datamatters24/research-document-archive huggingface dataset:
HR 3590 EAS/PP 
provides reimbursement only for the treatment or 
mitigation of— 
(i) a single disease or condition; or 
(ii) an unreasonably limited set of dis-
eases 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. 
(b) ENHANCING
COMPARATIVE
PURCHASING
OP-
TIONS.— 
(1) IN GENERAL.—Not later than 60 days after 
the date of enactment of this Act, the Secretary shall 
develop a standardized format to be used for the pres-
entation of information relating to the coverage op-
tions described in subsection (a)(2). Such format 
shall, at a minimum, require the inclusion of infor-
mation on the percentage of total premium revenue 
expended on nonclinical costs (as reported under sec-
HR 3590 EAS/PP 
tion 2718(a) of the Public Health Service Act), eligi-
bility, availability, premium rates, and cost sharing 
with respect to such coverage options and be con-
sistent with the standards adopted for the uniform ex-
planation of coverage as provided for in section 2715 
of the Public Health Service Act. 
(2) USE OF FORMAT.—The Secretary shall uti-
lize the format developed under paragraph (1) in 
compiling information concerning coverage options on 
the Internet website established under subsection (a). 
(c) AUTHORITY TO CONTRACT.—The Secretary may 
carry out this section through contracts entered into with 
qualified entities. 
SEC. 1104. ADMINISTRATIVE SIMPLIFICATION. 
(a) PURPOSE OF ADMINISTRATIVE SIMPLIFICATION.— 
Section 261 of the Health Insurance Portability and Ac-
countability Act of 1996 (42 U.S.C. 1320d note) is amend-
ed— 
(1) by inserting ‘‘uniform’’ before ‘‘standards’’; 
and 
(2) by inserting ‘‘and to reduce the clerical bur-
den on patients, health care providers, and health 
plans’’ before the period at the end. 
(b) OPERATING RULES FOR HEALTH INFORMATION 
TRANSACTIONS.—
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(1) DEFINITION OF OPERATING RULES.—Section 
1171 of the Social Security Act (42 U.S.C. 1320d) is 
amended by adding at the end the following: 
‘‘(9) OPERATING RULES.—The term ‘operating 
rules’ means the necessary business rules and guide-
lines for the electronic exchange of information that 
are not defined by a standard or its implementation 
specifications as adopted for purposes of this part.’’. 
(2) 
TRANSACTION
STANDARDS; 
OPERATING 
RULES AND COMPLIANCE.—Section 1173 of the Social 
Security Act (42 U.S.C. 1320d–2) is amended— 
(A) in subsection (a)(2), by adding at the 
end the following new subparagraph: 
‘‘(J) Electronic funds transfers.’’; 
(B) in subsection (a), by adding at the end 
the following new paragraph: 
‘‘(4) REQUIREMENTS FOR FINANCIAL AND ADMIN-
ISTRATIVE TRANSACTIONS.— 
‘‘(A) IN GENERAL.—The standards and as-
sociated operating rules adopted by the Secretary 
shall— 
‘‘(i) to the extent feasible and appro-
priate, enable determination of an individ-
ual’s eligibility and financial responsibility
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for specific services prior to or at the point 
of care; 
‘‘(ii) be comprehensive, requiring mini-
mal augmentation by paper or other com-
munications; 
‘‘(iii) provide for timely acknowledg-
ment, response, and status reporting that 
supports a transparent claims and denial 
management process (including adjudica-
tion and appeals); and 
‘‘(iv) describe all data elements (in-
cluding reason and remark codes) in unam-
biguous terms, require that such data ele-
ments be required or conditioned upon set 
values in other fields, and prohibit addi-
tional conditions (except where necessary to 
implement State or Federal law, or to pro-
tect against fraud and abuse). 
