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The Health Care Reform Bill From The House of Representatives

July 18, 2009

Congress passed the “America’s  Affordable Health Choices Act of 2009” this week.  They didn’t read it.  They didn’t have time.  They only debated the bill for three hours.  One has to wonder how one can debate a bill in excess of one thousand pages, unread, in only three hours, but Congress managed to find a way. 

President Obama has assured us that we could keep our health care plans and our doctors if we like them.  The bill passed by Congress doesn’t exactly read the way the President has told us that it would.  In Part 1, General Provisions is this:

“(20) Qualified health benefits plan.–The term “qualified health benefits plan” means a health benefits plan that meets
        the requirements for such a plan under title I and includes the public health insurance option.”

In other words, you can keep your health care plan if you like it, as long as it includes the public health plan, whether you like it or not.

Under SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE, is the wording that effectively kills private insurance.

“(1) Limitation on new enrollment.–
                    (A) In general.–Except as provided in this paragraph, the individual health insurance issuer
                offering such coverage does not enroll any individual in such coverage if the first effective date of
                coverage is on or after the first day of Y1.”

Insurance companies are like any other business, they need new customers in order to grow, they need to grow in order to stay in business.  When they are banned from enrolling new customers, they are condemned to going out of business.  When health insurance providers are forced out of business, you no longer have the option of “keeping you health insurance”, you are now required to accept the government plan.

The next question becomes “can you depend on the government health insurance?”  Simple answer is yes you can.  Congress included the Blackmail clause to insure that you have no choice but to depend on it.

“Subtitle E–States Failing To Adhere to Certain Employment Obligations

SEC. 2541. LIMITATION ON FEDERAL FUNDS.

    A State is eligible for Federal funds under the provisions of the Public Health Service Act (42 U.S.C. 201 et seq.) only if the State–
            (1) agrees to be subject in its capacity as an employer to each obligation under division A of this Act and the amendments made by such division applicable to persons in their capacity as an employer; and
            (2) assures that all political subdivisions in the State will do the same.”

So much for Obama’s welfare health plan being optional.

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6 Comments leave one →
  1. Jackie Durkee permalink
    July 23, 2009 11:21 am

    At http://www.FaithfulinPrayer.wordpress.com, I’m writing a series of articles outlining what the the actual House bill (h.r.3200) says.
    So far, I’m at Subtitle 2 of Title II of Division A. Tomorrow will be Subtitle 3.
    Join the Journey!

  2. dcbarton permalink*
    July 25, 2009 10:33 am

    It’s going to be a LONG journey, that is one really long bill.

  3. Ron permalink
    July 30, 2009 7:37 pm

    I have had to read very long governmental rules and regulation documents over the years. YOU CAN NOT take one paragraph out of a document and let it stand alone. You have to refer to the information above and below in order to have any clue of what each regulation refers to…the information on this topic is worthless when pulled out. As a matter of fact…you could interpret what you pulled out to mean whatever you want it to…inorder to inflame/control.

