,,ii #aadth ,,congress #b;d ,session ,s4 #beai ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,february #i1 #bjaf,mr4 ,mc,cain 7for himself and ,mr4 ,perdue7 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 #bjae4 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,subtitle ,a--,tax credit for health insurance coverage,sec4 #aja4 ,refundable tax credit for health insurance coverage4,sec4 #ajb4 ,election of tax credit instead of alternative government or group plan benefits4,subtitle ,b--,health savings accounts,sec4 #aaa4 ,refundable tax credit for health savings account contributions4,sec4 #aab4 ,allowing ,,hsa rollover to child or parent of account holder4,sec4 #aac4 ,maximum contribution limit to ,,hsa coordinated with retirement savings account limitation4,sec4 #aad4 ,transfer of required minimum distribution from retirement plan to health savings account4,sec4 #aae4 ,equivalent bankruptcy protections for health savings accounts as retirement funds4,sec4 #aaf4 ,allow both spouses to make catch-up contributions to the same ,,hsa account4,sec4 #aag4 ,provisions relating to ,medicare4,sec4 #aah4 ,individuals eligible for veterans benefits for a service-connected disability4,sec4 #aai4 ,individuals eligible for ,indian ,health ,service assistance4,sec4 #abj4 ,individuals eligible for ,,tricare coverage4,sec4 #aba4 ,,fsa and ,,hra interaction with ,h,s,as4,sec4 #abb4 ,special rule for certain medical expenses incurred before establishment of account4,sec4 #abc4 ,preventive care prescription drug clarification4,sec4 #abd4 ,administrative error correction before due date of return4,sec4 #abe4 ,members of health care sharing ministries eligible to establish health savings accounts4,sec4 #abf4 ,high deductible health plans renamed ,,hsa qualified plans4,sec4 #abg4 ,treatment of direct primary care service arrangements4,sec4 #abh4 ,certain provider fees to be treated as medical care4,sec4 #abi4 ,clarification of treatment of capitated primary care payments as amounts paid for medical care4,subtitle ,c--,other provisions,sec4 #aca4 ,limitation on employer-provided health care coverage4,sec4 #acb4 ,limitation on abortion funding4,sec4 #acc4 ,no government discrimination against certain health care entities4,sec4 #acd4 ,equal employer contribution rule to promote choice4,sec4 #ace4 ,limitations on ,state restrictions on employer auto-enrollment4,sec4 #acf4 ,credit for small employers adopting auto-enrollment and defined contribution options4,title ,,ii--,health ,care ,access and ,availability,subtitle ,a--,health ,insurance ,pooling ,mechanisms for ,individuals ,sec4 #bja4 ,federal grants for ,state insurance expenditures4,sec4 #bjb4 ,pool reform for individual membership expansion4,subtitle ,b--,small ,business ,health ,fairness,sec4 #baa4 ,short title4,sec4 #bab4 ,rules governing association health plans4,sec4 #bac4 ,clarification of treatment of single employer arrangements4,sec4 #bad4 ,enforcement provisions relating to association health plans4,sec4 #bae4 ,cooperation between ,federal and ,state authorities4,sec4 #baf4 ,effective date and transitional and other rules4,subtitle ,c--,health ,insurance ,reforms,sec4 #bba4 ,requirements for individual health insurance4,title ,,iii--,interstate ,market for ,health ,insurance,sec4 #cja4 ,cooperative governing of individual health insurance coverage4,title ,,iv--,lawsuit ,abuse ,reforms,sec4 #dja4 ,change in burden of proof based on compliance with clinical practice guidelines4,sec4 #djb4 ,state grants to create expert panels and administrative health care tribunals4,sec4 #djc4 ,payment of damages and recovery of costs in health care lawsuits4,sec4 #djd4 ,definitions4,sec4 #dje4 ,effect on other laws4,sec4 #djf4 ,applicability2 effective date4,title ,v--,wellness and ,prevention,sec4 #eja4 ,providing financial incentives for treatment compliance4,title ,,vi--,transparency and ,insurance ,reform ,measures,sec4 #fja4 ,receipt and response to requests for claim information4,title ,,vii--,quality,sec4 #gja4 ,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 #gjb4 ,establishment of performance-based quality measures4,title ,,viii--,state ,transparency ,plan ,portal,sec4 #hja4 ,providing information on health coverage options and health care providers4,title ,,ix--,patient ,freedom of ,choice ,sec4 #ija4 ,guaranteeing freedom of choice and contracting for patients under ,medicare4,sec4 #ijb4 ,preemption of ,state laws limiting charges for eligible professional services4,sec4 #ijc4 ,health care provider licensure cannot be conditioned on participation in a health plan4,sec4 #ijd4 ,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 #ije4 ,right of contract with health care providers4,title ,x--,quality ,health ,care ,coalition,sec4 #ajja4 ,quality ,health ,care ,coalition4 #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 ,a ,tax credit for health insurance coverage #aja4 ,refundable tax credit for health insurance coverage 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 coverage 7a7 ,in general ,in the case of an individual1 there shall be allowed as a credit against the tax imposed by subtitle ,a an amount equal to the aggregate monthly credit amounts determined under subsection 7b7 with respect to the taxpayer and the taxpayer's qualifying family members for eligible coverage months beginning during the taxable year4 7b7 ,monthly credit amounts 7#a7 ,in general ,the monthly credit amount with respect to any individual for any eligible coverage month is #a_/ab of-- 7,a7 #ijj in the case of an individual who has not attained age #ah as of the beginning of such month1 7,b7 #a1bjj in the case of an individual who has so attained age #ah but who has not so attained age #ce1 7,c7 #b1ajj in the case of an individual who has so attained age #ce1 but who has not so attained age #ej1 and 7,d7 #c1jjj in the case of an individual who has so attained age #ej4 7#b7 ,inflation adjustment ,in the case of any taxable year beginning in a calendar year after #bjaf1 each of the dollar amounts in paragraph 7#a7 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 #bjae 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 the members of which 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 ,credit in excess of premiums only payable to a health savings account 7,a7 ,in general ,if the credit determined under subsection 7a7 7determined without regard to clause 7ii77 for any taxable year exceeds the amount of premiums 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 year-- 7i7 at the request of the taxpayer1 the ,secretary shall pay the amount of such excess to one or more health savings accounts of the taxpayer or of any qualifying family member of the taxpayer1 and 7ii7 the amount of such excess shall not be treated as a credit against the tax imposed by subtitle ,a for such taxable year4 7,b7 ,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 subparagraph 7,a7 as premiums paid for coverage4 7,c7 ,insurance which covers other individuals ,for purposes of this paragraph1 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,d7 ,contributions treated as rollovers1 etc 7i7 ,in general ,any amount paid by the ,secretary to a health savings account under this paragraph shall be treated for purposes of this title in the same manner as a rollover contribution to such an account described in section #bbc7;f77#e71 except that the limitation under section #bbc7;f77#e77;,b7 shall not apply to such a contribution and such contribution shall not be taken into account in applying such limitation to any other amounts contributed4 7ii7 ,coordination with ,h,s,as ,nothing in any provision of law shall be construed-- 7,i7 to prevent an individual from establishing a health savings account 7as defined in section #bbc7;d77 merely because such individual is not an eligible individual 7as defined in section #bbc7;c771 or 7,,ii7 to prevent such an account from being treated as a health savings account merely because all or a substantial portion of the contributions to such account are described in this paragraph4 7#b7 ,coordination with advance payments of credit ,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#c7 ,coordination