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Sec. 252. Requirements. 
Sec. 253. Definitions. 
TITLE III—SHARED RESPONSIBILITY 
Subtitle A—Individual Responsibility 
Sec. 301. Individual responsibility. 
Subtitle B—Employer Responsibility 
PART 1—HEALTH COVERAGE PARTICIPATION REQUIREMENTS 
Sec. 311. Health coverage participation requirements. 
Sec. 312. Employer responsibility to contribute towards em-
ployee and dependent coverage. 
Sec. 313. Employer contributions in lieu of coverage. 
Sec. 314. Authority related to improper steering. 
PART 2—SATISFACTION OF HEALTH COVERAGE PARTICIPATION 
REQUIREMENTS 
Sec. 321. Satisfaction of health coverage participation require-
ments under the Employee Retirement Income Se-
curity Act of 1974. 
Sec. 324. Additional rules relating to health coverage participa-
tion requirements. 
[FOR TITLE IV, SEE TEXT OF INTRODUCED BILL.] 
(c) GENERAL DEFINITIONS.—Except as oth-
erwise provided, in this division: 
(1) ACCEPTABLE
COVERAGE.—The term 
‘‘acceptable coverage’’ has the meaning 
given such term in section 202(d)(2). 
(2) 
BASIC
PLAN.—The 
term 
‘‘basic 
plan’’ has the meaning given such term in 
section 203(c). 
(3) COMMISSIONER.—The term ‘‘Com-
missioner’’ means the Health Choices 
Commissioner established under section 
141. 
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(4) COST-SHARING.—The term ‘‘cost- 
sharing’’ includes deductibles, coinsur-
ance, copayments, and similar charges 
but does not include premiums or any net-
work payment differential for covered 
services or spending for non-covered serv-
ices. 
(5) DEPENDENT.—The term ‘‘depend-
ent’’ has the meaning given such term by 
the Commissioner and includes a spouse. 
(6) EMPLOYMENT-BASED HEALTH PLAN.— 
The 
term 
‘‘employment-based 
health 
plan’’— 
(A) means a group health plan (as 
defined in section 733(a)(1) of the Em-
ployee Retirement Income Security Act 
of 1974); 
(B) includes such a plan that is 
the following: 
(i) FEDERAL, STATE, AND TRIBAL 
GOVERNMENTAL
PLANS.—A govern-
mental plan (as defined in section 
3(32) of the Employee Retirement 
Income Security Act of 1974), in-
cluding a health benefits plan of-
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fered under chapter 89 of title 5, 
United States Code; or 
(ii) CHURCH PLANS.—A church 
plan (as defined in section 3(33) of 
the Employee Retirement Income 
Security Act of 1974); and 
(C) excludes coverage described in 
section 
202(d)(2)(E) 
(relating 
to 
TRICARE). 
(7) ENHANCED
PLAN.—The term ‘‘en-
hanced plan’’ has the meaning given such 
term in section 203(c). 
(8) ESSENTIAL BENEFITS PACKAGE.—The 
term ‘‘essential benefits package’’ is de-
fined in section 122(a). 
(9) FAMILY.—The term ‘‘family’’ means 
an individual and includes the individ-
ual’s dependents. 
(10) FEDERAL POVERTY LEVEL; FPL.—The 
terms ‘‘Federal poverty level’’ and ‘‘FPL’’ 
have the meaning given the term ‘‘poverty 
line’’ in section 673(2) of the Community 
Services Block Grant Act (42 U.S.C. 
9902(2)), including any revision required 
by such section. 
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(11) 
HEALTH
BENEFITS
PLAN.—The 
terms ‘‘health benefits plan’’ means health 
insurance coverage and an employment- 
based health plan and includes the public 
health insurance option. 
(12) 
HEALTH
INSURANCE
COVERAGE; 
HEALTH
INSURANCE
ISSUER.—The 
terms 
‘‘health insurance coverage’’ and ‘‘health 
insurance issuer’’ have the meanings 
given such terms in section 2791 of the 
Public Health Service Act. 
(13) HEALTH
INSURANCE
EXCHANGE.— 
The term ‘‘Health Insurance Exchange’’ 
means the Health Insurance Exchange es-
tablished under section 201. 
(14) MEDICAID.—The term ‘‘Medicaid’’ 
means a State plan under title XIX of the 
Social Security Act (whether or not the 
plan is operating under a waiver under 
section 1115 of such Act). 
(15) MEDICARE.—The term ‘‘Medicare’’ 
means the health insurance programs 
under title XVIII of the Social Security 
Act. 
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(16) PLAN
SPONSOR.—The term ‘‘plan 
sponsor’’ has the meaning given such term 
in section 3(16)(B) of the Employee Retire-
ment Income Security Act of 1974. 
(17) PLAN YEAR.—The term ‘‘plan year’’ 
means— 
(A) with respect to an employment- 
based health plan, a plan year as 
specified under such plan; or 
(B) with respect to a health bene-
fits plan other than an employment- 
based health plan, a 12-month period 
as specified by the Commissioner. 
(18) 
PREMIUM
PLAN; 
PREMIUM-PLUS 
PLAN.—The terms ‘‘premium plan’’ and 
‘‘premium-plus plan’’ have the meanings 
given such terms in section 203(c). 
(19) 
QHBP 
OFFERING
ENTITY.—The 
terms ‘‘QHBP offering entity’’ means, with 
respect to a health benefits plan that is— 
(A) a group health plan (as de-
fined, subject to subsection (d), in sec-
tion 733(a)(1) of the Employee Retire-
ment Income Security Act of 1974), the 
plan sponsor in relation to such group 
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health plan, except that, in the case of 
a plan maintained jointly by 1 or 
more employers and 1 or more em-
ployee organizations and with respect 
to which an employer is the primary 
source of financing, such term means 
such employer; 
(B) health insurance coverage, the 
health insurance issuer offering the 
coverage; 
(C) the public health insurance 
option, the Secretary of Health and 
Human Services; 
(D) a non-Federal governmental 
plan (as defined in section 2791(d) of 
the Public Health Service Act), the 
State or political subdivision of a 
State (or agency or instrumentality of 
such State or subdivision) which es-
tablishes or maintains such plan; or 
(E) a Federal governmental plan 
(as defined in section 2791(d) of the 
Public Health Service Act), the appro-
priate Federal official. 
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(20) 
QUALIFIED
HEALTH
BENEFITS 
PLAN.—The term ‘‘qualified health benefits 
plan’’ means a health benefits plan that 
meets the requirements for such a plan 
under title I and includes the public 
health insurance option. 
(21) PUBLIC
HEALTH
INSURANCE
OP-
TION.—The term ‘‘public health insurance 
option’’ means the public health insur-
ance option as provided under subtitle B 
of title II. 
(22) SERVICE
AREA; PREMIUM
RATING 
AREA.—The terms ‘‘service area’’ and ‘‘pre-
mium rating area’’ mean with respect to 
health insurance coverage— 
(A) offered other than through the 
Health Insurance Exchange, such an 
area as established by the QHBP offer-
ing entity of such coverage in accord-
ance with applicable State law; and 
(B) offered through the Health In-
surance Exchange, such an area as es-
tablished by such entity in accordance 
with applicable State law and appli-
cable rules of the Commissioner for 
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Exchange-participating health bene-
fits plans. 
(23) STATE.—The term ‘‘State’’ means 
the 50 States and the District of Colum-
bia. 
(24) 
STATE
MEDICAID
AGENCY.—The 
term ‘‘State Medicaid agency’’ means, with 
respect to a Medicaid plan, the single 
State 
agency 
responsible 
for 
admin-
istering such plan under title XIX of the 
Social Security Act. 
(25) Y1, Y2, ETC..—The terms ‘‘Y1’’ , 
‘‘Y2’’, ‘‘Y3’’, ‘‘Y4’’, ‘‘Y5’’, and similar subse-
quently numbered terms, mean 2013 and 
subsequent years, respectively. 
(26) EMPLOYEE
PREMIUM.—The term 
‘‘employee premium’’ does not include a 
collectively bargained premium in the 
case of a group health plan (as defined in 
section 733(a)(1) of the Employee Retire-
ment Income Security Act of 1974) that is 
a multiemployer plan (as defined in sec-
tion 3(37) of such Act). 
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TITLE 
I—PROTECTIONS 
AND 
STANDARDS FOR QUALIFIED 
HEALTH BENEFITS PLANS 
Subtitle A—General Standards 
SEC. 101. REQUIREMENTS REFORMING HEALTH INSURANCE 
MARKETPLACE. 