  4. dcbarton permalink*
    July 31, 2009 5:26 pm
    Ron, I didn’t “interpret” anything, the bill intreprets itself, and does so exactly the same as I did. However, if it makes you feel any better, I will try to do better now. The entire Section 102: “SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE. (a) Grandfathered Health Insurance Coverage Defined- Subject to the succeeding provisions of this section, for purposes of establishing acceptable coverage under this division, the term `grandfathered health insurance coverage’ means individual health insurance coverage that is offered and in force and effect before the first day of Y1 if the following conditions are met: (1) LIMITATION ON NEW ENROLLMENT- (A) IN GENERAL- Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1. (B) DEPENDENT COVERAGE PERMITTED- Subparagraph (A) shall not affect the subsequent enrollment of a dependent of an individual who is covered as of such first day. (2) LIMITATION ON CHANGES IN TERMS OR CONDITIONS- Subject to paragraph (3) and except as required by law, the issuer does not change any of its terms or conditions, including benefits and cost-sharing, from those in effect as of the day before the first day of Y1. (3) RESTRICTIONS ON PREMIUM INCREASES- The issuer cannot vary the percentage increase in the premium for a risk group of enrollees in specific grandfathered health insurance coverage without changing the premium for all enrollees in the same risk group at the same rate, as specified by the Commissioner. (b) Grace Period for Current Employment-based Health Plans- (1) GRACE PERIOD- (A) IN GENERAL- The Commissioner shall establish a grace period whereby, for plan years beginning after the end of the 5-year period beginning with Y1, an employment-based health plan in operation as of the day before the first day of Y1 must meet the same requirements as apply to a qualified health benefits plan under section 101, including the essential benefit package requirement under section 121. (B) EXCEPTION FOR LIMITED BENEFITS PLANS- Subparagraph (A) shall not apply to an employment-based health plan in which the coverage consists only of one or more of the following: (i) Any coverage described in section 3001(a)(1)(B)(ii)(IV) of division B of the American Recovery and Reinvestment Act of 2009 (Public Law 111-5). (ii) Excepted benefits (as defined in section 733(c) of the Employee Retirement Income Security Act of 1974), including coverage under a specified disease or illness policy described in paragraph (3)(A) of such section. (iii) Such other limited benefits as the Commissioner may specify. In no case shall an employment-based health plan in which the coverage consists only of one or more of the coverage or benefits described in clauses (i) through (iii) be treated as acceptable coverage under this division (2) TRANSITIONAL TREATMENT AS ACCEPTABLE COVERAGE- During the grace period specified in paragraph (1)(A), an employment-based health plan that is described in such paragraph shall be treated as acceptable coverage under this division. (c) Limitation on Individual Health Insurance Coverage- (1) IN GENERAL- Individual health insurance coverage that is not grandfathered health insurance coverage under subsection (a) may only be offered on or after the first day of Y1 as an Exchange-participating health benefits plan. (2) SEPARATE, EXCEPTED COVERAGE PERMITTED- Excepted benefits (as defined in section 2791(c) of the Public Health Service Act) are not included within the definition of health insurance coverage. Nothing in paragraph (1) shall prevent the offering, other than through the Health Insurance Exchange, of excepted benefits so long as it is offered and priced separately from health insurance coverage.” Oh gee, my mistake, I guess what it really says is the the private insurance plans have to be dictated by what government wants your health coverage to be, and let’s see, oh yeah, no private insurance companies can sign up new customers after the first day of the first year. Boy, Ron, I’m sure glad you caught me on that one, how could I have been so wrong? I couldn’t, it still says what I said it did, and then some. How about the next one? “(19) QHBP OFFERING ENTITY- The terms `QHBP offering entity’ means, with respect to a health benefits plan that is– (A) a group health plan (as defined, subject to subsection (d), in section 733(a)(1) of the Employee Retirement Income Security Act of 1974), the plan sponsor in relation to such group health plan, except that, in the case of a plan maintained jointly by 1 or more employers and 1 or more employee organizations and with respect to which an employer is the primary source of financing, such term means such employer; (B) health insurance coverage, the health insurance issuer offering the coverage; (C) the public health insurance option, the Secretary of Health and Human Services; (D) a non-Federal governmental plan (as defined in section 2791(d) of the Public Health Service Act), the State or political subdivision of a State (or agency or instrumentality of such State or subdivision) which establishes or maintains such plan; or (E) a Federal governmental plan (as defined in section 2791(d) of the Public Health Service Act), the appropriate Federal official. (20) QUALIFIED HEALTH BENEFITS PLAN- The term `qualified health benefits plan’ means a health benefits plan that meets the requirements for such a plan under title I and includes the public health insurance option. (21) PUBLIC HEALTH INSURANCE OPTION- The term `public health insurance option’ means the public health insurance option as provided under subtitle B of title II.” This doesn’t tell us much, except to look under title I. And title I says? It says this: “TITLE I–PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS Subtitle A–General Standards SEC. 101. REQUIREMENTS REFORMING HEALTH INSURANCE MARKETPLACE. (a) Purpose- The purpose of this title is to establish standards to ensure that new health insurance coverage and employment-based health plans that are offered meet standards guaranteeing access to affordable coverage, essential benefits, and other consumer protections. (b) Requirements for Qualified Health Benefits Plans- On or after the first day of Y1, a health benefits plan shall not be a qualified health benefits plan under this division unless the plan meets the applicable requirements of the following subtitles for the type of plan and plan year involved: (1) Subtitle B (relating to affordable coverage). (2) Subtitle C (relating to essential benefits). (3) Subtitle D (relating to consumer protection). (c) Terminology- In this division: (1) ENROLLMENT IN EMPLOYMENT-BASED HEALTH PLANS- An individual shall be treated as being `enrolled’ in an employment-based health plan if the individual is a participant or beneficiary (as such terms are defined in section 3(7) and 3(8), respectively, of the Employee Retirement Income Security Act of 1974) in such plan. (2) INDIVIDUAL AND GROUP HEALTH INSURANCE COVERAGE- The terms `individual health insurance coverage’ and `group health insurance coverage’ mean health insurance coverage offered in the individual market or large or small group market, respectively, as defined in section 2791 of the Public Health Service Act. SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE. (a) Grandfathered Health Insurance Coverage Defined- Subject to the succeeding provisions of this section, for purposes of establishing acceptable coverage under this division, the term `grandfathered health insurance coverage’ means individual health insurance coverage that is offered and in force and effect before the first day of Y1 if the following conditions are met: (1) LIMITATION ON NEW ENROLLMENT- (A) IN GENERAL- Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1. (B) DEPENDENT COVERAGE PERMITTED- Subparagraph (A) shall not affect the subsequent enrollment of a dependent of an individual who is covered as of such first day. (2) LIMITATION ON CHANGES IN TERMS OR CONDITIONS- Subject to paragraph (3) and except as required by law, the issuer does not change any of its terms or conditions, including benefits and cost-sharing, from those in effect as of the day before the first day of Y1. (3) RESTRICTIONS ON PREMIUM INCREASES- The issuer cannot vary the percentage increase in the premium for a risk group of enrollees in specific grandfathered health insurance coverage without changing the premium for all enrollees in the same risk group at the same rate, as specified by the Commissioner. (b) Grace Period for Current Employment-based Health Plans- (1) GRACE PERIOD- (A) IN GENERAL- The Commissioner shall establish a grace period whereby, for plan years beginning after the end of the 5-year period beginning with Y1, an employment-based health plan in operation as of the day before the first day of Y1 must meet the same requirements as apply to a qualified health benefits plan under section 101, including the essential benefit package requirement under section 121. (B) EXCEPTION FOR LIMITED BENEFITS PLANS- Subparagraph (A) shall not apply to an employment-based health plan in which the coverage consists only of one or more of the following: (i) Any coverage described in section 3001(a)(1)(B)(ii)(IV) of division B of the American Recovery and Reinvestment Act of 2009 (Public Law 111-5). (ii) Excepted benefits (as defined in section 733(c) of the Employee Retirement Income Security Act of 1974), including coverage under a specified disease or illness policy described in paragraph (3)(A) of such section. (iii) Such other limited benefits as the Commissioner may specify. In no case shall an employment-based health plan in which the coverage consists only of one or more of the coverage or benefits described in clauses (i) through (iii) be treated as acceptable coverage under this division (2) TRANSITIONAL TREATMENT AS ACCEPTABLE COVERAGE- During the grace period specified in paragraph (1)(A), an employment-based health plan that is described in such paragraph shall be treated as acceptable coverage under this division. (c) Limitation on Individual Health Insurance Coverage- (1) IN GENERAL- Individual health insurance coverage that is not grandfathered health insurance coverage under subsection (a) may only be offered on or after the first day of Y1 as an Exchange-participating health benefits plan. (2) SEPARATE, EXCEPTED COVERAGE PERMITTED- Excepted benefits (as defined in section 2791(c) of the Public Health Service Act) are not included within the definition of health insurance coverage. Nothing in paragraph (1) shall prevent the offering, other than through the Health Insurance Exchange, of excepted benefits so long as it is offered and priced separately from health insurance coverage. Subtitle B–Standards Guaranteeing Access to Affordable Coverage SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS. A qualified health benefits plan may not impose any pre-existing 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 subsections (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 individuals and employers in all individual and