with other provisions ,for purposes of any deduction allowed under section #afb7l71 #bac1 or #bbd1 and any credit allowed under section #ce1 any health insurance premiums which would 7but for this paragraph7 be taken into account shall be reduced 7but not below zero7 by the amount of the credit allowed under this section 7determined without regard to paragraphs 7#a7 and 7#b774 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 ,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 ,advance payment of credit 7#a7 ,in general ,chapter #gg of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following3 #gebi4 ,advance payment of credit for health insurance coverage 7a7 ,general rule ,not later than ,january #a1 #bjaf1 the ,secretary shall establish a program for making payments to-- 7#a7 providers of qualified health insurance 7as defined in section #cf;,b7e771 and 7#b7 as provided in subsection 7c71 health savings accounts1 on behalf of taxpayers eligible for the credit under section #cf;,b4 7b7 ,amount of payments ,the aggregate payments made under this section with respect to any taxpayer1 determined as of any time during any calendar year1 shall not exceed the monthly credit amounts determined with respect to such taxpayer under section #cf;,b for months during such calendar year which have ended as of such time4 7c7 ,application of rule that credits in excess of premiums only payable to a health savings account ,under rules similar to the rules of section #cf;,b7g77#a71 any amount otherwise payable on behalf of the taxpayer under subsection 7b7 with respect to any eligible coverage month which is in excess of the amount of premiums paid by the taxpayer for coverage of the taxpayer and the taxpayer's qualifying family members under qualified health insurance for such month shall be payable only to one or more health savings accounts of the taxpayer or of any qualifying family member of the taxpayer4 7d7 ,certification process and proof of coverage ,the ,secretary shall establish a process under which individuals are certified as eligible for payment under this section4 ,such process shall include an initial application by the taxpayer to determine eligibility and thereafter continued eligibility shall be determined1 to the maximum extent feasible1 by the ,secretary on the basis of information provided under section #fjej,x4 7e7 ,definitions ,for purposes of this section1 terms used in this section which are also used in section #cf;,b shall have the same meaning as when used in section #cf;,b4 4 7#b7 ,information reporting 7,a7 ,in general ,subpart ,b of part ,,iii of subchapter ,a of chapter #fa of such ,code is amended by adding at the end the following new section3 #fjej,x4 ,returns relating to credit for health insurance coverage 7a7 ,requirement of reporting ,every person who provides qualified health insurance for any month of any calendar year 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 ,with respect to any individual with respect to whom payments under section #gebi are made by the ,secretary1 the ,secretary may require that reporting under subsection 7b7 be made on a monthly basis4 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 contains1 with respect to each policy of qualified health insurance-- 7,a7 the name1 address1 and ,,tin of each individual covered under such policy1 7,b7 the premiums paid with respect to such policy1 and 7,c7 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 to which such statement relates4 7d7 ,definitions ,for purposes of this section1 terms used in this section which are also used in section #cf;,b shall have the same meaning as when used in section #cf;,b4 4 7,b7 ,assessable penalties 7i7 ,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 coverage71 and 4 7ii7 ,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 coverage74 4 7#c7 ,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 related to payments of the health insurance coverage credit ,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;e77 or a trustee of a health savings account 7and persons acting on behalf of such provider or such trustee71 return information with respect to any such taxpayer only to the extent necessary 7as prescribed by regulations issued by the ,secretary7 to carry out sections #cf;,b7g77#a7 7relating to credit in excess of premiums only payable to a health savings account7 and #gebi 7relating to advance payment of credit for health insurance coverage74 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 7#d7 ,effective date ,the amendments made by this section shall take effect on the date of the enactment of this ,act4 7c7 ,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 coverage4 4 7#c7 ,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 coverage4 4 7#d7 ,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 for health insurance coverage4 4 7d7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjae4 #ajb4 ,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 shall 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 #bjaf 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 ,b ,health savings accounts #aaa4 ,refundable tax credit for health savings account contributions 7a7 ,in general ,subpart ,c of part ,,iv of subchapter ,a of chapter #a of the ,internal ,revenue ,code of #aihf1 as amended by the preceding provisions of this ,act1 is amended by inserting after section #cf;,b the following new section3 #cf;,c4 ,health savings account contributions 7a7 ,in general ,in the case of an individual who is allowed a deduction under section #bbc7;a7 for any taxable year1 there shall be allowed as a credit against the tax imposed by subtitle ,a for such taxable year1 the lesser of-- 7#a7 the amount so allowed as a deduction1 or 7#b7 #a1jjj4 7b7 ,limitation ,the credit allowed under subsection 7a7 with respect to any individual for any taxable year shall not exceed the excess 7if any7 of-- 7#a7 #a1jjj1 over 7#b7 the aggregate credits allowed with respect to such individual under subsection 7a7 for all prior taxable years4 4 7b7 ,conforming amendments 7#a7 ,paragraph 7#b7 of section #acbd7;b7 of title #ca1 ,united ,states ,code1 as amended by the preceding provisions of this ,act1 is amended by inserting #cf;,c1 after #cf;,b14 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 the preceding provisions of this ,act1 is amended by inserting after the item relating to section #cf;,b the following new item3 ,sec4 #cf;,c4 ,health savings account contributions4 4 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #aab4 ,allowing ,,hsa rollover to child or parent of account holder 7a7 ,in general ,section #bbc7;f77#h77;,a7 of the ,internal ,revenue ,code of #aihf is amended-- 7#a7 by inserting child1 parent1 or grandparent after surviving spouse1 7#b7 by inserting child1 parent1 or grandparent1 as the case may be1 after the spouse1 7#c7 by inserting 1 child1 parent1 or grandparent after spouse in the heading thereof1 and 7#d7 by adding at the end the following3 ,in the case of a child who acquires such beneficiary's interest and with respect to whom a deduction under section #aea is allowable to another taxpayer for a taxable year beginning in the calendar year in which such individual's taxable year begins1 such health savings account shall be treated as a child health savings account of the child44 7b7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #aac4 ,maximum contribution limit to ,,hsa coordinated with retirement savings account limitation 7a7 ,self-,only coverage ,section #bbc7;b77#b77;,a7 of the ,internal ,revenue ,code of #aihf is amended by striking #b1bej and inserting the amount in effect under section #bai7;b77#e77;,a74 7b7 ,family coverage ,section #bbc7;b77#b77;,b7 of the ,internal ,revenue ,code of #aihf is amended by striking #d1ejj and inserting twice the amount in effect under subparagraph 7,a74 7c7 ,conforming amendments ,section #bbc7;g77#a7 of the ,internal ,revenue ,code of #aihf is amended-- 7#a7 in the matter preceding subparagraph 7,a71 by striking subsections 7b77#b7 and 7c77#b77;,a7 and inserting subsection 7c77#b77;,a71 7#b7 in subparagraph 7,b71 by striking by substituting