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Ppaca & Hcera; Public Laws 111-148 & 111-152: Consolidated Print—13
TITLE I—QUALITY, AFFORDABLE
HEALTH CARE FOR ALL AMERICANS
Subtitle A—Immediate Improvements in
Health Care Coverage for All Americans
SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.
Part A of title XXVII of the Public Health Service Act (42
U.S.C. 300gg et seq.) is amended—
(1) by striking the part heading and inserting the following:
‘‘PART A—INDIVIDUAL AND GROUP MARKET
REFORMS’’;
(2) by redesignating sections 2704 through 2707 as sections
2725 through 2728, respectively;
(3) by redesignating sections 2711 through 2713 as sections
2731 through 2733, respectively;
(4) by redesignating sections 2721 through 2723 as sections
2735 through 2737, respectively; and
(5) by inserting after section 2702, the following:
‘‘Subpart II—Improving Coverage
‘‘SEC. 2711. NO LIFETIME OR ANNUAL LIMITS.
øReplaced by section 10101(a)¿
‘‘(a) PROHIBITION.—
‘‘(1) IN GENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish—
‘‘(A) lifetime limits on the dollar value of benefits for
any participant or beneficiary; or
‘‘(B) except as provided in paragraph (2), annual limits
on the dollar value of benefits for any participant or beneficiary.
‘‘(2) ANNUAL LIMITS PRIOR TO 2014.—With respect to plan
years beginning prior to January 1, 2014, a group health plan
and a health insurance issuer offering group or individual
health insurance coverage may only establish a restricted
annual limit on the dollar value of benefits for any participant
or beneficiary with respect to the scope of benefits that are
essential health benefits under section 1302(b) of the Patient
Protection and Affordable Care Act, as determined by the Secretary. In defining the term ‘restricted annual limit’ for purposes of the preceding sentence, the Secretary shall ensure
that access to needed services is made available with a minimal
impact on premiums.
‘‘(b) PER BENEFICIARY LIMITS.—Subsection (a) shall not be construed to prevent a group health plan or health insurance coverage
from placing annual or lifetime per beneficiary limits on specific
covered benefits that are not essential health benefits under section
1302(b) of the Patient Protection and Affordable Care Act, to the
extent that such limits are otherwise permitted under Federal
or State law.
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‘‘SEC. 2712. PROHIBITION ON RESCISSIONS.
‘‘A group health plan and a health insurance issuer offering
group or individual health insurance coverage shall not rescind
such plan or coverage with respect to an enrollee once the enrollee
is covered under such plan or coverage involved, except that this
section shall not apply to a covered individual who has performed
an act or practice that constitutes fraud or makes an intentional
misrepresentation of material fact as prohibited by the terms of
the plan or coverage. Such plan or coverage may not be cancelled
except with prior notice to the enrollee, and only as permitted
under section 2702(c) or 2742(b).
‘‘SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES.
‘‘(a) IN GENERAL.—A group health plan and a health insurance
issuer offering group or individual health insurance coverage shall,
at a minimum provide coverage for and shall not impose any
cost sharing requirements for—
‘‘(1) evidence-based items or services that have in effect
a rating of ‘A’ or ‘B’ in the current recommendations of the
United States Preventive Services Task Force;
‘‘(2) immunizations that have in effect a recommendation
from the Advisory Committee on Immunization Practices of
the Centers for Disease Control and Prevention with respect
to the individual involved; and
‘‘(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for
in the comprehensive guidelines supported by the Health
Resources and Services Administration.
‘‘(4) with respect to women, such additional preventive
care and screenings not described in paragraph (1) as provided
for in comprehensive guidelines supported by the Health
Resources and Services Administration for purposes of this
paragraph.
‘‘(5) for the purposes of this Act, and for the purposes
of any other provision of law, the current recommendations
of the United States Preventive Service Task Force regarding
breast cancer screening, mammography, and prevention shall
be considered the most current other than those issued in
or around November 2009.
Nothing in this subsection shall be construed to prohibit a plan
or issuer from providing coverage for services in addition to those
recommended by United States Preventive Services Task Force
or to deny coverage for services that are not recommended by
such Task Force.
‘‘(b) INTERVAL.—
‘‘(1) IN GENERAL.—The Secretary shall establish a minimum
interval between the date on which a recommendation described
in subsection (a)(1) or (a)(2) or a guideline under subsection
(a)(3) is issued and the plan year with respect to which the
requirement described in subsection (a) is effective with respect
to the service described in such recommendation or guideline.
‘‘(2) MINIMUM.—The interval described in paragraph (1)
shall not be less than 1 year.
‘‘(c) VALUE-BASED INSURANCE DESIGN.—The Secretary may
develop guidelines to permit a group health plan and a health
insurance issuer offering group or individual health insurance coverage to utilize value-based insurance designs.
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Ppaca & Hcera; Public Laws 111-148 & 111-152: Consolidated Print—15
‘‘SEC. 2714. EXTENSION OF DEPENDENT COVERAGE.
‘‘(a) IN GENERAL.—A group health plan and a health insurance
issuer offering group or individual health insurance coverage that
provides dependent coverage of children shall continue to make
such coverage available for an adult child until the child turns
26 years of age. Nothing in this section shall require a health
plan or a health insurance issuer described in the preceding sentence to make coverage available for a child of a child receiving
dependent coverage. øAs revised by section 2301(b) of HCERA¿
‘‘(b) REGULATIONS.—The Secretary shall promulgate regulations
to define the dependents to which coverage shall be made available
under subsection (a).
‘‘(c) RULE OF CONSTRUCTION.—Nothing in this section shall
be construed to modify the definition of ‘dependent’ as used in
the Internal Revenue Code of 1986 with respect to the tax treatment
of the cost of coverage.
‘‘SEC. 2715. DEVELOPMENT AND UTILIZATION OF UNIFORM EXPLANATION OF COVERAGE DOCUMENTS AND STANDARDIZED
DEFINITIONS.
‘‘(a) IN GENERAL.—Not later than 12 months after the date
of enactment of the Patient Protection and Affordable Care Act,
the Secretary shall develop standards for use by a group health
plan and a health insurance issuer offering group or individual
health insurance coverage, in compiling and providing to applicants,
enrollees, and policyholders or certificate holders a summary of
benefits and coverage explanation that accurately describes the
benefits and coverage under the applicable plan or coverage. In
developing such standards, the Secretary shall consult with the
National Association of Insurance Commissioners (referred to in
this section as the ‘NAIC’), a working group composed of representatives of health insurance-related consumer advocacy organizations,
health insurance issuers, health care professionals, patient advocates including those representing individuals with limited English
proficiency, and other qualified individuals. øAs revised by section
10101(b)¿
‘‘(b) REQUIREMENTS.—The standards for the summary of benefits and coverage developed under subsection (a) shall provide for
the following:
‘‘(1) APPEARANCE.—The standards shall ensure that the
summary of benefits and coverage is presented in a uniform
format that does not exceed 4 pages in length and does not
include print smaller than 12-point font.
‘‘(2) LANGUAGE.—The standards shall ensure that the summary is presented in a culturally and linguistically appropriate
manner and utilizes terminology understandable by the average
plan enrollee.
‘‘(3) CONTENTS.—The standards shall ensure that the summary of benefits and coverage includes—
‘‘(A) uniform definitions of standard insurance terms
and medical terms (consistent with subsection (g)) so that
consumers may compare health insurance coverage and
understand the terms of coverage (or exception to such
coverage);
‘‘(B) a description of the coverage, including cost
sharing for—
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‘‘(i) each of the categories of the essential health
benefits described in subparagraphs (A) through (J)
of section 1302(b)(1) of the Patient Protection and
Affordable Care Act; and
‘‘(ii) other benefits, as identified by the Secretary;
‘‘(C) the exceptions, reductions, and limitations on coverage;
‘‘(D) the cost-sharing provisions, including deductible,
coinsurance, and co-payment obligations;
‘‘(E) the renewability and continuation of coverage
provisions;
‘‘(F) a coverage facts label that includes examples to
illustrate common benefits scenarios, including pregnancy
and serious or chronic medical conditions and related cost
sharing, such scenarios to be based on recognized clinical
practice guidelines;
‘‘(G) a statement of whether the plan or coverage—
‘‘(i) provides minimum essential coverage (as
defined under section 5000A(f) of the Internal Revenue
Code 1986); and
‘‘(ii) ensures that the plan or coverage share of
the total allowed costs of benefits provided under the
plan or coverage is not less than 60 percent of such
costs;
‘‘(H) a statement that the outline is a summary of
the policy or certificate and that the coverage document
itself should be consulted to determine the governing
contractual provisions; and
‘‘(I) a contact number for the consumer to call with
additional questions and an Internet web address where
a copy of the actual individual coverage policy or group
certificate of coverage can be reviewed and obtained.
