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ket, respectively, as defined in section 2791 of the 
Public Health Service Act. 
(d) TREATMENT OF QUALIFIED DIRECT PRIMARY 
CARE MEDICAL HOME PLANS.—The Commissioner may 
permit a qualified health benefits plan to provide coverage 
through a qualified direct primary care medical home plan 
so long as the qualified health benefits plan meets all re-
quirements that are otherwise applicable and the services 
covered by the medical home plan are coordinated with 
the QHBP offering entity. 
SEC. 202. 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-
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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. 
(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-
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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 201, including the essential 
benefit package requirement under section 221. 
(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 (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 
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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 (which may be a high deducible health plan, as 
defined in section 223(c)(2) of the Internal Revenue 
Code of 1986) that is described in such paragraph 
shall be treated as acceptable coverage under this di-
vision. 
(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-par-
ticipating health benefits plan. 
(2) SEPARATE, EXCEPTED
COVERAGE
PER-
MITTED.—Nothing in— 
(A) paragraph (1) shall prevent the offer-
ing of excepted benefits described in section 
2791(c) of the Public Health Service Act so 
long as such benefits are offered outside the 
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Health Insurance Exchange and are priced sep-
arately from health insurance coverage; and 
(B) this division shall be construed— 
(i) to prevent the offering of a stand- 
alone plan that offers coverage of excepted 
benefits described 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 
(ii) as applying requirements for a 
qualified health benefits plan to such a 
stand-alone plan that is offered and priced 
separately from a qualified health benefits 
plan. 
Subtitle 
B—Standards 
Guaran-
teeing Access to Affordable Cov-
erage 
SEC. 211. PROHIBITING PREEXISTING CONDITION EXCLU-
SIONS. 
A qualified health benefits plan may not impose any 
preexisting 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 
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on any of the following: health status, medical condition, 
claims experience, receipt of health care, medical history, 
genetic information, evidence of insurability, disability, or 
source of injury (including conditions arising out of acts 
of domestic violence) or any similar factors. 
SEC. 212. GUARANTEED ISSUE AND RENEWAL FOR IN-
SURED PLANS AND PROHIBITING RESCIS-
SIONS. 
The requirements of sections 2711 (other than sub-
sections (e) and (f)) 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 enrollee has an opportunity to correct such non-
payment. Rescissions of such coverage shall be prohibited 
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except in cases of fraud as defined in section 2712(b)(2) 
of such Act. 
SEC. 213. INSURANCE RATING RULES. 
(a) IN GENERAL.—The premium rate charged for a 
qualified health benefits plan that is health insurance cov-
erage 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.— 
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(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 
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 
midsize 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 
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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 
for small and midsize employers to self-insure or cre-
ate 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 Commis-
sioner shall submit to Congress and the applicable 
agencies an updated report on such study, including 
updates on such recommendations. 
SEC. 214. 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 section 702 of the Employee 
Retirement Income Security Act of 1974, section 2702 of 
the Public Health Service Act, and section 9802 of the 
Internal 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 
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C, the provisions of section 2705 (other than subsections 
(a)(1), (a)(2), and (c)) of the Public Health Service Act 
shall apply to a qualified health benefits plan, regardless 
of whether it is offered in the individual or group market, 
in the same manner as such provisions apply to health 
insurance coverage offered in the large group market. 
SEC. 215. 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 among providers participating in the network and 
policies for accessing out-of-network providers. 
(b) INTERNET ACCESS TO INFORMATION.—A quali-
fied health benefits plan that uses a provider network shall 
provide a current listing of all providers in its network 
on its Website and such data shall be available on the 
Health Insurance Exchange Website as a part of the basic 
information on that plan. The Commissioner shall also es-
tablish an on-line system whereby an individual may select 
by name any medical provider (as defined by the Commis-
sioner) and be informed of the plan or plans with which 
that provider is contracting. 
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(c) PROVIDER NETWORK DEFINED.—In this division, 
the term ‘‘provider network’’ means the providers with re-
spect to which covered benefits, treatments, and services 
are available under a health benefits plan. 
SEC. 216. REQUIRING THE OPTION OF EXTENSION OF DE-
PENDENT 
COVERAGE 
FOR 
UNINSURED 
YOUNG ADULTS. 