group health insurance coverage, whether offered to individuals or employers through the Health Insurance Exchange, through any employment-based health plan, or otherwise, in the same manner as such sections apply to employers and health insurance coverage offered in the small group market, except that such section 2712(b)(1) shall apply only if, before nonrenewal or discontinuation of coverage, the issuer has provided the enrollee with notice of non-payment of premiums and there is a grace period during which the enrollees 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 may not vary except 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 permitted by State insurance regulators or, in the case of Exchange-participating health benefits plans, as specified by the Commissioner in consultation with such regulators). (3) BY FAMILY ENROLLMENT- By family enrollment (such as variations within categories and compositions of families) so long as the ratio of the premium 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) 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 following: (A) The types of employers by key characteristics, 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 reserve levels of employers that self-insure by employer size. (D) The risk of self-insured employers not being able to pay obligations or otherwise becoming 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 (2) REPORTS- Not later than 18 months after the date of the enactment of this Act, the Commissioner shall submit to Congress and the applicable agencies a report on the study conducted under paragraph (1). Such report shall include any recommendations 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 insurers 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 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. (b) Parity in Mental Health and Substance Abuse Disorder Benefits- To the extent such provisions 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, regardless of whether it is offered in the individual or group market, 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 that uses a provider network for items and services shall meet such standards respecting provider networks as the Commissioner may establish to assure the adequacy of such networks in ensuring enrollee access to such items and services and transparency in the cost-sharing 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 respect 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 Commissioner. For any plan year in which the qualified health benefits plan does not meet such medical loss ratio, QHBP offering 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 definition and methodology developed by the Secretary of Health and Human Services under the amendments made by section 161 for determining how to calculate the medical loss ratio. Such methodology shall be set at the highest level medical 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 Guaranteeing Access to Essential Benefits SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE. (a) In General- A qualified health benefits plan shall provide coverage that at least meets the benefit standards adopted under section 124 for the essential benefits package described in section 122 for the plan year involved. (b) Choice of Coverage- (1) NON-EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS- In the case of a qualified health benefits plan that is not an Exchange-participating health benefits plan, such plan may offer such coverage in addition to the essential benefits package as the QHBP offering entity may specify. (2) EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS- In the case of an Exchange-participating 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 division shall be construed as affecting the offering of health benefits in the form of excepted benefits (described in section 102(b)(1)(B)(ii)) if such benefits are offered under a separate policy, contract, or certificate of insurance. (c) No Restrictions on Coverage Unrelated to Clinical Appropriateness- A qualified health benefits plan may not impose any restriction (other than cost-sharing) unrelated to clinical appropriateness on the coverage of the health care items and services. 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 provision of quality health care and financial security, that– (1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice; (2) limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c); (3) does not impose any annual or lifetime limit on the coverage of covered health care items and services; (4) complies with section 115(a) (relating to network adequacy); and (5) is equivalent, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage. (b) Minimum Services To Be Covered- The items and services described in this subsection are the following: (1) Hospitalization. (2) Outpatient hospital and outpatient clinic services, including emergency department services. (3) Professional services of physicians and other health professionals. (4) Such services, equipment, and supplies incident to the services of a physician’s or a health professional’s delivery of care in institutional settings, physician 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. (8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention. (9) Maternity care. (10) Well baby and well child care and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age. (c) Requirements Relating to Cost-sharing and Minimum Actuarial Value- (1) NO COST-SHARING FOR PREVENTIVE SERVICES- There shall be no cost-sharing under the essential benefits package for preventive items and services (as specified under the benefit standards), including well baby and well child care. (2) ANNUAL LIMITATION- (A) ANNUAL LIMITATION- The cost-sharing incurred under the essential benefits package with respect to an individual (or family) for a year does not exceed the applicable level specified in subparagraph (B). (B) APPLICABLE LEVEL- The applicable level specified in this subparagraph for Y1 is $5,000 for an individual and $10,000 for a family. Such levels shall be increased (rounded to the nearest $100) for each subsequent year by the annual percentage increase in the Consumer Price Index (United States city average) applicable to such year. (C) USE OF COPAYMENTS- In establishing cost-sharing levels for basic, enhanced, and premium plans under this subsection, the Secretary 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 DESCRIBED- The reference benefits package described in this subparagraph is the essential benefits package if there were no cost-sharing imposed. SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE. (a) Establishment- (1) IN GENERAL- There is established a private-public advisory committee which shall be a panel of medical and other experts to be known as the Health 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 Advisory Committee shall be composed of the following members, in addition to the Surgeon General: (A) 9 members who are not Federal employees or officers and who are appointed by the President. (B) 9 members who are not Federal employees 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. (4) TERMS- Each member of the Health Benefits 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 reflect 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 professional and an expert on children’s health and shall represent a balance among various sectors of the health care system so that no single sector unduly influences the recommendations of such Committee. (b) Duties- (1) RECOMMENDATIONS ON BENEFIT STANDARDS- The Health Benefits Advisory Committee shall recommend to the Secretary of Health and Human Services (in this subtitle referred to as the `Secretary’) benefit standards (as defined in paragraph (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 disparities. (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 Advisory Committee shall allow for public input as a part of developing recommendations under this subsection. (4) BENEFIT STANDARDS DEFINED- In this subtitle, 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; and (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 actuarial value of the benefits provided under the reference benefits package described in section 122(c)(3)(B). (B) PREMIUM PLAN- The level of cost-sharing for premium plans shall be designed so that such plans have benefits that are actuarially equivalent to approximately 95 percent of the actuarial value of the benefits provided under the reference benefits package described in section 122(c)(3)(B). (c) Operations- (1) PER DIEM PAY- Each member of the Health Benefits Advisory Committee shall receive travel expenses, including per diem in accordance with applicable provisions under subchapter I of chapter 57 of title 5, United States Code, and shall otherwise serve without additional pay. (2) MEMBERS NOT TREATED AS FEDERAL EMPLOYEES- 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 Advisory Committee Act (5 U.S.C. App.), other than section 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 Benefits Advisory Committee under this section. SEC. 124. PROCESS FOR ADOPTION OF RECOMMENDATIONS; ADOPTION OF BENEFIT STANDARDS. (a) Process for Adoption of Recommendations- (1) REVIEW OF RECOMMENDED STANDARDS- Not later than 45 days after the date of receipt of benefit standards recommended under section 123 (including such standards as modified under paragraph (2)(B)), the Secretary shall review such standards and shall determine whether to propose adoption of such standards as a package. (2) DETERMINATION TO ADOPT STANDARDS- If the Secretary determines– (A) to propose adoption of benefit 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 standards 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 opportunity to modify its previous recommendations and submit new recommendations to the Secretary 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 recommended standards by the deadline specified in subsection (b)(1), the Secretary shall, by regulation under section 553 of title 5, United States Code, propose adoption of initial benefit standards by such deadline. (4) PUBLICATION- The Secretary shall provide for publication in the Federal Register of all determinations made by the Secretary under this subsection. (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 consistent with subsection (a), adopt an initial set of benefit standards. (2) PERIODIC UPDATING STANDARDS- Under subsection (a), the Secretary shall provide for the periodic updating of the benefit standards previously adopted under this section. (3) REQUIREMENT- The Secretary may not adopt any benefit standards for an essential benefits package or for level of cost-sharing that are inconsistent with the requirements for such a package or level under sections 122 and 123(b)(5). Subtitle D–Additional Consumer Protections SEC. 131. REQUIRING FAIR MARKETING PRACTICES BY HEALTH INSURERS. The Commissioner shall establish uniform marketing standards that all insured QHBP offering