(a) PURPOSE.—The purpose of this title is 
to establish standards to ensure that new 
health insurance coverage and employment- 
based health plans that are offered meet 
standards guaranteeing access to affordable 
coverage, essential benefits, and other con-
sumer protections. 
(b) REQUIREMENTS FOR QUALIFIED HEALTH 
BENEFITS PLANS.—On or after the first day of 
Y1, a health benefits plan shall not be a quali-
fied health benefits plan under this division 
unless the plan meets the applicable require-
ments of the following subtitles for the type of 
plan and plan year involved: 
(1) Subtitle B (relating to affordable 
coverage). 
(2) Subtitle C (relating to essential 
benefits). 
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(3) Subtitle D (relating to consumer 
protection). 
(c) TERMINOLOGY.—In this division: 
(1) ENROLLMENT IN EMPLOYMENT-BASED 
HEALTH
PLANS.—An individual shall be 
treated as being ‘‘enrolled’’ in an employ-
ment-based health plan if the individual 
is a participant or beneficiary (as such 
terms are defined in section 3(7) and 3(8), 
respectively, of the Employee Retirement 
Income Security Act of 1974) in such plan. 
(2) INDIVIDUAL AND GROUP HEALTH IN-
SURANCE
COVERAGE.—The 
terms 
‘‘indi-
vidual health insurance coverage’’ and 
‘‘group health insurance coverage’’ mean 
health insurance coverage offered in the 
individual market or large or small group 
market, respectively, as defined in section 
2791 of the Public Health Service Act. 
(d) SENSE OF CONGRESS ON HEALTH CARE 
NEEDS OF UNITED STATES TERRITORIES.—It is 
the sense of the Congress that the reforms 
made by H.R. 3200, as introduced, must be 
strengthened to meaningfully address the 
health care needs of residents of American 
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Samoa, the Commonwealth of the Northern 
Mariana Islands, Guam, Puerto Rico, and the 
United States Virgin Islands and Congress is 
committed to working with the representatives 
of these territories to ensure that residents of 
these territories have access to high-quality 
and affordable health care in such a way that 
best serves their unique needs. 
SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT 
COVERAGE. 
(a) GRANDFATHERED
HEALTH
INSURANCE 
COVERAGE DEFINED.—Subject to the succeeding 
provisions of this section, for purposes of es-
tablishing acceptable coverage under this di-
vision, the term ‘‘grandfathered health insur-
ance coverage’’ means individual health in-
surance coverage that is offered and in force 
and effect before the first day of Y1 if the fol-
lowing conditions are met: 
(1) LIMITATION ON NEW ENROLLMENT.— 
(A) IN
GENERAL.—Except as pro-
vided in this paragraph, the indi-
vidual health insurance issuer offer-
ing such coverage does not enroll any 
individual in such coverage if the first 
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effective date of coverage is on or after 
the first day of Y1. 
(B) 
DEPENDENT
COVERAGE
PER-
MITTED.—Subparagraph (A) shall not 
affect the subsequent enrollment of a 
dependent of an individual who is 
covered as of such first day. 
(2) LIMITATION ON CHANGES IN TERMS 
OR CONDITIONS.—Subject to paragraph (3) 
and except as required by law, the issuer 
does not change any of its terms or condi-
tions, including benefits and cost-sharing, 
from those in effect as of the day before 
the first day of Y1. 
(3) 
RESTRICTIONS
ON
PREMIUM
IN-
CREASES.—The issuer cannot vary the per-
centage increase in the premium for a 
risk group of enrollees in specific grand-
fathered health insurance coverage with-
out changing the premium for all enroll-
ees in the same risk group at the same 
rate, as specified by the Commissioner. 
(b) GRACE PERIOD FOR CURRENT EMPLOY-
MENT-BASED HEALTH PLANS.— 
(1) GRACE PERIOD.— 
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(A) 
IN
GENERAL.—The 
Commis-
sioner shall establish a grace period 
whereby, for plan years beginning 
after the end of the 5-year period be-
ginning with Y1, an employment- 
based health plan in operation as of 
the day before the first day of Y1 must 
meet the same requirements as apply 
to a qualified health benefits plan 
under section 101, including the essen-
tial 
benefit 
package 
requirement 
under section 121. 
(B) EXCEPTION FOR LIMITED BENE-
FITS
PLANS.—Subparagraph (A) shall 
not apply to an employment-based 
health plan in which the coverage 
consists only of one or more of the fol-
lowing: 
(i) Any coverage described in 
section 3001(a)(1)(B)(ii)(IV) of di-
vision B of the American Recovery 
and Reinvestment Act of 2009 (PL 
111–5). 
(ii) Excepted benefits (as de-
fined in section 733(c) of the Em-
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ployee Retirement Income Security 
Act of 1974), including coverage 
under a specified disease or ill-
ness policy described in para-
graph (3)(A) of such section. 
(iii) Such other limited bene-
fits as the Commissioner may 
specify. 
In no case shall an employment-based 
health plan in which the coverage 
consists only of one or more of the cov-
erage or benefits described in clauses 
(i) through (iii) be treated as accept-
able coverage under this division 
(2) TRANSITIONAL
TREATMENT
AS
AC-
CEPTABLE COVERAGE.—During the grace pe-
riod specified in paragraph (1)(A), an em-
ployment-based health plan that is de-
scribed in such paragraph shall be treat-
ed as acceptable coverage under this divi-
sion. 
(3) EXCEPTION FOR CONSUMER-DIRECTED 
HEALTH PLANS AND ARRANGEMENTS.—In the 
case of a group health plan which con-
sists of a consumer-directed health plan 
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or arrangement (including a high deduct-
ible health plan, within the meaning of 
section 223(c)(2) of the Internal Revenue 
Code of 1986), such group health plan 
shall be treated as acceptable coverage 
under a current group health plan for 
purposes of this division. 
(c) LIMITATION ON INDIVIDUAL HEALTH IN-
SURANCE COVERAGE.— 
(1) IN GENERAL.—Individual health in-
surance coverage that is not grand-
fathered health insurance coverage under 
subsection (a) may only be offered on or 
after the first day of Y1 as an Exchange- 
participating health benefits plan. 
(2) SEPARATE, EXCEPTED COVERAGE PER-
MITTED.—Excepted benefits (as defined in 
section 2791(c) of the Public Health Serv-
ice Act) are not included within the defi-
nition of health insurance coverage. Noth-
ing in paragraph (1) shall prevent the of-
fering, other than through the Health In-
surance Exchange, of excepted benefits so 
long as it is offered and priced separately 
from health insurance coverage. 
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Subtitle 
B—Standards 
Guaran-
teeing Access to Affordable Cov-
erage 
SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLU-
SIONS. 
A qualified health benefits plan may not 
impose any pre-existing condition exclusion 
(as defined in section 2701(b)(1)(A) of the Pub-
lic Health Service Act) or otherwise impose 
any limit or condition on the coverage under 
the plan with respect to an individual or de-
pendent based on any health status-related 
factors (as defined in section 2791(d)(9) of the 
Public Health Service Act) in relation to the 
individual or dependent. 
SEC. 112. GUARANTEED ISSUE AND RENEWAL FOR INSURED 
PLANS. 
The requirements of sections 2711 (other 
than subsections (c) and (e)) and 2712 (other 
than paragraphs (3), and (6) of subsection (b) 
and subsection (e)) of the Public Health Serv-
ice Act, relating to guaranteed availability 
and renewability of health insurance cov-
erage, shall apply to individuals and employ-
ers in all individual and group health insur-
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ance coverage, whether offered to individuals 
or employers through the Health Insurance 
Exchange, through any employment-based 
health plan, or otherwise, in the same manner 
as such sections apply to employers and health 
insurance coverage offered in the small group 
market, except that such section 2712(b)(1) 
shall apply only if, before nonrenewal or dis-
continuation of coverage, the issuer has pro-
vided the enrollee with notice of non-payment 
of premiums and there is a grace period dur-
ing which the enrollees has an opportunity to 
correct such nonpayment. Rescissions of such 
coverage shall be prohibited except in cases of 
fraud as defined in sections 2712(b)(2) of such 
Act. 
SEC. 113. INSURANCE RATING RULES. 
(a) 
IN
GENERAL.—The 
premium 
rate 
charged for an insured qualified health bene-
fits plan may not vary except as follows: 
(1) 
LIMITED
AGE
VARIATION
PER-
MITTED.—By age (within such age cat-
egories as the Commissioner shall specify) 
so long as the ratio of the highest such 
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premium to the lowest such premium does 
not exceed the ratio of 2 to 1. 
(2) BY AREA.—By premium rating area 
(as permitted by State insurance regu-
lators or, in the case of Exchange-partici-
pating health benefits plans, as specified 
by the Commissioner in consultation with 
such regulators). 
