H. R. 3590—767 
‘‘(B) the lawful use, possession, or storage of a firearm 
or ammunition by an individual. 
‘‘(2) LIMITATION
ON
DATA
COLLECTION.—None of the 
authorities provided to the Secretary under the Patient Protec-
tion and Affordable Care Act or an amendment made by that 
Act shall be construed to authorize or may be used for the 
collection of any information relating to— 
‘‘(A) the lawful ownership or possession of a firearm 
or ammunition; 
‘‘(B) the lawful use of a firearm or ammunition; or 
‘‘(C) the lawful storage of a firearm or ammunition. 
‘‘(3) LIMITATION ON DATABASES OR DATA BANKS.—None of 
the authorities provided to the Secretary under the Patient 
Protection and Affordable Care Act or an amendment made 
by that Act shall be construed to authorize or may be used 
to maintain records of individual ownership or possession of 
a firearm or ammunition. 
‘‘(4) LIMITATION ON DETERMINATION OF PREMIUM RATES OR 
ELIGIBILITY FOR HEALTH INSURANCE.—A premium rate may not 
be increased, health insurance coverage may not be denied, 
and a discount, rebate, or reward offered for participation in 
a wellness program may not be reduced or withheld under 
any health benefit plan issued pursuant to or in accordance 
with the Patient Protection and Affordable Care Act or an 
amendment made by that Act on the basis of, or on reliance 
upon— 
‘‘(A) the lawful ownership or possession of a firearm 
or ammunition; or 
‘‘(B) the lawful use or storage of a firearm or ammuni-
tion. 
‘‘(5) LIMITATION ON DATA COLLECTION REQUIREMENTS FOR 
INDIVIDUALS.—No individual shall be required to disclose any 
information under any data collection activity authorized under 
the Patient Protection and Affordable Care Act or an amend-
ment made by that Act relating to— 
‘‘(A) the lawful ownership or possession of a firearm 
or ammunition; or 
‘‘(B) the lawful use, possession, or storage of a firearm 
or ammunition.’’. 
(f) Section 2718 of the Public Health Service Act, as added 
by section 1001(5), is amended to read as follows: 
‘‘SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE COVERAGE. 
‘‘(a) CLEAR ACCOUNTING FOR COSTS.—A health insurance issuer 
offering group or individual health insurance coverage (including 
a grandfathered health plan) shall, with respect to each plan year, 
submit to the Secretary a report concerning the ratio of the incurred 
loss (or incurred claims) plus the loss adjustment expense (or change 
in contract reserves) to earned premiums. Such report shall include 
the percentage of total premium revenue, after accounting for collec-
tions or receipts for risk adjustment and risk corridors and pay-
ments of reinsurance, that such coverage expends— 
‘‘(1) on reimbursement for clinical services provided to 
enrollees under such coverage; 
‘‘(2) for activities that improve health care quality; and
H. R. 3590—768 
‘‘(3) on all other non-claims costs, including an explanation 
of the nature of such costs, and excluding Federal and State 
taxes and licensing or regulatory fees. 
The Secretary shall make reports received under this section avail-
able to the public on the Internet website of the Department of 
Health and Human Services. 
‘‘(b) ENSURING THAT CONSUMERS RECEIVE VALUE FOR THEIR 
PREMIUM PAYMENTS.— 
‘‘(1) REQUIREMENT TO PROVIDE VALUE FOR PREMIUM PAY-
MENTS.— 
‘‘(A) REQUIREMENT.—Beginning not later than January 
1, 2011, a health insurance issuer offering group or indi-
vidual health insurance coverage (including a grand-
fathered health plan) shall, with respect to each plan year, 
provide an annual rebate to each enrollee under such cov-
erage, on a pro rata basis, if the ratio of the amount 
of premium revenue expended by the issuer on costs 
described in paragraphs (1) and (2) of subsection (a) to 
the total amount of premium revenue (excluding Federal 
and State taxes and licensing or regulatory fees and after 
accounting for payments or receipts for risk adjustment, 
risk corridors, and reinsurance under sections 1341, 1342, 
and 1343 of the Patient Protection and Affordable Care 
Act) for the plan year (except as provided in subparagraph 
(B)(ii)), is less than— 
‘‘(i) with respect to a health insurance issuer 
offering coverage in the large group market, 85 percent, 
or such higher percentage as a State may by regulation 
determine; or 
‘‘(ii) with respect to a health insurance issuer 
offering coverage in the small group market or in the 
individual market, 80 percent, or such higher percent-
age as a State may by regulation determine, except 
that the Secretary may adjust such percentage with 
respect to a State if the Secretary determines that 
the application of such 80 percent may destabilize the 
individual market in such State. 
‘‘(B) REBATE AMOUNT.— 
‘‘(i) CALCULATION OF AMOUNT.—The total amount 
of an annual rebate required under this paragraph 
shall be in an amount equal to the product of— 
‘‘(I) the amount by which the percentage 
described in clause (i) or (ii) of subparagraph (A) 
exceeds the ratio described in such subparagraph; 
and 
‘‘(II) the total amount of premium revenue 
(excluding Federal and State taxes and licensing 
or regulatory fees and after accounting for pay-
ments or receipts for risk adjustment, risk cor-
ridors, and reinsurance under sections 1341, 1342, 
and 1343 of the Patient Protection and Affordable 
Care Act) for such plan year. 
‘‘(ii) CALCULATION
BASED
ON
AVERAGE
RATIO.— 
Beginning on January 1, 2014, the determination made 
under subparagraph (A) for the year involved shall 
be based on the averages of the premiums expended 
on the costs described in such subparagraph and total
H. R. 3590—769 
premium revenue for each of the previous 3 years 
for the plan. 
‘‘(2) CONSIDERATION IN SETTING PERCENTAGES.—In deter-
mining the percentages under paragraph (1), a State shall 
seek to ensure adequate participation by health insurance 
issuers, competition in the health insurance market in the 
State, and value for consumers so that premiums are used 
for clinical services and quality improvements. 
‘‘(3) ENFORCEMENT.—The Secretary shall promulgate regu-
lations for enforcing the provisions of this section and may 
provide for appropriate penalties. 
‘‘(c) DEFINITIONS.—Not later than December 31, 2010, and sub-
ject to the certification of the Secretary, the National Association 
of Insurance Commissioners shall establish uniform definitions of 
the activities reported under subsection (a) and standardized meth-
odologies for calculating measures of such activities, including 
definitions of which activities, and in what regard such activities, 
constitute activities described in subsection (a)(2). Such methodolo-
gies shall be designed to take into account the special circumstances 
of smaller plans, different types of plans, and newer plans. 