(a) IN GENERAL.—A qualified health benefits plan 
shall make available, at the option of the principal enrollee 
under the plan, coverage for one or more qualified children 
(as defined in subsection (b)) of the enrollee. 
(b) QUALIFIED CHILD DEFINED.—In this section, 
the term ‘‘qualified child’’ means, with respect to a prin-
cipal enrollee in a qualified health benefits plan, an indi-
vidual who (but for age) would be treated as a dependent 
child of the enrollee under such plan and who— 
(1) is under 27 years of age; and 
(2) is not enrolled in a health benefits plan 
other than under this section. 
(c) PREMIUMS.—Nothing in this section shall be con-
strued as preventing a qualified health benefits plan from 
increasing the premiums otherwise required for coverage 
provided under this section consistent with standards es-
tablished by the Commissioner based upon family size 
under section 213(a)(3). 
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SEC. 217. CONSISTENCY OF COSTS AND COVERAGE UNDER 
QUALIFIED HEALTH BENEFITS PLANS DUR-
ING PLAN YEAR. 
In the case of health insurance coverage offered 
under a qualified health benefits plan, if the coverage de-
creases or the cost-sharing increases, the issuer of the cov-
erage shall notify enrollees of the change at least 90 days 
before the change takes effect (or such shorter period of 
time in cases where the change is necessary to ensure the 
health and safety of enrollees). 
Subtitle 
C—Standards 
Guaran-
teeing Access to Essential Bene-
fits 
SEC. 221. 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 224 for the essential ben-
efits package described in section 222 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-
erage in addition to the essential benefits package as 
the QHBP offering entity may specify. 
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(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 
outside of the Health Insurance Exchange and 
under State law of health benefits in the form of ex-
cepted 
benefits 
(described 
in 
section 
202(b)(1)(B)(ii)) if such benefits are offered under 
a separate policy, contract, or certificate of insur-
ance. 
(c) CLINICAL APPROPRIATENESS.—Nothing in this 
Act shall be construed to prohibit a group health plan or 
health insurance issuer from using medical management 
practices so long as such management practices are based 
on valid medical evidence and are relevant to the patient 
whose medical treatment is under review. 
(d) PROVISION OF BENEFITS.—Nothing in this divi-
sion shall be construed as prohibiting a qualified health 
benefits plan from subcontracting with stand-alone health 
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insurance issuers or insurers for the provision of dental, 
vision, mental health, and other benefits and services. 
SEC. 222. 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 224, to 
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 215(a) (relating to 
network adequacy); and 
(5) is equivalent in its scope of benefits, as cer-
tified by Office of the Actuary of the Centers for 
Medicare & Medicaid Services, to the average pre-
vailing employer-sponsored coverage in Y1. 
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In order to carry out paragraph (5), the Secretary of 
Labor shall conduct a survey of employer-sponsored cov-
erage to determine the benefits typically covered by em-
ployers, including multiemployer plans, and provide a re-
port on such survey to the Health Benefits Advisory Com-
mittee and to the Secretary of Health and Human Serv-
ices. 
(b) MINIMUM SERVICES TO BE COVERED.—Subject 
to subsection (d), the items and services described in this 
subsection are the following: 
(1) Hospitalization. 
(2) Outpatient hospital and outpatient clinic 
services, including emergency department services. 
(3) Professional services of physicians and other 
health professionals. 
(4) Such services, equipment, and supplies inci-
dent to the services of a physician’s or a health pro-
fessional’s delivery of care in institutional settings, 
physician offices, patients’ homes or place of resi-
dence, or other settings, as appropriate. 
(5) Prescription drugs. 
(6) Rehabilitative and habilitative services. 
(7) Mental health and substance use disorder 
services, including behavioral health treatments. 
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(A) ANNUAL LIMITATION.—The cost-shar-
ing incurred under the essential benefits pack-
age with respect to an individual (or family) for 
a year does not exceed the applicable level spec-
ified in subparagraph (B). 
