datamatters24/research-document-archive huggingface dataset:
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HR 3590 EAS/PP 
least one plan in the gold level in each such 
Exchange; 
(iii) agrees to charge the same pre-
mium rate for each qualified health plan of 
the issuer without regard to whether the 
plan is offered through an Exchange or 
whether the plan is offered directly from the 
issuer or through an agent; and 
(iv) complies with the regulations de-
veloped by the Secretary under section 
1311(d) and such other requirements as an 
applicable Exchange may establish. 
(2) INCLUSION OF CO-OP PLANS AND COMMUNITY 
HEALTH INSURANCE OPTION.—Any reference in this 
title to a qualified health plan shall be deemed to in-
clude a qualified health plan offered through the CO- 
OP program under section 1322 or a community 
health insurance option under section 1323, unless 
specifically provided for otherwise. 
(b) TERMS RELATING TO HEALTH PLANS.—In this 
title: 
(1) HEALTH PLAN.— 
(A) IN GENERAL.—The term ‘‘health plan’’ 
means health insurance coverage and a group 
health plan.
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(B) EXCEPTION FOR SELF-INSURED PLANS 
AND MEWAS.—Except to the extent specifically 
provided by this title, the term ‘‘health plan’’ 
shall not include a group health plan or multiple 
employer welfare arrangement to the extent the 
plan or arrangement is not subject to State in-
surance regulation under section 514 of the Em-
ployee Retirement Income Security Act of 1974. 
(2) 
HEALTH
INSURANCE
COVERAGE
AND 
ISSUER.—The terms ‘‘health insurance coverage’’ and 
‘‘health insurance issuer’’ have the meanings given 
such terms by section 2791(b) of the Public Health 
Service Act. 
(3) GROUP
HEALTH
PLAN.—The term ‘‘group 
health plan’’ has the meaning given such term by sec-
tion 2791(a) of the Public Health Service Act. 
SEC. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS. 
(a) ESSENTIAL HEALTH BENEFITS PACKAGE.—In 
this title, the term ‘‘essential health benefits package’’ 
means, with respect to any health plan, coverage that— 
(1) provides for the essential health benefits de-
fined by the Secretary under subsection (b); 
(2) limits cost-sharing for such coverage in ac-
cordance with subsection (c); and
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(3) subject to subsection (e), provides either the 
bronze, silver, gold, or platinum level of coverage de-
scribed in subsection (d). 
(b) ESSENTIAL HEALTH BENEFITS.— 
(1) IN GENERAL.—Subject to paragraph (2), the 
Secretary shall define the essential health benefits, ex-
cept that such benefits shall include at least the fol-
lowing general categories and the items and services 
covered within the categories: 
(A) Ambulatory patient services. 
(B) Emergency services. 
(C) Hospitalization. 
(D) Maternity and newborn care. 
(E) Mental health and substance use dis-
order services, including behavioral health treat-
ment. 
(F) Prescription drugs. 
(G) Rehabilitative and habilitative services 
and devices. 
(H) Laboratory services. 
(I) Preventive and wellness services and 
chronic disease management. 
(J) Pediatric services, including oral and 
vision care. 
(2) LIMITATION.—
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(A) IN GENERAL.—The Secretary shall en-
sure that the scope of the essential health benefits 
under paragraph (1) is equal to the scope of ben-
efits provided under a typical employer plan, as 
determined by the Secretary. To inform this de-
termination, the Secretary of Labor shall con-
duct a survey of employer-sponsored coverage to 
determine the benefits typically covered by em-
ployers, including multiemployer plans, and pro-
vide a report on such survey to the Secretary. 
(B) CERTIFICATION.—In defining the essen-
tial health benefits described in paragraph (1), 
and in revising the benefits under paragraph 
(4)(H), the Secretary shall submit a report to the 
appropriate committees of Congress containing a 
certification from the Chief Actuary of the Cen-
ters for Medicare & Medicaid Services that such 
essential health benefits meet the limitation de-
scribed in paragraph (2). 
(3) NOTICE AND HEARING.—In defining the es-
sential health benefits described in paragraph (1), 
and in revising the benefits under paragraph (4)(H), 
the Secretary shall provide notice and an opportunity 
for public comment.
