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(4) HEALTH DELIVERY REFORM.—This division 
institutes health delivery system reforms both to in-
crease quality and to reduce growth in health spend-
ing so that health care becomes more affordable for 
businesses, families, and Government. 
(b) TABLE OF CONTENTS OF DIVISION.—The table 
of contents of this division is as follows: 
Sec. 100. Purpose; table of contents of division; general definitions. 
TITLE I—IMMEDIATE REFORMS 
Sec. 101. National high-risk pool program. 
Sec. 102. Ensuring value and lower premiums. 
Sec. 103. Ending health insurance rescission abuse. 
Sec. 104. Sunshine on price gouging by health insurance issuers. 
Sec. 105. Requiring the option of extension of dependent coverage for unin-
sured young adults. 
Sec. 106. Limitations on preexisting condition exclusions in group health plans 
in advance of applicability of new prohibition of preexisting 
condition exclusions. 
Sec. 107. Prohibiting acts of domestic violence from being treated as pre-
existing conditions. 
Sec. 108. Ending health insurance denials and delays of necessary treatment 
for children with deformities. 
Sec. 109. Elimination of lifetime limits. 
Sec. 110. Prohibition against postretirement reductions of retiree health bene-
fits by group health plans. 
Sec. 111. Reinsurance program for retirees. 
Sec. 112. Wellness program grants. 
Sec. 113. Extension of COBRA continuation coverage. 
Sec. 114. State Health Access Program grants. 
Sec. 115. Administrative simplification. 
TITLE II—PROTECTIONS AND STANDARDS FOR QUALIFIED 
HEALTH BENEFITS PLANS 
Subtitle A—General Standards 
Sec. 201. Requirements reforming health insurance marketplace. 
Sec. 202. Protecting the choice to keep current coverage. 
Subtitle B—Standards Guaranteeing Access to Affordable Coverage 
Sec. 211. Prohibiting preexisting condition exclusions. 
Sec. 212. Guaranteed issue and renewal for insured plans and prohibiting re-
scissions. 
Sec. 213. Insurance rating rules. 
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Sec. 214. Nondiscrimination in benefits; parity in mental health and substance 
abuse disorder benefits. 
Sec. 215. Ensuring adequacy of provider networks. 
Sec. 216. Requiring the option of extension of dependent coverage for unin-
sured young adults. 
Sec. 217. Consistency of costs and coverage under qualified health benefits 
plans during plan year. 
Subtitle C—Standards Guaranteeing Access to Essential Benefits 
Sec. 221. Coverage of essential benefits package. 
Sec. 222. Essential benefits package defined. 
Sec. 223. Health Benefits Advisory Committee. 
Sec. 224. Process for adoption of recommendations; adoption of benefit stand-
ards. 
Subtitle D—Additional Consumer Protections 
Sec. 231. Requiring fair marketing practices by health insurers. 
Sec. 232. Requiring fair grievance and appeals mechanisms. 
Sec. 233. Requiring information transparency and plan disclosure. 
Sec. 234. Application to qualified health benefits plans not offered through the 
Health Insurance Exchange. 
Sec. 235. Timely payment of claims. 
Sec. 236. Standardized rules for coordination and subrogation of benefits. 
Sec. 237. Application of administrative simplification. 
Sec. 238. State prohibitions on discrimination against health care providers. 
Sec. 239. Protection of physician prescriber information. 
Sec. 240. Dissemination of advance care planning information. 
Subtitle E—Governance 
Sec. 241. Health Choices Administration; Health Choices Commissioner. 
Sec. 242. Duties and authority of Commissioner. 
Sec. 243. Consultation and coordination. 
Sec. 244. Health Insurance Ombudsman. 
Subtitle F—Relation to Other Requirements; Miscellaneous 
Sec. 251. Relation to other requirements. 
Sec. 252. Prohibiting discrimination in health care. 
Sec. 253. Whistleblower protection. 
Sec. 254. Construction regarding collective bargaining. 
Sec. 255. Severability. 
Sec. 256. Treatment of Hawaii Prepaid Health Care Act. 
Sec. 257. Actions by State attorneys general. 
Sec. 258. Application of State and Federal laws regarding abortion. 
Sec. 259. Nondiscrimination on abortion and respect for rights of conscience. 
Sec. 260. Authority of Federal Trade Commission. 
Sec. 261. Construction regarding standard of care. 
Sec. 262. Restoring application of antitrust laws to health sector insurers. 
Sec. 263. Study and report on methods to increase EHR use by small health 
care providers. 
Sec. 264. Performance assessment and accountability: application of GPRA. 
Sec. 265. Limitation on abortion funding. 
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TITLE III—HEALTH INSURANCE EXCHANGE AND RELATED 
PROVISIONS 
Subtitle A—Health Insurance Exchange 
Sec. 301. Establishment of Health Insurance Exchange; outline of duties; defi-
nitions. 
Sec. 302. Exchange-eligible individuals and employers. 
Sec. 303. Benefits package levels. 
Sec. 304. Contracts for the offering of Exchange-participating health benefits 
plans. 
