I 
114TH CONGRESS 
2D SESSION 
H. R. 4801 
To amend title XXVII of the Public Health Service Act, and title XVIII 
of the Social Security Act, to direct the Secretary of Health and Human 
Services to conduct audits of medical loss ratio reports submitted by 
health insurance issuers, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MARCH 17, 2016 
Ms. MICHELLE LUJAN GRISHAM of New Mexico (for herself and Ms. SCHA-
KOWSKY) introduced the following bill; which was referred to the Com-
mittee on Energy and Commerce, and in addition to the Committee on 
Ways and Means, for a period to be subsequently determined by the 
Speaker, in each case for consideration of such provisions as fall within 
the jurisdiction of the committee concerned 
A BILL 
To amend title XXVII of the Public Health Service Act, 
and title XVIII of the Social Security Act, to direct 
the Secretary of Health and Human Services to conduct 
audits of medical loss ratio reports submitted by health 
insurance issuers, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Medical Loss Ratio 
Accountability Act of 2016’’. 
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SEC. 2. AUDITS OF MEDICAL LOSS RATIO REPORTS SUB-
MITTED WITH RESPECT TO GROUP OR INDI-
VIDUAL HEALTH INSURANCE COVERAGE. 
Section 2718 of the Public Health Service Act (42 
U.S.C. 300gg–18) is amended— 
(1) in subsection (b)(3), by inserting ‘‘, includ-
ing with respect to the submission of any informa-
tion that, pursuant to an audit conducted under sub-
section (f), is found to be untruthful or inaccurate’’ 
after ‘‘penalties’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(f) AUDITS.— 
‘‘(1) IN
GENERAL.—Beginning with the first 
plan year that begins after the date of the enact-
ment of the Medical Loss Ratio Accountability Act 
of 2016, the Secretary shall, with respect to a statis-
tically significant percentage of the reports sub-
mitted under this section by health insurance issuers 
offering group or individual health insurance cov-
erage (including grandfathered health plans), con-
duct audits of the books and records (or such other 
information as may be necessary) of such health in-
surance issuers to verify that the information con-
tained in each such report is truthful and accurate. 
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‘‘(2) SELECTION OF REPORTS FOR AUDITS.—In 
selecting reports to be audited under paragraph (1), 
the Secretary shall ensure that, for a plan year, the 
health insurance issuers whose reports are selected 
for such audits are representative of the health in-
surance issuers that submitted such reports for such 
plan year. 
‘‘(3) AUTHORITY TO ENTER INTO CONTRACTS 
OR
COOPERATIVE
AGREEMENTS.—The Secretary 
may, for purposes of conducting audits under para-
graph (1), enter into a contract or cooperative agree-
ment with a private entity. 
‘‘(4) REPORT
TO
CONGRESS.—Beginning 18 
months after the date of the enactment of the Med-
ical Loss Ratio Accountability Act of 2016 and each 
year thereafter, the Secretary shall submit to Con-
gress a report on the results of audits conducted 
under this section with respect to the previous plan 
year.’’. 
SEC. 3. APPLICATION TO PARTS C AND D OF THE MEDI-
CARE PROGRAM. 
Section 1857(e)(4) of the Social Security Act (42 
U.S.C. 1395w–27(e)(4)) is amended by adding at the end 
the following new flush sentence: 
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