‘‘(d) ADJUSTMENTS.—The Secretary may adjust the rates 
described in subsection (b) if the Secretary determines appropriate 
on account of the volatility of the individual market due to the 
establishment of State Exchanges. 
‘‘(e) STANDARD HOSPITAL CHARGES.—Each hospital operating 
within the United States shall for each year establish (and update) 
and make public (in accordance with guidelines developed by the 
Secretary) a list of the hospital’s standard charges for items and 
services provided by the hospital, including for diagnosis-related 
groups established under section 1886(d)(4) of the Social Security 
Act.’’. 
(g) Section 2719 of the Public Health Service Act, as added 
by section 1001(4) of this Act, is amended to read as follows: 
‘‘SEC. 2719. APPEALS PROCESS. 
‘‘(a) INTERNAL CLAIMS APPEALS.— 
‘‘(1) IN GENERAL.—A group health plan and a health insur-
ance issuer offering group or individual health insurance cov-
erage shall implement an effective appeals process for appeals 
of coverage determinations and claims, under which the plan 
or issuer shall, at a minimum— 
‘‘(A) have in effect an internal claims appeal process; 
‘‘(B) provide notice to enrollees, in a culturally and 
linguistically appropriate manner, of available internal and 
external appeals processes, and the availability of any 
applicable office of health insurance consumer assistance 
or ombudsman established under section 2793 to assist 
such enrollees with the appeals processes; and 
‘‘(C) allow an enrollee to review their file, to present 
evidence and testimony as part of the appeals process, 
and to receive continued coverage pending the outcome 
of the appeals process. 
‘‘(2) ESTABLISHED PROCESSES.—To comply with paragraph 
(1)— 
‘‘(A) a group health plan and a health insurance issuer 
offering group health coverage shall provide an internal 
claims and appeals process that initially incorporates the
H. R. 3590—770 
claims and appeals procedures (including urgent claims) 
set forth at section 2560.503–1 of title 29, Code of Federal 
Regulations, as published on November 21, 2000 (65 Fed. 
Reg. 70256), and shall update such process in accordance 
with any standards established by the Secretary of Labor 
for such plans and issuers; and 
‘‘(B) a health insurance issuer offering individual 
health coverage, and any other issuer not subject to 
subparagraph (A), shall provide an internal claims and 
appeals process that initially incorporates the claims and 
appeals procedures set forth under applicable law (as in 
existence on the date of enactment of this section), and 
shall update such process in accordance with any standards 
established by the Secretary of Health and Human Services 
for such issuers. 
‘‘(b) EXTERNAL REVIEW.—A group health plan and a health 
insurance issuer offering group or individual health insurance cov-
erage— 
‘‘(1) shall comply with the applicable State external review 
process for such plans and issuers that, at a minimum, includes 
the consumer protections set forth in the Uniform External 
Review Model Act promulgated by the National Association 
of Insurance Commissioners and is binding on such plans; 
or 
‘‘(2) shall implement an effective external review process 
that meets minimum standards established by the Secretary 
through guidance and that is similar to the process described 
under paragraph (1)— 
‘‘(A) if the applicable State has not established an 
external review process that meets the requirements of 
paragraph (1); or 
‘‘(B) if the plan is a self-insured plan that is not subject 
to State insurance regulation (including a State law that 
establishes an external review process described in para-
graph (1)). 
‘‘(c) SECRETARY AUTHORITY.—The Secretary may deem the 
external review process of a group health plan or health insurance 
issuer, in operation as of the date of enactment of this section, 
to be in compliance with the applicable process established under 
subsection (b), as determined appropriate by the Secretary.’’. 
(h) Subpart II of part A of title XVIII of the Public Health 
Service Act, as added by section 1001(5) of this Act, is amended 
by inserting after section 2719 the following: 
‘‘SEC. 2719A. PATIENT PROTECTIONS. 
‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If a group health 
plan, or a health insurance issuer offering group or individual 
health insurance coverage, requires or provides for designation by 
a participant, beneficiary, or enrollee of a participating primary 
care provider, then the plan or issuer shall permit each participant, 
beneficiary, and enrollee to designate any participating primary 
care provider who is available to accept such individual. 
‘‘(b) COVERAGE OF EMERGENCY SERVICES.— 
‘‘(1) IN GENERAL.—If a group health plan, or a health insur-
ance issuer offering group or individual health insurance issuer, 
provides or covers any benefits with respect to services in 
an emergency department of a hospital, the plan or issuer
H. R. 3590—771 
shall cover emergency services (as defined in paragraph 
(2)(B))— 
‘‘(A) without the need for any prior authorization deter-
mination; 
‘‘(B) whether the health care provider furnishing such 
services is a participating provider with respect to such 
services; 
‘‘(C) in a manner so that, if such services are provided 
to a participant, beneficiary, or enrollee— 
‘‘(i) by a nonparticipating health care provider with 
or without prior authorization; or 
‘‘(ii)(I) such services will be provided without 
imposing any requirement under the plan for prior 
authorization of services or any limitation on coverage 
where the provider of services does not have a contrac-
tual relationship with the plan for the providing of 
services that is more restrictive than the requirements 
or limitations that apply to emergency department 
services received from providers who do have such 
a contractual relationship with the plan; and 
‘‘(II) if such services are provided out-of-network, 
the 
cost-sharing 
requirement 
(expressed 
as 
a 
copayment amount or coinsurance rate) is the same 
requirement that would apply if such services were 
provided in-network; 
‘‘(D) without regard to any other term or condition 
of such coverage (other than exclusion or coordination of 
benefits, or an affiliation or waiting period, permitted under 
section 2701 of this Act, section 701 of the Employee Retire-
ment Income Security Act of 1974, or section 9801 of the 
Internal Revenue Code of 1986, and other than applicable 
cost-sharing). 
‘‘(2) DEFINITIONS.—In this subsection: 
‘‘(A) EMERGENCY
MEDICAL
CONDITION.—The term 
‘emergency medical condition’ means a medical condition 
manifesting itself by acute symptoms of sufficient severity 
(including severe pain) such that a prudent layperson, who 
possesses an average knowledge of health and medicine, 
could reasonably expect the absence of immediate medical 
attention to result in a condition described in clause (i), 
(ii), or (iii) of section 1867(e)(1)(A) of the Social Security 
Act. 
‘‘(B) EMERGENCY SERVICES.—The term ‘emergency serv-
ices’ means, with respect to an emergency medical condi-
tion— 
‘‘(i) a medical screening examination (as required 
under section 1867 of the Social Security Act) that 
is within the capability of the emergency department 
of a hospital, including ancillary services routinely 
available to the emergency department to evaluate 
such emergency medical condition, and 
‘‘(ii) within the capabilities of the staff and facili-
ties available at the hospital, such further medical 
examination and treatment as are required under sec-
tion 1867 of such Act to stabilize the patient.
