I 

112TH CONGRESS 

2D SESSION H. R. 4224 

To repeal the Patient Protection and Affordable Care Act and the Health 

Care and Education Reconciliation Act of 2010, to amend the Internal 

Revenue Code of 1986 to repeal the percentage floor on medical expense 

deductions, expand the use of tax-preferred health care accounts, and 

establish a charity care credit, to amend the Social Security Act to 

create a Medicare Premium Assistance Program and reform EMTALA 

requirements, and to amend the Public Health Service Act to provide 

for cooperative governing of individual and group health insurance coverage offered in interstate commerce. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 20, 2012 

Mr. BROUN of Georgia introduced the following bill; which was referred to the 

Committee on Energy and Commerce, and in addition to the Committees 

on Ways and Means, Education and the Workforce, the Judiciary, Natural Resources, Rules, Appropriations, and House Administration, 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 repeal the Patient Protection and Affordable Care Act 

and the Health Care and Education Reconciliation Act 

of 2010, to amend the Internal Revenue Code of 1986 

to repeal the percentage floor on medical expense deductions, expand the use of tax-preferred health care accounts, and establish a charity care credit, to amend 

the Social Security Act to create a Medicare Premium 

Assistance Program and reform EMTALA requirements, 


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and to amend the Public Health Service Act to provide 

for cooperative governing of individual and group health 

insurance coverage offered in interstate commerce. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS; CON4 STRUCTION. 

5 (a) SHORT TITLE.—This Act may be cited as the 

6 ‘‘Offering Patients True Individualized Options Now Act 

7 of 2012’’ or the ‘‘OPTION Act of 2012’’. 

8 (b) TABLE OF CONTENTS.—The table of contents of 

9 this Act is as follows: 

Sec. 1. Short title; table of contents; construction. 

TITLE I—REPEAL OF PPACA AND HCERA 

Sec. 101. Repeal of PPACA and HCERA. 

TITLE II—HEALTH CARE TAX REFORM 

Subtitle A—HSA Reform 

Sec. 201. Repeal of high deductible health plan requirement. 

Sec. 202. Increase in deductible HSA contribution limitations. 

Sec. 203. Medicare eligible individuals eligible to contribute to HSA. 

Sec. 204. HSA Rollover to Medicare Advantage MSA. 

Sec. 205. Repeal of additional tax on distributions not used for qualified medical expenses. 

Subtitle B—Other Health Care Tax Reform 

Sec. 206. Elimination of 7.5-percent floor on medical expense deductions. 

Sec. 207. Repeal of prescribed drug limitation on certain tax benefits for medical expenses. 

Sec. 208. Repeal of 2-percent miscellaneous itemized deduction floor for medical expense deductions. 

Sec. 209. Charity care credit. 

Sec. 210. COBRA continuation coverage extended. 

Sec. 211. HSA charitable contributions. 

TITLE III—MEDICARE PREMIUM ASSISTANCE PROGRAM 

Sec. 301. Replacement of Medicare part A entitlement with Medicare Reform 

Premium Assistance Program. 


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TITLE IV—EMTALA REFORMS 

Sec. 401. EMTALA reforms. 

TITLE V—COOPERATIVE GOVERNING OF INDIVIDUAL AND GROUP 

HEALTH INSURANCE COVERAGE 

Sec. 501. Cooperative governing of individual and group health insurance coverage. 

1 (c) CONSTRUCTION.—Nothing in this Act shall be 

2 construed to preclude or prohibit a health care provider 

3 or health insurance issuer from publicly disclosing any 

4 pricing of services provided or covered. 

5 TITLE I—REPEAL OF PPACA AND 

6 HCERA 

7 SEC. 101. REPEAL OF PPACA AND HCERA. 

8 The Patient Protection and Affordable Care Act and 

9 the Health Care and Education Reconciliation Act of 2010 

10 are each repealed, effective as of the respective date of 

11 enactment of each such Act, and the provisions of law 

12 amended or repealed by such Acts are restored or revived 

13 as if such Acts had not been enacted. 

14 TITLE II—HEALTH CARE TAX 

15 REFORM 

16 Subtitle A—HSA Reform 

17 SEC. 201. REPEAL OF HIGH DEDUCTIBLE HEALTH PLAN RE18 QUIREMENT. 

19 (a) IN GENERAL.—Section 223 of the Internal Rev20 enue Code of 1986 is amended by striking subsection (c) 


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1 and redesignating subsections (d) through (h) as sub2 sections (c) through (g), respectively. 

3 (b) CONFORMING AMENDMENTS.— 

4 (1) Subsection (a) of section 223 of such Code 

5 is amended to read as follows: 

6 ‘‘(a) DEDUCTION ALLOWED.—In the case of an indi7 vidual, there shall be allowed as a deduction for a taxable 

8 year an amount equal to the aggregate amount paid in 

9 cash during such taxable year by or on behalf of such indi10 vidual to a health savings account of such individual.’’. 

11 (2) Subsection (b) of section 223 of such Code 

12 is amended by striking paragraph (8). 

13 (3) Subparagraph (A) of section 223(c)(1) of 

14 the Internal Revenue Code of 1986 (as redesignated 

15 by subsection (b)(1)) is amended— 

16 (A) by striking ‘‘subsection (f)(5)’’ and in17 serting ‘‘subsection (e)(5)’’, and 

18 (B) in clause (ii)— 

19 (i) by striking ‘‘the sum of—’’ and all 

20 that follows and inserting ‘‘the dollar 

21 amount in effect under subsection (b)(1).’’. 

22 (4) Section 223(f)(1) of such Code (as redesig23 nated by subsection (b)(1)) is amended by striking 

24 ‘‘Each dollar amount in subsections (b)(2) and 

25 (c)(2)(A)’’ and inserting ‘‘In the case of a taxable 


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1 year beginning after December 31, 2010, each dollar 

2 amount in subsection (b)(1)’’. 

3 (5) Section 26(b)(U) of such Code is amended 

4 by striking ‘‘section 223(f)(4)’’ and inserting ‘‘sec5 tion 223(e)(4)’’. 

6 (6) Sections 35(g)(3), 220(f)(5)(A), 

7 848(e)(1)(v), 4973(a)(5), and 6051(a)(12) of such 

8 Code are each amended by striking ‘‘section 223(d)’’ 

9 each place it appears and inserting ‘‘section 223(c)’’. 

10 (7) Section 106(d)(1) of such Code is amend11 ed— 

12 (A) by striking ‘‘who is an eligible indi13 vidual (as defined in section 223(c)(1))’’, and 

14 (B) by striking ‘‘section 223(d)’’ and in15 serting ‘‘section 223(c)’’. 

16 (8) Section 408(d)(9) of such Code is amend17 ed— 

18 (A) in subparagraph (A) by striking ‘‘who 

19 is an eligible individual (as defined in section 

20 223(c)) and’’, and 

21 (B) in subparagraph (C) by striking ‘‘com22 puted on the basis of the type of coverage under 

23 the high deductible health plan covering the in24 dividual at the time of the qualified HSA fund25 ing distribution’’. 


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1 (9) Section 877A(g)(6) of such Code is amend2 ed by striking ‘‘223(f)(4)’’ and inserting 

3 ‘‘223(e)(4)’’. 

4 (10) Section 4973(g) of such Code is amend5 ed— 

6 (A) by striking ‘‘section 223(d)’’ and in7 serting ‘‘section 223(c)’’, 

8 (B) in paragraph (2), by striking ‘‘section 

9 223(f)(2)’’ and inserting ‘‘section 223(e)(2)’’, 

10 and 

11 (C) by striking ‘‘section 223(f)(3)’’ and in12 serting ‘‘section 223(e)(3)’’. 

