development</header><text>In adopting such interim companion guide and rules, the Secretary shall comply with section 1172, except that a nonprofit entity that meets the following criteria shall also be consulted:</text> <paragraph id="HE1EED4EB85F54C418B0F33F9DDA20990"><enum>(1)</enum><text>The entity focuses its mission on administrative simplification.</text></paragraph> <paragraph id="H095D8FCD29A64891BD9F26F0516FE2C8"><enum>(2)</enum><text>The entity uses a multistakeholder process that creates consensus-based companion guides, including operating rules using a voting process that ensures balanced representation by the critical stakeholders (including health plans and health care providers) so that no one group dominates the entity and shall include others such as standards development organizations, and relevant Federal or State agencies.</text></paragraph> <paragraph id="H6084A492657F4538810BE3D045F02282"><enum>(3)</enum><text>The entity has in place a public set of guiding principles that ensure the companion guide and operating rules and process are open and transparent.</text></paragraph> <paragraph id="H087622F7C1D643C889D8E697EFCA5835"><enum>(4)</enum><text>The entity coordinates its activities with the HIT Policy Committee, and the HIT Standards Committee (established under title XXX of the Public Health Service Act) and complements the efforts of the Office of the National Healthcare Coordinator and its related health information exchange goals.</text></paragraph> <paragraph id="HEB26000916E84FF59129DA99E5AD30DC"><enum>(5)</enum><text>The entity incorporates the standards issued under Health Insurance Portability and Accountability Act of 1996 and this part, and in developing the companion guide and operating rules does not change the definition, data condition or use of a data element or segment in a standard, add any elements or segments to the maximum defined data set, use any codes or data elements that are either marked <quote>not used</quote> in the standard’s implementation specifications or are not in the standard’s implementation specifications, or change the meaning or intent of the standard’s implementation specifications.</text></paragraph> <paragraph id="H165297FC3C3B4A5FBE58CE2ACABB05BE"><enum>(6)</enum><text>The entity uses existing market research and proven best practices.</text></paragraph> <paragraph id="H772A81A5E2A34047A8453DA33A33AC86"><enum>(7)</enum><text>The entity has a set of measures that allow for the evaluation of their market impact and public reporting of aggregate stakeholder impact.</text></paragraph> <paragraph id="H0AC6067A03FF48B98163F1AD0D5D52E5"><enum>(8)</enum><text>The entity supports nondiscrimination and conflict of interest policies that demonstrate a commitment to open, fair, and nondiscriminatory practices.</text></paragraph> <paragraph id="H82CB1D21DE3A451EA6E9D4AB6EAF1DEF"><enum>(9)</enum><text>The entity allows for public reviews and comment on updates of the companion guide, including the operating rules.</text></paragraph></subsection> <subsection id="H453FFFAAC80B45F698D3DD47B822CF35"><enum>(c)</enum><header>Implementation</header><text>The Secretary shall adopt a single, binding companion guide, including operating rules under this section, for each transaction, to become effective with the X12 Version 5010 transaction implementation, or as soon thereafter as feasible. The companion guide, including operating rules for the transactions for eligibility for health plan and health claims status under this section shall be adopted not later than October 1, 2011, in a manner such that such set of rules is effective beginning not later than January 1, 2013. The companion guide, including operating rules for the remainder of the transactions described in section 1173(a)(2) shall be adopted not later than October 1, 2012, in a manner such that such set of rules is effective beginning not later than January 1, 2014.</text></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></paragraph> <paragraph id="H49AA0F5E2DAE40E1B284AF8E0990FE97"><enum>(2)</enum><header>Definitions</header><text>Section 1171 of such Act (42 U.S.C. 1320d) is amended—</text> <subparagraph id="H1243AA2E021E415AB6E369AB19297947"><enum>(A)</enum><text>in paragraph (1), by inserting <quote>, and associated operational guidelines and instructions, as determined appropriate by the Secretary</quote> after <quote>medical procedure codes</quote>; and</text></subparagraph> <subparagraph id="H9B02D08F93E04C358E347ABB0F9485E5"><enum>(B)</enum><text>by adding at the end the following new paragraph:</text> <quoted-block id="H48884D91AE9A454099AD426D6A564E26" style="OLC"> <paragraph id="HBFA174320C43460985E31BDE1301D2AC"><enum>(10)</enum><header>Operating rules</header><text display-inline="yes-display-inline">The term <term>operating rules</term> means business rules for using and processing transactions, such as service level requirements, which do not impact the implementation specifications or other data content requirements.</text></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph></paragraph> <paragraph id="H586E569011824E5F9BAF7D6CBF90D37E"><enum>(3)</enum><header>Conforming amendment</header><text display-inline="yes-display-inline">Section 1179(a) of such Act (42 U.S.C. 1320d–8(a)) is amended, in the matter before paragraph (1)—</text> <subparagraph id="H1672328C41594FFA97CE00D579264C48"><enum>(A)</enum><text>by inserting <quote>on behalf of an individual</quote> after <quote>1978)</quote>; and</text></subparagraph> <subparagraph id="H086B9268653549ECA13E24EA5CAB6156"><enum>(B)</enum><text>by inserting <quote>on behalf of an individual</quote> after <quote>for a financial institution</quote> and</text></subparagraph></paragraph></subsection> <subsection id="HA3E66118B3B945ECB48698C1CC594FB7"><enum>(b)</enum><header>Standards for claims attachments and coordination of benefits</header> <paragraph id="H31FED06B0B014D21A2D4CB1FEF0D7475"><enum>(1)</enum><header>Standard for health claims attachments</header><text>Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall promulgate an interim, final rule to establish 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.</text></paragraph> <paragraph id="H56069937C58148E79801A09FF4B968DB" commented="no"><enum>(2)</enum><header>Revision in processing payment transactions by financial institutions</header> <subparagraph id="H766297B4F68D4EAEB466A04B3E26A382" commented="no"><enum>(A)</enum><header>In general</header><text>Section 1179 of the Social Security Act (42 U.S.C. 1320d–8) is amended, in the matter before paragraph (1)—</text> <clause id="HD38A54A03F6F4821B20B0D66D3052B05" commented="no"><enum>(i)</enum><text>by striking <quote>or is engaged</quote> and inserting <quote>and is engaged</quote>; and</text></clause> <clause id="H43C00330430D4DF69F470C801BF50287" commented="no"><enum>(ii)</enum><text>by inserting <quote>(other than as a business associate for a covered entity)</quote> after <quote>for a financial institution</quote>.</text></clause></subparagraph> <subparagraph id="HD524C1871F534755A7BD4B4296C9770E" commented="no"><enum>(B)</enum><header>Compliance date</header><text>The amendments made by subparagraph (A) shall apply to transactions occurring on or after such date (not later than January 1, 2014) as the Secretary of Health and Human Services shall specify.</text></subparagraph></paragraph></subsection> <subsection id="HB5E7A82C6D7845908516ED1560B36A5C"><enum>(c)</enum><header>Standards for first report of injury</header><text display-inline="yes-display-inline">Not later than January 1, 2014, the Secretary of Health and Human Services shall promulgate an interim final rule to establish a standard for the first report of injury transaction described in section 1173(a)(2)(G) of the Social Security Act (42 U.S.C. 1320d–2(a)(2)(G)).</text></subsection> <subsection id="H3E91F32FE5464D18821B6365C8BF957A"><enum>(d)</enum><header>Unique health plan identifier</header><text display-inline="yes-display-inline">Not later October 1, 2012, the Secretary of Health and Human Services shall promulgate an interim final rule to establish a unique health plan identifier described in section 1173(b) of the Social Security Act (42 U.S.C. 1320d–2(b)) based on the input of the National Committee of Vital and Health Statistics and consultation with health plans, health care providers, and other interested parties.</text></subsection> <subsection id="H83D00FA915D24317B0B50F8038418E11"><enum>(e)</enum><header>Expansion of electronic transactions in medicare</header><text display-inline="yes-display-inline">Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended—</text> <paragraph id="H5205647F7ACE4422A48E1BD566A9C0C8"><enum>(1)</enum><text>in paragraph (23), by striking <quote>or</quote> at the end;</text></paragraph> <paragraph id="H437067CEE2274097824474E5F15A3020"><enum>(2)</enum><text>in paragraph (24), by striking the period and inserting <quote>; or</quote>; and</text></paragraph> <paragraph id="H80108E34F015433CAA2FAB86F2E34921"><enum>(3)</enum><text>by inserting after paragraph (24) the following new paragraph:</text> <quoted-block style="OLC" id="H801FA9D597D34E2291BD24ADC7EE0E06" display-inline="no-display-inline"> <paragraph id="H709D1E80ECD44660A4ED78BDEB38861B"><enum>(25)</enum><text display-inline="yes-display-inline">subject to subsection (h), not later than January 1, 2015, for which the payment is other than by electronic funds transfer (EFT) so long as the Secretary has adopted and implemented a standard for electronic funds transfer under section 1173A.</text></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection> <subsection id="HE08FCECE025C45A681575AC9F0CB1D66"><enum>(f)</enum><header>Expansion of penalties</header><text>Section 1176 of such Act (42 U.S.C. 1320d–5) is amended by adding at the end the following new subsection:</text> <quoted-block style="OLC" id="H66D6F78B8264486A98A030D3B6E681E6" display-inline="no-display-inline"> <subsection id="HAB9A8CBE24914757977C9978851ED9A6"><enum>(c)</enum><header>Expansion of penalty authority</header><text display-inline="yes-display-inline">The Secretary may, in addition to the penalties provided under subsections (a) and (b), provide for the imposition of penalties for violations of this part that are comparable—</text> <paragraph id="H8C71426529074861B132CB43B4F3AE82"><enum>(1)</enum><text>in the case of health plans, to the sanctions the Secretary is authorized to impose under part C or D of title XVIII in the case of a plan that violates a provision of such part; or</text></paragraph> <paragraph id="HB7D346EF1EAB44269A46A32F1C31F42A"><enum>(2)</enum><text>in the case of a health care provider, to the sanctions the Secretary is authorized to impose under part A, B, or D of title XVIII in the case of a health care provider that violations a provision of such part with respect to that provider.</text></paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block></subsection></section> <enum>II</enum><header>Protections and Standards for Qualified Health Benefits Plans</header> <subtitle id="H95A65CA9E9814325969007C20AAB011F"><enum>A</enum><header>General Standards</header> <section id="HD7CD74F3B4B142C99C5A962D85B2D7EB"><enum>201.</enum><header>Requirements reforming health insurance marketplace</header> <subsection id="HE88F923BB5914A12B4D836562AB129A0"><enum>(a)</enum><header>Purpose</header><text display-inline="yes-display-inline">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.</text></subsection> <subsection id="HF55315521CF24FF3BC00706F7BAF0374"><enum>(b)</enum><header>Requirements for qualified health benefits plans</header><text display-inline="yes-display-inline">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:</text> <paragraph id="H38DAD20A40584A07A1BDF7C1A3A8E528"><enum>(1)</enum><text>Subtitle B (relating to affordable coverage).</text></paragraph> <paragraph id="H973C94ACF4DD43E9B67BCAB6395647D8"><enum>(2)</enum><text>Subtitle C (relating to essential benefits).</text></paragraph> <paragraph id="H99828999E3D44E319D8423A09244A26B"><enum>(3)</enum><text>Subtitle D (relating to consumer protection).</text></paragraph></subsection> <subsection id="H01FB8921AFAE4CEBACF1EDA46AD937FD"><enum>(c)</enum><header>Terminology</header><text display-inline="yes-display-inline">In this division:</text> <paragraph id="HAB2C001FFE5F4EDFB111B5053D2958A8"><enum>(1)</enum><header>Enrollment in employment-based health plans</header><text display-inline="yes-display-inline">An individual shall be treated as being <quote>enrolled</quote> 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.</text></paragraph> <paragraph id="HA8266CC7D28E4AFCA9F20CE1D1B73022"><enum>(2)</enum><header>Individual and group health insurance coverage</header><text>The terms <term>individual health insurance coverage</term> and <term>group health insurance coverage</term> 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.</text></paragraph></subsection></section> <section id="H356343C5B9F84BC397181493120140B8"><enum>202.</enum><header>Protecting the choice to keep current coverage</header> <subsection id="HDC55695ACFFF483DAA3A974B4AFA4DD6"><enum>(a)</enum><header>Grandfathered health insurance coverage defined</header><text display-inline="yes-display-inline">Subject to the succeeding provisions of this section, for purposes of establishing acceptable coverage under this division, the term <term>grandfathered health insurance coverage</term> 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:</text> <paragraph id="HC84C7AAB2234468A92057B3A86A874F7" display-inline="no-display-inline"><enum>(1)</enum><header>Limitation on new enrollment</header> <subparagraph id="H34A47C7C4ED741739EEF0117966A6183"><enum>(A)</enum><header>In general</header><text>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.</text></subparagraph> <subparagraph id="H55A5244D546F47A5807E118C038D86E7"><enum>(B)</enum><header>Dependent coverage permitted</header><text>Subparagraph (A) shall not affect the subsequent enrollment of a dependent of an individual who is covered as of such first day.</text></subparagraph></paragraph> <paragraph id="H703581B3D2534489B27B805720E01C5A"><enum>(2)</enum><header>Limitation on changes in terms or conditions</header><text>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.</text></paragraph> <paragraph id="H9BF1ECDEAA94407F89547FBBE4704B7C"><enum>(3)</enum><header>Restrictions on premium increases</header><text display-inline="yes-display-inline">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. </text></paragraph></subsection> <subsection id="H89F91B49E5D44AC4AAEAC894D83884EF"><enum>(b)</enum><header>Grace period for current employment-Based health plans</header><text display-inline="yes-display-inline"/> <paragraph id="H3E833822207C4D8C9142E7B8437FBAE8"><enum>(1)</enum><header>Grace period</header> <subparagraph id="HB2A5F5B9B28C4EBE9B7911522EC656F7"><enum>(A)</enum><header>In general</header><text>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 requirements as apply to a qualified health benefits plan under section 201, including the essential benefit package requirement under section 221.</text></subparagraph> <subparagraph id="H7DC8A5E82E8544DD92BA96A1566DFFF9"><enum>(B)</enum><header>Exception for limited benefits plans</header><text>Subparagraph (A) shall not apply to an employment-based health plan in which the coverage consists only of one or more of the following:</text> <clause id="H2B49CEBE7AA94F939B29DA6C9E485B47"><enum>(i)</enum><text> Any coverage described in section 3001(a)(1)(B)(ii)(IV) of division B of the American Recovery and Reinvestment Act of 2009 (Public Law 111–5).</text></clause> <clause id="H88DAD25DC24642D88677AB5C680311F1"><enum>(ii)</enum><text>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.</text></clause> <clause id="HC1C0F002DDA64403A6E3E382CE3DC505"><enum>(iii)</enum><text>Such other limited benefits as the Commissioner may specify.</text></clause><continuation-text continuation-text-level="subparagraph">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.</continuation-text></subparagraph></paragraph> <paragraph id="H4FFB0C82F1D945BBB829C443AAEDBF97"><enum>(2)</enum><header>Transitional treatment as acceptable coverage</header><text display-inline="yes-display-inline">During the grace period specified in paragraph (1)(A), an employment-based health plan (which may be a high deducible health plan, as defined in section 223(c)(2) of the Internal Revenue Code of 1986) that is described in such paragraph shall be treated as acceptable coverage under this division.</text></paragraph></subsection> <subsection id="H294F558C3FCC4EA5BC95B7B67F761A76"><enum>(c)</enum><header>Limitation on individual health insurance coverage</header> <paragraph id="HFD5BC059A1834BFE8B8B1031996E95D2"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">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.</text></paragraph> <paragraph id="HAD444BC8650C4A76B322EC1E36CEA9E2"><enum>(2)</enum><header>Separate, excepted coverage permitted</header><text>Nothing in—</text> <subparagraph id="H7B20BE371E134A5EBE0EFD41BA255CB2"><enum>(A)</enum><text display-inline="yes-display-inline">paragraph (1) shall prevent the offering of excepted benefits described in section 2791(c) of the Public Health Service Act so long as such benefits are offered outside the Health Insurance Exchange and are priced separately from health insurance coverage; and</text></subparagraph> <subparagraph id="H81855E731D4B4880AE245B5026E6BE09" commented="no"><enum>(B)</enum><text>this division shall be construed—</text> <clause id="H6E621B875FDF473A935FF67EA100C58C" commented="no"><enum>(i)</enum><text>to prevent the offering of a stand-alone plan that offers coverage of excepted benefits described in section 2791(c)(2)(A) of the Public Health Service Act (relating to limited scope dental or vision benefits) for individuals and families from a State-licensed dental and vision carrier; or</text></clause> <clause id="H3695CDC18449469DBAEAD9BCFD597843" commented="no"><enum>(ii)</enum><text>as applying requirements for a qualified health benefits plan to such a stand-alone plan that is offered and priced separately from a qualified health benefits plan.</text></clause></subparagraph></paragraph></subsection></section></subtitle> <subtitle id="HB8B06758B0494C0FACD4CDBE00238115"><enum>B</enum><header>Standards Guaranteeing Access to Affordable Coverage</header> <section id="H14C38075EF1B44F69512171A3786C21B" display-inline="no-display-inline" section-type="subsequent-section"><enum>211.</enum><header>Prohibiting preexisting condition exclusions</header><text display-inline="no-display-inline">A qualified health benefits plan may not impose any preexisting 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 of the following: health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, disability, or source of injury (including conditions arising out of acts of domestic violence) or any similar factors.</text></section> <section id="HCE909BBB480C40238CEF452042FBD2E3"><enum>212.</enum><header>Guaranteed issue and renewal for insured plans and prohibiting rescissions</header><text display-inline="no-display-inline">The requirements of sections 2711 (other than subsections (e) and (f)) 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 nonpayment of premiums and there is a grace period during which the enrollee has an opportunity to correct such nonpayment. Rescissions of such coverage shall be prohibited except in cases of fraud as defined in section 2712(b)(2) of such Act. </text></section> <section id="H66E8686A7AA04CAA95BDCB5678DE215A"><enum>213.</enum><header>Insurance rating rules</header> <subsection id="HA23662C3A5B0427D9B86444FAC3DB41F"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">The premium rate charged for a qualified health benefits plan that is health insurance coverage may not vary except as follows:</text> <paragraph id="H0F214E197E0A4AF689B28578EE93B937"><enum>(1)</enum><header>Limited age variation permitted</header><text>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.</text></paragraph> <paragraph id="H1FB5D4CFB9D94F089177B881EE20CFEB"><enum>(2)</enum><header>By area</header><text>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).</text></paragraph> <paragraph id="HFA6EE7E53D3D42C9BCB37E15F585A5FA"><enum>(3)</enum><header>By family enrollment</header><text>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.</text></paragraph></subsection> <subsection id="H57C6B6E7AA024F9EAC395778CFB04505" display-inline="no-display-inline"><enum>(b)</enum><header>Actuarial value of optional service coverage</header> <paragraph id="HDA8019F05A2D46F49942BFE15CC20E85"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">The Commissioner shall estimate the basic per enrollee, per month cost, determined on an average actuarial basis, for including coverage under a basic plan of the services described in section 222(d)(4)(A).</text></paragraph> <paragraph id="HF6D1BDC9EF3141C18EBE396194BE1FFF"><enum>(2)</enum><header>Considerations</header><text>In making such estimate the Commissioner—</text> <subparagraph id="H27CE5E635D0743DF832D624A4126E953"><enum>(A)</enum><text display-inline="yes-display-inline">may take into account the impact on overall costs of the inclusion of such coverage, but may not take into account any cost reduction estimated to result from such services, including prenatal care, delivery, or postnatal care;</text></subparagraph> <subparagraph id="H45DBD6B5D0F34C55A68C6A130E6AAEB0"><enum>(B)</enum><text>shall estimate such costs as if such coverage were included for the entire population covered; and</text></subparagraph> <subparagraph id="H6E23D5FE7D18478D84D420B816346FF2"><enum>(C)</enum><text>may not estimate such a cost at less than $1 per enrollee, per month.</text></subparagraph></paragraph></subsection> <subsection id="H291B298BFD32449EB8A6E55C1802B83E"><enum>(c)</enum><header>Study and reports</header> <paragraph id="HD4448CB5D93F4BED933E98903356BE1F"><enum>(1)</enum><header>Study</header><text>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:</text> <subparagraph id="H84994B21964F466DA19DF1ED32D759B6"><enum>(A)</enum><text>The types of employers by key characteristics, including size, that purchase insured products versus those that self-insure.</text></subparagraph> <subparagraph id="H7E88A521CFD14A899EA9EC19B11A2BA8"><enum>(B)</enum><text>The similarities and differences between typical insured and self-insured health plans.</text></subparagraph> <subparagraph id="H5CAC48D0040F4A0292DFFDAC8F1D8F06"><enum>(C)</enum><text>The financial solvency and capital reserve levels of employers that self-insure by employer size.</text></subparagraph> <subparagraph id="HB39230D269DF43DEB66CD9716BC73B8C"><enum>(D)</enum><text>The risk of self-insured employers not being able to pay obligations or otherwise becoming financially insolvent.</text></subparagraph> <subparagraph id="H6BA552D3E1CE468A92561E2F1D530D55"><enum>(E)</enum><text display-inline="yes-display-inline">The extent to which rating rules are likely to cause adverse selection in the large group market or to encourage small and midsize employers to self-insure.</text></subparagraph></paragraph> <paragraph id="HD0696807EBF04EF29E26FC781B7C0C3C"><enum>(2)</enum><header>Reports</header><text>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 for small and midsize 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.</text></paragraph></subsection></section> <section id="HFE58B552B081418BADA0E24EF4390F77"><enum>214.</enum><header>Nondiscrimination in benefits; parity in mental health and substance abuse disorder benefits</header> <subsection id="H074A9D8B1A564679BF519B31DA1CCC90"><enum>(a)</enum><header>Nondiscrimination in benefits</header><text display-inline="yes-display-inline">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 section 702 of the Employee Retirement Income Security Act of 1974, section 2702 of the Public Health Service Act, and section 9802 of the Internal Revenue Code of 1986.</text></subsection> <subsection id="H739426D7AB5A4B7D8E440129991D629F"><enum>(b)</enum><header>Parity in mental health and substance abuse disorder benefits</header><text>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 the Public Health Service Act shall apply to a qualified health benefits plan, regardless of whether it is offered in the individual or group market, in the same manner as such provisions apply to health insurance coverage offered in the large group market.</text></subsection></section> <section id="H76A84DCFA74F42198D765F5BEA560FFA" display-inline="no-display-inline"><enum>215.</enum><header>Ensuring adequacy of provider networks</header> <subsection id="HC161DC64926C442DA07F9F54A681E4C1"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">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 among providers participating in the network and policies for accessing out-of-network providers.</text></subsection> <subsection id="H98E85054965A40D6AC3B230AE5C5BF48" display-inline="no-display-inline" commented="no"><enum>(b)</enum><header>Internet access to information</header><text display-inline="yes-display-inline">A qualified health benefits plan that uses a provider network shall provide a current listing of all providers in its network on its Website and such data shall be available on the Health Insurance Exchange Website as a part of the basic information on that plan. The Commissioner shall also establish an on-line system whereby an individual may select by name any medical provider (as defined by the Commissioner) and be informed of the plan or plans with which that provider is contracting.</text></subsection> <subsection id="HDE094B6622134031B9022D51E1848867"><enum>(c)</enum><header>Provider network defined</header><text>In this division, the term <term>provider network</term> means the providers with respect to which covered benefits, treatments, and services are available under a health benefits plan.</text></subsection></section> <section id="HFAF4D33A1C2D499F94BFA8BA7DF27E42"><enum>216.</enum><header>Requiring the option of extension of dependent coverage for uninsured young adults</header> <subsection id="HCE555308B65643DFAC717D1760D1DEE4"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">A qualified health benefits plan shall make available, at the option of the principal enrollee under the plan, coverage for one or more qualified children (as defined in subsection (b)) of the enrollee.</text></subsection> <subsection id="HC1DEF2635995466D8E812368E3E4E9A4"><enum>(b)</enum><header>Qualified child defined</header><text>In this section, the term <term>qualified child</term> means, with respect to a principal enrollee in a qualified health benefits plan, an individual who (but for age) would be treated as a dependent child of the enrollee under such plan and who—</text> <paragraph id="HB7CA604621804A54B23005A648B7A3DE"><enum>(1)</enum><text>is under 27 years of age; and</text></paragraph> <paragraph id="H2655220FD0504432865BA5D471484820"><enum>(2)</enum><text>is not enrolled in a health benefits plan other than under this section.</text></paragraph></subsection> <subsection id="H05B9A1255CB946069285BF5542445D03"><enum>(c)</enum><header>Premiums</header><text>Nothing in this section shall be construed as preventing a qualified health benefits plan from increasing the premiums otherwise required for coverage provided under this section consistent with standards established by the Commissioner based upon family size under section 213(a)(3).</text></subsection></section> <section id="HC715D834E21F4E7D88C9FF826D33B0F4" display-inline="no-display-inline" section-type="subsequent-section" commented="no"><enum>217.</enum><header>Consistency of costs and coverage under qualified health benefits plans during plan year</header><text display-inline="no-display-inline">In the case of health insurance coverage offered under a qualified health benefits plan, if the coverage decreases or the cost-sharing increases, the issuer of the coverage shall notify enrollees of the change at least 90 days before the change takes effect (or such shorter period of time in cases where the change is necessary to ensure the health and safety of enrollees). </text></section></subtitle> <subtitle id="HF8724FE503894766BF0DD5AAF0C2435B"><enum>C</enum><header>Standards Guaranteeing Access to Essential Benefits</header> <section id="H40A66574A9964A9FA27EB3A9D8F105C1"><enum>221.</enum><header>Coverage of essential benefits package</header> <subsection id="HD2BECB7B4F584518B61AA910D67D8A0B"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">A qualified health benefits plan shall provide coverage that at least meets the benefit standards adopted under section 224 for the essential benefits package described in section 222 for the plan year involved. </text></subsection> <subsection id="H7AABD0AD92C54263B2109923BC6E8239"><enum>(b)</enum><header>Choice of coverage</header> <paragraph id="H228AC5BA68F34DC5A52D5A4964663B3A"><enum>(1)</enum><header>Non-exchange-participating health benefits plans</header><text display-inline="yes-display-inline">In the case of a qualified health benefits plan that is not an Exchange-participating health benefits plan, such plan may offer such coverage in addition to the essential benefits package as the QHBP offering entity may specify.</text></paragraph> <paragraph id="H935BFC0AE3B64C5DA50496187BCBFABE"><enum>(2)</enum><header>Exchange-participating health benefits plans</header><text>In the case of an Exchange-participating 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.</text></paragraph> <paragraph id="H8AA812E14E494E98BF160CB8DF8AC11B"><enum>(3)</enum><header>Continuation of offering of separate excepted benefits coverage</header><text>Nothing in this division shall be construed as affecting the offering outside of the Health Insurance Exchange and under State law of health benefits in the form of excepted benefits (described in section 202(b)(1)(B)(ii)) if such benefits are offered under a separate policy, contract, or certificate of insurance.</text></paragraph></subsection> <subsection id="HF19146743EE24F1E93CB6B3CBA260C16"><enum>(c)</enum><header>Clinical appropriateness</header><text display-inline="yes-display-inline">Nothing in this Act shall be construed to prohibit a group health plan or health insurance issuer from using medical management practices so long as such management practices are based on valid medical evidence and are relevant to the patient whose medical treatment is under review. </text></subsection> <subsection id="HFC82FB3E39464DDE830073AAC418BD93" commented="no"><enum>(d)</enum><header>Provision of benefits</header><text display-inline="yes-display-inline">Nothing in this division shall be construed as prohibiting a qualified health benefits plan from subcontracting with stand-alone health insurance issuers or insurers for the provision of dental, vision, mental health, and other benefits and services.</text></subsection></section> <section id="H9A28BD5EFDC543CEB43E5459196FDB30" display-inline="no-display-inline" section-type="subsequent-section"><enum>222.</enum><header>Essential benefits package defined</header> <subsection id="H6675C1B736054E79A6B3068BA4215956"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">In this division, the term <term>essential benefits package</term> means health benefits coverage, consistent with standards adopted under section 224, to ensure the provision of quality health care and financial security, that—</text> <paragraph id="HB04C215E2F614669A49DEF609A65C67B"><enum>(1)</enum><text> 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; </text></paragraph> <paragraph id="H84D995E2758942FEA14B3DF1E41066E7"><enum>(2)</enum><text>limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c);</text></paragraph> <paragraph id="HF968F68A6112413FB2F022EE1FC6481B"><enum>(3)</enum><text display-inline="yes-display-inline">does not impose any annual or lifetime limit on the coverage of covered health care items and services; </text></paragraph> <paragraph id="H4D8E289CDFCA4EE98A4CC3694EC2B0F1"><enum>(4)</enum><text>complies with section 215(a) (relating to network adequacy); and</text></paragraph> <paragraph id="HC570D8DF0C56475991D6D7299B5F8427"><enum>(5)</enum><text display-inline="yes-display-inline">is equivalent in its scope of benefits, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage in Y1.</text></paragraph><continuation-text continuation-text-level="subsection"> In order to carry out paragraph (5), the Secretary of Labor shall conduct a survey of employer-sponsored coverage to determine the benefits typically covered by employers, including multiemployer plans, and provide a report on such survey to the Health Benefits Advisory Committee and to the Secretary of Health and Human Services.</continuation-text></subsection> <subsection id="H71BCA8C38D27470690F5615EAA40C143" commented="no"><enum>(b)</enum><header>Minimum services To be covered</header><text>Subject to subsection (d), the items and services described in this subsection are the following: </text> <paragraph id="H01DFBBB351384DDA8330E40B32ED7C5E" commented="no"><enum>(1)</enum><text display-inline="yes-display-inline">Hospitalization.</text></paragraph> <paragraph id="H9F3CD999DC824FE693AD998838564BB8" commented="no"><enum>(2)</enum><text>Outpatient hospital and outpatient clinic services, including emergency department services.</text></paragraph> <paragraph id="HD5AF5A9EE531449DA1B9CC0749CBCC7C" commented="no"><enum>(3)</enum><text>Professional services of physicians and other health professionals.</text></paragraph> <paragraph id="H11E39074B44648BFA500B36EBF94EFBA" commented="no"><enum>(4)</enum><text>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.</text></paragraph> <paragraph id="H412896D3EA1749E7859D93912A934F5E" commented="no"><enum>(5)</enum><text>Prescription drugs.</text></paragraph> <paragraph id="H07BDB12B1A2B4BACBE406F0F0AEE1924" commented="no"><enum>(6)</enum><text>Rehabilitative and habilitative services.</text></paragraph> <paragraph id="HD0A922D04D0C4E39A1B5E8CB9FD0C37F" commented="no"><enum>(7)</enum><text display-inline="yes-display-inline">Mental health and substance use disorder services, including behavioral health treatments.</text></paragraph> <paragraph id="H4BC8ADB6BF3C45A2ADCBB4751982DDEC" commented="no"><enum>(8)</enum><text>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.</text></paragraph> <paragraph id="HE02EBAD89DCF47068E0407EC20F568DF"><enum>(9)</enum><text>Maternity care.</text></paragraph> <paragraph id="H6BB7299ECBE646D7B007CE5E58D26A91" commented="no"><enum>(10)</enum><text>Well-baby and well-child care and oral health, vision, and hearing services, equipment, and supplies for children under 21 years of age.</text></paragraph> <paragraph id="HE586EE639ABA438BAA2F89F9D30E44B3" commented="no"><enum>(11)</enum><text>Durable medical equipment, prosthetics, orthotics and related supplies. </text></paragraph></subsection> <subsection id="H955F76C79B2548D9B483641D35FE58C3"><enum>(c)</enum><header>Requirements relating to cost-Sharing and minimum actuarial value</header> <paragraph id="HEC653AACFF3D4CA09DDB54ACBE73FD31"><enum>(1)</enum><header>No cost-sharing for preventive services</header><text>There shall be no cost-sharing under the essential benefits package for—</text> <subparagraph id="H741FC1FC570C4A55ACDFFDDE11E6607D"><enum>(A)</enum><text>preventive items and 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; or</text></subparagraph> <subparagraph id="H285EFADA96C5401483995DDF0DD3FF46"><enum>(B)</enum><text>well-baby and well-child care.</text></subparagraph></paragraph> <paragraph id="HB965A928FDF843CF8E7E01AF6B56158D"><enum>(2)</enum><header>Annual limitation</header> <subparagraph id="H83B5F71AEF06426D88F5D63151FD87EC"><enum>(A)</enum><header>Annual limitation</header><text>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).</text></subparagraph> <subparagraph id="H04662D1C78E94BD4A8816D273620F4B4"><enum>(B)</enum><header>Applicable level</header><text display-inline="yes-display-inline">The applicable level specified in this subparagraph for Y1 is not to exceed $5,000 for an individual and not to exceed $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 enrollment-weighted average of premium increases for basic plans applicable to such year, except that Secretary shall adjust such increase to ensure that the applicable level specified in this subparagraph meets the minimum actuarial value required under paragraph (3).</text></subparagraph> <subparagraph id="HED3FF9C2E63E43EE81E519C5C2FD04DC" commented="no"><enum>(C)</enum><header>Use of copayments</header><text>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.</text></subparagraph></paragraph> <paragraph id="HBC169D2C10FF419499F7BB3D15D6E849"><enum>(3)</enum><header>Minimum actuarial value</header> <subparagraph id="H53E0D0F3FB504122A8554AF49C881E91"><enum>(A)</enum><header>In general</header><text>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). </text></subparagraph> <subparagraph id="H4107D8844F164E6884BA67D11231554A" display-inline="no-display-inline"><enum>(B)</enum><header>Reference benefits package described</header><text display-inline="yes-display-inline">The reference benefits package described in this subparagraph is the essential benefits package if there were no cost-sharing imposed.</text></subparagraph></paragraph></subsection> <subsection id="H36DA41D66E7A4C3DAC10124E63615EC7"><enum>(d)</enum><header>Assessment and counseling for domestic violence</header><text>The Secretary shall support the need for an assessment and brief counseling for domestic violence as part of a behavioral health assessment or primary care visit and determine the appropriate coverage for such assessment and counseling.</text></subsection> <subsection id="H7283BF14C0444A088388EF73009EF349" display-inline="no-display-inline"><enum>(e)</enum><header>Abortion coverage prohibited as part of minimum benefits package</header> <paragraph id="H062107A8A50A46F79D4737ECB9562C43"><enum>(1)</enum><header>Prohibition of required coverage</header><text display-inline="yes-display-inline">The Health Benefits Advisory Committee may not recommend under section 223(b), and the Secretary may not adopt in standards under section 224(b), the services described in paragraph (4)(A) or (4)(B) as part of the essential benefits package and the Commissioner may not require such services for qualified health benefits plans to participate in the Health Insurance Exchange. </text></paragraph> <paragraph id="H1C182A0808E0410D9328666642F542CE"><enum>(2)</enum><header>Voluntary choice of coverage by plan</header><text display-inline="yes-display-inline">In the case of a qualified health benefits plan, the plan is not required (or prohibited) under this Act from providing coverage of services described in paragraph (4)(A) or (4)(B) and the QHBP offering entity shall determine whether such coverage is provided.</text></paragraph> <paragraph id="HAA3F4CE8F67F4D04960813114E4FEAAB"><enum>(3)</enum><header>Coverage under public health insurance option</header><text display-inline="yes-display-inline">The public health insurance option shall provide coverage for services described in paragraph (4)(B). Nothing in this Act shall be construed as preventing the public health insurance option from providing for or prohibiting coverage of services described in paragraph (4)(A).</text></paragraph> <paragraph id="HB67E6B772AD645949A514061CCF97ED4"><enum>(4)</enum><header>Abortion services</header> <subparagraph id="H1AADD5634A254A4B9FA6AF01A70D5801"><enum>(A)</enum><header>Abortions for which public funding is prohibited</header><text>The services described in this subparagraph are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is not permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved.</text></subparagraph> <subparagraph id="HD63FF0A735464A15A79B7A3B7AB322FA"><enum>(B)</enum><header>Abortions for which public funding is allowed</header><text>The services described in this subparagraph are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved.</text></subparagraph></paragraph></subsection> <subsection id="H9B2043324B1B47FD87FF20CE60D4ED7D" commented="no"><enum>(f)</enum><header>Report regarding inclusion of oral health care in essential benefits package</header><text display-inline="yes-display-inline">Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall submit to Congress a report containing the results of a study determining the need and cost of providing accessible and affordable oral health care to adults as part of the essential benefits package.</text></subsection></section> <section id="HAE7F41B3A2A947579B72470985F13C11"><enum>223.</enum><header>Health Benefits Advisory Committee</header> <subsection id="H75C6AF64FB5F4749A335430F51CB1762"><enum>(a)</enum><header>Establishment</header> <paragraph id="H29EB1C7D5B88434A999A3C76B8EC0B1E"><enum>(1)</enum><header>In general</header><text>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.</text></paragraph> <paragraph id="H6133AB1973664C2F9F8A02DD86CA086C"><enum>(2)</enum><header>Chair</header><text>The Surgeon General shall be a member and the chair of the Health Benefits Advisory Committee.</text></paragraph> <paragraph id="H16CB3ED05EAD4204A89BEE319F445C0D"><enum>(3)</enum><header>Membership</header><text>The Health Benefits Advisory Committee shall be composed of the following members, in addition to the Surgeon General:</text> <subparagraph id="H4735DEAC7BA147E18593EF5489F9D9CB"><enum>(A)</enum><text>Nine members who are not Federal employees or officers and who are appointed by the President.</text></subparagraph> <subparagraph id="H03AB31E283A644C5B20223C20F0BD864"><enum>(B)</enum><text>Nine 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.</text></subparagraph> <subparagraph id="HE6C8FA4FAEBB48229CF416F78619DAFF"><enum>(C)</enum><text>Such even number of members (not to exceed 8) who are Federal employees and officers, as the President may appoint.</text></subparagraph><continuation-text continuation-text-level="paragraph">Such initial appointments shall be made not later than 60 days after the date of the enactment of this Act.</continuation-text></paragraph> <paragraph id="HE60FA087A41F4051B205D12353D12C1D"><enum>(4)</enum><header>Terms</header><text display-inline="yes-display-inline">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.</text></paragraph> <paragraph id="H6537C3A808AB43F585FF49BD3BF53061" commented="no"><enum>(5)</enum><header>Participation</header><text display-inline="yes-display-inline">The membership of the Health Benefits Advisory Committee shall at least reflect providers, patient representatives, employers (including small employers), labor, health insurance issuers, experts in health care financing and delivery, experts in oral health care, experts in racial and ethnic disparities, experts on health care needs and disparities of individuals with disabilities, representatives of relevant governmental agencies, and at least one practicing physician or other health professional and an expert in child and adolescent 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.</text></paragraph></subsection> <subsection id="H0043246033B94C1E91EC610EFEE9AC6B"><enum>(b)</enum><header>Duties</header> <paragraph id="H26B76F43640943BEB50E9F86E0DC7DE8"><enum>(1)</enum><header>Recommendations on benefit standards</header><text display-inline="yes-display-inline">The Health Benefits Advisory Committee shall recommend to the Secretary of Health and Human Services (in this subtitle referred to as the <quote>Secretary</quote>) benefit standards (as defined in paragraph (5)), 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.</text></paragraph> <paragraph id="H2EFBA964437C4B998151670FFF35E7EE"><enum>(2)</enum><header>Deadline</header><text>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.</text></paragraph> <paragraph id="HD2F17EF10DFF4F4CBA4DA6C46B310E4E" display-inline="no-display-inline" commented="no"><enum>(3)</enum><header>State input</header><text display-inline="yes-display-inline">The Health Benefits Advisory Committee shall examine the health coverage laws and benefits of each State in developing recommendations under this subsection and may incorporate such coverage and benefits as the Committee determines to be appropriate and consistent with this Act. The Health Benefits Advisory Committee shall also seek input from the States and consider recommendations on how to ensure quality of health coverage in all States.</text></paragraph> <paragraph id="H960F88CA2BEC415B9E64D468ADDE41F9"><enum>(4)</enum><header>Public input</header><text display-inline="yes-display-inline">The Health Benefits Advisory Committee shall allow for public input as a part of developing recommendations under this subsection. </text></paragraph> <paragraph id="HFDFBC0535AAF4C0B9E47DC92763B4765"><enum>(5)</enum><header>Benefit standards defined</header><text>In this subtitle, the term <term>benefit standards</term> means standards respecting—</text> <subparagraph id="HE2A3A0850B2E4955B4E3C5E11B254774"><enum>(A)</enum><text>the essential benefits package described in section 222, including categories of covered treatments, items and services within benefit classes, and cost-sharing consistent with subsection (d) of such section; and</text></subparagraph> <subparagraph id="H920EEA772C5F45C39365E5BF0B2B6D37"><enum>(B)</enum><text>the cost-sharing levels for enhanced plans and premium plans (as provided under section 303(c)) consistent with paragraph (5).</text></subparagraph></paragraph> <paragraph id="H7694FFC1D36E46FBA0E6951431D2D252"><enum>(6)</enum><header>Levels of cost-sharing for enhanced and premium plans</header> <subparagraph id="H5B4A437225DC49ECBBB834372456B4B2"><enum>(A)</enum><header>Enhanced plan</header><text display-inline="yes-display-inline">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 222(c)(3)(B).</text></subparagraph> <subparagraph id="H8F7EB66363E94D9C86F3708C190BD6F2" display-inline="no-display-inline"><enum>(B)</enum><header>Premium plan</header><text display-inline="yes-display-inline">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 222(c)(3)(B).</text></subparagraph></paragraph></subsection> <subsection id="H77624641FDBF4A2180B1ACDDC00ED526"><enum>(c)</enum><header>Operations</header> <paragraph id="H114BD9B5D67348C2AD9E2FD100120363" display-inline="no-display-inline"><enum>(1)</enum><header>Per diem pay</header><text>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.</text></paragraph> <paragraph id="H429A7DD10B834DAC90CD064B715C0FAE"><enum>(2)</enum><header>Members not treated as Federal employees</header><text display-inline="yes-display-inline">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, except such members shall be considered to be within the meaning of section 202(a) of title 18, United States Code, for the purposes of disclosure and management of conflicts of interest.</text></paragraph> <paragraph id="HBB15C6F49AAA4C7F9EF67B3547F509D6"><enum>(3)</enum><header>Application of FACA</header><text display-inline="yes-display-inline">The Federal Advisory Committee Act (5 U.S.C. App.), other than section 14, shall apply to the Health Benefits Advisory Committee.</text></paragraph></subsection> <subsection id="H56037E4F3F5B4AB3B77828115F102C47"><enum>(d)</enum><header>Publication</header><text>The Secretary shall provide for publication in the Federal Register and the posting on the Internet Website of the Department of Health and Human Services of all recommendations made by the Health Benefits Advisory Committee under this section.</text></subsection></section> <section id="HFEE6EB8812824A15AB7659460BD4AC50"><enum>224.</enum><header>Process for adoption of recommendations; adoption of benefit standards</header> <subsection id="H1EC2C6A38D294FA9B9D286A351E72E9E"><enum>(a)</enum><header>Process for Adoption of Recommendations</header> <paragraph id="HACFA21B4E5B14FD7946BAD4AD88A61CD"><enum>(1)</enum><header>Review of recommended standards</header><text>Not later than 45 days after the date of receipt of benefit standards recommended under section 223 (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.</text></paragraph> <paragraph id="HFC27E980779E4B9194F57904718834C7"><enum>(2)</enum><header>Determination to adopt standards</header><text>If the Secretary determines—</text> <subparagraph id="H0A5174C3A151439AAB83E48D9F025662"><enum>(A)</enum><text>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 of such standards; or</text></subparagraph> <subparagraph id="H2D34A3D3999C46299DA0FBD56E5FFFE4"><enum>(B)</enum><text>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 recommendation and provide the Committee with a further opportunity to modify its previous recommendations and submit new recommendations to the Secretary on a timely basis.</text></subparagraph></paragraph> <paragraph id="H4F7B95F82DCA4E99A97974DE28ACD9AA"><enum>(3)</enum><header>Contingency</header><text>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.</text></paragraph> <paragraph id="H7AA0F23D482C4C439EC23643637EA5D9"><enum>(4)</enum><header>Publication</header><text>The Secretary shall provide for publication in the Federal Register of all determinations made by the Secretary under this subsection.</text></paragraph></subsection> <subsection id="H79E78AFF129F4250B457DD2DF21BA3B5"><enum>(b)</enum><header>Adoption of Standards</header><text/> <paragraph id="H73784CA451914D53B505D9993AA68B9B"><enum>(1)</enum><header>Initial standards</header><text>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. </text></paragraph> <paragraph id="H339665148C5F433498C2BB30BFBE73C4" commented="no"><enum>(2)</enum><header>Periodic updating standards</header><text>Under subsection (a), the Secretary shall provide for the periodic updating of the benefit standards previously adopted under this section.</text></paragraph> <paragraph id="H0B63EC865AB34FC6AE05EA9B0585B2B6"><enum>(3)</enum><header>Requirement</header><text>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 222 (including subsection (d)) and 223(b)(5).</text></paragraph></subsection></section></subtitle> <subtitle id="H5DF231005AC043089376E3B87EB68755"><enum>D</enum><header>Additional Consumer Protections</header> <section id="H96AC3A58987849EFB242A19569963842"><enum>231.</enum><header>Requiring fair marketing practices by health insurers</header><text display-inline="no-display-inline">The Commissioner shall establish uniform marketing standards that all QHBP offering entities shall meet with respect to qualified health benefits plans that are health insurance coverage.</text></section> <section id="H5A51AE395BEB4FCC9DB550271E976439" commented="no"><enum>232.</enum><header>Requiring fair grievance and appeals mechanisms</header> <subsection id="H282E755BBD4547669BDC417077FDC062" commented="no"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">A QHBP offering entity shall provide for timely grievance and appeals mechanisms with respect to qualified health benefits plans that the Commissioner shall establish consistent with this section. The Commissioner shall establish time limits for each of such mechanisms and implement them in a manner that is protective to the needs of patients.</text></subsection> <subsection id="H1957CB0581684BCE9A7557A3C2F20C77" commented="no"><enum>(b)</enum><header>Internal claims and appeals process</header><text display-inline="yes-display-inline">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 published on November 21, 2000 (65 Fed. Reg. 70246) and shall update such process in accordance with any standards that the Commissioner may establish.</text></subsection> <subsection id="H812E942983E2441380CBFB041034D6B4" commented="no"><enum>(c)</enum><header>External review process</header> <paragraph id="H8B80B7F44D374C4DB56FEE0DAEDC4A7D" commented="no"><enum>(1)</enum><header>In general</header><text>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. </text></paragraph> <paragraph id="H4E6131E36B9D40689001DFB0EEA98991" commented="no"><enum>(2)</enum><header>Requiring fair grievance and appeals mechanisms</header><text>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.</text></paragraph></subsection> <subsection id="HF003AD1BACB442C1A6135AB7AAE72BCA" commented="no"><enum>(d)</enum><header>Time limits</header><text>The Commissioner shall establish time limits for each of these processes and implement them in a manner that is protective to the patient.</text></subsection> <subsection id="H4C7DE4990FA64806B90A4D6E96CB6E23" commented="no"><enum>(e)</enum><header>Construction</header><text>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 251.</text></subsection></section> <section id="HCFAA7EB47BB34F9C800EF3DBDF7C5744"><enum>233.</enum><header>Requiring information transparency and plan disclosure</header> <subsection id="HB58D7FF311604625B758EBFD580BFE7B"><enum>(a)</enum><header>Accurate and timely disclosure</header> <paragraph id="H21B74E40B8D04C879157E965BFFD6C22"><enum>(1)</enum><header>For Exchange-participating health benefits plans</header><text display-inline="yes-display-inline">A QHBP offering entity offering an Exchange-participating health benefits plan shall comply with standards established by the Commissioner for the accurate and timely disclosure to the Commissioner and the public 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. </text></paragraph> <paragraph id="H549020B98B5C491185008D010279700A"><enum>(2)</enum><header>Employment-based health plans</header><text display-inline="yes-display-inline">The Secretary of Labor shall update and harmonize the Secretary’s rules concerning the accurate and timely disclosure to participants by group health plans of plan disclosure, plan terms and conditions, and periodic financial disclosure with the standards established by the Commissioner under paragraph (1).</text></paragraph> <paragraph id="HD4FD39F796F247089027072DC6C9F354"><enum>(3)</enum><header>Use of plain language</header> <subparagraph id="HBE042667B8B84845ABD28345D60BBE80"><enum>(A)</enum><header>In general</header><text display-inline="yes-display-inline">The disclosures under paragraphs (1) and (2) shall be provided in plain language.</text></subparagraph> <subparagraph id="HB95CAFD3005B4724BB305D642264856D"><enum>(B)</enum><header>Definition</header><text>In this paragraph, the term <term>plain language</term> means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is concise, well-organized, and follows other best practices of plain language writing.</text></subparagraph> <subparagraph id="H2DDED11C09844C4690AE2A48E90B8CF1"><enum>(C)</enum><header>Guidance</header><text>The Commissioner and the Secretary of Labor shall jointly develop and issue guidance on best practices of plain language writing.</text></subparagraph></paragraph> <paragraph id="H9224A3272BBE42A6ACFFE03C31C21B4C" commented="no"><enum>(4)</enum><header>Information on rights</header><text>The information disclosed under this subsection shall include information on enrollee and participant rights under this division.</text></paragraph> <paragraph id="H5E7F0C3149564D32A1E3CD2094D1C162"><enum>(5)</enum><header>Cost-sharing transparency</header><text display-inline="yes-display-inline">A qualified health benefits plan shall allow individuals to learn the amount of cost-sharing (including deductibles, copayments, and coinsurance) under the individual’s plan or coverage that the individual would be responsible for paying with respect to the furnishing of a specific item or service by a participating provider in a timely manner upon request. At a minimum, this information shall be made available to such individual via an Internet Website and other means for individuals without access to the Internet.</text></paragraph></subsection> <subsection id="HBA95C914C25341FF8C71A2BA6D4C4A0F"><enum>(b)</enum><header>Contracting reimbursement</header><text>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.</text></subsection> <subsection id="H4D0C013C6B7147928A0EBE797A9A8494" commented="no"><enum>(c)</enum><header>Pharmacy benefit managers transparency requirements</header> <paragraph id="H1F33796F73CD4B33BA2F08FE44DDA172" commented="no"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">If a QHBP offering entity contracts with a pharmacy benefit manager or other entity (in this subsection referred to as a <quote>PBM</quote>) to manage prescription drug coverage or otherwise control prescription drug costs under a qualified health benefits plan, the PBM shall provide at least annually to the Commissioner and to the QHBP offering entity offering such plan the following information, in a form and manner to be determined by the Commissioner:</text> <subparagraph id="H5AA49128478C48379795588BC33808C0" commented="no"><enum>(A)</enum><text display-inline="yes-display-inline">Information on the number and total cost of prescriptions under the contract that are filled via mail order and at retail pharmacies. </text></subparagraph> <subparagraph id="HE64600AD5F6B4D67930A9E3E0411DA6D" commented="no"><enum>(B)</enum><text>An estimate of aggregate average payments under the contract, per prescription (weighted by prescription volume), made to mail order and retail pharmacies, and the average amount, per prescription, that the PBM was paid by the plan for prescriptions filled at mail order and retail pharmacists.</text></subparagraph> <subparagraph id="H5EECD8B38A6745859573F6E396888048" commented="no"><enum>(C)</enum><text display-inline="yes-display-inline">An estimate of the aggregate average payment per prescription (weighted by prescription volume) under the contract received from pharmaceutical manufacturers, including all rebates, discounts, prices concessions, or administrative, and other payments from pharmaceutical manufacturers, and a description of the types of payments, and the amount of these payments that were shared with the plan, and a description of the percentage of prescriptions for which the PBM received such payments.</text></subparagraph> <subparagraph id="H398DBF3F7AF6448387D1475FF63D3C64" commented="no"><enum>(D)</enum><text>Information on the overall percentage of generic drugs dispensed under the contract at retail and mail order pharmacies, and the percentage of cases in which a generic drug is dispensed when available.</text></subparagraph> <subparagraph id="H05F67E6CD8B741549AEDD1F4BF11A01B" commented="no"><enum>(E)</enum><text display-inline="yes-display-inline">Information on the percentage and number of cases under the contract in which individuals were switched because of PBM policies or at the direct or indirect control of the PBM from a prescribed drug that had a lower cost for the QHBP offering entity to a drug that had a higher cost for the QHBP offering entity, the rationale for these switches, and a description of the PBM policies governing such switches.</text></subparagraph></paragraph> <paragraph id="H8EEE50641B3841E085F09E2B6065FB2D" commented="no"><enum>(2)</enum><header>Confidentiality of information</header><text display-inline="yes-display-inline">Information disclosed by a PBM to the Commissioner or a QHBP offering entity under this subsection is confidential and shall not be disclosed by the Commissioner or the QHBP offering entity in a form which discloses the identity of a specific PBM or prices charged by such PBM or a specific retailer, manufacturer, or wholesaler, except only by the Commissioner—</text> <subparagraph id="HC45E58B97F0B4291BC29321AA3875078" commented="no"><enum>(A)</enum><text display-inline="yes-display-inline">to permit State or Federal law enforcement authorities to use the information provided for program compliance purposes and for the purpose of combating waste, fraud, and abuse;</text></subparagraph> <subparagraph id="HD1544C06770946D48973DC5B9170D9F3" commented="no"><enum>(B)</enum><text display-inline="yes-display-inline">to permit the Comptroller General, the Medicare Payment Advisory Commission, or the Secretary of Health and Human Services to review the information provided; and</text></subparagraph> <subparagraph id="HBAF19905F4474209AF497A1814B00316" commented="no"><enum>(C)</enum><text>to permit the Director of the Congressional Budget Office to review the information provided.</text></subparagraph></paragraph> <paragraph id="H2BBC47E2ADE14022B26EA37D3478DB0D" commented="no"><enum>(3)</enum><header>Annual public report</header><text display-inline="yes-display-inline">On an annual basis, the Commissioner shall prepare a public report providing industrywide aggregate or average information to be used in assessing the overall impact of PBMs on prescription drug prices and spending. Such report shall not disclose the identity of a specific PBM, or prices charged by such PBM, or a specific retailer, manufacturer, or wholesaler, or any other confidential or trade secret information.</text></paragraph> <paragraph id="H87F59D7A50D64F9EB1943460DEB1D3D0" commented="no"><enum>(4)</enum><header>Penalties</header><text display-inline="yes-display-inline">The provisions of subsection (b)(3)(C) of section 1927 shall apply to a PBM that fails to provide information required under subsection (a) or that knowingly provides false information in the same manner as such provisions apply to a manufacturer with an agreement under such section that fails to provide information under subsection (b)(3)(A) of such section or knowingly provides false information under such section, respectively.</text></paragraph></subsection></section> <section id="H8ADBAFA0687849288DC0AA8F0A09C72E"><enum>234.</enum><header>Application to qualified health benefits plans not offered through the Health Insurance Exchange</header><text display-inline="no-display-inline">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.</text></section> <section id="HF2C64E33D5AF42ADA38C7B9CC1411D62"><enum>235.</enum><header>Timely payment of claims</header><text display-inline="no-display-inline">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 as a Medicare Advantage organization is required to comply with such requirements with respect to a Medicare Advantage plan it offers under part C of Medicare.</text></section> <section id="HA970FB16410547DCAC6184D795A66ABE"><enum>236.</enum><header>Standardized rules for coordination and subrogation of benefits</header><text display-inline="no-display-inline">The Commissioner shall establish standards for the coordination and subrogation of benefits and reimbursement of payments in cases of qualified health benefits plans involving individuals and multiple plan coverage.</text></section> <section id="HF03E571D49BD4AAFB74DCC6659B8E032"><enum>237.</enum><header>Application of administrative simplification</header><text display-inline="no-display-inline">A QHBP offering entity is required to comply with administrative simplification provisions under part C of title XI of the Social Security Act with respect to qualified health benefits plans it offers.</text></section> <section id="HD0116372066A41CB94FFF00FD23A440A" commented="no"><enum>238.</enum><header>State prohibitions on discrimination against health care providers</header><text display-inline="no-display-inline">This Act (and the amendments made by this Act) shall not be construed as superseding laws, as they now or hereinafter exist, of any State or jurisdiction designed to prohibit a qualified health benefits plan from discriminating with respect to participation, reimbursement, covered services, indemnification, or related requirements under such plan against a health care provider that is acting within the scope of that provider’s license or certification under applicable State law.</text></section> <section id="H7E0DDE6556B54B369626C28439C6EAFE"><enum>239.</enum><header>Protection of physician prescriber information</header> <subsection id="H6A4D64CC0C3044A996D6454D6051AFC7"><enum>(a)</enum><header>Study</header><text display-inline="yes-display-inline">The Secretary of Health and Human Services shall conduct a study on the use of physician prescriber information in sales and marketing practices of pharmaceutical manufacturers.</text></subsection> <subsection id="HA25C3D4F7DA54DC28CCCF5D7E96ABA59"><enum>(b)</enum><header>Report</header><text>Based on the study conducted under subsection (a), the Secretary shall submit to Congress a report on actions needed to be taken by the Congress or the Secretary to protect providers from biased marketing and sales practices.</text></subsection></section> <section id="H63DBC3A8CDC44F2CB4CDEEC7C0CC10B0" commented="no"><enum>240.</enum><header>Dissemination of advance care planning information</header> <subsection id="HC7113A18A53B4871BB4A434E79232083" commented="no"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">The QHBP offering entity —</text> <paragraph id="H05CFE9D477764A9FA146310A705FA218" commented="no"><enum>(1)</enum><text display-inline="yes-display-inline">shall provide for the dissemination of information related to end-of-life planning to individuals seeking enrollment in Exchange-participating health benefits plans offered through the Exchange; </text></paragraph> <paragraph id="HE8D569429FBB4EDD887B63E388DB0824" commented="no"><enum>(2)</enum><text>shall present such individuals with—</text> <subparagraph id="H2FDE8B98FBC84EE1B1383C0CD4FCBCA3" commented="no"><enum>(A)</enum><text>the option to establish advanced directives and physician’s orders for life sustaining treatment according to the laws of the State in which the individual resides; and</text></subparagraph> <subparagraph id="H49C559DE9CB64652A60E696F4FF1666F" commented="no"><enum>(B)</enum><text>information related to other planning tools; and</text></subparagraph></paragraph> <paragraph id="H6156F85DE43B4A6BBAED5F79396B35E9" commented="no"><enum>(3)</enum><text display-inline="yes-display-inline">shall not promote suicide, assisted suicide, euthanasia, or mercy killing.</text></paragraph><continuation-text continuation-text-level="subsection" commented="no">The information presented under paragraph (2) shall not presume the withdrawal of treatment and shall include end-of-life planning information that includes options to maintain all or most medical interventions.</continuation-text></subsection> <subsection id="HDE4EF60CD468485FB646B65A02AA9411" commented="no"><enum>(b)</enum><header>Construction</header><text> Nothing in this section shall be construed—</text> <paragraph id="H77D446B135B841BABC323BB55493C07B" commented="no"><enum>(1)</enum><text>to require an individual to complete an advanced directive or a physician’s order for life sustaining treatment or other end-of-life planning document; </text></paragraph> <paragraph id="H2EE653069903410D94A249E746DDC695" commented="no"><enum>(2)</enum><text>to require an individual to consent to restrictions on the amount, duration, or scope of medical benefits otherwise covered under a qualified health benefits plan; or</text></paragraph> <paragraph id="HE1DB0152DBB44910A7825E5CFB8F51F6" commented="no"><enum>(3)</enum><text display-inline="yes-display-inline">to promote suicide, assisted suicide, euthanasia, or mercy killing.</text></paragraph></subsection> <subsection id="H1FFD7B2BE3D143EF9F94370E0DC214AE" commented="no"><enum>(c)</enum><header>Advanced directive defined</header><text>In this section, the term <quote>advanced directive</quote> includes a living will, a comfort care order, or a durable power of attorney for health care.</text></subsection> <subsection id="H48239CF641B94BF6B6D1AC91F71ACB55" commented="no"><enum>(d)</enum><header>Prohibition on the promotion of assisted suicide</header> <paragraph id="H91C5F7B850E24227A57B650E3DD1D9A0" commented="no"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">Subject to paragraph (3), information provided to meet the requirements of subsection (a)(2) shall not include advanced directives or other planning tools that list or describe as an option suicide, assisted suicide, euthanasia, or mercy killing, regardless of legality.</text></paragraph> <paragraph id="H343237980B504355BF5FE9E6E06BF286" commented="no"><enum>(2)</enum><header>Construction</header><text>Nothing in paragraph (1) shall be construed to apply to or affect any option to—</text> <subparagraph id="HFC82ED9077B94C6CBBEBF9672FD117EE" commented="no"><enum>(A)</enum><text>withhold or withdraw of medical treatment or medical care;</text></subparagraph> <subparagraph id="H9AB8D672FA2B44268E45B5C104787EBC" commented="no"><enum>(B)</enum><text>withhold or withdraw of nutrition or hydration; and</text></subparagraph> <subparagraph id="HC9FDD1E029B2487E8D8A8C574E4800A5" commented="no"><enum>(C)</enum><text>provide palliative or hospice care or use an item, good, benefit, or service furnished for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death, so long as such item, good, benefit, or service is not also furnished for the purpose of causing, or the purpose of assisting in causing, death, for any reason.</text></subparagraph></paragraph> <paragraph id="H103385774D114643AB86E0D7C214EEFE" display-inline="no-display-inline" commented="no"><enum>(3)</enum><header>No preemption of State law</header><text display-inline="yes-display-inline">Nothing in this section shall be construed to preempt or otherwise have any effect on State laws regarding advance care planning, palliative care, or end-of-life decision-making.</text></paragraph></subsection></section></subtitle> <subtitle id="H3099FF3699864D22B1F75295C7CF1AE0"><enum>E</enum><header>Governance</header> <section id="H33EBF0DFE5D944719EB0E13B3C008358"><enum>241.</enum><header>Health Choices Administration; Health Choices Commissioner</header> <subsection id="H2B6A23226F5F437F903306DA065C0938"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">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 <quote>Administration</quote>).</text></subsection> <subsection id="H01E9DD2DFDB643ADACABAF610F3C8DA5"><enum>(b)</enum><header>Commissioner</header> <paragraph id="H3F3FB714A5D647E991E96CE878C79297"><enum>(1)</enum><header>In general</header><text>The Administration shall be headed by a Health Choices Commissioner (in this division referred to as the <quote>Commissioner</quote>) who shall be appointed by the President, by and with the advice and consent of the Senate.</text></paragraph> <paragraph id="H6F7B73E66655434EB0F51464B324CE93"><enum>(2)</enum><header>Compensation; etc</header><text>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 Commissioner of Social Security and the Social Security Administration.</text></paragraph></subsection> <subsection id="H5C8F810ACC02430F81284E3198AB6FCE" commented="no"><enum>(c)</enum><header>Inspector General</header><text>For provision establishing an Office of the Inspector General for the Health Choices Administration, see section 1647.</text></subsection></section> <section id="HD3453700FF9B4949A359213A56872741"><enum>242.</enum><header>Duties and authority of Commissioner</header> <subsection id="H67B06BB00F484B8C97A4EEFC6FB3FBBD"><enum>(a)</enum><header>Duties</header><text display-inline="yes-display-inline">The Commissioner is responsible for carrying out the following functions under this division: </text> <paragraph id="H52B91825A8C4490894DBA4E472A984AF"><enum>(1)</enum><header>Qualified plan standards</header><text>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.</text></paragraph> <paragraph id="HAB6A6202C79E46C783F917EDF83E2051"><enum>(2)</enum><header>Health Insurance Exchange</header><text>The establishment and operation of a Health Insurance Exchange under subtitle A of title III.</text></paragraph> <paragraph id="HFD379C9755484730800A1E3B77A156B4"><enum>(3)</enum><header>Individual affordability credits</header><text>The administration of individual affordability credits under subtitle C of title III, including determination of eligibility for such credits.</text></paragraph> <paragraph id="HEC4EBEB9ACC24E248028A092851CDDE2"><enum>(4)</enum><header>Additional functions</header><text>Such additional functions as may be specified in this division.</text></paragraph></subsection> <subsection id="H24124E5AF5224C88A4912EC700AF9D9E"><enum>(b)</enum><header>Promoting accountability</header> <paragraph id="H93585CC10217444681C9AE0600289EE1"><enum>(1)</enum><header>In general</header><text>The Commissioner shall undertake activities in accordance with this subtitle to promote accountability of QHBP offering entities in meeting Federal health insurance requirements, regardless of whether such accountability is with respect to qualified health benefits plans offered through the Health Insurance Exchange or outside of such Exchange.</text></paragraph> <paragraph id="HAFF426CA00C34B4DB1D2560145B615C6"><enum>(2)</enum><header>Compliance examination and audits</header> <subparagraph id="H71CA11CE1DFC4985819775C571466CC9"><enum>(A)</enum><header>In general</header><text>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 noncompliance. </text></subparagraph> <subparagraph id="HB11F08EC605143F7AA6AF3DB116B8E33"><enum>(B)</enum><header>Recoupment of costs in connection with examination and audits</header><text>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.</text></subparagraph></paragraph></subsection> <subsection id="H629A591FD90F4F88B44E8103754A013E"><enum>(c)</enum><header>Data collection</header><text display-inline="yes-display-inline">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.</text></subsection> <subsection id="H590591BA77FD4DF78F4350F216D98B8E"><enum>(d)</enum><header>Sanctions authority</header> <paragraph id="H05E163AD815142B1813AE523E82E787A"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">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). </text></paragraph> <paragraph id="HA16F1E955500481CBEB3B3D77810CECA"><enum>(2)</enum><header>Remedies</header><text>The remedies described in this paragraph, with respect to a qualified health benefits plan offered by a QHBP offering entity, are—</text> <subparagraph id="H259B480ACCF040618CA82B53EC4DFEE8" display-inline="no-display-inline"><enum>(A)</enum><text>civil money penalties of not more than the amount that would be applicable under similar circumstances for similar violations under section 1857(g) of the Social Security Act; </text></subparagraph> <subparagraph id="H311B5A7BFC8D42F89CADD9ED528E12E6"><enum>(B)</enum><text>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; </text></subparagraph> <subparagraph id="H664C519C6D054EA9B0F9AA36D069A665"><enum>(C)</enum><text>in the case of an Exchange-participating health benefits plan, suspension of payment to the entity under the Health Insurance 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</text></subparagraph> <subparagraph id="HBB63D5AF024B427B8507B674784A4AB9"><enum>(D)</enum><text>working with State insurance regulators to terminate plans for repeated failure by the offering entity to meet the requirements of this title.</text></subparagraph></paragraph></subsection> <subsection id="H619DF90AFBD545E8A51058D7649DDD5F"><enum>(e)</enum><header>Standard definitions of insurance and medical terms</header><text>The Commissioner shall provide for the development of standards for the definitions of terms used in health insurance coverage, including insurance-related terms.</text></subsection> <subsection id="H03D4A1DD9FFD4F299F8F30FCA947BEC6"><enum>(f)</enum><header>Efficiency in administration</header><text display-inline="yes-display-inline">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 308 and 341(b)(2), the use of State personnel who are employed in accordance with standards prescribed by the Office of Personnel Management pursuant to section 208 of the Intergovernmental Personnel Act of 1970 (42 U.S.C. 4728). </text></subsection></section> <section id="H0B881C09687346BA97DCB4119DD901C2"><enum>243.</enum><header>Consultation and coordination</header> <subsection id="H3C6C90EFA90A4DD49F4F94C022CF1D96" display-inline="no-display-inline"><enum>(a)</enum><header>Consultation</header><text>In carrying out the Commissioner’s duties under this division, the Commissioner, as appropriate, shall consult at least with the following:</text> <paragraph id="H3D9771DC6C6946F4BFDA2F6A3D37ACDB"><enum>(1)</enum><text display-inline="yes-display-inline">State attorneys general and State insurance regulators, including concerning the standards for health insurance coverage that is a qualified health benefits plan under this title and enforcement of such standards.</text></paragraph> <paragraph id="HB89351A7B9A94F918CFA3E43063184B1"><enum>(2)</enum><text>The National Association of Insurance Commissioners, including for purposes of using model guidelines established by such association for purposes of subtitles B and D.</text></paragraph> <paragraph id="H966A700BA9EB4293B7AE24B94160AC7C"><enum>(3)</enum><text>Appropriate State agencies, specifically concerning the administration of individual affordability credits under subtitle C of title III and the offering of Exchange-participating health benefits plans, to Medicaid eligible individuals under subtitle A of such title.</text></paragraph> <paragraph id="H38EBEC75B81E486CAB11E8582A97FA76"><enum>(4)</enum><text>The Federal Trade Commission, specifically concerning the development and issuance of guidance, rules, or standards regarding fair marketing practices under section 231 or otherwise, or any consumer disclosure requirements under section 233 or otherwise.</text></paragraph> <paragraph id="H7FD77F59B29A4A44800A0D7A678CD5CE" commented="no"><enum>(5)</enum><text>Other appropriate Federal agencies.</text></paragraph> <paragraph id="H0D2B678FF6BB44F691DAF2802B48DF08"><enum>(6)</enum><text>Indian tribes and tribal organizations.</text></paragraph></subsection> <subsection id="H5F21136DF3304624BD03F448579B1FF1"><enum>(b)</enum><header>Coordination</header> <paragraph id="H5F5022B7229345ED9ABC62D039D39EB1"><enum>(1)</enum><header>In general</header><text>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.</text></paragraph> <paragraph id="HAEA1949B4C514515B17DCBEFCBD9358F"><enum>(2)</enum><header>Uniform standards</header><text>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.</text></paragraph></subsection></section> <section id="H1B02F8CD752044EDA204AF27EBE1B180" commented="no"><enum>244.</enum><header>Health Insurance Ombudsman</header> <subsection id="H938CB7AE7536409180CF2B2B73530715" commented="no"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">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.