IB 
Union Calendar No. 168 
111TH CONGRESS 
1ST SESSION H. R. 3200 
[Report No. 111–299, Parts I, II, and III] 
To provide affordable, quality health care for all Americans and reduce 
the growth in health care spending, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 14, 2009 
Mr. DINGELL (for himself, Mr. RANGEL, Mr. WAXMAN, Mr. GEORGE MILLER 
of California, Mr. STARK, Mr. PALLONE, and Mr. ANDREWS) introduced 
the following bill; which was referred to the Committee on Energy and 
Commerce, and in addition to the Committees on Ways and Means, Edu-
cation and Labor, Oversight and Government Reform, and the Budget, 
for a period to be subsequently determined by the Speaker, in each case 
for consideration of such provisions as fall within the jurisdiction of the 
committee concerned 
OCTOBER 14, 2009 
Additional sponsors: Mr. KILDEE, Mrs. MALONEY, and Mr. BACA 
OCTOBER 14, 2009 
Reported from the Committee on Energy and Commerce with an amendment 
[Strike out all after the enacting clause (other than sections 321 and 322, title IV of division 
A, subtitle A of title I of division B, and title VIII of division B) and insert the part print-
ed in italic] 
[For text of sections 321 and 322, title IV of division A, subtitle A of title I of division B, 
and title VIII of division B, see copy of bill as introduced on July 14, 2009] 
OCTOBER 14, 2009 
Reported from the Committee on Ways and Means with an amendment 
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[Strike out all after the enacting clause (other than title VII of division B and division C) and 
insert the part printed in boldface roman] 
[For text of title VII of division B and for division C (and the original sections of the bill that 
fall within the jurisdiction of the Committee on Ways and Means), see copy of bill as intro-
duced on July 14, 2009] 
OCTOBER 14, 2009 
Reported from the Committee on Education and Labor with an amendment 
[Strike out all after the enacting clause (other than sections 161 through 163, 322, and 323 
and title IV of division A, division B, section 2002 and titles I through IV of division C, 
and subtitles A, B, C, and E of title V of division C) and insert the part printed in bold-
face italic] 
[For text of sections 161 through 163, 322, and 323 and title IV of division A, division B, 
section 2002 and titles I through IV of division C, and subtitles A, B, C, and E of title 
V of division C, see copy of bill as introduced on July 14, 2009] 
OCTOBER 14, 2009 
Committees on Oversight and Government Reform and the Budget discharged; 
committed to the Committee of the Whole House on the State of the 
Union and ordered to be printed 
A BILL 
To provide affordable, quality health care for all Americans 
and reduce the growth in health care spending, and 
for other purposes. 
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Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF DIVISIONS, TITLES, 
AND SUBTITLES. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘America’s Affordable Health Choices Act of 2009’’. 
(b) TABLE OF DIVISIONS, TITLES, AND SUBTITLES.— 
This Act is divided into divisions, titles, and subtitles as 
follows: 
DIVISION A—AFFORDABLE HEALTH CARE CHOICES 
TITLE I—PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH 
BENEFITS PLANS 
Subtitle A—General Standards 
Subtitle B—Standards Guaranteeing Access to Affordable Coverage 
Subtitle C—Standards Guaranteeing Access to Essential Benefits 
Subtitle D—Additional Consumer Protections 
Subtitle E—Governance 
Subtitle F—Relation to Other Requirements; Miscellaneous 
Subtitle G—Early Investments 
TITLE II—HEALTH INSURANCE EXCHANGE AND RELATED PROVI-
SIONS 
Subtitle A—Health Insurance Exchange 
Subtitle B—Public Health Insurance Option 
Subtitle C—Individual Affordability Credits 
Subtitle D—Health Insurance Cooperatives 
TITLE III—SHARED RESPONSIBILITY 
Subtitle A—Individual Responsibility 
Subtitle B—Employer Responsibility 
TITLE IV—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986 
Subtitle A—Shared Responsibility 