13 (11) Section 4975 of such Code is amended— 

14 (A) in subsection (c)(6)— 

15 (i) by striking ‘‘section 223(d)’’ and 

16 inserting ‘‘section 223(c)’’, and 

17 (ii) by striking ‘‘section 223(e)(2)’’ 

18 and inserting ‘‘section 223(d)(2)’’, and 

19 (B) in subsection (e)(1)(E), by striking 

20 ‘‘section 223(d)’’ and inserting ‘‘section 

21 223(c)’’. 

22 (12) Section 6693(a)(2)(C) of such Code is 

23 amended by striking ‘‘section 223(h)’’ and inserting 

24 ‘‘section 223(g)’’. 


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1 (c) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to taxable years beginning after 

3 December 31, 2011. 

4 SEC. 202. INCREASE IN DEDUCTIBLE HSA CONTRIBUTION 

5 LIMITATIONS. 

6 (a) IN GENERAL.—Paragraph (1) of section 223(b) 

7 of the Internal Revenue Code of 1986 is amended by strik8 ing ‘‘the sum of the monthly’’ and all that follows through 

9 ‘‘eligible individual’’ and inserting ‘‘$10,000 ($20,000 in 

10 the case of a joint return)’’. 

11 (b) CONFORMING AMENDMENTS.— 

12 (1) Subsection (b) of such Code is amended by 

13 striking paragraphs (2), (3), and (5) and by redesig14 nating paragraphs (4), (6), and (7) as paragraphs 

15 (2), (3), and (4), respectively. 

16 (2) Paragraph (2) of section 223(b) of such 

17 Code (as redesignated by paragraph (1)) is amended 

18 by striking the last sentence. 

19 (c) EFFECTIVE DATE.—The amendments made by 

20 this section shall apply to taxable years beginning after 

21 December 31, 2011. 

22 SEC. 203. MEDICARE ELIGIBLE INDIVIDUALS ELIGIBLE TO 

23 CONTRIBUTE TO HSA. 

24 (a) Subsection (b) of section 223 of the Internal Rev25 enue Code of 1986 is amended by striking paragraph (7). 


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1 (b) Paragraph (1) of section 223(c) of such Code is 

2 amended by adding at the end the following new subpara3 graph: 

4 ‘‘(C) SPECIAL RULE FOR INDIVIDUALS EN5 TITLED TO BENEFITS UNDER MEDICARE.—In 

6 the case of an individual— 

7 ‘‘(i) who is entitled to benefits under 

8 title XVIII of the Social Security Act, and 

9 ‘‘(ii) with respect to whom a health 

10 savings account is established in a month 

11 before the first month such individual is 

12 entitled to such benefits, 

13 such individual shall be deemed to be an eligible 

14 individual.’’. 

15 (c) EFFECTIVE DATE.—The amendments made by 

16 this section shall apply to taxable years beginning after 

17 December 31, 2011. 

18 SEC. 204. HSA ROLLOVER TO MEDICARE ADVANTAGE MSA. 

19 (a) IN GENERAL.—Paragraph (2) of section 138(b) 

20 of the Internal Revenue Code of 1986 is amended by strik21 ing ‘‘or’’ at the end of subparagraph (A), by adding ‘‘or’’ 

22 at the end of subparagraph (C), and by adding at the end 

23 the following new subparagraph: 

24 ‘‘(C) a HSA rollover contribution described 

25 in subsection (d)(5),’’. 


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1 (b) HSA ROLLOVER CONTRIBUTION.—Subsection (c) 

2 of section 138 of such Code is amended by adding at the 

3 end the following new paragraph: 

4 ‘‘(5) ROLLOVER CONTRIBUTION.—An amount is 

5 described in this paragraph as a rollover contribu6 tion if it meets the requirement of subparagraphs 

7 (A) and (B). 

8 ‘‘(A) IN GENERAL.—The requirements of 

9 this subparagraph are met in the case of an 

10 amount paid or distributed from a health sav11 ings to the account beneficiary to the extent the 

12 amount is received is paid into a Medicare Ad13 vantage MSA of such beneficiary not later than 

14 the 60th day after the day on which the bene15 ficiary receives the payment or distribution. 

16 ‘‘(B) LIMITATION.—This paragraph shall 

17 not apply to any amount described in subpara18 graph (A) received by an individual from a 

19 health savings account if, at any time during 

20 the 1-year period ending on the day of such re21 ceipt, such individual received any other amount 

22 described in subparagraph (A) from a health 

23 savings account which was not includible in the 

24 individual’s gross income because of the appli25 cation of section 223(f)(5)(A).’’. 


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1 (c) CONFORMING AMENDMENT.—Subparagraph (A) 

2 of section 223(f)(5) of such Code is amended by inserting 

3 ‘‘or Medicare Advantage MSA’’ after ‘‘into a health sav4 ings account’’. 

5 (d) EFFECTIVE DATE.—The amendments made by 

6 this section shall apply to taxable years beginning after 

7 December 31, 2011. 

8 SEC. 205. REPEAL OF ADDITIONAL TAX ON DISTRIBUTIONS 

9 NOT USED FOR QUALIFIED MEDICAL EX10 PENSES. 

11 (a) IN GENERAL.—Subsection (f) of section 223 of 

12 the Internal Revenue Code of 1986 is amended by striking 

13 paragraph (4) and redesignating paragraphs (5), (6), and 

14 (7) and paragraphs (4), (5), and (6), respectively. 

15 (b) CONFORMING AMENDMENTS.— 

16 (1) Paragraph (2) of section 25(b) of such Code 

17 is amended by striking subparagraph (U) and by re18 designating subparagraphs (V), (W), and (X) as 

19 subparagraphs (U), (V), and (W). 

20 (2) Subparagraph (C) of section 106(e)(4) of 

21 such Code is amended by striking ‘‘223(f)(5)’’ and 

22 inserting ‘‘223(f)(4)’’. 

23 (3) Paragraph (6) of section 877A(g) of such 

24 Code is amended by striking ‘‘223(f)(4),’’. 


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1 (4) Paragraph (1) of section 4973(g) of such 

2 Code is amended by striking ‘‘223(f)(5)’’ and insert3 ing ‘‘223(f)(4)’’. 

4 (c) EFFECTIVE DATE.—The amendments made by 

5 this section shall apply to taxable years beginning after 

6 December 31, 2011. 

7 Subtitle B—Other Health Care Tax 

8 Reform 

9 SEC. 206. ELIMINATION OF 7.5-PERCENT FLOOR ON MED10 ICAL EXPENSE DEDUCTIONS. 

11 (a) IN GENERAL.—Subsection (a) of section 213 of 

12 the Internal Revenue Code of 1986 is amended by striking 

13 ‘‘, to the extent that such expenses exceed 7.5 percent of 

14 adjusted gross income’’. 

15 (b) CONFORMING AMENDMENT.—Paragraph (1) of 

16 section 56(b) of such Code is amended by striking sub17 paragraph (B). 

18 (c) EFFECTIVE DATE.—The amendments made by 

19 this section shall apply to taxable years beginning after 

20 December 31, 2011. 

21 SEC. 207. REPEAL OF PRESCRIBED DRUG LIMITATION ON 

22 CERTAIN TAX BENEFITS FOR MEDICAL EX23 PENSES. 

24 (a) DEDUCTION FOR MEDICAL EXPENSES.— 


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1 (1) IN GENERAL.—Section 213 of the Internal 

2 Revenue Code of 1986 is amended by striking sub3 section (b). 

4 (2) CONFORMING AMENDMENT.—Subsection (d) 

5 of section 213 of such Code is amended by striking 

6 paragraph (3). 

7 (b) TREATMENT OF REIMBURSEMENTS UNDER ACCI8 DENT OR HEALTH PLANS.—Section 106 of such Code is 

9 amended by striking subsection (f). 

10 (c) HEALTH SAVINGS ACCOUNTS.—Subparagraph 

11 (A) of section 223(d)(2) of such Code is amended by strik12 ing the last sentence thereof. 

