I 
111TH CONGRESS 
1ST SESSION H. R. 3200 
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 
A BILL 
To provide affordable, quality health care for all Americans 
and reduce the growth in health care spending, and 
for other purposes. 
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’’. 
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(b) TABLE
OF
DIVISIONS, TITLES, AND
SUB-
TITLES.—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 
PROVISIONS 
Subtitle A—Health Insurance Exchange 
Subtitle B—Public Health Insurance Option 
Subtitle C—Individual Affordability Credits 
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 Part B 
Subtitle C—Provisions Related to Medicare Parts A and B 
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Subtitle D—Medicare Advantage Reforms 
Subtitle E—Improvements to Medicare Part D 
Subtitle F—Medicare Rural Access Protections 
TITLE II—MEDICARE BENEFICIARY IMPROVEMENTS 
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—Puerto Rico and the Territories 
Subtitle H—Miscellaneous 
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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—School-Based Health Clinics 
Subtitle C—National Medical Device Registry 
Subtitle D—Grants for Comprehensive Programs To Provide Education to 
Nurses and Create a Pipeline to Nursing 
Subtitle E—States Failing To Adhere to Certain Employment Obligations 
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 di-
vision achieves this purpose by building on what 
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works in today’s health care system, while repairing 
the aspects that are broken. 
(3) INSURANCE REFORMS.—This division— 
(A) enacts strong insurance market re-
forms; 
(B) creates a new Health Insurance Ex-
change, with a public health insurance option 
alongside private plans; 
(C) includes sliding scale affordability 
credits; and 
(D) initiates shared responsibility among 
workers, employers, and the government; 
so that all Americans have coverage of essential 
health benefits. 
(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. 
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Subtitle B—Standards Guaranteeing Access to Affordable Coverage 
Sec. 111. Prohibiting pre-existing 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 stand-
ards. 
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. 
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. 
Subtitle G—Early Investments 
Sec. 161. Ensuring value and lower premiums. 
Sec. 162. Ending health insurance rescission abuse. 
Sec. 163. Administrative simplification. 
Sec. 164. Reinsurance program for retirees. 
TITLE II—HEALTH INSURANCE EXCHANGE AND RELATED 
PROVISIONS 
Subtitle A—Health Insurance Exchange 
Sec. 201. Establishment of Health Insurance Exchange; outline of duties; defi-
nitions. 
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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 plan. 
Sec. 206. Other functions. 
Sec. 207. Health Insurance Exchange Trust Fund. 
Sec. 208. Optional operation of State-based health insurance exchanges. 
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. Payment rates for items and services. 
Sec. 224. Modernized payment initiatives and delivery system reform. 
Sec. 225. Provider participation. 
Sec. 226. Application of fraud and abuse provisions. 
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. 
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 depend-
ent 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 
Internal 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 require-
ments. 
TITLE IV—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986 
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Subtitle A—Shared Responsibility 
PART 1—INDIVIDUAL RESPONSIBILITY 
Sec. 401. Tax on individuals without acceptable health care coverage. 
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 
provided, in this division: 
(1) ACCEPTABLE COVERAGE.—The term ‘‘ac-
ceptable 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 
‘‘Commis-
sioner’’ means the Health Choices Commissioner es-
tablished under section 141. 
(4) COST-SHARING.—The term ‘‘cost-sharing’’ 
includes deductibles, coinsurance, copayments, and 
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similar charges but does not include premiums or 
any network payment differential for covered serv-
ices or spending for non-covered services. 
(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 Retire-
ment Income Security Act of 1974); and 
(B) includes such a plan that is the fol-
lowing: 
(i) FEDERAL, STATE, AND
TRIBAL 
GOVERNMENTAL 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 Em-
ployee Retirement Income Security Act of 
1974). 
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plan’’ have the meanings given such terms in section 
203(c). 
(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, 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; 
(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 insurance option. 
(21) PUBLIC
HEALTH
INSURANCE
OPTION.— 
The term ‘‘public health insurance option’’ means 
the public 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 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 
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and applicable rules of the Commissioner for 
Exchange-participating health benefits plans. 
(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, re-
spectively. 
TITLE 
I—PROTECTIONS 
AND 
STANDARDS FOR QUALIFIED 
HEALTH BENEFITS PLANS 
Subtitle A—General Standards 
SEC. 101. REQUIREMENTS REFORMING HEALTH INSUR-
ANCE MARKETPLACE. 