‘‘(c) PERIODIC REVIEW AND UPDATING.—The Secretary shall
periodically review and update, as appropriate, the standards developed under this section.
‘‘(d) REQUIREMENT TO PROVIDE.—
‘‘(1) IN GENERAL.—Not later than 24 months after the date
of enactment of the Patient Protection and Affordable Care
Act, each entity described in paragraph (3) shall provide, prior
to any enrollment restriction, a summary of benefits and coverage explanation pursuant to the standards developed by
the Secretary under subsection (a) to—
‘‘(A) an applicant at the time of application;
‘‘(B) an enrollee prior to the time of enrollment or
reenrollment, as applicable; and
‘‘(C) a policyholder or certificate holder at the time
of issuance of the policy or delivery of the certificate.
‘‘(2) COMPLIANCE.—An entity described in paragraph (3)
is deemed to be in compliance with this section if the summary
of benefits and coverage described in subsection (a) is provided
in paper or electronic form.
‘‘(3) ENTITIES IN GENERAL.—An entity described 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
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‘‘(B) in the case of a self-insured group health plan,
the plan sponsor or designated administrator of the plan
(as such terms are defined in section 3(16) of the Employee
Retirement Income Security Act of 1974).
‘‘(4) NOTICE OF MODIFICATIONS.—If a group health plan
or health insurance issuer makes any material 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
provided summary of benefits and coverage, the plan or issuer
shall provide notice of such modification to enrollees 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 provides less information to
consumers than that required to be provided under this section,
as determined by the Secretary.
‘‘(f) FAILURE TO PROVIDE.—An entity described in subsection
(d)(3) that willfully fails to provide the information 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 offense for purposes of this subsection.
‘‘(g) DEVELOPMENT OF STANDARD DEFINITIONS.—
‘‘(1) IN GENERAL.—The Secretary shall, by regulation, provide for the development of standards for the definitions of
terms used in health insurance coverage, including the insurance-related terms described in paragraph (2) and the medical
terms described in paragraph (3).
‘‘(2) INSURANCE-RELATED TERMS.—The insurance-related
terms described in this paragraph are premium, deductible,
co-insurance, co-payment, out-of-pocket limit, preferred provider, non-preferred provider, out-of-network co-payments, UCR
(usual, customary and reasonable) fees, excluded services, grievance and appeals, and such other terms as the Secretary determines are important to define so that consumers may compare
health insurance coverage and understand the terms of their
coverage.
‘‘(3) MEDICAL TERMS.—The medical terms described in this
paragraph are hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage,
durable medical equipment, home health care, skilled nursing
care, rehabilitation services, hospice services, emergency medical transportation, and such other terms as the Secretary
determines are important to define so that consumers may
compare the medical benefits offered by health insurance and
understand the extent of those medical benefits (or exceptions
to those benefits).
‘‘SEC. 2715A. PROVISION OF ADDITIONAL INFORMATION.
‘‘øAs added by section 10101(c)¿ A group health plan and a
health insurance issuer offering group or individual health insurance coverage shall comply with the provisions of section 1311(e)(3)
of the Patient Protection and Affordable Care Act, except that
a plan or coverage that is not offered through an Exchange shall
only be required to submit the information required to the Secretary
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Ppaca & Hcera; Public Laws 111-148 & 111-152: Consolidated Print—170
(2) CBO projects this Act will continue to reduce budget
deficits after 2019.
(3) Based on CBO estimates, this Act will extend the solvency of the Medicare HI Trust Fund.
(4) This Act will increase the surplus in the Social Security
Trust Fund, which should be reserved to strengthen the
finances of Social Security.
(5) The initial net savings generated by the Community
Living Assistance Services and Supports (CLASS) program are
necessary to ensure the long-term solvency of that program.
(b) SENSE OF THE SENATE.—It is the sense of the Senate that—
(1) the additional surplus in the Social Security Trust
Fund generated by this Act should be reserved for Social Security and not spent in this Act for other purposes; and
(2) the net savings generated by the CLASS program should
be reserved for the CLASS program and not spent in this
Act for other purposes.
øNote section 10108, p. 793, provides for free choice vouchers¿
TITLE II—ROLE OF PUBLIC PROGRAMS
Subtitle A—Improved Access to Medicaid
SEC. 2001. MEDICAID COVERAGE FOR THE LOWEST INCOME POPULATIONS.
(a) COVERAGE FOR INDIVIDUALS WITH INCOME AT OR BELOW
133 PERCENT OF THE POVERTY LINE.—
(1) BEGINNING 2014.—Section 1902(a)(10)(A)(i) of the Social
Security Act (42 U.S.C. 1396a) is amended—
(A) by striking ‘‘or’’ at the end of subclause (VI);
(B) by adding ‘‘or’’ at the end of subclause (VII); and
(C) by inserting after subclause (VII) the following:
‘‘(VIII) beginning January 1, 2014, who are
under 65 years of age, not pregnant, not entitled
to, or enrolled for, benefits under part A of title
XVIII, or enrolled for benefits under part B of
title XVIII, and are not described in a previous
subclause of this clause, and whose income (as
determined under subsection (e)(14)) does not
exceed 133 percent of the poverty line (as defined
in section 2110(c)(5)) applicable to a family of the
size involved, subject to subsection (k);’’.
(2) PROVISION OF AT LEAST MINIMUM ESSENTIAL COVERAGE.—
(A) IN GENERAL.—Section 1902 of such Act (42 U.S.C.
1396a) is amended by inserting after subsection (j) the
following:
‘‘(k)(1) The medical assistance provided to an individual
described in subclause (VIII) of subsection (a)(10)(A)(i) shall consist
of benchmark coverage described in section 1937(b)(1) or benchmark
equivalent coverage described in section 1937(b)(2). Such medical
assistance shall be provided subject to the requirements of section
1937, without regard to whether a State otherwise has elected
the option to provide medical assistance through coverage under
that section, unless an individual described in subclause (VIII)
of subsection (a)(10)(A)(i) is also an individual for whom, under
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Ppaca & Hcera; Public Laws 111-148 & 111-152: Consolidated Print—171
subparagraph (B) of section 1937(a)(2), the State may not require
enrollment in benchmark coverage described in subsection (b)(1)
of section 1937 or benchmark equivalent coverage described in
subsection (b)(2) of that section.’’.
(B) CONFORMING AMENDMENT.—Section 1903(i) of the
Social Security Act, as amended by section 6402(c), is
amended—
(i) in paragraph (24), by striking ‘‘or’’ at the end;
(ii) in paragraph (25), by striking the period and
inserting ‘‘; or’’; and
(iii) by adding at the end the following:
‘‘(26) with respect to any amounts expended for medical
assistance for individuals described in subclause (VIII) of subsection (a)(10)(A)(i) other than medical assistance provided
through benchmark coverage described in section 1937(b)(1)
or benchmark equivalent coverage described in section
1937(b)(2).’’.
(3) FEDERAL FUNDING FOR COST OF COVERING NEWLY
ELIGIBLE INDIVIDUALS.—Section 1905 of the Social Security Act
(42 U.S.C. 1396d), is amended—
(A) in subsection (b), in the first sentence, by inserting
‘‘subsection (y) and’’ before ‘‘section 1933(d)’’; and
(B) by adding at the end the following new subsection:
‘‘(y) INCREASED FMAP FOR MEDICAL ASSISTANCE FOR NEWLY
ELIGIBLE MANDATORY INDIVIDUALS.—
‘‘(1) AMOUNT OF INCREASE.—øReplaced by section 1201(1)(B)
of HCERA¿ Notwithstanding subsection (b), the Federal medical assistance percentage for a State that is one of the 50
States or the District of Columbia, with respect to amounts
expended by such State for medical assistance for newly eligible
individuals described in subclause (VIII) of section
1902(a)(10)(A)(i), shall be equal to—
‘‘(A) 100 percent for calendar quarters in 2014, 2015,
and 2016;
‘‘(B) 95 percent for calendar quarters in 2017;
‘‘(C) 94 percent for calendar quarters in 2018;
‘‘(D) 93 percent for calendar quarters in 2019; and
‘‘(E) 90 percent for calendar quarters in 2020 and each
year thereafter.