</text></subsection> <subsection id="HABD067A766CA483397E1677F961A276B" commented="no"><enum>(b)</enum><header>Duties</header><text display-inline="yes-display-inline">The Qualified Health Benefits Plan Ombudsman shall, in a linguistically appropriate manner—</text> <paragraph id="H0A90003FB22B4977BE6D0A7A2DACE177" commented="no"><enum>(1)</enum><text>receive complaints, grievances, and requests for information submitted by individuals through means such as the mail, by telephone, electronically, and in person;</text></paragraph> <paragraph id="H19A89978E8C9486D8D0CDD6B26C48893" commented="no"><enum>(2)</enum><text>provide assistance with respect to complaints, grievances, and requests referred to in paragraph (1), including—</text> <subparagraph id="HE82F9474707C4557928E8AB3C6A6740A" commented="no"><enum>(A)</enum><text>helping individuals determine the relevant information needed to seek an appeal of a decision or determination;</text></subparagraph> <subparagraph id="H755ED4CB7A1549F189378A6C27B137FA" commented="no"><enum>(B)</enum><text>assistance to such individuals in choosing a qualified health benefits plan in which to enroll; </text></subparagraph> <subparagraph id="H6BE95B5B9893418F82C6D784E01C9DF9" commented="no"><enum>(C)</enum><text>assistance to such individuals with any problems arising from disenrollment from such a plan; and</text></subparagraph> <subparagraph id="HDE7729EE9CEE4C8CBD6703488899B74C" commented="no"><enum>(D)</enum><text>assistance to such individuals in presenting information under subtitle C (relating to affordability credits); and</text></subparagraph></paragraph> <paragraph id="HCE10F1E9B26C405883BB8BAA92B5B95C" commented="no"><enum>(3)</enum><text>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. </text></paragraph></subsection></section></subtitle> <subtitle id="HCC14FC9B8FF84A12AF7B6539DD9DD915"><enum>F</enum><header>Relation to other requirements; Miscellaneous</header> <section id="HF4CC91D838CC4E7387EBC722D3C2E910" commented="no" display-inline="no-display-inline" section-type="subsequent-section"><enum>251.</enum><header>Relation to other requirements</header> <subsection id="H2664E0C472064D31B7B189D214C5CB5E" commented="no"><enum>(a)</enum><header>Coverage not offered through Exchange</header> <paragraph id="H4D6F276F9D234272B6F0A2051789B4BD"><enum>(1)</enum><header>In general</header><text>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.</text></paragraph> <paragraph id="H992FC4D8A50B44EC8C51A5EAC182CD0B" display-inline="no-display-inline"><enum>(2)</enum><header>Construction</header><text>Nothing in paragraphs (1) or (2) shall be construed as affecting the application of section 514 of the Employee Retirement Income Security Act of 1974.</text></paragraph></subsection> <subsection id="H7768C30F9EF74A168B84B9D3DFC0E0D2" commented="no"><enum>(b)</enum><header>Coverage offered through Exchange</header> <paragraph id="HCDDD5E543A6E4BAB936D3E7790189FAA"><enum>(1)</enum><header>In general</header><text>In the case of health insurance coverage offered through the Health Insurance Exchange—</text> <subparagraph id="H54C390FFD9434C90B53109B1F9C655A2"><enum>(A)</enum><text display-inline="yes-display-inline">the requirements of this title do not supercede any requirements (including requirements relating to genetic information nondiscrimination and mental health parity) 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</text></subparagraph> <subparagraph id="H1D5F6F201EE444F189A0904B17209B9F"><enum>(B)</enum><text>individual rights and remedies under State laws shall apply. </text></subparagraph></paragraph> <paragraph id="HEA914FE04D714739B98025BCCD03E8E9"><enum>(2)</enum><header>Construction</header><text display-inline="yes-display-inline">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 to health insurance issuers generally with respect to any requirement referred to in paragraph (1)(A). The previous sentence shall not be construed as providing for the applicability of rights or remedies under State laws with respect to requirements applicable to employers or other plan sponsors in connection with arrangements which are treated as group health plans under section 802(a)(1) of the Employee Retirement Income Security Act of 1974.</text></paragraph></subsection></section> <section id="H1329E37C8C0442B4A7ABBC8BA75C2D2C" display-inline="no-display-inline" section-type="subsequent-section"><enum>252.</enum><header>Prohibiting discrimination in health care</header> <subsection id="H8970FC79FDC9427EBBA4518CFC54DF2D"><enum>(a)</enum><header>In general</header><text>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.</text></subsection> <subsection id="HD9CFFD7D5A784E729E763E26E0DB2B5D"><enum>(b)</enum><header>Implementation</header><text display-inline="yes-display-inline">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.</text></subsection></section> <section id="HF0F40091E35041498DC44CB7C0CE4686" section-type="subsequent-section"><enum>253.</enum><header>Whistleblower protection</header> <subsection id="H1714CE42CDD14092A2FA6F95BA9C82F8"><enum>(a)</enum><header>Retaliation prohibited</header><text display-inline="yes-display-inline">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)—</text> <paragraph id="H5A78E8EE1C324D03913F42B9C5F890B9" display-inline="no-display-inline"><enum>(1)</enum><text>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 the employee reasonably believes to be a violation of any provision of this Act or any order, rule, or regulation promulgated under this Act;</text></paragraph> <paragraph id="HEA0D03E41AEF42208F000F6FA76DF4CB"><enum>(2)</enum><text>testified or is about to testify in a proceeding concerning such violation;</text></paragraph> <paragraph id="HD3B6F7AFFE554F669E0F7F0796022E0D"><enum>(3)</enum><text>assisted or participated or is about to assist or participate in such a proceeding; or</text></paragraph> <paragraph id="H1F33EC552ED84CF4A4F99AD600BEA751"><enum>(4)</enum><text>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.</text></paragraph></subsection> <subsection id="H9432B69F03064C1E9A27EEBB72680803"><enum>(b)</enum><header>Enforcement action</header><text display-inline="yes-display-inline">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)).</text></subsection> <subsection id="H2A6E1E4434524299B58718C8E290B583"><enum>(c)</enum><header>Employer defined</header><text display-inline="yes-display-inline">As used in this section, the term <term>employer</term> 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.</text></subsection> <subsection id="H68F9B48B62D34F648DC7F9FABE5E9E68"><enum>(d)</enum><header>Rule of construction</header><text display-inline="yes-display-inline">The rule of construction set forth in section 20109(h) of title 49, United States Code, shall also apply to this section.</text></subsection></section> <section id="H145E5DC797C14602A7D9B95EBEA92277"><enum>254.</enum><header>Construction regarding collective bargaining</header><text display-inline="no-display-inline">Nothing in this division shall be construed to alter or supersede any statutory or other obligation to engage in collective bargaining over the terms or conditions of employment related to health care. Any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement added by this division shall not be treated as a termination of such collective bargaining agreement.</text></section> <section id="H3FF214F143FD460297834CBF7F966DB8"><enum>255.</enum><header>Severability</header><text display-inline="no-display-inline">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.</text></section> <section id="H8271D9AFAFF448C491AB4EA648E56A33" commented="no"><enum>256.</enum><header>Treatment of Hawaii Prepaid Health Care Act</header> <subsection id="H3AA32F901F88429EA698138214AF2E4D" commented="no"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">Subject to this section—</text> <paragraph id="H88F09621348A49ADB111BD828499DCB9" commented="no"><enum>(1)</enum><text display-inline="yes-display-inline">nothing in this division (or an amendment made by this division) shall be construed to modify or limit the application of the exemption for the Hawaii Prepaid Health Care Act (Haw. Rev. Stat. §§ 393–1 et seq.) as provided for under section 514(b)(5) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1144(b)(5)), and such exemption shall also apply with respect to the provisions of this division; and</text></paragraph> <paragraph id="HFF47690E919E4CEA90FB043FA78E5E65" commented="no"><enum>(2)</enum><text display-inline="yes-display-inline">for purposes of this division (and the amendments made by this division), coverage provided pursuant to the Hawaii Prepaid Health Care Act shall be treated as a qualified health benefits plan providing acceptable coverage so long as the Secretary of Labor determines that such coverage for employees (taking into account the benefits and the cost to employees for such benefits) is substantially equivalent to or greater than the coverage provided for employees pursuant to the essential benefits package.</text></paragraph></subsection> <subsection id="H3D2CC0D2AB21426CB38067B40F6468A7" commented="no"><enum>(b)</enum><header>Coordination with State law of Hawaii</header><text>The Commissioner shall, based on ongoing consultation with the appropriate officials of the State of Hawaii, make adjustments to rules and regulations of the Commissioner under this division as may be necessary, as determined by the Commissioner, to most effectively coordinate the provisions of this division with the provisions of the Hawaii Prepaid Health Care Act, taking into account any changes made from time to time to the Hawaii Prepaid Health Care Act and related laws of such State. </text></subsection></section> <section id="HCD8D9B756E6349EFB6C3A60980F729C8" commented="no"><enum>257.</enum><header>Actions by State attorneys general</header><text display-inline="no-display-inline">Any State attorney general may bring a civil action in the name of such State as <italic>parens patriae</italic> on behalf of natural persons residing in such State, in any district court of the United States or State court having jurisdiction of the defendant to secure monetary or equitable relief for violation of any provisions of this title or regulations issued thereunder. Nothing in this section shall be construed as affecting the application of section 514 of the Employee Retirement Income Security Act of 1974.</text></section> <section id="HAF3656DA73E0436DB4C03173AEB8E2FD" commented="no"><enum>258.</enum><header>Application of State and Federal laws regarding abortion</header> <subsection id="HEBFAF978693D4265B837769855D1CAD9" commented="no"><enum>(a)</enum><header>No preemption of State laws regarding abortion</header><text>Nothing in this Act shall be construed to preempt or otherwise have any effect on State laws regarding the prohibition of (or requirement of) coverage, funding, or procedural requirements on abortions, including parental notification or consent for the performance of an abortion on a minor.</text></subsection> <subsection id="HC93F451F243C427EBADED162E1ACEA22" commented="no"><enum>(b)</enum><header>No effect on Federal laws regarding abortion</header> <paragraph id="H4BBA845C147B4546A9FC132A28168CAB" commented="no"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">Nothing in this Act shall be construed to have any effect on Federal laws regarding—</text> <subparagraph id="HF55E4C46D5E04B9A847636F79CBC1699" commented="no"><enum>(A)</enum><text>conscience protection;</text></subparagraph> <subparagraph id="H23750EB11B6D40728C8DC0ACDE26C465" commented="no"><enum>(B)</enum><text>willingness or refusal to provide abortion; and</text></subparagraph> <subparagraph id="H18E650A311D5410EA052824AEE646F47" commented="no"><enum>(C)</enum><text>discrimination on the basis of the willingness or refusal to provide, pay for, cover, or refer for abortion or to provide or participate in training to provide abortion.</text></subparagraph></paragraph></subsection> <subsection id="H67A83451F4894DB69B6B72CFBD84EA0F" commented="no"><enum>(c)</enum><header>No effect on federal civil rights law</header><text>Nothing in this section shall alter the rights and obligations of employees and employers under title VII of the Civil Rights Act of 1964.</text></subsection></section> <section id="H70100ECBDA8245048F2AEBCA2564DCE4" display-inline="no-display-inline" section-type="subsequent-section" commented="no"><enum>259.</enum><header>Nondiscrimination on abortion and respect for rights of conscience</header><text display-inline="yes-display-inline"/> <subsection id="HEC9D0DB3C68C40F89352511871A36A05" commented="no"><enum>(a)</enum><header>Nondiscrimination</header><text>A Federal agency or program, and any State or local government that receives Federal financial assistance under this Act (or an amendment made by this Act), may not—</text> <paragraph id="HBEF05B2F8EA64401A0E66D95FAD972B9" commented="no"><enum>(1)</enum><text>subject any individual or institutional health care entity to discrimination; or</text></paragraph> <paragraph id="H6C13CF795CE34D0BAD498A798EE1D2CB" commented="no"><enum>(2)</enum><text>require any health plan created or regulated under this Act (or an amendment made by this Act) to subject any individual or institutional health care entity to discrimination,</text></paragraph><continuation-text continuation-text-level="subsection" commented="no">on the basis that the health care entity does not provide, pay for, provide coverage of, or refer for abortions.</continuation-text></subsection> <subsection id="H4FD21632C62B464383F2512A5E14AC13" commented="no"><enum>(b)</enum><header>Definition</header><text>In this section, the term <quote>health care entity</quote> includes an individual physician or other health care professional, a hospital, a provider-sponsored organization, a health maintenance organization, a health insurance plan, or any other kind of health care facility, organization, or plan.</text></subsection> <subsection id="H54372202AB8A4427A5501F4DBBD48D60" commented="no"><enum>(c)</enum><header>Administration</header><text>The Office for Civil Rights of the Department of Health and Human Services is designated to receive complaints of discrimination based on this section, and coordinate the investigation of such complaints.</text></subsection></section> <section id="H98C50F4F471C4CC0BE6DE9AE3B67D51A" section-type="subsequent-section" commented="no"><enum>260.</enum><header>Authority of Federal Trade Commission</header><text display-inline="no-display-inline">Section 6 of the Federal Trade Commission Act (15 U.S.C. 46) is amended by striking <quote>and prepare reports</quote> and all that follows and inserting the following: <quote>and prepare reports, and to share information under clauses (f) and (k), relating to the business of insurance. Notwithstanding section 4, such authority shall include the authority to conduct studies and prepare reports, and to share information under clauses (f) and (k), relating to the business of insurance, without regard to whether the entity or entities that is the subject of such studies, reports, or information is a for-profit or not-for-profit entity.</quote>.</text></section> <section id="H1ADB30E22BE5465BBF05841259AC57AE" section-type="subsequent-section"><enum>261.</enum><header>Construction regarding standard of care</header> <subsection id="H339C416293194D3EA25EAC968DEA58EF"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">The development, recognition, or implementation of any guideline or other standard under a provision described in subsection (b) shall not be construed to establish the standard of care or duty of care owed by health care providers to their patients in any medical malpractice action or claim (as defined in section 431(7) of the Health Care Quality Improvement Act of 1986 (42 U.S.C. 11151(7)). </text></subsection> <subsection id="H46BEB62946F64FD18FA19D965419F531"><enum>(b)</enum><header>Provisions described</header><text>The provisions described in this subsection are the following:</text> <paragraph id="HB43009D2771C41DDA98C71D1BEB7D87C"><enum>(1)</enum><text>Section 324 (relating to modernized payment initiatives and delivery system reform under the public health option).</text></paragraph> <paragraph id="H57473E792F6B451BB2E687B6C2C2DC59"><enum>(2)</enum><text>The amendments made by section 1151 (relating to reducing potentially preventable hospital readmissions).</text></paragraph> <paragraph id="H80E2522F75F74384B8DB605F7C3B50B5"><enum>(3)</enum><text>The amendments made by section 1751 (relating to health care acquired conditions).</text></paragraph> <paragraph id="H03913AAEF6D244F89E66103366901390"><enum>(4)</enum><text>Section 3131 of the Public Health Service Act (relating to the Task Force on Clinical Preventive Services), added by section 2301.</text></paragraph> <paragraph id="HF04B209C2C7D41BA900EEB308E397EA5"><enum>(5)</enum><text>Part D of title IX of the Public Health Service Act (relating to implementation of best practices in the delivery of health care), added by section 2401.</text></paragraph></subsection></section> <section id="HCDE11AAB59AD4350B50F7545CD1189EC"><enum>262.</enum><header>Restoring application of antitrust laws to health sector insurers</header> <subsection id="H1A3268C8115A4EEC9C6A395E369EC9B4"><enum>(a)</enum><header>Amendment to McCarran-Ferguson Act</header><text display-inline="yes-display-inline">Section 3 of the Act of March 9, 1945 (15 U.S.C. 1013), commonly known as the McCarran-Ferguson Act, is amended by adding at the end the following:</text> <quoted-block id="HA8FE1CDA1BF843878D25E514A59CE7F9"> <subsection id="H7CDD76053AB9407CB2C1190A2235262B"><enum>(c)</enum> <paragraph id="HCFF89085D53D46D5BB9605797F607E87" display-inline="yes-display-inline"><enum>(1)</enum><text>Except as provided in paragraph (2), nothing contained in this Act shall modify, impair, or supersede the operation of any of the antitrust laws with respect to price fixing, market allocation, or monopolization (or attempting to monopolize) by—</text> <subparagraph id="HA911F36A0DB14B879BA94C6799D063E6" indent="up1"><enum>(A)</enum><text> a person engaged in the business of health insurance, in connection with providing health insurance; or</text></subparagraph> <subparagraph id="H6D32D41F87404220AAE1B30565A1CB5C" indent="up1"><enum>(B)</enum><text>a person engaged in the business of medical malpractice insurance, in connection with providing medical malpractice insurance.</text></subparagraph></paragraph> <paragraph id="H8888F49C98E64A8E9BE08556F45EDD9E" indent="up1"><enum>(2)</enum><text>Paragraph (1) shall not apply to—</text> <subparagraph id="H1BBF00A6377347288BD1CE9E00F6AC14"><enum>(A)</enum><text>collecting, compiling, classifying, or disseminating historical loss data;</text></subparagraph> <subparagraph id="HB0C5A6516C274EBAAEDA81A0AE3ED87F"><enum>(B)</enum><text>determining a loss development factor applicable to historical loss data;</text></subparagraph> <subparagraph id="H70C7BD4AD8C449A3BDDF124410A0B2E8"><enum>(C)</enum><text>performing actuarial services if doing so does not involve a restraint of trade; or</text></subparagraph> <subparagraph id="H746593E6E90D490AB344902568580A8F"><enum>(D)</enum><text>information gathering and rate setting activities of a State insurance commission or other State regulatory entity with authority to set insurance rates.</text></subparagraph></paragraph> <paragraph id="HE05C72A988D041138B0E1C626D7E9828" indent="up1"><enum>(3)</enum><text>For purposes of this subsection—</text> <subparagraph id="H9001F12C82A94430B25B82761D2CE84F"><enum>(A)</enum><text>the term <quote>antitrust laws</quote> has the meaning given it in subsection (a) of the first section of the Clayton Act, except that such term includes section 5 of the Federal Trade Commission Act to the extent that such section 5 applies to unfair methods of competition;</text></subparagraph> <subparagraph id="HC71B5E3E732D4987ACCB71078430688D"><enum>(B)</enum><text>the term <quote>historical loss data</quote> means information respecting claims paid, or reserves held for claims reported, by any person engaged in the business of insurance; and</text></subparagraph> <subparagraph id="H3CB1894202AE4D04B84ABB93D5B1D3DF"><enum>(C)</enum><text>the term <quote>loss development factor</quote> means an adjustment to be made to the aggregate of losses incurred during a prior period of time that have been paid, or for which claims have been received and reserves are being held, in order to estimate the aggregate of the losses incurred during such period that will ultimately be paid.</text></subparagraph></paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block></subsection> <subsection id="H4D17A6C912AA40F1B82E2AF0F7280406"><enum>(b)</enum><header>Related provision</header><text display-inline="yes-display-inline">For purposes of section 5 of the Federal Trade Commission Act (15 U.S.C. 45) to the extent such section applies to unfair methods of competition, section 3(c) of the McCarran-Ferguson Act shall apply with respect to the business of health insurance, and with respect to the business of medical malpractice insurance, without regard to whether such business is carried on for profit, notwithstanding the definition of <quote>Corporation</quote> contained in section 4 of the Federal Trade Commission Act.</text></subsection> <subsection id="H8876F068833C490199EA62A5D6F7E104"><enum>(c)</enum><header>Related preservation of antitrust laws</header><text>Except as provided in subsections (a) and (b), nothing in this Act, or in the amendments made by this Act, shall be construed to modify, impair, or supersede the operation of any of the antitrust laws. For purposes of the preceding sentence, the term “antitrust laws” has the meaning given it in subsection (a) of the first section of the Clayton Act, except that it includes section 5 of the Federal Trade Commission Act to the extent that such section 5 applies to unfair methods of competition.</text></subsection></section> <section id="H16941EE1C82F4C048D90F25C3FFF86AD" section-type="subsequent-section"><enum>263.</enum><header>Study and report on methods to increase EHR use by small health care providers</header> <subsection id="H8E0FDF69B9DE48728B9EBB159A2E10A4"><enum>(a)</enum><header>Study</header><text display-inline="yes-display-inline">The Secretary of Health and Human Services shall conduct a study of potential methods to increase the use of qualified electronic health records (as defined in section 3000(13) of the Public Health Service Act) by small health care providers. Such study shall consider at least the following methods:</text> <paragraph id="H33861CA1880C41A78A2EF036A59528C4"><enum>(1)</enum><text display-inline="yes-display-inline">Providing for higher rates of reimbursement or other incentives for such health care providers to use electronic health records (taking into consideration initiatives by private health insurance companies and incentives provided under Medicare under title XVIII of the Social Security Act, Medicaid under title XIX of such Act, and other programs).</text></paragraph> <paragraph id="H11695DB63F4B4CB0A4D4862682079A33"><enum>(2)</enum><text>Promoting low-cost electronic health record software packages that are available for use by such health care providers, including software packages that are available to health care providers through the Veterans Administration and other sources.</text></paragraph> <paragraph id="HDC9081F176C04CE19725724778AB1732"><enum>(3)</enum><text>Training and education of such health care providers on the use of electronic health records.</text></paragraph> <paragraph id="H8A063D46E670437FBBFC693BE542A78C"><enum>(4)</enum><text>Providing assistance to such health care providers on the implementation of electronic health records.</text></paragraph></subsection> <subsection id="H8610368CFE39460DA0593A69EBCD2798"><enum>(b)</enum><header>Report</header><text display-inline="yes-display-inline">Not later than December 31, 2013, the Secretary of Health and Human Services shall submit to Congress a report containing the results of the study conducted under subsection (a), including recommendations for legislation or administrative action to increase the use of electronic health records by small health care providers that include the use of both public and private funding sources.</text></subsection></section></subtitle> <enum>III</enum><header>Health Insurance Exchange and Related Provisions</header> <subtitle id="HFFABD6C3AA1A4EF490BE96B2529D2D9C"><enum>A</enum><header>Health Insurance Exchange</header> <section id="HCD8E999AAF594BCFB438454A961118C5"><enum>301.</enum><header>Establishment of Health Insurance Exchange; outline of duties; definitions</header> <subsection id="H67F658FF18D04953852C6672243FFC75"><enum>(a)</enum><header>Establishment</header><text display-inline="yes-display-inline">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.</text></subsection> <subsection id="H269EEBEA66A14A52881739622114A70B"><enum>(b)</enum><header>Outline of duties of Commissioner</header><text display-inline="yes-display-inline">In accordance with this subtitle and in coordination with appropriate Federal and State officials as provided under section 243(b), the Commissioner shall—</text> <paragraph id="H9468BFF19A5C4C7AA536B8DE8AAC28E0"><enum>(1)</enum><text display-inline="yes-display-inline">under section 304 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 303, and including with respect to oversight and enforcement; </text></paragraph> <paragraph id="H0C435E15804F41A4886EAA20DABCBDB8"><enum>(2)</enum><text>under section 305 facilitate outreach and enrollment in such plans of Exchange-eligible individuals and employers described in section 302; and</text></paragraph> <paragraph id="H1D7B8576C2DE45A691EA0A3B5C5F7E60"><enum>(3)</enum><text>conduct such activities related to the Health Insurance Exchange as required, including establishment of a risk pooling mechanism under section 306 and consumer protections under subtitle D of title II.</text></paragraph></subsection></section> <section id="H01732B4180DA486082196B1C69953C6E"><enum>302.</enum><header>Exchange-eligible individuals and employers</header> <subsection id="H6F9665879A2749B288304C40E49A7EB7"><enum>(a)</enum><header>Access to coverage</header><text display-inline="yes-display-inline">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.</text></subsection> <subsection id="HC1BC9C6C4468414C88168AB820B9BC57"><enum>(b)</enum><header>Definitions</header><text display-inline="yes-display-inline">In this division:</text> <paragraph id="H6A1E756A6F454658AD8258E14E384EBB"><enum>(1)</enum><header>Exchange-eligible individual</header><text>The term <term>Exchange-eligible individual</term> means an individual who is eligible under this section to be enrolled through the Health Insurance Exchange in an Exchange-participating health benefits plan and, with respect to family coverage, includes dependents of such individual. </text></paragraph> <paragraph id="H8C39D8B585B9425A93FA67C51A6E2436"><enum>(2)</enum><header>Exchange-eligible employer</header><text display-inline="yes-display-inline">The term <term>Exchange-eligible employer</term> 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. </text></paragraph> <paragraph id="HE93405ADABDC4799821169512E3430D4"><enum>(3)</enum><header>Employment-related definitions</header><text>The terms <term>employer</term>, <term>employee</term>, <term>full-time employee</term>, and <term>part-time employee</term> have the meanings given such terms by the Commissioner for purposes of this division. </text></paragraph></subsection> <subsection id="H0D4FC9C20B2B4FB0ADF8197914EEF926"><enum>(c)</enum><header>Transition</header><text>Individuals and employers shall only be eligible to enroll or participate in the Health Insurance Exchange in accordance with the following transition schedule:</text> <paragraph id="H5A752E89164043948AE444B24AE66682"><enum>(1)</enum><header>First year</header><text display-inline="yes-display-inline">In Y1 (as defined in section 100(c))—</text> <subparagraph id="H99EAEEC261984133BB7EFBC56B707022"><enum>(A)</enum><text>individuals described in subsection (d)(1), including individuals described in subsection (d)(3); and</text></subparagraph> <subparagraph id="HEEF896F10CEE4E49A1852B1EB98731D4"><enum>(B)</enum><text>smallest employers described in subsection (e)(1). </text></subparagraph></paragraph> <paragraph id="HE9F4F271CDAB4BDDB1145D16A121035E"><enum>(2)</enum><header>Second year</header><text>In Y2—</text> <subparagraph id="H3A942D64B5C341E98F7CE4BDCA2C7AAC"><enum>(A)</enum><text>individuals and employers described in paragraph (1); and </text></subparagraph> <subparagraph id="HAFFBF01BDB0848E2B0B6FE6F897FC9E7"><enum>(B)</enum><text>smaller employers described in subsection (e)(2).</text></subparagraph></paragraph> <paragraph id="HE0F3E84297F847F9B9C69A96976DB9E9" commented="no"><enum>(3)</enum><header>Third and subsequent years</header><text display-inline="yes-display-inline">In Y3—</text> <subparagraph id="H2DC43E21C8C149D8AA18BE08BAECDF40" commented="no"><enum>(A)</enum><text>individuals and employers described in paragraph (2); </text></subparagraph> <subparagraph id="HBA2B24E8E0344CE5AFF5A6E5A2724C5E" commented="no"><enum>(B)</enum><text>small employers described in subsection (e)(3); and</text></subparagraph> <subparagraph id="HF05F2171AFE4490F8877582087B4AC7C"><enum>(C)</enum><text>larger employers as permitted by the Commissioner under subsection (e)(4).</text></subparagraph></paragraph></subsection> <subsection id="HBC7B6C199AB14B90AC78EEE9D2CE17EB"><enum>(d)</enum><header>Individuals</header> <paragraph id="HF024DA7B57464B90AE4C3D37424C229D"><enum>(1)</enum><header>Individual described</header><text display-inline="yes-display-inline">Subject to the succeeding provisions of this subsection, an individual described in this paragraph is an individual who—</text> <subparagraph id="H395255E0D63744C9BCE6EC57D00F15C3"><enum>(A)</enum><text>is not enrolled in coverage described in subparagraph (C) or (D) of paragraph (2); and</text></subparagraph> <subparagraph id="H6126856522B14CCAA8BC2720A1F40315"><enum>(B)</enum><text display-inline="yes-display-inline">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 412. </text></subparagraph><continuation-text continuation-text-level="paragraph">For purposes of subparagraph (B), in the case of an individual who is self-employed, who has at least 1 employee, and who meets the requirements of section 412, such individual shall be deemed a full-time employee described in such subparagraph.</continuation-text></paragraph> <paragraph id="H3327839651324004B722376C422CB368" display-inline="no-display-inline"><enum>(2)</enum><header>Acceptable coverage</header><text>For purposes of this division, the term <term>acceptable coverage</term> means any of the following:</text> <subparagraph id="HCBADA3D247554F3690AE36BEAFF25677"><enum>(A)</enum><header>Qualified health benefits plan coverage</header><text>Coverage under a qualified health benefits plan. </text></subparagraph> <subparagraph id="HE7E70E12A2A04476A281A7BBD8D3A7EC"><enum>(B)</enum><header>Grandfathered health insurance coverage; coverage under current group health plan</header><text display-inline="yes-display-inline">Coverage under a grandfathered health insurance coverage (as defined in subsection (a) of section 202) or under a current group health plan (described in subsection (b) of such section).</text></subparagraph> <subparagraph id="H225DF6B067E94E6C94B41F68CD0CC00F"><enum>(C)</enum><header>Medicare</header><text>Coverage under part A of title XVIII of the Social Security Act.</text></subparagraph> <subparagraph id="H3EEAB51803FE4EE6B0E14E07962A4D12"><enum>(D)</enum><header>Medicaid</header><text>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.</text></subparagraph> <subparagraph id="H2348E911478444C1B554417AFB824073"><enum>(E)</enum><header>Members of the Armed Forces and dependents (including TRICARE)</header><text>Coverage under chapter 55 of title 10, United States Code, including similar coverage furnished under section 1781 of title 38 of such Code.</text></subparagraph> <subparagraph id="H604AC9C4056E4D01B8075D463CFB4708" commented="no"><enum>(F)</enum><header>VA</header><text display-inline="yes-display-inline">Coverage under the veteran’s health care program under chapter 17 of title 38, United States Code.</text></subparagraph> <subparagraph id="H9C72E16AB29A4E9D8EE1C5EBDF083464" commented="no"><enum>(G)</enum><header>Other coverage</header><text>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.</text></subparagraph><continuation-text continuation-text-level="paragraph">The Commissioner shall make determinations under this paragraph in coordination with the Secretary of the Treasury.</continuation-text></paragraph> <paragraph id="HA7DEC40412794B5EAF8E9BDDEA5C9398" commented="no"><enum>(3)</enum><header>Continuing eligibility permitted</header> <subparagraph id="H0D33880D12AD46CF8C5D4C15D2D825FB" commented="no"><enum>(A)</enum><header>In general</header><text>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 with an Exchange-participating health benefits plan.</text></subparagraph> <subparagraph id="H65DB1F665F7A4BF29632A5BA329F2968" commented="no"><enum>(B)</enum><header>Exceptions</header> <clause id="HECA91E619689433585F4A6EC60DA023F"><enum>(i)</enum><header>In general</header><text>Subparagraph (A) shall not apply to an individual once the individual becomes eligible for coverage—</text> <subclause id="H5D2DB3740FDE4E9C99E3F0D631E73228" commented="no"><enum>(I)</enum><text>under part A of the Medicare program;</text></subclause> <subclause id="H8B22B70CAE004619A696A5620FE1D924" commented="no"><enum>(II)</enum><text>under the Medicaid program as a Medicaid-eligible individual, except as permitted under clause (ii); or</text></subclause> <subclause id="H9DB7C882ECE54FCF84065F2390F2C1F8" commented="no"><enum>(III)</enum><text>in such other circumstances as the Commissioner may provide.</text></subclause></clause> <clause id="H38CA0B6285724CC6B64FC5D0B92E983F"><enum>(ii)</enum><header>Transition period</header><text>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 Commissioner determines it is administratively feasible, consistent with minimizing disruption in the individual’s access to health care.</text></clause></subparagraph></paragraph> <paragraph id="H0FEE1A8102F54A3F8B02B4AB969BCA65"><enum>(4)</enum><header>Transition for CHIP eligibles</header><text>An individual who is eligible for child health assistance under title XXI of the Social Security Act for a period during Y1 shall not be an Exchange-eligible individual during such period.</text></paragraph></subsection> <subsection id="H70488A4B4884411E97E7B85D1A68FAB0"><enum>(e)</enum><header>Employers</header> <paragraph id="HFD249F2E63AA467AB6D0129E8C087FCE"><enum>(1)</enum><header>Smallest employer</header><text display-inline="yes-display-inline">Subject to paragraph (5), smallest employers described in this paragraph are employers with 25 or fewer employees.</text></paragraph> <paragraph id="H98199697FF15415AAAA97FBD87DEDA99"><enum>(2)</enum><header>Smaller employers</header><text display-inline="yes-display-inline">Subject to paragraph (5), smaller employers described in this paragraph are employers that are not smallest employers described in paragraph (1) and have 50 or fewer employees.</text></paragraph> <paragraph id="HFE56F779874C4CD38F62379610CB7757" commented="no"><enum>(3)</enum><header>Small employers</header><text display-inline="yes-display-inline">Subject to paragraph (5), small employers described in this paragraph are employers that are not described in paragraph (1) or (2) and have 100 or fewer employees.</text></paragraph> <paragraph id="H884EEC56F37C4C5080CC5B8E5E64ECC9"><enum>(4)</enum><header>Larger employers</header> <subparagraph id="H2609732DF343463DA410DD86B12D870E"><enum>(A)</enum><header>In general</header><text display-inline="yes-display-inline">Beginning with Y3, the Commissioner may permit employers not described in paragraph (1), (2), or (3) to be Exchange-eligible employers.</text></subparagraph> <subparagraph id="H8FE3295203BE47039079319638E8F7E4"><enum>(B)</enum><header>Phase-in</header><text>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.</text></subparagraph></paragraph> <paragraph id="HDF64F2007E6D4F73B9056F346A675870"><enum>(5)</enum><header>Continuing eligibility</header><text>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 regardless of the number of employees involved unless and until the employer meets the requirement of section 411(a) through paragraph (1) of such section by offering a group health plan and not through offering an Exchange-participating health benefits plan.</text></paragraph> <paragraph id="H9F7759D0427C40BBAEA19DC37EEA41E7"><enum>(6)</enum><header>Employer participation and contributions</header> <subparagraph id="HE4E52514DA1F46B89D658925B7CE36B2"><enum>(A)</enum><header>Satisfaction of employer responsibility</header><text display-inline="yes-display-inline">For any year in which an employer is an Exchange-eligible employer, such employer may meet the requirements of section 412 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 IV.</text></subparagraph> <subparagraph id="H8B411FBED09246859875F3F31CD7D714"><enum>(B)</enum><header>Employee choice</header><text>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.</text></subparagraph></paragraph> <paragraph id="HB24CEB307D5E4B8B85E19847544074C1" display-inline="no-display-inline"><enum>(7)</enum><header>Affiliated groups</header><text>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.</text></paragraph> <paragraph id="H64073E0AA6D3476ABE749AB40CD7EB8D" commented="no"><enum>(8)</enum><header>Treatment of multi-employer plans</header><text>The plan sponsor of a group health plan (as defined in section 773(a) of the Employee Retirement Income Security Act of 1974) that is a multi-employer plan (as defined in section 3(37) of such Act) may obtain health insurance coverage with respect to participants in the plan through the Exchange to the same extent that an employer not described in paragraph (1) or (2) is permitted by the Commissioner to obtain health insurance coverage through the Exchange as an Exchange-eligible employer.</text></paragraph> <paragraph id="HE6E034E57BFA41E5A18508C784BAA5F6"><enum>(9)</enum><header>Other counting rules</header><text>The Commissioner shall establish rules relating to how employees are counted for purposes of carrying out this subsection.</text></paragraph></subsection> <subsection id="HFE04294A578A4CF9913A63A90BFD5D69" commented="no"><enum>(f)</enum><header>Special situation authority</header><text>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.</text></subsection> <subsection id="H54993D0FB89B4AA19BA2A0EC2C040766"><enum>(g)</enum><header>Surveys of individuals and employers</header><text>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.</text></subsection> <subsection id="H2A01145418734EB486A60382B4515C8C"><enum>(h)</enum><header>Exchange access study</header> <paragraph id="HE1CCD5B675FC4117AB89959D25D3DB51"><enum>(1)</enum><header>In general</header><text>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.</text></paragraph> <paragraph id="HDC11C8BE40E343A480BB938E47C438BD"><enum>(2)</enum><header>Items included in study</header><text>Such study also shall examine—</text> <subparagraph id="HEC8C0300DE714598AD4E55FE614F0485"><enum>(A)</enum><text>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</text></subparagraph> <subparagraph id="H1F07F21C51DF40B0857D3A908C8D2AB0"><enum>(B)</enum><text>the affordability-test standard for access of certain employed individuals to coverage in the Health Insurance Exchange.</text></subparagraph></paragraph> <paragraph id="H5FF5610AB3AE4402B016CACB865DA3D1"><enum>(3)</enum><header>Report</header><text>Not later than January 1 of Y3, in Y6, and thereafter, the Commissioner shall submit to Congress a report on the study conducted under this subsection and shall include in such report recommendations regarding changes in standards for Exchange eligibility for individuals and employers.</text></paragraph></subsection></section> <section id="H0755BF441D874CBE8F81F26A7D97B305"><enum>303.</enum><header>Benefits package levels</header> <subsection id="HBE5D14EFD426415E86974E9245AC9ACF" commented="no"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">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 II and this section.