13 (d) ARCHER MSAS.—Subparagraph (A) of section 

14 220(d)(2) of such Code is amended by striking the last 

15 sentence thereof. 

16 (e) EFFECTIVE DATE.—The amendments made by 

17 this section shall apply to taxable years beginning after 

18 December 31, 2011. 

19 SEC. 208. REPEAL OF 2-PERCENT MISCELLANEOUS 

20 ITEMIZED DEDUCTION FLOOR FOR MEDICAL 

21 EXPENSE DEDUCTIONS. 

22 (a) IN GENERAL.—Subsection (b) of section 67 of the 

23 Internal Revenue Code of 1986 is amended by striking 

24 paragraph (5). 


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1 (b) EFFECTIVE DATE.—The amendment made by 

2 this section shall apply to taxable years beginning after 

3 the December 31, 2011. 

4 SEC. 209. CHARITY CARE CREDIT. 

5 (a) IN GENERAL.—Subpart A of part IV of sub6 chapter A of chapter 1 of the Internal Revenue Code of 

7 1986 (relating to nonrefundable personal credits) is 

8 amended by inserting after section 25D the following new 

9 section: 

10 ‘‘SEC. 25E. CHARITY CARE CREDIT. 

11 ‘‘(a) ALLOWANCE OF CREDIT.—In the case of a phy12 sician, there shall be allowed as a credit against the tax 

13 imposed by this chapter for a taxable year the amount 

14 determined in accordance with the following table: 

‘‘If the physician has provided during such 

taxable year:.

The amount of 

the credit is: 

At least 25 but less than 30 qualified hours of 

charity care.

$2,000. 

At least 30 but less than 35 qualified hours of 

charity care.

$2,400. 

At least 35 but less than 40 qualified hours of 

charity care.

$2,800. 

At least 40 but less than 45 qualified hours of 

charity care.

$3,200. 

At least 45 but less than 50 qualified hours of 

charity care.

$3,600. 

At least 50 but less than 55 qualified hours of 

charity care.

$4,000. 

At least 55 but less than 60 qualified hours of 

charity care.

$4,400. 

At least 60 but less than 65 qualified hours of 

charity care.

$4,800. 

At least 65 but less than 70 qualified hours of 

charity care.

$5,200. 

At least 70 but less than 75 qualified hours of 

charity care.

$5,600. 

At least 75 but less than 80 qualified hours of 

charity care.

$6,000. 


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At least 80 but less than 85 qualified hours of 

charity care.

$6,400. 

At least 85 but less than 90 qualified hours of 

charity care.

$6,800. 

At least 90 but less than 95 qualified hours of 

charity care.

$7,200. 

At least 95 but less than 100 qualified hours of 

charity care.

$7,600. 

At least 100 hours of charity care ......................... $8,000. 

1 ‘‘(b) QUALIFIED HOURS OF CHARITY CARE.—For 

2 purposes of this section— 

3 ‘‘(1) QUALIFIED HOURS OF CHARITY CARE.— 

4 The term ‘qualified hours of charity care’ means the 

5 hours that a physician provides medical care (as de6 fined in section 213(d)(1)(A)) on a volunteer or pro 

7 bono basis. 

8 ‘‘(2) PHYSICIAN.—The term ‘physician’ has the 

9 meaning given to such term in section 1861(r) of the 

10 Social Security Act (42 U.S.C. 1395x(r)).’’. 

11 (b) CONFORMING AMENDMENT.—The table of sec12 tions for subpart A of part IV of subchapter A of chapter 

13 1 of such Code is amended by inserting after the item 

14 relating to section 25D the following new item: 

‘‘Sec. 25E. Charity care credit.’’. 

15 (c) EFFECTIVE DATE.—The amendments made by 

16 this section shall apply to taxable years beginning after 

17 December 31, 2011. 

18 SEC. 210. COBRA CONTINUATION COVERAGE EXTENDED. 

19 (a) UNDER IRC.—Subparagraph (B) of section 

20 4980B(f)(2) of the Internal Revenue Code of 1986 is 


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1 amended by striking clauses (i) and (v) and by redesig2 nating clauses (ii), (iii), and (iv) as clauses (i), (ii), and 

3 (iii), respectively. 

4 (b) UNDER ERISA.—Paragraph (2) of section 602 

5 of the Employee Retirement Income Security Act of 2009 

6 (29 U.S.C. 1162) is amended by striking subparagraphs 

7 (A) and (E) and by redesignating subparagraphs (B), (C), 

8 and (D) as subparagraphs (A), (B), and (C), respectively. 

9 (c) UNDER PHSA.—Paragraph (2) of section 

10 2202(2) of the Public Health Service Act (42 U.S.C. 

11 300bb–2(2)) is amended by striking subparagraphs (A) 

12 and (E) and by redesignating subparagraphs (B), (C), and 

13 (D) as subparagraphs (A), (B), and (C), respectively. 

14 (d) EFFECTIVE DATE.—The amendments made by 

15 this section shall apply with respect to group health plans, 

16 and health insurance coverage offered in connection with 

17 group health plans, for plan years beginning after the date 

18 of the enactment of this Act. 

19 SEC. 211. HSA CHARITABLE CONTRIBUTIONS. 

20 (a) IN GENERAL.—Subsection (f) of section 223 of 

21 the Internal Revenue Code of 1986 is amended by adding 

22 at the end the following new paragraph: 

23 ‘‘(9) DISTRIBUTIONS FOR CHARITABLE PUR24 POSES.—For purposes of this subsection— 


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1 ‘‘(A) IN GENERAL.—Paragraph (2) shall 

2 not apply to any qualified charitable distribu3 tions with respect to a taxpayer made during 

4 any taxable year. 

5 ‘‘(B) QUALIFIED CHARITABLE DISTRIBU6 TION.—For purposes of this paragraph, the 

7 term ‘qualified charitable distribution’ means 

8 any distribution from a health savings account 

9 which is made directly by the trustee to an or10 ganization described in section 170(b)(1)(A) 

11 (other than any organization described in sec12 tion 509(a)(3) or any fund or account described 

13 in section 4966(d)(2)). A distribution shall be 

14 treated as a qualified charitable distribution 

15 only to the extent that the distribution would be 

16 includible in gross income without regard to 

17 subparagraph (A). 

18 ‘‘(C) CONTRIBUTIONS MUST BE OTHER19 WISE DEDUCTIBLE.—For purposes of this para20 graph, a distribution to an organization de21 scribed in subparagraph (B) shall be treated as 

22 a qualified charitable distribution only if a de23 duction for the entire distribution would be al24 lowable under section 170 (determined without 


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1 regard to subsection (b) thereof and this para2 graph). 

3 ‘‘(D) DENIAL OF DEDUCTION.—Qualified 

4 charitable distributions which are not includible 

5 in gross income pursuant to subparagraph (A) 

6 shall not be taken into account in determining 

7 the deduction under section 170.’’. 

8 (b) EFFECTIVE DATE.—The amendment made by 

9 this section shall apply to taxable years beginning after 

10 December 31, 2011. 

11 TITLE III—MEDICARE PREMIUM 

12 ASSISTANCE PROGRAM 

13 SEC. 301. REPLACEMENT OF MEDICARE PART A ENTITLE14 MENT WITH MEDICARE REFORM PREMIUM 

15 ASSISTANCE PROGRAM. 

16 (a) IN GENERAL.—Section 226 of the Social Security 

17 Act (42 U.S.C. 426) is amended by adding at the end the 

18 following new subsections: 

19 ‘‘(k) REPLACEMENT OF ENTITLEMENT WITH PRE20 MIUM ASSISTANCE PROGRAM.— 

21 ‘‘(1) IN GENERAL.—Notwithstanding the pre22 vious provisions of this section, beginning the first 

23 January 1 after the date of the enactment of the Of24 fering Patients True Individualized Options Act of 


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1 2011, the Secretary shall establish procedures under 

2 which— 

3 ‘‘(A) in the case of an individual who, but 

4 for the application of this paragraph, would 

5 otherwise become entitled under subsection (a) 

6 on or after such January 1 to benefits under 

7 part A of title XVIII, subject to paragraph (4), 

8 the individual shall in lieu of such entitlement 

9 be automatically enrolled in the Medicare Re10 form Premium Assistance Program established 

11 under subsection (l); and 

12 ‘‘(B) in the case of an individual who be13 fore such January 1 is entitled under sub14 section (a) to benefits under part A of title 

15 XVIII, the individual may in lieu of such enti16 tlement elect on or after such January 1 to en17 roll in the Medicare Reform Premium Assist18 ance Program established under subsection (l). 