(B) APPLICABLE LEVEL.—The applicable 
level specified in this subparagraph for Y1 is 
not to exceed $5,000 for an individual and not 
to exceed $10,000 for a family. Such levels 
shall be increased (rounded to the nearest 
$100) for each subsequent year by the annual 
percentage increase in the enrollment-weighted 
average of premium increases for basic plans 
applicable to such year, except that Secretary 
shall adjust such increase to ensure that the ap-
plicable level specified in this subparagraph 
meets the minimum actuarial value required 
under paragraph (3). 
(C) USE OF COPAYMENTS.—In establishing 
cost-sharing levels for basic, enhanced, and pre-
mium plans under this subsection, the Sec-
retary shall, to the maximum extent possible, 
use only copayments and not coinsurance. 
(3) MINIMUM ACTUARIAL VALUE.— 
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(A) IN GENERAL.—The cost-sharing under 
the essential benefits package shall be designed 
to provide a level of coverage that is designed 
to provide benefits that are actuarially equiva-
lent to approximately 70 percent of the full ac-
tuarial value of the benefits provided under the 
reference benefits package described in sub-
paragraph (B). 
(B) REFERENCE BENEFITS PACKAGE DE-
SCRIBED.—The reference benefits package de-
scribed in this subparagraph is the essential 
benefits package if there were no cost-sharing 
imposed. 
(d) ASSESSMENT AND COUNSELING FOR DOMESTIC 
VIOLENCE.—The Secretary shall support the need for an 
assessment and brief counseling for domestic violence as 
part of a behavioral health assessment or primary care 
visit and determine the appropriate coverage for such as-
sessment and counseling. 
(e) ABORTION COVERAGE PROHIBITED AS PART OF 
MINIMUM BENEFITS PACKAGE.— 
(1) PROHIBITION OF REQUIRED COVERAGE.— 
The Health Benefits Advisory Committee may not 
recommend under section 223(b), and the Secretary 
may not adopt in standards under section 224(b), 
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the services described in paragraph (4)(A) or (4)(B) 
as part of the essential benefits package and the 
Commissioner may not require such services for 
qualified health benefits plans to participate in the 
Health Insurance Exchange. 
(2) VOLUNTARY
CHOICE
OF
COVERAGE
BY 
PLAN.—In the case of a qualified health benefits 
plan, the plan is not required (or prohibited) under 
this Act from providing coverage of services de-
scribed in paragraph (4)(A) or (4)(B) and the 
QHBP offering entity shall determine whether such 
coverage is provided. 
(3) ABORTION SERVICES.— 
(A) ABORTIONS FOR WHICH PUBLIC FUND-
ING IS PROHIBITED.—The services described in 
this subparagraph are abortions for which the 
expenditure of Federal funds appropriated for 
the Department of Health and Human Services 
is not permitted, based on the law as in effect 
as of the date that is 6 months before the be-
ginning of the plan year involved. 
(B) ABORTIONS FOR WHICH PUBLIC FUND-
ING
IS
ALLOWED.—The services described in 
this subparagraph are abortions for which the 
expenditure of Federal funds appropriated for 
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the Department of Health and Human Services 
is permitted, based on the law as in effect as 
of the date that is 6 months before the begin-
ning of the plan year involved. 
(f) REPORT
REGARDING
INCLUSION
OF
ORAL 
HEALTH CARE IN ESSENTIAL BENEFITS PACKAGE.—Not 
later than 1 year after the date of the enactment of this 
Act, the Secretary of Health and Human Services shall 
submit to Congress a report containing the results of a 
study determining the need and cost of providing acces-
sible and affordable oral health care to adults as part of 
the essential benefits package. 
SEC. 223. HEALTH BENEFITS ADVISORY COMMITTEE. 
(a) ESTABLISHMENT.— 
(1) IN GENERAL.—There is established a pri-
vate-public advisory committee which shall be a 
panel of medical and other experts to be known as 
the Health Benefits Advisory Committee to rec-
ommend covered benefits and essential, enhanced, 
and premium plans. 
(2) CHAIR.—The Surgeon General shall be a 
member and the chair of the Health Benefits Advi-
sory Committee. 
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(3) MEMBERSHIP.—The Health Benefits Advi-
sory Committee shall be composed of the following 
members, in addition to the Surgeon General: 
(A) Nine members who are not Federal 
employees or officers and who are appointed by 
the President. 
(B) Nine members who are not Federal 
employees or officers and who are appointed by 
the Comptroller General of the United States in 
a manner similar to the manner in which the 
Comptroller General appoints members to the 
Medicare Payment Advisory Commission under 
section 1805(c) of the Social Security Act. 
(C) Such even number of members (not to 
exceed 8) who are Federal employees and offi-
cers, as the President may appoint. 
Such initial appointments shall be made not later 
than 60 days after the date of the enactment of this 
Act. 
(4) TERMS.—Each member of the Health Bene-
fits Advisory Committee shall serve a 3-year term on 
the Committee, except that the terms of the initial 
members shall be adjusted in order to provide for a 
staggered term of appointment for all such mem-
bers. 
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(5) PARTICIPATION.—The membership of the 
Health Benefits Advisory Committee shall at least 
reflect providers, patient representatives, employers 
(including small employers), labor, health insurance 
issuers, experts in health care financing and deliv-
ery, experts in oral health care, experts in racial and 
ethnic disparities, experts on health care needs and 
disparities of individuals with disabilities, represent-
atives of relevant governmental agencies, and at 
least one practicing physician or other health profes-
sional and an expert in child and adolescent health 
and shall represent a balance among various sectors 
of the health care system so that no single sector 
unduly influences the recommendations of such 
Committee. 
(b) DUTIES.— 
(1) RECOMMENDATIONS
ON
BENEFIT
STAND-
ARDS.—The Health Benefits Advisory Committee 
shall recommend to the Secretary of Health and 
Human Services (in this subtitle referred to as the 
‘‘Secretary’’) benefit standards (as defined in para-
graph (5)), and periodic updates to such standards. 
In developing such recommendations, the Committee 
shall take into account innovation in health care and 
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consider how such standards could reduce health dis-
parities. 
(2) DEADLINE.—The Health Benefits Advisory 
Committee shall recommend initial benefit standards 
to the Secretary not later than 1 year after the date 
of the enactment of this Act. 
(3) STATE INPUT.—The Health Benefits Advi-
sory Committee shall examine the health coverage 
laws and benefits of each State in developing rec-
ommendations under this subsection and may incor-
porate such coverage and benefits as the Committee 
determines to be appropriate and consistent with 
this Act. The Health Benefits Advisory Committee 
shall also seek input from the States and consider 
recommendations on how to ensure quality of health 
coverage in all States. 
(4) PUBLIC INPUT.—The Health Benefits Advi-
sory Committee shall allow for public input as a part 
of developing recommendations under this sub-
section. 
(5) BENEFIT
STANDARDS
DEFINED.—In this 
subtitle, the term ‘‘benefit standards’’ means stand-
ards respecting— 
(A) the essential benefits package de-
scribed in section 222, including categories of 
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with applicable provisions under subchapter I of 
chapter 57 of title 5, United States Code, and shall 
otherwise serve without additional pay. 
(2) MEMBERS NOT TREATED AS FEDERAL EM-
PLOYEES.—Members of the Health Benefits Advi-
sory Committee shall not be considered employees of 
the Federal Government solely by reason of any 
service on the Committee, except such members shall 
be considered to be within the meaning of section 
202(a) of title 18, United States Code, for the pur-
poses of disclosure and management of conflicts of 
interest. 
(3) APPLICATION OF FACA.—The Federal Advi-
sory Committee Act (5 U.S.C. App.), other than sec-
tion 14, shall apply to the Health Benefits Advisory 
Committee. 
(d) PUBLICATION.—The Secretary shall provide for 
publication in the Federal Register and the posting on the 
Internet Website of the Department of Health and Human 
Services of all recommendations made by the Health Ben-
efits Advisory Committee under this section. 
SEC. 224. PROCESS FOR ADOPTION OF RECOMMENDA-
TIONS; ADOPTION OF BENEFIT STANDARDS. 
(a) PROCESS
FOR ADOPTION
OF RECOMMENDA-
TIONS.— 
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(1) REVIEW OF RECOMMENDED STANDARDS.— 
Not later than 45 days after the date of receipt of 
benefit standards recommended under section 223 
(including such standards as modified under para-
graph (2)(B)), the Secretary shall review such 
standards and shall determine whether to propose 
adoption of such standards as a package. 
