1023 
vate employers, and labor organizations including 
joint labor-management training programs, and 
which may include representatives from local govern-
ments, worker investment agency one-stop career 
centers, community-based organizations, community 
colleges, and accredited schools of nursing; or 
(4) a school of nursing (as defined in section 
801 of the Public Health Service Act (42 U.S.C. 
296)). 
(d) ADDITIONAL REQUIREMENTS FOR HEALTH CARE 
EMPLOYER DESCRIBED IN SUBSECTION (c).—To be eligi-
ble for a grant under this section, a health care employer 
described in subsection (c) shall demonstrate that it— 
(1) has an established program within their fa-
cility to encourage the retention of existing nurses; 
(2) provides wages and benefits to its nurses 
that are competitive for its market or that have been 
collectively bargained with a labor organization; and 
(3) supports programs funded under this sec-
tion through 1 or more of the following: 
(A) The provision of paid leave time and 
continued health coverage to incumbent health 
care workers to allow their participation in 
nursing career ladder programs, including cer-
tified nurse assistants, licensed practical nurses, 
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licensed 
vocational 
nurses, 
and 
registered 
nurses. 
(B) Contributions to a joint labor-manage-
ment training fund which administers the pro-
gram involved. 
(C) The provision of paid release time, in-
centive compensation, or continued health cov-
erage to staff nurses who desire to work full- or 
part-time in a faculty position. 
(D) The provision of paid release time for 
staff nurses to enable them to obtain a bachelor 
of science in nursing degree, other advanced 
nursing degrees, specialty training, or certifi-
cation program. 
(E) The payment of tuition assistance 
which is managed by a joint labor-management 
training fund or other jointly administered pro-
gram. 
(e) OTHER REQUIREMENTS.— 
(1) MATCHING REQUIREMENT.— 
(A) IN GENERAL.—The Secretary may not 
make a grant under this section unless the ap-
plicant involved agrees, with respect to the costs 
to be incurred by the applicant in carrying out 
the program under the grant, to make available 
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non-Federal contributions (in cash or in kind 
under subparagraph (B)) toward such costs in 
an amount equal to not less than $1 for each 
$1 of Federal funds provided in the grant. Such 
contributions may be made directly or through 
donations from public or private entities, or 
may be provided through the cash equivalent of 
paid release time provided to incumbent worker 
students. 
(B) DETERMINATION OF AMOUNT OF NON- 
FEDERAL
CONTRIBUTION.—Non-Federal con-
tributions required in subparagraph (A) may be 
in cash or in kind (including paid release time), 
fairly evaluated, including equipment or services 
(and excluding indirect or overhead costs). 
Amounts provided by the Federal Government, 
or services assisted or subsidized to any signifi-
cant extent by the Federal Government, may 
not be included in determining the amount of 
such non-Federal contributions. 
(2) REQUIRED COLLABORATION.—Entities car-
rying out or overseeing programs carried out with 
assistance provided under this section shall dem-
onstrate collaboration with accredited schools of 
nursing which may include community colleges and 
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other academic institutions providing associate, 
bachelor’s, or advanced nursing degree programs or 
specialty training or certification programs. 
(f) USE OF FUNDS.—Amounts awarded to an entity 
under a grant under this section shall be used for the fol-
lowing: 
(1) To carry out programs that provide edu-
cation and training to establish nursing career lad-
ders to educate incumbent health care workers to be-
come nurses (including certified nurse assistants, li-
censed practical nurses, licensed vocational nurses, 
and registered nurses). Such programs shall include 
one or more of the following: 
(A) Preparing incumbent workers to return 
to the classroom through English -as-a-second 
language education, GED education, pre-college 
counseling, college preparation classes, and sup-
port with entry level college classes that are a 
prerequisite to nursing. 
(B) Providing tuition assistance with pref-
erence for dedicated cohort classes in commu-
nity colleges, universities, accredited schools of 
nursing with supportive services including tu-
toring and counseling. 
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(C) Providing assistance in preparing for 
and meeting all nursing licensure tests and re-
quirements. 
(D) 
Carrying 
out 
orientation 
and 
mentorship programs that assist newly grad-
uated nurses in adjusting to working at the 
bedside 
to 
ensure 
their 
retention 
postgraduation, and ongoing programs to sup-
port nurse retention. 
(E) Providing stipends for release time and 
continued health care coverage to enable incum-
bent health care workers to participate in these 
programs. 
