1253 
(4) HEALTH
DELIVERY
REFORM.—This 
division institutes health delivery system 
reforms both to increase quality and to 
reduce growth in health spending 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 defini-
tions. 
TITLE I—PROTECTIONS AND STANDARDS FOR QUALIFIED 
HEALTH BENEFITS PLANS 
Subtitle A—General Standards 
Sec. 101. Requirements reforming health insurance market-
place. 
Sec. 102. Protecting the choice to keep current coverage. 
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 standards. 
Subtitle D—Additional Consumer Protections 
Sec. 131. Requiring fair marketing practices by health insur-
ers. 
Sec. 132. Requiring fair grievance and appeals mechanisms. 
Sec. 133. Requiring information transparency and plan disclo-
sure. 
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Sec. 134. Application to qualified health benefits plans not of-
fered 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 Com-
missioner. 
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; definitions. 
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 indi-
viduals and employers 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. 
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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 em-
ployee and dependent coverage. 
Sec. 313. Employer contributions in lieu of coverage. 
Sec. 314. Authority related to improper steering. 
PART 2—SATISFACTION OF HEALTH COVERAGE PARTICIPATION 
REQUIREMENTS 
Sec. 321. Satisfaction of health coverage participation require-
ments under the Employee Retirement Income Se-
curity Act of 1974. 
Sec. 322. Satisfaction of health coverage participation require-
ments under the Internal Revenue Code of 1986. 
Sec. 323. Satisfaction of health coverage participation require-
ments under the Public Health Service Act. 
Sec. 324. Additional rules relating to health coverage partici-
pation requirements. 
TITLE IV—AMENDMENTS TO INTERNAL REVENUE CODE 
OF 1986 
Subtitle A—Shared Responsibility 
PART 1—INDIVIDUAL RESPONSIBILITY 
Sec. 401. Tax on individuals without acceptable health care 
coverage. 
PART 2—EMPLOYER RESPONSIBILITY 
Sec. 411. Election to satisfy health coverage participation re-
quirements. 
Sec. 412. Responsibilities of nonelecting employers. 
Subtitle B—Credit for Small Business Employee Health 
Coverage Expenses 
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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. Distributions for medicine qualified only if for pre-
scribed drug or insulin. 
Sec. 443. Delay in application of worldwide allocation of inter-
est. 
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. 
PART 3—PARITY IN HEALTH BENEFITS 
Sec. 461. Certain health related benefits applicable to spouses 
and dependents extended to eligible beneficiaries. 
(c) GENERAL DEFINITIONS.—Except as oth-
erwise provided, in this division: 
(1) ACCEPTABLE COVERAGE.—The term 
‘‘acceptable 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 ‘‘Com-
missioner’’ means the Health Choices 
Commissioner established under section 
141. 
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(4) COST-SHARING.—The term ‘‘cost- 
sharing’’ includes deductibles, coinsur-
ance, copayments, and similar charges 
but does not include premiums or any 
network payment differential for covered 
services or spending for non-covered 
services. 
(5) DEPENDENT.—The term ‘‘depend-
ent’’ 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 Em-
ployee Retirement Income Security 
Act of 1974); and 
(B) includes such a plan that is 
the following: 
(i) FEDERAL, STATE, AND TRIBAL 
GOVERNMENTAL
PLANS.—A govern-
mental plan (as defined in section 
3(32) of the Employee Retirement 
Income Security Act of 1974), in-
cluding a health benefits plan of-
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fered under chapter 89 of title 5, 
United States Code. 
(ii) CHURCH PLANS.—A church 
plan (as defined in section 3(33) of 
the Employee Retirement Income 
Security Act of 1974). 
(7) ENHANCED
PLAN.—The term ‘‘en-
hanced plan’’ has the meaning given such 
term in section 203(c). 
(8) ESSENTIAL BENEFITS PACKAGE.—The 
term ‘‘essential benefits package’’ is de-
fined in section 122(a). 
(9) FAMILY.—The term ‘‘family’’ means 
an individual and includes the individ-
ual’s dependents. 
(10) FEDERAL
POVERTY
LEVEL; FPL.— 
The terms ‘‘Federal poverty level’’ and 
‘‘FPL’’ have the meaning given the term 
‘‘poverty line’’ in section 673(2) of the 
Community Services Block Grant Act (42 
U.S.C. 9902(2)), including any revision re-
quired by such section. 
(11) 
HEALTH
BENEFITS
PLAN.—The 
terms 
‘‘health 
benefits 
plan’’ 
means 
health insurance coverage and an em-
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ployment-based health plan and includes 
the public health insurance option. 
(12) 
HEALTH
INSURANCE
COVERAGE; 
HEALTH
INSURANCE
ISSUER.—The 
terms 
‘‘health insurance coverage’’ and ‘‘health 
insurance issuer’’ have the meanings 
given such terms in section 2791 of the 
Public Health Service Act. 
(13) HEALTH
INSURANCE
EXCHANGE.— 
The term ‘‘Health Insurance Exchange’’ 
means the Health Insurance Exchange es-
tablished under section 201. 
(14) MEDICAID.—The term ‘‘Medicaid’’ 
means a State plan under title XIX of the 
Social Security Act (whether or not the 
plan is operating under a waiver under 
section 1115 of such Act). 
(15) MEDICARE.—The term ‘‘Medicare’’ 
means the health insurance programs 
under title XVIII of the Social Security 
Act. 
(16) PLAN
SPONSOR.—The term ‘‘plan 
sponsor’’ has the meaning given such 
term in section 3(16)(B) of the Employee 
Retirement Income Security Act of 1974. 
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(17) PLAN YEAR.—The term ‘‘plan year’’ 
means— 
(A) with respect to an employ-
ment-based health plan, a plan year 
as specified under such plan; or 
(B) with respect to a health bene-
fits plan other than an employment- 
based health plan, a 12-month period 
as specified by the Commissioner. 
(18) 
PREMIUM
PLAN; 
PREMIUM-PLUS 
PLAN.—The terms ‘‘premium plan’’ and 
‘‘premium-plus 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 de-
fined, subject to subsection (d), in 
section 733(a)(1) of the Employee Re-
tirement 
Income 
Security 
Act 
of 
1974), the plan sponsor in relation to 
such group health plan, except that, 
in the case of a plan maintained joint-
ly by 1 or more employers and 1 or 
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more 
employee 
organizations 
and 
with respect to which an employer is 
the primary source of financing, such 
term means such employer; 
(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 es-
tablishes or maintains such plan; or 
(E) a Federal governmental plan 
(as defined in section 2791(d) of the 
Public Health Service Act), the appro-
priate Federal official. 
(20) 
QUALIFIED
HEALTH
BENEFITS 
PLAN.—The term ‘‘qualified health bene-
fits plan’’ means a health benefits plan 
that meets the requirements for such a 
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plan under title I and includes the public 
health insurance option. 
(21) PUBLIC
HEALTH
INSURANCE
OP-
TION.—The term ‘‘public health insurance 
option’’ means the public health insur-
ance option as provided under subtitle B 
of title II. 
(22) SERVICE
AREA; PREMIUM
RATING 
AREA.—The terms ‘‘service area’’ and ‘‘pre-
mium rating area’’ mean with respect to 
health insurance coverage— 
(A) offered other than through 
the Health Insurance Exchange, such 
an area as established by the QHBP 
offering entity of such coverage in ac-
cordance with applicable State law; 
and 
(B) offered through the Health In-
surance Exchange, such an area as 
established by such entity in accord-
ance with applicable State law and 
applicable rules of the Commissioner 
for 
Exchange-participating 
health 
benefits plans. 
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(23) STATE.—The term ‘‘State’’ means 
the 50 States and the District of Colum-
bia. 
(24) 
STATE
MEDICAID
AGENCY.—The 
term ‘‘State Medicaid agency’’ means, 
with respect to a Medicaid plan, the sin-
gle State agency responsible for admin-
istering such plan under title XIX of the 
Social Security Act. 
(25) Y1, Y2, ETC..—The terms ‘‘Y1’’ , 
‘‘Y2’’, ‘‘Y3’’, ‘‘Y4’’, ‘‘Y5’’, and similar subse-
quently numbered terms, mean 2013 and 
subsequent years, respectively. 
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 establish standards to ensure that new 
health insurance coverage and employment- 
based health plans that are offered meet 
standards guaranteeing access to affordable 
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coverage, essential benefits, and other con-
sumer protections. 
(b) REQUIREMENTS FOR QUALIFIED HEALTH 
BENEFITS PLANS.—On or after the first day of 
Y1, a health benefits plan shall not be a quali-
fied health benefits plan under this division 
unless the plan meets the applicable require-
ments of the following subtitles for the type 
of plan and plan year involved: 
(1) Subtitle B (relating to affordable 
coverage). 
(2) Subtitle C (relating to essential 
benefits). 
(3) Subtitle D (relating to consumer 
protection). 
(c) TERMINOLOGY.—In this division: 
(1) ENROLLMENT IN EMPLOYMENT-BASED 
HEALTH
PLANS.—An individual shall be 
treated as being ‘‘enrolled’’ in an employ-
ment-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 Security Act of 1974) in such 
plan. 
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(2) INDIVIDUAL AND GROUP HEALTH IN-
SURANCE
COVERAGE.—The 
terms 
‘‘indi-
vidual health insurance coverage’’ and 
‘‘group health insurance coverage’’ mean 
health insurance coverage offered in the 
individual market or large or small group 
market, respectively, as defined in sec-
tion 2791 of the Public Health Service 
Act. 
SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT 
COVERAGE. 
(a) GRANDFATHERED
HEALTH
INSURANCE 
COVERAGE
DEFINED.—Subject 
to 
the 
suc-
ceeding provisions of this section, for pur-
poses of establishing acceptable coverage 
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 pro-
vided in this paragraph, the indi-
vidual health insurance issuer offer-
ing such coverage does not enroll any 
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individual in such coverage if the 
first effective 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 condi-
tions, including benefits and cost-sharing, 
from those in effect as of the day before 
the first day of Y1. 
(3) 
RESTRICTIONS
ON
PREMIUM
IN-
CREASES.—The issuer cannot vary the per-
centage increase in the premium for a 
risk group of enrollees in specific grand-
fathered health insurance coverage with-
out changing the premium for all enroll-
ees in the same risk group at the same 
rate, as specified by the Commissioner. 
(b) GRACE PERIOD FOR CURRENT EMPLOY-
MENT-BASED HEALTH PLANS.— 
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(1) GRACE PERIOD.— 
(A) IN
GENERAL.—The Commis-
sioner shall establish a grace period 
whereby, for plan years beginning 
after the end of the 5-year period be-
ginning with Y1, an employment- 
based health plan in operation as of 
the day before the first day of Y1 
must meet the same requirements as 
apply to a qualified health benefits 
plan under section 101, including the 
essential benefit package require-
ment under section 121. 
(B) EXCEPTION FOR LIMITED BENE-
FITS
PLANS.—Subparagraph (A) shall 
not apply to an employment-based 
health plan in which the coverage 
consists only of one or more of the 
following: 
(i) Any coverage described in 
section 3001(a)(1)(B)(ii)(IV) of di-
vision B of the American Recov-
ery and Reinvestment Act of 2009 
(PL 111–5). 
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(ii) Excepted benefits (as de-
fined in section 733(c) of the Em-
ployee Retirement Income Secu-
rity Act of 1974), including cov-
erage under a specified disease or 
illness policy described in para-
graph (3)(A) of such section. 
(iii) Such other limited bene-
fits 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 divi-
sion 
(2) TRANSITIONAL
TREATMENT
AS
AC-
CEPTABLE
COVERAGE.—During the grace 
period specified in paragraph (1)(A), an 
employment-based health plan that is de-
scribed in such paragraph shall be treat-
ed as acceptable coverage under this di-
vision. 