(2) DETERMINATION TO ADOPT STANDARDS.— 
If the Secretary determines— 
(A) to propose adoption of benefit stand-
ards so recommended as a package, the Sec-
retary shall, by regulation under section 553 of 
title 5, United States Code, propose adoption of 
such standards; or 
(B) not to propose adoption of such stand-
ards as a package, the Secretary shall notify 
the Health Benefits Advisory Committee in 
writing of such determination and the reasons 
for not proposing the adoption of such rec-
ommendation and provide the Committee with a 
further opportunity to modify its previous rec-
ommendations and submit new recommenda-
tions to the Secretary on a timely basis. 
(3) CONTINGENCY.—If, because of the applica-
tion of paragraph (2)(B), the Secretary would other-
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wise be unable to propose initial adoption of such 
recommended standards by the deadline specified in 
subsection (b)(1), the Secretary shall, by regulation 
under section 553 of title 5, United States Code, 
propose adoption of initial benefit standards by such 
deadline. 
(4) PUBLICATION.—The Secretary shall provide 
for publication in the Federal Register of all deter-
minations made by the Secretary under this sub-
section. 
(b) ADOPTION OF STANDARDS.— 
(1) INITIAL
STANDARDS.—Not later than 18 
months after the date of the enactment of this Act, 
the Secretary shall, through the rulemaking process 
consistent with subsection (a), adopt an initial set of 
benefit standards. 
(2) PERIODIC UPDATING STANDARDS.—Under 
subsection (a), the Secretary shall provide for the 
periodic updating of the benefit standards previously 
adopted under this section. 
(3) REQUIREMENT.—The Secretary may not 
adopt any benefit standards for an essential benefits 
package or for level of cost-sharing that are incon-
sistent with the requirements for such a package or 
level under sections 222 and 223(b)(5). 
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Subtitle D—Additional Consumer 
Protections 
SEC. 231. REQUIRING FAIR MARKETING PRACTICES BY 
HEALTH INSURERS. 
The Commissioner shall establish uniform marketing 
standards that all QHBP offering entities shall meet with 
respect to qualified health benefits plans that are health 
insurance coverage. 
SEC. 232. REQUIRING FAIR GRIEVANCE AND APPEALS 
MECHANISMS. 
(a) IN GENERAL.—A QHBP offering entity shall pro-
vide for timely grievance and appeals mechanisms with re-
spect to qualified health benefits plans that the Commis-
sioner shall establish consistent with this section. The 
Commissioner shall establish time limits for each of such 
mechanisms and implement them in a manner that is pro-
tective to the needs of patients. 
(b) INTERNAL CLAIMS AND APPEALS PROCESS.— 
Under a qualified health benefits plan the QHBP offering 
entity shall provide an internal claims and appeals process 
that initially incorporates the claims and appeals proce-
dures (including urgent claims) set forth at section 
2560.503–1 of title 29, Code of Federal Regulations, as 
published on November 21, 2000 (65 Fed. Reg. 70246) 
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and shall update such process in accordance with any 
standards that the Commissioner may establish. 
(c) EXTERNAL REVIEW PROCESS.— 
(1) IN GENERAL.—The Commissioner shall es-
tablish an external review process (including proce-
dures for expedited reviews of urgent claims) that 
provides for an impartial, independent, and de novo 
review of denied claims under this division. 
(2) REQUIRING FAIR GRIEVANCE AND APPEALS 
MECHANISMS.—A determination made, with respect 
to a qualified health benefits plan offered by a 
QHBP offering entity, under the external review 
process established under this subsection shall be 
binding on the plan and the entity. 
(d) TIME LIMITS.—The Commissioner shall establish 
time limits for each of these processes and implement 
them in a manner that is protective to the patient. 
(e) CONSTRUCTION.—Nothing in this section shall be 
construed as affecting the availability of judicial review 
under State law for adverse decisions under subsection (b) 
or (c), subject to section 251. 
SEC. 233. REQUIRING INFORMATION TRANSPARENCY AND 
PLAN DISCLOSURE. 
