,,ii #aacth ,,congress #ast ,session ,s4 #ahea ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,december #ah1 #bjac,mr4 ,mc,cain introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to provide for incentives to encourage health insurance coverage1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,empowering ,patients ,first ,act of #bjac4 7b7 ,table of contents ,the table of contents for this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4,sec4 #b4 ,repeal of ,,ppaca and health care-related ,,hcera provisions4,sec4 #c4 ,no mandate of guaranteed issue or community rating4,title ,i--,tax ,incentives for ,maintaining ,health ,insurance ,coverage,sec4 #aja4 ,refundable tax credit for health insurance costs of low-income individuals4,sec4 #ajb4 ,advance payment of credit as premium payment for qualified health insurance4,sec4 #ajc4 ,election of tax credit instead of alternative government or group plan benefits4,sec4 #ajd4 ,deduction for qualified health insurance costs of individuals4,sec4 #aje4 ,limitation on abortion funding4,sec4 #ajf4 ,no government discrimination against certain health care entities4,sec4 #ajg4 ,equal employer contribution rule to promote choice4,sec4 #ajh4 ,limitations on ,state restrictions on employer auto-enrollment4,sec4 #aji4 ,credit for small employers adopting auto-enrollment and defined contribution options4,sec4 #aaj4 ,,hsa modifications and clarifications4,title ,,ii--,health ,insurance ,pooling ,mechanisms for ,individuals,subtitle ,a--,federal ,grants for ,state ,insurance ,expenditures,sec4 #bja4 ,federal grants for ,state insurance expenditures4,subtitle ,b--,health ,care ,access and ,availability,sec4 #baa4 ,expansion of access and choice through individual and small employer membership associations 7,i,m,as74,subtitle ,c--,small ,business ,health ,fairness,sec4 #bba4 ,short title4,sec4 #bbb4 ,rules governing association health plans4,sec4 #bbc4 ,clarification of treatment of single employer arrangements4,sec4 #bbd4 ,enforcement provisions relating to association health plans4,sec4 #bbe4 ,cooperation between ,federal and ,state authorities4,sec4 #bbf4 ,effective date and transitional and other rules4,title ,,iii--,interstate ,market for ,health ,insurance,sec4 #cja4 ,cooperative governing of individual health insurance coverage4,title ,,iv--,safety ,net ,reforms,sec4 #dja4 ,requiring outreach and coverage before expansion of eligibility4,sec4 #djb4 ,easing administrative barriers to ,state cooperation with employer-sponsored insurance coverage4,sec4 #djc4 ,improving beneficiary choice in ,,schip4,title ,v--,lawsuit ,abuse ,reforms,sec4 #eja4 ,change in burden of proof based on compliance with best practice guidelines4,sec4 #ejb4 ,state grants to create administrative health care tribunals4,sec4 #ejc4 ,authorization of payment of future damages to claimants in health care lawsuits4,sec4 #ejd4 ,definitions4,sec4 #eje4 ,effect on other laws4,sec4 #ejf4 ,applicability2 effective date4,title ,,vi--,wellness and ,prevention,sec4 #fja4 ,providing financial incentives for treatment compliance4,title ,,vii--,transparency and ,insurance ,reform ,measures,sec4 #gja4 ,receipt and response to requests for claim information4,title ,,viii--,quality,sec4 #hja4 ,prohibition on certain uses of data obtained from comparative effectiveness research or from patient-centered outcomes research2 accounting for personalized medicine and differences in patient treatment response4,sec4 #hjb4 ,establishment of performance-based quality measures4,title ,,ix--,state ,transparency ,plan ,portal,sec4 #ija4 ,providing information on health coverage options and health care providers4,title ,x--,patient ,freedom of ,choice ,sec4 #ajja4 ,guaranteeing freedom of choice and contracting for patients under ,medicare4,sec4 #ajjb4 ,preemption of ,state laws limiting charges for eligible professional services4,sec4 #ajjc4 ,health care provider licensure cannot be conditioned on participation in a health plan4,sec4 #ajjd4 ,bad debt deduction for doctors to partially offset the cost of providing uncompensated care required to be provided under amendments made by the ,emergency ,medical ,treatment and ,labor ,act4,sec4 #ajje4 ,right of contract with health care providers4,title ,,xi--,incentives to reduce physician shortages ,subtitle ,a--,federally ,supported ,student ,loan ,funds for ,medical ,students,sec4 #aaja4 ,federally supported student loan funds for medical students4,subtitle ,b--,loan ,forgiveness for ,primary ,care ,providers,sec4 #aaaa4 ,loan forgiveness for primary care providers4,title ,,xii--,quality ,health ,care ,coalition,sec4 #abja4 ,quality ,health ,care ,coalition4,title ,,xiii--,offsets,subtitle ,a--,discretionary spending limits,sec4 #acja4 ,discretionary spending limits4,subtitle ,b--,savings from health care efficiencies,sec4 #acaa4 ,medicare ,,dsh report and payment adjustments in response to coverage expansion4,sec4 #acab4 ,reduction in ,medicaid ,,dsh4,subtitle ,c--,fraud1 ,waste1 and ,abuse,sec4 #acba4 ,provide adequate funding to ,,hhs ,,oig and ,,hcfac4,sec4 #acbb4 ,improved enforcement of the ,medicare secondary payor provisions4,sec4 #acbc4 ,strengthen ,medicare provider enrollment standards and safeguards4,sec4 #acbd4 ,tracking banned providers across ,state lines4 #b4 ,repeal of ,,ppaca and health care-related ,,hcera provisions 7a7 ,,ppaca ,effective as of the enactment of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 such ,act is repealed1 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-,related ,provisions in the ,health ,care and ,education ,reconciliation ,act of #bjaj ,effective as of the enactment of the ,health ,care and ,education ,reconciliation ,act of #bjaj 7,public ,law #aaa-aeb71 title ,i and subtitle ,b of title ,,ii of such ,act are repealed1 and the provisions of law amended or repealed by such title or subtitle1 respectively1 are restored or revived as if such title and subtitle had not been enacted4 #c4 ,no mandate of guaranteed issue or community rating ,nothing in this ,act shall be construed to provide a mandate for guaranteed issue or community rating in the private insurance market4 ,i ,tax ,incentives for ,maintaining ,health ,insurance ,coverage #aja4 ,refundable tax credit for health insurance costs of low-income individuals 7a7 ,in general ,subpart ,c of part ,,iv of subchapter ,a of chapter #a of the ,internal ,revenue ,code of #aihf1 as amended by section #b1 is amended by inserting after section #cf;,a the following new section3 #cf;,b4 ,health insurance costs of low-income individuals 7a7 ,in general ,in the case of an individual1 there shall be allowed as a credit against the tax imposed by subtitle ,a the aggregate amount paid by the taxpayer for coverage of the taxpayer and the taxpayer's qualifying family members under qualified health insurance for eligible coverage months beginning in the taxable year4 7b7 ,limitations 7#a7 ,in general ,the amount allowable as a credit under subsection 7a7 for the taxable year shall not exceed the lesser of-- 7,a7 the sum of the monthly limitations for months during such taxable year that the taxpayer or the taxpayer's qualifying family members is an eligible individual1 and 7,b7 the aggregate premiums paid by the taxpayer for the taxable year for coverage described in subsection 7a74 7#b7 ,monthly limitation ,the monthly limitation for any month is the credit percentage of #a_/ab of the sum of-- 7,a7 #b1jjj for coverage of the taxpayer 7#d1jjj in the case of a joint return for coverage of the taxpayer and the taxpayer's spouse71 and 7,b7 #ejj for coverage of each dependent of the taxpayer4 7#c7 ,credit percentage 7,a7 ,in general ,for purposes of this section1 the term credit percentage means #ajj percent reduced by #a percentage point for each #a1jjj 7or fraction thereof7 by which the taxpayer's adjusted gross income for the taxable year exceeds the threshold amount4 7,b7 ,threshold amount ,for purposes of this paragraph1 the term threshold amount means1 with respect to any taxpayer for any taxable year1 #bjj percent of the ,federal poverty guideline 7as determined by the ,secretary of ,health and ,human ,services for the taxable year7 applicable to the taxpayer4 7#d7 ,only #b dependents taken into account ,not more than #b dependents of the taxpayer may be taken into account under paragraphs 7#b77;,c7 and 7#c77;,b74 7#e7 ,inflation adjustment ,in the case of any taxable year beginning in a calendar year after #bjac1 each dollar amount contained in paragraph 7#b7 shall be increased by an amount equal to-- 7,a7 such dollar amount1 multiplied by 7,b7 the cost-of-living adjustment determined under section #a7;f77#c7 for the calendar year in which the taxable year begins1 determined by substituting calendar year #bjab for calendar year #aiib in subparagraph 7,b7 thereof4 ,any increase determined under the preceding sentence shall be rounded to the nearest multiple of #ej4 7c7 ,eligible coverage month ,for purposes of this section1 the term eligible coverage month means1 with respect to any individual1 any month if1 as of the first day of such month1 the individual-- 7#a7 is covered by qualified health insurance1 7#b7 does not have other specified coverage1 and 7#c7 is not imprisoned under ,federal1 ,state1 or local authority4 7d7 ,qualifying family member ,for purposes of this section1 the term qualifying family member means-- 7#a7 in the case of a joint return1 the taxpayer's spouse1 and 7#b7 any dependent of the taxpayer4 7e7 ,qualified health insurance ,for purposes of this section1 the term qualified health insurance means health insurance coverage 7other than excepted benefits as defined in section #ihcb7;c77 which constitutes medical care4 7f7 ,other specified coverage ,for purposes of this section1 an individual has other specified coverage for any month if1 as of the first day of such month-- 7#a7 ,coverage under ,medicare1 ,medicaid1 or ,,schip ,such individual-- 7,a7 is entitled to benefits under part ,a of title ,,xviii of the ,social ,security ,act or is enrolled under part ,b of such title1 or 7,b7 is enrolled in the program under title ,,xix or ,,xxi of such ,act 7other than under section #aibh of such ,act74 7#b7 ,certain other coverage ,such individual-- 7,a7 is enrolled in a health benefits plan under chapter #hi of title #e1 ,united ,states ,code1 7,b7 is entitled to receive benefits under chapter #ee of title #aj1 ,united ,states ,code1 7,c7 is entitled to receive benefits under chapter #ag of title #ch1 ,united ,states ,code1 7,d7 is enrolled in a group health plan 7within the meaning of section #ejjj7;b77#a77 which is subsidized by the employer1 or 7,e7 is a member of a health care sharing ministry4 7#c7 ,health care sharing ministry ,for purposes of this subsection1 the term health care sharing ministry means an organization-- 7,a7 which is described in section #eja7;c77#c7 and is exempt from taxation under section #eja7;a71 7,b7 members of which share a common set of ethical or religious beliefs and share medical expenses among members in accordance with those beliefs and without regard to the ,state in which a member resides or is employed1 7,c7 members of which retain membership even after they develop a medical condition1 7,d7 which 7or a predecessor of which7 has been in existence at all times since ,december #ca1 #aiii1 and medical expenses of its members have been shared continuously and without interruption since at least ,december #ca1 #aiii1 and 7,e7 which conducts an annual audit which is performed by an independent certified public accounting firm in accordance with generally accepted accounting principles and which is made available to the public upon request4 7g7 ,special rules 7#a7 ,coordination with advance payments of credit2 recapture of excess advance payments ,with respect to any taxable year-- 7,a7 the amount which would 7but for this subsection7 be allowed as a credit to the taxpayer under subsection 7a7 shall be reduced 7but not below zero7 by the aggregate amount paid on behalf of such taxpayer under section #gebi for months beginning in such taxable year1 and 7,b7 the tax imposed by section #a for such taxable year shall be increased by the excess 7if any7 of-- 7i7 the aggregate amount paid on behalf of such taxpayer under section #gebi for months beginning in such taxable year1 over 7ii7 the amount which would 7but for this subsection7 be allowed as a credit to the taxpayer under subsection 7a74 7#b7 ,coordination with other deductions ,amounts taken into account under subsection 7a7 shall not be taken into account in determining-- 7,a7 any deduction allowed under section #afb7l71 #bac1 or #bbd1 or 7,b7 any credit allowed under section #ce4 7#c7 ,medical and health savings accounts ,amounts distributed from an ,archer ,,msa 7as defined in section #bbj7;d77 or from a health savings account 7as defined in section #bbc7;d77 shall not be taken into account under subsection 7a74 7#d7 ,denial of credit to dependents and nonpermanent resident alien individuals ,no credit shall be allowed under this section to any individual who is-- 7,a7 not a citizen or lawful permanent resident of the ,united ,states for the calendar year in which the taxable year begins1 or 7,b7 a dependent with respect to another taxpayer for a taxable year beginning in the calendar year in which such individual's taxable year begins4 7#e7 ,insurance which covers other individuals ,for purposes of this section1 rules similar to the rules of section #bac7;d77#f7 shall apply with respect to any contract for qualified health insurance under which amounts are payable for coverage of an individual other than the taxpayer and qualifying family members4 7#f7 ,treatment of payments ,for purposes of this section-- 7,a7 ,payments by secretary ,payments made by the ,secretary on behalf of any individual under section #gebi 7relating to advance payment of credit for health insurance costs of low-income individuals7 shall be treated as having been made by the taxpayer on the first day of the month for which such payment was made4 7,b7 ,payments by taxpayer ,payments made by the taxpayer for eligible coverage months shall be treated as having been made by the taxpayer on the first day of the month for which such payment was made4 7#g7 ,regulations ,the ,secretary may prescribe such regulations and other guidance as may be necessary or appropriate to carry out this section1 section #fjej,w1 and section #gebi4 4 7b7 ,conforming amendments 7#a7 ,paragraph 7#b7 of section #acbd7;b7 of title #ca1 ,united ,states ,code1 as amended by section #b1 is amended by inserting #cf;,b1 after #cf;,a14 7#b7 ,the table of sections for subpart ,c of part ,,iv of subchapter ,a of chapter #a of the ,internal ,revenue ,code of #aihf1 as amended by section #b1 is amended by inserting after the item relating to section #cf;,a the following new item3 ,sec4 #cf;,b4 ,health insurance costs of low-income individuals4 4 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjac4 7d7 ,sense of ,congress ,it is the sense of ,congress that the cost of the advanceable refundable credit under sections #cf;,b and #gebi of the ,internal ,revenue ,code of #aihf1 as added by this title1 will be offset by savings derived from the provisions of title ,,xiii4 #ajb4 ,advance payment of credit as premium payment for qualified health insurance 7a7 ,in general ,chapter #gg of the ,internal ,revenue ,code of #aihf 7relating to miscellaneous provisions7 is amended by adding at the end the following3 #gebi4 ,advance payment of credit as premium payment for qualified health insurance 7a7 ,general rule ,not later than ,january #a1 #bjad1 the ,secretary shall establish a program for making payments to providers of qualified health insurance 7as defined in section #cf;,b7e77 on behalf of taxpayers eligible for the credit under section #cf;,b4 ,except as otherwise provided by the ,secretary1 such payments shall be made on the basis of the adjusted gross income of the taxpayer for the preceding taxable year4 7b7 ,certification process and proof of coverage ,for purposes of this section1 payments may be made pursuant to subsection 7a7 only with respect to individuals for whom a qualified health insurance costs credit eligibility certificate is in effect4 4 7b7 ,disclosure of return information for purposes of advance payment of credit as premiums for qualified health insurance 7#a7 ,in general ,subsection 7l7 of section #fajc of such ,code1 as amended by section #b1 is amended by adding at the end the following new paragraph3 7#ba7 ,disclosure of return information for purposes of advance payment of credit as premiums for qualified health insurance ,the ,secretary may1 on behalf of taxpayers eligible for the credit under section #cf;,b1 disclose to a provider of qualified health insurance 7as defined in section #cf7;e771 and persons acting on behalf of such provider1 return information with respect to any such taxpayer only to the extent necessary 7as prescribed by regulations issued by the ,secretary7 to carry out the program established by section #gebi 7relating to advance payment of credit as premium payment for qualified health insurance74 4 7#b7 ,confidentiality of information ,paragraph 7#c7 of section #fajc7;a7 of such ,code1 as amended by section #b1 is amended by striking or 7#bj7 and inserting 7#bj71 or 7#ba74 7#c7 ,unauthorized disclosure ,paragraph 7#b7 of section #gbac7;a7 of such ,code1 as amended by section #b1 is amended by striking or 7#bj7 and inserting 7#bj71 or 7#ba74 7c7 ,information reporting 7#a7 ,in general ,subpart ,b of part ,,iii of subchapter ,a of chapter #fa of such ,code 7relating to information concerning transactions with other persons7 is amended by adding at the end the following new section3 #fjej,x4 ,returns relating to credit for health insurance costs of low-income individuals 7a7 ,requirement of reporting ,every person who is entitled to receive payments for any month of any calendar year under section #gebi 7relating to advance payment of credit as premium payment for qualified health insurance7 with respect to any individual shall1 at such time as the ,secretary may prescribe1 make the return described in subsection 7b7 with respect to each such individual4 7b7 ,form and manner of returns ,a return is described in this subsection if such return-- 7#a7 is in such form as the ,secretary may prescribe1 and 7#b7 contains-- 7,a7 the name1 address1 and ,,tin of each individual referred to in subsection 7a71 7,b7 the number of months for which amounts were entitled to be received with respect to such individual under section #gebi 7relating to advance payment of credit as premium payment for qualified health insurance71 7,c7 the amount entitled to be received for each such month1 and 7,d7 such other information as the ,secretary may prescribe4 7c7 ,statements ,to be furnished to individuals with respect to whom information is required ,every person required to make a return under subsection 7a7 shall furnish to each individual whose name is required to be set forth in such return a written statement showing-- 7#a7 the name and address of the person required to make such return and the phone number of the information contact for such person1 and 7#b7 the information required to be shown on the return with respect to such individual4 ,the written statement required under the preceding sentence shall be furnished on or before ,january #ca of the year following the calendar year for which the return under subsection 7a7 is required to be made4 4 7#b7 ,assessable penalties 7,a7 ,subparagraph 7,b7 of section #fgbd7;d77#a7 of such ,code1 as amended by section #b1 is amended by striking or at the end of clause 7xxii71 by striking and at the end of clause 7xxiii7 and inserting or1 and by inserting after clause 7xxiii7 the following new clause3 7xxiv7 section #fjej,x 7relating to returns relating to credit for health insurance costs of low-income individuals71 and 4 7,b7 ,paragraph 7#b7 of section #fgbd7;d7 of such ,code1 as amended by section #b1 is amended by striking or at the end of subparagraph 7,,ee71 by striking the period at the end of subparagraph 7,,ff7 and inserting 1 or1 and by adding after subparagraph 7,,ff7 the following new subparagraph3 7,,gg7 section #fjej,x 7relating to returns relating to credit for health insurance costs of low-income individuals74 4 7d7 ,clerical amendments 7#a7 ,the table of sections for chapter #gg of such ,code is amended by adding at the end the following new item3 ,sec4 #gebi4 ,advance payment of credit as premium payment for qualified health insurance4 4 7#b7 ,the table of sections for subpart ,b of part ,,iii of subchapter ,a of chapter #fa of such ,code is amended by adding at the end the following new item3 ,sec4 #fjej,x4 ,returns relating to credit for health insurance costs of low-income individuals4 4 7e7 ,effective date ,the amendments made by this section shall take effect on the date of the enactment of this ,act4 #ajc4 ,election of tax credit instead of alternative government or group plan benefits 7a7 ,in general ,notwithstanding any other provision of law1 an individual who is otherwise eligible for benefits under a health program 7as defined in subsection 7c77 may elect1 in a form and manner specified by the ,secretary of ,health and ,human ,services in consultation with the ,secretary of the ,treasury1 to receive a tax credit described in section #cf;,b of the ,internal ,revenue ,code of #aihf 7which may be used for the purpose of health insurance coverage7 in lieu of receiving any benefits under such program4 7b7 ,effective date ,an election under subsection 7a7 may first be made for calendar year #bjad and any such election shall be effective for such period 7not less than one calendar year7 as the ,secretary of ,health and ,human ,services shall specify1 in consultation with the ,secretary of the ,treasury4 7c7 ,health program defined ,for purposes of this section1 the term health program means any of the following3 7#a7 ,medicare ,the ,medicare program under part ,a of title ,,xviii of the ,social ,security ,act4 7#b7 ,medicaid ,the ,medicaid program under title ,,xix of such ,act 7including such a program operating under a ,statewide waiver under section #aaae of such ,act74 7#c7 ,,schip ,the ,state children's health insurance program under title ,,xxi of such ,act4 7#d7 ,,tricare ,the ,,tricare program under chapter #ee of title #aj1 ,united ,states ,code4 7#e7 ,veterans benefits ,coverage for benefits under chapter #ag of title #ch1 ,united ,states ,code4 7#f7 ,,fehbp ,coverage under chapter #hi of title #e1 ,united ,states ,code4 7#g7 ,subsidized group health plans ,coverage under a group health plan 7within the meaning of section #ejjj7;b77#a77 which is subsidized by the employer4 7d7 ,other ,social ,security benefits not waived ,an election to waive the benefits described in subsection 7c77#a7 shall not result in the waiver of any other benefits under the ,social ,security ,act4 #ajd4 ,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 deductions7 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 ,limitation ,in the case of any taxpayer for any taxable year1 the deduction under subsection 7a7 shall not exceed an amount that would cause the taxpayer's ,federal income tax liability to be reduced by more than the average value of the national health exclusion for employer-sponsored insurance as determined by calculating the value of the exclusion for each household followed by calculating the average of those values4 7c7 ,qualified health insurance ,for purposes of this section1 the term qualified health insurance has the meaning given such term by section #cf;,b7e74 7d7 ,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 or #cf;,b 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 #bjac4 #aje4 ,limitation on abortion funding ,no funds authorized under1 or credits or deductions allowed under the ,internal ,revenue ,code of #aihf by reason of1 this ,act 7or any amendment made by this ,act7 may be used to pay for any abortion or to cover any part of the costs of any health plan that includes coverage of abortion1 except 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 itself1 or unless the pregnancy is the result of an act of rape or incest4 #ajf4 ,no government discrimination against certain health care entities 7a7 ,non-,discrimination ,a ,federal agency or program1 and any ,state or local government that receives ,federal financial assistance under this ,act or any amendment made by this ,act 7either directly or indirectly71 may not subject any individual or institutional 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 7c7 ,remedies 7#a7 ,in general ,the courts of the ,united ,states shall have jurisdiction to prevent and redress actual or threatened violations of this section by issuing any form of legal or equitable relief1 including-- 7,a7 injunctions prohibiting conduct that violates this section2 and 7,b7 orders preventing the disbursement of all or a portion of ,federal financial assistance to a ,state or local government1 or to a specific offending agency or program of a ,state or local government1 until such time as the conduct prohibited by this section has ceased4 7#b7 ,commencement of action ,an action under this subsection may be instituted by-- 7,a7 any health care entity that has standing to complain of an actual or threatened violation of this section2 or 7,b7 the ,attorney ,general of the ,united ,states4 7d7 ,administration ,the ,secretary of ,health and ,human ,services shall designate the ,director of the ,office for ,civil ,rights of the ,department of ,health and ,human ,services-- 7#a7 to receive complaints alleging a violation of this section2 7#b7 subject to paragraph 7#c71 to pursue the investigation of such complaints in coordination with the ,attorney ,general2 and 7#c7 in the case of a complaint related to a ,federal agency 7other than with respect to the ,department of ,health and ,human ,services7 or program administered through such other agency or any ,state or local government receiving ,federal financial assistance through such other agency1 to refer the complaint to the appropriate office of such other agency4 #ajg4 ,equal employer contribution rule to promote choice 7a7 ,in general ,section #ejjj of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subsection3 7e7 ,health care contribution election 7#a7 ,in general ,subsection 7a7 shall not apply in the case of a group health plan with respect to which the requirements