(3) BY FAMILY ENROLLMENT.—By family 
enrollment (such as variations within cat-
egories and compositions of families) so 
long as the ratio of the premium for fam-
ily enrollment (or enrollments) to the pre-
mium for individual enrollment is uni-
form, as specified under State law and 
consistent with rules of the Commissioner. 
(b) STUDY AND REPORTS.— 
(1) STUDY.—The Commissioner, in co-
ordination with the Secretary of Health 
and Human Services and the Secretary of 
Labor, shall conduct a study of the large 
group insured and self-insured employer 
health care markets. Such study shall ex-
amine the following: 
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(A) The types of employers by key 
characteristics, including size, that 
purchase 
insured 
products 
versus 
those that self-insure. 
(B) 
The 
similarities 
and 
dif-
ferences between typical insured and 
self-insured health plans. 
(C) The financial solvency and 
capital reserve levels of employers 
that self-insure by employer size. 
(D) The risk of self-insured em-
ployers not being able to pay obliga-
tions or otherwise becoming finan-
cially insolvent. 
(E) The extent to which rating 
rules are likely to cause adverse selec-
tion in the large group market or to 
encourage small and mid size employ-
ers to self-insure 
(2) 
REPORTS.—Not 
later 
than 
months after the date of the enactment of 
this Act, the Commissioner shall submit to 
Congress and the applicable agencies a 
report on the study conducted under para-
graph (1). Such report shall include any 
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recommendations 
the 
Commissioner 
deems appropriate to ensure that the law 
does not provide incentives for small and 
mid-size employers to self-insure or create 
adverse selection in the risk pools of large 
group insurers and self-insured employ-
ers. Not later than 18 months after the 
first day of Y1, the Commissioner shall 
submit to Congress and the applicable 
agencies an updated report on such study, 
including updates on such recommenda-
tions. 
SEC. 114. NONDISCRIMINATION IN BENEFITS; PARITY IN 
MENTAL HEALTH AND SUBSTANCE ABUSE 
DISORDER BENEFITS. 
(a) NONDISCRIMINATION
IN
BENEFITS.—A 
qualified health benefits plan shall comply 
with standards established by the Commis-
sioner to prohibit discrimination in health 
benefits or benefit structures for qualified 
health benefits plans, building from sections 
702 of Employee Retirement Income Security 
Act of 1974, 2702 of the Public Health Service 
Act, and section 9802 of the Internal Revenue 
Code of 1986. 
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(b) PARITY
IN MENTAL HEALTH
AND SUB-
STANCE ABUSE DISORDER BENEFITS.—To the ex-
tent such provisions are not superceded by or 
inconsistent with subtitle C, the provisions of 
section 2705 (other than subsections (a)(1), 
(a)(2), and (c)) of section 2705 of the Public 
Health Service Act shall apply to a qualified 
health benefits plan, regardless of whether it 
is offered in the individual or group market, 
in the same manner as such provisions apply 
to health insurance coverage offered in the 
large group market. 
SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS. 
(a) IN GENERAL.—A qualified health bene-
fits plan that uses a provider network for 
items and services shall meet such standards 
respecting provider networks as the Commis-
sioner may establish to assure the adequacy of 
such networks in ensuring enrollee access to 
such items and services and transparency in 
the cost-sharing differentials between in-net-
work coverage and out-of-network coverage. 
(b) INTERNET ACCESS TO INFORMATION.—A 
qualified health benefits plan that uses a pro-
vider network shall provide a current listing 
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of all providers in its network on its website 
and such data shall be available on the 
Health Insurance Exchange website as a ‘click 
through’ from the basic information on that 
plan. The Commissioner shall also establish 
an on-line system whereby an individual may 
select by name any medical provider (as de-
fined by the Commissioner) and be informed of 
the plan or plans with which that provider is 
contracting. 
(c) PROVIDER NETWORK DEFINED.—In this 
division, the term ‘‘provider network’’ means 
the providers with respect to which covered 
benefits, treatments, and services are avail-
able under a health benefits plan. 
SEC. 116. ENSURING VALUE AND LOWER PREMIUMS. 
The QHBP offering entity shall provide 
that for any plan year in which a qualified 
health benefits plan that the entity offers has 
a medical loss ratio (expressed as a percent-
age) that is less than a percentage (not less 
than 85 percent) specified by the Commis-
sioner, the QHBP offering entity offering such 
plan shall provide for rebates to enrollees of 
payment sufficient to meet such loss ratio. The 
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Commissioner shall establish a uniform defi-
nition of medical loss ratio and methodology 
for determining how to calculate the medical 
loss ratio. Such methodology shall be designed 
to take into account the special circumstances 
of smaller and newer plans. 
SEC. 117. CONSISTENCY OF COSTS AND COVERAGE UNDER 
QUALIFIED HEALTH BENEFITS PLANS DUR-
ING PLAN YEAR. 
In the case of health insurance coverage 
offered under a qualified health benefits plan, 
the coverage and cost of coverage may not be 
changed during the course of a plan year ex-
cept to increase coverage to the enrollee or to 
lower costs to the enrollee. 
Subtitle 
C—Standards 
Guaran-
teeing Access to Essential Bene-
fits 
SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE. 
(a) IN GENERAL.—A qualified health bene-
fits plan shall provide coverage that at least 
meets the benefit standards adopted under sec-
tion 124 for the essential benefits package de-
scribed in section 122 for the plan year in-
volved. 
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(b) CHOICE OF COVERAGE.— 
(1) 
NON-EXCHANGE-PARTICIPATING 
HEALTH BENEFITS PLANS.—In the case of a 
qualified health benefits plan that is not 
an Exchange-participating health bene-
fits plan, such plan may offer such cov-
erage in addition to the essential benefits 
package as the QHBP offering entity may 
specify. 
(2) 
EXCHANGE-PARTICIPATING
HEALTH 
BENEFITS
PLANS.—In the case of an Ex-
change-participating 
health 
benefits 
plan, such plan is required under section 
203 to provide specified levels of benefits 
and, in the case of a plan offering a pre-
mium-plus level of benefits, provide addi-
tional benefits. 
(3) CONTINUATION OF OFFERING OF SEP-
ARATE
EXCEPTED
BENEFITS
COVERAGE.— 
Nothing in this division shall be con-
strued as affecting the offering of health 
benefits in the form of excepted benefits 
(described in section 102(b)(1)(B)(ii)) if 
such benefits are offered under a separate 
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policy, contract, or certificate of insur-
ance. 
(c) NO RESTRICTIONS ON COVERAGE UNRE-
LATED TO CLINICAL APPROPRIATENESS.—A quali-
fied health benefits plan may not impose any 
restriction (other than cost-sharing) unrelated 
to clinical appropriateness on the coverage of 
the health care items and services. 
SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED. 
(a) IN GENERAL.—In this division, the term 
‘‘essential benefits package’’ means health 
benefits coverage, consistent with standards 
adopted under section 124 to ensure the provi-
sion of quality health care and financial secu-
rity, that— 
(1) provides payment for the items and 
services described in subsection (b) in ac-
cordance with generally accepted stand-
ards of medical or other appropriate clin-
ical or professional practice; 
(2) limits cost-sharing for such cov-
ered health care items and services in ac-
cordance with such benefit standards, 
consistent with subsection (c); 
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(3) does not impose any annual or life-
time limit on the coverage of covered 
health care items and services; 
(4) complies with section 115(a) (relat-
ing to network adequacy); and 
(5) is equivalent, as certified by Office 
of the Actuary of the Centers for Medicare 
& Medicaid Services, to the average pre-
vailing employer-sponsored coverage. 
(b) MINIMUM SERVICES TO BE COVERED.— 
The items and services described in this sub-
section are the following: 
(1) Hospitalization. 
(2) Outpatient hospital and outpatient 
clinic services, including emergency de-
partment services. 
(3) Professional services of physicians 
and other health professionals. 
(4) Such services, equipment, and sup-
plies incident to the services of a physi-
cian’s or a health professional’s delivery 
of care in institutional settings, physician 
offices, patients’ homes or place of resi-
dence, or other settings, as appropriate. 
(5) Prescription drugs. 
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(6) Rehabilitative and habilitative 
services. 
(7) Mental health and substance use 
disorder services. 
(8) 
Preventive 
services, 
including 
those services recommended with a grade 
of A or B by the Task Force on Clinical 
Preventive Services and including mental 
health and substance abuse services rec-
ommended by the Task Force on Clinical 
Preventive Services and those mental 
health and substance abuse services with 
compelling research or evidence, includ-
ing Screening, Brief Intervention and Re-
ferral to Treatment (SBIRT), and those 
vaccines recommended for use by the Di-
rector of the Centers for Disease Control 
and Prevention. 