entities shall meet. SEC. 132. REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS. (a) In General- A QHBP offering entity shall provide for timely grievance and appeals mechanisms that the Commissioner shall establish. (b) Internal Claims and Appeals Process- Under a qualified health benefits plan the QHBP offering entity shall provide an internal claims and appeals process that initially incorporates the claims and appeals 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. Reg. 70246) and shall update such process in accordance with any standards that the Commissioner may establish. (c) External Review Process- (1) IN GENERAL- The Commissioner shall establish an external review process (including procedures for expedited reviews of urgent claims) that provides for an impartial, independent, and de novo review of denied claims under this division. (2) REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS- A determination made, with respect to a qualified health benefits plan offered by a QHBP offering entity, under the external review process established under this subsection shall be binding on the plan and the entity. (d) Construction- Nothing in this section shall be construed as affecting the availability of judicial review under State law for adverse decisions under subsection (b) or (c), subject to section 151. SEC. 133. REQUIRING INFORMATION TRANSPARENCY AND PLAN DISCLOSURE. (a) Accurate and Timely Disclosure- (1) IN GENERAL- A qualified health benefits plan shall comply with standards established by the Commissioner for the accurate and timely disclosure of plan documents, plan terms and conditions, claims payment policies and practices, periodic 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 Commissioner. The Commissioner shall require that such disclosure be provided in plain language. (2) PLAIN LANGUAGE- In this subsection, the term `plain language’ means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is clean, concise, well-organized, and follows other best practices of plain language writing. (3) GUIDANCE- The Commissioner shall develop and issue guidance on best practices of plain language writing. (b) Contracting Reimbursement- A qualified health benefits plan 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 shall not be made without such reasonable and timely advance notice to enrollees of such change. SEC. 134. APPLICATION TO QUALIFIED HEALTH BENEFITS PLANS NOT OFFERED THROUGH THE HEALTH INSURANCE EXCHANGE. The requirements of the previous provisions of this subtitle shall apply to qualified health benefits plans that are not being offered through the Health Insurance Exchange only to the extent specified by the Commissioner. SEC. 135. TIMELY PAYMENT OF CLAIMS. A QHBP offering entity shall comply with the requirements of section 1857(f) of the Social Security Act with respect to a qualified health benefits plan it offers in the same manner an Medicare Advantage organization is required to comply with such requirements with respect to a Medicare Advantage plan it offers under part C of Medicare. SEC. 136. STANDARDIZED RULES FOR COORDINATION AND SUBROGATION OF BENEFITS. The Commissioner shall establish standards for the coordination and subrogation of benefits and reimbursement of payments in cases involving individuals and multiple plan coverage. SEC. 137. APPLICATION OF ADMINISTRATIVE SIMPLIFICATION. A QHBP offering entity is required to comply with standards for electronic financial and administrative transactions under section 1173A of the Social Security Act, added by section 163(a). Subtitle E–Governance SEC. 141. HEALTH CHOICES ADMINISTRATION; HEALTH CHOICES COMMISSIONER. (a) In General- There is hereby established, as an independent agency in the executive branch of the Government, a Health Choices Administration (in this division referred to as the `Administration’). (b) Commissioner- (1) IN GENERAL- The Administration shall be headed by a Health Choices Commissioner (in this division referred to as the `Commissioner’) who shall be appointed by the President, by and with the advice and consent of the Senate. (2) COMPENSATION; ETC- The provisions of paragraphs (2), (5), and (7) of subsection (a) (relating to compensation, terms, general powers, rulemaking, and delegation) of section 702 of the Social Security Act (42 U.S.C. 902) shall apply to the Commissioner and the Administration in the same manner as such provisions apply to the Commissioner of Social Security and the Social Security Administration. SEC. 142. DUTIES AND AUTHORITY OF COMMISSIONER. (a) Duties- The Commissioner is responsible for carrying out the following functions under this division: (1) QUALIFIED PLAN STANDARDS- The establishment of qualified health benefits plan standards under this title, including the enforcement of such standards in coordination with State insurance regulators and the Secretaries of Labor and the Treasury. (2) HEALTH INSURANCE EXCHANGE- The establishment and operation of a Health Insurance Exchange under subtitle A of title II. (3) INDIVIDUAL AFFORDABILITY CREDITS- The administration of individual affordability credits under subtitle C of title II, including determination of eligibility for such credits. (4) ADDITIONAL FUNCTIONS- Such additional functions as may be specified in this division. (b) Promoting Accountability- (1) IN GENERAL- The Commissioner shall undertake activities in accordance with this subtitle to promote accountability of QHBP offering entities in meeting Federal health insurance requirements, regardless of whether such accountability is with respect to qualified health benefits plans offered through the Health Insurance Exchange or outside of such Exchange. (2) COMPLIANCE EXAMINATION AND AUDITS- (A) IN GENERAL- The commissioner shall, in coordination with States, conduct audits of qualified health benefits plan compliance with Federal requirements. Such audits may include random compliance audits and targeted audits in response to complaints or other suspected non-compliance. (B) RECOUPMENT OF COSTS IN CONNECTION WITH EXAMINATION AND AUDITS- The Commissioner is authorized to recoup from qualified health benefits plans reimbursement for the costs of such examinations and audit of such QHBP offering entities. (c) Data Collection- The Commissioner shall collect data for purposes of carrying out the Commissioner’s duties, including for purposes of promoting quality and value, protecting consumers, and addressing disparities in health and health care and may share such data with the Secretary of Health and Human Services. (d) Sanctions Authority- (1) IN GENERAL- In the case that the Commissioner determines that a QHBP offering entity violates a requirement of this title, the Commissioner may, in coordination with State insurance regulators and the Secretary of Labor, provide, in addition to any other remedies authorized by law, for any of the remedies described in paragraph (2). (2) REMEDIES- The remedies described in this paragraph, with respect to a qualified health benefits plan offered by a QHBP offering entity, are– (A) civil money penalties of not more than the amount that would be applicable under similar circumstances for similar violations under section 1857(g) of the Social Security Act; (B) suspension of enrollment of individuals under such plan after the date the Commissioner notifies the entity of a determination under paragraph (1) and until the Commissioner is satisfied that the basis for such determination has been corrected and is not likely to recur; (C) in the case of an Exchange-participating health benefits plan, suspension of payment to the entity under the Health Insurance Exchange for individuals enrolled in such plan after the date the Commissioner notifies the entity of a determination under paragraph (1) and until the Secretary is satisfied that the basis for such determination has been corrected and is not likely to recur; or (D) working with State insurance regulators to terminate plans for repeated failure by the offering entity to meet the requirements of this title. (e) Standard Definitions of Insurance and Medical Terms- The Commissioner shall provide for the development of standards for the definitions of terms used in health insurance coverage, including insurance-related terms. (f) Efficiency in Administration- The Commissioner shall issue regulations for the effective and efficient administration of the Health Insurance Exchange and affordability credits under subtitle C, including, with respect to the determination of eligibility for affordability credits, the use of personnel who are employed in accordance with the requirements of title 5, United States Code, to carry out the duties of the Commissioner or, in the case of sections 208 and 241(b)(2), the use of State personnel who are employed in accordance with standards prescribed by the Office of Personnel Management pursuant to section 208 of the Intergovernmental Personnel Act of 1970 (42 U.S.C. 4728). SEC. 143. CONSULTATION AND COORDINATION. (a) Consultation- In carrying out the Commissioner’s duties under this division, the Commissioner, as appropriate, shall consult with at least with the following: (1) The National Association of Insurance Commissioners, State attorneys general, and State insurance regulators, including concerning the standards for insured qualified health benefits plans under this title and enforcement of such standards. (2) Appropriate State agencies, specifically concerning the administration of individual affordability credits under subtitle C of title II and the offering of Exchange-participating health benefits plans, to Medicaid eligible individuals under subtitle A of such title. (3) Other appropriate Federal agencies. (4) Indian tribes and tribal organizations. (5) The National Association of Insurance Commissioners for purposes of using model guidelines established by such association for purposes of subtitles B and D. (b) Coordination- (1) IN GENERAL- In carrying out the functions of the Commissioner, including with respect to the enforcement of the provisions of this division, the Commissioner shall work in coordination with existing Federal and State entities to the maximum extent feasible consistent with this division and in a manner that prevents conflicts of interest in duties and ensures effective enforcement. (2) UNIFORM STANDARDS- The Commissioner, in coordination with such entities, shall seek to achieve uniform standards that adequately protect consumers in a manner that does not unreasonably affect employers and insurers. SEC. 144. HEALTH INSURANCE OMBUDSMAN. (a) In General- The Commissioner shall appoint within the Health Choices Administration a Qualified Health Benefits Plan Ombudsman who shall have expertise and experience in the fields of health care and education of (and assistance to) individuals. (b) Duties- The Qualified Health Benefits Plan Ombudsman shall, in a linguistically appropriate manner– (1) receive complaints, grievances, and requests for information submitted by individuals; (2) provide assistance with respect to complaints, grievances, and