Sec. 305. Outreach and enrollment of Exchange-eligible individuals and employ-
ers in Exchange-participating health benefits plan. 
Sec. 306. Other functions. 
Sec. 307. Health Insurance Exchange Trust Fund. 
Sec. 308. Optional operation of State-based health insurance exchanges. 
Sec. 309. Interstate health insurance compacts. 
Sec. 310. Health insurance cooperatives. 
Sec. 311. Retention of DOD and VA authority. 
Subtitle B—Public Health Insurance Option 
Sec. 321. Establishment and administration of a public health insurance option 
as an Exchange-qualified health benefits plan. 
Sec. 322. Premiums and financing. 
Sec. 323. Payment rates for items and services. 
Sec. 324. Modernized payment initiatives and delivery system reform. 
Sec. 325. Provider participation. 
Sec. 326. Application of fraud and abuse provisions. 
Sec. 327. Application of HIPAA insurance requirements. 
Sec. 328. Application of health information privacy, security, and electronic 
transaction requirements. 
Sec. 329. Enrollment in public health insurance option is voluntary. 
Sec. 330. Enrollment in public health insurance option by Members of Con-
gress. 
Sec. 331. Reimbursement of Secretary of Veterans Affairs. 
Subtitle C—Individual Affordability Credits 
Sec. 341. Availability through Health Insurance Exchange. 
Sec. 342. Affordable credit eligible individual. 
Sec. 343. Affordability premium credit. 
Sec. 344. Affordability cost-sharing credit. 
Sec. 345. Income determinations. 
Sec. 346. Special rules for application to territories. 
Sec. 347. No Federal payment for undocumented aliens. 
TITLE IV—SHARED RESPONSIBILITY 
Subtitle A—Individual Responsibility 
Sec. 401. Individual responsibility. 
Subtitle B—Employer Responsibility 
PART 1—HEALTH COVERAGE PARTICIPATION REQUIREMENTS 
Sec. 411. Health coverage participation requirements. 
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Sec. 412. Employer responsibility to contribute toward employee and dependent 
coverage. 
Sec. 413. Employer contributions in lieu of coverage. 
Sec. 414. Authority related to improper steering. 
Sec. 415. Impact study on employer responsibility requirements. 
Sec. 416. Study on employer hardship exemption. 
PART 2—SATISFACTION OF HEALTH COVERAGE PARTICIPATION 
REQUIREMENTS 
Sec. 421. Satisfaction of health coverage participation requirements under the 
Employee Retirement Income Security Act of 1974. 
Sec. 422. Satisfaction of health coverage participation requirements under the 
Internal Revenue Code of 1986. 
Sec. 423. Satisfaction of health coverage participation requirements under the 
Public Health Service Act. 
Sec. 424. Additional rules relating to health coverage participation require-
ments. 
TITLE V—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986 
Subtitle A—Provisions Relating to Health Care Reform 
PART 1—SHARED RESPONSIBILITY 
SUBPART A—INDIVIDUAL RESPONSIBILITY 
Sec. 501. Tax on individuals without acceptable health care coverage. 
SUBPART B—EMPLOYER RESPONSIBILITY 
Sec. 511. Election to satisfy health coverage participation requirements. 
Sec. 512. Health care contributions of nonelecting employers. 
PART 2—CREDIT FOR SMALL BUSINESS EMPLOYEE HEALTH COVERAGE 
EXPENSES 
Sec. 521. Credit for small business employee health coverage expenses. 
PART 3—LIMITATIONS ON HEALTH CARE RELATED EXPENDITURES 
Sec. 531. Distributions for medicine qualified only if for prescribed drug or in-
sulin. 
Sec. 532. Limitation on health flexible spending arrangements under cafeteria 
plans. 
Sec. 533. Increase in penalty for nonqualified distributions from health savings 
accounts. 
Sec. 534. Denial of deduction for federal subsidies for prescription drug plans 
which have been excluded from gross income. 
PART 4—OTHER PROVISIONS TO CARRY OUT HEALTH INSURANCE REFORM 
Sec. 541. Disclosures to carry out health insurance exchange subsidies. 
Sec. 542. Offering of exchange-participating health benefits plans through cafe-
teria plans. 
Sec. 543. Exclusion from gross income of payments made under reinsurance 
program for retirees. 
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Sec. 544. CLASS program treated in same manner as long-term care insur-
ance. 
Sec. 545. Exclusion from gross income for medical care provided for Indians. 
Subtitle B—Other Revenue Provisions 
PART 1—GENERAL PROVISIONS 
Sec. 551. Surcharge on high income individuals. 
Sec. 552. Excise tax on medical devices. 
Sec. 553. Expansion of information reporting requirements. 
Sec. 554. Repeal of worldwide allocation of interest. 
Sec. 555. Exclusion of unprocessed fuels from the cellulosic biofuel producer 
credit. 
PART 2—PREVENTION OF TAX AVOIDANCE 
Sec. 561. Limitation on treaty benefits for certain deductible payments. 
Sec. 562. Codification of economic substance doctrine; penalties. 
