1055 
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 Inter-
nal Revenue Code of 1986. 
(b) PARITY IN MENTAL HEALTH AND SUBSTANCE 
ABUSE DISORDER BENEFITS.—To the extent such provi-
sions are not superceded by or inconsistent with subtitle 
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 bene-
fits plan, regardless of whether it is offered in the indi-
vidual or group market, in the same manner as such provi-
sions apply to health insurance coverage offered in the 
large group market. 
SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS. 
(a) IN GENERAL.—A qualified health benefits plan 
that uses a provider network for items and services shall 
meet such standards respecting provider networks as the 
Commissioner may establish to assure the adequacy of 
such networks in ensuring enrollee access to such items 
and services and transparency in the cost-sharing differen-
tials between in-network coverage and out-of-network cov-
erage. 
(b) INTERNET ACCESS TO INFORMATION.—A quali-
fied health benefits plan that uses a provider network shall 
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provide a current listing of all providers in its network 
on its website and such data shall be available on the 
Health Insurance Exchange website as a ‘click through’ 
from the basic information on that plan. The Commis-
sioner shall also establish an on-line system whereby an 
individual may select by name any medical provider (as 
defined by the Commissioner) and be informed of the plan 
or plans with which that provider is contracting. 
(c) PROVIDER NETWORK DEFINED.—In this subdivi-
sion, the term ‘‘provider network’’ means the providers 
with respect to which covered benefits, treatments, and 
services are available under a health benefits plan. 
SEC. 116. ENSURING VALUE AND LOWER PREMIUMS. 
The QHBP offering entity shall provide that for any 
plan year in which a qualified health benefits plan that 
the entity offers has a medical loss ratio (expressed as a 
percentage) that is less than a percentage (not less than 
85 percent) specified by the Commissioner, the QHBP of-
fering entity offering such plan shall provide for rebates 
to enrollees of payment sufficient to meet such loss ratio. 
The Commissioner 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 account the special circumstances 
of smaller and newer plans. 
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SEC. 117. CONSISTENCY OF COSTS AND COVERAGE UNDER 
QUALIFIED HEALTH BENEFITS PLANS DUR-
ING PLAN YEAR. 
In the case of health insurance coverage offered 
under a qualified health benefits plan, the coverage and 
cost of coverage may not be changed during the course 
of a plan year except to increase coverage to the enrollee 
or to lower costs to the enrollee. 
Subtitle 
C—Standards 
Guaran-
teeing Access to Essential Bene-
fits 
SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE. 
(a) IN GENERAL.—A qualified health benefits plan 
shall provide coverage that at least meets the benefit 
standards adopted under section 124 for the essential ben-
efits package described in section 122 for the plan year 
involved. 
(b) CHOICE OF COVERAGE.— 
(1) NON-EXCHANGE-PARTICIPATING
HEALTH 
BENEFITS PLANS.—In the case of a qualified health 
benefits plan that is not an Exchange-participating 
health benefits plan, such plan may offer such cov-
erage in addition to the essential benefits package as 
the QHBP offering entity may specify. 
(2) EXCHANGE-PARTICIPATING HEALTH BENE-
FITS PLANS.—In the case of an Exchange-partici-
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pating health benefits plan, such plan is required 
under section 203 to provide specified levels of bene-
fits and, in the case of a plan offering a premium- 
plus level of benefits, provide additional benefits. 
(3) CONTINUATION OF OFFERING OF SEPARATE 
EXCEPTED BENEFITS COVERAGE.—Nothing in this 
subdivision shall be construed as affecting the offer-
ing of health benefits in the form of excepted bene-
fits (described in section 102(b)(1)(B)(ii)) if such 
benefits are offered under a separate policy, con-
tract, or certificate of insurance. 