(9) Maternity care. 
(10) Well baby and well child care and 
early and periodic screening, diagnostic, 
and treatment services (as defined in sec-
tion 1905(r) of the Social Security Act) at 
least for children under 21 years of age. 
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(11) Durable medical equipment, pros-
thetics, orthotics and related supplies. 
(c) REQUIREMENTS RELATING TO COST-SHAR-
ING AND MINIMUM ACTUARIAL VALUE.— 
(1) NO
COST-SHARING
FOR
PREVENTIVE 
SERVICES.—There shall be no cost-sharing 
under the essential benefits package for 
preventive items and services (as specified 
under the benefit standards), including 
well baby and well child care. 
(2) ANNUAL LIMITATION.— 
(A) ANNUAL LIMITATION.—The cost- 
sharing incurred under the essential 
benefits package with respect to an in-
dividual (or family) for a year does 
not exceed the applicable level speci-
fied in subparagraph (B). 
(B) APPLICABLE LEVEL.—The appli-
cable level specified in this subpara-
graph for Y1 is $5,000 for an indi-
vidual and $10,000 for a family. Such 
levels shall be increased (rounded to 
the nearest $100) for each subsequent 
year by the annual percentage in-
crease in the Consumer Price Index 
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(United States city average) applica-
ble to such year. 
(C) USE OF COPAYMENTS.—In estab-
lishing cost-sharing levels for basic, 
enhanced, and premium plans under 
this subsection, the Secretary shall, to 
the maximum extent possible, use only 
copayments and not coinsurance. 
(3) MINIMUM ACTUARIAL VALUE.— 
(A) IN GENERAL.—The cost-sharing 
under the essential benefits package 
shall be designed to provide a level of 
coverage that is designed to provide 
benefits that are actuarially equiva-
lent to approximately 70 percent of the 
full actuarial value of the benefits 
provided under the reference benefits 
package described in subparagraph 
(B). 
(B) REFERENCE
BENEFITS
PACKAGE 
DESCRIBED.—The 
reference 
benefits 
package described in this subpara-
graph is the essential benefits pack-
age if there were no cost-sharing im-
posed. 
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SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE. 
(a) ESTABLISHMENT.— 
(1) IN GENERAL.—There is established 
a 
private-public 
advisory 
committee 
which shall be a panel of medical and 
other experts to be known as the Health 
Benefits 
Advisory 
Committee 
to 
rec-
ommend covered benefits and essential, 
enhanced, and premium plans. 
(2) CHAIR.—The Surgeon General shall 
be a member and the chair of the Health 
Benefits Advisory Committee. 
(3) MEMBERSHIP.—The Health Benefits 
Advisory Committee shall be composed of 
the following members, in addition to the 
Surgeon General: 
(A) 9 members who are not Fed-
eral employees or officers and who are 
appointed by the President. 
(B) 9 members who are not Fed-
eral employees or officers and who are 
appointed by the Comptroller General 
of the United States in a manner simi-
lar to the manner in which the Comp-
troller General appoints members to 
the Medicare Payment Advisory Com-
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mission under section 1805(c) of the 
Social Security Act. 
(C) Such even number of members 
(not to exceed 8) who are Federal em-
ployees and officers, as the President 
may appoint. 
The membership of the Committee shall 
include one or more experts in scientific 
evidence and clinical practice of integra-
tive health care services. Such initial ap-
pointments shall be made not later than 
60 days after the date of the enactment of 
this Act. 
(4) 
TERMS.—Each 
member 
of 
the 
Health Benefits Advisory Committee shall 
serve a 3-year term on the Committee, ex-
cept that the terms of the initial members 
shall be adjusted in order to provide for a 
staggered term of appointment for all 
such members. 
(5) PARTICIPATION.—The membership 
of the Health Benefits Advisory Committee 
shall at least reflect providers, employers, 
labor, health insurance issuers, experts in 
health care financing and delivery, ex-
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perts in racial and ethnic disparities, ex-
perts in care for those with disabilities, 
representatives of relevant governmental 
agencies. and at least one practicing phy-
sician or other health professional and an 
expert on children’s health and shall rep-
resent a balance among various sectors of 
the health care system so that no single 
sector unduly influences the recommenda-
tions of such Committee. The membership 
of the Committee shall also include edu-
cated patients, consumer advocates, or 
both, who shall include persons who rep-
resent individuals affected by a specific 
disease or medical condition, are knowl-
edgeable about the health care system, 
and have received training regarding 
health, medical, and scientific matters. 
(b) DUTIES.— 
(1) 
RECOMMENDATIONS
ON
BENEFIT 
STANDARDS.—The Health Benefits Advisory 
Committee shall recommend to the Sec-
retary of Health and Human Services (in 
this subtitle referred to as the ‘‘Sec-
retary’’) benefit standards (as defined in 
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paragraph (4)), and periodic updates to 
such standards. In developing such rec-
ommendations, the Committee shall— 
(A) take into account innovation 
in health care, 
(B) consider how such standards 
could reduce health disparities, 
(C) take into account integrative 
health care services, and 
(D) take into account typical mul-
tiemployer plan benefit structures and 
the impact of the essential benefit 
package on such plans. 
(2) DEADLINE.—The Health Benefits 
Advisory Committee shall recommend ini-
tial benefit standards to the Secretary not 
later than 1 year after the date of the en-
actment of this Act. 
(3) STATE INPUT.—The Health Benefits 
Advisory Committee shall examine the 
health coverage laws and benefits of each 
State 
in 
developing 
recommendations 
under this subsection and may incor-
porate such coverage and benefits as the 
Committee determines to be appropriate 
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and consistent with this Act. The Health 
Benefits Advisory Committee shall also 
seek input from the States and consider 
recommendations on how to ensure that 
the quality of health coverage does not de-
cline in any State. 
(4) PUBLIC
INPUT.—The Health Bene-
fits Advisory Committee shall allow for 
public input as a part of developing rec-
ommendations under this subsection. 
(5) BENEFIT
STANDARDS
DEFINED.—In 
this subtitle, the term ‘‘benefit standards’’ 
means standards respecting— 
(A) the essential benefits package 
described in section 122, including 
categories of covered treatments, items 
and services within benefit classes, 
and cost-sharing; and 
(B) the cost-sharing levels for en-
hanced plans and premium plans (as 
provided under section 203(c)) con-
sistent with paragraph (5). 
(6) LEVELS
OF
COST-SHARING
FOR
EN-
HANCED AND PREMIUM PLANS.— 
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(A) ENHANCED PLAN.—The level of 
cost-sharing for enhanced plans shall 
be designed so that such plans have 
benefits that are actuarially equiva-
lent to approximately 85 percent of the 
actuarial value of the benefits pro-
vided under the reference benefits 
package 
described 
in 
section 
122(c)(3)(B). 
(B) PREMIUM
PLAN.—The level of 
cost-sharing for premium plans shall 
be designed so that such plans have 
benefits that are actuarially equiva-
lent to approximately 95 percent of the 
actuarial value of the benefits pro-
vided under the reference benefits 
package 
described 
in 
section 
122(c)(3)(B). 
(7) RECOMMENDATIONS OF INTEGRATIVE 
HEALTH CARE SERVICES TASK FORCE.— 
(A) INCLUSION IN COMMITTEE’S REC-
OMMENDATIONS.—The Health Benefits 
Advisory Committee shall include in 
its 
recommendations 
under 
para-
graph (1) the recommendations made 
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by the Integrative Health Care Serv-
ices Task Force established under sub-
paragraph (B). 
(B) 
ESTABLISHMENT
OF
TASK 
FORCE.—The Health Benefits Advisory 
Committee shall establish an Integra-
tive Health Care Services Task Force. 
Such Task Force shall consist of 5 ex-
perts with expertise in research in, 
and practice of, integrative health 
care. Such experts shall be appointed 
by the Committee from among experts 
nominated by the Secretary, in con-
sultation with the National Center for 
Complementary and Alternative Medi-
cine at the National Institutes of 
Health. The duty of the Task Force 
shall be to make recommendations to 
the 
Committee 
on 
evidence-based, 
clinically effective, and safe integra-
tive care services. 
(c) OPERATIONS.— 
(1) PER DIEM PAY.—Each member of the 
Health Benefits Advisory Committee shall 
receive travel expenses, including per 
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diem in accordance with applicable provi-
sions under subchapter I of chapter 57 of 
title 5, United States Code, and shall oth-
erwise serve without additional pay. 