H. R. 3590—772 
‘‘(C) STABILIZE.—The term ‘to stabilize’, with respect 
to an emergency medical condition (as defined in subpara-
graph (A)), has the meaning give in section 1867(e)(3) of 
the Social Security Act (42 U.S.C. 1395dd(e)(3)). 
‘‘(c) ACCESS TO PEDIATRIC CARE.— 
‘‘(1) PEDIATRIC CARE.—In the case of a person who has 
a child who is a participant, beneficiary, or enrollee under 
a group health plan, or health insurance coverage offered by 
a health insurance issuer in the group or individual market, 
if the plan or issuer requires or provides for the designation 
of a participating primary care provider for the child, the plan 
or issuer shall permit such person to designate a physician 
(allopathic or osteopathic) who specializes in pediatrics as the 
child’s primary care provider if such provider participates in 
the network of the plan or issuer. 
‘‘(2) CONSTRUCTION.—Nothing in paragraph (1) shall be 
construed to waive any exclusions of coverage under the terms 
and conditions of the plan or health insurance coverage with 
respect to coverage of pediatric care. 
‘‘(d) PATIENT ACCESS
TO OBSTETRICAL
AND GYNECOLOGICAL 
CARE.— 
‘‘(1) GENERAL RIGHTS.— 
‘‘(A) DIRECT ACCESS.—A group health plan, or health 
insurance issuer offering group or individual health insur-
ance coverage, described in paragraph (2) may not require 
authorization or referral by the plan, issuer, or any person 
(including a primary care provider described in paragraph 
(2)(B)) in the case of a female participant, beneficiary, 
or enrollee who seeks coverage for obstetrical or gyneco-
logical care provided by a participating health care profes-
sional who specializes in obstetrics or gynecology. Such 
professional shall agree to otherwise adhere to such plan’s 
or issuer’s policies and procedures, including procedures 
regarding referrals and obtaining prior authorization and 
providing services pursuant to a treatment plan (if any) 
approved by the plan or issuer. 
‘‘(B) OBSTETRICAL AND GYNECOLOGICAL CARE.—A group 
health plan or health insurance issuer described in para-
graph (2) shall treat the provision of obstetrical and gyneco-
logical care, and the ordering of related obstetrical and 
gynecological items and services, pursuant to the direct 
access described under subparagraph (A), by a participating 
health care professional who specializes in obstetrics or 
gynecology as the authorization of the primary care pro-
vider. 
‘‘(2) APPLICATION
OF
PARAGRAPH.—A group health plan, 
or health insurance issuer offering group or individual health 
insurance coverage, described in this paragraph is a group 
health plan or coverage that— 
‘‘(A) provides coverage for obstetric or gynecologic care; 
and 
‘‘(B) requires the designation by a participant, bene-
ficiary, or enrollee of a participating primary care provider. 
‘‘(3) CONSTRUCTION.—Nothing in paragraph (1) shall be 
construed to— 
‘‘(A) waive any exclusions of coverage under the terms 
and conditions of the plan or health insurance coverage
H. R. 3590—773 
with respect to coverage of obstetrical or gynecological care; 
or 
‘‘(B) preclude the group health plan or health insurance 
issuer involved from requiring that the obstetrical or 
gynecological provider notify the primary care health care 
professional or the plan or issuer of treatment decisions.’’. 
(i) Section 2794 of the Public Health Service Act, as added 
by section 1003 of this Act, is amended— 
(1) in subsection (c)(1)— 
(A) in subparagraph (A), by striking ‘‘and’’ at the end; 
(B) in subparagraph (B), by striking the period and 
inserting ‘‘; and’’; and 
(C) by adding at the end the following: 
‘‘(C) in establishing centers (consistent with subsection 
(d)) at academic or other nonprofit institutions to collect 
medical reimbursement information from health insurance 
issuers, to analyze and organize such information, and 
to make such information available to such issuers, health 
care providers, health researchers, health care policy mak-
ers, and the general public.’’; and 
(2) by adding at the end the following: 
‘‘(d) MEDICAL REIMBURSEMENT DATA CENTERS.— 
‘‘(1) FUNCTIONS.—A center established under subsection 
(c)(1)(C) shall— 
‘‘(A) develop fee schedules and other database tools 
that fairly and accurately reflect market rates for medical 
services and the geographic differences in those rates; 
‘‘(B) use the best available statistical methods and 
data processing technology to develop such fee schedules 
and other database tools; 
‘‘(C) regularly update such fee schedules and other 
database tools to reflect changes in charges for medical 
services; 
‘‘(D) make health care cost information readily avail-
able to the public through an Internet website that allows 
consumers to understand the amounts that health care 
providers in their area charge for particular medical serv-
ices; and 
‘‘(E) regularly publish information concerning the 
statistical methodologies used by the center to analyze 
health charge data and make such data available to 
researchers and policy makers. 
‘‘(2) CONFLICTS OF INTEREST.—A center established under 
subsection (c)(1)(C) shall adopt by-laws that ensures that the 
center (and all members of the governing board of the center) 
is independent and free from all conflicts of interest. Such 
by-laws shall ensure that the center is not controlled or influ-
enced by, and does not have any corporate relation to, any 
individual or entity that may make or receive payments for 
health care services based on the center’s analysis of health 
care costs. 
‘‘(3) RULE OF CONSTRUCTION.—Nothing in this subsection 
shall be construed to permit a center established under sub-
section (c)(1)(C) to compel health insurance issuers to provide 
data to the center.’’.
H. R. 3590—774 
SEC. 10102. AMENDMENTS TO SUBTITLE B. 
(a) Section 1102(a)(2)(B) of this Act is amended— 
(1) in the matter preceding clause (i), by striking ‘‘group 
health benefits plan’’ and inserting ‘‘group benefits plan pro-
viding health benefits’’; and 
(2) in clause (i)(I), by inserting ‘‘or any agency or instrumen-
tality of any of the foregoing’’ before the closed parenthetical. 
(b) Section 1103(a) of this Act is amended— 
(1) in paragraph (1), by inserting ‘‘, or small business 
in,’’ after ‘‘residents of any’’; and 
(2) by striking paragraph (2) and inserting the following: 
‘‘(2) CONNECTING TO AFFORDABLE COVERAGE.—An Internet 
website established under paragraph (1) shall, to the extent 
practicable, provide ways for residents of, and small businesses 
in, any State to receive information on at least the following 
coverage options: 
‘‘(A) Health insurance coverage offered by health insur-
ance issuers, other than coverage that provides reimburse-
ment only for the treatment or mitigation of— 
‘‘(i) a single disease or condition; or 
‘‘(ii) an unreasonably limited set of diseases or 
conditions (as determined by the Secretary). 