(c) NO RESTRICTIONS ON COVERAGE UNRELATED 
TO CLINICAL APPROPRIATENESS.—A qualified health ben-
efits plan may not impose any restriction (other than cost- 
sharing) unrelated 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 subdivision, the term ‘‘es-
sential benefits package’’ means health benefits coverage, 
consistent with standards adopted under section 124 to 
ensure the provision of quality health care and financial 
security, that— 
(1) provides payment for the items and services 
described in subsection (b) in accordance with gen-
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erally accepted standards of medical or other appro-
priate clinical or professional practice; 
(2) limits cost-sharing for such covered health 
care items and services in accordance with such ben-
efit standards, consistent with subsection (c); 
(3) does not impose any annual or lifetime limit 
on the coverage of covered health care items and 
services; 
(4) complies with section 115(a) (relating to 
network adequacy); and 
(5) is equivalent, as certified by Office of the 
Actuary of the Centers for Medicare & Medicaid 
Services, to the average prevailing employer-spon-
sored coverage. 
(b) MINIMUM SERVICES
TO BE COVERED.—The 
items and services described in this subsection are the fol-
lowing: 
(1) Hospitalization. 
(2) Outpatient hospital and outpatient clinic 
services, including emergency department services. 
(3) Professional services of physicians and other 
health professionals. 
(4) Such services, equipment, and supplies inci-
dent to the services of a physician’s or a health pro-
fessional’s delivery of care in institutional settings, 
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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 including 
mental health and substance abuse services rec-
ommended by the Task Force on Clinical Preventive 
Services and those mental health and substance 
abuse services with compelling research or evidence, 
including Screening, Brief Intervention and Referral 
to Treatment (SBIRT), and those vaccines rec-
ommended for use by the Director of the Centers for 
Disease Control and Prevention. 
(9) Maternity care. 
(10) Well baby and well child care and early 
and periodic screening, diagnostic, and treatment 
services (as defined in section 1905(r) of the Social 
Security Act) at least for children under 21 years of 
age. 
(11) Durable medical equipment, prosthetics, 
orthotics and related supplies. 
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(c) REQUIREMENTS RELATING
TO COST-SHARING 
AND MINIMUM ACTUARIAL VALUE.— 
(1) NO COST-SHARING FOR PREVENTIVE SERV-
ICES.—There shall be no cost-sharing under the es-
sential benefits package for preventive items and 
services (as specified under the benefit standards), 
including well baby and well child care. 
(2) ANNUAL LIMITATION.— 
(A) ANNUAL LIMITATION.—The cost-shar-
ing incurred under the essential benefits pack-
age with respect to an individual (or family) for 
a year does not exceed the applicable level spec-
ified in subparagraph (B). 
(B) APPLICABLE LEVEL.—The applicable 
level specified in this subparagraph for Y1 is 
$5,000 for an individual and $10,000 for a 
family. Such levels shall be increased (rounded 
to the nearest $100) for each subsequent year 
by the annual percentage increase in the Con-
sumer Price Index (United States city average) 
applicable to such year. 
(C) USE OF COPAYMENTS.—In establishing 
cost-sharing levels for basic, enhanced, and pre-
mium plans under this subsection, the Sec-
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retary shall, to the maximum extent possible, 
use only copayments and not coinsurance. 
(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 ac-
tuarial value of the benefits provided under the 
reference benefits package described in sub-
paragraph (B). 
(B) REFERENCE BENEFITS PACKAGE DE-
SCRIBED.—The reference benefits package de-
scribed in this subparagraph is the essential 
benefits package if there were no cost-sharing 
imposed. 
SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE. 
(a) ESTABLISHMENT.— 
(1) IN GENERAL.—There is established a pri-
vate-public advisory committee which shall be a 
panel of medical and other experts to be known as 
the Health Benefits Advisory Committee to rec-
ommend covered benefits and essential, enhanced, 
and premium plans. 
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(2) CHAIR.—The Surgeon General shall be a 
member and the chair of the Health Benefits Advi-
sory Committee. 
(3) MEMBERSHIP.—The Health Benefits Advi-
sory Committee shall be composed of the following 
members, in addition to the Surgeon General: 
(A) 9 members who are not Federal em-
ployees or officers and who are appointed by 
the President. 
(B) 9 members who are not Federal em-
ployees or officers and who are appointed by 
the Comptroller General of the United States in 
a manner similar to the manner in which the 
Comptroller General appoints members to the 
Medicare Payment Advisory Commission under 
section 1805(c) of the Social Security Act. 
(C) Such even number of members (not to 
exceed 8) who are Federal employees and offi-
cers, as the President may appoint. 