‘‘(2) DEFINITIONS.—In this subsection:
‘‘(A) NEWLY ELIGIBLE.—The term ‘newly eligible’
means, with respect to an individual described in subclause
(VIII) of section 1902(a)(10)(A)(i), an individual who is not
under 19 years of age (or such higher age as the State
may have elected) and who, as of December 1, 2009, is
not eligible under the State plan or under a waiver of
the plan for full benefits or for benchmark coverage
described in subparagraph (A), (B), or (C) of section
1937(b)(1) or benchmark equivalent coverage described in
section 1937(b)(2) that has an aggregate actuarial value
that is at least actuarially equivalent to benchmark coverage described in subparagraph (A), (B), or (C) of section
1937(b)(1), or is eligible but not enrolled (or is on a waiting
list) for such benefits or coverage through a waiver under
the plan that has a capped or limited enrollment that
is full. øAs revised by section 10201(c)(3)(B)¿
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‘‘(B) FULL BENEFITS.—The term ‘full benefits’ means,
with respect to an individual, medical assistance for all
services covered under the State plan under this title that
is not less in amount, duration, or scope, or is determined
by the Secretary to be substantially equivalent, to the
medical assistance available for an individual described
in section 1902(a)(10)(A)(i).
øDrafting note: subclause (II) of paragraph (1)(B)(ii), as originally added by section 2001(a)(3) and as amended by section
10201(c)(3)(A), was redesignated as paragraph (5) of subsection (z)
and is shown in subsection (z), p. 797, as added by section
10201(c)(4)¿
(4) STATE OPTIONS TO OFFER COVERAGE EARLIER AND
PRESUMPTIVE ELIGIBILITY; CHILDREN REQUIRED TO HAVE COVERAGE FOR PARENTS TO BE ELIGIBLE.—
(A) IN GENERAL.—Subsection (k) of section 1902 of
the Social Security Act (as added by paragraph (2)), is
amended by inserting after paragraph (1) the following:
‘‘(2) øAs revised by section 10201(b)¿ Beginning with the first
day of any fiscal year quarter that begins on or after April 1,
2010, and before January 1, 2014, a State may elect through a
State plan amendment to provide medical assistance to individuals
who would be described in subclause (VIII) of subsection (a)(10)(A)(i)
if that subclause were effective before January 1, 2014. A State
may elect to phase-in the extension of eligibility for medical assistance to such individuals based on income, so long as the State
does not extend such eligibility to individuals described in such
subclause with higher income before making individuals described
in such subclause with lower income eligible for medical assistance.
‘‘(3) If an individual described in subclause (VIII) of subsection
(a)(10)(A)(i) is the parent of a child who is under 19 years of
age (or such higher age as the State may have elected) who is
eligible for medical assistance under the State plan or under a
waiver of such plan (under that subclause or under a State plan
amendment under paragraph (2), the individual may not be enrolled
under the State plan unless the individual’s child is enrolled under
the State plan or under a waiver of the plan or is enrolled in
other health insurance coverage. For purposes of the preceding
sentence, the term ‘parent’ includes an individual treated as a
caretaker relative for purposes of carrying out section 1931.’’.
(B) PRESUMPTIVE ELIGIBILITY.—Section 1920 of the
Social Security Act (42 U.S.C. 1396r–1) is amended by
adding at the end the following:
‘‘(e) If the State has elected the option to provide a presumptive
eligibility period under this section or section 1920A, the State
may elect to provide a presumptive eligibility period (as defined
in subsection (b)(1)) for individuals who are eligible for medical
assistance under clause (i)(VIII) of subsection (a)(10)(A) or section
1931 in the same manner as the State provides for such a period
under this section or section 1920A, subject to such guidance as
the Secretary shall establish.’’.
(5) CONFORMING AMENDMENTS.—
(A) Section 1902(a)(10) of such Act (42 U.S.C.
1396a(a)(10)) is amended in the matter following subparagraph (G), by striking ‘‘and (XIV)’’ and inserting ‘‘(XIV)’’
and by inserting ‘‘and (XV) the medical assistance made
available to an individual described in subparagraph
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Ppaca & Hcera; Public Laws 111-148 & 111-152: Consolidated Print—173
(A)(i)(VIII) shall be limited to medical assistance described
in subsection (k)(1)’’ before the semicolon. øNote that section
10201(a)(2) made an additional conforming amendment to
reflect overlap with subparagraph (A)(i)(IX), added by section 2004(a)¿
(B) Section 1902(l)(2)(C) of such Act (42 U.S.C.
1396a(l)(2)(C)) is amended by striking ‘‘100’’ and inserting
‘‘133’’.
(C) Section 1905(a) of such Act (42 U.S.C. 1396d(a))
is amended in the matter preceding paragraph (1)—
(i) by striking ‘‘or’’ at the end of clause (xii);
(ii) by inserting ‘‘or’’ at the end of clause (xiii);
and
(iii) by inserting after clause (xiii) the following:
‘‘(xiv)
individuals
described
in
section
1902(a)(10)(A)(i)(VIII),’’.
(D) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4))
is amended by inserting ‘‘1902(a)(10)(A)(i)(VIII),’’ after
‘‘1902(a)(10)(A)(i)(VII),’’.
(E) Section 1937(a)(1)(B) of such Act (42 U.S.C. 1396u–
7(a)(1)(B)) is amended by inserting ‘‘subclause (VIII) of
section 1902(a)(10)(A)(i) or under’’ after ‘‘eligible under’’.
(b) MAINTENANCE OF MEDICAID INCOME ELIGIBILITY.—Section
1902 of the Social Security Act (42 U.S.C. 1396a) is amended—
(1) in subsection (a)—
(A) by striking ‘‘and’’ at the end of paragraph (72);
(B) by striking the period at the end of paragraph
(73) and inserting ‘‘; and’’; and
(C) by inserting after paragraph (73) the following
new paragraph:
‘‘(74) provide for maintenance of effort under the State
plan or under any waiver of the plan in accordance with subsection (gg).’’; and
(2) by adding at the end the following new subsection:
‘‘(gg) MAINTENANCE OF EFFORT.—
‘‘(1) GENERAL REQUIREMENT TO MAINTAIN ELIGIBILITY
STANDARDS UNTIL STATE EXCHANGE IS FULLY OPERATIONAL.—
Subject to the succeeding paragraphs of this subsection, during
the period that begins on the date of enactment of the Patient
Protection and Affordable Care Act and ends on the date on
which the Secretary determines that an Exchange established
by the State under section 1311 of the Patient Protection and
Affordable Care Act is fully operational, as a condition for
receiving any Federal payments under section 1903(a) for calendar quarters occurring during such period, a State shall
not have in effect eligibility standards, methodologies, or procedures under the State plan under this title or under any waiver
of such plan that is in effect during that period, that are
more restrictive than the eligibility standards, methodologies,
or procedures, respectively, under the plan or waiver that are
in effect on the date of enactment of the Patient Protection
and Affordable Care Act.
‘‘(2) CONTINUATION OF ELIGIBILITY STANDARDS FOR CHILDREN UNTIL OCTOBER 1, 2019.—The requirement under paragraph (1) shall continue to apply to a State through September
30, 2019, with respect to the eligibility standards, methodologies, and procedures under the State plan under this title
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or under any waiver of such plan that are applicable to determining the eligibility for medical assistance of any child who
is under 19 years of age (or such higher age as the State
may have elected).
‘‘(3) NONAPPLICATION.—During the period that begins on
January 1, 2011, and ends on December 31, 2013, the requirement under paragraph (1) shall not apply to a State with
respect to nonpregnant, nondisabled adults who are eligible
for medical assistance under the State plan or under a waiver
of the plan at the option of the State and whose income exceeds
133 percent of the poverty line (as defined in section 2110(c)(5))
applicable to a family of the size involved if, on or after
December 31, 2010, the State certifies to the Secretary that,
with respect to the State fiscal year during which the certification is made, the State has a budget deficit, or with respect
to the succeeding State fiscal year, the State is projected to
have a budget deficit. Upon submission of such a certification
to the Secretary, the requirement under paragraph (1) shall
not apply to the State with respect to any remaining portion
of the period described in the preceding sentence.