‘‘(B) Medicaid coverage under title XIX of the Social 
Security Act. 
‘‘(C) Coverage under title XXI of the Social Security 
Act. 
‘‘(D) A State health benefits high risk pool, to the 
extent that such high risk pool is offered in such State; 
and 
‘‘(E) Coverage under a high risk pool under section 
1101. 
‘‘(F) Coverage within the small group market for small 
businesses and their employees, including reinsurance for 
early retirees under section 1102, tax credits available 
under section 45R of the Internal Revenue Code of 1986 
(as added by section 1421), and other information specifi-
cally for small businesses regarding affordable health care 
options.’’. 
SEC. 10103. AMENDMENTS TO SUBTITLE C. 
(a) Section 2701(a)(5) of the Public Health Service Act, as 
added by section 1201(4) of this Act, is amended by inserting 
‘‘(other than self-insured group health plans offered in such market)’’ 
after ‘‘such market’’. 
(b) Section 2708 of the Public Health Service Act, as added 
by section 1201(4) of this Act, is amended by striking ‘‘or individual’’. 
(c) Subpart I of part A of title XXVII of the Public Health 
Service Act, as added by section 1201(4) of this Act, is amended 
by inserting after section 2708, the following: 
‘‘SEC. 
2709. 
COVERAGE 
FOR 
INDIVIDUALS 
PARTICIPATING 
IN 
APPROVED CLINICAL TRIALS. 
‘‘(a) COVERAGE.— 
‘‘(1) IN GENERAL.—If a group health plan or a health insur-
ance issuer offering group or individual health insurance cov-
erage provides coverage to a qualified individual, then such 
plan or issuer—
H. R. 3590—775 
‘‘(A) may not deny the individual participation in the 
clinical trial referred to in subsection (b)(2); 
‘‘(B) subject to subsection (c), may not deny (or limit 
or impose additional conditions on) the coverage of routine 
patient costs for items and services furnished in connection 
with participation in the trial; and 
‘‘(C) may not discriminate against the individual on 
the basis of the individual’s participation in such trial. 
‘‘(2) ROUTINE PATIENT COSTS.— 
‘‘(A) INCLUSION.—For purposes of paragraph (1)(B), 
subject to subparagraph (B), routine patient costs include 
all items and services consistent with the coverage provided 
in the plan (or coverage) that is typically covered for a 
qualified individual who is not enrolled in a clinical trial. 
‘‘(B) EXCLUSION.—For purposes of paragraph (1)(B), 
routine patient costs does not include— 
‘‘(i) the investigational item, device, or service, 
itself; 
‘‘(ii) items and services that are provided solely 
to satisfy data collection and analysis needs and that 
are not used in the direct clinical management of the 
patient; or 
‘‘(iii) a service that is clearly inconsistent with 
widely accepted and established standards of care for 
a particular diagnosis. 
‘‘(3) USE OF IN-NETWORK PROVIDERS.—If one or more partici-
pating providers is participating in a clinical trial, nothing 
in paragraph (1) shall be construed as preventing a plan or 
issuer from requiring that a qualified individual participate 
in the trial through such a participating provider if the provider 
will accept the individual as a participant in the trial. 
‘‘(4) USE OF OUT-OF-NETWORK.—Notwithstanding paragraph 
(3), paragraph (1) shall apply to a qualified individual partici-
pating in an approved clinical trial that is conducted outside 
the State in which the qualified individual resides. 
‘‘(b) QUALIFIED INDIVIDUAL DEFINED.—For purposes of sub-
section (a), the term ‘qualified individual’ means an individual 
who is a participant or beneficiary in a health plan or with coverage 
described in subsection (a)(1) and who meets the following condi-
tions: 
‘‘(1) The individual is eligible to participate in an approved 
clinical trial according to the trial protocol with respect to 
treatment of cancer or other life-threatening disease or condi-
tion. 
‘‘(2) Either— 
‘‘(A) the referring health care professional is a partici-
pating health care provider and has concluded that the 
individual’s participation in such trial would be appropriate 
based upon the individual meeting the conditions described 
in paragraph (1); or 
‘‘(B) the participant or beneficiary provides medical 
and scientific information establishing that the individual’s 
participation in such trial would be appropriate based upon 
the individual meeting the conditions described in para-
graph (1). 
‘‘(c) LIMITATIONS ON COVERAGE.—This section shall not be con-
strued to require a group health plan, or a health insurance issuer
H. R. 3590—776 
offering group or individual health insurance coverage, to provide 
benefits for routine patient care services provided outside of the 
plan’s (or coverage’s) health care provider network unless out-of- 
network benefits are otherwise provided under the plan (or cov-
erage). 
‘‘(d) APPROVED CLINICAL TRIAL DEFINED.— 
‘‘(1) IN GENERAL.—In this section, the term ‘approved clin-
ical trial’ means a phase I, phase II, phase III, or phase IV 
clinical trial that is conducted in relation to the prevention, 
detection, or treatment of cancer or other life-threatening dis-
ease or condition and is described in any of the following 
subparagraphs: 
‘‘(A) FEDERALLY FUNDED TRIALS.—The study or inves-
tigation is approved or funded (which may include funding 
through in-kind contributions) by one or more of the fol-
lowing: 
‘‘(i) The National Institutes of Health. 
‘‘(ii) The Centers for Disease Control and Preven-
tion. 
‘‘(iii) The Agency for Health Care Research and 
Quality. 
‘‘(iv) The Centers for Medicare & Medicaid Serv-
ices. 
‘‘(v) cooperative group or center of any of the enti-
ties described in clauses (i) through (iv) or the Depart-
ment of Defense or the Department of Veterans Affairs. 
‘‘(vi) A qualified non-governmental research entity 
identified in the guidelines issued by the National 
Institutes of Health for center support grants. 
‘‘(vii) Any of the following if the conditions 
described in paragraph (2) are met: 
‘‘(I) The Department of Veterans Affairs. 
‘‘(II) The Department of Defense. 
‘‘(III) The Department of Energy. 
‘‘(B) The study or investigation is conducted under 
an investigational new drug application reviewed by the 
Food and Drug Administration. 
‘‘(C) The study or investigation is a drug trial that 
is exempt from having such an investigational new drug 
application. 
‘‘(2) 
CONDITIONS
FOR
DEPARTMENTS.—The 
conditions 
described in this paragraph, for a study or investigation con-
ducted by a Department, are that the study or investigation 
has been reviewed and approved through a system of peer 
review that the Secretary determines— 
‘‘(A) to be comparable to the system of peer review 
of studies and investigations used by the National 
Institutes of Health, and 
‘‘(B) assures unbiased review of the highest scientific 
standards by qualified individuals who have no interest 
in the outcome of the review. 
‘‘(e) LIFE-THREATENING CONDITION DEFINED.—In this section, 
the term ‘life-threatening condition’ means any disease or condition 
from which the likelihood of death is probable unless the course 
of the disease or condition is interrupted. 
‘‘(f) CONSTRUCTION.—Nothing in this section shall be construed 
to limit a plan’s or issuer’s coverage with respect to clinical trials.
H. R. 3590—777 
‘‘(g) APPLICATION TO FEHBP.—Notwithstanding any provision 
of chapter 89 of title 5, United States Code, this section shall 
apply to health plans offered under the program under such chapter. 
‘‘(h) PREEMPTION.—Notwithstanding any other provision of this 
Act, nothing in this section shall preempt State laws that require 
a clinical trials policy for State regulated health insurance plans 
that is in addition to the policy required under this section.’’. 
(d) Section 1251(a) of this Act is amended— 
(1) in paragraph (2), by striking ‘‘With’’ and inserting 
‘‘Except as provided in paragraph (3), with’’; and 
(2) by adding at the end the following: 
‘‘(3) APPLICATION OF CERTAIN PROVISIONS.—The provisions 
of sections 2715 and 2718 of the Public Health Service Act 
(as added by subtitle A) shall apply to grandfathered health 
plans for plan years beginning on or after the date of enactment 
of this Act.’’. 
(e) Section 1253 of this Act is amended insert before the period 
the following: ‘‘, except that— 
‘‘(1) section 1251 shall take effect on the date of enactment 
of this Act; and 
‘‘(2) the provisions of section 2704 of the Public Health 
Service Act (as amended by section 1201), as they apply to 
enrollees who are under 19 years of age, shall become effective 
for plan years beginning on or after the date that is 6 months 
after the date of enactment of this Act.’’. 
(f) Subtitle C of title I of this Act is amended— 
(1) by redesignating section 1253 as section 1255; and 
(2) by inserting after section 1252, the following: 
‘‘SEC. 1253. ANNUAL REPORT ON SELF-INSURED PLANS. 
‘‘Not later than 1 year after the date of enactment of this 
Act, and annually thereafter, the Secretary of Labor shall prepare 
an aggregate annual report, using data collected from the Annual 
Return/Report of Employee Benefit Plan (Department of Labor Form 
5500), that shall include general information on self-insured group 
health plans (including plan type, number of participants, benefits 
offered, funding arrangements, and benefit arrangements) as well 
as data from the financial filings of self-insured employers 
(including information on assets, liabilities, contributions, invest-
ments, and expenses). The Secretary shall submit such reports 
to the appropriate committees of Congress. 
‘‘SEC. 1254. STUDY OF LARGE GROUP MARKET. 
‘‘(a) IN GENERAL.—The Secretary of Health and Human Services 
shall conduct a study of the fully-insured and self-insured group 
health plan markets to— 
‘‘(1) compare the characteristics of employers (including 
industry, size, and other characteristics as determined appro-
priate by the Secretary), health plan benefits, financial sol-
vency, capital reserve levels, and the risks of becoming insol-
vent; and 
‘‘(2) determine the extent to which new insurance market 
reforms are likely to cause adverse selection in the large group 
market or to encourage small and midsize employers to self- 
insure. 
‘‘(b) COLLECTION OF INFORMATION.—In conducting the study 
under subsection (a), the Secretary, in coordination with the Sec-
retary of Labor, shall collect information and analyze—
H. R. 3590—778 
‘‘(1) the extent to which self-insured group health plans 
can offer less costly coverage and, if so, whether lower costs 
are due to more efficient plan administration and lower over-
head or to the denial of claims and the offering very limited 
benefit packages; 
‘‘(2) claim denial rates, plan benefit fluctuations (to 
evaluate the extent that plans scale back health benefits during 
economic downturns), and the impact of the limited recourse 
options on consumers; and 
‘‘(3) any potential conflict of interest as it relates to the 
health care needs of self-insured enrollees and self-insured 
employer’s financial contribution or profit margin, and the 
impact of such conflict on administration of the health plan. 
‘‘(c) REPORT.—Not later than 1 year after the date of enactment 
of this Act, the Secretary shall submit to the appropriate committees 
of Congress a report concerning the results of the study conducted 
under subsection (a).’’. 
SEC. 10104. AMENDMENTS TO SUBTITLE D. 
(a) Section 1301(a) of this Act is amended by striking paragraph 
(2) and inserting the following: 
‘‘(2) INCLUSION OF CO–OP PLANS AND MULTI-STATE QUALI-
FIED HEALTH PLANS.—Any reference in this title to a qualified 
health plan shall be deemed to include a qualified health plan 
offered through the CO–OP program under section 1322, and 
a multi-State plan under section 1334, unless specifically pro-
vided for otherwise. 
‘‘(3) TREATMENT OF QUALIFIED DIRECT PRIMARY CARE MED-
ICAL HOME PLANS.—The Secretary of Health and Human Serv-
ices shall permit a qualified health plan to provide coverage 
through a qualified direct primary care medical home plan 
that meets criteria established by the Secretary, so long as 
the qualified health plan meets all requirements that are other-
wise applicable and the services covered by the medical home 
plan are coordinated with the entity offering the qualified 
health plan. 
‘‘(4) VARIATION BASED ON RATING AREA.—A qualified health 
plan, including a multi-State qualified health plan, may as 
appropriate vary premiums by rating area (as defined in section 
2701(a)(2) of the Public Health Service Act).’’. 
(b) Section 1302 of this Act is amended— 
(1) in subsection (d)(2)(B), by striking ‘‘may issue’’ and 
inserting ‘‘shall issue’’; and 
(2) by adding at the end the following: 
‘‘(g) PAYMENTS TO FEDERALLY-QUALIFIED HEALTH CENTERS.— 
If any item or service covered by a qualified health plan is provided 
by a Federally-qualified health center (as defined in section 
1905(l)(2)(B) of the Social Security Act (42 U.S.C. 1396d(l)(2)(B)) 
to an enrollee of the plan, the offeror of the plan shall pay to 
the center for the item or service an amount that is not less 
than the amount of payment that would have been paid to the 
center under section 1902(bb) of such Act (42 U.S.C. 1396a(bb)) 
for such item or service.’’. 