‘‘(B) REDUCTION OF CLERICAL BURDEN.— 
In adopting standards and operating rules for 
the transactions referred to under paragraph (1), 
the Secretary shall seek to reduce the number 
and complexity of forms (including paper and 
electronic forms) and data entry required by pa-
tients and providers.’’; and
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(C) by adding at the end the following new 
subsections: 
‘‘(g) OPERATING RULES.— 
‘‘(1) IN GENERAL.—The Secretary shall adopt a 
single set of operating rules for each transaction re-
ferred to under subsection (a)(1) with the goal of cre-
ating as much uniformity in the implementation of 
the electronic standards as possible. Such operating 
rules shall be consensus-based and reflect the necessary 
business rules affecting health plans and health care 
providers and the manner in which they operate pur-
suant to standards issued under Health Insurance 
Portability and Accountability Act of 1996. 
‘‘(2) OPERATING
RULES
DEVELOPMENT.—In 
adopting operating rules under this subsection, the 
Secretary shall consider recommendations for oper-
ating rules developed by a qualified nonprofit entity 
that meets the following requirements: 
‘‘(A) The entity focuses its mission on ad-
ministrative simplification. 
‘‘(B) The entity demonstrates a multi-stake-
holder and consensus-based process for develop-
ment of operating rules, including representation 
by or participation from health plans, health 
care providers, vendors, relevant Federal agen-
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cies, and other standard development organiza-
tions. 
‘‘(C) The entity has a public set of guiding 
principles that ensure the operating rules and 
process are open and transparent, and supports 
nondiscrimination and conflict of interest poli-
cies that demonstrate a commitment to open, 
fair, and nondiscriminatory practices. 
‘‘(D) The entity builds on the transaction 
standards issued under Health Insurance Port-
ability and Accountability Act of 1996. 
‘‘(E) The entity allows for public review 
and updates of the operating rules. 
‘‘(3) REVIEW AND RECOMMENDATIONS.—The Na-
tional Committee on Vital and Health Statistics 
shall— 
‘‘(A) advise the Secretary as to whether a 
nonprofit entity meets the requirements under 
paragraph (2); 
‘‘(B) review the operating rules developed 
and recommended by such nonprofit entity; 
‘‘(C) determine whether such operating rules 
represent a consensus view of the health care 
stakeholders and are consistent with and do not 
conflict with other existing standards;
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‘‘(D) evaluate whether such operating rules 
are consistent with electronic standards adopted 
for health information technology; and 
‘‘(E) submit to the Secretary a rec-
ommendation as to whether the Secretary should 
adopt such operating rules. 
‘‘(4) IMPLEMENTATION.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
adopt operating rules under this subsection, by 
regulation in accordance with subparagraph (C), 
following consideration of the operating rules de-
veloped by the non-profit entity described in 
paragraph (2) and the recommendation sub-
mitted by the National Committee on Vital and 
Health Statistics under paragraph (3)(E) and 
having ensured consultation with providers. 
‘‘(B) ADOPTION REQUIREMENTS; EFFECTIVE 
DATES.— 
‘‘(i) ELIGIBILITY FOR A HEALTH PLAN 
AND
HEALTH
CLAIM
STATUS.—The set of 
operating rules for eligibility for a health 
plan and health claim status transactions 
shall be adopted not later than July 1, 
2011, in a manner ensuring that such oper-
ating rules are effective not later than Jan-
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uary 1, 2013, and may allow for the use of 
a machine readable identification card. 
‘‘(ii) ELECTRONIC FUNDS TRANSFERS 
AND HEALTH CARE PAYMENT AND REMIT-
TANCE ADVICE.—The set of operating rules 
for electronic funds transfers and health 
care payment and remittance advice trans-
actions shall— 
‘‘(I) allow for automated rec-
onciliation of the electronic payment 
with the remittance advice; and 
‘‘(II) be adopted not later than 
July 1, 2012, in a manner ensuring 
that such operating rules are effective 
not later than January 1, 2014. 
