I 

111TH CONGRESS 

1ST SESSION H. R. 2427 

To amend title XXVII of the Public Health Service Act to establish Federal 

standards for health insurance forms, quality, fair marketing, and honesty in out-of-network coverage in the group and individual health insurance markets, to improve transparency and accountability in those markets, and to establish a Federal Office of Health Insurance Oversight 

to monitor performance in those markets, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 14, 2009 

Ms. DELAURO (for herself, Ms. SCHWARTZ, Ms. SCHAKOWSKY, Mr. LIPINSKI, 

Mrs. CHRISTENSEN, Mrs. CAPPS, Mr. MCGOVERN, Mr. COURTNEY, Mr. 

BLUMENAUER, Mr. BERMAN, Mr. DELAHUNT, and Mrs. LOWEY) 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 Labor, and Oversight and Government Reform, 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 amend title XXVII of the Public Health Service Act 

to establish Federal standards for health insurance 

forms, quality, fair marketing, and honesty in out-ofnetwork coverage in the group and individual health insurance markets, to improve transparency and accountability in those markets, and to establish a Federal Office of Health Insurance Oversight to monitor performance in those markets, and for other purposes. 


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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. 

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

5 ‘‘Informed Consumer Choices in Health Care Act of 

6 2009’’. 

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

8 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Findings. 

Sec. 3. New minimum Federal standards for health insurance forms, quality, 

fair marketing, and honesty in out-of-network coverage. 

Sec. 4. Health Insurance accountability initiatives. 

Sec. 5. Health insurance transparency initiatives. 

Sec. 6. Office of Health Insurance Oversight. 

Sec. 7. Standards and accountability and transparency initiatives for group 

health plans through Departments of Labor and the Treasury. 

9 SEC. 2. FINDINGS. 

10 Congress finds the following: 

11 (1) Effective competition in private health in12 surance markets requires that consumers must have 

13 extensive and meaningful information about what 

14 health insurance covers, what it costs, and how it 

15 works. 

16 (2) Based on the information currently provided 

17 by health insurers, patients are unable to predict 

18 what their health insurance coverage limits or out19 of-pocket costs would be if they had a serious illness. 

20 72 million adults under age 65 had problems paying 

21 medical bills or were paying off medical debt in 


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1 2007, and 61 percent of those were insured at the 

2 time care was provided. 

3 (3) It is difficult to impossible for consumers to 

4 obtain a copy of a health insurance policy from an 

5 insurance company before they purchase it. 

6 (4) Consumers often find it difficult to navigate 

7 and evaluate their choices in today’s health insur8 ance markets and many select a sub-optimal plan as 

9 a result. 

10 (5) The Institute of Medicine of the National 

11 Academy of Sciences has estimated that nearly half 

12 of all American adults—90 million people—have dif13 ficulty understanding and using health information. 

14 (6) The Office of Disease Prevention and 

15 Health Promotion in the Department of Health and 

16 Human Services reports that only 12 percent of the 

17 population using a table can calculate an employee’s 

18 share of health insurance costs for a year. 

19 (7) A RAND Corporation study found that 

20 making it easier to get information about insurance 

21 products and simplifying the applications process 

22 would increase purchase rates as much as modest 

23 subsidies would, and all these reports prove the need 

24 for a fundamental improvement in the way insurance 

25 choices are made available to consumers. 


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1 (8) Insurance forms provided to patients and 

2 providers are often confusing, difficult to reconcile 

3 with medical bills, and vary widely from insurer to 

4 insurer, thereby adding complexity and administra5 tive waste to the health care system. 

6 (9) Research indicates that physicians divert 

7 substantial resources, as much as 14 percent of their 

8 total revenue, to ensure accurate insurance pay9 ments for their services. Hospitals spend as much as 

10 11 percent of their total revenue on billing and in11 surance-related costs. These include time spent de12 termining patient insurance eligibility and benefit 

13 structure. One study found that paperwork adds at 

14 least 30 minutes to every hour of patient care. 

15 (10) According to the American Medical Asso16 ciation, there is wide variation in how often health 

17 insurers pay nothing in response to a physician 

18 claim and in how they explain the reason for the de19 nial. There is no consistency in the application of 

20 codes used to explain the denials, making it ex21 tremely expensive for physician practices to deter22 mine how to respond. 

23 (11) According to the American Medical Asso24 ciation, more than half of health insurers in a recent 

25 study did not provide physicians with the transVerDate Nov 24 2008 22:11 May 15, 2009 Jkt 079200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H2427.IH H2427

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1 parency necessary for an efficient claims processing 

2 system. 

3 (12) According to the American Medical Asso4 ciation, payers vary widely on how often they use 

5 proprietary rather than public claims edits to reduce 

6 payments (ranging from zero to as high as nearly 72 

7 percent). The use of undisclosed proprietary edits in8 hibits the flow of transparent information to physi9 cians, adding additional administrative costs to rec10 oncile claims. 

11 (13) The Federal government currently lacks 

12 capacity to carry out responsibility for oversight and 

13 enforcement of current law requirements on health 

14 insurance issuers and to provide States with tech15 nical assistance in effectively enforcing Federal min16 imum standards for health insurance. 

17 (14) In order to improve the functioning of the 

18 private health insurance market, assure the applica19 tion of existing requirements to health insurance 

20 coverage, and reduce administrative hassles for pa21 tients and providers, there is a need for periodic ex22 aminations and audits of such coverage, for greater 

23 disclosure of information regarding the terms and 

24 conditions of such coverage, and for the establishVerDate Nov 24 2008 22:11 May 15, 2009 Jkt 079200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H2427.IH H2427

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1 ment of a Federal oversight office to ensure enforce2 ment of standards. 

3 SEC. 3. NEW MINIMUM FEDERAL STANDARDS FOR HEALTH 

4 INSURANCE FORMS, QUALITY, FAIR MAR5 KETING, AND HONESTY IN OUT-OF-NETWORK 

6 COVERAGE. 

7 (a) GROUP HEALTH INSURANCE.—Title XXVII of 

8 the Public Health Service Act is amended by inserting 

9 after section 2707 the following new section: 

10 ‘‘SEC. 2708. STANDARDS FOR HEALTH INSURANCE FORMS, 

11 QUALITY, FAIR MARKETING, AND HONESTY 

12 IN OUT-OF-NETWORK COVERAGE. 

13 ‘‘(a) DEFINING INSURANCE TERMS; STANDARDIZING

14 INSURANCE FORMS.— 

15 ‘‘(1) IN GENERAL.—The Secretary shall provide 

16 for the development of standards for the information 

17 that health insurance issuers are required to provide 

18 to group health plans to promote informed choice of 

19 health insurance coverage by such plans. 

20 ‘‘(2) STANDARD DEFINITIONS OF INSURANCE

21 AND MEDICAL TERMS.— 

22 ‘‘(A) IN GENERAL.—The Secretary shall 

23 provide for the development of standards for 

24 the definitions of terms used in group health in25 surance coverage, including insurance-related 


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1 terms (including the insurance-related terms de2 scribed in subparagraph (B)) and medical 

3 terms (including the medical terms described in 

4 subparagraph (C)). 

5 ‘‘(B) INSURANCE-RELATED TERMS.—The 

6 insurance-related terms described in this sub7 paragraph are premium, deductible, co-insur8 ance, co-payment, out-of-pocket limit, preferred 

9 provider, non-preferred provider, out-of-network 

10 co-payments, UCR (usual, customary and rea11 sonable) fees, excluded services, grievance and 

12 appeals, and such other terms as the Secretary 

13 determines are important to define so that con14 sumers may compare health insurance coverage 

15 and understand the terms of their coverage. 

16 ‘‘(C) MEDICAL TERMS.—The medical 

17 terms described in this subparagraph are hos18 pitalization, hospital outpatient care, emergency 

19 room care, physician services, prescription drug 

20 coverage, durable medical equipment, home 

21 health care, skilled nursing care, rehabilitation 

22 services, hospice services, emergency medical 

23 transportation, and such other terms as the 

24 Secretary determines are important to define so 

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1 fits offered by insurance health insurance and 

2 understand the extent of those medical benefits 

3 (or exceptions to those benefits). 

4 ‘‘(3) STANDARDIZATION OF INSURANCE

5 FORMS.—The Secretary shall provide for the devel6 opment of standards for the forms used in connec7 tion with group health insurance coverage, including 

8 for— 

9 ‘‘(A) applications for health insurance cov10 erage; 

11 ‘‘(B) explanations of benefits for such cov12 erage; 

13 ‘‘(C) filing of complaints, grievances, and 

14 appeals respecting such coverage; and 

15 ‘‘(D) other common functions relating to 

16 such coverage as the Secretary deems appro17 priate. 

18 ‘‘(4) COVERAGE FACTS LABELS FOR PATIENT

19 CLAIMS SCENARIOS.—The Secretary shall develop 

20 standards for coverage facts labels based on the pa21 tient claims scenarios described in section 

22 2794(b)(4), which include information on estimated 

23 out-of-pocket cost-sharing and significant exclusions 

24 or benefit limits for such scenarios. 


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1 ‘‘(5) PERSONALIZED STATEMENT.—The Sec2 retary shall develop standards for an annual person3 alized statement that summarizes use of health care 

4 services and payment of claims with respect to an 

5 enrollee (and covered dependents) under group 

6 health insurance coverage in the preceding year. 

7 ‘‘(6) APPLICATION OF STANDARDS.—No group 

8 health insurance coverage may be offered for sale 

9 after the date that is two years after date of the en10 actment of this section unless— 

11 ‘‘(A) the benefits and other terms of cov12 erage are consistent with the definitional stand13 ards developed under paragraph (2); 

14 ‘‘(B) the application and form of coverage 

15 and related forms are consistent with the stand16 ardized forms developed under paragraph (3); 

17 and 

18 ‘‘(C) there is provided coverage facts labels 

19 described in paragraph (4) with respect to the 

20 coverage. 

21 ‘‘(7) PERIODIC REVIEW AND UPDATING.—The 

22 Secretary shall periodically review and update, as 

23 appropriate, the standards developed under this sub24 section. 


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1 ‘‘(8) EVALUATION OF INFORMATION RE2 SOURCES.—In developing, reviewing, and updating 

3 standards under this subsection, the Secretary shall 

4 provide for testing and evaluation of information re5 sources in general and to specific audiences includ6 ing those with low literacy skills. 

7 ‘‘(9) CONSULTATION.—In developing reviewing, 

8 and updating standards under this subsection, the 

9 Secretary shall consult with, among others, the Na10 tional Association of Insurance Commissioners, 

11 health care professionals, researchers, health insur12 ance issuers, group health plans, patient advocates, 

13 and literacy experts. 

14 ‘‘(b) QUALITY ASSURANCES FOR HEALTH INSUR15 ANCE.— 

16 ‘‘(1) IN GENERAL.—The Secretary shall provide 

17 for the development of standards to assure the qual18 ity of benefits under group health insurance cov19 erage. Such standards shall include standards relat20 ing to at least— 

21 ‘‘(A) network adequacy and stability; 

22 ‘‘(B) guaranteed coverage for one year of 

23 contracted benefits; 

24 ‘‘(C) adequacy and stability of prescription 

25 drug networks; 


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1 ‘‘(D) utilization control systems; and 

2 ‘‘(E) grievances and appeals. 

3 ‘‘(2) APPLICATION OF PROVISIONS.—The provi4 sions of paragraphs (5) through (9) of subsection 

5 (a) apply to standards developed under this sub6 section in the same manner as such provisions apply 

7 to standards developed under subsection (a). 

8 ‘‘(c) MARKETING.— 

9 ‘‘(1) IN GENERAL.—The Secretary shall provide 

10 for the development of standards for the marketing 

11 of group health insurance coverage. Such standards 

12 shall include standards for at least— 

13 ‘‘(A) marketing materials; and 

14 ‘‘(B) sales commissions. 

15 ‘‘(2) NONDISCRIMINATION.—No group health 

16 insurance coverage may be offered for sale after the 

17 date that is two years after date of the enactment 

18 of this section unless the issuer provides the Sec19 retary with a written certification that all marketing 

20 materials, seminars, and other outreach efforts in 

21 connection with the offering of such coverage do not 

22 discriminate on the basis of income, race, gender, 

23 ethnicity, or other demographic factors as deter24 mined by the Secretary. 


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1 ‘‘(3) APPLICATION OF PROVISIONS.—The provi2 sions of paragraphs (7) through (9) of subsection 

3 (a) apply to standards developed under this sub4 section in the same manner as such provisions apply 

5 to standards developed under subsection (a). 

6 ‘‘(d) HONESTY IN COVERAGE OF OUT-OF-NETWORK

7 PROVIDERS.—The Secretary shall provide for the develop8 ment of standards for the accuracy and clarity of coverage 

9 for out-of-network providers, including cost sharing and 

10 payments to such providers, for health insurance issuers 

11 in group health insurance coverage that provide such cov12 erage.’’. 

13 (b) APPLICATION IN THE INDIVIDUAL MARKET.— 

14 Such title is further amended by inserting after section 

15 2745 the following new section: 

16 ‘‘SEC. 2746. STANDARDS FOR HEALTH INSURANCE INSUR17 ANCE FORMS, QUALITY, FAIR MARKETING, 

18 AND HONESTY IN OUT-OF-NETWORK COV19 ERAGE. 

20 ‘‘The provisions of section 2708 shall apply under 

21 this part to individual health insurance coverage and en22 rollees in such coverage in the same manner as such provi23 sions apply under part A in the case of group health insur24 ance coverage and group health plans and participants 

25 and beneficiaries.’’. 


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1 (c) APPLICATION TO THE MEDICARE ADVANTAGE

2 PROGRAM AND THE MEDICARE PRESCRIPTION DRUG

3 PROGRAM.— 

4 (1) MEDICARE ADVANTAGE PROGRAM.—Section 

5 1852 of the Social Security Act (42 U.S.C. 1395w– 

6 22) is amended by adding at the end the following 

7 new subsection: 

8 ‘‘(m) STANDARDS FOR HEALTH INSURANCE FORMS, 

9 QUALITY, FAIR MARKETING, AND HONESTY IN OUT-OF10 NETWORK COVERAGE.—The provisions of section 2708(a) 

11 of the Public Health Service Act shall apply to Medicare 

12 Advantage organizations, Medicare Advantage plans, and 

13 enrollees in such plans in the same manner as such provi14 sions apply under such section to group health insurance 

15 coverage and group health plans and participants and 

16 beneficiaries.’’. 