of paragraphs 7#b7 and 7#c7 are met4 7#b7 ,contribution election ,the requirement of this paragraph is met with respect to a group health plan if any employee of an employer 7who but for this paragraph would be covered by such plan7 may elect to have the employer or employee organization pay an amount which is not less than the contribution amount to any provider of health insurance coverage 7other than excepted benefits as defined in section #ihcb7;c77 which constitutes medical care of the individual or individual's spouse or dependents in lieu of such group health plan coverage otherwise provided or contributed to by the employer with respect to such employee4 7#c7 ,pre-existing conditions 7,a7 ,in general ,the requirement of this paragraph is met with respect to health insurance coverage provided to a participant or beneficiary by any health insurance issuer if1 under such plan the requirements of section #ihja are met with respect to the participant or beneficiary4 7,b7 ,enforcement with respect to individual election ,for purposes of subparagraph 7,a71 any health insurance coverage with respect to the participant or beneficiary shall be treated as health insurance coverage under a group health plan to which section #ihja applies4 7#d7 ,contribution amount ,for purposes of this section1 the term contribution amount means1 with respect to an individual under a group health plan1 the portion of the applicable premium of such individual under such plan 7as determined under section #dihj;,b7f77#d77 which is not paid by the individual4 ,in the case that the employer offers more than one group health plan1 the contribution amount shall be the average amount of the applicable premiums under such plans4 7#e7 ,group health plan ,for purposes of this subsection1 subsection 7d7 shall not apply4 7#f7 ,application to ,,fehbp ,notwithstanding any other provision of law1 the ,office of ,personnel ,management shall carry out the health benefits program under chapter #hi of title #e1 ,united ,states ,code1 consistent with the requirements of this subsection4 4 7b7 ,requirement of equal contributions to all ,,fehbp plans ,section #hijf of title #e1 ,united ,states ,code1 is amended by adding at the end the following new subsection3 7j7 ,notwithstanding the previous provisions of this section the ,office of ,personnel ,management shall revise the amount of the ,government contribution made under this section in a manner so that-- 7#a7 the amount of such contribution does not change based on the health benefits plan in which the individual is enrolled2 and 7#b7 the aggregate amount of such contributions is estimated to be equal to the aggregate amount of such contributions if this subsection did not apply4 4 7c7 ,employee ,retirement ,income ,security ,act of #aigd conforming amendments 7#a7 ,exception from ,,hipaa requirements for benefits provided under health care contribution election ,section #gcb of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aaia;a7 is amended by adding at the end the following new subsection3 7e7 ,health care contribution election 7#a7 ,in general ,the requirements of this part shall not apply in the case of health insurance coverage 7other than excepted benefits as defined in section #ihcb7;c7 of the ,internal ,revenue ,code of #aihf7-- 7,a7 which is provided to a participant or beneficiary by a health insurance issuer under a group health plan1 and 7,b7 with respect to which the requirements of paragraphs 7#b7 and 7#c7 are met4 7#b7 ,contribution election ,the requirement of this paragraph is met with respect to health insurance coverage provided to a participant or beneficiary by any health insurance issuer under a group health plan if1 under such plan-- 7,a7 the participant may elect such coverage for any period of coverage in lieu of health insurance coverage otherwise provided under such plan for such period1 and 7,b7 in the case of such an election1 the plan sponsor is required to pay to such issuer for the elected coverage for such period an amount which is not less than the contribution amount for such health insurance coverage otherwise provided under such plan for such period4 7#c7 ,pre-existing conditions 7,a7 ,in general ,the requirement of this paragraph is met with respect to health insurance coverage provided to a participant or beneficiary by any health insurance issuer if1 under such plan the requirements of section #gja are met with respect to the participant or beneficiary4 7,b7 ,enforcement with respect to individual election ,for purposes of subparagraph 7,a71 any health insurance coverage with respect to the participant or beneficiary shall be treated as health insurance coverage under a group health plan to which section #gja applies4 7#d7 ,contribution amount 7,a7 ,in general ,for purposes of this section1 the term contribution amount means1 with respect to any period of health insurance coverage offered to a participant or beneficiary1 the portion of the applicable premium of such participant or beneficiary under such plan which is not paid by such participant or beneficiary4 ,in the case that the employer offers more than one group health plan1 the contribution amount shall be the average amount of the applicable premiums under such plans4 7,b7 ,applicable premium ,for purposes of subparagraph 7,a71 the term applicable premium means1 with respect to any period of health insurance coverage of a participant or beneficiary under a group health plan1 the cost to the plan for such period of such coverage for similarly situated beneficiaries 7without regard to whether such cost is paid by the plan sponsor or the participant or beneficiary74 4 7#b7 ,exemption from fiduciary liability ,section #djd of such ,act 7#bi ,u4,s4,c4 #aajd7 is amended by adding at the end the following new subsection3 7e7 ,the plan sponsor of a group health plan 7as defined in section #gcc7;a77 shall not be treated as breaching any of the responsibilities1 obligations1 or duties imposed upon fiduciaries by this title in the case of any individual who is a participant or beneficiary under such plan solely because of the extent to which the plan sponsor provides1 in the case of such individual1 some or all of such benefits by means of payment of contribution amounts pursuant to a contribution election under section #gcb7;e71 irrespective of the amount or type of benefits that would otherwise be provided to such individual under such plan4 4 7d7 ,exception from ,,hipaa requirements under ,,irc for benefits provided under health care contribution election ,section #ihca of the ,internal ,revenue ,code of #aihf 7relating to general exceptions7 is amended by adding at the end the following new subsection3 7d7 ,health care contribution election 7#a7 ,in general ,the requirements of this chapter shall not apply in the case of health insurance coverage 7other than excepted benefits as defined in section #ihcb7;c77-- 7,a7 which is provided to a participant or beneficiary by a health insurance issuer under a group health plan1 and 7,b7 with respect to which the requirements of paragraphs 7#b7 and 7#c7 are met4 7#b7 ,contribution election ,the requirement of this paragraph is met with respect to health insurance coverage provided to a participant or beneficiary by any health insurance issuer under a group health plan if1 under such plan-- 7,a7 the participant may elect such coverage for any period of coverage in lieu of health insurance coverage otherwise provided under such plan for such period1 and 7,b7 in the case of such an election1 the plan sponsor is required to pay to such issuer for the elected coverage for such period an amount which is not less than the contribution amount for such health insurance coverage otherwise provided under such plan for such period4 7#c7 ,pre-existing conditions 7,a7 ,in general ,the requirement of this paragraph is met with respect to health insurance coverage provided to a participant or beneficiary by any health insurance issuer if1 under such plan the requirements of section #ihja are met with respect to the participant or beneficiary4 7,b7 ,enforcement with respect to individual election ,for purposes of subparagraph 7,a71 any health insurance coverage with respect to the participant or beneficiary shall be treated as health insurance coverage under a group health plan to which section #ihja applies4 7#d7 ,contribution amount 7,a7 ,in general ,for purposes of this subsection1 the term contribution amount means1 with respect to any period of health insurance coverage offered to a participant or beneficiary1 the portion of the applicable premium of such participant or beneficiary under such plan which is not paid by such participant or beneficiary4 ,in the case that the employer offers more than one group health plan1 the contribution amount shall be the average amount of the applicable premiums under such plans4 7,b7 ,applicable premium ,for purposes of subparagraph 7,a71 the term applicable premium means1 with respect to any period of health insurance coverage of a participant or beneficiary under a group health plan1 the cost to the plan for such period of such coverage for similarly situated beneficiaries 7without regard to whether such cost is paid by the plan sponsor or the participant or beneficiary74 4 7e7 ,exception from ,,hipaa requirements under the ,,phsa for benefits provided under health care contribution election ,section #bgba of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ba7 is amended-- 7#a7 by redesignating subsection 7e7 as subsection 7f72 and 7#b7 by inserting after subsection 7d7 the following new subsection3 7e7 ,health care contribution election 7#a7 ,in general ,the requirements of subparts #a through #c shall not apply in the case of health insurance coverage 7other than excepted benefits as defined in section #ihcb7;c7 of the ,internal ,revenue ,code of #aihf7-- 7,a7 which is provided to a participant or beneficiary by a health insurance issuer under a group health plan1 and 7,b7 with respect to which the requirements of paragraphs 7#b7 and 7#c7 are met4 7#b7 ,contribution election ,the requirement of this paragraph is met with respect to health insurance coverage provided to a participant or beneficiary by any health insurance issuer under a group health plan if1 under such plan-- 7,a7 the participant may elect such coverage for any period of coverage in lieu of health insurance coverage otherwise provided under such plan for such period1 and 7,b7 in the case of such an election1 the plan sponsor is required to pay to such issuer for the elected coverage for such period an amount which is not less than the contribution amount for such health insurance coverage otherwise provided under such plan for such period4 7#c7 ,pre-existing conditions 7,a7 ,in general ,the requirement of this paragraph is met with respect to health insurance coverage provided to a participant or beneficiary by any health insurance issuer if1 under such plan the requirements of section #bgja are met with respect to the participant or beneficiary4 7,b7 ,enforcement with respect to individual election ,for purposes of subparagraph 7,a71 any health insurance coverage with respect to the participant or beneficiary shall be treated as health insurance coverage under a group health plan to which section #bgja applies4 7#d7 ,contribution amount 7,a7 ,in general ,for purposes of this section1 the term contribution amount means1 with respect to any period of health insurance coverage offered to a participant or beneficiary1 the portion of the applicable premium of such participant or beneficiary under such plan which is not paid by such participant or beneficiary4 ,in the case that the employer offers more than one group health plan1 the contribution amount shall be the average amount of the applicable premiums under such plans4 7,b7 ,applicable premium ,for purposes of subparagraph 7,a71 the term applicable premium means1 with respect to any period of health insurance coverage of a participant or beneficiary under a group health plan1 the cost to the plan for such period of such coverage for similarly situated beneficiaries 7without regard to whether such cost is paid by the plan sponsor or the participant or beneficiary74 4 #ajh4 ,limitations on ,state restrictions on employer auto-enrollment 7a7 ,in general ,no ,state shall establish a law that prevents an employer that is allowed an exclusion from gross income1 a deduction1 or a credit for ,federal income tax purposes for health benefits furnished to a participant or beneficiary from instituting auto-enrollment which meets the requirements of subsection 7b7 for coverage of a participant or beneficiary under a group health plan1 or health insurance coverage offered in connection with such a plan1 so long as the participant or beneficiary has the option of declining such coverage4 7b7 ,automatic enrollment for employer-,sponsored health benefits 7#a7 ,in general ,the requirement of this subsection with respect to an employer and an employee is that the employer automatically enroll such employee into the employment-based health benefits plan for individual coverage under the plan option with the lowest applicable employee premium4 7#b7 ,opt-out ,in no case may an employer automatically enroll an employee in a plan under paragraph 7#a7 if such employee makes an affirmative election to opt-out of such plan or to elect coverage under an employment-based health benefits plan offered by such employer4 ,an employer shall provide an employee with a #cj-;day period to make such an affirmative election before the employer may automatically enroll the employee in such a plan4 7#c7 ,notice requirements 7,a7 ,in general ,each employer described in paragraph 7#a7 who automatically enrolls an employee into a plan as described in such paragraph shall provide the employees1 within a reasonable period before the beginning of each plan year 7or1 in the case of new employees1 within a reasonable period before the end of the enrollment period for such a new employee71 written notice of the employees' rights and obligations relating to the automatic enrollment requirement under such paragraph4 ,such notice must be comprehensive and understood by the average employee to whom the automatic enrollment requirement applies4 7,b7 ,inclusion of specific information ,the written notice under subparagraph 7,a7 must explain an employee's right to opt out of being automatically enrolled in a plan and in the case that more than one level of benefits or employee premium level is offered by the employer involved1 the notice must explain which level of benefits and employee premium level the employee will be automatically enrolled in the absence of an affirmative election by the employee4 7c7 ,construction ,nothing in this section shall be construed to supersede ,state law which establishes1 implements1 or continues in effect any standard or requirement relating to employers in connection with payroll or the sponsoring of employer-sponsored health insurance coverage except to the extent that such standard or requirement prevents an employer from instituting the auto-enrollment described in subsection 7a74 7d7 ,non-,application to excepted benefits ,for purposes of this section1 the term group health plan does not include excepted benefits 7as defined in section #bgha7;c7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ia7;c7774 #aji4 ,credit for small employers adopting auto-enrollment and defined contribution options 7a7 ,in general ,subpart ,d of part ,,iv of subchapter ,a of chapter #a of the ,internal ,revenue ,code of #aihf1 as amended by section #b1 is amended by adding at the end the following new section3 #de,r4 ,auto-enrollment and defined contribution option for health benefits plans of small employers 7a7 ,in general ,for purposes of section #ch1 in the case of a small employer1 the health benefits plan implementation credit determined under this section for the taxable year is an amount equal to #ajj percent of the amount paid or incurred by the taxpayer during the taxable year for qualified health benefits expenses4 7b7 ,limitation ,the credit determined under subsection 7a7 with respect to any taxpayer for any taxable year shall not exceed the excess of-- 7#a7 #a1ejj1 over 7#b7 sum of the credits determined under subsection 7a7 with respect to such taxpayer for all preceding taxable years4 7c7 ,qualified health benefits expenses ,for purposes of this section1 the term qualified health benefits auto-enrollment expenses means1 with respect to any taxable year1 amounts paid or incurred by the taxpayer during such taxable year for-- 7#a7 establishing auto-enrollment which meets the requirements of section #ajg of the ,empowering ,patients ,first ,act of #bjac for coverage of a participant or beneficiary under a group health plan1 or health insurance coverage offered in connection with such a plan1 and 7#b7 implementing the employer contribution option for health insurance coverage pursuant to section #ejjj7;e77#b74 7d7 ,qualified small employer ,for purposes of this section1 the term qualified small employer means any employer for any taxable year if the number of employees employed by such employer during such taxable year does not exceed #ej4 ,all employers treated as a single employer under section 7a7 or 7b7 of section #eb shall be treated as a single employer for purposes of this section4 7e7 ,no double benefit ,no deduction or credit shall be allowed under any other provision of this chapter with respect to the amount of the credit determined under this section4 7f7 ,termination ,subsection 7a7 shall not apply to any taxable year beginning after the date which is #b years after the date of the enactment of this section4 4 7b7 ,credit ,to be part of general business credit ,subsection 7b7 of section #ch of such ,code1 as amended by section #b1 is amended by striking plus at the end of paragraph 7#cd71 by striking the period at the end of paragraph 7#ce7 and inserting 1 plus1 and by adding at the end the following new paragraph3 7#cf7 in the case of a small employer 7as defined in section #de,r7d771 the health benefits plan implementation credit determined under section #de,r7a74 4 7c7 ,clerical amendment ,the table of sections for subpart ,d of part ,,iv of subchapter ,a of chapter #a of such ,code1 as amended by section #b1 is amended by inserting after the item relating to section #de,q the following new item3 ,sec4 #de,r4 ,auto-enrollment and defined contribution option for health benefits plans of small employers4 4 7d7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #aaj4 ,,hsa modifications and clarifications 7a7 ,clarification of treatment of capitated primary care payments as amounts paid for medical care ,section #bac7;d7 of the ,internal ,revenue ,code of #aihf 7relating to definitions7 is amended by adding at the end the following new paragraph3 7#ab7 ,treatment of capitated primary care payments ,capitated primary care payments shall be treated as amounts paid for medical care4 4 7b7 ,special rule for individuals eligible for veterans or ,indian health benefits ,section #bbc7;c77#a7 of such ,code 7defining eligible individual7 is amended by adding at the end the following new subparagraph3 7,c7 ,special rule for individuals eligible for veterans or ,indian health benefits ,for purposes of subparagraph 7,a77ii71 an individual shall not be treated as covered under a health plan described in such subparagraph merely because the individual receives periodic hospital care or medical services under any law administered by the ,secretary of ,veterans ,affairs or the ,bureau of ,indian ,affairs4 4 7c7 ,certain physician fees ,to be treated as medical care ,section #bac7;d7 of such ,code is amended by adding at the end the following new paragraph3 7#ac7 ,pre-paid physician fees ,the term medical care shall include amounts paid by patients to their primary physician in advance for the right to receive medical services on an as-needed basis4 4 7d7 ,application to health care sharing ministries ,section #bbc of such ,code is amended by adding at the end the following new subsection3 7i7 ,application to health care sharing ministries ,for purposes of this section1 membership in a health care sharing ministry 7as defined in section #cf;,b7f77#c77 shall be treated as coverage under a high deductible health plan4 4 7e7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 ,,ii ,health ,insurance ,pooling ,mechanisms for ,individuals ,a ,federal ,grants for ,state ,insurance ,expenditures #bja4 ,federal grants for ,state insurance expenditures 7a7 ,in ,general ,subject to the succeeding provisions of this section1 each ,state shall receive from the ,secretary of ,health and ,human ,services 7in this subtitle referred to as the ,secretary7 a grant for the ,state's providing for the use1 in connection with providing health benefits coverage1 of a qualifying high-risk pool or a reinsurance pool or other risk-adjustment mechanism used for the purpose of subsidizing the purchase of private health insurance4 7b7 ,funding amount 7#a7 ,in general ,there are hereby appropriated1 out of any funds in the ,treasury not otherwise appropriated1 #cjj1jjj1jjj for each of fiscal years #bjad1 #bjae1 and #bjaf for grants under this section4 ,such amount shall be divided among the ,states as determined by the ,secretary4 7#b7 ,construction ,nothing in this section shall be construed as preventing a ,state from using funding under section #bgde of the ,public ,health ,service ,act for purposes of funding reinsurance or other risk mechanisms4 7c7 ,limitation ,funding under subsection 7a7 may only be used for the following3 7#a7 ,qualifying high-risk pools 7,a7 ,current pools ,a qualifying high-risk pool created before the date of the enactment of this ,act that only cover high-risk populations and individuals 7and their spouse and dependents7 receiving a health care tax credit under section #ce of the ,internal ,revenue ,code of #aihf for a limited period of time as determined by the ,secretary or under section #bgda of ,public ,health ,service ,act4 7,b7 ,new pools ,a qualifying high-risk pool created on or after such date that only covers populations and individuals described in subparagraph 7,a7 if the pool-- 7i7 offers at least the option of one or more high-deductible plan options1 in combination with a contribution into a health savings account2 7ii7 offers multiple competing health plan options2 and 7iii7 covers only high-risk populations4 7#b7 ,risk insurance pool or other risk-adjustment mechanisms 7,a7 ,current reinsurance ,a reinsurance pool1 or other risk-adjustment mechanism1 created before the date of the enactment of this ,act that only covers populations and individuals described in paragraph 7#a77;,a74 7,b7 ,new pools ,a reinsurance pool or other risk-adjustment mechanism created on or after such date that provides reinsurance only covers populations and individuals described in paragraph 7#a77;,a7 and only on a prospective basis under which a health insurance issuer cedes covered lives to the pool in exchange for payment of a reinsurance premium4 7#c7 ,transition ,nothing in this section shall be construed as preventing a ,state from using funds available to transition from an existing high-risk pool to a reinsurance pool4 7d7 ,bonus payments ,with respect to any amounts made available to the ,states under this section1 the ,secretary shall set aside a portion of such amounts that shall only be available for the following activities by such ,states3 7#a7 ,providing guaranteed availability of individual health insurance coverage to certain individuals with prior group coverage under part ,b of title ,,xxvii of the ,public ,health ,service ,act4 7#b7 ,a reduction in premium trends1 actual premiums1 or other cost-sharing requirements4 7#c7 ,an expansion or broadening of the pool of high-risk individuals eligible for coverage4 7#d7 ,states that adopt the ,model ,health ,plan for ,uninsurable ,individuals ,act of the ,national ,association of ,insurance ,commissioners 7if and when updated by such ,association74 ,the ,secretary may request such ,association to update such ,model ,health ,plan as needed by #bjae4 7e7 ,administration ,the ,secretary shall provide for the administration of this section and may establish such terms and conditions1 including the requirement of an application1 as may be appropriate to carry out this section4 7f7 ,construction ,nothing in this section shall be construed as requiring a ,state to operate a reinsurance pool 7or other risk-adjustment mechanism7 under this section or as preventing a ,state from operating such a pool or mechanism through one or more private entities4 7g7 ,definitions ,in this section3 7#a7 ,qualifying high-risk pool ,the term qualifying high-risk pool means any qualified high-risk pool 7as defined in subsection 7g77#a77;,a7 of section #bgde of the ,public ,health ,service ,act7 that meets the conditions to receive a grant under section 7b77#a7 of such section4 7#b7 ,reinsurance pool or other risk-,adjustment mechanism defined ,the term reinsurance pool or other risk-adjustment mechanism means any ,state-based risk spreading mechanism to subsidize the purchase of private health insurance for the high-risk population4 7#c7 ,high-,risk population ,the term high-risk population means-- 7,a7 individuals who1 by reason of the existence or history of a medical condition1 are able to acquire health coverage only at rates which are at least #aej percent of the standard risk rates for such coverage 7in a non-community-rated non-guaranteed issue ,state71 and 7,b7 individuals who are provided health coverage by a high-risk pool4 7#d7 ,state defined ,the term ,state includes the ,district of ,columbia1 ,puerto ,rico1 the ,virgin ,islands1 ,guam1 ,american ,samoa1 and the ,northern ,mariana ,islands4 7h7 ,extending funding ,section #bgde7;d77#b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#de7;d77#b77 is amended-- 7#a7 in the heading1 by inserting and #bjad through #bjaf after #bjaj2 and 7#b7 by inserting and for each of fiscal years #bjad through #bjaf after for each of fiscal years #bjjg through #bjaj4 7i7 ,sunset ,funds made available under this section shall not be used for the purpose of subsidizing the purchase of private health insurance on or after ,october #a1 #bjaf4 ,b ,health ,care ,access and ,availability #baa4 ,expansion of access and choice through individual and small employer membership associations 7,i,m,as7 ,the ,public ,health ,service ,act1 as amended by section #b1 is further amended by inserting after title ,,xxx the following new title3 ,,xxxi ,individual and ,small ,employer ,membership ,associations #caja4 ,definition of individual and small employer membership association 7,,ima7 7a7 ,in ,general ,for purposes of this title1 the terms individual and small employer membership association and ,,ima mean a legal entity that meets the following requirements3 7#a7 ,organization ,the ,,ima is an organization operated under the direction of an association 7as defined in section #cajd7a774 7#b7 ,offering health benefits coverage 7,a7 ,different groups ,the ,,ima1 in conjunction with those health insurance issuers that offer health benefits coverage through the ,,ima1 makes available health benefits coverage in the manner described in subsection 7b7 to all members of the ,,ima and the dependents of such members 7and1 in the case of small employers1 employees and their dependents7 in the manner described in subsection 7c77#b7 at rates that are established by the health insurance issuer on a policy or product specific basis and that may vary only as permissible under ,state law4 7,b7 ,nondiscrimination in coverage offered 7i7 ,in ,general ,subject to clause 7ii71 the ,,ima may not offer health benefits coverage to a member of an ,,ima unless the same coverage is offered to all such members of the ,,ima4 7ii7 ,construction ,nothing in this title shall be construed as requiring or permitting a health insurance issuer to provide coverage outside the service area of the issuer1 as approved under ,state law1 or requiring a health insurance issuer from excluding or limiting the coverage on any individual1 subject to the requirement of section #bgda4 7,c7 ,no financial underwriting ,the ,,ima provides health benefits coverage only through contracts with health insurance issuers and does not assume insurance risk with respect to such coverage4 7#c7 ,geographic areas ,nothing in this title shall be construed as preventing the establishment and operation of more than one ,,ima in a geographic area or as limiting the number of ,i,m,as that may operate in any area4 7#d7 ,provision of administrative services to purchasers 7,a7 ,in ,general ,the ,,ima may provide administrative services for members4 ,such services may include accounting1 billing1 and enrollment information4 7,b7 ,construction ,nothing in this subsection shall be construed as preventing an ,,ima from serving as an administrative service organization to any entity4 7#e7 ,filing information ,the ,,ima files with the ,secretary information that demonstrates the ,,ima's compliance with the applicable requirements of this title4 7b7 ,health benefits coverage requirements 7#a7 ,compliance with consumer protection requirements ,any health benefits coverage offered through an ,,ima shall-- 7,a7 be underwritten by a health insurance issuer that-- 7i7 is licensed 7or otherwise regulated7 under ,state law1 and 7ii7 meets all applicable ,state standards relating to consumer protection1 subject to section #cajb7;b71 and 7,b7 subject to paragraph 7#b71 be approved or otherwise permitted to be offered under ,state law4 7#b7 ,examples of types of coverage ,the benefits coverage made available through an ,,ima may include1 but is not limited to1 any of the following if it meets the other applicable requirements of this title3 7,a7 ,coverage through a health maintenance organization4 7,b7 ,coverage in connection with a preferred provider organization4 7,c7 ,coverage in connection with a licensed provider-sponsored organization4 7,d7 ,indemnity coverage through an insurance company4 7,e7 ,coverage offered in connection with a contribution into a medical savings account or flexible spending account4 7,f7 ,coverage that includes a point-of-service option4 7,g7 ,any combination of such types of coverage4 7#c7 ,wellness bonuses for health promotion ,nothing in this title shall be construed as precluding a health insurance issuer offering health benefits coverage through an ,,ima from establishing premium discounts or rebates for members or from modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention so long as such programs are agreed to in advance by the ,,ima and comply with all other provisions of this title and do not discriminate among similarly situated members4 7c7 ,members2 health insurance issuers 7#a7 ,members 7,a7 ,in ,general ,under rules established to carry out this title1 with respect to an individual or small employer who is a member of an ,,ima1 the individual may enroll for health benefits coverage 7including coverage for dependents of such individual7 or employer may enroll employees for health benefits coverage 7including coverage for dependents of such employees7 offered by a health insurance issuer through the ,,ima4 7,b7 ,rules for enrollment ,nothing in this paragraph shall preclude an ,,ima from establishing rules of enrollment and reenrollment of members4 ,such rules shall be applied consistently to all members within the ,,ima and shall not be based in any manner on health status-related factors4 7#b7 ,health insurance issuers ,the contract between an ,,ima and a health insurance issuer shall provide1 with respect to a member enrolled with health benefits coverage offered by the issuer through the ,,ima1 for the payment of the premiums collected by the issuer4 #cajb4 ,application of certain laws and requirements ,state laws insofar as they relate to any of the following are superseded and shall not apply to health benefits coverage made available through an ,,ima3 7#a7 ,benefit requirements for health benefits coverage offered through an ,,ima1 including 7but not limited to7 requirements relating to coverage of specific providers1 specific services or conditions1 or the amount1 duration1 or scope of benefits1 but not including requirements to the extent required to implement title ,,xxvii or other ,federal law and to the extent the requirement prohibits an exclusion of a specific disease from such coverage4 7#b7 ,any other requirements 7including limitations on compensation arrangements7 that1 directly or indirectly1 preclude 7or have the effect of precluding7 the offering of such coverage through an ,,ima1 if the ,,ima meets the requirements of this title4 ,any ,state law or regulation relating to the composition or organization of an ,,ima is preempted to the extent the law or regulation is inconsistent with the provisions of this title4 #cajc4 ,administration 7a7 ,in ,general ,the ,secretary shall administer this title and is authorized to issue such regulations as may be required to carry out this title4 ,such regulations shall be subject to ,congressional review under the provisions of chapter #h of title #e1 ,united ,states ,code4 ,the ,secretary shall incorporate the process of deemed file and use with respect to the information filed under section #caja7;a77#e77;,a7 and shall determine whether information filed by an ,,ima demonstrates compliance with the applicable requirements of this title4 ,the ,secretary shall exercise authority under this title in a manner that fosters and promotes the development of ,i,m,as in order to improve access to health care coverage and services4 7b7 ,periodic reports ,the ,secretary shall submit to ,congress a report every #cj months1 during the #aj-year period beginning on the effective date of the rules promulgated by the ,secretary to carry out this title1 on the effectiveness of this title in promoting coverage of uninsured individuals4 ,the ,secretary may provide for the production of such reports through one or more contracts with appropriate private entities4 #cajd4 ,definitions ,for purposes of this title3 7#a7 ,association ,the term association means1 with respect to health insurance coverage offered in a ,state1 a legal entity which-- 7,a7 has been actively in existence for at least #e years2 7,b7 has been formed and maintained in good faith for purposes other than obtaining insurance2 7,c7 does not condition membership in the association on any health status-related factor relating to an individual 7including an employee of an employer or a dependent of an employee72 and 7,d7 does not make health insurance coverage offered through the association available other than in connection with a member of the association4 7#b7 ,dependent ,the term dependent1 as applied to health insurance coverage offered by a health insurance issuer licensed 7or otherwise regulated7 in a ,state1 shall have the meaning applied to such term with respect to such coverage under the laws of the ,state relating to such coverage and such an issuer4 ,such term may include the spouse and children of the individual involved4 7#c7 ,health benefits coverage ,the term health benefits coverage has the meaning given the term health insurance coverage in section #bgia7;b77#a71 and does not include excepted benefits 7as defined in section #bgia7;c774 7#d7 ,health insurance issuer ,the term health insurance issuer has the meaning given such term in section #bgia7;b77#b74 7#e7 ,health status-related factor ,the term health status-related factor has the meaning given such term in section #bgia7;d77#i74 7#f7 ,,ima2 individual and small employer membership association ,the terms ,,ima and individual and small employer membership association are defined in section #caja7;a74 7#g7 ,member ,the term member means1 with respect to an ,,ima1 an individual or small employer who is a member of the association to which the ,,ima is offering coverage4 7#h7 ,small employer ,the term small employer has the meaning given such term in section #hab7;a77#ac7 of the ,employee ,retirement and ,income ,security ,act of #aigd4 4 ,c ,small ,business ,health ,fairness #bba4 ,short title ,this subtitle may be cited as the ,small ,business ,health ,fairness ,act of #bjac4 #bbb4 ,rules governing association health plans 7a7 ,in ,general ,subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd is amended by adding after part #g the following new part3 #h ,,rules ,,governing ,,association ,,health ,,plans #hja4 ,association health plans 7a7 ,in ,general ,for purposes of this part1 the term association health plan means a 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 or providing 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 membership in the sponsor2 and 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 participation4 ,any sponsor consisting of an association of entities which meet the requirements of paragraphs 7#a71 7#b71 and 7#c7 shall be deemed to be a sponsor described in this subsection4 #hjb4 ,certification of association health plans 7a7 ,in ,general ,the applicable authority shall prescribe by regulation a procedure under which1 subject to subsection 7b71 the applicable authority shall certify association health plans which apply for certification as meeting the requirements of this part4 7b7 ,standards ,under the procedure prescribed pursuant to subsection 7a71 in the case of an association health plan that provides at least one benefit option which does not consist of health insurance coverage1 the applicable authority shall certify such plan as meeting the requirements of this part only if the applicable authority is satisfied that the applicable requirements of this part are met 7or1 upon the date on which the plan is to commence operations1 will be met7 with respect to the plan4 7c7 ,requirements ,applicable to ,certified ,plans ,an association 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 7d7 ,requirements for ,continued ,certification ,the applicable authority may provide by regulation for continued certification of association health plans under this part4 7e7 ,class ,certification for ,fully ,insured ,plans ,the applicable authority shall establish a class certification procedure for association health plans under which all benefits consist of health insurance coverage4 ,under such procedure1 the applicable authority shall provide for the granting of certification under this part to the plans in each class of such association health plans upon appropriate filing under such procedure in connection with plans in such class and payment of the prescribed fee under section #hjg7;a74 7f7 ,certification of ,self-,insured ,association ,health ,plans ,an association health plan which offers one or more benefit options which do not consist of health insurance coverage may be certified under this part only if such plan consists of any of the following3 7#a7 a plan which offered such coverage on the date of the enactment of the ,small ,business ,health ,fairness ,act of #bjac1 7#b7 a plan under which the sponsor does not restrict membership to one or more trades and businesses or industries and whose eligible participating employers represent a broad cross-section of trades and businesses or industries1 or 7#c7 a plan whose eligible participating employers represent one or more trades or businesses1 or one or more industries1 consisting of any of the following3 agriculture2 equipment and automobile dealerships2 barbering and cosmetology2 certified public accounting practices2 child care2 construction2 dance1 theatrical and orchestra productions2 disinfecting and pest control2 financial services2 fishing2 food service establishments2 hospitals2 labor organizations2 logging2 manufacturing 7metals72 mining2 medical and dental practices2 medical laboratories2 professional consulting services2 sanitary services2 transportation 7local and freight72 warehousing2 wholesaling_/distributing2 or any other trade or business or industry which has been indicated as having average or above-average risk or health claims experience by reason of ,state rate filings1 denials of coverage1 proposed premium rate levels1 or other means demonstrated by such plan in accordance with regulations4 #hjc4 ,requirements relating to sponsors and boards of trustees 7a7 ,sponsor ,the requirements of this subsection are met with respect to an association 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 an association health plan if the following requirements are met3 7#a7 ,fiscal control ,the plan is operated1 pursuant to a trust agreement1 by a board of trustees which 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 an association health plan which is in existence on the date of the enactment of the ,small ,business ,health ,fairness ,act of #bjac4 7,b7 ,sole authority ,the board has sole authority under the plan to approve applications for participation in the plan and to contract with a service provider to administer the day-to-day affairs of the plan4 7c7 ,treatment of ,franchise ,networks ,in the case of a group health plan which is established and maintained by a franchiser for a franchise network consisting of 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 franchiser were deemed to be the sponsor referred to in section #hja7;b71 such network were deemed to be an association described in section #hja7;b71 and each franchisee were deemed to be a member 7of the association and the sponsor7 referred to in section #hja7;b72 and 7#b7 the requirements of section #hjd7;a77#a7 shall be deemed met4 ,the ,secretary may by regulation define for purposes of this subsection the terms franchiser1 franchise network1 and franchisee4 #hjd4 ,participation and coverage requirements 7a7 ,covered ,employers and ,individuals ,the requirements of this subsection are met with respect to an association health plan if1 under the terms of the plan-- 7#a7 each participating employer must be-- 7,a7 a member of the sponsor1 7,b7 the sponsor1 or 7,c7 an affiliated member of the sponsor with respect to which the requirements of subsection 7b7 are met1 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 beneficiaries of individuals described in subparagraph 7,a74 7b7 ,coverage of ,previously ,uninsured ,employees ,in the case of an association health plan in existence on the date of the enactment of the ,small ,business ,health ,fairness ,act of #bjac1 an affiliated member of the sponsor of the plan may be offered coverage under the plan as a participating employer only if-- 7#a7 the affiliated member was an affiliated member on the date of certification under this part2 or 7#b7 during the #ab-month period preceding the date of the offering of such coverage1 the affiliated member has not maintained or contributed to a group health plan with respect to any of its employees who would otherwise be eligible to participate in such association health plan4 7c7 ,individual ,market ,unaffected ,the requirements of this subsection are met with respect to an association 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 7d7 ,prohibition of ,discrimination ,against ,employers and ,employees ,eligible ,to ,participate ,the requirements of this subsection are met with respect to an association 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 upon request1 any employer eligible to participate is furnished information regarding all coverage options available under the plan2 and 7#c7 the applicable requirements of sections #gja1 #gjb1 and #gjc are met with respect to the plan4 #hje4 ,other requirements relating to plan documents1 contribution rates1 and benefit options 7a7 ,in ,general ,the requirements of this section are met with respect to an association health plan if the following requirements are met3 7#a7 ,contents of governing instruments ,the instruments governing the plan include a written instrument1 meeting the requirements of an instrument required under section #djb7;a77#a71 which-- 7,a7 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 7,b7 provides that the sponsor of the plan is to serve as plan sponsor 7referred to in section #c7af77;,b772 and 7,c7 incorporates the requirements of section #hjf4 7#b7 ,contribution rates must be nondiscriminatory 7,a7 ,the contribution rates for any participating small employer do not vary on the basis of any health status-related factor in relation to employees of such employer or their beneficiaries and do not vary on the basis of the type of business or industry in which such employer is engaged4 7,b7 ,nothing in this title or any other provision of law shall be construed to preclude an association health plan1 or a health insurance issuer offering health insurance coverage in connection with an association health plan1 from-- 7i7 setting contribution rates based on the claims experience of the plan2 or 7ii7 varying contribution rates for small employers in a ,state to the extent that such rates could vary using the same methodology employed in such ,state for regulating premium rates in the small group market with respect to health insurance coverage offered in connection with bona fide associations 7within the meaning of section #bgia7;d77#c7 of the ,public ,health ,service ,act71 subject to the requirements of section #gjb7;b7 relating to contribution rates4 7#c7 ,floor for number of covered individuals with respect to certain plans ,if any benefit option under the plan does not consist of health insurance coverage1 the plan has as of the beginning of the plan year not fewer than #a1jjj participants and beneficiaries4 7#d7 ,marketing requirements 7,a7 ,in general ,if a benefit option which consists of health insurance coverage is offered under the plan1 ,state-licensed insurance agents shall be used to distribute to small employers coverage which does not consist of health insurance coverage in a manner comparable to the manner in which such agents are used to distribute health insurance coverage4 7,b7 ,state-licensed insurance agents ,for purposes of subparagraph 7,a71 the term ,state-licensed insurance agents means one or more agents who are licensed in a ,state and are subject to the laws of such ,state relating to licensure1 qualification1 testing1 examination1 and continuing education of persons authorized to offer1 sell1 or solicit health insurance coverage in such ,state4 7#e7 ,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 ,association ,health ,plans ,to ,design ,benefit ,options ,subject to section #ead7;d71 nothing in this part or any provision of ,state law 7as defined in section #ead7;c77#a77 shall be construed to preclude an association health plan1 or a health insurance issuer offering health insurance coverage in connection with an association health plan1 from exercising its sole discretion in selecting the specific items and services consisting of medical care to be included as benefits under such plan or coverage1 except 7subject to section #ead7 in the case of 7#a7 any law to the extent that it is not preempted under section #gca7;a77#a7 with respect to matters governed by section #gaa1 #gab1 or #gac1 or 7#b7 any law of the ,state with which filing and approval of a policy type offered by the plan was initially obtained to the extent that such law prohibits an exclusion of a specific disease from such coverage4 #hjf4 ,maintenance of reserves and provisions for solvency for plans providing health benefits in addition to health insurance coverage 7a7 ,in ,general ,the requirements of this section are met with respect to an association health plan if-- 7#a7 the benefits under the plan consist solely of health insurance coverage2 or 7#b7 if the plan provides any additional benefit options which do not consist of health insurance coverage1 the plan-- 7,a7 establishes and maintains reserves with respect to such additional benefit options1 in amounts recommended by the qualified health actuary1 consisting of-- 7i7 a reserve sufficient for unearned contributions2 7ii7 a reserve sufficient for benefit liabilities which have been incurred1 which have not been satisfied1 and for which risk of loss has not yet been transferred1 and for expected administrative costs with respect to such benefit liabilities2 7iii7 a reserve sufficient for any other obligations of the plan2 and 7iv7 a reserve sufficient for a margin of error and other fluctuations1 taking into account the specific circumstances of the plan2 and 7,b7 establishes and maintains aggregate and specific excess_/stop loss insurance and solvency indemnification1 with respect to such additional benefit options for which risk of loss has not yet been transferred1 as follows3 7i7 ,the plan shall secure aggregate excess_/stop loss insurance for the plan with an attachment point which is not greater than #abe percent of expected gross annual claims4 ,the applicable authority may by regulation provide for upward adjustments in the amount of such percentage in specified circumstances in which the plan specifically provides for and maintains reserves in excess of the amounts required under subparagraph 7,a74 7ii7 ,the plan shall secure specific excess_/stop loss insurance for the plan with an attachment point which is at least equal to an amount recommended by the plan's qualified health actuary4 ,the applicable authority may by regulation provide for adjustments in the amount of such insurance in specified circumstances in which the plan specifically provides for and maintains reserves in excess of the amounts required under subparagraph 7,a74 7iii7 ,the plan shall secure indemnification insurance for any claims which the plan is unable to satisfy by reason of a plan termination4 ,any person issuing to a plan insurance described in clause 7i71 7ii71 or 7iii7 of subparagraph 7,b7 shall notify the ,secretary of any failure of premium payment meriting cancellation of the policy prior to undertaking such a cancellation4 ,any regulations prescribed by the applicable authority pursuant to clause 7i7 or 7ii7 of subparagraph 7,b7 may allow for such adjustments in the required levels of excess_/stop loss insurance as the qualified health actuary may recommend1 taking into account the specific circumstances of the plan4 7b7 ,minimum ,surplus in ,addition to ,claims ,reserves ,in the case of any association health plan described in subsection 7a77#b71 the requirements of this subsection are met if the plan establishes and maintains surplus in an amount at least equal to-- 7#a7 #ejj1jjj1 or 7#b7 such greater amount 7but not greater than #b1jjj1jjj7 as may be set forth in regulations prescribed by the applicable authority1 considering the level of aggregate and specific excess_/stop loss insurance provided with respect to such plan and other factors related to solvency risk1 such as the plan's projected levels of participation or claims1 the nature of the plan's liabilities1 and the types of assets available to assure that such liabilities are met4 7c7 ,additional ,requirements ,in the case of any association health plan described in subsection 7a77#b71 the applicable authority may provide such additional requirements relating to reserves1 excess_/stop loss insurance1 and indemnification insurance as the applicable authority considers appropriate4 ,such requirements may be provided by regulation with respect to any such plan or any class of such plans4 7d7 ,adjustments for ,excess_/,stop ,loss ,insurance ,the applicable authority may provide for adjustments to the levels of reserves otherwise required under subsections 7a7 and 7b7 with respect to any plan or class of plans to take into account excess_/stop loss insurance provided with respect to such plan or plans4 7e7 ,alternative ,means of ,compliance ,the applicable authority may permit an association health plan described in subsection 7a77#b7 to substitute1 for all or part of the requirements of this section 7except subsection 7a77#b77;,b77iii771 such security1 guarantee1 hold-harmless arrangement1 or other financial arrangement as the applicable authority determines to be adequate to enable the plan to fully meet all its financial obligations on a timely basis and is otherwise no less protective of the interests of participants and beneficiaries than the requirements for which it is substituted4 ,the applicable authority may take into account1 for purposes of this subsection1 evidence provided by the plan or sponsor which demonstrates an assumption of liability with respect to the plan4 ,such evidence may be in the form of a contract of indemnification1 lien1 bonding1 insurance1 letter of credit1 recourse under applicable terms of the plan in the form of assessments of participating employers1 security1 or other financial arrangement4 7f7 ,measures ,to ,ensure ,continued ,payment of ,benefits by ,certain ,plans in ,distress 7#a7 ,payments by certain plans to association health plan fund 7,a7 ,in general ,in the case of an association health