requests referred to in paragraph (1), including– (A) helping individuals determine the relevant information needed to seek an appeal of a decision or determination; (B) assistance to such individuals with any problems arising from disenrollment from such a plan; (C) assistance to such individuals in choosing a qualified health benefits plan in which to enroll; and (D) assistance to such individuals in presenting information under subtitle C (relating to affordability credits); and (3) submit annual reports to Congress and the Commissioner that describe the activities of the Ombudsman and that include such recommendations for improvement in the administration of this division as the Ombudsman determines appropriate. The Ombudsman shall not serve as an advocate for any increases in payments or new coverage of services, but may identify issues and problems in payment or coverage policies. Subtitle F–Relation to Other Requirements; Miscellaneous SEC. 151. RELATION TO OTHER REQUIREMENTS. (a) Coverage Not Offered Through Exchange- (1) IN GENERAL- In the case of health insurance coverage not offered through the Health Insurance Exchange (whether or not offered in connection with an employment-based health plan), and in the case of employment-based health plans, the requirements of this title do not supercede any requirements applicable under titles XXII and XXVII of the Public Health Service Act, parts 6 and 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974, or State law, except insofar as such requirements prevent the application of a requirement of this division, as determined by the Commissioner. (2) CONSTRUCTION- Nothing in paragraph (1) shall be construed as affecting the application of section 514 of the Employee Retirement Income Security Act of 1974. (b) Coverage Offered Through Exchange- (1) IN GENERAL- In the case of health insurance coverage offered through the Health Insurance Exchange– (A) the requirements of this title do not supercede any requirements (including requirements relating to genetic information nondiscrimination and mental health) applicable under title XXVII of the Public Health Service Act or under State law, except insofar as such requirements prevent the application of a requirement of this division, as determined by the Commissioner; and (B) individual rights and remedies under State laws shall apply. (2) CONSTRUCTION- In the case of coverage described in paragraph (1), nothing in such paragraph shall be construed as preventing the application of rights and remedies under State laws with respect to any requirement referred to in paragraph (1)(A). SEC. 152. PROHIBITING DISCRIMINATION IN HEALTH CARE. (a) In General- Except as otherwise explicitly permitted by this Act and by subsequent regulations consistent with this Act, all health care and related services (including insurance coverage and public health activities) covered by this Act shall be provided without regard to personal characteristics extraneous to the provision of high quality health care or related services. (b) Implementation- To implement the requirement set forth in subsection (a), the Secretary of Health and Human Services shall, not later than 18 months after the date of the enactment of this Act, promulgate such regulations as are necessary or appropriate to insure that all health care and related services (including insurance coverage and public health activities) covered by this Act are provided (whether directly or through contractual, licensing, or other arrangements) without regard to personal characteristics extraneous to the provision of high quality health care or related services. SEC. 153. WHISTLEBLOWER PROTECTION. (a) Retaliation Prohibited- No employer may discharge any employee or otherwise discriminate against any employee with respect to his compensation, terms, conditions, or other privileges of employment because the employee (or any person acting pursuant to a request of the employee)– (1) provided, caused to be provided, or is about to provide or cause to be provided to the employer, the Federal Government, or the attorney general of a State information relating to any violation of, or any act or omission the employee reasonably believes to be a violation of any provision of this Act or any order, rule, or regulation promulgated under this Act; (2) testified or is about to testify in a proceeding concerning such violation; (3) assisted or participated or is about to assist or participate in such a proceeding; or (4) objected to, or refused to participate in, any activity, policy, practice, or assigned task that the employee (or other such person) reasonably believed to be in violation of any provision of this Act or any order, rule, or regulation promulgated under this Act. (b) Enforcement Action- An employee covered by this section who alleges discrimination by an employer in violation of subsection (a) may bring an action governed by the rules, procedures, legal burdens of proof, and remedies set forth in section 40(b) of the Consumer Product Safety Act (15 U.S.C. 2087(b)). (c) Employer Defined- As used in this section, the term `employer’ means any person (including one or more individuals, partnerships, associations, corporations, trusts, professional membership organization including a certification, disciplinary, or other professional body, unincorporated organizations, nongovernmental organizations, or trustees) engaged in profit or nonprofit business or industry whose activities are governed by this Act, and any agent, contractor, subcontractor, grantee, or consultant of such person. (d) Rule of Construction- The rule of construction set forth in section 20109(h) of title 49, United States Code, shall also apply to this section. SEC. 154. CONSTRUCTION REGARDING COLLECTIVE BARGAINING. Nothing in this division shall be construed to alter of supercede any statutory or other obligation to engage in collective bargaining over the terms and conditions of employment related to health care. SEC. 155. SEVERABILITY. If any provision of this Act, or any application of such provision to any person or circumstance, is held to be unconstitutional, the remainder of the provisions of this Act and the application of the provision to any other person or circumstance shall not be affected. Subtitle G–Early Investments SEC. 161. ENSURING VALUE AND LOWER PREMIUMS. (a) Group Health Insurance Coverage- Title XXVII of the Public Health Service Act is amended by inserting after section 2713 the following new section: `SEC. 2714. ENSURING VALUE AND LOWER PREMIUMS. `(a) In General- Each health insurance issuer that offers health insurance coverage in the small or large group market shall provide that for any plan year in which the coverage has a medical loss ratio below a level specified by the Secretary, the issuer shall provide in a manner specified by the Secretary for rebates to enrollees of payment sufficient to meet such loss ratio. Such methodology shall be set at the highest level medical loss ratio possible that is designed to ensure adequate participation by issuers, competition in the health insurance market, and value for consumers so that their premiums are used for services. `(b) Uniform Definitions- The Secretary shall establish a uniform definition of medical loss ratio and methodology for determining how to calculate the medical loss ratio. Such methodology shall be designed to take into account the special circumstances of smaller plans, different types of plans, and newer plans.’. (b) Individual Health Insurance Coverage- Such title is further amended by inserting after section 2753 the following new section: `SEC. 2754. ENSURING VALUE AND LOWER PREMIUMS. `The provisions of section 2714 shall apply to health insurance coverage offered in the individual market in the same manner as such provisions apply to health insurance coverage offered in the small or large group market.’. (c) Immediate Implementation- The amendments made by this section shall apply in the group and individual market for plan years beginning on or after January 1, 2011. SEC. 162. ENDING HEALTH INSURANCE RESCISSION ABUSE. (a) Clarification Regarding Application of Guaranteed Renewability of Individual Health Insurance Coverage- Section 2742 of the Public Health Service Act (42 U.S.C. 300gg-42) is amended– (1) in its heading, by inserting `and continuation in force, including prohibition of rescission,’ after `guaranteed renewability’; and (2) in subsection (a), by inserting `, including without rescission,’ after `continue in force’. (b) Secretarial Guidance Regarding Rescissions- Section 2742 of such Act (42 U.S.C. 300gg-42) is amended by adding at the end the following: `(f) Rescission- A health insurance issuer may rescind health insurance coverage only upon clear and convincing evidence of fraud described in subsection (b)(2). The Secretary, no later than July 1, 2010, shall issue guidance implementing this requirement, including procedures for independent, external third party review.’. (c) Opportunity for Independent, External Third Party Review in Certain Cases- Subpart 1 of part B of title XXVII of such Act (42 U.S.C. 300gg-41 et seq.) is amended by adding at the end the following: `SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD PARTY REVIEW IN CASES OF RESCISSION. `(a) Notice and Review Right- If a health insurance issuer determines to rescind health insurance coverage for an individual in the individual market, before such rescission may take effect the issuer shall provide the individual with notice of such proposed rescission and an opportunity for a review of such determination by an independent, external third party under procedures specified by the Secretary under section 2742(f). `(b) Independent Determination- If the individual requests such review by an independent, external third party of a rescission of health insurance coverage, the coverage shall remain in effect until such third party determines that the coverage may be rescinded under the guidance issued by the Secretary under section 2742(f).’