,i #aacth ,,congress #ast ,session ,h4 ,r4 #cafe ,,in ,,the ,,house ,,of ,,representatives ,september #bj1 #bjac,mr4 ,latham introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committees on ,ways and ,means1 ,education and the ,workforce1 ,natural ,resources1 the ,judiciary1 ,house ,administration1 ,rules1 and ,appropriations1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to repeal the ,patient ,protection and ,affordable ,care ,act and to take meaningful steps to lower health care costs and increase access to health insurance coverage without raising taxes1 cutting ,medicare benefits for seniors1 adding to the national deficit1 intervening in the doctor-patient relationship1 or instituting a government takeover of health care4 #a4 ,short title2 purpose2 table of contents 7a7 ,short title ,this ,act may be cited as the ,common ,sense ,health ,reform ,americans ,actually ,want ,act4 7b7 ,purpose ,the purpose of this ,act is to take meaningful steps to lower health care costs and increase access to health insurance coverage 7especially for individuals with preexisting conditions7 without-- 7#a7 raising taxes2 7#b7 cutting ,medicare benefits for seniors2 7#c7 adding to the national deficit2 7#d7 intervening in the doctor-patient relationship2 or 7#e7 instituting a government takeover of health care4 7c7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 purpose2 table of contents4,sec4 #b4 ,repeal of the ,patient ,protection and ,affordable ,care ,act and the ,health ,care and ,education ,reconciliation ,act of #bjaj4;,division ,a--,ensuring coverage for individuals with preexisting conditions and multiple health care needs,sec4 #aja4 ,establish universal access programs to improve high risk pools and reinsurance markets4,sec4 #ajb4 ,no annual or lifetime spending caps4,sec4 #ajc4 ,preventing unjust cancellation of insurance coverage4,division ,b--,reducing ,health ,care ,premiums and the ,number of ,uninsured ,americans,title ,i--,expanding ,access and ,lowering ,costs for ,small ,businesses,subtitle ,a--,enhanced ,marketplace ,pools,sec4 #bja4 ,rules governing enhanced marketplace pools4,sec4 #bjb4 ,cooperation between ,federal and ,state authorities4,sec4 #bjc4 ,effective date and transitional and other rules4,subtitle ,b--,market ,relief,sec4 #bjd4 ,market relief4,title ,,ii--,targeted ,efforts to ,expand ,access,sec4 #baa4 ,extending coverage of dependents4,sec4 #bab4 ,prohibiting preexisting condition exclusions for enrollees under age #ai4,sec4 #bac4 ,health plan finders4,title ,,iii--,expanding ,choices by ,allowing ,americans to ,buy ,health ,care ,coverage ,across ,state ,lines,sec4 #bba4 ,interstate purchasing of health insurance4,title ,,iv--,improving ,health ,savings ,accounts,sec4 #bca4 ,,hsa funds for premiums for high deductible health plans4,sec4 #bcb4 ,requiring greater coordination between ,,hdhp administrators and ,,hsa account administrators so that enrollees can enroll in both at the same time4,sec4 #bcc4 ,special rule for certain medical expenses incurred before establishment of account4,title ,v--,tax-,related ,health ,incentives,sec4 #bda4 ,,seca tax deduction for health insurance costs4,sec4 #bdb4 ,deduction for qualified health insurance costs of individuals4,division ,c--,enacting ,real ,medical ,liability ,reform,sec4 #cja4 ,cap on non-economic damages against health care practitioners4,sec4 #cjb4 ,cap on non-economic damages against health care institutions4,sec4 #cjc4 ,cap1 in wrongful death cases1 on total damages against any single health care practitioner4,sec4 #cjd4 ,limitation of insurer liability when insurer rejects certain settlement offers4,sec4 #cje4 ,mandatory jury instruction on cap on damages4,sec4 #cjf4 ,determination of negligence2 mandatory jury instruction4,sec4 #cjg4 ,expert reports required to be served in civil actions4,sec4 #cjh4 ,expert opinions relating to physicians may be provided only by actively practicing physicians4,sec4 #cji4 ,payment of future damages on periodic or accrual basis4,sec4 #caj4 ,unanimous jury required for punitive or exemplary damages4,sec4 #caa4 ,proportionate liability4,sec4 #cab4 ,defense-initiated settlement process4,sec4 #cac4 ,statute of limitations2 statute of repose4,sec4 #cad4 ,limitation on liability for ,good ,samaritans providing emergency health care4,sec4 #cae4 ,definitions4,division ,d--,protecting the ,doctor-,patient ,relationship,sec4 #dja4 ,rule of construction4,sec4 #djb4 ,repeal of ,federal ,coordinating ,council for ,comparative ,effectiveness ,research4,division ,e--,incentivizing ,wellness and ,quality ,improvements,sec4 #eja4 ,incentives for prevention and wellness programs4,division ,f--,protecting ,taxpayers,sec4 #fja4 ,permanently prohibiting taxpayer funded abortions and ensuring conscience protections4,sec4 #fjb4 ,improved enforcement of the ,medicare and ,medicaid secondary payer provisions4,sec4 #fjc4 ,strengthen ,medicare provider enrollment standards and safeguards4,sec4 #fjd4 ,tracking banned providers across ,state lines4 #b4 ,repeal of the ,patient ,protection and ,affordable ,care ,act and the ,health ,care and ,education ,reconciliation ,act of #bjaj 7a7 ,patient ,protection and ,affordable ,care ,act ,the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh7 is repealed and the provisions of law amended or repealed by such ,act are restored or revived as if such ,act had not been enacted4 7b7 ,health ,care and ,education ,reconciliation ,act of #bjaj ,the ,health ,care and ,education ,reconciliation ,act of #bjaj 7,public ,law #aaa-aeb7 is repealed and the provisions of law amended or repealed by such ,act are restored or revived as if such ,act had not been enacted4 ,a ,ensuring coverage for individuals with preexisting conditions and multiple health care needs #aja4 ,establish universal access programs to improve high risk pools and reinsurance markets 7a7 ,state requirement 7#a7 ,in general ,not later than #ij days after the date of the enactment of this ,act1 each ,state shall-- 7,a7 subject to paragraph 7#c71 operate a qualifying ,state high risk pool described in subsection 7b77#a72 and 7,b7 subject to paragraph 7#c71 apply to the operation of such a program from ,state funds an amount equivalent to the portion of ,state funds derived from ,state premium assessments 7as defined by the ,secretary7 that are not otherwise used on ,state health care programs4 7#b7 ,relation to current qualified high risk pool program 7,a7 ,states not operating a qualified high risk pool ,in the case of a ,state that is not operating a current section #bgde qualified high risk pool as of the date of the enactment of this ,act1 the ,state's operation of a qualifying ,state high risk pool described in subsection 7b77#a7 shall be treated1 for purposes of section #bgde of the ,public ,health ,service ,act1 as the operation of a qualified high risk pool described in such section4 7,b7 ,state operating a qualified high risk pool ,in the case of a ,state that is operating a current section #bgde qualified high risk pool as of the date of the enactment of this ,act1 as of the date that is #ij days after the date of the enactment of this ,act1 such a pool shall not be treated as a qualified high risk pool under section #bgde of the ,public ,health ,service ,act unless the pool is a qualifying ,state high risk pool described in subsection 7b77#a74 7#c7 ,application of funds ,if the pool operated under paragraph 7#a77;,a7 is in strong fiscal health1 as determined in accordance with standards established by the ,national ,association of ,insurance ,commissioners and as approved by the ,state ,insurance ,commissioner involved1 the requirement of paragraph 7#a77;,b7 shall be deemed to be met4 7b7 ,qualifying ,state high risk pool 7#a7 ,in general ,a qualifying ,state high risk pool described in this subsection means a current section #bgde qualified high risk pool that meets the following requirements3 7,a7 ,the pool must be funded with a stable funding source4 7,b7 ,the pool must eliminate any waiting lists so that all eligible residents who are seeking coverage through the pool should be allowed to receive coverage through the pool4 7,c7 ,the pool must allow for coverage of individuals who1 but for the #bd-month disability waiting period under section #bbf7;b7 of the ,social ,security ,act1 would be eligible for ,medicare during the period of such waiting period4 7,d7 ,the pool must limit the pool premiums to no more than #aej percent of the average premium for applicable standard risk rates in that ,state4 7,e7 ,the pool must conduct education and outreach initiatives so that residents and brokers understand that the pool is available to eligible residents4 7,f7 ,the pool must provide coverage for preventive services and disease management for chronic diseases4 7,g7 ,subject to subparagraph 7,c71 an individual may only be eligible for coverage through the pool if the individual has a pre-existing condition1 as determined in a manner consistent with guidance ussed by the ,secretary of ,health and ,human ,services and-- 7i7 was denied health insurance coverage in the individual market because of a pre-existing condition or health status2 or 7ii7 was offered such coverage-- 7,i7 under terms that limit the coverage for such a pre-existing condition2 or 7,,ii7 at a premium rate that is above the premium rate for coverage through the pool pursuant to this section4 7,h7 ,no pre-existing condition exclusion period may be imposed on coverage through the pool4 7,i7 ,the pool shall not require an individual to be uninsured for any period as a condition of eligibility to receive coverage through the pool4 7#b7 ,verification of citizenship or alien qualification 7,a7 ,in general ,notwithstanding any other provision of law1 only citizens and nationals of the ,united ,states shall be eligible to participate in a qualifying ,state high risk pool that receives funds under section #bgde of the ,public ,health ,service ,act or this section4 7,b7 ,condition of participation ,as a condition of a ,state receiving such funds1 the ,secretary shall require the ,state to certify1 to the satisfaction of the ,secretary1 that such ,state requires all applicants for coverage in the qualifying ,state high risk pool to provide satisfactory documentation of citizenship or nationality in a manner consistent with section #aijc7x7 of the ,social ,security ,act4 7,c7 ,records ,the ,secretary shall keep sufficient records such that a determination of citizenship or nationality only has to be made once for any individual under this paragraph4 7#c7 ,relation to section #bgde ,as of ,january #a1 #bjab1 a pool shall not qualify as qualified high risk pool under section #bgde of the ,public ,health ,service ,act unless the pool is a qualifying ,state high risk pool described in paragraph 7#a74 7c7 ,waivers ,in order to accommodate new and innovative programs1 the ,secretary may waive such requirements of this section for qualifying ,state high risk pools as the ,secretary deems appropriate4 7d7 ,funding ,in addition to any other amounts appropriated1 there is appropriated to carry out section #bgde of the ,public ,health ,service ,act 7including through a pool described in subsection 7a77#a77-- 7#a7 #ae1jjj1jjj1jjj for the period of fiscal years #bjaa through #bjba2 and 7#b7 an additional #aj1jjj1jjj1jjj for the period of fiscal years #bjag through #bjba4 7e7 ,definitions ,in this section3 7#a7 ,health insurance coverage2 health insurance issuer ,the terms health insurance coverage and health insurance issuer have the meanings given such terms in section #bgia of the ,public ,health ,service ,act4 7#b7 ,current section #bgde qualified high risk pool ,the term current section #bgde qualified high risk pool has the meaning given the term qualified high risk pool under section #bgde7;g7 of the ,public ,health ,service ,act as in effect as of the date of the enactment of this ,act4 7#c7 ,secretary ,the term ,secretary means ,secretary of ,health and ,human ,services4 7#d7 ,standard risk rate ,the term standard risk rate means a rate that-- 7,a7 is determined under the ,state high risk pool by considering the premium rates charged by other health insurance issuers offering health insurance coverage to individuals in the insurance market served2 7,b7 is established using reasonable actuarial techniques2 and 7,c7 reflects anticipated claims experience and expenses for the coverage involved4 7#e7 ,state ,the term ,state means any of the #ej ,states or the ,district of ,columbia4 #ajb4 ,no annual or lifetime spending caps ,notwithstanding any other provision of law1 a health insurance issuer 7including an entity licensed to sell insurance with respect to a ,state or group health plan7 may not apply an annual or lifetime aggregate spending cap on any health insurance coverage or plan offered by such issuer4 #ajc4 ,preventing unjust cancellation of insurance coverage 7a7 ,clarification regarding application of guaranteed renewability of individual health insurance coverage ,section #bgdb of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#db71 as restored by section #b1 is amended-- 7#a7 in its heading1 by inserting 1 continuation in force1 including prohibition of rescission1 after ,guaranteed renewability2 7#b7 in subsection 7a71 by inserting 1 including without rescission1 after continue in force2 and 7#c7 in subsection 7b77#b71 by inserting before the period at the end the following3 1 including intentional concealment of material facts regarding a health condition related to the condition for which coverage is being claimed4 7b7 ,opportunity for independent1 external third party review in certain cases ,subpart #a of part ,b of title ,,xxvii of the ,public ,health ,service ,act1 as restored by section #b1 is amended by adding at the end the following new section3 #bgdf4 ,opportunity for independent1 external third party review in certain cases 7a7 ,notice and review right ,if a health insurance issuer determines to nonrenew or not continue in force1 including rescind1 health insurance coverage for an individual in the individual market on the basis described in section #bgdb7;b77#b7 before such nonrenewal1 discontinuation1 or rescission1 may take effect the issuer shall provide the individual with notice of such proposed nonrenewal1 discontinuation1 or rescission and an opportunity for a review of such determination by an independent1 external third party under procedures specified by the ,secretary4 7b7 ,independent determination ,if the individual requests such review by an independent1 external third party of a nonrenewal1 discontinuation1 or rescission of health insurance coverage1 the coverage shall remain in effect until such third party determines that the coverage may be nonrenewed1 discontinued1 or rescinded under section #bgdb7;b77#b74 4 7c7 ,effective date ,the amendments made by this section shall apply after the date of the enactment of this ,act with respect to health insurance coverage issued before1 on1 or after such date4 ,b ,reducing ,health ,care ,premiums and the ,number of ,uninsured ,americans ,i ,expanding ,access and ,lowering ,costs for ,small ,businesses ,a ,enhanced ,marketplace ,pools #bja4 ,rules governing enhanced marketplace pools 7a7 ,in general ,subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd1 as restored by section #b1 is amended by adding after part #g the following new part3 #h ,rules governing enhanced marketplace pools #hja4 ,small business health plans 7a7 ,in general ,for purposes of this part1 the term small business health plan means a fully insured group health plan whose sponsor is 7or is deemed under this part to be7 described in subsection 7b74 7b7 ,sponsorship ,the sponsor of a group health plan is described in this subsection if such sponsor-- 7#a7 is organized and maintained in good faith1 with a constitution and bylaws specifically stating its purpose and providing for periodic meetings on at least an annual basis1 as a bona fide trade association1 a bona fide industry association 7including a rural electric cooperative association or a rural telephone cooperative association71 a bona fide professional association1 or a bona fide chamber of commerce 7or similar bona fide business association1 including a corporation or similar organization that operates on a cooperative basis 7within the meaning of section #acha of the ,internal ,revenue ,code of #aihf771 for substantial purposes other than that of obtaining medical care2 7#b7 is established as a permanent entity which receives the active support of its members and requires for membership payment on a periodic basis of dues or payments necessary to maintain eligibility for membership2 7#c7 does not condition membership1 such dues or payments1 or coverage under the plan on the basis of health status-related factors with respect to the employees of its members 7or affiliated members71 or the dependents of such employees1 and does not condition such dues or payments on the basis of group health plan participation2 and 7#d7 does not condition membership on the basis of a minimum group size4 ,any sponsor consisting of an association of entities which meet the requirements of paragraphs 7#a71 7#b71 7#c71 and 7#d7 shall be deemed to be a sponsor described in this subsection4 #hjb4 ,alternative ,market ,pooling ,organizations 7a7 ,in general ,the ,secretary1 not later than #a year after the date of enactment of this part1 shall promulgate regulations that apply the rules and standards of this part1 as necessary1 to circumstances in which a pooling entity other 7hereinafter ,alternative ,market ,pooling ,organizations7 is not made up principally of employers and their employees1 or not a professional organization or such small business health plan entity identified in section #hja4 7b7 ,adaption of standards ,in developing and promulgating regulations pursuant to subsection 7a71 the ,secretary1 in consultation with the ,secretary of ,health and ,human ,services1 small business health plans1 small and large employers1 large and small insurance issuers1 consumer representatives1 and state insurance commissioners1 shall-- 7#a7 adapt the standards of this part1 to the maximum degree practicable1 to assure balanced and comparable oversight standards for both small business health plans and alternative market pooling organizations2 7#b7 permit the participation as alternative market pooling organizations unions1 churches and other faith-based organizations1 or other organizations composed of individuals and groups which may have little or no association with employment1 provided however1 that such alternative market pooling organizations meet1 and continue meeting on an ongoing basis1 to satisfy standards1 rules1 and requirements materially equivalent to those set forth in this part with respect to small business health plans2 7#c7 conduct periodic verification of such compliance by alternative market pooling organizations1 in consultation with the ,secretary of ,health and ,human ,services and the ,national ,association of ,insurance ,commissioners1 except that such periodic verification shall not materially impede market entry or participation as pooling entities comparable to that of small business health plans2 7#d7 assure that consistent1 clear1 and regularly monitored standards are applied with respect to alternative market pooling organizations to avert material risk-selection within or among the composition of such organizations2 7#e7 the expedited and deemed certification procedures provided in section #hje7;d7 shall not apply to alternative market pooling organizations until sooner of the promulgation of regulations under this subsection or the expiration of one year following enactment of this ,act2 and 7#f7 make such other appropriate adjustments to the requirements of this part as the ,secretary may reasonably deem appropriate to fit the circumstances of an individual alternative market pooling organization or category of such organization1 including but not limited to the application of the membership payment requirements of section #hja7;b77#b7 to alternative market pooling organizations composed primarily of church- or faith-based membership4 #hjc4 ,certification of small business health plans 7a7 ,in general ,not later than #f months after the date of enactment of this part1 the applicable authority shall prescribe by interim final rule a procedure under which the applicable authority shall certify small business health plans which apply for certification as meeting the requirements of this part4 7b7 ,requirements applicable to certified