</text></subsection> <subsection id="H524A2A80627E4B5C938A0C5BB5695D18" display-inline="no-display-inline"><enum>(b)</enum><header>Limitation on health benefits plans offered by offering entities</header><text>The Commissioner may not enter into a contract with a QHBP offering entity under section 304(c) for the offering of an Exchange-participating health benefits plan in a service area unless the following requirements are met:</text> <paragraph id="HB8ED76E1961441EF8B37E9E1382E1311"><enum>(1)</enum><header>Required offering of basic plan</header><text>The entity offers only one basic plan for such service area.</text></paragraph> <paragraph id="H01FEB4B50E954062A34A0C2C293CE657"><enum>(2)</enum><header>Optional offering of enhanced plan</header><text>If and only if the entity offers a basic plan for such service area, the entity may offer one enhanced plan for such area.</text></paragraph> <paragraph id="HFAC9BD1FDF5948038D8FB2013F0CB21C"><enum>(3)</enum><header>Optional offering of premium plan</header><text>If and only if the entity offers an enhanced plan for such service area, the entity may offer one premium plan for such area.</text></paragraph> <paragraph id="H088024E2EC3B4E579D9E693874E7416E"><enum>(4)</enum><header>Optional offering of premium-plus plans</header><text>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.</text></paragraph><continuation-text continuation-text-level="subsection">All such plans may be offered under a single contract with the Commissioner.</continuation-text></subsection> <subsection id="HE5251E60E711429590D3F06EFE0A16BE"><enum>(c)</enum><header>Specification of benefit levels for plans</header> <paragraph id="HA7C45613BF9844DB9BF9399863AA17B9"><enum>(1)</enum><header>In general</header><text>The Commissioner shall establish the following standards consistent with this subsection and title II:</text> <subparagraph id="H6031065270884A2BAE8C5EE7F474835F"><enum>(A)</enum><header>Basic, enhanced, and premium plans</header><text display-inline="yes-display-inline">Standards for 3 levels of Exchange-participating health benefits plans: basic, enhanced, and premium (in this division referred to as a <quote>basic plan</quote>, <quote>enhanced plan</quote>, and <quote>premium plan</quote>, respectively).</text></subparagraph> <subparagraph id="H4473743EAD2648C1A31EE2485BFBC15D"><enum>(B)</enum><header>Premium-plus plan benefits</header><text>Standards for additional benefits that may be offered, consistent with this subsection and subtitle C of title II, under a premium plan (such a plan with additional benefits referred to in this division as a <quote>premium-plus plan</quote>) .</text></subparagraph></paragraph> <paragraph id="HE3085D124A9842248A62F04BCD88BB1D"><enum>(2)</enum><header>Basic plan</header> <subparagraph id="H88676B53F5A94CB3B6ED58CB7285ED68"><enum>(A)</enum><header>In general</header><text>A basic plan shall offer the essential benefits package required under title II for a qualified health benefits plan with an actuarial value of 70 percent of the full actuarial value of the benefits provided under the reference benefits package.</text></subparagraph> <subparagraph id="HC1CCDBCB333C4D3EBDD9FC914012A387"><enum>(B)</enum><header>Tiered cost-sharing for affordable credit eligible individuals</header><text>In the case of an affordable credit eligible individual (as defined in section 342(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 324(c).</text></subparagraph></paragraph> <paragraph id="HD65386137F364493BCD2823E2835D80E"><enum>(3)</enum><header>Enhanced plan</header><text display-inline="yes-display-inline">An 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 II consistent with section 223(b)(5)(A).</text></paragraph> <paragraph id="HF1040D2B479144BABE13A4B5B7ADE916"><enum>(4)</enum><header>Premium plan</header><text display-inline="yes-display-inline">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 II consistent with section 223(b)(5)(B).</text></paragraph> <paragraph id="H75B4EC2E9B5E4B3D86CA1BA75430B836"><enum>(5)</enum><header>Premium-plus plan</header><text>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 premium that is attributable to such additional benefits shall be separately specified.</text></paragraph> <paragraph id="H6EAB9F982B0E4C669381AB1C1F947B9E"><enum>(6)</enum><header>Range of permissible variation in cost-sharing</header><text display-inline="yes-display-inline">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 222. Nothing in this subtitle shall be construed as prohibiting tiering in cost-sharing, including through preferred and participating providers and prescription drugs. In applying this paragraph, a health benefits plan may increase the cost-sharing by 10 percent within each category or tier, as applicable, and may decrease or eliminate cost-sharing in any category or tier as compared to the essential benefits package.</text></paragraph></subsection> <subsection id="H1BA6630AC80243F895807EA7BDC8D69C"><enum>(d)</enum><header>Treatment of State benefit mandates</header><text>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.</text></subsection> <subsection id="H79DD014C1AF94F319A20F9D211C27D05"><enum>(e)</enum><header>Rules regarding coverage of and affordability credits for specified services</header> <paragraph id="HE6CCEFFBEAE0456F818C013BA35FFFE0"><enum>(1)</enum><header>Assured availability of varied coverage through the Health Insurance Exchange</header><text display-inline="yes-display-inline">The Commissioner shall assure that, of the Exchange participating health benefits plan offered in each premium rating area of the Health Insurance Exchange—</text> <subparagraph id="HFCD8B1662F6B4516B1F6567E3B904F3B"><enum>(A)</enum><text>there is at least one such plan that provides coverage of services described in subparagraphs (A) and (B) of section 222(d)(4); and</text></subparagraph> <subparagraph id="HD6F2EE838D9046EBA8530C056892B600"><enum>(B)</enum><text>there is at least one such plan that does not provide coverage of services described in section 222(d)(4)(A) which plan may also be one that does not provide coverage of services described in section 222(d)(4)(B).</text></subparagraph></paragraph> <paragraph id="HFC6102ABE2984096A531458F28517B2F"><enum>(2)</enum><header>Segregation of funds</header><text>If a qualified health benefits plan provides coverage of services described in section 222(d)(4)(A), the plan shall provide assurances satisfactory to the Commissioner that—</text> <subparagraph id="H2C6520F671DC43A68FF41E0E4B8FD491"><enum>(A)</enum><text>any affordability credits provided under subtitle C of title II are not used for purposes of paying for such services; and</text></subparagraph> <subparagraph id="H05FDE5E3ACB84D80A6207AE85E1C02F0" commented="no"><enum>(B)</enum><text>only premium amounts attributable to the actuarial value described in section 213(b) are used for such purpose.</text></subparagraph></paragraph></subsection></section> <section id="HFD5A97FE2E08471A90DB757BDD31A381"><enum>304.</enum><header>Contracts for the offering of Exchange-participating health benefits plans</header> <subsection id="H9319DCBF6A43482097CBC4E37BB57BB7"><enum>(a)</enum><header>Contracting duties</header><text>In carrying out section 301(b)(1) and consistent with this subtitle:</text> <paragraph id="H9957919F7C2D482AB64FC0343241F40E"><enum>(1)</enum><header>Offering entity and plan standards</header><text>The Commissioner shall—</text> <subparagraph id="HEF52A24156CC4152AC5B817A4EE3C9DC"><enum>(A)</enum><text>establish standards necessary to implement the requirements of this title and title II for—</text> <clause id="H1FA8225C18B4436384CB84635CE7EFA8"><enum>(i)</enum><text display-inline="yes-display-inline">QHBP offering entities for the offering of an Exchange-participating health benefits plan; and</text></clause> <clause id="HC644E6AC02264A17897BA0523BD2394A"><enum>(ii)</enum><text>Exchange-participating health benefits plans; and</text></clause></subparagraph> <subparagraph id="H39581625ED50447E8154419B54C99C73"><enum>(B)</enum><text>certify QHBP offering entities and qualified health benefits plans as meeting such standards and requirements of this title and title II for purposes of this subtitle.</text></subparagraph></paragraph> <paragraph id="H44643577D1C44C5F98D66F2E8F4BD48D"><enum>(2)</enum><header>Soliciting and negotiating bids; contracts</header> <subparagraph id="HB9AC87C534EA4CF4BD7FE75E9CD1AB6A"><enum>(A)</enum><header>Bid solicitation</header><text display-inline="yes-display-inline">The Commissioner shall solicit bids from QHBP offering entities for the offering of Exchange-participating health benefits plans. Such bids shall include justification for proposed premiums.</text></subparagraph> <subparagraph id="HD6E236D594AB42888C1A22A0E0065D4C"><enum>(B)</enum><header>Bid review and negotiation</header><text display-inline="yes-display-inline">The Commissioner shall, based upon a review of such bids including the premiums and their affordability, negotiate with such entities for the offering of such plans.</text></subparagraph> <subparagraph id="H4A217106F02F4F95B3BB7E8EDCB9EB25" commented="no"><enum>(C)</enum><header>Denial of excessive premiums</header><text display-inline="yes-display-inline">The Commissioner shall deny excessive premiums and premium increases.</text></subparagraph> <subparagraph id="HFD64CC4B67594F03981464EE3D71526B"><enum>(D)</enum><header>Contracts</header><text display-inline="yes-display-inline">The Commissioner shall 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.</text></subparagraph></paragraph> <paragraph id="HF622CF0F5B6945F797CCFB5BA1DE070F"><enum>(3)</enum><header>Federal Acquisition Regulation</header><text display-inline="yes-display-inline">In carrying out this subtitle, the Commissioner may waive such provisions of the Federal Acquisition Regulation that the Commissioner determines to be inconsistent with the furtherance of this subtitle, other than provisions relating to confidentiality of information. Competitive procedures shall be used in awarding contracts under this subtitle to the extent that such procedures are consistent with this subtitle. </text></paragraph></subsection> <subsection id="HAFBA558D52054E72BE647B4C0A14ABA6"><enum>(b)</enum><header>Standards for QHBP offering entities To offer Exchange-Participating health benefits plans</header><text display-inline="yes-display-inline">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:</text> <paragraph id="H66C3EB153C1947C7944AE978D0A0F268"><enum>(1)</enum><header>Licensed</header><text>The entity shall be licensed to offer health insurance coverage under State law for each State in which it is offering such coverage. </text></paragraph> <paragraph id="H4FD99304A3914CE99039CDFC428C917C"><enum>(2)</enum><header>Data reporting</header><text display-inline="yes-display-inline">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 306(b) and information to address disparities in health and health care.</text></paragraph> <paragraph id="H4230536C3A484A9A871E250A540E8245"><enum>(3)</enum><header>Affordability</header><text display-inline="yes-display-inline">The entity shall provide for affordable premiums.</text></paragraph> <paragraph id="H95AA0AE78C26405A8BC5C17DC5F9EEE2"><enum>(4)</enum><header>Implementing affordability credits</header><text>The entity shall provide for implementation of the affordability credits provided for enrollees under subtitle C, including the reduction in cost-sharing under section 344(c).</text></paragraph> <paragraph id="H9E40A2A13E3D4661BB225F993A21EE3B"><enum>(5)</enum><header>Enrollment</header><text>The entity shall accept all enrollments under this subtitle, subject to such exceptions (such as capacity limitations) in accordance with the requirements under title II 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.</text></paragraph> <paragraph id="H3B099FEF8E5947ADBCB76025E7BD0118"><enum>(6)</enum><header>Risk pooling participation</header><text>The entity shall participate in such risk pooling mechanism as the Commissioner establishes under section 306(b).</text></paragraph> <paragraph id="HA5C5FEAA10B04D39BFE20344BA322780" commented="no"><enum>(7)</enum><header>Essential community providers</header><text display-inline="yes-display-inline">With respect to the basic plan offered by the entity, the entity shall include within the plan network those essential community providers, where available, that serve predominantly low-income, medically-underserved individuals, such as health care providers defined in section 340B(a)(4) of the Public Health Service Act and providers described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act (as amended by section 221 of Public Law 111–8). 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 substantially all benefits through a health maintenance organization, as defined in section 2791(b)(3) of the Public Health Service Act. This paragraph shall not be construed to require a basic plan to contract with a provider if such provider refuses to accept the generally applicable payment rates of such plan.</text></paragraph> <paragraph id="HF218655A7FE848118E10190B22613020"><enum>(8)</enum><header>Culturally and linguistically appropriate services and communications</header><text>The entity shall provide for culturally and linguistically appropriate communication and health services.</text></paragraph> <paragraph id="HD71F550DB4C54E93BEA79EA87B87FB74" commented="no"><enum>(9)</enum><header>Special rules with respect to Indian enrollees and Indian health care providers</header> <subparagraph id="HACC22BA14CED425387BC0947AAF4AD73" commented="no"><enum>(A)</enum><header>Choice of providers</header><text>The entity shall—</text> <clause id="H42C635358B804ACD9DB28E53866DE854" commented="no"><enum>(i)</enum><text>demonstrate to the satisfaction of the Commissioner that it has contracted with a sufficient number of Indian health care providers to ensure timely access to covered services furnished by such providers to individual Indians through the entity’s Exchange-participating health benefits plan; and</text></clause> <clause id="H649597584A0B410883C503308A2CF4A2" commented="no"><enum>(ii)</enum><text display-inline="yes-display-inline">agree to pay Indian health care providers, whether such providers are participating or nonparticipating providers with respect to the entity, for covered services provided to those enrollees who are eligible to receive services from such providers at a rate that is not less than the level and amount of payment which the entity would make for the services of a participating provider which is not an Indian health care provider.</text></clause></subparagraph> <subparagraph id="H1046F313F5C2415483912B39664A922E" commented="no"><enum>(B)</enum><header>Special rule relating to Indian health care providers</header><text display-inline="yes-display-inline">Provision of services by an Indian health care provider exclusively to Indians and their dependents shall not constitute discrimination under this Act.</text></subparagraph></paragraph> <paragraph id="HAF3CAE546A0A445DABABB59F2C52A847"><enum>(10)</enum><header>Program integrity standards</header><text>The entity shall establish and operate a program to protect and promote the integrity of Exchange-participating health benefits plans it offers, in accordance with standards and functions established by the Commissioner.</text></paragraph> <paragraph id="HD2F22841AFF945C18DB5B2035BBB0F40"><enum>(11)</enum><header>Additional requirements</header><text display-inline="yes-display-inline">The entity shall comply with other applicable requirements of this title, as specified by the Commissioner, which shall include standards regarding billing and collection 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.</text></paragraph></subsection> <subsection id="HB51321D7074646F199B1B354D8E1B3A5" commented="no"><enum>(c)</enum><header>Contracts</header> <paragraph id="H4E720C45F9F84D95A19805AD2C91C763" commented="no" display-inline="no-display-inline"><enum>(1)</enum><header>Bid application</header><text>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 information as the Commissioner may require.</text></paragraph> <paragraph id="H9E74E4813E344482AB3A07BF4A6963E4" commented="no"><enum>(2)</enum><header>Term</header><text>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 automatically renewable from term to term in the absence of notice of termination by either party.</text></paragraph> <paragraph id="H4973C42B430340F8BB609AD4B4FB1931" commented="no"><enum>(3)</enum><header>Enforcement of network adequacy</header><text display-inline="yes-display-inline">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—</text> <subparagraph id="HF1FAF20CF3674B3AAE748DA465111A73" commented="no"><enum>(A)</enum><text>the Commissioner determines that such provider network does not meet such standards as the Commissioner shall establish under section 215; and</text></subparagraph> <subparagraph id="H297DAB093E4A4228986F9951ABDC6B24" commented="no"><enum>(B)</enum><text>an individual enrolled in such plan receives an item or service from a provider that is not within such network; </text></subparagraph><continuation-text continuation-text-level="paragraph" commented="no">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.</continuation-text></paragraph> <paragraph id="H375B721C2ABA4A6A8C6E9EF3ACBE8A9C" display-inline="no-display-inline"><enum>(4)</enum><header>Oversight and enforcement responsibilities</header><text display-inline="yes-display-inline">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, including the marketing of such plans. Such processes shall include the following:</text> <subparagraph id="HB691837AAFCB43E498BC2E3FB8515A69"><enum>(A)</enum><header>Grievance and complaint mechanisms</header><text>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.</text></subparagraph> <subparagraph id="H5C29715BBBA04D25B193B4527E2946B2" commented="no"><enum>(B)</enum><header>Enforcement</header><text>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 242(d).</text></subparagraph> <subparagraph id="HE94362722C04454E84C15817DD0FE9CE" commented="no" display-inline="no-display-inline"><enum>(C)</enum><header>Termination</header> <clause id="HB4E958E5644346A8A41816835610732C"><enum>(i)</enum><header>In general</header><text>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—</text> <subclause id="H97E844FE3E1B44F1AD91122B5E6BEA65"><enum>(I)</enum><text>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 </text></subclause> <subclause id="H053A1B833DC14D6FAE866D01F7B26DDC"><enum>(II)</enum><text>the Commissioner provides the entity with reasonable notice and opportunity for hearing (including the right to appeal an initial decision) before terminating the contract. </text></subclause></clause> <clause id="H9B4DF35A4B10430AB717275A0913BF64"><enum>(ii)</enum><header>Exception for imminent and serious risk to health</header><text>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.</text></clause></subparagraph> <subparagraph id="HC25C6B1135F0471CA18CF6AB3DF2A843"><enum>(D)</enum><header>Construction</header><text>Nothing in this subsection shall be construed as preventing the application of other sanctions under subtitle E of title II with respect to an entity for a violation of such a requirement.</text></subparagraph></paragraph> <paragraph id="H427405498D3043EA99E0743F38CC6DE5" commented="no"><enum>(5)</enum><header>Special rule related to cost-sharing and Indian health care providers</header><text display-inline="yes-display-inline">The contract under this section with a QHBP offering entity for a health benefits plan shall provide that if an individual who is an Indian is enrolled in such a plan and such individual receives a covered item or service from an Indian health care provider (regardless of whether such provider is in the plan’s provider network), the cost-sharing for such item or service shall be equal to the amount of cost-sharing that would be imposed if such item or service—</text> <subparagraph id="H225458D3D7C24DDBB6E2E9D34600D693" commented="no"><enum>(A)</enum><text>had been furnished by another provider in the plan’s provider network; or</text></subparagraph> <subparagraph id="HAE70CC2484C2446CAFD03ABFDB8AABE0" commented="no"><enum>(B)</enum><text>in the case that the plan has no such network, was furnished by a non-Indian provider.</text></subparagraph></paragraph> <paragraph id="HF0A61EF4904B434A8991E6546150E35E" commented="no"><enum>(6)</enum><header>National plan</header><text>Nothing in this section shall be construed as preventing the Commissioner from entering into a contract under this subsection with a QHBP offering entity for the offering of a health benefits plan with the same benefits in every State so long as such entity is licensed to offer such plan in each State and the benefits meet the applicable requirements in each such State.</text></paragraph></subsection> <subsection id="H3224A8D73B304317B7DA6D344ED4D122" display-inline="no-display-inline"><enum>(d)</enum><header>No discrimination on the basis of provision of abortion</header><text display-inline="yes-display-inline">No Exchange participating health benefits plan may discriminate against any individual health care provider or health care facility because of its willingness or unwillingness to provide, pay for, provide coverage of, or refer for abortions. </text></subsection></section> <section id="HA0F16872D91F4E8F8EFB938894B06053"><enum>305.</enum><header>Outreach and enrollment of Exchange-eligible individuals and employers in Exchange-participating health benefits plan</header> <subsection id="HC529437E011B4CCE826946AFE28B9D1A"><enum>(a)</enum><header>In general</header> <paragraph id="HC6D47E46CA5D40E591BBABFD735C671C"><enum>(1)</enum><header>Outreach</header><text>The Commissioner shall conduct outreach activities consistent with subsection (c), including through use of appropriate entities as described in paragraph (3) 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. </text></paragraph> <paragraph id="HB739CD9EE5654E1AA94460444B532F5C"><enum>(2)</enum><header>Eligibility</header><text>The Commissioner shall make timely determinations of whether individuals and employers are Exchange-eligible individuals and employers (as defined in section 302).</text></paragraph> <paragraph id="HF4A67551F7DB485C998F6C4F38E58AEB"><enum>(3)</enum><header>Enrollment</header><text>The Commissioner shall establish and carry out an enrollment process for Exchange-eligible individuals and employers, including at community locations, in accordance with subsection (b).</text></paragraph></subsection> <subsection id="HD8F85E4F9B17415BAFA1FC615302B175"><enum>(b)</enum><header>Enrollment process</header> <paragraph id="HF29571EB00134842B8BAF5131FD4B9C5"><enum>(1)</enum><header>In general</header><text>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.</text></paragraph> <paragraph id="HCD953A8948C446FCBA3674CDF3A40E60" display-inline="no-display-inline"><enum>(2)</enum><header>Enrollment periods</header> <subparagraph id="HFAD1191469EA447A859CE2CE8CEAD0F7"><enum>(A)</enum><header>Open enrollment period</header><text display-inline="yes-display-inline">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 subtitle 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.</text></subparagraph> <subparagraph id="HF9E03B3099E6487695F89B4A7769B26D"><enum>(B)</enum><header>Special enrollment</header><text>The Commissioner shall also provide for special enrollment periods to take into account special circumstances of individuals and employers, such as an individual who—</text> <clause id="H8098E57845A94F41A68AD651D463B15A"><enum>(i)</enum><text>loses acceptable coverage;</text></clause> <clause id="HCDE1E159820F4B65B92BA5767FFB0A62"><enum>(ii)</enum><text>experiences a change in marital or other dependent status; </text></clause> <clause id="H17EE083B2F554F2DBE001D20687F1783"><enum>(iii)</enum><text>moves outside the service area of the Exchange-participating health benefits plan in which the individual is enrolled; or</text></clause> <clause id="H7084CA0980BB4C4FA27C007CEB26243A"><enum>(iv)</enum><text>experiences a significant change in income.</text></clause></subparagraph> <subparagraph id="H86A38CD9AED64E3EA2F2D13ED7F2C21E"><enum>(C)</enum><header>Enrollment Information</header><text>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.</text></subparagraph></paragraph> <paragraph id="H26F041FA08A4432B8B06E1F44BA1D62E" commented="no"><enum>(3)</enum><header>Automatic enrollment for non-Medicaid eligible individuals</header> <subparagraph id="H881DF4B13F8F44B3BA2BB2D5B13C7087" commented="no"><enum>(A)</enum><header>In general</header><text>The Commissioner shall provide for a process under which individuals who are Exchange-eligible individuals described in subparagraph (B) are automatically 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. </text></subparagraph> <subparagraph id="H90BC8346FAFD4ADBB6C6682FD257C5C7" commented="no"><enum>(B)</enum><header>Subsidized individuals described</header><text>An individual described in this subparagraph is an Exchange-eligible individual who is either of the following:</text> <clause id="HD98CD16D26184F27983130F10E15F518"><enum>(i)</enum><header>Affordability credit eligible individuals</header><text>The individual—</text> <subclause id="H013AB5D1ED23479E88FA469074BFF5C8"><enum>(I)</enum><text>has applied for, and been determined eligible for, affordability credits under subtitle C;</text></subclause> <subclause id="HBC2BE92A58C94490BCCCEC75A7B7C49C"><enum>(II)</enum><text>has not opted out from receiving such affordability credit; and</text></subclause> <subclause id="HA28B9226B0D4467AAD7B2123B41D626F"><enum>(III)</enum><text>does not otherwise enroll in another Exchange-participating health benefits plan.</text></subclause></clause> <clause id="HADDBC372E5A14D3FB8395CE8B85B4EAB"><enum>(ii)</enum><header>Individuals enrolled in a terminated plan</header><text>The individual who is enrolled in an Exchange-participating health benefits plan that is terminated (during or at the end of a plan year) and who does not otherwise enroll in another Exchange-participating health benefits plan.</text></clause></subparagraph></paragraph> <paragraph id="H3E7835DDD57648D8827D2E7280822B15"><enum>(4)</enum><header>Direct payment of premiums to plans</header><text>Under the enrollment process, individuals enrolled in an Exchange-participating health benefits plan shall pay such plans directly, and not through the Commissioner or the Health Insurance Exchange.</text></paragraph></subsection> <subsection id="H6F3E174BC70542FEBADB9CC1F6145EE2" display-inline="no-display-inline" commented="no"><enum>(c)</enum><header>Coverage information and assistance</header> <paragraph id="H1C3AAAD637934E4E879E175AF02FFF4B" commented="no"><enum>(1)</enum><header>Coverage information</header><text>The Commissioner 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.</text></paragraph> <paragraph id="HCB83690459884E2F83E5D8D491E33263" commented="no"><enum>(2)</enum><header>Consumer assistance with choice</header><text display-inline="yes-display-inline">To provide assistance to Exchange-eligible individuals and employers, the Commissioner shall—</text> <subparagraph id="H4E61E21F2170449C8BDB66FCDA623976" commented="no"><enum>(A)</enum><text display-inline="yes-display-inline">provide for the operation of a toll-free telephone hotline to respond to requests for assistance and maintain an Internet Web site through which individuals may obtain information on coverage under Exchange-participating health benefits plans and file complaints;</text></subparagraph> <subparagraph id="HFB2529E98C8046D9837746C59AEC3CF9" commented="no"><enum>(B)</enum><text display-inline="yes-display-inline">develop and disseminate information to Exchange-eligible enrollees on their rights and responsibilities; </text></subparagraph> <subparagraph id="HB6AE6660C25548E8805395C0491667C3" commented="no"><enum>(C)</enum><text display-inline="yes-display-inline">assist Exchange-eligible individuals in selecting Exchange-participating health benefits plans and obtaining benefits through such plans; and</text></subparagraph> <subparagraph id="HA7042DD9319744A0B48ABAAB2D4EAC5C"><enum>(D)</enum><text>ensure that the Internet Web site described in subparagraph (A) and the information described in subparagraph (B) is developed using plain language (as defined in section 233(a)(2)).</text></subparagraph></paragraph> <paragraph id="HCBC48D3159894CA2A603B347212359CE"><enum>(3)</enum><header>Use of other entities</header><text>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).</text></paragraph></subsection> <subsection id="H30E63AA0E29B4BAE830CD634F551983A" commented="no"><enum>(d)</enum><header>Coverage for certain newborns under Medicaid</header> <paragraph id="H9C08436CFCB644BF9A82B56E04FB6ED4"><enum>(1)</enum><header>In general</header><text>In the case of a child born in the United States who at the time of birth is not otherwise covered under acceptable coverage, for the period of time beginning on the date of birth and ending on the date the child otherwise is covered under acceptable coverage (or, if earlier, the end of the month in which the 60-day period, beginning on the date of birth, ends), the child shall be deemed—</text> <subparagraph id="HB747623614254FA6BD069550360F4724" commented="no"><enum>(A)</enum><text>to be a Medicaid eligible individual for purposes of this division and Medicaid; and</text></subparagraph> <subparagraph id="H10AA3F92F16C412EB9398CFCA67A71D1" commented="no"><enum>(B)</enum><text>to be automatically enrolled in Medicaid as a traditional Medicaid eligible individual (as defined in section 1943(c) of the Social Security Act).</text></subparagraph></paragraph> <paragraph id="HB39793B5255C4B99B3B98B32FE2AD6D9"><enum>(2)</enum><header>Extended treatment as Medicaid eligible individual</header><text>In the case of a child described in paragraph (1) who at the end of the period referred to in such paragraph is not otherwise covered under acceptable coverage, the child shall be deemed (until such time as the child obtains such coverage or the State otherwise makes a determination of the child’s eligibility for medical assistance under its Medicaid plan pursuant to section 1943(b)(1) of the Social Security Act) to be a Medicaid eligible individual described in section 1902(l)(1)(B) of such Act.</text></paragraph></subsection> <subsection id="HDA4DE8B8D79B4F0691A2703DA5919DB0" commented="no"><enum>(e)</enum><header>Medicaid coverage for Medicaid eligible individuals</header><text display-inline="yes-display-inline"/> <paragraph id="H8B6F6B1974A74BEA90E19EF3D7A66A64" commented="no"><enum>(1)</enum><header>Medicaid enrollment obligation</header><text display-inline="yes-display-inline">An individual may apply, in the manner described in section 341(b)(1), for a determination of whether the individual is a Medicaid-eligible individual. If the individual is determined to be so eligible, the Commissioner, through the Medicaid memorandum of understanding under paragraph (2), shall provide for the enrollment of the individual under the State Medicaid plan in accordance with such memorandum of understanding. In the case of such an enrollment, the State shall provide for the same periodic redetermination of eligibility under Medicaid as would otherwise apply if the individual had directly applied for medical assistance to the State Medicaid agency.</text></paragraph> <paragraph id="HEA3A9F83EBA14E52A3152A6558B9F943" commented="no"><enum>(2)</enum><header>Coordinated enrollment with State through memorandum of understanding</header><text display-inline="yes-display-inline">The Commissioner, in consultation with the Secretary of Health and Human Services, shall enter into a memorandum of understanding with each State with respect to coordinating enrollment of individuals in Exchange-participating health benefits plans and under the State’s Medicaid program consistent with this section and to otherwise coordinate the implementation of the provisions of this division with respect to the Medicaid program. Such memorandum shall permit the exchange of information consistent with the limitations described in section 1902(a)(7) of the Social Security Act. Nothing in this section shall be construed as permitting such memorandum to modify or vitiate any requirement of a State Medicaid plan.</text></paragraph></subsection> <subsection id="H1EEC26E414A14A6AAE235E5D652789E5"><enum>(f)</enum><header>Effective culturally and linguistically appropriate communication</header><text>In carrying out this section, the Commissioner shall establish effective methods for communicating in plain language and a culturally and linguistically appropriate manner.</text></subsection> <subsection id="HEF55259B790B4AF8BB2599F750B1064B" commented="no"><enum>(g)</enum><header>Role for enrollment agents and brokers</header><text display-inline="yes-display-inline">Nothing in this division shall be construed to affect the role of enrollment agents and brokers under State law, including with regard to the enrollment of individuals and employers in qualified health benefits plans including the public health insurance option. </text></subsection> <subsection id="HA1B6CF280BEF4B49BD4C6A9B45184CE9" commented="no"><enum>(h)</enum><header>Assistance for small employers</header> <paragraph id="H4A12D01C405F4792ACF37AA20AA550BA" commented="no"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">The Commissioner, in consultation with the Small Business Administration, shall establish and carry out a program to provide to small employers counseling and technical assistance with respect to the provision of health insurance to employees of such employers through the Health Insurance Exchange.</text></paragraph> <paragraph id="H18F30A3FC98143A290967420CDC6C69A" commented="no"><enum>(2)</enum><header>Duties</header><text>The program established under paragraph (1) shall include the following services:</text> <subparagraph id="H2716BEBC2A994ECFB4D90BDDB4EC724F" commented="no"><enum>(A)</enum><text display-inline="yes-display-inline">Educational activities to increase awareness of the Health Insurance Exchange and available small employer health plan options.</text></subparagraph> <subparagraph id="H31D11ECE134848AAA7B9CFE508C01422" commented="no"><enum>(B)</enum><text>Distribution of information to small employers with respect to the enrollment and selection process for health plans available under the Health Insurance Exchange, including standardized comparative information on the health plans available under the Health Insurance Exchange.</text></subparagraph> <subparagraph id="H764CBEDB8E324E008CB06CC3FC1A9272" commented="no"><enum>(C)</enum><text display-inline="yes-display-inline">Distribution of information to small employers with respect to available affordability credits or other financial assistance.</text></subparagraph> <subparagraph id="HDEAE4016D84F4BAA9844365A15F559EB" commented="no"><enum>(D)</enum><text>Referrals to appropriate entities of complaints and questions relating to the Health Insurance Exchange.</text></subparagraph> <subparagraph id="H8E33C346956C43058F5040952B9C558C" commented="no"><enum>(E)</enum><text>Enrollment and plan selection assistance for employers with respect to the Health Insurance Exchange.</text></subparagraph> <subparagraph id="HE8AEDDF9EE894661A56C53F8769893A6" commented="no"><enum>(F)</enum><text display-inline="yes-display-inline">Responses to questions relating to the Health Insurance Exchange and the program established under paragraph (1).</text></subparagraph></paragraph> <paragraph id="H8AEFDF7285A74EC48EBE397AA2485BE4" commented="no"><enum>(3)</enum><header>Authority to provide services directly or by contract</header><text>The Commissioner may provide services under paragraph (2) directly or by contract with nonprofit entities that the Commissioner determines capable of carrying out such services.</text></paragraph> <paragraph id="H7F3951EB933F4E889F3D30693F98307F" commented="no"><enum>(4)</enum><header>Small employer defined</header><text>In this subsection, the term <quote>small employer</quote> means an employer with less than 100 employees. </text></paragraph></subsection> <subsection id="H1B03429D793847F1B493B9DB407AB3A1" commented="no"><enum>(i)</enum><header>Participation of small employer benefit arrangements</header> <paragraph id="H35209D24500441A8A399B245235F2201" commented="no"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">The Commissioner may enter into contracts with small employer benefit arrangements to provide consumer information, outreach, and assistance in the enrollment of small employers (and their employees) who are members of such an arrangement under Exchange participating health benefits plans.</text></paragraph> <paragraph id="HBB77A15C9D0A4703959C1606AD01D621" commented="no" display-inline="no-display-inline"><enum>(2)</enum><header>Small employer benefit arrangement defined</header><text>In this subsection, the term <quote>small employer benefit arrangement</quote> means a not-for-profit agricultural or other cooperative that—</text> <subparagraph id="H8BFE4343911148569BAE7B1E6E2503F2" commented="no"><enum>(A)</enum><text>consists solely of its members and is operated for the primary purpose of providing affordable employee benefits to its members;</text></subparagraph> <subparagraph id="H6CEA241FC810489A846257C5E5A8E72E" commented="no"><enum>(B)</enum><text>only has as members small employers in the same industry or line of business;</text></subparagraph> <subparagraph id="H35FEEA5CE5EF48648F5F2FBA7E23A676" commented="no"><enum>(C)</enum><text>has no member that has more than a 5 percent voting interest in the cooperative; and</text></subparagraph> <subparagraph id="HC1081F33D29F433A8944CBCD2AF8E5C7" commented="no"><enum>(D)</enum><text>is governed by a board of directors elected by its members.</text></subparagraph></paragraph></subsection></section> <section id="H0779CCBD26CC47DB9CB15E6205A0FA05"><enum>306.</enum><header>Other functions</header> <subsection id="HAA64B70348F64C9FB35CABAD3DA397CD"><enum>(a)</enum><header>Coordination of affordability credits</header><text display-inline="yes-display-inline">The Commissioner shall coordinate the distribution of affordability premium and cost-sharing credits under subtitle C to QHBP offering entities offering Exchange-participating health benefits plans.</text></subsection> <subsection id="HBC2B2A2025A940FAACB2F0343AE9DB32"><enum>(b)</enum><header>Coordination of risk pooling</header><text display-inline="yes-display-inline">The Commissioner shall establish a mechanism whereby there is an adjustment made of the premium amounts payable among QHBP offering entities offering Exchange-participating health benefits plans of premiums collected for such plans that takes into account (in a manner specified by the Commissioner) the differences in the risk characteristics of individuals and employees enrolled under the different Exchange-participating health benefits plans offered by such entities so as to minimize the impact of adverse selection of enrollees among the plans offered by such entities. For purposes of the previous sentence, the Commissioner may utilize data regarding enrollee demographics, inpatient and outpatient diagnoses (in a similar manner as such data are used under parts C and D of title XVIII of the Social Security Act), and such other information as the Secretary determines may be necessary, such as the actual medical costs of enrollees during the previous year.