plan described in subsection 7a77#b71 the requirements of this subsection are met if the plan makes payments into the ,association ,health ,plan ,fund under this subparagraph when they are due4 ,such payments shall consist of annual payments in the amount of #e1jjj1 and1 in addition to such annual payments1 such supplemental payments as the ,secretary may determine to be necessary under paragraph 7#b74 ,payments under this paragraph are payable to the ,fund at the time determined by the ,secretary4 ,initial payments are due in advance of certification under this part4 ,payments shall continue to accrue until a plan's assets are distributed pursuant to a termination procedure4 7,b7 ,penalties for failure to make payments ,if any payment is not made by a plan when it is due1 a late payment charge of not more than #ajj percent of the payment which was not timely paid shall be payable by the plan to the ,fund4 7,c7 ,continued duty of the secretary ,the ,secretary shall not cease to carry out the provisions of paragraph 7#b7 on account of the failure of a plan to pay any payment when due4 7#b7 ,payments by secretary to continue excess_/stop loss insurance coverage and indemnification insurance coverage for certain plans ,in any case in which the applicable authority determines that there is1 or that there is reason to believe that there will be3 7,a7 a failure to take necessary corrective actions under section #hji7;a7 with respect to an association health plan described in subsection 7a77#b72 or 7,b7 a termination of such a plan under section #hji7;b7 or #haj7;b77#h7 7and1 if the applicable authority is not the ,secretary1 certifies such determination to the ,secretary71 the ,secretary shall determine the amounts necessary to make payments to an insurer 7designated by the ,secretary7 to maintain in force excess_/stop loss insurance coverage or indemnification insurance coverage for such plan1 if the ,secretary determines that there is a reasonable expectation that1 without such payments1 claims would not be satisfied by reason of termination of such coverage4 ,the ,secretary shall1 to the extent provided in advance in appropriation ,acts1 pay such amounts so determined to the insurer designated by the ,secretary4 7#c7 ,association health plan fund 7,a7 ,in general ,there is established on the books of the ,treasury a fund to be known as the ,association ,health ,plan ,fund4 ,the ,fund shall be available for making payments pursuant to paragraph 7#b74 ,the ,fund shall be credited with payments received pursuant to paragraph 7#a77;,a71 penalties received pursuant to paragraph 7#a77;,b71 and earnings on investments of amounts of the ,fund under subparagraph 7,b74 7,b7 ,investment ,whenever the ,secretary determines that the moneys of the fund are in excess of current needs1 the ,secretary may request the investment of such amounts as the ,secretary determines advisable by the ,secretary of the ,treasury in obligations issued or guaranteed by the ,united ,states4 7g7 ,excess_/,stop ,loss ,insurance ,for purposes of this section-- 7#a7 ,aggregate excess_/stop loss insurance ,the term aggregate excess_/stop loss insurance means1 in connection with an association health plan1 a contract-- 7,a7 under which an insurer 7meeting such minimum standards as the applicable authority may prescribe by regulation7 provides for payment to the plan with respect to aggregate claims under the plan in excess of an amount or amounts specified in such contract2 7,b7 which is guaranteed renewable2 and 7,c7 which allows for payment of premiums by any third party on behalf of the insured plan4 7#b7 ,specific excess_/stop loss insurance ,the term specific excess_/stop loss insurance means1 in connection with an association health plan1 a contract-- 7,a7 under which an insurer 7meeting such minimum standards as the applicable authority may prescribe by regulation7 provides for payment to the plan with respect to claims under the plan in connection with a covered individual in excess of an amount or amounts specified in such contract in connection with such covered individual2 7,b7 which is guaranteed renewable2 and 7,c7 which allows for payment of premiums by any third party on behalf of the insured plan4 7h7 ,indemnification ,insurance ,for purposes of this section1 the term indemnification insurance means1 in connection with an association health plan1 a contract-- 7#a7 under which an insurer 7meeting such minimum standards as the applicable authority may prescribe by regulation7 provides for payment to the plan with respect to claims under the plan which the plan is unable to satisfy by reason of a termination pursuant to section #hji7;b7 7relating to mandatory termination72 7#b7 which is guaranteed renewable and noncancellable for any reason 7except as the applicable authority may prescribe by regulation72 and 7#c7 which allows for payment of premiums by any third party on behalf of the insured plan4 7i7 ,reserves ,for purposes of this section1 the term reserves means1 in connection with an association health plan1 plan assets which meet the fiduciary standards under part #d and such additional requirements regarding liquidity as the applicable authority may prescribe by regulation4 7j7 ,solvency ,standards ,working ,group 7#a7 ,in general ,within #ij days after the date of the enactment of the ,small ,business ,health ,fairness ,act of #bjac1 the applicable authority shall establish a ,solvency ,standards ,working ,group4 ,in prescribing the initial regulations under this section1 the applicable authority shall take into account the recommendations of such ,working ,group4 7#b7 ,membership ,the ,working ,group shall consist of not more than #ae members appointed by the applicable authority4 ,the applicable authority shall include among persons invited to membership on the ,working ,group at least one of each of the following3 7,a7 ,a representative of the ,national ,association of ,insurance ,commissioners4 7,b7 ,a representative of the ,american ,academy of ,actuaries4 7,c7 ,a representative of the ,state governments1 or their interests4 7,d7 ,a representative of existing self-insured arrangements1 or their interests4 7,e7 ,a representative of associations of the type referred to in section #hja7;b77#a71 or their interests4 7,f7 ,a representative of multiemployer plans that are group health plans1 or their interests4 #hjg4 ,requirements for application and related requirements 7a7 ,filing ,fee ,under the procedure prescribed pursuant to section #hjb7;a71 an association 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 association 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 plan and contract administrators and other service providers4 7#f7 ,funding report ,in the case of association health plans providing benefits options in addition to health insurance coverage1 a report setting forth information with respect to such additional benefit options determined as of a date within the #abj-;day period ending with the date of the application1 including the following3 7,a7 ,reserves ,a statement1 certified by the board of trustees of the plan1 and a statement of actuarial opinion1 signed by a qualified health actuary1 that all applicable requirements of section #hjf are or will be met in accordance with regulations which the applicable authority shall prescribe4 7,b7 ,adequacy of contribution rates ,a statement of actuarial opinion1 signed by a qualified health actuary1 which sets forth a description of the extent to which contribution rates are adequate to provide for the payment of all obligations and the maintenance of required reserves under the plan for the #ab-month period beginning with such date within such #abj-;day period1 taking into account the expected coverage and experience of the plan4 ,if the contribution rates are not fully adequate1 the statement of actuarial opinion shall indicate the extent to which the rates are inadequate and the changes needed to ensure adequacy4 7,c7 ,current and projected value of assets and liabilities ,a statement of actuarial opinion signed by a qualified health actuary1 which sets forth the current value of the assets and liabilities accumulated under the plan and a projection of the assets1 liabilities1 income1 and expenses of the plan for the #ab-month period referred to in subparagraph 7,b74 ,the income statement shall identify separately the plan's administrative expenses and claims4 7,d7 ,costs of coverage to be charged and other expenses ,a statement of the costs of coverage to be charged1 including an itemization of amounts for administration1 reserves1 and other expenses associated with the operation of the plan4 7,e7 ,other information ,any other information as may be determined by the applicable authority1 by regulation1 as necessary to carry out the purposes of this part4 7c7 ,filing ,notice of ,certification ,with ,states ,a certification granted under this part to an association health plan shall not be effective unless written notice of such certification is filed with the applicable ,state authority of each ,state in which at least #be percent of the participants and beneficiaries under the plan are located4 ,for purposes of this subsection1 an individual shall be considered to be located in the ,state in which a known address of such individual is located or in which such individual is employed4 7d7 ,notice of ,material ,changes ,in the case of any association 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 7e7 ,reporting ,requirements for ,certain ,association ,health ,plans ,an association health plan certified under this part which provides benefit options in addition to health insurance coverage for such plan year shall meet the requirements of section #ajc by filing an annual report under such section which shall include information described in subsection 7b77#f7 with respect to the plan year and1 notwithstanding section #ajd7;a77#a77;,a71 shall be filed with the applicable authority not later than #ij days after the close of the plan year 7or on such later date as may be prescribed by the applicable authority74 ,the applicable authority may require by regulation such interim reports as it considers appropriate4 7f7 ,engagement of ,qualified ,health ,actuary ,the board of trustees of each association health plan which provides benefits options in addition to health insurance coverage and which is applying for certification under this part or is certified under this part shall engage1 on behalf of all participants and beneficiaries1 a qualified health actuary who shall be responsible for the preparation of the materials comprising information necessary to be submitted by a qualified health actuary under this part4 ,the qualified health actuary shall utilize such assumptions and techniques as are necessary to enable such actuary to form an opinion as to whether the contents of the matters reported under this part-- 7#a7 are in the aggregate reasonably related to the experience of the plan and to reasonable expectations2 and 7#b7 represent such actuary's best estimate of anticipated experience under the plan4 ,the opinion by the qualified health actuary shall be made with respect to1 and shall be made a part of1 the annual report4 #hjh4 ,notice requirements for voluntary termination ,except as provided in section #hji7;b71 an association 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 ,corrective actions and mandatory termination 7a7 ,actions ,to ,avoid ,depletion of ,reserves ,an association health plan which is certified under this part and which provides benefits other than health insurance coverage shall continue to meet the requirements of section #hjf1 irrespective of whether such certification continues in effect4 ,the board of trustees of such plan shall determine quarterly whether the requirements of section #hjf are met4 ,in any case in which the board determines that there is reason to believe that there is or will be a failure to meet such requirements1 or the applicable authority makes such a determination and so notifies the board1 the board shall immediately notify the qualified health actuary engaged by the plan1 and such actuary shall1 not later than the end of the next following month1 make such recommendations to the board for corrective action as the actuary determines necessary to ensure compliance with section #hjf4 ,not later than #cj days after receiving from the actuary recommendations for corrective actions1 the board shall notify the applicable authority 7in such form and manner as the applicable authority may prescribe by regulation7 of such recommendations of the actuary for corrective action1 together with a description of the actions 7if any7 that the board has taken or plans to take in response to such recommendations4 ,the board shall thereafter report to the applicable authority1 in such form and frequency as the applicable authority may specify to the board1 regarding corrective action taken by the board until the requirements of section #hjf are met4 7b7 ,mandatory ,termination ,in any case in which-- 7#a7 the applicable authority has been notified under subsection 7a7 7or by an issuer of excess_/stop loss insurance or indemnity insurance pursuant to section #hjf7;a77 of a failure of an association health plan which is or has been certified under this part and is described in section #hjf7;a77#b7 to meet the requirements of section #hjf and has not been notified by the board of trustees of the plan that corrective action has restored compliance with such requirements2 and 7#b7 the applicable authority determines that there is a reasonable expectation that the plan will continue to fail to meet the requirements of section #hjf1 the board of trustees of the plan shall1 at the direction of the applicable authority1 terminate the plan and1 in the course of the termination1 take such actions as the applicable authority may require1 including satisfying any claims referred to in section #hjf7;a77#b77;,b77iii7 and recovering for the plan any liability under subsection 7a77#b77;,b77iii7 or 7e7 of section #hjf1 as necessary to ensure that the affairs of the plan will be1 to the maximum extent possible1 wound up in a manner which will result in timely provision of all benefits for which the plan is obligated4 #haj4 ,trusteeship by the ,secretary of insolvent association health plans providing health benefits in addition to health insurance coverage 7a7 ,appointment of ,secretary as ,trustee for ,insolvent ,plans ,whenever the ,secretary determines that an association health plan which is or has been certified under this part and which is described in section #hjf7;a77#b7 will be unable to provide benefits when due or is otherwise in a financially hazardous condition1 as shall be defined by the ,secretary by regulation1 the ,secretary shall1 upon notice to the plan1 apply to the appropriate ,united ,states district court for appointment of the ,secretary as trustee to administer the plan for the duration of the insolvency4 ,the plan may appear as a party and other interested persons may intervene in the proceedings at the discretion of the court4 ,the court shall appoint such ,secretary trustee if the court determines that the trusteeship is necessary to protect the interests of the participants and beneficiaries or providers of medical care or to avoid any unreasonable deterioration of the financial condition of the plan4 ,the trusteeship of such ,secretary shall continue until the conditions described in the first sentence of this subsection are remedied or the plan is terminated4 7b7 ,powers as ,trustee ,the ,secretary1 upon appointment as trustee under subsection 7a71 shall have the power-- 7#a7 to do any act authorized by the plan1 this title1 or other applicable provisions of law to be done by the plan administrator or any trustee of the plan2 7#b7 to require the transfer of all 7or any part7 of the assets and records of the plan to the ,secretary as trustee2 7#c7 to invest any assets of the plan which the ,secretary holds in accordance with the provisions of the plan1 regulations prescribed by the ,secretary1 and applicable provisions of law2 7#d7 to require the sponsor1 the plan administrator1 any participating employer1 and any employee organization representing plan participants to furnish any information with respect to the plan which the ,secretary as trustee may reasonably need in order to administer the plan2 7#e7 to collect for the plan any amounts due the plan and to recover reasonable expenses of the trusteeship2 7#f7 to commence1 prosecute1 or defend on behalf of the plan any suit or proceeding involving the plan2 7#g7 to issue1 publish1 or file such notices1 statements1 and reports as may be required by the ,secretary by regulation or required by any order of the court2 7#h7 to terminate the plan 7or provide for its termination in accordance with section #hji7;b77 and liquidate the plan assets1 to restore the plan to the responsibility of the sponsor1 or to continue the trusteeship2 7#i7 to provide for the enrollment of plan participants and beneficiaries under appropriate coverage options2 and 7#aj7 to do such other acts as may be necessary to comply with this title or any order of the court and to protect the interests of plan participants and beneficiaries and providers of medical care4 7c7 ,notice of ,appointment ,as soon as practicable after the ,secretary's appointment as trustee1 the ,secretary shall give notice of such appointment to-- 7#a7 the sponsor and plan administrator2 7#b7 each participant2 7#c7 each participating employer2 and 7#d7 if applicable1 each employee organization which1 for purposes of collective bargaining1 represents plan participants4 7d7 ,additional ,duties ,except to the extent inconsistent with the provisions of this title1 or as may be otherwise ordered by the court1 the ,secretary1 upon appointment as trustee under this section1 shall be subject to the same duties as those of a trustee under section #gjd of title #aa1 ,united ,states ,code1 and shall have the duties of a fiduciary for purposes of this title4 7e7 ,other ,proceedings ,an application by the ,secretary under this subsection may be filed notwithstanding the pendency in the same or any other court of any bankruptcy1 mortgage foreclosure1 or equity receivership proceeding1 or any proceeding to reorganize1 conserve1 or liquidate such plan or its property1 or any proceeding to enforce a lien against property of the plan4 7f7 ,jurisdiction of ,court 7#a7 ,in general ,upon the filing of an application for the appointment as trustee or the issuance of a decree under this section1 the court to which the application is made shall have exclusive jurisdiction of the plan involved and its property wherever located with the powers1 to the extent consistent with the purposes of this section1 of a court of the ,united ,states having jurisdiction over cases under chapter #aa of title #aa1 ,united ,states ,code4 ,pending an adjudication under this section such court shall stay1 and upon appointment by it of the ,secretary as trustee1 such court shall continue the stay of1 any pending mortgage foreclosure1 equity receivership1 or other proceeding to reorganize1 conserve1 or liquidate the plan1 the sponsor1 or property of such plan or sponsor1 and any other suit against any receiver1 conservator1 or trustee of the plan1 the sponsor1 or property of the plan or sponsor4 ,pending such adjudication and upon the appointment by it of the ,secretary as trustee1 the court may stay any proceeding to enforce a lien against property of the plan or the sponsor or any other suit against the plan or the sponsor4 7#b7 ,venue ,an action under this section may be brought in the judicial district where the sponsor or the plan administrator resides or does business or where any asset of the plan is situated4 ,a district court in which such action is brought may issue process with respect to such action in any other judicial district4 7g7 ,personnel ,in accordance with regulations which shall be prescribed by the ,secretary1 the ,secretary shall appoint1 retain1 and compensate accountants1 actuaries1 and other professional service personnel as may be necessary in connection with the ,secretary's service as trustee under this section4 #haa4 ,state assessment authority 7a7 ,in ,general ,notwithstanding section #ead1 a ,state may impose by law a contribution tax on an association health plan described in section #hjf7;a77#b71 if the plan commenced operations in such ,state after the date of the enactment of the ,small ,business ,health ,fairness ,act of #bjac4 7b7 ,contribution ,tax ,for purposes of this section1 the term contribution tax imposed by a ,state on an association health plan means any tax imposed by such ,state if-- 7#a7 such tax is computed by applying a rate to the amount of premiums or contributions1 with respect to individuals covered under the plan who are residents of such ,state1 which are received by the plan from participating employers located in such ,state or from such individuals2 7#b7 the rate of such tax does not exceed the rate of any tax imposed by such ,state on premiums or contributions received by insurers or health maintenance organizations for health insurance coverage offered in such ,state in connection with a group health plan2 7#c7 such tax is otherwise nondiscriminatory2 and 7#d7 the amount of any such tax assessed on the plan is reduced by the amount of any tax or assessment otherwise imposed by the ,state on premiums1 contributions1 or both received by insurers or health maintenance organizations for health insurance coverage1 aggregate excess_/stop loss insurance 7as defined in section #hjf7;g77#a771 specific excess_/stop loss insurance 7as defined in section #hjf7;g77#b771 other insurance related to the provision of medical care under the plan1 or any combination thereof provided by such insurers or health maintenance organizations in such ,state in connection with such plan4 #hab4 ,definitions and rules of construction 7a7 ,definitions ,for purposes of this part-- 7#a7 ,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#b7 ,medical care ,the term medical care has the meaning provided in section #gcc7;a77#b74 7#c7 ,health insurance coverage ,the term health insurance coverage has the meaning provided in section #gcc7;b77#a74 7#d7 ,health insurance issuer ,the term health insurance issuer has the meaning provided in section #gcc7;b77#b74 7#e7 ,applicable authority ,the term applicable authority means the ,secretary1 except that1 in connection with any exercise of the ,secretary's authority regarding 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#f7 ,health status-related factor ,the term health status-related factor has the meaning provided in section #gcc7;d77#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 ,participating employer ,the term participating employer means1 in connection with an association 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#i7 ,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#aj7 ,qualified health actuary ,the term qualified health actuary means an individual who is a member of the ,american ,academy of ,actuaries with expertise in health care4 7#aa7 ,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 7,b7 in the case of a sponsor with members which consist of associations1 a person who is a member of any such association and elects an affiliated status with the sponsor1 or 7,c7 in the case of an association health plan in existence on the date of the enactment of the ,small ,business ,health ,fairness ,act of #bjac1 a person eligible to be a member of the sponsor or one of its member associations4 7#ab7 ,large employer ,the term large employer means1 in connection with a group health plan with respect to a plan year1 an employer who employed an average of at least #ea employees on business days during the preceding calendar year and who employs at least #b employees on the first day of the plan year4 7#ac7 ,small employer ,the term small employer means1 in connection with a group health plan with respect to a plan year1 an employer who is not a large employer4 7b7 ,rules of ,construction 7#a7 ,employers and employees ,for purposes of determining whether a plan1 fund1 or program is an employee welfare benefit plan which is an association 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 7#b7 ,plans1 funds1 and programs treated as employee welfare benefit plans ,in the case of any plan1 fund1 or program which was established or is maintained for the purpose of providing medical care 7through the purchase of insurance or otherwise7 for employees 7or their dependents7 covered thereunder and which demonstrates to the ,secretary that all requirements for certification under this part would be met with respect to such plan1 fund1 or program if such plan1 fund1 or program were a group health plan1 such plan1 fund1 or program shall be treated for purposes of this title as an employee welfare benefit plan on and after the date of such demonstration4 7#c7 ,exception for certain benefits ,the requirements of this part shall not apply to a group health plan in relation to its provision of excepted benefits1 as defined in section #gjf7;c74 4 7b7 ,conforming ,amendments to ,preemption ,rules 7#a7 ,section #ead7;b77#f7 of such ,act 7#bi ,u4,s4,c4 #aadd7;b77#f77 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 an association health plan which is certified under part #h4 4 7#b7 ,section #ead of such ,act 7#bi ,u4,s4,c4 #aadd7 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 preclude1 or have the effect of precluding1 a health insurance issuer from offering health insurance coverage in connection with an association health plan which is certified under part #h4 7#b7 ,except as provided in paragraphs 7#d7 and 7#e7 of subsection 7b7 of this section-- 7,a7 ,in any case in which health insurance coverage of any policy type is offered under an association 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 preclude a health insurance issuer from offering health insurance coverage of the same policy type to other employers operating in the ,state which are eligible for coverage under such association health plan1 whether or not such other employers are participating employers in such plan4 7,b7 ,in any case in which health insurance coverage of any policy type is offered in a ,state under an association health plan certified under part #h and the filing1 with the applicable ,state authority 