and all that follows through the end of clause 7ii7 and inserting by substituting calendar year #bjjc for calendar year #aiib in subparagraph 7,b7 thereof41 and 7#c7 in the matter following subparagraph 7,b71 by striking subsections 7b77#b7 and 7c77#b77;,a7 and inserting subsection 7c77#b77;,a74 7d7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #aad4 ,transfer of required minimum distribution from retirement plan to health savings account 7a7 ,transfer from retirement plan 7#a7 ,individual retirement accounts ,section #djh7;d7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new paragraph3 7#aj7 ,required minimum distribution transferred to health savings account 7,a7 ,in general ,in the case of an individual who has attained the age of #gj and who elects the application of this paragraph for a taxable year1 gross income of the individual for the taxable year does not include a qualified ,,hsa transfer to the extent such transfer is otherwise includible in gross income4 7,b7 ,qualified ,,hsa transfer ,for purposes of this paragraph1 the term qualified ,,hsa transfer means any distribution from an individual retirement plan-- 7i7 to a health savings account of the individual in a direct trustee-to-trustee transfer1 and 7ii7 to the extent such distribution does not exceed the required minimum distribution determined under section #dja7;a77#i7 for the distribution calendar year ending during the taxable year4 7,c7 ,application of section #gb ,notwithstanding section #gb1 in determining the extent to which an amount is treated as otherwise includible in gross for purposes of subparagraph 7,a71 the aggregate amount distributed from an individual retirement plan shall be treated as includible in gross income to the extent that such amount does not exceed the aggregate amount which would have been so includible if all amounts from all individual retirement plans were distributed4 ,proper adjustments shall be made in applying section #gb to other distributions in such taxable year and subsequent taxable years4 7,d7 ,coordination ,an election may not be made under subparagraph 7,a7 for a taxable year for which an election is in effect under paragraph 7#i74 4 7#b7 ,other retirement plans ,section #djb of such ,code is amended by adding at the end the following new subsection3 7m7 ,required minimum distribution transferred to health savings account 7#a7 ,in general ,in the case of an individual who has attained the age of #gj and who elects the application of this subsection for a taxable year1 gross income of the individual for the taxable year does not include a qualified ,,hsa transfer to the extent such transfer is otherwise includible in gross income4 7#b7 ,qualified ,,hsa transfer ,for purposes of this subsection1 the term qualified ,,hsa transfer means any distribution from a retirement plan-- 7,a7 to a health savings account of the individual in a direct trustee-to-trustee transfer1 and 7,b7 to the extent such distribution does not exceed the required minimum distribution determined under section #dja7;a77#i7 for the distribution calendar year ending during the taxable year4 7#c7 ,application of section #gb ,notwithstanding section #gb1 in determining the extent to which an amount is treated as otherwise includible in gross for purposes of paragraph 7#a71 the aggregate amount distributed from an individual retirement plan shall be treated as includible in gross income to the extent that such amount does not exceed the aggregate amount which would have been so includible if all amounts from all individual retirement plans were distributed4 ,proper adjustments shall be made in applying section #gb to other distributions in such taxable year and subsequent taxable years4 7#d7 ,eligible retirement plan ,for purposes of this subsection1 the term eligible retirement plan has the meaning given such term by subsection 7c77#h77;,b7 7determined without regard to clauses 7i7 and 7ii7 thereof74 4 7b7 ,transfer to health savings account 7#a7 ,in general ,section #bbc7;d77#a77;,a7 of the ,internal ,revenue ,code of #aihf is amended by striking or at the end of clause 7i71 by striking the period at the end of clause 7ii77,,ii7 and inserting 1 or1 and by adding at the end the following new clause3 7iii7 unless it is a qualified ,,hsa transfer described in section #djh7;d77#aj7 or #djb7m74 4 7#b7 ,excise tax inapplicable to qualified ,,hsa transfer ,section #digc7;g77#a7 of such ,code is amended by inserting or a qualified ,,hsa transfer described in section #djh7;d77#aj7 or #djb7m7 after or #bbc7;f77#e74 7c7 ,effective date ,the amendments made by this section shall apply to distributions made after the date of the enactment of this ,act4 #aae4 ,equivalent bankruptcy protections for health savings accounts as retirement funds 7a7 ,in general ,section #ebb of title #aa1 ,united ,states ,code1 is amended by adding at the end the following3 7r7 ,treatment of health savings accounts ,for purposes of this section1 any health savings account 7as described in section #bbc of the ,internal ,revenue ,code of #aihf7 shall be treated in the same manner as an individual retirement account described in section #djh of such ,code4 4 7b7 ,effective date ,the amendment made by this section shall apply to cases commencing under title #aa1 ,united ,states ,code1 after the date of enactment of this ,act4 #aaf4 ,allow both spouses to make catch-up contributions to the same ,,hsa account 7a7 ,in general ,section #bbc7;b77#c7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subparagraph3 7,c7 ,special rule where both spouses are eligible individuals with #a account ,if-- 7i7 an individual and the individual's spouse have both attained age #ee before the close of the taxable year1 and 7ii7 the spouse is not an account beneficiary of a health savings account as of the close of such year1 the additional contribution amount shall be twice the amount otherwise determined under subparagraph 7,b74 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #aag4 ,provisions relating to ,medicare 7a7 ,individuals over age #fe only enrolled in ,medicare ,part ,a ,section #bbc7;b77#g7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following3 ,this paragraph shall not apply to any individual during any period for which the individual's only entitlement to such benefits is an entitlement to hospital insurance benefits under part ,a of title ,,xviii of such ,act pursuant to an enrollment for such hospital insurance benefits under section #bbf7;a77#a7 of such ,act44 7b7 ,medicare beneficiaries participating in ,medicare advantage ,,msa may contribute their own money to their ,,msa 7#a7 ,in general ,section #ach7;b7 of such ,code is amended by striking paragraph 7#b7 and by redesignating paragraphs 7#c7 and 7#d7 as paragraphs 7#b7 and 7#c71 respectively4 7#b7 ,conforming amendment ,section #ach7;c77#d7 of such ,code is amended by striking and paragraph 7#b74 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #aah4 ,individuals eligible for veterans benefits for a service-connected disability 7a7 ,in general ,subparagraph 7,c7 of section #bbc7;c77#a7 of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7,c7 ,special rule for individuals eligible for certain veterans 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 for a service-connected disability under any law administered by the ,secretary of ,veterans ,affairs but only if the individual is not eligible to receive such care or services for any condition other than a service-connected disability4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #aai4 ,individuals eligible for ,indian ,health ,service assistance 7a7 ,in general ,section #bbc7;c77#a7 of the ,internal ,revenue ,code of #aihf1 as amended by the preceding provisions of this ,act1 is amended by adding at the end the following new subparagraph3 7,d7 ,special rule for individuals eligible for assistance under ,indian ,health ,service programs ,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 hospital care or medical services under a medical care program of the ,indian ,health ,service or of a tribal organization4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #abj4 ,individuals