plans ,a small business health plan with respect to which certification under this part is in effect shall meet the applicable requirements of this part1 effective on the date of certification 7or1 if later1 on the date on which the plan is to commence operations74 7c7 ,requirements for continued certification ,the applicable authority may provide by regulation for continued certification of small business health plans under this part4 ,such regulation shall provide for the revocation of a certification if the applicable authority finds that the small business health plan involved is failing to comply with the requirements of this part4 7d7 ,expedited and deemed certification 7#a7 ,in general ,if the ,secretary fails to act on an application for certification under this section within #ij days of receipt of such application1 the applying small business health plan shall be deemed certified until such time as the ,secretary may deny for cause the application for certification4 7#b7 ,civil penalty ,the ,secretary may assess a civil penalty against the board of trustees and plan sponsor 7jointly and severally7 of a small business health plan that is deemed certified under paragraph 7#a7 of up to #ejj1jjj in the event the ,secretary determines that the application for certification of such small business health plan was willfully or with gross negligence incomplete or inaccurate4 #hjd4 ,requirements relating to sponsors and boards of trustees 7a7 ,sponsor ,the requirements of this subsection are met with respect to a small business health plan if the sponsor has met 7or is deemed under this part to have met7 the requirements of section #hja7;b7 for a continuous period of not less than #c years ending with the date of the application for certification under this part4 7b7 ,board of trustees ,the requirements of this subsection are met with respect to a small business health plan if the following requirements are met3 7#a7 ,fiscal control ,the plan is operated1 pursuant to a plan document1 by a board of trustees which pursuant to a trust agreement has complete fiscal control over the plan and which is responsible for all operations of the plan4 7#b7 ,rules of operation and financial controls ,the board of trustees has in effect rules of operation and financial controls1 based on a #c-year plan of operation1 adequate to carry out the terms of the plan and to meet all requirements of this title applicable to the plan4 7#c7 ,rules governing relationship to participating employers and to contractors 7,a7 ,board membership 7i7 ,in general ,except as provided in clauses 7ii7 and 7iii71 the members of the board of trustees are individuals selected from individuals who are the owners1 officers1 directors1 or employees of the participating employers or who are partners in the participating employers and actively participate in the business4 7ii7 ,limitation 7,i7 ,general rule ,except as provided in subclauses 7,,ii7 and 7,,iii71 no such member is an owner1 officer1 director1 or employee of1 or partner in1 a contract administrator or other service provider to the plan4 7,,ii7 ,limited exception for providers of services solely on behalf of the sponsor ,officers or employees of a sponsor which is a service provider 7other than a contract administrator7 to the plan may be members of the board if they constitute not more than #be percent of the membership of the board and they do not provide services to the plan other than on behalf of the sponsor4 7,,iii7 ,treatment of providers of medical care ,in the case of a sponsor which is an association whose membership consists primarily of providers of medical care1 subclause 7,i7 shall not apply in the case of any service provider described in subclause 7,i7 who is a provider of medical care under the plan4 7iii7 ,certain plans excluded ,clause 7i7 shall not apply to a small business health plan which is in existence on the date of the enactment of this part4 7,b7 ,sole authority ,the board has sole authority under the plan to approve applications for participation in the plan and to contract with insurers4 7c7 ,treatment of franchises ,in the case of a group health plan which is established and maintained by a franchiser for a franchisor or for its franchisees-- 7#a7 the requirements of subsection 7a7 and section #hja7;a7 shall be deemed met if such requirements would otherwise be met if the franchisor were deemed to be the sponsor referred to in section #hja7;b7 and each franchisee were deemed to be a member 7of the sponsor7 referred to in section #hja7;b72 and 7#b7 the requirements of section #hjd7;a77#a7 shall be deemed met4 ,for purposes of this subsection the terms franchisor and franchisee shall have the meanings given such terms for purposes of sections #dcf4b7;a7 through #dcf4b7;c7 of title #af1 ,code of ,federal ,regulations 7including any such amendments to such regulation after the date of enactment of this part74 #hje4 ,participation and coverage requirements 7a7 ,covered employers and individuals ,the requirements of this subsection are met with respect to a small business health plan if1 under the terms of the plan-- 7#a7 each participating employer must be-- 7,a7 a member of the sponsor2 7,b7 the sponsor2 or 7,c7 an affiliated member of the sponsor1 except that1 in the case of a sponsor which is a professional association or other individual-based association1 if at least one of the officers1 directors1 or employees of an employer1 or at least one of the individuals who are partners in an employer and who actively participates in the business1 is a member or such an affiliated member of the sponsor1 participating employers may also include such employer2 and 7#b7 all individuals commencing coverage under the plan after certification under this part must be-- 7,a7 active or retired owners 7including self-employed individuals71 officers1 directors1 or employees of1 or partners in1 participating employers2 or 7,b7 the dependents of individuals described in subparagraph 7,a74 7b7 ,individual market unaffected ,the requirements of this subsection are met with respect to a small business health plan if1 under the terms of the plan1 no participating employer may provide health insurance coverage in the individual market for any employee not covered under the plan which is similar to the coverage contemporaneously provided to employees of the employer under the plan1 if such exclusion of the employee from coverage under the plan is based on a health status-related factor with respect to the employee and such employee would1 but for such exclusion on such basis1 be eligible for coverage under the plan4 7c7 ,prohibition of discrimination against employers and employees eligible ,to participate ,the requirements of this subsection are met with respect to a small business health plan if-- 7#a7 under the terms of the plan1 all employers meeting the preceding requirements of this section are eligible to qualify as participating employers for all geographically available coverage options1 unless1 in the case of any such employer1 participation or contribution requirements of the type referred to in section #bgaa of the ,public ,health ,service ,act are not met2 7#b7 information regarding all coverage options available under the plan is made readily available to any employer eligible to participate2 and 7#c7 the applicable requirements of sections #gja1 #gjb1 and #gjc are met with respect to the plan4 #hjf4 ,other requirements relating to plan documents1 contribution rates1 and benefit options 7a7 ,in general ,the requirements of this section are met with respect to a small business health plan if the following requirements are met3 7#a7 ,contents of governing instruments 7,a7 ,in general ,the instruments governing the plan include a written instrument1 meeting the requirements of an instrument required under section #djb7;a77#a71 which-- 7i7 provides that the board of trustees serves as the named fiduciary required for plans under section #djb7;a77#a7 and serves in the capacity of a plan administrator 7referred to in section #c7af77;,a772 and 7ii7 provides that the sponsor of the plan is to serve as plan sponsor 7referred to in section #c7af77;,b774 7,b7 ,description of material provisions ,the terms of the health insurance coverage 7including the terms of any individual certificates that may be offered to individuals in connection with such coverage7 describe the material benefit and rating1 and other provisions set forth in this section and such material provisions are included in the summary plan description4 7#b7 ,contribution rates must be nondiscriminatory 7,a7 ,in general ,the contribution rates for any participating small employer shall not vary on the basis of any health status-related factor in relation to employees of such employer or their beneficiaries and shall not vary on the basis of the type of business or industry in which such employer is engaged1 subject to subparagraph 7,b7 and the terms of this title4 7,b7 ,effect of title ,nothing in this title or any other provision of law shall be construed to preclude a health insurance issuer offering health insurance coverage in connection with a small business health plan that meets the requirements of this part1 and at the request of such small business health plan1 from-- 7i7 setting contribution rates for the small business health plan based on the claims experience of the small business health plan so long as any variation in such rates for participating small employers complies with the requirements of clause 7ii71 except that small business health plans shall not be subject1 in non-adopting states1 to subparagraphs 7,a77ii7 and 7,c7 of section #biab7;a77#b7 of the ,public ,health ,service ,act1 and in adopting states1 to any ,state law that would have the effect of imposing requirements as outlined in such subparagraphs 7,a77ii7 and 7,c72 or 7ii7 varying contribution rates for participating small employers in a small business health plan in a ,state to the extent that such rates could vary using the same methodology employed in such ,state for regulating small group premium rates1 subject to the terms of part ,i of subtitle ,a of title ,,xxxi of the ,public ,health ,service ,act 7relating to rating requirements71 as added by subtitle ,b of title ,,ii of the ,health ,security for ,all ,americans ,act of #bjaj4 7#c7 ,exceptions regarding self-employed and large employers 7,a7 ,self-employed 7i7 ,in general ,small business health plans with participating employers who are self-employed individuals 7and their dependents7 shall enroll such self-employed participating employers in accordance with rating rules that do not violate the rating rules for self-employed individuals in the ,state in which such self-employed participating employers are located4 7ii7 ,guarantee issue ,small business health plans with participating employers who are self-employed individuals 7and their dependents7 may decline to guarantee issue to such participating employers in ,states in which guarantee issue is not otherwise required for the self-employed in that ,state4 7,b7 ,large employers ,small business health plans with participating employers that are larger than small employers 7as defined in section #hjh7;a77#aj77 shall enroll such large participating employers in accordance with rating rules that do not violate the rating rules for large employers in the ,state in which such large participating employers are located4 7#d7 ,regulatory requirements ,such other requirements as the applicable authority determines are necessary to carry out the purposes of this part1 which shall be prescribed by the applicable authority by regulation4 7b7 ,ability of small business health plans ,to design benefit options ,nothing in this part or any provision of ,state law 7as defined in section #ead7;c77#a77 shall be construed to preclude a small business health plan or a health insurance issuer offering health insurance coverage in connection with a small business health plan from exercising its sole discretion in selecting the specific benefits and services consisting of medical care to be included as benefits under such plan or coverage1 except that such benefits and services must meet the terms and specifications of part ,,ii of subtitle ,a of title ,,xxxi of the ,public ,health ,service ,act 7relating to lower cost plans71 as added by subtitle ,b of title ,,ii of the ,health ,security for ,all ,americans ,act of #bjaj4 7c7 ,domicile and non-,domicile ,states 7#a7 ,domicile state ,coverage shall be issued to a small business health plan in the ,state in which the sponsor's principal place of business is located4 7#b7 ,non-domicile states ,with respect to a ,state 7other than the domicile ,state7 in which participating employers of a small business health plan are located but in which the insurer of the small business health plan in the domicile ,state is not yet licensed1 the following shall apply3 7,a7 ,temporary preemption ,if1 upon the expiration of the #ij-;day period following the submission of a licensure application by such insurer 7that includes a certified copy of an approved licensure application as submitted by such insurer in the domicile ,state7 to such ,state1 such ,state has not approved or denied such application1 such ,state's health insurance licensure laws shall be temporarily preempted and the insurer shall be permitted to operate in such ,state1 subject to the following terms3 7i7 ,application of non-domicile ,state law ,except with respect to licensure and with respect to the terms of subtitle ,a of title ,,xxxi of the ,public ,health ,service ,act 7relating to rating and benefits as added by subtitle ,b of title ,,ii of the ,health ,security for ,all ,americans ,act of #bjaj71 the laws and authority of the non-domicile ,state shall remain in full force and effect4 7ii7 ,revocation of preemption ,the preemption of a non-domicile ,state's health insurance licensure laws pursuant to this subparagraph1 shall be terminated upon the occurrence of either of the following3 7,i7 ,approval or denial of application ,the approval of denial of an insurer's licensure application1 following the laws and regulations of the non-domicile ,state with respect to licensure4 7,,ii7 ,determination of material violation ,a determination by a non-domicile ,state that an insurer operating in a non-domicile ,state pursuant to the preemption provided for in this subparagraph is in material violation of the insurance laws 7other than licensure and with respect to the terms of subtitle ,a of title ,,xxxi of the ,public ,health ,service ,act 7relating to rating and benefits added by subtitle ,b of title ,,ii of the ,health ,security for ,all ,americans ,act of #bjaj77 of such ,state4 7,b7 ,no prohibition on promotion ,nothing in this paragraph shall be construed to prohibit a small business health plan or an insurer from promoting coverage prior to the expiration of the #ij-;day period provided for in subparagraph 7,a71 except that no enrollment or collection of contributions shall occur before the expiration of such #ij-;day period4 7,c7 licensure ,except with respect to the application of the temporary preemption provision of this paragraph1 nothing in this part shall be construed to limit the requirement that insurers issuing coverage to small business health plans shall be licensed in each ,state in which the small business health plans operate4 7,d7 ,servicing by licensed insurers ,notwithstanding subparagraph 7,c71 the requirements of this subsection may also be satisfied if the participating employers of a small business health plan are serviced by a licensed insurer in that ,state1 even where such insurer is not the insurer of such small business health plan in the ,state in which such small business health plan is domiciled4 #hjg4 ,requirements for application and related requirements 7a7 ,filing fee ,under the procedure prescribed pursuant to section #hjb7;a71 a small business health plan shall pay to the applicable authority at the time of filing an application for certification under this part a filing fee in the amount of #e1jjj1 which shall be available in the case of the ,secretary1 to the extent provided in appropriation ,acts1 for the sole purpose of administering the certification procedures applicable with respect to small business health plans4 7b7 ,information ,to be included in application for certification ,an application for certification under this part meets the requirements of this section only if it includes1 in a manner and form which shall be prescribed by the applicable authority by regulation1 at least the following information3 7#a7 ,identifying information ,the names and addresses of-- 7,a7 the sponsor2 and 7,b7 the members of the board of trustees of the plan4 7#b7 ,states in which plan intends to do business ,the ,states in which participants and beneficiaries under the plan are to be located and the number of them expected to be located in each such ,state4 7#c7 ,bonding requirements ,evidence provided by the board of trustees that the bonding requirements of section #dab will be met as of the date of the application or 7if later7 commencement of operations4 7#d7 ,plan documents ,a copy of the documents governing the plan 7including any bylaws and trust agreements71 the summary plan description1 and other material describing the benefits that will be provided to participants and beneficiaries under the plan4 7#e7 ,agreements with service providers ,a copy of any agreements between the plan1 health insurance issuer1 and contract administrators and other service providers4 7c7 ,filing notice of certification with ,states ,a certification granted under this part to a small business health plan shall not be effective unless written notice of such certification is filed with the applicable ,state authority of each ,state in which the small business health plans operate4 7d7 ,notice of material changes ,in the case of any small business health plan certified under this part1 descriptions of material changes in any information which was required to be submitted with the application for the certification under this part shall be filed in such form and manner as shall be prescribed by the applicable authority by regulation4 ,the applicable authority may require by regulation prior notice of material changes with respect to specified matters which might serve as the basis for suspension or revocation of the certification4 #hjh4 ,notice requirements for voluntary termination ,a small business health plan which is or has been certified under this part may terminate 7upon or at any time after cessation of accruals in benefit liabilities7 only if the board of trustees1 not less than #fj days before the proposed termination date-- 7#a7 provides to the participants and beneficiaries a written notice of intent to terminate stating that such termination is intended and the proposed termination date2 7#b7 develops a plan for winding up the affairs of the plan in connection with such termination in a manner which will result in timely payment of all benefits for which the plan is obligated2 and 7#c7 submits such plan in writing to the applicable authority4 ,actions required under this section shall be taken in such form and manner as may be prescribed by the applicable authority by regulation4 #hji4 ,implementation and application authority by ,secretary ,the ,secretary shall1 through promulgation and implementation of such regulations as the ,secretary may reasonably determine necessary or appropriate1 and in consultation with a balanced spectrum of effected entities and persons1 modify the implementation and application of this part to accommodate with minimum disruption such changes to ,state or ,federal law provided in this part and the 7and the amendments made by such ,act7 or in regulations issued thereto4 #haj4 ,definitions and rules of construction 7a7 ,definitions ,for purposes of this part-- 7#a7 ,affiliated member ,the term affiliated member means1 in connection with a sponsor-- 7,a7 a person who is otherwise eligible to be a member of the sponsor but who elects an affiliated status with the sponsor1 or 7,b7 in the case of a sponsor with members which consist of associations1 a person who is a member or employee of any such association and elects an affiliated status with the sponsor4 7#b7 ,applicable authority ,the term applicable authority means the ,secretary of ,labor1 except that1 in connection with any exercise of the ,secretary's authority with respect to which the ,secretary is required under section #ejf7;d7 to consult