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(4) 
REQUIRED
ELEMENTS
FOR
CONSIDER-
ATION.—In defining the essential health benefits 
under paragraph (1), the Secretary shall— 
(A) ensure that such essential health benefits 
reflect an appropriate balance among the cat-
egories described in such subsection, so that bene-
fits are not unduly weighted toward any cat-
egory; 
(B) not make coverage decisions, determine 
reimbursement rates, establish incentive pro-
grams, or design benefits in ways that discrimi-
nate against individuals because of their age, 
disability, or expected length of life; 
(C) take into account the health care needs 
of diverse segments of the population, including 
women, children, persons with disabilities, and 
other groups; 
(D) ensure that health benefits established 
as essential not be subject to denial to individ-
uals against their wishes on the basis of the indi-
viduals’ age or expected length of life or of the 
individuals’ present or predicted disability, de-
gree of medical dependency, or quality of life; 
(E) provide that a qualified health plan 
shall not be treated as providing coverage for the
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essential health benefits described in paragraph 
(1) unless the plan provides that— 
(i) coverage for emergency department 
services will be provided without imposing 
any requirement under the plan for prior 
authorization of services or any limitation 
on coverage where the provider of services 
does not have a contractual relationship 
with the plan for the providing of services 
that is more restrictive than the require-
ments or limitations that apply to emer-
gency department services received from 
providers who do have such a contractual 
relationship with the plan; and 
(ii) if such services are provided out-of- 
network, the cost-sharing requirement (ex-
pressed as a copayment amount or coinsur-
ance rate) is the same requirement that 
would apply if such services were provided 
in-network; 
(F) provide that if a plan described in sec-
tion 1311(b)(2)(B)(ii) (relating to stand-alone 
dental benefits plans) is offered through an Ex-
change, another health plan offered through such 
Exchange shall not fail to be treated as a quali-
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fied health plan solely because the plan does not 
offer coverage of benefits offered through the 
stand-alone plan that are otherwise required 
under paragraph (1)(J); and 
(G) periodically review the essential health 
benefits under paragraph (1), and provide a re-
port to Congress and the public that contains— 
(i) an assessment of whether enrollees 
are facing any difficulty accessing needed 
services for reasons of coverage or cost; 
(ii) an assessment of whether the essen-
tial health benefits needs to be modified or 
updated to account for changes in medical 
evidence or scientific advancement; 
(iii) information on how the essential 
health benefits will be modified to address 
any such gaps in access or changes in the 
evidence base; 
(iv) an assessment of the potential of 
additional or expanded benefits to increase 
costs and the interactions between the addi-
tion or expansion of benefits and reductions 
in existing benefits to meet actuarial limi-
tations described in paragraph (2); and
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(H) periodically update the essential health 
benefits under paragraph (1) to address any 
gaps in access to coverage or changes in the evi-
dence base the Secretary identifies in the review 
conducted under subparagraph (G). 
(5) RULE OF CONSTRUCTION.—Nothing in this 
title shall be construed to prohibit a health plan from 
providing benefits in excess of the essential health ben-
efits described in this subsection. 
(c) REQUIREMENTS RELATING TO COST-SHARING.— 
(1) ANNUAL LIMITATION ON COST-SHARING.— 
(A) 2014.—The cost-sharing incurred under 
a health plan with respect to self-only coverage 
or coverage other than self-only coverage for a 
plan year beginning in 2014 shall not exceed the 
dollar 
amounts 
in 
effect 
under 
section 
223(c)(2)(A)(ii) of the Internal Revenue Code of 
1986 for self-only and family coverage, respec-
tively, for taxable years beginning in 2014. 
(B) 2015 AND LATER.—In the case of any 
plan year beginning in a calendar year after 
2014, the limitation under this paragraph 
shall— 
(i) in the case of self-only coverage, be 
equal to the dollar amount under subpara-
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graph (A) for self-only coverage for plan 
years beginning in 2014, increased by an 
amount equal to the product of that amount 
and the premium adjustment percentage 
under paragraph (4) for the calendar year; 
and 
(ii) in the case of other coverage, twice 
the amount in effect under clause (i). 
If the amount of any increase under clause (i) 
is not a multiple of $50, such increase shall be 
rounded to the next lowest multiple of $50. 
(2) ANNUAL LIMITATION ON DEDUCTIBLES FOR 
EMPLOYER-SPONSORED PLANS.— 
(A) IN GENERAL.—In the case of a health 
plan offered in the small group market, the de-
ductible under the plan shall not exceed— 
(i) $2,000 in the case of a plan cov-
ering a single individual; and 
(ii) $4,000 in the case of any other 
plan. 