(2) To carry out programs that assist nurses in 
obtaining advanced degrees and completing specialty 
training or certification programs and to establish 
incentives for nurses to assume nurse faculty posi-
tions on a part-time or full-time basis. Such pro-
grams shall include one or more of the following: 
(A) Increasing the pool of nurses with ad-
vanced degrees who are interested in teaching 
by funding programs that enable incumbent 
nurses to return to school. 
(B) Establishing incentives for advanced 
degree bedside nurses who wish to teach in 
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nursing programs so they can obtain a leave 
from their bedside position to assume a full- or 
part-time position as adjunct or full-time fac-
ulty without the loss of salary or benefits. 
(C) Collaboration with accredited schools 
of nursing which may include community col-
leges and other academic institutions providing 
associate, bachelor’s, or advanced nursing de-
gree programs, or specialty training or certifi-
cation programs, for nurses to carry out innova-
tive nursing programs which meet the needs of 
bedside nursing and health care providers. 
(g) PREFERENCE.—In awarding grants under this 
section the Secretary shall give preference to programs 
that— 
(1) provide for improving nurse retention; 
(2) provide for improving the diversity of the 
new nurse graduates to reflect changes in the demo-
graphics of the patient population; 
(3) provide for improving the quality of nursing 
education to improve patient care and safety; 
(4) have demonstrated success in upgrading in-
cumbent health care workers to become nurses or 
which have established effective programs or pilots 
to increase nurse faculty; or 
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(5) are modeled after or affiliated with such 
programs described in paragraph (4). 
(h) EVALUATION.— 
(1) PROGRAM
EVALUATIONS.—An entity that 
receives a grant under this section shall annually 
evaluate, and submit to the Secretary a report on, 
the activities carried out under the grant and the 
outcomes of such activities. Such outcomes may in-
clude— 
(A) an increased number of incumbent 
workers entering an accredited school of nurs-
ing and in the pipeline for nursing programs; 
(B) an increasing number of graduating 
nurses and improved nurse graduation and li-
censure rates; 
(C) improved nurse retention; 
(D) an increase in the number of staff 
nurses at the health care facility involved; 
(E) an increase in the number of nurses 
with advanced degrees in nursing; 
(F) an increase in the number of nurse 
faculty; 
(G) improved measures of patient quality 
(which may include staffing ratios of nurses, 
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patient satisfaction rates, patient safety meas-
ures); and 
(H) an increase in the diversity of new 
nurse graduates relative to the patient popu-
lation. 
(2) GENERAL REPORT.—Not later than 2 years 
after the date of the enactment of this Act, and an-
nually thereafter, the Secretary of Labor shall, using 
data and information from the reports received 
under paragraph (1), submit to the Congress a re-
port concerning the overall effectiveness of the grant 
program carried out under this section. 
(i) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated to carry out this section 
such sums as may be necessary. 
Subtitle E—States Failing To Ad-
here to Certain Employment Ob-
ligations 
SEC. 2541. LIMITATION ON FEDERAL FUNDS. 
A State is eligible for Federal funds under the provi-
sions of the Public Health Service Act (42 U.S.C. 201 et 
seq.) only if the State— 
(1) agrees to be subject in its capacity as an 
employer to each obligation under subdivision A of 
this division and the amendments made by such sub-
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division applicable to persons in their capacity as an 
employer; and 
(2) assures that all political subdivisions in the 
State will do the same. 
DIVISION 
II—COMMITTEE 
ON 
EDUCATION 
AND 
LABOR: 
HEALTH CARE REFORM 
SECTION 1. SHORT TITLE; TABLE OF SUBDIVISIONS, TI-
TLES, AND SUBTITLES. 
(a) TABLE OF SUBDIVISIONS, TITLES, AND SUB-
TITLES.—This division is divided into subdivisions, titles, 
and subtitles as follows: 
SUBDIVISION A—AFFORDABLE HEALTH CARE CHOICES 
TITLE I—PROTECTIONS AND STANDARDS FOR QUALIFIED 
HEALTH BENEFITS PLANS 
Subtitle A—General Standards 
Subtitle B—Standards Guaranteeing Access to Affordable Coverage 
Subtitle C—Standards Guaranteeing Access to Essential Benefits 
Subtitle D—Additional Consumer Protections 
Subtitle E—Governance 
Subtitle F—Relation to Other Requirements; Miscellaneous 
Subtitle G—Early Investments 
TITLE II—HEALTH INSURANCE EXCHANGE AND RELATED 
PROVISIONS 
Subtitle A—Health Insurance Exchange 
Subtitle B—Public Health Insurance Option 
Subtitle C—Individual Affordability Credits 
Subtitle D—State Innovation. 