19 ‘‘(2) TREATMENT UNDER THE INTERNAL REV20 ENUE CODE OF 1986.—An individual who is enrolled 

21 under the Medicare Reform Premium Assistance 

22 Program under paragraph (1) shall not be treated 

23 as entitled to benefits under title XVIII for purposes 

24 of section 223(b)(7) of the Internal Revenue Code of 

25 1986. 


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1 ‘‘(3) INELIGIBILITY FOR PART B OR D BENE2 FITS.—An individual shall not be eligible for benefits 

3 under part B or D of title XVIII once the individual 

4 is enrolled in the Medicare Reform Premium Assist5 ance Program under paragraph (1). 

6 ‘‘(4) OPT OUT.— 

7 ‘‘(A) IN GENERAL.—Any individual who is 

8 otherwise eligible for automatic enrollment in 

9 the Medicare Reform Premium Assistance Pro10 gram under paragraph (1)(A) may elect (in 

11 such form and manner as may be specified by 

12 the Secretary of Health and Human Services) 

13 to not be so enrolled. 

14 ‘‘(B) INDIVIDUALS ELECTING TO OPT OUT

15 NOT TREATED AS ENTITLED TO MEDICARE

16 BENEFITS.—In the case of an individual who 

17 makes an election under subparagraph (A)— 

18 ‘‘(i) such individual shall not be eligi19 ble for benefits under part A of title 

20 XVIII; and 

21 ‘‘(ii) the provisions of paragraphs (2) 

22 and (3) shall apply to such individual in 

23 the same manner as such paragraphs apply 

24 to an individual enrolled under the MediVerDate Mar 15 2010 00:52 Mar 21, 2012 Jkt 019200 PO 00000 Frm 00019 Fmt 6652 Sfmt 6201 E:\BILLS\H4224.IH H4224

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1 care Reform Premium Assistance Program 

2 under paragraph (1). 

3 ‘‘(l) MEDICARE REFORM PREMIUM ASSISTANCE.— 

4 ‘‘(1) ESTABLISHMENT OF PREMIUM ASSIST5 ANCE PROGRAM.—The Secretary shall establish a 

6 program to be known as the Medicare Reform Pre7 mium Assistance Program (in this subsection re8 ferred to as the ‘premium assistance program’) con9 sistent with this subsection. 

10 ‘‘(2) AUTOMATIC ENROLLMENT.—An individual 

11 otherwise entitled under subsection (a) to benefits 

12 under part A of title XVIII shall, subject to sub13 section (k)(4), be enrolled in the premium assistance 

14 program for the period during which such individual 

15 would otherwise be so entitled to benefits. 

16 ‘‘(3) AMOUNT OF PREMIUM ASSISTANCE.— 

17 ‘‘(A) IN GENERAL.—Subject to clause (ii), 

18 for each year that an individual is enrolled in 

19 the premium assistance program, the Secretary 

20 shall provide premium assistance to such indi21 vidual in an amount determined by the Sec22 retary that is based on the geographic location 

23 of the individual and the cost of applicable 

24 health insurance coverage and benefits in such 

25 area. 


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1 ‘‘(B) COMPUTATION OF PREMIUM ASSIST2 ANCE AMOUNTS.—The amount of premium as3 sistance provided to an individual located in a 

4 geographic area for a year shall be computed at 

5 120 percent of the sum of the median premium 

6 and median deductible payment for such year 

7 for all health insurance coverage offered by 

8 health insurance issuers in the individual mar9 ket serving such area. 

10 ‘‘(4) PERMISSIBLE USE OF PREMIUM ASSIST11 ANCE.—Premium assistance under paragraph (3) 

12 may be used only for the following purposes: 

13 ‘‘(A) For payment of premiums, 

14 deductibles, copayments, or other cost-sharing 

15 for enrollment of such individual for health in16 surance coverage offered by health insurance 

17 issuers in the individual market. 

18 ‘‘(B) As a contribution into a MSA plan 

19 established by such individual, as defined in 

20 section 138(b)(2) of the Internal Revenue Code 

21 of 1986. 

22 ‘‘(5) MSA DEPOSITS.—The amount of the pre23 mium assistance received by an individual under this 

24 subsection shall be deposited, on behalf of such indi25 vidual, into the MSA plan of such individual.’’. 


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1 (b) EFFECTIVE DATE.—The amendment made by 

2 this section shall take effect on the first January 1 after 

3 the date of the enactment of this Act. 

4 TITLE IV—EMTALA REFORMS 

5 SEC. 401. EMTALA REFORMS. 

6 (a) USE OF QUALIFIED EMERGENCY DEPARTMENT

7 PERSONNEL IN PERFORMING INITIAL SCREENING.—Sub8 section (a) of section 1867 of the Social Security Act (42 

9 U.S.C. 1395dd) is amended— 

10 (1) by designating the sentence beginning with 

11 ‘‘In the case of’’ as paragraph (1), with the heading 

12 ‘‘IN GENERAL.—’’ and appropriate indentation; and 

13 (2) by adding at the end the following new 

14 paragraph: 

15 ‘‘(2) PERMITTING APPLICATION OF ER

16 TRIAGE.— 

17 ‘‘(A) IN GENERAL.—The requirement of 

18 paragraph (1) that a hospital conduct an appro19 priate medical screening examination of an indi20 vidual is deemed to be satisfied if a qualified 

21 emergency screener (as defined in subparagraph 

22 (B)) performs a preliminary triage-type screen23 ing in which the personnel— 

24 ‘‘(i) assesses the nature and extent of 

25 the individual’s illness or injury; and 


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1 ‘‘(ii) determines, based on such as2 sessment, that an emergency medical con3 dition does not exist. 

4 ‘‘(B) QUALIFIED EMERGENCY SCREENER

5 DEFINED.—In this paragraph, the term ‘quali6 fied emergency screener’ means a physician, li7 censed practical nurse or registered nurse, 

8 qualified emergency medical technician, or other 

9 individual with basic, health care education that 

10 meets standards specified by the Secretary as 

11 being sufficient to perform the screening de12 scribed in subparagraph (A).’’. 

13 (b) REVISION OF EMERGENCY MEDICAL CONDITION

14 DEFINITION.—Subsection (e)(1)(A) of such section is 

15 amended to read as follows: 

16 ‘‘(A) a medical condition manifesting itself 

17 by symptoms of sufficient severity (including se18 vere pain) and with an onset or of a course 

19 such that the absence of immediate medical at20 tention could reasonably be expected to pose an 

21 immediate risk to life or long-term health of the 

22 individual (or, with respect to a pregnant 

23 woman, the life or long-term health of the 

24 woman or her unborn child); or’’. 


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1 (c) EFFECTIVE DATE.—The amendments made by 

2 this section shall take effect on the date of the enactment 

3 of this Act and shall apply to individuals who come to an 

4 emergency room on or after the date that is 30 days after 

5 the date of the enactment of this Act. 

6 TITLE V—COOPERATIVE GOV7 ERNING OF INDIVIDUAL AND 

8 GROUP HEALTH INSURANCE 

9 COVERAGE 

10 SEC. 501. COOPERATIVE GOVERNING OF INDIVIDUAL AND 

11 GROUP HEALTH INSURANCE COVERAGE. 

12 (a) IN GENERAL.—Title XXVII of the Public Health 

13 Service Act (42 U.S.C. 300gg et seq.) is amended by add14 ing at the end the following new part: 

15 ‘‘PART D—COOPERATIVE GOVERNING OF INDI16 VIDUAL AND GROUP HEALTH INSURANCE 

17 COVERAGE 

18 ‘‘SEC. 2795. DEFINITIONS. 

19 ‘‘In this part: 

20 ‘‘(1) PRIMARY STATE.—The term ‘primary 

21 State’ means, with respect to individual or group 

22 health insurance coverage offered by a health insur23 ance issuer, the State designated by the issuer as 

24 the State whose covered laws shall govern the health 

25 insurance issuer in the sale of such coverage under 


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1 this part. An issuer, with respect to a particular pol2 icy, may only designate one such State as its pri3 mary State with respect to all such coverage it of4 fers. Such an issuer may not change the designated 

5 primary State with respect to individual or group 

6 health insurance coverage once the policy is issued, 

7 except that such a change may be made upon re8 newal of the policy. With respect to such designated 

9 State, the issuer is deemed to be doing business in 

10 that State. 

11 ‘‘(2) SECONDARY STATE.—The term ‘secondary 

12 State’ means, with respect to individual or group 

13 health insurance coverage offered by a health insur14 ance issuer, any State that is not the primary State. 

15 In the case of a health insurance issuer that is sell16 ing a policy in, or to a resident of, a secondary 

17 State, the issuer is deemed to be doing business in 

18 that secondary State. 

19 ‘‘(3) HEALTH INSURANCE ISSUER.—The term 

20 ‘health insurance issuer’ has the meaning given such 

21 term in section 2791(b)(2), except that such an 

22 issuer must be licensed in the primary State and be 

23 qualified to sell individual health insurance coverage 

24 in that State. 


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1 ‘‘(4) INDIVIDUAL HEALTH INSURANCE COV2 ERAGE.—The term ‘individual health insurance cov3 erage’ means health insurance coverage offered in 

4 the individual market, as defined in section 

5 2791(e)(1). 

6 ‘‘(5) GROUP HEALTH INSURANCE COVERAGE.— 

7 The term ‘group health insurance coverage’ has the 

8 meaning given such term in 2791(b)(4). 

9 ‘‘(6) APPLICABLE STATE AUTHORITY.—The 

10 term ‘applicable State authority’ means, with respect 

11 to a health insurance issuer in a State, the State in12 surance commissioner or official or officials des13 ignated by the State to enforce the requirements of 

14 this title for the State with respect to the issuer. 

15 ‘‘(7) HAZARDOUS FINANCIAL CONDITION.—The 

16 term ‘hazardous financial condition’ means that, 

17 based on its present or reasonably anticipated finan18 cial condition, a health insurance issuer is unlikely 

19 to be able— 

20 ‘‘(A) to meet obligations to policyholders 

21 with respect to known claims and reasonably 

22 anticipated claims; or 

23 ‘‘(B) to pay other obligations in the normal 

24 course of business. 

25 ‘‘(8) COVERED LAWS.— 


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1 ‘‘(A) IN GENERAL.—The term ‘covered 

2 laws’ means the laws, rules, regulations, agree3 ments, and orders governing the insurance busi4 ness pertaining to— 

5 ‘‘(i) individual or group health insur6 ance coverage issued by a health insurance 

7 issuer; 

8 ‘‘(ii) the offer, sale, rating (including 

9 medical underwriting), renewal, and 

10 issuance of individual or group health in11 surance coverage to an individual; 

12 ‘‘(iii) the provision to an individual in 

13 relation to individual or group health in14 surance coverage of health care and insur15 ance related services; 

16 ‘‘(iv) the provision to an individual in 

17 relation to individual or group health in18 surance coverage of management, oper19 ations, and investment activities of a 

20 health insurance issuer; and 

21 ‘‘(v) the provision to an individual in 

22 relation to individual or group health in23 surance coverage of loss control and claims 

24 administration for a health insurance 


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1 issuer with respect to liability for which 

2 the issuer provides insurance. 

3 ‘‘(B) EXCEPTION.—Such term does not in4 clude any law, rule, regulation, agreement, or 

5 order governing the use of care or cost manage6 ment techniques, including any requirement re7 lated to provider contracting, network access or 

8 adequacy, health care data collection, or quality 

9 assurance. 

10 ‘‘(9) STATE.—The term ‘State’ means the 50 

11 States and includes the District of Columbia, Puerto 

12 Rico, the Virgin Islands, Guam, American Samoa, 

13 and the Northern Mariana Islands. 

14 ‘‘(10) UNFAIR CLAIMS SETTLEMENT PRAC15 TICES.—The term ‘unfair claims settlement prac16 tices’ means only the following practices: 

17 ‘‘(A) Knowingly misrepresenting to claim18 ants and insured individuals relevant facts or 

19 policy provisions relating to coverage at issue. 

20 ‘‘(B) Failing to acknowledge with reason21 able promptness pertinent communications with 

22 respect to claims arising under policies. 

23 ‘‘(C) Failing to adopt and implement rea24 sonable standards for the prompt investigation 

25 and settlement of claims arising under policies. 


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1 ‘‘(D) Failing to effectuate prompt, fair, 

2 and equitable settlement of claims submitted in 

3 which liability has become reasonably clear. 

4 ‘‘(E) Refusing to pay claims without con5 ducting a reasonable investigation. 

6 ‘‘(F) Failing to affirm or deny coverage of 

7 claims within a reasonable period of time after 

8 having completed an investigation related to 

9 those claims. 

10 ‘‘(G) A pattern or practice of compelling 

11 insured individuals or their beneficiaries to in12 stitute suits to recover amounts due under its 

13 policies by offering substantially less than the 

14 amounts ultimately recovered in suits brought 

15 by them. 

16 ‘‘(H) A pattern or practice of attempting 

17 to settle or settling claims for less than the 

18 amount that a reasonable person would believe 

19 the insured individual or his or her beneficiary 

20 was entitled by reference to written or printed 

21 advertising material accompanying or made 

22 part of an application. 

23 ‘‘(I) Attempting to settle or settling claims 

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1 ally altered without notice to, or knowledge or 

2 consent of, the insured. 

3 ‘‘(J) Failing to provide forms necessary to 

4 present claims within 15 calendar days of a re5 quests with reasonable explanations regarding 

6 their use. 

7 ‘‘(K) Attempting to cancel a policy in less 

8 time than that prescribed in the policy or by the 

9 law of the primary State. 

10 ‘‘(11) FRAUD AND ABUSE.—The term ‘fraud 

11 and abuse’ means an act or omission committed by 

12 a person who, knowingly and with intent to defraud, 

13 commits, or conceals any material information con14 cerning, one or more of the following: 

15 ‘‘(A) Presenting, causing to be presented 

16 or preparing with knowledge or belief that it 

17 will be presented to or by an insurer, a rein18 surer, broker or its agent, false information as 

19 part of, in support of or concerning a fact ma20 terial to one or more of the following: 

21 ‘‘(i) An application for the issuance or 

22 renewal of an insurance policy or reinsur23 ance contract. 

24 ‘‘(ii) The rating of an insurance policy 

25 or reinsurance contract. 


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1 ‘‘(iii) A claim for payment or benefit 

2 pursuant to an insurance policy or reinsur3 ance contract. 

4 ‘‘(iv) Premiums paid on an insurance 

5 policy or reinsurance contract. 

6 ‘‘(v) Payments made in accordance 

7 with the terms of an insurance policy or 

8 reinsurance contract. 

9 ‘‘(vi) A document filed with the com10 missioner or the chief insurance regulatory 

11 official of another jurisdiction. 

12 ‘‘(vii) The financial condition of an in13 surer or reinsurer. 

14 ‘‘(viii) The formation, acquisition, 

15 merger, reconsolidation, dissolution or 

16 withdrawal from one or more lines of in17 surance or reinsurance in all or part of a 

18 State by an insurer or reinsurer. 

19 ‘‘(ix) The issuance of written evidence 

20 of insurance. 

21 ‘‘(x) The reinstatement of an insur22 ance policy. 

23 ‘‘(B) Solicitation or acceptance of new or 

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1 ness of insurance by a person who knows or 

2 should know that the insurer or other person 

3 responsible for the risk is insolvent at the time 

4 of the transaction. 

5 ‘‘(C) Transaction of the business of insur6 ance in violation of laws requiring a license, cer7 tificate of authority or other legal authority for 

8 the transaction of the business of insurance. 

9 ‘‘(D) Attempt to commit, aiding or abet10 ting in the commission of, or conspiracy to com11 mit the acts or omissions specified in this para12 graph. 

13 ‘‘SEC. 2796. APPLICATION OF LAW. 

14 ‘‘(a) IN GENERAL.—The covered laws of the primary 

15 State shall apply to individual and group health insurance 

16 coverage offered by a health insurance issuer in the pri17 mary State and in any secondary State, but only if the 

18 coverage and issuer comply with the conditions of this sec19 tion with respect to the offering of coverage in any sec20 ondary State. 

21 ‘‘(b) EXEMPTIONS FROM COVERED LAWS IN A SEC22 ONDARY STATE.—Except as provided in this section, a 

23 health insurance issuer with respect to its offer, sale, rat24 ing (including medical underwriting), renewal, and 

25 issuance of individual or group health insurance coverage 


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1 in any secondary State is exempt from any covered laws 

2 of the secondary State (and any rules, regulations, agree3 ments, or orders sought or issued by such State under or 

4 related to such covered laws) to the extent that such laws 

5 would— 

6 ‘‘(1) make unlawful, or regulate, directly or in7 directly, the operation of the health insurance issuer 

8 operating in the secondary State, except that any 

9 secondary State may require such an issuer— 

10 ‘‘(A) to pay, on a nondiscriminatory basis, 

11 applicable premium and other taxes (including 

12 high risk pool assessments) which are levied on 

13 insurers and surplus lines insurers, brokers, or 

14 policyholders under the laws of the State; 

15 ‘‘(B) to register with and designate the 

16 State insurance commissioner as its agent solely 

17 for the purpose of receiving service of legal doc18 uments or process; 

19 ‘‘(C) to submit to an examination of its fi20 nancial condition by the State insurance com21 missioner in any State in which the issuer is 

22 doing business to determine the issuer’s finan23 cial condition, if— 

24 ‘‘(i) the State insurance commissioner 

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1 amination within the period recommended 

2 by the National Association of Insurance 

3 Commissioners; and 

4 ‘‘(ii) any such examination is con5 ducted in accordance with the examiners’ 

6 handbook of the National Association of 

7 Insurance Commissioners and is coordi8 nated to avoid unjustified duplication and 

9 unjustified repetition; 

10 ‘‘(D) to comply with a lawful order 

11 issued— 

12 ‘‘(i) in a delinquency proceeding com13 menced by the State insurance commis14 sioner if there has been a finding of finan15 cial impairment under subparagraph (C); 

16 or 

17 ‘‘(ii) in a voluntary dissolution pro18 ceeding; 

19 ‘‘(E) to comply with an injunction issued 

20 by a court of competent jurisdiction, upon a pe21 tition by the State insurance commissioner al22 leging that the issuer is in hazardous financial 

23 condition; 

24 ‘‘(F) to participate, on a nondiscriminatory 

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1 sociation or similar association to which a 

2 health insurance issuer in the State is required 

3 to belong; 

4 ‘‘(G) to comply with any State law regard5 ing fraud and abuse (as defined in section 

6 2795(10)), except that if the State seeks an in7 junction regarding the conduct described in this 

8 subparagraph, such injunction must be obtained 

9 from a court of competent jurisdiction; 

10 ‘‘(H) to comply with any State law regard11 ing unfair claims settlement practices (as de12 fined in section 2795(9)); or 

13 ‘‘(I) to comply with the applicable require14 ments for independent review under section 

15 2798 with respect to coverage offered in the 

16 State; 

17 ‘‘(2) require any individual or group health in18 surance coverage issued by the issuer to be counter19 signed by an insurance agent or broker residing in 

20 that Secondary State; or 

21 ‘‘(3) otherwise discriminate against the issuer 

22 issuing insurance in both the primary State and in 

23 any secondary State. 

24 ‘‘(c) CLEAR AND CONSPICUOUS DISCLOSURE.—A 

25 health insurance issuer shall provide the following notice, 


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1 in 12-point bold type, in any insurance coverage offered 

2 in a secondary State under this part by such a health in3 surance issuer and at renewal of the policy, with the 5 

4 blank spaces therein being appropriately filled with the 

5 name of the health insurance issuer, the name of primary 

6 State, the name of the secondary State, the name of the 

7 secondary State, and the name of the secondary State, re8 spectively, for the coverage concerned: ‘Notice: This policy 

9 is issued by llll and is governed by the laws and 

10 regulations of the State of llll, and it has met all 

11 the laws of that State as determined by that State’s De12 partment of Insurance. This policy may be less expensive 

13 than others because it is not subject to all of the insurance 

14 laws and regulations of the State of lllll, includ15 ing coverage of some services or benefits mandated by the 

16 law of the State of lllll. Additionally, this policy 

17 is not subject to all of the consumer protection laws or 

18 restrictions on rate changes of the State of lllll. 

19 As with all insurance products, before purchasing this pol20 icy, you should carefully review the policy and determine 

21 what health care services the policy covers and what bene22 fits it provides, including any exclusions, limitations, or 

23 conditions for such services or benefits.’ 

24 ‘‘(d) PROHIBITION ON CERTAIN RECLASSIFICATIONS

25 AND PREMIUM INCREASES.— 


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1 ‘‘(1) IN GENERAL.—For purposes of this sec2 tion, a health insurance issuer that provides indi3 vidual or group health insurance coverage to an indi4 vidual under this part in a primary or secondary 

5 State may not upon renewal— 

6 ‘‘(A) move or reclassify the individual in7 sured under the health insurance coverage from 

8 the class such individual is in at the time of 

9 issue of the contract based on the health status10 related factors of the individual; or 

11 ‘‘(B) increase the premiums assessed the 

12 individual for such coverage based on a health 

13 status-related factor or change of a health sta14 tus-related factor or the past or prospective 

15 claim experience of the insured individual. 

16 ‘‘(2) CONSTRUCTION.—Nothing in paragraph 

17 (1) shall be construed to prohibit a health insurance 

18 issuer— 

19 ‘‘(A) from terminating or discontinuing 

20 coverage or a class of coverage in accordance 

21 with subsections (b) and (c) of section 2742; 

22 ‘‘(B) from raising premium rates for all 

23 policy holders within a class based on claims ex24 perience; 


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1 ‘‘(C) from changing premiums or offering 

2 discounted premiums to individuals who engage 

3 in wellness activities at intervals prescribed by 

4 the issuer, if such premium changes or incen5 tives— 

6 ‘‘(i) are disclosed to the consumer in 

7 the insurance contract; 

8 ‘‘(ii) are based on specific wellness ac9 tivities that are not applicable to all indi10 viduals; and 

11 ‘‘(iii) are not obtainable by all individ12 uals to whom coverage is offered; 

13 ‘‘(D) from reinstating lapsed coverage; or 

14 ‘‘(E) from retroactively adjusting the rates 

15 charged an insured individual if the initial rates 

16 were set based on material misrepresentation by 

17 the individual at the time of issue. 