with a ,state1 such term means the ,secretary1 in consultation with such ,state4 7#c7 ,applicable ,state authority ,the term applicable ,state authority means1 with respect to a health insurance issuer in a ,state1 the ,state insurance commissioner or official or officials designated by the ,state to enforce the requirements of title ,,xxvii of the ,public ,health ,service ,act for the ,state involved with respect to such issuer4 7#d7 ,group health plan ,the term group health plan has the meaning provided in section #gcc7;a77#a7 7after applying subsection 7b7 of this section74 7#e7 ,health insurance coverage ,the term health insurance coverage has the meaning provided in section #gcc7;b77#a71 except that such term shall not include excepted benefits 7as defined in section #gcc7;c774 7#f7 ,health insurance issuer ,the term health insurance issuer has the meaning provided in section #gcc7;b77#b74 7#g7 ,individual market 7,a7 ,in general ,the term individual market means the market for health insurance coverage offered to individuals other than in connection with a group health plan4 7,b7 ,treatment of very small groups 7i7 ,in general ,subject to clause 7ii71 such term includes coverage offered in connection with a group health plan that has fewer than #b participants as current employees or participants described in section #gcb7;d77#c7 on the first day of the plan year4 7ii7 ,state exception ,clause 7i7 shall not apply in the case of health insurance coverage offered in a ,state if such ,state regulates the coverage described in such clause in the same manner and to the same extent as coverage in the small group market 7as defined in section #bgia7;e77#e7 of the ,public ,health ,service ,act7 is regulated by such ,state4 7#h7 ,medical care ,the term medical care has the meaning provided in section #gcc7;a77#b74 7#i7 ,participating employer ,the term participating employer means1 in connection with a small business health plan1 any employer1 if any individual who is an employee of such employer1 a partner in such employer1 or a self-employed individual who is such employer 7or any dependent1 as defined under the terms of the plan1 of such individual7 is or was covered under such plan in connection with the status of such individual as such an employee1 partner1 or self-employed individual in relation to the plan4 7#aj7 ,small employer ,the term small employer means1 in connection with a group health plan with respect to a plan year1 a small employer as defined in section #bgia7;e77#d74 7#aa7 ,trade association and professional association ,the terms trade association and professional association mean an entity that meets the requirements of section #a4eja7;c77#f7-a of title #bf1 ,code of ,federal ,regulations 7as in effect on the date of enactment of this ,act74 7b7 ,rule of construction ,for purposes of determining whether a plan1 fund1 or program is an employee welfare benefit plan which is a small business health plan1 and for purposes of applying this title in connection with such plan1 fund1 or program so determined to be such an employee welfare benefit plan-- 7#a7 in the case of a partnership1 the term employer 7as defined in section #c7e77 includes the partnership in relation to the partners1 and the term employee 7as defined in section #c7f77 includes any partner in relation to the partnership2 and 7#b7 in the case of a self-employed individual1 the term employer 7as defined in section #c7e77 and the term employee 7as defined in section #c7f77 shall include such individual4 7c7 ,renewal ,notwithstanding any provision of law to the contrary1 a participating employer in a small business health plan shall not be deemed to be a plan sponsor in applying requirements relating to coverage renewal4 7d7 ,health savings accounts ,nothing in this part shall be construed to create any mandates for coverage of benefits for ,,hsa-qualified health plans that would require reimbursements in violation of section #bbc7;c77#b7 of the ,internal ,revenue ,code of #aihf4 4 7b7 ,conforming amendments to preemption rules 7#a7 ,section #ead7;b77#f7 of such ,act 7#bi ,u4,s4,c4 #aadd7;b77#f771 as restored by section #b1 is amended by adding at the end the following new subparagraph3 7,e7 ,the preceding subparagraphs of this paragraph do not apply with respect to any ,state law in the case of a small business health plan which is certified under part #h4 4 7#b7 ,section #ead of such ,act 7#bi ,u4,s4,c4 #aadd71 as restored by section #b1 is amended-- 7,a7 in subsection 7b77#d71 by striking ,subsection 7a7 and inserting ,subsections 7a7 and 7d72 7,b7 in subsection 7b77#e71 by striking subsection 7a7 in subparagraph 7,a7 and inserting subsection 7a7 of this section and subsections 7a77#b77;,b7 and 7b7 of section #hje1 and by striking subsection 7a7 in subparagraph 7,b7 and inserting subsection 7a7 of this section or subsection 7a77#b77;,b7 or 7b7 of section #hje2 7,c7 by redesignating subsection 7d7 as subsection 7e72 and 7,d7 by inserting after subsection 7c7 the following new subsection3 7d7 7#a7 ,except as provided in subsection 7b77#d71 the provisions of this title shall supersede any and all ,state laws insofar as they may now or hereafter preclude a health insurance issuer from offering health insurance coverage in connection with a small business health plan which is certified under part #h4 7#b7 ,in any case in which health insurance coverage of any policy type is offered under a small business health plan certified under part #h to a participating employer operating in such ,state1 the provisions of this title shall supersede any and all laws of such ,state insofar as they may establish rating and benefit requirements that would otherwise apply to such coverage1 provided the requirements of subtitle ,a of title ,,xxxi of the ,public ,health ,service ,act 7as added by title ,,ii of the ,health ,security for ,all ,americans ,act of #bjaj7 7concerning health plan rating and benefits7 are met4 4 7c7 ,plan sponsor ,section #c7af77;,b7 of such ,act 7#bi ,u4,s4,c4 #ajb7af77;,b771 as restored by section #b1 is amended by adding at the end the following new sentence3 ,such term also includes a person serving as the sponsor of a small business health plan under part #h44 7d7 ,savings clause ,section #gca7;c7 of such ,act1 as restored by section #b1 is amended by inserting or part #h after this part4 7e7 ,clerical amendment ,the table of contents in section #a of the ,employee ,retirement ,income ,security ,act of #aigd1 as restored by section #b1 is amended by inserting after the item relating to section #gcd the following new items3 ,part #h--,rules governing small business health plans#hja4 ,small business health plans4#hjb4 ,alternative market pooling organizations4#hjc4 ,certification of small business health plans4#hjd4 ,requirements relating to sponsors and boards of trustees4#hje4 ,participation and coverage requirements4#hjf4 ,other requirements relating to plan documents1 contribution rates1 and benefit options4#hjg4 ,requirements for application and related requirements4#hjh4 ,notice requirements for voluntary termination4#hji4 ,implementation and application authority by ,secretary4#haj4 ,definitions and rules of construction4 4 #bjb4 ,cooperation between ,federal and ,state authorities ,section #ejf of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aacf71 as restored by section #b1 is amended by adding at the end the following new subsection3 7d7 ,consultation with ,states with respect to small business health plans 7#a7 ,agreements with ,states ,the ,secretary shall consult with the ,state recognized under paragraph 7#b7 with respect to a small business health plan regarding the exercise of-- 7,a7 the ,secretary's authority under sections #ejb and #ejd to enforce the requirements for certification under part #h2 and 7,b7 the ,secretary's authority to certify small business health plans under part #h in accordance with regulations of the ,secretary applicable to certification under part #h4 7#b7 ,recognition of domicile ,state ,in carrying out paragraph 7#a71 the ,secretary shall ensure that only one ,state will be recognized1 with respect to any particular small business health plan1 as the ,state with which consultation is required4 ,in carrying out this paragraph such ,state shall be the domicile ,state1 as defined in section #hje7;c74 4 #bjc4 ,effective date and transitional and other rules 7a7 ,effective date ,the amendments made by this subtitle shall take effect #ab months after the date of the enactment of this ,act4 ,the ,secretary of ,labor shall first issue all regulations necessary to carry out the amendments made by this subtitle within #f months after the date of the enactment of this ,act4 7b7 ,treatment of certain existing health benefits programs 7#a7 ,in general ,in any case in which1 as of the date of the enactment of this ,act1 an arrangement is maintained in a ,state for the purpose of providing benefits consisting of medical care for the employees and beneficiaries of its participating employers1 at least #bjj participating employers make contributions to such arrangement1 such arrangement has been in existence for at least #aj years1 and such arrangement is licensed under the laws of one or more ,states to provide such benefits to its participating employers1 upon the filing with the applicable authority 7as defined in section #hjh7;a77#b7 of the ,employee ,retirement ,income ,security ,act of #aigd 7as amended by this subtitle77 by the arrangement of an application for certification of the arrangement under part #h of subtitle ,b of title ,i of such ,act-- 7,a7 such arrangement shall be deemed to be a group health plan for purposes of title ,i of such ,act2 7,b7 the requirements of sections #hja7;a7 and #hjc7;a7 of the ,employee ,retirement ,income ,security ,act of #aigd shall be deemed met with respect to such arrangement2 7,c7 the requirements of section #hjc7;b7 of such ,act shall be deemed met1 if the arrangement is operated by a board of trustees which has control over the arrangement2 7,d7 the requirements of section #hjd7;a7 of such ,act shall be deemed met with respect to such arrangement2 and 7,e7 the arrangement may be certified by any applicable authority with respect to its operations in any ,state only if it operates in such ,state on the date of certification4 ,the provisions of this subsection shall cease to apply with respect to any such arrangement at such time after the date of the enactment of this ,act as the applicable requirements of this subsection are not met with respect to such arrangement or at such time that the arrangement provides coverage to participants and beneficiaries in any ,state other than the ,states in which coverage is provided on such date of enactment4 7#b7 ,definitions ,for purposes of this subsection1 the terms group health plan1 medical care1 and participating employer shall have the meanings provided in section #hjh of the ,employee ,retirement ,income ,security ,act of #aigd1 except that the reference in paragraph 7#g7 of such section to an small business health plan shall be deemed a reference to an arrangement referred to in this subsection4 ,b ,market ,relief #bjd4 ,market relief ,the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bja et seq471 as restored by section #b1 is amended by inserting after title ,,xxx the following3 ,,xxxi ,health care insurance marketplace modernization #caja4 ,general insurance definitions ,in this title1 the terms health insurance coverage1 health insurance issuer1 group health plan1 and individual health insurance shall have the meanings given such terms in section #bgia4 #cajb4 ,implementation and application authority by ,secretary ,the ,secretary shall1 through promulgation and implementation of such regulations as the ,secretary may reasonably determine necessary or appropriate1 and in consultation with a balanced spectrum of effected entities and persons1 modify the implementation and application of this title to accommodate with minimum disruption such changes to ,state or ,federal law provided in this title and the 7and the amendments made by such ,act7 or in regulations issued thereto4 ,a ,market relief ,i ,rating requirements #caaa4 ,definitions ,in this part3 7#a7 ,adopting state ,the term adopting ,state means a ,state that1 with respect to the small group market1 has enacted small group rating rules that meet the minimum standards set forth in section #caab7;a77#a7 or1 as applicable1 transitional small group rating rules set forth in section #caab7;b74 7#b7 ,applicable ,state authority ,the term applicable ,state authority means1 with respect to a health insurance issuer in a ,state1 the ,state insurance commissioner or official or officials designated by the ,state to enforce the insurance laws of such ,state4 7#c7 ,base premium rate ,the term base premium rate means1 for each class of business with respect to a rating period1 the lowest premium rate charged or that could have been charged under a rating system for that class of business by the small employer carrier to small employers with similar case characteristics for health benefit plans with the same or similar coverage4 7#d7 ,eligible insurer ,the term eligible insurer means a health insurance issuer that is licensed in a ,state and that-- 7,a7 notifies the ,secretary1 not later than #cj days prior to the offering of coverage described in this subparagraph1 that the issuer intends to offer health insurance coverage consistent with the ,model ,small ,group ,rating ,rules or1 as applicable1 transitional small group rating rules in a ,state2 7,b7 notifies the insurance department of a nonadopting ,state 7or other ,state agency71 not later than #cj days prior to the offering of coverage described in this subparagraph1 that the issuer intends to offer small group health insurance coverage in that ,state consistent with the ,model ,small ,group ,rating ,rules1 and provides with such notice a copy of any insurance policy that it intends to offer in the ,state1 its most recent annual and quarterly financial reports1 and any other information required to be filed with the insurance department of the ,state 7or other ,state agency72 and 7,c7 includes in the terms of the health insurance coverage offered in nonadopting ,states 7including in the terms of any individual certificates that may be offered to individuals in connection with such group health coverage7 and filed with the ,state pursuant to subparagraph 7,b71 a description in the insurer's contract of the ,model ,small ,group ,rating ,rules and an affirmation that such ,rules are included in the terms of such contract4 7#e7 ,health insurance coverage ,the term health insurance coverage means any coverage issued in the small group health insurance market1 except that such term shall not include excepted benefits 7as defined in section #bgia7;c774 7#f7 ,index rate ,the term index rate means for each class of business with respect to the rating period for small employers with similar case characteristics1 the arithmetic average of the applicable base premium rate and the corresponding highest premium rate4 7#g7 ,model ,small ,group ,rating ,rules ,the term ,model ,small ,group ,rating ,rules means the rules set forth in section #caab7;a77#b74 7#h7 ,nonadopting state ,the term nonadopting ,state means a ,state that is not an adopting ,state4 7#i7 ,small group insurance market ,the term small group insurance market shall have the meaning given the term small group market in section #bgia7;e77#e74 7#aj7 ,state law ,the term ,state law means all laws1 decisions1 rules1 regulations1 or other ,state actions 7including actions by a ,state agency7 having the effect of law1 of any ,state4 7#aa7 ,variation limits 7,a7 ,composite variation limit 7i7 ,in general ,the term composite variation limit means the total variation in premium rates charged by a health insurance issuer in the small group market as permitted under applicable ,state law based on the following factors or case characteristics3 7,i7 ,age4 7,,ii7 ,duration of coverage4 7,,iii7 ,claims experience4 7,,iv7 ,health status4 7ii7 ,use of factors ,with respect to the use of the factors described in clause 7i7 in setting premium rates1 a health insurance issuer shall use one or both of the factors described in subclauses 7,i7 or 7,,iv7 of such clause and may use the factors described in subclauses 7,,ii7 or 7,,iii7 of such clause4 7,b7 ,total variation limit ,the term total variation limit means the total variation in premium rates charged by a health insurance issuer in the small group market as permitted under applicable ,state law based on all factors and case characteristics 7as described in section #caab7;a77#a774 #caab4 ,rating rules 7a7 ,establishment of minimum standards for premium variations and model small group rating rules ,not later than #f months after the date of enactment of this title1 the ,secretary shall promulgate regulations establishing the following ,minimum ,standards and ,model ,small ,group ,rating ,rules3 7#a7 ,minimum standards for premium variations 7,a7 ,composite variation limit ,the composite variation limit shall not be less than #c3a4 7,b7 ,total variation limit ,the total variation limit shall not be less than #e3a4 7,c7 ,prohibition on use of certain case characteristics ,for purposes of this paragraph1 in calculating the total variation limit1 the ,state shall not use case characteristics other than those used in calculating the composite variation limit and industry1 geographic area1 group size1 participation rate1 class of business1 and participation in wellness programs4 7#b7 ,model ,small ,group ,rating ,rules ,the following apply to an eligible insurer in a non-adopting ,state3 7,a7 ,premium rates ,premium rates for small group health benefit plans to which this title applies shall comply with the following provisions relating to premiums1 except as provided for under subsection 7b73 7i7 ,variation in premium rates ,the plan may not vary premium rates by more than the minimum standards provided for under paragraph 7#a74 7ii7 ,index rate ,the index rate for a rating period for any class of business shall not exceed the index rate for any other class of business by more than #bj percent1 excluding those classes of business related to association groups under this title4 7iii7 ,class of businesses ,with respect to a class of business1 the premium rates charged during a rating period to small employers with similar case characteristics for the same or similar coverage or the rates that could be charged to such employers under the rating system for that class of business1 shall not vary from the index rate by more than #be percent of the index rate under clause 7ii74 7iv7 ,increases for new rating periods ,the percentage increase in the premium rate charged to a small employer for a new rating period may not exceed the sum of the following3 7,i7 ,the percentage change in the new business premium rate measured from the first day of the prior rating period to the first day of the new rating period4 ,in the case of a health benefit plan into which the small employer carrier is no longer enrolling new small employers1 the small employer carrier shall use the percentage change in the base premium rate1 except that such change shall not exceed1 on a percentage basis1 the change in the new business premium rate for the most similar health benefit plan into which the small employer carrier is actively enrolling new small employers4 7,,ii7 ,any adjustment1 not to exceed #ae percent annually and adjusted pro rata for rating periods of less then #a year1 due to the claim experience1 health status or duration of coverage of the employees or dependents of the small employer as determined from the small employer carrier's rate manual for the class of business involved4 7,,iii7 ,any adjustment due to change in coverage or change in the case characteristics of the small employer as determined from the small employer carrier's rate manual for the class of business4 7v7 ,uniform application of adjustments ,adjustments in premium rates for claim experience1 health status1 or duration of coverage shall not be charged to individual employees or dependents4 ,any such adjustment shall be applied uniformly to the rates charged for all employees and dependents of the small employer4 7vi7 ,prohibition on use of certain case characteristic ,a small employer carrier shall not utilize case characteristics1 other than those permitted under paragraph 7#a77;,c71 without the prior approval of the applicable ,state authority4 7vii7 ,consistent