TITLE III—SHARED RESPONSIBILITY 
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Subtitle A—Individual Responsibility 
Subtitle B—Employer Responsibility 
TITLE IV—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986 
Subtitle A—Shared Responsibility 
Subtitle B—Credit for Small Business Employee Health Coverage Expenses 
Subtitle C—Disclosures To Carry Out Health Insurance Exchange Subsidies 
Subtitle D—Other Revenue Provisions 
SUBDIVISION B—MEDICARE AND MEDICAID IMPROVEMENTS 
TITLE I—IMPROVING HEALTH CARE VALUE 
Subtitle A—Provisions Related to Medicare Part A 
Subtitle B—Provisions Related to Part B 
Subtitle C—Provisions Related to Medicare Parts A and B 
Subtitle D—Medicare Advantage Reforms 
Subtitle E—Improvements to Medicare Part D 
Subtitle F—Medicare Rural Access Protections 
TITLE II—MEDICARE BENEFICIARY IMPROVEMENTS 
Subtitle A—Improving and Simplifying Financial Assistance for Low Income 
Medicare Beneficiaries 
Subtitle B—Reducing Health Disparities 
Subtitle C—Miscellaneous Improvements 
TITLE III—PROMOTING PRIMARY CARE, MENTAL HEALTH 
SERVICES, AND COORDINATED CARE 
TITLE IV—QUALITY 
Subtitle A—Comparative Effectiveness Research 
Subtitle B—Nursing Home Transparency 
Subtitle C—Quality Measurements 
Subtitle D—Physician Payments Sunshine Provision 
Subtitle E—Public Reporting on Health Care-Associated Infections 
TITLE V—MEDICARE GRADUATE MEDICAL EDUCATION 
TITLE VI—PROGRAM INTEGRITY 
Subtitle A—Increased Funding To Fight Waste, Fraud, and Abuse 
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Subtitle B—Enhanced Penalties for Fraud and Abuse 
Subtitle C—Enhanced Program and Provider Protections 
Subtitle D—Access to Information Needed To Prevent Fraud, Waste, and 
Abuse 
TITLE VII—MEDICAID AND CHIP 
Subtitle A—Medicaid and Health Reform 
Subtitle B—Prevention 
Subtitle C—Access 
Subtitle D—Coverage 
Subtitle E—Financing 
Subtitle F—Waste, Fraud, and Abuse 
Subtitle G—Puerto Rico and the Territories 
Subtitle H—Miscellaneous 
TITLE VIII—REVENUE-RELATED PROVISIONS 
TITLE IX—MISCELLANEOUS PROVISIONS 
SUBDIVISION C—PUBLIC HEALTH AND WORKFORCE DEVELOPMENT 
TITLE I—COMMUNITY HEALTH CENTERS 
TITLE II—WORKFORCE 
Subtitle A—Primary Care Workforce 
Subtitle B—Nursing Workforce 
Subtitle C—Public Health Workforce 
Subtitle D—Adapting Workforce to Evolving Health System Needs 
TITLE III—PREVENTION AND WELLNESS 
TITLE IV—QUALITY AND SURVEILLANCE 
TITLE V—OTHER PROVISIONS 
Subtitle A—Drug Discount for Rural and Other Hospitals 
Subtitle B—School-Based Health Clinics 
Subtitle C—National Medical Device Registry 
Subtitle D—Grants for Comprehensive Programs to Provide Education to 
Nurses and Create a Pipeline to Nursing 
Subtitle E—States Failing To Adhere to Certain Employment Obligations 
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Subtitle F—Standards for Accessibility to Medical Equipment for Individuals 
With Disabilities 
Subtitle G—Other Grant Programs 
Subtitle H—Long-term Care and Family Caregiver Support 
Subtitle I—Online Resources 
(b) SHORT TITLE.—This division may be cited as the 
‘‘America’s Affordable Health Choices Act of 2009’’. 
SUBDIVISION A—AFFORDABLE 
HEALTH CARE CHOICES 
SEC. 100. PURPOSE; TABLE OF CONTENTS OF SUBDIVISION; 
GENERAL DEFINITIONS. 
(a) PURPOSE.— 
(1) IN GENERAL.—The purpose of this subdivi-
sion is to provide affordable, quality health care for 
all Americans and reduce the growth in health care 
spending. 
(2) BUILDING
ON
CURRENT
SYSTEM.—This 
subdivision achieves this purpose by building on 
what works in today’s health care system, while re-
pairing the aspects that are broken. 
