(c) CONFORMING AMENDMENT.—Subparagraph (A) 
of section 223(f)(5) of such Code is amended by inserting 
‘‘or Medicare Advantage MSA’’ after ‘‘into a health sav-
ings account’’. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
December 31, 2011. 
SEC. 205. REPEAL OF ADDITIONAL TAX ON DISTRIBUTIONS 
NOT USED FOR QUALIFIED MEDICAL EX-
PENSES. 
(a) IN GENERAL.—Subsection (f) of section 223 of 
the Internal Revenue Code of 1986 is amended by striking 
paragraph (4) and redesignating paragraphs (5), (6), and 
(7) and paragraphs (4), (5), and (6), respectively. 
(b) CONFORMING AMENDMENTS.— 
(1) Paragraph (2) of section 25(b) of such Code 
is amended by striking subparagraph (U) and by re-
designating subparagraphs (V), (W), and (X) as 
subparagraphs (U), (V), and (W). 
(2) Subparagraph (C) of section 106(e)(4) of 
such Code is amended by striking ‘‘223(f)(5)’’ and 
inserting ‘‘223(f)(4)’’. 
(3) Paragraph (6) of section 877A(g) of such 
Code is amended by striking ‘‘223(f)(4),’’. 
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(4) Paragraph (1) of section 4973(g) of such 
Code is amended by striking ‘‘223(f)(5)’’ and insert-
ing ‘‘223(f)(4)’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
December 31, 2011. 
Subtitle B—Other Health Care Tax 
Reform 
SEC. 206. ELIMINATION OF 7.5-PERCENT FLOOR ON MED-
ICAL EXPENSE DEDUCTIONS. 
(a) IN GENERAL.—Subsection (a) of section 213 of 
the Internal Revenue Code of 1986 is amended by striking 
‘‘, to the extent that such expenses exceed 7.5 percent of 
adjusted gross income’’. 
(b) CONFORMING AMENDMENT.—Paragraph (1) of 
section 56(b) of such Code is amended by striking sub-
paragraph (B). 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
December 31, 2011. 
SEC. 207. REPEAL OF PRESCRIBED DRUG LIMITATION ON 
CERTAIN TAX BENEFITS FOR MEDICAL EX-
PENSES. 
(a) DEDUCTION FOR MEDICAL EXPENSES.— 
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(1) IN GENERAL.—Section 213 of the Internal 
Revenue Code of 1986 is amended by striking sub-
section (b). 
(2) CONFORMING AMENDMENT.—Subsection (d) 
of section 213 of such Code is amended by striking 
paragraph (3). 
(b) TREATMENT OF REIMBURSEMENTS UNDER ACCI-
DENT OR HEALTH PLANS.—Section 106 of such Code is 
amended by striking subsection (f). 
(c) HEALTH SAVINGS ACCOUNTS.—Subparagraph 
(A) of section 223(d)(2) of such Code is amended by strik-
ing the last sentence thereof. 
(d) ARCHER MSAS.—Subparagraph (A) of section 
220(d)(2) of such Code is amended by striking the last 
sentence thereof. 
(e) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
December 31, 2011. 
SEC. 
208. 
REPEAL 
OF 
2-PERCENT 
MISCELLANEOUS 
ITEMIZED DEDUCTION FLOOR FOR MEDICAL 
EXPENSE DEDUCTIONS. 
(a) IN GENERAL.—Subsection (b) of section 67 of the 
Internal Revenue Code of 1986 is amended by striking 
paragraph (5). 
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(b) EFFECTIVE DATE.—The amendment made by 
this section shall apply to taxable years beginning after 
the December 31, 2011. 
SEC. 209. CHARITY CARE CREDIT. 
(a) IN GENERAL.—Subpart A of part IV of sub-
chapter A of chapter 1 of the Internal Revenue Code of 
1986 (relating to nonrefundable personal credits) is 
amended by inserting after section 25D the following new 
section: 
‘‘SEC. 25E. CHARITY CARE CREDIT. 
‘‘(a) ALLOWANCE OF CREDIT.—In the case of a phy-
sician, there shall be allowed as a credit against the tax 
imposed by this chapter for a taxable year the amount 
determined in accordance with the following table: 
‘‘If the physician has provided during such 
taxable year:.
The amount of 
the credit is: 
At least 25 but less than 30 qualified hours of 
charity care.
$2,000. 
At least 30 but less than 35 qualified hours of 
charity care.
$2,400. 
At least 35 but less than 40 qualified hours of 
charity care.
$2,800. 
At least 40 but less than 45 qualified hours of 
charity care.
$3,200. 
At least 45 but less than 50 qualified hours of 
charity care.
$3,600. 
At least 50 but less than 55 qualified hours of 
charity care.
$4,000. 
At least 55 but less than 60 qualified hours of 
charity care.
$4,400. 
At least 60 but less than 65 qualified hours of 
charity care.
$4,800. 
At least 65 but less than 70 qualified hours of 
charity care.
$5,200. 
At least 70 but less than 75 qualified hours of 
charity care.
$5,600. 
At least 75 but less than 80 qualified hours of 
charity care.
$6,000. 
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At least 80 but less than 85 qualified hours of 
charity care.
$6,400. 