(a) ACCURATE AND TIMELY DISCLOSURE.— 
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(1) FOR
EXCHANGE-PARTICIPATING
HEALTH 
BENEFITS PLANS.—A QHBP offering entity offering 
an Exchange-participating health benefits plan shall 
comply with standards established by the Commis-
sioner for the accurate and timely disclosure to the 
Commissioner and the public of plan documents, 
plan terms and conditions, claims payment policies 
and practices, periodic financial disclosure, data on 
enrollment, data on disenrollment, data on the num-
ber of claims denials, data on rating practices, infor-
mation on cost-sharing and payments with respect to 
any out-of-network coverage, and other information 
as determined appropriate by the Commissioner. 
(2) EMPLOYMENT-BASED HEALTH PLANS.—The 
Secretary of Labor shall update and harmonize the 
Secretary’s rules concerning the accurate and timely 
disclosure to participants by group health plans of 
plan disclosure, plan terms and conditions, and peri-
odic financial disclosure with the standards estab-
lished by the Commissioner under paragraph (1). 
(3) USE OF PLAIN LANGUAGE.— 
(A) IN GENERAL.—The disclosures under 
paragraphs (1) and (2) shall be provided in 
plain language. 
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(B) DEFINITION.—In this paragraph, the 
term ‘‘plain language’’ means language that the 
intended audience, including individuals with 
limited English proficiency, can readily under-
stand and use because that language is concise, 
well-organized, and follows other best practices 
of plain language writing. 
(C) GUIDANCE.—The Commissioner and 
the Secretary of Labor shall jointly develop and 
issue guidance on best practices of plain lan-
guage writing. 
(4) INFORMATION ON RIGHTS.—The informa-
tion disclosed under this subsection shall include in-
formation on enrollee and participant rights under 
this division. 
(5) COST-SHARING
TRANSPARENCY.—A quali-
fied health benefits plan shall allow individuals to 
learn 
the 
amount 
of 
cost-sharing 
(including 
deductibles, copayments, and coinsurance) under the 
individual’s plan or coverage that the individual 
would be responsible for paying with respect to the 
furnishing of a specific item or service by a partici-
pating provider in a timely manner upon request. At 
a minimum, this information shall be made available 
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to such individual via an Internet Website and other 
means for individuals without access to the Internet. 
(b) CONTRACTING REIMBURSEMENT.—A qualified 
health benefits plan shall comply with standards estab-
lished by the Commissioner to ensure transparency to each 
health care provider relating to reimbursement arrange-
ments between such plan and such provider. 
(c) PHARMACY BENEFIT MANAGERS TRANSPARENCY 
REQUIREMENTS.— 
(1) IN GENERAL.—If a QHBP offering entity 
contracts with a pharmacy benefit manager or other 
entity (in this subsection referred to as a ‘‘PBM’’) 
to manage prescription drug coverage or otherwise 
control prescription drug costs under a qualified 
health benefits plan, the PBM shall provide at least 
annually to the Commissioner and to the QHBP of-
fering entity offering such plan the following infor-
mation, in a form and manner to be determined by 
the Commissioner: 
(A) Information on the number and total 
cost of prescriptions under the contract that are 
filled via mail order and at retail pharmacies. 
(B) An estimate of aggregate average pay-
ments under the contract, per prescription 
(weighted by prescription volume), made to mail 
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order and retail pharmacies, and the average 
amount, per prescription, that the PBM was 
paid by the plan for prescriptions filled at mail 
order and retail pharmacists. 
(C) An estimate of the aggregate average 
payment per prescription (weighted by prescrip-
tion volume) under the contract received from 
pharmaceutical manufacturers, including all re-
bates, discounts, prices concessions, or adminis-
trative, and other payments from pharma-
ceutical manufacturers, and a description of the 
types of payments, and the amount of these 
payments that were shared with the plan, and 
a description of the percentage of prescriptions 
for which the PBM received such payments. 
(D) Information on the overall percentage 
of generic drugs dispensed under the contract 
at retail and mail order pharmacies, and the 
percentage of cases in which a generic drug is 
dispensed when available. 
(E) Information on the percentage and 
number of cases under the contract in which in-
dividuals were switched because of PBM poli-
cies or at the direct or indirect control of the 
PBM from a prescribed drug that had a lower 
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cost for the QHBP offering entity to a drug 
that had a higher cost for the QHBP offering 
entity, the rationale for these switches, and a 
description of the PBM policies governing such 
switches. 