(c) Section 1303 of this Act is amended to read as follows: 
‘‘SEC. 1303. SPECIAL RULES. 
‘‘(a) STATE OPT-OUT OF ABORTION COVERAGE.—
H. R. 3590—779 
‘‘(1) IN GENERAL.—A State may elect to prohibit abortion 
coverage in qualified health plans offered through an Exchange 
in such State if such State enacts a law to provide for such 
prohibition. 
‘‘(2) TERMINATION OF OPT OUT.—A State may repeal a law 
described in paragraph (1) and provide for the offering of such 
services through the Exchange. 
‘‘(b) SPECIAL RULES RELATING TO COVERAGE OF ABORTION SERV-
ICES.— 
‘‘(1) VOLUNTARY CHOICE OF COVERAGE OF ABORTION SERV-
ICES.— 
‘‘(A) IN GENERAL.—Notwithstanding any other provi-
sion of this title (or any amendment made by this title)— 
‘‘(i) nothing in this title (or any amendment made 
by this title), shall be construed to require a qualified 
health plan to provide coverage of services described 
in subparagraph (B)(i) or (B)(ii) as part of its essential 
health benefits for any plan year; and 
‘‘(ii) subject to subsection (a), the issuer of a quali-
fied health plan shall determine whether or not the 
plan provides coverage of services described in subpara-
graph (B)(i) or (B)(ii) as part of such benefits for the 
plan year. 
‘‘(B) ABORTION SERVICES.— 
‘‘(i) ABORTIONS
FOR
WHICH
PUBLIC
FUNDING
IS 
PROHIBITED.—The services described in this clause are 
abortions for which the expenditure of Federal funds 
appropriated for the Department of Health and Human 
Services is not permitted, based on the law as in effect 
as of the date that is 6 months before the beginning 
of the plan year involved. 
‘‘(ii) ABORTIONS
FOR
WHICH
PUBLIC
FUNDING
IS 
ALLOWED.—The services described in this clause are 
abortions for which the expenditure of Federal funds 
appropriated for the Department of Health and Human 
Services is permitted, based on the law as in effect 
as of the date that is 6 months before the beginning 
of the plan year involved. 
‘‘(2) PROHIBITION ON THE USE OF FEDERAL FUNDS.— 
‘‘(A) IN GENERAL.—If a qualified health plan provides 
coverage of services described in paragraph (1)(B)(i), the 
issuer of the plan shall not use any amount attributable 
to any of the following for purposes of paying for such 
services: 
‘‘(i) The credit under section 36B of the Internal 
Revenue Code of 1986 (and the amount (if any) of 
the advance payment of the credit under section 1412 
of the Patient Protection and Affordable Care Act). 
‘‘(ii) Any cost-sharing reduction under section 1402 
of the Patient Protection and Affordable Care Act (and 
the amount (if any) of the advance payment of the 
reduction under section 1412 of the Patient Protection 
and Affordable Care Act). 
‘‘(B) ESTABLISHMENT
OF
ALLOCATION
ACCOUNTS.—In 
the case of a plan to which subparagraph (A) applies, 
the issuer of the plan shall—
H. R. 3590—780 
‘‘(i) collect from each enrollee in the plan (without 
regard to the enrollee’s age, sex, or family status) 
a separate payment for each of the following: 
‘‘(I) an amount equal to the portion of the 
premium to be paid directly by the enrollee for 
coverage under the plan of services other than 
services described in paragraph (1)(B)(i) (after 
reduction for credits and cost-sharing reductions 
described in subparagraph (A)); and 
‘‘(II) an amount equal to the actuarial value 
of the coverage of services described in paragraph 
(1)(B)(i), and 
‘‘(ii) shall deposit all such separate payments into 
separate allocation accounts as provided in subpara-
graph (C). 
In the case of an enrollee whose premium for coverage 
under the plan is paid through employee payroll deposit, 
the separate payments required under this subparagraph 
shall each be paid by a separate deposit. 
‘‘(C) SEGREGATION OF FUNDS.— 
‘‘(i) IN GENERAL.—The issuer of a plan to which 
subparagraph (A) applies shall establish allocation 
accounts described in clause (ii) for enrollees receiving 
amounts described in subparagraph (A). 
‘‘(ii) ALLOCATION ACCOUNTS.—The issuer of a plan 
to which subparagraph (A) applies shall deposit— 
‘‘(I) all payments described in subparagraph 
(B)(i)(I) into a separate account that consists solely 
of such payments and that is used exclusively to 
pay for services other than services described in 
paragraph (1)(B)(i); and 
‘‘(II) all payments described in subparagraph 
(B)(i)(II) into a separate account that consists 
solely of such payments and that is used exclu-
sively to pay for services described in paragraph 
(1)(B)(i). 
‘‘(D) ACTUARIAL VALUE.— 
‘‘(i) IN GENERAL.—The issuer of a qualified health 
plan shall estimate the basic per enrollee, per month 
cost, determined on an average actuarial basis, for 
including coverage under the qualified health plan of 
the services described in paragraph (1)(B)(i). 
‘‘(ii) CONSIDERATIONS.—In making such estimate, 
the issuer— 
‘‘(I) may take into account the impact on 
overall costs of the inclusion of such coverage, 
but may not take into account any cost reduction 
estimated to result from such services, including 
prenatal care, delivery, or postnatal care; 
‘‘(II) shall estimate such costs as if such cov-
erage were included for the entire population cov-
ered; and 
‘‘(III) may not estimate such a cost at less 
than $1 per enrollee, per month. 
‘‘(E) 
ENSURING
COMPLIANCE
WITH
SEGREGATION 
REQUIREMENTS.—
H. R. 3590—781 
‘‘(i) IN
GENERAL.—Subject to clause (ii), State 
health insurance commissioners shall ensure that 
health plans comply with the segregation requirements 
in this subsection through the segregation of plan funds 
in accordance with applicable provisions of generally 
accepted accounting requirements, circulars on funds 
management of the Office of Management and Budget, 
and guidance on accounting of the Government 
Accountability Office. 
‘‘(ii) CLARIFICATION.—Nothing in clause (i) shall 
prohibit the right of an individual or health plan to 
appeal such action in courts of competent jurisdiction. 
‘‘(3) RULES RELATING TO NOTICE.— 
‘‘(A) NOTICE.—A qualified health plan that provides 
for coverage of the services described in paragraph (1)(B)(i) 
shall provide a notice to enrollees, only as part of the 
summary of benefits and coverage explanation, at the time 
of enrollment, of such coverage. 
