Title I, Subtitle D
(C) with respect to covered items and serv-
ices, may not specify (in this Act or by regula-
tions) particular procedures or treatments, or
classes thereof;
(D) may not establish limitations or cost
sharing requirements with respect to services
for severe mental illness that do not apply with
respect to other items or services; and
(E) with respect to section 1301(b)(9),
shall, after consultation with the Federal Avia-
tion Administration, provide for maximum flexi-
bility to air ambulance services, consistent with
basic public safety requirements, in order to
avoid an adverse change in health outcomes
(within the meaning of section 1301(d)(1)(A))
for persons using such services.
(2) SPECIFICATION OF COST SHARING.—A spec-
ification of the precise deductibles, copayments, coin-
surance, and out-of-pocket limits on cost sharing
that are to apply to the standard package and the
catastrophic package under section 1301(c). Such
specification—
(A) shall establish multiple cost sharing
schedules that vary depending on the delivery
100
Title I, Subtitle D
system by which health care is delivered to indi-
viduals enrolled in a qualified health plan; and
(B) shall provide that the general deduct-
ible amount described in section 1301(c)(2) is
greater than any general deductible amount ap-
plicable to the standard package.
(3) COST ESTIMATE.—An estimate of the cost
of the standard package and the catastrophic pack-
age in 5 diverse regions of the United States.
(4) NO ADDITION OF BENEFITS.—A clarifica-
tion under this subsection may not add a new cat-
egory of items or services.
(b) RESUBMISSION OF INITIAL PROPOSAL.—If the
proposal described in subsection (a) is not approved by
the Congress, the Commission shall submit to the Con-
gress a second proposal conforming to the requirements
of subsection (a) not later than the termination of the 6-
month period beginning on the date an approval resolution
with respect to the first proposal is subject to a vote on
final passage in the last House to consider the resolution
under section 1314. If such second proposal is not ap-
proved, the Commission shall submit to the Congress a
third proposal in accordance with the procedure described
in the preceding sentence. If such third proposal is not
approved by the Congress, the members of the Commis-
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Title I, Subtitle D
sion shall vacate their positions, and new members shall
be appointed under section 1313 to fill such vacancies.
Such new members shall submit to the Congress not more
than three proposals conforming to the requirements of
subsection (a) in accordance with the procedure described
in this subsection.
(c) PROPOSED MODIFICATIONS.—
(1) IN GENERAL.—Not earlier than January 1
of the year that occurs 1 year after a legislative pro-
posal described in subsection (a) or (b) is enacted,
and not more frequently than annually, the Commis-
sion may submit to the Congress a proposal for leg-
islation containing recommended modifications to
such enactment. Such a proposal shall be treated as
an initial proposal under subsection (a) for purposes
of consideration in the Congress under section 1314
and implementation under section 1315. Subsection
(a)(4) shall not apply to such a proposal.
(2) SUBMISSION OF PROPOSAL IF DEFICIT.—If
the Commission receives a report concerning a defi-
cit under section 1003(d)(5)(A) for a year, within 60
days after receiving such report, the Commission
may submit under paragraph (1) a proposal to make
modifications (which may only include modifications
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Title I, Subtitle D
described in paragraph (3)) that will result in the
sum of—
(A) the amount of the reduction in Federal
expenditures for vouchers under section 1003,
and
(B) the amount of the increase in Federal
revenues,
for the next fiscal year being equal to the aggregate
amount of such deficit. The Commission shall sub-
mit such a proposal in the case of any year after the
full 
phase-in 
year 
(as 
defined 
in 
section
1003(d)(5)(B)(iii)).
(3) MODIFICATIONS.—Modifications described
in this paragraph are—
(A) changes in the items, services, and cost
sharing under sections 1301(b) and 1301(c);
(B) a reduction in the applicable phase-in
percentage (specified in the table under section
1003(b)(2));
(C) reductions in expenditures under the
medicare program, the medicaid program, or
both; and
(D) a reduction in the applicable dollar
limit determined under section 91(b)(2) of the
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Title I, Subtitle D
Internal Revenue Code of 1986, based on fam-
ily income.
SEC. 1313. OPERATION OF THE COMMISSION.
(a) MEMBERSHIP.—
(1) IN
GENERAL.—The Commission shall be
composed of 5 members appointed by the President.
(2) CONSULTATION.—In selecting individuals
for nominations for appointments for the Commis-
sion, the President should consult with—
(A) the Speaker of the House of Rep-
resentatives concerning the appointment of 1
member;
(B) the Majority Leader of the Senate con-
cerning the appointment of 1 member;
(C) the Minority Leader of the House of
Representatives concerning the appointment of
1 member; and
(D) the Minority Leader of the Senate con-
cerning the appointment of 1 member.