Subtitle B—Credit for Small Business Employee Health Coverage Expenses 
Subtitle C—Disclosures To Carry Out Health Insurance Exchange Subsidies 
Subtitle D—Other Revenue Provisions 
DIVISION B—MEDICARE AND MEDICAID IMPROVEMENTS 
TITLE I—IMPROVING HEALTH CARE VALUE 
Subtitle A—Provisions Related to Medicare Part A 
Subtitle B—Provisions Related to Medicare Part B 
Subtitle C—Provisions Related to Medicare Parts A and B 
Subtitle D—Medicare Advantage Reforms 
Subtitle E—Improvements to Medicare Part D 
Subtitle F—Medicare Rural Access Protections 
TITLE II—MEDICARE BENEFICIARY IMPROVEMENTS 
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Subtitle A—Improving and Simplifying Financial Assistance for Low Income 
Medicare Beneficiaries 
Subtitle B—Reducing Health Disparities 
Subtitle C—Miscellaneous Improvements 
TITLE III—PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, 
AND COORDINATED CARE 
TITLE IV—QUALITY 
Subtitle A—Comparative Effectiveness Research 
Subtitle B—Nursing Home Transparency 
Subtitle C—Quality Measurements 
Subtitle D—Physician Payments Sunshine Provision 
Subtitle E—Public Reporting on Health Care-Associated Infections 
TITLE V—MEDICARE GRADUATE MEDICAL EDUCATION 
TITLE VI—PROGRAM INTEGRITY 
Subtitle A—Increased Funding To Fight Waste, Fraud, and Abuse 
Subtitle B—Enhanced Penalties for Fraud and Abuse 
Subtitle C—Enhanced Program and Provider Protections 
Subtitle D—Access to Information Needed To Prevent Fraud, Waste, and Abuse 
TITLE VII—MEDICAID AND CHIP 
Subtitle A—Medicaid and Health Reform 
Subtitle B—Prevention 
Subtitle C—Access 
Subtitle D—Coverage 
Subtitle E—Financing 
Subtitle F—Waste, Fraud, and Abuse 
Subtitle G—Payments to the Territories 
Subtitle H—Miscellaneous 
TITLE VIII—REVENUE-RELATED PROVISIONS 
TITLE IX—MISCELLANEOUS PROVISIONS 
DIVISION C—PUBLIC HEALTH AND WORKFORCE DEVELOPMENT 
TITLE I—COMMUNITY HEALTH CENTERS 
TITLE II—WORKFORCE 
Subtitle A—Primary Care Workforce 
Subtitle B—Nursing Workforce 
Subtitle C—Public Health Workforce 
Subtitle D—Adapting Workforce to Evolving Health System Needs 
TITLE III—PREVENTION AND WELLNESS 
TITLE IV—QUALITY AND SURVEILLANCE 
TITLE V—OTHER PROVISIONS 
Subtitle A—Drug Discount for Rural and Other Hospitals 
Subtitle B—Programs 
Subtitle C—Food and Drug Administration 
Subtitle D—Community Living Assistance Services and Supports 
Subtitle E—Miscellaneous 
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DIVISION A—AFFORDABLE 
HEALTH CARE CHOICES 
SEC. 100. PURPOSE; TABLE OF CONTENTS OF DIVISION; 
GENERAL DEFINITIONS. 
(a) PURPOSE.— 
(1) IN GENERAL.—The purpose of this division 
is to provide affordable, quality health care for all 
Americans and reduce the growth in health care 
spending. 
(2) BUILDING ON CURRENT SYSTEM.—This divi-
sion achieves this purpose by building on what works 
in today’s health care system, while repairing the as-
pects that are broken. 
(3) INSURANCE REFORMS.—This division— 
(A) enacts strong insurance market reforms; 
(B) creates a new Health Insurance Ex-
change, with a public health insurance option 
alongside private plans and cooperatives under 
subtitle D of title II; 
(C) includes sliding scale affordability cred-
its; and 
(D) initiates shared responsibility among 
workers, employers, and the government; 
so that all Americans have coverage of essential health 
benefits. 
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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—PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH 
BENEFITS PLANS 
Subtitle A—General Standards 
Sec. 101. Requirements reforming health insurance marketplace. 
Sec. 102. Protecting the choice to keep current coverage. 
Subtitle B—Standards Guaranteeing Access to Affordable Coverage 
Sec. 111. Prohibiting preexisting condition exclusions. 
Sec. 112. Guaranteed issue and renewal for insured plans. 
Sec. 113. Insurance rating rules. 
Sec. 114. Nondiscrimination in benefits; parity in mental health and substance 
abuse disorder benefits. 
Sec. 115. Ensuring adequacy of provider networks. 
Sec. 116. Ensuring value and lower premiums. 