(3) INSURANCE REFORMS.—This subdivision— 
(A) enacts strong insurance market re-
forms; 
(B) creates a new Health Insurance Ex-
change, with a public health insurance option 
alongside private plans; 
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(C) includes sliding scale affordability 
credits; and 
(D) initiates shared responsibility among 
workers, employers, and the government; 
so that all Americans have coverage of essential 
health benefits. 
(4) HEALTH DELIVERY REFORM.—This subdivi-
sion institutes health delivery system reforms both to 
increase quality and to reduce growth in health 
spending so that health care becomes more afford-
able for businesses, families, and government. 
(b) TABLE OF CONTENTS OF SUBDIVISION.—The 
table of contents of this subdivision is as follows: 
Sec. 100. Purpose; table of contents of subdivision; general definitions. 
TITLE I—PROTECTIONS AND STANDARDS FOR QUALIFIED 
HEALTH BENEFITS PLANS 
Subtitle A—General Standards 
Sec. 101. Requirements reforming health insurance marketplace. 
Sec. 102. Protecting the choice to keep current coverage. 
Subtitle B—Standards Guaranteeing Access to Affordable Coverage 
Sec. 111. Prohibiting pre-existing condition exclusions. 
Sec. 112. Guaranteed issue and renewal for insured plans. 
Sec. 113. Insurance rating rules. 
Sec. 114. Nondiscrimination in benefits; parity in mental health and substance 
abuse disorder benefits. 
Sec. 115. Ensuring adequacy of provider networks. 
Sec. 116. Ensuring value and lower premiums. 
Sec. 117. Consistency of costs and coverage under qualified health benefits 
plans during plan year. 
Subtitle C—Standards Guaranteeing Access to Essential Benefits 
Sec. 121. Coverage of essential benefits package. 
Sec. 122. Essential benefits package defined. 
Sec. 123. Health Benefits Advisory Committee. 
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Sec. 124. Process for adoption of recommendations; adoption of benefit stand-
ards. 
Sec. 125. Prohibition of discrimination in health care services based on reli-
gious or spiritual content. 
Subtitle D—Additional Consumer Protections 
Sec. 131. Requiring fair marketing practices by health insurers. 
Sec. 132. Requiring fair grievance and appeals mechanisms. 
Sec. 133. Requiring information transparency and plan disclosure. 
Sec. 134. Application to qualified health benefits plans not offered through the 
Health Insurance Exchange. 
Sec. 135. Timely payment of claims. 
Sec. 136. Standardized rules for coordination and subrogation of benefits. 
Sec. 137. Application of administrative simplification. 
Sec. 138. Records relative to prescription information. 
Subtitle E—Governance 
Sec. 141. Health Choices Administration; Health Choices Commissioner. 
Sec. 142. Duties and authority of Commissioner. 
Sec. 143. Consultation and coordination. 
Sec. 144.
Health Insurance Ombudsman. 
Subtitle F—Relation to Other Requirements; Miscellaneous 
Sec. 151. Relation to other requirements. 
Sec. 152. Prohibiting discrimination in health care. 
Sec. 153. Whistleblower protection. 
Sec. 154. Construction regarding collective bargaining. 
Sec. 155. Severability. 
Sec. 156. Rule of construction regarding Hawaii Prepaid Health Care Act. 
Sec. 157. Increasing meaningful use of electronic health records. 
Sec. 158. Private right of contract with health care providers. 
Subtitle G—Early Investments 
Sec. 161. Ensuring value and lower premiums. 
Sec. 162. Ending health insurance rescission abuse. 
Sec. 163. Administrative simplification. 
Sec. 164. Reinsurance program for retirees. 
Sec. 165. Prohibition against post-retirement reductions of retiree health bene-
fits by group health plans. 
Sec. 166. Limitations on preexisting condition exclusions in group health plans 
in advance of applicability of new prohibition of preexisting 
condition exclusions. 
Sec. 167. Extension of COBRA continuation coverage. 
TITLE II—HEALTH INSURANCE EXCHANGE AND RELATED 
PROVISIONS 
Subtitle A—Health Insurance Exchange 
Sec. 201. Establishment of Health Insurance Exchange; outline of duties; defi-
nitions. 
Sec. 202. Exchange-eligible individuals and employers. 
Sec. 203. Benefits package levels. 
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Sec. 204. Contracts for the offering of Exchange-participating health benefits 
plans. 
Sec. 205. Outreach and enrollment of Exchange-eligible individuals and employ-
ers in Exchange-participating health benefits plan. 
Sec. 206. Other functions. 
Sec. 207. Health Insurance Exchange Trust Fund. 