‘‘(B) RULES
RELATING
TO
PAYMENTS.—The notice 
described in subparagraph (A), any advertising used by 
the issuer with respect to the plan, any information pro-
vided by the Exchange, and any other information specified 
by the Secretary shall provide information only with respect 
to the total amount of the combined payments for services 
described in paragraph (1)(B)(i) and other services covered 
by the plan. 
‘‘(4) NO DISCRIMINATION ON BASIS OF PROVISION OF ABOR-
TION.—No qualified health plan offered through an Exchange 
may discriminate against any individual health care provider 
or health care facility because of its unwillingness to provide, 
pay for, provide coverage of, or refer for abortions 
‘‘(c) APPLICATION
OF STATE
AND FEDERAL LAWS REGARDING 
ABORTION.— 
‘‘(1) NO
PREEMPTION
OF
STATE
LAWS
REGARDING
ABOR-
TION.—Nothing in this Act shall be construed to preempt or 
otherwise have any effect on State laws regarding the prohibi-
tion of (or requirement of) coverage, funding, or procedural 
requirements on abortions, including parental notification or 
consent for the performance of an abortion on a minor. 
‘‘(2) NO EFFECT ON FEDERAL LAWS REGARDING ABORTION.— 
‘‘(A) IN GENERAL.—Nothing in this Act shall be con-
strued to have any effect on Federal laws regarding— 
‘‘(i) conscience protection; 
‘‘(ii) willingness or refusal to provide abortion; and 
‘‘(iii) discrimination on the basis of the willingness 
or refusal to provide, pay for, cover, or refer for abortion 
or to provide or participate in training to provide abor-
tion. 
‘‘(3) NO EFFECT ON FEDERAL CIVIL RIGHTS LAW.—Nothing 
in this subsection shall alter the rights and obligations of 
employees and employers under title VII of the Civil Rights 
Act of 1964. 
‘‘(d) APPLICATION OF EMERGENCY SERVICES LAWS.—Nothing in 
this Act shall be construed to relieve any health care provider 
from providing emergency services as required by State or Federal 
law, including section 1867 of the Social Security Act (popularly 
known as ‘EMTALA’).’’.
H. R. 3590—782 
(d) Section 1304 of this Act is amended by adding at the 
end the following: 
‘‘(e) EDUCATED HEALTH CARE CONSUMERS.—The term ‘educated 
health care consumer’ means an individual who is knowledgeable 
about the health care system, and has background or experience 
in making informed decisions regarding health, medical, and sci-
entific matters.’’. 
(e) Section 1311(d) of this Act is amended— 
(1) in paragraph (3)(B), by striking clause (ii) and inserting 
the following: 
‘‘(ii) STATE
MUST
ASSUME
COST.—A State shall 
make payments— 
‘‘(I) to an individual enrolled in a qualified 
health plan offered in such State; or 
‘‘(II) on behalf of an individual described in 
subclause (I) directly to the qualified health plan 
in which such individual is enrolled; 
to defray the cost of any additional benefits described 
in clause (i).’’; and 
(2) in paragraph (6)(A), by inserting ‘‘educated’’ before 
‘‘health care’’. 
(f) Section 1311(e) of this Act is amended— 
(1) in paragraph (2), by striking ‘‘may’’ in the second sen-
tence and inserting ‘‘shall’’; and 
(2) by adding at the end the following: 
‘‘(3) TRANSPARENCY IN COVERAGE.— 
‘‘(A) IN GENERAL.—The Exchange shall require health 
plans seeking certification as qualified health plans to 
submit to the Exchange, the Secretary, the State insurance 
commissioner, and make available to the public, accurate 
and timely disclosure of the following information: 
‘‘(i) Claims payment policies and practices. 
‘‘(ii) Periodic financial disclosures. 
‘‘(iii) Data on enrollment. 
‘‘(iv) Data on disenrollment. 
‘‘(v) Data on the number of claims that are denied. 
‘‘(vi) Data on rating practices. 
‘‘(vii) Information on cost-sharing and payments 
with respect to any out-of-network coverage. 
‘‘(viii) Information on enrollee and participant 
rights under this title. 
‘‘(ix) Other information as determined appropriate 
by the Secretary. 
‘‘(B) USE
OF
PLAIN
LANGUAGE.—The information 
required to be submitted under subparagraph (A) shall 
be provided in plain language. The term ‘plain language’ 
means language that the intended audience, including 
individuals with limited English proficiency, can readily 
understand and use because that language is concise, well- 
organized, and follows other best practices of plain lan-
guage writing. The Secretary and the Secretary of Labor 
shall jointly develop and issue guidance on best practices 
of plain language writing. 
‘‘(C) COST
SHARING
TRANSPARENCY.—The Exchange 
shall require health plans seeking certification as qualified 
health plans to permit individuals to learn the amount 
of cost-sharing (including deductibles, copayments, and
H. R. 3590—783 
coinsurance) under the individual’s plan or coverage that 
the individual would be responsible for paying with respect 
to the furnishing of a specific item or service by a partici-
pating provider in a timely manner upon the request of 
the individual. At a minimum, such information shall be 
made available to such individual through an Internet 
website and such other means for individuals without 
access to the Internet. 
‘‘(D) GROUP HEALTH PLANS.—The Secretary of Labor 
shall update and harmonize the Secretary’s rules con-
cerning the accurate and timely disclosure to participants 
by group health plans of plan disclosure, plan terms and 
conditions, and periodic financial disclosure with the stand-
ards established by the Secretary under subparagraph 
(A).’’. 
(g) Section 1311(g)(1) of this Act is amended— 
(1) in subparagraph (C), by striking ‘‘; and’’ and inserting 
a semicolon; 
(2) in subparagraph (D), by striking the period and 
inserting ‘‘; and’’; and 
(3) by adding at the end the following: 
‘‘(E) the implementation of activities to reduce health 
and health care disparities, including through the use of 
language services, community outreach, and cultural com-
petency trainings.’’. 
(h) Section 1311(i)(2)((B) of this Act is amended by striking 
‘‘small business development centers’’ and inserting ‘‘resource part-
ners of the Small Business Administration’’. 
(i) Section 1312 of this Act is amended— 
(1) in subsection (a)(1), by inserting ‘‘and for which such 
individual is eligible’’ before the period; 
(2) in subsection (e)— 
(A) in paragraph (1), by inserting ‘‘and employers’’ 
after ‘‘enroll individuals’’; and 
(B) by striking the flush sentence at the end; and 
(3) in subsection (f)(1)(A)(ii), by striking the parenthetical. 
(j)(1) Subparagraph (B) of section 1313(a)(6) of this Act is 
hereby deemed null, void, and of no effect. 
