Subtitle 
B—Standards 
Guaran-
teeing Access to Affordable Cov-
erage 
SEC. 111. PROHIBITING PREEXISTING CONDITION EXCLU-
SIONS. 
A qualified health benefits plan may not impose any 
preexisting condition exclusion (as defined in section 
2701(b)(1)(A) of the Public Health Service Act) or otherwise 
impose any limit or condition on the coverage under the 
plan with respect to an individual or dependent based on 
any health status-related factors (as defined in section 
2791(d)(9) of the Public Health Service Act) in relation to 
the individual or dependent. 
SEC. 112. GUARANTEED ISSUE AND RENEWAL FOR INSURED 
PLANS. 
The requirements of sections 2711 (other than sub-
sections (c) and (e)) and 2712 (other than paragraphs (3), 
and (6) of subsection (b) and subsection (e)) of the Public 
Health Service Act, relating to guaranteed availability and 
renewability of health insurance coverage, shall apply to in-
dividuals and employers in all individual and group health 
insurance coverage, whether offered to individuals or em-
ployers through the Health Insurance Exchange, through 
any employment-based health plan, or otherwise, and shall 
apply to the public health insurance option, in the same 
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manner as such sections apply to employers and health in-
surance coverage offered in the small group market, except 
that such section 2712(b)(1) shall apply only if, before non-
renewal or discontinuation of coverage, the issuer has pro-
vided the enrollee with notice of non-payment of premiums 
and there is a grace period during which the enrollee has 
an opportunity to correct such nonpayment. Rescissions of 
such coverage shall be prohibited except in cases of fraud 
as defined in sections 2712(b)(2) of such Act. 
SEC. 113. INSURANCE RATING RULES. 
(a) IN GENERAL.—The premium rate charged for an 
insured qualified health benefits plan and for coverage 
under the public health insurance option may not vary ex-
cept as follows: 
(1) LIMITED AGE VARIATION PERMITTED.—By 
age (within such age categories as the Commissioner 
shall specify) so long as the ratio of the highest such 
premium to the lowest such premium does not exceed 
the ratio of 2 to 1. 
(2) BY AREA.—By premium rating area (as per-
mitted by State insurance regulators or, in the case 
of Exchange-participating health benefits plans, as 
specified by the Commissioner in consultation with 
such regulators). 
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(3) BY FAMILY ENROLLMENT.—By family enroll-
ment (such as variations within categories and com-
positions of families) so long as the ratio of the pre-
mium for family enrollment (or enrollments) to the 
premium for individual enrollment is uniform, as 
specified under State law and consistent with rules of 
the Commissioner. 
(b) ACTUARIAL VALUE OF OPTIONAL SERVICE COV-
ERAGE.— 
(1) IN GENERAL.—The Commissioner shall esti-
mate the basic per enrollee, per month cost, deter-
mined on an average actuarial basis, for including 
coverage under a basic plan of the services described 
in section 122(d)(4)(A). 
(2) CONSIDERATIONS.—In making such estimate 
the Commissioner— 
(A) may take into account the impact on 
overall costs of the inclusion of such coverage, but 
may not take into account any cost reduction es-
timated to result from such services, including 
prenatal care, delivery, or postnatal care; 
(B) shall estimate such costs as if such cov-
erage were included for the entire population 
covered; and 
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(C) may not estimate such a cost at less 
than $1 per enrollee, per month. 
(c) STUDY AND REPORTS.— 
(1) STUDY.—The Commissioner, in coordination 
with the Secretary of Health and Human Services 
and the Secretary of Labor, shall conduct a study of 
the large group insured and self-insured employer 
health care markets. Such study shall examine the fol-
lowing: 
(A) The types of employers by key charac-
teristics, including size, that purchase insured 
products versus those that self-insure. 
(B) The similarities and differences between 
typical insured and self-insured health plans. 
(C) The financial solvency and capital re-
serve levels of employers that self-insure by em-
ployer size. 
(D) The risk of self-insured employers not 
being able to pay obligations or otherwise becom-
ing financially insolvent. 