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(c) LIMITATION ON INDIVIDUAL HEALTH IN-
SURANCE COVERAGE.— 
(1) IN GENERAL.—Individual health in-
surance coverage that is not grand-
fathered 
health 
insurance 
coverage 
under subsection (a) may only be offered 
on or after the first day of Y1 as an Ex-
change-participating 
health 
benefits 
plan. 
(2) SEPARATE, EXCEPTED COVERAGE PER-
MITTED.—Excepted benefits (as defined in 
section 2791(c) of the Public Health Serv-
ice Act) are not included within the defi-
nition 
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 offered and priced 
separately from health insurance cov-
erage. 
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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 Pub-
lic Health Service Act) or otherwise impose 
any limit or condition on the coverage under 
the plan with respect to an individual or de-
pendent based on any health status-related 
factors (as defined in section 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 subsections (c) and (e)) and 2712 (other 
than paragraphs (3), and (6) of subsection (b) 
and subsection (e)) of the Public Health Serv-
ice Act, relating to guaranteed availability 
and renewability of health insurance cov-
erage, shall apply to individuals and employ-
ers in all individual and group health insur-
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ance 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 non-
renewal 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 sec-
tions 2712(b)(2) of such Act. 
SEC. 113. INSURANCE RATING RULES. 
(a) 
IN
GENERAL.—The 
premium 
rate 
charged for an insured qualified health bene-
fits plan may not vary except as follows: 
(1) 
LIMITED
AGE
VARIATION
PER-
MITTED.—By age (within such age cat-
egories as the Commissioner shall speci-
fy) so long as the ratio of the highest 
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such premium to the lowest such pre-
mium does not exceed the ratio of 2 to 1. 
(2) BY AREA.—By premium rating area 
(as permitted by State insurance regu-
lators or, in the case of Exchange-partici-
pating health benefits plans, as specified 
by the Commissioner in consultation with 
such regulators). 
(3) BY FAMILY ENROLLMENT.—By family 
enrollment (such as variations within cat-
egories and compositions of families) so 
long as the ratio of the premium for fam-
ily enrollment (or enrollments) to the 
premium for individual enrollment is uni-
form, as specified under State law and 
consistent with rules of the Commis-
sioner. 
(b) STUDY AND REPORTS.— 
(1) STUDY.—The Commissioner, in co-
ordination with the Secretary of Health 
and Human Services 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: 
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(A) The types of employers by key 
characteristics, including size, that 
purchase insured products versus 
those that self-insure. 
(B) 
The 
similarities 
and 
dif-
ferences between typical insured and 
self-insured health plans. 
(C) The financial solvency and 
capital reserve levels of employers 
that self-insure by employer size. 
(D) The risk of self-insured em-
ployers not being able to pay obliga-
tions or otherwise becoming finan-
cially insolvent. 
(E) The extent to which rating 
rules are likely to cause adverse se-
lection in the large group market or 
to encourage small and mid size em-
ployers to self-insure 
(2) 
REPORTS.—Not 
later 
than 
months after the date of the enactment of 
this Act, the Commissioner shall submit 
to Congress and the applicable agencies a 
report on the study conducted under 
paragraph (1). Such report shall include 
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any recommendations the Commissioner 
deems appropriate to ensure that the law 
does not provide incentives for small and 
mid-size employers to self-insure or cre-
ate adverse selection in the risk pools of 
large group insurers and self-insured em-
ployers. Not later than 18 months after 
the first day of Y1, the Commissioner 
shall submit to Congress and the applica-
ble agencies an updated report on such 
study, including updates on such rec-
ommendations. 
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 established by the Commis-
sioner 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 Internal Revenue 
Code of 1986. 
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(b) PARITY
IN MENTAL HEALTH
AND SUB-
STANCE ABUSE DISORDER BENEFITS.—To the ex-
tent such provisions 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 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. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS. 
(a) IN GENERAL.—A qualified health bene-
fits plan that uses a provider network for 
items and services shall meet such standards 
respecting provider networks as the Commis-
sioner may establish to assure the adequacy 
of such networks in ensuring enrollee access 
to such items and services and transparency 
in the cost-sharing differentials between in- 
network coverage and out-of-network cov-
erage. 
(b) PROVIDER NETWORK DEFINED.—In this 
division, the term ‘‘provider network’’ means 
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the providers with respect to which covered 
benefits, treatments, and services are avail-
able under a health benefits plan. 
SEC. 116. ENSURING VALUE AND LOWER PREMIUMS. 
(a) IN GENERAL.—A qualified health bene-
fits plan shall meet a medical loss ratio as de-
fined by the Commissioner. 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 sufficient to meet such 
loss ratio. 
(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 cal-
culate the medical loss ratio. Such method-
ology shall be set at the highest level medical 
loss ratio possible that is designed to ensure 
adequate participation by QHBP offering en-
tities, competition in the health insurance 
market in and out of the Health Insurance Ex-
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change, and value for consumers 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 bene-
fits plan shall provide coverage that at least 
meets the benefit standards adopted under 
section 124 for the essential benefits package 
described in section 122 for the plan year in-
volved. 
(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 bene-
fits plan, such plan may offer such cov-
erage in addition to the essential benefits 
package as the QHBP offering entity may 
specify. 
(2) EXCHANGE-PARTICIPATING
HEALTH 
BENEFITS
PLANS.—In the case of an Ex-
change-participating 
health 
benefits 
plan, such plan is required under section 
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203 to provide specified levels of benefits 
and, in the case of a plan offering a pre-
mium-plus level of benefits, provide addi-
tional benefits. 
(3) CONTINUATION OF OFFERING OF SEP-
ARATE
EXCEPTED
BENEFITS
COVERAGE.— 
Nothing in this division shall be con-
strued as affecting the offering of health 
benefits in the form of excepted benefits 
(described in section 102(b)(1)(B)(ii)) if 
such benefits are offered under a sepa-
rate policy, contract, or certificate of in-
surance. 
(c) NO RESTRICTIONS ON COVERAGE UNRE-
LATED TO CLINICAL APPROPRIATENESS.—A quali-
fied health benefits plan may not impose any 
restriction (other than cost-sharing) unre-
lated 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 
‘‘essential benefits package’’ means health 
benefits coverage, consistent with standards 
adopted under section 124 to ensure the pro-
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vision of quality health care and financial se-
curity, that— 
(1) provides payment for the items 
and services described in subsection (b) 
in accordance with generally accepted 
standards of medical or other appro-
priate clinical or professional practice; 
(2) limits cost-sharing for such cov-
ered health care items and services in ac-
cordance with such benefit 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) (relat-
ing to network adequacy); and 
(5) is equivalent, as certified by Office 
of the Actuary of the Centers for Medi-
care & Medicaid Services, to the average 
prevailing employer-sponsored coverage. 
(b) MINIMUM SERVICES TO BE COVERED.— 
The items and services described in this sub-
section are the following: 
(1) Hospitalization. 
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(2) 
Outpatient 
hospital 
and 
out-
patient clinic services, including emer-
gency department services. 
(3) Professional services of physicians 
and other health professionals. 
(4) Such services, equipment, and 
supplies incident to the services of a phy-
sician’s or a health professional’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. 
(8) 
Preventive 
services, 
including 
those services recommended with a grade 
of A or B by the Task Force on Clinical 
Preventive Services and those vaccines 
recommended for use by the Director of 
the Centers for Disease Control and Pre-
vention. 
(9) Maternity care. 
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(10) Well baby and well child care and 
oral health, vision, and hearing services, 
equipment, and supplies at least for chil-
dren under 21 years of age. 
(c) REQUIREMENTS RELATING TO COST-SHAR-
ING AND MINIMUM ACTUARIAL VALUE.— 
(1) NO COST-SHARING FOR PREVENTIVE 
SERVICES.—There shall be no cost-sharing 
under the essential benefits package for 
preventive items and services (as speci-
fied under the benefit standards), includ-
ing well baby and well child care. 
(2) ANNUAL LIMITATION.— 
(A) ANNUAL LIMITATION.—The cost- 
sharing incurred under the essential 
benefits package with respect to an 
individual (or family) for a year does 
not exceed the applicable level speci-
fied in subparagraph (B). 
(B) APPLICABLE LEVEL.—The appli-
cable level specified in this subpara-
graph for Y1 is $5,000 for an indi-
vidual and $10,000 for a family. Such 
levels shall be increased (rounded to 
the nearest $100) for each subsequent 
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year by the annual percentage in-
crease in the Consumer Price Index 
(United States city average) applica-
ble to such year. 
(C) USE OF COPAYMENTS.—In estab-
lishing cost-sharing levels for basic, 
enhanced, and premium plans under 
this subsection, the Secretary shall, 
to the maximum extent possible, use 
only copayments and not coinsur-
ance. 
(3) MINIMUM ACTUARIAL VALUE.— 
(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 actuarial value of the benefits 
provided under the reference benefits 
package described in subparagraph 
(B). 
(B) REFERENCE BENEFITS PACKAGE 
DESCRIBED.—The 
reference 
benefits 
package described in this subpara-
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graph is the essential benefits pack-
age if there were no cost-sharing im-
posed. 
SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE. 
(a) ESTABLISHMENT.— 
(1) IN GENERAL.—There is established 
a 
private-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 Advisory Committee. 
(3) MEMBERSHIP.—The Health Benefits 
Advisory Committee shall be composed of 
the following members, in addition to the 
Surgeon General: 
(A) 9 members who are not Fed-
eral employees or officers and who 
are appointed by the President. 
(B) 9 members who are not Fed-
eral employees or officers and who 
are appointed by the Comptroller 
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General of the United States in a 
manner similar to the manner in 
which the Comptroller General ap-
points members to the Medicare Pay-
ment Advisory Commission under 
section 1805(c) of the Social Security 
Act. 
(C) Such even number of mem-
bers (not to exceed 8) who are Fed-
eral employees and officers, 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 Benefits Advisory Committee shall 
serve a 3-year term on the Committee, ex-
cept that the terms of the initial members 
shall be adjusted in order to provide for 
a staggered term of appointment for all 
such members. 
(5) PARTICIPATION.—The membership 
of the Health Benefits Advisory Com-
mittee shall at least reflect providers, 
consumer 
representatives, 
employers, 
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labor, health insurance issuers, experts 
in health care financing and delivery, ex-
perts in racial and ethnic disparities, ex-
perts in care for those with disabilities, 
representatives of relevant governmental 
agencies. and at least one practicing phy-
sician or other health professional and an 
expert on children’s health and shall rep-
resent a balance among various sectors of 
the health care system so that no single 
sector 
unduly 
influences 
the 
rec-
ommendations of such Committee. 
(b) DUTIES.— 
(1) 
RECOMMENDATIONS
ON
BENEFIT 
STANDARDS.—The Health Benefits Advi-
sory Committee shall recommend to the 
Secretary of Health and Human Services 
(in this subtitle referred to as the ‘‘Sec-
retary’’) benefit standards (as defined in 
paragraph (4)), and periodic updates to 
such standards. In developing such rec-
ommendations, the Committee shall take 
into account innovation in health care 
and consider how such standards could 
reduce health disparities. 
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(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) PUBLIC INPUT.—The Health Bene-
fits Advisory Committee shall allow for 
public input as a part of developing rec-
ommendations under this subsection. 
(4) BENEFIT
STANDARDS
DEFINED.—In 
this subtitle, the term ‘‘benefit standards’’ 
means standards respecting— 
(A) the essential benefits package 
described in section 122, including 
categories 
of 
covered 
treatments, 
items and services within benefit 
classes, and cost-sharing; and 
(B) the cost-sharing levels for en-
hanced plans and premium plans (as 
provided under section 203(c)) con-
sistent with paragraph (5). 