7as defined in section #hab7;a77#i771 of the policy form in connection with such policy type is approved by such ,state authority1 the provisions of this title shall supersede any and all laws of any other ,state in which health insurance coverage of such type is offered1 insofar as they may preclude1 upon the filing in the same form and manner of such policy form with the applicable ,state authority in such other ,state1 the approval of the filing in such other ,state4 7#c7 ,nothing in subsection 7b77#f77;,e7 or the preceding provisions of this subsection shall be construed1 with respect to health insurance issuers or health insurance coverage1 to supersede or impair the law of any ,state-- 7,a7 providing solvency standards or similar standards regarding the adequacy of insurer capital1 surplus1 reserves1 or contributions1 or 7,b7 relating to prompt payment of claims4 7#d7 ,for additional provisions relating to association health plans1 see subsections 7a77#b77;,b7 and 7b7 of section #hje4 7#e7 ,for purposes of this subsection1 the term association health plan has the meaning provided in section #hja7;a71 and the terms health insurance coverage1 participating employer1 and health insurance issuer have the meanings provided such terms in section #hab1 respectively4 4 7#c7 ,section #ead7;b77#f77;,a7 of such ,act 7#bi ,u4,s4,c4 #aadd7;b77#f77;,a77 is amended-- 7,a7 in clause 7i77,,ii71 by striking and at the end2 7,b7 in clause 7ii71 by inserting and which does not provide medical care 7within the meaning of section #gcc7;a77#b771 after arrangement11 and by striking title4 and inserting title1 and2 and 7,c7 by adding at the end the following new clause3 7iii7 subject to subparagraph 7,e71 in the case of any other employee welfare benefit plan which is a multiple employer welfare arrangement and which provides medical care 7within the meaning of section #gcc7;a77#b771 any law of any ,state which regulates insurance may apply4 4 7#d7 ,section #ead7;e7 of such ,act 7as redesignated by paragraph 7#b77;,c77 is amended-- 7,a7 by striking ,nothing and inserting 7#a7 ,except as provided in paragraph 7#b71 nothing2 and 7,b7 by adding at the end the following new paragraph3 7#b7 ,nothing in any other provision of law enacted on or after the date of the enactment of the ,small ,business ,health ,fairness ,act of #bjac shall be construed to alter1 amend1 modify1 invalidate1 impair1 or supersede any provision of this title1 except by specific cross-reference to the affected section4 4 7c7 ,plan ,sponsor ,section #c7af77;,b7 of such ,act 7#bi ,u4,s4,c4 #ajb7af77;,b77 is amended by adding at the end the following new sentence3 ,such term also includes a person serving as the sponsor of an association health plan under part #h44 7d7 ,disclosure of ,solvency ,protections ,related to ,self-,insured and ,fully ,insured ,options ,under ,association ,health ,plans ,section #ajb7;b7 of such ,act 7#bi ,u4,s4,c4 #ajb7;b77 is amended by adding at the end the following3 ,an association health plan shall include in its summary plan description1 in connection with each benefit option1 a description of the form of solvency or guarantee fund protection secured pursuant to this ,act or applicable ,state law1 if any44 7e7 ,savings ,clause ,section #gca7;c7 of such ,act is amended by inserting or part #h after this part4 7f7 ,report to the ,congress ,regarding ,certification of ,self-,insured ,association ,health ,plans ,not later than ,january #a1 #bjaf1 the ,secretary of ,labor shall report to the ,committee on ,education and the ,workforce of the ,house of ,representatives and the ,committee on ,health1 ,education1 ,labor1 and ,pensions of the ,senate the effect association health plans have had1 if any1 on reducing the number of uninsured individuals4 7g7 ,clerical ,amendment ,the table of contents in section #a of the ,employee ,retirement ,income ,security ,act of #aigd is amended by inserting after the item relating to section #gcd the following new items3 ,part #h--,rules ,governing ,association ,health ,plans#hja4 ,association health plans4#hjb4 ,certification of association health plans4#hjc4 ,requirements relating to sponsors and boards of trustees4#hjd4 ,participation and coverage requirements4#hje4 ,other requirements relating to plan documents1 contribution rates1 and benefit options4#hjf4 ,maintenance of reserves and provisions for solvency for plans providing health benefits in addition to health insurance coverage4#hjg4 ,requirements for application and related requirements4#hjh4 ,notice requirements for voluntary termination4#hji4 ,corrective actions and mandatory termination4#haj4 ,trusteeship by the ,secretary of insolvent association health plans providing health benefits in addition to health insurance coverage4#haa4 ,state assessment authority4#hab4 ,definitions and rules of construction4 4 #bbc4 ,clarification of treatment of single employer arrangements ,section #c7dj77;,b7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #ajjb7dj77;,b77 is amended-- 7#a7 in clause 7i71 by inserting after control group1 the following3 except that1 in any case in which the benefit referred to in subparagraph 7,a7 consists of medical care 7as defined in section #hab7;a77#b771 two or more trades or businesses1 whether or not incorporated1 shall be deemed a single employer for any plan year of such plan1 or any fiscal year of such other arrangement1 if such trades or businesses are within the same control group during such year or at any time during the preceding #a-year period12 7#b7 in clause 7iii71 by striking 7iii7 the determination and inserting the following3 7iii7 7,i7 in any case in which the benefit referred to in subparagraph 7,a7 consists of medical care 7as defined in section #hab7;a77#b771 the determination of whether a trade or business is under common control with another trade or business shall be determined under regulations of the ,secretary applying principles consistent and coextensive with the principles applied in determining whether employees of two or more trades or businesses are treated as employed by a single employer under section #djja7;b71 except that1 for purposes of this paragraph1 an interest of greater than #be percent may not be required as the minimum interest necessary for common control1 or 7,,ii7 in any other case1 the determination 2 7#c7 by redesignating clauses 7iv7 and 7v7 as clauses 7v7 and 7vi71 respectively2 and 7#d7 by inserting after clause 7iii7 the following new clause3 7iv7 in any case in which the benefit referred to in subparagraph 7,a7 consists of medical care 7as defined in section #hab7;a77#b771 in determining1 after the application of clause 7i71 whether benefits are provided to employees of two or more employers1 the arrangement shall be treated as having only one participating employer if1 after the application of clause 7i71 the number of individuals who are employees and former employees of any one participating employer and who are covered under the arrangement is greater than #ge percent of the aggregate number of all individuals who are employees or former employees of participating employers and who are covered under the arrangement1 4 #bbd4 ,enforcement provisions relating to association health plans 7a7 ,criminal ,penalties for ,certain ,willful ,misrepresentations ,section #eja of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aaca7 is amended-- 7#a7 by inserting 7a7 after ,sec4 #eja42 and 7#b7 by adding at the end the following new subsection3 7b7 ,any person who willfully falsely represents1 to any employee1 any employee's beneficiary1 any employer1 the ,secretary1 or any ,state1 a plan or other arrangement established or maintained for the purpose of offering or providing any benefit described in section #c7a7 to employees or their beneficiaries as-- 7#a7 being an association health plan which has been certified under part #h2 7#b7 having been established or maintained under or pursuant to one or more collective bargaining agreements which are reached pursuant to collective bargaining described in section #h7;d7 of the ,national ,labor ,relations ,act 7#bi ,u4,s4,c4 #aeh7;d77 or paragraph ,fourth of section #b of the ,railway ,labor ,act 7#de ,u4,s4,c4 #aeb1 paragraph ,fourth7 or which are reached pursuant to labor-management negotiations under similar provisions of ,state public employee relations laws2 or 7#c7 being a plan or arrangement described in section #c7dj77;,a77i71 shall1 upon conviction1 be imprisoned not more than #e years1 be fined under title #ah1 ,united ,states ,code1 or both4 4 7b7 ,cease ,activities ,orders ,section #ejb of such ,act 7#bi ,u4,s4,c4 #aacb7 is amended by adding at the end the following new subsection3 7n7 ,association ,health ,plan ,cease and ,desist ,orders 7#a7 ,in general ,subject to paragraph 7#b71 upon application by the ,secretary showing the operation1 promotion1 or marketing of an association health plan 7or similar arrangement providing benefits consisting of medical care 7as defined in section #gcc7;a77#b777 that-- 7,a7 is not certified under part #h1 is subject under section #ead7;b77#f7 to the insurance laws of any ,state in which the plan or arrangement offers or provides benefits1 and is not licensed1 registered1 or otherwise approved under the insurance laws of such ,state2 or 7,b7 is an association health plan certified under part #h and is not operating in accordance with the requirements under part #h for such certification1 a district court of the ,united ,states shall enter an order requiring that the plan or arrangement cease activities4 7#b7 ,exception ,paragraph 7#a7 shall not apply in the case of an association health plan or other arrangement if the plan or arrangement shows that-- 7,a7 all benefits under it referred to in paragraph 7#a7 consist of health insurance coverage2 and 7,b7 with respect to each ,state in which the plan or arrangement offers or provides benefits1 the plan or arrangement is operating in accordance with applicable ,state laws that are not superseded under section #ead4 7#c7 ,additional equitable relief ,the court may grant such additional equitable relief1 including any relief available under this title1 as it deems necessary to protect the interests of the public and of persons having claims for benefits against the plan4 4 7c7 ,responsibility for ,claims ,procedure ,section #ejc of such ,act 7#bi ,u4,s4,c4 #aacc7 is amended by inserting 7a7 ,in general4-- before ,in accordance1 and by adding at the end the following new subsection3 7b7 ,association ,health ,plans ,the terms of each association health plan which is or has been certified under part #h shall require the board of trustees or the named fiduciary 7as applicable7 to ensure that the requirements of this section are met in connection with claims filed under the plan4 4 #bbe4 ,cooperation between ,federal and ,state authorities ,section #ejf of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aacf7 is amended by adding at the end the following new subsection3 7d7 ,consultation ,with ,states ,with ,respect to ,association ,health ,plans 7#a7 ,agreements with states ,the ,secretary shall consult with the ,state recognized under paragraph 7#b7 with respect to an association 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 association health plans under part #h in accordance with regulations of the ,secretary applicable to certification under part #h4 7#b7 ,recognition of primary domicile state ,in carrying out paragraph 7#a71 the ,secretary shall ensure that only one ,state will be recognized1 with respect to any particular association health plan1 as the ,state with which consultation is required4 ,in carrying out this paragraph-- 7,a7 in the case of a plan which provides health insurance coverage 7as defined in section #hab7;a77#c771 such ,state shall be the ,state with which filing and approval of a policy type offered by the plan was initially obtained1 and 7,b7 in any other case1 the ,secretary shall take into account the places of residence of the participants and beneficiaries under the plan and the ,state in which the trust is maintained4 4 #bbf4 ,effective date and transitional and other rules 7a7 ,effective ,date ,the amendments made by this subtitle shall take effect #a year 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 #a year 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 #hab7;a77#e7 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 directors which-- 7i7 is elected by the participating employers1 with each employer having one vote2 and 7ii7 has complete fiscal control over the arrangement and which is responsible for all operations of 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 arrangement4 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 #hab of the ,employee ,retirement ,income ,security ,act of #aigd1 except that the reference in paragraph 7#g7 of such section to an association health plan shall be deemed a reference to an arrangement referred to in this subsection4 ,,iii ,interstate ,market for ,health ,insurance #cja4 ,cooperative governing of individual health insurance coverage 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#a71 but does not include excepted benefits described in section #bgia7;c74 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 only the #ej ,states and the ,district of ,columbia4 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 insurer1 reinsurer1 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 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 ,limitation on individual purchase in secondary ,state ,effective beginning two years after the date of enactment of this part1 an individual in a ,state may not buy individual health insurance coverage in a secondary ,state if the premium for individual health insurance in the primary ,state 7with respect to the individual7 exceeds the national average premium by #aj percent or more4 #bgii4 ,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 one 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 #bhjj4 ,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 pre-existing 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 7d7 ,severability ,if any provision of the section or the application of such provision to any person or circumstance is held to be unconstitutional1 the remainder of this section and the application of the provisions of such to any other person or circumstance shall not be affected4 ,,iv ,safety ,net ,reforms #dja4 ,requiring outreach and coverage before expansion of eligibility 7a7 ,state child health plan required ,to specify how it will achieve coverage for #ij percent of targeted low-,income children 7#a7 ,in general ,section #bajb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;bb7a77 is amended-- 7,a7 in paragraph 7#f71 by striking and at the end2 7,b7 in paragraph 7#g71 by striking the period at the end and inserting 2 and2 and 7,c7 by adding at the end the following new paragraph3 7#h7 how the eligibility and benefits provided for under the plan for each fiscal year 7beginning with fiscal year #bjae7 will allow for the ,state's annual funding allotment to cover at least #ij percent of the eligible targeted low-income children in the ,state4 4 7#b7 ,effective date ,the amendments made by paragraph 7#a7 shall apply to ,state child health plans for fiscal years beginning with fiscal year #bjae4 7b7 ,limitation on program expansions until lowest income eligible individuals enrolled ,section #baje7;c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;dd7c77 is amended by adding at the end the following new paragraph3 7#ab7 ,limitation on increased coverage of higher income children 7,a7 ,in general ,for child health assistance furnished in a fiscal year beginning with fiscal year #bjae3 7i7 ,no payment for children with family income above #cjj percent of poverty line ,payment shall not be made under this section for child health assistance for a targeted low-income child in a family the income of which exceeds #cjj percent of the poverty line applicable to a family of the size involved4 7ii7 ,special rules for payment for children with family income above #bjj percent of poverty line ,in the case of child health assistance for a targeted low-income child in a family the income of which exceeds #bjj percent 7but does not exceed #cjj percent7 of the poverty line applicable to a family of the size involved no payment shall be made under this section for such assistance unless the ,state demonstrates to the satisfaction of the ,secretary that-- 7,i7 the ,state has met the #ij percent retrospective coverage test specified in subparagraph 7,b77i7 for the previous fiscal year2 and 7,,ii7 the ,state will meet the #ij percent prospective coverage test specified in subparagraph 7,b77ii7 for the fiscal year4 7,b7 #ij percent coverage tests 7i7 ,retrospective test ,the #ij percent retrospective coverage test specified in this clause is1 for a ,state for a fiscal year1 that on average during the fiscal year1 the ,state has enrolled under this title or title ,,xix at least #ij percent of the individuals residing in the ,state who-- 7,i7 are children under #ai years of age 7or are pregnant women7 and are eligible for medical assistance under title ,,xix2 or 7,,ii7 are targeted low-income children whose family income does not exceed #bjj percent of the poverty line and who are eligible for child health assistance under this title4 7ii7 ,prospective test ,the #ij percent prospective test specified in this clause is1 for a ,state for a fiscal year1 that on average during the fiscal year1 the ,state will enroll under this title or title ,,xix at least #ij percent of the individuals residing in the ,state who-- 7,i7 are children under #ai years of age 7or are pregnant women7 and are eligible for medical assistance under title ,,xix2 or 7,,ii7 are targeted low-income children whose family income does not exceed such percent of the poverty line 7in excess of #bjj percent7 as the ,state elects consistent with this paragraph and who are eligible for child health assistance under this title4 7,c7 ,grandfather ,clauses 7i7 and 7ii7 of subparagraph 7,a7 shall not apply to the provision of child health assistance-- 7i7 to a targeted low-income child who is enrolled for child health assistance under this title as of ,september #cj1 #bjab2 7ii7 to a pregnant woman who is enrolled for assistance under this title as of ,september #cj1 #bjac1 through the completion of the post-partum period following completion of her pregnancy2 and 7iii7 for items and services furnished before ,october #a1 #bjad1 to an individual who is not a targeted low-income child and who is enrolled for assistance under this title as of ,september #cj1 #bjac4 7,d7 ,treatment of pregnant women ,in this paragraph and sections #bajb7;a77#h7 and #bajd7;a77#b71 the term targeted low-income child includes an individual under age #ai1 including the period from conception to birth1 who is eligible for child health assistance under this title by virtue of the definition of the term child under section #deg4aj of title #db1 ,code of ,federal ,regulations4 4 7c7 ,standardization of income determinations 7#a7 ,in general ,section #baaj of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;jj7 is amended by adding at the end the following new subsection3 7d7 ,standardization of income determinations ,in determining family income under this title 7including in the case of a ,state child health plan that provides health benefits coverage in the manner described in section #baja7;a77#b771 a ,state shall base such determination on gross income 7including amounts that would be included in gross income if they were not exempt from income taxation7 and may only take into consideration such income disregards as the ,secretary shall develop4 4 7#b7 ,effective date 7,a7 ,subject to subparagraph 7,b71 the amendment made by paragraph 7#a7 shall apply to determinations 7and redeterminations7 of income made on or after ,april #a1 #bjab4 7,b7 ,in the case of a ,state child health plan under title ,,xxi of the ,social ,security ,act which the ,secretary of ,health and ,human ,services determines requires ,state legislation 7other than legislation appropriating funds7 in order for the plan to meet the additional requirement imposed by the amendment made by paragraph 7#a71 the ,state child health plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the ,state legislature that begins after the date of the enactment of this ,act4 ,for purposes of the previous sentence1 in the case of a ,state that has a #b-year legislative session1 each year of such session shall be deemed to be a separate regular session of the ,state legislature4 #djb4 ,easing administrative barriers to ,state cooperation with employer-sponsored insurance coverage 7a7 ,requiring some coverage for employer-,sponsored insurance under ,,chip ,section #bajb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;b7a771 as amended by section #dja7;a71 is amended-- 7#a7 in paragraph 7#g71 by striking and at the end2 7#b7 in paragraph 7#h71 by striking the period at the end and inserting 2 and2 and 7#c7 by adding at the end the following new paragraph3 7#i7 effective for plan years beginning on or after ,october #a1 #bjad1 how the plan will provide for child health assistance with respect to targeted low-income children covered under a group health plan4 4 7b7 ,federal financial participation for employer-,sponsored insurance ,section #baje of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;d7 is amended-- 7#a7 in subsection 7a77#a77;,c71 by inserting before the semicolon at the end the following3 and1 subject to paragraph 7#c77;,c71 in the form of payment of the premiums for coverage under a group health plan that includes coverage of targeted low-income children and benefits supplemental to such coverage2 and 7#b7 by amending paragraph 7#c7 of subsection 7c7 to read as follows3 7#c7 ,purchase of employer-sponsored insurance 7,a7 ,in general ,payment may be made to a ,state under subsection 7a77#a77;,c71 subject to the provisions of this paragraph1 for the purchase of family coverage under a group health plan that includes coverage of targeted low-income children unless such coverage would otherwise substitute for coverage that would be provided to such children but for the purchase of family coverage4 7,b7 ,waiver of certain provisions ,with respect to coverage described in subparagraph 7,a7-- 7i7 notwithstanding section #bajb1 no minimum benefits requirement 7other than those otherwise applicable with respect to services referred to in section #bajb7;a77#g77 under this title shall apply2 and 7ii7 no limitation on beneficiary cost-sharing otherwise applicable under this title or title ,,xix shall apply4 7,c7 ,required provision of supplemental benefits ,if the coverage described in subparagraph 7,a7 does not provide coverage for the services referred to in section #bajb7;a77#g71 the ,state child health plan shall provide coverage of such services as supplemental benefits4 7,d7 ,limitation on ,,ffp ,the amount of the payment under paragraph 7#a77;,c7 for coverage described in subparagraph 7,a7 7and supplemental benefits under subparagraph 7,c7 for individuals so covered7 during a fiscal year may not exceed the product of-- 7i7 the national per capita expenditure under this title 7taking into account both ,federal and ,state expenditures7 for the previous fiscal year 7as determined by the ,secretary using the best available data72 7ii7 the enhanced ,,fmap for the ,state and fiscal year involved2 and 7iii7 the number of targeted low-income children for whom such coverage is provided4 7,e7 ,voluntary enrollment ,a ,state child health plan-- 7i7 may not require a targeted low-income child to enroll in coverage described in subparagraph 7,a7 in order to obtain child health assistance under this title2 7ii7 before providing such child health assistance for such coverage of a child1 shall make available 7which may be through an ,internet ,web site or other means including the ,state transparency plan portal established under section #ija of the ,empowering ,patients ,first ,act of #bjac7 to the parent or guardian of the child information on the coverage available under this title1 including benefits and cost-sharing2 and 7iii7 shall provide at least one opportunity per fiscal year for beneficiaries to switch coverage under this title from coverage described in subparagraph 7,a7 to the coverage that is otherwise made available under this title4 7,f7 ,information on coverage options ,a ,state child health plan shall-- 7i7 describe how the ,state will notify potential beneficiaries of coverage described in subparagraph 7,a72 7ii7 provide such notification in writing at least during the initial application for enrollment under this title and during redeterminations of eligibility if the individual was enrolled before ,october #a1 #bjad2 and 7iii7 post a description of these coverage options on any official ,web site that may be established by the ,state in connection with the plan1 including the ,state transparency plan portal established under section #ija of the ,empowering ,patients ,first ,act of #bjac4 7,g7 ,semiannual verification of coverage ,if coverage described in subparagraph 7,a7 is provided under a group health plan with respect to a targeted low-income child1 the ,state child health plan shall provide for the collection1 at least once every six months1 of proof from the plan that the child is enrolled in such coverage4 7,h7 ,rule of construction ,nothing in this section is to be construed to prohibit a ,state from-- 7i7 offering wrap around benefits in order for a group health plan to meet any ,state-established minimum benefit requirements2 7ii7 establishing a cost-effectiveness test to qualify for coverage under such a plan2 7iii7 establishing limits on beneficiary cost-sharing under such a plan2 7iv7 paying all or part of a beneficiary's cost-sharing requirements under such a plan2 7v7 paying less than the full cost of the employee's share of the premium under such a plan1 including prorating the cost of the premium to pay for only what the ,state determines is the portion of the premium that covers targeted low-income children2 7vi7 using ,state funds to pay for benefits above the ,federal upper limit established under subparagraph 7,c72 7vii7 allowing beneficiaries enrolled in group health plans from changing plans to another coverage option available under this title at any time2 or 