application of factors ,small employer carriers shall apply rating factors1 including case characteristics1 consistently with respect to all small employers in a class of business4 ,rating factors shall produce premiums for identical groups which differ only by the amounts attributable to plan design and do not reflect differences due to the nature of the groups assumed to select particular health benefit plans4 7viii7 ,treatment of plans as having same rating period ,a small employer carrier shall treat all health benefit plans issued or renewed in the same calendar month as having the same rating period4 7ix7 ,require compliance ,premium rates for small business health benefit plans shall comply with the requirements of this subsection notwithstanding any assessments paid or payable by a small employer carrier as required by a ,state's small employer carrier reinsurance program4 7,b7 ,establishment of separate class of business ,subject to subparagraph 7,c71 a small employer carrier may establish a separate class of business only to reflect substantial differences in expected claims experience or administrative costs related to the following3 7i7 ,the small employer carrier uses more than one type of system for the marketing and sale of health benefit plans to small employers4 7ii7 ,the small employer carrier has acquired a class of business from another small employer carrier4 7iii7 ,the small employer carrier provides coverage to one or more association groups that meet the requirements of this title4 7,c7 ,limitation ,a small employer carrier may establish up to #i separate classes of business under subparagraph 7,b71 excluding those classes of business related to association groups under this title4 7,d7 ,limitation on transfers ,a small employer carrier shall not transfer a small employer involuntarily into or out of a class of business4 ,a small employer carrier shall not offer to transfer a small employer into or out of a class of business unless such offer is made to transfer all small employers in the class of business without regard to case characteristics1 claim experience1 health status or duration of coverage since issue4 7b7 ,transitional ,model ,small ,group ,rating ,rules 7#a7 ,in general ,not later than #f months after the date of enactment of this title and to the extent necessary to provide for a graduated transition to the minimum standards for premium variation as provided for in subsection 7a77#a71 the ,secretary1 in consultation with the ,national ,association of ,insurance ,commissioners 7,,naic71 shall promulgate ,state-specific transitional small group rating rules in accordance with this subsection1 which shall be applicable with respect to non-adopting ,states and eligible insurers operating in such ,states for a period of not to exceed #c years from the date of the promulgation of the minimum standards for premium variation pursuant to subsection 7a74 7#b7 ,compliance with transitional model small group rating rules ,during the transition period described in paragraph 7#a71 a ,state that1 on the date of enactment of this title1 has in effect a small group rating rules methodology that allows for a variation that is less than the variation provided for under subsection 7a77#a7 7concerning minimum standards for premium variation71 shall be deemed to be an adopting ,state if the ,state complies with the transitional small group rating rules as promulgated by the ,secretary pursuant to paragraph 7#a74 7#c7 ,transitioning of old business 7,a7 ,in general ,in developing the transitional small group rating rules under paragraph 7#a71 the ,secretary shall1 after consultation with the ,national ,association of ,insurance ,commissioners and representatives of insurers operating in the small group health insurance market in non-adopting ,states1 promulgate special transition standards with respect to independent rating classes for old and new business1 to the extent reasonably necessary to protect health insurance consumers and to ensure a stable and fair transition for old and new market entrants4 7,b7 ,period for operation of independent rating classes ,in developing the special transition standards pursuant to subparagraph 7,a71 the ,secretary shall permit a carrier in a non-adopting ,state1 at its option1 to maintain independent rating classes for old and new business for a period of up to #e years1 with the commencement of such #e-year period to begin at such time1 but not later than the date that is #c years after the date of enactment of this title1 as the carrier offers a book of business meeting the minimum standards for premium variation provided for in subsection 7a77#a7 or the transitional small group rating rules under paragraph 7#a74 7#d7 ,other transitional authority ,in developing the transitional small group rating rules under paragraph 7#a71 the ,secretary shall provide for the application of the transitional small group rating rules in transition ,states as the ,secretary may determine necessary for a an effective transition4 7c7 ,market re-,entry 7#a7 ,in general ,notwithstanding any other provision of law1 a health insurance issuer that has voluntarily withdrawn from providing coverage in the small group market prior to the date of enactment of this title shall not be excluded from re-entering such market on a date that is more than #ahj days after such date of enactment4 7#b7 ,termination ,the provision of this subsection shall terminate on the date that is #bd months after the date of enactment of this title4 #caac4 ,application and preemption 7a7 ,superseding of state law 7#a7 ,in general ,this part shall supersede any and all ,state laws of a non-adopting ,state insofar as such ,state laws 7whether enacted prior to or after the date of enactment of this subtitle7 relate to rating in the small group insurance market as applied to an eligible insurer1 or small group health insurance coverage issued by an eligible insurer1 including with respect to coverage issued to a small employer through a small business health plan1 in a ,state4 7#b7 ,nonadopting states ,this part shall supersede any and all ,state laws of a nonadopting ,state insofar as such ,state laws 7whether enacted prior to or after the date of enactment of this subtitle7-- 7,a7 prohibit an eligible insurer from offering1 marketing1 or implementing small group health insurance coverage consistent with the ,model ,small ,group ,rating ,rules or transitional model small group rating rules2 or 7,b7 have the effect of retaliating against or otherwise punishing in any respect an eligible insurer for offering1 marketing1 or implementing small group health insurance coverage consistent with the ,model ,small ,group ,rating ,rules or transitional model small group rating rules4 7b7 ,savings clause and construction 7#a7 ,nonapplication to adopting states ,subsection 7a7 shall not apply with respect to adopting states4 7#b7 ,nonapplication to certain insurers ,subsection 7a7 shall not apply with respect to insurers that do not qualify as eligible insurers that offer small group health insurance coverage in a nonadopting ,state4 7#c7 ,nonapplication where obtaining relief under state law ,subsection 7a77#a7 shall not supercede any ,state law in a nonadopting ,state to the extent necessary to permit individuals or the insurance department of the ,state 7or other ,state agency7 to obtain relief under ,state law to require an eligible insurer to comply with the ,model ,small ,group ,rating ,rules or transitional model small group rating rules4 7#d7 ,no effect on preemption ,in no case shall this part be construed to limit or affect in any manner the preemptive scope of sections #ejb and #ead of the ,employee ,retirement ,income ,security ,act of #aigd4 ,in no case shall this part be construed to create any cause of action under ,federal or ,state law or enlarge or affect any remedy available under the ,employee ,retirement ,income ,security ,act of #aigd4 7#e7 ,preemption limited to rating ,subsection 7a7 shall not preempt any ,state law that does not have a reference to or a connection with ,state rating rules that would otherwise apply to eligible insurers4 7c7 ,effective date ,this section shall apply1 at the election of the eligible insurer1 beginning in the first plan year or the first calendar year following the issuance of the final rules by the ,secretary under the ,model ,small ,group ,rating ,rules or1 as applicable1 the ,transitional ,model ,small ,group ,rating ,rules1 but in no event earlier than the date that is #ab months after the date of enactment of this title4 #caad4 ,civil actions and jurisdiction 7a7 ,in general ,the courts of the ,united ,states shall have exclusive jurisdiction over civil actions involving the interpretation of this part4 7b7 ,actions ,an eligible insurer may bring an action in the district courts of the ,united ,states for injunctive or other equitable relief against any officials or agents of a nonadopting ,state in connection with any conduct or action1 or proposed conduct or action1 by such officials or agents which violates1 or which would if undertaken violate1 section #caac4 7c7 ,direct filing in ,court of ,appeals ,at the election of the eligible insurer1 an action may be brought under subsection 7b7 directly in the ,united ,states ,court of ,appeals for the circuit in which the nonadopting ,state is located by the filing of a petition for review in such ,court4 7d7 ,expedited review 7#a7 ,district court ,in the case of an action brought in a district court of the ,united ,states under subsection 7b71 such court shall complete such action1 including the issuance of a judgment1 prior to the end of the #abj-;day period beginning on the date on which such action is filed1 unless all parties to such proceeding agree to an extension of such period4 7#b7 ,court of ,appeals ,in the case of an action brought directly in a ,united ,states ,court of ,appeal under subsection 7c71 or in the case of an appeal of an action brought in a district court under subsection 7b71 such ,court shall complete all action on the petition1 including the issuance of a judgment1 prior to the end of the #fj-;day period beginning on the date on which such petition is filed with the ,court1 unless all parties to such proceeding agree to an extension of such period4 7e7 ,standard of review ,a court in an action filed under this section1 shall render a judgment based on a review of the merits of all questions presented in such action and shall not defer to any conduct or action1 or proposed conduct or action1 of a nonadopting ,state4 #caae4 ,ongoing review ,not later than #e years after the date on which the ,model ,small ,group ,rating ,rules are issued under this part1 and every #e years thereafter1 the ,secretary1 in consultation with the ,national ,association of ,insurance ,commissioners1 shall prepare and submit to the appropriate committees of ,congress a report that assesses the effect of the ,model ,small ,group ,rating ,rules on access1 cost1 and market functioning in the small group market4 ,such report may1 if the ,secretary1 in consultation with the ,national ,association of ,insurance ,commissioners1 determines such is appropriate for improving access1 costs1 and market functioning1 contain legislative proposals for recommended modification to such ,model ,small ,group ,rating ,rules4 ,,ii ,affordable ,plans #caba4 ,definitions ,in this part3 7#a7 ,adopting state ,the term adopting ,state means a ,state that has enacted a law providing that small group1 individual1 and large group health insurers in such ,state may offer and sell products in accordance with the ,list of ,required ,benefits and the ,terms of ,application as provided for in section #cabb7;b74 7#b7 ,eligible insurer ,the term eligible insurer means a health insurance issuer that is licensed in a nonadopting ,state and that-- 7,a7 notifies the ,secretary1 not later than #cj days prior to the offering of coverage described in this subparagraph1 that the issuer intends to offer health insurance coverage consistent with the ,list of ,required ,benefits and ,terms of ,application in a nonadopting ,state2 7,b7 notifies the insurance department of a nonadopting ,state 7or other applicable ,state agency71 not later than #cj days prior to the offering of coverage described in this subparagraph1 that the issuer intends to offer health insurance coverage in that ,state consistent with the ,list of ,required ,benefits and ,terms of ,application1 and provides with such notice a copy of any insurance policy that it intends to offer in the ,state1 its most recent annual and quarterly financial reports1 and any other information required to be filed with the insurance department of the ,state 7or other ,state agency7 by the ,secretary in regulations2 and 7,c7 includes in the terms of the health insurance coverage offered in nonadopting ,states 7including in the terms of any individual certificates that may be offered to individuals in connection with such group health coverage7 and filed with the ,state pursuant to subparagraph 7,b71 a description in the insurer's contract of the ,list of ,required ,benefits and a description of the ,terms of ,application1 including a description of the benefits to be provided1 and that adherence to such standards is included as a term of such contract4 7#c7 ,health insurance coverage ,the term health insurance coverage means any coverage issued in the small group1 individual1 or large group health insurance markets1 including with respect to small business health plans1 except that such term shall not include excepted benefits 7as defined in section #bgia7;c774 7#d7 ,list of ,required ,benefits ,the term ,list of ,required ,benefits means the ,list issued under section #cabb7;a74 7#e7 ,nonadopting state ,the term nonadopting ,state means a ,state that is not an adopting ,state4 7#f7 ,state law ,the term ,state law means all laws1 decisions1 rules1 regulations1 or other ,state actions 7including actions by a ,state agency7 having the effect of law1 of any ,state4 7#g7 ,state ,provider ,freedom of ,choice ,law ,the term ,state ,provider ,freedom of ,choice ,law means a ,state law requiring that a health insurance issuer1 with respect to health insurance coverage1 not discriminate with respect to participation1 reimbursement1 or indemnification as to any provider who is acting within the scope of the provider's license or certification under applicable ,state law4 7#h7 ,terms of ,application ,the term ,terms of ,application means terms provided under section #cabb7;a74 #cabb4 ,offering affordable plans 7a7 ,list of ,required ,benefits ,not later than #c months after the date of enactment of this title1 the ,secretary1 in consultation with the ,national ,association of ,insurance ,commissioners1 shall issue by interim final rule a list 7to be known as the ,list of ,required ,benefits7 of covered benefits1 services1 or categories of providers that are required to be provided by health insurance issuers1 in each of the small group1 individual1 and large group markets1 in at least #bf ,states as a result of the application of ,state covered benefit1 service1 and category of provider mandate laws4 ,with respect to plans sold to or through small business health plans1 the ,list of ,required ,benefits applicable to the small group market shall apply4 7b7 ,terms of ,application 7#a7 ,state with mandates ,with respect to a ,state that has a covered benefit1 service1 or category of provider mandate in effect that is covered under the ,list of ,required ,benefits under subsection 7a71 such ,state mandate shall1 subject to paragraph 7#c7 7concerning uniform application71 apply to a coverage plan or plan in1 as applicable1 the small group1 individual1 or large group market or through a small business health plan in such ,state4 7#b7 ,states without mandates ,with respect to a ,state that does not have a covered benefit1 service1 or category of provider mandate in effect that is covered under the ,list of ,required ,benefits under subsection 7a71 such mandate shall not apply1 as applicable1 to a coverage plan or plan in the small group1 individual1 or large group market or through a small business health plan in such ,state4 7#c7 ,uniform application of laws 7,a7 ,in general ,with respect to a ,state described in paragraph 7#a71 in applying a covered benefit1 service1 or category of provider mandate that is on the ,list of ,required ,benefits under subsection 7a7 the ,state shall permit a coverage plan or plan offered in the small group1 individual1 or large group market or through a small business health plan in such ,state to apply such benefit1 service1 or category of provider coverage in a manner consistent with the manner in which such coverage is applied under one of the three most heavily subscribed national health plans offered under the ,federal ,employee ,health ,benefits ,program under chapter #hi of title #e1 ,united ,states ,code 7as determined by the ,secretary in consultation with the ,director of the ,office of ,personnel ,management71 and consistent with the ,publication of ,benefit ,applications under subsection 7c74 ,in the event a covered benefit1 service1 or category of provider appearing in the ,list of ,required ,benefits is not offered in one of the three most heavily subscribed national health plans offered under the ,federal ,employees ,health ,benefits ,program1 such covered benefit1 service1 or category of provider requirement shall be applied in a manner consistent with the manner in which such coverage is offered in the remaining most heavily subscribed plan of the remaining ,federal ,employees ,health ,benefits ,program plans1 as determined by the ,secretary1 in consultation with the ,director of the ,office of ,personnel ,management4 7,b7 ,exception regarding ,state provider freedom of choice laws ,notwithstanding subparagraph 7,a71 in the event a category of provider mandate is included in the ,list of ,covered ,benefits1 any ,state ,provider ,freedom of ,choice ,law 7as defined in section #caba7g77 that is in effect in any ,state in which such category of provider mandate is in effect shall not be preempted1 with respect to that category of provider1 by this part4 7c7 ,publication of benefit applications ,not later than #c months after the date of enactment of this title1 and on the first day of every calendar year thereafter1 the ,secretary1 in consultation with the ,director of the ,office of ,personnel ,management1 shall publish in the ,federal ,register a description of such covered benefits1 services1 and categories of providers covered in that calendar year by each of the three most heavily subscribed nationally available ,federal ,employee ,health ,benefits ,plan options which are also included on the ,list of ,required ,benefits4 7d7 ,effective dates 7#a7 ,small business health plans ,with respect to health insurance provided to participating employers of small business health plans1 the requirements of this part 7concerning lower cost plans7 shall apply beginning on the date that is #ab months after the date of enactment of this title4 7#b7 ,non-association coverage ,with respect to health insurance provided to groups or individuals other than participating employers of small business health plans1 the requirements of this part shall apply beginning on the date that is #ae months after the date of enactment of this title4 7e7 ,updating of list of required benefits ,not later than #b years after the date on which the list of required benefits is issued under subsection 7a71 and every #b years thereafter1 the ,secretary1 in consultation with the ,national ,association of ,insurance ,commissioners1 shall update the list based on changes in the laws and regulations of the ,states4 ,the ,secretary shall issue the updated list by regulation1 and such updated list shall be effective upon the first plan year following the issuance of such regulation4 #cabc4 ,application and preemption 7a7 ,superceding of state law 7#a7 ,in general ,this part shall supersede any and all ,state laws insofar as such laws relate to mandates relating to covered benefits1 services1 or categories of provider in the health insurance market as applied to an eligible insurer1 or health insurance coverage issued by an eligible insurer1 including with respect to coverage issued to a small business health plan1 in a nonadopting ,state4 7#b7 ,nonadopting states ,this part shall supersede any and all ,state laws of a nonadopting ,state 7whether enacted prior to or after the date of enactment of this title7 insofar as