(a) PURPOSE.—The purpose of this title is to estab-
lish standards to ensure that new health insurance cov-
erage and employment-based health plans that are offered 
meet standards guaranteeing access to affordable cov-
erage, essential benefits, and other consumer protections. 
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(b) REQUIREMENTS FOR QUALIFIED HEALTH BENE-
FITS PLANS.—On or after the first day of Y1, a health 
benefits plan shall not be a qualified health benefits plan 
under this division unless the plan meets the applicable 
requirements 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 protec-
tion). 
(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), 
respectively, of the Employee Retirement Income Se-
curity Act of 1974) in such plan. 
(2) INDIVIDUAL AND GROUP HEALTH INSUR-
ANCE COVERAGE.—The terms ‘‘individual health in-
surance coverage’’ and ‘‘group health insurance cov-
erage’’ mean health insurance coverage offered in 
the individual market or large or small group mar-
ket, respectively, as defined in section 2791 of the 
Public Health Service Act. 
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SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT 
COVERAGE. 
(a) GRANDFATHERED HEALTH INSURANCE COV-
ERAGE DEFINED.—Subject to the succeeding provisions of 
this section, for purposes of establishing acceptable cov-
erage under this division, the term ‘‘grandfathered health 
insurance coverage’’ 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 ef-
fective date of coverage is on or after the first 
day of Y1. 
(B) 
DEPENDENT
COVERAGE
PER-
MITTED.—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 
CONDITIONS.—Subject to paragraph (3) and except 
as required by law, the issuer does not change any 
of its terms or conditions, including benefits and 
cost-sharing, from those in effect as of the day be-
fore the first day of Y1. 
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(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 
changing the premium for all enrollees in the same 
risk group at the same rate, as specified by the 
Commissioner. 
(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 pe-
riod beginning with Y1, an employment-based 
health plan in operation as of the day before 
the first day of Y1 must meet the same require-
ments as apply to a qualified health benefits 
plan under section 101, including the essential 
benefit package 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: 
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(i) Any coverage described in section 
3001(a)(1)(B)(ii)(IV) of division B of the 
American Recovery and Reinvestment Act 
of 2009 (Public Law 111–5). 
(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 ill-
ness 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
ACCEPT-
ABLE 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.— 
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(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-par-
ticipating health benefits plan. 
(2) SEPARATE, EXCEPTED
COVERAGE
PER-
MITTED.—Excepted benefits (as defined in section 
2791(c) of the Public Health Service Act) are not 
included within the definition of health insurance 
coverage. Nothing in paragraph (1) shall prevent the 
offering, other than through the Health Insurance 
Exchange, of excepted benefits so long as it is of-
fered and priced separately from health insurance 
coverage. 
Subtitle 
B—Standards 
Guaran-
teeing Access to Affordable Cov-
erage 
SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLU-
SIONS. 
A qualified health benefits plan may not impose any 
pre-existing condition exclusion (as defined in section 
2701(b)(1)(A) of the Public Health Service Act) or other-
wise impose any limit or condition on the coverage under 
the plan with respect to an individual or dependent based 
on any health status-related factors (as defined in section 
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2791(d)(9) of the Public Health Service Act) in relation 
to the individual or dependent. 
SEC. 112. GUARANTEED ISSUE AND RENEWAL FOR IN-
SURED PLANS. 
The requirements of sections 2711 (other than sub-
sections (c) and (e)) and 2712 (other than paragraphs (3), 
and (6) of subsection (b) and subsection (e)) of the Public 
Health Service Act, relating to guaranteed availability and 
renewability of health insurance coverage, shall apply to 
individuals and employers in all individual and group 
health insurance coverage, whether offered to individuals 
or employers through the Health Insurance Exchange, 
through any employment-based health plan, or otherwise, 
in the same manner as such sections apply to employers 
and health insurance coverage offered in the small group 
market, except that such section 2712(b)(1) shall apply 
only if, before nonrenewal or discontinuation of coverage, 
the issuer has provided the enrollee with notice of non- 
payment of premiums and there is a grace period during 
which the enrollees has an opportunity to correct such 
nonpayment. Rescissions of such coverage shall be prohib-
ited except in cases of fraud as defined in sections 
2712(b)(2) of such Act. 
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SEC. 113. INSURANCE RATING RULES. 