eligible for ,,tricare coverage 7a7 ,in general ,section #bbc7;c77#a7 of the ,internal ,revenue ,code of #aihf1 as amended by the preceding provisions of this ,act1 is amended by adding at the end the following new subparagraph3 7,e7 ,special rule for individuals eligible for assistance under tricare ,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 is eligible to receive hospital care1 medical services1 or prescription drugs under ,,tricare ,extra or ,,tricare ,standard and such individual is not enrolled in ,,tricare ,prime4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #aba4 ,,fsa and ,,hra interaction with ,h,s,as 7a7 ,eligible individuals include ,,fsa and ,,hra participants ,section #bbc7;c77#a77;,b7 of the ,internal ,revenue ,code of #aihf is amended-- 7#a7 by striking and at the end of clause 7ii71 7#b7 by striking the period at the end of clause 7iii7 and inserting 1 and1 and 7#c7 by inserting after clause 7iii7 the following new clause3 7iv7 for months during a plan year in which a qualified ,,hsa distribution 7as defined in section #ajf7;e77#b77 is made on behalf of an individual1 coverage under a health flexible spending arrangement or a health reimbursement arrangement if1 after the qualified ,,hsa distribution is made and for the remaining duration of the plan year1 the coverage provided under the health flexible spending arrangement or health reimbursement arrangement is converted to coverage which-- 7,i7 does not pay or reimburse any medical expense incurred before the minimum annual deductible under paragraph 7#b77;,a77i7 7prorated for the period occurring after the qualified ,,hsa distribution is made7 is satisfied1 7,,ii7 does not pay or reimburse any medical expense incurred after the qualified ,,hsa distribution is made other than preventive care as defined in paragraph 7#b77;,c71 7,,iii7 pays or reimburses benefits for coverage described in clause 7ii7 7but not through insurance or for long-term care services71 7,,iv7 pays or reimburses benefits for permitted insurance or coverage described in clause 7ii7 7but not for long-term care services71 7,v7 pays or reimburses only those medical expenses incurred after an individual's retirement 7and no expenses incurred before retirement71 or 7,,vi7 is suspended1 pursuant to an election made on or before the date the individual elects the qualified ,,hsa distribution or1 if later1 on the date of the individual enrolls in a high deductible health plan1 and which does not pay or reimburse1 at any time1 any medical expense incurred during the suspension period except as defined in the preceding subclauses of this clause4 4 7b7 ,qualified ,,hsa distribution shall not affect flexible spending arrangement ,section #ajf7;e77#a7 of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7#a7 ,in general ,a plan shall not fail to be treated as a health flexible spending arrangement under this section1 section #aje1 or section #abe1 or as a health reimbursement arrangement under this section or section #aje1 merely because such plan provides for a qualified ,,hsa distribution4 4 7c7 ,,fsa balances at year end shall not forfeit ,section #abe7;d77#b7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subparagraph3 7,e7 ,exception for qualified ,,hsa distributions ,subparagraph 7,a7 shall not apply to the extent that there is an amount remaining in a health flexible spending account at the end of a plan year that an individual elects to contribute to a health savings account pursuant to a qualified ,,hsa distribution 7as defined in section #ajf7;e77#b774 4 7d7 ,simplification of limitations on ,,fsa and ,,hra rollovers ,section #ajf7;e77#b7 of such ,code is amended to read as follows3 7#b7 ,qualified ,,hsa distribution 7,a7 ,in general ,the term qualified ,,hsa distribution means a distribution from a health flexible spending arrangement or health reimbursement arrangement to the extent that such distribution does not exceed the lesser of-- 7i7 the balance in such arrangement as of the date of such distribution1 or 7ii7 the amount determined under subparagraph 7,b74 ,such term shall not include more than #a distribution with respect to any arrangement4 7,b7 ,dollar limitations 7i7 ,distributions from a health flexible spending arrangement ,a qualified ,,hsa distribution from a health flexible spending arrangement shall not exceed the applicable amount4 7ii7 ,distributions from a health reimbursement arrangement ,a qualified ,,hsa distribution from a health reimbursement arrangement shall not exceed-- 7,i7 the applicable amount divided by #ab1 multiplied by 7,,ii7 the number of months during which the individual is a participant in the health reimbursement arrangement4 7iii7 ,applicable amount ,for purposes of this subparagraph1 the applicable amount is-- 7,i7 the dollar amount in effect under section #bbc7;b77#b77;,a7 in the case of an eligible individual who has self-only coverage under a high deductible health plan at the time of such distribution1 and 7,,ii7 twice the dollar amount in effect under subclause 7,i7 in the case of an eligible individual who has family coverage under a high deductible health plan at the time of such distribution4 4 7e7 ,elimination of additional tax for failure ,to maintain high deductible health plan coverage ,section #ajf7;e7 of the ,internal ,revenue ,code of #aihf is amended-- 7#a7 by striking paragraph 7#c7 and redesignating paragraphs 7#d7 and 7#e7 as paragraphs 7#c7 and 7#d71 respectively1 and 7#b7 by striking subparagraph 7,a7 of paragraph 7#c71 as so redesignated1 and redesignating subparagraphs 7,b7 and 7,c7 of such paragraph as subparagraphs 7,a7 and 7,b7 thereof1 respectively4 7f7 ,limited purpose ,f,s,as and ,h,r,as ,section #ajf7;e7 of the ,internal ,revenue ,code of #aihf1 as amended by this section1 is amended by adding at the end the following new paragraph3 7#e7 ,limited purpose ,f,s,as and ,h,r,as ,a plan shall not fail to be a health flexible spending arrangement or health reimbursement arrangement under this section or section #aje merely because the plan converts coverage for individuals who enroll in a high deductible health plan described in section #bbc7;c77#b7 to coverage described in section #bbc7;c77#a77;,b77iv74 ,coverage for such individuals may be converted as of the date of enrollment in the high deductible health plan1 without regard to the period of coverage under the health flexible spending arrangement or health reimbursement arrangement1 and without requiring any change in coverage to individuals who do not enroll in a high deductible health plan4 4 7g7 ,disclaimer of disqualifying coverage ,section #bbc7;c77#a77;,b7 of the ,internal ,revenue ,code of #aihf1 as amended by this section1 is amended-- 7#a7 by striking and at the end of clause 7iii71 7#b7 by striking the period at the end of clause 7iv7 and inserting 1 and1 and 7#c7 by inserting after clause 7iv7 the following new clause3 7v7 coverage 7including prospective coverage7 under a health plan that is not a high deductible health plan which is disclaimed in writing1 at the time of the creation or organization of the health savings account1 including by execution of a trust described in subsection 7d77#a7 through a governing instrument that includes such a disclaimer1 or by acceptance of an amendment to such a trust that includes such a disclaimer4 4 7h7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #abb4 ,special rule for certain medical expenses incurred before establishment of account 7a7 ,in general ,section #bbc7;d77#b7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subparagraph3 7,d7 ,certain medical expenses incurred before establishment of account treated as qualified ,an expense shall not fail to be treated as a qualified medical expense solely because such expense was incurred before the establishment of the health savings account if such expense was incurred-- 7i7 during either-- 7,i7 the taxable year in which the health savings account was established1 or 7,,ii7 the preceding taxable year in the case of a health savings account established after the taxable year in which such expense was incurred but before the time prescribed by law for filing the return for