Sec. 208. Optional operation of State-based health insurance exchanges. 
Sec. 209. Participation of small employer benefit arrangements. 
Subtitle B—Public Health Insurance Option 
Sec. 221. Establishment and administration of a public health insurance option 
as an Exchange-qualified health benefits plan. 
Sec. 222. Premiums and financing. 
Sec. 223. Payment rates for items and services. 
Sec. 224. Modernized payment initiatives and delivery system reform. 
Sec. 225. Provider participation. 
Sec. 226. Application of fraud and abuse provisions. 
Sec. 227. Sense of the House regarding enrollment of Members in the public 
option. 
Subtitle C—Individual Affordability Credits 
Sec. 241. Availability through Health Insurance Exchange. 
Sec. 242. Affordable credit eligible individual. 
Sec. 243. Affordable premium credit. 
Sec. 244. Affordability cost-sharing credit. 
Sec. 245. Income determinations. 
Sec. 246. No Federal payment for undocumented aliens. 
Subtitle D—State Innovation 
Sec. 251. Waiver of ERISA limitation; application instead of state single payer 
system. 
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 employee and depend-
ent 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 requirements under the 
Employee Retirement Income Security Act of 1974. 
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Sec. 322. Satisfaction of health coverage participation requirements under the 
Internal Revenue Code of 1986. 
Sec. 323. Satisfaction of health coverage participation requirements under the 
Public Health Service Act. 
Sec. 324. Additional rules relating to health coverage participation require-
ments. 
TITLE IV—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986 
Subtitle A—Shared Responsibility 
PART 1—INDIVIDUAL RESPONSIBILITY 
Sec. 401. Tax on individuals without acceptable health care coverage. 
PART 2—EMPLOYER RESPONSIBILITY 
Sec. 411. Election to satisfy health coverage participation requirements. 
Sec. 412. Responsibilities of nonelecting employers. 
Subtitle B—Credit for Small Business Employee Health Coverage Expenses 
Sec. 421. Credit for small business employee health coverage expenses. 
Subtitle C—Disclosures To Carry Out Health Insurance Exchange Subsidies 
Sec. 431. Disclosures to carry out health insurance exchange subsidies. 
Subtitle D—Other Revenue Provisions 
PART 1—GENERAL PROVISIONS 
Sec. 441. Surcharge on high income individuals. 
Sec. 442. Delay in application of worldwide allocation of interest. 
PART 2—PREVENTION OF TAX AVOIDANCE 
Sec. 451. Limitation on treaty benefits for certain deductible payments. 
Sec. 452. Codification of economic substance doctrine. 
Sec. 453. Penalties for underpayments. 
(c) GENERAL DEFINITIONS.—Except as otherwise 
provided, in this subdivision: 
(1) ACCEPTABLE COVERAGE.—The term ‘‘ac-
ceptable 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). 
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(3) 
COMMISSIONER.—The 
term 
‘‘Commis-
sioner’’ means the Health Choices Commissioner es-
tablished under section 141. 
(4) COST-SHARING.—The term ‘‘cost-sharing’’ 
includes deductibles, coinsurance, copayments, and 
similar charges but does not include premiums or 
any network payment differential for covered serv-
ices or spending for non-covered services. 
(5) DEPENDENT.—The term ‘‘dependent’’ 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 Employee Retire-
ment Income Security Act of 1974); 
(B) includes such a plan that is the fol-
lowing: 
(i) FEDERAL, STATE, AND
TRIBAL 
GOVERNMENTAL PLANS.—A governmental 
plan (as defined in section 3(32) of the 
Employee Retirement Income Security Act 
of 1974), including a health benefits plan 
offered under chapter 89 of title 5, United 
States Code; or 
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(ii) CHURCH PLANS.—A church plan 
(as defined in section 3(33) of the Em-
ployee 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 ‘‘enhanced 
plan’’ has the meaning given such term in section 
203(c). 
(8) ESSENTIAL BENEFITS PACKAGE.—The term 
‘‘essential benefits package’’ is defined in section 
122(a). 
(9) FAMILY.—The term ‘‘family’’ means an in-
dividual and includes the individual’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. 
(11) HEALTH
BENEFITS
PLAN.—The terms 
‘‘health benefits plan’’ means health insurance cov-
erage and an employment-based health plan and in-
cludes the public health insurance option. 
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(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 established under sec-
tion 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. 
(16) PLAN SPONSOR.—The term ‘‘plan spon-
sor’’ has the meaning given such term in section 
3(16)(B) of the Employee Retirement Income Secu-
rity 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 
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(B) with respect to a health benefits plan 
other than an employment-based health plan, a 
12-month period as specified by the Commis-
sioner. 