(2) CONFIDENTIALITY OF INFORMATION.—In-
formation disclosed by a PBM to the Commissioner 
or a QHBP offering entity under this subsection is 
confidential and shall not be disclosed by the Com-
missioner or the QHBP offering entity in a form 
which discloses the identity of a specific PBM or 
prices charged by such PBM or a specific retailer, 
manufacturer, or wholesaler, except only by the 
Commissioner— 
(A) to permit State or Federal law enforce-
ment authorities to use the information pro-
vided for program compliance purposes and for 
the purpose of combating waste, fraud, and 
abuse; 
(B) to permit the Comptroller General, the 
Medicare Payment Advisory Commission, or the 
Secretary of Health and Human Services to re-
view the information provided; and 
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(C) to permit the Director of the Congres-
sional Budget Office to review the information 
provided. 
(3) ANNUAL PUBLIC REPORT.—On an annual 
basis, the Commissioner shall prepare a public re-
port providing industrywide aggregate or average in-
formation to be used in assessing the overall impact 
of PBMs on prescription drug prices and spending. 
Such report shall not disclose the identity of a spe-
cific PBM, or prices charged by such PBM, or a 
specific retailer, manufacturer, or wholesaler, or any 
other confidential or trade secret information. 
(4) PENALTIES.—The provisions of subsection 
(b)(3)(C) of section 1927 shall apply to a PBM that 
fails to provide information required under sub-
section (a) or that knowingly provides false informa-
tion in the same manner as such provisions apply to 
a manufacturer with an agreement under such sec-
tion that fails to provide information under sub-
section (b)(3)(A) of such section or knowingly pro-
vides false information under such section, respec-
tively. 
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SEC. 234. APPLICATION TO QUALIFIED HEALTH BENEFITS 
PLANS 
NOT 
OFFERED 
THROUGH 
THE 
HEALTH INSURANCE EXCHANGE. 
The requirements of the previous provisions of this 
subtitle shall apply to qualified health benefits plans that 
are not being offered through the Health Insurance Ex-
change only to the extent specified by the Commissioner. 
SEC. 235. TIMELY PAYMENT OF CLAIMS. 
A QHBP offering entity shall comply with the re-
quirements of section 1857(f) of the Social Security Act 
with respect to a qualified health benefits plan it offers 
in the same manner as a Medicare Advantage organization 
is required to comply with such requirements with respect 
to a Medicare Advantage plan it offers under part C of 
Medicare. 
SEC. 236. STANDARDIZED RULES FOR COORDINATION AND 
SUBROGATION OF BENEFITS. 
The Commissioner shall establish standards for the 
coordination and subrogation of benefits and reimburse-
ment of payments in cases of qualified health benefits 
plans involving individuals and multiple plan coverage. 
SEC. 237. APPLICATION OF ADMINISTRATIVE SIMPLIFICA-
TION. 
A QHBP offering entity is required to comply with 
administrative simplification provisions under part C of 
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title XI of the Social Security Act with respect to qualified 
health benefits plans it offers. 
SEC. 
238. 
STATE 
PROHIBITIONS 
ON 
DISCRIMINATION 
AGAINST HEALTH CARE PROVIDERS. 
This Act (and the amendments made by this Act) 
shall not be construed as superseding laws, as they now 
or hereinafter exist, of any State or jurisdiction designed 
to prohibit a qualified health benefits plan from discrimi-
nating with respect to participation, reimbursement, cov-
ered services, indemnification, or related requirements 
under such plan against a health care provider that is act-
ing within the scope of that provider’s license or certifi-
cation under applicable State law. 
SEC. 239. PROTECTION OF PHYSICIAN PRESCRIBER INFOR-
MATION. 
(a) STUDY.—The Secretary of Health and Human 
Services shall conduct a study on the use of physician pre-
scriber information in sales and marketing practices of 
pharmaceutical manufacturers. 
(b) REPORT.—Based on the study conducted under 
subsection (a), the Secretary shall submit to Congress a 
report on actions needed to be taken by the Congress or 
the Secretary to protect providers from biased marketing 
and sales practices. 