</text></subsection></section> <section id="HEC990F05D2AF4C25BC12BDAA804D68AA" display-inline="no-display-inline" section-type="subsequent-section"><enum>307.</enum><header>Health Insurance Exchange Trust Fund</header> <subsection display-inline="no-display-inline" id="H0D80305AB48C40C3872867CE1756B178"><enum>(a)</enum><header>Establishment of Health Insurance Exchange Trust Fund</header><text display-inline="yes-display-inline">There is created within the Treasury of the United States a trust fund to be known as the <quote>Health Insurance Exchange Trust Fund</quote> (in this section referred to as the <quote>Trust Fund</quote>), consisting of such amounts as may be appropriated or credited to the Trust Fund under this section or any other provision of law.</text></subsection> <subsection id="H765C03DD48F1422992B070AF7C641F51"><enum>(b)</enum><header>Payments from Trust Fund</header><text>The Commissioner shall pay from time to time from the Trust Fund such amounts as the Commissioner determines are necessary to make payments to operate the Health Insurance Exchange, including payments under subtitle C (relating to affordability credits).</text></subsection> <subsection id="H6DE9EC89D5A040B9836A56307BD5FBF7" display-inline="no-display-inline"><enum>(c)</enum><header>Transfers to Trust Fund</header> <paragraph id="HA3AF6B4A81FC4E1986E1A044AD44DB02"><enum>(1)</enum><header>Dedicated payments</header><text>There are hereby appropriated to the Trust Fund amounts equivalent to the following:</text> <subparagraph id="H4ECA60BCE6B5476A86C02EB65754CB33"><enum>(A)</enum><header>Taxes on individuals not obtaining acceptable coverage</header><text display-inline="yes-display-inline">The amounts received in the Treasury under section 59B of the Internal Revenue Code of 1986 (relating to requirement of health insurance coverage for individuals).</text></subparagraph> <subparagraph id="H6097DA5EC4FB4DEBBAE3308954A618FB"><enum>(B)</enum><header>Employment taxes on employers not providing acceptable coverage</header><text>The amounts received in the Treasury under sections 3111(c) and 3221(c) of the Internal Revenue Code of 1986 (relating to employers electing to not provide health benefits).</text></subparagraph> <subparagraph id="H4F524FF7C7B24C838867F26BD4E3A77E" commented="no"><enum>(C)</enum><header>Excise tax on failures to meet certain health coverage requirements</header><text display-inline="yes-display-inline">The amounts received in the Treasury under section 4980H(b) (relating to excise tax with respect to failure to meet health coverage participation requirements).</text></subparagraph></paragraph> <paragraph id="H704CC1BEF37540EF9E66CABB6776AA88"><enum>(2)</enum><header>Appropriations to cover government contributions</header><text display-inline="yes-display-inline">There are hereby appropriated, out of any moneys in the Treasury not otherwise appropriated, to the Trust Fund, an amount equivalent to the amount of payments made from the Trust Fund under subsection (b) plus such amounts as are necessary reduced by the amounts deposited under paragraph (1).</text></paragraph></subsection> <subsection id="HF3C7EF47CF194F27B7CDFF983F5C420D"><enum>(d)</enum><header>Application of certain rules</header><text display-inline="yes-display-inline">Rules similar to the rules of subchapter B of chapter 98 of the Internal Revenue Code of 1986 shall apply with respect to the Trust Fund. </text></subsection></section> <section id="H429B177E886A46648654318E7DDA51FB"><enum>308.</enum><header>Optional operation of State-based health insurance exchanges</header> <subsection id="H50DB413BE14E47E5B8F6ED24AEA58EFD"><enum>(a)</enum><header>In general</header><text>If—</text> <paragraph id="HAF2276D2D16F4DE1A24768DCD14EC075"><enum>(1)</enum><text>a State (or group of States, subject to the approval of the Commissioner) applies to the Commissioner for approval of a State-based Health Insurance Exchange to operate in the State (or group of States); and</text></paragraph> <paragraph id="H925EA138E1FC4AADBBBE99760CD3EBF7"><enum>(2)</enum><text>the Commissioner approves such State-based Health Insurance Exchange,</text></paragraph><continuation-text continuation-text-level="subsection">then, subject to subsections (c) and (d), the State-based Health Insurance Exchange shall operate, instead of the Health Insurance Exchange, with respect to such State (or group of States). The Commissioner shall approve a State-based Health Insurance Exchange if it meets the requirements for approval under subsection (b).</continuation-text></subsection> <subsection id="HE6F21B901C6145C78A4E23CD11CEC9B4"><enum>(b)</enum><header>Requirements for approval</header> <paragraph id="H36C66D8E987943DAB58C8826D9EF728E"><enum>(1)</enum><header>In general</header><text>The Commissioner may not approve a State-based Health Insurance Exchange under this section unless the following requirements are met:</text> <subparagraph id="H07255536B1434B769715480DEFF04C15"><enum>(A)</enum><text>The State-based Health Insurance Exchange must demonstrate the capacity to and provide assurances satisfactory to the Commissioner that the State-based Health Insurance Exchange will carry out the functions specified for the Health Insurance Exchange in the State (or States) involved, including—</text> <clause id="HE988018AFA9349ED9EAF5584120F145E"><enum>(i)</enum><text>negotiating and contracting with QHBP offering entities for the offering of Exchange-participating health benefits plans, which satisfy the standards and requirements of this title and title II; </text></clause> <clause id="H0FE1AF69683446E994237A4081548713"><enum>(ii)</enum><text>enrolling Exchange-eligible individuals and employers in such State in such plans; </text></clause> <clause id="H59E2BD6FB0384A0FA18222B27685C8B0"><enum>(iii)</enum><text display-inline="yes-display-inline">the establishment of sufficient local offices to meet the needs of Exchange-eligible individuals and employers; </text></clause> <clause id="H913A0F31B1D2430181FB2A62CB2A4165"><enum>(iv)</enum><text>administering affordability credits under subtitle B using the same methodologies (and at least the same income verification methods) as would otherwise apply under such subtitle and at a cost to the Federal Government which does exceed the cost to the Federal Government if this section did not apply; and</text></clause> <clause id="H791C62695D00468C9E56CAEA1FEBCD5C"><enum>(v)</enum><text>enforcement activities consistent with Federal requirements.</text></clause></subparagraph> <subparagraph id="HA985F811B34D45C2824093B2021E2A84"><enum>(B)</enum><text>There is no more than one Health Insurance Exchange operating with respect to any one State.</text></subparagraph> <subparagraph id="H6B7ABF265F3248C69A298699F55E69FB"><enum>(C)</enum><text>The State provides assurances satisfactory to the Commissioner that approval of such an Exchange will not result in any net increase in expenditures to the Federal Government.</text></subparagraph> <subparagraph id="HA39526C712A54E9BBB776C2694FE55B3"><enum>(D)</enum><text>The State provides for reporting of such information as the Commissioner determines and assurances satisfactory to the Commissioner that it will vigorously enforce violations of applicable requirements.</text></subparagraph> <subparagraph id="H30AA24EFF07D4EAEBAD954D1F1358D0E"><enum>(E)</enum><text>Such other requirements as the Commissioner may specify.</text></subparagraph></paragraph> <paragraph id="H067D63C9DC164C61B23B98415A682C49" display-inline="no-display-inline" commented="no"><enum>(2)</enum><header>Presumption for certain State-operated Exchanges</header> <subparagraph id="HBB973DA187BD4F66B85C7765564F17D5" commented="no"><enum>(A)</enum><header>In general</header><text display-inline="yes-display-inline">In the case of a State operating an Exchange prior to January 1, 2010, that seeks to operate the State-based Health Insurance Exchange under this section, the Commissioner shall presume that such Exchange meets the standards under this section unless the Commissioner determines, after completion of the process established under subparagraph (B), that the Exchange does not comply with such standards.</text></subparagraph> <subparagraph id="H6302798B977A487F8DBF29A66D780003" commented="no"><enum>(B)</enum><header>Process</header><text display-inline="yes-display-inline">The Commissioner shall establish a process to work with a State described in subparagraph (A) to provide assistance necessary to assure that the State’s Exchange comes into compliance with the standards for approval under this section.</text></subparagraph></paragraph></subsection> <subsection id="HABFAA7021A804BEDB9A7CD3606428A68"><enum>(c)</enum><header>Ceasing operation</header> <paragraph id="H18A878326B024D42BC9DB164F578D90E"><enum>(1)</enum><header>In general</header><text>A State-based Health Insurance Exchange may, at the option of each State involved, and only after providing timely and reasonable notice to the Commissioner, cease operation as such an Exchange, in which case the Health Insurance Exchange shall operate, instead of such State-based Health Insurance Exchange, with respect to such State (or States).</text></paragraph> <paragraph id="H766C82DFDF694C8E9334A005799AE19C"><enum>(2)</enum><header>Termination; Health Insurance Exchange resumption of functions</header><text>The Commissioner may terminate the approval (for some or all functions) of a State-based Health Insurance Exchange under this section if the Commissioner determines that such Exchange no longer meets the requirements of subsection (b) or is no longer capable of carrying out such functions in accordance with the requirements of this subtitle. In lieu of terminating such approval, the Commissioner may temporarily assume some or all functions of the State-based Health Insurance Exchange until such time as the Commissioner determines the State-based Health Insurance Exchange meets such requirements of subsection (b) and is capable of carrying out such functions in accordance with the requirements of this subtitle.<italic/></text></paragraph> <paragraph id="H2E5994EB97294CA5A63DF872DD3A3995"><enum>(3)</enum><header>Effectiveness</header><text>The ceasing or termination of a State-based Health Insurance Exchange under this subsection shall be effective in such time and manner as the Commissioner shall specify.</text></paragraph></subsection> <subsection id="H61621C675A0A443B8D240B6F29444686"><enum>(d)</enum><header>Retention of authority</header> <paragraph id="H843E8CF85DCA44BA93CBF052DAD1C13E"><enum>(1)</enum><header>Authority retained</header><text>Enforcement authorities of the Commissioner shall be retained by the Commissioner.</text></paragraph> <paragraph id="H6E45C43068FB42808284DC81C65F4A6D"><enum>(2)</enum><header>Discretion to retain additional authority</header><text>The Commissioner may specify functions of the Health Insurance Exchange that—</text> <subparagraph id="H2B92381A04564441AE7F3B34B6A0BF3B"><enum>(A)</enum><text>may not be performed by a State-based Health Insurance Exchange under this section; or</text></subparagraph> <subparagraph id="HA00D2B3ADC164909B3202FA17C30A6DB"><enum>(B)</enum><text>may be performed by the Commissioner and by such a State-based Health Insurance Exchange.</text></subparagraph></paragraph></subsection> <subsection id="HD75FF96036FA4513B7C1AF26BBBC83E9" commented="no"><enum>(e)</enum><header>References</header><text>In the case of a State-based Health Insurance Exchange, except as the Commissioner may otherwise specify under subsection (d), any references in this subtitle to the Health Insurance Exchange or to the Commissioner in the area in which the State-based Health Insurance Exchange operates shall be deemed a reference to the State-based Health Insurance Exchange and the head of such Exchange, respectively.</text></subsection> <subsection id="H71A10DE2B20349D9B56C7BC347E3DA1B" commented="no"><enum>(f)</enum><header>Funding</header><text>In the case of a State-based Health Insurance Exchange, there shall be assistance provided for the operation of such Exchange in the form of a matching grant with a State share of expenditures required.</text></subsection></section> <section id="H636E07EA677B48348CB8B0DB5212ADDB"><enum>309.</enum><header>Interstate health insurance compacts</header> <subsection id="H282ECC8E228E4D0EBE898F267DB08980"><enum>(a)</enum><header>In general</header><text>Effective January 1, 2015, 2 or more States may form Health Care Choice Compacts (in this section referred to as <quote>compacts</quote>) to facilitate the purchase of individual health insurance coverage across State lines.</text></subsection> <subsection id="H0B583BB30CD84CF0A4368C546C0484B2"><enum>(b)</enum><header>Model guidelines</header><text>The Secretary of Health and Human Services (in this section referred to as the <quote>Secretary</quote>) shall request the National Association of Insurance Commissioners (in this section referred to as <quote>NAIC</quote>) to develop model guidelines for the creation of compacts. In developing such guidelines, the NAIC shall consult with consumers, health insurance issuers, the Secretary, and other interested parties. Such guidelines shall—</text> <paragraph id="HFDAFEF638BA143D8850DAAA2B6A0048B"><enum>(1)</enum><text>provide for the sale of health insurance coverage to residents of all compacting States subject to the laws and regulations of a primary State designated by the health insurance issuer;</text></paragraph> <paragraph id="HA68892BA87FD4D35AFD484EB752265CF"><enum>(2)</enum><text>require health insurance issuers issuing health insurance coverage in secondary States to maintain licensure in every such State;</text></paragraph> <paragraph id="H98EB27C8250F419E8FA4AD4256571305"><enum>(3)</enum><text>preserve the authority of the State of an individual’s residence to address—</text> <subparagraph id="H90BE6FAC601A4E39A718814A2D8F79C3"><enum>(A)</enum><text>market conduct;</text></subparagraph> <subparagraph id="H4DFDC7DE537A4311882F3CAC61FBBD78"><enum>(B)</enum><text>unfair trade practices;</text></subparagraph> <subparagraph id="H20F0475AC4F54A94B7C28F548C032A5C"><enum>(C)</enum><text>network adequacy;</text></subparagraph> <subparagraph id="H6BCA82992355458DB13682B09BA1EBDF"><enum>(D)</enum><text>consumer protection standards;</text></subparagraph> <subparagraph id="H22B1EEB19FFB49D88B5328E8719039AE"><enum>(E)</enum><text>grievance and appeals;</text></subparagraph> <subparagraph id="HC9E63C336E05427D96C188AA81F66963"><enum>(F)</enum><text>fair claims payment requirements; and</text></subparagraph> <subparagraph id="H31AECA1E7E3B45C793C61D1301208A45"><enum>(G)</enum><text>prompt payment of claims;</text></subparagraph></paragraph> <paragraph id="HD62B0EF01213467EB52ED83502D5B9B3"><enum>(4)</enum><text>permit State insurance commissioners and other State agencies in secondary States access to the records of a health insurance issuer to the same extent as if the policy were written in that State; and</text></paragraph> <paragraph id="H161D166D7CB44E66AE15C4B29370FED0"><enum>(5)</enum><text>provide for clear and conspicuous disclosure to consumers that the policy may not be subject to all the laws and regulations of the State in which the purchaser resides.</text></paragraph></subsection> <subsection id="H92076A63C3294798B471F2B470570F74"><enum>(c)</enum><header>Required consideration</header><text>If model guidelines developed under subsection (b) are submitted to the Secretary by January 1, 2013, the Secretary shall issue them as regulations. If the NAIC fails to submit such model guidelines by such date, the Secretary shall, no later than October 1, 2013, develop and promulgate the regulations implementing model guidelines described in subsection (b).</text></subsection> <subsection id="HF2C536182ED74A549BB4A4B03F3EE874"><enum>(d)</enum><header>No requirement to compact</header><text>Nothing in this section shall be construed to require a State to join a compact.</text></subsection> <subsection id="H6B7012A6571D491486462D8845393005"><enum>(e)</enum><header>State authority</header><text>A State may not enter into a compact under this subsection unless the State enacts a law after the date of enactment of this Act that specifically authorizes the State to enter into such compact.</text></subsection> <subsection id="HF74BF5E47D5142E0ABF1AD3A9CAB2299"><enum>(f)</enum><header>Consumer protections</header><text>If a State enters into a compact it must retain responsibility for the consumer protections of its residents and its residents retain the right to bring a claim in a State court in the State in which the resident resides.</text></subsection> <subsection id="H4F6D458C7B654D3D850FF44075519891" commented="no"><enum>(g)</enum><header>Assistance to compacting states</header> <paragraph id="H40440A69903B400C9E0D15A7AE50473A" commented="no"><enum>(1)</enum><header>In general</header><text>Beginning January 1, 2015, the Secretary shall make awards, from amounts appropriated under paragraph (5), to States in the amount specified in paragraph (2) for the uses described in paragraph (3).</text></paragraph> <paragraph id="H572128D79959446F8855265690845F6C" commented="no"><enum>(2)</enum><header>Amount specified</header> <subparagraph id="H80A4D89FF7BE44DCA74072C659C8BB8D" commented="no"><enum>(A)</enum><header>In general</header><text>For each fiscal year, the Secretary shall determine the total amount that the Secretary will make available for grants under this subsection.</text></subparagraph> <subparagraph id="H4EF141341D8B4B17BA6395DF8E140D8A" commented="no"><enum>(B)</enum><header>State amount</header><text display-inline="yes-display-inline">For each State that is awarded a grant under paragraph (1), the amount of such grants shall be based on a formula established by the Secretary, not to exceed $1 million per State, under which States shall receive an award in the amount that is based on the following two components:</text> <clause id="H68EFD5F28F3D4B299137AFECD6782EC9" commented="no"><enum>(i)</enum><text>A minimum amount for each State.</text></clause> <clause id="H60BBC3DED6D747B3BD8B8B1AF98B8E36" commented="no"><enum>(ii)</enum><text>An additional amount based on population of the State.</text></clause></subparagraph></paragraph> <paragraph id="HE4302B80F255485EB98912816E3002B9" commented="no"><enum>(3)</enum><header>Use of funds</header><text>A State shall use amounts awarded under this subsection for activities (including planning activities) related regulating health insurance coverage sold in secondary States.</text></paragraph> <paragraph id="HAC27EF059A38458DAF037CD19737C390" commented="no"><enum>(4)</enum><header>Renewability of grant</header><text>The Secretary may renew a grant award under paragraph (1) if the State receiving the grant continues to be a member of a compact.</text></paragraph> <paragraph id="H8BA8854457A944DCA087673F7F2C095D" commented="no"><enum>(5)</enum><header>Authorization of appropriations</header><text>There are authorized to be appropriated such sums as may be necessary to carry out this subsection in each of fiscal years 2015 through 2020.</text></paragraph></subsection></section> <section id="HD321D1EB8D294269A372D783B79BC00D"><enum>310.</enum><header>Health insurance cooperatives</header> <subsection id="H040E7FF8B89840AEB2DB5A7326B0CB54"><enum>(a)</enum><header>Establishment</header><text>Not later than 6 months after the date of the enactment of this Act, the Commissioner, in consultation with the Secretary of the Treasury, shall establish a Consumer Operated and Oriented Plan program (in this section referred to as the <quote>CO–OP program</quote>) under which the Commissioner may make grants and loans for the establishment and initial operation of not-for-profit, member–run health insurance cooperatives (in this section individually referred to as a <quote>cooperative</quote>) that provide insurance through the Health Insurance Exchange or a State-based Health Insurance Exchange under section 308. Nothing in this section shall be construed as requiring a State to establish such a cooperative.</text></subsection> <subsection id="HCF50FC24C334475BB89D2949237D57ED"><enum>(b)</enum><header>Start-up and solvency grants and loans</header> <paragraph id="H830FD04ED2894A87960A08521221C82B"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">Not later than 36 months after the date of the enactment of this Act, the Commissioner, acting through the CO–OP program, may make—</text> <subparagraph id="H1BB0E86E44F64B92ABB4AB32D6DDAE53"><enum>(A)</enum><text>loans (of such period and with such terms as the Secretary may specify) to cooperatives to assist such cooperatives with start-up costs; and</text></subparagraph> <subparagraph id="H986DF797DC8145269298DEEFB2D5919D"><enum>(B)</enum><text>grants to cooperatives to assist such cooperatives in meeting State solvency requirements in the States in which such cooperative offers or issues insurance coverage.</text></subparagraph></paragraph> <paragraph id="H0069FD8C8ED34DE8914AF95CC520D51E"><enum>(2)</enum><header> Conditions</header><text display-inline="yes-display-inline">A grant or loan may not be awarded under this subsection with respect to a cooperative unless the following conditions are met:</text> <subparagraph id="H1B67082FBF6E4F29958F6C139F62F7D0"><enum>(A)</enum><text display-inline="yes-display-inline">The cooperative is structured as a not-for-profit, member organization under the law of each State in which such cooperative offers, intends to offer, or issues insurance coverage, with the membership of the cooperative being made up entirely of beneficiaries of the insurance coverage offered by such cooperative.</text></subparagraph> <subparagraph id="H608997C5E0AD449A9370688BC9FD2CC3"><enum>(B)</enum><text>The cooperative did not offer insurance on or before July 16, 2009, and the cooperative is not an affiliate or successor to an insurance company offering insurance on or before such date.</text></subparagraph> <subparagraph id="H15D90842812A4D0E9A50AC0037F6AE4E"><enum>(C)</enum><text display-inline="yes-display-inline">The governing documents of the cooperative incorporate ethical and conflict of interest standards designed to protect against insurance industry involvement and interference in the governance of the cooperative.</text></subparagraph> <subparagraph id="H305E7CCB42D54997B792E0E74596724B"><enum>(D)</enum><text>The cooperative is not sponsored by a State government.</text></subparagraph> <subparagraph id="H2F413C7550324FE2942C2840160A6E60"><enum>(E)</enum><text>Substantially all of the activities of the cooperative consist of the issuance of qualified health benefits plans through the Health Insurance Exchange or a State-based health insurance exchange.</text></subparagraph> <subparagraph id="HB296F0EF02FD4037A28EB154E9AFF423"><enum>(F)</enum><text>The cooperative is licensed to offer insurance in each State in which it offers insurance.</text></subparagraph> <subparagraph id="HB957EA91B736484AB6EC03E504638207"><enum>(G)</enum><text>The governance of the cooperative must be subject to a majority vote of its members.</text></subparagraph> <subparagraph id="HCA35BFE37BCE4FC8B65525485015295C"><enum>(H)</enum><text>As provided in guidance issued by the Secretary of Health and Human Services, the cooperative operates with a strong consumer focus, including timeliness, responsiveness, and accountability to members.</text></subparagraph> <subparagraph id="HFB64AC64525D41F2B7FF075989C8DDF5"><enum>(I)</enum><text>Any profits made by the cooperative are used to lower premiums, improve benefits, or to otherwise improve the quality of health care delivered to members.</text></subparagraph></paragraph> <paragraph id="H8276E125F60A4167861718C369593D15"><enum>(3)</enum><header>Priority</header><text>The Commissioner, in making grants and loans under this subsection, shall give priority to cooperatives that—</text> <subparagraph id="H91E1BE495ECD4294A0B060FE41A68F2D"><enum>(A)</enum><text>operate on a statewide basis;</text></subparagraph> <subparagraph id="HDEC77E8E4B884083BEF5F5A7AE8FD250"><enum>(B)</enum><text>use an integrated delivery system; or</text></subparagraph> <subparagraph id="H936EE025C720420DB279E5B2C13CD24E"><enum>(C)</enum><text>have a significant level of financial support from nongovernmental sources.</text></subparagraph></paragraph> <paragraph id="H4CCB21EC24724990AF32CAC5C134D5B9" commented="no" display-inline="no-display-inline"><enum>(4)</enum><header>Rules of construction</header><text>Nothing in this section shall be construed to prevent a cooperative established in one State from integrating with a cooperative established in another State the administration, issuance of coverage, or other activities related to acting as a QHBP offering entity. Nothing in this section shall be construed as preventing State governments from taking actions to permit such integration.</text></paragraph> <paragraph id="HBD71F5DF1DF64590AB3A045F856DB2DC"><enum>(5)</enum><header>Amortization of grants and loans</header><text>The Secretary shall provide for the repayment of grants or loans provided under this subsection to the Treasury in an amortized manner over a 10-year period.</text></paragraph> <paragraph id="H413C18B0C94E42D8A85BDF769BB4FC43"><enum>(6)</enum><header>Repayment for violations of terms of program</header><text display-inline="yes-display-inline">If a cooperative violates the terms of the CO–OP program and fails to correct the violation within a reasonable period of time, as determined by the Commissioner, the cooperative shall repay the total amount of any loan or grant received by such cooperative under this section, plus interest (at a rate determined by the Secretary).</text></paragraph> <paragraph id="H51287DA370C2446CADE5A73761A90A6A"><enum>(7)</enum><header>Authorization of appropriations</header><text>There is authorized to be appropriated $5,000,000,000 for the period of fiscal years 2010 through 2014 to provide for grants and loans under this subsection.</text></paragraph></subsection> <subsection id="H944C43631F784CF4BC78166300A0E41C" display-inline="no-display-inline"><enum>(c)</enum><header>Definitions</header><text>For purposes of this section:</text> <paragraph id="HAD6F0C3B8D4D434DAF3CDCF3C27ED92D"><enum>(1)</enum><header>State</header><text display-inline="yes-display-inline">The term <term>State</term> means each of the 50 States and the District of Columbia. </text></paragraph> <paragraph id="H448B83E11DCF4C3D865CDADEE6183738"><enum>(2)</enum><header>Member</header><text display-inline="yes-display-inline">The term <term>member</term>, with respect to a cooperative, means an individual who, after the cooperative offers health insurance coverage, is enrolled in such coverage.</text></paragraph></subsection></section> <section id="HCCF869BB29C44D5EA335F733A31B07A3" commented="no"><enum>311.</enum><header>Retention of DOD and VA authority</header><text display-inline="no-display-inline"> Nothing in this subtitle shall be construed as affecting any authority under title 38, United States Code, or chapter 55 of title 10, United States Code.</text></section></subtitle> <subtitle id="H12B7F7DF156A4BF098E8097B970AFC7F" commented="no"><enum>B</enum><header>Public Health Insurance Option</header> <section id="H554BD9F549DC4DFC8A95B9ACF25255F2" commented="no"><enum>321.</enum><header>Establishment and administration of a public health insurance option as an Exchange-qualified health benefits plan</header> <subsection id="H11BEB7287B1E46DA90E1CAC22D76583C" commented="no"><enum>(a)</enum><header>Establishment</header><text>For years beginning with Y1, the Secretary of Health and Human Services (in this subtitle referred to as the <quote>Secretary</quote>) shall provide for the offering of an Exchange-participating health benefits plan (in this division referred to as the <quote>public health insurance option</quote>) that ensures choice, competition, and stability of affordable, high quality coverage throughout the United States in accordance with this subtitle. In designing the option, the Secretary’s primary responsibility is to create a low-cost plan without compromising quality or access to care.</text></subsection> <subsection id="H81C1EE2FBC9C4EE89960A771A0182BAB" display-inline="no-display-inline" commented="no"><enum>(b)</enum><header>Offering as an Exchange-participating health benefits plan</header> <paragraph id="H74BE20028F2943F2AF8F014CDF0C7CA7" commented="no"><enum>(1)</enum><header>Exclusive to the Exchange</header><text>The public health insurance option shall only be made available through the Health Insurance Exchange.</text></paragraph> <paragraph id="HF6D51C6CA6634775930D3A211CD75642" commented="no"><enum>(2)</enum><header>Ensuring a level playing field</header><text display-inline="yes-display-inline">Consistent with this subtitle, the public health insurance option shall comply with requirements that are applicable under this title to an Exchange-participating health benefits plan, including requirements related to benefits, benefit levels, provider networks, notices, consumer protections, and cost-sharing.</text></paragraph> <paragraph id="HDA71436ECFAE493AA5B113DA9648E822" display-inline="no-display-inline" commented="no"><enum>(3)</enum><header>Provision of benefit levels</header><text>The public health insurance option—</text> <subparagraph id="HCAA81DFE78674E1A9312753E4C13459B" commented="no"><enum>(A)</enum><text>shall offer basic, enhanced, and premium plans; and</text></subparagraph> <subparagraph id="HDD4FB85E98B8410E9E02072FAA0959AC" commented="no"><enum>(B)</enum><text>may offer premium-plus plans.</text></subparagraph></paragraph></subsection> <subsection id="H4318220FE8D24E2B9C083A1C8AD3B4EF" commented="no"><enum>(c)</enum><header>Administrative contracting</header><text display-inline="yes-display-inline">The Secretary may enter into contracts for the purpose of performing administrative functions (including functions described in subsection (a)(4) of section 1874A of the Social Security Act) with respect to the public health insurance option in the same manner as the Secretary may enter into contracts under subsection (a)(1) of such section. The Secretary has the same authority with respect to the public health insurance option as the Secretary has under subsections (a)(1) and (b) of section 1874A of the Social Security Act with respect to title XVIII of such Act. Contracts under this subsection shall not involve the transfer of insurance risk to such entity.</text></subsection> <subsection id="H6506E3471F1A41E2A9BAAD464891BE3D" commented="no"><enum>(d)</enum><header>Ombudsman</header><text display-inline="yes-display-inline">The Secretary shall establish an office of the ombudsman for the public health insurance option which shall have duties with respect to the public health insurance option similar to the duties of the Medicare Beneficiary Ombudsman under section 1808(c)(2) of the Social Security Act.</text></subsection> <subsection id="H0F1F6CB5FF8E4204827F4B047BA698E5" commented="no"><enum>(e)</enum><header>Data collection</header><text display-inline="yes-display-inline">The Secretary shall collect such data as may be required to establish premiums and payment rates for the public health insurance option and for other purposes under this subtitle, including to improve quality and to reduce racial, ethnic, and other disparities in health and health care. Nothing in this subtitle may be construed as authorizing the Secretary (or any employee or contractor) to create or maintain lists of non-medical personal property.</text></subsection> <subsection id="H2C34EBA5ED7F4C3B8C06163E67295D72" commented="no"><enum>(f)</enum><header>Treatment of public health insurance option</header><text>With respect to the public health insurance option, the Secretary shall be treated as a QHBP offering entity offering an Exchange-participating health benefits plan.</text></subsection> <subsection id="H8B9D11C95F234FA28C140C158548A817" commented="no"><enum>(g)</enum><header>Access to Federal courts</header><text>The provisions of Medicare (and related provisions of title II of the Social Security Act) relating to access of Medicare beneficiaries to Federal courts for the enforcement of rights under Medicare, including with respect to amounts in controversy, shall apply to the public health insurance option and individuals enrolled under such option under this title in the same manner as such provisions apply to Medicare and Medicare beneficiaries.</text></subsection></section> <section id="HEEA618DFD77B4F8C835B88A6B910798D" commented="no"><enum>322.</enum><header>Premiums and financing</header> <subsection id="H24B256D071974DD8B5E6415276C37CC7" commented="no"><enum>(a)</enum><header>Establishment of premiums</header> <paragraph id="HE499DDD57A0F4F29869663E772E2BA76" commented="no"><enum>(1)</enum><header>In general</header><text>The Secretary shall establish geographically adjusted premium rates for the public health insurance option—</text> <subparagraph id="H34A298603FC74966BF8E037F7CC8D2F1" commented="no"><enum>(A)</enum><text display-inline="yes-display-inline">in a manner that complies with the premium rules established by the Commissioner under section 213 for Exchange-participating health benefits plans; and</text></subparagraph> <subparagraph id="H04B1425F9AC0439D98E0DDC5CB1C7928" commented="no"><enum>(B)</enum><text>at a level sufficient to fully finance the costs of—</text> <clause id="H54450D313C614D6AA873B085C2DA504D" commented="no"><enum>(i)</enum><text>health benefits provided by the public health insurance option; and</text></clause> <clause id="H0BCF4642C77946DCA88065EE9A6354B4" commented="no"><enum>(ii)</enum><text>administrative costs related to operating the public health insurance option.</text></clause></subparagraph></paragraph> <paragraph id="H54A6E66D82484A5F845A2B157EF287B1" commented="no"><enum>(2)</enum><header>Contingency margin</header><text display-inline="yes-display-inline">In establishing premium rates under paragraph (1), the Secretary shall include an appropriate amount for a contingency margin (which shall be not less than 90 days of estimated claims). Before setting such appropriate amount for years starting with Y3, the Secretary shall solicit a recommendation on such amount from the American Academy of Actuaries.</text></paragraph></subsection> <subsection id="H61435201D5764CC88011B09A72A02A02" commented="no"><enum>(b)</enum><header>Account</header> <paragraph id="H0986C1D62A42477B8ECD0F9AE7814B0B" commented="no"><enum>(1)</enum><header>Establishment</header><text>There is established in the Treasury of the United States an Account for the receipts and disbursements attributable to the operation of the public health insurance option, including the start-up funding under paragraph (2). Section 1854(g) of the Social Security Act shall apply to receipts described in the previous sentence in the same manner as such section applies to payments or premiums described in such section.</text></paragraph> <paragraph id="H4663FD2204A1437B94E38211019C4BDF" commented="no"><enum>(2)</enum><header>Start-up funding</header> <subparagraph id="H75D4A9B75F8C47098EAD9BC5858C97D6" commented="no"><enum>(A)</enum><header>In general</header><text>In order to provide for the establishment of the public health insurance option, there is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $2,000,000,000. In order to provide for initial claims reserves before the collection of premiums, there are hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, such sums as necessary to cover 90 days worth of claims reserves based on projected enrollment.</text></subparagraph> <subparagraph id="H8419DD2B1FD941828D8BEC5CC524FA46" commented="no"><enum>(B)</enum><header>Amortization of start-up funding</header><text display-inline="yes-display-inline">The Secretary shall provide for the repayment of the startup funding provided under subparagraph (A) to the Treasury in an amortized manner over the 10-year period beginning with Y1.</text></subparagraph> <subparagraph id="H70231542B7F6442282190CE8AA58CA74" commented="no"><enum>(C)</enum><header>Limitation on funding</header><text>Nothing in this section shall be construed as authorizing any additional appropriations to the Account, other than such amounts as are otherwise provided with respect to other Exchange-participating health benefits plans.</text></subparagraph></paragraph> <paragraph id="HA14E5D2EBC364D78B57C175A31CCC756" commented="no"><enum>(3)</enum><header>No bailouts</header><text display-inline="yes-display-inline">In no case shall the public health insurance option receive any Federal funds for purposes of insolvency in any manner similar to the manner in which entities receive Federal funding under the Troubled Assets Relief Program of the Secretary of the Treasury.</text></paragraph></subsection></section> <section id="H0FF127DB6A7749C98AE0B6842D62869E" commented="no"><enum>323.</enum><header>Payment rates for items and services</header> <subsection id="H32F0BB023AAF4450BFF28C2DCB6975FD" display-inline="no-display-inline"><enum>(a)</enum><header>Negotiation of payment rates</header> <paragraph id="HAE85273FF3084FC09BE7296064C19CFF"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">The Secretary shall negotiate payment for the public health insurance option for health care providers and items and services, including prescription drugs, consistent with this section and section 324.</text></paragraph> <paragraph id="H7C91943530B8494ABB4E9C9DA844F10A"><enum>(2)</enum><header>Manner of negotiation</header><text display-inline="yes-display-inline">The Secretary shall negotiate such rates in a manner that results in payment rates that are not lower, in the aggregate, than rates under title XVIII of the Social Security Act, and not higher, in the aggregate, than the average rates paid by other QHBP offering entities for services and health care providers.</text></paragraph> <paragraph id="H43A949BAC49642CE905FA77FD0A94972" commented="no"><enum>(3)</enum><header>Innovative payment methods</header><text display-inline="yes-display-inline">Nothing in this subsection shall be construed as preventing the use of innovative payment methods such as those described in section 324 in connection with the negotiation of payment rates under this subsection.</text></paragraph></subsection> <subsection id="HA84243AC419C4AA5A9EF4A2D5090DE82" display-inline="no-display-inline" commented="no"><enum>(b)</enum><header>Establishment of a provider network</header> <paragraph id="H38DFF946B9424ACFB39664415CD91D05" commented="no"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">Health care providers (including physicians and hospitals) participating in Medicare are participating providers in the public health insurance option unless they opt out in a process established by the Secretary consistent with this subsection.</text></paragraph> <paragraph id="H726D0B02F6DE4D718B30B8CF32F12DAF" commented="no"><enum>(2)</enum><header>Requirements for opt-out process</header><text>Under the process established under paragraph (1)—</text> <subparagraph id="HA88BFCEE8CD347A7A9F122AD403AE5E9" commented="no"><enum>(A)</enum><text>providers described in such paragraph shall be provided at least a 1-year period prior to the first day of Y1 to opt out of participating in the public health insurance option; </text></subparagraph> <subparagraph id="HD9F77081D408492E8EFC86F2EE635C61" commented="no"><enum>(B)</enum><text>no provider shall be subject to a penalty for not participating in the public health insurance option;</text></subparagraph> <subparagraph id="H3A4C22ABB1544C51B8FBD76C2F525638" commented="no"><enum>(C)</enum><text display-inline="yes-display-inline"> the Secretary shall include information on how providers participating in Medicare who chose to opt out of participating in the public health insurance option may opt back in; and</text></subparagraph> <subparagraph id="HB3268C32D325423BAFAB9941EEE52B90" commented="no"><enum>(D)</enum><text display-inline="yes-display-inline">there shall be an annual enrollment period in which providers may decide whether to participate in the public health insurance option.