datamatters24/research-document-archive huggingface dataset:
HR 3590 EAS/PP 
‘‘(2) COMPLIANCE.—An entity described in para-
graph (3) is deemed to be in compliance with this sec-
tion if the summary of benefits and coverage described 
in subsection (a) is provided in paper or electronic 
form. 
‘‘(3) ENTITIES
IN
GENERAL.—An entity de-
scribed in this paragraph is— 
‘‘(A) a health insurance issuer (including a 
group health plan that is not a self-insured plan) 
offering health insurance coverage within the 
United States; or 
‘‘(B) in the case of a self-insured group 
health plan, the plan sponsor or designated ad-
ministrator of the plan (as such terms are de-
fined in section 3(16) of the Employee Retire-
ment Income Security Act of 1974). 
‘‘(4) NOTICE
OF
MODIFICATIONS.—If a group 
health plan or health insurance issuer makes any ma-
terial modification in any of the terms of the plan or 
coverage involved (as defined for purposes of section 
102 of the Employee Retirement Income Security Act 
of 1974) that is not reflected in the most recently pro-
vided summary of benefits and coverage, the plan or 
issuer shall provide notice of such modification to en-
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rollees not later than 60 days prior to the date on 
which such modification will become effective. 
‘‘(e) PREEMPTION.—The standards developed under 
subsection (a) shall preempt any related State standards 
that require a summary of benefits and coverage that pro-
vides less information to consumers than that required to 
be provided under this section, as determined by the Sec-
retary. 
‘‘(f) FAILURE TO PROVIDE.—An entity described in 
subsection (d)(3) that willfully fails to provide the informa-
tion required under this section shall be subject to a fine 
of not more than $1,000 for each such failure. Such failure 
with respect to each enrollee shall constitute a separate of-
fense for purposes of this subsection. 
‘‘(g) DEVELOPMENT OF STANDARD DEFINITIONS.— 
‘‘(1) IN GENERAL.—The Secretary shall, by regu-
lation, provide for the development of standards for 
the definitions of terms used in health insurance cov-
erage, including the insurance-related terms described 
in paragraph (2) and the medical terms described in 
paragraph (3). 
‘‘(2) INSURANCE-RELATED
TERMS.—The insur-
ance-related terms described in this paragraph are 
premium, deductible, co-insurance, co-payment, out- 
of-pocket limit, preferred provider, non-preferred pro-
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vider, out-of-network co-payments, UCR (usual, cus-
tomary and reasonable) fees, excluded services, griev-
ance and appeals, and such other terms as the Sec-
retary determines are important to define so that con-
sumers may compare health insurance coverage and 
understand the terms of their coverage. 
‘‘(3) MEDICAL TERMS.—The medical terms de-
scribed in this paragraph are hospitalization, hospital 
outpatient care, emergency room care, physician serv-
ices, prescription drug coverage, durable medical 
equipment, home health care, skilled nursing care, re-
habilitation services, hospice services, emergency med-
ical transportation, and such other terms as the Sec-
retary determines are important to define so that con-
sumers may compare the medical benefits offered by 
health insurance and understand the extent of those 
medical benefits (or exceptions to those benefits). 
‘‘SEC. 2716. PROHIBITION OF DISCRIMINATION BASED ON 
SALARY. 
‘‘(a) IN GENERAL.—The plan sponsor of a group 
health plan (other than a self-insured plan) may not estab-
lish rules relating to the health insurance coverage eligi-
bility (including continued eligibility) of any full-time em-
ployee under the terms of the plan that are based on the 
total hourly or annual salary of the employee or otherwise
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establish eligibility rules that have the effect of discrimi-
nating in favor of higher wage employees. 
‘‘(b) LIMITATION.—Subsection (a) shall not be con-
strued to prohibit a plan sponsor from establishing con-
tribution requirements for enrollment in the plan or cov-
erage that provide for the payment by employees with lower 
hourly or annual compensation of a lower dollar or percent-
age contribution than the payment required of similarly sit-
uated employees with a higher hourly or annual compensa-
tion. 