‘‘(4) DETERMINATION OF COMPLIANCE.—
‘‘(A) STATES SHALL APPLY MODIFIED ADJUSTED GROSS
INCOME.—A State’s determination of income in accordance
with subsection (e)(14) shall not be considered to be eligibility standards, methodologies, or procedures that are
more restrictive than the standards, methodologies, or
procedures in effect under the State plan or under a waiver
of the plan on the date of enactment of the Patient Protection and Affordable Care Act for purposes of determining
compliance with the requirements of paragraph (1), (2),
or (3). øAs revised by section 1004(b)(1)(B) of HCERA¿
‘‘(B) STATES MAY EXPAND ELIGIBILITY OR MOVE
WAIVERED POPULATIONS INTO COVERAGE UNDER THE STATE
PLAN.—With respect to any period applicable under para-
graph (1), (2), or (3), a State that applies eligibility standards, methodologies, or procedures under the State plan
under this title or under any waiver of the plan that
are less restrictive than the eligibility standards, methodologies, or procedures, applied under the State plan or
under a waiver of the plan on the date of enactment of
the Patient Protection and Affordable Care Act, or that
makes individuals who, on such date of enactment, are
eligible for medical assistance under a waiver of the State
plan, after such date of enactment eligible for medical
assistance through a State plan amendment with an income
eligibility level that is not less than the income eligibility
level that applied under the waiver, or as a result of
the
application
of
subclause
(VIII)
of
section
1902(a)(10)(A)(i), shall not be considered to have in effect
eligibility standards, methodologies, or procedures that are
more restrictive than the standards, methodologies, or
procedures in effect under the State plan or under a waiver
of the plan on the date of enactment of the Patient Protection and Affordable Care Act for purposes of determining
compliance with the requirements of paragraph (1), (2),
or (3).’’.
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(c) MEDICAID BENCHMARK BENEFITS MUST CONSIST OF AT LEAST
MINIMUM ESSENTIAL COVERAGE.—Section 1937(b) of such Act (42
U.S.C. 1396u–7(b)) is amended—
(1) in paragraph (1), in the matter preceding subparagraph
(A), by inserting ‘‘subject to paragraphs (5) and (6),’’ before
‘‘each’’;
(2) in paragraph (2)—
(A) in the matter preceding subparagraph (A), by
inserting ‘‘subject to paragraphs (5) and (6)’’ after ‘‘subsection (a)(1),’’;
(B) in subparagraph (A)—
(i) by redesignating clauses (iv) and (v) as clauses
(vi) and (vii), respectively; and
(ii) by inserting after clause (iii), the following:
‘‘(iv) Coverage of prescription drugs.
‘‘(v) Mental health services.’’; and
(C) in subparagraph (C)—
(i) by striking clauses (i) and (ii); and
(ii) by redesignating clauses (iii) and (iv) as clauses
(i) and (ii), respectively; and
(3) by adding at the end the following new paragraphs:
‘‘(5) MINIMUM STANDARDS.—Effective January 1, 2014, any
benchmark benefit package under paragraph (1) or benchmark
equivalent coverage under paragraph (2) must provide at least
essential health benefits as described in section 1302(b) of
the Patient Protection and Affordable Care Act.
‘‘(6) MENTAL HEALTH SERVICES PARITY.—
‘‘(A) IN GENERAL.—In the case of any benchmark benefit package under paragraph (1) or benchmark equivalent
coverage under paragraph (2) that is offered by an entity
that is not a medicaid managed care organization and
that provides both medical and surgical benefits and mental
health or substance use disorder benefits, the entity shall
ensure that the financial requirements and treatment
limitations applicable to such mental health or substance
use disorder benefits comply with the requirements of section 2705(a) of the Public Health Service Act in the same
manner as such requirements apply to a group health
plan.
‘‘(B) DEEMED COMPLIANCE.—Coverage provided with
respect to an individual described in section 1905(a)(4)(B)
and covered under the State plan under section
1902(a)(10)(A) of the services described in section
1905(a)(4)(B) (relating to early and periodic screening, diagnostic, and treatment services defined in section 1905(r))
and provided in accordance with section 1902(a)(43), shall
be deemed to satisfy the requirements of subparagraph
(A).’’.
(d) ANNUAL REPORTS ON MEDICAID ENROLLMENT.—
(1) STATE REPORTS.—Section 1902(a) of the Social Security
Act (42 U.S.C. 1396a(a)), as amended by subsection (b), is
amended—
(A) by striking ‘‘and’’ at the end of paragraph (73);
(B) by striking the period at the end of paragraph
(74) and inserting ‘‘; and’’; and
(C) by inserting after paragraph (74) the following
new paragraph:
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‘‘(75) provide that, beginning January 2015, and annually
thereafter, the State shall submit a report to the Secretary
that contains—
‘‘(A) the total number of enrolled and newly enrolled
individuals in the State plan or under a waiver of the
plan for the fiscal year ending on September 30 of the
preceding calendar year, disaggregated by population,
including children, parents, nonpregnant childless adults,
disabled individuals, elderly individuals, and such other
categories or sub-categories of individuals eligible for medical assistance under the State plan or under a waiver
of the plan as the Secretary may require;
‘‘(B) a description, which may be specified by population, of the outreach and enrollment processes used by
the State during such fiscal year; and
‘‘(C) any other data reporting determined necessary
by the Secretary to monitor enrollment and retention of
individuals eligible for medical assistance under the State
plan or under a waiver of the plan.’’.
(2) REPORTS TO CONGRESS.—Beginning April 2015, and
annually thereafter, the Secretary of Health and Human Services shall submit a report to the appropriate committees of
Congress on the total enrollment and new enrollment in Medicaid for the fiscal year ending on September 30 of the preceding
calendar year on a national and State-by-State basis, and shall
include in each such report such recommendations for administrative or legislative changes to improve enrollment in the
Medicaid program as the Secretary determines appropriate.
(e) STATE OPTION FOR COVERAGE FOR INDIVIDUALS WITH
INCOME THAT EXCEEDS 133 PERCENT OF THE POVERTY LINE.—
(1) COVERAGE AS OPTIONAL CATEGORICALLY NEEDY GROUP.—
Section 1902 of the Social Security Act (42 U.S.C. 1396a) is
amended—
(A) in subsection (a)(10)(A)(ii)—
(i) in subclause (XVIII), by striking ‘‘or’’ at the
end;
(ii) in subclause (XIX), by adding ‘‘or’’ at the end;
and
(iii) by adding at the end the following new subclause:
‘‘(XX) beginning January 1, 2014, who are
under 65 years of age and are not described in
or enrolled under a previous subclause of this
clause, and whose income (as determined under
subsection (e)(14)) exceeds 133 percent of the poverty line (as defined in section 2110(c)(5))
applicable to a family of the size involved but
does not exceed the highest income eligibility level
established under the State plan or under a waiver
of the plan, subject to subsection (hh);’’ and
(B) by adding at the end the following new subsection:
‘‘(hh)(1) A State may elect to phase-in the extension of eligibility
for medical assistance to individuals described in subclause (XX)
of subsection (a)(10)(A)(ii) based on the categorical group (including
nonpregnant childless adults) or income, so long as the State does
not extend such eligibility to individuals described in such subclause
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Ppaca & Hcera; Public Laws 111-148 & 111-152: Consolidated Print—177
with higher income before making individuals described in such
subclause with lower income eligible for medical assistance.
‘‘(2) If an individual described in subclause (XX) of subsection
(a)(10)(A)(ii) is the parent of a child who is under 19 years of
age (or such higher age as the State may have elected) who is
eligible for medical assistance under the State plan or under a
waiver of such plan, the individual may not be enrolled under
the State plan unless the individual’s child is enrolled under the
State plan or under a waiver of the plan or is enrolled in other
health insurance coverage. For purposes of the preceding sentence,
the term ‘parent’ includes an individual treated as a caretaker
relative for purposes of carrying out section 1931.’’.
(2) CONFORMING AMENDMENTS.—
(A) Section 1905(a) of such Act (42 U.S.C. 1396d(a)),
as amended by subsection (a)(5)(C), is amended in the
matter preceding paragraph (1)—
(i) by striking ‘‘or’’ at the end of clause (xiii);
(ii) by inserting ‘‘or’’ at the end of clause (xiv);
and
(iii) by inserting after clause (xiv) the following:
‘‘(xv)
individuals
described
in
section
1902(a)(10)(A)(ii)(XX),’’.
(B) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4))
is amended by inserting ‘‘1902(a)(10)(A)(ii)(XX),’’ after
‘‘1902(a)(10)(A)(ii)(XIX),’’.
(C) Section 1920(e) of such Act (42 U.S.C. 1396r–1(e)),
as added by subsection (a)(4)(B), is amended by inserting
‘‘or clause (ii)(XX)’’ after ‘‘clause (i)(VIII)’’.
SEC. 2002. INCOME ELIGIBILITY FOR NONELDERLY DETERMINED
USING MODIFIED GROSS INCOME.