</text></subparagraph></paragraph> <paragraph id="HF7605D2ADEFE493884289E57CD9F4034" commented="no"><enum>(3)</enum><header>Rulemaking</header><text>Not later than 18 months before the first day of Y1, the Secretary shall promulgate rules (pursuant to notice and comment) for the process described in paragraph (1).</text></paragraph></subsection> <subsection id="H1B780E0D98034E00AD6070A949F3D605" commented="no"><enum>(c)</enum><header>Limitations on review</header><text display-inline="yes-display-inline">There shall be no administrative or judicial review of a payment rate or methodology established under this section or under section 324.</text></subsection></section> <section id="HC7AA902CD9054E73B418B5CAED14905C" display-inline="no-display-inline" section-type="subsequent-section" commented="no"><enum>324.</enum><header>Modernized payment initiatives and delivery system reform</header> <subsection id="HE36C5B9FA27242D6BB8174D9C8B56321" display-inline="no-display-inline" commented="no"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">For plan years beginning with Y1, the Secretary may utilize innovative payment mechanisms and policies to determine payments for items and services under the public health insurance option. The payment mechanisms and policies under this section may include patient-centered medical home and other care management payments, accountable care organizations, value-based purchasing, bundling of services, differential payment rates, performance or utilization based payments, partial capitation, and direct contracting with providers.</text></subsection> <subsection id="H753E02BC196748A38F72D7DF624B81F4" commented="no"><enum>(b)</enum><header>Requirements for innovative payments</header><text display-inline="yes-display-inline">The Secretary shall design and implement the payment mechanisms and policies under this section in a manner that—</text> <paragraph id="HAF099856882C4935B8CB218816720BBA" commented="no"><enum>(1)</enum><text display-inline="yes-display-inline">seeks to—</text> <subparagraph id="HF714DFB8FA0548B69638FD084BA72145" commented="no"><enum>(A)</enum><text>improve health outcomes;</text></subparagraph> <subparagraph id="H89F8E534F06843DDBF6F0EEFF397EC6C" commented="no"><enum>(B)</enum><text>reduce health disparities (including racial, ethnic, and other disparities);</text></subparagraph> <subparagraph id="HEF730F9047854F05A22BC79D60AB2042" commented="no"><enum>(C)</enum><text>provide efficient and affordable care;</text></subparagraph> <subparagraph id="HEFDBBBCF245C40D8B6C1EE735599529F" commented="no"><enum>(D)</enum><text>address geographic variation in the provision of health services; or</text></subparagraph> <subparagraph id="H219830E926614B10AAAADCD4EB289E67" commented="no"><enum>(E)</enum><text>prevent or manage chronic illness; and</text></subparagraph></paragraph> <paragraph id="HE4ADFE31FE054B7FBC9BEA24E67EB535" commented="no"><enum>(2)</enum><text>promotes care that is integrated, patient-centered, quality, and efficient.</text></paragraph></subsection> <subsection id="HF13DAB6B074C4DF3876E0A35AFD44C9E" commented="no"><enum>(c)</enum><header>Encouraging the use of high value services</header><text>To the extent allowed by the benefit standards applied to all Exchange-participating health benefits plans, the public health insurance option may modify cost-sharing and payment rates to encourage the use of services that promote health and value. </text></subsection> <subsection id="HF730B473AB8B4EBD98C5CD0796E9BF95" commented="no"><enum>(d)</enum><header>Promotion of delivery system reform</header><text display-inline="yes-display-inline">The Secretary shall monitor and evaluate the progress of payment and delivery system reforms under this Act and shall seek to implement such reforms subject to the following:</text> <paragraph id="HD3171BFE6F7E4150AF8CF28C9B7D0211" commented="no"><enum>(1)</enum><text>To the extent that the Secretary finds a payment and delivery system reform successful in improving quality and reducing costs, the Secretary shall implement such reform on as large a geographic scale as practical and economical.</text></paragraph> <paragraph id="H5CCA2093D4014C448B7A79099B7E9860" commented="no"><enum>(2)</enum><text>The Secretary may delay the implementation of such a reform in geographic areas in which such implementation would place the public health insurance option at a competitive disadvantage.</text></paragraph> <paragraph id="H34C88B40CE38489DAAC072FFE9502510" commented="no"><enum>(3)</enum><text>The Secretary may prioritize implementation of such a reform in high cost geographic areas or otherwise in order to reduce total program costs or to promote high value care.</text></paragraph></subsection> <subsection id="H5D38FF61A46340AC84291F453106BCF4" commented="no"><enum>(e)</enum><header>Non-uniformity permitted</header><text display-inline="yes-display-inline">Nothing in this subtitle shall prevent the Secretary from varying payments based on different payment structure models (such as accountable care organizations and medical homes) under the public health insurance option for different geographic areas.</text></subsection></section> <section id="H97B3AB54700240108ACFDEFDE6CA7AE3" display-inline="no-display-inline" commented="no"><enum>325.</enum><header>Provider participation</header> <subsection id="H38F2CCA1E5B546458796DBA5E5113C81" commented="no"><enum>(a)</enum><header>In general</header><text>The Secretary shall establish conditions of participation for health care providers under the public health insurance option.</text></subsection> <subsection id="HEBE8C217A46841C59C2962D4D695350D" commented="no"><enum>(b)</enum><header>Licensure or certification</header> <paragraph id="H7FC9C43ACC294F029B63F0BC7C34D3B5" commented="no"><enum>(1)</enum><header>In general</header><text>Except as provided in paragraph (2), the Secretary shall not allow a health care provider to participate in the public health insurance option unless such provider is appropriately licensed, certified, or otherwise permitted to practice under State law.</text></paragraph> <paragraph id="HEDF160B6D956409F9C3DFA7C20FAE356" commented="no"><enum>(2)</enum><header>Special rule for IHS facilities and providers</header><text>The requirements under paragraph (1) shall not apply to—</text> <subparagraph id="HD47D00191BFE442BA42A4A43995252C7" commented="no"><enum>(A)</enum><text display-inline="yes-display-inline">a facility that is operated by the Indian Health Service;</text></subparagraph> <subparagraph id="HCB65597B37B744C7934DD60424DBDF5E" commented="no"><enum>(B)</enum><text>a facility operated by an Indian Tribe or tribal organization under the Indian Self-Determination Act (Public Law 93–638); </text></subparagraph> <subparagraph id="H4EC2E7C01FF645B3A3C954EBFCC3C6AB" commented="no"><enum>(C)</enum><text>a health care professional employed by the Indian Health Service; or</text></subparagraph> <subparagraph id="HCF87CC77C4814FEE94E09BF25100F348" commented="no"><enum>(D)</enum><text>a health care professional—</text> <clause id="HE5BDB91E18B34A6A86BB42A4D34E005F" commented="no"><enum>(i)</enum><text>who is employed to provide health care services in a facility operated by an Indian Tribe or tribal organization under the Indian Self-Determination Act; and</text></clause> <clause id="H508CB9278E0A47B29F11E9D1C4F8F0EE" commented="no"><enum>(ii)</enum><text>who is licensed or certified in any State.</text></clause></subparagraph></paragraph></subsection> <subsection id="HDCA38B120B0349B2A99E2AB70DAFF59B" commented="no"><enum>(c)</enum><header>Payment terms for providers</header> <paragraph id="HEEB5E1C878474C848BAAF6B8B367205F" commented="no"><enum>(1)</enum><header>Physicians</header><text>The Secretary shall provide for the annual participation of physicians under the public health insurance option, for which payment may be made for services furnished during the year, in one of 2 classes:</text> <subparagraph id="HCCBC8D0466544F04BC8D0A3346AE8297" commented="no"><enum>(A)</enum><header>Preferred physicians</header><text>Those physicians who agree to accept the payment under section 323 (without regard to cost-sharing) as the payment in full. </text></subparagraph> <subparagraph id="H049B32519B10491DBA17DBC7F64E2233" commented="no"><enum>(B)</enum><header>Participating, non-preferred physicians</header><text display-inline="yes-display-inline">Those physicians who agree not to impose charges (in relation to the payment described in section 323 for such physicians) that exceed the sum of the in-network cost-sharing plus 15 percent of the total payment for each item and service. The Secretary shall reduce the payment described in section 323 for such physicians.</text></subparagraph></paragraph> <paragraph id="H3D2ACDEAD0A244088348E110E2D647A2" commented="no"><enum>(2)</enum><header>Other providers</header><text display-inline="yes-display-inline">The Secretary shall provide for the participation (on an annual or other basis specified by the Secretary) of health care providers (other than physicians) under the public health insurance option under which payment shall only be available if the provider agrees to accept the payment under section 323 (without regard to cost-sharing) as the payment in full. </text></paragraph></subsection> <subsection id="H4BA5AE8FD9F54286879DA2BDEEA99298" commented="no"><enum>(d)</enum><header>Exclusion of certain providers</header><text>The Secretary shall exclude from participation under the public health insurance option a health care provider that is excluded from participation in a Federal health care program (as defined in section 1128B(f) of the Social Security Act).</text></subsection></section> <section id="HE2C2DA89C08F4848B131510AFBDD705B" commented="no"><enum>326.</enum><header>Application of fraud and abuse provisions</header><text display-inline="no-display-inline">Provisions of civil law identified by the Secretary by regulation, in consultation with the Inspector General of the Department of Health and Human Services, that impose sanctions with respect to waste, fraud, and abuse under Medicare, such as sections 3729 through 3733 of title 31, United States Code (commonly known as the False Claims Act), shall also apply to the public health insurance option. </text></section> <section id="HFD47CC3AE9BD4428BEB7489885C0C1DC" commented="no"><enum>327.</enum><header>Application of HIPAA insurance requirements</header><text display-inline="no-display-inline">The requirements of sections 2701 through 2792 of the Public Health Service Act shall apply to the public health insurance option in the same manner as they apply to health insurance coverage offered by a health insurance issuer in the individual market.</text></section> <section id="H600CDE3F0BC649CD9E767B15D4C442A5" commented="no"><enum>328.</enum><header>Application of health information privacy, security, and electronic transaction requirements</header><text display-inline="no-display-inline">Part C of title XI of the Social Security Act, relating to standards for protections against the wrongful disclosure of individually identifiable health information, health information security, and the electronic exchange of health care information, shall apply to the public health insurance option in the same manner as such part applies to other health plans (as defined in section 1171(5) of such Act).</text></section> <section id="H848629BF1A3E4085897A4D6AE337B424" commented="no"><enum>329.</enum><header>Enrollment in public health insurance option is voluntary</header><text display-inline="no-display-inline">Nothing in this division shall be construed as requiring anyone to enroll in the public health insurance option. Enrollment in such option is voluntary.</text></section> <section id="H5D3E51B5406A4513B7565B654BD2A098" commented="no"><enum>330.</enum><header>Enrollment in public health insurance option by Members of Congress</header><text display-inline="no-display-inline">Notwithstanding any other provision of this Act, Members of Congress may enroll in the public health insurance option.</text></section> <section id="HBF7AEE86AD4E4BB391B05589B119AA40" commented="no"><enum>331.</enum><header>Reimbursement of Secretary of Veterans Affairs</header><text display-inline="no-display-inline">The Secretary of Health and Human Services shall seek to enter into a memorandum of understanding with the Secretary of Veterans Affairs regarding the recovery of costs related to non-service-connected care or services provided by the Secretary of Veterans Affairs to an individual covered under the public health insurance option in a manner consistent with recovery of costs related to non-service-connected care from private health insurance plans.</text></section></subtitle> <subtitle id="H8CDB9FC6076D4B6288CF1F1ACC3E9440"><enum>C</enum><header>Individual Affordability Credits</header> <section id="HE4188DF212CD452E8337534DCBBB8CAE"><enum>341.</enum><header>Availability through Health Insurance Exchange</header> <subsection id="H1B2E52069F394595AE561D0659533437" display-inline="no-display-inline"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">Subject to the succeeding provisions of this subtitle, in the case of an affordable credit eligible individual enrolled in an Exchange-participating health benefits plan—</text> <paragraph id="H9F044EA8A2634AD5B024D1769B8C9417"><enum>(1)</enum><text>the individual shall be eligible for, in accordance with this subtitle, affordability credits consisting of—</text> <subparagraph id="H4CAD5C15FBCF4D908756FAB7B6388813"><enum>(A)</enum><text display-inline="yes-display-inline">an affordability premium credit under section 343 to be applied against the premium for the Exchange-participating health benefits plan in which the individual is enrolled; and</text></subparagraph> <subparagraph id="HCF19E9BF74F14639825AC4B46064E3C3"><enum>(B)</enum><text>an affordability cost-sharing credit under section 344 to be applied as a reduction of the cost-sharing otherwise applicable to such plan; and</text></subparagraph></paragraph> <paragraph id="HF514BBF976C04B869D903E0FCE7DD8A3"><enum>(2)</enum><text display-inline="yes-display-inline">the Commissioner shall pay the QHBP offering entity that offers such plan from the Health Insurance Exchange Trust Fund the aggregate amount of affordability credits for all affordable credit eligible individuals enrolled in such plan.</text></paragraph></subsection> <subsection id="HBA7E2545A585490992D6CB66FC77BE74"><enum>(b)</enum><header>Application</header> <paragraph id="HCCF8531B2E4D4746AE2492DA73EC6909"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">An Exchange eligible individual may apply to the Commissioner through the Health Insurance Exchange or through another entity under an arrangement made with the Commissioner, in a form and manner specified by the Commissioner. The Commissioner through the Health Insurance Exchange or through another public entity under an arrangement made with the Commissioner shall make a determination as to eligibility of an individual for affordability credits under this subtitle. The Commissioner shall establish a process whereby, on the basis of information otherwise available, individuals may be deemed to be affordable credit eligible individuals. In carrying this subtitle, the Commissioner shall establish effective methods that ensure that individuals with limited English proficiency are able to apply for affordability credits. </text></paragraph> <paragraph id="HEC774355A40B4F13967082211782999E"><enum>(2)</enum><header>Use of State Medicaid agencies</header><text>If the Commissioner determines that a State Medicaid agency has the capacity to make a determination of eligibility for affordability credits under this subtitle and under the same standards as used by the Commissioner, under the Medicaid memorandum of understanding under section 305(e)(2)—</text> <subparagraph id="HA12736B675534472807C642BAB892171"><enum>(A)</enum><text>the State Medicaid agency is authorized to conduct such determinations for any Exchange-eligible individual who requests such a determination; and</text></subparagraph> <subparagraph id="H79A5A82E8D9A42E1B0386A68010FF977"><enum>(B)</enum><text>the Commissioner shall reimburse the State Medicaid agency for the costs of conducting such determinations.</text></subparagraph></paragraph> <paragraph id="HE682E66D45C747358FED0ADEA5F3666C"><enum>(3)</enum><header>Medicaid screen and enroll obligation</header><text display-inline="yes-display-inline">In the case of an application made under paragraph (1), there shall be a determination of whether the individual is a Medicaid-eligible individual. If the individual is determined to be so eligible, the Commissioner, through the Medicaid memorandum of understanding under section 305(e)(2), shall provide for the enrollment of the individual under the State Medicaid plan in accordance with such Medicaid memorandum of understanding. In the case of such an enrollment, the State shall provide for the same periodic redetermination of eligibility under Medicaid as would otherwise apply if the individual had directly applied for medical assistance to the State Medicaid agency.</text></paragraph> <paragraph id="H84B1A1767A2940F992C5300877839D83"><enum>(4)</enum><header>Application and verification of requirement of citizenship or lawful presence in the United States</header> <subparagraph id="HA0022F9FD057493EBF9CE181AAF98086"><enum>(A)</enum><header>Requirement</header><text display-inline="yes-display-inline">No individual shall be an affordable credit eligible individual (as defined in section 342(a)(1)) unless the individual is a citizen or national of the United States or is lawfully present in a State in the United States (other than as a nonimmigrant described in a subparagraph (excluding subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of the Immigration and Nationality Act).</text></subparagraph> <subparagraph id="H7A74247C60EA42F48B03AE4393ADE967"><enum>(B)</enum><header>Declaration of citizenship or lawful immigration status</header><text display-inline="yes-display-inline">No individual shall be an affordable credit eligible individual unless there has been a declaration made, in a form and manner specified by the Health Choices Commissioner similar to the manner required under section 1137(d)(1) of the Social Security Act and under penalty of perjury, that the individual—</text> <clause id="HB6AEADE97E294288B5A897209AC6BFB0"><enum>(i)</enum><text>is a citizen or national of the United States; or</text></clause> <clause id="H946CA3FE917E40B1A74065017DC8390D"><enum>(ii)</enum><text display-inline="yes-display-inline"> is not such a citizen or national but is lawfully present in a State in the United States (other than as a nonimmigrant described in a subparagraph (excluding subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of the Immigration and Nationality Act).</text></clause><continuation-text continuation-text-level="subparagraph">Such declaration shall be verified in accordance with subparagraph (C) or (D), as the case may be.</continuation-text></subparagraph> <subparagraph id="H2696C0168B7143FC9255EEB030D11F00"><enum>(C)</enum><header>Verification process for citizens</header> <clause id="H26D8EE85CDAD479D94F8AFEB81284EDB"><enum>(i)</enum><header>In general</header><text display-inline="yes-display-inline">In the case of an individual making the declaration described in subparagraph (B)(i), subject to clause (ii), section 1902(ee) of the Social Security Act shall apply to such declaration in the same manner as such section applies to a declaration described in paragraph (1) of such section.</text></clause> <clause id="H8688DFAB78274A13A1D7399D23A23F18"><enum>(ii)</enum><header>Special rules</header><text>In applying section 1902(ee) of such Act under clause (i)—</text> <subclause id="H2557084184FE4FD48D1504AC7FBAC8D9"><enum>(I)</enum><text display-inline="yes-display-inline"> any reference in such section to a State is deemed a reference to the Commissioner (or other public entity making the eligibility determination);</text></subclause> <subclause id="HD9213D1D15364A5CA917588AC2E2D594"><enum>(II)</enum><text>any reference to medical assistance or enrollment under a State plan is deemed a reference to provision of affordability credits under this subtitle;</text></subclause> <subclause id="HD1DE829628824FFFAE77FA66BD18C878"><enum>(III)</enum><text>a reference to a newly enrolled individual under paragraph (2)(A) of such section is deemed a reference to an individual newly in receipt of an affordability credit under this subtitle;</text></subclause> <subclause id="H14994EB86DB54D7CA6218259ED51866A" commented="no"><enum>(IV)</enum><text>approval by the Secretary shall not be required in applying paragraph (2)(B)(ii) of such section; </text></subclause> <subclause id="HDD222752A2F34419BF7C831D75DD0344" commented="no"><enum>(V)</enum><text>paragraph (3) of such section shall not apply; and</text></subclause> <subclause id="H84B517EAECD248159FEC45BB75B95E28"><enum>(VI)</enum><text display-inline="yes-display-inline">before the end of Y2, the Health Choices Commissioner, in consultation with the Commissioner of Social Security, may extend the periods specified in paragraph (1)(B)(ii) of such section.</text></subclause></clause></subparagraph> <subparagraph id="H8FAB5567B40C45A78A45FA2739CF514D"><enum>(D)</enum><header>Verification process for noncitizens</header> <clause id="H11690A8F3E41499D9C8DB484B7FA59C7"><enum>(i)</enum><header>In general</header><text display-inline="yes-display-inline">In the case of an individual making the declaration described in subparagraph (B)(ii), subject to clause (ii), the verification procedures of paragraphs (2) through (5) of section 1137(d) of the Social Security Act shall apply to such declaration in the same manner as such procedures apply to a declaration described in paragraph (1) of such section.</text></clause> <clause id="HE4B054385D8E4F899DF33B5707A17D91" display-inline="no-display-inline"><enum>(ii)</enum><header>Special rules</header><text>In applying such paragraphs of section 1137(d) of such Act under clause (i)—</text> <subclause id="HE1F4DC02C1204B2AB7DBBBB5686645E7"><enum>(I)</enum><text display-inline="yes-display-inline"> any reference in such paragraphs to a State is deemed a reference to the Health Choices Commissioner; and</text></subclause> <subclause id="H6B0148DF971A4F8BA6F12308C6A15EC3"><enum>(II)</enum><text>any reference to benefits under a program is deemed a reference to affordability credits under this subtitle.</text></subclause></clause> <clause id="H8777BC7979D442D396048DEDD179A46A" display-inline="no-display-inline"><enum>(iii)</enum><header>Application to State-based exchanges</header><text display-inline="yes-display-inline">In the case of the application of the verification process under this subparagraph to a State-based Health Insurance Exchange approved under section 308, section 1137(e) of such Act shall apply to the Health Choices Commissioner in relation to the State.</text></clause></subparagraph> <subparagraph id="H61A064A743BE4B0EA06D8B4CF4E567C3"><enum>(E)</enum><header>Annual reports</header><text>The Health Choices Commissioner shall report to Congress annually on the number of applicants for affordability credits under this subtitle, their citizenship or immigration status, and the disposition of their applications. Such report shall be made publicly available and shall include information on—</text> <clause id="HD6121A50E0594B019A417E463B7E6F42"><enum>(i)</enum><text>the number of applicants whose declaration of citizenship or immigration status, name, or social security account number was not consistent with records maintained by the Commissioner of Social Security or the Department of Homeland Security and, of such applicants, the number who contested the inconsistency and sought to document their citizenship or immigration status, name, or social security account number or to correct the information maintained in such records and, of those, the results of such contestations; and</text></clause> <clause id="H57DF3C8B9D464EB4A7BEDD715D348345"><enum>(ii)</enum><text>the administrative costs of conducting the status verification under this paragraph.</text></clause></subparagraph> <subparagraph id="HFFFE1F9CAC034C01977091AA5060227D"><enum>(F)</enum><header>GAO report</header><text>Not later than the end of Y2, the Comptroller General of the United States shall submit to the Committee on Ways and Means, the Committee on Energy and Commerce, the Committee on Education and Labor, and the Committee on the Judiciary of the House of Representatives and the Committee on Finance, the Committee on Health, Education, Labor, and Pensions, and the Committee on the Judiciary of the Senate a report examining the effectiveness of the citizenship and immigration verification systems applied under this paragraph. Such report shall include an analysis of the following:</text> <clause id="H2A648DF8911C476A827E1C537E03F819"><enum>(i)</enum><text>The causes of erroneous determinations under such systems.</text></clause> <clause id="HED0AF15B25E34B4582938E001F659C67"><enum>(ii)</enum><text>The effectiveness of the processes used in remedying such erroneous determinations.</text></clause> <clause id="H00F1665A15FD4B79A571765464012CB5"><enum>(iii)</enum><text display-inline="yes-display-inline">The impact of such systems on individuals, health care providers, and Federal and State agencies, including the effect of erroneous determinations under such systems.</text></clause> <clause id="H17956A010D904578892BB29187B89360"><enum>(iv)</enum><text>The effectiveness of such systems in preventing ineligible individuals from receiving for affordability credits.</text></clause> <clause id="HE528DCCFB356425FB609369706851B87"><enum>(v)</enum><text>The characteristics of applicants described in subparagraph (E)(i).</text></clause></subparagraph> <subparagraph id="HEB611783391B4F22A65F19275A4B8393" commented="no"><enum>(G)</enum><header>Prohibition of database</header><text>Nothing in this paragraph or the amendments made by paragraph (6) shall be construed as authorizing the Health Choices Commissioner or the Commissioner of Social Security to establish a database of information on citizenship or immigration status.</text></subparagraph> <subparagraph id="HD77EB33599B1479EBE669A6C90BFF201"><enum>(H)</enum><header>Initial funding</header> <clause id="H00F4FDC9492A4E41A47BB1C67C473327"><enum>(i)</enum><header>In general</header><text>Out of any funds in the Treasury not otherwise appropriated, there is appropriated to the Commissioner of Social Security $30,000,000, to be available without fiscal year limit to carry out this paragraph and section 205(v) of the Social Security Act.</text></clause> <clause id="HEFF381C61F084841AE80E8C7A9D4510D" commented="no" display-inline="no-display-inline"><enum>(ii)</enum><header>Funding limitation</header><text>In no case shall funds from the Social Security Administration’s Limitation on Administrative Expenses be used to carry out activities related to this paragraph or section 205(v) of the Social Security Act.</text></clause></subparagraph></paragraph> <paragraph id="H8A84176F50FF4E1C85B2092EB960ED4C"><enum>(5)</enum><header>Agreement with Social Security Commissioner</header> <subparagraph id="H30D5C230168243449C98E79330FC3298"><enum>(A)</enum><header>In general</header><text>The Health Choices Commissioner shall enter into and maintain an agreement described in section 205(v)(2) of the Social Security Act with the Commissioner of Social Security.</text></subparagraph> <subparagraph id="H357D8200D45C490ABEB6F455B8DB8FEA" display-inline="no-display-inline"><enum>(B)</enum><header>Funding</header><text>The agreement entered into under subparagraph (A) shall, for each fiscal year (beginning with fiscal year 2013)—</text> <clause id="H087AECFC40B442868EEC821EA21A039D"><enum>(i)</enum><text display-inline="yes-display-inline">provide funds to the Commissioner of Social Security for the full costs of the responsibilities of the Commissioner of Social Security under paragraph (4), including—</text> <subclause id="HA7394E725BA84B80BCC029C9F317280A"><enum>(I)</enum><text>acquiring, installing, and maintaining technological equipment and systems necessary for the fulfillment of the responsibilities of the Commissioner of Social Security under paragraph (4), but only that portion of such costs that are attributable to such responsibilities; and </text></subclause> <subclause id="H24F39F3BC4C24C4CBAFAE2702F2F7F42"><enum>(II)</enum><text>responding to individuals who contest with the Commissioner of Social Security a reported inconsistency with records maintained by the Commissioner of Social Security or the Department of Homeland Security relating to citizenship or immigration status, name, or social security account number under paragraph (4);</text></subclause></clause> <clause id="HE69F2126BB5443EEAAE00E6CCB076ACE"><enum>(ii)</enum><text>based on an estimating methodology agreed to by the Commissioner of Social Security and the Health Choices Commissioner, provide such funds, within 10 calendar days of the beginning of the fiscal year for the first quarter and in advance for all subsequent quarters in that fiscal year; and</text></clause> <clause id="H356425637E1E45C5AA85060810EBDA2C"><enum>(iii)</enum><text>provide for an annual accounting and reconciliation of the actual costs incurred and the funds provided under the agreement.</text></clause></subparagraph> <subparagraph id="HC47DBA4C83C44D1D938BC855F4376F48"><enum>(C)</enum><header>Review of accounting</header><text display-inline="yes-display-inline">The annual accounting and reconciliation conducted pursuant to subparagraph (B)(iii) shall be reviewed by the Inspectors General of the Social Security Administration and the Health Choices Administration, including an analysis of consistency with the requirements of paragraph (4).</text></subparagraph> <subparagraph id="HA5AE95010C774CF3B778A8211562AB22"><enum>(D)</enum><header>Contingency</header><text display-inline="yes-display-inline">In any case in which agreement with respect to the provisions required under subparagraph (B) for any fiscal year has not been reached as of the first day of such fiscal year, the latest agreement with respect to such provisions shall be deemed in effect on an interim basis for such fiscal year until such time as an agreement relating to such provisions is subsequently reached. In any case in which an interim agreement applies for any fiscal year under this subparagraph, the Commissioner of Social Security shall, not later than the first day of such fiscal year, notify the appropriate Committees of the Congress of the failure to reach the agreement with respect to such provisions for such fiscal year. Until such time as the agreement with respect to such provisions has been reached for such fiscal year, the Commissioner of Social Security shall, not later than the end of each 90-day period after October 1 of such fiscal year, notify such Committees of the status of negotiations between such Commissioner and the Health Choices Commissioner in order to reach such an agreement.</text></subparagraph> <subparagraph id="H8253F9786D8E469EA68C0C6BAED826AD"><enum>(E)</enum><header>Application to public entities administering affordability credits</header><text>If the Health Choices Commissioner provides for the conduct of verifications under paragraph (4) through a public entity, the Health Choices Commissioner shall require the public entity to enter into an agreement with the Commissioner of Social Security which provides the same terms as the agreement described in this paragraph (and section 205(v) of the Social Security Act) between the Health Choices Commissioner and the Commissioner of Social Security, except that the Health Choices Commissioner shall be responsible for providing funds for the Commissioner of Social Security in accordance with subparagraphs (B) through (D).</text></subparagraph></paragraph> <paragraph id="HE5F0B31E27514602AA214ED8B2978C18"><enum>(6)</enum><header>Amendments to Social Security Act</header> <subparagraph id="H4D2ABCA063844F4DAE25DB16995B89D5"><enum>(A)</enum><header>Coordination of information between Social Security Administration and Health Choices Administration</header> <clause id="H71C041051B13451C99D42B2569F9C5EC"><enum>(i)</enum><header>In general</header><text display-inline="yes-display-inline">Section 205 of the Social Security Act (42 U.S.C. 405) is amended by adding at the end the following new subsection:</text> <quoted-block style="other" id="HC9783B99A71945E2972635C72A33FD2A" display-inline="no-display-inline" other-style="archaic"> <subsection id="H03831FCBF66A49BF9A00D0E53E19FB35"><enum>(v)</enum><header>Coordination of information with Health Choices Administration</header> <paragraph id="H38E4D13EF44644FD828C56014E074B67" display-inline="yes-display-inline"><enum>(1)</enum><text display-inline="yes-display-inline">The Health Choices Commissioner may collect and use the names and social security account numbers of individuals as required to provide for verification of citizenship under subsection (b)(4)(C) of section 341 of the Affordable Health Care for America Act in connection with determinations of eligibility for affordability credits under such section.</text></paragraph> <paragraph id="HAC1FB436E7B948B9A549B019B016B5FC" indent="up1"><enum>(2)</enum> <subparagraph id="HF5769B6266A3473E93FC330CF274895E" display-inline="yes-display-inline"><enum>(A)</enum><text display-inline="yes-display-inline">The Commissioner of Social Security shall enter into and maintain an agreement with the Health Choices Commissioner for the purpose of establishing, in compliance with the requirements of section 1902(ee) as applied pursuant to section 341(b)(4)(C) of the Affordable Health Care for America Act, a program for verifying information required to be collected by the Health Choices Commissioner under such section 341(b)(4)(C).</text></subparagraph> <subparagraph id="H49F75AFABD0A4357B40A6F4B5C823229" indent="up1"><enum>(B)</enum><text>The agreement entered into pursuant to subparagraph (A) shall include such safeguards as are necessary to ensure the maintenance of confidentiality of any information disclosed for purposes of verifying information described in subparagraph (A) and to provide procedures for permitting the Health Choices Commissioner to use the information for purposes of maintaining the records of the Health Choices Administration.</text></subparagraph> <subparagraph id="HDF732A948AB34DA3A9F2199115B053B6" indent="up1"><enum>(C)</enum><text>The agreement entered into pursuant to subparagraph (A) shall provide that information provided by the Commissioner of Social Security to the Health Choices Commissioner pursuant to the agreement shall be provided at such time, at such place, and in such manner as the Commissioner of Social Security determines appropriate.</text></subparagraph> <subparagraph id="H4474C8006CE3401F8837F4623771DBE9" indent="up1"><enum>(D)</enum><text>Information provided by the Commissioner of Social Security to the Health Choices Commissioner pursuant to an agreement entered into pursuant to subparagraph (A) shall be considered as strictly confidential and shall be used only for the purposes described in this paragraph and for carrying out such agreement. Any officer or employee or former officer or employee of the Health Choices Commissioner, or any officer or employee or former officer or employee of a contractor of the Health Choices Commissioner, who, without the written authority of the Commissioner of Social Security, publishes or communicates any information in such individual’s possession by reason of such employment or position as such an officer shall be guilty of a felony and, upon conviction thereof, shall be fined or imprisoned, or both, as described in section 208.</text></subparagraph></paragraph> <paragraph id="H7A09BA28529547CD97EA38E26BC5B5AC" indent="up1"><enum>(3)</enum><text display-inline="yes-display-inline">The agreement entered into under paragraph (2) shall provide for funding to the Commissioner of Social Security consistent with section 341(b)(5) of Affordable Health Care for America Act.</text></paragraph> <paragraph id="H74D6C0611B1A47C6B5FDABFEB98B7C50" display-inline="no-display-inline" indent="up1"><enum>(4)</enum><text display-inline="yes-display-inline"> This subsection shall apply in the case of a public entity that conducts verifications under section 341(b)(4) of the Affordable Health Care for America Act and the obligations of this subsection shall apply to such an entity in the same manner as such obligations apply to the Health Choices Commissioner when such Commissioner is conducting such verifications.</text></paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block></clause> <clause id="H6F5E53287B9C4A2BA86B4814E0754A23"><enum>(ii)</enum><header>Conforming amendment</header><text>Section 205(c)(2)(C) of such Act (42 U.S.C. 405(c)(2)(C)) is amended by adding at the end the following new clause:</text> <quoted-block style="traditional" id="H98129A569BE94E068B33B717BF68C796" display-inline="no-display-inline"> <clause id="H5B08EC82DFFE4F86BC0ACDC53CCBBC66" indent="up3"><enum>(x)</enum><text display-inline="yes-display-inline">For purposes of the administration of the verification procedures described in section 341(b)(4) of the Affordable Health Care for America Act, the Health Choices Commissioner may collect and use social security account numbers as provided for in section 205(v)(1).</text></clause><after-quoted-block>.</after-quoted-block></quoted-block></clause></subparagraph> <subparagraph id="H585637B4BCD34F2C8C5078EC4F1EDC71" commented="no"><enum>(B)</enum><header>Improving the integrity of data and effectiveness of SAVE</header><text>Section 1137(d) of the Social Security Act (42 U.S.C. 1320b–7(d)) is amended by adding at the end the following new paragraphs:</text> <quoted-block style="traditional" id="HFAB04B02468C4F54BBEAF22D9E930D65" display-inline="no-display-inline"> <paragraph id="H8682DA89337B4A6EB8769E1F472C56A2" indent="up1" commented="no"><enum>(6)</enum> <subparagraph id="H3174045CDF0F42C78B3A251A3C69F19D" display-inline="yes-display-inline" commented="no"><enum>(A)</enum><text display-inline="yes-display-inline">With respect to the use by any agency of the system described in subsection (b) by programs specified in subsection (b) or any other use of such system, the U.S. Citizenship and Immigration Services and any other agency charged with the management of the system shall establish appropriate safeguards necessary to protect and improve the integrity and accuracy of data relating to individuals by—</text> <clause id="HA49CE78C017B45F088815F201D83533E" indent="up1" commented="no"><enum>(i)</enum><text> establishing a process though which such individuals are provided access to, and the ability to amend, correct, and update, their own personally identifiable information contained within the system;</text></clause> <clause id="HF2E3D0B1C28B4FC692B390E127AA15CF" indent="up1" commented="no"><enum>(ii)</enum><text display-inline="yes-display-inline">providing a written response, without undue delay, to any individual who has made such a request to amend, correct, or update such individual’s own personally identifiable information contained within the system; and</text></clause> <clause id="H978CFC460507423C9C6AE007BDACC773" indent="up1" commented="no"><enum>(iii)</enum><text>developing a written notice for user agencies to provide to individuals who are denied a benefit due to a determination of ineligibility based on a final verification determination under the system.