(5) LEVELS
OF
COST-SHARING
FOR
EN-
HANCED AND PREMIUM PLANS.— 
(A) ENHANCED PLAN.—The level of 
cost-sharing for enhanced plans shall 
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be designed so that such plans have 
benefits that are actuarially equiva-
lent to approximately 85 percent of 
the actuarial value of the benefits 
provided under the reference benefits 
package 
described 
in 
section 
122(c)(3)(B). 
(B) PREMIUM
PLAN.—The level of 
cost-sharing for premium plans shall 
be designed so that such plans have 
benefits that are actuarially equiva-
lent to approximately 95 percent of 
the actuarial value of the benefits 
provided under the reference benefits 
package 
described 
in 
section 
122(c)(3)(B). 
(c) OPERATIONS.— 
(1) PER
DIEM
PAY.—Each member of 
the Health Benefits Advisory Committee 
shall receive travel expenses, including 
per diem in accordance with applicable 
provisions under subchapter I of chapter 
57 of title 5, United States Code, and shall 
otherwise serve without additional pay. 
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(2) MEMBERS NOT TREATED AS FEDERAL 
EMPLOYEES.—Members of the Health Ben-
efits Advisory Committee shall not be 
considered employees of the Federal gov-
ernment solely by reason of any service 
on the Committee. 
(3) APPLICATION
OF
FACA.—The Fed-
eral Advisory Committee Act (5 U.S.C. 
App.), other than section 14, shall apply 
to the Health Benefits Advisory Com-
mittee. 
(d) PUBLICATION.—The Secretary shall pro-
vide 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. 124. PROCESS FOR ADOPTION OF RECOMMENDA-
TIONS; ADOPTION OF BENEFIT STANDARDS. 
(a) 
PROCESS
FOR
ADOPTION
OF
REC-
OMMENDATIONS.— 
(1) REVIEW
OF
RECOMMENDED
STAND-
ARDS.—Not later than 45 days after the 
date of receipt of benefit standards rec-
ommended under section 123 (including 
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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
STAND-
ARDS.—If the Secretary determines— 
(A) to propose adoption of benefit 
standards so recommended as a pack-
age, the Secretary shall, by regulation 
under section 553 of title 5, United 
States Code, propose adoption such 
standards; or 
(B) not to propose adoption of 
such standards as a package, the Sec-
retary shall notify the Health Benefits 
Advisory Committee in writing of 
such determination and the reasons 
for not proposing the adoption of 
such recommendation and provide 
the Committee with a further oppor-
tunity to modify its previous rec-
ommendations and submit new rec-
ommendations to the Secretary on a 
timely basis. 
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(3) CONTINGENCY.—If, because of the 
application of paragraph (2)(B), the Sec-
retary would otherwise be unable to pro-
pose 
initial 
adoption 
of 
such 
rec-
ommended standards by the deadline 
specified in subsection (b)(1), the Sec-
retary 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 determinations made by 
the Secretary under this subsection. 
(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 ben-
efit standards. 
(2) PERIODIC
UPDATING
STANDARDS.— 
Under subsection (a), the Secretary shall 
provide for the periodic updating of the 
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benefit 
standards 
previously 
adopted 
under this section. 
(3) REQUIREMENT.—The Secretary may 
not adopt any benefit standards for an es-
sential benefits package or for level of 
cost-sharing that are inconsistent with 
the requirements for such a package or 
level under sections 122 and 123(b)(5). 
Subtitle D—Additional Consumer 
Protections 
SEC. 131. REQUIRING FAIR MARKETING PRACTICES BY 
HEALTH INSURERS. 
The Commissioner shall establish uniform 
marketing standards that all insured QHBP 
offering entities shall meet. 
SEC. 132. REQUIRING FAIR GRIEVANCE AND APPEALS 
MECHANISMS. 
(a) IN GENERAL.—A QHBP offering entity 
shall provide for timely grievance and ap-
peals mechanisms that the Commissioner 
shall establish. 
(b) INTERNAL CLAIMS AND APPEALS PROC-
ESS.—Under a qualified health benefits plan 
the QHBP offering entity shall provide an in-
ternal claims and appeals process that ini-
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tially incorporates the claims and appeals 
procedures (including urgent claims) set forth 
at section 2560.503–1 of title 29, Code of Fed-
eral Regulations, as published on November 
21, 2000 (65 Fed. Reg. 70246) and shall update 
such process in accordance with any stand-
ards that the Commissioner may establish. 
(c) EXTERNAL REVIEW PROCESS.— 
(1) IN
GENERAL.—The Commissioner 
shall establish an external review process 
(including procedures for expedited re-
views of urgent claims) that provides for 
an impartial, independent, and de novo 
review of denied claims under this divi-
sion. 
(2) REQUIRING FAIR GRIEVANCE AND AP-
PEALS
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) CONSTRUCTION.—Nothing in this sec-
tion shall be construed as affecting the avail-
ability of judicial review under State law for 
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adverse decisions under subsection (b) or (c), 
subject to section 151. 
SEC. 133. REQUIRING INFORMATION TRANSPARENCY AND 
PLAN DISCLOSURE. 
(a) ACCURATE AND TIMELY DISCLOSURE.— 
(1) IN
GENERAL.—A qualified health 
benefits plan shall comply with standards 
established by the Commissioner for the 
accurate and timely disclosure of plan 
documents, plan terms and conditions, 
claims payment policies and practices, 
periodic financial disclosure, data on en-
rollment, data on disenrollment, data on 
the number of claims denials, data on rat-
ing practices, information on cost-sharing 
and payments with respect to any out-of- 
network coverage, and other information 
as determined appropriate by the Com-
missioner. The Commissioner shall re-
quire that such disclosure be provided in 
plain language. 
(2) PLAIN
LANGUAGE.—In this sub-
section, the term ‘‘plain language’’ means 
language that the intended audience, in-
cluding individuals with limited English 
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proficiency, can readily understand and 
use because that language is clean, con-
cise, well-organized, and follows other 
best practices of plain language writing. 
(3) 
GUIDANCE.—The 
Commissioner 
shall develop and issue guidance on best 
practices of plain language writing. 
(b) 
CONTRACTING
REIMBURSEMENT.—A 
qualified health benefits plan shall comply 
with standards established by the Commis-
sioner to ensure transparency to each health 
care provider relating to reimbursement ar-
rangements between such plan and such pro-
vider. 
(c) ADVANCE NOTICE OF PLAN CHANGES.—A 
change in a qualified health benefits plan 
shall not be made without such reasonable 
and timely advance notice to enrollees of such 
change. 
SEC. 134. APPLICATION TO QUALIFIED HEALTH BENEFITS 
PLANS 
NOT 
OFFERED 
THROUGH 
THE 
HEALTH INSURANCE EXCHANGE. 
The requirements of the previous provi-
sions of this subtitle shall apply to qualified 
health benefits plans that are not being of-
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fered through the Health Insurance Exchange 
only to the extent specified by the Commis-
sioner. 
SEC. 135. TIMELY PAYMENT OF CLAIMS. 
A QHBP offering entity shall comply with 
the requirements of section 1857(f) of the So-
cial Security Act with respect to a qualified 
health benefits plan it offers in the same man-
ner an 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. 136. STANDARDIZED RULES FOR COORDINATION AND 
SUBROGATION OF BENEFITS. 
The Commissioner shall establish stand-
ards for the coordination and subrogation of 
benefits and reimbursement of payments in 
cases involving individuals and multiple plan 
coverage. 
SEC. 137. APPLICATION OF ADMINISTRATIVE SIMPLIFICA-
TION. 
A QHBP offering entity is required to 
comply with standards for electronic finan-
cial and administrative transactions under 
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section 1173A of the Social Security Act, 
added by section 163(a). 
Subtitle E—Governance 
SEC. 141. HEALTH CHOICES ADMINISTRATION; HEALTH 
CHOICES COMMISSIONER. 
(a) IN GENERAL.—There is hereby estab-
lished, as an independent agency in the exec-
utive branch of the Government, a Health 
Choices Administration (in this division re-
ferred to as the ‘‘Administration’’). 
(b) COMMISSIONER.— 
(1) IN
GENERAL.—The Administration 
shall be headed by a Health Choices Com-
missioner (in this division referred to as 
the ‘‘Commissioner’’) who shall be ap-
pointed by the President, by and with the 
advice and consent of the Senate. 
(2) COMPENSATION; ETC.—The provi-
sions of paragraphs (2), (5), and (7) of 
subsection (a) (relating to compensation, 
terms, general powers, rulemaking, and 
delegation) of section 702 of the Social 
Security Act (42 U.S.C. 902) shall apply to 
the Commissioner and the Administra-
tion in the same manner as such provi-
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sions apply to the Commissioner of Social 
Security and the Social Security Adminis-
tration. 
SEC. 142. DUTIES AND AUTHORITY OF COMMISSIONER. 
(a) DUTIES.—The Commissioner is respon-
sible for carrying out the following functions 
under this division: 
(1) QUALIFIED
PLAN
STANDARDS.—The 
establishment of qualified health benefits 
plan standards under this title, including 
the enforcement of such standards in co-
ordination with State insurance regu-
lators and the Secretaries of Labor and 
the Treasury. 
(2) HEALTH INSURANCE EXCHANGE.—The 
establishment and operation of a Health 
Insurance Exchange under subtitle A of 
title II. 
(3) INDIVIDUAL
AFFORDABILITY
CRED-
ITS.—The administration of individual af-
fordability credits under subtitle C of 
title II, including determination of eligi-
bility for such credits. 
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(4) ADDITIONAL
FUNCTIONS.—Such ad-
ditional functions as may be specified in 
this division. 
(b) PROMOTING ACCOUNTABILITY.— 
(1) IN
GENERAL.—The Commissioner 
shall undertake activities in accordance 
with this subtitle to promote account-
ability of QHBP offering entities in meet-
ing Federal health insurance require-
ments, regardless of whether such ac-
countability is with respect to qualified 
health benefits plans offered through the 
Health Insurance Exchange or outside of 
such Exchange. 
(2) COMPLIANCE EXAMINATION AND AU-
DITS.— 
(A) 
IN
GENERAL.—The 
commis-
sioner shall, in coordination with 
States, conduct audits of qualified 
health benefits plan compliance with 
Federal requirements.
Such audits 
may include random compliance au-
dits and targeted audits in response 
to complaints or other suspected non- 
compliance. 
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(B) RECOUPMENT OF COSTS IN CON-
NECTION
WITH
EXAMINATION
AND
AU-
DITS.—The Commissioner is author-
ized to recoup from qualified health 
benefits plans reimbursement for the 
costs of such examinations and audit 
of such QHBP offering entities. 
(c) DATA COLLECTION.—The Commissioner 
shall collect data for purposes of carrying out 
the Commissioner’s duties, including for pur-
poses of promoting quality and value, pro-
tecting consumers, and addressing disparities 
in health and health care and may share such 
data with the Secretary of Health and Human 
Services. 
(d) SANCTIONS AUTHORITY.— 
(1) IN GENERAL.—In the case that the 
Commissioner determines that a QHBP 
offering entity violates a requirement of 
this title, the Commissioner may, in co-
ordination with State insurance regu-
lators and the Secretary of Labor, pro-
vide, in addition to any other remedies 
authorized by law, for any of the rem-
edies described in paragraph (2). 
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(2) 
REMEDIES.—The 
remedies 
de-
scribed in this paragraph, with respect to 
a qualified health benefits plan offered 
by a QHBP offering entity, are— 
(A) civil money penalties of not 
more than the amount that would be 
applicable 
under 
similar 
cir-
cumstances 
for 
similar 
violations 
under section 1857(g) of the Social Se-
curity Act; 
(B) suspension of enrollment of 
individuals under such plan after the 
date the Commissioner notifies the 
entity of a determination under para-
graph (1) and until the Commissioner 
is satisfied that the basis for such de-
termination has been corrected and is 
not likely to recur; 
(C) in the case of an Exchange- 
participating health benefits plan, 
suspension of payment to the entity 
under 
the 
Health 
Insurance 
Ex-
change for individuals enrolled in 
such plan after the date the Commis-
sioner notifies the entity of a deter-
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mination under paragraph (1) and 
until the Secretary is satisfied that 
the basis for such determination has 
been corrected and is not likely to 
recur; or 
(D) working with State insurance 
regulators to terminate plans for re-
peated failure by the offering entity 
to meet the requirements of this title. 