(E) The extent to which rating rules are 
likely to cause adverse selection in the large 
group market or to encourage small and mid size 
employers to self-insure 
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(2) REPORTS.—Not later than 18 months after 
the date of the enactment of this Act, the Commis-
sioner shall submit to Congress and the applicable 
agencies a report on the study conducted under para-
graph (1). Such report shall include any rec-
ommendations the Commissioner deems appropriate 
to ensure that the law does not provide incentives for 
small and mid-size employers to self-insure or create 
adverse selection in the risk pools of large group in-
surers and self-insured employers. Not later than 18 
months after the first day of Y1, the Commissioner 
shall submit to Congress and the applicable agencies 
an updated report on such study, including updates 
on such recommendations. 
SEC. 114. NONDISCRIMINATION IN BENEFITS; PARITY IN 
MENTAL HEALTH AND SUBSTANCE ABUSE 
DISORDER BENEFITS. 
(a) NONDISCRIMINATION IN BENEFITS.—A qualified 
health benefits plan (including the public health insurance 
option) shall comply with standards established by the 
Commissioner to prohibit discrimination in health benefits 
or benefit structures for qualifying health benefits plans, 
building from sections 702 of Employee Retirement Income 
Security Act of 1974, 2702 of the Public Health Service Act, 
and section 9802 of the Internal Revenue Code of 1986. 
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(b) PARITY
IN MENTAL HEALTH
AND 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 benefits plan, regard-
less of whether it is offered in the individual or group mar-
ket, in the same manner as such provisions apply to health 
insurance coverage offered in the large group market. 
SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS. 
(a) IN GENERAL.—A qualified health benefits plan 
(including the public health insurance option) that uses a 
provider network for items and services shall meet such 
standards respecting provider networks as the Commis-
sioner may establish to assure the adequacy of such net-
works in ensuring enrollee access to such items and services 
and transparency in the cost-sharing differentials between 
in-network coverage and out-of-network coverage. 
(b) PROVIDER NETWORK DEFINED.—In this division, 
the term ‘‘provider network’’ means the providers with re-
spect to which covered benefits, treatments, and services are 
available under a health benefits plan. 
SEC. 116. ENSURING VALUE AND LOWER PREMIUMS. 
(a) IN GENERAL.—A qualified health benefits plan 
shall meet a medical loss ratio as defined by the Commis-
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sioner. For any plan year in which the qualified health ben-
efits plan does not meet such medical loss ratio, QHBP of-
fering entity shall provide in a manner specified by the 
Commissioner for rebates to enrollees of payment sufficient 
to meet such loss ratio. 
(b) BUILDING ON INTERIM RULES.—In implementing 
subsection (a), the Commissioner shall build on the defini-
tion and methodology developed by the Secretary of Health 
and Human Services under the amendments made by sec-
tion 161 for determining how to calculate the medical loss 
ratio. Such methodology shall be set at the highest level med-
ical loss ratio possible that is designed to ensure adequate 
participation by QHBP offering entities, competition in the 
health insurance market in and out of the Health Insurance 
Exchange, and value for consumers so that their premiums 
are used for services. 
Subtitle 
C—Standards 
Guaran-
teeing Access to Essential Bene-
fits 
SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE. 
(a) IN GENERAL.—A qualified health benefits plan 
shall provide coverage that at least meets the benefit stand-
ards adopted under section 124 for the essential benefits 
package described in section 122 for the plan year involved. 
(b) CHOICE OF COVERAGE.— 
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(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-
pating health benefits plan, such plan is required 
under section 203 to provide specified levels of benefits 
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 di-
vision shall be construed as affecting the offering of 
health benefits in the form of excepted benefits (de-
scribed in section 102(b)(1)(B)(ii)) if such benefits 
are offered under a separate policy, contract, or cer-
tificate of insurance. 
(c) NO RESTRICTIONS ON COVERAGE UNRELATED TO 
CLINICAL APPROPRIATENESS.—A qualified health benefits 
plan may not impose any restriction (other than cost-shar-
ing) unrelated to clinical appropriateness on the coverage 
of the health care items and services. 
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SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED. 