17 (2) MEDICARE PRESCRIPTION DRUG PRO18 GRAM.—Section 1860D–4 of the Social Security Act 

19 (42 U.S.C. 1395w–104) is amended by adding at 

20 the end the following new subsection: 

21 ‘‘(m) STANDARDS FOR HEALTH INSURANCE FORMS, 

22 QUALITY, FAIR MARKETING, AND HONESTY IN OUT-OF23 NETWORK COVERAGE.—The provisions of section 2708(a) 

24 of the Public Health Service Act shall apply to PDP spon25 sors, prescription drug plans, and enrollees in such plans 


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1 in the same manner as such provisions apply under such 

2 section to group health insurance coverage and group 

3 health plans and participants and beneficiaries.’’. 

4 (3) EFFECTIVE DATE.—The amendments made 

5 by this subsection shall apply to plan years begin6 ning after the date that is 2 years after the date of 

7 the enactment of this Act. 

8 (d) APPLICATION TO FEHBP.—The provisions of 

9 section 2708(a) of the Public Health Service Act shall 

10 apply to the Federal Employees Health Benefits Program 

11 under chapter 89 of title 5, United States Code, and to 

12 contractors, health plans, and enrollees in such plans in 

13 the same manner as such provisions apply under such sec14 tion to group health insurance coverage and group health 

15 plans and participants and beneficiaries. 

16 SEC. 4. HEALTH INSURANCE ACCOUNTABILITY INITIA17 TIVES. 

18 (a) IMPROVED HEALTH INSURANCE ACCOUNT19 ABILITY.—Title XXVII of the Public Health Service Act 

20 is amended by adding at the end the following new section: 

21 ‘‘SEC. 2793. ACCOUNTABILITY INITIATIVES. 

22 ‘‘(a) IN GENERAL.—The Secretary, acting through 

23 the Office of Health Insurance Oversight established 

24 under section 2795, shall undertake activities in accord25 ance with this section to promote accountability of health 


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1 insurance issuers in meeting Federal health insurance re2 quirements, regardless of whether this relates to health in3 surance in the individual or group market. 

4 ‘‘(b) COMPLIANCE EXAMINATIONS AND AUDITS.— 

5 ‘‘(1) IN GENERAL.—Without regard to whether 

6 or not there is a determination under section 

7 2722(a)(2) or 2761(a)(2) with respect to a health 

8 insurance issuer, in carrying out this section, the 

9 Secretary shall conduct independent market conduct 

10 examinations and audits to monitor and verify the 

11 compliance of an health insurance issuer with Fed12 eral health insurance requirements. Such audits may 

13 include random compliance audits and targeted au14 dits in response to complaints or other suspected 

15 non-compliance. 

16 ‘‘(2) RECOUPMENT OF COSTS.—In connection 

17 with such examinations and audits, the Secretary is 

18 authorized to recoup from health insurance issuers 

19 reimbursement for the costs of such examinations 

20 and audits of such issuers. 

21 ‘‘(3) RELATION TO OTHER AUTHORITY.—The 

22 authorities under this section are in addition to any 

23 authorities of the Secretary, including authorities 

24 under sections 2722(b) and 2761(b). 

25 ‘‘(c) DATA COLLECTION AND REVIEW.— 


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1 ‘‘(1) IN GENERAL.—The Secretary shall collect 

2 and review data from health insurance issuers on 

3 health insurance coverage to monitor compliance 

4 with Federal health insurance requirements applica5 ble to such issuers and coverage. Upon request by 

6 the Secretary, such issuers shall provide such data 

7 to the Secretary on a timely basis. 

8 ‘‘(2) ELEMENTS TO REVIEW.—In carrying out 

9 this subsection, the Secretary shall review at least 

10 the following: 

11 ‘‘(A) Underwriting guidelines to ensure 

12 compliance with applicable Federal health in13 surance requirements. 

14 ‘‘(B) Rating practices to ensure compliance 

15 with such requirements. 

16 ‘‘(C) Enrollment and disenrollment data, 

17 including information the Secretary may need 

18 to detect patterns of discrimination against in19 dividuals based on health status or other char20 acteristics, to ensure compliance with such re21 quirements (including nondiscrimination in 

22 group coverage, guaranteed issue, guaranteed 

23 renewability requirements applicable in all mar24 kets). 


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1 ‘‘(D) Post-claims underwriting and rescis2 sion practices to ensure compliance with such 

3 requirements relating to guaranteed renew4 ability. 

5 ‘‘(E) Marketing materials and agent guide6 lines to ensure compliance with applicable Fed7 eral health insurance requirements. 

8 ‘‘(F) Data on the imposition of pre-exist9 ing condition exclusion periods and claims sub10 jected to such exclusion periods. 

11 ‘‘(G) Information on issuance of certifi12 cates of creditable coverage. 

13 ‘‘(H) Information on cost-sharing and pay14 ments with respect to any out-of-network cov15 erage. 

16 ‘‘(I) Such other information as the Sec17 retary may determine to be necessary to verify 

18 compliance with requirements of this title. 

19 ‘‘(J) The application to issuers of penalties 

20 for violation of such requirements, including the 

21 failure to produce requested information. 

22 ‘‘(3) TREATMENT OF PROPRIETARY INFORMA23 TION.—The Secretary may request under this sub24 section information that is proprietary or that re25 veals a trade secret, but such information shall not 


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1 be subject to further disclosure to the general public 

2 in a manner that reveals proprietary information or 

3 a trade secret. 

4 ‘‘(4) FORM AND MANNER OF INFORMATION.— 

5 Information under paragraph (1) shall be pro6 vided— 

7 ‘‘(A) in a form and manner specified by 

8 the Secretary; and 

9 ‘‘(B) within 30 days of the date of receipt 

10 of the request for the information, or within 

11 such longer time period as the Secretary deems 

12 appropriate. 

13 ‘‘(5) ENFORCEMENT.—The Secretary shall have 

14 the same authority in relation to enforcement of re15 quests for data under paragraph (1) as the Sec16 retary has under section 2722(b). 

17 ‘‘(6) COORDINATION WITH STATES.— 

18 ‘‘(A) IN GENERAL.—The Secretary shall 

19 coordinate with State insurance regulators so 

20 that data with respect to health insurance 

21 issuers and coverage are collected and reported 

22 in a common format. 

23 ‘‘(B) CLEARINGHOUSE.—The Secretary 

24 shall establish a clearinghouse for the sharing 

25 of data reported by health insurance issuers 


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1 and for the findings from audits and investiga2 tions. Such clearinghouse may be established in 

3 conjunction with the National Association of In4 surance Commissioners. 

5 ‘‘(7) COORDINATION WITH DEPARTMENTS OF

6 LABOR AND TREASURY.—The Secretary shall coordi7 nate with the Secretaries of Labor and Treasury 

8 with respect to requirements to report data that af9 fect health insurance coverage sold in connection 

10 with group health plans. 

11 ‘‘(d) HEALTH INSURANCE ACCOUNTABILITY GRANTS

12 TO STATES.— 

13 ‘‘(1) IN GENERAL.—The Secretary shall provide 

14 for grants to Departments of Insurance in States to 

15 strengthen their enforcement of Federal health in16 surance requirements with respect to health insur17 ance issuers operating in such States. Such a grant 

18 shall only be made pursuant to an application made 

19 to the Secretary. 

20 ‘‘(2) FUNDING.— 

21 ‘‘(A) IN GENERAL.—Of the funds appro22 priated under subparagraph (B) for grants 

23 under this subsection, the Secretary shall pro24 vide a grant to each State with an application 

25 approved under paragraph (1). 


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1 ‘‘(B) ALLOCATION.—Funds so appro2 priated for any fiscal year shall be apportioned 

3 among the States in accordance with a formula 

4 determined by the Secretary that takes into ac5 count the scope of health insurance subject to 

6 regulation under this title in each State and 

7 such other factors as the Secretary may specify. 

8 ‘‘(C) APPROPRIATIONS AND AUTHORIZA9 TIONS.—There is hereby appropriated, out of 

10 any funds in the Treasury not otherwise appro11 priated for the first fiscal year in which this 

12 section is in effect, $10,000,000 for grants 

13 under this subsection, to be available until ex14 pended. For each subsequent fiscal year there is 

15 authorized to be appropriated such sums as 

16 may be necessary for such grants. 

17 ‘‘(e) FEDERAL HEALTH INSURANCE REQUIREMENTS

18 DEFINED.—In this part, the term ‘Federal health insur19 ance requirements’ means the requirements under this 

20 title insofar as they relate to health insurance issuers and 

21 health insurance coverage, whether in the individual or 

22 group market, and includes other requirements imposed 

23 under Federal law specifically in relation to the offering 

24 of health insurance coverage by health insurance issuers.’’. 


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1 SEC. 5. HEALTH INSURANCE TRANSPARENCY INITIATIVES. 

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

3 Service Act, as amended by section 3, is further amended 

4 by adding at the end the following new section: 

5 ‘‘SEC. 2794. TRANSPARENCY INITIATIVES. 

6 ‘‘(a) IN GENERAL.—The Secretary, acting through 

7 the Office of Health Insurance Oversight established 

8 under section 2795, shall undertake activities in accord9 ance with this section to promote transparency in costs, 

10 market practices, and other factors for health insurance 

11 coverage, regardless of whether the coverage is offered or 

12 in effect in the individual or group market. 

13 ‘‘(b) DEVELOPMENT AND DISCLOSURE OF STAND14 ARDIZED INFORMATION.— 

15 ‘‘(1) IN GENERAL.—In carrying out this sec16 tion, the Secretary shall provide for the development 

17 of— 

18 ‘‘(A) standards for information about 

19 health insurance issuers, their health insurance 

20 policies, and their market practices with respect 

21 to such policies; and 

22 ‘‘(B) standards for the disclosure of such 

23 information in a timely, consistent, and accu24 rate manner by health insurance issuers about 

25 each health insurance policy marketed and in 

26 force. 


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1 ‘‘(2) INFORMATION TO BE DISCLOSED.— 

2 ‘‘(A) IN GENERAL.—In carrying out this 

3 section, the Secretary shall require health insur4 ance issuers to disclose to enrollees, potential 

5 enrollees, in-network health care providers, and 

6 others through a publicly available Internet 

7 website and other appropriate means at least 

8 the following concerning each policy of health 

9 insurance coverage marketed or in force, in 

10 such standardized manner as the Secretary 

11 specifies: 

12 ‘‘(i) Full policy contract language. 

13 ‘‘(ii) A summary of the information 

14 described in paragraph (3). 

15 ‘‘(iii) For each of the scenarios devel16 oped under paragraph (4), the coverage 

17 facts label information developed under 

18 section 2709(a)(4). 

19 ‘‘(B) PERSONALIZED STATEMENT.—In 

20 carrying out this section, the Secretary shall re21 quire health insurance issuers to disclose to en22 rollees, in such standardized manner as the 

23 Secretary specifies, an annual personalized 

24 statement described in section 2708(a)(5). 


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1 ‘‘(3) INFORMATION TO BE DISCLOSED.—The in2 formation described in this paragraph is at least the 

3 following: 

4 ‘‘(A) Data on the price of each new policy 

5 of health insurance coverage and renewal rating 

6 practices. 

7 ‘‘(B) Information on claims payment poli8 cies and practices, including how many and how 

9 quickly claims were paid. 

10 ‘‘(C) Information on provider fee schedules 

11 and usual, customary, and reasonable fees (for 

12 both network and out-of-network providers). 

13 ‘‘(D) Information on provider participation 

14 and provider directories. 

15 ‘‘(E) Information on loss ratios, including 

16 detailed information about amount and type of 

17 non-claims expenses. 

18 ‘‘(F) Information on covered benefits, cost19 sharing, and amount of payment provided to20 ward each type of service identified as a covered 

21 benefit, including preventive care services rec22 ommended by the United States Preventive 

23 Services Task Force. 


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1 ‘‘(G) Information on civil or criminal ac2 tions successfully concluded against the issuer 

3 by any governmental entity. 

4 ‘‘(H) Benefit exclusions and limits. 

5 ‘‘(4) DEVELOPMENT OF PATIENT CLAIMS SCE6 NARIOS.— 

7 ‘‘(A) IN GENERAL.—In order to improve 

8 the ability of individuals and group health plans 

9 to compare the coverage and value provided 

10 under different health insurance coverage, the 

11 Secretary shall develop a series of patient 

12 claims scenarios under which benefits (including 

13 out-of-pocket costs) under such coverage can be 

14 simulated for certain common or expensive con15 ditions or courses of treatment, such as mater16 nity care, breast cancer, heart disease, diabetes 

17 management, and well-child visits. 

18 ‘‘(B) CONSULTATION AND BASIS.—The 

19 Secretary shall develop the scenarios under this 

20 paragraph— 

21 ‘‘(i) in consultation with the National 

22 Institutes of Health, the Centers for Dis23 ease Control and Prevention, the Agency 

24 for Healthcare Research and Quality, 

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1 cates, and others as deemed necessary by 

2 the Secretary; and 

3 ‘‘(ii) based upon recognized clinical 

4 practice guidelines. 

5 ‘‘(5) MANNER OF DISCLOSURE.— 

6 ‘‘(A) IN GENERAL.—The standards under 

7 paragraph (1)(B) shall provide for health insur8 ance issuers to disclose the information under 

9 this subsection— 

10 ‘‘(i) with all marketing materials; 

11 ‘‘(ii) on the web site of the issuer; and 

12 ‘‘(iii) at other times upon request. 

13 ‘‘(B) CONTRACT LANGUAGE.—Such stand14 ards also shall require the disclosure of full pol15 icy contract language in printed form upon re16 quest. 