</text></clause></subparagraph> <subparagraph id="H6C6792C38A3F4277BD2BC98DF185465C" indent="up1" commented="no"><enum>(B)</enum><text>The notice described in subparagraph (A)(ii) shall include—</text> <clause id="HE5A40C8B87A34433B1F646FE5FF10D35" commented="no"><enum>(i)</enum><text>information about the reason for such notice;</text></clause> <clause id="H5718E58DC16C4C0D909F981698ACDA03" commented="no"><enum>(ii)</enum><text>a description of the right of the recipient of the notice under subparagraph (A)(i) to contest such notice;</text></clause> <clause id="H3B2C33D2261947488219DE7BCAF11160" commented="no"><enum>(iii)</enum><text>a description of the right of the recipient under subparagraph (A)(i) to access and attempt to amend, correct, and update the recipient’s own personally identifiable information contained within records of the system described in paragraph (3); and</text></clause> <clause id="H22F794914C234DD6938191A813241D88" commented="no"><enum>(iv)</enum><text>instructions on how to contest such notice and attempt to correct records of such system relating to the recipient, including contact information for relevant agencies.</text></clause></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph> <subparagraph id="H13C4358490674BC8AD8589D2F6803298"><enum>(C)</enum><header>Streamlining administration of verification process for United States citizens</header><text>Section 1902(ee)(2) of the Social Security Act (42 U.S.C. 1396a(ee)(2)) is amended by adding at the end the following: </text> <quoted-block style="traditional" id="H0F5DFE3B329F42E29F61E3F93A84DC7B" display-inline="no-display-inline"> <subparagraph id="H7AAEDFE4DD7D4D89B29DC10CEC7A7A15" indent="up2"><enum>(D)</enum><text display-inline="yes-display-inline">In carrying out the verification procedures under this subsection with respect to a State, if the Commissioner of Social Security determines that the records maintained by such Commissioner are not consistent with an individual’s allegation of United States citizenship, pursuant to procedures which shall be established by the State in coordination with the Commissioner of Social Security, the Secretary of Homeland Security, and the Secretary of Health and Human Services—</text> <clause id="H2F7A207D6A414EBFB675A8F98D8BF107"><enum>(i)</enum><text>the Commissioner of Social Security shall inform the State of the inconsistency;</text></clause> <clause id="H2647118AAC704274ADFAEC4233985B9D"><enum>(ii)</enum><text>upon being so informed of the inconsistency, the State shall submit the information on the individual to the Secretary of Homeland Security for a determination of whether the records of the Department of Homeland Security indicate that the individual is a citizen; </text></clause> <clause id="HE72F2FC0BE08451EAFA916CEB91E041F"><enum>(iii)</enum><text>upon making such determination, the Department of Homeland Security shall inform the State of such determination; and</text></clause> <clause id="H1E9D357C4EAF441BACE0915084F3353F"><enum>(iv)</enum><text>information provided by the Commissioner of Social Security shall be considered as strictly confidential and shall only be used by the State and the Secretary of Homeland Security for the purposes of such verification procedures.</text></clause></subparagraph> <subparagraph id="H31C6458CF8E84C308D6772FC12038E47" indent="up2"><enum>(E)</enum><text>Verification of status eligibility pursuant to the procedures established under this subsection shall be deemed a verification of status eligibility for purposes of this title, title XXI, and affordability credits under section 341(b)(4) of the Affordable Health Care for America Act, regardless of the program in which the individual is applying for benefits.</text></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph></paragraph></subsection> <subsection id="H938B8E9CC1444398BC4086EBD5380B7A"><enum>(c)</enum><header>Use of affordability credits</header> <paragraph id="H754F9287C9CB4F8C9C30A183E213A012"><enum>(1)</enum><header>In general</header><text>In Y1 and Y2 an affordable credit eligible individual may use an affordability credit only with respect to a basic plan.</text></paragraph> <paragraph id="HF50FD27CB5D947D2A46B86BD1A809F03" display-inline="no-display-inline"><enum>(2)</enum><header>Flexibility in plan enrollment authorized</header><text display-inline="yes-display-inline">Beginning with Y3, the Commissioner shall establish a process to allow an affordability premium credit under section 343, but not the affordability cost-sharing credit under section 344, to be used for enrollees in enhanced or premium plans. In the case of an affordable credit eligible individual who enrolls in an enhanced or premium plan, the individual shall be responsible for any difference between the premium for such plan and the affordability credit amount otherwise applicable if the individual had enrolled in a basic plan.</text></paragraph> <paragraph id="HA35D3458728340C6A4CF65858C840839"><enum>(3)</enum><header>Prohibition of use of public funds for abortion coverage</header><text display-inline="yes-display-inline">An affordability credit may not be used for payment for services described in section 222(d)(4)(A).</text></paragraph></subsection> <subsection id="H08E580838EFD4F158820CC00FBE6B0E1"><enum>(d)</enum><header>Access to data</header><text display-inline="yes-display-inline">In carrying out this subtitle, the Commissioner shall request from the Secretary of the Treasury consistent with section 6103 of the Internal Revenue Code of 1986 such information as may be required to carry out this subtitle.</text></subsection> <subsection id="H96E421BF06B849BAA1E10812FA635835"><enum>(e)</enum><header>No cash rebates</header><text>In no case shall an affordable credit eligible individual receive any cash payment as a result of the application of this subtitle.</text></subsection></section> <section id="HF289603164CA4418B36E28CA63CED5BB"><enum>342.</enum><header>Affordable credit eligible individual</header> <subsection id="H1C63F848C5E04BED8A803E0A77C8A1DD"><enum>(a)</enum><header>Definition</header> <paragraph id="HAD89DBFF0C95491796F48BC976D8D324"><enum>(1)</enum><header>In general</header><text>For purposes of this division, the term <term>affordable credit eligible individual</term> means, subject to subsection (b) and section 346, an individual who is lawfully present in a State in the United States (other than as a nonimmigrant described in a subparagraph (excluding subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of the Immigration and Nationality Act)—</text> <subparagraph id="H2514AB3AAE3A48D78A845AF18C4C0A9A"><enum>(A)</enum><text>who is enrolled under an Exchange-participating health benefits plan and is not enrolled under such plan as an employee (or dependent of an employee) through an employer qualified health benefits plan that meets the requirements of section 412; </text></subparagraph> <subparagraph id="H8479C6EF15AC436ABDB687A95C79B694"><enum>(B)</enum><text>with modified adjusted gross income below 400 percent of the Federal poverty level for a family of the size involved; </text></subparagraph> <subparagraph id="HEF612DD1FCD341D1B443F80FFF4C345D"><enum>(C)</enum><text>who is not a Medicaid eligible individual, other than an individual during a transition period under section 302(d)(3)(B)(ii); and</text></subparagraph> <subparagraph id="H3FE02E83A40D4CD5984365C9E9758A99" commented="no"><enum>(D)</enum><text> subject to paragraph (3), who is not enrolled in acceptable coverage (other than an Exchange-participating health benefits plan).</text></subparagraph></paragraph> <paragraph id="HFEC961EA33084560A196A99B68DCB1D0"><enum>(2)</enum><header>Treatment of family</header><text>Except as the Commissioner may otherwise provide, members of the same family who are affordable credit eligible individuals shall be treated as a single affordable credit individual eligible for the applicable credit for such a family under this subtitle.</text></paragraph> <paragraph id="H5C244426782541479590A2AE281A1CBC" commented="no"><enum>(3)</enum><header>Special rule for Indians</header><text display-inline="yes-display-inline">Subparagraph (D) of paragraph (1) shall not apply to an individual who has coverage that is treated as acceptable coverage for purposes of section 59B(d)(2) of the Internal Revenue Code of 1986 but is not treated as acceptable coverage for purposes of this division.</text></paragraph></subsection> <subsection id="HF510CC22ACED48F487AA19C6307DFD31"><enum>(b)</enum><header>Limitations on employee and dependent disqualification</header><text display-inline="yes-display-inline"/> <paragraph id="HDD3A6161C3694BE69F99F52CC89BC210"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">Subject to paragraph (2), the term <term>affordable credit eligible individual</term> does not include a full-time employee of an employer if the employer offers the employee coverage (for the employee and dependents) as a full-time employee under a group health plan if the coverage and employer contribution under the plan meet the requirements of section 412. </text></paragraph> <paragraph id="H5C6E5E67FBCA49B2B3C7F5DE906D4E8F"><enum>(2)</enum><header>Exceptions</header> <subparagraph id="H4E91FEE7528E4C01A5189A1D0C9724FB"><enum>(A)</enum><header>For certain family circumstances</header><text>The Commissioner shall establish such exceptions and special rules in the case described in paragraph (1) as may be appropriate in the case of a divorced or separated individual or such a dependent of an employee who would otherwise be an affordable credit eligible individual.</text></subparagraph> <subparagraph id="H8BF1A913E7E74D87AF7BB621B510A236"><enum>(B)</enum><header>For unaffordable employer coverage</header><text>Beginning in Y2, in the case of full-time employees for which the cost of the employee premium for coverage under a group health plan would exceed 12 percent of current modified adjusted gross income (determined by the Commissioner on the basis of verifiable documentation), paragraph (1) shall not apply.</text></subparagraph></paragraph></subsection> <subsection id="HE32F1FB1A8E34E19ABC12EFD308BB3EB" display-inline="no-display-inline"><enum>(c)</enum><header>Income defined</header> <paragraph id="HAE3328B14922423682CAA20ABDA61F83"><enum>(1)</enum><header>In general</header><text>In this title, the term <term>income</term> means modified adjusted gross income (as defined in section 59B of the Internal Revenue Code of 1986).</text></paragraph> <paragraph id="H3034E11CB33540C38C6D3AE59CBF0F2D" commented="no"><enum>(2)</enum><header>Study of income disregards</header><text>The Commissioner shall conduct a study that examines the application of income disregards for purposes of this subtitle. Not later than the first day of Y2, the Commissioner shall submit to Congress a report on such study and shall include such recommendations as the Commissioner determines appropriate.</text></paragraph></subsection> <subsection id="H81705C018C2D45C0AA3B58AAFB3070A4" display-inline="no-display-inline"><enum>(d)</enum><header>Clarification of treatment of affordability credits</header><text>Affordability credits under this subtitle shall not be treated, for purposes of title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, to be a benefit provided under section 403 of such title.</text></subsection></section> <section id="HA82AFE51166D4495B9B8EE7A76AC6F8D"><enum>343.</enum><header>Affordability premium credit</header> <subsection id="H7FA2D67CBDC34513878AB7B3954B2AED"><enum>(a)</enum><header>In general</header><text>The affordability premium credit under this section for an affordable credit eligible individual enrolled in an Exchange-participating health benefits plan is in an amount equal to the amount (if any) by which the reference premium amount specified in subsection (c), exceeds the affordable premium amount specified in subsection (b) for the individual, except that in no case shall the affordable premium credit exceed the premium for the plan.</text></subsection> <subsection id="HC51645694AD84009A793A7A4F4298E1B"><enum>(b)</enum><header>Affordable premium amount</header> <paragraph id="HCD050C7DB5A549EF9567419D6CF61C09"><enum>(1)</enum><header>In general</header><text>The affordable premium amount specified in this subsection for an individual for the annual premium in a plan year shall be equal to the product of—</text> <subparagraph id="H7F5CCEA9A8E94A03A3A234E572ADE79A"><enum>(A)</enum><text>the premium percentage limit specified in paragraph (2) for the individual based upon the individual’s modified adjusted gross income for the plan year; and</text></subparagraph> <subparagraph id="H0054306FA13043F7940F8C969880B07B"><enum>(B)</enum><text>the individual’s modified adjusted gross income for such plan year. </text></subparagraph></paragraph> <paragraph id="H324831FA32B246EB9682F4BB106B1EB0" display-inline="no-display-inline"><enum>(2)</enum><header>Premium percentage limits based on table</header><text display-inline="yes-display-inline">The Commissioner shall establish premium percentage limits so that for individuals whose modified adjusted gross income is within an income tier specified in the table in subsection (d) such percentage limits shall increase, on a sliding scale in a linear manner, from the initial premium percentage to the final premium percentage specified in such table for such income tier.</text></paragraph></subsection> <subsection id="H90FD3E8472434C9E8C326FC46C5F3E7F" display-inline="no-display-inline"><enum>(c)</enum><header>Reference premium amount</header><text>The reference premium amount specified in this subsection for a plan year for an individual in a premium rating area is equal to the average premium for the 3 basic plans in the area for the plan year with the lowest premium levels. In computing such amount the Commissioner may exclude plans with extremely limited enrollments.</text></subsection> <subsection id="HBC13311874F64215B98324327DEAF2CE"><enum>(d)</enum><header>Table of premium percentage limits, actuarial value percentages, and out-of-pocket limits for Y1 based on income tier</header> <paragraph id="HB1B4FF536FEF4BB79600F64FDF7487C9" commented="no"><enum>(1)</enum><header>In general</header><text>For purposes of this subtitle, subject to paragraph (3) and section 346, the table specified in this subsection is as follows:</text> <table table-type="" frame="none" colsep="0" rowsep="0" line-rules="no-gen" rule-weights="0.0.0.0.0.4"> <tgroup cols="5" rowsep="0" no-carding="1"><colspec colnum="0" colname="column1" coldef="txt-no-ldr" min-data-value="74" colwidth="78pts"/><colspec colnum="1" colname="column3" align="center" coldef="txt-no-ldr" min-data-value="50" colwidth="53pts"/><colspec colnum="2" colname="column4" align="center" coldef="txt-no-ldr" min-data-value="50" colwidth="53pts"/><colspec colnum="3" colname="column5" align="center" coldef="txt-no-ldr" min-data-value="50" colwidth="53pts"/><colspec colnum="4" colname="dcyrfxyrve" coldef="fig" min-data-value="10" colwidth="56pts"/><thead> <row><entry namest="column1" morerows="0" align="left" colname="column1">In the case of modified adjusted gross income (expressed as a percent of FPL) within the following income tier:</entry><entry namest="column3" morerows="0" colname="column3">The initial premium percentage is—</entry><entry namest="column4" morerows="0" colname="column4">The final premium percentage is—</entry><entry namest="column5" morerows="0" colname="column5">The actuarial value percentage is—</entry><entry namest="dcyrfxyrve" morerows="0" colname="dcyrfxyrve">The out-of-pocket limit for Y1 is—</entry></row></thead> <tbody> <row><entry leader-modify="clr-ldr" colname="column1">133% through 150%</entry><entry leader-modify="clr-ldr" colname="column3">1.5%</entry><entry leader-modify="clr-ldr" colname="column4">3.0%</entry><entry leader-modify="clr-ldr" colname="column5">97%</entry><entry colname="dcyrfxyrve">$500</entry></row> <row><entry leader-modify="clr-ldr" colname="column1">150% through 200%</entry><entry leader-modify="clr-ldr" colname="column3">3.0%</entry><entry leader-modify="clr-ldr" colname="column4">5.5%</entry><entry leader-modify="clr-ldr" colname="column5">93%</entry><entry colname="dcyrfxyrve">$1,000</entry></row> <row><entry leader-modify="clr-ldr" colname="column1">200% through 250%</entry><entry leader-modify="clr-ldr" colname="column3">5.5%</entry><entry leader-modify="clr-ldr" colname="column4">8.0%</entry><entry leader-modify="clr-ldr" colname="column5">85%</entry><entry colname="dcyrfxyrve">$2,000</entry></row> <row><entry leader-modify="clr-ldr" colname="column1">250% through 300%</entry><entry leader-modify="clr-ldr" colname="column3">8.0%</entry><entry leader-modify="clr-ldr" colname="column4">10.0%</entry><entry leader-modify="clr-ldr" colname="column5">78%</entry><entry colname="dcyrfxyrve">$4,000</entry></row> <row><entry leader-modify="clr-ldr" colname="column1">300% through 350%</entry><entry leader-modify="clr-ldr" colname="column3">10.0%</entry><entry leader-modify="clr-ldr" colname="column4">11.0%</entry><entry leader-modify="clr-ldr" colname="column5">72%</entry><entry colname="dcyrfxyrve">$4,500</entry></row> <row><entry leader-modify="clr-ldr" colname="column1">350% through 400%</entry><entry leader-modify="clr-ldr" colname="column3">11.0%</entry><entry leader-modify="clr-ldr" colname="column4">12.0%</entry><entry leader-modify="clr-ldr" colname="column5">70%</entry><entry colname="dcyrfxyrve">$5,000</entry></row></tbody></tgroup></table></paragraph> <paragraph id="HDAC0E6A5BB004FF09732EB8530D18246"><enum>(2)</enum><header>Special rules</header><text display-inline="yes-display-inline">For purposes of applying the table under paragraph (1):</text> <subparagraph id="H25AC4B7919F546C193AA2724D45DCF77"><enum>(A)</enum><header>For lowest level of income</header><text display-inline="yes-display-inline">In the case of an individual with income that does not exceed 133 percent of FPL, the individual shall be considered to have income that is 133 percent of FPL.</text></subparagraph> <subparagraph id="HBA55C6AEC9AE4C6399F747704A704D07"><enum>(B)</enum><header>Application of higher actuarial value percentage at tier transition points</header><text display-inline="yes-display-inline">If two actuarial value percentages may be determined with respect to an individual, the actuarial value percentage shall be the higher of such percentages.</text></subparagraph></paragraph> <paragraph id="H00002357FAC54A71B21DFC6AB2407329"><enum>(3)</enum><header>Indexing</header><text>For years after Y1, the Commissioner shall adjust the initial and final premium percentages to maintain the ratio of governmental to enrollee shares of premiums over time, for each income tier identified in the table in paragraph (1).</text></paragraph></subsection></section> <section id="H47B77D6E05DA442BAE803B3EBE76B286"><enum>344.</enum><header>Affordability cost-sharing credit</header> <subsection id="H4957864D06C94F6F94DB4FB68DCD392D" display-inline="no-display-inline"><enum>(a)</enum><header>In general</header><text>The affordability cost-sharing credit under this section for an affordable credit eligible individual enrolled in an Exchange-participating health benefits plan is in the form of the cost-sharing reduction described in subsection (b) provided under this section for the income tier in which the individual is classified based on the individual’s modified adjusted gross income.</text></subsection> <subsection id="H3420BE6C788C42C4B7A702A57A61BE54"><enum>(b)</enum><header>Cost-sharing reductions</header><text display-inline="yes-display-inline">The Commissioner shall specify a reduction in cost-sharing amounts and the annual limitation on cost-sharing specified in section 222(c)(2)(B) under a basic plan for each income tier specified in the table under section 343(d), with respect to a year, in a manner so that, as estimated by the Commissioner—</text> <paragraph id="HE238A3A6D6B845EEA070102F10A483C6"><enum>(1)</enum><text>the actuarial value of the coverage with such reduced cost-sharing amounts (and the reduced annual cost-sharing limit) is equal to the actuarial value percentage (specified in the table under section 343(d) for the income tier involved) of the full actuarial value if there were no cost-sharing imposed under the plan; and</text></paragraph> <paragraph id="HBA4ED9C07A164B3BA7E86B7F8ED76BA8"><enum>(2)</enum><text>the annual limitation on cost-sharing specified in section 222(c)(2)(B) is reduced to a level that does not exceed the maximum out-of-pocket limit specified in subsection (c).</text></paragraph></subsection> <subsection id="H9EBB764DEE7345E8AEC925749C436918"><enum>(c)</enum><header>Maximum out-of-pocket limit</header> <paragraph id="H910F606783CA494FB261271DDFBCFD98"><enum>(1)</enum><header>In general</header><text>Subject to paragraph (2), the maximum out-of-pocket limit specified in this subsection for an individual within an income tier—</text> <subparagraph id="H75A3EE852FF6459CB943E00B30009784"><enum>(A)</enum><text display-inline="yes-display-inline">for individual coverage—</text> <clause id="H1783BB6C4B6C4989AFC640318D65992D"><enum>(i)</enum><text>for Y1 is the out-of-pocket limit for Y1 specified in subsection (c) in the table under section 343(d) for the income tier involved; or</text></clause> <clause id="HE1DB5C297D54425CBC3D8908CA4FB424"><enum>(ii)</enum><text display-inline="yes-display-inline">for a subsequent year is such out-of-pocket limit for the previous year under this subparagraph increased (rounded to the nearest $10) for each subsequent year by the percentage increase in the enrollment-weighted average of premium increases for basic plans applicable to such year; or</text></clause></subparagraph> <subparagraph id="H2758C059D1604A9C8BF877BEE41734EE"><enum>(B)</enum><text>for family coverage is twice the maximum out-of-pocket limit under subparagraph (A) for the year involved.</text></subparagraph></paragraph> <paragraph id="H47A6F0DD4331422FBA05FB151DFD454B" commented="no"><enum>(2)</enum><header>Adjustment</header><text display-inline="yes-display-inline">The Commissioner shall adjust the maximum out-of-pocket limits under paragraph (1) to ensure that such limits meet the actuarial value percentage specified in the table under section 343(d) for the income tier involved.</text></paragraph></subsection> <subsection id="HFCFE32C4934B47C1A3D34FAE12719D32" commented="no"><enum>(d)</enum><header>Determination and payment of cost-sharing affordability credit</header><text>In the case of an affordable credit eligible individual in a tier enrolled in an Exchange-participating health benefits plan offered by a QHBP offering entity, the Commissioner shall provide for payment to the offering entity of an amount equivalent to the increased actuarial value of the benefits under the plan provided under section 303(c)(2)(B) resulting from the reduction in cost-sharing described in subsections (b) and (c). </text></subsection></section> <section id="H09F5E41094A34CEAA10C26582612DA1A"><enum>345.</enum><header>Income determinations</header> <subsection id="H954454EC34764BFA93A2F25000BEF220"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">In applying this subtitle for an affordability credit for an individual for a plan year, the individual’s income shall be the income (as defined in section 342(c)) for the individual for the most recent taxable year (as determined in accordance with rules of the Commissioner). The Federal poverty level applied shall be such level in effect as of the date of the application.</text></subsection> <subsection id="H53C1DD8B387E45758393BB6358D27BC7"><enum>(b)</enum><header>Program integrity; Income verification procedures</header> <paragraph id="H72A0B36F875248B2946BD085445121DC" commented="no"><enum>(1)</enum><header>Program integrity</header><text>The Commissioner shall take such steps as may be appropriate to ensure the accuracy of determinations and redeterminations under this subtitle.</text></paragraph> <paragraph id="H487802AF4DFC47C7812D0931A7D821FB"><enum>(2)</enum><header>Income verification</header> <subparagraph id="H35D80A8B93624E51A90D7C3489DF69E6"><enum>(A)</enum><header>In general</header><text>Upon an initial application of an individual for an affordability credit under this subtitle (or in applying section 342(b)) or upon an application for a change in the affordability credit based upon a significant change in modified adjusted gross income described in subsection (c)(1)—</text> <clause id="HB2E0213E00DB4BB895A6D7135AC625A0"><enum>(i)</enum><text>the Commissioner shall request from the Secretary of the Treasury the disclosure to the Commissioner of such information as may be permitted to verify the information contained in such application; and</text></clause> <clause id="H6DC20BD26AD1400C82289BD8622FC329"><enum>(ii)</enum><text>the Commissioner shall use the information so disclosed to verify such information.</text></clause></subparagraph> <subparagraph id="H30C3EB04408447D3A7A90D1444ADCCE9"><enum>(B)</enum><header>Alternative procedures</header><text>The Commissioner shall establish procedures for the verification of income for purposes of this subtitle if no income tax return is available for the most recent completed tax year.</text></subparagraph></paragraph></subsection> <subsection id="H6712572897454FD9BB3F10A299AA27F3"><enum>(c)</enum><header>Special rules</header> <paragraph id="H1F4DEE4C24644777B034514A23875CC2"><enum>(1)</enum><header>Changes in income as a percent of FPL</header><text>In the case that an individual’s income (expressed as a percentage of the Federal poverty level for a family of the size involved) for a plan year is expected (in a manner specified by the Commissioner) to be significantly different from the income (as so expressed) used under subsection (a), the Commissioner shall establish rules requiring an individual to report, consistent with the mechanism established under paragraph (2), significant changes in such income (including a significant change in family composition) to the Commissioner and requiring the substitution of such income for the income otherwise applicable.</text></paragraph> <paragraph id="HCBE2796BF2994202B1D52CD614CFD468" commented="no" display-inline="no-display-inline"><enum>(2)</enum><header>Reporting of significant changes in income</header><text display-inline="yes-display-inline">The Commissioner shall establish rules under which an individual determined to be an affordable credit eligible individual would be required to inform the Commissioner when there is a significant change in the modified adjusted gross income of the individual (expressed as a percentage of the FPL for a family of the size involved) and of the information regarding such change. Such mechanism shall provide for guidelines that specify the circumstances that qualify as a significant change, the verifiable information required to document such a change, and the process for submission of such information. If the Commissioner receives new information from an individual regarding the modified adjusted gross income of the individual, the Commissioner shall provide for a redetermination of the individual’s eligibility to be an affordable credit eligible individual.</text></paragraph> <paragraph id="HA8CF0843D1CA489086EAF0CED79D9FE2"><enum>(3)</enum><header>Transition for CHIP</header><text>In the case of a child described in section 302(d)(2), the Commissioner shall establish rules under which the modified adjusted gross income of the child is deemed to be no greater than the family income of the child as most recently determined before Y1 by the State under title XXI of the Social Security Act.</text></paragraph> <paragraph id="H4FB401AC33A849FEA1DAAA15476520DA" commented="no"><enum>(4)</enum><header>Study of geographic variation in application of FPL</header> <subparagraph id="H4C400F64F96A480A8915CC6DD3A1539E"><enum>(A)</enum><header>In general</header><text>The Secretary of Health and Human Services shall conduct a study to examine the feasibility and implication of adjusting the application of the Federal poverty level under this subtitle for different geographic areas so as to reflect the variations in cost-of-living among different areas within the United States. If the Secretary determines that an adjustment is feasible, the study should include a methodology to make such an adjustment. Not later than the first day of Y1, the Secretary shall submit to Congress a report on such study and shall include such recommendations as the Secretary determines appropriate.</text></subparagraph> <subparagraph id="H7EE9453C11864B788937AD5F5F63316F"><enum>(B)</enum><header>Inclusion of territories</header> <clause id="HC7984153355040D3B87221ECF08E3B13"><enum>(i)</enum><header>In general</header><text display-inline="yes-display-inline">The Secretary shall ensure that the study under subparagraph (A) covers the territories of the United States and that special attention is paid to the disparity that exists among poverty levels and the cost of living in such territories and to the impact of such disparity on efforts to expand health coverage and ensure health care.</text></clause> <clause id="H27E415AAD46449228C3A45CA36730579"><enum>(ii)</enum><header>Territories defined</header><text display-inline="yes-display-inline">In this subparagraph, the term <quote>territories of the United States</quote> includes the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, the Northern Mariana Islands, and any other territory or possession of the United States.</text></clause></subparagraph></paragraph></subsection> <subsection id="H4C2797F24CE4483FA58DDDB723BDDB82"><enum>(d)</enum><header>Penalties for misrepresentation</header><text>In the case of an individual who intentionally misrepresents modified adjusted gross income or the individual fails (without regard to intent) to disclose to the Commissioner a significant change in modified adjusted gross income under subsection (c) in a manner that results in the individual becoming an affordable credit eligible individual when the individual is not or in the amount of the affordability credit exceeding the correct amount—</text> <paragraph id="H4006E194CCD94A0EAA68531434BE2FD8"><enum>(1)</enum><text>the individual is liable for repayment of the amount of the improper affordability credit; and</text></paragraph> <paragraph id="H8D5E59BB0FE74D61B000111A4E410708"><enum>(2)</enum><text>in the case of such an intentional misrepresentation or other egregious circumstances specified by the Commissioner, the Commissioner may impose an additional penalty.</text></paragraph></subsection></section> <section id="HEBBCEFD6835A43D2B4AFC5FAC9D18B22"><enum>346.</enum><header>Special rules for application to territories</header> <subsection id="H093B5155E1DD4928820EDE4A6EB6E3FC"><enum>(a)</enum><header>One-time election for treatment and application of funding</header> <paragraph id="H967729F1EEC94E93BE1A5F2AD5BA358D" commented="no"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">A territory may elect, in a form and manner specified by the Commissioner in consultation with the Secretary of Health and Human Services and the Secretary of the Treasury and not later than October 1, 2012, either—</text> <subparagraph id="HE8054BB5E90748CA80F22BB7C21992BC" commented="no"><enum>(A)</enum><text display-inline="yes-display-inline">to be treated as a State for purposes of applying this title and title II; or</text></subparagraph> <subparagraph id="HCB0C5CD60F3C4BABBD6B5FF426820604" commented="no"><enum>(B)</enum><text display-inline="yes-display-inline">not to be so treated but instead, to have the dollar limitation otherwise applicable to the territory under subsections (f) and (g) of section 1108 of the Social Security Act (42 U.S.C. 1308) for a fiscal year increased by a dollar amount equivalent to the cap amount determined under subsection (c)(2) for the territory as applied by the Secretary for the fiscal year involved.</text></subparagraph></paragraph> <paragraph id="HD7F1B2730CD546779790FC626012AA43" commented="no"><enum>(2)</enum><header>Conditions for acceptance</header><text display-inline="yes-display-inline">The Commissioner has the nonreviewable authority to accept or reject an election described in paragraph (1)(A). Any such acceptance is—</text> <subparagraph id="H3528453010F543F6BBD3F205C698B640" commented="no"><enum>(A)</enum><text>contingent upon entering into an agreement described in subsection (b) between the Commissioner and the territory and subsection (c); and</text></subparagraph> <subparagraph id="HACB064C309864EF98639E87D4EA21B11" commented="no"><enum>(B)</enum><text>subject to the approval of the Secretary of Health and Human Services and the Secretary of the Treasury and subject to such other terms and conditions as the Commissioner, in consultation with such Secretaries, may specify.</text></subparagraph></paragraph> <paragraph id="HA2A47CBC5F3B46AF8B5E1AC04F0DC210"><enum>(3)</enum><header>Default rule</header><text>A territory failing to make such an election (or having an election under paragraph (1)(A) not accepted under paragraph (2)) shall be treated as having made the election described in paragraph (1)(B).</text></paragraph></subsection> <subsection id="H1E9AADBA06D94D0D81BC8A6A9DEF3AED" display-inline="no-display-inline"><enum>(b)</enum><header>Agreement for substitution of percentages for affordability credits</header> <paragraph id="H75F0CF3CB05540D286935C34D911EDC7"><enum>(1)</enum><header>Negotiation</header><text display-inline="yes-display-inline">In the case of a territory making an election under subsection (a)(1)(A) (in this section referred to as an <quote>electing territory</quote>) , the Commissioner, in consultation with the Secretaries of Health and Human Services and the Treasury, shall enter into negotiations with the government of such territory so that, before Y1, there is an agreement reached between the parties on the percentages that shall be applied under paragraph (2) for that territory. The Commissioner shall not enter into such an agreement unless—</text> <subparagraph id="HB0000ADC2C6E4E408B8B9E1293A935BC"><enum>(A)</enum><text display-inline="yes-display-inline">payments made under this subtitle with respect to residents of the territory are consistent with the cap established under subsection (c) for such territory and with subsection (d); and</text></subparagraph> <subparagraph id="H2FBD192D2B594894903D8BDC77AD93DB"><enum>(B)</enum><text>the requirements of paragraphs (3) and (4) are met.</text></subparagraph></paragraph> <paragraph id="H0FACB10D01E0475EB10622EE0455CE6A"><enum>(2)</enum><header>Application of substitute percentages and dollar amounts</header><text display-inline="yes-display-inline">In the case of an electing territory, there shall be substituted in section 342(a)(1)(B) and in the table in section 341(d)(1) for 400 percent, 133 percent, and other percentages and dollar amounts specified in such table, such respective percentages and dollar amounts as are established under the agreement under paragraph (1) consistent with the following:</text> <subparagraph id="HB8B8F05D78A947F1A12DF12E5B7A15A7" commented="no"><enum>(A)</enum><header>No income gap between medicaid and affordability credits</header><text>The substituted percentages shall be specified in a manner so as to prevent any gap in coverage for individuals between income level at which medical assistance is available through Medicaid and the income level at which affordability credits are available.</text></subparagraph> <subparagraph id="H5A86F89E3EC04CF5A987FC39E9E744BC" commented="no"><enum>(B)</enum><header>Adjustment for out-of-pocket responsibility for premiums and cost-sharing in relation to income</header><text>The substituted percentages of FPL for income tiers under such table shall be specified in a manner so that—</text> <clause id="H9B6F647E19C84BAA8686F6C4489F2D08" commented="no"><enum>(i)</enum><text>affordable credit eligible individuals residing in the territory bear the same out-of-pocket responsibility for premiums and cost-sharing in relation to average income for residents in that territory, as</text></clause> <clause id="HF051C035CF9E44C3AEC3D595B5924E33" commented="no"><enum>(ii)</enum><text>the out-of-pocket responsibility for premiums and cost-sharing for affordable credit eligible individuals residing in the 50 States or the District of Columbia in relation to average income for such residents.</text></clause></subparagraph></paragraph> <paragraph id="H7F739994419342219089AAD919023EB2" commented="no"><enum>(3)</enum><header>Special rules with respect to application of tax and penalty provisions</header><text>The electing territory shall enact one or more laws under which provisions similar to the following provisions apply with respect to such territory:</text> <subparagraph id="H6114A1EC26364A73B52F705A64B9B5ED" commented="no"><enum>(A)</enum><text display-inline="yes-display-inline">Section 59B of the Internal Revenue Code of 1986, except that any resident of the territory who is not an affordable credit eligible individual but who would be an affordable credit eligible individual if such resident were a resident of one of the 50 States (and any qualifying child residing with such individual) may be treated as covered by acceptable coverage.</text></subparagraph> <subparagraph id="H1EB3B4547DE345F3B54B0894F3F70617" commented="no"><enum>(B)</enum><text>Section 4980H of the Internal Revenue Code of 1986 and section 502(c)(11) of the Employee Retirement Income Security Act of 1974.</text></subparagraph> <subparagraph id="H07ACAAE1FCF14619AC77F185F09B6FC8" commented="no"><enum>(C)</enum><text>Section 3121(c) of the Internal Revenue Code of 1986.</text></subparagraph></paragraph> <paragraph id="HE858063794A644AD94C1069639640F95"><enum>(4)</enum><header>Implementation of insurance reform and consumer protection requirements</header><text display-inline="yes-display-inline">The electing territory shall enact and implement such laws and regulations as may be required to apply the requirements of title II with respect to health insurance coverage offered in the territory.</text></paragraph></subsection> <subsection id="HB1DE16FD098D450F85CD87565B1F4135"><enum>(c)</enum><header>Cap on additional expenditures</header> <paragraph id="H08AAC79986E0464A90135CCF0F7611BB"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">In entering into an agreement with an electing territory under subsection (b), the Commissioner shall ensure that the aggregate expenditures under this subtitle with respect to residents of such territory during the period beginning with Y1 and ending with 2019 will not exceed the cap amount specified in paragraph (2) for such territory. The Commissioner shall adjust from time to time the percentages applicable under such agreement as needed in order to carry out the previous sentence.