II 

111TH CONGRESS 

1ST SESSION S. 1050 

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 SENATE OF THE UNITED STATES 

MAY 14, 2009 

Mr. REID (for Mr. ROCKEFELLER (for himself, Mr. KOHL, and Mr. LEVIN)) 

introduced the following bill; which was read twice and referred to the 

Committee on Health, Education, Labor, and Pensions 

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. 

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


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1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

3 ‘‘Informed Consumer Choices in Health Care Act of 

4 2009’’. 

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

6 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. 

7 SEC. 2. FINDINGS. 

8 Congress finds the following: 

9 (1) Effective competition in private health in10 surance markets requires that consumers must have 

11 extensive and meaningful information about what 

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

13 works. 

14 (2) Based on the information currently provided 

15 by health insurers, patients are unable to predict 

16 what their health insurance coverage limits or out17 of-pocket costs would be if they had a serious illness. 

18 72 million adults under age 65 had problems paying 

19 medical bills or were paying off medical debt in 

20 2007, and 61 percent of those were insured at the 

21 time care was provided. 


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

2 obtain a copy of a health insurance policy from an 

3 insurance company before they purchase it. 

4 (4) Consumers often find it difficult to navigate 

5 and evaluate their choices in today’s health insur6 ance markets and many select a suboptimal plan as 

7 a result. 

8 (5) The Institute of Medicine of the National 

9 Academy of Sciences has estimated that nearly half 

10 of all American adults—90 million people—have dif11 ficulty understanding and using health information. 

12 (6) The Office of Disease Prevention and 

13 Health Promotion in the Department of Health and 

14 Human Services reports that only 12 percent of the 

15 population using a table can calculate an employee’s 

16 share of health insurance costs for a year. 

17 (7) A RAND Corporation study found that 

18 making it easier to get information about insurance 

19 products and simplifying the applications process 

20 would increase purchase rates as much as modest 

21 subsidies would, and all these reports prove the need 

22 for a fundamental improvement in the way insurance 

23 choices are made available to consumers. 

24 (8) Insurance forms provided to patients and 

25 providers are often confusing, difficult to reconcile 


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1 with medical bills, and vary widely from insurer to 

2 insurer, thereby adding complexity and administra3 tive waste to the health care system. 

4 (9) Research indicates that physicians divert 

5 substantial resources, as much as 14 percent of their 

6 total revenue, to ensure accurate insurance pay7 ments for their services. Hospitals spend as much as 

8 11 percent of their total revenue on billing and in9 surance-related costs. These include time spent de10 termining patient insurance eligibility and benefit 

11 structure. One study found that paperwork adds at 

12 least 30 minutes to every hour of patient care. 

13 (10) According to the American Medical Asso14 ciation, there is wide variation in how often health 

15 insurers pay nothing in response to a physician 

16 claim and in how they explain the reason for the de17 nial. There is no consistency in the application of 

18 codes used to explain the denials, making it ex19 tremely expensive for physician practices to deter20 mine how to respond. 

21 (11) According to the American Medical Asso22 ciation, more than half of health insurers in a recent 

23 study did not provide physicians with the trans24 parency necessary for an efficient claims processing 

25 system. 


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1 (12) According to the American Medical Asso2 ciation, payers vary widely on how often they use 

3 proprietary rather than public claims edits to reduce 

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

5 percent). The use of undisclosed proprietary edits in6 hibits the flow of transparent information to physi7 cians, adding additional administrative costs to rec8 oncile claims. 

9 (13) The Federal Government currently lacks 

10 capacity to carry out responsibility for oversight and 

11 enforcement of current law requirements on health 

12 insurance issuers and to provide States with tech13 nical assistance in effectively enforcing Federal min14 imum standards for health insurance. 