(2) MEMBERS NOT TREATED AS FEDERAL 
EMPLOYEES.—Members of the Health Bene-
fits Advisory Committee shall not be con-
sidered employees of the Federal govern-
ment solely by reason of any service on the 
Committee. 
(3) APPLICATION OF FACA.—The Federal 
Advisory Committee Act (5 U.S.C. App.), 
other than section 14, shall apply to the 
Health Benefits Advisory Committee. 
(d) PUBLICATION.—The Secretary shall pro-
vide for publication in the Federal Register 
and the posting on the Internet website of the 
Department of Health and Human Services of 
all recommendations made by the Health Ben-
efits Advisory Committee under this section. 
SEC. 124. PROCESS FOR ADOPTION OF RECOMMENDATIONS; 
ADOPTION OF BENEFIT STANDARDS. 
(a) 
PROCESS
FOR
ADOPTION
OF
REC-
OMMENDATIONS.— 
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(1) REVIEW
OF
RECOMMENDED
STAND-
ARDS.—Not later than 45 days after the 
date of receipt of benefit standards rec-
ommended under section 123 (including 
such standards as modified under para-
graph (2)(B)), the Secretary shall review 
such 
standards 
and 
shall 
determine 
whether to propose adoption of such 
standards as a package. 
(2) DETERMINATION
TO
ADOPT
STAND-
ARDS.—If the Secretary determines— 
(A) to propose adoption of benefit 
standards so recommended as a pack-
age, the Secretary shall, by regulation 
under section 553 of title 5, United 
States Code, propose adoption such 
standards; or 
(B) not to propose adoption of 
such standards as a package, the Sec-
retary shall notify the Health Benefits 
Advisory Committee in writing of such 
determination and the reasons for not 
proposing the adoption of such rec-
ommendation and provide the Com-
mittee with a further opportunity to 
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modify its previous recommendations 
and submit new recommendations to 
the Secretary on a timely basis. 
(3) CONTINGENCY.—If, because of the 
application of paragraph (2)(B), the Sec-
retary would otherwise be unable to pro-
pose 
initial 
adoption 
of 
such 
rec-
ommended standards by the deadline 
specified in subsection (b)(1), the Sec-
retary shall, by regulation under section 
553 of title 5, United States Code, propose 
adoption of initial benefit standards by 
such deadline. 
(4) PUBLICATION.—The Secretary shall 
provide for publication in the Federal 
Register of all determinations made by 
the Secretary under this subsection. 
(b) ADOPTION OF STANDARDS.— 
(1) INITIAL STANDARDS.—Not later than 
18 months after the date of the enactment 
of this Act, the Secretary shall, through 
the rulemaking process consistent with 
subsection (a), adopt an initial set of ben-
efit standards. 
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(2) PERIODIC
UPDATING
STANDARDS.— 
Under subsection (a), the Secretary shall 
provide for the periodic updating of the 
benefit 
standards 
previously 
adopted 
under this section. 
(3) REQUIREMENT.—The Secretary may 
not adopt any benefit standards for an es-
sential benefits package or for level of 
cost-sharing that are inconsistent with 
the requirements for such a package or 
level under sections 122 and 123(b)(5). 
SEC. 125. PROHIBITION OF DISCRIMINATION IN HEALTH 
CARE SERVICES BASED ON RELIGIOUS OR 
SPIRITUAL CONTENT. 
Neither the Commissioner nor any health 
insurance issuer offering health insurance 
coverage through the Exchange shall discrimi-
nate in approving or covering a health care 
service on the basis of its religious or spiritual 
content if expenditures for such a health care 
service are allowable as a deduction under 
213(d) of the Internal Revenue Code of 1986, as 
in effect on January 1, 2009. 
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Subtitle D—Additional Consumer 
Protections 
SEC. 131. REQUIRING FAIR MARKETING PRACTICES BY 
HEALTH INSURERS. 
The Commissioner shall establish uniform 
marketing standards that all insured QHBP 
offering entities shall meet. 
SEC. 132. REQUIRING FAIR GRIEVANCE AND APPEALS 
MECHANISMS. 
(a) IN GENERAL.—A QHBP offering entity 
shall provide for timely grievance and appeals 
mechanisms that the Commissioner shall es-
tablish. 
(b) INTERNAL CLAIMS AND APPEALS PROC-
ESS.—Under a qualified health benefits plan 
the QHBP offering entity shall provide an in-
ternal claims and appeals process that ini-
tially incorporates the claims and appeals 
procedures (including urgent claims) set forth 
at section 2560.503–1 of title 29, Code of Fed-
eral Regulations, as published on November 
21, 2000 (65 Fed. Reg. 70246) and shall update 
such process in accordance with any stand-
ards that the Commissioner may establish. 
(c) EXTERNAL REVIEW PROCESS.— 
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(1) IN
GENERAL.—The Commissioner 
shall establish an external review process 
(including procedures for expedited re-
views of urgent claims) that provides for 
an impartial, independent, and de novo 
review of denied claims under this divi-
sion. 
(2) REQUIRING FAIR GRIEVANCE AND AP-
PEALS
MECHANISMS.—A 
determination 
made, with respect to a qualified health 
benefits plan offered by a QHBP offering 
entity, under the external review process 
established under this subsection shall be 
binding on the plan and the entity. 
(d) CONSTRUCTION.—Nothing in this sec-
tion shall be construed as affecting the avail-
ability of judicial review under State law for 
adverse decisions under subsection (b) or (c), 
subject to section 151. 
SEC. 133. REQUIRING INFORMATION TRANSPARENCY AND 
PLAN DISCLOSURE. 
(a) ACCURATE AND TIMELY DISCLOSURE.— 
(1) IN
GENERAL.—A qualified health 
benefits plan shall comply with standards 
established by the Commissioner for the 
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accurate and timely disclosure of plan 
documents, plan terms and conditions, 
claims payment policies and practices, 
periodic financial disclosure, data on en-
rollment, data on disenrollment, data on 
the number of claims denials, data on rat-
ing practices, information on cost-sharing 
and payments with respect to any out-of- 
network coverage, and other information 
as determined appropriate by the Com-
missioner. The Commissioner shall re-
quire that such disclosure be provided in 
plain language. 
(2) PLAIN
LANGUAGE.—In this sub-
section, the term ‘‘plain language’’ means 
language that the intended audience, in-
cluding individuals with limited English 
proficiency, can readily understand and 
use because that language is clean, con-
cise, well-organized, and follows other 
best practices of plain language writing. 
(3) 
GUIDANCE.—The 
Commissioner 
shall develop and issue guidance on best 
practices of plain language writing. 
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(b) 
CONTRACTING
REIMBURSEMENT.—A 
qualified health benefits plan shall comply 
with standards established by the Commis-
sioner to ensure transparency to each health 
care provider relating to reimbursement ar-
rangements between such plan and such pro-
vider. 
(c) ADVANCE NOTICE OF PLAN CHANGES.—A 
change in a qualified health benefits plan 
shall not be made without such reasonable 
and timely advance notice to enrollees of such 
change. 
(d) IDENTIFICATION OF PROVIDERS TRAINED 
AND ACCREDITED IN INTEGRATIVE MEDICINE.—A 
qualified health benefit plan shall include in 
the disclosure required under subsection (a) 
identification to enrollees of any providers of 
services under the plan that are trained and 
accredited in integrative health medicine. 
SEC. 134. APPLICATION TO QUALIFIED HEALTH BENEFITS 
PLANS NOT OFFERED THROUGH THE HEALTH 
INSURANCE EXCHANGE. 
The requirements of the previous provi-
sions of this subtitle shall apply to qualified 
health benefits plans that are not being of-
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fered through the Health Insurance Exchange 
only to the extent specified by the Commis-
sioner. 
SEC. 135. TIMELY PAYMENT OF CLAIMS. 
A QHBP offering entity shall comply with 
the requirements of section 1857(f) of the So-
cial Security Act with respect to a qualified 
health benefits plan it offers in the same man-
ner an Medicare Advantage organization is re-
quired to comply with such requirements with 
respect to a Medicare Advantage plan it offers 
under part C of Medicare. 
SEC. 136. STANDARDIZED RULES FOR COORDINATION AND 
SUBROGATION OF BENEFITS. 
The Commissioner shall establish stand-
ards for the coordination and subrogation of 
benefits and reimbursement of payments in 
cases involving individuals and multiple plan 
coverage. 
SEC. 137. APPLICATION OF ADMINISTRATIVE SIMPLIFICA-
TION. 
A QHBP offering entity is required to com-
ply with standards for electronic financial 
and administrative transactions under section 
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1173A of the Social Security Act, added by sec-
tion 163(a). 