17 ‘‘(c) APPLICATION OF ENFORCEMENT PROVISIONS.— 

18 The provisions of sections 2722 and 2671 shall apply to 

19 enforcement of the requirements of this section in the 

20 same manner as such provisions apply to the provisions 

21 of part A or part B, respectively. Under such provisions 

22 the States shall have initial (and primary) enforcement au23 thority with respect to such requirements, except that the 

24 Secretary under section 2793 may directly monitor compli25 ance with such provisions as well.’’. 


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1 (b) CONFORMING AMENDMENTS REGARDING DIS2 CLOSURE OF INFORMATION.— 

3 (1) REFERENCE IN THE GROUP MARKET.—Sec4 tion 2713 of the Public Health Service Act (42 

5 U.S.C. 300gg–13)) is amended by adding at the end 

6 the following new subsection: 

7 ‘‘(c) REFERENCE TO DISCLOSURE OF INFORMA8 TION.—For provision requiring disclosure of information 

9 by health insurance issuers, see section 2794(d).’’. 

10 (2) REFERENCE IN THE INDIVIDUAL MAR11 KET.—Section 2761 of the Public Health Service 

12 Act is amended by adding at the end the following 

13 new subsection: 

14 ‘‘(c) REFERENCE TO DISCLOSURE OF INFORMA15 TION.—For provision requiring disclosure of information 

16 by health insurance issuers, see section 2794(d).’’. 

17 SEC. 6. OFFICE OF HEALTH INSURANCE OVERSIGHT. 

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

19 Service Act, as amended by sections 3 and 4, is amended 

20 by adding at the end of part C the following new section: 

21 ‘‘SEC. 2795. OFFICE OF HEALTH INSURANCE OVERSIGHT. 

22 ‘‘(a) ESTABLISHMENT.—There is established within 

23 the Department of Health and Human Services an Office 

24 of Health Insurance Oversight (referred to in this section 

25 as the ‘Office’). The Office shall be headed by a Director 


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1 of Health Insurance Oversight (referred to in this section 

2 as the ‘Director’) who shall be appointed by and report 

3 directly to the Secretary. 

4 ‘‘(b) DUTIES.— 

5 ‘‘(1) PROMOTION OF ACCOUNTABILITY IN

6 HEALTH INSURANCE.— 

7 ‘‘(A) IN GENERAL.—The Director shall im8 plement accountability initiatives under section 

9 2793. 

10 ‘‘(B) CLEARINGHOUSE.—The Director 

11 shall provide, in consultation with the National 

12 Association of Insurance Commissioners, for a 

13 clearinghouse for State health insurance regu14 lators to share information concerning, and help 

15 them to enact and enforce, Federal health in16 surance requirements. 

17 ‘‘(2) PROMOTE TRANSPARENCY IN HEALTH IN18 SURANCE.—The Director shall implement trans19 parency initiatives under section 2794. 

20 ‘‘(3) CONSUMER INFORMATION, ASSISTANCE.— 

21 ‘‘(A) IN GENERAL.—The Director shall 

22 provide for consumer information assistance on 

23 health insurance coverage, and Federal health 

24 insurance consumer protections under this title, 


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1 including through carrying out activities under 

2 this paragraph. 

3 ‘‘(B) INFORMATION RESOURCES.—The Di4 rector shall develop health insurance informa5 tion resources for consumers, including cov6 erage facts labels for patient claims scenarios 

7 developed under section 2794(b)(4) and web8 based information on average price ranges for 

9 out-of-network services based on geography. 

10 ‘‘(C) SERVICE.—The Director shall estab11 lish a consumer assistance service that, directly 

12 or in coordination with State health insurance 

13 regulators and consumer assistance organiza14 tions, receives and responds to inquiries and 

15 complaints concerning health insurance cov16 erage with respect to Federal health insurance 

17 requirements and under State law. 

18 ‘‘(4) HEALTH INSURANCE CONSUMER ASSIST19 ANCE GRANTS.— 

20 ‘‘(A) IN GENERAL.—The Director shall 

21 provide for grants to public, private or not-for22 profit consumer assistance organizations to de23 velop, support, and evaluate consumer assist24 ance programs related to selecting and navi25 gating health care coverage. Such a grant shall 


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1 only be made pursuant to an application made 

2 to the Director. In making such grants, the Di3 rector shall attempt to ensure regional and geo4 graphic equity. 

5 ‘‘(B) GRANT REQUIREMENT.—As a condi6 tion of receiving such a grant, an organization 

7 shall be required to collect and report data to 

8 the Director on the types of problems and in9 quiries encountered by consumers they serve. 

10 Data shall be used by the Director to inform 

11 enforcement activities and be shared with State 

12 insurance regulators, the Department of Labor, 

13 and the Secretary of the Treasury. 

14 ‘‘(C) APPROPRIATIONS AND AUTHORIZA15 TIONS.—There is hereby appropriated, out of 

16 any funds in the Treasury not otherwise appro17 priated for the first fiscal year in which this 

18 section is in effect, $30,000,000 for grants 

19 under this paragraph, to be available until ex20 pended. For each subsequent fiscal year there 

21 are authorized to be appropriated such sums as 

22 may be necessary for such grants. 