The amounts under clauses (i) and (ii) may be 
increased by the maximum amount of reimburse-
ment which is reasonably available to a partici-
pant under a flexible spending arrangement de-
scribed in section 106(c)(2) of the Internal Rev-
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in this subsection, the issuer may only offer the plan 
in the individual market. 
(f) CHILD-ONLY PLANS.—If a qualified health plan is 
offered through the Exchange in any level of coverage speci-
fied under subsection (d), the issuer shall also offer that 
plan through the Exchange in that level as a plan in which 
the only enrollees are individuals who, as of the beginning 
of a plan year, have not attained the age of 21, and such 
plan shall be treated as a qualified health plan. 
SEC. 1303. SPECIAL RULES. 
(a) SPECIAL RULES RELATING
TO COVERAGE
OF 
ABORTION SERVICES.— 
(1) VOLUNTARY CHOICE OF COVERAGE OF ABOR-
TION SERVICES.— 
(A) IN
GENERAL.—Notwithstanding any 
other provision of this title (or any amendment 
made by this title), and subject to subparagraphs 
(C) and (D)— 
(i) nothing in this title (or any amend-
ment made by this title), shall be construed 
to require a qualified health plan to provide 
coverage of services described in subpara-
graph (B)(i) or (B)(ii) as part of its essen-
tial health benefits for any plan year; and
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(III) may not estimate such a cost 
at less than $1 per enrollee, per month. 
(3) PROVIDER
CONSCIENCE
PROTECTIONS.—No 
individual health care provider or health care facility 
may be discriminated against because of a willingness 
or an unwillingness, if doing so is contrary to the re-
ligious or moral beliefs of the provider or facility, to 
provide, pay for, provide coverage of, or refer for 
abortions. 
(b) APPLICATION OF STATE AND FEDERAL LAWS RE-
GARDING ABORTION.— 
(1) NO PREEMPTION OF STATE LAWS REGARDING 
ABORTION.—Nothing in this Act shall be construed to 
preempt or otherwise have any effect on State laws re-
garding the prohibition of (or requirement of) cov-
erage, funding, or procedural requirements on abor-
tions, including parental notification or consent for 
the performance of an abortion on a minor. 
(2) NO EFFECT ON FEDERAL LAWS REGARDING 
ABORTION.— 
(A) IN GENERAL.—Nothing in this Act shall 
be construed to have any effect on Federal laws 
regarding— 
(i) conscience protection;
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(ii) willingness or refusal to provide 
abortion; and 
(iii) discrimination on the basis of the 
willingness or refusal to provide, pay for, 
cover, or refer for abortion or to provide or 
participate in training to provide abortion. 
(3) NO
EFFECT
ON
FEDERAL
CIVIL
RIGHTS 
LAW.—Nothing in this subsection shall alter the rights 
and obligations of employees and employers under 
title VII of the Civil Rights Act of 1964. 
(c) APPLICATION OF EMERGENCY SERVICES LAWS.— 
Nothing in this Act shall be construed to relieve any health 
care provider from providing emergency services as required 
by State or Federal law, including section 1867 of the So-
cial Security Act (popularly known as ‘‘EMTALA’’). 
SEC. 1304. RELATED DEFINITIONS. 
(a) DEFINITIONS RELATING TO MARKETS.—In this 
title: 
(1) GROUP MARKET.—The term ‘‘group market’’ 
means the health insurance market under which indi-
viduals obtain health insurance coverage (directly or 
through any arrangement) on behalf of themselves 
(and their dependents) through a group health plan 
maintained by an employer.