such laws-- 7,a7 prohibit an eligible insurer from offering1 marketing1 or implementing health insurance coverage consistent with the ,benefit ,choice ,standards1 as provided for in section #cabb7;a72 or 7,b7 have the effect of retaliating against or otherwise punishing in any respect an eligible insurer for offering1 marketing1 or implementing health insurance coverage consistent with the ,benefit ,choice ,standards4 7b7 ,savings clause and construction 7#a7 ,nonapplication to adopting states ,subsection 7a7 shall not apply with respect to adopting ,states4 7#b7 ,nonapplication to certain insurers ,subsection 7a7 shall not apply with respect to insurers that do not qualify as eligible insurers who offer health insurance coverage in a nonadopting ,state4 7#c7 ,nonapplication where obtaining relief under state law ,subsection 7a77#a7 shall not supercede any ,state law of a nonadopting ,state to the extent necessary to permit individuals or the insurance department of the ,state 7or other ,state agency7 to obtain relief under ,state law to require an eligible insurer to comply with the ,benefit ,choice ,standards4 7#d7 ,no effect on preemption ,in no case shall this part be construed to limit or affect in any manner the preemptive scope of sections #ejb and #ead of the ,employee ,retirement ,income ,security ,act of #aigd4 ,in no case shall this part be construed to create any cause of action under ,federal or ,state law or enlarge or affect any remedy available under the ,employee ,retirement ,income ,security ,act of #aigd4 7#e7 ,preemption limited to benefits ,subsection 7a7 shall not preempt any ,state law that does not have a reference to or a connection with ,state mandates regarding covered benefits1 services1 or categories of providers that would otherwise apply to eligible insurers4 #cabd4 ,civil actions and jurisdiction 7a7 ,in general ,the courts of the ,united ,states shall have exclusive jurisdiction over civil actions involving the interpretation of this part4 7b7 ,actions ,an eligible insurer may bring an action in the district courts of the ,united ,states for injunctive or other equitable relief against any officials or agents of a nonadopting ,state in connection with any conduct or action1 or proposed conduct or action1 by such officials or agents which violates1 or which would if undertaken violate1 section #cabc4 7c7 ,direct filing in ,court of ,appeals ,at the election of the eligible insurer1 an action may be brought under subsection 7b7 directly in the ,united ,states ,court of ,appeals for the circuit in which the nonadopting ,state is located by the filing of a petition for review in such ,court4 7d7 ,expedited review 7#a7 ,district court ,in the case of an action brought in a district court of the ,united ,states under subsection 7b71 such court shall complete such action1 including the issuance of a judgment1 prior to the end of the #abj-;day period beginning on the date on which such action is filed1 unless all parties to such proceeding agree to an extension of such period4 7#b7 ,court of ,appeals ,in the case of an action brought directly in a ,united ,states ,court of ,appeal under subsection 7c71 or in the case of an appeal of an action brought in a district court under subsection 7b71 such ,court shall complete all action on the petition1 including the issuance of a judgment1 prior to the end of the #fj-;day period beginning on the date on which such petition is filed with the ,court1 unless all parties to such proceeding agree to an extension of such period4 7e7 ,standard of review ,a court in an action filed under this section1 shall render a judgment based on a review of the merits of all questions presented in such action and shall not defer to any conduct or action1 or proposed conduct or action1 of a nonadopting ,state4 #cabe4 ,rules of construction 7a7 ,in general ,notwithstanding any other provision of ,federal or ,state law1 a health insurance issuer in an adopting ,state or an eligible insurer in a non-adopting ,state may amend its existing policies to be consistent with the terms of this subtitle 7concerning rating and benefits74 7b7 ,health savings accounts ,nothing in this subtitle shall be construed to create any mandates for coverage of benefits for ,,hsa-qualified health plans that would require reimbursements in violation of section #bbc7;c77#b7 of the ,internal ,revenue ,code of #aihf4 4 ,,ii ,targeted ,efforts to ,expand ,access #baa4 ,extending coverage of dependents 7a7 ,employee ,retirement ,income ,security ,act of #aigd 7#a7 ,in general ,part #g of subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd is amended by inserting after section #gad the following new section3 #gae4 ,extending coverage of dependents 7a7 ,in general ,in the case of a group health plan1 or health insurance coverage offered in connection with a group health plan1 that treats as a beneficiary under the plan an individual who is a dependent child of a participant or beneficiary under the plan1 the plan or coverage shall continue to treat the individual as a dependent child without regard to the individual's age until the individual turns #bf years of age4 7b7 ,construction ,nothing in this section shall be construed as requiring a group health plan to provide benefits for dependent children as beneficiaries under the plan or to require a participant to elect coverage of dependent children4 4 7#b7 ,clerical amendment ,the table of contents of such ,act is amended by inserting after the item relating to section #gad the following new item3 ,sec4 #gae4 ,extending coverage of dependents4 4 7b7 ,,phsa ,title ,,xxvii of the ,public ,health ,service ,act1 as restored by section #b1 is amended by inserting after section #bgjg the following new section3 #bgjh4 ,extending coverage of dependents 7a7 ,in general ,in the case of a group health plan1 or health insurance coverage offered in connection with a group health plan1 that treats as a beneficiary under the plan an individual who is a dependent child of a participant or beneficiary under the plan1 the plan or coverage shall continue to treat the individual as a dependent child without regard to the individual's age until the individual turns #bf years of age4 7b7 ,construction ,nothing in this section shall be construed as requiring a group health plan to provide benefits for dependent children as beneficiaries under the plan or to require a participant to elect coverage of dependent children4 4 7c7 ,,irc 7#a7 ,in general ,subchapter ,b of chapter #ajj of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new section3 #ihad4 ,extending coverage of dependents 7a7 ,in general ,in the case of a group health plan that treats as a beneficiary under the plan an individual who is a dependent child of a participant or beneficiary under the plan1 the plan shall continue to treat the individual as a dependent child without regard to the individual's age until the individual turns #bf years of age4 7b7 ,construction ,nothing in this section shall be construed as requiring a group health plan to provide coverage for dependent children as beneficiaries under the plan or to require a participant to elect coverage of dependent children4 4 7#b7 ,clerical amendment ,the table of sections in such subchapter is amended by adding at the end the following new item3 ,sec4 #ihad4 ,extending coverage of dependents4 4 7d7 ,effective date ,the amendments made by subsections 7a71 7b71 and 7c7 shall apply to group health plans for plan years beginning more than #c months after the date of the enactment of this ,act and shall apply to individuals who are dependent children under a group health plan1 or health insurance coverage offered in connection with such a plan1 on or after such date4 7e7 ,adult dependents 7#a7 ,exclusion of amounts expended for medical care ,the first sentence of section #aje7;b7 of the ,internal ,revenue ,code of #aihf 7relating to amounts expended for medical care7 is amended-- 7,a7 by striking and his dependents and inserting his dependents2 and 7,b7 by inserting before the period the following3 1 and any child 7as defined in section #aeb7;f77#a77 of the taxpayer who as of the end of the taxable year has not attained age #bg4 7#b7 ,self-employed health insurance deduction ,section #afb7l77#a7 of such ,code is amended to read as follows3 7#a7 ,allowance of deduction ,in the case of a taxpayer who is an employee within the meaning of section #dja7;c77#a71 there shall be allowed as a deduction under this section an amount equal to the amount paid during the taxable year for insurance which constitutes medical care for 7,a7 the taxpayer1 7,b7 the taxpayer's spouse1 7,c7 the taxpayer's dependents1 and 7,d7 any child 7as defined in section #aeb7;f77#a77 of the taxpayer who as of the end of the taxable year has not attained age #bg4 4 7#c7 ,coverage under self-employed deduction ,section #afb7l77#b77;,b7 of such ,code is amended by inserting 1 or any dependent1 or individual described in subparagraph 7,d7 of paragraph 7#a7 with respect to1 after spouse of4 7#d7 ,sick and accident benefits provided to members of a voluntary employees' beneficiary association and their dependents ,section #eja7;c77#i7 of such ,code is amended by adding at the end the following new sentence3 ,for purposes of providing for the payment of sick and accident benefits to members of such an association and their dependents1 the term dependent shall include any individual who is a child 7as defined in section #aeb7;f77#a77 of a member who as of the end of the calendar year has not attained age #bg44 7#e7 ,medical and other benefits for retired employees ,section #dja7;h7 of such ,code is amended by adding at the end the following3 ,for purposes of this subsection1 the term dependent shall include any individual who is a child 7as defined in section #aeb7;f77#a77 of a retired employee who as of the end of the calendar year has not attained age #bg44 #bab4 ,prohibiting preexisting condition exclusions for enrollees under age #ai 7a7 ,,phsa ,section #bgja7;a7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg7a771 as restored by section #b1 is amended-- 7#a7 in the matter preceding paragraph 7#a71 by inserting and the last sentence of this subsection after subsection 7d72 and 7#b7 by adding at the end the following new sentence3 ,in the case of a participant or beneficiary who is under #ai years of age1 a group health plan and a health insurance issuer offering group or individual health insurance coverage may not impose any preexisting condition exclusion with respect to such plan or coverage4 4 7b7 ,,erisa ,section #gja7;a7 of the ,employee ,retirement ,income ,security ,act of #aigd1 as restored by section #b1 is amended-- 7#a7 in the matter preceding paragraph 7#a71 by inserting and the last sentence of this subsection after subsection 7d72 and 7#b7 by adding at the end the following new sentence3 ,in the case of a participant or beneficiary who is under #ai years of age1 a group health plan and a health insurance issuer offering group or individual health insurance coverage may not impose any preexisting condition exclusion with respect to such plan or coverage4 4 7c7 ,,irc ,section #ihja of the ,internal ,revenue ,code of #aihf1 as restored by section #b1 is amended-- 7#a7 in the matter preceding paragraph 7#a71 by inserting and the last sentence of this subsection after subsection 7d72 and 7#b7 by adding at the end the following new sentence3 ,in the case of a participant or beneficiary who is under #ai years of age1 a group health plan may not impose any preexisting condition exclusion with respect to such plan4 4 #bac4 ,health plan finders 7a7 ,state plan finders ,not later than #ab months after the date of the enactment of this ,act1 each ,state may contract with a private entity to develop and operate a plan finder website 7referred to in this section as a ,state plan finder7 which shall provide information to individuals in such ,state on plans of health insurance coverage that are available to individuals in such ,state 7in this section referred to as a health insurance plan7 4 ,such ,state may not operate a plan finder itself4 7b7 ,multi-,state plan finders 7#a7 ,in general ,a private entity may operate a multi-,state finder that operates under this section in the ,states involved in the same manner as a ,state plan finder would operate in a single ,state4 7#b7 ,sharing of information ,states shall regulate the manner in which data is shared between plan finders to ensure consistency and accuracy in the information about health insurance plans contained in such finders4 7c7 ,requirements for plan finders ,each plan finder shall meet the following requirements3 7#a7 ,the plan finder shall ensure that each health insurance plan in the plan finder meets the requirements for such plans under subsection 7d74 7#b7 ,the plan finder shall present complete information on the costs and benefits of health insurance plans 7including information on monthly premium1 copayments1 and deductibles7 in a uniform manner that-- 7,a7 uses the standard definitions developed under paragraph 7#c72 and 7,b7 is designed to allow consumers to easily compare such plans4 7#c7 ,the plan finder shall be available on the ,internet and accessible to all individuals in the ,state or1 in the case of a multi-,state plan finder1 in all ,states covered by the multi-,state plan finder4 7#d7 ,the plan finder shall allow consumers to search and sort data on the health insurance plans in the plan finder on criteria such as coverage of specific benefits 7such as coverage of disease management services or pediatric care services71 as well as data available on quality4 7#e7 ,the plan finder shall meet all relevant ,state laws and regulations1 including laws and regulations related to the marketing of insurance products4 ,in the case of a multi-,state plan finder1 the finder shall meet such laws and regulations for all of the ,states involved4 7#f7 ,the plan finder shall meet solvency1 financial1 and privacy requirements established by the ,state or ,states in which the plan finder operates or the ,secretary for multi-,state finders4 7#g7 ,the plan finder and the employees of the plan finder shall be appropriately licensed in the ,state or ,states in which the plan finder operates1 if such licensure is required by such ,state or ,states4 7#h7 ,notwithstanding subsection 7f77#a71 the plan finder shall assist individuals who are eligible for the ,medicaid program under title ,,xix of the ,social ,security ,act or ,state ,children's ,health ,insurance ,program under title ,,xxi of such ,act by including information on ,medicaid options1 eligibility1 and how to enroll4 7d7 ,requirements for plans participating in a plan finder 7#a7 ,in general ,each ,state shall ensure that health insurance plans participating in the ,state plan finder or in a multi-,state plan finder meet the requirements of paragraph 7#b7 7relating to adequacy of insurance coverage1 consumer protection1 and financial strength74 7#b7 ,specific requirements ,in order to participate in a plan finder1 a health insurance plan must meet all of the following requirements1 as determined by each ,state in which such plan operates3 7,a7 ,the health insurance plan shall be actuarially sound4 7,b7 ,the health insurance plan may not have a history of abusive policy rescissions4 7,c7 ,the health insurance plan shall meet financial and solvency requirements4 7,d7 ,the health insurance plan shall disclose-- 7i7 all financial arrangements involving the sale and purchase of health insurance1 such as the payment of fees and commissions2 and 7ii7 such arrangements may not be abusive4 7,e7 ,the health insurance plan shall maintain electronic health records that comply with the requirements of the ,american ,recovery and ,reinvestment ,act of #bjji 7,public ,law #aaa-e7 related to electronic health records4 7,f7 ,the health insurance plan shall make available to plan enrollees via the finder1 whether by information provided to the finder or by a website link directing the enrollee from the finder to the health insurance plan website1 data that includes the price and cost to the individual of services offered by a provider according to the terms and conditions of the health plan4 ,data described in this paragraph is not made public by the finder1 only made available to the individual once enrolled in the health plan4 7e7 ,prohibitions 7#a7 ,direct ,enrollment ,the ,state plan finder may not directly enroll individuals in health insurance plans4 7#b7 ,conflicts of interest 7,a7 ,companies ,a health insurance issuer offering a health insurance plan through a plan finder may not-- 7i7 be the private entity developing and maintaining a plan finder under subsections 7a7 and 7b72 or 7ii7 have an ownership interest in such private entity or in the plan finder4 7,b7 ,individuals ,an individual employed by a health insurance issuer offering a health insurance plan through a plan finder may not serve as a director or officer for-- 7i7 the private entity developing and maintaining a plan finder under subsections 7a7 and 7b72 or 7ii7 the plan finder4 7f7 ,construction ,nothing in this section shall be construed to allow the ,secretary authority to regulate benefit packages or to prohibit health insurance brokers and agents from-- 7#a7 utilizing the plan finder for any purpose2 or 7#b7 marketing or offering health insurance products4 7g7 ,plan finder defined ,for purposes of this section1 the term plan finder means a ,state plan finder under subsection 7a7 or a multi-,state plan finder under subsection 7b74 7h7 ,state defined ,in this section1 the term ,state has the meaning given such term for purposes of title ,,xix of the ,social ,security ,act4 ,,iii ,expanding ,choices by ,allowing ,americans to ,buy ,health ,care ,coverage ,across ,state ,lines #bba4 ,interstate purchasing of health insurance 7a7 ,in ,general ,title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg et seq471 as restored by section #b1 is amended by adding at the end the following new part3 ,d ,cooperative ,governing of ,individual ,health ,insurance ,coverage #bgie4 ,definitions ,in this part3 7#a7 ,primary state ,the term primary ,state means1 with respect to individual health insurance coverage offered by a health insurance issuer1 the ,state designated by the issuer as the ,state whose covered laws shall govern the health insurance issuer in the sale of such coverage under this part4 ,an issuer1 with respect to a particular policy1 may only designate one such ,state as its primary ,state with respect to all such coverage it offers4 ,such an issuer may not change the designated primary ,state with respect to individual health insurance coverage once the policy is issued1 except that such a change may be made upon renewal of the policy4 ,with respect to such designated ,state1 the issuer is deemed to be doing business in that ,state4 7#b7 ,secondary state ,the term secondary ,state means1 with respect to individual health insurance coverage offered by a health insurance issuer1 any ,state that is not the primary ,state4 ,in the case of a health insurance issuer that is selling a policy in1 or to a resident of1 a secondary ,state1 the issuer is deemed to be doing business in that secondary ,state4 7#c7 ,health insurance issuer ,the term health insurance issuer has the meaning given such term in section #bgia7;b77#b71 except that such an issuer must be licensed in the primary ,state and be qualified to sell individual health insurance coverage in that ,state4 7#d7 ,individual health insurance coverage ,the term individual health insurance coverage means health insurance coverage offered in the individual market1 as defined in section #bgia7;e77#a74 7#e7 ,applicable state authority ,the term applicable ,state authority means1 with respect to a health insurance issuer in a ,state1 the ,state insurance commissioner or official or officials designated by the ,state to enforce the requirements of this title for the ,state with respect to the issuer4 7#f7 ,hazardous financial condition ,the term hazardous financial condition means that1 based on its present or reasonably anticipated financial condition1 a health insurance issuer is unlikely to be able-- 7,a7 to meet obligations to policyholders with respect to known claims and reasonably anticipated claims2 or 7,b7 to pay other obligations in the normal course of business4 7#g7 ,covered laws 7,a7 ,in general ,the term covered laws means the laws1 rules1 regulations1 agreements1 and orders governing the insurance business pertaining to-- 7i7 individual