Subtitle C—Standards Guaranteeing Access to Essential Benefits 
Sec. 121. Coverage of essential benefits package. 
Sec. 122. Essential benefits package defined. 
Sec. 123. Health Benefits Advisory Committee. 
Sec. 124. Process for adoption of recommendations; adoption of benefit standards. 
Sec. 125. Prohibition of discrimination in health care services based on religious 
or spiritual content. 
Subtitle D—Additional Consumer Protections 
Sec. 131. Requiring fair marketing practices by health insurers. 
Sec. 132. Requiring fair grievance and appeals mechanisms. 
Sec. 133. Requiring information transparency and plan disclosure. 
Sec. 134. Application to qualified health benefits plans not offered through the 
Health Insurance Exchange. 
Sec. 135. Timely payment of claims. 
Sec. 136. Standardized rules for coordination and subrogation of benefits. 
Sec. 137. Application of administrative simplification. 
Sec. 138. Information on end-of-life planning. 
Sec. 139. Utilization review activities. 
Sec. 139A. Internal appeals procedures. 
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Sec. 139B. External appeals procedures. 
Subtitle E—Governance 
Sec. 141. Health Choices Administration; Health Choices Commissioner. 
Sec. 142. Duties and authority of Commissioner. 
Sec. 143. Consultation and coordination. 
Sec. 144.
Health Insurance Ombudsman. 
Subtitle F—Relation to Other Requirements; Miscellaneous 
Sec. 151. Relation to other requirements. 
Sec. 152. Prohibiting discrimination in health care. 
Sec. 153. Whistleblower protection. 
Sec. 154. Construction regarding collective bargaining. 
Sec. 155. Severability. 
Sec. 156. Application of State and Federal laws regarding abortion. 
Sec. 157. Non-discrimination on abortion and respect for rights of conscience. 
Subtitle G—Early Investments 
Sec. 161. Ensuring value and lower premiums. 
Sec. 162. Ending health insurance rescission abuse. 
Sec. 163. Ending health insurance denials and delays of necessary treatment for 
children with deformities. 
Sec. 164. Administrative simplification. 
Sec. 165. Expansion of electronic transactions in medicare. 
Sec. 166. Reinsurance program for retirees. 
Sec. 167. Limitations on preexisting condition exclusions in group health plans 
and health insurance coverage in the group and individual mar-
kets in advance of applicability of new prohibition of preexisting 
condition exclusions. 
TITLE II—HEALTH INSURANCE EXCHANGE AND RELATED 
PROVISIONS 
Subtitle A—Health Insurance Exchange 
Sec. 201. Establishment of Health Insurance Exchange; outline of duties; defini-
tions. 
Sec. 202. Exchange-eligible individuals and employers. 
Sec. 203. Benefits package levels. 
Sec. 204. Contracts for the offering of Exchange-participating health benefits 
plans. 
Sec. 205. Outreach and enrollment of Exchange-eligible individuals and employ-
ers in Exchange-participating health benefits plans. 
Sec. 206. Other functions. 
Sec. 207. Health Insurance Exchange Trust Fund. 
Sec. 208. Optional operation of State-based health insurance exchanges. 
Sec. 209. Limitation on premium increases under Exchange-participating health 
benefits plans. 
Subtitle B—Public Health Insurance Option 
Sec. 221. Establishment and administration of a public health insurance option 
as an Exchange-qualified health benefits plan. 
Sec. 222. Premiums and financing. 
Sec. 223. Negotiated payment rates for items and services. 
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Sec. 224. Modernized payment initiatives and delivery system reform. 
Sec. 225. Provider participation. 
Sec. 226. Application of fraud and abuse provisions. 
Sec. 227. Application of HIPAA insurance requirements. 
Sec. 228. Application of health information privacy, security, and electronic 
transaction requirements. 
Sec. 229. Enrollment in public health insurance option is voluntary. 
Subtitle C—Individual Affordability Credits 
Sec. 241. Availability through Health Insurance Exchange. 
Sec. 242. Affordable credit eligible individual. 
Sec. 243. Affordable premium credit. 
Sec. 244. Affordability cost-sharing credit. 
Sec. 245. Income determinations. 
Sec. 246. No Federal payment for undocumented aliens. 
Subtitle D—Health Insurance Cooperatives 
Sec. 251. Establishment. 
Sec. 252. Start-up and solvency grants and loans. 
Sec. 253. Definitions. 