(2) Section 3730(e) of title 31, United States Code, is amended 
by striking paragraph (4) and inserting the following: 
‘‘(4)(A) The court shall dismiss an action or claim under 
this section, unless opposed by the Government, if substantially 
the same allegations or transactions as alleged in the action 
or claim were publicly disclosed— 
‘‘(i) in a Federal criminal, civil, or administrative 
hearing in which the Government or its agent is a party; 
‘‘(ii) in a congressional, Government Accountability 
Office, or other Federal report, hearing, audit, or investiga-
tion; or 
‘‘(iii) from the news media, 
unless the action is brought by the Attorney General or the 
person bringing the action is an original source of the informa-
tion. 
‘‘(B) For purposes of this paragraph, ‘‘original source’’ 
means an individual who either (i) prior to a public disclosure 
under subsection (e)(4)(a), has voluntarily disclosed to the
H. R. 3590—784 
Government the information on which allegations or trans-
actions in a claim are based, or (2) who has knowledge that 
is independent of and materially adds to the publicly disclosed 
allegations or transactions, and who has voluntarily provided 
the information to the Government before filing an action under 
this section.’’. 
(k) Section 1313(b) of this Act is amended— 
(1) in paragraph (3), by striking ‘‘and’’ at the end; 
(2) by redesignating paragraph (4) as paragraph (5); and 
(3) by inserting after paragraph (3) the following: 
‘‘(4) a survey of the cost and affordability of health care 
insurance provided under the Exchanges for owners and 
employees of small business concerns (as defined under section 
3 of the Small Business Act (15 U.S.C. 632)), including data 
on enrollees in Exchanges and individuals purchasing health 
insurance coverage outside of Exchanges; and’’. 
(l) Section 1322(b) of this Act is amended— 
(1) by redesignating paragraph (3) as paragraph (4); and 
(2) by inserting after paragraph (2), the following: 
‘‘(3) REPAYMENT OF LOANS AND GRANTS.—Not later than 
July 1, 2013, and prior to awarding loans and grants under 
the CO–OP program, the Secretary shall promulgate regula-
tions with respect to the repayment of such loans and grants 
in a manner that is consistent with State solvency regulations 
and other similar State laws that may apply. In promulgating 
such regulations, the Secretary shall provide that such loans 
shall be repaid within 5 years and such grants shall be repaid 
within 15 years, taking into consideration any appropriate State 
reserve requirements, solvency regulations, and requisite sur-
plus note arrangements that must be constructed in a State 
to provide for such repayment prior to awarding such loans 
and grants.’’. 
(m) Part III of subtitle D of title I of this Act is amended 
by striking section 1323. 
(n) Section 1324(a) of this Act is amended by striking ‘‘, a 
community health’’ and all that follows through ‘‘1333(b)’’ and 
inserting ‘‘, or a multi-State qualified health plan under section 
1334’’. 
(o) Section 1331 of this Act is amended— 
(1) in subsection (d)(3)(A)(i), by striking ‘‘85’’ and inserting 
‘‘95’’; and 
(2) in subsection (e)(1)(B), by inserting before the semicolon 
the following: ‘‘, or, in the case of an alien lawfully present 
in the United States, whose income is not greater than 133 
percent of the poverty line for the size of the family involved 
but who is not eligible for the Medicaid program under title 
XIX of the Social Security Act by reason of such alien status’’. 
(p) Section 1333 of this Act is amended by striking subsection 
(b). 
(q) Part IV of subtitle D of title I of this Act is amended 
by adding at the end the following: 
‘‘SEC. 1334. MULTI-STATE PLANS. 
‘‘(a) OVERSIGHT BY THE OFFICE OF PERSONNEL MANAGEMENT.— 
‘‘(1) IN GENERAL.—The Director of the Office of Personnel 
Management (referred to in this section as the ‘Director’) shall 
enter into contracts with health insurance issuers (which may
H. R. 3590—785 
include a group of health insurance issuers affiliated either 
by common ownership and control or by the common use of 
a nationally licensed service mark), without regard to section 
5 of title 41, United States Code, or other statutes requiring 
competitive bidding, to offer at least 2 multi-State qualified 
health plans through each Exchange in each State. Such plans 
shall provide individual, or in the case of small employers, 
group coverage. 
‘‘(2) TERMS.—Each contract entered into under paragraph 
(1) shall be for a uniform term of at least 1 year, but may 
be made automatically renewable from term to term in the 
absence of notice of termination by either party. In entering 
into such contracts, the Director shall ensure that health bene-
fits coverage is provided in accordance with the types of cov-
erage provided for under section 2701(a)(1)(A)(i) of the Public 
Health Service Act. 
‘‘(3) NON-PROFIT
ENTITIES.—In entering into contracts 
under paragraph (1), the Director shall ensure that at least 
one contract is entered into with a non-profit entity. 
‘‘(4) ADMINISTRATION.—The Director shall implement this 
subsection in a manner similar to the manner in which the 
Director implements the contracting provisions with respect 
to carriers under the Federal employees health benefit program 
under chapter 89 of title 5, United States Code, including 
(through negotiating with each multi-state plan)— 
‘‘(A) a medical loss ratio; 
‘‘(B) a profit margin; 
‘‘(C) the premiums to be charged; and 
‘‘(D) such other terms and conditions of coverage as 
are in the interests of enrollees in such plans. 
‘‘(5) AUTHORITY
TO
PROTECT
CONSUMERS.—The Director 
may prohibit the offering of any multi-State health plan that 
does not meet the terms and conditions defined by the Director 
with respect to the elements described in subparagraphs (A) 
through (D) of paragraph (4). 
‘‘(6) ASSURED
AVAILABILITY
OF
VARIED
COVERAGE.—In 
entering into contracts under this subsection, the Director shall 
ensure that with respect to multi-State qualified health plans 
offered in an Exchange, there is at least one such plan that 
does not provide coverage of services described in section 
1303(b)(1)(B)(i). 
‘‘(7) WITHDRAWAL.—Approval of a contract under this sub-
section may be withdrawn by the Director only after notice 
and opportunity for hearing to the issuer concerned without 
regard to subchapter II of chapter 5 and chapter 7 of title 
5, United States Code. 
‘‘(b) ELIGIBILITY.—A health insurance issuer shall be eligible 
to enter into a contract under subsection (a)(1) if such issuer— 
‘‘(1) agrees to offer a multi-State qualified health plan 
that meets the requirements of subsection (c) in each Exchange 
in each State; 
‘‘(2) is licensed in each State and is subject to all require-
ments of State law not inconsistent with this section, including 
the standards and requirements that a State imposes that 
do not prevent the application of a requirement of part A 
of title XXVII of the Public Health Service Act or a requirement 
of this title;