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(A) meet marketing requirements, and not 
employ marketing practices or benefit designs 
that have the effect of discouraging the enroll-
ment in such plan by individuals with signifi-
cant health needs; 
(B) ensure a sufficient choice of providers 
(in a manner consistent with applicable network 
adequacy provisions under section 2702(c) of the 
Public Health Service Act), and provide infor-
mation to enrollees and prospective enrollees on 
the availability of in-network and out-of-network 
providers; 
(C) include within health insurance plan 
networks those essential community providers, 
where available, that serve predominately low-in-
come, medically-underserved individuals, such as 
health 
care 
providers 
defined 
in 
section 
340B(a)(4) of the Public Health Service Act and 
providers 
described 
in 
section 
1927(c)(1)(D)(i)(IV) of the Social Security Act 
as set forth by section 221 of Public Law 111– 
8, except that nothing in this subparagraph shall 
be construed to require any health plan to pro-
vide coverage for any specific medical procedure;
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(D)(i) be accredited with respect to local 
performance on clinical quality measures such as 
the Healthcare Effectiveness Data and Informa-
tion Set, patient experience ratings on a stand-
ardized Consumer Assessment of Healthcare Pro-
viders and Systems survey, as well as consumer 
access, utilization management, quality assur-
ance, provider credentialing, complaints and ap-
peals, network adequacy and access, and patient 
information programs by any entity recognized 
by the Secretary for the accreditation of health 
insurance issuers or plans (so long as any such 
entity has transparent and rigorous methodo-
logical and scoring criteria); or 
(ii) receive such accreditation within a pe-
riod established by an Exchange for such accred-
itation that is applicable to all qualified health 
plans; 
(E) implement a quality improvement 
strategy described in subsection (g)(1); 
(F) utilize a uniform enrollment form that 
qualified individuals and qualified employers 
may use (either electronically or on paper) in 
enrolling in qualified health plans offered 
through such Exchange, and that takes into ac-
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count criteria that the National Association of 
Insurance Commissioners develops and submits 
to the Secretary; 
(G) utilize the standard format established 
for presenting health benefits plan options; and 
(H) provide information to enrollees and 
prospective enrollees, and to each Exchange in 
which the plan is offered, on any quality meas-
ures for health plan performance endorsed under 
section 399JJ of the Public Health Service Act, 
as applicable. 
(2) RULE OF CONSTRUCTION.—Nothing in para-
graph (1)(C) shall be construed to require a qualified 
health plan to contract with a provider described in 
such paragraph if such provider refuses to accept the 
generally applicable payment rates of such plan. 
(3) RATING SYSTEM.—The Secretary shall de-
velop a rating system that would rate qualified health 
plans offered through an Exchange in each benefits 
level on the basis of the relative quality and price. 
The Exchange shall include the quality rating in the 
information provided to individuals and employers 
through the Internet portal established under para-
graph (4).
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(4) ENROLLEE SATISFACTION SYSTEM.—The Sec-
retary shall develop an enrollee satisfaction survey 
system that would evaluate the level of enrollee satis-
faction with qualified health plans offered through an 
Exchange, for each such qualified health plan that 
had more than 500 enrollees in the previous year. The 
Exchange shall include enrollee satisfaction informa-
tion in the information provided to individuals and 
employers through the Internet portal established 
under paragraph (5) in a manner that allows indi-
viduals to easily compare enrollee satisfaction levels 
between comparable plans. 
(5) INTERNET PORTALS.—The Secretary shall— 
(A) continue to operate, maintain, and up-
date the Internet portal developed under section 
1103(a) and to assist States in developing and 
maintaining their own such portal; and 
(B) make available for use by Exchanges a 
model template for an Internet portal that may 
be used to direct qualified individuals and quali-
fied employers to qualified health plans, to assist 
such individuals and employers in determining 
whether they are eligible to participate in an 
Exchange or eligible for a premium tax credit or 
cost-sharing reduction, and to present standard-
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ized information (including quality ratings) re-
garding qualified health plans offered through an 
Exchange to assist consumers in making easy 
health insurance choices. 
Such template shall include, with respect to each 
qualified health plan offered through the Exchange in 
each rating area, access to the uniform outline of cov-
erage the plan is required to provide under section 
2716 of the Public Health Service Act and to a copy 
of the plan’s written policy. 
(6) ENROLLMENT PERIODS.—The Secretary shall 
require an Exchange to provide for— 
(A) an initial open enrollment, as deter-
mined by the Secretary (such determination to 
be made not later than July 1, 2012); 
(B) annual open enrollment periods, as de-
termined by the Secretary for calendar years 
after the initial enrollment period; 
(C) special enrollment periods specified in 
section 9801 of the Internal Revenue Code of 
1986 and other special enrollment periods under 
circumstances similar to such periods under part 
D of title XVIII of the Social Security Act; and
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(D) special monthly enrollment periods for 
Indians (as defined in section 4 of the Indian 
Health Care Improvement Act). 
(d) REQUIREMENTS.— 
(1) IN GENERAL.—An Exchange shall be a gov-
ernmental agency or nonprofit entity that is estab-
lished by a State. 
(2) OFFERING OF COVERAGE.— 
(A) IN GENERAL.—An Exchange shall make 
available qualified health plans to qualified indi-
viduals and qualified employers. 