(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 defined, sub-
ject to subsection (d), in section 733(a)(1) of 
the Employee Retirement Income Security Act 
of 1974), the plan sponsor in relation to such 
group health plan, except that, in the case of a 
plan maintained jointly by 1 or more employers 
and 1 or more employee organizations and with 
respect to which an employer is the primary 
source of financing, such term means such em-
ployer; 
(B) health insurance coverage, the health 
insurance issuer offering the coverage; 
(C) the public health insurance option, the 
Secretary of Health and Human Services; 
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(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 establishes or main-
tains such plan; or 
(E) a Federal governmental plan (as de-
fined in section 2791(d) of the Public Health 
Service Act), the appropriate Federal official. 
(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
OPTION.— 
The term ‘‘public health insurance option’’ means 
the public health insurance option as provided under 
subtitle B of title II. 
(22) SERVICE AREA; PREMIUM RATING AREA.— 
The terms ‘‘service area’’ and ‘‘premium rating 
area’’ mean with respect to health insurance cov-
erage— 
(A) offered other than through the Health 
Insurance Exchange, such an area as estab-
lished by the QHBP offering entity of such cov-
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erage in accordance with applicable State law; 
and 
(B) offered through the Health Insurance 
Exchange, such an area as established by such 
entity in accordance with applicable State law 
and applicable rules of the Commissioner for 
Exchange-participating health benefits plans. 
(23) STATE.—The term ‘‘State’’ means the 50 
States and the District of Columbia. 
(24) STATE
MEDICAID
AGENCY.—The term 
‘‘State Medicaid agency’’ means, with respect to a 
Medicaid plan, the single State agency responsible 
for administering such plan under title XIX of the 
Social Security Act. 
(25) Y1, Y2, ETC..—The terms ‘‘Y1’’ , ‘‘Y2’’, 
‘‘Y3’’, ‘‘Y4’’, ‘‘Y5’’, and similar subsequently num-
bered terms, mean 2013 and subsequent years, re-
spectively. 
(26) EMPLOYEE
PREMIUM.—The term ‘‘em-
ployee premium’’ does not include a collectively bar-
gained premium in the case of a group health plan 
(as defined in section 733(a)(1) of the Employee Re-
tirement Income Security Act of 1974) that is a 
multiemployer plan (as defined in section 3(37) of 
such Act). 
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1045 
TITLE 
I—PROTECTIONS 
AND 
STANDARDS FOR QUALIFIED 
HEALTH BENEFITS PLANS 
Subtitle A—General Standards 
SEC. 101. REQUIREMENTS REFORMING HEALTH INSUR-
ANCE MARKETPLACE. 
(a) PURPOSE.—The purpose of this title is to estab-
lish standards to ensure that new health insurance cov-
erage and employment-based health plans that are offered 
meet standards guaranteeing access to affordable cov-
erage, essential benefits, and other consumer protections. 
(b) REQUIREMENTS FOR QUALIFIED HEALTH BENE-
FITS PLANS.—On or after the first day of Y1, a health 
benefits plan shall not be a qualified health benefits plan 
under this subdivision unless the plan meets the applicable 
requirements 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). 
(3) Subtitle D (relating to consumer protec-
tion). 
(c) TERMINOLOGY.—In this subdivision: 
(1) 
ENROLLMENT
IN
EMPLOYMENT-BASED 
HEALTH PLANS.—An individual shall be treated as 
being ‘‘enrolled’’ in an employment-based health 
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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 Se-
curity Act of 1974) in such plan. 
(2) INDIVIDUAL AND GROUP HEALTH INSUR-
ANCE COVERAGE.—The terms ‘‘individual health in-
surance coverage’’ and ‘‘group health insurance cov-
erage’’ mean health insurance coverage offered in 
the individual market or large or small group mar-
ket, 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 intro-
duced, must be strengthened to meaningfully address the 
health care needs of residents of American 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 terri-
tories have access to high-quality and affordable health 
care in such a way that best serves their unique needs. 
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SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT 
COVERAGE. 
(a) GRANDFATHERED HEALTH INSURANCE COV-
ERAGE DEFINED.—Subject to the succeeding provisions of 
this section, for purposes of establishing acceptable cov-
erage under this subdivision, the term ‘‘grandfathered 
health insurance coverage’’ means individual health insur-
ance coverage that is offered and in force and effect before 
the first day of Y1 if the following conditions are met: 
(1) LIMITATION ON NEW ENROLLMENT.— 
(A) IN GENERAL.—Except as provided in 
this paragraph, the individual health insurance 
issuer offering such coverage does not enroll 
any individual in such coverage if the first ef-
fective 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 conditions, including benefits and 
cost-sharing, from those in effect as of the day be-
fore the first day of Y1. 