At least 85 but less than 90 qualified hours of 
charity care.
$6,800. 
At least 90 but less than 95 qualified hours of 
charity care.
$7,200. 
At least 95 but less than 100 qualified hours of 
charity care.
$7,600. 
At least 100 hours of charity care .........................
$8,000. 
‘‘(b) QUALIFIED HOURS OF CHARITY CARE.—For 
purposes of this section— 
‘‘(1) QUALIFIED HOURS OF CHARITY CARE.— 
The term ‘qualified hours of charity care’ means the 
hours that a physician provides medical care (as de-
fined in section 213(d)(1)(A)) on a volunteer or pro 
bono basis. 
‘‘(2) PHYSICIAN.—The term ‘physician’ has the 
meaning given to such term in section 1861(r) of the 
Social Security Act (42 U.S.C. 1395x(r)).’’. 
(b) CONFORMING AMENDMENT.—The table of sec-
tions for subpart A of part IV of subchapter A of chapter 
1 of such Code is amended by inserting after the item 
relating to section 25D the following new item: 
‘‘Sec. 25E. Charity care credit.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
December 31, 2011. 
SEC. 210. COBRA CONTINUATION COVERAGE EXTENDED. 
(a) UNDER IRC.—Subparagraph (B) of section 
4980B(f)(2) of the Internal Revenue Code of 1986 is 
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amended by striking clauses (i) and (v) and by redesig-
nating clauses (ii), (iii), and (iv) as clauses (i), (ii), and 
(iii), respectively. 
(b) UNDER ERISA.—Paragraph (2) of section 602 
of the Employee Retirement Income Security Act of 2009 
(29 U.S.C. 1162) is amended by striking subparagraphs 
(A) and (E) and by redesignating subparagraphs (B), (C), 
and (D) as subparagraphs (A), (B), and (C), respectively. 
(c) UNDER
PHSA.—Paragraph (2) of section 
2202(2) of the Public Health Service Act (42 U.S.C. 
300bb–2(2)) is amended by striking subparagraphs (A) 
and (E) and by redesignating subparagraphs (B), (C), and 
(D) as subparagraphs (A), (B), and (C), respectively. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to group health plans, 
and health insurance coverage offered in connection with 
group health plans, for plan years beginning after the date 
of the enactment of this Act. 
SEC. 211. HSA CHARITABLE CONTRIBUTIONS. 
(a) IN GENERAL.—Subsection (f) of section 223 of 
the Internal Revenue Code of 1986 is amended by adding 
at the end the following new paragraph: 
‘‘(9) DISTRIBUTIONS
FOR
CHARITABLE
PUR-
POSES.—For purposes of this subsection— 
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‘‘(A) IN
GENERAL.—Paragraph (2) shall 
not apply to any qualified charitable distribu-
tions with respect to a taxpayer made during 
any taxable year. 
‘‘(B) QUALIFIED
CHARITABLE
DISTRIBU-
TION.—For purposes of this paragraph, the 
term ‘qualified charitable distribution’ means 
any distribution from a health savings account 
which is made directly by the trustee to an or-
ganization described in section 170(b)(1)(A) 
(other than any organization described in sec-
tion 509(a)(3) or any fund or account described 
in section 4966(d)(2)). A distribution shall be 
treated as a qualified charitable distribution 
only to the extent that the distribution would be 
includible in gross income without regard to 
subparagraph (A). 
‘‘(C) CONTRIBUTIONS
MUST
BE
OTHER-
WISE DEDUCTIBLE.—For purposes of this para-
graph, a distribution to an organization de-
scribed in subparagraph (B) shall be treated as 
a qualified charitable distribution only if a de-
duction for the entire distribution would be al-
lowable under section 170 (determined without 
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regard to subsection (b) thereof and this para-
graph). 
‘‘(D) DENIAL OF DEDUCTION.—Qualified 
charitable distributions which are not includible 
in gross income pursuant to subparagraph (A) 
shall not be taken into account in determining 
the deduction under section 170.’’. 
(b) EFFECTIVE DATE.—The amendment made by 
this section shall apply to taxable years beginning after 
December 31, 2011. 
TITLE III—MEDICARE PREMIUM 
ASSISTANCE PROGRAM 
SEC. 301. REPLACEMENT OF MEDICARE PART A ENTITLE-
MENT WITH MEDICARE REFORM PREMIUM 
ASSISTANCE PROGRAM. 
(a) IN GENERAL.—Section 226 of the Social Security 
Act (42 U.S.C. 426) is amended by adding at the end the 
following new subsections: 
‘‘(k) REPLACEMENT OF ENTITLEMENT WITH PRE-
MIUM ASSISTANCE PROGRAM.— 
‘‘(1) IN GENERAL.—Notwithstanding the pre-
vious provisions of this section, beginning the first 
January 1 after the date of the enactment of the Of-
fering Patients True Individualized Options Act of 
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2011, the Secretary shall establish procedures under 
which— 
‘‘(A) in the case of an individual who, but 
for the application of this paragraph, would 
otherwise become entitled under subsection (a) 
on or after such January 1 to benefits under 
part A of title XVIII, subject to paragraph (4), 
the individual shall in lieu of such entitlement 
be automatically enrolled in the Medicare Re-
form Premium Assistance Program established 
under subsection (l); and 
‘‘(B) in the case of an individual who be-
fore such January 1 is entitled under sub-
section (a) to benefits under part A of title 
XVIII, the individual may in lieu of such enti-
tlement elect on or after such January 1 to en-
roll in the Medicare Reform Premium Assist-
ance Program established under subsection (l). 