(3) CHAIRPERSON.—The President shall des-
ignate 1 individual described in paragraph (1) who
shall serve as Chairperson of the Commission.
(b) COMPOSITION.—The membership of the Commis-
sion shall include individuals with national recognition for
their expertise in health economics, hospital and health
104
Title I, Subtitle D
plan management, health services, medical research and
effectiveness, and other related fields, who provide a mix
of different professions, broad geographic representation,
and a balance between urban and rural representatives,
including physicians and other providers of health care
services, employers, third party payors, individuals skilled
in the conduct and interpretation of biomedical, health
services, and health economics research, and individuals
having expertise in the research and development of tech-
nological and scientific advances in health care.
(c) TERMS.—The terms of members of the Commis-
sion shall be for 3 years, except that of the members first
appointed 2 shall be appointed for a term of 1 year and
2 shall be appointed for a term of 2 years.
(d) VACANCIES.—A vacancy in the Commission shall
be filled in the same manner as the original appointment,
but the individual appointed to fill the vacancy shall serve
only for the unexpired portion of the term for which the
individual’s predecessor was appointed.
(e) ADMINISTRATIVE PROVISIONS.—
(1) MEETINGS.—Each meeting of the Commis-
sion shall be open to the public.
(2) PAY AND TRAVEL EXPENSES.—
(A) IN
GENERAL.—Each member, other
than the chairperson of the Commission, shall
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Title I, Subtitle D
be paid at a rate equal to the daily equivalent
of the minimum annual rate of basic pay pay-
able for level IV of the Executive Schedule
under section 5315 of title 5, United States
Code, for each day (including travel time) dur-
ing which the member is engaged in the actual
performance of duties vested in the Commis-
sion.
(B) CHAIRPERSON.—The chairperson of
the Commission shall be paid for each day re-
ferred to in subparagraph (A) at a rate equal
to the daily equivalent of the minimum annual
rate of basic pay payable for level III of the Ex-
ecutive Schedule under section 5314 of title 5,
United States Code.
(C) TRAVEL
EXPENSES.—Members shall
receive travel expenses, including per diem in
lieu of subsistence, in accordance with sections
5702 and 5703 of title 5, United States Code.
(3) DIRECTOR OF STAFF.—
(A) IN GENERAL.—The Commission shall,
without regard to section 5311(b) of title 5,
United States Code, appoint a Director.
(B) PAY.—The Director shall be paid at
the rate of basic pay payable for level IV of the
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Title I, Subtitle D
Executive Schedule under section 5315 of title
5, United States Code.
(4) STAFF.—
(A) IN
GENERAL.—Subject to subpara-
graphs (B) and (C), the Director, with the ap-
proval of the Commission, may appoint and fix
the pay of additional personnel.
(B) PAY.—The Director may make such
appointments without regard to the provisions
of title 5, United States Code, governing ap-
pointments in the competitive service, and any
personnel so appointed may be paid without re-
gard to the provisions of chapter 51 and sub-
chapter III of chapter 53 of such title, relating
to classification and General Schedule pay
rates, except that an individual so appointed
may not receive pay in excess of 120 percent of
the annual rate of basic pay payable for GS–15
of the General Schedule.
(C) DETAILED PERSONNEL.—
(i) IN
GENERAL.—Upon request of
the Director, the head of any Federal de-
partment or agency may detail any of the
personnel of that department or agency to
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Title I, Subtitle D
the Commission to assist the Commission
in carrying out its duties under this Act.
(ii) AGREEMENT WITH COMPTROLLER
GENERAL.—The Comptroller General of
the United States shall provide assistance,
including the detailing of employees, to the
Commission in accordance with an agree-
ment entered into with the Commission.
(5) OTHER AUTHORITY.—
(A) CONTRACT SERVICES.—The Commis-
sion may procure by contract, to the extent
funds are available, the temporary or intermit-
tent services of experts or consultants pursuant
to section 3109 of title 5, United States Code.
(B) LEASES AND PROPERTY.—The Com-
mission may lease space and acquire personal
property to the extent funds are available.
SEC. 1314. CONGRESSIONAL CONSIDERATION OF COMMIS-
SION PROPOSALS.
(a) CONSIDERATION.—A legislative proposal submit-
ted to the Congress by the Commission (except in the case
of a proposal submitted pursuant to the second sentence
of section 1003(d)(5)(A)) shall be considered by the Con-
gress under the procedures described in this section.