‘‘(iii) HEALTH CLAIMS OR EQUIVALENT 
ENCOUNTER
INFORMATION, 
ENROLLMENT 
AND DISENROLLMENT IN A HEALTH PLAN, 
HEALTH PLAN PREMIUM PAYMENTS, REFER-
RAL CERTIFICATION AND AUTHORIZATION.— 
The set of operating rules for health claims 
or equivalent encounter information, enroll-
ment and disenrollment in a health plan, 
health plan premium payments, and refer-
ral certification and authorization trans-
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actions shall be adopted not later than July 
1, 2014, in a manner ensuring that such 
operating rules are effective not later than 
January 1, 2016. 
‘‘(C) EXPEDITED RULEMAKING.—The Sec-
retary shall promulgate an interim final rule 
applying any standard or operating rule rec-
ommended by the National Committee on Vital 
and Health Statistics pursuant to paragraph 
(3). The Secretary shall accept and consider pub-
lic comments on any interim final rule published 
under this subparagraph for 60 days after the 
date of such publication. 
‘‘(h) COMPLIANCE.— 
‘‘(1) HEALTH PLAN CERTIFICATION.— 
‘‘(A) ELIGIBILITY
FOR
A
HEALTH
PLAN, 
HEALTH
CLAIM
STATUS, ELECTRONIC
FUNDS 
TRANSFERS, HEALTH CARE PAYMENT AND RE-
MITTANCE ADVICE.—Not later than December 31, 
2013, a health plan shall file a statement with 
the Secretary, in such form as the Secretary may 
require, certifying that the data and information 
systems for such plan are in compliance with 
any applicable standards (as described under 
paragraph (7) of section 1171) and associated
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operating rules (as described under paragraph 
(9) of such section) for electronic funds transfers, 
eligibility for a health plan, health claim status, 
and health care payment and remittance advice, 
respectively. 
‘‘(B) HEALTH CLAIMS OR EQUIVALENT EN-
COUNTER
INFORMATION, 
ENROLLMENT
AND 
DISENROLLMENT IN A HEALTH PLAN, HEALTH 
PLAN PREMIUM PAYMENTS, HEALTH CLAIMS AT-
TACHMENTS, REFERRAL CERTIFICATION AND AU-
THORIZATION.—Not later than December 31, 
2015, a health plan shall file a statement with 
the Secretary, in such form as the Secretary may 
require, certifying that the data and information 
systems for such plan are in compliance with 
any applicable standards and associated oper-
ating rules for health claims or equivalent en-
counter 
information, 
enrollment 
and 
disenrollment in a health plan, health plan pre-
mium payments, health claims attachments, and 
referral certification and authorization, respec-
tively. A health plan shall provide the same level 
of documentation to certify compliance with such 
transactions as is required to certify compliance
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with the transactions specified in subparagraph 
(A). 
‘‘(2) 
DOCUMENTATION
OF
COMPLIANCE.—A 
health plan shall provide the Secretary, in such form 
as the Secretary may require, with adequate docu-
mentation of compliance with the standards and op-
erating rules described under paragraph (1). A health 
plan shall not be considered to have provided ade-
quate documentation and shall not be certified as 
being in compliance with such standards, unless the 
health plan— 
‘‘(A) demonstrates to the Secretary that the 
plan conducts the electronic transactions speci-
fied in paragraph (1) in a manner that fully 
complies with the regulations of the Secretary; 
and 
‘‘(B) provides documentation showing that 
the plan has completed end-to-end testing for 
such transactions with their partners, such as 
hospitals and physicians. 
‘‘(3) SERVICE CONTRACTS.—A health plan shall 
be required to ensure that any entities that provide 
services pursuant to a contract with such health plan 
shall comply with any applicable certification and 
compliance requirements (and provide the Secretary
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‘‘(E) PENALTY
LIMIT.—A penalty fee as-
sessed against a health plan under this sub-
section shall not exceed, on an annual basis— 
‘‘(i) an amount equal to $20 per cov-
ered life under such plan; or 
‘‘(ii) an amount equal to $40 per cov-
ered life under the plan if such plan has 
knowingly provided inaccurate or incom-
plete information (as described under sub-
paragraph (C)). 