(a) IN GENERAL.—Section 1902(e) of the Social Security Act
(42 U.S.C. 1396a(e)) is amended by adding at the end the following:
‘‘(14) INCOME DETERMINED USING MODIFIED ADJUSTED GROSS
INCOME.—øAs revised by section 1004(b)(1)(A) & 1004(e) of
HCERA¿
‘‘(A) IN GENERAL.—Notwithstanding subsection (r) or
any other provision of this title, except as provided in
subparagraph (D), for purposes of determining income eligibility for medical assistance under the State plan or under
any waiver of such plan and for any other purpose
applicable under the plan or waiver for which a determination of income is required, including with respect to the
imposition of premiums and cost-sharing, a State shall
use the modified adjusted gross income of an individual
and, in the case of an individual in a family greater than
1, the household income of such family. A State shall
establish income eligibility thresholds for populations to
be eligible for medical assistance under the State plan
or a waiver of the plan using modified adjusted gross
income and household income that are not less than the
effective income eligibility levels that applied under the
State plan or waiver on the date of enactment of the
Patient Protection and Affordable Care Act. For purposes
of complying with the maintenance of effort requirements
under subsection (gg) during the transition to modified
adjusted gross income and household income, a State shall,
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Ppaca & Hcera; Public Laws 111-148 & 111-152: Consolidated Print—18
and the State insurance commissioner, and make such information
available to the public.
‘‘SEC. 2716. PROHIBITION ON DISCRIMINATION IN FAVOR OF HIGHLY
COMPENSATED INDIVIDUALS.
øReplaced by section 10101(d)¿
‘‘(a) IN GENERAL.—A group health plan (other than a selfinsured plan) shall satisfy the requirements of section 105(h)(2)
of the Internal Revenue Code of 1986 (relating to prohibition on
discrimination in favor of highly compensated individuals).
‘‘(b) RULES AND DEFINITIONS.—For purposes of this section—
‘‘(1) CERTAIN RULES TO APPLY.—Rules similar to the rules
contained in paragraphs (3), (4), and (8) of section 105(h) of
such Code shall apply.
‘‘(2) HIGHLY COMPENSATED INDIVIDUAL.—The term ‘highly
compensated individual’ has the meaning given such term by
section 105(h)(5) of such Code.
‘‘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
offering 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 reporting, effective case
management, care coordination, chronic disease management, and medication and care compliance initiatives,
including through the use of the medical homes model
as defined for purposes of section 3602 of the Patient
Protection and Affordable Care Act, for treatment or services under the plan or coverage;
‘‘(B) implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional;
‘‘(C) implement activities to improve patient safety and
reduce medical errors through the appropriate use of best
clinical practices, evidence based medicine, and health
information technology under the plan or coverage; and
‘‘(D) implement wellness and health promotion activities.
‘‘(2) REPORTING REQUIREMENTS.—
‘‘(A) IN GENERAL.—A group health plan and a health
insurance issuer offering group or individual health insurance coverage shall annually submit to the Secretary, and
to enrollees under the plan or coverage, a report on whether
the benefits under the plan or coverage satisfy the elements
described in subparagraphs (A) through (D) of paragraph
(1).
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Ppaca & Hcera; Public Laws 111-148 & 111-152: Consolidated Print—19
‘‘(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 Secretary shall
make reports submitted under subparagraph (A) available
to the public through an Internet website.
‘‘(D) PENALTIES.—In developing the reporting requirements under paragraph (1), the Secretary may develop
and impose appropriate penalties for non-compliance with
such requirements.
‘‘(E) EXCEPTIONS.—In developing the reporting requirements under paragraph (1), the Secretary may provide
for exceptions to such requirements for group health plans
and health insurance issuers that substantially meet the
goals of this section.
‘‘(b) WELLNESS AND PREVENTION PROGRAMS.—For purposes of
subsection (a)(1)(D), wellness and health promotion activities may
include personalized wellness and prevention services, which are
coordinated, maintained or delivered by a health care provider,
a wellness and prevention plan manager, or a health, wellness
or prevention services organization that conducts health risk assessments or offers ongoing face-to-face, telephonic or web-based intervention 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) PROTECTION OF SECOND AMENDMENT GUN RIGHTS.—øAs
added by section 10101(e)(2)¿
‘‘(1) WELLNESS AND PREVENTION PROGRAMS.—A wellness
and health promotion activity implemented under subsection
(a)(1)(D) may not require the disclosure or collection of any
information relating to—
‘‘(A) the presence or storage of a lawfully-possessed
firearm or ammunition in the residence or on the property
of an individual; or
‘‘(B) the lawful use, possession, or storage of a firearm
or ammunition by an individual.
‘‘(2) LIMITATION ON DATA COLLECTION.—None of the
authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that
Act shall be construed to authorize or may be used for the
collection of any information relating to—
‘‘(A) the lawful ownership or possession of a firearm
or ammunition;
‘‘(B) the lawful use of a firearm or ammunition; or
‘‘(C) the lawful storage of a firearm or ammunition.
‘‘(3) LIMITATION ON DATABASES OR DATA BANKS.—None of
the authorities provided to the Secretary under the Patient
Protection and Affordable Care Act or an amendment made
by that Act shall be construed to authorize or may be used
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Ppaca & Hcera; Public Laws 111-148 & 111-152: Consolidated Print—20
to maintain records of individual ownership or possession of
a firearm or ammunition.
‘‘(4) LIMITATION ON DETERMINATION OF PREMIUM RATES OR
ELIGIBILITY FOR HEALTH INSURANCE.—A premium rate may not
be increased, health insurance coverage may not be denied,
and a discount, rebate, or reward offered for participation in
a wellness program may not be reduced or withheld under
any health benefit plan issued pursuant to or in accordance
with the Patient Protection and Affordable Care Act or an
amendment made by that Act on the basis of, or on reliance
upon—
‘‘(A) the lawful ownership or possession of a firearm
or ammunition; or
‘‘(B) the lawful use or storage of a firearm or ammunition.
‘‘(5) LIMITATION ON DATA COLLECTION REQUIREMENTS FOR
INDIVIDUALS.—No individual shall be required to disclose any
information under any data collection activity authorized under
the Patient Protection and Affordable Care Act or an amendment made by that Act relating to—
‘‘(A) the lawful ownership or possession of a firearm
or ammunition; or
‘‘(B) the lawful use, possession, or storage of a firearm
or ammunition.
‘‘(d) 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).
‘‘(e) 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 to the Committee on Health,
Education, Labor, and Pensions of the Senate and the Committee
on Energy and Commerce 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.
øReplaced by section 10101(f)¿
‘‘(a) CLEAR ACCOUNTING FOR COSTS.—A health insurance issuer
offering group or individual health insurance coverage (including
a grandfathered health plan) shall, with respect to each plan year,
submit to the Secretary a report concerning the ratio of the incurred
loss (or incurred claims) plus the loss adjustment expense (or change
in contract reserves) to earned premiums. Such report shall include
the percentage of total premium revenue, after accounting for collections or receipts for risk adjustment and risk corridors and payments of reinsurance, that such coverage expends—
‘‘(1) on reimbursement for clinical services provided to
enrollees under such coverage;
‘‘(2) for activities that improve health care quality; and
‘‘(3) on all other non-claims costs, including an explanation
of the nature of such costs, and excluding Federal and State
taxes and licensing or regulatory fees.
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Ppaca & Hcera; Public Laws 111-148 & 111-152: Consolidated Print—21
The Secretary shall make reports received under this section available to the public on the Internet website of the Department of
Health and Human Services.
‘‘(b) ENSURING THAT CONSUMERS RECEIVE VALUE FOR THEIR
PREMIUM PAYMENTS.—
‘‘(1) REQUIREMENT TO PROVIDE VALUE FOR PREMIUM PAYMENTS.—
‘‘(A) REQUIREMENT.—Beginning not later than January
1, 2011, a health insurance issuer offering group or individual health insurance coverage (including a grandfathered health plan) shall, with respect to each plan year,
provide an annual rebate to each enrollee under such coverage, on a pro rata basis, if the ratio of the amount
of premium revenue expended by the issuer on costs
described in paragraphs (1) and (2) of subsection (a) to
the total amount of premium revenue (excluding Federal
and State taxes and licensing or regulatory fees and after
accounting for payments or receipts for risk adjustment,
risk corridors, and reinsurance under sections 1341, 1342,
and 1343 of the Patient Protection and Affordable Care
Act) for the plan year (except as provided in subparagraph
(B)(ii)), is less than—
‘‘(i) with respect to a health insurance issuer
offering coverage in the large group market, 85 percent,
or such higher percentage as a State may by regulation
determine; or
‘‘(ii) with respect to a health insurance issuer
offering coverage in the small group market or in the
individual market, 80 percent, or such higher percentage as a State may by regulation determine, except
that the Secretary may adjust such percentage with
respect to a State if the Secretary determines that
the application of such 80 percent may destabilize the
individual market in such State.