</text></paragraph> <paragraph id="H205811F447F3472580646E2AF029BBA9"><enum>(2)</enum><header>Cap amount</header> <subparagraph id="H0182B97266234F8B87B55BDE07D80822"><enum>(A)</enum><header>In general</header><text>The cap amount specified in this paragraph—</text> <clause id="H0F4F11E0BBED43DB9ECE88C107836390"><enum>(i)</enum><text>for Puerto Rico is $3,700,000,000 increased by the amount (if any) elected under subparagraph (C); or</text></clause> <clause id="HBFDAE96024C5418B869EC6522FEF416B"><enum>(ii)</enum><text>for another territory is the portion of $300,000,000 negotiated for such territory under subparagraph (B).</text></clause></subparagraph> <subparagraph id="HA2A51005D0004EE29820425820834045"><enum>(B)</enum><header>Negotiation for certain territories</header><text>The Commissioner in consultation with the Secretary of Health and Human Services shall negotiate with the governments of the territories (other than Puerto Rico) to allocate the amount specified in subparagraph (A)(ii) among such territories.</text></subparagraph> <subparagraph id="HF0680E21852C4BF5BF68B3D83A29C1CB"><enum>(C)</enum><header>Optional supplementation for Puerto Rico</header> <clause id="H40D8CA814D3044DAAF84DF5B22B81E42"><enum>(i)</enum><header>In general</header><text display-inline="yes-display-inline">Puerto Rico may elect, in a form and manner specified by the Secretary of Health and Human Services in consultation with the Commissioner to increase the dollar amount specified in subparagraph (A)(i) by up to $1,000,000,000.</text></clause> <clause id="H14D88F5E403847B5B7529AB8D5534582"><enum>(ii)</enum><header>Offset in Medicaid cap</header><text display-inline="yes-display-inline">If Puerto Rico makes the election described in clause (i), the Secretary shall decrease the dollar limitation otherwise applicable to Puerto Rico under subsections (f) and (g) of section 1108 of the Social Security Act (42 U.S.C. 1308) for a fiscal year by the additional aggregate payments the Secretary estimates will be payable under this section for the fiscal year because of such election.</text></clause></subparagraph></paragraph></subsection> <subsection id="HC12C942421CB4705B6C8AC2EE4FB1FB3"><enum>(d)</enum><header>Limitation on funding</header><text display-inline="yes-display-inline">In no case shall this section (including the agreement under subsection (b)) permit—</text> <paragraph id="H0DB6AEBCB354457DBD577B5E7983B239"><enum>(1)</enum><text>the obligation of funds for expenditures under this subtitle for periods beginning on or after January 1, 2020; or</text></paragraph> <paragraph id="H63739CFA2E1A46159D5078F164F14A87"><enum>(2)</enum><text>any increase in the dollar limitation described in subsection (a)(1)(B) for any portion of any fiscal year occurring on or after such date. </text></paragraph></subsection></section> <section id="H079FF1FCE0E04878965F80F13C67D942"><enum>347.</enum><header>No Federal payment for undocumented aliens</header><text display-inline="no-display-inline">Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States.</text></section></subtitle> <enum>IV</enum><header>Shared responsibility</header> <subtitle id="H0FA91F87DC534E8AA3F322CE256CE61E"><enum>A</enum><header>Individual responsibility</header> <section id="HB50884EA9B594260857F93A78D1ED660" section-type="subsequent-section"><enum>401.</enum><header>Individual responsibility</header><text display-inline="no-display-inline">For an individual’s responsibility to obtain acceptable coverage, see section 59B of the Internal Revenue Code of 1986 (as added by section 501 of this Act). </text></section></subtitle> <subtitle id="H8E6386C23A634D52B6C92A8671A37E82"><enum>B</enum><header>Employer Responsibility</header> <part id="H0F3D390F014742CBA523C7EDDA43306F"><enum>1</enum><header>Health coverage participation requirements</header> <section id="H688A524AF0E1402FAEECB246D7F14F8C"><enum>411.</enum><header>Health coverage participation requirements</header><text display-inline="no-display-inline">An employer meets the requirements of this section if such employer does all of the following:</text> <paragraph id="H3F751368E566460492F4AE2D13F7FAA2" display-inline="no-display-inline"><enum>(1)</enum><header>Offer of coverage</header><text>The employer offers each employee individual and family coverage under a qualified health benefits plan (or under a current employment-based health plan (within the meaning of section 202(b))) in accordance with section 412.</text></paragraph> <paragraph id="H9732E6B532094203898C15AADCEC0DA2"><enum>(2)</enum><header>Contribution towards coverage</header><text>If an employee accepts such offer of coverage, the employer makes timely contributions towards such coverage in accordance with section 412.</text></paragraph> <paragraph id="HECE0AB65904A4A0E82BCCBA461E22888" commented="no"><enum>(3)</enum><header>Contribution in lieu of coverage</header><text display-inline="yes-display-inline">Beginning with Y2, if an employee declines such offer but otherwise obtains coverage in an Exchange-participating health benefits plan (other than by reason of being covered by family coverage as a spouse or dependent of the primary insured), the employer shall make a timely contribution to the Health Insurance Exchange with respect to each such employee in accordance with section 413.</text></paragraph></section> <section id="H13980472CBF44B11B0635A4F68D634F0"><enum>412.</enum><header>Employer responsibility to contribute toward employee and dependent coverage</header> <subsection id="H6B437C6FAD714BDF8FF8D9BCF32D8D43" display-inline="no-display-inline"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">An employer meets the requirements of this section with respect to an employee if the following requirements are met:</text> <paragraph id="H70F89E1FB7D346529CB15FB09525C524"><enum>(1)</enum><header>Offering of coverage</header><text display-inline="yes-display-inline">The employer offers the coverage described in section 411(1). In the case of an Exchange-eligible employer, the employer may offer such coverage either through an Exchange-participating health benefits plan or other than through such a plan.</text></paragraph> <paragraph id="H5CDCA3A45A294037B1A3B479A01FC0C1"><enum>(2)</enum><header>Employer required contribution</header><text>The employer timely pays to the issuer of such coverage an amount not less than the employer required contribution specified in subsection (b) for such coverage.</text></paragraph> <paragraph id="H7662885E537D4BC28DDE6309E856354B" commented="no"><enum>(3)</enum><header>Provision of information</header><text display-inline="yes-display-inline">The employer provides the Health Choices Commissioner, the Secretary of Labor, the Secretary of Health and Human Services, and the Secretary of the Treasury, as applicable, with such information as the Commissioner may require to ascertain compliance with the requirements of this section, including the following:</text> <subparagraph id="H318F33B512374037B0A87C84C4966472"><enum>(A)</enum><text>The name, date, and employer identification number of the employer.</text></subparagraph> <subparagraph id="H5AB95C9A343C4F5D8D1D4F311D7031AD"><enum>(B)</enum><text display-inline="yes-display-inline">A certification as to whether the employer offers to its full-time employees (and their dependents) the opportunity to enroll in a qualified health benefits plan or a current employment-based health plan (within the meaning of section 202(b)).</text></subparagraph> <subparagraph id="H230C8C553F624237B0A9FF146001FA7E"><enum>(C)</enum><text>If the employer certifies that the employer did offer to its full-time employees (and their dependents) the opportunity to so enroll—</text> <clause id="H55F7A613CB1F4F49885E206A9418785F"><enum>(i)</enum><text>the months during the calendar year for which such coverage was available; and</text></clause> <clause id="H3F29A41C15164C3CB76A6B292A4D0783"><enum>(ii)</enum><text>the monthly premium for the lowest cost option in each of the enrollment categories under each such plan offered to employees.</text></clause></subparagraph> <subparagraph id="HD8BD1C284A6E45BAA0C152265C75BDB6"><enum>(D)</enum><text>The name, address, and TIN of each full-time employee during the calendar year and the months (if any) during which such employee (and any dependents) were covered under any such plans.</text></subparagraph></paragraph> <paragraph id="H08C1A2F0D2554371ADD498DE9C35D621"><enum>(4)</enum><header>Autoenrollment of employees</header><text>The employer provides for autoenrollment of the employee in accordance with subsection (c). </text></paragraph><continuation-text continuation-text-level="subsection">This subsection shall supersede any law of a State which would prevent automatic payroll deduction of employee contributions to an employment-based health plan. </continuation-text></subsection> <subsection id="H0C6EF5B7FFFE41D6B68179732CBCBAD1"><enum>(b)</enum><header>Reduction of employee premiums through minimum employer contribution</header> <paragraph id="H502E8B6EC3204FD39ED8905B6D9DFA9F"><enum>(1)</enum><header>Full-time employees</header><text display-inline="yes-display-inline">The minimum employer contribution described in this subsection for coverage of a full-time employee (and, if any, the employee’s spouse and qualifying children (as defined in section 152(c) of the Internal Revenue Code of 1986)) under a qualified health benefits plan (or current employment-based health plan) is equal to—</text> <subparagraph id="H4512237290764F51BA23C75F3D88DFD4"><enum>(A)</enum><text display-inline="yes-display-inline">in case of individual coverage, not less than 72.5 percent of the applicable premium (as defined in section 4980B(f)(4) of such Code, subject to paragraph (2)) of the lowest cost plan offered by the employer that is a qualified health benefits plan (or is such current employment-based health plan); and</text></subparagraph> <subparagraph id="H1D43B07145CD40A9A38B7E2B931CC874"><enum>(B)</enum><text display-inline="yes-display-inline">in the case of family coverage which includes coverage of such spouse and children, not less 65 percent of such applicable premium of such lowest cost plan.</text></subparagraph></paragraph> <paragraph id="H212E49F2215C4B7B9F305030A57EFA92" commented="no"><enum>(2)</enum><header>Applicable premium for Exchange coverage</header><text display-inline="yes-display-inline">In this subtitle, the amount of the applicable premium of the lowest cost plan with respect to coverage of an employee under an Exchange-participating health benefits plan is the reference premium amount under section 343(c) for individual coverage (or, if elected, family coverage) for the premium rating area in which the individual or family resides.</text></paragraph> <paragraph id="H71659F80286046B1BB1B306093401E84"><enum>(3)</enum><header>Minimum employer contribution for employees other than full-time employees</header><text display-inline="yes-display-inline">In the case of coverage for an employee who is not a full-time employee, the amount of the minimum employer contribution under this subsection shall be a proportion (as determined in accordance with rules of the Health Choices Commissioner, the Secretary of Labor, the Secretary of Health and Human Services, and the Secretary of the Treasury, as applicable) of the minimum employer contribution under this subsection with respect to a full-time employee that reflects the proportion of—</text> <subparagraph id="HDB177D055A2146FFA66961FF939683A6"><enum>(A)</enum><text>the average weekly hours of employment of the employee by the employer, to</text></subparagraph> <subparagraph id="H67B5581FDF1D48DB9C17E63AABC68659"><enum>(B)</enum><text>the minimum weekly hours specified by the Commissioner for an employee to be a full-time employee.</text></subparagraph></paragraph> <paragraph id="H5E1AC3D0EF4F4AD0B9A2C824DB95DA13"><enum>(4)</enum><header>Salary reductions not treated as employer contributions</header><text>For purposes of this section, any contribution on behalf of an employee with respect to which there is a corresponding reduction in the compensation of the employee shall not be treated as an amount paid by the employer.</text></paragraph></subsection> <subsection id="H054D8A938E7C42FAB18C47F3BA7BBE61"><enum>(c)</enum><header>Automatic enrollment for employer sponsored health benefits</header> <paragraph id="HE63DD51E8FAA4643972CA53185F26390"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">The requirement of this subsection with respect to an employer and an employee is that the employer automatically enroll such employee into the employment-based health benefits plan for individual coverage under the plan option with the lowest applicable employee premium.</text></paragraph> <paragraph id="H558C2737F59A4109B9D846B62DB2581C"><enum>(2)</enum><header>Opt-out</header><text>In no case may an employer automatically enroll an employee in a plan under paragraph (1) if such employee makes an affirmative election to opt out of such plan or to elect coverage under an employment-based health benefits plan offered by such employer. An employer shall provide an employee with a 30-day period to make such an affirmative election before the employer may automatically enroll the employee in such a plan. </text></paragraph> <paragraph id="H22ECF13F0DC24742B97C6741CA45285A"><enum>(3)</enum><header>Notice requirements</header> <subparagraph id="H0D9BD2B8C32743719E0E077425650D83"><enum>(A)</enum><header>In general</header><text>Each employer described in paragraph (1) who automatically enrolls an employee into a plan as described in such paragraph shall provide the employees, within a reasonable period before the beginning of each plan year (or, in the case of new employees, within a reasonable period before the end of the enrollment period for such a new employee), written notice of the employees’ rights and obligations relating to the automatic enrollment requirement under such paragraph. Such notice must be comprehensive and understood by the average employee to whom the automatic enrollment requirement applies.</text></subparagraph> <subparagraph id="H4984FE9FB6D34EE98D22D2653AD90FEA"><enum>(B)</enum><header>Inclusion of specific information</header><text>The written notice under subparagraph (A) must explain an employee’s right to opt out of being automatically enrolled in a plan and in the case that more than one level of benefits or employee premium level is offered by the employer involved, the notice must explain which level of benefits and employee premium level the employee will be automatically enrolled in the absence of an affirmative election by the employee. </text></subparagraph></paragraph></subsection></section> <section id="H98FC04B1493248988F1DF9E089A7DB46"><enum>413.</enum><header>Employer contributions in lieu of coverage</header> <subsection id="H89444F1B444E4BBF99F2864EADB8C3B9"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">A contribution is made in accordance with this section with respect to an employee if such contribution is equal to an amount equal to 8 percent of the average wages paid by the employer during the period of enrollment (determined by taking into account all employees of the employer and in such manner as the Commissioner provides, including rules providing for the appropriate aggregation of related employers) but not to exceed the minimum employer contribution described in section 412(b)(1)(A). Any such contribution—</text> <paragraph id="HF656681756BE4EF78D810C1677E27907"><enum>(1)</enum><text>shall be paid to the Health Choices Commissioner for deposit into the Health Insurance Exchange Trust Fund; and</text></paragraph> <paragraph id="H5D09DFB2D38E433EAC454675A5C3E6A5"><enum>(2)</enum><text>shall not be applied against the premium of the employee under the Exchange-participating health benefits plan in which the employee is enrolled.</text></paragraph></subsection> <subsection id="H5B8C0736D5A64C198060BF4177E15D8C" display-inline="no-display-inline"><enum>(b)</enum><header>Special rules for small employers</header> <paragraph id="H215AA2153EA244EEBEA3D1FAB9FE4670"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">In the case of any employer who is a small employer for any calendar year, subsection (a) shall be applied by substituting the applicable percentage determined in accordance with the following table for <quote>8 percent</quote>: </text> <table table-type="" align-to-level="section" frame="none" colsep="0" rowsep="0" blank-lines-before="1" line-rules="no-gen" rule-weights="0.0.0.0.0.0" table-template-name="Entry: 2 text, bold hds"> <tgroup cols="2" rowsep="0" thead-tbody-ldg-size="0.10.12" grid-typeface="1.1"><colspec colname="column1" colwidth="230pts" colsep="0" rowsep="0" coldef="txt" min-data-value="190"/><colspec colname="column2" colwidth="95pts" colsep="0" rowsep="0" coldef="txt-no-ldr-no-spread" min-data-value="95"/> <tbody> <row><entry colname="column1" rowsep="0" stub-definition="txt-clr" stub-hierarchy="1" leader-modify="clr-ldr"><bold>If the annual payroll of such employer for the preceding calendar year:</bold></entry><entry colname="column2" leader-modify="clr-ldr"><bold>The applicable percentage is:</bold></entry></row> <row><entry colname="column1" rowsep="0" stub-definition="txt-ldr" stub-hierarchy="2">Does not exceed $500,000</entry><entry colname="column2" rowsep="0" leader-modify="clr-ldr">0 percent</entry></row> <row><entry colname="column1" rowsep="0" stub-definition="txt-ldr" stub-hierarchy="2">Exceeds $500,000, but does not exceed $585,000</entry><entry colname="column2" rowsep="0" leader-modify="clr-ldr">2 percent</entry></row> <row><entry colname="column1" rowsep="0" stub-definition="txt-ldr" stub-hierarchy="2">Exceeds $585,000, but does not exceed $670,000</entry><entry colname="column2" rowsep="0" leader-modify="clr-ldr">4 percent</entry></row> <row><entry colname="column1" rowsep="0" stub-definition="txt-ldr" stub-hierarchy="2">Exceeds $670,000, but does not exceed $750,000</entry><entry colname="column2" rowsep="0" leader-modify="clr-ldr">6 percent</entry></row></tbody></tgroup></table></paragraph> <paragraph id="HA445F1E9762A4E358F0D4F30927FD54E"><enum>(2)</enum><header>Small employer</header><text>For purposes of this subsection, the term <term>small employer</term> means any employer for any calendar year if the annual payroll of such employer for the preceding calendar year does not exceed $750,000.</text></paragraph> <paragraph id="H99A72E14034943BEB84A73974B020817"><enum>(3)</enum><header>Annual payroll</header><text display-inline="yes-display-inline">For purposes of this paragraph, the term <term>annual payroll</term> means, with respect to any employer for any calendar year, the aggregate wages paid by the employer during such calendar year.</text></paragraph> <paragraph id="HCFCB1B9C4F5C4597AC2EBBB06F9DFC06"><enum>(4)</enum><header>Aggregation rules</header><text>Related employers and predecessors shall be treated as a single employer for purposes of this subsection.</text></paragraph></subsection></section> <section id="HA4032B6A44B64B5B82D6E8DCFE888E35" commented="no"><enum>414.</enum><header>Authority related to improper steering</header><text display-inline="no-display-inline">The Health Choices Commissioner (in coordination with the Secretary of Labor, the Secretary of Health and Human Services, and the Secretary of the Treasury) shall have authority to set standards for determining whether employers or insurers are undertaking any actions to affect the risk pool within the Health Insurance Exchange by inducing individuals to decline coverage under a qualified health benefits plan (or current employment-based health plan (within the meaning of section 202(b)) offered by the employer and instead to enroll in an Exchange-participating health benefits plan. An employer violating such standards shall be treated as not meeting the requirements of this section.</text></section> <section id="H4286922DAEEE4C88B86F181FCCB0F9E8"><enum>415.</enum><header>Impact study on employer responsibility requirements</header> <subsection id="HE99CD0155AFD4825BFC9BEBEAA12A27F"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">The Secretary of Labor shall conduct a study to examine the effect of the exemptions under section 512(a) and coverage thresholds under this division (in this section referred to collectively as "employer responsibility requirements)on employment-based health plan sponsorship, generally and within specific industries, and the effect of such requirements and thresholds on employers, employment-based health plans, and employees in each industry.</text></subsection> <subsection id="H723408D77A024B6F8AB1E85211BC3C50"><enum>(b)</enum><header>Annual report</header><text>The Secretary of Labor annually shall submit to Congress a report on findings on how employer responsibility requirements have impacted and are likely to impact employers, plans, and employees during the previous year and projected trends.</text></subsection> <subsection id="H45011D4FBF054B269914266168097FFD"><enum>(c)</enum><header>Legislative recommendations</header><text>No later than January 1, 2012 and on an annual basis thereafter, the Secretary of Labor shall submit legislative recommendations to Congress to modify the employer responsibility requirements if the Secretary determines that the requirements are detrimentally affecting or will detrimentally affect employer plan sponsorship or otherwise creating inequities among employers, health plans, and employees. The Secretary may also submit such recommendations as the Secretary determines necessary to improve and strengthen employment-based health plan sponsorship, employer responsibility, and related proposals that would enhance the delivery of health care benefits between employers and employees.</text></subsection></section> <section id="H736A56B2E0464D5F84B12CAC48C3E661"><enum>416.</enum><header>Study on employer hardship exemption</header> <subsection id="HCDB815AC44F142BDA0088FE6D223DF57"><enum>(a)</enum><header>In general</header><text>The Secretary of Labor together with the Secretary of Treasury, the Secretary of Health and Human Services, and the Commissioner, shall conduct a study to examine the impact of the employer responsibility requirements described in section 415(a) and make a recommendation to Congress about whether an employer hardship exemption would be appropriate.</text></subsection> <subsection id="H61D981DFC8CC4D2F8B44B1C384921FC5"><enum>(b)</enum><header>Items included in study</header><text display-inline="yes-display-inline">Within such study the Secretaries and Commissioner shall examine cases where such employer responsibility requirements may pose a particular hardship, and specifically look at employers by industry, profit margin, length of time in business, and size. In this examination, the economic conditions shall be considered, including the rate of increase in business costs, the availability of short-term credit lines, and abilities to restructure debt. In addition, the study shall examine the impact an employer hardship waiver could have on employees.</text></subsection> <subsection id="H0E1F69246F3446E88C186081ED9C0BF3"><enum>(c)</enum><header>Report</header><text>Not later than January 1, 2012, the Secretaries and Commissioner shall report to Congress on their findings and make a recommendation regarding the need or lack of need for a partial or complete employer hardship waiver. The Secretaries and Commissioner may also submit recommendations about the criteria Congress should include when developing eligibility requirements for the employer hardship waiver and what safeguards are necessary to protect the employees of that employer.</text></subsection></section></part> <part id="H6D35B337719540B29E976FC228EC2D2E"><enum>2</enum><header>Satisfaction of Health Coverage Participation Requirements</header> <section id="H5791BB0035DC4B62A75ABC1108A6F169" display-inline="no-display-inline"><enum>421.</enum><header>Satisfaction of health coverage participation requirements under the Employee Retirement Income Security Act of 1974</header> <subsection id="HEA2DF745042F4B5AB4AC690C815F827F"><enum>(a)</enum><header>In general</header><text>Subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by adding at the end the following new part:</text> <quoted-block style="OLC" id="HD7F2D99128F8425A8C8097600A0BB7E8" display-inline="no-display-inline"> <part id="HD35AEF42F6924AC69FC5D37422B4CD01"><enum>8</enum><header>National Health Coverage Participation Requirements</header> <section id="H64ABEF29AF7E455C8B4EB8FB09CFA18F"><enum>801.</enum><header display-inline="yes-display-inline">Election of employer to be subject to national health coverage participation requirements</header> <subsection id="HE197126BD6BF4864928227AD27539A6C"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">An employer may make an election with the Secretary to be subject to the health coverage participation requirements.</text></subsection> <subsection id="H222A428FB1B5409C9007B6D719D23844"><enum>(b)</enum><header>Time and manner</header><text display-inline="yes-display-inline">An election under subsection (a) may be made at such time and in such form and manner as the Secretary may prescribe.</text></subsection></section> <section id="HD126F2309AAD45689B7B71EC17D241FC"><enum>802.</enum><header>Treatment of coverage resulting from election</header> <subsection id="HD0E5783346AE4151964CAF256A0342A3"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">If an employer makes an election to the Secretary under section 801—</text> <paragraph id="HD4F4EC5A0EDA442A8FB15C43331F9A53"><enum>(1)</enum><text>such election shall be treated as the establishment and maintenance of a group health plan (as defined in section 733(a)) for purposes of this title, subject to section 251 of the ; and</text></paragraph> <paragraph id="HBF77D54E657E4CC79522F36C46DED756"><enum>(2)</enum><text display-inline="yes-display-inline">the health coverage participation requirements shall be deemed to be included as terms and conditions of such plan.</text></paragraph></subsection> <subsection id="H00B54E2651FF4CC6BEE1BC011EFFCB8E"><enum>(b)</enum><header>Periodic investigations To discover noncompliance</header><text>The Secretary shall regularly audit a representative sampling of employers and group health plans and conduct investigations and other activities under section 504 with respect to such sampling of plans so as to discover noncompliance with the health coverage participation requirements in connection with such plans. The Secretary shall communicate findings of noncompliance made by the Secretary under this subsection to the Secretary of the Treasury and the Health Choices Commissioner. The Secretary shall take such timely enforcement action as appropriate to achieve compliance.</text></subsection> <subsection id="HACAED68FC7BE481C9D68C0914EB88CE6" commented="no"><enum>(c)</enum><header>Recordkeeping</header><text display-inline="yes-display-inline">To facilitate the audits described in subsection (b), the Secretary shall promulgate recordkeeping requirements for employers to account for both employees of the employer and individuals whom the employer has not treated as employees of the employer but with whom the employer, in the course of its trade or business, has engaged for the performance of labor or services. The scope and content of such recordkeeping requirements shall be determined by the Secretary and shall be designed to ensure that employees who are not properly treated as such may be identified and properly treated.</text></subsection></section> <section id="H1C3B31F2703544EE879F356394D0B2D8" display-inline="no-display-inline"><enum>803.</enum><header>Health coverage participation requirements</header><text display-inline="no-display-inline">For purposes of this part, the term <term>health coverage participation requirements</term> means the requirements of part 1 of subtitle B of title IV of division A of (as in effect on the date of the enactment of such Act).</text></section> <section id="H8FAFDFD3146B4A0C9747F86928B4B16D"><enum>804.</enum><header>Rules for applying requirements</header> <subsection id="HFD354D10CB154B90A3432018E25396D1"><enum>(a)</enum><header>Affiliated groups</header><text>In the case of 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, the election under section 801 shall be made by such employer as the Secretary may provide. Any such election, once made, shall apply to all members of such group.</text></subsection> <subsection id="HC766E63D96D540E3BD4BE5E9E4D0B436"><enum>(b)</enum><header>Separate elections</header><text>Under regulations prescribed by the Secretary, separate elections may be made under section 801 with respect to—</text> <paragraph id="HD31375141B96457D88D6C887FD95D8AB"><enum>(1)</enum><text>separate lines of business, and</text></paragraph> <paragraph id="H3423EDDA2CFF4EF2A0D4BA44A63117A9"><enum>(2)</enum><text>full-time employees and employees who are not full-time employees.</text></paragraph></subsection></section> <section id="H1EF6BBE82ED3426D8C064475F71B0E3C"><enum>805.</enum><header>Termination of election in cases of substantial noncompliance</header><text display-inline="no-display-inline">The Secretary may terminate the election of any employer under section 801 if the Secretary (in coordination with the Health Choices Commissioner) determines that such employer is in substantial noncompliance with the health coverage participation requirements and shall refer any such determination to the Secretary of the Treasury as appropriate.</text></section> <section id="H41EB975D08B04F7DBD5AE1F16DB1480F"><enum>806.</enum><header>Regulations</header><text display-inline="no-display-inline">The Secretary may promulgate such regulations as may be necessary or appropriate to carry out the provisions of this part, in accordance with section 424(a) of the . The Secretary may promulgate any interim final rules as the Secretary determines are appropriate to carry out this part.</text></section></part><after-quoted-block>.</after-quoted-block></quoted-block></subsection> <subsection id="HB952D64A183B49A692EBC4935D2516AF"><enum>(b)</enum><header>Enforcement of health coverage participation requirements</header><text>Section 502 of such Act (29 U.S.C. 1132) is amended—</text> <paragraph id="H76688BC4A8034D5F93AE664500964BC8"><enum>(1)</enum><text>in subsection (a)(6), by striking <quote>paragraph</quote> and all that follows through <quote>subsection (c)</quote> and inserting <quote>paragraph (2), (4), (5), (6), (7), (8), (9), (10), or (11) of subsection (c)</quote>; and</text></paragraph> <paragraph id="HB5A60E9146C54B209BB67AACF0DE067E"><enum>(2)</enum><text display-inline="yes-display-inline">in subsection (c), by redesignating the second paragraph (10) as paragraph (12) and by inserting after the first paragraph (10) the following new paragraph:</text> <quoted-block style="OLC" id="HCE09021415C143CFB070CF63443A1572" display-inline="no-display-inline"> <paragraph id="H017C66973B344A22851B8183309BCAA6"><enum>(11)</enum><header>Health coverage participation requirements</header> <subparagraph id="HA2CC07A815A54482ACFE43419B4B092E"><enum>(A)</enum><header>Civil penalties</header><text>In the case of any employer who fails (during any period with respect to which an election under section 801(a) is in effect) to satisfy the health coverage participation requirements with respect to any employee, the Secretary may assess a civil penalty against the employer of $100 for each day in the period beginning on the date such failure first occurs and ending on the date such failure is corrected.</text></subparagraph> <subparagraph id="H7777F6EEEFD64B87AAA4A5225C55AD7C"><enum>(B)</enum><header>Health coverage participation requirements</header><text>For purposes of this paragraph, the term <term>health coverage participation requirements</term> has the meaning provided in section 803. </text></subparagraph> <subparagraph id="H0B658B01A6724DC891D8771548F66519"><enum>(C)</enum><header>Limitations on amount of penalty</header> <clause id="HBDD494D1B0844B4697B9536A77951410"><enum>(i)</enum><header>Penalty not to apply where failure not discovered exercising reasonable diligence</header><text display-inline="yes-display-inline">No penalty shall be assessed under subparagraph (A) with respect to any failure during any period for which it is established to the satisfaction of the Secretary that the employer did not know, or exercising reasonable diligence would not have known, that such failure existed. </text></clause> <clause id="HF14A4B6A35044AD093D7DB22FD014DFD"><enum>(ii)</enum><header>Penalty not to apply to failures corrected within 30 days</header><text>No penalty shall be assessed under subparagraph (A) with respect to any failure if—</text> <subclause id="H94F5529401DC4D9FA45784CDD68DFC5E"><enum>(I)</enum><text>such failure was due to reasonable cause and not to willful neglect, and </text></subclause> <subclause id="H28815F452B794917AE8DDE680A449FB7"><enum>(II)</enum><text>such failure is corrected during the 30-day period beginning on the 1st date that the employer knew, or exercising reasonable diligence would have known, that such failure existed. </text></subclause></clause> <clause id="H25898095F9EC4825B5BC72274328DF25"><enum>(iii)</enum><header>Overall limitation for unintentional failures</header><text display-inline="yes-display-inline">In the case of failures which are due to reasonable cause and not to willful neglect, the penalty assessed under subparagraph (A) for failures during any 1-year period shall not exceed the amount equal to the lesser of—</text> <subclause id="HE4905483E2184056A1F97480D9A737D6"><enum>(I)</enum><text>10 percent of the aggregate amount paid or incurred by the employer (or predecessor employer) during the preceding 1-year period for group health plans, or</text></subclause> <subclause id="H5037DAE0040043E7AEBC21CA3AA21A63"><enum>(II)</enum><text>$500,000.</text></subclause></clause></subparagraph> <subparagraph id="H8B97372F70944ED1B88F0F22DC424B93"><enum>(D)</enum><header>Advance notification of failure prior to assessment</header><text>Before a reasonable time prior to the assessment of any penalty under this paragraph with respect to any failure by an employer, the Secretary shall inform the employer in writing of such failure and shall provide the employer information regarding efforts and procedures which may be undertaken by the employer to correct such failure.</text></subparagraph> <subparagraph id="HEFFF87B296804C86849ABC66FC340B16" commented="no"><enum>(E)</enum><header>Coordination with excise tax</header><text display-inline="yes-display-inline">Under regulations prescribed in accordance with section 424 of the , the Secretary and the Secretary of the Treasury shall coordinate the assessment of penalties under this section in connection with failures to satisfy health coverage participation requirements with the imposition of excise taxes on such failures under section 4980H(b) of the Internal Revenue Code of 1986 so as to avoid duplication of penalties with respect to such failures.</text></subparagraph> <subparagraph id="H726424DC79FB42259642FAA0446868FE"><enum>(F)</enum><header>Deposit of penalty collected</header><text display-inline="yes-display-inline">Any amount of penalty collected under this paragraph shall be deposited as miscellaneous receipts in the Treasury of the United States. </text></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection> <subsection id="H62EA82579DBF4E91B24604352E518DA6"><enum>(c)</enum><header>Clerical amendments</header><text>The table of contents in section 1 of such Act is amended by inserting after the item relating to section 734 the following new items:</text> <quoted-block style="OLC" id="H33641F4FB09445E3B4DE4BD4C0186E13" display-inline="no-display-inline"> <toc container-level="quoted-block-container" quoted-block="no-quoted-block" lowest-level="section" idref="HD7F2D99128F8425A8C8097600A0BB7E8" regeneration="yes-regeneration" lowest-bolded-level="division-lowest-bolded"> <toc-entry idref="HD35AEF42F6924AC69FC5D37422B4CD01" level="part">Part 8—National Health Coverage Participation Requirements</toc-entry> <toc-entry idref="H64ABEF29AF7E455C8B4EB8FB09CFA18F" level="section">Sec. 801. Election of employer to be subject to national health coverage participation requirements.</toc-entry> <toc-entry idref="HD126F2309AAD45689B7B71EC17D241FC" level="section">Sec. 802. Treatment of coverage resulting from election.</toc-entry> <toc-entry idref="H1C3B31F2703544EE879F356394D0B2D8" level="section">Sec. 803. Health coverage participation requirements.</toc-entry> <toc-entry idref="H8FAFDFD3146B4A0C9747F86928B4B16D" level="section">Sec. 804. Rules for applying requirements.</toc-entry> <toc-entry idref="H1EF6BBE82ED3426D8C064475F71B0E3C" level="section">Sec. 805. Termination of election in cases of substantial noncompliance.</toc-entry> <toc-entry idref="H41EB975D08B04F7DBD5AE1F16DB1480F" level="section">Sec. 806. Regulations.</toc-entry></toc><after-quoted-block>.</after-quoted-block></quoted-block></subsection> <subsection id="H78C0E531F7CF4FBD8DDA3B52E7810519"><enum>(d)</enum><header>Effective date</header><text>The amendments made by this section shall apply to periods beginning after December 31, 2012.</text></subsection></section> <section id="H6BEB0C86241948B49090363AB511A32B"><enum>422.</enum><header>Satisfaction of health coverage participation requirements under the Internal Revenue Code of 1986</header> <subsection id="H45A2A6D52D274B15BBACB201C05A549F"><enum>(a)</enum><header>Failure To elect, or substantially comply with, health coverage participation requirements</header><text display-inline="yes-display-inline">For employment tax on employers who fail to elect, or substantially comply with, the health coverage participation requirements described in part 1, see section 3111(c) of the Internal Revenue Code of 1986 (as added by section 512 of this Act).</text></subsection> <subsection id="H0A7B6A5328D442EAA677C49A963C566C"><enum>(b)</enum><header>Other failures</header><text>For excise tax on other failures of electing employers to comply with such requirements, see section 4980H of the Internal Revenue Code of 1986 (as added by section 511 of this Act).</text></subsection></section> <section id="H6D6B5C56F3FD4B4686FEB8B455BEF1FC" display-inline="no-display-inline" section-type="subsequent-section"><enum>423.</enum><header>Satisfaction of health coverage participation requirements under the Public Health Service Act</header> <subsection id="H2E484AF85532463389FF15CFA9739D6D"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">Part C of title XXVII of the Public Health Service Act is amended by adding at the end the following new section:</text> <quoted-block style="OLC" display-inline="no-display-inline" id="H09B19CCA93C140DE814E89E720E9519F"> <section id="H9482FAE781C045E2B08A73B576D5A9AD"><enum>2793.</enum><header>National health coverage participation requirements</header> <subsection id="H6F7709208C364265A2D7133182DCC854" display-inline="no-display-inline"><enum>(a)</enum><header>Election of employer To be subject to national health coverage participation requirements</header> <paragraph id="H68263386A79E41049C3100DF240B36F0"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">An employer may make an election with the Secretary to be subject to the health coverage participation requirements.</text></paragraph> <paragraph id="H92839AD00F4045ADBB93A49CEAE9E2A2"><enum>(2)</enum><header>Time and manner</header><text display-inline="yes-display-inline">An election under paragraph (1) may be made at such time and in such form and manner as the Secretary may prescribe.</text></paragraph></subsection> <subsection id="HB468B2F1C9DA4255AAC53E