‘‘SEC. 2717. ENSURING THE QUALITY OF CARE. 
‘‘(a) QUALITY REPORTING.— 
‘‘(1) IN GENERAL.—Not later than 2 years after 
the date of enactment of the Patient Protection and 
Affordable Care Act, the Secretary, in consultation 
with experts in health care quality and stakeholders, 
shall develop reporting requirements for use by a 
group health plan, and a health insurance issuer of-
fering group or individual health insurance coverage, 
with respect to plan or coverage benefits and health 
care provider reimbursement structures that— 
‘‘(A) improve health outcomes through the 
implementation of activities such as quality re-
porting, effective case management, care coordi-
nation, chronic disease management, and medi-
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cation and care compliance initiatives, including 
through the use of the medical homes model as 
defined for purposes of section 3602 of the Pa-
tient Protection and Affordable Care Act, for 
treatment or services under the plan or coverage; 
‘‘(B) implement activities to prevent hos-
pital readmissions through a comprehensive pro-
gram for hospital discharge that includes pa-
tient-centered education and counseling, com-
prehensive discharge planning, and post dis-
charge reinforcement by an appropriate health 
care professional; 
‘‘(C) implement activities to improve pa-
tient safety and reduce medical errors through 
the appropriate use of best clinical practices, evi-
dence based medicine, and health information 
technology under the plan or coverage; and 
‘‘(D) implement wellness and health pro-
motion activities. 
‘‘(2) REPORTING REQUIREMENTS.— 
‘‘(A) IN GENERAL.—A group health plan 
and a health insurance issuer offering group or 
individual health insurance coverage shall annu-
ally submit to the Secretary, and to enrollees 
under the plan or coverage, a report on whether
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the benefits under the plan or coverage satisfy 
the elements described in subparagraphs (A) 
through (D) of paragraph (1). 
‘‘(B) TIMING OF REPORTS.—A report under 
subparagraph (A) shall be made available to an 
enrollee under the plan or coverage during each 
open enrollment period. 
‘‘(C) AVAILABILITY OF REPORTS.—The Sec-
retary shall make reports submitted under sub-
paragraph (A) available to the public through an 
Internet website. 
‘‘(D) PENALTIES.—In developing the re-
porting requirements under paragraph (1), the 
Secretary may develop and impose appropriate 
penalties for non-compliance with such require-
ments. 
‘‘(E) EXCEPTIONS.—In developing the re-
porting requirements under paragraph (1), the 
Secretary may provide for exceptions to such re-
quirements for group health plans and health in-
surance issuers that substantially meet the goals 
of this section. 
‘‘(b) WELLNESS AND PREVENTION PROGRAMS.—For 
purposes of subsection (a)(1)(D), wellness and health pro-
motion activities may include personalized wellness and
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prevention services, which are coordinated, maintained or 
delivered by a health care provider, a wellness and preven-
tion plan manager, or a health, wellness or prevention serv-
ices organization that conducts health risk assessments or 
offers ongoing face-to-face, telephonic or web-based interven-
tion efforts for each of the program’s participants, and 
which may include the following wellness and prevention 
efforts: 
‘‘(1) Smoking cessation. 
‘‘(2) Weight management. 
‘‘(3) Stress management. 
‘‘(4) Physical fitness. 
‘‘(5) Nutrition. 
‘‘(6) Heart disease prevention. 
‘‘(7) Healthy lifestyle support. 
‘‘(8) Diabetes prevention. 
‘‘(c) REGULATIONS.—Not later than 2 years after the 
date of enactment of the Patient Protection and Affordable 
Care Act, the Secretary shall promulgate regulations that 
provide criteria for determining whether a reimbursement 
structure is described in subsection (a). 