‘‘(2) TREATMENT UNDER THE INTERNAL REV-
ENUE CODE OF 1986.—An individual who is enrolled 
under the Medicare Reform Premium Assistance 
Program under paragraph (1) shall not be treated 
as entitled to benefits under title XVIII for purposes 
of section 223(b)(7) of the Internal Revenue Code of 
1986. 
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‘‘(3) INELIGIBILITY FOR PART B OR D BENE-
FITS.—An individual shall not be eligible for benefits 
under part B or D of title XVIII once the individual 
is enrolled in the Medicare Reform Premium Assist-
ance Program under paragraph (1). 
‘‘(4) OPT OUT.— 
‘‘(A) IN GENERAL.—Any individual who is 
otherwise eligible for automatic enrollment in 
the Medicare Reform Premium Assistance Pro-
gram under paragraph (1)(A) may elect (in 
such form and manner as may be specified by 
the Secretary of Health and Human Services) 
to not be so enrolled. 
‘‘(B) INDIVIDUALS ELECTING TO OPT OUT 
NOT
TREATED
AS
ENTITLED
TO
MEDICARE 
BENEFITS.—In the case of an individual who 
makes an election under subparagraph (A)— 
‘‘(i) such individual shall not be eligi-
ble for benefits under part A of title 
XVIII; and 
‘‘(ii) the provisions of paragraphs (2) 
and (3) shall apply to such individual in 
the same manner as such paragraphs apply 
to an individual enrolled under the Medi-
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care Reform Premium Assistance Program 
under paragraph (1). 
‘‘(l) MEDICARE REFORM PREMIUM ASSISTANCE.— 
‘‘(1) ESTABLISHMENT
OF
PREMIUM
ASSIST-
ANCE
PROGRAM.—The Secretary shall establish a 
program to be known as the Medicare Reform Pre-
mium Assistance Program (in this subsection re-
ferred to as the ‘premium assistance program’) con-
sistent with this subsection. 
‘‘(2) AUTOMATIC ENROLLMENT.—An individual 
otherwise entitled under subsection (a) to benefits 
under part A of title XVIII shall, subject to sub-
section (k)(4), be enrolled in the premium assistance 
program for the period during which such individual 
would otherwise be so entitled to benefits. 
‘‘(3) AMOUNT OF PREMIUM ASSISTANCE.— 
‘‘(A) IN GENERAL.—Subject to clause (ii), 
for each year that an individual is enrolled in 
the premium assistance program, the Secretary 
shall provide premium assistance to such indi-
vidual in an amount determined by the Sec-
retary that is based on the geographic location 
of the individual and the cost of applicable 
health insurance coverage and benefits in such 
area. 
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‘‘(B) COMPUTATION OF PREMIUM ASSIST-
ANCE AMOUNTS.—The amount of premium as-
sistance provided to an individual located in a 
geographic area for a year shall be computed at 
120 percent of the sum of the median premium 
and median deductible payment for such year 
for all health insurance coverage offered by 
health insurance issuers in the individual mar-
ket serving such area. 
‘‘(4) PERMISSIBLE USE OF PREMIUM ASSIST-
ANCE.—Premium assistance under paragraph (3) 
may be used only for the following purposes: 
‘‘(A) 
For 
payment 
of 
premiums, 
deductibles, copayments, or other cost-sharing 
for enrollment of such individual for health in-
surance coverage offered by health insurance 
issuers in the individual market. 
‘‘(B) As a contribution into a MSA plan 
established by such individual, as defined in 
section 138(b)(2) of the Internal Revenue Code 
of 1986. 
‘‘(5) MSA DEPOSITS.—The amount of the pre-
mium assistance received by an individual under this 
subsection shall be deposited, on behalf of such indi-
vidual, into the MSA plan of such individual.’’. 
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(b) EFFECTIVE DATE.—The amendment made by 
this section shall take effect on the first January 1 after 
the date of the enactment of this Act. 
TITLE IV—EMTALA REFORMS 
SEC. 401. EMTALA REFORMS. 
(a) USE OF QUALIFIED EMERGENCY DEPARTMENT 
PERSONNEL IN PERFORMING INITIAL SCREENING.—Sub-
section (a) of section 1867 of the Social Security Act (42 
U.S.C. 1395dd) is amended— 
(1) by designating the sentence beginning with 
‘‘In the case of’’ as paragraph (1), with the heading 
‘‘IN GENERAL.—’’ and appropriate indentation; and 
(2) by adding at the end the following new 
paragraph: 
‘‘(2) 
PERMITTING
APPLICATION
OF
ER 
TRIAGE.— 
‘‘(A) IN
GENERAL.—The requirement of 
paragraph (1) that a hospital conduct an appro-
priate medical screening examination of an indi-
vidual is deemed to be satisfied if a qualified 
emergency screener (as defined in subparagraph 
(B)) performs a preliminary triage-type screen-
ing in which the personnel— 
‘‘(i) assesses the nature and extent of 
the individual’s illness or injury; and 
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‘‘(ii) determines, based on such as-
sessment, that an emergency medical con-
dition does not exist. 