(a) IN GENERAL.—In this division, the term ‘‘essential 
benefits package’’ means health benefits coverage, consistent 
with standards adopted under section 124 to ensure the pro-
vision of quality health care and financial security, that— 
(1) provides payment for the items and services 
described in subsection (b) in accordance with gen-
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 serv-
ices; 
(4) complies with section 115(a) (relating to net-
work adequacy); and 
(5) is equivalent, as certified by Office of the Ac-
tuary of the Centers for Medicare & Medicaid Serv-
ices, to the average prevailing employer-sponsored 
coverage. 
(b) MINIMUM SERVICES TO BE COVERED.—Subject to 
subsection (d), the items and services described in this sub-
section are the following: 
(1) Hospitalization. 
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(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 profes-
sional’s delivery of care in institutional settings, phy-
sician offices, patients’ homes or place of residence, or 
other settings, as appropriate. 
(5) Prescription drugs. 
(6) Rehabilitative and habilitative services. 
(7) Mental health and substance use disorder 
services, including behavioral health treatments. 
(8) Preventive services, including those services 
recommended with a grade of A or B by the Task 
Force on Clinical Preventive Services and those vac-
cines recommended for use by the Director of the Cen-
ters for Disease Control and Prevention. 
(9) Maternity care. 
(10) Well baby and well child care; treatment of 
a congenital or developmental deformity, disease, or 
injury; and oral health, vision, and hearing services, 
equipment, and supplies at least for children under 
21 years of age. 
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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 equivalent 
to approximately 70 percent of the full actuarial 
value of the benefits provided under the reference 
benefits package described in subparagraph (B). 
(B) REFERENCE
BENEFITS
PACKAGE
DE-
SCRIBED.—The reference benefits package de-
scribed in this subparagraph is the essential ben-
efits package if there were no cost-sharing im-
posed. 
(d) ABORTION COVERAGE PROHIBITED AS PART OF 
MINIMUM BENEFITS PACKAGE.— 
(1) PROHIBITION OF REQUIRED COVERAGE.—The 
Health Benefits Advisory Committee may not rec-
ommend under section 123(b) and the Secretary may 
not adopt in standards under section 124(b), the serv-
ices described in paragraph (4)(A) or (4)(B) as part 
of the essential benefits package and the Commis-
sioner may not require such services for qualified 
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health benefits plans to participate in the Health In-
surance Exchange. 
(2) VOLUNTARY
CHOICE
OF
COVERAGE
BY 
PLAN.—In the case of a qualified health benefits plan, 
the plan is not required (or prohibited) under this Act 
from providing coverage of services described in para-
graph (4)(A) or (4)(B) and the QHBP offering entity 
shall determine whether such coverage is provided. 
(3) COVERAGE UNDER PUBLIC HEALTH INSUR-
ANCE OPTION.—The public health insurance option 
shall provide coverage for services described in para-
graph (4)(B). Nothing in this Act shall be construed 
as preventing the public health insurance option from 
providing for or prohibiting coverage of services de-
scribed in paragraph (4)(A). 
(4) ABORTION SERVICES.— 
(A) ABORTIONS FOR WHICH PUBLIC FUND-
ING IS PROHIBITED.—The services described in 
this subparagraph are abortions for which the 
expenditure of Federal funds appropriated for 
the Department of Health and Human Services 
is not permitted, based on the law as in effect as 
of the date that is 6 months before the beginning 
of the plan year involved. 
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(B) ABORTIONS FOR WHICH PUBLIC FUND-
ING IS ALLOWED.—The services described in this 
subparagraph are abortions for which the ex-
penditure of Federal funds appropriated for the 
Department of Health and Human Services is 
permitted, based on the law as in effect as of the 
date that is 6 months before the beginning of the 
plan year involved. 
(e) STAND-ALONE COVERAGE.— 
(1) NO
APPLICATION
TO
ADULT
COVERAGE.— 
Nothing in this subtitle shall be construed as requir-
ing an individual who is 21 years of age or older to 
be provided stand-alone dental-only or vision-only 
coverage. 
(2) TREATMENT OF COMBINED COVERAGE.—The 
combination of stand-alone coverage described in 
paragraph (1) and a qualified health benefits plan 
without coverage of such oral and vision services shall 
be treated as satisfying the essential benefits package 
under this division. 
SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE. 