(e) STANDARD DEFINITIONS
OF INSURANCE 
AND MEDICAL TERMS.—The Commissioner shall 
provide for the development of standards for 
the definitions of terms used in health insur-
ance coverage, including insurance-related 
terms. 
(f) EFFICIENCY
IN
ADMINISTRATION.—The 
Commissioner shall issue regulations for the 
effective and efficient administration of the 
Health Insurance Exchange and affordability 
credits under subtitle C, including, with re-
spect to the determination of eligibility for af-
fordability credits, the use of personnel who 
are employed in accordance with the require-
ments of title 5, United States Code, to carry 
out the duties of the Commissioner or, in the 
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case of sections 208 and 241(b)(2), the use of 
State personnel who are employed in accord-
ance with standards prescribed by the Office 
of Personnel Management pursuant to section 
208 of the Intergovernmental Personnel Act of 
1970 (42 U.S.C. 4728). 
SEC. 143. CONSULTATION AND COORDINATION. 
(a) CONSULTATION.—In carrying out the 
Commissioner’s duties under this division, 
the Commissioner, as appropriate, shall con-
sult with at least with the following: 
(1) The National Association of Insur-
ance Commissioners, State attorneys gen-
eral, and State insurance regulators, in-
cluding concerning the standards for in-
sured qualified health benefits plans 
under this title and enforcement of such 
standards. 
(2) Appropriate State agencies, spe-
cifically concerning the administration of 
individual 
affordability 
credits 
under 
subtitle C of title II and the offering of 
Exchange-participating 
health 
benefits 
plans, to Medicaid eligible individuals 
under subtitle A of such title. 
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(3) Other appropriate Federal agen-
cies. 
(4) Indian tribes and tribal organiza-
tions. 
(5) The National Association of Insur-
ance 
Commissioners 
for 
purposes 
of 
using model guidelines established by 
such association for purposes of subtitles 
B and D. 
(b) COORDINATION.— 
(1) IN GENERAL.—In carrying out the 
functions of the Commissioner, including 
with respect to the enforcement of the 
provisions of this division, the Commis-
sioner shall work in coordination with 
existing Federal and State entities to the 
maximum extent feasible consistent with 
this division and in a manner that pre-
vents conflicts of interest in duties and 
ensures effective enforcement. 
(2) UNIFORM
STANDARDS.—The Com-
missioner, in coordination with such enti-
ties, shall seek to achieve uniform stand-
ards that adequately protect consumers 
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in a manner that does not unreasonably 
affect employers and insurers. 
SEC. 144. HEALTH INSURANCE OMBUDSMAN. 
(a) IN GENERAL.—The Commissioner shall 
appoint within the Health Choices Adminis-
tration a Qualified Health Benefits Plan Om-
budsman who shall have expertise and experi-
ence in the fields of health care and education 
of (and assistance to) individuals. 
(b) DUTIES.—The Qualified Health Bene-
fits Plan Ombudsman shall, in a linguistically 
appropriate manner— 
(1) receive complaints, grievances, 
and requests for information submitted 
by individuals; 
(2) provide assistance with respect to 
complaints, grievances, and requests re-
ferred to in paragraph (1), including— 
(A) helping individuals determine 
the relevant information needed to 
seek an appeal of a decision or deter-
mination; 
(B) assistance to such individuals 
with 
any 
problems 
arising 
from 
disenrollment from such a plan; 
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(C) assistance to such individuals 
in choosing a qualified health bene-
fits plan in which to enroll; and 
(D) assistance to such individuals 
in presenting information under sub-
title C (relating to affordability cred-
its); and 
(3) submit annual reports to Congress 
and the Commissioner that describe the 
activities of the Ombudsman and that in-
clude such recommendations for im-
provement in the administration of this 
division as the Ombudsman determines 
appropriate. The Ombudsman shall not 
serve as an advocate for any increases in 
payments or new coverage of services, 
but may identify issues and problems in 
payment or coverage policies. 
Subtitle F—Relation to Other 
Requirements; Miscellaneous 
SEC. 151. RELATION TO OTHER REQUIREMENTS. 
(a) COVERAGE NOT OFFERED THROUGH EX-
CHANGE.— 
(1) IN GENERAL.—In the case of health 
insurance coverage not offered through 
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the Health Insurance Exchange (whether 
or not offered in connection with an em-
ployment-based health plan), and in the 
case of employment-based health plans, 
the requirements of this title do not 
supercede any requirements applicable 
under titles XXII and XXVII of the Public 
Health Service Act, parts 6 and 7 of sub-
title B of title I of the Employee Retire-
ment Income Security Act of 1974, or 
State law, except insofar as such require-
ments prevent the application of a re-
quirement of this division, as determined 
by the Commissioner. 
(2) CONSTRUCTION.—Nothing in para-
graph (1) shall be construed as affecting 
the application of section 514 of the Em-
ployee Retirement Income Security Act of 
1974. 
(b) 
COVERAGE
OFFERED
THROUGH
EX-
CHANGE.— 
(1) IN GENERAL.—In the case of health 
insurance coverage offered through the 
Health Insurance Exchange— 
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(A) the requirements of this title 
do not supercede any requirements 
(including requirements relating to 
genetic information nondiscrimina-
tion and mental health) applicable 
under title XXVII of the Public Health 
Service Act or under State law, ex-
cept insofar as such requirements 
prevent the application of a require-
ment of this division, as determined 
by the Commissioner; and 
(B) individual rights and rem-
edies under State laws shall apply. 
(2) CONSTRUCTION.—In the case of cov-
erage described in paragraph (1), nothing 
in such paragraph shall be construed as 
preventing the application of rights and 
remedies under State laws with respect 
to any requirement referred to in para-
graph (1)(A). 
SEC. 152. PROHIBITING DISCRIMINATION IN HEALTH CARE. 
(a) IN GENERAL.—Except as otherwise ex-
plicitly permitted by this Act and by subse-
quent regulations consistent with this Act, all 
health care and related services (including in-
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surance coverage and public health activities) 
covered by this Act shall be provided without 
regard to personal characteristics extraneous 
to the provision of high quality health care or 
related services. 
(b) IMPLEMENTATION.—To implement the 
requirement set forth in subsection (a), the 
Secretary of Health and Human Services 
shall, not later than 18 months after the date 
of the enactment of this Act, promulgate such 
regulations as are necessary or appropriate to 
insure that all health care and related serv-
ices (including insurance coverage and public 
health activities) covered by this Act are pro-
vided (whether directly or through contrac-
tual, licensing, or other arrangements) with-
out regard to personal characteristics extra-
neous to the provision of high quality health 
care or related services. 
SEC. 153. WHISTLEBLOWER PROTECTION. 
(a) 
RETALIATION
PROHIBITED.—No 
em-
ployer may discharge any employee or other-
wise discriminate against any employee with 
respect to his compensation, terms, condi-
tions, or other privileges of employment be-
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cause the employee (or any person acting pur-
suant to a request of the employee)— 
(1) provided, caused to be provided, 
or is about to provide or cause to be pro-
vided to the employer, the Federal Gov-
ernment, or the attorney general of a 
State information relating to any viola-
tion of, or any act or omission the em-
ployee reasonably believes to be a viola-
tion of any provision of this Act or any 
order, rule, or regulation promulgated 
under this Act; 
(2) testified or is about to testify in a 
proceeding concerning such violation; 
(3) assisted or participated or is 
about to assist or participate in such a 
proceeding; or 
(4) objected to, or refused to partici-
pate in, any activity, policy, practice, or 
assigned task that the employee (or other 
such person) reasonably believed to be in 
violation of any provision of this Act or 
any order, rule, or regulation promul-
gated under this Act. 
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(b) ENFORCEMENT ACTION.—An employee 
covered by this section who alleges discrimi-
nation by an employer in violation of sub-
section (a) may bring an action governed by 
the rules, procedures, legal burdens of proof, 
and remedies set forth in section 40(b) of the 
Consumer Product Safety Act (15 U.S.C. 
2087(b)). 
(c) EMPLOYER DEFINED.—As used in this 
section, the term ‘‘employer’’ means any per-
son (including one or more individuals, part-
nerships, associations, corporations, trusts, 
professional membership organization includ-
ing a certification, disciplinary, or other pro-
fessional body, unincorporated organizations, 
nongovernmental organizations, or trustees) 
engaged in profit or nonprofit business or in-
dustry whose activities are governed by this 
Act, and any agent, contractor, subcontractor, 
grantee, or consultant of such person. 
(d) RULE OF CONSTRUCTION.—The rule of 
construction set forth in section 20109(h) of 
title 49, United States Code, shall also apply 
to this section. 
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SEC. 154. CONSTRUCTION REGARDING COLLECTIVE BAR-
GAINING. 
Nothing in this division shall be con-
strued to alter of supercede any statutory or 
other obligation to engage in collective bar-
gaining over the terms and conditions of em-
ployment related to health care. 
SEC. 155. SEVERABILITY. 
If any provision of this Act, or any appli-
cation of such provision to any person or cir-
cumstance, is held to be unconstitutional, the 
remainder of the provisions of this Act and 
the application of the provision to any other 
person or circumstance shall not be affected. 
Subtitle G—Early Investments 
SEC. 161. ENSURING VALUE AND LOWER PREMIUMS. 
(a) GROUP HEALTH INSURANCE COVERAGE.— 
Title XXVII of the Public Health Service Act 
is amended by inserting after section 2713 the 
following new section: 
‘‘SEC. 2714. ENSURING VALUE AND LOWER PREMIUMS. 
‘‘(a) IN GENERAL.—Each health insurance 
issuer that offers health insurance coverage 
in the small or large group market shall pro-
vide that for any plan year in which the cov-
erage has a medical loss ratio below a level 
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specified by the Secretary, the issuer shall 
provide in a manner specified by the Sec-
retary for rebates to enrollees of payment suf-
ficient to meet such loss ratio. Such method-
ology shall be set at the highest level medical 
loss ratio possible that is designed to ensure 
adequate participation by issuers, competi-
tion in the health insurance market, and 
value for consumers so that their premiums 
are used for services. 
‘‘(b) UNIFORM DEFINITIONS.—The Secretary 
shall establish a uniform definition of medical 
loss ratio and methodology for determining 
how to calculate the medical loss ratio. Such 
methodology shall be designed to take into ac-
count the special circumstances of smaller 
plans, different types of plans, and newer 
plans.’’. 
(b) INDIVIDUAL HEALTH INSURANCE COV-
ERAGE.—Such title is further amended by in-
serting after section 2753 the following new 
section: 
‘‘SEC. 2754. ENSURING VALUE AND LOWER PREMIUMS. 
‘‘The provisions of section 2714 shall apply 
to health insurance coverage offered in the in-
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dividual market in the same manner as such 
provisions apply to health insurance coverage 
offered in the small or large group market.’’. 
(c) 
IMMEDIATE
IMPLEMENTATION.—The 
amendments made by this section shall apply 
in the group and individual market for plan 
years beginning on or after January 1, 2011. 
SEC. 162. ENDING HEALTH INSURANCE RESCISSION ABUSE. 
(a) CLARIFICATION REGARDING APPLICATION 
OF GUARANTEED RENEWABILITY OF INDIVIDUAL 
HEALTH INSURANCE COVERAGE.—Section 2742 
of the Public Health Service Act (42 U.S.C. 