‘‘(d) STUDY AND REPORT.—Not later than 180 days 
after the date on which regulations are promulgated under 
subsection (c), the Government Accountability Office shall 
review such regulations and conduct a study and submit
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to the Committee on Health, Education, Labor, and Pen-
sions of the Senate and the Committee on Energy and Com-
merce of the House of Representatives a report regarding 
the impact the activities under this section have had on the 
quality and cost of health care. 
‘‘SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE 
COVERAGE. 
‘‘(a) CLEAR ACCOUNTING FOR COSTS.—A health in-
surance issuer offering group or individual health insur-
ance coverage shall, with respect to each plan year, submit 
to the Secretary a report concerning the percentage of total 
premium revenue that such coverage expends— 
‘‘(1) on reimbursement for clinical services pro-
vided to enrollees under such coverage; 
‘‘(2) for activities that improve health care qual-
ity; and 
‘‘(3) on all other non-claims costs, including an 
explanation of the nature of such costs, and excluding 
State taxes and licensing or regulatory fees. 
The Secretary shall make reports received under this section 
available to the public on the Internet website of the Depart-
ment of Health and Human Services. 
‘‘(b) ENSURING THAT CONSUMERS RECEIVE VALUE 
FOR THEIR PREMIUM PAYMENTS.—
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‘‘(1) REQUIREMENT
TO
PROVIDE
VALUE
FOR 
PREMIUM PAYMENTS.—A health insurance issuer of-
fering group or individual health insurance coverage 
shall, with respect to each plan year, provide an an-
nual rebate to each enrollee under such coverage, on 
a pro rata basis, in an amount that is equal to the 
amount by which premium revenue expended by the 
issuer on activities described in subsection (a)(3) ex-
ceeds— 
‘‘(A) with respect to a health insurance 
issuer offering coverage in the group market, 20 
percent, or such lower percentage as a State may 
by regulation determine; or 
‘‘(B) with respect to a health insurance 
issuer offering coverage in the individual market, 
25 percent, or such lower percentage as a State 
may by regulation determine, except that such 
percentage shall be adjusted to the extent the Sec-
retary determines that the application of such 
percentage with a State may destabilize the ex-
isting individual market in such State. 
‘‘(2) CONSIDERATION
IN
SETTING
PERCENT-
AGES.—In determining the percentages under para-
graph (1), a State shall seek to ensure adequate par-
ticipation by health insurance issuers, competition in
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the health insurance market in the State, and value 
for consumers so that premiums are used for clinical 
services and quality improvements. 
‘‘(3) TERMINATION.—The provisions of this sub-
section shall have no force or effect after December 31, 
2013. 
‘‘(c) STANDARD HOSPITAL CHARGES.—Each hospital 
operating within the United States shall for each year es-
tablish (and update) and make public (in accordance with 
guidelines developed by the Secretary) a list of the hospital’s 
standard charges for items and services provided by the hos-
pital, including for diagnosis-related groups established 
under section 1886(d)(4) of the Social Security Act. 
‘‘(d) DEFINITIONS.—The Secretary, in consultation 
with the National Association of Insurance Commissions, 
shall establish uniform definitions for the activities reported 
under subsection (a). 
‘‘SEC. 2719. APPEALS PROCESS. 
‘‘A group health plan and a health insurance issuer 
offering group or individual health insurance coverage shall 
implement an effective appeals process for appeals of cov-
erage determinations and claims, under which the plan or 
issuer shall, at a minimum— 
‘‘(1) have in effect an internal claims appeal 
process;
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‘‘(2) provide notice to enrollees, in a culturally 
and linguistically appropriate manner, of available 
internal and external appeals processes, and the 
availability of any applicable office of health insur-
ance consumer assistance or ombudsman established 
under section 2793 to assist such enrollees with the 
appeals processes; 
‘‘(3) allow an enrollee to review their file, to 
present evidence and testimony as part of the appeals 
process, and to receive continued coverage pending the 
outcome of the appeals process; and 
‘‘(4) provide an external review process for such 
plans and issuers that, at a minimum, includes the 
consumer protections set forth in the Uniform Exter-
nal Review Model Act promulgated by the National 
Association of Insurance Commissioners and is bind-
ing on such plans.’’. 
SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION. 
Part C of title XXVII of the Public Health Service Act 
(42 U.S.C. 300gg–91 et seq.) is amended by adding at the 
end the following: 
‘‘SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION. 
‘‘(a) IN GENERAL.—The Secretary shall award grants 
to States to enable such States (or the Exchanges operating
HR 3590 EAS/PP 
in such States) to establish, expand, or provide support 
for— 
‘‘(1) offices of health insurance consumer assist-
ance; or 
‘‘(2) health insurance ombudsman programs. 
‘‘(b) ELIGIBILITY.— 
‘‘(1) IN GENERAL.—To be eligible to receive a 
grant, a State shall designate an independent office of 
health insurance consumer assistance, or an ombuds-
man, that, directly or in coordination with State 
health insurance regulators and consumer assistance 
organizations, receives and responds to inquiries and 
complaints concerning health insurance coverage with 
respect to Federal health insurance requirements and 
under State law. 
‘‘(2) CRITERIA.—A State that receives a grant 
under this section shall comply with criteria estab-
lished by the Secretary for carrying out activities 
under such grant. 
‘‘(c) DUTIES.—The office of health insurance consumer 
assistance or health insurance ombudsman shall— 
‘‘(1) assist with the filing of complaints and ap-
peals, including filing appeals with the internal ap-
peal or grievance process of the group health plan or
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health insurance issuer involved and providing infor-
mation about the external appeal process; 
‘‘(2) collect, track, and quantify problems and 
inquiries encountered by consumers; 
‘‘(3) educate consumers on their rights and re-
sponsibilities with respect to group health plans and 
health insurance coverage; 
‘‘(4) assist consumers with enrollment in a group 
health plan or health insurance coverage by providing 
information, referral, and assistance; and 
‘‘(5) resolve problems with obtaining premium 
tax credits under section 36B of the Internal Revenue 
Code of 1986. 
‘‘(d) DATA COLLECTION.—As a condition of receiving 
a grant under subsection (a), an office of health insurance 
consumer assistance or ombudsman program shall be re-
quired to collect and report data to the Secretary on the 
types of problems and inquiries encountered by consumers. 
The Secretary shall utilize such data to identify areas where 
more enforcement action is necessary and shall share such 
information with State insurance regulators, the Secretary 
of Labor, and the Secretary of the Treasury for use in the 
enforcement activities of such agencies. 
‘‘(e) FUNDING.—
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‘‘(1) INITIAL FUNDING.—There is hereby appro-
priated to the Secretary, out of any funds in the 
Treasury not otherwise appropriated, $30,000,000 for 
the first fiscal year for which this section applies to 
carry out this section. Such amount shall remain 
available without fiscal year limitation. 
‘‘(2) 
AUTHORIZATION
FOR
SUBSEQUENT 
YEARS.—There is authorized to be appropriated to the 
Secretary for each fiscal year following the fiscal year 
described in paragraph (1), such sums as may be nec-
essary to carry out this section.’’. 
SEC. 1003. ENSURING THAT CONSUMERS GET VALUE FOR 
THEIR DOLLARS. 
Part C of title XXVII of the Public Health Service Act 
(42 U.S.C. 300gg–91 et seq.), as amended by section 1002, 
is further amended by adding at the end the following: 
‘‘SEC. 2794. ENSURING THAT CONSUMERS GET VALUE FOR 
THEIR DOLLARS. 
‘‘(a) INITIAL PREMIUM REVIEW PROCESS.— 
‘‘(1) IN GENERAL.—The Secretary, in conjunc-
tion with States, shall establish a process for the an-
nual review, beginning with the 2010 plan year and 
subject to subsection (b)(2)(A), of unreasonable in-
creases in premiums for health insurance coverage.