(a) ESTABLISHMENT.— 
(1) IN GENERAL.—There is established a private- 
public advisory committee which shall be a panel of 
medical and other experts to be known as the Health 
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Benefits Advisory Committee to recommend covered 
benefits and essential, enhanced, and premium plans. 
(2) CHAIR.—The Surgeon General shall be a 
member and the chair of the Health Benefits Advisory 
Committee. 
(3) MEMBERSHIP.—The Health Benefits Advi-
sory Committee shall be composed of the following 
members, in addition to the Surgeon General: 
(A) 9 members who are not Federal employ-
ees or officers and who are appointed by the 
President. 
(B) 9 members who are not Federal employ-
ees 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 officers, 
as the President may appoint. 
Such initial appointments shall be made not later 
than 60 days after the date of the enactment of this 
Act. 
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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 members. 
(5) PARTICIPATION.—The membership of the 
Health Benefits Advisory Committee shall at least re-
flect providers, consumer representatives, employers, 
labor, health insurance issuers, experts in health care 
financing and delivery, 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 pro-
fessional 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 in-
fluences the recommendations of such Committee. Not 
less than 25 percent of the members of the Committee 
shall be practicing health care practitioners who, as 
of the date of their appointment, practice in a rural 
area and who have practiced in a rural area for at 
least the 5-year period preceding such date. 
(b) DUTIES.— 
(1) RECOMMENDATIONS
ON
BENEFIT
STAND-
ARDS.—The Health Benefits Advisory Committee 
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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 take into account innovation in health care and 
consider how such standards could reduce health dis-
parities. 
(2) DEADLINE.—The Health Benefits Advisory 
Committee shall recommend initial benefit standards 
to the Secretary not later than 1 year after the date 
of the enactment of this Act. 
(3) PUBLIC INPUT.—The Health Benefits Advi-
sory Committee shall allow for public input as a part 
of developing recommendations under this subsection. 
(4) BENEFIT STANDARDS DEFINED.—In this sub-
title, the term ‘‘benefit standards’’ means standards 
respecting— 
(A) the essential benefits package described 
in section 122, including categories of covered 
treatments, items and services within benefit 
classes, and cost-sharing consistent with sub-
section (d) of such section; and 
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(B) the cost-sharing levels for enhanced 
plans and premium plans (as provided under 
section 203(c)) consistent with paragraph (5). 
(5) LEVELS OF COST-SHARING FOR ENHANCED 
AND PREMIUM PLANS.— 
(A) ENHANCED
PLAN.—The level of cost- 
sharing for enhanced plans shall be designed so 
that such plans have benefits that are actuarially 
equivalent to approximately 85 percent of the ac-
tuarial value of the benefits provided under the 
reference benefits package described in section 
122(c)(3)(B). 
(B) PREMIUM PLAN.—The level of cost-shar-
ing for premium plans shall be designed so that 
such plans have benefits that are actuarially 
equivalent to approximately 95 percent of the ac-
tuarial value of the benefits provided under the 
reference benefits package described in section 
122(c)(3)(B). 
(c) OPERATIONS.— 
(1) PER DIEM PAY.—Each member of the Health 
Benefits Advisory Committee shall receive travel ex-
penses, including per diem in accordance with appli-
cable provisions under subchapter I of chapter 57 of 
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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 Advisory 
Committee shall not be considered employees of the 
Federal government solely by reason of any service on 
the Committee. 
(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 Bene-
fits Advisory Committee under this section. 
SEC. 124. PROCESS FOR ADOPTION OF RECOMMENDATIONS; 
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 ben-
efit standards recommended under section 123 (in-
cluding such standards as modified under paragraph 
(2)(B)), the Secretary shall review such standards 
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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 standards 
so recommended as a package, the Secretary 
shall, by regulation under section 553 of title 5, 
United States Code, propose adoption such 
standards; or 
(B) not to propose adoption of such 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 recommendation 
and provide the Committee with a further oppor-
tunity to modify its previous recommendations 
and submit new recommendations to the Sec-
retary on a timely basis. 