. (d) Effective Date- The amendments made by this section shall apply on and after October 1, 2010, with respect to health insurance coverage issued before, on, or after such date. SEC. 163. ADMINISTRATIVE SIMPLIFICATION. (a) Standardizing Electronic Administrative Transactions- (1) IN GENERAL- Part C of title XI of the Social Security Act (42 U.S.C. 1320d et seq.) is amended by inserting after section 1173 the following new section: `SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE TRANSACTIONS. `(a) Standards for Financial and Administrative Transactions- `(1) IN GENERAL- The Secretary shall adopt and regularly update standards consistent with the goals described in paragraph (2). `(2) GOALS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS- The goals for standards under paragraph (1) are that such standards shall– `(A) be unique with no conflicting or redundant standards; `(B) be authoritative, permitting no additions or constraints for electronic transactions, including companion guides; `(C) be comprehensive, efficient and robust, requiring minimal augmentation by paper transactions or clarification by further communications; `(D) enable the real-time (or near real-time) determination of an individual’s financial responsibility at the point of service and, to the extent possible, prior to service, including whether the individual is eligible for a specific service with a specific physician at a specific facility, which may include utilization of a machine-readable health plan beneficiary identification card; `(E) enable, where feasible, near real-time adjudication of claims; `(F) provide for timely acknowledgment, response, and status reporting applicable to any electronic transaction deemed appropriate by the Secretary; `(G) describe all data elements (such as reason and remark codes) in unambiguous terms, not permit optional fields, require that data elements be either required or conditioned upon set values in other fields, and prohibit additional conditions; and `(H) harmonize all common data elements across administrative and clinical transaction standards. `(3) TIME FOR ADOPTION- Not later than 2 years after the date of implementation of the X12 Version 5010 transaction standards implemented under this part, the Secretary shall adopt standards under this section. `(4) REQUIREMENTS FOR SPECIFIC STANDARDS- The standards under this section shall be developed, adopted and enforced so as to– `(A) clarify, refine, complete, and expand, as needed, the standards required under section 1173; `(B) require paper versions of standardized transactions to comply with the same standards as to data content such that a fully compliant, equivalent electronic transaction can be populated from the data from a paper version; `(C) enable electronic funds transfers, in order to allow automated reconciliation with the related health care payment and remittance advice; `(D) require timely and transparent claim and denial management processes, including tracking, adjudication, and appeal processing; `(E) require the use of a standard electronic transaction with which health care providers may quickly and efficiently enroll with a health plan to conduct the other electronic transactions provided for in this part; and `(F) provide for other requirements relating to administrative simplification as identified by the Secretary, in consultation with stakeholders. `(5) BUILDING ON EXISTING STANDARDS- In developing the standards under this section, the Secretary shall build upon existing and planned standards. `(6) IMPLEMENTATION AND ENFORCEMENT- Not later than 6 months after the date of the enactment of this section, the Secretary shall submit to the appropriate committees of Congress a plan for the implementation and enforcement, by not later than 5 years after such date of enactment, of the standards under this section. Such plan shall include– `(A) a process and timeframe with milestones for developing the complete set of standards; `(B) an expedited upgrade program for continually developing and approving additions and modifications to the standards as often as annually to improve their quality and extend their functionality to meet evolving requirements in health care; `(C) programs to provide incentives for, and ease the burden of, implementation for certain health care providers, with special consideration given to such providers serving rural or underserved areas and ensure coordination with standards, implementation specifications, and certification criteria being adopted under the HITECH Act; `(D) programs to provide incentives for, and ease the burden of, health care providers who volunteer to participate in the process of setting standards for electronic transactions; `(E) an estimate of total funds needed to ensure timely completion of the implementation plan; and `(F) an enforcement process that includes timely investigation of complaints, random audits to ensure compliance, civil monetary and programmatic penalties for non-compliance consistent with existing laws and regulations, and a fair and reasonable appeals process building off of enforcement provisions under this part. `(b) Limitations on Use of Data- Nothing in this section shall be construed to permit the use of information collected under this section in a manner that would adversely affect any individual. `(c) Protection of Data- The Secretary shall ensure (through the promulgation of regulations or otherwise) that all data collected pursuant to subsection (a) are– `(1) used and disclosed in a manner that meets the HIPAA privacy and security law (as defined in section 3009(a)(2) of the Public Health Service Act), including any privacy or security standard adopted under section 3004 of such Act; and `(2) protected from all inappropriate internal use by any entity that collects, stores, or receives the data, including use of such data in determinations of eligibility (or continued eligibility) in health plans, and from other inappropriate uses, as defined by the Secretary.’. (2) DEFINITIONS- Section 1171 of such Act (42 U.S.C. 1320d) is amended– (A) in paragraph (7), by striking `with reference to’ and all that follows and inserting `with reference to a transaction or data element of health information in section 1173 means implementation specifications, certification criteria, operating rules, messaging formats, codes, and code sets adopted or established by the Secretary for the electronic exchange and use of information’; and (B) by adding at the end the following new paragraph: `(9) OPERATING RULES- The term `operating rules’ means business rules for using and processing transactions. Operating rules should address the following: `(A) Requirements for data content using available and established national standards. `(B) Infrastructure requirements that establish best practices for streamlining data flow to yield timely execution of transactions. `(C) Policies defining the transaction related rights and responsibilities for entities that are transmitting or receiving data.’. (3) CONFORMING AMENDMENT- Section 1179(a) of such Act (42 U.S.C. 1320d-8(a)) is amended, in the matter before paragraph (1)– (A) by inserting `on behalf of an individual’ after `1978)’; and (B) by inserting `on behalf of an individual’ after `for a financial institution.’ (b) Standards for Claims Attachments and Coordination of Benefits – (1) STANDARD FOR HEALTH CLAIMS ATTACHMENTS- Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall promulgate a final rule to establish a standard for health claims attachment transaction described in section 1173(a)(2)(B) of the Social Security Act (42 U.S.C. 1320d-2(a)(2)(B)) and coordination of benefits. (2) REVISION IN PROCESSING PAYMENT TRANSACTIONS BY FINANCIAL INSTITUTIONS- (A) IN GENERAL- Section 1179 of the Social Security Act (42 U.S.C. 1320d-8) is amended, in the matter before paragraph (1)– (i) by striking `or is engaged’ and inserting `and is engaged’; and (ii) by inserting `(other than as a business associate for a covered entity)’ after `for a financial institution’. (B) EFFECTIVE DATE- The amendments made by paragraph (1) shall apply to transactions occurring on or after such date (not later than 6 months after the date of the enactment of this Act) as the Secretary of Health and Human Services shall specify. SEC. 164. REINSURANCE PROGRAM FOR RETIREES. (a) Establishment- (1) IN GENERAL- Not later than 90 days after the date of the enactment of this Act, the Secretary of Health and Human Services shall establish a temporary reinsurance program (in this section referred to as the `reinsurance program’) to provide reimbursement to assist participating employment-based plans with the cost of providing health benefits to retirees and to eligible spouses, surviving spouses and dependents of such retirees. (2) DEFINITIONS- For purposes of this section: (A) The term `eligible employment-based plan’ means a group health benefits plan that– (i) is maintained by one or more employers, former employers or employee associations, or a voluntary employees’ beneficiary association, or a committee or board of individuals appointed to administer such plan, and (ii) provides health benefits to retirees. (B) The term `health benefits’ means medical, surgical, hospital, prescription drug, and such other benefits as shall be determined by the Secretary, whether self-funded or delivered through the purchase of insurance or otherwise. (C) The term `participating employment-based plan’ means an eligible employment-based plan that is participating in the reinsurance program. (D) The term `retiree’ means, with respect to a participating employment-benefit plan, an individual who– (i) is 55 years of age or older; (ii) is not eligible for coverage under title XVIII of the Social Security Act; and (iii) is not an active employee of an employer maintaining the plan or of any employer that makes or has made substantial contributions to fund such plan. (E) The term `Secretary’ means Secretary of Health and Human Services. (b) Participation- To be eligible to participate in the reinsurance program, an eligible employment-based plan shall submit to the Secretary an application for participation in the program, at such time, in such manner, and containing such information as the Secretary shall require. (c) Payment- (1) SUBMISSION OF CLAIMS- (A) IN GENERAL- Under the reinsurance program, a participating employment-based plan shall submit claims for reimbursement to the Secretary which shall contain documentation of the actual costs of the items and services for which each claim is being submitted. (B) BASIS FOR CLAIMS- Each claim submitted under subparagraph (A) shall be based on the actual amount expended by the participating employment-based plan involved within the plan year for the appropriate employment based health benefits provided to a retiree or to the spouse, surviving spouse, or dependent of a retiree. In determining the amount of any claim for purposes of this subsection, the participating employment-based plan shall take into account any negotiated price concessions (such as discounts, direct or indirect subsidies, rebates, and direct or indirect remunerations) obtained by such plan with respect to such health benefits. For purposes of calculating the amount of any claim, the costs paid by the retiree or by the spouse, surviving spouse, or dependent of the retiree in the form of deductibles, co-payments, and co-insurance shall be included along with the amounts paid by the participating employment-based plan. (2) PROGRAM PAYMENTS AND LIMIT- If the Secretary determines that a participating employment-based plan has submitted a valid claim under paragraph (1), the Secretary shall reimburse such plan for 80 percent of that portion of the costs attributable to such claim that exceeds $15,000, but is less than $90,000. Such amounts shall be adjusted each year based on the percentage increase in the medical care component of the Consumer Price Index (rounded to the nearest multiple of $1,000) for the year involved. (3) USE OF PAYMENTS- Amounts paid to
  5. joseph conlan permalink
    August 6, 2009 2:47 pm