300gg–42) is amended— 
(1) in its heading, by inserting ‘‘AND 
CONTINUATION IN FORCE, INCLUDING PROHI-
BITION OF RESCISSION,’’ after ‘‘GUARANTEED 
RENEWABILITY’’; and 
(2) in subsection (a), by inserting ‘‘, 
including without rescission,’’ after ‘‘con-
tinue in force’’. 
(b) SECRETARIAL GUIDANCE REGARDING RE-
SCISSIONS.—Section 2742 of such Act (42 U.S.C. 
300gg–42) is amended by adding at the end the 
following: 
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‘‘(f) 
RESCISSION.—A 
health 
insurance 
issuer may rescind health insurance coverage 
only upon clear and convincing evidence of 
fraud described in subsection (b)(2). The Sec-
retary, no later than July 1, 2010, shall issue 
guidance implementing this requirement, in-
cluding procedures for independent, external 
third party review.’’. 
(c) OPPORTUNITY FOR INDEPENDENT, EXTER-
NAL THIRD PARTY REVIEW IN CERTAIN CASES.— 
Subpart 1 of part B of title XXVII of such Act 
(42 U.S.C. 300gg–41 et seq.) is amended by add-
ing at the end the following: 
‘‘SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL 
THIRD PARTY REVIEW IN CASES OF RESCIS-
SION. 
‘‘(a) NOTICE
AND
REVIEW
RIGHT.—If a 
health insurance issuer determines to rescind 
health insurance coverage for an individual 
in the individual market, before such rescis-
sion may take effect the issuer shall provide 
the individual with notice of such proposed 
rescission and an opportunity for a review of 
such determination by an independent, exter-
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nal third party under procedures specified by 
the Secretary under section 2742(f). 
‘‘(b) INDEPENDENT DETERMINATION.—If the 
individual requests such review by an inde-
pendent, external third party of a rescission 
of health insurance coverage, the coverage 
shall remain in effect until such third party 
determines that the coverage may be re-
scinded under the guidance issued by the Sec-
retary under section 2742(f).’’. 
(d) EFFECTIVE
DATE.—The amendments 
made by this section shall apply on and after 
October 1, 2010, with respect to health insur-
ance coverage issued before, on, or after such 
date. 
SEC. 163. ADMINISTRATIVE SIMPLIFICATION. 
(a) STANDARDIZING ELECTRONIC ADMINIS-
TRATIVE TRANSACTIONS.— 
(1) IN GENERAL.—Part C of title XI of 
the Social Security Act (42 U.S.C. 1320d et 
seq.) is amended by inserting after sec-
tion 1173 the following new section: 
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‘‘SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE 
TRANSACTIONS. 
‘‘(a) STANDARDS FOR FINANCIAL AND ADMIN-
ISTRATIVE TRANSACTIONS.— 
‘‘(1) IN GENERAL.—The Secretary shall 
adopt and regularly update standards 
consistent with the goals described in 
paragraph (2). 
‘‘(2) GOALS FOR FINANCIAL AND ADMINIS-
TRATIVE
TRANSACTIONS.—The 
goals 
for 
standards under paragraph (1) are that 
such standards shall— 
‘‘(A) be unique with no conflicting 
or redundant standards; 
‘‘(B) be authoritative, permitting 
no additions or constraints for elec-
tronic transactions, including com-
panion guides; 
‘‘(C) be comprehensive, efficient 
and robust, requiring minimal aug-
mentation by paper transactions or 
clarification by further communica-
tions; 
‘‘(D) enable the real-time (or near 
real-time) determination of an indi-
vidual’s financial responsibility at the 
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point of service and, to the extent 
possible, prior to service, including 
whether the individual is eligible for 
a specific service with a specific phy-
sician at a specific facility, which 
may include utilization of a machine- 
readable 
health 
plan 
beneficiary 
identification card; 
‘‘(E) enable, where feasible, near 
real-time adjudication of claims; 
‘‘(F) provide for timely acknowl-
edgment, response, and status report-
ing applicable to any electronic trans-
action deemed appropriate by the 
Secretary; 
‘‘(G) describe all data elements 
(such as reason and remark codes) in 
unambiguous terms, not permit op-
tional fields, require that data ele-
ments be either required or condi-
tioned upon set values in other fields, 
and prohibit additional conditions; 
and 
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‘‘(H) harmonize all common data 
elements across administrative and 
clinical transaction standards. 
‘‘(3) TIME
FOR
ADOPTION.—Not later 
than 2 years after the date of implemen-
tation of the X12 Version 5010 transaction 
standards implemented under this part, 
the 
Secretary 
shall 
adopt 
standards 
under this section. 
‘‘(4) 
REQUIREMENTS
FOR
SPECIFIC 
STANDARDS.—The standards under this 
section shall be developed, adopted, and 
enforced so as to— 
‘‘(A) clarify, refine, complete, and 
expand, as needed, the standards re-
quired under section 1173; 
‘‘(B) require paper versions of 
standardized transactions to comply 
with the same standards as to data 
content such that a fully compliant, 
equivalent electronic transaction can 
be populated from the data from a 
paper version; 
‘‘(C) 
enable 
electronic 
funds 
transfers, in order to allow auto-
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mated reconciliation with the related 
health care payment and remittance 
advice; 
‘‘(D) require timely and trans-
parent claim and denial management 
processes, including tracking, adju-
dication, and appeal processing ; 
‘‘(E) require the use of a standard 
electronic transaction with which 
health care providers may quickly 
and efficiently enroll with a health 
plan to conduct the other electronic 
transactions provided for in this part; 
and 
‘‘(F) provide for other require-
ments relating to administrative sim-
plification as identified by the Sec-
retary, in consultation with stake-
holders. 
‘‘(5) 
BUILDING
ON
EXISTING
STAND-
ARDS.—In developing the standards under 
this section, the Secretary shall build 
upon existing and planned standards. 
‘‘(6) IMPLEMENTATION
AND
ENFORCE-
MENT.—Not later than 6 months after the 
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date of the enactment of this section, the 
Secretary shall submit to the appropriate 
committees of Congress a plan for the im-
plementation and enforcement, by not 
later than 5 years after such date of en-
actment, of the standards under this sec-
tion. Such plan shall include— 
‘‘(A) a process and timeframe with 
milestones for developing the com-
plete set of standards; 
‘‘(B) an expedited upgrade pro-
gram for continually developing and 
approving additions and modifica-
tions to the standards as often as an-
nually to improve their quality and 
extend their functionality to meet 
evolving requirements in health care; 
‘‘(C) programs to provide incen-
tives for, and ease the burden of, im-
plementation for certain health care 
providers, with special consideration 
given to such providers serving rural 
or underserved areas and ensure co-
ordination with standards, implemen-
tation 
specifications, 
and 
certifi-
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cation criteria being adopted under 
the HITECH Act; 
‘‘(D) programs to provide incen-
tives for, and ease the burden of, 
health care providers who volunteer 
to participate in the process of set-
ting standards for electronic trans-
actions; 
‘‘(E) an estimate of total funds 
needed to ensure timely completion 
of the implementation plan; and 
‘‘(F) an enforcement process that 
includes timely investigation of com-
plaints, random audits to ensure com-
pliance, 
civil 
monetary 
and 
pro-
grammatic penalties for non-compli-
ance consistent with existing laws 
and regulations, and a fair and rea-
sonable appeals process building off 
of enforcement provisions under this 
part. 
‘‘(b) LIMITATIONS ON USE OF DATA.—Noth-
ing in this section shall be construed to per-
mit the use of information collected under 
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this section in a manner that would adversely 
affect any individual. 
‘‘(c) PROTECTION OF DATA.—The Secretary 
shall ensure (through the promulgation of 
regulations or otherwise) that all data col-
lected pursuant to subsection (a) are— 
‘‘(1) used and disclosed in a manner 
that meets the HIPAA privacy and secu-
rity law (as defined in section 3009(a)(2) 
of the Public Health Service Act), includ-
ing any privacy or security standard 
adopted under section 3004 of such Act; 
and 
‘‘(2) protected from all inappropriate 
internal use by any entity that collects, 
stores, or receives the data, including use 
of such data in determinations of eligi-
bility (or continued eligibility) in health 
plans, and from other inappropriate uses, 
as defined by the Secretary.’’. 
(2) DEFINITIONS.—Section 1171 of such 
Act (42 U.S.C. 1320d) is amended— 
(A) in paragraph (7), by striking 
‘‘with reference to’’ and all that fol-
lows and inserting ‘‘with reference to 
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a transaction or data element of 
health information in section 1173 
means implementation specifications, 
certification criteria, operating rules, 
messaging formats, codes, and code 
sets adopted or established by the 
Secretary for the electronic exchange 
and use of information’’; and 
(B) by adding at the end the fol-
lowing new paragraph: 
‘‘(9) OPERATING RULES.—The term ‘op-
erating rules’ means business rules for 
using and processing transactions. Oper-
ating rules should address the following: 
‘‘(A) Requirements for data con-
tent using available and established 
national standards. 
‘‘(B) Infrastructure requirements 
that 
establish 
best 
practices 
for 
streamlining data flow to yield timely 
execution of transactions. 
‘‘(C) Policies defining the trans-
action related rights and responsibil-
ities for entities that are transmitting 
or receiving data.’’. 
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(3) CONFORMING AMENDMENT.—Section 
1179(a) of such Act (42 U.S.C. 1320d–8(a)) 
is amended, in the matter before para-
graph (1)— 
(A) by inserting ‘‘on behalf of an 
individual’’ after ‘‘1978)’’; and 
(B) by inserting ‘‘on behalf of an 
individual’’ after ‘‘for a financial insti-
tution’’ and 
(b) STANDARDS FOR CLAIMS ATTACHMENTS 
AND COORDINATION OF BENEFITS .— 
(1) STANDARD FOR HEALTH CLAIMS AT-
TACHMENTS.—Not later than 1 year after 
the date of the enactment of this Act, the 
Secretary of Health and Human Services 
shall promulgate a final rule to establish 
a standard for health claims attachment 
transaction 
described 
in 
section 
1173(a)(2)(B) of the Social Security Act 
(42 U.S.C. 1320d-2(a)(2)(B)) and coordina-
tion of benefits. 
(2) REVISION
IN
PROCESSING
PAYMENT 
TRANSACTIONS
BY
FINANCIAL
INSTITU-
TIONS.— 
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(A) IN GENERAL.—Section 1179 of 
the Social Security Act (42 U.S.C. 
1320d–8) is amended, in the matter 
before paragraph (1)— 
(i) by striking ‘‘or is engaged’’ 
and inserting ‘‘and is engaged’’; 
and 
(ii) by inserting ‘‘(other than 
as a business associate for a cov-
ered entity)’’ after ‘‘for a financial 
institution’’. 
(B) EFFECTIVE DATE.—The amend-
ments made by paragraph (1) shall 
apply to transactions occurring on or 
after such date (not later than 6 
months after the date of the enact-
ment of this Act) as the Secretary of 
Health and Human Services shall 
specify. 
SEC. 164. REINSURANCE PROGRAM FOR RETIREES. 
(a) ESTABLISHMENT.— 
(1) IN
GENERAL.—Not later than 90 
days after the date of the enactment of 
this Act, the Secretary of Health and 
Human Services shall establish a tem-
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porary reinsurance program (in this sec-
tion referred to as the ‘‘reinsurance pro-
gram’’) to provide reimbursement to as-
sist 
participating 
employment-based 
plans with the cost of providing health 
benefits 
to 
retirees 
and 
to 
eligible 
spouses, surviving spouses and depend-
ents of such retirees. 
(2) DEFINITIONS.—For purposes of this 
section: 
(A) The term ‘‘eligible employ-
ment-based plan’’ means a group 
health benefits plan that— 
(i) is maintained by one or 
more employers, former employ-
ers or employee associations, or a 
voluntary employees’ beneficiary 
association, or a committee or 
board of individuals appointed to 
administer such plan, and 
(ii) provides health benefits to 
retirees. 