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SEC. 240. DISSEMINATION OF ADVANCE CARE PLANNING 
INFORMATION. 
(a) IN GENERAL.—The QHBP offering entity — 
(1) shall provide for the dissemination of infor-
mation related to end-of-life planning to individuals 
seeking enrollment in Exchange-participating health 
benefits plans offered through the Exchange; 
(2) shall present such individuals with— 
(A) the option to establish advanced direc-
tives and physician’s orders for life sustaining 
treatment according to the laws of the State in 
which the individual resides; and 
(B) information related to other planning 
tools; and 
(3) shall not promote suicide, assisted suicide, 
euthanasia, or mercy killing. 
The information presented under paragraph (2) shall not 
presume the withdrawal of treatment and shall include 
end-of-life planning information that includes options to 
maintain all or most medical interventions. 
(b) CONSTRUCTION.— Nothing in this section shall 
be construed— 
(1) to require an individual to complete an ad-
vanced directive or a physician’s order for life sus-
taining treatment or other end-of-life planning docu-
ment; 
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(2) to require an individual to consent to re-
strictions on the amount, duration, or scope of med-
ical benefits otherwise covered under a qualified 
health benefits plan; or 
(3) to promote suicide, assisted suicide, eutha-
nasia, or mercy killing. 
(c) ADVANCED DIRECTIVE DEFINED.—In this sec-
tion, the term ‘‘advanced directive’’ includes a living will, 
a comfort care order, or a durable power of attorney for 
health care. 
(d) PROHIBITION ON THE PROMOTION OF ASSISTED 
SUICIDE.— 
(1) IN GENERAL.—Subject to paragraph (3), 
information provided to meet the requirements of 
subsection (a)(2) shall not include advanced direc-
tives or other planning tools that list or describe as 
an option suicide, assisted suicide, euthanasia, or 
mercy killing, regardless of legality. 
(2) CONSTRUCTION.—Nothing in paragraph (1) 
shall be construed to apply to or affect any option 
to— 
(A) withhold or withdraw of medical treat-
ment or medical care; 
(B) withhold or withdraw of nutrition or 
hydration; and 
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(C) provide palliative or hospice care or 
use an item, good, benefit, or service furnished 
for the purpose of alleviating pain or discom-
fort, even if such use may increase the risk of 
death, so long as such item, good, benefit, or 
service is not also furnished for the purpose of 
causing, or the purpose of assisting in causing, 
death, for any reason. 
(3) NO PREEMPTION OF STATE LAW.—Nothing 
in this section shall be construed to preempt or oth-
erwise have any effect on State laws regarding ad-
vance care planning, palliative care, or end-of-life de-
cision-making. 
Subtitle E—Governance 
SEC. 241. HEALTH CHOICES ADMINISTRATION; HEALTH 
CHOICES COMMISSIONER. 
(a) IN GENERAL.—There is hereby established, as an 
independent agency in the executive branch of the Govern-
ment, a Health Choices Administration (in this division 
referred to as the ‘‘Administration’’). 
(b) COMMISSIONER.— 
(1) IN GENERAL.—The Administration shall be 
headed by a Health Choices Commissioner (in this 
division referred to as the ‘‘Commissioner’’) who 
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(ii) The effectiveness of the processes 
used in remedying such erroneous deter-
minations. 
(iii) The impact of such systems on 
individuals, health care providers, and Fed-
eral and State agencies, including the ef-
fect of erroneous determinations under 
such systems. 
(iv) The effectiveness of such systems 
in preventing ineligible individuals from re-
ceiving for affordability credits. 
(v) The characteristics of applicants 
described in subparagraph (E)(i). 
(G) PROHIBITION OF DATABASE.—Nothing 
in this paragraph or the amendments made by 
paragraph (6) shall be construed as authorizing 
the Health Choices Commissioner or the Com-
missioner of Social Security to establish a data-
base of information on citizenship or immigra-
tion status. 
(H) INITIAL FUNDING.— 
(i) IN GENERAL.—Out of any funds in 
the Treasury not otherwise appropriated, 
there is appropriated to the Commissioner 
of Social Security $30,000,000, to be avail-
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