‘‘(F) DETERMINATION OF COVERED INDIVID-
UALS.—The Secretary shall determine the num-
ber of covered lives under a health plan based 
upon the most recent statements and filings that 
have been submitted by such plan to the Securi-
ties and Exchange Commission. 
‘‘(2) NOTICE
AND
DISPUTE
PROCEDURE.—The 
Secretary shall establish a procedure for assessment of 
penalty fees under this subsection that provides a 
health plan with reasonable notice and a dispute reso-
lution procedure prior to provision of a notice of as-
sessment by the Secretary of the Treasury (as de-
scribed under paragraph (4)(B)). 
‘‘(3) PENALTY
FEE
REPORT.—Not later than 
May 1, 2014, and annually thereafter, the Secretary
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‘‘(9) Any other health status-related factor deter-
mined appropriate by the Secretary. 
‘‘(j) PROGRAMS OF HEALTH PROMOTION OR DISEASE 
PREVENTION.— 
‘‘(1) GENERAL PROVISIONS.— 
‘‘(A) GENERAL RULE.—For purposes of sub-
section (b)(2)(B), a program of health promotion 
or disease prevention (referred to in this sub-
section as a ‘wellness program’) shall be a pro-
gram offered by an employer that is designed to 
promote health or prevent disease that meets the 
applicable requirements of this subsection. 
‘‘(B) NO
CONDITIONS
BASED
ON
HEALTH 
STATUS FACTOR.—If none of the conditions for 
obtaining a premium discount or rebate or other 
reward for participation in a wellness program 
is based on an individual satisfying a standard 
that is related to a health status factor, such 
wellness program shall not violate this section if 
participation in the program is made available 
to all similarly situated individuals and the re-
quirements of paragraph (2) are complied with. 
‘‘(C) CONDITIONS BASED ON HEALTH STA-
TUS FACTOR.—If any of the conditions for ob-
taining a premium discount or rebate or other
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ginning on July 1, 2017 expand such demonstration 
project to include additional participating States. 
‘‘(3) REQUIREMENTS.— 
‘‘(A) MAINTENANCE
OF
COVERAGE.—The 
Secretary, in consultation with the Secretary of 
the Treasury and the Secretary of Labor, shall 
not approve the participation of a State in the 
demonstration project under this section unless 
the Secretaries determine that the State’s project 
is designed in a manner that— 
‘‘(i) will not result in any decrease in 
coverage; and 
‘‘(ii) will not increase the cost to the 
Federal Government in providing credits 
under section 36B of the Internal Revenue 
Code of 1986 or cost-sharing assistance 
under section 1402 of the Patient Protection 
and Affordable Care Act. 
‘‘(B) OTHER REQUIREMENTS.—States that 
participate in the demonstration project under 
this subsection— 
‘‘(i) may permit premium discounts or 
rebates or the modification of otherwise ap-
plicable copayments or deductibles for ad-
herence to, or participation in, a reasonably
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designed program of health promotion and 
disease prevention; 
‘‘(ii) shall ensure that requirements of 
consumer protection are met in programs of 
health promotion in the individual market; 
‘‘(iii) shall require verification from 
health insurance issuers that offer health in-
surance coverage in the individual market 
of such State that premium discounts— 
‘‘(I) do not create undue burdens 
for individuals insured in the indi-
vidual market; 
‘‘(II) do not lead to cost shifting; 
and 
‘‘(III) are not a subterfuge for dis-
crimination; 
‘‘(iv) shall ensure that consumer data 
is protected in accordance with the require-
ments of section 264(c) of the Health Insur-
ance Portability and Accountability Act of 
1996 (42 U.S.C. 1320d–2 note); and 
‘‘(v) shall ensure and demonstrate to 
the satisfaction of the Secretary that the 
discounts or other rewards provided under 
the project reflect the expected level of par-
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ticipation in the wellness program involved 
and the anticipated effect the program will 
have on utilization or medical claim costs. 