(a) IN GENERAL.—The premium rate charged for an 
insured qualified health benefits plan may not vary except 
as follows: 
(1) LIMITED AGE VARIATION PERMITTED.—By 
age (within such age categories as the Commissioner 
shall specify) so long as the ratio of the highest such 
premium to the lowest such premium does not ex-
ceed the ratio of 2 to 1. 
(2) BY
AREA.—By premium rating area (as 
permitted by State insurance regulators or, in the 
case of Exchange-participating health benefits plans, 
as specified by the Commissioner in consultation 
with such regulators). 
(3) BY FAMILY ENROLLMENT.—By family en-
rollment (such as variations within categories and 
compositions of families) so long as the ratio of the 
premium for family enrollment (or enrollments) to 
the premium for individual enrollment is uniform, as 
specified under State law and consistent with rules 
of the Commissioner. 
(b) STUDY AND REPORTS.— 
(1) STUDY.—The Commissioner, in coordina-
tion with the Secretary of Health and Human Serv-
ices and the Secretary of Labor, shall conduct a 
study of the large group insured and self-insured 
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employer health care markets. Such study shall ex-
amine the following: 
(A) The types of employers by key charac-
teristics, including size, that purchase insured 
products versus those that self-insure. 
(B) The similarities and differences be-
tween typical insured and self-insured health 
plans. 
(C) The financial solvency and capital re-
serve levels of employers that self-insure by em-
ployer size. 
(D) The risk of self-insured employers not 
being able to pay obligations or otherwise be-
coming financially insolvent. 
(E) The extent to which rating rules are 
likely to cause adverse selection in the large 
group market or to encourage small and mid 
size employers to self-insure 
(2) REPORTS.—Not later than 18 months after 
the date of the enactment of this Act, the Commis-
sioner shall submit to Congress and the applicable 
agencies a report on the study conducted under 
paragraph (1). Such report shall include any rec-
ommendations the Commissioner deems appropriate 
to ensure that the law does not provide incentives 
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jlentini on DSKJ8SOYB1PROD with BILLS
for small and mid-size employers to self-insure or 
create adverse selection in the risk pools of large 
group insurers and self-insured employers. Not later 
than 18 months after the first day of Y1, the Com-
missioner shall submit to Congress and the applica-
ble agencies an updated report on such study, in-
cluding updates on such recommendations. 
SEC. 114. NONDISCRIMINATION IN BENEFITS; PARITY IN 
MENTAL HEALTH AND SUBSTANCE ABUSE 
DISORDER BENEFITS. 
(a) NONDISCRIMINATION IN BENEFITS.—A qualified 
health benefits plan shall comply with standards estab-
lished by the Commissioner to prohibit discrimination in 
health benefits or benefit structures for qualifying health 
benefits plans, building from sections 702 of Employee 
Retirement Income Security Act of 1974, 2702 of the 
Public Health Service Act, and section 9802 of the Inter-
nal Revenue Code of 1986. 
(b) PARITY IN MENTAL HEALTH AND SUBSTANCE 
ABUSE DISORDER BENEFITS.—To the extent such provi-
sions are not superceded by or inconsistent with subtitle 
C, the provisions of section 2705 (other than subsections 
(a)(1), (a)(2), and (c)) of section 2705 of the Public 
Health Service Act shall apply to a qualified health bene-
fits plan, regardless of whether it is offered in the indi-
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jlentini on DSKJ8SOYB1PROD with BILLS
vidual or group market, in the same manner as such provi-
sions apply to health insurance coverage offered in the 
large group market. 
SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS. 
(a) IN GENERAL.—A qualified health benefits plan 
that uses a provider network for items and services shall 
meet such standards respecting provider networks as the 
Commissioner may establish to assure the adequacy of 
such networks in ensuring enrollee access to such items 
and services and transparency in the cost-sharing differen-
tials between in-network coverage and out-of-network cov-
erage. 
(b) PROVIDER NETWORK DEFINED.—In this divi-
sion, the term ‘‘provider network’’ means the providers 
with respect to which covered benefits, treatments, and 
services are available under a health benefits plan. 
SEC. 116. ENSURING VALUE AND LOWER PREMIUMS. 
(a) IN GENERAL.—A qualified health benefits plan 
shall meet a medical loss ratio as defined by the Commis-
sioner. For any plan year in which the qualified health 
benefits plan does not meet such medical loss ratio, QHBP 
offering entity shall provide in a manner specified by the 
Commissioner for rebates to enrollees of payment suffi-
cient to meet such loss ratio. 