(B) LIMITATION.— 
(i) IN GENERAL.—An Exchange may 
not make available any health plan that is 
not a qualified health plan. 
(ii) OFFERING OF STAND-ALONE DEN-
TAL BENEFITS.—Each Exchange within a 
State shall allow an issuer of a plan that 
only provides limited scope dental benefits 
meeting 
the 
requirements 
of 
section 
9832(c)(2)(A) of the Internal Revenue Code 
of 1986 to offer the plan through the Ex-
change (either separately or in conjunction 
with a qualified health plan) if the plan
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provides pediatric dental benefits meeting 
the requirements of section 1302(b)(1)(J)). 
(3) RULES RELATING TO ADDITIONAL REQUIRED 
BENEFITS.— 
(A) IN GENERAL.—Except as provided in 
subparagraph (B), an Exchange may make 
available a qualified health plan notwith-
standing any provision of law that may require 
benefits other than the essential health benefits 
specified under section 1302(b). 
(B) STATES
MAY
REQUIRE
ADDITIONAL 
BENEFITS.— 
(i) IN
GENERAL.—Subject to the re-
quirements of clause (ii), a State may re-
quire that a qualified health plan offered in 
such State offer benefits in addition to the 
essential health benefits specified under sec-
tion 1302(b). 
(ii) STATE
MUST
ASSUME
COST.—A 
State shall make payments to or on behalf 
of an individual eligible for the premium 
tax credit under section 36B of the Internal 
Revenue Code of 1986 and any cost-sharing 
reduction under section 1402 to defray the 
cost to the individual of any additional ben-
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efits described in clause (i) which are not el-
igible for such credit or reduction under sec-
tion 36B(b)(3)(D) of such Code and section 
1402(c)(4). 
(4) FUNCTIONS.—An Exchange shall, at a min-
imum— 
(A) implement procedures for the certifi-
cation, recertification, and decertification, con-
sistent with guidelines developed by the Sec-
retary under subsection (c), of health plans as 
qualified health plans; 
(B) provide for the operation of a toll-free 
telephone hotline to respond to requests for assist-
ance; 
(C) maintain an Internet website through 
which enrollees and prospective enrollees of 
qualified health plans may obtain standardized 
comparative information on such plans; 
(D) assign a rating to each qualified health 
plan offered through such Exchange in accord-
ance with the criteria developed by the Secretary 
under subsection (c)(3); 
(E) utilize a standardized format for pre-
senting health benefits plan options in the Ex-
change, including the use of the uniform outline
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of coverage established under section 2715 of the 
Public Health Service Act; 
(F) in accordance with section 1413, inform 
individuals of eligibility requirements for the 
medicaid program under title XIX of the Social 
Security Act, the CHIP program under title XXI 
of such Act, or any applicable State or local pub-
lic program and if through screening of the ap-
plication by the Exchange, the Exchange deter-
mines that such individuals are eligible for any 
such program, enroll such individuals in such 
program; 
(G) establish and make available by elec-
tronic means a calculator to determine the ac-
tual cost of coverage after the application of any 
premium tax credit under section 36B of the In-
ternal Revenue Code of 1986 and any cost-shar-
ing reduction under section 1402; 
(H) subject to section 1411, grant a certifi-
cation attesting that, for purposes of the indi-
vidual responsibility penalty under section 
5000A of the Internal Revenue Code of 1986, an 
individual is exempt from the individual re-
quirement or from the penalty imposed by such 
section because—
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subsection (a) or (b) of section 52 of 
the Internal Revenue Code of 1986 as 
a member of the same controlled group 
of corporations (or under common con-
trol with) as a health insurance issuer; 
or 
(ii) the State medicaid agency under 
title XIX of the Social Security Act. 
(g) REWARDING QUALITY THROUGH MARKET-BASED 
INCENTIVES.— 
(1) STRATEGY DESCRIBED.—A strategy described 
in this paragraph is a payment structure that pro-
vides increased reimbursement or other incentives 
for— 
(A) improving health outcomes through the 
implementation of activities that shall include 
quality reporting, effective case management, 
care coordination, chronic disease management, 
medication and care compliance initiatives, in-
cluding through the use of the medical home 
model, for treatment or services under the plan 
or coverage; 
(B) the implementation of activities to pre-
vent hospital readmissions through a comprehen-
sive program for hospital discharge that includes