‘‘(m) REPORT.— 
‘‘(1) IN GENERAL.—Not later than 3 years after 
the date of enactment of the Patient Protection and 
Affordable Care Act, the Secretary, in consultation 
with the Secretary of the Treasury and the Secretary 
of Labor, shall submit a report to the appropriate 
committees of Congress concerning— 
‘‘(A) the effectiveness of wellness programs 
(as defined in subsection (j)) in promoting health 
and preventing disease; 
‘‘(B) the impact of such wellness programs 
on the access to care and affordability of cov-
erage for participants and non-participants of 
such programs; 
‘‘(C) the impact of premium-based and cost- 
sharing incentives on participant behavior and 
the role of such programs in changing behavior; 
and 
‘‘(D) the effectiveness of different types of re-
wards. 
‘‘(2) DATA COLLECTION.—In preparing the re-
port described in paragraph (1), the Secretaries shall
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gather relevant information from employers who pro-
vide employees with access to wellness programs, in-
cluding State and Federal agencies. 
‘‘(n) REGULATIONS.—Nothing in this section shall be 
construed as prohibiting the Secretaries of Labor, Health 
and Human Services, or the Treasury from promulgating 
regulations in connection with this section. 
‘‘SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE. 
‘‘(a) PROVIDERS.—A group health plan and a health 
insurance issuer offering group or individual health insur-
ance coverage shall not discriminate with respect to partici-
pation under the plan or coverage against any health care 
provider who is acting within the scope of that provider’s 
license or certification under applicable State law. This sec-
tion shall not require that a group health plan or health 
insurance issuer contract with any health care provider 
willing to abide by the terms and conditions for participa-
tion established by the plan or issuer. Nothing in this sec-
tion shall be construed as preventing a group health plan, 
a health insurance issuer, or the Secretary from establishing 
varying reimbursement rates based on quality or perform-
ance measures. 
‘‘(b) INDIVIDUALS.—The provisions of section 1558 of 
the Patient Protection and Affordable Care Act (relating 
to non-discrimination) shall apply with respect to a group
HR 3590 EAS/PP 
health plan or health insurance issuer offering group or in-
dividual health insurance coverage. 
‘‘SEC. 2707. COMPREHENSIVE HEALTH INSURANCE COV-
ERAGE. 
‘‘(a) COVERAGE FOR ESSENTIAL HEALTH BENEFITS 
PACKAGE.—A health insurance issuer that offers health in-
surance coverage in the individual or small group market 
shall ensure that such coverage includes the essential health 
benefits package required under section 1302(a) of the Pa-
tient Protection and Affordable Care Act. 
‘‘(b) 
COST-SHARING
UNDER
GROUP
HEALTH 
PLANS.—A group health plan shall ensure that any annual 
cost-sharing imposed under the plan does not exceed the 
limitations provided for under paragraphs (1) and (2) of 
section 1302(c). 
‘‘(c) CHILD-ONLY PLANS.—If a health insurance issuer 
offers health insurance coverage in any level of coverage 
specified under section 1302(d) of the Patient Protection 
and Affordable Care Act, the issuer shall also offer such cov-
erage in that level as a plan in which the only enrollees 
are individuals who, as of the beginning of a plan year, 
have not attained the age of 21. 
‘‘(d) DENTAL ONLY.—This section shall not apply to 
a plan described in section 1302(d)(2)(B)(ii)(I).
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‘‘SEC. 2708. PROHIBITION ON EXCESSIVE WAITING PERIODS. 
‘‘A group health plan and a health insurance issuer 
offering group or individual health insurance coverage shall 
not apply any waiting period (as defined in section 
2704(b)(4)) that exceeds 90 days.’’. 
PART II—OTHER PROVISIONS 
SEC. 1251. PRESERVATION OF RIGHT TO MAINTAIN EXIST-
ING COVERAGE. 