Sec. 563. Certain large or publicly traded persons made subject to a more likely 
than not standard for avoiding penalties on underpayments. 
PART 3—PARITY IN HEALTH BENEFITS 
Sec. 571. Certain health related benefits applicable to spouses and dependents 
extended to eligible beneficiaries. 
(c) GENERAL DEFINITIONS.—Except as otherwise 
provided, in this division: 
(1) ACCEPTABLE COVERAGE.—The term ‘‘ac-
ceptable coverage’’ has the meaning given such term 
in section 302(d)(2). 
(2) BASIC PLAN.—The term ‘‘basic plan’’ has 
the meaning given such term in section 303(c). 
(3) 
COMMISSIONER.—The 
term 
‘‘Commis-
sioner’’ means the Health Choices Commissioner es-
tablished under section 241. 
(4) COST-SHARING.—The term ‘‘cost-sharing’’ 
includes deductibles, coinsurance, copayments, and 
similar charges, but does not include premiums, bal-
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(7) ENHANCED
PLAN.—The term ‘‘enhanced 
plan’’ has the meaning given such term in section 
303(c). 
(8) ESSENTIAL BENEFITS PACKAGE.—The term 
‘‘essential benefits package’’ is defined in section 
222(a). 
(9) EXCHANGE-PARTICIPATING HEALTH BENE-
FITS
PLAN.—The term ‘‘Exchange-participating 
health benefits plan’’ means a qualified health bene-
fits plan that is offered through the Health Insur-
ance Exchange and may be purchased directly from 
the entity offering the plan or through enrollment 
agents and brokers. 
(10) FAMILY.—The term ‘‘family’’ means an 
individual and includes the individual’s dependents. 
(11) 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. 
(12) HEALTH
BENEFITS
PLAN.—The term 
‘‘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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(13) HEALTH
INSURANCE
COVERAGE.—The 
term ‘‘health insurance coverage’’ has the meaning 
given such term in section 2791 of the Public 
Health Service Act, but does not include coverage in 
relation to its provision of excepted benefits— 
(A) described in paragraph (1) of sub-
section (c) of such section; or 
(B) described in paragraph (2), (3), or (4) 
of such subsection if the benefits are provided 
under a separate policy, certificate, or contract 
of insurance. 
(14) HEALTH INSURANCE ISSUER.—The term 
‘‘health insurance issuer’’ has the meaning given 
such term in section 2791(b)(2) of the Public Health 
Service Act. 
(15) HEALTH
INSURANCE
EXCHANGE.—The 
term ‘‘Health Insurance Exchange’’ means the 
Health Insurance Exchange established under sec-
tion 301. 
(16) INDIAN.—The term ‘‘Indian’’ has the 
meaning given such term in section 4 of the Indian 
Health Care Improvement Act (24 U.S.C. 1603). 
(17) INDIAN
HEALTH
CARE
PROVIDER.—The 
term ‘‘Indian health care provider’’ means a health 
care program operated by the Indian Health Service, 
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an Indian tribe, tribal organization, or urban Indian 
organization as such terms are defined in section 4 
of the Indian Health Care Improvement Act (25 
U.S.C. 1603). 
(18) 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). 
(19) MEDICAID
ELIGIBLE
INDIVIDUAL.—The 
term ‘‘Medicaid eligible individual’’ means an indi-
vidual who is eligible for medical assistance under 
Medicaid. 
(20) MEDICARE.—The term ‘‘Medicare’’ means 
the health insurance programs under title XVIII of 
the Social Security Act. 
(21) 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. 
(22) 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. 
(23) PREMIUM PLAN; PREMIUM-PLUS PLAN.— 
The terms ‘‘premium plan’’ and ‘‘premium-plus 
plan’’ have the meanings given such terms in section 
303(c). 
(24) 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. 
(25) QUALIFIED
HEALTH
BENEFITS
PLAN.— 
The term ‘‘qualified health benefits plan’’ means a 
health benefits plan that— 
(A) meets the requirements for such a plan 
under title II and includes the public health in-
surance option; and 
(B) is offered by a QHBP offering entity 
that meets the applicable requirements of such 
title with respect to such plan. 
(26) PUBLIC
HEALTH
INSURANCE
OPTION.— 
The term ‘‘public health insurance option’’ means 
the public health insurance option as provided under 
subtitle B of title III. 
(27) SERVICE AREA; PREMIUM RATING AREA.— 
The terms ‘‘service area’’ and ‘‘premium rating 
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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-
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. 
(28) STATE.—The term ‘‘State’’ means the 50 
States and the District of Columbia and includes— 
(A) for purposes of title I, Puerto Rico, the 
Virgin Islands, Guam, American Samoa, and 
the Northern Mariana Islands; and 
(B) for purposes of titles II and III, as 
elected under and subject to section 346, Puer-
to Rico, the Virgin Islands, Guam, American 
Samoa, and the Northern Mariana Islands. 
(29) STATE
MEDICAID
AGENCY.—The term 
‘‘State Medicaid agency’’ means, with respect to a 
Medicaid plan, the single State agency responsible 
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