health insurance coverage issued by a health insurance issuer2 7ii7 the offer1 sale1 rating 7including medical underwriting71 renewal1 and issuance of individual health insurance coverage to an individual2 7iii7 the provision to an individual in relation to individual health insurance coverage of health care and insurance related services2 7iv7 the provision to an individual in relation to individual health insurance coverage of management1 operations1 and investment activities of a health insurance issuer2 and 7v7 the provision to an individual in relation to individual health insurance coverage of loss control and claims administration for a health insurance issuer with respect to liability for which the issuer provides insurance4 7,b7 ,exception ,such term does not include any law1 rule1 regulation1 agreement1 or order governing the use of care or cost management techniques1 including any requirement related to provider contracting1 network access or adequacy1 health care data collection1 or quality assurance4 7#h7 ,state ,the term ,state means the #ej ,states and includes the ,district of ,columbia1 ,puerto ,rico1 the ,virgin ,islands1 ,guam1 ,american ,samoa1 and the ,northern ,mariana ,islands4 7#i7 ,unfair claims settlement practices ,the term unfair claims settlement practices means only the following practices3 7,a7 ,knowingly misrepresenting to claimants and insured individuals relevant facts or policy provisions relating to coverage at issue4 7,b7 ,failing to acknowledge with reasonable promptness pertinent communications with respect to claims arising under policies4 7,c7 ,failing to adopt and implement reasonable standards for the prompt investigation and settlement of claims arising under policies4 7,d7 ,failing to effectuate prompt1 fair1 and equitable settlement of claims submitted in which liability has become reasonably clear4 7,e7 ,refusing to pay claims without conducting a reasonable investigation4 7,f7 ,failing to affirm or deny coverage of claims within a reasonable period of time after having completed an investigation related to those claims4 7,g7 ,a pattern or practice of compelling insured individuals or their beneficiaries to institute suits to recover amounts due under its policies by offering substantially less than the amounts ultimately recovered in suits brought by them4 7,h7 ,a pattern or practice of attempting to settle or settling claims for less than the amount that a reasonable person would believe the insured individual or his or her beneficiary was entitled by reference to written or printed advertising material accompanying or made part of an application4 7,i7 ,attempting to settle or settling claims on the basis of an application that was materially altered without notice to1 or knowledge or consent of1 the insured4 7,j7 ,failing to provide forms necessary to present claims within #ae calendar days of a requests with reasonable explanations regarding their use4 7,k7 ,attempting to cancel a policy in less time than that prescribed in the policy or by the law of the primary ,state4 7#aj7 ,fraud and abuse ,the term fraud and abuse means an act or omission committed by a person who1 knowingly and with intent to defraud1 commits1 or conceals any material information concerning1 one or more of the following3 7,a7 ,presenting1 causing to be presented or preparing with knowledge or belief that it will be presented to or by an insurer1 a reinsurer1 broker or its agent1 false information as part of1 in support of or concerning a fact material to one or more of the following3 7i7 ,an application for the issuance or renewal of an insurance policy or reinsurance contract4 7ii7 ,the rating of an insurance policy or reinsurance contract4 7iii7 ,a claim for payment or benefit pursuant to an insurance policy or reinsurance contract4 7iv7 ,premiums paid on an insurance policy or reinsurance contract4 7v7 ,payments made in accordance with the terms of an insurance policy or reinsurance contract4 7vi7 ,a document filed with the commissioner or the chief insurance regulatory official of another jurisdiction4 7vii7 ,the financial condition of an insurer or reinsurer4 7viii7 ,the formation1 acquisition1 merger1 reconsolidation1 dissolution or withdrawal from one or more lines of insurance or reinsurance in all or part of a ,state by an insurer or reinsurer4 7ix7 ,the issuance of written evidence of insurance4 7x7 ,the reinstatement of an insurance policy4 7,b7 ,solicitation or acceptance of new or renewal insurance risks on behalf of an insurer reinsurer or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction4 7,c7 ,transaction of the business of insurance in violation of laws requiring a license1 certificate of authority or other legal authority for the transaction of the business of insurance4 7,d7 ,attempt to commit1 aiding or abetting in the commission of1 or conspiracy to commit the acts or omissions specified in this paragraph4 #bgif4 ,application of law 7a7 ,in ,general ,the covered laws of the primary ,state shall apply to individual health insurance coverage offered by a health insurance issuer in the primary ,state and in any secondary ,state1 but only if the coverage and issuer comply with the conditions of this section with respect to the offering of coverage in any secondary ,state4 7b7 ,exemptions ,from ,covered ,laws in a ,secondary ,state ,except as provided in this section1 a health insurance issuer with respect to its offer1 sale1 rating 7including medical underwriting71 renewal1 and issuance of individual health insurance coverage in any secondary ,state is exempt from any covered laws of the secondary ,state 7and any rules1 regulations1 agreements1 or orders sought or issued by such ,state under or related to such covered laws7 to the extent that such laws would-- 7#a7 make unlawful1 or regulate1 directly or indirectly1 the operation of the health insurance issuer operating in the secondary ,state1 except that any secondary ,state may require such an issuer-- 7,a7 to pay1 on a nondiscriminatory basis1 applicable premium and other taxes 7including high risk pool assessments7 which are levied on insurers and surplus lines insurers1 brokers1 or policyholders under the laws of the ,state2 7,b7 to register with and designate the ,state insurance commissioner as its agent solely for the purpose of receiving service of legal documents or process2 7,c7 to submit to an examination of its financial condition by the ,state insurance commissioner in any ,state in which the issuer is doing business to determine the issuer's financial condition1 if-- 7i7 the ,state insurance commissioner of the primary ,state has not done an examination within the period recommended by the ,national ,association of ,insurance ,commissioners2 and 7ii7 any such examination is conducted in accordance with the examiners' handbook of the ,national ,association of ,insurance ,commissioners and is coordinated to avoid unjustified duplication and unjustified repetition2 7,d7 to comply with a lawful order issued-- 7i7 in a delinquency proceeding commenced by the ,state insurance commissioner if there has been a finding of financial impairment under subparagraph 7,c72 or 7ii7 in a voluntary dissolution proceeding2 7,e7 to comply with an injunction issued by a court of competent jurisdiction1 upon a petition by the ,state insurance commissioner alleging that the issuer is in hazardous financial condition2 7,f7 to participate1 on a nondiscriminatory basis1 in any insurance insolvency guaranty association or similar association to which a health insurance issuer in the ,state is required to belong2 7,g7 to comply with any ,state law regarding fraud and abuse 7as defined in section #bgie7aj771 except that if the ,state seeks an injunction regarding the conduct described in this subparagraph1 such injunction must be obtained from a court of competent jurisdiction2 7,h7 to comply with any ,state law regarding unfair claims settlement practices 7as defined in section #bgie7i772 or 7,i7 to comply with the applicable requirements for independent review under section #bgih with respect to coverage offered in the ,state2 7#b7 require any individual health insurance coverage issued by the issuer to be countersigned by an insurance agent or broker residing in that ,secondary ,state2 or 7#c7 otherwise discriminate against the issuer issuing insurance in both the primary ,state and in any secondary ,state4 7c7 ,clear and ,conspicuous ,disclosure ,a health insurance issuer shall provide the following notice1 in #ab-point bold type1 in any insurance coverage offered in a secondary ,state under this part by such a health insurance issuer and at renewal of the policy1 with the #e blank spaces therein being appropriately filled with the name of the health insurance issuer1 the name of primary ,state1 the name of the secondary ,state1 the name of the secondary ,state1 and the name of the secondary ,state1 respectively1 for the coverage concerned3 ,this policy is issued by and is governed by the laws and regulations of the ,state of 1 and it has met all the laws of that ,state as determined by that ,state's ,department of ,insurance4 ,this policy may be less expensive than others because it is not subject to all of the insurance laws and regulations of the ,state of 1 including coverage of some services or benefits mandated by the law of the ,state of 4 ,additionally1 this policy is not subject to all of the consumer protection laws or restrictions on rate changes of the ,state of 4 ,as with all insurance products1 before purchasing this policy1 you should carefully review the policy and determine what health care services the policy covers and what benefits it provides1 including any exclusions1 limitations1 or conditions for such services or benefits4 4 7d7 ,prohibition on ,certain ,reclassifications and ,premium ,increases 7#a7 ,in general ,for purposes of this section1 a health insurance issuer that provides individual health insurance coverage to an individual under this part in a primary or secondary ,state may not upon renewal-- 7,a7 move or reclassify the individual insured under the health insurance coverage from the class such individual is in at the time of issue of the contract based on the health-status related factors of the individual2 or 7,b7 increase the premiums assessed the individual for such coverage based on a health status-related factor or change of a health status-related factor or the past or prospective claim experience of the insured individual4 7#b7 ,construction ,nothing in paragraph 7#a7 shall be construed to prohibit a health insurance issuer-- 7,a7 from terminating or discontinuing coverage or a class of coverage in accordance with subsections 7b7 and 7c7 of section #bgdb2 7,b7 from raising premium rates for all policy holders within a class based on claims experience2 7,c7 from changing premiums or offering discounted premiums to individuals who engage in wellness activities at intervals prescribed by the issuer1 if such premium changes or incentives-- 7i7 are disclosed to the consumer in the insurance contract2 7ii7 are based on specific wellness activities that are not applicable to all individuals2 and 7iii7 are not obtainable by all individuals to whom coverage is offered2 7,d7 from reinstating lapsed coverage2 or 7,e7 from retroactively adjusting the rates charged an insured individual if the initial rates were set based on material misrepresentation by the individual at the time of issue4 7e7 ,prior ,offering of ,policy in ,primary ,state ,a health insurance issuer may not offer for sale individual health insurance coverage in a secondary ,state unless that coverage is currently offered for sale in the primary ,state4 7f7 ,licensing of ,agents or ,brokers for ,health ,insurance ,issuers ,any ,state may require that a person acting1 or offering to act1 as an agent or broker for a health insurance issuer with respect to the offering of individual health insurance coverage obtain a license from that ,state1 with commissions or other compensation subject to the provisions of the laws of that ,state1 except that a ,state may not impose any qualification or requirement which discriminates against a nonresident agent or broker4 7g7 ,documents for ,submission to ,state ,insurance ,commissioner ,each health insurance issuer issuing individual health insurance coverage in both primary and secondary ,states shall submit-- 7#a7 to the insurance commissioner of each ,state in which it intends to offer such coverage1 before it may offer individual health insurance coverage in such ,state-- 7,a7 a copy of the plan of operation or feasibility study or any similar statement of the policy being offered and its coverage 7which shall include the name of its primary ,state and its principal place of business72 7,b7 written notice of any change in its designation of its primary ,state2 and 7,c7 written notice from the issuer of the issuer's compliance with all the laws of the primary ,state2 and 7#b7 to the insurance commissioner of each secondary ,state in which it offers individual health insurance coverage1 a copy of the issuer's quarterly financial statement submitted to the primary ,state1 which statement shall be certified by an independent public accountant and contain a statement of opinion on loss and loss adjustment expense reserves made by-- 7,a7 a member of the ,american ,academy of ,actuaries2 or 7,b7 a qualified loss reserve specialist4 7h7 ,power of ,courts ,to ,enjoin ,conduct ,nothing in this section shall be construed to affect the authority of any ,federal or ,state court to enjoin-- 7#a7 the solicitation or sale of individual health insurance coverage by a health insurance issuer to any person or group who is not eligible for such insurance2 or 7#b7 the solicitation or sale of individual health insurance coverage that violates the requirements of the law of a secondary ,state which are described in subparagraphs 7,a7 through 7,h7 of section #bgif7;b77#a74 7i7 ,power of ,secondary ,states ,to ,take ,administrative ,action ,nothing in this section shall be construed to affect the authority of any ,state to enjoin conduct in violation of that ,state's laws described in section #bgif7;b77#a74 7j7 ,state ,powers ,to ,enforce ,state ,laws 7#a7 ,in general ,subject to the provisions of subsection 7b77#a77;,g7 7relating to injunctions7 and paragraph 7#b71 nothing in this section shall be construed to affect the authority of any ,state to make use of any of its powers to enforce the laws of such ,state with respect to which a health insurance issuer is not exempt under subsection 7b74 7#b7 ,courts of competent jurisdiction ,if a ,state seeks an injunction regarding the conduct described in paragraphs 7#a7 and 7#b7 of subsection 7h71 such injunction must be obtained from a ,federal or ,state court of competent jurisdiction4 7k7 ,states' ,authority ,to ,sue ,nothing in this section shall affect the authority of any ,state to bring action in any ,federal or ,state court4 7l7 ,generally ,applicable ,laws ,nothing in this section shall be construed to affect the applicability of ,state laws generally applicable to persons or corporations4 7m7 ,guaranteed ,availability of ,coverage to ,,hipaa ,eligible ,individuals ,to the extent that a health insurance issuer is offering coverage in a primary ,state that does not accommodate residents of secondary ,states or does not provide a working mechanism for residents of a secondary ,state1 and the issuer is offering coverage under this part in such secondary ,state which has not adopted a qualified high risk pool as its acceptable alternative mechanism 7as defined in section #bgdd7;c77#b771 the issuer shall1 with respect to any individual health insurance coverage offered in a secondary ,state under this part1 comply with the guaranteed availability requirements for eligible individuals in section #bgda4 #bgig4 ,primary ,state must meet ,federal floor before issuer may sell into secondary ,states ,a health insurance issuer may not offer1 sell1 or issue individual health insurance coverage in a secondary ,state if the ,state insurance commissioner does not use a risk-based capital formula for the determination of capital and surplus requirements for all health insurance issuers4 #bgih4 ,independent external appeals procedures 7a7 ,right to ,external ,appeal ,a health insurance issuer may not offer1 sell1 or issue individual health insurance coverage in a secondary ,state under the provisions of this title unless-- 7#a7 both the secondary ,state and the primary ,state have legislation or regulations in place establishing an independent review process for individuals who are covered by individual health insurance coverage1 or 7#b7 in any case in which the requirements of subparagraph 7,a7 are not met with respect to the either of such ,states1 the issuer provides an independent review mechanism substantially identical 7as determined by the applicable ,state authority of such ,state7 to that prescribed in the ,health ,carrier ,external ,review ,model ,act of the ,national ,association of ,insurance ,commissioners for all individuals who purchase insurance coverage under the terms of this part1 except that1 under such mechanism1 the review is conducted by an independent medical reviewer1 or a panel of such reviewers1 with respect to whom the requirements of subsection 7b7 are met4 7b7 ,qualifications of ,independent ,medical ,reviewers ,in the case of any independent review mechanism referred to in subsection 7a77#b7-- 7#a7 ,in general ,in referring a denial of a claim to an independent medical reviewer1 or to any panel of such reviewers1 to conduct independent medical review1 the issuer shall ensure that-- 7,a7 each independent medical reviewer meets the qualifications described in paragraphs 7#b7 and 7#c72 7,b7 with respect to each review1 each reviewer meets the requirements of paragraph 7#d7 and the reviewer1 or at least #a reviewer on the panel1 meets the requirements described in paragraph 7#e72 and 7,c7 compensation provided by the issuer to each reviewer is consistent with paragraph 7#f74 7#b7 ,licensure and expertise ,each independent medical reviewer shall be a physician 7allopathic or osteopathic7 or health care professional who-- 7,a7 is appropriately credentialed or licensed in #a or more ,states to deliver health care services2 and 7,b7 typically treats the condition1 makes the diagnosis1 or provides the type of treatment under review4 7#c7 ,independence 7,a7 ,in general ,subject to subparagraph 7,b71 each independent medical reviewer in a case shall-- 7i7 not be a related party 7as defined in paragraph 7#g772 7ii7 not have a material familial1 financial1 or professional relationship with such a party2 and 7iii7 not otherwise have a conflict of interest with such a party 7as determined under regulations74 7,b7 ,exception ,nothing in subparagraph 7,a7 shall be construed to-- 7i7 prohibit an individual1 solely on the basis of affiliation with the issuer1 from serving as an independent medical reviewer if-- 7,i7 a non-affiliated individual is not reasonably available2 7,,ii7 the affiliated individual is not involved in the provision of items or services in the case under review2 7,,iii7 the fact of such an affiliation is disclosed to the issuer and the enrollee 7or authorized representative7 and neither party objects2 and 7,,iv7 the affiliated individual is not an employee of the issuer and does not provide services exclusively or primarily to or on behalf of the issuer2 7ii7 prohibit an individual who has staff privileges at the institution where the treatment involved takes place from serving as an independent medical reviewer merely on the basis of such affiliation if the affiliation is disclosed to the issuer and the enrollee 7or authorized representative71 and neither party objects2 or 7iii7 prohibit receipt of compensation by an independent medical reviewer from an entity if the compensation is provided consistent with paragraph 7#f74 7#d7 ,practicing health care professional in same field 7,a7 ,in general ,in a case involving treatment1 or the provision of items or services-- 7i7 by a physician1 a reviewer shall be a practicing physician 7allopathic or osteopathic7 of the same or similar specialty1 as a physician who1 acting within the appropriate scope of practice within the ,state in which the service is provided or rendered1 typically treats the condition1 makes the diagnosis1 or provides the type of treatment under review2 or 7ii7 by a non-physician health care professional1 the reviewer1 or at least #a member of the review panel1 shall be a