(a) NO CHANGES TO EXISTING COVERAGE.— 
(1) IN GENERAL.—Nothing in this Act (or an 
amendment made by this Act) shall be construed to 
require that an individual terminate coverage under 
a group health plan or health insurance coverage in 
which such individual was enrolled on the date of en-
actment of this Act. 
(2) CONTINUATION OF COVERAGE.—With respect 
to a group health plan or health insurance coverage 
in which an individual was enrolled on the date of 
enactment of this Act, this subtitle and subtitle A 
(and the amendments made by such subtitles) shall 
not apply to such plan or coverage, regardless of 
whether the individual renews such coverage after 
such date of enactment. 
(b) ALLOWANCE FOR FAMILY MEMBERS TO JOIN CUR-
RENT COVERAGE.—With respect to a group health plan or 
health insurance coverage in which an individual was en-
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HR 3590 EAS/PP 
rolled on the date of enactment of this Act and which is 
renewed after such date, family members of such individual 
shall be permitted to enroll in such plan or coverage if such 
enrollment is permitted under the terms of the plan in effect 
as of such date of enactment. 
(c) ALLOWANCE FOR NEW EMPLOYEES TO JOIN CUR-
RENT PLAN.—A group health plan that provides coverage 
on the date of enactment of this Act may provide for the 
enrolling of new employees (and their families) in such 
plan, and this subtitle and subtitle A (and the amendments 
made by such subtitles) shall not apply with respect to such 
plan and such new employees (and their families). 
(d) EFFECT
ON COLLECTIVE BARGAINING AGREE-
MENTS.—In the case of health insurance coverage main-
tained pursuant to one or more collective bargaining agree-
ments between employee representatives and one or more 
employers that was ratified before the date of enactment of 
this Act, the provisions of this subtitle and subtitle A (and 
the amendments made by such subtitles) shall not apply 
until the date on which the last of the collective bargaining 
agreements relating to the coverage terminates. Any cov-
erage amendment made pursuant to a collective bargaining 
agreement relating to the coverage which amends the cov-
erage solely to conform to any requirement added by this
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HR 3590 EAS/PP 
subtitle or subtitle A (or amendments) shall not be treated 
as a termination of such collective bargaining agreement. 
(e) DEFINITION.—In this title, the term ‘‘grand-
fathered health plan’’ means any group health plan or 
health insurance coverage to which this section applies. 
SEC. 1252. RATING REFORMS MUST APPLY UNIFORMLY TO 
ALL 
HEALTH 
INSURANCE 
ISSUERS 
AND 
GROUP HEALTH PLANS. 
Any standard or requirement adopted by a State pur-
suant to this title, or any amendment made by this title, 
shall be applied uniformly to all health plans in each insur-
ance market to which the standard and requirements apply. 
The preceding sentence shall also apply to a State standard 
or requirement relating to the standard or requirement re-
quired by this title (or any such amendment) that is not 
the same as the standard or requirement but that is not 
preempted under section 1321(d). 
SEC. 1253. EFFECTIVE DATES. 
This subtitle (and the amendments made by this sub-
title) shall become effective for plan years beginning on or 
after January 1, 2014.
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HR 3590 EAS/PP 
Subtitle D—Available Coverage 
Choices for All Americans 
PART I—ESTABLISHMENT OF QUALIFIED HEALTH 
PLANS 
SEC. 1301. QUALIFIED HEALTH PLAN DEFINED. 
(a) QUALIFIED HEALTH PLAN.—In this title: 
(1) IN
GENERAL.—The term ‘‘qualified health 
plan’’ means a health plan that— 
(A) has in effect a certification (which may 
include a seal or other indication of approval) 
that such plan meets the criteria for certification 
described in section 1311(c) issued or recognized 
by each Exchange through which such plan is of-
fered; 
(B) provides the essential health benefits 
package described in section 1302(a); and 
(C) is offered by a health insurance issuer 
that— 
(i) is licensed and in good standing to 
offer health insurance coverage in each 
State in which such issuer offers health in-
surance coverage under this title; 
(ii) agrees to offer at least one quali-
fied health plan in the silver level and at