‘‘(B) QUALIFIED
EMERGENCY
SCREENER 
DEFINED.—In this paragraph, the term ‘quali-
fied emergency screener’ means a physician, li-
censed practical nurse or registered nurse, 
qualified emergency medical technician, or other 
individual with basic, health care education that 
meets standards specified by the Secretary as 
being sufficient to perform the screening de-
scribed in subparagraph (A).’’. 
(b) REVISION OF EMERGENCY MEDICAL CONDITION 
DEFINITION.—Subsection (e)(1)(A) of such section is 
amended to read as follows: 
‘‘(A) a medical condition manifesting itself 
by symptoms of sufficient severity (including se-
vere pain) and with an onset or of a course 
such that the absence of immediate medical at-
tention could reasonably be expected to pose an 
immediate risk to life or long-term health of the 
individual (or, with respect to a pregnant 
woman, the life or long-term health of the 
woman or her unborn child); or’’. 
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(c) EFFECTIVE DATE.—The amendments made by 
this section shall take effect on the date of the enactment 
of this Act and shall apply to individuals who come to an 
emergency room on or after the date that is 30 days after 
the date of the enactment of this Act. 
TITLE 
V—COOPERATIVE 
GOV-
ERNING OF INDIVIDUAL AND 
GROUP HEALTH INSURANCE 
COVERAGE 
SEC. 501. COOPERATIVE GOVERNING OF INDIVIDUAL AND 
GROUP HEALTH INSURANCE COVERAGE. 
(a) IN GENERAL.—Title XXVII of the Public Health 
Service Act (42 U.S.C. 300gg et seq.) is amended by add-
ing at the end the following new part: 
‘‘PART D—COOPERATIVE GOVERNING OF INDI-
VIDUAL AND GROUP HEALTH INSURANCE 
COVERAGE 
‘‘SEC. 2795. DEFINITIONS. 
‘‘In this part: 
‘‘(1) PRIMARY
STATE.—The term ‘primary 
State’ means, with respect to individual or group 
health insurance coverage offered by a health insur-
ance issuer, the State designated by the issuer as 
the State whose covered laws shall govern the health 
insurance issuer in the sale of such coverage under 
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this part. An issuer, with respect to a particular pol-
icy, may only designate one such State as its pri-
mary State with respect to all such coverage it of-
fers. Such an issuer may not change the designated 
primary State with respect to individual or group 
health insurance coverage once the policy is issued, 
except that such a change may be made upon re-
newal of the policy. With respect to such designated 
State, the issuer is deemed to be doing business in 
that State. 
‘‘(2) SECONDARY STATE.—The term ‘secondary 
State’ means, with respect to individual or group 
health insurance coverage offered by a health insur-
ance issuer, any State that is not the primary State. 
In the case of a health insurance issuer that is sell-
ing a policy in, or to a resident of, a secondary 
State, the issuer is deemed to be doing business in 
that secondary State. 
‘‘(3) HEALTH INSURANCE ISSUER.—The term 
‘health insurance issuer’ has the meaning given such 
term in section 2791(b)(2), except that such an 
issuer must be licensed in the primary State and be 
qualified to sell individual health insurance coverage 
in that State. 
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‘‘(4) INDIVIDUAL
HEALTH
INSURANCE
COV-
ERAGE.—The term ‘individual health insurance cov-
erage’ means health insurance coverage offered in 
the individual market, as defined in section 
2791(e)(1). 
‘‘(5) GROUP HEALTH INSURANCE COVERAGE.— 
The term ‘group health insurance coverage’ has the 
meaning given such term in 2791(b)(4). 
‘‘(6) APPLICABLE
STATE
AUTHORITY.—The 
term ‘applicable State authority’ means, with respect 
to a health insurance issuer in a State, the State in-
surance commissioner or official or officials des-
ignated by the State to enforce the requirements of 
this title for the State with respect to the issuer. 
‘‘(7) HAZARDOUS FINANCIAL CONDITION.—The 
term ‘hazardous financial condition’ means that, 
based on its present or reasonably anticipated finan-
cial condition, a health insurance issuer is unlikely 
to be able— 
‘‘(A) to meet obligations to policyholders 
with respect to known claims and reasonably 
anticipated claims; or 
‘‘(B) to pay other obligations in the normal 
course of business. 
‘‘(8) COVERED LAWS.— 
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‘‘(A) IN
GENERAL.—The term ‘covered 
laws’ means the laws, rules, regulations, agree-
ments, and orders governing the insurance busi-
ness pertaining to— 
‘‘(i) individual or group health insur-
ance coverage issued by a health insurance 
issuer; 
‘‘(ii) the offer, sale, rating (including 
medical 
underwriting), 
renewal, 
and 
issuance of individual or group health in-
surance coverage to an individual; 
‘‘(iii) the provision to an individual in 
relation to individual or group health in-
surance coverage of health care and insur-
ance related services; 
‘‘(iv) the provision to an individual in 
relation to individual or group health in-
surance coverage of management, oper-
ations, and investment activities of a 
health insurance issuer; and 
‘‘(v) the provision to an individual in 
relation to individual or group health in-
surance coverage of loss control and claims 
administration for a health insurance 
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issuer with respect to liability for which 
the issuer provides insurance. 