practicing non-physician health care professional of the same or similar specialty as the non-physician health care professional who1 acting within the appropriate scope of practice within the ,state in which the service is provided or rendered1 typically treats the condition1 makes the diagnosis1 or provides the type of treatment under review4 7,b7 ,practicing defined ,for purposes of this paragraph1 the term practicing means1 with respect to an individual who is a physician or other health care professional1 that the individual provides health care services to individual patients on average at least #b days per week4 7#e7 ,pediatric expertise ,in the case of an external review relating to a child1 a reviewer shall have expertise under paragraph 7#b7 in pediatrics4 7#f7 ,limitations on reviewer compensation ,compensation provided by the issuer to an independent medical reviewer in connection with a review under this section shall-- 7,a7 not exceed a reasonable level2 and 7,b7 not be contingent on the decision rendered by the reviewer4 7#g7 ,related party defined ,for purposes of this section1 the term related party means1 with respect to a denial of a claim under a coverage relating to an enrollee1 any of the following3 7,a7 ,the issuer involved1 or any fiduciary1 officer1 director1 or employee of the issuer4 7,b7 ,the enrollee 7or authorized representative74 7,c7 ,the health care professional that provides the items or services involved in the denial4 7,d7 ,the institution at which the items or services 7or treatment7 involved in the denial are provided4 7,e7 ,the manufacturer of any drug or other item that is included in the items or services involved in the denial4 7,f7 ,any other party determined under any regulations to have a substantial interest in the denial involved4 7#h7 ,definitions ,for purposes of this subsection3 7,a7 ,enrollee ,the term enrollee means1 with respect to health insurance coverage offered by a health insurance issuer1 an individual enrolled with the issuer to receive such coverage4 7,b7 ,health care professional ,the term health care professional means an individual who is licensed1 accredited1 or certified under ,state law to provide specified health care services and who is operating within the scope of such licensure1 accreditation1 or certification4 #bgii4 ,enforcement 7a7 ,in ,general ,subject to subsection 7b71 with respect to specific individual health insurance coverage the primary ,state for such coverage has sole jurisdiction to enforce the primary ,state's covered laws in the primary ,state and any secondary ,state4 7b7 ,secondary ,state's ,authority ,nothing in subsection 7a7 shall be construed to affect the authority of a secondary ,state to enforce its laws as set forth in the exception specified in section #bgif7;b77#a74 7c7 ,court ,interpretation ,in reviewing action initiated by the applicable secondary ,state authority1 the court of competent jurisdiction shall apply the covered laws of the primary ,state4 7d7 ,notice of ,compliance ,failure ,in the case of individual health insurance coverage offered in a secondary ,state that fails to comply with the covered laws of the primary ,state1 the applicable ,state authority of the secondary ,state may notify the applicable ,state authority of the primary ,state4 4 7b7 ,effective ,date ,the amendment made by subsection 7a7 shall apply to individual health insurance coverage offered1 issued1 or sold after the date that is one year after the date of the enactment of this ,act4 7c7 ,,gao ,ongoing ,study and ,reports 7#a7 ,study ,the ,comptroller ,general of the ,united ,states shall conduct an ongoing study concerning the effect of the amendment made by subsection 7a7 on-- 7,a7 the number of uninsured and under-insured2 7,b7 the availability and cost of health insurance policies for individuals with preexisting medical conditions2 7,c7 the availability and cost of health insurance policies generally2 7,d7 the elimination or reduction of different types of benefits under health insurance policies offered in different ,states2 and 7,e7 cases of fraud or abuse relating to health insurance coverage offered under such amendment and the resolution of such cases4 7#b7 ,annual reports ,the ,comptroller ,general shall submit to ,congress an annual report1 after the end of each of the #e years following the effective date of the amendment made by subsection 7a71 on the ongoing study conducted under paragraph 7#a74 ,,iv ,improving ,health ,savings ,accounts #bca4 ,,hsa funds for premiums for high deductible health plans 7a7 ,in general ,subparagraph 7,c7 of section #bbc7;d77#b7 of the ,internal ,revenue ,code of #aihf1 as restored by section #b1 is amended by striking or at the end of clause 7iii71 by striking the period at the end of clause 7iv7 and inserting 1 or1 and by adding at the end the following3 7v7 a high deductible health plan if-- 7,i7 such plan is not offered in connection with a group health plan1 7,,ii7 no portion of any premium 7within the meaning of applicable premium under section #dihj;,b7f77#d77 for such plan is excludable from gross income under section #ajf1 and 7,,iii7 the account beneficiary demonstrates1 using procedures deemed appropriate by the ,secretary1 that after payment of the premium for such insurance the balance in the health savings account is at least twice the minimum deductible in effect under subsection 7c77#b77;,a77i7 which is applicable to such plan4 4 7b7 ,effective ,date ,the amendment made by subsection 7a7 shall apply to premiums for a high deductible health plan for periods beginning after ,december #ca1 #bjaa4 #bcb4 ,requiring greater coordination between ,,hdhp administrators and ,,hsa account administrators so that enrollees can enroll in both at the same time ,the ,secretary of the ,treasury1 through the issuance of regulations or other guidance1 shall encourage administrators of health plans and trustees of health savings accounts to provide for simultaneous enrollment in high deductible health plans and setup of health savings accounts4 #bcc4 ,special rule for certain medical expenses incurred before establishment of account 7a7 ,in general ,subsection 7d7 of section #bbc of the ,internal ,revenue ,code of #aihf1 as restored by section #b1 is amended by redesignating paragraph 7#d7 as paragraph 7#e7 and by inserting after paragraph 7#c7 the following new paragraph3 7#d7 ,certain medical expenses incurred before establishment of account treated as qualified 7,a7 ,in general ,for purposes of paragraph 7#b71 an expense shall not fail to be treated as a qualified medical expense solely because such expense was incurred before the establishment of the health savings account if such expense was incurred during the #fj-;day period beginning on the date on which the high deductible health plan is first effective4 7,b7 ,special rules ,for purposes of subparagraph 7,a7-- 7i7 an individual shall be treated as an eligible individual for any portion of a month for which the individual is described in subsection 7c77#a71 determined without regard to whether the individual is covered under a high deductible health plan on the #ast day of such month1 and 7ii7 the effective date of the health savings account is deemed to be the date on which the high deductible health plan is first effective after the date of the enactment of this paragraph4 4 7b7 ,effective date ,the amendment made by this section shall apply with respect to insurance purchased after the date of the enactment of this ,act in taxable years beginning after such date4 ,v ,tax-,related ,health ,incentives #bda4 ,,seca tax deduction for health insurance costs 7a7 ,in ,general ,subsection 7l7 of section #afb of the ,internal ,revenue ,code of #aihf 7relating to special rules for health insurance costs of self-employed individuals7 is amended by striking paragraph 7#d7 and by redesignating paragraph 7#e7 as paragraph 7#d74 7b7 ,effective ,date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjaj4 #bdb4 ,deduction for qualified health insurance costs of individuals 7a7 ,in ,general ,part ,,vii of subchapter ,b of chapter #a of the ,internal ,revenue ,code of #aihf 7relating to additional itemized deductions for individuals7 is amended by redesignating section #bbd as section #bbe and by inserting after section #bbc the following new section3 #bbd4 ,costs of qualified health insurance 7a7 ,in ,general ,in the case of an individual1 there shall be allowed as a deduction an amount equal to the amount paid during the taxable year for coverage for the taxpayer1 his spouse1 and dependents under qualified health insurance4 7b7 ,qualified ,health ,insurance ,for purposes of this section1 the term qualified health insurance means insurance which constitutes medical care1 other than insurance substantially all of the coverage of which is of excepted benefits described in section #ihcb7;c74 7c7 ,special ,rules 7#a7 ,coordination with medical deduction1 etc ,any amount paid by a taxpayer for insurance to which subsection 7a7 applies shall not be taken into account in computing the amount allowable to the taxpayer as a deduction under section #afb7l7 or #bac7;a74 ,any amount taken into account in determining the credit allowed under section #ce shall not be taken into account for purposes of this section4 7#b7 ,deduction not allowed for self-employment tax purposes ,the deduction allowable by reason of this section shall not be taken into account in determining an individual's net earnings from self-employment 7within the meaning of section #adjb7;a77 for purposes of chapter #b4 4 7b7 ,deduction ,allowed in ,computing ,adjusted ,gross ,income ,subsection 7a7 of section #fb of such ,code is amended by inserting before the last sentence the following new paragraph3 7#bb7 ,costs of qualified health insurance ,the deduction allowed by section #bbd4 4 7c7 ,clerical ,amendment ,the table of sections for part ,,vii of subchapter ,b of chapter #a of such ,code is amended by redesignating the item relating to section #bbd as an item relating to section #bbe and inserting before such item the following new item3 ,sec4 #bbd4 ,costs of qualified health insurance4 4 7d7 ,effective ,date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjaj4 ,c ,enacting ,real ,medical ,liability ,reform #cja4 ,cap on non-economic damages against health care practitioners ,when an individual is injured or dies as the result of health care1 a person entitled to non-economic damages may not recover1 from the class of liable health care practitioners 7regardless of the theory of liability71 more than #bej1jjj such damages4 #cjb4 ,cap on non-economic damages against health care institutions ,when an individual is injured or dies as the result of health care1 a person entitled to non-economic damages may not recover-- 7#a7 from any single liable health care institution 7regardless of the theory of liability71 more than #bej1jjj such damages2 and 7#b7 from the class of liable health care institutions 7regardless of the theory of liability71 more than #ejj1jjj such damages4 #cjc4 ,cap1 in wrongful death cases1 on total damages against any single health care practitioner 7a7 ,in general ,when an individual dies as the result of health care1 a person entitled to damages may not recover1 from any single liable health care practitioner 7regardless of the theory of liability71 more than #a1djj1jjj in total damages4 7b7 ,total damages defined ,in this section1 the term total damages includes compensatory damages1 punitive damages1 statutory damages1 and any other type of damages4 7c7 ,adjustment for inflation ,for each calendar year after the calendar year of the enactment of this ,act1 the dollar amount referred to in subsection 7a7 shall be adjusted to reflect changes in the ,consumer ,price ,index of the ,bureau of ,labor ,statistics of the ,department of ,labor4 ,the adjustment shall be based on the relationship between-- 7#a7 the ,consumer ,price ,index data most recently published as of ,january #a of the calendar year of the enactment of this ,act2 and 7#b7 the ,consumer ,price ,index data most recently published as of ,january #a of the calendar year concerned4 7d7 ,applicability of adjustment ,the dollar amount that applies to a recovery is the dollar amount for the calendar year during which the amount of the recovery is made final4 #cjd4 ,limitation of insurer liability when insurer rejects certain settlement offers ,in a civil action1 to the extent the civil action seeks damages for the injury or death of an individual as the result of health care1 when the insurer of a health care practitioner or health care institution rejects a reasonable settlement offer within policy limits1 the insurer is not1 by reason of that rejection1 liable for damages in an amount that exceeds the liability of the insured4 #cje4 ,mandatory jury instruction on cap on damages ,in a civil action tried to a jury1 to the extent the civil action seeks damages for the injury or death of an individual as the result of health care1 the court shall instruct the jury that the jury is not to consider whether1 or to what extent1 a limitation on damages applies4 #cjf4 ,determination of negligence2 mandatory jury instruction 7a7 ,in general ,when an individual is injured or dies as the result of health care1 liability for negligence may not be based solely on a bad result4 7b7 ,mandatory jury instruction ,in a civil action tried to a jury1 to the extent the civil action seeks damages for the injury or death of an individual as the result of health care and alleges liability for negligence1 the court shall instruct the jury as provided in subsection 7a74 #cjg4 ,expert reports required to be served in civil actions 7a7 ,service required ,to the extent a pleading filed in a civil action seeks damages against a health care practitioner for the injury or death of an individual as the result of health care1 the party filing the pleading shall1 not later than #abj days after the date on which the pleading was filed1 serve on each party against whom such damages are sought a qualified expert report4 7b7 ,qualified expert report ,as used in subsection 7a71 a qualified expert report is a written report of a qualified health care expert that-- 7#a7 includes a curriculum vitae for that expert2 and 7#b7 sets forth a summary of the expert opinion of that expert as to-- 7,a7 the standard of care applicable to that practitioner2 7,b7 how that practitioner failed to meet that standard of care2 and 7,c7 the causal relationship between that failure and the injury or death of the individual4 7c7 ,motion ,to enforce ,a party not served as required by subsection 7a7 may move the court to enforce that subsection4 ,on such a motion1 the court-- 7#a7 shall dismiss1 with prejudice1 the pleading as it relates to that party2 and 7#b7 shall award to that party the attorney fees reasonably incurred by that party to respond to that pleading4 7d7 ,use of expert report 7#a7 ,in general ,except as otherwise provided in this section1 a qualified expert report served under subsection 7a7 may not1 in that civil action-- 7,a7 be offered by any party as evidence2 7,b7 be used by any party in discovery or any other pretrial proceeding2 or 7,c7 be referred to by any party at trial4 7#b7 ,violations 7,a7 ,by other party ,if paragraph 7#a7 is violated by a party other than the party who served the report1 the court shall1 on motion of any party or on its own motion1 take such measures as the court considers appropriate1 which may include the imposition of sanctions4 7,b7 ,by serving party ,if paragraph 7#a7 is violated by the party who served the report1 paragraph 7#a7 shall no longer apply to any party4 #cjh4 ,expert opinions relating to physicians may be provided only by actively practicing physicians 7a7 ,in general ,a physician-related opinion may be provided only by an actively practicing physician who is determined by the court to be qualified on the basis of training and experience to render that opinion4 7b7 ,considerations required ,in determining whether an actively practicing physician is qualified under subsection 7a71 the court shall1 except on good cause shown1 consider whether that physician is board-certified1 or has other substantial training1 in an area of medical practice relevant to the health care to which the opinion relates4 7c7 ,definitions ,in this section3 7#a7 ,the term actively practicing physician means an individual who-- 7,a7 is licensed to practice medicine in the ,united ,states or1 if the individual is a defendant providing a physician-related opinion with respect to the health care provided by that defendant1 is a graduate of a medical school accredited by the ,liaison ,committee on ,medical ,education or the ,american ,osteopathic ,association2 7,b7 is practicing medicine when the opinion is rendered1 or was practicing medicine when the health care was provided2 and 7,c7 has knowledge of the accepted standards of care for the health care to which the opinion relates4 7#b7 ,the term physician-related opinion means an expert opinion as to any one or more of the following3 7,a7 ,the standard of care applicable to a physician4 7,b7 ,whether a physician failed to meet such a standard of care4 7,c7 ,whether there was a causal relationship between such a failure by a physician and the injury or death of an individual4 7#c7 ,the term practicing medicine includes training residents or students at an accredited school of medicine or osteopathy1 and serving as a consulting physician to other physicians who provide direct patient care4 #cji4 ,payment of future damages on periodic or accrual basis 7a7 ,in general ,when future damages are awarded against a health care practitioner to a person for the injury or death of an individual as a result of health care1 and the present value of those future damages is #ajj1jjj or more1 that health care practitioner may move that the court order payment on a periodic or accrual basis of those damages4 ,on such a motion1 the court-- 7#a7 shall order that payment be made on an accrual basis of future damages described in subsection 7b77#a72 and 7#b7 may order that payment be made on a periodic or accrual basis of any other future damages that the court considers appropriate4 7b7 ,future damages defined ,in this section1 the term future damages means-- 7#a7 the future costs of medical1 health care1 or custodial services2 7#b7 noneconomic damages1 such as pain and suffering or loss of consortium2 7#c7 loss of future earnings2 and 7#d7 any other damages incurred after the award is made4 #caj4 ,unanimous jury required for punitive or exemplary damages ,when an individual is injured or dies as the result of health care1 a jury may not award punitive or exemplary damages against a health care practitioner or health care institution unless the jury is unanimous with regard to both the liability of that party for such damages and the amount of the award of such damages4 #caa4 ,proportionate liability ,when an individual is injured or dies as the result of health care and a person is entitled to damages for that injury or death1 each person responsible is liable only for a proportionate share of the total damages that directly corresponds to that person's proportionate share of the total responsibility4 #cab4 ,defense-initiated settlement process 7a7 ,in general ,in a civil action1 to the extent the civil action seeks damages for the injury or death of an individual as the result of health care1 a health care practitioner or health care institution against which such damages are sought may serve one or more qualified settlement offers under this section to a person seeking such damages4 ,if the person seeking such damages does not accept such an offer1 that person may thereafter serve one or more qualified settlement offers under this section to the party whose offer was not accepted4 7b7 ,qualified settlement offer ,a qualified settlement offer under this section is an offer1 in writing1 to settle the matter as between the offeror and the offeree1 which-- 7#a7 specifies that it is made under this section2 7#b7 states the terms of settlement2 and 7#c7 states the deadline within which the offer must be accepted4 7c7 ,effect of offer ,if the offeree of a qualified settlement offer does not accept that offer1 and thereafter receives a judgment at trial that1 as between the offeror and the offeree1 is significantly less favorable than the terms of settlement in that offer1 that offeree is responsible for those litigation costs reasonably incurred1 after the deadline stated in the offer1 by the offeror to