I 

114TH CONGRESS 

2D SESSION H. R. 4801 

To amend title XXVII of the Public Health Service Act, and title XVIII 

of the Social Security Act, to direct the Secretary of Health and Human 

Services to conduct audits of medical loss ratio reports submitted by 

health insurance issuers, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 17, 2016 

Ms. MICHELLE LUJAN GRISHAM of New Mexico (for herself and Ms. SCHAKOWSKY) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on 

Ways and Means, 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, 

and title XVIII of the Social Security Act, to direct 

the Secretary of Health and Human Services to conduct 

audits of medical loss ratio reports submitted by health 

insurance issuers, and for other purposes. 

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. 

4 This Act may be cited as the ‘‘Medical Loss Ratio 

5 Accountability Act of 2016’’. 


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1 SEC. 2. AUDITS OF MEDICAL LOSS RATIO REPORTS SUB2 MITTED WITH RESPECT TO GROUP OR INDI3 VIDUAL HEALTH INSURANCE COVERAGE. 

4 Section 2718 of the Public Health Service Act (42 

5 U.S.C. 300gg–18) is amended— 

6 (1) in subsection (b)(3), by inserting ‘‘, includ7 ing with respect to the submission of any informa8 tion that, pursuant to an audit conducted under sub9 section (f), is found to be untruthful or inaccurate’’ 

10 after ‘‘penalties’’; and 

11 (2) by adding at the end the following new sub12 section: 

13 ‘‘(f) AUDITS.— 

14 ‘‘(1) IN GENERAL.—Beginning with the first 

15 plan year that begins after the date of the enact16 ment of the Medical Loss Ratio Accountability Act 

17 of 2016, the Secretary shall, with respect to a statis18 tically significant percentage of the reports sub19 mitted under this section by health insurance issuers 

20 offering group or individual health insurance cov21 erage (including grandfathered health plans), con22 duct audits of the books and records (or such other 

23 information as may be necessary) of such health in24 surance issuers to verify that the information con25 tained in each such report is truthful and accurate. 


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1 ‘‘(2) SELECTION OF REPORTS FOR AUDITS.—In 

2 selecting reports to be audited under paragraph (1), 

3 the Secretary shall ensure that, for a plan year, the 

4 health insurance issuers whose reports are selected 

5 for such audits are representative of the health in6 surance issuers that submitted such reports for such 

7 plan year. 

8 ‘‘(3) AUTHORITY TO ENTER INTO CONTRACTS

9 OR COOPERATIVE AGREEMENTS.—The Secretary 

10 may, for purposes of conducting audits under para11 graph (1), enter into a contract or cooperative agree12 ment with a private entity. 

13 ‘‘(4) REPORT TO CONGRESS.—Beginning 18 

14 months after the date of the enactment of the Med15 ical Loss Ratio Accountability Act of 2016 and each 

16 year thereafter, the Secretary shall submit to Con17 gress a report on the results of audits conducted 

18 under this section with respect to the previous plan 

19 year.’’. 

20 SEC. 3. APPLICATION TO PARTS C AND D OF THE MEDI21 CARE PROGRAM. 

22 Section 1857(e)(4) of the Social Security Act (42 

23 U.S.C. 1395w–27(e)(4)) is amended by adding at the end 

24 the following new flush sentence: 


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1 ‘‘In the case that audits have been conducted by the Sec2 retary (such as the audits conducted under section 2718(f) 

3 of the Public Health Service Act) of the books and records 

4 (or of such other information as may be necessary) of an 

5 MA plan for a contract year that begins on or after the 

6 date of the enactment of the Medical Loss Ratio Account7 ability Act of 2016, a determination that is made under 

8 this paragraph for such MA plan for such contract year 

9 shall be based upon one or more reports (or other submis10 sions of information) by the MA plan with respect to which 

11 the Secretary has verified, through such audits of such 

12 MA plan, that the information contained in such reports 

13 (or other submissions) is truthful and accurate.’’. 

Æ 


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