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(3) RESTRICTIONS ON PREMIUM INCREASES.— 
The issuer cannot vary the percentage increase in 
the premium for a risk group of enrollees in specific 
grandfathered health insurance coverage without 
changing the premium for all enrollees in the same 
risk group at the same rate, as specified by the 
Commissioner. 
(b) GRACE PERIOD FOR CURRENT EMPLOYMENT- 
BASED HEALTH PLANS.— 
(1) GRACE PERIOD.— 
(A) IN
GENERAL.—The Commissioner 
shall establish a grace period whereby, for plan 
years beginning after the end of the 5-year pe-
riod beginning with Y1, an employment-based 
health plan in operation as of the day before 
the first day of Y1 must meet the same require-
ments as apply to a qualified health benefits 
plan under section 101, including the essential 
benefit package requirement under section 121. 
(B) EXCEPTION FOR LIMITED BENEFITS 
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: 
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(i) Any coverage described in section 
3001(a)(1)(B)(ii)(IV) of division B of the 
American Recovery and Reinvestment Act 
of 2009 (PL 111–5). 
(ii) Excepted benefits (as defined in 
section 733(c) of the Employee Retirement 
Income Security Act of 1974), including 
coverage under a specified disease or ill-
ness policy described in paragraph (3)(A) 
of such section. 
(iii) Such other limited benefits 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 coverage or benefits described in 
clauses (i) through (iii) be treated as acceptable 
coverage under this subdivision 
(2) TRANSITIONAL
TREATMENT
AS
ACCEPT-
ABLE COVERAGE.—During the grace period specified 
in paragraph (1)(A), an employment-based health 
plan that is described in such paragraph shall be 
treated as acceptable coverage under this subdivi-
sion. 
(3) 
EXCEPTION
FOR
CONSUMER-DIRECTED 
HEALTH PLANS AND ARRANGEMENTS.—In the case 
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of a group health plan which consists of a consumer- 
directed health plan or arrangement (including a 
high deductible 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 ac-
ceptable coverage under a current group health plan 
for purposes of this subdivision. 
(c) LIMITATION ON INDIVIDUAL HEALTH INSURANCE 
COVERAGE.— 
(1) IN GENERAL.—Individual health insurance 
coverage that is not grandfathered health insurance 
coverage under subsection (a) may only be offered 
on or after the first day of Y1 as an Exchange-par-
ticipating health benefits plan. 
(2) SEPARATE, EXCEPTED
COVERAGE
PER-
MITTED.—Excepted benefits (as defined in section 
2791(c) of the Public Health Service Act) are not 
included within the definition of health insurance 
coverage. Nothing in paragraph (1) shall prevent the 
offering, other than through the Health Insurance 
Exchange, of excepted benefits so long as it is of-
fered 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 Public Health Service Act) or other-
wise impose any limit or condition on the coverage under 
the plan with respect to an individual or dependent 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 IN-
SURED PLANS. 
The requirements of sections 2711 (other than sub-
sections (c) and (e)) and 2712 (other than paragraphs (3), 
and (6) of subsection (b) and subsection (e)) of the Public 
Health Service Act, relating to guaranteed availability and 
renewability of health insurance coverage, shall apply to 
individuals and employers in all individual and group 
health insurance 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 
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and health insurance coverage offered in the small group 
market, except that such section 2712(b)(1) shall apply 
only if, before nonrenewal or discontinuation of coverage, 
the issuer has provided the enrollee with notice of non- 
payment of premiums and there is a grace period during 
which the enrollees has an opportunity to correct such 
nonpayment. Rescissions of such coverage shall be prohib-
ited 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 benefits plan may not vary except 
as follows: 
(1) LIMITED AGE VARIATION PERMITTED.—By 
age (within such age categories as the Commissioner 
shall specify) so long as the ratio of the highest such 
premium to the lowest such premium does not ex-
ceed the ratio of 2 to 1. 
(2) BY
AREA.—By premium rating area (as 
permitted by State insurance regulators or, in the 
case of Exchange-participating health benefits plans, 
as specified by the Commissioner in consultation 
with such regulators). 