‘‘(B) EXCEPTION.—Such term does not in-
clude any law, rule, regulation, agreement, or 
order governing the use of care or cost manage-
ment techniques, including any requirement re-
lated to provider contracting, network access or 
adequacy, health care data collection, or quality 
assurance. 
‘‘(9) STATE.—The term ‘State’ means the 50 
States and includes the District of Columbia, Puerto 
Rico, the Virgin Islands, Guam, American Samoa, 
and the Northern Mariana Islands. 
‘‘(10) UNFAIR
CLAIMS
SETTLEMENT
PRAC-
TICES.—The term ‘unfair claims settlement prac-
tices’ means only the following practices: 
‘‘(A) Knowingly misrepresenting to claim-
ants and insured individuals relevant facts or 
policy provisions relating to coverage at issue. 
‘‘(B) Failing to acknowledge with reason-
able promptness pertinent communications with 
respect to claims arising under policies. 
‘‘(C) Failing to adopt and implement rea-
sonable standards for the prompt investigation 
and settlement of claims arising under policies. 
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‘‘(D) Failing to effectuate prompt, fair, 
and equitable settlement of claims submitted in 
which liability has become reasonably clear. 
‘‘(E) Refusing to pay claims without con-
ducting a reasonable investigation. 
‘‘(F) Failing to affirm or deny coverage of 
claims within a reasonable period of time after 
having completed an investigation related to 
those claims. 
‘‘(G) A pattern or practice of compelling 
insured individuals or their beneficiaries to in-
stitute suits to recover amounts due under its 
policies by offering substantially less than the 
amounts ultimately recovered in suits brought 
by them. 
‘‘(H) A pattern or practice of attempting 
to settle or settling claims for less than the 
amount that a reasonable person would believe 
the insured individual or his or her beneficiary 
was entitled by reference to written or printed 
advertising material accompanying or made 
part of an application. 
‘‘(I) Attempting to settle or settling claims 
on the basis of an application that was materi-
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ally altered without notice to, or knowledge or 
consent of, the insured. 
‘‘(J) Failing to provide forms necessary to 
present claims within 15 calendar days of a re-
quests with reasonable explanations regarding 
their use. 
‘‘(K) Attempting to cancel a policy in less 
time than that prescribed in the policy or by the 
law of the primary State. 
‘‘(11) FRAUD AND ABUSE.—The term ‘fraud 
and abuse’ means an act or omission committed by 
a person who, knowingly and with intent to defraud, 
commits, or conceals any material information con-
cerning, one or more of the following: 
‘‘(A) Presenting, causing to be presented 
or preparing with knowledge or belief that it 
will be presented to or by an insurer, a rein-
surer, broker or its agent, false information as 
part of, in support of or concerning a fact ma-
terial to one or more of the following: 
‘‘(i) An application for the issuance or 
renewal of an insurance policy or reinsur-
ance contract. 
‘‘(ii) The rating of an insurance policy 
or reinsurance contract. 
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‘‘(iii) A claim for payment or benefit 
pursuant to an insurance policy or reinsur-
ance contract. 
‘‘(iv) Premiums paid on an insurance 
policy or reinsurance contract. 
‘‘(v) Payments made in accordance 
with the terms of an insurance policy or 
reinsurance contract. 
‘‘(vi) A document filed with the com-
missioner or the chief insurance regulatory 
official of another jurisdiction. 
‘‘(vii) The financial condition of an in-
surer or reinsurer. 
‘‘(viii) The formation, acquisition, 
merger, 
reconsolidation, 
dissolution 
or 
withdrawal from one or more lines of in-
surance or reinsurance in all or part of a 
State by an insurer or reinsurer. 
‘‘(ix) The issuance of written evidence 
of insurance. 
‘‘(x) The reinstatement of an insur-
ance policy. 
‘‘(B) Solicitation or acceptance of new or 
renewal insurance risks on behalf of an insurer 
reinsurer or other person engaged in the busi-
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ness of insurance by a person who knows or 
should know that the insurer or other person 
responsible for the risk is insolvent at the time 
of the transaction. 
‘‘(C) Transaction of the business of insur-
ance in violation of laws requiring a license, cer-
tificate of authority or other legal authority for 
the transaction of the business of insurance. 
‘‘(D) Attempt to commit, aiding or abet-
ting in the commission of, or conspiracy to com-
mit the acts or omissions specified in this para-
graph. 
‘‘SEC. 2796. APPLICATION OF LAW. 
‘‘(a) IN GENERAL.—The covered laws of the primary 
State shall apply to individual and group health insurance 
coverage offered by a health insurance issuer in the pri-
mary State and in any secondary State, but only if the 
coverage and issuer comply with the conditions of this sec-
tion with respect to the offering of coverage in any sec-
ondary State. 