18 ‘‘(e) PRIOR OFFERING OF POLICY IN PRIMARY

19 STATE.—A health insurance issuer may not offer for sale 

20 individual or group health insurance coverage in a sec21 ondary State unless that coverage is currently offered for 

22 sale in the primary State. 

23 ‘‘(f) LICENSING OF AGENTS OR BROKERS FOR

24 HEALTH INSURANCE ISSUERS.—Any State may require 

25 that a person acting, or offering to act, as an agent or 


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1 broker for a health insurance issuer with respect to the 

2 offering of individual or group health insurance coverage 

3 obtain a license from that State, with commissions or 

4 other compensation subject to the provisions of the laws 

5 of that State, except that a State may not impose any 

6 qualification or requirement which discriminates against 

7 a nonresident agent or broker. 

8 ‘‘(g) DOCUMENTS FOR SUBMISSION TO STATE IN9 SURANCE COMMISSIONER.—Each health insurance issuer 

10 issuing individual or group health insurance coverage in 

11 both primary and secondary States shall submit— 

12 ‘‘(1) to the insurance commissioner of each 

13 State in which it intends to offer such coverage, be14 fore it may offer individual or group health insur15 ance coverage in such State— 

16 ‘‘(A) a copy of the plan of operation or fea17 sibility study or any similar statement of the 

18 policy being offered and its coverage (which 

19 shall include the name of its primary State and 

20 its principal place of business); 

21 ‘‘(B) written notice of any change in its 

22 designation of its primary State; and 

23 ‘‘(C) written notice from the issuer of the 

24 issuer’s compliance with all the laws of the pri25 mary State; and 


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1 ‘‘(2) to the insurance commissioner of each sec2 ondary State in which it offers individual or group 

3 health insurance coverage, a copy of the issuer’s 

4 quarterly financial statement submitted to the pri5 mary State, which statement shall be certified by an 

6 independent public accountant and contain a state7 ment of opinion on loss and loss adjustment expense 

8 reserves made by— 

9 ‘‘(A) a member of the American Academy 

10 of Actuaries; or 

11 ‘‘(B) a qualified loss reserve specialist. 

12 ‘‘(h) POWER OF COURTS TO ENJOIN CONDUCT.— 

13 Nothing in this section shall be construed to affect the 

14 authority of any Federal or State court to enjoin— 

15 ‘‘(1) the solicitation or sale of individual or 

16 group health insurance coverage by a health insur17 ance issuer to any person or group who is not eligi18 ble for such insurance; or 

19 ‘‘(2) the solicitation or sale of individual or 

20 group health insurance coverage that violates the re21 quirements of the law of a secondary State which 

22 are described in subparagraphs (A) through (H) of 

23 section 2796(b)(1). 

24 ‘‘(i) POWER OF SECONDARY STATES TO TAKE AD25 MINISTRATIVE ACTION.—Nothing in this section shall be 


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1 construed to affect the authority of any State to enjoin 

2 conduct in violation of that State’s laws described in sec3 tion 2796(b)(1). 

4 ‘‘(j) STATE POWERS TO ENFORCE STATE LAWS.— 

5 ‘‘(1) IN GENERAL.—Subject to the provisions of 

6 subsection (b)(1)(G) (relating to injunctions) and 

7 paragraph (2), nothing in this section shall be con8 strued to affect the authority of any State to make 

9 use of any of its powers to enforce the laws of such 

10 State with respect to which a health insurance issuer 

11 is not exempt under subsection (b). 

12 ‘‘(2) COURTS OF COMPETENT JURISDICTION.— 

13 If a State seeks an injunction regarding the conduct 

14 described in paragraphs (1) and (2) of subsection 

15 (h), such injunction must be obtained from a Fed16 eral or State court of competent jurisdiction. 

17 ‘‘(k) STATES’ AUTHORITY TO SUE.—Nothing in this 

18 section shall affect the authority of any State to bring ac19 tion in any Federal or State court. 

20 ‘‘(l) GENERALLY APPLICABLE LAWS.—Nothing in 

21 this section shall be construed to affect the applicability 

22 of State laws generally applicable to persons or corpora23 tions. 

24 ‘‘(m) GUARANTEED AVAILABILITY OF COVERAGE TO

25 HIPAA ELIGIBLE INDIVIDUALS.—To the extent that a 


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1 health insurance issuer is offering coverage in a primary 

2 State that does not accommodate residents of secondary 

3 States or does not provide a working mechanism for resi4 dents of a secondary State, and the issuer is offering cov5 erage under this part in such secondary State which has 

6 not adopted a qualified high risk pool as its acceptable 

7 alternative mechanism (as defined in section 2744(c)(2)), 

8 the issuer shall, with respect to any individual or group 

9 health insurance coverage offered in a secondary State 

10 under this part, comply with the guaranteed availability 

11 requirements for eligible individuals in section 2741. 

12 ‘‘SEC. 2797. PRIMARY STATE MUST MEET FEDERAL FLOOR 

13 BEFORE ISSUER MAY SELL INTO SECONDARY 

14 STATES. 

15 ‘‘A health insurance issuer may not offer, sell, or 

16 issue individual or group health insurance coverage in a 

17 secondary State if the State insurance commissioner does 

18 not use a risk-based capital formula for the determination 

19 of capital and surplus requirements for all health insur20 ance issuers. 

21 ‘‘SEC. 2798. INDEPENDENT EXTERNAL APPEALS PROCE22 DURES. 

23 ‘‘(a) RIGHT TO EXTERNAL APPEAL.—A health insur24 ance issuer may not offer, sell, or issue individual or group 


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1 health insurance coverage in a secondary State under the 

2 provisions of this title unless— 

3 ‘‘(1) both the secondary State and the primary 

4 State have legislation or regulations in place estab5 lishing an independent review process for individuals 

6 who are covered by individual health insurance cov7 erage or group health insurance offered by a health 

8 insurance issuer, repsectively, or 

9 ‘‘(2) in any case in which the requirements of 

10 subparagraph (A) are not met with respect to the ei11 ther of such States, the issuer provides an inde12 pendent review mechanism substantially identical (as 

13 determined by the applicable State authority of such 

14 State) to that prescribed in the ‘Health Carrier Ex15 ternal Review Model Act’ of the National Association 

16 of Insurance Commissioners for all individuals who 

17 purchase insurance coverage under the terms of this 

18 part, except that, under such mechanism, the review 

19 is conducted by an independent medical reviewer, or 

20 a panel of such reviewers, with respect to whom the 

21 requirements of subsection (b) are met. 

22 ‘‘(b) QUALIFICATIONS OF INDEPENDENT MEDICAL

23 REVIEWERS.—In the case of any independent review 

24 mechanism referred to in subsection (a)(2): 


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1 ‘‘(1) IN GENERAL.—In referring a denial of a 

2 claim to an independent medical reviewer, or to any 

3 panel of such reviewers, to conduct independent 

4 medical review, the issuer shall ensure that— 

5 ‘‘(A) each independent medical reviewer 

6 meets the qualifications described in paragraphs 

7 (2) and (3); 

8 ‘‘(B) with respect to each review, each re9 viewer meets the requirements of paragraph (4) 

10 and the reviewer, or at least 1 reviewer on the 

11 panel, meets the requirements described in 

12 paragraph (5); and 

13 ‘‘(C) compensation provided by the issuer 

14 to each reviewer is consistent with paragraph 

15 (6). 

16 ‘‘(2) LICENSURE AND EXPERTISE.—Each inde17 pendent medical reviewer shall be a physician 

18 (allopathic or osteopathic) or health care profes19 sional who— 

20 ‘‘(A) is appropriately credentialed or li21 censed in 1 or more States to deliver health 

22 care services; and 

23 ‘‘(B) typically treats the condition, makes 

24 the diagnosis, or provides the type of treatment 

25 under review. 