such taxable year 7not including extensions thereof71 and 7ii7 for medical care of an individual during a period that such individual was covered by a high deductible health plan and met the requirements of subsection 7c77#a77;,a77ii7 7after application of subsection 7c77#a77;,b774 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #abc4 ,preventive care prescription drug clarification 7a7 ,clarify use of drugs in preventive care ,section #bbc7;c77#b77;,c7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following3 ,for purposes of the preceding sentence1 the term preventative care includes prescription and over-the-counter drugs and medicines which have the primary purpose of preventing the onset of1 further deterioration from1 or complications associated with chronic conditions1 illnesses1 or diseases44 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjjc4 #abd4 ,administrative error correction before due date of return 7a7 ,in general ,section #bbc7;f77#d7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subparagraph3 7,d7 ,exception for administrative errors corrected before due date of return ,subparagraph 7,a7 shall not apply if any payment or distribution is made to correct an administrative1 clerical or payroll contribution error and if-- 7i7 such distribution is received by the individual on or before the last day prescribed by law 7including extensions of time7 for filing such individual's return for such taxable year1 and 7ii7 such distribution is accompanied by the amount of net income attributable to such contribution4 ,any net income described in clause 7ii7 shall be included in the gross income of the individual for the taxable year in which it is received4 4 7b7 ,effective date ,the amendment made by this section shall take effect on the date of the enactment of this ,act4 #abe4 ,members of health care sharing ministries eligible to establish health savings accounts 7a7 ,in general ,section #bbc of the ,internal ,revenue ,code of #aihf 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 #ejjj;,a7d77#b77;,b77ii77 shall be treated as coverage under a high deductible health plan4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #abf4 ,high deductible health plans renamed ,,hsa qualified plans 7a7 ,in general ,section #bbc of the ,internal ,revenue ,code of #aihf1 as amended by this ,act1 is amended by striking high deductible health plan each place it appears and inserting ,,hsa qualified health plan4 7b7 ,conforming amendments 7#a7 ,section #ajf7;e7 of the ,internal ,revenue ,code of #aihf1 as amended by this ,act1 is amended by striking high deductible health plan each place it appears and inserting ,,hsa qualified health plan4 7#b7 ,the heading for section #bbc7;c77#b7 of such ,code is amended by striking ,high deductible health plan and inserting ,,hsa qualified health plan4 7#c7 ,section #djh7;d77#i7 of such ,code is amended-- 7,a7 by striking high deductible health plan each place it appears in subparagraph 7,c7 and inserting ,,hsa qualified health plan1 and 7,b7 by striking ,high deductible health plan in the heading of subparagraph 7,d7 and inserting ,,hsa qualified health plan4 #abg4 ,treatment of direct primary care service arrangements 7a7 ,in general ,section #bbc7;c7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new paragraph3 7#f7 ,treatment of direct primary care service arrangements ,an arrangement under which an individual is provided coverage restricted to primary care services in exchange for a fixed periodic fee-- 7,a7 shall not be treated as a health plan for purposes of paragraph 7#a77;,a77ii71 and 7,b7 shall not be treated as insurance for purposes of subsection 7d77#b77;,b74 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #abh4 ,certain provider fees to be treated as medical care 7a7 ,in general ,section #bac7;d7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new paragraph3 7#ab7 ,periodic provider fees ,the term medical care includes periodic fees paid to a primary care physician for the right to receive medical services on an as-needed basis4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #abi4 ,clarification of treatment of capitated primary care payments as amounts paid for medical care 7a7 ,in general ,section #bac7;d7 of the ,internal ,revenue ,code of #aihf1 as amended by the preceding provisions of this ,act1 is amended by adding at the end the following new paragraph3 7#ac7 ,treatment of capitated primary care payments ,capitated primary care payments shall be treated as amounts paid for medical care4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 ,c ,other provisions #aca4 ,limitation on employer-provided health care coverage 7a7 ,in general ,section #ajf of the ,internal ,revenue ,code of #aihf1 as amended by the preceding provisions of this ,act1 is amended by adding at the end the following new subsection3 7f7 ,limitation on employer-,provided health care coverage 7#a7 ,in general ,the amount of any exclusion under subsection 7a7 for any taxable year with respect to-- 7,a7 any employer-provided coverage under an accident or health plan which constitutes medical care1 and 7,b7 any employer contribution to an ,archer ,,msa or a health savings account which is treated by subsection 7b7 or 7d7 as employer-provided coverage for medical expenses under an accident or health plan1 shall not exceed #h1jjj per employee for self-only coverage and #bj1jjj for family coverage4 7#b7 ,inflation adjustment ,in the case of any taxable year beginning in a calendar year after #bjaf1 each of the dollar amounts in paragraph 7#a7 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 #bjae 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 7#c7 ,medical care ,for purposes of paragraph 7#a71 the term medical care has the meaning given to such term in section #bac7;d7 determined without regard to-- 7,a7 paragraph 7#a77;,c7 thereof1 and 7,b7 so much of paragraph 7#a77;,d7 thereof as relates to qualified long-term care insurance4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjae4 #acb4 ,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 #acc4 ,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 #acd4 ,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 which constitutes medical care of the individual or individual's spouse or dependents 7other than excepted benefits as defined in section #ihcb7;c77 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 following3 7j7 ,notwithstanding subsections 7a7 through 7i71 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 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 #ace4 ,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 #acf4 ,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 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 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 x of the short title 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 subsection 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 the ,internal ,revenue ,code of #aihf1 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 the ,internal ,revenue ,code of #aihf1 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 ,,ii ,health ,care ,access and ,availability ,a ,health ,insurance ,pooling ,mechanisms for ,individuals #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 #a1jjj1jjj1jjj for each of fiscal years #bjaf1 #bjag1 and #bjah 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 covers 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 ,requirements for receipt of bonus payments ,the requirements of this subsection1 for the availability of bonus payments to a ,state under subsection 7d71 are as follows1 in the case of an individual who is covered under a high-risk pool or other pool or mechanism described in subsection 7b7 operating in the ,state for which funds under this section may be applied3 7#a7 ,limitation on annual premiums for each individual based on adjusted gross family income ,the premiums imposed for coverage of each individual under health insurance coverage offered through such pool or mechanism may not exceed 7on an annual basis7 the following3 7,a7 ,if the adjusted gross income 7as defined in section #fb of the ,internal ,revenue ,code of #aihf7 of all individuals in the individual's family does not exceed the poverty line 7as defined in section #fgc7b7 of the ,community ,services ,block ,grant ,act 7#db ,u4,s4,c4 #iijb7b771 including any revision required by such section7 applicable to a family of the size involved1 #b percent of such income4 7,b7 ,if such adjusted gross income for all individuals in the individual's family exceeds such applicable poverty line1 the sum of-- 7i7 #b percent of such applicable poverty line2 and 7ii7 #aj percent of the amount of such income that exceeds such applicable poverty line4 7#b7 ,limitation on annual out-of-pocket costs for each individual ,there shall be a limit on the annual out-of-pocket expenditures 7including annual premiums7 for each individual for coverage under such pool or mechanism equal to twice the maximum allowable premiums for such individual permitted under paragraph 7#a74 7f7 ,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 7g7 ,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 7h7 ,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 7i7 ,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 #bjaf through #bjah after #bjaj2 and 7#b7 by inserting and for each of fiscal years #bjaf through #bjah after for each of fiscal years #bjjg through #bjaj4 7j7 ,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 #bjah4 #bjb4 ,pool reform for individual membership expansion ,the ,public ,health ,service ,act1 as amended by section #b1 is further amended by inserting after title ,,xxx the following new title3 ,,xxxi ,pool ,reform for ,individual ,membership ,expansion #cajj4 ,purpose ,the purpose of this title is to provide1 through the establishment of independent health pools 7referred to in this title as ,,ihp71 for the reform of1 and expansion of enrollment in1 health insurance coverage for individuals and small employers4 #caja4 ,definition of independent health pool 7a7 ,in ,general ,for purposes of this title1 the terms individual health pool and ,,ihp mean a legal nonprofit entity that meets the following requirements3 7#a7 ,organization ,the ,,ihp-- 7,a7 has been formed and maintained in good faith for a purpose that includes the formation of a risk pool in order to offer health insurance coverage to its members2 7,b7 does not condition membership in the ,,ihp on any health status-related factor relating to an individual 7including an employee of an employer or a dependent of an employee72 7,c7 does not make health insurance coverage offered through the ,,ihp available other than in connection with a member of the ,,ihp2 7,d7 is not a health insurance issuer2 and 7,e7 does not receive any consideration directly or indirectly from any health insurance issuer in connection with the enrollment of any individuals1 or employees of employers1 in any health insurance coverage1 except in conjunction with services offered through the ,,ihp4 7#b7 ,offering health benefits coverage 7,a7 ,different groups ,the ,,ihp1 in conjunction with those health insurance issuers that offer health benefits coverage through the ,,ihp1 makes available health benefits coverage in the manner described in subsection 7b7 to all members of the ,,ihp 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 for individuals covered through an ,,ihp4 7,b7 ,nondiscrimination in coverage offered 7i7 ,in general ,subject to clause 7ii71 the ,,ihp may not offer health benefits coverage to a member of an ,,ihp unless the same coverage is offered to all such members of the ,,ihp4 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 preventing a health insurance issuer from underwriting or from excluding or limiting the coverage on any individual1 subject to the requirement of section #bgda 7relating to guaranteed availability of individual health insurance coverage to certain individuals with prior group coverage74 7,c7 ,no assumption of insurance risk by ,,ihp ,the ,,ihp 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 ,,ihp in a geographic area or as limiting the number of ,i,h,ps that may operate in any area4 7#d7 ,provision of administrative services to purchasers ,the ,,ihp may provide administrative services for members4 ,such services may include accounting1 billing1 and enrollment information4 7b7 ,health benefits coverage requirements 7#a7 ,compliance with consumer protection requirements ,except as provided in section #cajb1 any health benefits coverage offered through an ,,ihp-- 7,a7 shall be issued by a health insurance issuer that meets all applicable ,state standards relating to consumer protection2 7,b7 shall be approved or otherwise permitted to be offered under ,state law2 and 7,c7 may not impose any exclusion of a specific disease from such coverage4 7#b7 ,wellness bonuses for health promotion ,nothing in this title shall be construed as precluding a health insurance issuer offering health benefits coverage through an ,,ihp 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 ,,ihp 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 ,,ihp1 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 ,,ihp4 7,b7 ,rules for enrollment ,nothing in this paragraph shall preclude an ,,ihp from establishing rules of enrollment and reenrollment of members4 ,such rules shall be applied consistently to all members within the ,,ihp and shall not be based in any manner on health status-related factors4 7#b7 ,health insurance issuers ,the contract between an ,,ihp and a health insurance issuer shall provide1 with respect to a member enrolled with health benefits coverage offered by the issuer through the ,,ihp1 for the payment to the issuer of the premiums 7if any7 collected by the ,,ihp for health insurance coverage offered by the issuer4 #cajb4 ,application of certain laws and requirements 7a7 ,preemption of ,state laws restricting formation of ,i,h,ps ,any ,state law or regulation relating to the composition or organization of an ,,ihp is preempted to the extent the law or regulation is inconsistent with the provisions of this title4 7b7 ,preemption of ,state requirements relating to health benefit coverage 7#a7 ,benefit requirements 7,a7 ,in general ,subject to subparagraph 7,b71 ,state laws are superseded1 and shall not apply to health benefits coverage made available through an ,,ihp1 insofar as such laws impose benefit requirements for such coverage1 including requirements relating to coverage of specific providers1 specific services or conditions1 or the amount1 duration1 or scope of benefits4 7,b7 ,exception for ,federally imposed requirements and for requirements prohibiting disease-specific exclusions ,subparagraph 7,a7 shall not apply to a requirement to the extent the requirement-- 7i7 implements title ,,xxvii or other ,federal law2 or 7ii7 prohibits imposition of an exclusion of a specific disease from health benefits coverage4 7#b7 ,other requirements preventing offering of coverage through an ,,ihp ,state laws are superseded1 and shall not apply to health benefits coverage made available through an ,,ihp1 insofar as such laws impose 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 ,,ihp1 if the ,,ihp meets the requirements of this title4 7c7 ,preemption of ,state premium rating requirements ,state laws are superseded1 and shall not apply to the premiums imposed for health benefits coverage made available through an ,,ihp1 insofar as such laws impose restrictions on the variation of premiums among such coverage offered to members of the ,,ihp4 #cajc4 ,definitions ,for purposes of this title3 7#a7 ,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#b7 ,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#c7 ,health insurance issuer ,the term health insurance issuer has the meaning given such term in section #bgia7;b77#b74 7#d7 ,health status-related factor ,the term health status-related factor has the meaning given such term in section #bgia7;d77#i74 7#e7 ,member ,the term member means1 with respect to an ,,ihp1 an individual or small employer who is a member of the legal entity described in section #caja7;a77#a7 to which the ,,ihp is offering coverage4 7#f7 ,small employer ,the term small employer has the meaning given such