‘‘(b) EXEMPTIONS FROM COVERED LAWS IN A SEC-
ONDARY STATE.—Except as provided in this section, a 
health insurance issuer with respect to its offer, sale, rat-
ing (including medical underwriting), renewal, and 
issuance of individual or group health insurance coverage 
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in any secondary State is exempt from any covered laws 
of the secondary State (and any rules, regulations, agree-
ments, or orders sought or issued by such State under or 
related to such covered laws) to the extent that such laws 
would— 
‘‘(1) make unlawful, or regulate, directly or in-
directly, the operation of the health insurance issuer 
operating in the secondary State, except that any 
secondary State may require such an issuer— 
‘‘(A) to pay, on a nondiscriminatory basis, 
applicable premium and other taxes (including 
high risk pool assessments) which are levied on 
insurers and surplus lines insurers, brokers, or 
policyholders under the laws of the State; 
‘‘(B) to register with and designate the 
State insurance commissioner as its agent solely 
for the purpose of receiving service of legal doc-
uments or process; 
‘‘(C) to submit to an examination of its fi-
nancial condition by the State insurance com-
missioner in any State in which the issuer is 
doing business to determine the issuer’s finan-
cial condition, if— 
‘‘(i) the State insurance commissioner 
of the primary State has not done an ex-
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amination within the period recommended 
by the National Association of Insurance 
Commissioners; and 
‘‘(ii) any such examination is con-
ducted in accordance with the examiners’ 
handbook of the National Association of 
Insurance Commissioners and is coordi-
nated to avoid unjustified duplication and 
unjustified repetition; 
‘‘(D) to comply with a lawful order 
issued— 
‘‘(i) in a delinquency proceeding com-
menced by the State insurance commis-
sioner if there has been a finding of finan-
cial impairment under subparagraph (C); 
or 
‘‘(ii) in a voluntary dissolution pro-
ceeding; 
‘‘(E) to comply with an injunction issued 
by a court of competent jurisdiction, upon a pe-
tition by the State insurance commissioner al-
leging that the issuer is in hazardous financial 
condition; 
‘‘(F) to participate, on a nondiscriminatory 
basis, in any insurance insolvency guaranty as-
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sociation or similar association to which a 
health insurance issuer in the State is required 
to belong; 
‘‘(G) to comply with any State law regard-
ing fraud and abuse (as defined in section 
2795(10)), except that if the State seeks an in-
junction regarding the conduct described in this 
subparagraph, such injunction must be obtained 
from a court of competent jurisdiction; 
‘‘(H) to comply with any State law regard-
ing unfair claims settlement practices (as de-
fined in section 2795(9)); or 
‘‘(I) to comply with the applicable require-
ments for independent review under section 
2798 with respect to coverage offered in the 
State; 
‘‘(2) require any individual or group health in-
surance coverage issued by the issuer to be counter-
signed by an insurance agent or broker residing in 
that Secondary State; or 
‘‘(3) otherwise discriminate against the issuer 
issuing insurance in both the primary State and in 
any secondary State. 
‘‘(c) CLEAR
AND CONSPICUOUS DISCLOSURE.—A 
health insurance issuer shall provide the following notice, 
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in 12-point bold type, in any insurance coverage offered 
in a secondary State under this part by such a health in-
surance issuer and at renewal of the policy, with the 5 
blank spaces therein being appropriately filled with the 
name of the health insurance issuer, the name of primary 
State, the name of the secondary State, the name of the 
secondary State, and the name of the secondary State, re-
spectively, for the coverage concerned: ‘Notice: This policy 
is issued by llll and is governed by the laws and 
regulations of the State of llll, and it has met all 
the laws of that State as determined by that State’s De-
partment of Insurance. This policy may be less expensive 
than others because it is not subject to all of the insurance 
laws and regulations of the State of lllll, includ-
ing coverage of some services or benefits mandated by the 
law of the State of lllll. Additionally, this policy 
is not subject to all of the consumer protection laws or 
restrictions on rate changes of the State of lllll. 
As with all insurance products, before purchasing this pol-
icy, you should carefully review the policy and determine 
what health care services the policy covers and what bene-
fits it provides, including any exclusions, limitations, or 
conditions for such services or benefits.’ 
‘‘(d) PROHIBITION ON CERTAIN RECLASSIFICATIONS 
AND PREMIUM INCREASES.— 
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‘‘(1) IN GENERAL.—For purposes of this sec-
tion, a health insurance issuer that provides indi-
vidual or group health insurance coverage to an indi-
vidual under this part in a primary or secondary 
State may not upon renewal— 
‘‘(A) move or reclassify the individual in-
sured under the health insurance coverage from 
the class such individual is in at the time of 
issue of the contract based on the health status- 
related factors of the individual; or 
‘‘(B) increase the premiums assessed the 
individual for such coverage based on a health 
status-related factor or change of a health sta-
tus-related factor or the past or prospective 
claim experience of the insured individual. 