TITLE III—SHARED RESPONSIBILITY 
Subtitle A—Individual Responsibility 
Sec. 301. Individual responsibility. 
Subtitle B—Employer Responsibility 
PART 1—HEALTH COVERAGE PARTICIPATION REQUIREMENTS 
Sec. 311. Health coverage participation requirements. 
Sec. 312. Employer responsibility to contribute towards employee and dependent 
coverage. 
Sec. 313. Employer contributions in lieu of coverage. 
Sec. 314. Authority related to improper steering. 
PART 2—SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS 
Sec. 321. Satisfaction of health coverage participation requirements under the 
Employee Retirement Income Security Act of 1974. 
Sec. 322. Satisfaction of health coverage participation requirements under the In-
ternal Revenue Code of 1986. 
Sec. 323. Satisfaction of health coverage participation requirements under the 
Public Health Service Act. 
Sec. 324. Additional rules relating to health coverage participation requirements. 
TITLE IV—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986 
Subtitle A—Shared Responsibility 
PART 1—INDIVIDUAL RESPONSIBILITY 
Sec. 401. Tax on individuals without acceptable health care coverage. 
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PART 2—EMPLOYER RESPONSIBILITY 
Sec. 411. Election to satisfy health coverage participation requirements. 
Sec. 412. Responsibilities of nonelecting employers. 
Subtitle B—Credit for Small Business Employee Health Coverage Expenses 
Sec. 421. Credit for small business employee health coverage expenses. 
Subtitle C—Disclosures To Carry Out Health Insurance Exchange Subsidies 
Sec. 431. Disclosures to carry out health insurance exchange subsidies. 
Subtitle D—Other Revenue Provisions 
PART 1—GENERAL PROVISIONS 
Sec. 441. Surcharge on high income individuals. 
Sec. 442. Delay in application of worldwide allocation of interest. 
PART 2—PREVENTION OF TAX AVOIDANCE 
Sec. 451. Limitation on treaty benefits for certain deductible payments. 
Sec. 452. Codification of economic substance doctrine. 
Sec. 453. Penalties for underpayments. 
(c) GENERAL DEFINITIONS.—Except as otherwise pro-
vided, in this division: 
(1) ACCEPTABLE COVERAGE.—The term ‘‘accept-
able coverage’’ has the meaning given such term in 
section 202(d)(2). 
(2) BASIC PLAN.—The term ‘‘basic plan’’ has the 
meaning given such term in section 203(c). 
(3) COMMISSIONER.—The term ‘‘Commissioner’’ 
means the Health Choices Commissioner established 
under section 141. 
(4) COST-SHARING.—The term ‘‘cost-sharing’’ in-
cludes deductibles, coinsurance, copayments, and 
similar charges but does not include premiums or any 
network payment differential for covered services or 
spending for non-covered services. 
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(5) DEPENDENT.—The term ‘‘dependent’’ has the 
meaning given such term by the Commissioner and 
includes a spouse. 
(6) EMPLOYMENT-BASED
HEALTH
PLAN.—The 
term ‘‘employment-based health plan’’— 
(A) means a group health plan (as defined 
in section 733(a)(1) of the Employee Retirement 
Income Security Act of 1974); and 
(B) includes such a plan that is the fol-
lowing: 
(i) FEDERAL, STATE, AND TRIBAL GOV-
ERNMENTAL PLANS.—A governmental plan 
(as defined in section 3(32) of the Employee 
Retirement Income Security Act of 1974), 
including a health benefits plan offered 
under chapter 89 of title 5, United States 
Code. 
(ii) CHURCH PLANS.—A church plan 
(as defined in section 3(33) of the Employee 
Retirement Income Security Act of 1974). 
(7) ENHANCED
PLAN.—The term ‘‘enhanced 
plan’’ has the meaning given such term in section 
203(c). 
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(8) ESSENTIAL BENEFITS PACKAGE.—The term 
‘‘essential benefits package’’ is defined in section 
122(a). 
(9) FAMILY.—The term ‘‘family’’ means an indi-
vidual and includes the individual’s dependents. 
(10) FEDERAL POVERTY LEVEL; FPL.—The terms 
‘‘Federal poverty level’’ and ‘‘FPL’’ have the meaning 
given the term ‘‘poverty line’’ in section 673(2) of the 
Community Services Block Grant Act (42 U.S.C. 
9902(2)), including any revision required by such sec-
tion. 