7viii7 providing any guidance or information it deems appropriate in order to help beneficiaries make an informed decision regarding the option to enroll in coverage described in subparagraph 7,a74 7,i7 ,group health plan defined ,in this paragraph1 the term group health plan has the meaning given such term in section #bgia7;a77#a7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ia7;a77#a774 4 7c7 ,application under ,medicaid ,the ,secretary of ,health and ,human ,services shall provide for the application of the amendments made by subsections 7a7 and 7b7 under the ,medicaid program under title ,,xix of the ,social ,security ,act in the same manner as such amendments apply to ,,schip under title ,,xxi of such ,act4 #djc4 ,improving beneficiary choice in ,,schip 7a7 ,requiring offering of alternative coverage options ,section #bajb of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;b71 as amended by sections #dja7;a7 and #djb7;a71 is amended-- 7#a7 in subsection 7a7-- 7,a7 in paragraph 7#h71 by striking and at the end2 7,b7 in paragraph 7#i71 by striking the period at the end and inserting 2 and2 and 7,c7 by adding at the end the following new paragraph3 7#aj7 effective for plan years beginning on or after ,october #a1 #bjad1 how the plan will provide for child health assistance with respect to targeted low-income children through alternative coverage options in accordance with subsection 7e74 2 and 7#b7 by adding at the end the following new subsection3 7d7 ,alternative coverage options 7#a7 ,in general ,effective ,october #a1 #bjad1 a ,state child health plan shall provide for the offering of any qualified alternative coverage that a qualified entity seeks to offer to targeted low-income children through the plan in the ,state4 7#b7 ,application of uniform financial limitation for all alternative coverage options ,with respect to all qualified alternative coverage offered in a ,state1 the ,state child health plan shall establish a uniform dollar limitation on the per capita monthly amount that will be paid by the ,state to the qualified entity with respect to such coverage provided to a targeted low-income child4 ,such limitation may not be less than #ij percent of the per capita monthly payment made for coverage offered under the ,state child health plan that is not in the form of an alternative coverage option4 ,nothing in this paragraph shall be construed-- 7,a7 as requiring a ,state to provide for the full payment of premiums for qualified alternative coverage2 7,b7 as preventing a ,state from charging additional premiums to cover the difference between the cost of qualified alternative coverage and the amount of such payment limitation2 or 7,c7 as preventing a ,state from using its own funds to provide a dollar limitation that exceeds the ,federal financial participation as limited under section #baje7;c77#aj74 7#c7 ,treatment of low cost coverage 7,a7 ,in general ,except as provided in subparagraph 7,b71 if the uniform dollar limitation under paragraph 7#b7 exceeds the premium for qualified alternative coverage for an enrollee1 then such excess shall be refunded to the ,federal and ,state governments in the same proportion as is otherwise applicable to recovered funds under this title4 7,b7 ,exception for high-deductible health plans ,in the case of coverage under a high-deductible health plan1 the excess described in subparagraph 7,a7 shall be deposited into a health savings account established with respect to such plan4 7#d7 ,exemption ,a ,state is not subject to the requirement of paragraph 7#a7 if the ,state child health plan provides1 as of the date of the enactment of this subsection1 for a cash out or health savings account type option for those enrolled under the plan4 7#e7 ,qualified alternative coverage defined ,in this section1 the term qualified alternative coverage means health insurance coverage that-- 7,a7 meets the coverage requirements of section #bajc 7other than cost-sharing requirements of such section72 and 7,b7 is offered by a qualified insurer1 and not directly by the ,state4 7#f7 ,qualified insurer defined ,in this section1 the term qualified insurer means1 with respect to a ,state1 an entity that is licensed to offer health insurance coverage in the ,state4 4 7b7 ,federal financial participation for qualified alternative coverage ,section #baje of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;d7 is amended-- 7#a7 in subsection 7a77#a77;,c71 as amended by section #djb7;b71 by inserting before the semicolon at the end the following3 and1 subject to paragraph 7#ac77;,c71 in the form of payment of the premiums for coverage for qualified alternative coverage2 and 7#b7 in subsection 7c71 as amended by section #dja7;b7 by adding at the end the following new paragraph3 7#ac7 ,purchase of qualified alternative coverage 7,a7 ,in general ,payment may be made to a ,state under subsection 7a77#a77;,c71 subject to the provisions of this paragraph1 for the purchase of qualified alternative coverage4 7,b7 ,waiver of certain provisions ,with respect to coverage described in subparagraph 7,a71 no limitation on beneficiary cost-sharing otherwise applicable under this title or title ,,xix shall apply4 7,c7 ,limitation on ,,ffp ,the amount of the payment under paragraph 7#a77;,c7 for coverage described in subparagraph 7,a7 during a fiscal year in the aggregate for all such coverage in the ,state may not exceed the product of-- 7i7 the national per capita expenditure under this title 7taking into account both ,federal and ,state expenditures7 for the previous fiscal year 7as determined by the ,secretary using the best available data72 7ii7 the enhanced ,,fmap for the ,state and fiscal year involved2 and 7iii7 the number of targeted low-income children for whom such coverage is provided4 7,d7 ,voluntary enrollment ,a ,state child health plan-- 7i7 may not require a targeted low-income child to enroll in coverage described in subparagraph 7,a7 in order to obtain child health assistance under this title2 7ii7 before providing such child health assistance for such coverage of a child1 shall make available 7which may be through an ,internet ,web site or other means7 to the parent or guardian of the child information on the coverage available under this title1 including benefits and cost-sharing2 and 7iii7 shall provide at least one opportunity per fiscal year for beneficiaries to switch coverage under this title from coverage described in subparagraph 7,a7 to the coverage that is otherwise made available under this title4 7,e7 ,information on coverage options ,a ,state child health plan shall-- 7i7 describe how the ,state will notify potential beneficiaries of coverage described in subparagraph 7,a72 7ii7 provide such notification in writing at least during the initial application for enrollment under this title and during redeterminations of eligibility if the individual was enrolled before ,october #a1 #bjad2 and 7iii7 post a description of these coverage options on any official ,web site that may be established by the ,state in connection with the plan4 7,f7 ,rule of construction ,nothing in this section is to be construed to prohibit a ,state from-- 7i7 establishing limits on beneficiary cost-sharing under such alternative coverage2 7ii7 paying all or part of a beneficiary's cost-sharing requirements under such coverage2 7iii7 paying less than the full cost of a child's share of the premium under such coverage1 insofar as the premium for such coverage exceeds the limitation established by the ,state under subparagraph 7,c72 7iv7 using ,state funds to pay for benefits above the ,federal upper limit established under subparagraph 7,c72 or 7v7 providing any guidance or information it deems appropriate in order to help beneficiaries make an informed decision regarding the option to enroll in coverage described in subparagraph 7,a74 4 7c7 ,application under ,medicaid ,the ,secretary of ,health and ,human ,services shall provide for the application of the amendments made by subsections 7a7 and 7b7 under the ,medicaid program under title ,,xix of the ,social ,security ,act in the same manner as such amendments apply to ,,schip under title ,,xxi of such ,act4 ,v ,lawsuit ,abuse ,reforms #eja4 ,change in burden of proof based on compliance with best practice guidelines 7a7 ,selection and issuance of best practices guidelines 7#a7 ,in general ,the ,secretary of ,health and ,human ,services 7in this section referred to as the ,secretary7 shall provide for the selection and issuance of best practice guidelines for treatment of medical conditions 7each in this subsection referred to as a guideline7 in accordance with paragraphs 7#b7 and 7#c74 7#b7 ,development process ,not later than #ij days after the date of enactment of this title1 the ,secretary shall enter into a contract with a qualified physician consensus-building organization 7such as the ,physician ,consortium for ,performance ,improvement71 in concert and agreement with physician specialty organizations1 to develop guidelines4 ,the contract shall require that the organization submit guidelines to the agency not later than #ah months after the date of the enactment of this title4 7#c7 ,issuance 7,a7 ,in general ,not later than #b years after the date of the enactment of this title1 the ,secretary shall1 after notice and opportunity for public comment1 make a rule that provides for the issuance of the guidelines submitted under paragraph 7#b74 7,b7 ,limitation ,the ,secretary may not make a rule that includes guidelines other than those submitted under paragraph 7#b74 7,c7 ,dissemination ,the ,secretary shall post such guidelines on the public ,internet ,web page of the ,department of ,health and ,human ,services4 7#d7 ,maintenance ,not later than #d years after the date of enactment of this title1 and every #b years thereafter1 the ,secretary shall review the guidelines and shall1 as necessary1 enter into contracts similar to the contract described in paragraph 7#b71 and issue guidelines in a manner similar to the issuance of guidelines under paragraph 7#c74 7b7 ,use 7#a7 ,use by defendant to change the burden of proof ,if a defendant in a health care lawsuit relating to treatment of an individual establishes by a preponderance of the evidence that the treatment was provided in a manner consistent with an applicable guideline issued under subsection 7a71 the defendant may not be held liable unless the plaintiff establishes the liability of the defendant by clear and convincing evidence4 7#b7 ,limitation on introduction as evidence against a defendant ,guidelines issued under subsection 7a7 may not be introduced as evidence of negligence or deviation in the standard of care in any health care lawsuit unless they have previously been introduced by the defendant4 7#c7 ,no presumption of negligence against a defendant ,there shall be no presumption of negligence with respect to treatment if a health care provider provides the treatment in a manner inconsistent with such guidelines4 7c7 ,construction ,nothing in this section shall be construed as preventing a ,state from-- 7#a7 replacing their current medical malpractice rules with rules that rely1 as a defense1 upon a health care provider's compliance with a guideline issued under subsection 7a72 or 7#b7 applying additional guidelines or limitations on liability that are in addition to1 but not in lieu of1 the guidelines issued under subsection 7a74 #ejb4 ,state grants to create administrative health care tribunals ,part ,p of title ,,iii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bhj;g et seq47 is amended by adding at the end the following3 #cii,t4 ,state grants to create administrative health care tribunals 7a7 ,in general ,the ,secretary may award grants to ,states for the development1 implementation1 and evaluation of administrative health care tribunals that comply with this section1 for the resolution of disputes concerning injuries allegedly caused by health care providers4 7b7 ,conditions for demonstration grants ,to be eligible to receive a grant under this section1 a ,state shall submit to the ,secretary an application at such time1 in such manner1 and containing such information as may be required by the ,secretary4 ,a grant shall be awarded under this section on such terms and conditions as the ,secretary determines appropriate4 7c7 ,representation by counsel ,a ,state that receives a grant under this section may not preclude any party to a dispute before an administrative health care tribunal operated under such grant from obtaining legal representation during any review by the expert panel under subsection 7d71 the administrative health care tribunal under subsection 7e71 or a ,state court under subsection 7f74 7d7 ,expert panel review and early offer guidelines 7#a7 ,in general ,prior to the submission of any dispute concerning injuries allegedly caused by health care providers to an administrative health care tribunal under this section1 such allegations shall first be reviewed by an expert panel4 7#b7 ,composition 7,a7 ,in general ,the members of each expert panel under this subsection shall be appointed by the head of the ,state agency responsible for health4 ,each expert panel shall be composed of no fewer than #c members and not more than #g members4 ,at least one-half of such members shall be medical experts 7either physicians or health care professionals74 7,b7 ,licensure and expertise ,each physician or health care professional appointed to an expert panel under subparagraph 7,a7 shall-- 7i7 be appropriately credentialed or licensed in one or more ,states to deliver health care services2 and 7ii7 typically treat the condition1 make the diagnosis1 or provide the type of treatment that is under review4 7,c7 ,independence 7i7 ,in general ,subject to clause 7ii71 each individual appointed to an expert panel under this paragraph shall-- 7,i7 not have a material familial1 financial1 or professional relationship with a party involved in the dispute reviewed by the panel2 and 7,,ii7 not otherwise have a conflict of interest with such a party4 7ii7 ,exception ,nothing in clause 7i7 shall be construed to prohibit an individual who has staff privileges at an institution where the treatment involved in the dispute was provided from serving as a member of an expert panel merely on the basis of such affiliation1 if the affiliation is disclosed to the parties and neither party objects4 7,d7 ,practicing health care professional in same field 7i7 ,in general ,in a dispute before an expert panel that involves treatment1 or the provision of items or services-- 7,i7 by a physician1 the medical experts on the expert panel shall be practicing physicians 7allopathic or osteopathic7 of the same or similar specialty as a physician who typically treats the condition1 makes the diagnosis1 or provides the type of treatment under review2 or 7,,ii7 by a health care professional other than a physician1 at least two medical experts on the expert panel shall be practicing physicians 7allopathic or osteopathic7 of the same or similar specialty as the health care professional who typically treats the condition1 makes the diagnosis1 or provides the type of treatment under review1 and1 if determined appropriate by the ,state agency1 an additional medical expert shall be a practicing health care professional 7other than such a physician7 of such a same or similar specialty4 7ii7 ,practicing defined ,in 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 a week4 7,e7 ,pediatric expertise ,in the case of dispute relating to a child1 at least #a medical expert on the expert panel shall have expertise described in subparagraph 7,d77i7 in pediatrics4 7#c7 ,determination ,after a review under paragraph 7#a71 an expert panel shall make a determination as to the liability of the parties involved and compensation4 7#d7 ,acceptance ,if the parties to a dispute before an expert panel under this subsection accept the determination of the expert panel concerning liability and compensation1 such compensation shall be paid to the claimant and the claimant shall agree to forgo any further action against the health care providers involved4 7#e7 ,failure to accept ,if any party decides not to accept the expert panel's determination1 the matter shall be referred to an administrative health care tribunal created pursuant to this section4 7e7 ,administrative health care tribunals 7#a7 ,in general ,upon the failure of any party to accept the determination of an expert panel under subsection 7d71 the parties shall have the right to request a hearing concerning the liability or compensation involved by an administrative health care tribunal established by the ,state involved4 7#b7 ,requirements ,in establishing an administrative health care tribunal under this section1 a ,state shall-- 7,a7 ensure that such tribunals are presided over by special judges with health care expertise2 7,b7 provide authority to such judges to make binding rulings1 rendered in written decisions1 on standards of care1 causation1 compensation1 and related issues with reliance on independent expert witnesses commissioned by the tribunal2 7,c7 establish gross negligence as the legal standard for the tribunal2 7,d7 allow the admission into evidence of the recommendation made by the expert panel under subsection 7d72 and 7,e7 provide for an appeals process to allow for review of decisions by ,state courts4 7f7 ,review by ,state court after exhaustion of administrative remedies 7#a7 ,right to file ,if any party to a dispute before a health care tribunal under subsection 7e7 is not satisfied with the determinations of the tribunal1 the party shall have the right to file their claim in a ,state court of competent jurisdiction4 7#b7 ,forfeit of awards ,any party filing an action in a ,state court in accordance with paragraph 7#a7 shall forfeit any compensation award made under subsection 7e74 7#c7 ,admissibility ,the determinations of the expert panel and the administrative health care tribunal pursuant to subsections 7d7 and 7e7 with respect to a ,state court proceeding under paragraph 7#a7 shall be admissible into evidence in any such ,state court proceeding4 7g7 ,definition ,in this section1 the term health care provider means any person or entity required by ,state or ,federal laws or regulations to be licensed1 registered1 or certified to provide health care services1 and being either so licensed1 registered1 or certified1 or exempted from such requirement by other statute or regulation4 7h7 ,authorization of appropriations ,there are authorized to be appropriated for any fiscal year such sums as may be necessary for purposes of making grants to ,states under this section4 4 #ejc4 ,authorization of payment of future damages to claimants in health care lawsuits 7a7 ,in general ,in any health care lawsuit1 if an award of future damages1 without reduction to present value1 equaling or exceeding #ej1jjj is made against a party with sufficient insurance or other assets to fund a periodic payment of such a judgment1 the court shall1 at the request of any party1 enter a judgment ordering that the future damages be paid by periodic payments1 in accordance with the ,uniform ,periodic ,payment of ,judgments ,act promulgated by the ,national ,conference of ,commissioners on ,uniform ,state ,laws4 7b7 ,applicability ,this section applies to all actions which have not been first set for trial or retrial before the effective date of this title4 #ejd4 ,definitions ,in this title3 7#a7 ,alternative dispute resolution system2 ,,adr ,the term alternative dispute resolution system or ,,adr means a system that provides for the resolution of health care lawsuits in a manner other than through a civil action brought in a ,state or ,federal court4 7#b7 ,claimant ,the term claimant means any person who brings a health care lawsuit1 including a person who asserts or claims a right to legal or equitable contribution1 indemnity1 or subrogation1 arising out of a health care liability claim or action1 and any person on whose behalf such a claim is asserted or such an action is brought1 whether deceased1 incompetent1 or a minor4 7#c7 ,federal tax benefit ,a claimant shall be treated as receiving a ,federal tax benefit with respect to payment for items or services if-- 7,a7 such payment is compensation by insurance-- 7i7 which constitutes medical care1 and 7ii7 with respect to the payment of premiums for which the claimant1 or the employer of the claimant1 was allowed an exclusion from gross income1 a deduction1 or a credit for ,federal income tax purposes1 7,b7 a deduction was allowed with respect to such payment for ,federal income tax purposes1 or 7,c7 such payment was from an ,archer ,,msa 7as defined in section #bbj7;d7 of the ,internal ,revenue ,code of #aihf71 a health savings account 7as defined in section #bbc7;d7 of such ,code71 a flexible spending arrangement 7as defined in section #ajf7;c77#b7 of such ,code71 or a health reimbursement arrangement which is treated as employer-provided coverage under an accident or health plan for purposes of section #ajf of such ,code4 7#d7 ,health care lawsuit ,the term health care lawsuit means any health care liability claim concerning the provision of health care goods or services brought in a ,federal court or in a ,state court or pursuant to an alternative dispute resolution system1 if such claim concerns items or services for which coverage is provided under title ,,xviii1 ,,xix1 or ,,xxi of the ,social ,security ,act or for which the claimant receives a ,federal tax benefit1 against a health care provider1 a health care organization1 or the manufacturer1 distributor1 supplier1 marketer1 promoter1 or seller of a medical product1 regardless of the theory of liability on which the claim is based1 or the number of claimants1 plaintiffs1 defendants1 or other parties1 or the number of claims or causes of action1 in which the claimant alleges a health care liability claim4 ,such term does not include a claim or action which is based on criminal liability2 which seeks civil fines or penalties paid to ,federal government2 or which is grounded in antitrust4 7#e7 ,health care liability action ,the term health care liability action means a civil action brought in a ,state or ,federal court or pursuant to an alternative dispute resolution system1 against a health care provider1 a health care organization1 or the manufacturer1 distributor1 supplier1 marketer1 promoter1 or seller of a medical product1 regardless of the theory of liability on which the claim is based1 or the number of plaintiffs1 defendants1 or other parties1 or the number of causes of action1 in which the claimant alleges a health care liability claim4 7#f7 ,health care liability claim ,the term health care liability claim means a demand by any person1 whether or not pursuant to ,,adr1 against a health care provider1 health care organization1 or the manufacturer1 distributor1 supplier1 marketer1 promoter1 or seller of a medical product1 including1 but not limited to1 third-party claims1 cross-claims1 counter-claims1 or contribution claims1 which are based upon the provision of1 use of1 or payment for 7or the failure to provide1 use1 or pay for7 health care services or medical products1 regardless of the theory of liability on which the claim is based1 or the number of plaintiffs1 defendants1 or other parties1 or the number of causes of action4 7#g7 ,health care organization ,the term health care organization means any person or entity which is obligated to provide or pay for health benefits under any health plan1 including any person or entity acting under a contract or arrangement with a health care organization to provide or administer any health benefit4 7#h7 ,health care provider ,the term health care provider means any person or entity required by ,state or ,federal laws or regulations to be licensed1 registered1 or certified to provide health care services1 and being either so licensed1 registered1 or certified1 or exempted from such requirement by other statute or regulation4 7#i7 ,health care goods or services ,the term health care goods or services means any goods or services provided by a health care organization1 provider1 or by any individual working under the supervision of a health care provider1 that relates to the diagnosis1 prevention1 or treatment of any human disease or impairment1 or the assessment or care of the health of human beings4 7#aj7 ,medical product ,the term medical product means a drug1 device1 or biological product intended for humans1 and the terms drug1 device1 and biological product have the meanings given such terms in sections #bja7;g77#a7 and #bja7;h7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act 7#ba ,u4,s4,c4 #cba7;g77#a7 and 7h77 and section #cea7;a7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bfb7;a771 respectively1 including any component or raw material used therein1 but excluding health care services4 7#aa7 ,medical treatment ,the term medical treatment means the provision of any goods or services by a health care provider or by any individual working under the supervision of a health care provider1 that relates to the diagnosis1 prevention1 or treatment of any human disease or impairment1 or the assessment or care of the health of human beings4 7#ab7 ,recovery ,the term recovery means the net sum recovered after deducting any disbursements or costs incurred in connection with prosecution or settlement of the claim1 including all costs paid or advanced by any person4 ,costs of health care incurred by the plaintiff and the attorneys' office overhead costs or charges for legal services are not deductible disbursements or costs for such purpose4 7#ac7 ,state ,the term ,state means each of the several ,states1 the ,district of ,columbia1 the ,commonwealth of ,puerto ,rico1 the ,virgin ,islands1 ,guam1 ,american ,samoa1 the ,northern ,mariana ,islands1 the ,trust ,territory of the ,pacific ,islands1 and any other territory or possession of the ,united ,states1 or any political subdivision thereof4 #eje4 ,effect on other laws 7a7 ,vaccine ,injury 7#a7 ,to the extent that title ,,xxi of the ,public ,health ,service ,act establishes a ,federal rule of law applicable to a civil action brought for a vaccine-related injury or death-- 7,a7 this title does not affect the application of the rule of law to such an action2 and 7,b7 any rule of law prescribed by this title in conflict with a rule of law of such title ,,xxi shall not apply to such action4 