respond to the claims of the offeree4 7d7 ,litigation costs defined ,in this section1 the term litigation costs include court costs1 filing fees1 expert witness fees1 attorney fees1 and any other costs directly related to carrying out the litigation4 7e7 ,significantly less favorable defined ,for purposes of this section1 a judgment is significantly less favorable than the terms of settlement if-- 7#a7 in the case of an offeree seeking damages1 the offeree's award at trial is less than #hj percent of the value of the terms of settlement2 and 7#b7 in the case of an offeree against whom damages are sought1 the offeror's award at trial is more than #abj percent of the value of the terms of settlement4 #cac4 ,statute of limitations2 statute of repose 7a7 ,statute of limitations ,when an individual is injured or dies as the result of health care1 the statute of limitations shall be as follows3 7#a7 ,individuals of age #ab and over ,if the individual has attained the age of #ab years1 the claim must be brought either-- 7,a7 within #b years after the negligence occurred2 or 7,b7 within #b years after the health care on which the claim is based is completed4 7#b7 ,individuals under age #ab ,if the individual has not attained the age of #ab years1 the claim must be brought before the individual attains the age of #ad years4 7b7 ,statute of repose ,when an individual is injured or dies as the result of health care1 the statute of repose shall be as follows3 ,the claim must be brought within #aj years after the act or omission on which the claim is based is completed4 7c7 ,tolling 7#a7 ,statute of limitations ,the statute of limitations required by subsection 7a7 may be tolled if applicable law so provides1 except that it may not be tolled on the basis of minority4 7#b7 ,statute of repose ,the statute of repose required by subsection 7b7 may not be tolled for any reason4 #cad4 ,limitation on liability for ,good ,samaritans providing emergency health care 7a7 ,willful or wanton negligence required ,a health care practitioner or health care institution that provides emergency health care on a ,good ,samaritan basis is not liable for damages caused by that care except for willful or wanton negligence or more culpable misconduct4 7b7 ,good ,samaritan basis ,for purposes of this section1 care is provided on a ,good ,samaritan basis if it is not provided for or in expectation of remuneration4 ,being entitled to remuneration is relevant to1 but is not determinative of1 whether it is provided for or in expectation of remuneration4 #cae4 ,definitions ,in this division3 7#a7 ,health care institution ,the term health care institution includes institutions such as-- 7,a7 an ambulatory surgical center2 7,b7 an assisted living facility2 7,c7 an emergency medical services provider2 7,d7 a home health agency2 7,e7 a hospice2 7,f7 a hospital2 7,g7 a hospital system2 7,h7 an intermediate care facility for the mentally retarded2 7,i7 a nursing home2 and 7,j7 an end stage renal disease facility4 7#b7 ,health care practitioner ,the term health care practitioner includes a physician and a physician entity4 7#c7 ,physician entity ,the term physician entity includes-- 7,a7 a partnership or limited liability partnership created by a group of physicians2 7,b7 a company created by physicians2 and 7,c7 a nonprofit health corporation whose board is composed of physicians4 ,d ,protecting the ,doctor-,patient ,relationship #dja4 ,rule of construction ,nothing in this ,act shall be construed to interfere with the doctor-patient relationship or the practice of medicine4 #djb4 ,repeal of ,federal ,coordinating ,council for ,comparative ,effectiveness ,research ,effective on the date of the enactment of this ,act1 section #hjd of the ,american ,recovery and ,reinvestment ,act of #bjji is repealed4 ,e ,incentivizing ,wellness and ,quality ,improvements #eja4 ,incentives for prevention and wellness programs 7a7 ,employee ,retirement ,income ,security ,act of #aigd limitation on exception for wellness programs under ,,hipaa discrimination rules 7#a7 ,in general ,section #gjb7;b77#b7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahb7;b77#b771 as restored by section #b1 is amended by adding after and below subparagraph 7,b7 the following3 ,in applying subparagraph 7,b71 a group health plan 7or a health insurance issuer with respect to health insurance coverage7 may vary premiums and cost-sharing by up to #ej percent of the value of the benefits under the plan 7or coverage7 based on participation in a standards-based wellness program4 4 7#b7 ,effective date ,the amendment made by paragraph 7#a7 shall apply to plan years beginning more than #a year after the date of the enactment of this ,act4 7b7 ,conforming amendments to ,,phsa 7#a7 ,group market rules 7,a7 ,in general ,section #bgjb7;b77#b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#a7;b77#b771 as restored by section #b1 is amended by adding after and below subparagraph 7,b7 the following3 ,in applying subparagraph 7,b71 a group health plan 7or a health insurance issuer with respect to health insurance coverage7 may vary premiums and cost-sharing by up to #ej percent of the value of the benefits under the plan 7or coverage7 based on participation in a standards-based wellness program4 4 7,b7 ,effective date ,the amendment made by subparagraph 7,a7 shall apply to plan years beginning more than #a year after the date of the enactment of this ,act4 7#b7 ,individual market rules relating to guaranteed availability 7,a7 ,in general ,section #bgda7;f7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#a7;b77#b771 as restored by section #b1 is amended by adding after and below paragraph 7#a7 the following3 ,in applying paragraph 7#b71 a health insurance issuer may vary premiums and cost-sharing under health insurance coverage by up to #ej percent of the value of the benefits under the coverage based on participation in a standards-based wellness program4 4 7,b7 ,effective date ,the amendment made by paragraph 7#a7 shall apply to health insurance coverage offered or renewed on and after the date that is #a year after the date of the enactment of this ,act4 7c7 ,conforming amendments to ,,irc 7#a7 ,in general ,section #ihjb7;b77#b7 of the ,internal ,revenue ,code of #aihf1;as restored by section #b1 is amended by adding after and below subparagraph 7,b7 the following3 ,in applying subparagraph 7,b71 a group health plan 7or a health insurance issuer with respect to health insurance coverage7 may vary premiums and cost-sharing by up to #ej percent of the value of the benefits under the plan 7or coverage7 based on participation in a standards-based wellness program4 4 7#b7 ,effective date ,the amendment made by paragraph 7#a7 shall apply to plan years beginning more than #a year after the date of the enactment of this ,act4 ,f ,protecting ,taxpayers #fja4 ,permanently prohibiting taxpayer funded abortions and ensuring conscience protections ,title #a of the ,united ,states ,code is amended by adding at the end the following new chapter3 #d ,permanently prohibiting taxpayer funded abortions and ensuring conscience protections #cja4 ,prohibition on funding for abortions ,no funds authorized or appropriated by ,federal law1 and none of the funds in any trust fund to which funds are authorized or appropriated by ,federal law1 shall be expended for any abortion4 #cjb4 ,prohibition on funding for health benefits plans that cover abortion ,none of the funds authorized or appropriated by federal law1 and none of the funds in any trust fund to which funds are authorized or appropriated by federal law1 shall be expended for a health benefits plan that includes coverage of abortion4 #cjc4 ,treatment of abortions related to rape1 incest1 or preserving the life of the mother ,the limitations established in sections #cja and #cjb shall not apply to an abortion-- 7#a7 if the pregnancy is the result of an act of rape or incest2 or 7#b7 in the case where a woman suffers from a physical disorder1 physical injury1 or physical illness that would1 as certified by a physician1 place the woman in danger of death unless an abortion is performed1 including a life-endangering physical condition caused by or arising from the pregnancy itself4 #cjd4 ,construction relating to supplemental coverage ,nothing in this chapter shall be construed as prohibiting any individual1 entity1 or ,state or locality from purchasing separate supplemental abortion plan or coverage that includes abortion so long as such plan or coverage is paid for entirely using only funds not authorized or appropriated by federal law and such plan or coverage shall not be purchased using matching funds required for a federally subsidized program1 including a ,state's or locality's contribution of ,medicaid matching funds4 #cje4 ,construction relating to the use of non-,federal funds for health coverage ,nothing in this chapter shall be construed as restricting the ability of any managed care provider or other organization from offering abortion coverage or the ability of a ,state to contract separately with such a provider or organization for such coverage with funds not authorized or appropriated by federal law and such plan or coverage shall not be purchased using matching funds required for a federally subsidized program1 including a ,state's or locality's contribution of ,medicaid matching funds4 #cjf4 ,no government discrimination against certain health care entities 7a7 ,in general ,no funds authorized or appropriated by federal law may be made available to a ,federal agency or program1 or to a ,state or local government1 if such agency1 program1 or government subjects any institutional or individual health care entity to discrimination on the basis that the health care entity does not provide1 pay for1 provide coverage of1 or refer for abortions4 7b7 ,health care entity defined ,for purposes of this section1 the term health care entity includes an individual physician or other health care professional1 a hospital1 a provider-sponsored organization1 a health maintenance organization1 a health insurance plan1 or any other kind of health care facility1 organization1 or plan4 4 #fjb4 ,improved enforcement of the ,medicare and ,medicaid secondary payer provisions 7a7 ,medicare 7#a7 ,in general ,the ,secretary of ,health and ,human ,services1 in coordination with the ,inspector ,general of the ,department of ,health and ,human ,services1 shall provide through the ,coordination of ,benefits ,contractor for the identification of instances where the ,medicare program should be1 but is not1 acting as a secondary payer to an individual's private health benefits coverage under section #ahfb7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey7b774 7#b7 ,updating procedures ,the ,secretary shall update procedures for identifying and resolving credit balance situations which occur under the ,medicare program when payment under such title and from other health benefit plans exceed the providers' charges or the allowed amount4 7#c7 ,report on improved enforcement ,not later than #a year after the date of the enactment of this ,act1 the ,secretary shall submit a report to ,congress on progress made in improved enforcement of the ,medicare secondary payer provisions1 including recoupment of credit balances4 7b7 ,medicaid ,section #aijc of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7 is amended by adding at the end the following new subsection3 7aa7 ,enforcement of payer of last resort provisions 7#a7 ,submission of state plan amendment ,each ,state shall submit1 not later than #a year after the date of the enactment of this subsection1 a ,state plan amendment that details how the ,state will become fully compliant with the requirements of section #aijb7;a77#be74 7#b7 ,bonus for compliance ,if a ,state submits a timely ,state plan amendment under paragraph 7#a7 that the ,secretary determines provides for full compliance of the ,state with the requirements of section #aijb7;a77#be71 the ,secretary shall provide for an additional payment to the ,state of #a1jjj1jjj4 ,if a ,state certifies1 to the ,secretary's satisfaction1 that it is already fully compliant with such requirements1 such amount shall be increased to #b1jjj1jjj4 7#c7 ,reduction for noncompliance ,if a ,state does not submit such an amendment1 the ,secretary shall reduce the ,federal medical assistance percentage otherwise applicable under this title by #a percentage point until the ,state submits such an amendment4 7#d7 ,ongoing reduction ,if at any time the ,secretary determines that a ,state is not in compliance with section #aijb7;a77#be71 regardless of the status of the ,state's submission of a ,state plan amendment under this subsection or previous determinations of compliance such requirements1 the ,secretary shall reduce the ,federal medical assistance percentage otherwise applicable under this title for the ,state by #a percentage point during the period of non-compliance as determined by the ,secretary4 4 #fjc4 ,strengthen ,medicare provider enrollment standards and safeguards 7a7 ,protecting against the fraudulent use of ,medicare provider numbers ,subject to subsection 7c77#b7-- 7#a7 ,screening new providers ,as a condition of a provider of services or a supplier1 including durable medical equipment suppliers and home health agencies1 applying for the first time for a provider number under the ,medicare program under title ,,xviii of the ,social ,security ,act and before granting billing privileges under such title1 the ,secretary of ,health and ,human ,services shall screen the provider or supplier for a criminal background or other financial or operational irregularities through fingerprinting1 licensure checks1 site-visits1 other database checks4 7#b7 ,application fees ,the ,secretary shall impose an application charge on such a provider or supplier in order to cover the ,secretary's costs in performing the screening required under paragraph 7#a7 and that is revenue neutral to the ,federal government4 7#c7 ,provisional approval ,during an initial1 provisional period 7specified by the ,secretary7 in which such a provider or supplier has been issued such a number1 the ,secretary shall provide enhanced oversight of the activities of such provider or supplier under the ,medicare program1 such as through prepayment review and payment limitations4 7#d7 ,penalties for false statements ,in the case of a provider or supplier that makes a false statement in an application for such a number1 the ,secretary may exclude the provider or supplier from participation under the ,medicare program1 or may impose a civil money penalty 7in the amount described in section #aabh;,a7a77#d7 of the ,social ,security ,act71 in the same manner as the ,secretary may impose such an exclusion or penalty under sections #aabh and #aabh;,a1 respectively1 of such ,act in the case of knowing presentation of a false claim described in section #aabh;,a7a77#a77;,a7 of such ,act4 7#e7 ,disclosure requirements ,with respect to approval of such an application1 the ,secretary-- 7,a7 shall require applicants to disclose previous affiliation with enrolled entities that have uncollected debt related to the ,medicare or ,medicaid programs2 7,b7 may deny approval if the ,secretary determines that these affiliations pose undue risk to the ,medicare or ,medicaid program1 subject to an appeals process for the applicant as determined by the ,secretary2 and 7,c7 may implement enhanced safeguards 7such as surety bonds74 7b7 ,moratoria ,the ,secretary of ,health and ,human ,services may impose moratoria on approval of provider and supplier numbers under the ,medicare program for new providers of services and suppliers as determined necessary to prevent or combat fraud a period of delay for any one applicant cannot exceed #cj days unless cause is shown by the ,secretary4 7c7 ,funding 7#a7 ,in general ,there are authorized to be appropriated to carry out this section such sums as may be necessary4 7#b7 ,condition ,the provisions of paragraphs 7#a7 and 7#b7 of subsection 7a7 shall not apply unless and until funds are appropriated to carry out such provisions4 #fjd4 ,tracking banned providers across ,state lines 7a7 ,greater coordination ,the ,secretary of ,health and ,human ,services shall provide for increased coordination between the ,administrator of the ,centers for ,medicare ,medicaid ,services 7in this section referred to as ,,cms7 and its regional offices to ensure that providers of services and suppliers that have operated in one ,state and are excluded from participation in the ,medicare program are unable to begin operation and participation in the ,medicare program in another ,state4 7b7 ,improved information systems 7#a7 ,in general ,the ,secretary shall improve information systems to allow greater integration between databases under the ,medicare program so that-- 7,a7 ,medicare administrative contractors1 fiscal intermediaries1 and carriers have immediate access to information identifying providers and suppliers excluded from participation in the ,medicare and ,medicaid program and other ,federal health care programs2 and 7,b7 such information can be shared across ,federal health care programs and agencies1 including between the ,departments of ,health and ,human ,services1 the ,social ,security ,administration1 the ,department of ,veterans ,affairs1 the ,department of ,defense1 the ,department of ,justice1 and the ,office of ,personnel ,management4 7c7 ,medicare_/,medicaid ,one ,,pi database ,the ,secretary shall implement a database that includes claims and payment data for all components of the ,medicare program and the ,medicaid program4 7d7 ,authorizing expanded data matching ,notwithstanding any provision of the ,computer ,matching and ,privacy ,protection ,act of #aihh to the contrary-- 7#a7 the ,secretary and the ,inspector ,general in the ,department of ,health and ,human ,services may perform data matching of data from the ,medicare program with data from the ,medicaid program2 and 7#b7 the ,commissioner of ,social ,security and the ,secretary may perform data matching of data of the ,social ,security ,administration with data from the ,medicare and ,medicaid programs4 7e7 ,consolidation of databases ,the ,secretary shall consolidate and expand into a centralized database for individuals and entities that have been excluded from ,federal health care programs the ,healthcare ,integrity and ,protection ,data ,bank1 the ,national ,practitioner ,data ,bank1 the ,list of ,excluded ,individuals_/,entities1 and a national patient abuse_/neglect registry4 7f7 ,comprehensive provider database 7#a7 ,establishment ,the ,secretary shall establish a comprehensive database that includes information on providers of services1 suppliers1 and related entities participating in the ,medicare program1 the ,medicaid program1 or both4 ,such database shall include1 information on ownership and business relationships1 history of adverse actions1 results of site visits or other monitoring by any program4 7#b7 ,use ,prior to issuing a provider or supplier number for an entity under the ,medicare program1 the ,secretary shall obtain information on the entity from such database to assure the entity qualifies for the issuance of such a number4 7g7 ,comprehensive sanctions database ,the ,secretary shall establish a comprehensive sanctions database on sanctions imposed on providers of services1 suppliers1 and related entities4 ,such database shall be overseen by the ,inspector ,general of the ,department of ,health and ,human ,services and shall be linked to related databases maintained by ,state licensure boards and by ,federal or ,state law enforcement agencies4 7h7 ,access to claims and payment databases ,the ,secretary shall ensure that the ,inspector ,general of the ,department of ,health and ,human ,services and ,federal law enforcement agencies have direct access to all claims and payment databases of the ,secretary under the ,medicare or ,medicaid programs4 7i7 ,civil money penalties for submission of erroneous information ,in the case of a provider of services1 supplier1 or other entity that submits erroneous information that serves as a basis for payment of any entity under the ,medicare or ,medicaid program1 the ,secretary may impose a civil money penalty of not to exceed #ej1jjj for each such erroneous submission4 ,a civil money penalty under this subsection shall be imposed and collected in the same manner as a civil money penalty under subsection 7a7 of section #aabh;,a of the ,social ,security ,act is imposed and collected under that section4