SEC. 138. RECORDS RELATIVE TO PRESCRIPTION INFORMA-
TION. 
(a) IN GENERAL.—A qualified health bene-
fits plan shall ensure that its records relative 
to prescription information containing patient 
identifiable and prescriber-identifiable data 
are maintained in accordance with this sec-
tion.’’ 
(b) REQUIREMENTS.— 
(1) IN GENERAL.—Records described in 
subsection (a) may not be licensed, trans-
ferred, used, or sold by any pharmacy ben-
efits manager, insurance company, elec-
tronic transmission intermediary, retail, 
mail order, or Internet pharmacy or other 
similar entity, for any commercial pur-
pose, except for the limited purposes of— 
(A) pharmacy reimbursement; 
(B) formulary compliance; 
(C) care management; 
(D) utilization review by a health 
care provider, the patient’s insurance 
provider or the agent of either; 
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(E) health care research; or 
(F) as otherwise provided by law. 
(2) COMMERCIAL
PURPOSE.—For pur-
poses of paragraph (1), the term ‘‘commer-
cial purpose’’ includes, but is not limited 
to, advertising, marketing, promotion, or 
any activity that could be used to influ-
ence sales or market share of a pharma-
ceutical product, influence or evaluate 
the prescribing behavior of an individual 
health care professional, or evaluate the 
effectiveness of a professional pharma-
ceutical detailing sales force. 
(c) CONSTRUCTION.— 
(1) PERMITTED PRACTICES.—Nothing in 
this section shall prohibit— 
(A) the dispensing of prescription 
medications to a patient or to the pa-
tient’s authorized representative; 
(B) the transmission of prescrip-
tion information between an author-
ized prescriber and a licensed phar-
macy; 
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(C) the transfer of prescription in-
formation 
between 
licensed 
phar-
macies; 
(D) the transfer of prescription 
records that may occur in the event a 
pharmacy ownership is changed or 
transferred; 
(E) care management educational 
communications provided to a patient 
about the patient’s health condition, 
adherence to a prescribed course of 
therapy, or other information about 
the drug being dispensed, treatment 
options, or clinical trials. 
(2) DE-IDENTIFIED
DATA.—Nothing in 
this section shall prohibit the collection, 
use, transfer, or sale of patient and pre-
scriber de-identified data by zip code, geo-
graphic region, or medical specialty for 
commercial purposes. 
Subtitle E—Governance 
SEC. 141. HEALTH CHOICES ADMINISTRATION; HEALTH 
CHOICES COMMISSIONER. 
(a) IN GENERAL.—There is hereby estab-
lished, as an independent agency in the execu-
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tive branch of the Government, a Health 
Choices Administration (in this division re-
ferred to as the ‘‘Administration’’). 
(b) COMMISSIONER.— 
(1) IN
GENERAL.—The Administration 
shall be headed by a Health Choices Com-
missioner (in this division referred to as 
the ‘‘Commissioner’’) who shall be ap-
pointed by the President, by and with the 
advice and consent of the Senate. 
(2) COMPENSATION; 
ETC.—The provi-
sions of paragraphs (2), (5) and (7) of sub-
section (a) (relating to compensation, 
terms, general powers, rulemaking, and 
delegation) of section 702 of the Social Se-
curity Act (42 U.S.C. 902) shall apply to 
the Commissioner and the Administration 
in the same manner as such provisions 
apply to the Commissioner of Social Secu-
rity and the Social Security Administra-
tion. 
SEC. 142. DUTIES AND AUTHORITY OF COMMISSIONER. 
(a) DUTIES.—The Commissioner is respon-
sible for carrying out the following functions 
under this division: 
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(1) QUALIFIED
PLAN
STANDARDS.—The 
establishment of qualified health benefits 
plan standards under this title, including 
the enforcement of such standards in co-
ordination with State insurance regu-
lators and the Secretaries of Labor and 
the Treasury. 
(2) HEALTH INSURANCE EXCHANGE.—The 
establishment and operation of a Health 
Insurance Exchange under subtitle A of 
title II. 
(3) INDIVIDUAL
AFFORDABILITY
CRED-
ITS.—The administration of individual af-
fordability credits under subtitle C of title 
II, including determination of eligibility 
for such credits. 
(4) ADDITIONAL FUNCTIONS.—Such ad-
ditional functions as may be specified in 
this division. 
(b) PROMOTING ACCOUNTABILITY.— 
(1) IN
GENERAL.—The Commissioner 
shall undertake activities in accordance 
with this subtitle to promote account-
ability of QHBP offering entities in meet-
ing Federal health insurance require-
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ments, regardless of whether such ac-
countability is with respect to qualified 
health benefits plans offered through the 
Health Insurance Exchange or outside of 
such Exchange. 
(2) COMPLIANCE EXAMINATION AND AU-
DITS.— 
(A) 
IN
GENERAL.—The 
commis-
sioner shall, in coordination with 
States, conduct audits of qualified 
health benefits plan compliance with 
Federal requirements.
Such audits 
may include random compliance au-
dits and targeted audits in response 
to complaints or other suspected non- 
compliance. 
(B) RECOUPMENT OF COSTS IN CON-
NECTION
WITH
EXAMINATION
AND
AU-
DITS.—The Commissioner is author-
ized to recoup from qualified health 
benefits plans reimbursement for the 
costs of such examinations and audit 
of such QHBP offering entities. 
(c) DATA COLLECTION.—The Commissioner 
shall collect data for purposes of carrying out 
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the Commissioner’s duties, including for pur-
poses of promoting quality and value, pro-
tecting consumers, and addressing disparities 
in health and health care and may share such 
data with the Secretary of Health and Human 
Services. 
(d) SANCTIONS AUTHORITY.— 
(1) IN GENERAL.—In the case that the 
Commissioner determines that a QHBP of-
fering entity violates a requirement of this 
title, the Commissioner may, in coordina-
tion with State insurance regulators and 
the Secretary of Labor, provide, in addi-
tion to any other remedies authorized by 
law, for any of the remedies described in 
paragraph (2). 
(2) REMEDIES.—The remedies described 
in this paragraph, with respect to a quali-
fied health benefits plan offered by a 
QHBP offering entity, are— 
(A) civil money penalties of not 
more than the amount that would be 
applicable 
under 
similar 
cir-
cumstances 
for 
similar 
violations 
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under section 1857(g) of the Social Se-
curity Act; 
(B) suspension of enrollment of in-
dividuals under such plan after the 
date the Commissioner notifies the en-
tity of a determination under para-
graph (1) and until the Commissioner 
is satisfied that the basis for such de-
termination has been corrected and is 
not likely to recur; 
(C) in the case of an Exchange- 
participating health benefits plan, 
suspension of payment to the entity 
under the Health Insurance Exchange 
for individuals enrolled in such plan 
after the date the Commissioner noti-
fies the entity of a determination 
under paragraph (1) and until the 
Secretary is satisfied that the basis 
for such determination has been cor-
rected and is not likely to recur; or 
(D) working with State insurance 
regulators to terminate plans for re-
peated failure by the offering entity to 
meet the requirements of this title. 
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(e) STANDARD DEFINITIONS
OF INSURANCE 
AND MEDICAL TERMS.—The Commissioner shall 
provide for the development of standards for 
the definitions of terms used in health insur-
ance coverage, including insurance-related 
terms. 
(f) EFFICIENCY
IN
ADMINISTRATION.—The 
Commissioner shall issue regulations for the 
effective and efficient administration of the 
Health Insurance Exchange and affordability 
credits under subtitle C, including, with re-
spect to the determination of eligibility for af-
fordability credits, the use of personnel who 
are employed in accordance with the require-
ments of title 5, United States Code, to carry 
out the duties of the Commissioner or, in the 
case of sections 208 and 241(b)(2), the use of 
State personnel who are employed in accord-
ance with standards prescribed by the Office 
of Personnel Management pursuant to section 
208 of the Intergovernmental Personnel Act of 
1970 (42 U.S.C. 4728). 
SEC. 143. CONSULTATION AND COORDINATION. 
(a) CONSULTATION.—In carrying out the 
Commissioner’s duties under this division, the 
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Commissioner, as appropriate, shall consult 
with at least with the following: 
(1) The National Association of Insur-
ance Commissioners, State attorneys gen-
eral, and State insurance regulators, in-
cluding concerning the standards for in-
sured qualified health benefits plans 
under this title and enforcement of such 
standards. 
(2) Appropriate State agencies, spe-
cifically concerning the administration of 
individual 
affordability 
credits 
under 
subtitle C of title II and the offering of Ex-
change-participating 
health 
benefits 
plans, to Medicaid eligible individuals 
under subtitle A of such title. 