‘‘(2) CONSTRUCTION.—Nothing in paragraph 
(1) shall be construed to prohibit a health insurance 
issuer— 
‘‘(A) from terminating or discontinuing 
coverage or a class of coverage in accordance 
with subsections (b) and (c) of section 2742; 
‘‘(B) from raising premium rates for all 
policy holders within a class based on claims ex-
perience; 
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‘‘(C) from changing premiums or offering 
discounted premiums to individuals who engage 
in wellness activities at intervals prescribed by 
the issuer, if such premium changes or incen-
tives— 
‘‘(i) are disclosed to the consumer in 
the insurance contract; 
‘‘(ii) are based on specific wellness ac-
tivities that are not applicable to all indi-
viduals; and 
‘‘(iii) are not obtainable by all individ-
uals to whom coverage is offered; 
‘‘(D) from reinstating lapsed coverage; or 
‘‘(E) from retroactively adjusting the rates 
charged an insured individual if the initial rates 
were set based on material misrepresentation by 
the individual at the time of issue. 
‘‘(e) PRIOR OFFERING
OF POLICY
IN PRIMARY 
STATE.—A health insurance issuer may not offer for sale 
individual or group health insurance coverage in a sec-
ondary State unless that coverage is currently offered for 
sale in the primary State. 
‘‘(f) LICENSING
OF AGENTS
OR BROKERS
FOR 
HEALTH INSURANCE ISSUERS.—Any State may require 
that a person acting, or offering to act, as an agent or 
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broker for a health insurance issuer with respect to the 
offering of individual or group health insurance coverage 
obtain a license from that State, with commissions or 
other compensation subject to the provisions of the laws 
of that State, except that a State may not impose any 
qualification or requirement which discriminates against 
a nonresident agent or broker. 
‘‘(g) DOCUMENTS FOR SUBMISSION TO STATE IN-
SURANCE COMMISSIONER.—Each health insurance issuer 
issuing individual or group health insurance coverage in 
both primary and secondary States shall submit— 
‘‘(1) to the insurance commissioner of each 
State in which it intends to offer such coverage, be-
fore it may offer individual or group health insur-
ance coverage in such State— 
‘‘(A) a copy of the plan of operation or fea-
sibility study or any similar statement of the 
policy being offered and its coverage (which 
shall include the name of its primary State and 
its principal place of business); 
‘‘(B) written notice of any change in its 
designation of its primary State; and 
‘‘(C) written notice from the issuer of the 
issuer’s compliance with all the laws of the pri-
mary State; and 
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‘‘(2) to the insurance commissioner of each sec-
ondary State in which it offers individual or group 
health insurance coverage, a copy of the issuer’s 
quarterly financial statement submitted to the pri-
mary State, which statement shall be certified by an 
independent public accountant and contain a state-
ment of opinion on loss and loss adjustment expense 
reserves made by— 
‘‘(A) a member of the American Academy 
of Actuaries; or 
‘‘(B) a qualified loss reserve specialist. 
‘‘(h) POWER OF COURTS TO ENJOIN CONDUCT.— 
Nothing in this section shall be construed to affect the 
authority of any Federal or State court to enjoin— 
‘‘(1) the solicitation or sale of individual or 
group health insurance coverage by a health insur-
ance issuer to any person or group who is not eligi-
ble for such insurance; or 
‘‘(2) the solicitation or sale of individual or 
group health insurance coverage that violates the re-
quirements of the law of a secondary State which 
are described in subparagraphs (A) through (H) of 
section 2796(b)(1). 
‘‘(i) POWER OF SECONDARY STATES TO TAKE AD-
MINISTRATIVE ACTION.—Nothing in this section shall be 
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construed to affect the authority of any State to enjoin 
conduct in violation of that State’s laws described in sec-
tion 2796(b)(1). 
‘‘(j) STATE POWERS TO ENFORCE STATE LAWS.— 
‘‘(1) IN GENERAL.—Subject to the provisions of 
subsection (b)(1)(G) (relating to injunctions) and 
paragraph (2), nothing in this section shall be con-
strued to affect the authority of any State to make 
use of any of its powers to enforce the laws of such 
State with respect to which a health insurance issuer 
is not exempt under subsection (b). 
‘‘(2) COURTS OF COMPETENT JURISDICTION.— 
If a State seeks an injunction regarding the conduct 
described in paragraphs (1) and (2) of subsection 
(h), such injunction must be obtained from a Fed-
eral or State court of competent jurisdiction. 
‘‘(k) STATES’ AUTHORITY TO SUE.—Nothing in this 
section shall affect the authority of any State to bring ac-
tion in any Federal or State court. 
‘‘(l) GENERALLY APPLICABLE LAWS.—Nothing in 
this section shall be construed to affect the applicability 
of State laws generally applicable to persons or corpora-
tions. 
‘‘(m) GUARANTEED AVAILABILITY OF COVERAGE TO 
HIPAA ELIGIBLE INDIVIDUALS.—To the extent that a 
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health insurance issuer is offering coverage in a primary 
State that does not accommodate residents of secondary 
States or does not provide a working mechanism for resi-
dents of a secondary State, and the issuer is offering cov-
erage under this part in such secondary State which has 
not adopted a qualified high risk pool as its acceptable 
alternative mechanism (as defined in section 2744(c)(2)), 
the issuer shall, with respect to any individual or group 
health insurance coverage offered in a secondary State 
under this part, comply with the guaranteed availability 
requirements for eligible individuals in section 2741. 
‘‘SEC. 2797. PRIMARY STATE MUST MEET FEDERAL FLOOR 
BEFORE ISSUER MAY SELL INTO SECONDARY 
STATES. 