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

16 private health insurance market, assure the applica17 tion of existing requirements to health insurance 

18 coverage, and reduce administrative hassles for pa19 tients and providers, there is a need for periodic ex20 aminations and audits of such coverage, for greater 

21 disclosure of information regarding the terms and 

22 conditions of such coverage, and for the establish23 ment of a Federal oversight office to ensure enforce24 ment of standards. 


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1 SEC. 3. NEW MINIMUM FEDERAL STANDARDS FOR HEALTH 

2 INSURANCE FORMS, QUALITY, FAIR MAR3 KETING, AND HONESTY IN OUT-OF-NETWORK 

4 COVERAGE. 

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

6 the Public Health Service Act is amended by inserting 

7 after section 2707 the following new section: 

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

9 QUALITY, FAIR MARKETING, AND HONESTY 

10 IN OUT-OF-NETWORK COVERAGE. 

11 ‘‘(a) DEFINING INSURANCE TERMS; STANDARDIZING

12 INSURANCE FORMS.— 

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

14 for the development of standards for the information 

15 that health insurance issuers are required to provide 

16 to group health plans to promote informed choice of 

17 health insurance coverage by such plans. 

18 ‘‘(2) STANDARD DEFINITIONS OF INSURANCE

19 AND MEDICAL TERMS.— 

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

21 provide for the development of standards for 

22 the definitions of terms used in group health in23 surance coverage, including insurance-related 

24 terms (including the insurance-related terms de25 scribed in subparagraph (B)) and medical 


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1 terms (including the medical terms described in 

2 subparagraph (C)). 

3 ‘‘(B) INSURANCE-RELATED TERMS.—The 

4 insurance-related terms described in this sub5 paragraph are premium, deductible, co-insur6 ance, co-payment, out-of-pocket limit, preferred 

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

8 co-payments, UCR (usual, customary and rea9 sonable) fees, excluded services, grievance and 

10 appeals, and such other terms as the Secretary 

11 determines are important to define so that con12 sumers may compare health insurance coverage 

13 and understand the terms of their coverage. 

14 ‘‘(C) MEDICAL TERMS.—The medical 

15 terms described in this subparagraph are hos16 pitalization, hospital outpatient care, emergency 

17 room care, physician services, prescription drug 

18 coverage, durable medical equipment, home 

19 health care, skilled nursing care, rehabilitation 

20 services, hospice services, emergency medical 

21 transportation, and such other terms as the 

22 Secretary determines are important to define so 

23 that consumers may compare the medical bene24 fits offered by insurance health insurance and 


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1 understand the extent of those medical benefits 

2 (or exceptions to those benefits). 

3 ‘‘(3) STANDARDIZATION OF INSURANCE

4 FORMS.—The Secretary shall provide for the devel5 opment of standards for the forms used in connec6 tion with group health insurance coverage, including 

7 for— 

8 ‘‘(A) applications for health insurance cov9 erage; 

10 ‘‘(B) explanations of benefits for such cov11 erage; 

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

13 appeals respecting such coverage; and 

14 ‘‘(D) other common functions relating to 

15 such coverage as the Secretary deems appro16 priate. 

17 ‘‘(4) COVERAGE FACTS LABELS FOR PATIENT

18 CLAIMS SCENARIOS.—The Secretary shall develop 

19 standards for coverage facts labels based on the pa20 tient claims scenarios described in section 

21 2794(b)(4), which include information on estimated 

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

23 or benefit limits for such scenarios. 

24 ‘‘(5) PERSONALIZED STATEMENT.—The Sec25 retary shall develop standards for an annual personVerDate Nov 24 2008 06:29 May 16, 2009 Jkt 079200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S1050.IS S1050

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1 alized statement that summarizes use of health care 

2 services and payment of claims with respect to an 

3 enrollee (and covered dependents) under group 

4 health insurance coverage in the preceding year. 

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

6 health insurance coverage may be offered for sale 

7 after the date that is two years after date of the en8 actment of this section unless— 

9 ‘‘(A) the benefits and other terms of cov10 erage are consistent with the definitional stand11 ards developed under paragraph (2); 

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

13 and related forms are consistent with the stand14 ardized forms developed under paragraph (3); 

15 and 

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

17 described in paragraph (4) with respect to the 

18 coverage. 