The membership of the Committee shall include one 
or more experts in scientific evidence and clinical 
practice of integrative health care services. Such ini-
tial appointments shall be made not later than 60 
days after the date of the enactment of this Act. 
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(4) TERMS.—Each member of the Health Bene-
fits Advisory Committee shall serve a 3-year term on 
the Committee, except that the terms of the initial 
members shall be adjusted in order to provide for a 
staggered term of appointment for all such mem-
bers. 
(5) PARTICIPATION.—The membership of the 
Health Benefits Advisory Committee shall at least 
reflect providers, employers, labor, health insurance 
issuers, experts in health care financing and deliv-
ery, experts in racial and ethnic disparities, experts 
in care for those with disabilities, representatives of 
relevant governmental agencies. and at least one 
practicing physician or other health professional and 
an expert on children’s health and shall represent a 
balance among various sectors of the health care 
system so that no single sector unduly influences the 
recommendations of such Committee. The member-
ship of the Committee shall also include educated 
patients, consumer advocates, or both, who shall in-
clude persons who represent individuals affected by 
a specific disease or medical condition, are knowl-
edgeable about the health care system, and have re-
ceived training regarding health, medical, and sci-
entific matters. 
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(b) DUTIES.— 
(1) RECOMMENDATIONS
ON
BENEFIT
STAND-
ARDS.—The Health Benefits Advisory Committee 
shall recommend to the Secretary of Health and 
Human Services (in this subtitle referred to as the 
‘‘Secretary’’) benefit standards (as defined in para-
graph (4)), and periodic updates to such standards. 
In developing such recommendations, the Committee 
shall— 
(A) take into account innovation in health 
care, 
(B) consider how such standards could re-
duce health disparities, 
(C) take into account integrative health 
care services, and 
(D) take into account typical multiem-
ployer plan benefit structures and the impact of 
the essential benefit package on such plans. 
(2) DEADLINE.—The Health Benefits Advisory 
Committee shall recommend initial benefit standards 
to the Secretary not later than 1 year after the date 
of the enactment of this Act. 
(3) STATE INPUT.—The Health Benefits Advi-
sory Committee shall examine the health coverage 
laws and benefits of each State in developing rec-
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ommendations under this subsection and may incor-
porate such coverage and benefits as the Committee 
determines to be appropriate and consistent with 
this division. The Health Benefits Advisory Com-
mittee shall also seek input from the States and con-
sider recommendations on how to ensure that the 
quality of health coverage does not decline in any 
State. 
(4) PUBLIC INPUT.—The Health Benefits Advi-
sory Committee shall allow for public input as a part 
of developing recommendations under this sub-
section. 
(5) BENEFIT
STANDARDS
DEFINED.—In this 
subtitle, the term ‘‘benefit standards’’ means stand-
ards respecting— 
(A) the essential benefits package de-
scribed in section 122, including categories of 
covered treatments, items and services within 
benefit classes, and cost-sharing; and 
(B) the cost-sharing levels for enhanced 
plans and premium plans (as provided under 
section 203(c)) consistent with paragraph (5). 
(6) LEVELS OF COST-SHARING FOR ENHANCED 
AND PREMIUM PLANS.— 
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(A) ENHANCED PLAN.—The level of cost- 
sharing for enhanced plans shall be designed so 
that such plans have benefits that are actuari-
ally equivalent 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 actuari-
ally equivalent to approximately 95 percent of 
the actuarial value of the benefits provided 
under the reference benefits package described 
in section 122(c)(3)(B). 
(7) 
RECOMMENDATIONS
OF
INTEGRATIVE 
HEALTH CARE SERVICES TASK FORCE.— 
(A) INCLUSION
IN
COMMITTEE’S
REC-
OMMENDATIONS.—The Health Benefits Advi-
sory Committee shall include in its rec-
ommendations under paragraph (1) the rec-
ommendations made by the Integrative Health 
Care Services Task Force established under 
subparagraph (B). 