‘‘A health insurance issuer may not offer, sell, or 
issue individual or group health insurance coverage in a 
secondary State if the State insurance commissioner does 
not use a risk-based capital formula for the determination 
of capital and surplus requirements for all health insur-
ance issuers. 
‘‘SEC. 2798. INDEPENDENT EXTERNAL APPEALS PROCE-
DURES. 
‘‘(a) RIGHT TO EXTERNAL APPEAL.—A health insur-
ance issuer may not offer, sell, or issue individual or group 
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health insurance coverage in a secondary State under the 
provisions of this title unless— 
‘‘(1) both the secondary State and the primary 
State have legislation or regulations in place estab-
lishing an independent review process for individuals 
who are covered by individual health insurance cov-
erage or group health insurance offered by a health 
insurance issuer, repsectively, or 
‘‘(2) in any case in which the requirements of 
subparagraph (A) are not met with respect to the ei-
ther of such States, the issuer provides an inde-
pendent review mechanism substantially identical (as 
determined by the applicable State authority of such 
State) to that prescribed in the ‘Health Carrier Ex-
ternal Review Model Act’ of the National Association 
of Insurance Commissioners for all individuals who 
purchase insurance coverage under the terms of this 
part, except that, under such mechanism, the review 
is conducted by an independent medical reviewer, or 
a panel of such reviewers, with respect to whom the 
requirements of subsection (b) are met. 
‘‘(b) QUALIFICATIONS OF INDEPENDENT MEDICAL 
REVIEWERS.—In the case of any independent review 
mechanism referred to in subsection (a)(2): 
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‘‘(1) IN GENERAL.—In referring a denial of a 
claim to an independent medical reviewer, or to any 
panel of such reviewers, to conduct independent 
medical review, the issuer shall ensure that— 
‘‘(A) each independent medical reviewer 
meets the qualifications described in paragraphs 
(2) and (3); 
‘‘(B) with respect to each review, each re-
viewer meets the requirements of paragraph (4) 
and the reviewer, or at least 1 reviewer on the 
panel, meets the requirements described in 
paragraph (5); and 
‘‘(C) compensation provided by the issuer 
to each reviewer is consistent with paragraph 
(6). 
‘‘(2) LICENSURE AND EXPERTISE.—Each inde-
pendent medical reviewer shall be a physician 
(allopathic or osteopathic) or health care profes-
sional who— 
‘‘(A) is appropriately credentialed or li-
censed in 1 or more States to deliver health 
care services; and 
‘‘(B) typically treats the condition, makes 
the diagnosis, or provides the type of treatment 
under review. 
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‘‘(3) INDEPENDENCE.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), each independent medical reviewer 
in a case shall— 
‘‘(i) not be a related party (as defined 
in paragraph (7)); 
‘‘(ii) not have a material familial, fi-
nancial, or professional relationship with 
such a party; and 
‘‘(iii) not otherwise have a conflict of 
interest with such a party (as determined 
under regulations). 
‘‘(B) EXCEPTION.—Nothing in subpara-
graph (A) shall be construed to— 
‘‘(i) prohibit an individual, solely on 
the basis of affiliation with the issuer, 
from serving as an independent medical re-
viewer if— 
‘‘(I) a non-affiliated individual is 
not reasonably available; 
‘‘(II) the affiliated individual is 
not involved in the provision of items 
or services in the case under review; 
‘‘(III) the fact of such an affili-
ation is disclosed to the issuer and the 
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enrollee (or authorized representative) 
and neither party objects; and 
‘‘(IV) the affiliated individual is 
not an employee of the issuer and 
does not provide services exclusively or 
primarily to or on behalf of the issuer; 
‘‘(ii) prohibit an individual who has 
staff privileges at the institution where the 
treatment involved takes place from serv-
ing as an independent medical reviewer 
merely on the basis of such affiliation if 
the affiliation is disclosed to the issuer and 
the enrollee (or authorized representative), 
and neither party objects; or 
‘‘(iii) prohibit receipt of compensation 
by an independent medical reviewer from 
an entity if the compensation is provided 
consistent with paragraph (6). 
‘‘(4) PRACTICING HEALTH CARE PROFESSIONAL 
IN SAME FIELD.— 
‘‘(A) IN
GENERAL.—In a case involving 
treatment, or the provision of items or serv-
ices— 
‘‘(i) by a physician, a reviewer shall be 
a practicing physician (allopathic or osteo-
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pathic) of the same or similar specialty, as 
a physician who, acting within the appro-
priate scope of practice within the State in 
which the service is provided or rendered, 
typically treats the condition, makes the 
diagnosis, or provides the type of treat-
ment under review; or 
‘‘(ii) by a non-physician health care 
professional, the reviewer, or at least 1 
member of the review panel, shall be a 
practicing non-physician health care pro-
fessional of the same or similar specialty 
as the non-physician health care profes-
sional who, acting within the appropriate 
scope of practice within the State in which 
the service is provided or rendered, typi-
cally treats the condition, makes the diag-
nosis, or provides the type of treatment 
under review. 
‘‘(B) PRACTICING
DEFINED.—For pur-
poses of this paragraph, the term ‘practicing’ 
means, with respect to an individual who is a 
physician or other health care professional, that 
the individual provides health care services to 
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