108
Title I, Subtitle D
(b) RULES OF HOUSE OF REPRESENTATIVES AND
SENATE.—This section is enacted by the Congress—
(1) as an exercise of the rulemaking power of
the House of Representatives and the Senate, re-
spectively, and as such is deemed a part of the rules
of each House, respectively, but applicable only with
respect to the procedure to be followed in that
House in the case of approval resolutions described
in subsection (c), and supersedes other rules only to
the extent that such rules are inconsistent therewith;
and
(2) with full recognition of the constitutional
right of either House to change the rules (so far as
relating to the procedure of that House) at any time,
in the same manner and to the same extent as in
the case of any other rule of that House.
(c) TERMS OF THE RESOLUTION.—For purposes of
this part, the term ‘‘approval resolution’’ means only a
joint resolution of the two Houses of the Congress, provid-
ing in—
(1) the matter after the resolving clause of
which is as follows: ‘‘That the Congress approves the
recommendations of the Benefits Commission as
submitted 
by 
the 
Commission 
on
109
Title I, Subtitle D
llllllllllllll’’, the blank space
being filled in with the appropriate date; and
(2) the title of which is as follows: ‘‘Joint Reso-
lution approving the recommendation of the Benefits
Commission’’.
(d) INTRODUCTION AND REFERRAL.—On the day on
which a recommendation of the Commission is transmitted
to the House of Representatives and the Senate, an ap-
proval resolution with respect to such recommendation
shall be introduced (by request) in the House of Rep-
resentatives by the majority leader of the House, for him-
self or herself and the minority leader of the House, or
by Members of the House designated by the majority lead-
er and minority leader of the House; and shall be intro-
duced (by request) in the Senate by the majority leader
of the Senate, for himself or herself and the minority lead-
er of the Senate, or by Members of the Senate designated
by the majority leader and minority leader of the Senate.
If either House is not in session on the day on which such
recommendation is transmitted, the approval resolution
with respect to such recommendation shall be introduced
in the House, as provided in the preceding sentence, on
the first day thereafter on which the House is in session.
The approval resolution introduced in the House of Rep-
110
Title I, Subtitle D
resentatives and the Senate shall be referred to the appro-
priate committees of each House.
(e) AMENDMENTS PROHIBITED.—No amendment to
an approval resolution shall be in order in either the
House of Representatives or the Senate; and no motion
to suspend the application of this subsection shall be in
order in either House, nor shall it be in order in either
House for the Presiding Officer to entertain a request to
suspend the application of this subsection by unanimous
consent.
(f) PERIOD FOR COMMITTEE AND FLOOR CONSIDER-
ATION.—
(1) IN GENERAL.—Except as provided in para-
graph (2), if the committee or committees of either
House to which an approval resolution has been re-
ferred have not reported it at the close of the 30th
day after its introduction, such committee or com-
mittees shall be automatically discharged from fur-
ther consideration of the approval resolution and it
shall be placed on the appropriation calendar. A vote
on final passage of the approval resolution shall be
taken in each House on or before the close of the
30th day after the approval resolution is reported by
the committees or committee of that House to which
it was referred, or after such committee or commit-
111
Title I, Subtitle D
tees have been discharged from further consideration
of the approval resolution. If prior to the passage by
one House of an approval resolution of that House,
that House receives the same approval resolution
from the other House then—
(A) the procedure in that House shall be
the same as if no approval resolution had been
received from the other House; but
(B) the vote on final passage shall be on
the approval resolution of the other House.
(2) COMPUTATION OF DAYS.—For purposes of
paragraph (1), in computing a number of days in ei-
ther House, there shall be excluded any day on
which the House is not in session.
(g) FLOOR CONSIDERATION IN THE HOUSE OF REP-
RESENTATIVES.—
(1) MOTION TO PROCEED.—A motion in the
House of Representatives to proceed to the consider-
ation of an approval resolution shall be highly privi-
leged and not debatable. An amendment to the mo-
tion shall not be in order, nor shall it be in order
to move to reconsider the vote by which the motion
is agreed to or disagreed to.
(2) DEBATE.—Debate in the House of Rep-
resentatives on an approval resolution shall be lim-
112
Title I, Subtitle D
ited to not more than 20 hours, which shall be di-
vided equally between those favoring and those op-
posing the bill or resolution. A motion further to
limit debate shall not be debatable. It shall not be
in order to move to recommit an approval resolution
or to move to reconsider the vote by which an ap-
proval resolution is agreed to or disagreed to.