(B) ESTABLISHMENT OF TASK FORCE.— 
The Health Benefits Advisory Committee shall 
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establish an Integrative Health Care Services 
Task Force. Such Task Force shall consist of 
5 experts with expertise in research in, and 
practice of, integrative health care. Such ex-
perts shall be appointed by the Committee from 
among experts nominated by the Secretary, in 
consultation with the National Center for Com-
plementary and Alternative Medicine at the Na-
tional Institutes of Health. The duty of the 
Task Force shall be to make recommendations 
to the Committee on evidence-based, clinically 
effective, and safe integrative care services. 
(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. 
(2) MEMBERS NOT TREATED AS FEDERAL EM-
PLOYEES.—Members of the Health Benefits Advi-
sory Committee shall not be considered employees of 
the Federal government solely by reason of any serv-
ice on the Committee. 
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(3) APPLICATION OF FACA.—The Federal Advi-
sory Committee Act (5 U.S.C. App.), other than sec-
tion 14, shall apply to the Health Benefits Advisory 
Committee. 
(d) PUBLICATION.—The Secretary shall provide for 
publication in the Federal Register and the posting on the 
Internet website of the Department of Health and Human 
Services of all recommendations made by the Health Ben-
efits Advisory Committee under this section. 
SEC. 124. PROCESS FOR ADOPTION OF RECOMMENDA-
TIONS; ADOPTION OF BENEFIT STANDARDS. 
(a) PROCESS
FOR ADOPTION
OF RECOMMENDA-
TIONS.— 
(1) REVIEW OF RECOMMENDED STANDARDS.— 
Not later than 45 days after the date of receipt of 
benefit standards recommended under section 123 
(including such standards as modified under para-
graph (2)(B)), the Secretary shall review such 
standards and shall determine whether to propose 
adoption of such standards as a package. 
(2) DETERMINATION TO ADOPT STANDARDS.— 
If the Secretary determines— 
(A) to propose adoption of benefit stand-
ards so recommended as a package, the Sec-
retary shall, by regulation under section 553 of 
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title 5, United States Code, propose adoption 
such standards; or 
(B) not to propose adoption of such stand-
ards as a package, the Secretary shall notify 
the Health Benefits Advisory Committee in 
writing of such determination and the reasons 
for not proposing the adoption of such rec-
ommendation and provide the Committee with a 
further opportunity to modify its previous rec-
ommendations and submit new recommenda-
tions to the Secretary on a timely basis. 
(3) CONTINGENCY.—If, because of the applica-
tion of paragraph (2)(B), the Secretary would other-
wise be unable to propose initial adoption of such 
recommended standards by the deadline specified in 
subsection (b)(1), the Secretary shall, by regulation 
under section 553 of title 5, United States Code, 
propose adoption of initial benefit standards by such 
deadline. 
(4) PUBLICATION.—The Secretary shall provide 
for publication in the Federal Register of all deter-
minations made by the Secretary under this sub-
section. 
(b) ADOPTION OF STANDARDS.— 
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(1) INITIAL
STANDARDS.—Not later than 18 
months after the date of the enactment of this Act, 
the Secretary shall, through the rulemaking process 
consistent with subsection (a), adopt an initial set of 
benefit standards. 
(2) PERIODIC UPDATING STANDARDS.—Under 
subsection (a), the Secretary shall provide for the 
periodic updating of the benefit standards previously 
adopted under this section. 
(3) REQUIREMENT.—The Secretary may not 
adopt any benefit standards for an essential benefits 
package or for level of cost-sharing that are incon-
sistent with the requirements for such a package or 
level under sections 122 and 123(b)(5). 
SEC. 125. PROHIBITION OF DISCRIMINATION IN HEALTH 
CARE SERVICES BASED ON RELIGIOUS OR 
SPIRITUAL CONTENT. 
Neither the Commissioner nor any health insurance 
issuer offering health insurance coverage through the Ex-
change shall discriminate in approving or covering a 
health care service on the basis of its religious or spiritual 
content if expenditures for such a health care service are 
allowable as a deduction under 213(d) of the Internal Rev-
enue Code of 1986, as in effect on January 1, 2009. 
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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 pro-
vide for timely grievance and appeals mechanisms that the 
Commissioner shall establish. 