(3) CONTINGENCY.—If, because of the application 
of paragraph (2)(B), the Secretary would otherwise be 
unable to propose initial adoption of such rec-
ommended standards by the deadline specified in sub-
section (b)(1), the Secretary shall, by regulation 
under section 553 of title 5, United States Code, pro-
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pose 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.— 
(1) INITIAL
STANDARDS.—Not later than 18 
months after the date of the enactment of this Act, the 
Secretary shall, through the rulemaking process con-
sistent 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 (including subsection (d)) 
and 123(b)(5). 
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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 Health 
Insurance Exchange 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 section 213(d) 
of the Internal Revenue Code of 1986, as in effect on Janu-
ary 1, 2009. 
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 QHBP offering entity shall provide for timely griev-
ance and appeals mechanisms as the Commissioner shall 
establish consistent with sections 139 through 139B. 
SEC. 133. REQUIRING INFORMATION TRANSPARENCY AND 
PLAN DISCLOSURE. 
(a) ACCURATE AND TIMELY DISCLOSURE.— 
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(1) IN
GENERAL.—A qualified health benefits 
plan (including the public health insurance option) 
shall comply with standards established by the Com-
missioner for the accurate and timely disclosure of 
plan documents, plan terms and conditions, claims 
payment policies and practices, periodic financial 
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 appropriate by the Com-
missioner. 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 develop 
and issue guidance on best practices of plain lan-
guage writing. 
(b) CONTRACTING
REIMBURSEMENT.—A qualified 
health benefits plan (including the public health insurance 
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option) shall comply with standards established by the 
Commissioner to ensure transparency to each health care 
provider relating to reimbursement arrangements between 
such plan and such provider. 
(c) ADVANCE NOTICE OF PLAN CHANGES.—A change 
in a qualified health benefits plan (including the public 
health insurance option) shall not be made without such 
reasonable and timely advance notice to enrollees of such 
change. 
(d) PHARMACY BENEFIT MANAGERS TRANSPARENCY 
REQUIREMENTS.— 
(1) IN
GENERAL.—Notwithstanding any other 
provision of law, a qualified health benefits plan shall 
enter into a contract with a pharmacy benefit man-
agers (in this subsection referred to as a ‘‘PBM’’) to 
manage the prescription drug coverage provided 
under such plan, or to control the costs of such pre-
scription drug coverage, only if as a condition of such 
contract the PBM is required to provide at least an-
nually to the Commissioner and to the QHBP offer-
ing entity offering such plan the following informa-
tion: 
(A) Information on the volume of prescrip-
tions under the contract that are filled via mail 
order and at retail pharmacies. 
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(B) An estimate of aggregate average pay-
ments under the contract, per prescription 
(weighted by prescription volume), made to mail 
order and retail pharmacists, and the average 
amount, per prescription, that the PBM was 
paid by the plan for prescriptions filled at mail 
order and retail pharmacists. 
(C) An estimate of the aggregate average 
payment per prescription (weighted by prescrip-
tion volume) under the contract received from 
pharmaceutical manufacturers, including all re-
bates, discounts, prices concessions, or adminis-
trative, and other payments from pharma-
ceutical manufacturers, and a description of the 
types of payments, and the amount of these pay-
ments that were shared with the plan, and a de-
scription of the percentage of prescriptions for 
which the PBM received such payments. 
(D) Information on the overall percentage of 
generic drugs dispensed under the contract at re-
tail and mail order pharmacies, and the percent-
age of cases in which a generic drug is dispensed 
when available. 
(E) Information on the percentage and 
number of cases under the contract in which in-
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dividuals were switched from a prescribed drug 
that was less expensive to a drug that was more 
expensive, the rationale for these switches, and a 
description of the PBM policies governing such 
switches. 
(2) CONFIDENTIALITY
OF
INFORMATION.—Not-
withstanding any other provision of law, information 
disclosed by a PBM to the Commissioner or a QHBP 
offering entity under this subsection is confidential 
and shall not be disclosed by the Commissioner or the 
QHBP offering entity in a form which discloses the 
identity of a specific PBM or prices charged by such 
PBM or a specific retailer, manufacturer, or whole-
saler, except— 
(A) as the Commissioner determines to be 
necessary to carry out this subsection; 
(B) to permit the Comptroller General to re-
view the information provided; 
(C) to permit the Director of the Congres-
sional Budget Office to review the information 
provided; and 
(D) to permit the Commissioner to disclose 
industry-wide aggregate or average information 
to be used in assessing the overall impact of 
PBMs on prescription drug prices and spending. 