(3) MOTION TO POSTPONE.—Motions to post-
pone, made in the House of Representatives with re-
spect to the consideration of an approval resolution,
and motions to proceed to the consideration of other
business, shall be decided without debate.
(4) APPEALS.—All appeals from the decisions
of the chairperson relating to the application of the
Rules of the House of Representatives to the proce-
dure relating to an approval resolution shall be de-
cided without debate.
(5) GENERAL RULES APPLY.—Except to the ex-
tent specifically provided in the preceding provisions
of this subsection, consideration of an approval reso-
lution shall be governed by the Rules of the House
of Representatives applicable to other bills and reso-
lutions in similar circumstances.
(h) FLOOR CONSIDERATION IN THE SENATE.—
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Title I, Subtitle D
(1) MOTION TO PROCEED.—A motion in the
Senate to proceed to the consideration of an ap-
proval resolution shall be privileged and not debat-
able. An amendment to the motion shall not be in
order, nor shall it be in order to move to reconsider
the vote by which the motion is agreed to or dis-
agreed to.
(2) GENERAL DEBATE.—Debate in the Senate
on an approval resolution, and all debatable motions
and appeals in connection therewith, shall be limited
to not more than 20 hours. The time shall be equally
divided between, and controlled by, the majority
leader and the minority leader or their designees.
(3) DEBATE OF MOTIONS AND APPEALS.—De-
bate in the Senate on any debatable motion or ap-
peal in connection with an approval resolution shall
be limited to not more than 1 hour, to be equally di-
vided between, and controlled by, the mover and the
manager of the approval resolution, except that in
the event the manager of the approval resolution is
in favor of any such motion or appeal, the time in
opposition thereto, shall be controlled by the Minor-
ity Leader or his designee. Such leaders, or either of
them, may, from time under their control on the
passage of an approval resolution, allot additional
114
Title I, Subtitle E
time to any Senator during the consideration of any
debatable motion or appeal.
(4) OTHER MOTIONS.—A motion in the Senate
to further limit debate is not debatable. A motion to
recommit an approval resolution is not in order.
SEC. 1315. IMPLEMENTATION.
The provisions of a legislative proposal approved
under section 1314 shall become effective and a part of
the certification process of each State (and the Secretary)
on January 1 of the year following the year of the date
of approval of such proposal (unless such period of time
is less than 3 months, in which case such provisions shall
become effective on January 1 of the second year following
the date of approval of such proposal).
Subtitle E—State and Federal Re-
sponsibilities 
in 
Relation 
to
Qualified Health Plans
PART I—STATE RESPONSIBILITIES
Subpart A—General Responsibilities
SEC. 1401. ESTABLISHMENT OF STATE INSURANCE MARKET
REFORM PROGRAMS.
(a) IN GENERAL.—Each State shall establish a pro-
gram (in this part referred to as a ‘‘State program’’) to
carry out State responsibilities specified in this part.
115
Title I, Subtitle E
(b) SUMMARY OF RESPONSIBILITIES.—The State re-
sponsibilities under this subtitle include—
(1) the certification of insured health plans as
qualified insured health plans under section 1402,
including the enforcement of the insurance reform
standards;
(2) dissemination of information under section
1403;
(3) establishment of procedures for establish-
ment and operation of purchasing groups under sec-
tion 1404;
(4) preparation of information concerning plans
and purchasing groups under section 1405;
(5) providing for a risk adjustment program
and adjustment for differences in nonpayments
among qualified insured health plans under section
1406;
(6) development of a binding arbitration process
under section 1407; and
(7) specification of an annual general enroll-
ment period under section 1408.
(c) DEADLINE.—
(1) IN GENERAL.—Each State shall establish a
State program under this section by not later than
the deadline specified in paragraph (2).
116
Title I, Subtitle E
(2) DEADLINE.—The deadline specified in this
paragraph is the date that occurs 1 year after the
date of the insurance reform standards are estab-
lished under section 1102.
(d) PERIODIC SECRETARIAL REVIEW OF STATE PRO-
GRAMS.—
(1) IN GENERAL.—The Secretary may periodi-
cally review State programs established under sub-
section (a) to determine if such programs continue
to meet the requirements of subsection (b).
(2) REPORTING REQUIREMENTS OF STATES.—
For purposes of paragraph (1), each State shall sub-
mit to the Secretary, at intervals established by the
Secretary, a report on the compliance of the State
with the requirements of subsection (b).