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‘‘(2) JUSTIFICATION
AND
DISCLOSURE.—The 
process established under paragraph (1) shall require 
health insurance issuers to submit to the Secretary 
and the relevant State a justification for an unrea-
sonable premium increase prior to the implementa-
tion of the increase. Such issuers shall prominently 
post such information on their Internet websites. The 
Secretary shall ensure the public disclosure of infor-
mation on such increases and justifications for all 
health insurance issuers. 
‘‘(b) CONTINUING PREMIUM REVIEW PROCESS.— 
‘‘(1) INFORMING
SECRETARY
OF
PREMIUM
IN-
CREASE PATTERNS.—As a condition of receiving a 
grant under subsection (c)(1), a State, through its 
Commissioner of Insurance, shall— 
‘‘(A) provide the Secretary with informa-
tion about trends in premium increases in health 
insurance coverage in premium rating areas in 
the State; and 
‘‘(B) make recommendations, as appro-
priate, to the State Exchange about whether par-
ticular health insurance issuers should be ex-
cluded from participation in the Exchange based 
on a pattern or practice of excessive or unjusti-
fied premium increases.
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‘‘(2) MONITORING BY SECRETARY OF PREMIUM 
INCREASES.— 
‘‘(A) IN
GENERAL.—Beginning with plan 
years beginning in 2014, the Secretary, in con-
junction with the States and consistent with the 
provisions of subsection (a)(2), shall monitor 
premium increases of health insurance coverage 
offered through an Exchange and outside of an 
Exchange. 
‘‘(B) CONSIDERATION
IN
OPENING
EX-
CHANGE.—In 
determining 
under 
section 
1312(f)(2)(B) of the Patient Protection and Af-
fordable Care Act whether to offer qualified 
health plans in the large group market through 
an Exchange, the State shall take into account 
any excess of premium growth outside of the Ex-
change as compared to the rate of such growth 
inside the Exchange. 
‘‘(c) GRANTS IN SUPPORT OF PROCESS.— 
‘‘(1) PREMIUM
REVIEW
GRANTS
DURING
2010 
THROUGH 2014.—The Secretary shall carry out a pro-
gram to award grants to States during the 5-year pe-
riod beginning with fiscal year 2010 to assist such 
States in carrying out subsection (a), including—
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(1) is a citizen or national of the United States 
or is lawfully present in the United States (as deter-
mined in accordance with section 1411); 
(2) has not been covered under creditable cov-
erage (as defined in section 2701(c)(1) of the Public 
Health Service Act as in effect on the date of enact-
ment of this Act) during the 6-month period prior to 
the date on which such individual is applying for 
coverage through the high risk pool; and 
(3) has a pre-existing condition, as determined 
in a manner consistent with guidance issued by the 
Secretary. 
(e) PROTECTION AGAINST DUMPING RISK BY INSUR-
ERS.— 
(1) IN GENERAL.—The Secretary shall establish 
criteria for determining whether health insurance 
issuers and employment-based health plans have dis-
couraged an individual from remaining enrolled in 
prior coverage based on that individual’s health sta-
tus. 
(2) SANCTIONS.—An issuer or employment-based 
health plan shall be responsible for reimbursing the 
program under this section for the medical expenses 
incurred by the program for an individual who, based 
on criteria established by the Secretary, the Secretary
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(c) PAYMENTS.— 
(1) SUBMISSION OF CLAIMS.— 
(A) IN GENERAL.—A participating employ-
ment-based plan shall submit claims for reim-
bursement to the Secretary which shall contain 
documentation of the actual costs of the items 
and services for which each claim is being sub-
mitted. 