(3) Other appropriate Federal agen-
cies. 
(4) Indian tribes and tribal organiza-
tions. 
(5) The National Association of Insur-
ance Commissioners for purposes of using 
model guidelines established by such asso-
ciation for purposes of subtitles B and D. 
(b) COORDINATION.— 
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(1) IN GENERAL.—In carrying out the 
functions of the Commissioner, including 
with respect to the enforcement of the pro-
visions of this division, the Commissioner 
shall work in coordination with existing 
Federal and State entities to the max-
imum extent feasible consistent with this 
division and in a manner that prevents 
conflicts of interest in duties and ensures 
effective enforcement. 
(2) UNIFORM
STANDARDS.—The Com-
missioner, in coordination with such enti-
ties, shall seek to achieve uniform stand-
ards that adequately protect consumers in 
a manner that does not unreasonably af-
fect employers and insurers. 
SEC. 144. HEALTH INSURANCE OMBUDSMAN. 
(a) IN GENERAL.—The Commissioner shall 
appoint within the Health Choices Adminis-
tration a Qualified Health Benefits Plan Om-
budsman who shall have expertise and experi-
ence in the fields of health care and education 
of (and assistance to) individuals. 
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(b) DUTIES.—The Qualified Health Benefits 
Plan Ombudsman shall, in a linguistically ap-
propriate manner— 
(1) 
receive 
complaints, 
grievances, 
and requests for information submitted by 
individuals; 
(2) provide assistance with respect to 
complaints, grievances, and requests re-
ferred to in paragraph (1), including— 
(A) helping individuals determine 
the relevant information needed to 
seek an appeal of a decision or deter-
mination; 
(B) assistance to such individuals 
with 
any 
problems 
arising 
from 
disenrollment from such a plan; 
(C) assistance to such individuals 
in choosing a qualified health benefits 
plan in which to enroll; and 
(D) assistance to such individuals 
in presenting information under sub-
title C (relating to affordability cred-
its); 
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(3) consult with educated patients and 
consumer advocates (described in section 
123(a)(5)); and 
(4) submit annual reports to Congress 
and the Commissioner that describe the 
activities of the Ombudsman and that in-
clude such recommendations for improve-
ment in the administration of this divi-
sion as the Ombudsman determines ap-
propriate. The Ombudsman shall not 
serve as an advocate for any increases in 
payments or new coverage of services, but 
may identify issues and problems in pay-
ment or coverage policies. 
Subtitle F—Relation to Other 
Requirements; Miscellaneous 
SEC. 151. RELATION TO OTHER REQUIREMENTS. 
(a) COVERAGE NOT OFFERED THROUGH EX-
CHANGE.— 
(1) IN GENERAL.—In the case of health 
insurance coverage not offered through 
the Health Insurance Exchange (whether 
or not offered in connection with an em-
ployment-based health plan), and in the 
case of employment-based health plans, 
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the requirements of this title do not 
supercede any requirements applicable 
under titles XXII and XXVII of the Public 
Health Service Act, parts 6 and 7 of sub-
title B of title I of the Employee Retire-
ment Income Security Act of 1974, or State 
law, except insofar as such requirements 
prevent the application of a requirement 
of this division, as determined by the Com-
missioner. 
(2) CONSTRUCTION.—Nothing in para-
graph (1) shall be construed as affecting 
the application of section 514 of the Em-
ployee Retirement Income Security Act of 
1974. 
(b) 
COVERAGE
OFFERED
THROUGH
EX-
CHANGE.— 
(1) IN GENERAL.—In the case of health 
insurance coverage offered through the 
Health Insurance Exchange— 
(A) the requirements of this title 
do not supercede any requirements 
(including requirements relating to 
genetic information nondiscrimina-
tion and mental health) applicable 
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under title XXVII of the Public Health 
Service Act or under State law, except 
insofar as such requirements prevent 
the application of a requirement of 
this division, as determined by the 
Commissioner; and 
(B) individual rights and rem-
edies under State laws shall apply. 
(2) CONSTRUCTION.—In the case of cov-
erage described in paragraph (1), nothing 
in such paragraph shall be construed as 
preventing the application of rights and 
remedies under State laws with respect to 
any requirement referred to in paragraph 
(1)(A). 
SEC. 152. PROHIBITING DISCRIMINATION IN HEALTH CARE. 
(a) IN GENERAL.—Except as otherwise ex-
plicitly permitted by this Act and by subse-
quent regulations consistent with this Act, all 
health care and related services (including in-
surance coverage and public health activities) 
covered by this Act shall be provided without 
regard to personal characteristics extraneous 
to the provision of high quality health care or 
related services. 
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(b) IMPLEMENTATION.—To implement the re-
quirement set forth in subsection (a), the Sec-
retary of Health and Human Services shall, 
not later than 18 months after the date of the 
enactment of this Act, promulgate such regula-
tions as are necessary or appropriate to insure 
that all health care and related services (in-
cluding insurance coverage and public health 
activities) covered by this Act are provided 
(whether directly or through contractual, li-
censing, or other arrangements) without re-
gard to personal characteristics extraneous to 
the provision of high quality health care or re-
lated services. 
SEC. 153. WHISTLEBLOWER PROTECTION. 
(a) RETALIATION PROHIBITED.—No employer 
may discharge any employee or otherwise dis-
criminate against any employee with respect 
to his compensation, terms, conditions, or 
other privileges of employment because the em-
ployee (or any person acting pursuant to a re-
quest of the employee)— 
(1) provided, caused to be provided, or 
is about to provide or cause to be provided 
to the employer, the Federal Government, 
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or the attorney general of a State infor-
mation relating to any violation of, or any 
act or omission the employee reasonably 
believes to be a violation of any provision 
of this Act or any order, rule, or regula-
tion promulgated under this Act; 
(2) testified or is about to testify in a 
proceeding concerning such violation; 
(3) assisted or participated or is about 
to assist or participate in such a pro-
ceeding; or 
(4) objected to, or refused to partici-
pate in, any activity, policy, practice, or 
assigned task that the employee (or other 
such person) reasonably believed to be in 
violation of any provision of this Act or 
any order, rule, or regulation promul-
gated under this Act. 
(b) ENFORCEMENT
ACTION.—An employee 
covered by this section who alleges discrimina-
tion by an employer in violation of subsection 
(a) may bring an action governed by the rules, 
procedures, legal burdens of proof, and rem-
edies set forth in section 40(b) of the Consumer 
Product Safety Act (15 U.S.C. 2087(b)). 
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(c) EMPLOYER DEFINED.—As used in this 
section, the term ‘‘employer’’ means any person 
(including one or more individuals, partner-
ships, associations, corporations, trusts, pro-
fessional membership organization including 
a certification, disciplinary, or other profes-
sional body, unincorporated organizations, 
nongovernmental organizations, or trustees) 
engaged in profit or nonprofit business or in-
dustry whose activities are governed by this 
Act, and any agent, contractor, subcontractor, 
grantee, or consultant of such person. 
(d) RULE OF CONSTRUCTION.—The rule of 
construction set forth in section 20109(h) of 
title 49, United States Code, shall also apply 
to this section. 
SEC. 154. CONSTRUCTION REGARDING COLLECTIVE BAR-
GAINING. 
Nothing in this division shall be construed 
to alter or supercede any statutory or other ob-
ligation to engage in collective bargaining 
over the terms and conditions of employment 
related to health care. 
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SEC. 155. SEVERABILITY. 
If any provision of this Act, or any applica-
tion of such provision to any person or cir-
cumstance, is held to be unconstitutional, the 
remainder of the provisions of this Act and the 
application of the provision to any other per-
son or circumstance shall not be affected. 
SEC. 156. RULE OF CONSTRUCTION REGARDING HAWAII 
PREPAID HEALTH CARE ACT. 
(a) IN GENERAL.—Subject to this section— 
(1) nothing in this division (or an 
amendment made by this division) shall 
be construed to modify or limit the appli-
cation of the exemption for the Hawaii 
Prepaid Health Care Act (Haw. Rev. Stat. 
§§ 393-1 et seq.) as provided for under sec-
tion 514(b)(5) of the Employee Retirement 
Income Security Act of 1974 (29 U.S.C. 
1144(b)(5)), and such exemption shall also 
apply with respect to the provisions of this 
division, and 
(2) for purposes of this division (and 
the amendments made by this division), 
coverage provided pursuant to the Hawaii 
Prepaid Health Care Act shall be treated 
as a qualified health benefits plan pro-
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viding acceptable coverage so long as the 
Secretary of Labor determines that such 
coverage for employees (taking into ac-
count the benefits and the cost to employ-
ees for such benefits) is substantially 
equivalent to or greater than the coverage 
provided for employees pursuant to the es-
sential benefits package. 