    where is the medicare advantage plan and how is it affected. I see where they are removing 500 million from these plans to help fund this plan. How is it affecting medicare advantage plans.

  6. dcbarton permalink*
    August 8, 2009 4:53 pm

    Joseph,
    I have, as of yet, failed to find any mention of the Medicare Advantage Plan in the health care reform bill, however, the USA Today has mentioned it, and Obama’s thoughts on the plan. This was dated 08-04-2009:
    “WASHINGTON — One of the largest spending cuts Congress could rely on to pay for an overhaul of the nation’s health care system comes from a Medicare program President Obama has called a “wasteful” subsidy for the health insurance industry.
    Don’t tell that to cancer survivor Maurice Engleman, 82, who says the controversial Medicare Advantage program — which allows seniors to buy Medicare coverage through private insurance companies — helped him beat cancer.

    “There was a seamless link between the medical support and the emotional support,” said Engleman, who was diagnosed with tongue cancer last year within a week of his wife’s death. “I don’t believe Medicare would have taken care of the kind of services I required.”

    Debate over Medicare Advantage, which has 10.2 million enrollees — about one-fifth of all Medicare participants — illustrates a broader struggle Congress and Obama face as they look for ways to pay for a $1 trillion overhaul of health care without raising taxes on the middle class or compromising care.

    HEALTH CARE DEBATE: Share your story, view with our reporter

    It has raised concerns among some seniors who might have to pay more for the program or enroll in regular Medicare instead. A Gallup Poll last week found 20% of Americans over 65 say an overhaul will improve their health care — the lowest showing of three age groups.

    FIND MORE STORIES IN: Barack Obama | Kaiser Family Foundation | AARP
    Medicare Advantage has its roots in the 1970s but was bolstered in 2003 in hopes that private companies could manage Medicare patients more efficiently. Partly because it often has lower out-of-pocket costs than traditional Medicare, enrollment has nearly doubled over six years, according to a Kaiser Family Foundation report.

    Critics, including Obama, say the plans offer lower premiums because insurance companies are subsidized by taxpayers at a rate 14% higher per patient than regular Medicare. Lawmakers initially set a higher reimbursement rate to draw private insurers into the program. The non-partisan Congressional Budget Office says eliminating the disparity would save $150 billion over 10 years.

    At a recent virtual town hall meeting intended to quell seniors’ concerns, Obama said the cuts would not affect care. He said the Medicare Advantage program amounted to “giveaways that boost insurance company profits but don’t make you any healthier.”

    Congress is considering changing the reimbursement formula or, as Obama has proposed, increasing competition when private insurers bid for Medicare business.

    “We’re overpaying plans that were basically promising greater competition,” said David Certner, legislative policy director for AARP, which supports cutting the added payment to Medicare Advantage. “It’s not sustainable.”

    Engleman, who came to Washington last month to press lawmakers on the issue, is enrolled in a Southern California medical group called Desert Oasis Healthcare. The group, he said, uses case managers who check on patients to coordinate care and reduce hospital readmissions.

    Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, the insurance trade group, said seniors in the plans receive checkups and vision and drug coverage not offered in traditional Medicare. Some get free gym memberships.

    Cuts could lead to a “reduction in benefits and higher premiums,” he said.

    But there are also downsides for seniors in the plans, said Judith Stein, executive director of the Center for Medicare Advocacy, a private, non-profit group. Enrollees are often required to visit in-network physicians. If they get sick away from home, care may not be covered.

    “I would not let my mother join a private plan,” she said.”
    One thing in the health care reform bill that should be of more of a concern to anyone over 65, and to everyone who will one day be over 65 is Section 1233:
    SEC. 1233. ADVANCE CARE PLANNING CONSULTATION.