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SEC. 134. APPLICATION TO QUALIFIED HEALTH BENEFITS 
PLANS NOT OFFERED THROUGH THE HEALTH 
INSURANCE EXCHANGE. 
The requirements of the previous provisions of this sub-
title shall apply to qualified health benefits plans that are 
not being offered through the Health Insurance Exchange 
only to the extent specified by the Commissioner. 
SEC. 135. TIMELY PAYMENT OF CLAIMS. 
A QHBP offering entity shall comply with the require-
ments of section 1857(f) of the Social Security Act with re-
spect 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 Medi-
care 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 co-
ordination and subrogation of benefits and reimbursement 
of payments in cases involving individuals and multiple 
plan coverage. 
SEC. 137. APPLICATION OF ADMINISTRATIVE SIMPLIFICA-
TION. 
A QHBP offering entity is required to comply with 
standards for electronic financial and administrative trans-
actions under section 1173A of the Social Security Act and 
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the operating rules under section 1173B of such Act, as 
added by section 163(a). 
SEC. 138. INFORMATION ON END-OF-LIFE PLANNING. 
(a) IN GENERAL.—The QHBP offering entity — 
(1) shall provide for the dissemination of infor-
mation related to end-of-life planning to individuals 
seeking enrollment in Exchange-participating health 
benefits plans offered through the Exchange; 
(2) shall present such individuals with— 
(A) the option to establish advanced direc-
tives and physician’s orders for life sustaining 
treatment according to the laws of the State in 
which the individual resides; and 
(B) information related to other planning 
tools; and 
(3) shall not promote suicide, assisted suicide, or 
the active hastening of death. 
The information presented under paragraph (2) shall not 
presume the withdrawal of treatment and shall include end- 
of-life planning information that includes options to main-
tain all or most medical interventions. 
(b) CONSTRUCTION.—Nothing in this section shall be 
construed— 
(1) to require an individual to complete an ad-
vanced directive or a physician’s order for life sus-
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taining treatment or other end-of-life planning docu-
ment; 
(2) to require an individual to consent to restric-
tions on the amount, duration, or scope of medical 
benefits otherwise covered under a qualified health 
benefits plan; or 
(3) to encourage the hastening of death or the 
promotion of assisted suicide. 
(c) ADVANCED DIRECTIVE DEFINED.—In this section, 
the term ‘‘advanced directive’’ includes a living will, a com-
fort care order, or a durable power of attorney for health 
care 
(d) PROHIBITION ON THE PROMOTION OF ASSISTED 
SUICIDE.— 
(1) IN GENERAL.—Subject to paragraph (3), in-
formation provided to meet the requirements of sub-
section (a)(2) shall not include advanced directives or 
other planning tools that list or describe as an option 
suicide, assisted suicide or the intentional hastening 
of death regardless of legality. 
(2) CONSTRUCTION.—Nothing in paragraph (1) 
shall be construed to apply to or affect any option 
to— 
(A) the withhold or withdraw of medical 
treatment or medical care; 
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(B) withhold or withdraw of nutrition or 
hydration; and 
(C) provide palliative or hospice care or use 
an item, good, benefit, or service furnished for 
the purpose of alleviating pain or discomfort, 
even if such use may increase the risk of death, 
so long as such item, good, benefit, or service is 
not also furnished for the purpose of causing, or 
the purpose of assisting in causing, death, for 
any reason. 
(3) EXEMPTION.—The requirements of subsection 
(a) shall not apply to any State that as of August 1, 
2009, requires the inclusion of information prohibited 
in such paragraph in advanced directives or other 
planning tools. 
SEC. 139. UTILIZATION REVIEW ACTIVITIES. 
(a) COMPLIANCE WITH REQUIREMENTS.— 
(1) IN
GENERAL.—A qualified health benefits 
plan, and a QHBP offering entity that offers such 
plan, shall conduct utilization review activities in 
connection with the provision of benefits under such 
plan only in accordance with a utilization review 
program that meets the requirements of this section. 