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1 ‘‘(3) INDEPENDENCE.— 

2 ‘‘(A) IN GENERAL.—Subject to subpara3 graph (B), each independent medical reviewer 

4 in a case shall— 

5 ‘‘(i) not be a related party (as defined 

6 in paragraph (7)); 

7 ‘‘(ii) not have a material familial, fi8 nancial, or professional relationship with 

9 such a party; and 

10 ‘‘(iii) not otherwise have a conflict of 

11 interest with such a party (as determined 

12 under regulations). 

13 ‘‘(B) EXCEPTION.—Nothing in subpara14 graph (A) shall be construed to— 

15 ‘‘(i) prohibit an individual, solely on 

16 the basis of affiliation with the issuer, 

17 from serving as an independent medical re18 viewer if— 

19 ‘‘(I) a non-affiliated individual is 

20 not reasonably available; 

21 ‘‘(II) the affiliated individual is 

22 not involved in the provision of items 

23 or services in the case under review; 

24 ‘‘(III) the fact of such an affili25 ation is disclosed to the issuer and the 


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1 enrollee (or authorized representative) 

2 and neither party objects; and 

3 ‘‘(IV) the affiliated individual is 

4 not an employee of the issuer and 

5 does not provide services exclusively or 

6 primarily to or on behalf of the issuer; 

7 ‘‘(ii) prohibit an individual who has 

8 staff privileges at the institution where the 

9 treatment involved takes place from serv10 ing as an independent medical reviewer 

11 merely on the basis of such affiliation if 

12 the affiliation is disclosed to the issuer and 

13 the enrollee (or authorized representative), 

14 and neither party objects; or 

15 ‘‘(iii) prohibit receipt of compensation 

16 by an independent medical reviewer from 

17 an entity if the compensation is provided 

18 consistent with paragraph (6). 

19 ‘‘(4) PRACTICING HEALTH CARE PROFESSIONAL

20 IN SAME FIELD.— 

21 ‘‘(A) IN GENERAL.—In a case involving 

22 treatment, or the provision of items or serv23 ices— 

24 ‘‘(i) by a physician, a reviewer shall be 

25 a practicing physician (allopathic or osteoVerDate Mar 15 2010 00:52 Mar 21, 2012 Jkt 019200 PO 00000 Frm 00046 Fmt 6652 Sfmt 6201 E:\BILLS\H4224.IH H4224

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1 pathic) of the same or similar specialty, as 

2 a physician who, acting within the appro3 priate scope of practice within the State in 

4 which the service is provided or rendered, 

5 typically treats the condition, makes the 

6 diagnosis, or provides the type of treat7 ment under review; or 

8 ‘‘(ii) by a non-physician health care 

9 professional, the reviewer, or at least 1 

10 member of the review panel, shall be a 

11 practicing non-physician health care pro12 fessional of the same or similar specialty 

13 as the non-physician health care profes14 sional who, acting within the appropriate 

15 scope of practice within the State in which 

16 the service is provided or rendered, typi17 cally treats the condition, makes the diag18 nosis, or provides the type of treatment 

19 under review. 

20 ‘‘(B) PRACTICING DEFINED.—For pur21 poses of this paragraph, the term ‘practicing’ 

22 means, with respect to an individual who is a 

23 physician or other health care professional, that 

24 the individual provides health care services to 


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1 individual patients on average at least 2 days 

2 per week. 

3 ‘‘(5) PEDIATRIC EXPERTISE.—In the case of an 

4 external review relating to a child, a reviewer shall 

5 have expertise under paragraph (2) in pediatrics. 

6 ‘‘(6) LIMITATIONS ON REVIEWER COMPENSA7 TION.—Compensation provided by the issuer to an 

8 independent medical reviewer in connection with a 

9 review under this section shall— 

10 ‘‘(A) not exceed a reasonable level; and 

11 ‘‘(B) not be contingent on the decision ren12 dered by the reviewer. 

13 ‘‘(7) RELATED PARTY DEFINED.—For purposes 

14 of this section, the term ‘related party’ means, with 

15 respect to a denial of a claim under a coverage relat16 ing to an enrollee, any of the following: 

17 ‘‘(A) The issuer involved, or any fiduciary, 

18 officer, director, or employee of the issuer. 

19 ‘‘(B) The enrollee (or authorized represent20 ative). 

21 ‘‘(C) The health care professional that pro22 vides the items or services involved in the de23 nial. 


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1 ‘‘(D) The institution at which the items or 

2 services (or treatment) involved in the denial 

3 are provided. 

4 ‘‘(E) The manufacturer of any drug or 

5 other item that is included in the items or serv6 ices involved in the denial. 

7 ‘‘(F) Any other party determined under 

8 any regulations to have a substantial interest in 

9 the denial involved. 

10 ‘‘(8) DEFINITIONS.—For purposes of this sub11 section: 

12 ‘‘(A) ENROLLEE.—The term ‘enrollee’ 

13 means, with respect to health insurance cov14 erage offered by a health insurance issuer, an 

15 individual enrolled with the issuer to receive 

16 such coverage. 

17 ‘‘(B) HEALTH CARE PROFESSIONAL.—The 

18 term ‘health care professional’ means an indi19 vidual who is licensed, accredited, or certified 

20 under State law to provide specified health care 

21 services and who is operating within the scope 

22 of such licensure, accreditation, or certification. 

23 ‘‘SEC. 2799. ENFORCEMENT. 

24 ‘‘(a) IN GENERAL.—Subject to subsection (b), with 

25 respect to specific individual or group health insurance 


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1 coverage the primary State for such coverage has sole ju2 risdiction to enforce the primary State’s covered laws in 

3 the primary State and any secondary State. 

4 ‘‘(b) SECONDARY STATE’S AUTHORITY.—Nothing in 

5 subsection (a) shall be construed to affect the authority 

6 of a secondary State to enforce its laws as set forth in 

7 the exception specified in section 2796(b)(1). 

8 ‘‘(c) COURT INTERPRETATION.—In reviewing action 

9 initiated by the applicable secondary State authority, the 

10 court of competent jurisdiction shall apply the covered 

11 laws of the primary State. 

12 ‘‘(d) NOTICE OF COMPLIANCE FAILURE.—In the case 

13 of individual health insurance coverage offered in a sec14 ondary State, or group health insurance coveraged offered 

15 by a health insurance issuer in a secondary State, that 

16 fails to comply with the covered laws of the primary State, 

17 the applicable State authority of the secondary State may 

18 notify the applicable State authority of the primary 

19 State.’’. 

20 (b) EFFECTIVE DATE.—The amendment made by 

21 subsection (a) shall apply to health insurance coverage of22 fered, issued, or sold after the date that is one year after 

23 the date of the enactment of this Act. 

24 (c) GAO ONGOING STUDY AND REPORTS.— 


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1 (1) STUDY.—The Comptroller General of the 

2 United States shall conduct an ongoing study con3 cerning the effect of the amendment made by sub4 section (a) on— 

5 (A) the number of uninsured and under-in6 sured; 

7 (B) the availability and cost of health in8 surance policies for individuals with pre-existing 

9 medical conditions; 

10 (C) the availability and cost of health in11 surance policies generally; 

12 (D) the elimination or reduction of dif13 ferent types of benefits under health insurance 

14 policies offered in different States; and 

15 (E) cases of fraud or abuse relating to 

16 health insurance coverage offered under such 

17 amendment and the resolution of such cases. 

18 (2) ANNUAL REPORTS.—The Comptroller Gen19 eral shall submit to Congress an annual report, after 

20 the end of each of the 5 years following the effective 

21 date of the amendment made by subsection (a), on 

22 the ongoing study conducted under paragraph (1). 

Æ 


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