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

20 Secretary shall periodically review and update, as 

21 appropriate, the standards developed under this sub22 section. 

23 ‘‘(8) EVALUATION OF INFORMATION RE24 SOURCES.—In developing, reviewing, and updating 

25 standards under this subsection, the Secretary shall 


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1 provide for testing and evaluation of information re2 sources in general and to specific audiences includ3 ing those with low literacy skills. 

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

5 and updating standards under this subsection, the 

6 Secretary shall consult with, among others, the Na7 tional Association of Insurance Commissioners, 

8 health care professionals, researchers, health insur9 ance issuers, group health plans, patient advocates, 

10 and literacy experts. 

11 ‘‘(b) QUALITY ASSURANCES FOR HEALTH INSUR12 ANCE.— 

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

14 for the development of standards to assure the qual15 ity of benefits under group health insurance cov16 erage. Such standards shall include standards relat17 ing to at least— 

18 ‘‘(A) network adequacy and stability; 

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

20 contracted benefits; 

21 ‘‘(C) adequacy and stability of prescription 

22 drug networks; 

23 ‘‘(D) utilization control systems; and 

24 ‘‘(E) grievances and appeals. 


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1 ‘‘(2) APPLICATION OF PROVISIONS.—The provi2 sions of paragraphs (5) 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 ‘‘(c) MARKETING.— 

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

8 for the development of standards for the marketing 

9 of group health insurance coverage. Such standards 

10 shall include standards for at least— 

11 ‘‘(A) marketing materials; and 

12 ‘‘(B) sales commissions. 

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

14 insurance coverage may be offered for sale after the 

15 date that is two years after date of the enactment 

16 of this section unless the issuer provides the Sec17 retary with a written certification that all marketing 

18 materials, seminars, and other outreach efforts in 

19 connection with the offering of such coverage do not 

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

21 ethnicity, or other demographic factors as deter22 mined by the Secretary. 

23 ‘‘(3) APPLICATION OF PROVISIONS.—The provi24 sions of paragraphs (7) through (9) of subsection 

25 (a) apply to standards developed under this subVerDate Nov 24 2008 06:29 May 16, 2009 Jkt 079200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S1050.IS S1050

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1 section in the same manner as such provisions apply 

2 to standards developed under subsection (a). 

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

4 PROVIDERS.—The Secretary shall provide for the develop5 ment of standards for the accuracy and clarity of coverage 

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

7 payments to such providers, for health insurance issuers 

8 in group health insurance coverage that provide such cov9 erage.’’. 

10 (b) APPLICATION IN THE INDIVIDUAL MARKET.— 

11 Such title is further amended by inserting after section 

12 2745 the following new section: 

13 ‘‘SEC. 2746. STANDARDS FOR HEALTH INSURANCE FORMS, 

14 QUALITY, FAIR MARKETING, AND HONESTY 

15 IN OUT-OF-NETWORK COVERAGE. 

16 ‘‘The provisions of section 2708 shall apply under 

17 this part to individual health insurance coverage and en18 rollees in such coverage in the same manner as such provi19 sions apply under part A in the case of group health insur20 ance coverage and group health plans and participants 

21 and beneficiaries.’’. 

22 (c) APPLICATION TO THE MEDICARE ADVANTAGE

23 PROGRAM AND THE MEDICARE PRESCRIPTION DRUG

24 PROGRAM.— 


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1 (1) MEDICARE ADVANTAGE PROGRAM.—Section 

2 1852 of the Social Security Act (42 U.S.C. 1395w– 

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

4 new subsection: 

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

6 QUALITY, FAIR MARKETING, AND HONESTY IN OUT-OF7 NETWORK COVERAGE.—The provisions of section 2708(a) 

8 of the Public Health Service Act shall apply to Medicare 

9 Advantage organizations, Medicare Advantage plans, and 

10 enrollees in such plans in the same manner as such provi11 sions apply under such section to group health insurance 

12 coverage and group health plans and participants and 

13 beneficiaries.’’. 