7#b7 ,if there is an aspect of a civil action brought for a vaccine-related injury or death to which a ,federal rule of law under title ,,xxi of the ,public ,health ,service ,act does not apply1 then this title or otherwise applicable law 7as determined under this title7 will apply to such aspect of such action4 7b7 ,other federal law ,except as provided in this section1 nothing in this title shall be deemed to affect any defense available to a defendant in a health care lawsuit or action under any other provision of ,federal law4 #ejf4 ,applicability2 effective date ,this title shall apply to any health care lawsuit brought in a ,federal or ,state court1 or subject to an alternative dispute resolution system1 that is initiated on or after the date of the enactment of this title1 except that any health care lawsuit arising from an injury occurring prior to the date of the enactment of this title shall be governed by the applicable statute of limitations provisions in effect at the time the injury occurred4 ,,vi ,wellness and ,prevention #fja4 ,providing financial incentives for treatment compliance 7a7 ,limitation on exception for wellness programs under ,,hipaa discrimination rules 7#a7 ,employee ,retirement ,income ,security ,act of #aigd amendment ,section #gjb7;b77#b7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahb7;b77#b77 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 7or lack of participation7 in a standards-based wellness program4 4 7#b7 ,,phsa amendment ,section #bgjb7;b77#b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#a7;b77#b77 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 7or lack of participation7 in a standards-based wellness program4 4 7#c7 ,,irc amendment ,section #ihjb7;b77#b7 of the ,internal ,revenue ,code of #aihf is amended by adding after and below subparagraph 7,b7 the following3 ,in applying subparagraph 7,b71 a group health plan may vary premiums and cost-sharing by up to #ej percent of the value of the benefits under the plan based on participation 7or lack of participation7 in a standards-based wellness program4 4 7b7 ,effective date ,the amendments made by subsection 7a7 shall apply to plan years beginning more than #a year after the date of the enactment of this ,act4 ,,vii ,transparency and ,insurance ,reform ,measures #gja4 ,receipt and response to requests for claim information 7a7 ,in general ,title ,,xxvii of the ,public ,health ,service ,act is amended by inserting after section #bgac the following new section3 #bgad4 ,receipt and response to requests for claim information 7a7 ,requirement 7#a7 ,in general ,in the case of health insurance coverage offered in connection with a group health plan1 not later than the #cjth day after the date a health insurance issuer receives a written request for a written report of claim information from the plan1 plan sponsor1 or plan administrator1 the health insurance issuer shall provide the requesting party the report1 subject to the succeeding provisions of this section4 7#b7 ,exception ,the health insurance issuer is not obligated to provide a report under this subsection regarding a particular employer or group health plan more than twice in any #ab-month period and is not obligated to provide such a report in the case of an employer with fewer than #ej employees4 7#c7 ,deadline ,a plan1 plan sponsor1 or plan administrator must request a report under this subsection before or on the second anniversary of the date of termination of coverage under a group health plan issued by the health insurance issuer4 7b7 ,form of report2 information ,to be included 7#a7 ,in general ,a health insurance issuer shall provide the report of claim information under subsection 7a7-- 7,a7 in a written report2 7,b7 through an electronic file transmitted by secure electronic mail or a file transfer protocol site2 or 7,c7 by making the required information available through a secure ,web site or ,web portal accessible by the requesting plan1 plan sponsor1 or plan administrator4 7#b7 ,information to be included ,a report of claim information provided under subsection 7a7 shall contain all information available to the health insurance issuer that is responsive to the request made under such subsection1 including1 subject to subsection 7c71 protected health information1 for the #cf-month period preceding the date of the report or the period specified by subparagraphs 7,d71 7,e71 and 7,f7 of paragraph 7#c71 if applicable1 or for the entire period of coverage1 whichever period is shorter4 7#c7 ,required information ,subject to subsection 7c71 a report provided under subsection 7a7 shall include the following3 7,a7 ,aggregate paid claims experience by month1 including claims experience for medical1 dental1 and pharmacy benefits1 as applicable4 7,b7 ,total premium paid by month4 7,c7 ,total number of covered employees on a monthly basis by coverage tier1 including whether coverage was for-- 7i7 an employee only2 7ii7 an employee with dependents only2 7iii7 an employee with a spouse only2 or 7iv7 an employee with a spouse and dependents4 7,d7 ,the total dollar amount of claims pending as of the date of the report4 7,e7 ,a separate description and individual claims report for any individual whose total paid claims exceed #ae1jjj during the #ab-month period preceding the date of the report1 including the following information related to the claims for that individual-- 7i7 a unique identifying number1 characteristic1 or code for the individual2 7ii7 the amounts paid2 7iii7 dates of service2 and 7iv7 applicable procedure codes and diagnosis codes4 7,f7 ,for claims that are not part of the information described in a previous subparagraph1 a statement describing precertification requests for hospital stays of #e days or longer that were made during the #cj-;day period preceding the date of the report4 7c7 ,limitations on disclosure 7#a7 ,in general ,a health insurance issuer may not disclose protected health information in a report of claim information provided under this section if the health insurance issuer is prohibited from disclosing that information under another ,state or ,federal law that imposes more stringent privacy restrictions than those imposed under ,federal law under the ,,hipaa privacy regulations4 ,to withhold information in accordance with this subsection1 the health insurance issuer must-- 7,a7 notify the plan1 plan sponsor1 or plan administrator requesting the report that information is being withheld2 and 7,b7 provide to the plan1 plan sponsor1 or plan administrator a list of categories of claim information that the health insurance issuer has determined are subject to the more stringent privacy restrictions under another ,state or ,federal law4 7#b7 ,protection ,a plan sponsor is entitled to receive protected health information under subparagraphs 7,e7 and 7,f7 of subsection 7b77#c7 and subsection 7d7 only after an appropriately authorized representative of the plan sponsor makes to the health insurance issuer a certification substantially similar to the following certification3 ,i hereby certify that the plan documents comply with the requirements of section #afd4ejd7;f77#b7 of title #de1 ,code of ,federal ,regulations1 and that the plan sponsor will safeguard and limit the use and disclosure of protected health information that the plan sponsor may receive from the group health plan to perform the plan administration functions44 7#c7 ,results ,a plan sponsor that does not provide the certification required by paragraph 7#b7 is not entitled to receive the protected health information described by subparagraphs 7,e7 and 7,f7 of subsection 7b77#c7 and subsection 7d71 but is entitled to receive a report of claim information that includes the information described by subparagraphs 7,a7 through 7,d7 of subsection 7b77#c74 7#d7 ,information ,in the case of a request made under subsection 7a7 after the date of termination of coverage1 the report must contain all information available to the health insurance issuer as of the date of the report that is responsive to the request1 including protected health information1 and including the information described by subsection 7b77#c71 for the period described by subsection 7b77#b7 preceding the date of termination of coverage or for the entire policy period1 whichever period is shorter4 ,notwithstanding this subsection1 the report may not include the protected health information described by subparagraphs 7,e7 and 7,f7 of subsection 7b77#c7 unless a certification has been provided in accordance with paragraph 7#b74 7d7 ,request for additional information 7#a7 ,review ,on receipt of the report required by subsection 7a71 the plan1 plan sponsor1 or plan administrator may review the report and1 not later than the #ajth day after the date the report is received1 may make a written request to the health insurance issuer for additional information in accordance with this subsection for specified individuals4 7#b7 ,request ,with respect to a request for additional information concerning specified individuals for whom claims information has been provided under subsection 7b77#c77;,e71 the health insurance issuer shall provide additional information on the prognosis or recovery if available and1 for individuals in active case management1 the most recent case management information1 including any future expected costs and treatment plan1 that relate to the claims for that individual4 7#c7 ,response ,the health insurance issuer must respond to the request for additional information under this subsection not later than the #aeth day after the date of such request unless the requesting plan1 plan sponsor1 or plan administrator agrees to a request for additional time4 7#d7 ,limitation ,the health insurance issuer is not required to produce the report described by this subsection unless a certification has been provided in accordance with subsection 7c77#b74 7#e7 ,compliance with section does not create liability ,a health insurance issuer that releases information1 including protected health information1 in accordance with this subsection has not violated a standard of care and is not liable for civil damages resulting from1 and is not subject to criminal prosecution for1 releasing that information4 7e7 ,limitation on preemption ,nothing in this section is meant to limit ,states from enacting additional laws in addition to the provisions of this section1 but not in lieu of such provisions4 7f7 ,definitions ,in this section3 7#a7 ,the terms employer1 plan administrator1 and plan sponsor have the meanings given such terms in section #c of the ,employee ,retirement ,income ,security ,act of #aigd4 7#b7 ,the term ,,hipaa privacy regulations has the meaning given such term in section #aahj7;b77#c7 of the ,social ,security ,act4 7#c7 ,the term protected health information has the meaning given such term under the ,,hipaa privacy regulations4 4 7b7 ,effective date ,the amendment made by subsection 7a7 shall take effect on the date of the enactment of this ,act4 ,,viii ,quality #hja4 ,prohibition on certain uses of data obtained from comparative effectiveness research or from patient-centered outcomes research2 accounting for personalized medicine and differences in patient treatment response 7a7 ,in general ,notwithstanding any other provision of law1 the ,secretary of ,health and ,human ,services-- 7#a7 shall not use data obtained from the conduct of comparative effectiveness research or patient-centered outcomes research1 including such research that is conducted or supported using funds appropriated under the ,american ,recovery and ,reinvestment ,act of #bjji 7,public ,law #aaa-e71 to deny coverage of an item or service under a ,federal health care program 7as defined in section #aabh;,b7f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;b7f7772 and 7#b7 shall ensure that comparative effectiveness research and patient-centered outcomes research conducted or supported by the ,federal ,government accounts for factors contributing to differences in the treatment response and treatment preferences of patients1 including patient-reported outcomes1 genomics and personalized medicine1 the unique needs of health disparity populations1 and indirect patient benefits4 7b7 ,consultation and approval required ,nothing the ,federal ,coordinating ,council for ,comparative ,effectiveness ,research finds can be released in final form until after consultation with and approved by relevant physician specialty organizations4 7c7 ,rule of construction ,nothing in this section shall be construed as affecting the authority of the ,commissioner of ,food and ,drugs under the ,federal ,food1 ,drug1 and ,cosmetic ,act or the ,public ,health ,service ,act4 #hjb4 ,establishment of performance-based quality measures ,not later than ,january #a1 #bjad1 the ,secretary of ,health and ,human ,services shall submit to ,congress a proposal for a formalized process for the development of performance-based quality measures that could be applied to physicians' services under the ,medicare program under title ,,xviii of the ,social ,security ,act4 ,such proposal shall be in concert and agreement with the ,physician ,consortium for ,performance ,improvement and shall only utilize measures agreed upon by each physician specialty organization4 ,,ix ,state ,transparency ,plan ,portal #ija4 ,providing information on health coverage options and health care providers 7a7 ,state-,based portal ,a ,state 7by itself or jointly with other ,states7 may contract with a private entity to establish a ,health ,plan and ,provider ,portal ,web site 7referred to in this section as a plan portal7 for the purposes of providing standardized information-- 7#a7 on health insurance plans that have been certified to be available for purchase in that ,state2 and 7#b7 on price and quality information on health care providers 7including physicians1 hospitals1 and other health care institutions74 7b7 ,prohibitions 7#a7 ,direct ,enrollment ,a plan portal may not directly enroll individuals in health insurance plans or under a ,state ,medicaid plan or a ,state children's health insurance plan4 7#b7 ,conflicts of interest 7,a7 ,companies ,a health insurance issuer offering a health insurance plan through a plan portal may not-- 7i7 be the private entity developing and maintaining a plan portal under this section2 or 7ii7 have an ownership interest in such private entity or in the plan portal4 7,b7 ,individuals ,an individual employed by a health insurance issuer offering a health insurance plan through a plan portal may not serve as a director or officer for-- 7i7 the private entity developing and maintaining a plan portal under this section2 or 7ii7 the plan portal4 7c7 ,construction ,nothing in this section shall be construed to prohibit health insurance brokers and agents from-- 7#a7 utilizing the plan portal for any purpose2 or 7#b7 marketing or offering health insurance products4 7d7 ,state defined ,in this section1 the term ,state has the meaning given such term for purposes of title ,,xix of the ,social ,security ,act4 7e7 ,health insurance plans ,for purposes of this section1 the term health insurance plan does not include coverage of excepted benefits1 as defined in section #bgia7;c7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ia7;c774 ,x ,patient ,freedom of ,choice #ajja4 ,guaranteeing freedom of choice and contracting for patients under ,medicare 7a7 ,in general ,section #ahjb of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;a7 is amended to read as follows3 #ahjb4 ,freedom of choice and contracting by patient guaranteed 7a7 ,basic freedom of choice ,any individual entitled to insurance benefits under this title may obtain health services from any institution1 agency1 or person qualified to participate under this title if such institution1 agency1 or person undertakes to provide that individual such services4 7b7 ,freedom ,to contract by ,medicare beneficiaries 7#a7 ,in general ,subject to the provisions of this subsection1 nothing in this title shall prohibit a ,medicare beneficiary from entering into a contract with an eligible professional 7whether or not the professional is a participating or non-participating physician or practitioner7 for any item or service covered under this title4 7#b7 ,submission of claims ,any ,medicare beneficiary that enters into a contract under this section with an eligible professional shall be permitted to submit a claim for payment under this title for services furnished by such professional1 and such payment shall be made in the amount that would otherwise apply to such professional under this title except that where such professional is considered to be non-participating1 payment shall be paid as if the professional were participating4 ,payment made under this title for any item or service provided under the contract shall not render the professional a participating or non-participating physician or practitioner1 and as such1 requirements of this title that may otherwise apply to a participating or non-participating physician or practitioner would not apply with respect to any items or services furnished under the contract4 7#c7 ,beneficiary protections 7,a7 ,in general ,paragraph 7#a7 shall not apply to any contract unless-- 7i7 the contract is in writing1 is signed by the ,medicare beneficiary and the eligible professional1 and establishes all terms of the contract 7including specific payment for items and services covered by the contract7 before any item or service is provided pursuant to the contract1 and the beneficiary shall be held harmless for any subsequent payment charged for an item or service in excess of the amount established under the contract during the period the contract is in effect2 7ii7 the contract contains the items described in subparagraph 7,b72 and 7iii7 the contract is not entered into at a time when the ,medicare beneficiary is facing an emergency medical condition or urgent health care situation4 7,b7 ,items required to be included in contract ,any contract to provide items and services to which paragraph 7#a7 applies shall clearly indicate to the ,medicare beneficiary that by signing such contract the beneficiary-- 7i7 agrees to be responsible for payment to such eligible professional for such items or services under the terms of and amounts established under the contract2 7ii7 agrees to be responsible for submitting claims under this title to the ,secretary1 and to any other supplemental insurance plan that may provide supplemental insurance1 for such items or services furnished under the contract if such items or services are covered by this title1 unless otherwise provided in the contract under subparagraph 7,c77i72 and 7iii7 acknowledges that no limits or other payment incentives that may otherwise apply under this title 7such as the limits under subsection 7g7 of section #ahdh or incentives under subsection 7a77#e71 7m71 7q71 and 7p7 of such section7 shall apply to amounts that may be charged1 or paid to a beneficiary for1 such items or services4 ,such contract shall also clearly indicate whether the eligible professional is excluded from participation under the ,medicare program under section #aabh4 7,c7 ,beneficiary elections under the contract ,any ,medicare beneficiary that enters into a contract under this section may elect to negotiate1 as a term of the contract1 a provision under which-- 7i7 the eligible professional shall file claims on behalf of the beneficiary with the ,secretary and any supplemental insurance plan for items or services furnished under the contract if such items or services are covered under this title or under the plan2 and 7ii7 the beneficiary assigns payment to the eligible professional for any claims filed by1 or on behalf of1 the beneficiary with the ,secretary and any supplemental insurance plan for items or services furnished under the contract4 7,d7 ,exclusion of dual eligible individuals ,paragraph 7#a7 shall not apply to any contract if a beneficiary who is eligible for medical assistance under title ,,xix is a party to the contract4 7#d7 ,limitation on actual charge and claim submission requirement not applicable ,section #ahdh7;g7 shall not apply with respect to any item or service provided to a ,medicare beneficiary under a contract described in paragraph 7#a74 7#e7 ,construction ,nothing in this section shall be construed-- 7,a7 to prohibit any eligible professional from maintaining an election and acting as a participating or non-participating physician or practitioner with respect to any patient not covered under a contract established under this section2 and 7,b7 as changing the items and services for which an eligible professional may bill under this title4 7#f7 ,definitions ,in this subsection3 7,a7 ,medicare beneficiary ,the term ,medicare beneficiary means an individual who is entitled to benefits under part ,a or enrolled under part ,b4 7,b7 ,eligible professional ,the term eligible professional has the meaning given such term in section #ahdh7k77#c77;,b74 7,c7 ,emergency medical condition ,the term emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity 7including severe pain7 such that a prudent layperson1 with an average knowledge of health and medicine1 could reasonably expect the absence of immediate medical attention to result in-- 7i7 serious jeopardy to the health of the individual or1 in the case of a pregnant woman1 the health of the woman or her unborn child2 7ii7 serious impairment to bodily functions2 or 7iii7 serious dysfunction of any bodily organ or part4 7,d7 ,urgent health care situation ,the term urgent health care situation means services furnished to an individual who requires services to be furnished within #ab hours in order to avoid the likely onset of an emergency medical condition4 4 #ajjb4 ,preemption of ,state laws limiting charges for eligible professional services 7a7 ,in general ,no ,state may impose a limit on the amount of charges for services1 furnished by an eligible professional 7as defined in subsection 7k77#c77;,b7 of section #ahdh of the ,social ,security ,act1 #db ,u4,s4,c4 #aciew-#d71 for which payment is made under such section1 and any such limit is hereby preempted4 7b7 ,state ,in this section1 the term ,state includes the ,district of ,columbia1 ,puerto ,rico1 the ,virgin ,islands1 ,guam1 and ,american ,samoa4 #ajjc4 ,health care provider licensure cannot be conditioned on participation in a health plan 7a7 ,in general ,the ,secretary of ,health and ,human ,services and any ,state 7as a condition of receiving ,federal financial participation under title ,,xix of the ,social ,security ,act7 may not require any health care provider to participate in any health plan as a condition of licensure of the provider in any ,state4 7b7 ,definitions ,in this section3 7#a7 ,health plan ,the term health plan has the meaning given such term in section #aaga7e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;d7#e774 7#b7 ,health care provider ,the term health care provider means any person or entity that is required by ,state or ,federal laws or regulations to be licensed1 registered1 or certified to provide health care services and is so licensed1 registered1 or certified1 or exempted from such requirement by other statute or regulation4 7#c7 ,state ,the term ,state has the meaning given such term for purposes of title ,,xix of the ,social ,security ,act4 #ajjd4 ,bad debt deduction for doctors to partially offset the cost of providing uncompensated care required to be provided under amendments made by the ,emergency ,medical ,treatment and ,labor ,act 7a7 ,in general ,section #aff of the ,internal ,revenue ,code of #aihf 7relating to bad debts7 is amended by redesignating subsection 7f7 as subsection 7g7 and by inserting after subsection 7e7 the following new subsection3 7f7 ,bad debt treatment for doctors ,to partially offset cost of providing uncompensated care required ,to be provided 7#a7 ,amount of deduction 7,a7 ,in general ,for purposes of subsection 7a71 the basis for determining the amount of any deduction for an eligible ,,emtala debt shall be treated as being equal to the ,medicare payment amount4 7,b7 ,medicare payment amount ,for purposes of subparagraph 7,a71 the ,medicare payment amount with respect to an eligible ,,emtala debt is the fee schedule amount established under section #ahdh of the ,social ,security ,act for the physicians' service 7to which such debt relates7 as if the service were provided to an individual enrolled under part ,b of title ,,xviii of such ,act4 7#b7 ,eligible ,,emtala debt ,for purposes of this section1 the term eligible ,,emtala debt means any debt if-- 7,a7 such debt arose as a result of physicians' services-- 7i7 which were performed in an ,,emtala hospital by a board-certified physician 7whether as part of medical screening or necessary stabilizing treatment and whether as an emergency department physician1 as an on-call physician1 or otherwise71 and 7ii7 which were required to be provided under section #ahfg of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;dd71 and 7,b7 such debt is owed-- 7i7 to such physician1 or 7ii7 to an entity if-- 7,i7 such entity is a corporation and the sole shareholder of such corporation is such physician1 or 7,,ii7 such entity is a partnership and any deduction under this subsection with respect to such debt is allocated to such physician or to an entity described in subclause 7,i74 7#c7 ,board-certified physician ,for purposes of this subsection1 the term board-certified physician means any physician 7as defined in section #ahfa7r7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7r777 who is certified by the ,american ,board of ,emergency ,medicine or other appropriate medical specialty board for the specialty in which the physician practices1 or who meets comparable requirements1 as identified by the ,secretary of the ,treasury in consultation with the ,secretary of ,health and ,human ,services4 7#d7 ,other definitions ,for purposes of this subsection-- 7,a7 ,,emtala hospital ,the term ,,emtala hospital means any hospital having a hospital emergency department which is required to comply with section #ahfg of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;dd7 7relating to examination and treatment for emergency medical conditions and women in labor74 7,b7 ,physicians' services ,the term physicians' services has the meaning given such term in section #ahfa7q7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7q774 