(B) The term ‘‘health benefits’’ 
means 
medical, 
surgical, 
hospital, 
prescription drug, and such other 
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benefits as shall be determined by the 
Secretary, whether self-funded or de-
livered through the purchase of in-
surance or otherwise. 
(C) The term ‘‘participating em-
ployment-based plan’’ means an eligi-
ble employment-based plan that is 
participating in the reinsurance pro-
gram. 
(D) The term ‘‘retiree’’ means, 
with respect to a participating em-
ployment-benefit plan, an individual 
who— 
(i) is 55 years of age or older; 
(ii) is not eligible for coverage 
under title XVIII of the Social Se-
curity Act; and 
(iii) is not an active employee 
of an employer maintaining the 
plan or of any employer that 
makes or has made substantial 
contributions to fund such plan. 
(E) The term ‘‘Secretary’’ means 
Secretary of Health and Human Serv-
ices. 
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(b) PARTICIPATION.—To be eligible to par-
ticipate in the reinsurance program, an eligi-
ble employment-based plan shall submit to 
the Secretary an application for participation 
in the program, at such time, in such manner, 
and containing such information as the Sec-
retary shall require. 
(c) PAYMENT.— 
(1) SUBMISSION OF CLAIMS.— 
(A) IN GENERAL.—Under the rein-
surance program, a participating em-
ployment-based 
plan 
shall 
submit 
claims for reimbursement to the Sec-
retary which shall contain docu-
mentation of the actual costs of the 
items and services for which each 
claim is being submitted. 
(B) BASIS FOR CLAIMS.—Each claim 
submitted under subparagraph (A) 
shall be based on the actual amount 
expended by the participating em-
ployment-based plan involved within 
the plan year for the appropriate em-
ployment based health benefits pro-
vided to a retiree or to the spouse, 
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surviving spouse, or dependent of a 
retiree. In determining the amount of 
any claim for purposes of this sub-
section, 
the 
participating 
employ-
ment-based plan shall take into ac-
count any negotiated price conces-
sions (such as discounts, direct or in-
direct subsidies, rebates, and direct 
or indirect remunerations) obtained 
by such plan with respect to such 
health benefits. For purposes of cal-
culating the amount of any claim, the 
costs paid by the retiree or by the 
spouse, surviving spouse, or depend-
ent of the retiree in the form of 
deductibles, co-payments, and co-in-
surance shall be included along with 
the amounts paid by the participating 
employment-based plan. 
(2) PROGRAM PAYMENTS AND LIMIT.—If 
the Secretary determines that a partici-
pating employment-based plan has sub-
mitted a valid claim under paragraph (1), 
the Secretary shall reimburse such plan 
for 80 percent of that portion of the costs 
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attributable to such claim that exceeds 
$15,000, but is less than $90,000. Such 
amounts shall be adjusted each year 
based on the percentage increase in the 
medical care component of the Consumer 
Price Index (rounded to the nearest mul-
tiple of $1,000) for the year involved. 
(3) USE OF PAYMENTS.—Amounts paid 
to a participating employment-based plan 
under this subsection shall be used to 
lower the costs borne directly by the par-
ticipants and beneficiaries for health 
benefits provided under such plan in the 
form 
of 
premiums, 
co-payments, 
deductibles, co-insurance, or other out-of- 
pocket costs. Such payments shall not be 
used to reduce the costs of an employer 
maintaining the participating employ-
ment-based plan. The Secretary shall de-
velop a mechanism to monitor the appro-
priate use of such payments by such 
plans. 
(4) APPEALS
AND
PROGRAM
PROTEC-
TIONS.—The Secretary shall establish— 
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(A) an appeals process to permit 
participating 
employment-based 
plans to appeal a determination of 
the Secretary with respect to claims 
submitted under this section; and 
(B) procedures to protect against 
fraud, waste, and abuse under the 
program. 
(5) AUDITS.—The Secretary shall con-
duct annual audits of claims data sub-
mitted 
by 
participating 
employment- 
based plans under this section to ensure 
that they are in compliance with the re-
quirements of this section. 
(d) RETIREE RESERVE TRUST FUND.— 
(1) ESTABLISHMENT.— 
(A) IN
GENERAL.—There is estab-
lished in the Treasury of the United 
States a trust fund to be known as 
the ‘‘Retiree Reserve Trust Fund’’ (re-
ferred to in this section as the ‘‘Trust 
Fund’’), that shall consist of such 
amounts as may be appropriated or 
credited to the Trust Fund as pro-
vided for in this subsection to enable 
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the Secretary to carry out the rein-
surance program. Such amounts shall 
remain available until expended. 
(B) FUNDING.—There are hereby 
appropriated to the Trust Fund, out 
of any moneys in the Treasury not 
otherwise appropriated, an amount 
requested by the Secretary as nec-
essary to carry out this section, ex-
cept 
that 
the 
total 
of 
all 
such 
amounts requested shall not exceed 
$10,000,000,000. 
(C) 
APPROPRIATIONS
FROM
THE 
TRUST FUND.— 
(i) IN
GENERAL.—Amounts in 
the Trust Fund are appropriated 
to provide funding to carry out 
the 
reinsurance 
program 
and 
shall be used to carry out such 
program. 
(ii) BUDGETARY IMPLICATIONS.— 
Amounts 
appropriated 
under 
clause (i), and outlays flowing 
from such appropriations, shall 
not be taken into account for pur-
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poses of any budget enforcement 
procedures including allocations 
under section 302(a) and (b) of 
the Balanced Budget and Emer-
gency Deficit Control Act and 
budget resolutions for fiscal years 
during which appropriations are 
made from the Trust Fund. 
(iii) LIMITATION
TO
AVAILABLE 
FUNDS.—The Secretary has the au-
thority to stop taking applica-
tions for participation in the pro-
gram or take such other steps in 
reducing expenditures under the 
reinsurance program in order to 
ensure that expenditures under 
the reinsurance program do not 
exceed the funds available under 
this subsection. 
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TITLE II—HEALTH INSURANCE 
EXCHANGE 
AND 
RELATED 
PROVISIONS 
Subtitle A—Health Insurance 
Exchange 
SEC. 201. ESTABLISHMENT OF HEALTH INSURANCE EX-
CHANGE; OUTLINE OF DUTIES; DEFINITIONS. 
(a) ESTABLISHMENT.—There is established 
within the Health Choices Administration and 
under the direction of the Commissioner a 
Health Insurance Exchange in order to facili-
tate access of individuals and employers, 
through a transparent process, to a variety of 
choices of affordable, quality health insur-
ance coverage, including a public health in-
surance option. 
(b) OUTLINE OF DUTIES OF COMMISSIONER.— 
In accordance with this subtitle and in co-
ordination with appropriate Federal and 
State officials as provided under section 
143(b), the Commissioner shall— 
(1) under section 204 establish stand-
ards for, accept bids from, and negotiate 
and enter into contracts with, QHBP of-
fering entities for the offering of health 
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benefits plans through the Health Insur-
ance Exchange, with different levels of 
benefits required under section 203, and 
including with respect to oversight and 
enforcement; 
(2) under section 205 facilitate out-
reach and enrollment in such plans of Ex-
change-eligible individuals and employ-
ers described in section 202; and 
(3) conduct such activities related to 
the Health Insurance Exchange as re-
quired, including establishment of a risk 
pooling mechanism under section 206 and 
consumer protections under subtitle D of 
title I. 
(c) EXCHANGE-PARTICIPATING HEALTH BENE-
FITS PLAN DEFINED.—In this division, the term 
‘‘Exchange-participating health benefits plan’’ 
means a qualified health benefits plan that is 
offered through the Health Insurance Ex-
change. 
SEC. 202. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOY-
ERS. 
(a) ACCESS TO COVERAGE.—In accordance 
with this section, all individuals are eligible 
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to obtain coverage through enrollment in an 
Exchange-participating health benefits plan 
offered through the Health Insurance Ex-
change unless such individuals are enrolled 
in another qualified health benefits plan or 
other acceptable coverage. 
(b) DEFINITIONS.—In this division: 
(1) EXCHANGE-ELIGIBLE
INDIVIDUAL.— 
The term ‘‘Exchange-eligible individual’’ 
means an individual who is eligible 
under this section to be enrolled through 
the Health Insurance Exchange in an Ex-
change-participating health benefits plan 
and, with respect to family coverage, in-
cludes dependents of such individual. 
(2) 
EXCHANGE-ELIGIBLE
EMPLOYER.— 
The term ‘‘Exchange-eligible employer’’ 
means an employer that is eligible under 
this section to enroll through the Health 
Insurance Exchange employees of the em-
ployer (and their dependents) in Ex-
change-eligible health benefits plans. 
(3) 
EMPLOYMENT-RELATED
DEFINI-
TIONS.—The 
terms 
‘‘employer’’, 
‘‘em-
ployee’’, ‘‘full-time employee’’, and ‘‘part- 
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time employee’’ have the meanings given 
such terms by the Commissioner for pur-
poses of this division. 
(c) TRANSITION.—Individuals and employ-
ers shall only be eligible to enroll or partici-
pate in the Health Insurance Exchange in ac-
cordance with the following transition sched-
ule: 
(1) FIRST YEAR.—In Y1 (as defined in 
section 100(c))— 
(A) individuals described in sub-
section (d)(1), including individuals 
described in paragraphs (3) and (4) of 
subsection (d); and 
(B) smallest employers described 
in subsection (e)(1). 
(2) SECOND YEAR.—In Y2— 
(A) individuals and employers de-
scribed in paragraph (1); and 
(B) smaller employers described 
in subsection (e)(2). 
(3) THIRD AND SUBSEQUENT YEARS.—In 
Y3 and subsequent years— 
(A) individuals and employers de-
scribed in paragraph (2); and 
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(B) larger employers as permitted 
by the Commissioner under sub-
section (e)(3). 
(d) INDIVIDUALS.— 
(1) INDIVIDUAL DESCRIBED.—Subject to 
the succeeding provisions of this sub-
section, an individual described in this 
paragraph is an individual who— 
(A) is not enrolled in coverage de-
scribed in subparagraphs (C) through 
(F) of paragraph (2); and 
(B) is not enrolled in coverage as 
a full-time employee (or as a depend-
ent of such an employee) under a 
group health plan if the coverage and 
an employer contribution under the 
plan meet the requirements of section 
312. 
For purposes of subparagraph (B), in the 
case of an individual who is self-em-
ployed, who has at least 1 employee, and 
who meets the requirements of section 
312, such individual shall be deemed a 
full-time employee described in such sub-
paragraph. 
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(2) ACCEPTABLE
COVERAGE.—For pur-
poses of this division, the term ‘‘accept-
able coverage’’ means any of the fol-
lowing: 
(A) QUALIFIED
HEALTH
BENEFITS 
PLAN
COVERAGE.—Coverage under a 
qualified health benefits plan. 
(B) GRANDFATHERED HEALTH INSUR-
ANCE COVERAGE; COVERAGE UNDER CUR-
RENT GROUP HEALTH PLAN.—Coverage 
under a grandfathered health insur-
ance coverage (as defined in sub-
section (a) of section 102) or under a 
current group health plan (described 
in subsection (b) of such section). 
(C) MEDICARE.—Coverage under 
part A of title XVIII of the Social Se-
curity Act. 
(D) MEDICAID.—Coverage for med-
ical assistance under title XIX of the 
Social Security Act, excluding such 
coverage that is only available be-
cause of the application of subsection 
(u), (z), or (aa) of section 1902 of such 
Act 
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(E) 
MEMBERS
OF
THE
ARMED 
FORCES
AND
DEPENDENTS
(INCLUDING 
TRICARE).—Coverage under chapter 55 
of title 10, United States Code, includ-
ing similar coverage furnished under 
section 1781 of title 38 of such Code. 