    (a) Medicare-

    (1) IN GENERAL- Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended–

    (A) in subsection (s)(2)–

    (i) by striking `and’ at the end of subparagraph (DD);

    (ii) by adding `and’ at the end of subparagraph (EE); and

    (iii) by adding at the end the following new subparagraph:

    `(FF) advance care planning consultation (as defined in subsection (hhh)(1));’; and

    (B) by adding at the end the following new subsection:

    `Advance Care Planning Consultation

    `(hhh)(1) Subject to paragraphs (3) and (4), the term `advance care planning consultation’ means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years. Such consultation shall include the following:

    `(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to.

    `(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses.

    `(C) An explanation by the practitioner of the role and responsibilities of a health care proxy.

    `(D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act of 1965).

    `(E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title.

    `(F)(i) Subject to clause (ii), an explanation of orders regarding life sustaining treatment or similar orders, which shall include–

    `(I) the reasons why the development of such an order is beneficial to the individual and the individual’s family and the reasons why such an order should be updated periodically as the health of the individual changes;

    `(II) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and

    `(III) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy).

    `(ii) The Secretary shall limit the requirement for explanations under clause (i) to consultations furnished in a State–

    `(I) in which all legal barriers have been addressed for enabling orders for life sustaining treatment to constitute a set of medical orders respected across all care settings; and

    `(II) that has in effect a program for orders for life sustaining treatment described in clause (iii).

    `(iii) A program for orders for life sustaining treatment for a States described in this clause is a program that–

    `(I) ensures such orders are standardized and uniquely identifiable throughout the State;

    `(II) distributes or makes accessible such orders to physicians and other health professionals that (acting within the scope of the professional’s authority under State law) may sign orders for life sustaining treatment;

    `(III) provides training for health care professionals across the continuum of care about the goals and use of orders for life sustaining treatment; and

    `(IV) is guided by a coalition of stakeholders includes representatives from emergency medical services, emergency department physicians or nurses, state long-term care association, state medical association, state surveyors, agency responsible for senior services, state department of health, state hospital association, home health association, state bar association, and state hospice association.

    `(2) A practitioner described in this paragraph is–

    `(A) a physician (as defined in subsection (r)(1)); and

    `(B) a nurse practitioner or physician’s assistant who has the authority under State law to sign orders for life sustaining treatments.

    `(3)(A) An initial preventive physical examination under subsection (WW), including any related discussion during such examination, shall not be considered an advance care planning consultation for purposes of applying the 5-year limitation under paragraph (1).

    `(B) An advance care planning consultation with respect to an individual may be conducted more frequently than provided under paragraph (1) if there is a significant change in the health condition of the individual, including diagnosis of a chronic, progressive, life-limiting disease, a life-threatening or terminal diagnosis or life-threatening injury, or upon admission to a skilled nursing facility, a long-term care facility (as defined by the Secretary), or a hospice program.

    `(4) A consultation under this subsection may include the formulation of an order regarding life sustaining treatment or a similar order.

    `(5)(A) For purposes of this section, the term `order regarding life sustaining treatment’ means, with respect to an individual, an actionable medical order relating to the treatment of that individual that–

    `(i) is signed and dated by a physician (as defined in subsection (r)(1)) or another health care professional (as specified by the Secretary and who is acting within the scope of the professional’s authority under State law in signing such an order, including a nurse practitioner or physician assistant) and is in a form that permits it to stay with the individual and be followed by health care professionals and providers across the continuum of care;

    `(ii) effectively communicates the individual’s preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual;

    `(iii) is uniquely identifiable and standardized within a given locality, region, or State (as identified by the Secretary); and

    `(iv) may incorporate any advance directive (as defined in section 1866(f)(3)) if executed by the individual.

    `(B) The level of treatment indicated under subparagraph (A)(ii) may range from an indication for full treatment to an indication to limit some or all or specified interventions. Such indicated levels of treatment may include indications respecting, among other items–

    `(i) the intensity of medical intervention if the patient is pulse less, apneic, or has serious cardiac or pulmonary problems;

    `(ii) the individual’s desire regarding transfer to a hospital or remaining at the current care setting;

    `(iii) the use of antibiotics; and

    `(iv) the use of artificially administered nutrition and hydration.’.

    (2) PAYMENT- Section 1848(j)(3) of such Act (42 U.S.C. 1395w-4(j)(3)) is amended by inserting `(2)(FF),’ after `(2)(EE),’.

    (3) FREQUENCY LIMITATION- Section 1862(a) of such Act (42 U.S.C. 1395y(a)) is amended–

    (A) in paragraph (1)–

    (i) in subparagraph (N), by striking `and’ at the end;

    (ii) in subparagraph (O) by striking the semicolon at the end and inserting `, and’; and

    (iii) by adding at the end the following new subparagraph:

    `(P) in the case of advance care planning consultations (as defined in section 1861(hhh)(1)), which are performed more frequently than is covered under such section;’; and

    (B) in paragraph (7), by striking `or (K)’ and inserting `(K), or (P)’.

    (4) EFFECTIVE DATE- The amendments made by this subsection shall apply to consultations furnished on or after January 1, 2011.

    (b) Expansion of Physician Quality Reporting Initiative for End of Life Care-

    (1) Physician’S QUALITY REPORTING INITIATIVE- Section 1848(k)(2) of the Social Security Act (42 U.S.C. 1395w-4(k)(2)) is amended by adding at the end the following new paragraphs:

    `(3) Physician’S QUALITY REPORTING INITIATIVE-

    `(A) IN GENERAL- For purposes of reporting data on quality measures for covered professional services furnished during 2011 and any subsequent year, to the extent that measures are available, the Secretary shall include quality measures on end of life care and advanced care planning that have been adopted or endorsed by a consensus-based organization, if appropriate. Such measures shall measure both the creation of and adherence to orders for life-sustaining treatment.

    `(B) PROPOSED SET OF MEASURES- The Secretary shall publish in the Federal Register proposed quality measures on end of life care and advanced care planning that the Secretary determines are described in subparagraph (A) and would be appropriate for eligible professionals to use to submit data to the Secretary. The Secretary shall provide for a period of public comment on such set of measures before finalizing such proposed measures.’.

    (c) Inclusion of Information in Medicare & You Handbook-

    (1) MEDICARE & YOU HANDBOOK-

    (A) IN GENERAL- Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall update the online version of the Medicare & You Handbook to include the following:

    (i) An explanation of advance care planning and advance directives, including–

    (I) living wills;

    (II) durable power of attorney;

    (III) orders of life-sustaining treatment; and

    (IV) health care proxies.

    (ii) A description of Federal and State resources available to assist individuals and their families with advance care planning and advance directives, including–

    (I) available State legal service organizations to assist individuals with advance care planning, including those organizations that receive funding pursuant to the Older Americans Act of 1965 (42 U.S.C. 93001 et seq.);

    (II) website links or addresses for State-specific advance directive forms; and

    (III) any additional information, as determined by the Secretary.

    (B) UPDATE OF PAPER AND SUBSEQUENT VERSIONS- The Secretary shall include the information described in subparagraph (A) in all paper and electronic versions of the Medicare & You Handbook that are published on or after the date that is 1 year after the date of the enactment of this Act.”
    Section 1233 could better be called the “Duty to Die Clause.”

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