4 7b7 ,effective date ,the amendments made by this section shall apply to debts arising from services performed in taxable years beginning after the date of the enactment of this ,act4 #ajje4 ,right of contract with health care providers 7a7 ,in general ,the ,secretary of ,health and ,human ,services shall not preclude an enrollee1 participant1 or beneficiary in a health benefits plan from entering into any contract or arrangement for health care with any health care provider4 7b7 ,health benefits plan defined 7#a7 ,in general ,in this section1 subject to paragraph 7#b71 the term health benefits plan means any of the following3 7,a7 ,group health plan 7as defined in section #bgia of the ,public ,health ,service ,act74 7,b7 ,health insurance coverage 7as defined in section #bgia of such ,act74 7,c7 ,a health benefits plan under chapter #hi of title #e1 ,united ,states ,code4 7#b7 ,exclusion of ,medicaid and ,,tricare ,such term does not include a health plan participating in-- 7,a7 the ,medicaid program under title ,,xix of the ,social ,security ,act2 or 7,b7 the ,,tricare program under chapter #ee of title #aj1 ,united ,states ,code4 7c7 ,health care provider defined ,in this section1 the term health care provider means-- 7#a7 a physician1 as defined in paragraphs 7#a71 7#b71 7#c71 and 7#d7 of section #ahfa7r7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7r772 and 7#b7 a health care practitioner described in section #ahdb7;b77#ah77;,c7 of such ,act 7#db ,u4,s4,c4 #acieu7b77#ah77;,c774 ,,xi ,incentives to reduce physician shortages ,a ,federally ,supported ,student ,loan ,funds for ,medical ,students #aaja4 ,federally supported student loan funds for medical students 7a7 ,primary health care medical students ,subpart ,,ii of part ,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bibq et seq47 is amended-- 7#a7 by redesignating section #gce as section #gbi2 and 7#b7 in subsection 7f7 of section #gbi 7as so redesignated71 by striking is authorized to be appropriated #aj1jjj1jjj for each of the fiscal years #aiid through #aiif and inserting are authorized to be appropriated such sums as may be necessary for fiscal year #bjad and each fiscal year thereafter4 7b7 ,other medical students ,part ,a of title ,,vii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bib et seq47 is amended by adding at the end the following3 ,,iii ,federally ,supported ,student ,loan ,funds for ,certain ,medical ,students #gcj4 ,school loan funds for certain medical students 7a7 ,fund agreements ,for the purpose described in subsection 7b71 the ,secretary is authorized to enter into an agreement for the establishment and operation of a student loan fund with any public or nonprofit school of medicine or osteopathic medicine4 7b7 ,purpose ,the purpose of this subpart is to provide for loans to medical students who would be eligible for a loan under subpart ,,ii1 except for the student's decision to enter a residency training program in a field other than primary health care4 7c7 ,commencement of repayment period ,the repayment period for a loan under this section shall not begin before the end of any period during which the student is participating in an internship1 residency1 or fellowship training program directly related to the field of medicine which the student agrees to enter pursuant to subsection 7d74 7d7 ,requirements for students ,each agreement under this section for the establishment of a student loan fund shall provide that the school of medicine or osteopathic medicine will make a loan to a student from such fund only if the student agrees-- 7#a7 to enter and complete a residency training program 7in a field of medicine other than primary health care7 not later than a period determined by the ,secretary to be reasonable after the date on which the student graduates from such school2 and 7#b7 to practice medicine through the date on which the loan is repaid in full4 7e7 ,requirements for schools ,the provisions of section #gbc7;b7 7regarding graduates in primary health care7 shall not apply to a student loan fund established under this section4 7f7 ,applicability of other provisions ,except as inconsistent with this section1 the provisions of subpart ,,ii shall apply to the program of student loan funds established under this section to the same extent and in the same manner as such provisions apply to the program of student loan funds established under subpart ,,ii4 7g7 ,authorization of appropriations ,to carry out this section1 there are authorized to be appropriated such sums as may be necessary for fiscal year #bjad and each fiscal year thereafter4 4 ,b ,loan ,forgiveness for ,primary ,care ,providers #aaaa4 ,loan forgiveness for primary care providers 7a7 ,in general ,the ,secretary of ,health and ,human ,services shall carry out a program of entering into contracts with eligible individuals under which-- 7#a7 the individual agrees to serve for a period of not less than #e years as a primary care provider2 and 7#b7 in consideration of such service1 the ,secretary agrees to pay not more than #ej1jjj on the principal and interest on the individual's graduate educational loans4 7b7 ,eligibility ,to be eligible to enter into a contract under subsection 7a71 an individual must-- 7#a7 have a graduate degree in medicine1 osteopathic medicine1 or another health profession from an accredited 7as determined by the ,secretary of ,health and ,human ,services7 institution of higher education2 and 7#b7 have practiced as a primary care provider for a period 7excluding any residency or fellowship training period7 of not less than-- 7,a7 #e years2 or 7,b7 #c years in a medically underserved community 7as defined in section #gii;,b of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #biep774 7c7 ,installments ,payments under this section may be made in installments of not more than #aj1jjj for each year of service described in subsection 7a77#a74 7d7 ,applicability of certain provisions ,the provisions of subpart ,,iii of part ,d of title ,,iii of the ,public ,health ,service ,act shall1 except as inconsistent with this section1 apply to the program established under this section in the same manner and to the same extent as such provisions apply to the ,national ,health ,service ,corps ,loan ,repayment ,program established in such subpart4 ,,xii ,quality ,health ,care ,coalition #abja4 ,quality ,health ,care ,coalition 7a7 ,application of the ,federal antitrust laws to health care professionals negotiating with health plans 7#a7 ,in general ,any health care professionals who are engaged in negotiations with a health plan regarding the terms of any contract under which the professionals provide health care items or services for which benefits are provided under such plan shall1 in connection with such negotiations1 be exempt from the ,federal antitrust laws4 7#b7 ,limitation 7,a7 ,no new right for collective cessation of service ,the exemption provided in paragraph 7#a7 shall not confer any new right to participate in any collective cessation of service to patients not already permitted by existing law4 7,b7 ,no change in ,national ,labor ,relations ,act ,this section applies only to health care professionals excluded from the ,national ,labor ,relations ,act4 ,nothing in this section shall be construed as changing or amending any provision of the ,national ,labor ,relations ,act1 or as affecting the status of any group of persons under that ,act4 7#c7 ,no application to ,federal programs ,nothing in this section shall apply to negotiations between health care professionals and health plans pertaining to benefits provided under any of the following3 7,a7 ,the ,medicare ,program under title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq474 7,b7 ,the ,medicaid program under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq474 7,c7 ,the ,,schip program under title ,,xxi of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;aa et seq474 7,d7 ,chapter #ee of title #aj1 ,united ,states ,code 7relating to medical and dental care for members of the uniformed services74 7,e7 ,chapter #ag of title #ch1 ,united ,states ,code 7relating to ,veterans' medical care74 7,f7 ,chapter #hi of title #e1 ,united ,states ,code 7relating to the ,federal employees' health benefits program74 7,g7 ,the ,indian ,health ,care ,improvement ,act 7#be ,u4,s4,c4 #afja et seq474 7b7 ,definitions ,in this section1 the following definitions shall apply3 7#a7 ,antitrust laws ,the term antitrust laws-- 7,a7 has the meaning given it in subsection 7a7 of the first section of the ,clayton ,act 7#ae ,u4,s4,c4 #ab7;a771 except that such term includes section #e of the ,federal ,trade ,commission ,act 7#ae ,u4,s4,c4 #de7 to the extent such section applies to unfair methods of competition2 and 7,b7 includes any ,state law similar to the laws referred to in subparagraph 7,a74 7#b7 ,group health plan ,the term group health plan means an employee welfare benefit plan to the extent that the plan provides medical care 7including items and services paid for as medical care7 to employees or their dependents 7as defined under the terms of the plan7 directly or through insurance1 reimbursement1 or otherwise4 7#c7 ,group health plan1 health insurance issuer ,the terms group health plan and health insurance issuer include a third-party administrator or other person acting for or on behalf of such plan or issuer4 7#d7 ,health care services ,the term health care services means any services for which payment may be made under a health plan1 including services related to the delivery or administration of such services4 7#e7 ,health care professional ,the term health care professional means any individual or entity that provides health care items or services1 treatment1 assistance with activities of daily living1 or medications to patients and who1 to the extent required by ,state or ,federal law1 possesses specialized training that confers expertise in the provision of such items or services1 treatment1 assistance1 or medications4 7#f7 ,health insurance coverage ,the term health insurance coverage means benefits consisting of medical care 7provided directly1 through insurance or reimbursement1 or otherwise and including items and services paid for as medical care7 under any hospital or medical service policy or certificate1 hospital or medical service plan contract1 or health maintenance organization contract offered by a health insurance issuer4 7#g7 ,health insurance issuer ,the term health insurance issuer means an insurance company1 insurance service1 or insurance organization 7including a health maintenance organization7 that is licensed to engage in the business of insurance in a ,state and that is subject to ,state law regulating insurance4 ,such term does not include a group health plan4 7#h7 ,health maintenance organization ,the term health maintenance organization means-- 7,a7 a federally qualified health maintenance organization 7as defined in section #acja7;a7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;e7a7772 7,b7 an organization recognized under ,state law as a health maintenance organization2 or 7,c7 a similar organization regulated under ,state law for solvency in the same manner and to the same extent as such a health maintenance organization4 7#i7 ,health plan ,the term health plan means a group health plan or a health insurance issuer that is offering health insurance coverage4 7#aj7 ,medical care ,the term medical care means amounts paid for-- 7,a7 the diagnosis1 cure1 mitigation1 treatment1 or prevention of disease1 or amounts paid for the purpose of affecting any structure or function of the body2 and 7,b7 transportation primarily for and essential to receiving items and services referred to in subparagraph 7,a74 7#aa7 ,person ,the term person includes a ,state or unit of local government4 7#ab7 ,state ,the term ,state includes the several ,states1 the ,district of ,columbia1 ,puerto ,rico1 the ,virgin ,islands of the ,united ,states1 ,guam1 ,american ,samoa1 and the ,commonwealth of the ,northern ,mariana ,islands4 7c7 ,effective date ,this section shall take effect on the date of the enactment of this ,act and shall not apply with respect to conduct occurring before such date4 ,,xiii ,offsets ,a ,discretionary spending limits #acja4 ,discretionary spending limits ,the ,balanced ,budget and ,emergency ,deficit ,control ,act of #aihe1 as amended by section #aja of the ,budget ,control ,act of #bjaa1 is amended-- 7#a7 in section #bea7;c7 7#b ,u4,s4,c4 #ija7;c77-- 7,a7 by striking and at the end of paragraph 7#i72 and 7,b7 by inserting after paragraph 7#aj7 the following3 7#aa7 with respect to fiscal year #bjbb-- 7,a7 for the security category1 #ffb1efb1eaj1jjj in budget authority2 and 7,b7 for the nonsecurity category1 #dif1gbg1dij1jjj in budget authority2 and 7#ab7 with respect to fiscal year #bjbc-- 7,a7 for the security category1 #fhi1gjd1bij1jjj in budget authority2 and 7,b7 for the nonsecurity category1 #die1cbe1gaj1jjj2 2 and 7#b7 in section #bea;,a7#b7 7#b ,u4,s4,c4 #ija;a7#b77-- 7,a7 in subparagraph 7,b77ii71 by striking #eaj1jjj1jjj1jjj and inserting #daj1bca1bej1jjj2 7,b7 in subparagraph 7,c77ii71 by striking #ebj1jjj1jjj1jjj and inserting #dbd1cgg1cfj1jjj2 7,c7 in subparagraph 7,d77ii71 by striking #ecj1jjj1jjj1jjj and inserting #dcd1dfd1dgj1jjj2 7,d7 in subparagraph 7,e77ii71 by striking #eda1jjj1jjj1jjj and inserting #dde1cfh1jjj1jjj2 7,e7 in subparagraph 7,f77ii71 by striking #eec1jjj1jjj1jjj and inserting #deg1fdi1bhj1jjj2 7,f7 in subparagraph 7,g77ii71 by striking #eff1jjj1jjj1jjj and inserting #dgb1jih1cfj1jjj2 7,g7 in subparagraph 7,h77ii71 by striking #egh1jjj1jjj1jjj and inserting #dhe1dff1cjj1jjj2 and 7,h7 in subparagraph 7,i77ii71 by striking #eij1jjj1jjj1jjj and inserting #dih1jid1gdj1jjj4 ,b ,savings from health care efficiencies #acaa4 ,medicare ,,dsh report and payment adjustments in response to coverage expansion 7a7 ,,dsh report 7#a7 ,in general ,not later than ,january #a1 #bjah1 the ,secretary of ,health and ,human ,services shall submit to ,congress a report on ,medicare ,,dsh taking into account the impact of the health care reforms carried out under this ,act in reducing the number of uninsured individuals4 ,the report shall include recommendations relating to the following3 7,a7 ,the appropriate amount1 targeting1 and distribution of ,medicare ,,dsh to compensate for higher ,medicare costs associated with serving low-income beneficiaries 7taking into account variations in the empirical justification for ,medicare ,,dsh attributable to hospital characteristics1 including bed size71 consistent with the original intent of ,medicare ,,dsh4 7,b7 ,the appropriate amount1 targeting1 and distribution of ,medicare ,,dsh to hospitals given their continued uncompensated care costs1 to the extent such costs remain4 7#b7 ,coordination with ,medicaid ,,dsh report ,the ,secretary shall coordinate the report under this subsection with the report on ,medicaid ,,dsh under section #acbb7;a74 7b7 ,payment adjustments in response to coverage expansion 7#a7 ,in general ,if there is a significant decrease in the national rate of uninsurance as a result of this ,act 7as determined under paragraph 7#b77;,a771 then the ,secretary of ,health and ,human ,services shall1 beginning in fiscal year #bjai1 implement the following adjustments to ,medicare ,,dsh3 7,a7 ,in lieu of the amount of ,medicare ,,dsh payment that would otherwise be made under section #ahhf7;d77#e77;,f7 of the ,social ,security ,act1 the amount of ,medicare ,,dsh payment shall be an amount based on the recommendations of the report under subsection 7a77#a77;,a7 and shall take into account variations in the empirical justification for ,medicare ,,dsh attributable to hospital characteristics1 including bed size4 7,b7 ,subject to paragraph 7#c71 make an additional payment to a hospital by an amount that is estimated based on the amount of uncompensated care provided by the hospital based on criteria for uncompensated care as determined by the ,secretary1 which shall exclude bad debt4 7#b7 ,significant decrease in national rate of uninsurance as a result of this ,act ,for purposes of this subsection-- 7,a7 ,in general ,there is a significant decrease in the national rate of uninsurance as a result of this ,act if there is a decrease in the national rate of uninsurance 7as defined in subparagraph 7,b77 from #bjad to #bjaf that exceeds #h percentage points4 7,b7 ,national rate of uninsurance defined ,the term national rate of uninsurance means1 for a year1 such rate for the under-#fe population for the year as determined and published by the ,bureau of the ,census in its ,current ,population ,survey in or about ,september of the succeeding year4 7#c7 ,uncompensated care increase 7,a7 ,computation of ,,dsh savings ,for each fiscal year 7beginning with fiscal year #bjag71 the ,secretary shall estimate the aggregate reduction in ,medicare ,,dsh that will result from the adjustment under paragraph 7#a77;,a74 7,b7 ,structure of payment increase ,the ,secretary shall compute the increase in ,medicare ,,dsh under paragraph 7#a77;,b7 for a fiscal year in accordance with a formula established by the ,secretary that provides that-- 7i7 the aggregate amount of such increase for the fiscal year does not exceed #ej percent of the aggregate reduction in ,medicare ,,dsh estimated by the ,secretary for such fiscal year2 and 7ii7 hospitals with higher levels of uncompensated care receive a greater increase4 7c7 ,medicare ,,dsh ,in this section1 the term ,medicare ,,dsh means adjustments in payments under section #ahhf7;d77#e77;,f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,f77 for inpatient hospital services furnished by disproportionate share hospitals4 #acab4 ,reduction in ,medicaid ,,dsh 7a7 ,report 7#a7 ,in general ,not later than ,january #a1 #bjah1 the ,secretary of ,health and ,human ,services 7in this title referred to as the ,secretary7 shall submit to ,congress a report concerning the extent to which1 based upon the impact of the health care reforms carried out under this ,act in reducing the number of uninsured individuals1 there is a continued role for ,medicaid ,,dsh4 ,in preparing the report1 the ,secretary shall consult with community-based health care networks serving low-income beneficiaries4 7#b7 ,matters to be included ,the report shall include the following3 7,a7 ,recommendations ,recommendations regarding-- 7i7 the appropriate targeting of ,medicaid ,,dsh within ,states2 and 7ii7 the distribution of ,medicaid ,,dsh among the ,states4 7,b7 ,specification of ,,dsh ,health ,reform methodology ,the ,,dsh ,health ,reform methodology described in paragraph 7#b7 of subsection 7b7 for purposes of implementing the requirements of such subsection4 7#c7 ,coordination with ,medicare ,,dsh report ,the ,secretary shall coordinate the report under this subsection with the report on ,medicare ,,dsh under section #acba4 7#d7 ,medicaid ,,dsh ,in this section1 the term ,medicaid ,,dsh means adjustments in payments under section #aibc of the ,social ,security ,act for inpatient hospital services furnished by disproportionate share hospitals4 7b7 ,medicaid ,,dsh reductions 7#a7 ,in general ,if there is a significant decrease in the national rate of uninsurance as a result of this ,act 7as determined under section #acba7;a77#b77;,a771 then the ,secretary of ,health and ,human ,services shall reduce ,medicaid ,,dsh so as to reduce total ,federal payments to all ,states for such purpose by #a1ejj1jjj1jjj in fiscal year #bjai1 #b1ejj1jjj1jjj in fiscal year #bjbj1 and #f1jjj1jjj1jjj in fiscal year #bjba4 7#b7 ,,dsh ,health ,reform methodology ,the ,secretary shall carry out paragraph 7#a7 through use of a ,,dsh ,health ,reform methodology issued by the ,secretary that imposes the largest percentage reductions on the ,states that-- 7,a7 have the lowest percentages of uninsured individuals 7determined on the basis of audited hospital cost reports7 during the most recent year for which such data are available2 or 7,b7 do not target their ,,dsh payments on-- 7i7 hospitals with high volumes of ,medicaid inpatients 7as defined in section #aibc7;b77#a77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#d7;b77#a77;,a7772 and 7ii7 hospitals that have high levels of uncompensated care 7excluding bad debt74 7#c7 ,,dsh allotment publications 7,a7 ,in general ,not later than the publication deadline specified in subparagraph 7,b71 the ,secretary shall publish in the ,federal ,register a notice specifying the ,,dsh allotment to each ,state under #aibc7;f7 of the ,social ,security ,act for the respective fiscal year specified in such subparagraph1 consistent with the application of the ,,dsh ,health ,reform methodology described in paragraph 7#b74 7,b7 ,publication deadline ,the publication deadline specified in this subparagraph is-- 7i7 ,january #a1 #bjah1 with respect to ,,dsh allotments described in subparagraph 7,a7 for fiscal year #bjai2 7ii7 ,january #a1 #bjai1 with respect to ,,dsh allotments described in subparagraph 7,a7 for fiscal year #bjbj2 and 7iii7 ,january #a1 #bjbj1 with respect to ,,dsh allotments described in subparagraph 7,a7 for fiscal year #bjba4 7c7 ,conforming amendments 7#a7 ,section #aibc7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#d7;f77 is amended-- 7,a7 by redesignating paragraph 7#g7 as paragraph 7#h72 and 7,b7 by inserting after paragraph 7#f7 the following new paragraph3 7#g7 ,special rule for fiscal years #bjai1 #bjbj1 and #bjba ,notwithstanding paragraph 7#b71 if the ,secretary makes a reduction under section #acbb7;b77#a7 of the ,empowering ,patients ,first ,act of #bjac1 the total ,,dsh allotments for all ,states for-- 7,a7 fiscal year #bjai1 shall be the total ,,dsh allotments that would otherwise be determined under this subsection for such fiscal year decreased by #a1ejj1jjj1jjj2 7,b7 fiscal year #bjbj1 shall be the total ,,dsh allotments that would otherwise be determined under this subsection for such fiscal year decreased by #b1ejj1jjj1jjj2 and 7,c7 fiscal year #bjba1 shall be the total ,,dsh allotments that would otherwise be determined under this subsection for such fiscal year decreased by #f1jjj1jjj1jjj4 4 7#b7 ,section #aibc7;b77#d7 of such ,act 7#db ,u4,s4,c4 #acifr-#d7;b77#d77 is amended by adding before the period the following3 or to affect the authority of the ,secretary to issue and implement the ,,dsh ,health ,reform methodology under section #acbb7;b77#b7 of the ,empowering ,patients ,first ,act of #bjac4 7d7 ,disproportionate share hospitals 7,,dsh7 and essential access hospital 7,,eah7 non-,discrimination 7#a7 ,in general ,section #aibc7;d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#d7 is amended by adding at the end the following new paragraph3 7#d7 ,no hospital may be defined or deemed as a disproportionate share hospital1 or as an essential access hospital 7for purposes of subsection 7f77#f77;,a77iv771 under a ,state plan under this title or subsection 7b7 of this section 7including any waiver under section #aaae7 unless the hospital-- 7,a7 provides services to beneficiaries under this title without discrimination on the ground of race1 color1 national origin1 creed1 source of payment1 status as a beneficiary under this title1 or any other ground unrelated to such beneficiary's need for the services or the availability of the needed services in the hospital2 and 7,b7 makes arrangements for1 and accepts1 reimbursement under this title for services provided to eligible beneficiaries under this title4 4 7#b7 ,effective date ,the amendment made by subsection 7a7 shall be apply to expenditures made on or after ,july #a1 #bjad4 ,c ,fraud1 ,waste1 and ,abuse #acba4 ,provide adequate funding to ,,hhs ,,oig and ,,hcfac 7a7 ,,hcfac funding ,section #ahag7k77#c77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7k77#c77;,a77 is amended-- 7#a7 in clause 7i7-- 7,a7 in subclause 7,,iii71 by striking at the end and2 7,b7 in subclause 7,,iv7-- 7i7 by inserting and before fiscal year #bjad after for each fiscal year after fiscal year #bjjf2 and 7ii7 by striking the period at the end and inserting 2 and2 and 7,c7 by adding at the end the following new subclause3 7,v7 for each fiscal year after fiscal year #bjac1 #cjj1jjj1jjj4 2 and 7#b7 in clause 7ii7-- 7,a7 in subclause 7,,viii71 by striking at the end and2 7,b7 in subclause 7,,ix7-- 7i7 by inserting and before fiscal year #bjad after for each fiscal year after fiscal year #bjjg2 and 7ii7 by striking the period at the end and inserting 2 and2 and 7,c7 by adding at the end the following new subclause3 7,x7 for each fiscal year after fiscal year #bjac1 not less than the amount required under this clause for fiscal year #bjac1 plus the amount by which the amount made available under clause 7i77,v7 for fiscal year #bjad exceeds the amount made available under clause 7i77,,iv7 for fiscal year #bjac4 4 7b7 ,,oig funding ,there are authorized to be appropriated for each of fiscal years #bjad through #bjbc #ajj1jjj1jjj for the ,office of the ,inspector ,general of the ,department of ,health and ,human ,services for fraud prevention activities under the ,medicare and ,medicaid programs4 #acbb4 ,improved enforcement of the ,medicare secondary payor provisions 7a7 ,in general ,the ,secretary1 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 7b7 ,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 7c7 ,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 payor provisions1 including recoupment of credit balances4 #acbc4 ,strengthen ,medicare provider enrollment standards and safeguards 7a7 ,strengthening ,medicare provider numbers 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 7referred to in this section as the ,secretary7 shall screen the provider or supplier for a criminal background or other financial or operational irregularities through fingerprinting1 licensure checks1 site-visits1 and 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#a74 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 knowingly 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 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 ,there are authorized to be appropriated to carry out this section such sums as may be necessary4 #acbd4 ,tracking banned providers across ,state lines 7a7 ,greater coordination ,the ,secretary of ,health and ,human ,services 7in this section referred to as the ,secretary7 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 knowingly 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