(F) VA.—Coverage under the vet-
eran’s health care program under 
chapter 17 of title 38, United States 
Code, but only if the coverage for the 
individual involved is determined by 
the Commissioner in coordination 
with the Secretary of Treasury to be 
not less than a level specified by the 
Commissioner and Secretary of Vet-
eran’s Affairs, in coordination with 
the Secretary of Treasury, based on 
the individual’s priority for services 
as provided under section 1705(a) of 
such title. 
(G) OTHER COVERAGE.—Such other 
health benefits coverage, such as a 
State health benefits risk pool, as the 
Commissioner, in coordination with 
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the Secretary of the Treasury, recog-
nizes for purposes of this paragraph. 
The Commissioner shall make determina-
tions under this paragraph in coordina-
tion with the Secretary of the Treasury. 
(3) TREATMENT OF CERTAIN NON-TRADI-
TIONAL
MEDICAID
ELIGIBLE
INDIVIDUALS.— 
An individual who is a non-traditional 
Medicaid eligible individual (as defined 
in section 205(e)(4)(C)) in a State may be 
an Exchange-eligible individual if the in-
dividual was enrolled in a qualified 
health 
benefits 
plan, 
grandfathered 
health insurance coverage, or current 
group health plan during the 6 months 
before the individual became a non-tradi-
tional Medicaid eligible individual. Dur-
ing the period in which such an indi-
vidual has chosen to enroll in an Ex-
change-participating 
health 
benefits 
plan, the individual is not also eligible 
for medical assistance under Medicaid. 
(4) 
CONTINUING
ELIGIBILITY
PER-
MITTED.— 
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(A) IN
GENERAL.—Except as pro-
vided in subparagraph (B), once an 
individual qualifies as an Exchange- 
eligible individual under this sub-
section (including as an employee or 
dependent of an employee of an Ex-
change-eligible employer) and enrolls 
under 
an 
Exchange-participating 
health benefits plan through the 
Health Insurance Exchange, the indi-
vidual shall continue to be treated as 
an Exchange-eligible individual until 
the individual is no longer enrolled 
with 
an 
Exchange-participating 
health benefits plan. 
(B) EXCEPTIONS.— 
(i) 
IN
GENERAL.—Subpara-
graph (A) shall not apply to an in-
dividual once the individual be-
comes eligible for coverage— 
(I) under part A of the 
Medicare program; 
(II) under the Medicaid 
program as a Medicaid eligi-
ble individual, except as per-
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mitted under paragraph (3) or 
clause (ii); or 
(III) in such other cir-
cumstances as the Commis-
sioner may provide. 
(ii) TRANSITION PERIOD.—In the 
case described in clause (i)(II), 
the Commissioner shall permit 
the individual to continue treat-
ment 
under 
subparagraph 
(A) 
until such limited time as the 
Commissioner determines it is ad-
ministratively feasible, consistent 
with minimizing disruption in the 
individual’s access to health care. 
(e) EMPLOYERS.— 
(1) SMALLEST
EMPLOYER.—Subject to 
paragraph (4), smallest employers de-
scribed in this paragraph are employers 
with 10 or fewer employees. 
(2) SMALLER
EMPLOYERS.—Subject to 
paragraph (4), smaller employers de-
scribed in this paragraph are employers 
that are not smallest employers described 
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in paragraph (1) and have 20 or fewer 
employees. 
(3) LARGER EMPLOYERS.— 
(A) IN
GENERAL.—Beginning with 
Y3, the Commissioner may permit em-
ployers not described in paragraph 
(1) or (2) to be Exchange-eligible em-
ployers. 
(B) PHASE-IN.—In applying sub-
paragraph (A), the Commissioner may 
phase-in the application of such sub-
paragraph based on the number of 
full-time employees of an employer 
and such other considerations as the 
Commissioner deems appropriate. 
(4) CONTINUING ELIGIBILITY.—Once an 
employer is permitted to be an Exchange- 
eligible employer under this subsection 
and 
enrolls 
employees 
through 
the 
Health Insurance Exchange, the em-
ployer shall continue to be treated as an 
Exchange-eligible employer for each sub-
sequent plan year regardless of the num-
ber of employees involved unless and 
until the employer meets the requirement 
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of section 311(a) through paragraph (1) of 
such section by offering a group health 
plan and not through offering an Ex-
change-participating 
health 
benefits 
plan. 
(5) EMPLOYER PARTICIPATION AND CON-
TRIBUTIONS.— 
(A) SATISFACTION OF EMPLOYER RE-
SPONSIBILITY.—For any year in which 
an employer is an Exchange-eligible 
employer, such employer may meet 
the requirements of section 312 with 
respect to employees of such em-
ployer by offering such employees the 
option of enrolling with Exchange- 
participating health benefits plans 
through the Health Insurance Ex-
change consistent with the provisions 
of subtitle B of title III. 
(B) EMPLOYEE
CHOICE.—Any em-
ployee 
offered 
Exchange-partici-
pating health benefits plans by the 
employer of such employee under 
subparagraph (A) may choose cov-
erage under any such plan. That 
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choice includes, with respect to fam-
ily coverage, coverage of the depend-
ents of such employee. 
(6) AFFILIATED GROUPS.—Any employer 
which is part of a group of employers 
who are treated as a single employer 
under subsection (b), (c), (m), or (o) of 
section 414 of the Internal Revenue Code 
of 1986 shall be treated, for purposes of 
this subtitle, as a single employer. 
(7) OTHER COUNTING RULES.—The Com-
missioner shall establish rules relating to 
how employees are counted for purposes 
of carrying out this subsection. 
(f) SPECIAL
SITUATION
AUTHORITY.—The 
Commissioner shall have the authority to es-
tablish such rules as may be necessary to deal 
with special situations with regard to unin-
sured individuals and employers partici-
pating as Exchange-eligible individuals and 
employers, such as transition periods for indi-
viduals and employers who gain, or lose, Ex-
change-eligible participation status, and to es-
tablish grace periods for premium payment. 
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(g) SURVEYS OF INDIVIDUALS AND EMPLOY-
ERS.—The Commissioner shall provide for 
periodic surveys of Exchange-eligible individ-
uals and employers concerning satisfaction of 
such individuals and employers with the 
Health Insurance Exchange and Exchange- 
participating health benefits plans. 
(h) EXCHANGE ACCESS STUDY.— 
(1) IN
GENERAL.—The Commissioner 
shall conduct a study of access to the 
Health Insurance Exchange for individ-
uals and for employers, including individ-
uals and employers who are not eligible 
and enrolled in Exchange-participating 
health benefits plans. The goal of the 
study is to determine if there are signifi-
cant groups and types of individuals and 
employers who are not Exchange eligible 
individuals or employers, but who would 
have improved benefits and affordability 
if made eligible for coverage in the Ex-
change. 
(2) ITEMS
INCLUDED
IN
STUDY.—Such 
study also shall examine— 
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(A) the terms, conditions, and af-
fordability of group health coverage 
offered by employers and QHBP of-
fering entities outside of the Ex-
change compared to Exchange-par-
ticipating health benefits plans; and 
(B) the affordability-test standard 
for access of certain employed indi-
viduals to coverage in the Health In-
surance Exchange. 
(3) REPORT.—Not later than January 1 
of Y3, in Y6, and thereafter, the Commis-
sioner shall submit to Congress on the 
study conducted under this subsection 
and shall include in such report rec-
ommendations 
regarding 
changes 
in 
standards for Exchange eligibility for in-
dividuals and employers. 
SEC. 203. BENEFITS PACKAGE LEVELS. 
(a) IN GENERAL.—The Commissioner shall 
specify the benefits to be made available 
under Exchange-participating health benefits 
plans during each plan year, consistent with 
subtitle C of title I and this section. 
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(b) LIMITATION ON HEALTH BENEFITS PLANS 
OFFERED BY OFFERING ENTITIES.—The Commis-
sioner may not enter into a contract with a 
QHBP offering entity under section 204(c) for 
the offering of an Exchange-participating 
health benefits plan in a service area unless 
the following requirements are met: 
(1) 
REQUIRED
OFFERING
OF
BASIC 
PLAN.—The entity offers only one basic 
plan for such service area. 
(2) OPTIONAL
OFFERING
OF
ENHANCED 
PLAN.—If and only if the entity offers a 
basic plan for such service area, the enti-
ty may offer one enhanced plan for such 
area. 
(3) OPTIONAL
OFFERING
OF
PREMIUM 
PLAN.—If and only if the entity offers an 
enhanced plan for such service area, the 
entity may offer one premium plan for 
such area. 
(4) OPTIONAL
OFFERING
OF
PREMIUM- 
PLUS PLANS.—If and only if the entity of-
fers a premium plan for such service 
area, the entity may offer one or more 
premium-plus plans for such area. 
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All such plans may be offered under a single 
contract with the Commissioner. 
(c) SPECIFICATION OF BENEFIT LEVELS FOR 
PLANS.— 
(1) IN
GENERAL.—The Commissioner 
shall establish the following standards 
consistent with this subsection and title 
I: 
(A) BASIC, ENHANCED, AND PREMIUM 
PLANS.—Standards for 3 levels of Ex-
change-participating health benefits 
plans: basic, enhanced, and premium 
(in this division referred to as a 
‘‘basic plan’’, ‘‘enhanced plan’’, and 
‘‘premium plan’’, respectively). 
(B) 
PREMIUM-PLUS
PLAN
BENE-
FITS.—Standards for additional bene-
fits that may be offered, consistent 
with this subsection and subtitle C of 
title I, under a premium plan (such a 
plan with additional benefits referred 
to in this division as a ‘‘premium-plus 
plan’’) . 
(2) BASIC PLAN.— 
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(A) IN
GENERAL.—A basic plan 
shall offer the essential benefits pack-
age required under title I for a quali-
fied health benefits plan. 
(B) TIERED COST-SHARING FOR AF-
FORDABLE
CREDIT
ELIGIBLE
INDIVID-
UALS.—In the case of an affordable 
credit eligible individual (as defined 
in section 242(a)(1)) enrolled in an Ex-
change-participating health benefits 
plan, the benefits under a basic plan 
are modified to provide for the re-
duced cost-sharing for the income 
tier 
applicable 
to 
the 
individual 
under section 244(c). 
(3) ENHANCED
PLAN.—An enhanced 
plan shall offer, in addition to the level of 
benefits under the basic plan, a lower 
level of cost-sharing as provided under 
title I consistent with section 123(b)(5)(A). 
(4) PREMIUM PLAN.—A premium plan 
shall offer, in addition to the level of ben-
efits under the basic plan, a lower level 
of cost-sharing as provided under title I 
consistent with section 123(b)(5)(B). 
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(5) PREMIUM-PLUS PLAN.—A premium- 
plus plan is a premium plan that also 
provides additional benefits, such as 
adult oral health and vision care, ap-
proved by the Commissioner. The portion 
of the premium that is attributable to 
such additional benefits shall be sepa-
rately specified. 
(6) RANGE OF PERMISSIBLE VARIATION IN 
COST-SHARING.—The Commissioner shall 
establish a permissible range of variation 
of cost-sharing for each basic, enhanced, 
and premium plan, except with respect to 
any benefit for which there is no cost- 
sharing permitted under the essential 
benefits package. Such variation shall 
permit a variation of not more than plus 
(or minus) 10 percent in cost-sharing 
with respect to each benefit category 
specified under section 122. 
(d) TREATMENT
OF STATE BENEFIT MAN-
DATES.—Insofar as a State requires a health 
insurance issuer offering health insurance 
coverage to include benefits beyond the es-
sential benefits package, such requirement 
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shall continue to apply to an Exchange-par-
ticipating health benefits plan, if the State 
has entered into an arrangement satisfactory 
to the Commissioner to reimburse the Com-
missioner for the amount of any net increase 
in affordability premium credits under sub-
title C as a result of an increase in premium 
in basic plans as a result of application of 
such requirement. 