14 (2) MEDICARE PRESCRIPTION DRUG PRO15 GRAM.—Section 1860D–4 of the Social Security Act 

16 (42 U.S.C. 1395w–104) is amended by adding at 

17 the end the following new subsection: 

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

19 QUALITY, FAIR MARKETING, AND HONESTY IN OUT-OF20 NETWORK COVERAGE.—The provisions of section 2708(a) 

21 of the Public Health Service Act shall apply to PDP spon22 sors, prescription drug plans, and enrollees in such plans 

23 in the same manner as such provisions apply under such 

24 section to group health insurance coverage and group 

25 health plans and participants and beneficiaries.’’. 


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1 (3) EFFECTIVE DATE.—The amendments made 

2 by this subsection shall apply to plan years begin3 ning after the date that is 2 years after the date of 

4 the enactment of this Act. 

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

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

7 apply to the Federal Employees Health Benefits Program 

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

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

10 the same manner as such provisions apply under such sec11 tion to group health insurance coverage and group health 

12 plans and participants and beneficiaries. 

13 SEC. 4. HEALTH INSURANCE ACCOUNTABILITY INITIA14 TIVES. 

15 (a) IMPROVED HEALTH INSURANCE ACCOUNT16 ABILITY.—Title XXVII of the Public Health Service Act 

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

18 ‘‘SEC. 2793. ACCOUNTABILITY INITIATIVES. 

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

20 the Office of Health Insurance Oversight established 

21 under section 2795, shall undertake activities in accord22 ance with this section to promote accountability of health 

23 insurance issuers in meeting Federal health insurance re24 quirements, regardless of whether this relates to health in25 surance in the individual or group market. 


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

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

3 or not there is a determination under section 

4 2722(a)(2) or 2761(a)(2) with respect to a health 

5 insurance issuer, in carrying out this section, the 

6 Secretary shall conduct independent market conduct 

7 examinations and audits to monitor and verify the 

8 compliance of a health insurance issuer with Federal 

9 health insurance requirements. Such audits may in10 clude random compliance audits and targeted audits 

11 in response to complaints or other suspected non12 compliance. 

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

14 with such examinations and audits, the Secretary is 

15 authorized to recoup from health insurance issuers 

16 reimbursement for the costs of such examinations 

17 and audits of such issuers. 

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

19 authorities under this section are in addition to any 

20 authorities of the Secretary, including authorities 

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

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

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

24 and review data from health insurance issuers on 

25 health insurance coverage to monitor compliance 


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1 with Federal health insurance requirements applica2 ble to such issuers and coverage. Upon request by 

3 the Secretary, such issuers shall provide such data 

4 to the Secretary on a timely basis. 

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

6 this subsection, the Secretary shall review at least 

7 the following: 

8 ‘‘(A) Underwriting guidelines to ensure 

9 compliance with applicable Federal health in10 surance requirements. 

11 ‘‘(B) Rating practices to ensure compliance 

12 with such requirements. 

13 ‘‘(C) Enrollment and disenrollment data, 

14 including information the Secretary may need 

15 to detect patterns of discrimination against in16 dividuals based on health status or other char17 acteristics, to ensure compliance with such re18 quirements (including nondiscrimination in 

19 group coverage, guaranteed issue, and guaran20 teed renewability requirements applicable in all 

21 markets). 

22 ‘‘(D) Post-claims underwriting and rescis23 sion practices to ensure compliance with such 

24 requirements relating to guaranteed renew25 ability. 


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1 ‘‘(E) Marketing materials and agent guide2 lines to ensure compliance with applicable Fed3 eral health insurance requirements. 