(3) BY FAMILY ENROLLMENT.—By family en-
rollment (such as variations within categories and 
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compositions of families) so long as the ratio of the 
premium for family enrollment (or enrollments) to 
the premium for individual enrollment is uniform, as 
specified under State law and consistent with rules 
of the Commissioner. 
(b) STUDY AND REPORTS.— 
(1) STUDY.—The Commissioner, in coordina-
tion with the Secretary of Health and Human Serv-
ices 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: 
(A) The types of employers by key charac-
teristics, including size, that purchase insured 
products versus those that self-insure. 
(B) The similarities and differences be-
tween typical insured and self-insured health 
plans. 
(C) The financial solvency and capital re-
serve levels of employers that self-insure by em-
ployer size. 
(D) The risk of self-insured employers not 
being able to pay obligations or otherwise be-
coming financially insolvent. 
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(E) The extent to which rating rules are 
likely to cause adverse selection in the large 
group market or to encourage small and mid 
size employers to self-insure 
(2) REPORTS.—Not later than 18 months after 
the date of the enactment of this Act, the Commis-
sioner shall submit to Congress and the applicable 
agencies a report on the study conducted under 
paragraph (1). Such report shall include any rec-
ommendations 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 employers. Not later 
than 18 months after the first day of Y1, the Com-
missioner shall submit to Congress and the applica-
ble agencies an updated report on such study, in-
cluding updates on such recommendations. 
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 estab-
lished by the Commissioner to prohibit discrimination in 
health benefits or benefit structures for qualified health 
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(2) promoting the use by health care providers 
of low-cost available electronic health record soft-
ware packages, such as software made available to 
health care providers by the Veterans Administra-
tion. 
(b) REPORT.—Not later than 2 years after the date 
of the enactment of this Act, the Commissioner shall sub-
mit to the Congress a report containing— 
(1) the results of the study under subsection 
(a); and 
(2) recommendations concerning whether quali-
fied health benefits plans should increase reimburse-
ment rates to health care providers to increase 
meaningful use of electronic health records by such 
providers. 
(c) REQUIREMENTS.— 
(1) IN
GENERAL.—Not later than one year 
after the date the report is submitted to the Con-
gress under subsection (b), if, under subsection 
(b)(2), the Commissioner recommends increased re-
imbursement rates, the Commissioner shall require 
that qualified health benefits plans increase reim-
bursement rates for health care providers that show 
meaningful use of electronic health records. 
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1135 
(A) IN GENERAL.—A basic plan shall offer 
the essential benefits package required under 
title I for a qualified health benefits plan. 
(B) TIERED COST-SHARING FOR AFFORD-
ABLE CREDIT ELIGIBLE INDIVIDUALS.—In the 
case of an affordable credit eligible individual 
(as defined in section 242(a)(1)) enrolled in an 
Exchange-participating health benefits plan, the 
benefits under a basic plan are modified to pro-
vide for the reduced cost-sharing for the income 
tier applicable to the individual under section 
244(c). 
(3) ENHANCED PLAN.—A enhanced plan shall 
offer, in addition to the level of benefits under the 
basic plan, a lower level of cost-sharing as provided 
under title I consistent with section 123(b)(5)(A). 
(4) PREMIUM
PLAN.—A premium plan shall 
offer, in addition to the level of benefits under the 
basic plan, a lower level of cost-sharing as provided 
under title I consistent with section 123(b)(5)(B). 
(5) PREMIUM-PLUS
PLAN.—A premium-plus 
plan is a premium plan that also provides additional 
benefits, such as adult oral health and vision care, 
approved by the Commissioner. The portion of the 
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(A) may not be performed by a State- 
based Health Insurance Exchange under this 
section; or 
(B) may be performed by the Commis-
sioner and by such a State-based Health Insur-
ance Exchange. 
(e) REFERENCES.—In the case of a State-based 
Health Insurance Exchange, except as the Commissioner 
may otherwise specify under subsection (d), any references 
in this subtitle to the Health Insurance Exchange or to 
the Commissioner in the area in which the State-based 
Health Insurance Exchange operates shall be deemed a 
reference to the State-based Health Insurance Exchange 
and the head of such Exchange, respectively. 
(f) FUNDING.—In the case of a State-based Health 
Insurance Exchange, there shall be assistance provided for 
the operation of such Exchange in the form of a matching 
grant with a State share of expenditures required. 
SEC. 209. PARTICIPATION OF SMALL EMPLOYER BENEFIT 
ARRANGEMENTS. 
(a) IN GENERAL.—The Commissioner may enter into 
contracts with small employer benefit arrangements to 
provide consumer information, outreach, and assistance in 
the enrollment of small employers (and their employees) 
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