(11) HEALTH
BENEFITS
PLAN.—The terms 
‘‘health benefits plan’’ means health insurance cov-
erage and an employment-based health plan and in-
cludes the public health insurance option and co-
operatives under subtitle D of title II. 
(12) HEALTH
INSURANCE
COVERAGE; HEALTH 
INSURANCE
ISSUER.—The terms ‘‘health insurance 
coverage’’ and ‘‘health insurance issuer’’ have the 
meanings given such terms in section 2791 of the 
Public Health Service Act. 
(13) HEALTH INSURANCE EXCHANGE.—The term 
‘‘Health Insurance Exchange’’ means the Health In-
surance Exchange established under section 201. 
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(14) MEDICAID.—The term ‘‘Medicaid’’ means a 
State plan under title XIX of the Social Security Act 
(whether or not the plan is operating under a waiver 
under section 1115 of such Act). 
(15) MEDICARE.—The term ‘‘Medicare’’ means 
the health insurance programs under title XVIII of 
the Social Security Act. 
(16) PLAN SPONSOR.—The term ‘‘plan sponsor’’ 
has the meaning given such term in section 3(16)(B) 
of the Employee Retirement Income Security Act of 
1974. 
(17) PLAN
YEAR.—The term ‘‘plan year’’ 
means— 
(A) with respect to an employment-based 
health plan, a plan year as specified under such 
plan; or 
(B) with respect to a health benefits plan 
other than an employment-based health plan, a 
12-month period as specified by the Commis-
sioner. 
(18) PREMIUM PLAN; PREMIUM-PLUS PLAN.—The 
terms ‘‘premium plan’’ and ‘‘premium-plus plan’’ 
have the meanings given such terms in section 203(c). 
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(19) QHBP 
OFFERING
ENTITY.—The terms 
‘‘QHBP offering entity’’ means, with respect to a 
health benefits plan that is— 
(A) a group health plan (as defined, subject 
to subsection (d), in section 733(a)(1) of the Em-
ployee Retirement Income Security Act of 1974), 
the plan sponsor in relation to such group health 
plan, except that, in the case of a plan main-
tained jointly by 1 or more employers and 1 or 
more employee organizations and with respect to 
which an employer is the primary source of fi-
nancing, such term means such employer; 
(B) health insurance coverage, the health in-
surance issuer offering the coverage, including a 
cooperative under subtitle D of title II; 
(C) the public health insurance option, the 
Secretary of Health and Human Services; 
(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 
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(E) a Federal governmental plan (as de-
fined in section 2791(d) of the Public Health 
Service Act), the appropriate Federal official. 
(20) QUALIFIED HEALTH BENEFITS PLAN.—The 
term ‘‘qualified health benefits plan’’ means a health 
benefits plan that meets the requirements for such a 
plan under title I and includes the public health in-
surance option and cooperatives under subtitle D of 
title II. 
(21) PUBLIC HEALTH INSURANCE OPTION.—The 
term ‘‘public health insurance option’’ means the pub-
lic health insurance option as provided under subtitle 
B of title II. 
(22) SERVICE AREA; PREMIUM RATING AREA.— 
The terms ‘‘service area’’ and ‘‘premium rating area’’ 
mean with respect to health insurance coverage— 
(A) offered other than through the Health 
Insurance Exchange, such an area as established 
by the QHBP offering entity of such coverage 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 Ex-
change-participating health benefits plans. 
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(23) STATE.—The term ‘‘State’’ means the 50 
States and the District of Columbia. 
(24) STATE
MEDICAID
AGENCY.—The term 
‘‘State Medicaid agency’’ means, with respect to a 
Medicaid plan, the single State agency responsible for 
administering such plan under title XIX of the Social 
Security Act. 
(25) Y1, Y2, ETC..—The terms ‘‘Y1’’ , ‘‘Y2’’, 
‘‘Y3’’, ‘‘Y4’’, ‘‘Y5’’, and similar subsequently num-
bered terms, mean 2013 and subsequent years, respec-
tively. 
TITLE 
I—PROTECTIONS 
AND 
STANDARDS FOR QUALIFIED 
HEALTH BENEFITS PLANS 
Subtitle A—General Standards 
SEC. 101. REQUIREMENTS REFORMING HEALTH INSURANCE 
MARKETPLACE. 