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(b) BUILDING
ON
INTERIM
RULES.—In imple-
menting subsection (a), the Commissioner shall build on 
the definition and methodology developed by the Secretary 
of Health and Human Services under the amendments 
made by section 161 for determining how to calculate the 
medical loss ratio. Such methodology shall be set at the 
highest level medical loss ratio possible that is designed 
to ensure adequate participation by QHBP offering enti-
ties, competition in the health insurance market in and 
out of the Health Insurance Exchange, and value for con-
sumers so that their premiums are used for services. 
Subtitle 
C—Standards 
Guaran-
teeing Access to Essential Bene-
fits 
SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE. 
(a) IN GENERAL.—A qualified health benefits plan 
shall provide coverage that at least meets the benefit 
standards adopted under section 124 for the essential ben-
efits package described in section 122 for the plan year 
involved. 
(b) CHOICE OF COVERAGE.— 
(1) NON-EXCHANGE-PARTICIPATING
HEALTH 
BENEFITS PLANS.—In the case of a qualified health 
benefits plan that is not an Exchange-participating 
health benefits plan, such plan may offer such cov-
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erage in addition to the essential benefits package as 
the QHBP offering entity may specify. 
(2) EXCHANGE-PARTICIPATING HEALTH BENE-
FITS PLANS.—In the case of an Exchange-partici-
pating health benefits plan, such plan is required 
under section 203 to provide specified levels of bene-
fits and, in the case of a plan offering a premium- 
plus level of benefits, provide additional benefits. 
(3) CONTINUATION OF OFFERING OF SEPARATE 
EXCEPTED BENEFITS COVERAGE.—Nothing in this 
division shall be construed as affecting the offering 
of health benefits in the form of excepted benefits 
(described in section 102(b)(1)(B)(ii)) if such bene-
fits are offered under a separate policy, contract, or 
certificate of insurance. 
(c) NO RESTRICTIONS ON COVERAGE UNRELATED 
TO CLINICAL APPROPRIATENESS.—A qualified health ben-
efits plan may not impose any restriction (other than cost- 
sharing) unrelated to clinical appropriateness on the cov-
erage of the health care items and services. 
SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED. 
(a) IN GENERAL.—In this division, the term ‘‘essen-
tial benefits package’’ means health benefits coverage, 
consistent with standards adopted under section 124 to 
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jlentini on DSKJ8SOYB1PROD with BILLS
ensure the provision of quality health care and financial 
security, that— 
(1) provides payment for the items and services 
described in subsection (b) in accordance with gen-
erally accepted standards of medical or other appro-
priate clinical or professional practice; 
(2) limits cost-sharing for such covered health 
care items and services in accordance with such ben-
efit standards, consistent with subsection (c); 
(3) does not impose any annual or lifetime limit 
on the coverage of covered health care items and 
services; 
(4) complies with section 115(a) (relating to 
network adequacy); and 
(5) is equivalent, as certified by Office of the 
Actuary of the Centers for Medicare & Medicaid 
Services, to the average prevailing employer-spon-
sored coverage. 
(b) MINIMUM SERVICES TO BE COVERED.—The 
items and services described in this subsection are the fol-
lowing: 
(1) Hospitalization. 
(2) Outpatient hospital and outpatient clinic 
services, including emergency department services. 
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jlentini on DSKJ8SOYB1PROD with BILLS
(I) the Commissioner provides 
the entity with the reasonable oppor-
tunity to develop and implement a 
corrective action plan to correct the 
deficiencies that were the basis of the 
Commissioner’s determination; and 
(II) the Commissioner provides 
the entity with reasonable notice and 
opportunity for hearing (including the 
right to appeal an initial decision) be-
fore terminating the contract. 
(ii) EXCEPTION FOR IMMINENT AND 
SERIOUS
RISK
TO
HEALTH.—Clause (i) 
shall not apply if the Commissioner deter-
mines that a delay in termination, result-
ing from compliance with the procedures 
specified in such clause prior to termi-
nation, would pose an imminent and seri-
ous risk to the health of individuals en-
rolled under the qualified health benefits 
plan of the QHBP offering entity. 
(D) CONSTRUCTION.—Nothing in this sub-
section shall be construed as preventing the ap-
plication of other sanctions under subtitle E of 
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