‘‘(B) REBATE AMOUNT.—
‘‘(i) CALCULATION OF AMOUNT.—The total amount
of an annual rebate required under this paragraph
shall be in an amount equal to the product of—
‘‘(I) the amount by which the percentage
described in clause (i) or (ii) of subparagraph (A)
exceeds the ratio described in such subparagraph;
and
‘‘(II) the total amount of premium revenue
(excluding Federal and State taxes and licensing
or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance under sections 1341, 1342,
and 1343 of the Patient Protection and Affordable
Care Act) for such plan year.
‘‘(ii) CALCULATION BASED ON AVERAGE RATIO.—
Beginning on January 1, 2014, the determination made
under subparagraph (A) for the year involved shall
be based on the averages of the premiums expended
on the costs described in such subparagraph and total
premium revenue for each of the previous 3 years
for the plan.
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‘‘(2) CONSIDERATION IN SETTING PERCENTAGES.—In determining the percentages under paragraph (1), a State shall
seek to ensure adequate participation by health insurance
issuers, competition in the health insurance market in the
State, and value for consumers so that premiums are used
for clinical services and quality improvements.
‘‘(3) ENFORCEMENT.—The Secretary shall promulgate regulations for enforcing the provisions of this section and may
provide for appropriate penalties.
‘‘(c) DEFINITIONS.—Not later than December 31, 2010, and subject to the certification of the Secretary, the National Association
of Insurance Commissioners shall establish uniform definitions of
the activities reported under subsection (a) and standardized methodologies for calculating measures of such activities, including
definitions of which activities, and in what regard such activities,
constitute activities described in subsection (a)(2). Such methodologies shall be designed to take into account the special circumstances
of smaller plans, different types of plans, and newer plans.
‘‘(d) ADJUSTMENTS.—The Secretary may adjust the rates
described in subsection (b) if the Secretary determines appropriate
on account of the volatility of the individual market due to the
establishment of State Exchanges.
‘‘(e) STANDARD HOSPITAL CHARGES.—Each hospital operating
within the United States shall for each year establish (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 hospital, including for diagnosis-related
groups established under section 1886(d)(4) of the Social Security
Act.
‘‘SEC. 2719. APPEALS PROCESS.
øReplaced by section 10101(g)¿
‘‘(a) INTERNAL CLAIMS APPEALS.—
‘‘(1) IN GENERAL.—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 coverage determinations and claims, under which the plan
or issuer shall, at a minimum—
‘‘(A) have in effect an internal claims appeal process;
‘‘(B) 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 insurance consumer assistance
or ombudsman established under section 2793 to assist
such enrollees with the appeals processes; and
‘‘(C) 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.
‘‘(2) ESTABLISHED PROCESSES.—To comply with paragraph
(1)—
‘‘(A) a group health plan and a health insurance issuer
offering group health coverage shall provide an internal
claims and appeals process that initially incorporates the
claims and appeals procedures (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.
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Reg. 70256), and shall update such process in accordance
with any standards established by the Secretary of Labor
for such plans and issuers; and
‘‘(B) a health insurance issuer offering individual
health coverage, and any other issuer not subject to
subparagraph (A), shall provide an internal claims and
appeals process that initially incorporates the claims and
appeals procedures set forth under applicable law (as in
existence on the date of enactment of this section), and
shall update such process in accordance with any standards
established by the Secretary of Health and Human Services
for such issuers.
‘‘(b) EXTERNAL REVIEW.—A group health plan and a health
insurance issuer offering group or individual health insurance coverage—
‘‘(1) shall comply with the applicable State external review
process for such plans and issuers that, at a minimum, includes
the consumer protections set forth in the Uniform External
Review Model Act promulgated by the National Association
of Insurance Commissioners and is binding on such plans;
or
‘‘(2) shall implement an effective external review process
that meets minimum standards established by the Secretary
through guidance and that is similar to the process described
under paragraph (1)—
‘‘(A) if the applicable State has not established an
external review process that meets the requirements of
paragraph (1); or
‘‘(B) if the plan is a self-insured plan that is not subject
to State insurance regulation (including a State law that
establishes an external review process described in paragraph (1)).
‘‘(c) SECRETARY AUTHORITY.—The Secretary may deem the
external review process of a group health plan or health insurance
issuer, in operation as of the date of enactment of this section,
to be in compliance with the applicable process established under
subsection (b), as determined appropriate by the Secretary.
‘‘SEC. 2719A. PATIENT PROTECTIONS.
øSection inserted by section 10101(h)¿
‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If a group health
plan, or a health insurance issuer offering group or individual
health insurance coverage, requires or provides for designation by
a participant, beneficiary, or enrollee of a participating primary
care provider, then the plan or issuer shall permit each participant,
beneficiary, and enrollee to designate any participating primary
care provider who is available to accept such individual.
‘‘(b) COVERAGE OF EMERGENCY SERVICES.—
‘‘(1) IN GENERAL.—If a group health plan, or a health insurance issuer offering group or individual health insurance issuer,
provides or covers any benefits with respect to services in
an emergency department of a hospital, the plan or issuer
shall cover emergency services (as defined in paragraph
(2)(B))—
‘‘(A) without the need for any prior authorization determination;
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Ppaca & Hcera; Public Laws 111-148 & 111-152: Consolidated Print—24
‘‘(B) whether the health care provider furnishing such
services is a participating provider with respect to such
services;
‘‘(C) in a manner so that, if such services are provided
to a participant, beneficiary, or enrollee—
‘‘(i) by a nonparticipating health care provider with
or without prior authorization; or
‘‘(ii)(I) such services will be provided without
imposing any requirement under the plan for prior
authorization of services or any limitation on coverage
where the provider of services does not have a contractual relationship with the plan for the providing of
services that is more restrictive than the requirements
or limitations that apply to emergency department
services received from providers who do have such
a contractual relationship with the plan; and
‘‘(II) if such services are provided out-of-network,
the cost-sharing requirement (expressed as a
copayment amount or coinsurance rate) is the same
requirement that would apply if such services were
provided in-network;
‘‘(D) without regard to any other term or condition
of such coverage (other than exclusion or coordination of
benefits, or an affiliation or waiting period, permitted under
section 2701 of this Act, section 701 of the Employee Retirement Income Security Act of 1974, or section 9801 of the
Internal Revenue Code of 1986, and other than applicable
cost-sharing).
‘‘(2) DEFINITIONS.—In this subsection:
‘‘(A) EMERGENCY MEDICAL CONDITION.—The term
‘emergency medical condition’ means a medical condition
manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent layperson, who
possesses an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical
attention to result in a condition described in clause (i),
(ii), or (iii) of section 1867(e)(1)(A) of the Social Security
Act.
‘‘(B) EMERGENCY SERVICES.—The term ‘emergency services’ means, with respect to an emergency medical condition—
‘‘(i) a medical screening examination (as required
under section 1867 of the Social Security Act) that
is within the capability of the emergency department
of a hospital, including ancillary services routinely
available to the emergency department to evaluate
such emergency medical condition, and
‘‘(ii) within the capabilities of the staff and facilities available at the hospital, such further medical
examination and treatment as are required under section 1867 of such Act to stabilize the patient.
‘‘(C) STABILIZE.—The term ‘to stabilize’, with respect
to an emergency medical condition (as defined in subparagraph (A)), has the meaning give in section 1867(e)(3) of
the Social Security Act (42 U.S.C. 1395dd(e)(3)).
‘‘(c) ACCESS TO PEDIATRIC CARE.—
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‘‘(1) PEDIATRIC CARE.—In the case of a person who has
a child who is a participant, beneficiary, or enrollee under
a group health plan, or health insurance coverage offered by
a health insurance issuer in the group or individual market,
if the plan or issuer requires or provides for the designation
of a participating primary care provider for the child, the plan
or issuer shall permit such person to designate a physician
(allopathic or osteopathic) who specializes in pediatrics as the
child’s primary care provider if such provider participates in
the network of the plan or issuer.
‘‘(2) CONSTRUCTION.—Nothing in paragraph (1) shall be
construed to waive any exclusions of coverage under the terms
and conditions of the plan or health insurance coverage with
respect to coverage of pediatric care.