(a) PURPOSE.—The purpose of this title is to establish 
standards to ensure that new health insurance coverage and 
employment-based health plans that are offered meet stand-
ards guaranteeing access to affordable coverage, essential 
benefits, and other consumer protections. 
(b) REQUIREMENTS FOR QUALIFIED HEALTH BENE-
FITS PLANS.—On or after the first day of Y1, a health bene-
fits plan shall not be a qualified health benefits plan under 
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this division unless the plan meets the applicable require-
ments of the following subtitles for the type of plan and 
plan year involved: 
(1) Subtitle B (relating to affordable coverage). 
(2) Subtitle C (relating to essential benefits). 
(3) Subtitle D (relating to consumer protection). 
(c) TERMINOLOGY.—In this division: 
(1) 
ENROLLMENT
IN
EMPLOYMENT-BASED 
HEALTH PLANS.—An individual shall be treated as 
being ‘‘enrolled’’ in an employment-based health plan 
if the individual is a participant or beneficiary (as 
such terms are defined in section 3(7) and 3(8), re-
spectively, of the Employee Retirement Income Secu-
rity Act of 1974) in such plan. 
(2) INDIVIDUAL AND GROUP HEALTH INSURANCE 
COVERAGE.—The terms ‘‘individual health insurance 
coverage’’ and ‘‘group health insurance coverage’’ 
mean health insurance coverage offered in the indi-
vidual market or large or small group market, respec-
tively, as defined in section 2791 of the Public Health 
Service Act. 
SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT 
COVERAGE. 
(a) GRANDFATHERED HEALTH INSURANCE COVERAGE 
DEFINED.—Subject to the succeeding provisions of this sec-
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tion, for purposes of establishing acceptable coverage under 
this division, the term ‘‘grandfathered health insurance cov-
erage’’ means individual health insurance coverage that is 
offered and in force and effect before the first day of Y1 
if the following conditions are met: 
(1) LIMITATION ON NEW ENROLLMENT.— 
(A) IN GENERAL.—Except as provided in 
this paragraph, the individual health insurance 
issuer offering such coverage does not enroll any 
individual in such coverage if the first effective 
date of coverage is on or after the first day of Y1. 
(B) DEPENDENT COVERAGE PERMITTED.— 
Subparagraph (A) shall not affect the subsequent 
enrollment of a dependent of an individual who 
is covered as of such first day. 
(2) LIMITATION ON CHANGES IN TERMS OR CON-
DITIONS.—Subject to paragraph (3) and except as re-
quired by law, the issuer does not change any of its 
terms or conditions, including benefits and cost-shar-
ing, from those in effect as of the day before the first 
day of Y1. 
(3) RESTRICTIONS ON PREMIUM INCREASES.— 
The issuer cannot vary the percentage increase in the 
premium for a risk group of enrollees in specific 
grandfathered health insurance coverage without 
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changing the premium for all enrollees in the same 
risk group at the same rate, as specified by the Com-
missioner. 
(b) GRACE PERIOD
FOR CURRENT EMPLOYMENT- 
BASED HEALTH PLANS.— 
(1) GRACE PERIOD.— 
(A) IN GENERAL.—The Commissioner shall 
establish a grace period whereby, for plan years 
beginning after the end of the 5-year period be-
ginning with Y1, an employment-based health 
plan in operation as of the day before the first 
day of Y1 must meet the same requirements as 
apply to a qualified health benefits plan under 
section 101, including the essential benefit pack-
age requirement under section 121. 
(B) EXCEPTION
FOR
LIMITED
BENEFITS 
PLANS.—Subparagraph (A) shall not apply to 
an employment-based health plan in which the 
coverage consists only of one or more of the fol-
lowing: 
(i) Any coverage described in section 
3001(a)(1)(B)(ii)(IV) of division B of the 
American Recovery and Reinvestment Act 
of 2009 (PL 111–5). 
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(ii) Excepted benefits (as defined in 
section 733(c) of the Employee Retirement 
Income Security Act of 1974), including 
coverage under a specified disease or illness 
policy described in paragraph (3)(A) of 
such section. 
(iii) Such other limited benefits as the 
Commissioner may specify. 
In no case shall an employment-based health 
plan in which the coverage consists only of one 
or more of the coverage or benefits described in 
clauses (i) through (iii) be treated as acceptable 
coverage under this division 
(2) TRANSITIONAL TREATMENT AS ACCEPTABLE 
COVERAGE.—During the grace period specified in 
paragraph (1)(A), an employment-based health plan 
that is described in such paragraph shall be treated 
as acceptable coverage under this division. 