(3) FAILURE OF STATE.—If the Secretary finds
that a State has failed to establish a State program
under subsection (a) by the deadline specified in
subsection (c)(2) or its State program has failed to
meet the requirements of subsection (b), the Sec-
retary shall notify the State of such finding and
shall assume, with respect to insured health plans
and groups in the State, the responsibilities of the
State with such a program under this part.
117
Title I, Subtitle E
SEC. 1402. CERTIFICATION OF INSURED HEALTH PLANS.
Each State program shall provide for the certification
of insured health plans as qualified insured health plans
if the appropriate certifying authority finds that the plan
meets the applicable requirements of subtitle B.
SEC. 1403. ESTABLISHMENT OF HEALTH CARE COVERAGE
AREAS.
(a) ESTABLISHMENT.—Each State program shall
provide, by not later than the deadline specified in section
1401(c)(2), for the division of the State into 1 or more
health care coverage areas or HCCAs. The program may
revise the boundaries of such areas from time to time con-
sistent with this section.
(b) MULTIPLE AREAS.—With respect to a HCCA—
(1) no metropolitan statistical area in a State
may be incorporated into more than 1 HCCA in
such State;
(2) the number of individuals residing within a
HCCA may not be less than 250,000; and
(3) no area incorporated in a HCCA may be in-
corporated into another HCCA.
(c) INTERSTATE AREAS.—Two or more contiguous
States may provide for the establishment of a HCCA that
includes adjoining portions of the States so long as all por-
tions of any metropolitan statistical area within such
States are within the same HCCA.
118
Title I, Subtitle E
SEC. 1404. PROCEDURES FOR PURCHASING GROUPS.
(a) PROCEDURES.—Consistent with part II of sub-
title B, each State program shall have procedures for the
establishment and operation of individual and small em-
ployer purchasing groups with respect to HCCAs within
such State.
(b) VOTING RIGHTS.—Such procedures shall specify
the voting rights of members of a purchasing group.
SEC. 1405. PREPARATION OF INFORMATION CONCERNING
PLANS AND PURCHASING GROUPS.
Each State program shall prepare and make available
to purchasing groups and employers located in the State
(and to eligible individuals upon request) information, in
comparative form, concerning the qualified health plans
certified by such State and purchasing groups operating
in the State. Such information shall include a description
of the following:
(1) The prices, outcomes, enrollee satisfaction,
and other information pertaining to the quality of
such plans.
(2) The HCCAs in the State and the qualified
health plans available with respect to each HCCA.
(3) The existence of purchasing groups within
each such HCCA.
(4) Any other information determined appro-
priate by the State.
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Title I, Subtitle E
SEC. 1407. DEVELOPMENT OF BINDING ARBITRATION
PROCESS.
Each State program shall establish an arbitration
process that—
(1) resolves in a timely manner disputes con-
cerning—
(A) a claim for payment or provision of
benefits under a qualified insured health plan;
(B) a request for preauthorization of items
or services which is submitted to such a plan
prior to receipt of the items or services; or
(C) decisions by a plan relating to the cov-
erage of a particular item or service for enroll-
ees generally; and
(2) with respect to disputes involving a deter-
mination by a plan that an item or service is not
medically necessary or appropriate with respect to a
specific enrollee, requires a person who contests such
determination to demonstrate to an arbitrator by a
preponderance of the evidence that the determina-
tion is inappropriate based on the available scientific
evidence.
SEC. 1408. SPECIFICATION OF ANNUAL GENERAL ENROLL-
MENT PERIOD.
Each State program shall specify an annual period,
of not less than 30 days, during which eligible employees
121
Title I, Subtitle E
and eligible individuals in the State may enroll in qualified
insured health plans or change the qualified insured health
plan in which the individual is enrolled.
Subpart B—Waiver of Requirements
SEC. 1421. ALTERNATE STATE SYSTEMS ALLOWED.
(a) WAIVER AUTHORITY.—
(1) IN GENERAL.—In accordance with this sec-
tion, each State may submit an application to the
Secretary to waive the requirements specified in sub-
section (b) as they apply to the State (and to quali-
fied insured health plans and purchasing groups in
the State).
(2) ESTABLISHMENT OF CRITERIA.—The Sec-
retary shall establish criteria for the approval of
such waiver applications.
(3) EXPEDITED
PROCEDURE.—The Secretary
shall establish an expedited procedure for the consid-
eration and disposition of waiver applications under
this subsection. The procedure established by the
Secretary shall provide that such consideration and
disposition shall be completed within 90 days.
(b) REQUIREMENTS SPECIFIED.—The requirements
specified in this subsection are as follows: