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‘‘(II) the total amount of pre-
mium 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 sec-
tions 1341, 1342, and 1343 of the Pa-
tient Protection and Affordable Care 
Act) for such plan year. 
‘‘(ii) CALCULATION
BASED
ON
AVER-
AGE
RATIO.—Beginning on January 1, 
2014, the determination made under sub-
paragraph (A) for the year involved shall be 
based on the averages of the premiums ex-
pended on the costs described in such sub-
paragraph and total premium revenue for 
each of the previous 3 years for the plan. 
‘‘(2) CONSIDERATION
IN
SETTING
PERCENT-
AGES.—In determining the percentages under para-
graph (1), a State shall seek to ensure adequate par-
ticipation 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.
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‘‘(3) ENFORCEMENT.—The Secretary shall pro-
mulgate regulations for enforcing the provisions of 
this section and may provide for appropriate pen-
alties. 
‘‘(c) DEFINITIONS.—Not later than December 31, 2010, 
and subject to the certification of the Secretary, the Na-
tional Association of Insurance Commissioners shall estab-
lish uniform definitions of the activities reported under sub-
section (a) and standardized methodologies for calculating 
measures of such activities, including definitions of which 
activities, and in what regard such activities, constitute ac-
tivities described in subsection (a)(2). Such methodologies 
shall be designed to take into account the special cir-
cumstances 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 es-
tablish (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 hos-
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pital, 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 insurance issuer offering group or individual 
health insurance coverage 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 ap-
peal process; 
‘‘(B) provide notice to enrollees, in a cul-
turally and linguistically appropriate manner, 
of available internal and external appeals proc-
esses, and the availability of any applicable of-
fice of health insurance consumer assistance or 
ombudsman established under section 2793 to as-
sist such enrollees with the appeals processes; 
and 
‘‘(C) allow an enrollee to review their file, 
to present evidence and testimony as part of the
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appeals process, and to receive continued cov-
erage pending the outcome of the appeals process. 
‘‘(2) ESTABLISHED
PROCESSES.—To comply 
with paragraph (1)— 
‘‘(A) a group health plan and a health in-
surance issuer offering group health coverage 
shall provide an internal claims and appeals 
process that initially incorporates the 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 indi-
vidual health coverage, and any other issuer not 
subject to subparagraph (A), shall provide an in-
ternal 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.
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‘‘(b) EXTERNAL REVIEW.—A group health plan and 
a health insurance issuer offering group or individual 
health insurance coverage— 
‘‘(1) shall comply with the applicable State ex-
ternal review process for such plans and issuers that, 
at a minimum, includes the consumer protections set 
forth in the Uniform External Review Model Act pro-
mulgated 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 estab-
lished 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 (in-
cluding a State law that establishes an external 
review process described in paragraph (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 enact-
ment of this section, to be in compliance with the applicable
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process established under subsection (b), as determined ap-
propriate 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 insurance issuer offering group or individual 
health insurance issuer, provides or covers any bene-
fits with respect to services in an emergency depart-
ment of a hospital, the plan or issuer shall cover 
emergency 
services 
(as 
defined 
in 
paragraph 
(2)(B))— 
‘‘(A) without the need for any prior author-
ization determination;
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‘‘(B) whether the health care provider fur-
nishing 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 en-
rollee— 
‘‘(i) by a nonparticipating health care 
provider with or without prior authoriza-
tion; 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 pro-
viding of services that is more restrictive 
than the requirements or limitations that 
apply to emergency department services re-
ceived 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 coin-
surance rate) is the same requirement that
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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 Retirement 
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 pos-
sesses an average knowledge of health and medi-
cine, could reasonably expect the absence of im-
mediate medical attention to result in a condi-
tion described in clause (i), (ii), or (iii) of sec-
tion 1867(e)(1)(A) of the Social Security Act. 
‘‘(B) EMERGENCY
SERVICES.—The term 
‘emergency services’ means, with respect to an 
emergency medical condition—
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‘‘(i) a medical screening examination 
(as required under section 1867 of the So-
cial Security Act) that is within the capa-
bility of the emergency department of a hos-
pital, including ancillary services routinely 
available to the emergency department to 
evaluate such emergency medical condition, 
and 
‘‘(ii) within the capabilities of the staff 
and facilities available at the hospital, such 
further medical examination and treatment 
as are required under section 1867 of such 
Act to stabilize the patient. 
‘‘(C) STABILIZE.—The term ‘to stabilize’, 
with respect to an emergency medical condition 
(as defined in subparagraph (A)), has the mean-
ing give in section 1867(e)(3) of the Social Secu-
rity 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 insur-
ance 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 partici-
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pating primary care provider for the child, the plan 
or issuer shall permit such person to designate a phy-
sician (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 pedi-
atric care. 
‘‘(d) PATIENT ACCESS TO OBSTETRICAL AND GYNECO-
LOGICAL CARE.— 
‘‘(1) GENERAL RIGHTS.— 
‘‘(A) DIRECT
ACCESS.—A group health 
plan, or health insurance issuer offering group 
or individual health insurance coverage, de-
scribed in paragraph (2) may not require au-
thorization or referral by the plan, issuer, or any 
person (including a primary care provider de-
scribed in paragraph (2)(B)) in the case of a fe-
male participant, beneficiary, or enrollee who 
seeks coverage for obstetrical or gynecological 
care provided by a participating health care pro-
fessional who specializes in obstetrics or gyne-
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cology. Such professional shall agree to otherwise 
adhere to such plan’s or issuer’s policies and 
procedures, including procedures regarding refer-
rals and obtaining prior authorization and pro-
viding 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 paragraph (2) shall treat the 
provision of obstetrical and gynecological care, 
and the ordering of related obstetrical and gyne-
cological items and services, pursuant to the di-
rect access described under subparagraph (A), by 
a participating health care professional who spe-
cializes in obstetrics or gynecology as the author-
ization of the primary care provider. 
‘‘(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
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‘‘(B) requires the designation by a partici-
pant, beneficiary, 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 with respect to coverage of ob-
stetrical or gynecological care; or 
‘‘(B) preclude the group health plan or 
health insurance issuer involved from requiring 
that the obstetrical or gynecological provider no-
tify 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 in-
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formation from health insurance issuers, to ana-
lyze and organize such information, and to make 
such information available to such issuers, health 
care providers, health researchers, health care 
policy makers, 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 data-
base tools that fairly and accurately reflect mar-
ket rates for medical services and the geographic 
differences in those rates; 
‘‘(B) use the best available statistical meth-
ods 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 available to the public through an Inter-
net website that allows consumers to understand 
the amounts that health care providers in their 
area charge for particular medical services; and
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‘‘(E) regularly publish information con-
cerning 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 estab-
lished 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 en-
sure that the center is not controlled or influenced by, 
and does not have any corporate relation to, any in-
dividual 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 estab-
lished under subsection (c)(1)(C) to compel health in-
surance issuers to provide data to the center.’’. 
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 strik-
ing ‘‘group health benefits plan’’ and inserting 
‘‘group benefits plan providing health benefits’’; and
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(2) in clause (i)(I), by inserting ‘‘or any agency 
or instrumentality 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 resi-
dents of, and small businesses in, any State to receive 
information on at least the following coverage options: 
‘‘(A) Health insurance coverage offered by 
health insurance issuers, other than coverage that 
provides reimbursement 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.
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‘‘(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 mar-
ket for small businesses and their employees, in-
cluding reinsurance for early retirees under sec-
tion 1102, tax credits available under section 
45R of the Internal Revenue Code of 1986 (as 
added by section 1421), and other information 
specifically for small businesses regarding afford-
able 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:
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‘‘SEC. 2709. COVERAGE FOR INDIVIDUALS PARTICIPATING 
IN APPROVED CLINICAL TRIALS. 
‘‘(a) COVERAGE.— 
‘‘(1) IN GENERAL.—If a group health plan or a 
health insurance issuer offering group or individual 
health insurance coverage provides coverage to a 
qualified individual, then such plan or issuer— 
‘‘(A) may not deny the individual partici-
pation in the clinical trial referred to in sub-
section (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 participa-
tion in the trial; and 
‘‘(C) may not discriminate against the in-
dividual on the basis of the individual’s partici-
pation in such trial. 
‘‘(2) ROUTINE PATIENT COSTS.— 
‘‘(A) INCLUSION.—For purposes of para-
graph (1)(B), subject to subparagraph (B), rou-
tine 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.
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‘‘(B) EXCLUSION.—For purposes of para-
graph (1)(B), routine patient costs does not in-
clude— 
‘‘(i) the investigational item, device, or 
service, itself; 
‘‘(ii) items and services that are pro-
vided 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 incon-
sistent with widely accepted and established 
standards of care for a particular diagnosis. 
‘‘(3) USE OF IN-NETWORK PROVIDERS.—If one or 
more participating providers is participating in a 
clinical trial, nothing in paragraph (1) shall be con-
strued 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.—Notwith-
standing paragraph (3), paragraph (1) shall apply to 
a qualified individual participating in an approved
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clinical trial that is conducted outside the State in 
which the qualified individual resides. 
‘‘(b) QUALIFIED INDIVIDUAL DEFINED.—For purposes 
of subsection (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 conditions: 
‘‘(1) The individual is eligible to participate in 
an approved clinical trial according to the trial pro-
tocol with respect to treatment of cancer or other life- 
threatening disease or condition. 
‘‘(2) Either— 
‘‘(A) the referring health care professional is 
a participating 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 paragraph 
(1).
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‘‘(c) LIMITATIONS ON COVERAGE.—This section shall 
not be construed to require a group health plan, or a health 
insurance issuer offering group or individual health insur-
ance 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 coverage). 
‘‘(d) APPROVED CLINICAL TRIAL DEFINED.— 
‘‘(1) IN GENERAL.—In this section, the term ‘ap-
proved clinical trial’ means a phase I, phase II, phase 
III, or phase IV clinical trial that is conducted in re-
lation to the prevention, detection, or treatment of 
cancer or other life-threatening disease or condition 
and is described in any of the following subpara-
graphs: 
‘‘(A) FEDERALLY
FUNDED
TRIALS.—The 
study or investigation is approved or funded 
(which may include funding through in-kind 
contributions) by one or more of the following: 
‘‘(i) The National Institutes of Health. 
‘‘(ii) The Centers for Disease Control 
and Prevention. 
‘‘(iii) The Agency for Health Care Re-
search and Quality.
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‘‘(iv) The Centers for Medicare & Med-
icaid Services. 
‘‘(v) cooperative group or center of any 
of the entities described in clauses (i) 
through (iv) or the Department of Defense 
or the Department of Veterans Affairs. 
‘‘(vi) A qualified non-governmental re-
search entity identified in the guidelines 
issued by the National Institutes of Health 
for center support grants. 
‘‘(vii) Any of the following if the condi-
tions 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 con-
ducted under an investigational new drug appli-
cation reviewed by the Food and Drug Adminis-
tration. 
‘‘(C) The study or investigation is a drug 
trial that is exempt from having such an inves-
tigational new drug application. 
‘‘(2) CONDITIONS FOR DEPARTMENTS.—The con-
ditions described in this paragraph, for a study or in-
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vestigation conducted by a Department, are that the 
study or investigation has been reviewed and ap-
proved through a system of peer review that the Sec-
retary 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 in-
terrupted. 
‘‘(f) CONSTRUCTION.—Nothing in this section shall be 
construed to limit a plan’s or issuer’s coverage with respect 
to clinical trials. 
‘‘(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 pro-
gram under such chapter. 
‘‘(h) PREEMPTION.—Notwithstanding any other provi-
sion of this Act, nothing in this section shall preempt State 
laws that require a clinical trials policy for State regulated
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health insurance plans that is in addition to the policy re-
quired 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 Pub-
lic 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 enact-
ment of this Act.’’. 
(f) Subtitle C of title I of this Act is amended—
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(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 col-
lected 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 (in-
cluding 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, 
investments, 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 appropriate by the Secretary), health plan 
benefits, financial solvency, capital reserve levels, and 
the risks of becoming insolvent; and
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‘‘(2) determine the extent to which new insur-
ance market reforms are likely to cause adverse selec-
tion 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 coordina-
tion with the Secretary of Labor, shall collect information 
and analyze— 
‘‘(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 administra-
tion and lower overhead 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 re-
lates 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 ad-
ministration 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
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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 QUALIFIED 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
PRI-
MARY CARE MEDICAL HOME PLANS.—The Secretary of 
Health and Human Services 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 
otherwise applicable and the services covered by the 
medical home plan are coordinated with the entity of-
fering the qualified health plan. 
‘‘(4) VARIATION
BASED
ON
RATING
AREA.—A 
qualified health plan, including a multi-State quali-
fied health plan, may as appropriate vary premiums
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HR 3590 EAS/PP 
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 cen-
ter (as defined in section 1905(l)(2)(B) of the Social Secu-
rity 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 fol-
lows: 
‘‘SEC. 1303. SPECIAL RULES. 
‘‘(a) STATE OPT-OUT OF ABORTION COVERAGE.— 
‘‘(1) IN GENERAL.—A State may elect to pro-
hibit abortion coverage in qualified health plans of-
fered through an Exchange in such State if such State 
enacts a law to provide for such prohibition.
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‘‘(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 SERVICES.— 
‘‘(1) VOLUNTARY
CHOICE
OF
COVERAGE
OF 
ABORTION SERVICES.— 
‘‘(A) IN
GENERAL.—Notwithstanding any 
other provision 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 qualified health plan shall deter-
mine whether or not the plan provides cov-
erage of services described in subparagraph 
(B)(i) or (B)(ii) as part of such benefits for 
the plan year. 
‘‘(B) ABORTION SERVICES.—
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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 coverage were included for the 
entire population covered; and 
‘‘(III) may not estimate such a 
cost at less than $1 per enrollee, per 
month. 
‘‘(E) ENSURING
COMPLIANCE
WITH
SEG-
REGATION REQUIREMENTS.— 
‘‘(i) IN
GENERAL.—Subject to clause 
(ii), State health insurance commissioners 
shall ensure that health plans comply with 
the segregation requirements in this sub-
section through the segregation of plan 
funds in accordance with applicable provi-
sions of generally accepted accounting re-
quirements, circulars on funds management 
of the Office of Management and Budget, 
and guidance on accounting of the Govern-
ment Accountability Office. 
‘‘(ii) 
CLARIFICATION.—Nothing 
in 
clause (i) shall prohibit the right of an indi-
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vidual 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 en-
rollees, only as part of the summary of benefits 
and coverage explanation, at the time of enroll-
ment, of such coverage. 
‘‘(B) RULES RELATING TO PAYMENTS.—The 
notice described in subparagraph (A), any adver-
tising used by the issuer with respect to the plan, 
any information provided 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 PROVI-
SION OF ABORTION.—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, pro-
vide coverage of, or refer for abortions