(b) COORDINATION WITH STATE LAW OF HA-
WAII.—The Commissioner shall, based on ongo-
ing consultation with the appropriate officials 
of the State of Hawaii, make adjustments to 
rules and regulations of the Commissioner 
under this division as may be necessary, as de-
termined by the Commissioner, to most effec-
tively coordinate the provisions of this division 
with the provisions of the Hawaii Prepaid 
Health Care Act, taking into account any 
changes made from time to time to the Hawaii 
Prepaid Health Care Act and related laws of 
such State. 
SEC. 157. INCREASING MEANINGFUL USE OF ELECTRONIC 
HEALTH RECORDS. 
(a) STUDY.—The Commissioner shall con-
duct a study on methods that QHBP offering 
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entities can use to encourage increased mean-
ingful use of electronic health records by 
health care providers, including— 
(1) qualified health benefits plans of-
fering higher reimbursement rates for 
such meaningful use; and 
(2) promoting the use by health care 
providers of low-cost available electronic 
health record software packages, such as 
software made available to health care 
providers by the Veterans Administration. 
(b) REPORT.—Not later than 2 years after 
the date of the enactment of this Act, the Com-
missioner shall submit to the Congress a re-
port containing— 
(1) the results of the study under sub-
section (a); and 
(2) 
recommendations 
concerning 
whether qualified health benefits plans 
should increase reimbursement rates to 
health care providers to increase mean-
ingful use of electronic health records by 
such providers. 
(c) REQUIREMENTS.— 
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(1) IN
GENERAL.—Not later than one 
year after the date the report is submitted 
to the Congress under subsection (b), if, 
under subsection (b)(2), the Commissioner 
recommends 
increased 
reimbursement 
rates, the Commissioner shall require that 
qualified health benefits plans increase 
reimbursement rates for health care pro-
viders that show meaningful use of elec-
tronic health records. 
(2) COST LIMITATION.—An increase in 
rates under paragraph (1) shall not result 
in any increase in affordability premium 
or cost-sharing credits under subtitle C of 
title II of this division. 
SEC. 158. PRIVATE RIGHT OF CONTRACT WITH HEALTH 
CARE PROVIDERS. 
Nothing in this Act shall be construed to 
preclude any participant or beneficiary in a 
group health plan from entering into any con-
tract or arrangement for health care with any 
health care provider. 
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Subtitle G—Early Investments 
SEC. 161–163. ƒFor sections 161 through 163, see the text of bill, 
as introduced on July 14, 2009.≈ 
SEC. 164. REINSURANCE PROGRAM FOR RETIREES. 
(a) ESTABLISHMENT.— 
(1) IN
GENERAL.—Not later than 90 
days after the date of the enactment of 
this Act, the Secretary of Health and 
Human Services shall establish a tem-
porary reinsurance program (in this sec-
tion referred to as the ‘‘reinsurance pro-
gram’’) to provide reimbursement to assist 
participating 
employment-based 
plans 
with the cost of providing health benefits 
to retirees and to eligible spouses, sur-
viving spouses and dependents of such re-
tirees. 
(2) DEFINITIONS.—For purposes of this 
section: 
(A) The term ‘‘eligible employ-
ment-based plan’’ means a group 
health benefits plan that— 
(i) is maintained by one or 
more employers, former employers 
or employee associations, or a vol-
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untary employees’ beneficiary as-
sociation, or a committee or board 
of individuals appointed to ad-
minister such plan, and 
(ii) provides health benefits to 
retirees. 
(B) The term ‘‘health benefits’’ 
means medical, surgical, hospital, 
prescription drug, and such other ben-
efits as shall be determined by the 
Secretary, whether self-funded or de-
livered through the purchase of insur-
ance or otherwise. 
(C) The term ‘‘participating em-
ployment-based plan’’ means an eligi-
ble employment-based plan that is 
participating in the reinsurance pro-
gram. 
(D) The term ‘‘retiree’’ means, with 
respect to a participating employ-
ment-benefit 
plan, 
an 
individual 
who— 
(i) is 55 years of age or older; 
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2277 
(ii) is not eligible for coverage 
under title XVIII of the Social Se-
curity Act; and 
(iii) is not an active employee 
of an employer maintaining the 
plan or of any employer that 
makes or has made substantial 
contributions to fund such plan. 
(E) The term ‘‘Secretary’’ means 
Secretary of Health and Human Serv-
ices. 
(b) PARTICIPATION.—To be eligible to par-
ticipate in the reinsurance program, an eligi-
ble employment-based plan shall submit to the 
Secretary an application for participation in 
the program, at such time, in such manner, 
and containing such information as the Sec-
retary shall require. 
(c) PAYMENT.— 
(1) SUBMISSION OF CLAIMS.— 
(A) IN GENERAL.—Under the rein-
surance program, a participating em-
ployment-based 
plan 
shall 
submit 
claims for reimbursement to the Sec-
retary 
which 
shall 
contain 
docu-
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mentation of the actual costs of the 
items and services for which each 
claim is being submitted. 
(B) BASIS FOR CLAIMS.—Each claim 
submitted under subparagraph (A) 
shall be based on the actual amount 
expended by the participating employ-
ment-based plan involved within the 
plan year for the appropriate employ-
ment based health benefits provided 
to a retiree or to the spouse, surviving 
spouse, or dependent of a retiree. In 
determining the amount of any claim 
for purposes of this subsection, the 
participating employment-based plan 
shall take into account any negotiated 
price concessions (such as discounts, 
direct or indirect subsidies, rebates, 
and direct or indirect remunerations) 
obtained by such plan with respect to 
such health benefits. For purposes of 
calculating the amount of any claim, 
the costs paid by the retiree or by the 
spouse, surviving spouse, or dependent 
of 
the 
retiree 
in 
the 
form 
of 
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bajohnson on DSK2BSOYB1PROD with BILLS
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deductibles, co-payments, and co-in-
surance shall be included along with 
the amounts paid by the participating 
employment-based plan. 
(2) PROGRAM PAYMENTS AND LIMIT.—If 
the Secretary determines that a partici-
pating employment-based plan has sub-
mitted a valid claim under paragraph (1), 
the Secretary shall reimburse such plan 
for 80 percent of that portion of the costs 
attributable to such claim that exceeds 
$15,000, but is less than $90,000. Such 
amounts shall be adjusted each year 
based on the percentage increase in the 
medical care component of the Consumer 
Price Index (rounded to the nearest mul-
tiple of $1,000) for the year involved. 
(3) USE OF PAYMENTS.—Amounts paid 
to a participating employment-based plan 
under this subsection shall be used to 
lower the costs borne directly by the par-
ticipants and beneficiaries for health ben-
efits provided under such plan in the form 
of premiums, co-payments, deductibles, co- 
insurance, or other out-of-pocket costs. 
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Such payments shall not be used to reduce 
the costs of an employer maintaining the 
participating employment-based plan. The 
Secretary shall develop a mechanism to 
monitor the appropriate use of such pay-
ments by such plans. 
(4) APPEALS
AND
PROGRAM
PROTEC-
TIONS.—The Secretary shall establish— 
(A) an appeals process to permit 
participating employment-based plans 
to appeal a determination of the Sec-
retary with respect to claims sub-
mitted under this section; and 
(B) procedures to protect against 
fraud, waste, and abuse under the 
program. 
(5) AUDITS.—The Secretary shall con-
duct annual audits of claims data sub-
mitted by participating employment-based 
plans under this section to ensure that 
they are in compliance with the require-
ments of this section. 
(d) RETIREE RESERVE TRUST FUND.— 
(1) ESTABLISHMENT.— 
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(A) IN
GENERAL.—There is estab-
lished in the Treasury of the United 
States a trust fund to be known as the 
‘‘Retiree Reserve Trust Fund’’ (re-
ferred to in this section as the ‘‘Trust 
Fund’’), that shall consist of such 
amounts as may be appropriated or 
credited to the Trust Fund as pro-
vided for in this subsection to enable 
the Secretary to carry out the reinsur-
ance program. Such amounts shall re-
main available until expended. 
(B) FUNDING.—There are hereby 
appropriated to the Trust Fund, out of 
any moneys in the Treasury not other-
wise appropriated, an amount re-
quested by the Secretary as necessary 
to carry out this section, except that 
the total of all such amounts re-
quested 
shall 
not 
exceed 
$10,000,000,000. 
(C) 
APPROPRIATIONS
FROM
THE 
TRUST FUND.— 
(i) IN
GENERAL.—Amounts in 
the Trust Fund are appropriated 
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