(b) INTERNAL CLAIMS AND APPEALS PROCESS.— 
Under a qualified health benefits plan the QHBP offering 
entity shall provide an internal claims and appeals process 
that initially incorporates the claims and appeals proce-
dures (including urgent claims) set forth at section 
2560.503–1 of title 29, Code of Federal Regulations, as 
published on November 21, 2000 (65 Fed. Reg. 70246) 
and shall update such process in accordance with any 
standards that the Commissioner may establish. 
(c) EXTERNAL REVIEW PROCESS.— 
(1) IN GENERAL.—The Commissioner shall es-
tablish an external review process (including proce-
dures for expedited reviews of urgent claims) that 
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provides for an impartial, independent, and de novo 
review of denied claims under this subdivision. 
(2) REQUIRING FAIR GRIEVANCE AND APPEALS 
MECHANISMS.—A determination made, with respect 
to a qualified health benefits plan offered by a 
QHBP offering entity, under the external review 
process established under this subsection shall be 
binding on the plan and the entity. 
(d) CONSTRUCTION.—Nothing in this section shall be 
construed as affecting the availability of judicial review 
under State law for adverse decisions under subsection (b) 
or (c), subject to section 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 fi-
nancial disclosure, data on enrollment, data on 
disenrollment, data on the number of claims denials, 
data on rating practices, information on cost-sharing 
and payments with respect to any out-of-network 
coverage, and other information as determined ap-
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propriate by the Commissioner. The Commissioner 
shall require that such disclosure be provided in 
plain language. 
(2) PLAIN LANGUAGE.—In this subsection, the 
term ‘‘plain language’’ means language that the in-
tended audience, including individuals with limited 
English proficiency, can readily understand and use 
because that language is clean, concise, well-orga-
nized, and follows other best practices of plain lan-
guage writing. 
(3) GUIDANCE.—The Commissioner shall de-
velop and issue guidance on best practices of plain 
language writing. 
(b) CONTRACTING REIMBURSEMENT.—A qualified 
health benefits plan shall comply with standards estab-
lished by the Commissioner to ensure transparency to each 
health care provider relating to reimbursement arrange-
ments between such plan and such provider. 
(c) 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. 
(d) IDENTIFICATION OF PROVIDERS TRAINED AND 
ACCREDITED IN INTEGRATIVE MEDICINE.—A qualified 
health benefit plan shall include in the disclosure required 
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under subsection (a) identification to enrollees of any pro-
viders of services under the plan that are trained and ac-
credited in integrative health medicine. 
SEC. 134. APPLICATION TO QUALIFIED HEALTH BENEFITS 
PLANS 
NOT 
OFFERED 
THROUGH 
THE 
HEALTH INSURANCE EXCHANGE. 
The requirements of the previous provisions of this 
subtitle shall apply to qualified health benefits plans that 
are not being offered through the Health Insurance Ex-
change only to the extent specified by the Commissioner. 
SEC. 135. TIMELY PAYMENT OF CLAIMS. 
A QHBP offering entity shall comply with the re-
quirements of section 1857(f) of the Social Security Act 
with respect to a qualified health benefits plan it offers 
in the same manner 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 standards for the 
coordination and subrogation of benefits and reimburse-
ment of payments in cases involving individuals and mul-
tiple plan coverage. 
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SEC. 137. APPLICATION OF ADMINISTRATIVE SIMPLIFICA-
TION. 
A QHBP offering entity is required to comply with 
standards for electronic financial and administrative 
transactions under section 1173A of the Social Security 
Act, added by section 163(a). 
SEC. 138. RECORDS RELATIVE TO PRESCRIPTION INFORMA-
TION. 
(a) IN GENERAL.—A qualified health benefits plan 
shall ensure that its records relative to prescription infor-
mation containing patient identifiable and prescriber-iden-
tifiable data are maintained in accordance with this sec-
tion.’’ 
(b) REQUIREMENTS.— 
(1) IN GENERAL.—Records described in sub-
section (a) may not be licensed, transferred, used, or 
sold by any pharmacy benefits manager, insurance 
company, electronic transmission intermediary, re-
tail, mail order, or Internet pharmacy or other simi-
lar entity, for any commercial purpose, except for 
the limited purposes of— 
(A) pharmacy reimbursement; 
(B) formulary compliance; 
(C) care management; 
VerDate Nov 24 2008 
23:53 Mar 17, 2010
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