23 ‘‘(5) ADMINISTRATION OF HIGH RISK POOL.— 

24 The Director shall administer the high risk pool pro25 gram under section 2745. 


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1 ‘‘(6) ADMINISTRATION OF GRANTS TO STATE

2 INSURANCE DEPARTMENTS.—The Director shall ad3 minister the program of grants to State insurance 

4 departments under section 2793(d). 

5 ‘‘(c) PERIODIC REPORTS.—The Director shall submit 

6 periodic reports to Congress on the Office’s activities. 

7 ‘‘(d) COORDINATION.— 

8 ‘‘(1) FEDERAL OFFICIALS.—The Director shall 

9 coordinate, with the Secretaries of Labor and Treas10 ury, activities under this section with respect to re11 quirements that affect health insurance coverage of12 fered in connection with group health plans, includ13 ing coordination in — 

14 ‘‘(A) development and dissemination of in15 formation; and 

16 ‘‘(B) consumer inquiries and complaints 

17 relating to Federal health insurance require18 ments. 

19 ‘‘(2) STATE HEALTH INSURANCE REGU20 LATORS.—In carrying out the Office’s activities, the 

21 Director shall— 

22 ‘‘(A) coordinate with State health insur23 ance regulators regarding data collection and 

24 disclosure and audit and enforcement activities 


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1 in order to avoid duplication and to use regu2 latory resources most efficiently; 

3 ‘‘(B) monitor State efforts to implement 

4 and enforce consumer protections consistent 

5 with Federal health insurance requirements; 

6 ‘‘(C) provide technical assistance to States 

7 seeking to implement and enforce consumer 

8 protections consistent with such requirements; 

9 and 

10 ‘‘(D) provide for regular communication 

11 with such regulators to coordinate enforcement 

12 efforts and sharing of information 

13 ‘‘(e) TRANSFER OF PERSONNEL AND RESOURCES.— 

14 The Secretary shall provide for the transfer to the Office 

15 of those personnel and resources within the Department 

16 of Health and Human Services that, as of the date of the 

17 enactment of this section, relate directly to the responsibil18 ities of the Director under this section. 

19 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—In addi20 tion to amounts made available under subsection 

21 (b)(4)(C), there are authorized to be appropriated to carry 

22 out this section $20,000,000 for the first fiscal year begin23 ning after the date of the enactment of this section and 

24 such sums as may be necessary for subsequent fiscal 

25 years.’’. 


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1 (b) CONFORMING AMENDMENTS REGARDING ADDI2 TIONAL AUTHORITY.— 

3 (1) GROUP MARKET.—Section 2722 of such Act 

4 (42 U.S.C. 300gg–22) is amended by adding at the 

5 end the following new subsection: 

6 ‘‘(c) REFERENCE TO ADDITIONAL AUTHORITY.—For 

7 additional Secretarial authorities with respect to require8 ments under this part, see sections 2793 and 2794.’’. 

9 (2) INDIVIDUAL MARKET.—Section 2761 of 

10 such Act (42 U.S.C. 300gg–61) is amended by add11 ing at the end the following new subsection: 

12 ‘‘(c) REFERENCE TO ADDITIONAL AUTHORITY.—For 

13 additional Secretarial authorities with respect to require14 ments under this part, see sections 2793 and 2794.’’. 

15 SEC. 7. STANDARDS AND ACCOUNTABILITY AND TRANS16 PARENCY INITIATIVES FOR GROUP HEALTH 

17 PLANS THROUGH DEPARTMENTS OF LABOR 

18 AND THE TREASURY. 

19 (a) STANDARDS.—In coordination with the Secretary 

20 of Health and Human Services, the Secretaries of Labor 

21 and the Treasury shall establish for group health plans 

22 standards comparable to the standards developed by the 

23 Secretary of Health and Human Services for group health 

24 insurance coverage under section 2708 of the Public 

25 Health Service Act, as added by section 3(a), in order to 


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1 promote quality, fair marketing, and honesty in out-of-net2 work coverage under such plans and to permit participants 

3 to make an informed decision in cases where they are of4 fered a choice of coverage under such a plan. 

5 (b) ACCOUNTABILITY AND TRANSPARENCY INITIA6 TIVES.—In coordination with the Secretary of Health and 

7 Human Services, the Secretaries of Labor and the Treas8 ury shall jointly undertake accountability and trans9 parency initiatives with respect to group health plans simi10 lar to those undertaken by the Secretary of Health and 

11 Human Services with respect to group and individual 

12 health insurance coverage under sections 2793 and 2794 

13 of the Public Health Service Act, as added by sections 4 

14 and 5 of this Act. 

15 (c) GROUP HEALTH PLAN DEFINED.—In this sec16 tion, with respect to the Secretary of Labor and the Sec17 retary of the Treasury, the term ‘‘group health plan’’ has 

18 the meaning such term for purposes of part 7 of subtitle 

19 B of title I of the Employee Retirement Income Security 

20 Act of 1974 and chapter 100 of the Internal Revenue Code 

21 of 1986, respectively. 

Æ 


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