(c) LIMITATION ON INDIVIDUAL HEALTH INSURANCE 
COVERAGE.— 
(1) IN GENERAL.—Individual health insurance 
coverage that is not grandfathered health insurance 
coverage under subsection (a) may only be offered on 
or after the first day of Y1 as an Exchange-partici-
pating health benefits plan. 
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(2) SEPARATE, 
EXCEPTED
COVERAGE
PER-
MITTED.—Excepted benefits (as defined in section 
2791(c) of the Public Health Service Act) are not in-
cluded within the definition of health insurance cov-
erage. Nothing in paragraph (1) shall prevent the of-
fering, other than through the Health Insurance Ex-
change, of excepted benefits so long as it is offered and 
priced separately from health insurance coverage. 
(3) STAND-ALONE DENTAL AND VISION COVERAGE 
PERMITTED.—Nothing in this division shall be con-
strued— 
(A) to prevent the offering of a stand-alone 
plans that offer coverage of excepted benefits de-
scribed in section 2791(c)(2)(A) of the Public 
Health Service Act (relating to limited scope 
dental or vision benefits)for individuals and 
families from a State licensed dental and vision 
carrier; or 
(B) as applying requirements for a quali-
fied health benefits plan to such stand-alone 
plans that is offered and priced separately from 
a qualified health benefits plan. 
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(c) REQUIREMENTS RELATING TO COST-SHARING AND 
MINIMUM ACTUARIAL VALUE.— 
(1) NO COST-SHARING FOR PREVENTIVE SERV-
ICES.—There shall be no cost-sharing under the essen-
tial benefits package for preventive items and services 
(as specified under the benefit standards), including 
well baby and well child care. 
(2) ANNUAL LIMITATION.— 
(A) ANNUAL LIMITATION.—The cost-sharing 
incurred under the essential benefits package 
with respect to an individual (or family) for a 
year does not exceed the applicable level specified 
in subparagraph (B). 
(B) APPLICABLE
LEVEL.—The applicable 
level specified in this subparagraph for Y1 is 
$5,000 for an individual and $10,000 for a fam-
ily. Such levels shall be increased (rounded to the 
nearest $100) for each subsequent year by the 
annual percentage increase in the Consumer 
Price Index (United States city average) appli-
cable to such year. 
(C) USE OF COPAYMENTS.—In establishing 
cost-sharing levels for basic, enhanced, and pre-
mium plans under this subsection, the Secretary 
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Failure to issue such a decision by such deadline 
shall be treated as a final decision affirming the 
denial of claim. 
(B) DEADLINE.— 
(i) IN
GENERAL.—Subject to clauses 
(ii) and (iii), the deadline specified in this 
subparagraph is 14 days after the date of 
receipt of the request for internal review. 
(ii) EXTENSION
PERMITTED
WHERE 
NOTICE OF ADDITIONAL INFORMATION RE-
QUIRED.—If a qualified health benefits plan 
of QHBP offering entity— 
(I) receives a request for internal 
review, 
(II) determines that additional 
information is necessary to complete 
the review and make the determination 
on the request, and 
(III) notifies the requester, not 
later than 5 business days after the 
date of receiving the request, of the 
need for such specified additional in-
formation, 
the deadline specified in this subparagraph 
is 14 days after the date the plan or entity 
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177 
(A) IN GENERAL.—In the case of a State 
operating an Exchange prior to January 1, 2010 
that seeks to operate the State-based Health In-
surance Exchange under this section, the Com-
missioner shall presume that such Exchange 
meets the standards under this section unless the 
Commissioner determines, after completion of the 
process established under subparagraph (B), that 
the Exchange does not comply with such stand-
ards. 
(B) PROCESS.—The Commissioner shall es-
tablish a process to work with a State described 
in subparagraph (A) to provide assistance nec-
essary to assure that the State’s Exchange comes 
into compliance with the standards for approval 
under this section. 
(c) CEASING OPERATION.— 
(1) IN GENERAL.—A State-based Health Insur-
ance Exchange may, at the option of each State in-
volved, and only after providing timely and reason-
able notice to the Commissioner, cease operation as 
such an Exchange, in which case the Health Insur-
ance Exchange shall operate, instead of such State- 
based Health Insurance Exchange, with respect to 
such State (or States). 
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