4 ‘‘(F) Data on the imposition of pre-exist5 ing condition exclusion periods and claims sub6 jected to such exclusion periods. 

7 ‘‘(G) Information on issuance of certifi8 cates of creditable coverage. 

9 ‘‘(H) Information on cost-sharing and pay10 ments with respect to any out-of-network cov11 erage. 

12 ‘‘(I) Such other information as the Sec13 retary may determine to be necessary to verify 

14 compliance with requirements of this title. 

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

16 for violation of such requirements, including the 

17 failure to produce requested information. 

18 ‘‘(3) TREATMENT OF PROPRIETARY INFORMA19 TION.—The Secretary may request under this sub20 section information that is proprietary or that re21 veals a trade secret, but such information shall not 

22 be subject to further disclosure to the general public 

23 in a manner that reveals proprietary information or 

24 a trade secret. 


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

2 Information under paragraph (1) shall be pro3 vided— 

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

5 the Secretary; and 

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

7 of the request for the information, or within 

8 such longer time period as the Secretary deems 

9 appropriate. 

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

11 the same authority in relation to enforcement of re12 quests for data under paragraph (1) as the Sec13 retary has under section 2722(b). 

14 ‘‘(6) COORDINATION WITH STATES.— 

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

16 coordinate with State insurance regulators so 

17 that data with respect to health insurance 

18 issuers and coverage are collected and reported 

19 in a common format. 

20 ‘‘(B) CLEARINGHOUSE.—The Secretary 

21 shall establish a clearinghouse for the sharing 

22 of data reported by health insurance issuers 

23 and for the findings from audits and investiga24 tions. Such clearinghouse may be established in 


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1 conjunction with the National Association of In2 surance Commissioners. 

3 ‘‘(7) COORDINATION WITH DEPARTMENTS OF

4 LABOR AND TREASURY.—The Secretary shall coordi5 nate with the Secretaries of Labor and Treasury 

6 with respect to requirements to report data that af7 fect health insurance coverage sold in connection 

8 with group health plans. 

9 ‘‘(d) HEALTH INSURANCE ACCOUNTABILITY GRANTS

10 TO STATES.— 

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

12 for grants to Departments of Insurance in States to 

13 strengthen their enforcement of Federal health in14 surance requirements with respect to health insur15 ance issuers operating in such States. Such a grant 

16 shall only be made pursuant to an application made 

17 to the Secretary. 

18 ‘‘(2) FUNDING.— 

19 ‘‘(A) IN GENERAL.—Of the funds appro20 priated under subparagraph (B) for grants 

21 under this subsection, the Secretary shall pro22 vide a grant to each State with an application 

23 approved under paragraph (1). 

24 ‘‘(B) ALLOCATION.—Funds so appro25 priated for any fiscal year shall be apportioned 


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1 among the States in accordance with a formula 

2 determined by the Secretary that takes into ac3 count the scope of health insurance subject to 

4 regulation under this title in each State and 

5 such other factors as the Secretary may specify. 

6 ‘‘(C) APPROPRIATIONS AND AUTHORIZA7 TIONS.—There is hereby appropriated, out of 

8 any funds in the Treasury not otherwise appro9 priated for the first fiscal year in which this 

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

11 under this subsection, to be available until ex12 pended. For each subsequent fiscal year there is 

13 authorized to be appropriated such sums as 

14 may be necessary for such grants. 

15 ‘‘(e) FEDERAL HEALTH INSURANCE REQUIREMENTS

16 DEFINED.—In this part, the term ‘Federal health insur17 ance requirements’ means the requirements under this 

18 title insofar as they relate to health insurance issuers and 

19 health insurance coverage, whether in the individual or 

20 group market, and includes other requirements imposed 

21 under Federal law specifically in relation to the offering 

22 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 given such term for purposes of part 7 of 

19 subtitle B of title I of the Employee Retirement Income 

20 Security Act of 1974 and chapter 100 of the Internal Rev21 enue Code of 1986, respectively. 

Æ 


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