‘‘(d) PATIENT ACCESS TO OBSTETRICAL AND GYNECOLOGICAL
CARE.—
‘‘(1) GENERAL RIGHTS.—
‘‘(A) DIRECT ACCESS.—A group health plan, or health
insurance issuer offering group or individual health insurance coverage, described in paragraph (2) may not require
authorization or referral by the plan, issuer, or any person
(including a primary care provider described in paragraph
(2)(B)) in the case of a female participant, beneficiary,
or enrollee who seeks coverage for obstetrical or gynecological care provided by a participating health care professional who specializes in obstetrics or gynecology. Such
professional shall agree to otherwise adhere to such plan’s
or issuer’s policies and procedures, including procedures
regarding referrals and obtaining prior authorization and
providing services pursuant to a treatment plan (if any)
approved by the plan or issuer.
‘‘(B) OBSTETRICAL AND GYNECOLOGICAL CARE.—A group
health plan or health insurance issuer described in paragraph (2) shall treat the provision of obstetrical and gynecological care, and the ordering of related obstetrical and
gynecological items and services, pursuant to the direct
access described under subparagraph (A), by a participating
health care professional who specializes in obstetrics or
gynecology as the authorization of the primary care provider.
‘‘(2) APPLICATION OF PARAGRAPH.—A group health plan,
or health insurance issuer offering group or individual health
insurance coverage, described in this paragraph is a group
health plan or coverage that—
‘‘(A) provides coverage for obstetric or gynecologic care;
and
‘‘(B) requires the designation by a participant, beneficiary, or enrollee of a participating primary care provider.
‘‘(3) CONSTRUCTION.—Nothing in paragraph (1) shall be
construed to—
‘‘(A) waive any exclusions of coverage under the terms
and conditions of the plan or health insurance coverage
with respect to coverage of obstetrical or gynecological care;
or
‘‘(B) preclude the group health plan or health insurance
issuer involved from requiring that the obstetrical or
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Ppaca & Hcera; Public Laws 111-148 & 111-152: Consolidated Print—26
gynecological provider notify the primary care health care
professional or the plan or issuer of treatment decisions.’’.
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 in such States)
to establish, expand, or provide support for—
‘‘(1) offices of health insurance consumer assistance; 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 ombudsman, 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 established 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 appeals,
including filing appeals with the internal appeal or grievance
process of the group health plan or health insurance issuer
involved and providing information about the external appeal
process;
‘‘(2) collect, track, and quantify problems and inquiries
encountered by consumers;
‘‘(3) educate consumers on their rights and responsibilities
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 required 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.—
‘‘(1) INITIAL FUNDING.—There is hereby appropriated 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.
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plan shall be deemed to include a qualified health plan offered
through the CO-OP program under section 1322, and a multiState plan under section 1334, unless specifically provided for
otherwise.
(3) TREATMENT OF QUALIFIED DIRECT PRIMARY CARE MEDICAL HOME PLANS.—The Secretary of Health and Human Services shall permit a qualified health plan to provide coverage
through a qualified direct primary care medical home plan
that meets criteria established by the Secretary, so long as
the qualified health plan meets all requirements that are otherwise applicable and the services covered by the medical home
plan are coordinated with the entity offering the qualified
health plan.
(4) VARIATION BASED ON RATING AREA.—A qualified health
plan, including a multi-State qualified health plan, may as
appropriate vary premiums by rating area (as defined in section
2701(a)(2) of the Public Health Service Act).
(b) TERMS RELATING TO HEALTH PLANS.—In this title:
(1) HEALTH PLAN.—
(A) IN GENERAL.—The term ‘‘health plan’’ means health
insurance coverage and a group health plan.
(B) EXCEPTION FOR SELF-INSURED PLANS AND MEWAS.—
Except to the extent specifically provided by this title,
the term ‘‘health plan’’ shall not include a group health
plan or multiple employer welfare arrangement to the
extent the plan or arrangement is not subject to State
insurance regulation under section 514 of the Employee
Retirement Income Security Act of 1974.
(2) HEALTH INSURANCE COVERAGE AND ISSUER.—The terms
‘‘health insurance coverage’’ and ‘‘health insurance issuer’’ have
the meanings given such terms by section 2791(b) of the Public
Health Service Act.
(3) GROUP HEALTH PLAN.—The term ‘‘group health plan’’
has the meaning given such term by section 2791(a) of the
Public Health Service Act.
SEC. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS.
(a) ESSENTIAL HEALTH BENEFITS PACKAGE.—In this title, the
term ‘‘essential health benefits package’’ means, with respect to
any health plan, coverage that—
(1) provides for the essential health benefits defined by
the Secretary under subsection (b);
(2) limits cost-sharing for such coverage in accordance with
subsection (c); and
(3) subject to subsection (e), provides either the bronze,
silver, gold, or platinum level of coverage described in subsection (d).
(b) ESSENTIAL HEALTH BENEFITS.—
(1) IN GENERAL.—Subject to paragraph (2), the Secretary
shall define the essential health benefits, except that such
benefits shall include at least the following general categories
and the items and services covered within the categories:
(A) Ambulatory patient services.
(B) Emergency services.
(C) Hospitalization.
(D) Maternity and newborn care.
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(E) Mental health and substance use disorder services,
including behavioral health treatment.
(F) Prescription drugs.
(G) Rehabilitative and habilitative services and devices.
(H) Laboratory services.
(I) Preventive and wellness services and chronic disease management.
(J) Pediatric services, including oral and vision care.
(2) LIMITATION.—
(A) IN GENERAL.—The Secretary shall ensure that the
scope of the essential health benefits under paragraph (1)
is equal to the scope of benefits provided under a typical
employer plan, as determined by the Secretary. To inform
this determination, the Secretary of Labor shall conduct
a survey of employer-sponsored coverage to determine the
benefits typically covered by employers, including multiemployer plans, and provide a report on such survey to the
Secretary.
(B) CERTIFICATION.—In defining the essential health
benefits described in paragraph (1), and in revising the
benefits under paragraph (4)(H), the Secretary shall submit
a report to the appropriate committees of Congress containing a certification from the Chief Actuary of the Centers
for Medicare & Medicaid Services that such essential health
benefits meet the limitation described in paragraph (2).
(3) NOTICE AND HEARING.—In defining the essential health
benefits described in paragraph (1), and in revising the benefits
under paragraph (4)(H), the Secretary shall provide notice and
an opportunity for public comment.
(4) REQUIRED ELEMENTS FOR CONSIDERATION.—In defining
the essential health benefits under paragraph (1), the Secretary
shall—
(A) ensure that such essential health benefits reflect
an appropriate balance among the categories described in
such subsection, so that benefits are not unduly weighted
toward any category;
(B) not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits
in ways that discriminate against individuals because of
their age, disability, or expected length of life;
(C) take into account the health care needs of diverse
segments of the population, including women, children,
persons with disabilities, and other groups;
(D) ensure that health benefits established as essential
not be subject to denial to individuals against their wishes
on the basis of the individuals’ age or expected length
of life or of the individuals’ present or predicted disability,
degree of medical dependency, or quality of life;
(E) provide that a qualified health plan shall not be
treated as providing coverage for the essential health benefits described in paragraph (1) unless the plan provides
that—
(i) coverage for emergency department services will
be provided without imposing any requirement under
the plan for prior authorization of services or any
limitation on coverage where the provider of services
does not have a contractual relationship with the plan
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for the providing of services that is more restrictive
than the requirements or limitations that apply to
emergency department services received from providers
who do have such a contractual relationship with the
plan; and
(ii) if such services are provided out-of-network,
the cost-sharing requirement (expressed as a
copayment amount or coinsurance rate) is the same
requirement that would apply if such services were
provided in-network;
(F) provide that if a plan described in section
1311(b)(2)(B)(ii) (relating to stand-alone dental benefits
plans) is offered through an Exchange, another health plan
offered through such Exchange shall not fail to be treated
as a qualified health plan solely because the plan does
not offer coverage of benefits offered through the standalone plan that are otherwise required under paragraph
(1)(J); and
(G) periodically review the essential health benefits
under paragraph (1), and provide a report to Congress
and the public that contains—
(i) an assessment of whether enrollees are facing
any difficulty accessing needed services for reasons
of coverage or cost;
(ii) an assessment of whether the essential health
benefits needs to be modified or updated to account
for changes in medical evidence or scientific advancement;
(iii) information on how the essential health benefits will be modified to address any such gaps in access
or changes in the evidence base;
(iv) an assessment of the potential of additional
or expanded benefits to increase costs and the interactions between the addition or expansion of benefits
and reductions in existing benefits to meet actuarial
limitations described in paragraph (2); and
(H) periodically update the essential health benefits
under paragraph (1) to address any gaps in access to coverage or changes in the evidence base the Secretary identifies in the review conducted under subparagraph (G).