SEC. 204. CONTRACTS FOR THE OFFERING OF EXCHANGE- 
PARTICIPATING HEALTH BENEFITS PLANS. 
(a) CONTRACTING DUTIES.—In carrying out 
section 201(b)(1) and consistent with this sub-
title: 
(1) OFFERING ENTITY AND PLAN STAND-
ARDS.—The Commissioner shall— 
(A) establish standards necessary 
to implement the requirements of this 
title and title I for— 
(i) QHBP offering entities for 
the offering of an Exchange-par-
ticipating health benefits plan; 
and 
(ii) 
for 
Exchange-partici-
pating health benefits plans; and 
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(B) certify QHBP offering entities 
and qualified health benefits plans as 
meeting such standards and require-
ments of this title and title I for pur-
poses of this subtitle. 
(2) SOLICITING AND NEGOTIATING BIDS; 
CONTRACTS.—The Commissioner shall— 
(A) solicit bids from QHBP offer-
ing entities for the offering of Ex-
change-participating health benefits 
plans; 
(B) based upon a review of such 
bids, negotiate with such entities for 
the offering of such plans; and 
(C) enter into contracts with such 
entities for the offering of such plans 
through the Health Insurance Ex-
change under terms (consistent with 
this title) negotiated between the 
Commissioner and such entities. 
(3) FAR NOT APPLICABLE.—The provi-
sions of the Federal Acquisition Regula-
tion shall not apply to contracts between 
the Commissioner and QHBP offering en-
tities for the offering of Exchange-partici-
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pating health benefits plans under this 
title. 
(b) STANDARDS FOR QHBP OFFERING ENTI-
TIES
TO
OFFER
EXCHANGE-PARTICIPATING 
HEALTH BENEFITS PLANS.—The standards es-
tablished under subsection (a)(1)(A) shall re-
quire that, in order for a QHBP offering entity 
to offer an Exchange-participating health 
benefits plan, the entity must meet the fol-
lowing requirements: 
(1) LICENSED.—The entity shall be li-
censed to offer health insurance coverage 
under State law for each State in which 
it is offering such coverage. 
(2) DATA REPORTING.—The entity shall 
provide for the reporting of such infor-
mation as the Commissioner may specify, 
including information necessary to ad-
minister the risk pooling mechanism de-
scribed in section 206(b) and information 
to address disparities in health and 
health care. 
(3) IMPLEMENTING AFFORDABILITY CRED-
ITS.—The entity shall provide for imple-
mentation of the affordability credits pro-
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vided for enrollees under subtitle C, in-
cluding the reduction in cost-sharing 
under section 244(c). 
(4) ENROLLMENT.—The entity shall ac-
cept all enrollments under this subtitle, 
subject to such exceptions (such as ca-
pacity limitations) in accordance with 
the requirements under title I for a quali-
fied health benefits plan. The entity shall 
notify the Commissioner if the entity 
projects or anticipates reaching such a 
capacity limitation that would result in a 
limitation in enrollment. 
(5) RISK POOLING PARTICIPATION.—The 
entity shall participate in such risk pool-
ing mechanism as the Commissioner es-
tablishes under section 206(b). 
(6) ESSENTIAL COMMUNITY PROVIDERS.— 
With respect to the basic plan offered by 
the entity, the entity shall contract for 
outpatient services with covered entities 
(as defined in section 340B(a)(4) of the 
Public Health Service Act, as in effect as 
of July 1, 2009). The Commissioner shall 
specify the extent to which and manner 
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in which the previous sentence shall 
apply in the case of a basic plan with re-
spect to which the Commissioner deter-
mines provides substantially all benefits 
through a health maintenance organiza-
tion, as defined in section 2791(b)(3) of 
the Public Health Service Act. 
(7) CULTURALLY
AND
LINGUISTICALLY 
APPROPRIATE
SERVICES
AND
COMMUNICA-
TIONS.—The entity shall provide for cul-
turally 
and 
linguistically 
appropriate 
communication and health services. 
(8) ADDITIONAL
REQUIREMENTS.—The 
entity shall comply with other applicable 
requirements of this title, as specified by 
the Commissioner, which shall include 
standards regarding billing and collec-
tion practices for premiums and related 
grace periods and which may include 
standards to ensure that the entity does 
not use coercive practices to force pro-
viders not to contract with other entities 
offering coverage through the Health In-
surance Exchange. 
(c) CONTRACTS.— 
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(1) BID APPLICATION.—To be eligible to 
enter into a contract under this section, a 
QHBP offering entity shall submit to the 
Commissioner a bid at such time, in such 
manner, and containing such information 
as the Commissioner may require. 
(2) 
TERM.—Each 
contract 
with 
a 
QHBP offering entity under this section 
shall be for a term of not less than one 
year, but may be made automatically re-
newable from term to term in the ab-
sence of notice of termination by either 
party. 
(3) ENFORCEMENT
OF
NETWORK
ADE-
QUACY.—In the case of a health benefits 
plan of a QHBP offering entity that uses 
a provider network, the contract under 
this section with the entity shall provide 
that if— 
(A) the Commissioner determines 
that such provider network does not 
meet such standards as the Commis-
sioner shall establish under section 
115; and 
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(B) an individual enrolled in such 
plan receives an item or service from 
a provider that is not within such 
network; 
then any cost-sharing for such item or 
service shall be equal to the amount of 
such cost-sharing that would be imposed 
if such item or service was furnished by 
a provider within such network. 
(4) OVERSIGHT
AND
ENFORCEMENT
RE-
SPONSIBILITIES.—The Commissioner shall 
establish processes, in coordination with 
State insurance regulators, to oversee, 
monitor, and enforce applicable require-
ments of this title with respect to QHBP 
offering entities offering Exchange-par-
ticipating health benefits plans and such 
plans, including the marketing of such 
plans. Such processes shall include the 
following: 
(A) 
GRIEVANCE
AND
COMPLAINT 
MECHANISMS.—The 
Commissioner 
shall establish, in coordination with 
State insurance regulators, a process 
under which Exchange-eligible indi-
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viduals and employers may file com-
plaints concerning violations of such 
standards. 
(B) 
ENFORCEMENT.—In 
carrying 
out authorities under this division re-
lating to the Health Insurance Ex-
change, the Commissioner may im-
pose one or more of the intermediate 
sanctions described in section 142(c). 
(C) TERMINATION.— 
(i) IN GENERAL.—The Commis-
sioner may terminate a contract 
with 
a 
QHBP 
offering 
entity 
under this section for the offering 
of 
an 
Exchange-participating 
health benefits plan if such entity 
fails to comply with the applica-
ble requirements of this title. Any 
determination by the Commis-
sioner to terminate a contract 
shall be made in accordance with 
formal investigation and compli-
ance procedures established by 
the Commissioner under which— 
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(I) the Commissioner pro-
vides the entity with the rea-
sonable opportunity to de-
velop and implement a correc-
tive action plan to correct the 
deficiencies 
that 
were 
the 
basis of the Commissioner’s 
determination; and 
(II) the Commissioner pro-
vides the entity with reason-
able notice and opportunity 
for 
hearing 
(including 
the 
right to appeal an initial deci-
sion) before terminating the 
contract. 
(ii) EXCEPTION
FOR
IMMINENT 
AND
SERIOUS
RISK
TO
HEALTH.— 
Clause (i) shall not apply if the 
Commissioner determines that a 
delay in termination, resulting 
from compliance with the proce-
dures specified in such clause 
prior to termination, would pose 
an imminent and serious risk to 
the health of individuals enrolled 
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under the qualified health bene-
fits plan of the QHBP offering en-
tity. 
(D) 
CONSTRUCTION.—Nothing 
in 
this subsection shall be construed as 
preventing the application of other 
sanctions under subtitle E of title I 
with respect to an entity for a viola-
tion of such a requirement. 
SEC. 205. OUTREACH AND ENROLLMENT OF EXCHANGE-EL-
IGIBLE INDIVIDUALS AND EMPLOYERS IN EX-
CHANGE-PARTICIPATING HEALTH BENEFITS 
PLAN. 
(a) IN GENERAL.— 
(1) 
OUTREACH.—The 
Commissioner 
shall conduct outreach activities con-
sistent with subsection (c), including 
through use of appropriate entities as de-
scribed in paragraph (4) of such sub-
section, to inform and educate individ-
uals and employers about the Health In-
surance Exchange and Exchange-partici-
pating health benefits plan options. Such 
outreach shall include outreach specific 
to vulnerable populations, such as chil-
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dren, individuals with disabilities, indi-
viduals with mental illness, and individ-
uals with other cognitive impairments. 
(2) ELIGIBILITY.—The Commissioner 
shall 
make 
timely 
determinations 
of 
whether individuals and employers are 
Exchange-eligible individuals and em-
ployers (as defined in section 202). 
(3) ENROLLMENT.—The Commissioner 
shall establish and carry out an enroll-
ment process for Exchange-eligible indi-
viduals and employers, including at com-
munity locations, in accordance with sub-
section (b). 
(b) ENROLLMENT PROCESS.— 
(1) IN
GENERAL.—The Commissioner 
shall establish a process consistent with 
this title for enrollments in Exchange- 
participating health benefits plans. Such 
process shall provide for enrollment 
through means such as the mail, by tele-
phone, electronically, and in person. 
(2) ENROLLMENT PERIODS.— 
(A) OPEN
ENROLLMENT
PERIOD.— 
The Commissioner shall establish an 
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has the same authority with respect to the 
public health insurance option as the Sec-
retary has under subsections (a)(1) and (b) of 
section 1874A of the Social Security Act with 
respect to title XVIII of such Act. Contracts 
under this subsection shall not involve the 
transfer of insurance risk to such entity. 
(d) OMBUDSMAN.—The Secretary shall es-
tablish an office of the ombudsman for the 
public health insurance option which shall 
have duties with respect to the public health 
insurance option similar to the duties of the 
Medicare Beneficiary Ombudsman under sec-
tion 1808(c)(2) of the Social Security Act. 
(e) DATA COLLECTION.—The Secretary shall 
collect such data as may be required to estab-
lish premiums and payment rates for the pub-
lic health insurance option and for other pur-
poses under this subtitle, including to im-
prove quality and to reduce racial, ethnic, 
and other disparities in health and health 
care. 
(f) TREATMENT OF PUBLIC HEALTH INSUR-
ANCE
OPTION.—With respect to the public 
health insurance option, the Secretary shall 
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1471 
‘‘(2) SPECIAL RULES FOR SMALL EMPLOY-
ERS.— 
‘‘(A) IN
GENERAL.—In the case of 
any employer who is small employer 
for any calendar year, paragraph (1) 
shall be applied by substituting the 
applicable percentage determined in 
accordance with the following table 
for ‘8 percent’: 
‘‘If the annual payroll of such employer for 
the preceding calendar year: 
The applicable 
percentage is: 
Does not exceed $250,000 ...........................
0 percent 
Exceeds $250,000, but does not exceed 
$300,000.
2 percent 
Exceeds $300,000, but does not exceed 
$350,000.
4 percent 
Exceeds $350,000, but does not exceed 
$400,000.
6 percent 
‘‘(B) SMALL
EMPLOYER.—For pur-
poses of this paragraph, the term 
‘small employer’ means any employer 
for any calendar year if the annual 
payroll of such employer for the pre-
ceding calendar year does not exceed 
$400,000. 
‘‘(C) ANNUAL
PAYROLL.—For pur-
poses of this paragraph, the term ‘an-
nual payroll’ means, with respect to 
any employer for any calendar year, 
the aggregate wages (as defined in 
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03:16 Oct 15, 2009
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