(2) USE OF OUTSIDE AGENTS.—Nothing in this 
section shall be construed as preventing a qualified 
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health benefits plan or QHBP offering entity from ar-
ranging through a contract or otherwise for persons 
or entities to conduct utilization review activities on 
behalf of the plan entity, so long as such activities are 
conducted in accordance with a utilization review 
program that meets the requirements of this section. 
(3) UTILIZATION REVIEW DEFINED.—For pur-
poses of this section, the terms ‘‘utilization review’’ 
and ‘‘utilization review activities’’ mean procedures 
used to monitor or evaluate the use or coverage, clin-
ical necessity, appropriateness, efficacy, or efficiency 
of health care services, procedures or settings, and in-
cludes prospective review, concurrent review, second 
opinions, case management, discharge planning, or 
retrospective review. 
(b) WRITTEN POLICIES AND CRITERIA.— 
(1) WRITTEN
POLICIES.—A utilization review 
program shall be conducted consistent with written 
policies and procedures that govern all aspects of the 
program. 
(2) USE OF WRITTEN CRITERIA.— 
(A) IN GENERAL.—Such a program shall 
utilize written clinical review criteria developed 
with input from a range of appropriate actively 
practicing health care professionals, as deter-
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mined by the plan, pursuant to the program. 
Such criteria shall include written clinical re-
view criteria that are based on valid clinical evi-
dence where available and that are directed spe-
cifically at meeting the needs of at-risk popu-
lations and covered individuals with chronic 
conditions or severe illnesses, including gender- 
specific criteria and pediatric-specific criteria 
where available and appropriate. 
(B) CONTINUING
USE
OF
STANDARDS
IN 
RETROSPECTIVE REVIEW.—If a health care serv-
ice has been specifically pre-authorized or ap-
proved for an enrollee under such a program, the 
program shall not, pursuant to retrospective re-
view, revise or modify the specific standards, cri-
teria, or procedures used for the utilization re-
view for procedures, treatment, and services de-
livered to the enrollee during the same course of 
treatment. 
(C) REVIEW OF SAMPLE OF CLAIMS DENI-
ALS.—Such a program shall provide for an eval-
uation of the clinical appropriateness of at least 
a sample of denials of claims for benefits. 
(c) CONDUCT OF PROGRAM ACTIVITIES.— 
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process) of the external appeal determina-
tion. 
(I) COMPLIANCE WITH DETERMINATION.—If 
the external appeal entity reverses or modifies 
the denial of a claim for benefits, the plan 
shall— 
(i) upon the receipt of the determina-
tion, authorize benefits in accordance with 
such determination; 
(ii) take such actions as may be nec-
essary to provide benefits (including items 
or services) in a timely manner consistent 
with such determination; and 
(iii) submit information to the entity 
documenting compliance with the entity’s 
determination and this subparagraph. 
(c) QUALIFICATIONS
OF EXTERNAL APPEAL ENTI-
TIES.— 
(1) IN GENERAL.—For purposes of this section, 
the term ‘‘qualified external appeal entity’’ means, in 
relation to a plan or issuer, an entity that is certified 
under paragraph (2) as meeting the following require-
ments: 
(A) The entity meets the independence re-
quirements of paragraph (3). 
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135 
such terms by the Commissioner for purposes of this 
division. 
(c) TRANSITION.—Individuals and employers shall 
only be eligible to enroll or participate in the Health Insur-
ance Exchange in accordance with the following transition 
schedule: 
(1) FIRST YEAR.—In Y1 (as defined in section 
100(c))— 
(A) individuals described in subsection 
(d)(1), including individuals described in para-
graphs (3) and (4) of subsection (d); and 
(B) smallest employers described in sub-
section (e)(1). 
(2) SECOND YEAR.—In Y2— 
(A) individuals and employers described in 
paragraph (1); and 
(B) smaller employers described in sub-
section (e)(2). 
(3) THIRD
AND
SUBSEQUENT
YEARS.—In Y3 
and subsequent years— 
(A) individuals and employers described in 
paragraph (2); and 
(B) larger employers as permitted by the 
Commissioner under subsection (e)(3). 
(d) INDIVIDUALS.— 
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