(5) RULE OF CONSTRUCTION.—Nothing in this title shall
be construed to prohibit a health plan from providing benefits
in excess of the essential health benefits described in this
subsection.
(c) REQUIREMENTS RELATING TO COST-SHARING.—
(1) ANNUAL LIMITATION ON COST-SHARING.—
(A) 2014.—The cost-sharing incurred under a health
plan with respect to self-only coverage or coverage other
than self-only coverage for a plan year beginning in 2014
shall not exceed the dollar amounts in effect under section
223(c)(2)(A)(ii) of the Internal Revenue Code of 1986 for
self-only and family coverage, respectively, for taxable years
beginning in 2014.
(B) 2015 AND LATER.—In the case of any plan year
beginning in a calendar year after 2014, the limitation
under this paragraph shall—
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(i) in the case of self-only coverage, be equal to
the dollar amount under subparagraph (A) for selfonly coverage for plan years beginning in 2014,
increased by an amount equal to the product of that
amount and the premium adjustment percentage under
paragraph (4) for the calendar year; and
(ii) in the case of other coverage, twice the amount
in effect under clause (i).
If the amount of any increase under clause (i) is not a
multiple of $50, such increase shall be rounded to the
next lowest multiple of $50.
(2) ANNUAL LIMITATION ON DEDUCTIBLES FOR EMPLOYERSPONSORED PLANS.—
(A) IN GENERAL.—In the case of a health plan offered
in the small group market, the deductible under the plan
shall not exceed—
(i) $2,000 in the case of a plan covering a single
individual; and
(ii) $4,000 in the case of any other plan.
The amounts under clauses (i) and (ii) may be increased
by the maximum amount of reimbursement which is
reasonably available to a participant under a flexible
spending arrangement described in section 106(c)(2) of the
Internal Revenue Code of 1986 (determined without regard
to any salary reduction arrangement).
(B) INDEXING OF LIMITS.—In the case of any plan year
beginning in a calendar year after 2014—
(i) the dollar amount under subparagraph (A)(i)
shall be increased by an amount equal to the product
of that amount and the premium adjustment percentage under paragraph (4) for the calendar year; and
(ii) the dollar amount under subparagraph (A)(ii)
shall be increased to an amount equal to twice the
amount in effect under subparagraph (A)(i) for plan
years beginning in the calendar year, determined after
application of clause (i).
If the amount of any increase under clause (i) is not a
multiple of $50, such increase shall be rounded to the
next lowest multiple of $50.
(C) ACTUARIAL VALUE.—The limitation under this paragraph shall be applied in such a manner so as to not
affect the actuarial value of any health plan, including
a plan in the bronze level.
(D) COORDINATION WITH PREVENTIVE LIMITS.—Nothing
in this paragraph shall be construed to allow a plan to
have a deductible under the plan apply to benefits described
in section 2713 of the Public Health Service Act.
(3) COST-SHARING.—In this title—
(A) IN GENERAL.—The term ‘‘cost-sharing’’ includes—
(i) deductibles, coinsurance, copayments, or similar
charges; and
(ii) any other expenditure required of an insured
individual which is a qualified medical expense (within
the meaning of section 223(d)(2) of the Internal Revenue Code of 1986) with respect to essential health
benefits covered under the plan.
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(B) EXCEPTIONS.—Such term does not include premiums, balance billing amounts for non-network providers,
or spending for non-covered services.
(4) PREMIUM ADJUSTMENT PERCENTAGE.—For purposes of
paragraphs (1)(B)(i) and (2)(B)(i), the premium adjustment
percentage for any calendar year is the percentage (if any)
by which the average per capita premium for health insurance
coverage in the United States for the preceding calendar year
(as estimated by the Secretary no later than October 1 of
such preceding calendar year) exceeds such average per capita
premium for 2013 (as determined by the Secretary).
(d) LEVELS OF COVERAGE.—
(1) LEVELS OF COVERAGE DEFINED.—The levels of coverage
described in this subsection are as follows:
(A) BRONZE LEVEL.—A plan in the bronze level shall
provide a level of coverage that is designed to provide
benefits that are actuarially equivalent to 60 percent of
the full actuarial value of the benefits provided under
the plan.
(B) SILVER LEVEL.—A plan in the silver level shall
provide a level of coverage that is designed to provide
benefits that are actuarially equivalent to 70 percent of
the full actuarial value of the benefits provided under
the plan.
(C) GOLD LEVEL.—A plan in the gold level shall provide
a level of coverage that is designed to provide benefits
that are actuarially equivalent to 80 percent of the full
actuarial value of the benefits provided under the plan.
(D) PLATINUM LEVEL.—A plan in the platinum level
shall provide a level of coverage that is designed to provide
benefits that are actuarially equivalent to 90 percent of
the full actuarial value of the benefits provided under
the plan.
(2) ACTUARIAL VALUE.—
(A) IN GENERAL.—Under regulations issued by the Secretary, the level of coverage of a plan shall be determined
on the basis that the essential health benefits described
in subsection (b) shall be provided to a standard population
(and without regard to the population the plan may actually
provide benefits to).
(B) EMPLOYER CONTRIBUTIONS.—øAs revised by section
10104(b)(1)¿ The Secretary shall issue regulations under
which employer contributions to a health savings account
(within the meaning of section 223 of the Internal Revenue
Code of 1986) may be taken into account in determining
the level of coverage for a plan of the employer.
(C) APPLICATION.—In determining under this title, the
Public Health Service Act, or the Internal Revenue Code
of 1986 the percentage of the total allowed costs of benefits
provided under a group health plan or health insurance
coverage that are provided by such plan or coverage, the
rules contained in the regulations under this paragraph
shall apply.
(3) ALLOWABLE VARIANCE.—The Secretary shall develop
guidelines to provide for a de minimis variation in the actuarial
valuations used in determining the level of coverage of a plan
to account for differences in actuarial estimates.
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(4) PLAN REFERENCE.—In this title, any reference to a
bronze, silver, gold, or platinum plan shall be treated as a
reference to a qualified health plan providing a bronze, silver,
gold, or platinum level of coverage, as the case may be.
(e) CATASTROPHIC PLAN.—
(1) IN GENERAL.—A health plan not providing a bronze,
silver, gold, or platinum level of coverage shall be treated
as meeting the requirements of subsection (d) with respect
to any plan year if—
(A) the only individuals who are eligible to enroll in
the plan are individuals described in paragraph (2); and
(B) the plan provides—
(i) except as provided in clause (ii), the essential
health benefits determined under subsection (b), except
that the plan provides no benefits for any plan year
until the individual has incurred cost-sharing expenses
in an amount equal to the annual limitation in effect
under subsection (c)(1) for the plan year (except as
provided for in section 2713); and
(ii) coverage for at least three primary care visits.
(2) INDIVIDUALS ELIGIBLE FOR ENROLLMENT.—An individual
is described in this paragraph for any plan year if the individual—
(A) has not attained the age of 30 before the beginning
of the plan year; or
(B) has a certification in effect for any plan year under
this title that the individual is exempt from the requirement under section 5000A of the Internal Revenue Code
of 1986 by reason of—
(i) section 5000A(e)(1) of such Code (relating to
individuals without affordable coverage); or
(ii) section 5000A(e)(5) of such Code (relating to
individuals with hardships).
(3) RESTRICTION TO INDIVIDUAL MARKET.—If a health insurance issuer offers a health plan described in this subsection,
the issuer may only offer the plan in the individual market.
(f) CHILD-ONLY PLANS.—If a qualified health plan is offered
through the Exchange in any level of coverage specified under
subsection (d), the issuer shall also offer that plan through the
Exchange in that level as a plan in which the only enrollees are
individuals who, as of the beginning of a plan year, have not
attained the age of 21, and such plan shall be treated as a qualified
health plan.
(g) PAYMENTS TO FEDERALLY-QUALIFIED HEALTH CENTERS.—
øAs added by section 10104(b)(2)¿ If any item or service covered
by a qualified health plan is provided by a Federally-qualified
health center (as defined in section 1905(l)(2)(B) of the Social Security Act (42 U.S.C. 1396d(l)(2)(B)) to an enrollee of the plan, the
offeror of the plan shall pay to the center for the item or service
an amount that is not less than the amount of payment that
would have been paid to the center under section 1902(bb) of
such Act (42 U.S.C. 1396a(bb)) for such item or service.
SEC. 1303. SPECIAL RULES.
øReplaced by section 10104(c)¿
(a) STATE OPT-OUT OF ABORTION COVERAGE.—
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| File Type | application/pdf |
| File Title | C:\TEMP\PPACA-~1.XML |
| File Modified | 2012-03-02 |
| File Created | 2012-02-08 |