(B) BASIS FOR CLAIMS.—Claims submitted 
under subparagraph (A) shall be based on the ac-
tual amount expended by the participating em-
ployment-based plan involved within the plan 
year for the health benefits provided to an early 
retiree or the spouse, surviving spouse, or de-
pendent of such retiree. In determining the 
amount of a claim for purposes of this sub-
section, the participating employment-based plan 
shall take into account any negotiated price con-
cessions (such as discounts, direct or indirect 
subsidies, rebates, and direct or indirect remu-
nerations) obtained by such plan with respect to 
such health benefit. For purposes of determining 
the amount of any such claim, the costs paid by 
the early retiree or the retiree’s spouse, surviving 
spouse, or dependent in the form of deductibles,
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co-payments, or co-insurance shall be included in 
the amounts paid by the participating employ-
ment-based plan. 
(2) PROGRAM PAYMENTS.—If the Secretary de-
termines that a participating employment-based plan 
has submitted a valid claim under paragraph (1), the 
Secretary shall reimburse such plan for 80 percent of 
that portion of the costs attributable to such claim 
that exceed $15,000, subject to the limits contained in 
paragraph (3). 
(3) LIMIT.—To be eligible for reimbursement 
under the program, a claim submitted by a partici-
pating employment-based plan shall not be less than 
$15,000 nor greater than $90,000. Such amounts 
shall be adjusted each fiscal year based on the per-
centage increase in the Medical Care Component of 
the Consumer Price Index for all urban consumers 
(rounded to the nearest multiple of $1,000) for the 
year involved. 
(4) USE OF PAYMENTS.—Amounts paid to a par-
ticipating employment-based plan under this sub-
section shall be used to lower costs for the plan. Such 
payments may be used to reduce premium costs for 
an entity described in subsection (a)(2)(B)(i) or to re-
duce 
premium 
contributions, 
co-payments,
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deductibles, co-insurance, or other out-of-pocket costs 
for plan participants. Such payments shall not be 
used as general revenues for an entity described in 
subsection (a)(2)(B)(i). The Secretary shall develop a 
mechanism to monitor the appropriate use of such 
payments by such entities. 
(5) PAYMENTS NOT TREATED AS INCOME.—Pay-
ments received under this subsection shall not be in-
cluded in determining the gross income of an entity 
described in subsection (a)(2)(B)(i) that is maintain-
ing or currently contributing to a participating em-
ployment-based plan. 
(6) APPEALS.—The Secretary shall establish— 
(A) an appeals process to permit partici-
pating employment-based plans to appeal a de-
termination of the Secretary with respect to 
claims submitted under this section; and 
(B) procedures to protect against fraud, 
waste, and abuse under the program. 
(d) AUDITS.—The Secretary shall conduct annual au-
dits of claims data submitted by participating employment- 
based plans under this section to ensure that such plans 
are in compliance with the requirements of this section. 
(e) FUNDING.—There is appropriated to the Secretary, 
out of any moneys in the Treasury not otherwise appro-
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priated, $5,000,000,000 to carry out the program under this 
section. Such funds shall be available without fiscal year 
limitation. 
(f) LIMITATION.—The Secretary has the authority to 
stop taking applications for participation in the program 
based on the availability of funding under subsection (e). 
SEC. 1103. IMMEDIATE INFORMATION THAT ALLOWS CON-
SUMERS TO IDENTIFY AFFORDABLE COV-
ERAGE OPTIONS. 
(a) INTERNET PORTAL TO AFFORDABLE COVERAGE 
OPTIONS.— 
(1) IMMEDIATE
ESTABLISHMENT.—Not later 
than July 1, 2010, the Secretary, in consultation with 
the States, shall establish a mechanism, including an 
Internet website, through which a resident of any 
State may identify affordable health insurance cov-
erage options in that State. 
(2) CONNECTING TO AFFORDABLE COVERAGE.— 
An Internet website established under paragraph (1) 
shall, to the extent practicable, provide ways for resi-
dents of any State to receive information on at least 
the following coverage options: 
(A) Health insurance coverage offered by 
health insurance issuers, other than coverage that