term in section #gab7;c77#a77;,b7 of the ,employee ,retirement and ,income ,security ,act of #aigd4 4 ,b ,small ,business ,health ,fairness #baa4 ,short title ,this subtitle may be cited as the ,small ,business ,health ,fairness ,act of #bjae4 #bab4 ,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-- 7#a7 a plan which offered such coverage on the date of the enactment of the ,small ,business ,health ,fairness ,act of #bjae2 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 industries2 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 #bjae4 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 sponsor2 7,b7 the sponsor2 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 #bjae1 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 #ejj1jjj2 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 in 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 section3 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 #bjae1 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 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 #bjae4 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 #bjae1 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 7ii7-- 7i7 by inserting and which does not provide medical care 7within the meaning of section #gcc7;a77#b771 after arrangement12 and 7ii7 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 #bjae 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 #ajbb7;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 #bjah1 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 #bac4 ,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 #b 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 #b 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 #b 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 #bad4 ,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-- 7#a7 by inserting 7a7 ,in general4-- before ,in accordance2 and 7#b7 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 #bae4 ,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 obtained2 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 #baf4 ,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 ,c ,health ,insurance ,reforms #bba4 ,requirements for individual health insurance 7a7 ,in general ,section #bgda of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#da71 as restored and revived by section #b of this ,act1 is amended-- 7#a7 in subsection 7a7-- 7,a7 in the heading1 by striking to certain individuals with prior group coverage2 7,b7 in paragraph 7#a71 by striking and section #bgdd2 7,c7 in paragraph 7#a77;,b71 by inserting unless such exclusion complies with paragraph 7#b7 before the period2 and 7,d7 by striking paragraph 7#b7 and inserting the following new paragraphs3 7#b7 ,limitation on preexisting condition exclusion period 7,a7 ,limitation ,a health insurance issuer offering health insurance coverage in the individual market may not1 with respect to an enrollee in such coverage1 impose any preexisting condition exclusion if such enrollee has at least #ah months of continuous creditable coverage 7as defined in section #bgja7;c77#a77 immediately preceding the enrollment date4 7,b7 ,imposition of exclusion ,notwithstanding paragraph 7#a77;,b71 a health insurance issuer offering health insurance coverage in the individual market may1 with respect to an enrollee in such coverage who is not described in subparagraph 7,a71 impose a preexisting condition exclusion only if-- 7i7 such exclusion relates to a condition 7whether physical or mental71 regardless of the cause of the condition1 for which medical advice1 diagnosis1 care1 or treatment was recommended or received within the #f-month period ending on the enrollment date2 7ii7 such exclusion extends for a period of not more than #ah months after the enrollment date2 and 7iii7 the period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage 7if any1 as defined in section #bgja7;c77#a77 applicable to the enrollee as of the enrollment date4 7,c7 ,premium surcharge ,notwithstanding paragraph 7#f71 with respect to an enrollee described in subparagraph 7,b71 a health insurance issuer may charge a premium for the coverage involved that does not exceed #aej percent of the applicable standard rate1 for not to exceed #b years 7or #c years if the health insurance issuer does not impose any preexisting condition exclusion with respect to such enrollee71 reduced by the aggregate of the periods of creditable coverage 7if any1 as defined in section #bgja7;c77#a77 applicable to the enrollee as of the enrollment date4 ,for purposes of this subsection1 the term applicable standard rate means the standard premium rate that the issuer charges for the coverage involved with respect to an individual described in subparagraph 7,a7 with the same rating characteristics or rating factors as the enrollee described in subparagraph 7,b71 provided that any variations in standard premium rates are based on the uniform application of rating characteristics or rating factors that are permitted by ,state law and are not otherwise prohibited by paragraph 7#f74 7#c7 ,exceptions ,notwithstanding paragraph 7#b71 and subject to subparagraph 7,d71 a health insurance issuer offering health insurance coverage in the individual market1 may not impose any of the following preexisting condition exclusion3 7,a7 ,exclusion not applicable to certain newborns ,in the case of an individual who1 as of the last day of the #cj-;day period beginning with the date of birth1 is a dependent of an enrollee in such coverage4 7,b7 ,exclusion not applicable to certain adopted children ,in the case of a child who is adopted or placed for adoption before attaining #ah years of age and who1 as of the last day of the #cj-;day period beginning on the date of the adoption or placement for adoption1 is a dependent of an enrollee in such coverage4 ,the previous sentence shall not apply to coverage before the date of such adoption or placement for adoption4 7,c7 ,exclusion not applicable to pregnancy ,relating to pregnancy as a preexisting condition4 7,d7 ,loss if break in coverage ,subparagraphs 7,a7 and 7,b7 shall no longer apply to an individual after the end of the first #fc-;day period during all of which the individual was not covered under any creditable coverage4 7#d7 ,open enrollment periods ,a health insurance issuer offering health insurance coverage in the individual market may limit the applicability of the provisions of paragraph 7#a7 to scheduled open enrollment periods1 provided that-- 7,a7 any such open enrollment period shall not be less than #cj days2 7,b7 any period between scheduled open enrollment periods shall not exceed #bd months2 and 7,c7 such limitation shall not apply to any individual who qualifies for a special enrollment period under paragraph 7#e74 7#e7 ,special enrollment periods 7,a7 ,in general ,subject to subparagraphs 7,b7 and 7,c71 a health insurance issuer offering health insurance coverage in the individual market shall permit an individual who is an eligible individual or a dependent to enroll in coverage during a special enrollment period if the individual experiences any of the following qualifying events3 7i7 ,for dependent beneficiaries ,the individual becomes1 by reason of marriage1 birth1 adoption or placement for adoption1 a dependent of an individual enrolled in a plan offered by the health insurance issuer and such individual otherwise qualifies1 under the terms of the plan1 as eligible for coverage as a dependent of such enrollee4 7ii7 ,loss of group coverage ,the individual loses coverage under a group health plan as a result of-- 7,i7 loss of eligibility for the coverage 7including as a result of legal separation1 divorce1 death1 attaining an age at which eligibility terminates1 termination of employment1 or reduction in the number of hours of employment72 or 7,,ii7 termination of the coverage by the plan sponsor4 7iii7 ,loss of individual coverage ,the individual loses individual market coverage as a result of-- 7,i7 discontinuation of a plan as a result of a health insurance issuer ceasing to offer coverage in the individual market in accordance with section #bgdb7;c77#b72 7,,ii7 expiration of ,,cobra1 or other1 continuation coverage2 7,,iii7 ceasing to qualify1 under the terms of the coverage1 as a dependent 7including as a result of legal separation1 divorce1 death1 or attaining an age at which eligibility terminates72 or 7,,iv7 permanently moving outside the ,state in which the coverage was issued1 or in the case of a network plan1 outside the plan's service area4 7iv7 ,loss of eligibility for a government coverage program ,the individual loses coverage by ceasing to be eligible for coverage under any of the following3 7,i7 ,part ,a or part ,b of title ,,xviii of the ,social ,security ,act4 7,,ii7 ,title ,,xix of the ,social ,security ,act1 other than coverage consisting solely of benefits under section #aibh of such title4 7,,iii7 ,title ,,xxi of the ,social ,security ,act4 7,,iv7 ,chapter #ee of title #aj4 7,v7 ,chapter #hi of title #e4 7,,vi7 ,a ,state health benefits risk pool4 7,b7 ,loss of coverage defined ,for purposes of this paragraph1 loss of coverage shall not include any of the following3 7i7 ,voluntary termination of coverage by an individual1 except if such termination is the result of circumstances described in clause 7iii77,,iv74 7ii7 ,termination of coverage by the issuer or the plan sponsor of the coverage for any reason described in paragraph 7#a7 or 7#b7 of section #bgdb7;b74 7iii7 ,loss of any coverage that consists solely of coverage of excepted benefits 7as defined in section #bgia74 7,c7 ,special enrollment period ,any special enrollment period shall not be less than #fj days and shall begin on the date of the qualifying event4 7#f7 ,standard premium rates ,with respect to the premium rate charged by a health insurance issuer for health insurance coverage offered in the individual market1 such rate1 with respect to the particular plan or coverage involved1 shall not vary based on any of the following health status-related factors in relation to an eligible individual or dependent3 7,a7 ,health status4 7,b7 ,medical condition 7including physical and mental illnesses74 7,c7 ,claims experience4 7,d7 ,receipt of health care4 7,e7 ,medical history4 7,f7 ,genetic information4 7,g7 ,evidence of insurability 7including conditions arising out of acts of domestic violence74 7,h7 ,disability4 2 7#b7 by amending subsection 7b7 to read as follows3 7b7 ,definitions ,for purposes of this section3 7#a7 ,eligible individual ,the term eligible individual means an individual who is eligible under applicable ,state law to purchase individual health insurance coverage in the ,state4 7#b7 ,dependent ,the term dependent means an individual who1 under the terms of the coverage and applicable ,state law1 qualifies to enroll in such coverage as a dependent of an individual described in paragraph 7#a74 2 7#c7 by striking subsection 7c72 and 7#d7 by redesignating subsection 7d7 and the first subsection 7e7 as subsections 7c7 and 7d71 respectively4 7b7 ,conforming amendment ,section #bgdd of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#dd71 as restored and revived by section #b of this ,act1 is repealed4 7c7 ,effective date ,the amendments made by this section shall apply with respect to health insurance coverage offered for plan years beginning after the date of the enactment of this ,act4 ,,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 #bgii 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 #b 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 coverage2 or 7#b7 in any case in which the requirements of paragraph 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#b73 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 #bgii;,a4 ,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 ,lawsuit ,abuse ,reforms #dja4 ,change in burden of proof based on compliance with clinical practice guidelines 7a7 ,selection and issuance of clinical 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 clinical 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 site 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 #djb4 ,state grants to create expert panels and 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,u4 ,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 ,if1 in any health care liability action against a health care provider1 the health care provider alleges1 in any response to the claimant's filing1 that the health care provider adhered to an applicable practice guideline in the provision of health care items or services to the claimant1 then further proceedings on the health care liability action shall be suspended prior to discovery proceedings1 until the completion of a review of the action by an independent expert panel in accordance with this subsection4 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 #e 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 #b 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,f7 ,no civil liability for members ,no civil action shall be brought in any court against any member of an expert panel for any act done1 failure to act1 or statement or opinion made1 within the scope of the individual's duties as a member of the expert panel4 7#c7 ,determination 7,a7 ,in general ,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,b7 ,considerations in making determinations ,in making a determination under this subsection as to the liability of parties involved and compensation1 the following shall apply3 7i7 ,treatment of clinical practice guidelines ,an expert panel shall acknowledge the ability of physicians to depart from the recommendations in clinical practice guidelines1 when appropriate1 in the care of individual patients4 7ii7 ,limitation ,an expert panel shall not make a finding of negligence from the mere fact that a treatment or procedure was unsuccessful or failed to bring the best result4 7#d7 ,early offer ,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 and 7,d7 allow the admission into evidence of the recommendation made by the expert panel under subsection 7d74 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 7#d7 ,treatment of certain expert panel and administrative health care tribunal findings 7,a7 ,work product ,no finding by an expert panel under subsection 7d7 or administrative health care tribunal under subsection 7e7 that the defendant applicable eligible professional breached the standard of care as set forth under the prescribed practice guidelines shall constitute negligence per se or conclusive evidence of liability4 7,b7 ,finding relating to clinical practice guidelines ,if an administrative health care tribunal did not make a finding under subsection 7e7 that there was an applicable clinical practice guideline that the defendant adhered to1 with respect to the ,state court proceeding under paragraph 7#a7 the ,state court may issue summary judgment in favor of the defendant health care professional unless the claimant is able to show otherwise by clear and convincing evidence4 ,if an administrative health care tribunal made a finding under subsection 7e7 that there was an applicable clinical practice guideline that the defendant adhered to1 with respect to a ,state court proceeding under paragraph 7#a7 the ,state court shall issue summary judgment in favor of the applicable health care professional unless the claimant is able to show otherwise by clear and convincing evidence4 7,c7 ,finding relating to standard of care ,any finding of an expert panel or administrative health care tribunal under subsection 7d7 or 7e71 respectively1 that the defendant did not breach the standard of care as set forth under the prescribed clinical practice guidelines or that the defendant's failure to conform to the required standard was neither the cause in fact nor the proximate cause of the plaintiff's injury or that the plaintiff did not incur any damages as a result shall be given deference by the ,state court involved and shall entitle the defendant to summary judgment unless the plaintiff is able to show by clear and convincing evidence that the expert panel or health care tribunal1 respectively1 was in error and that there is a genuine issue as to a material fact in the case4 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 #djc4 ,payment of damages and recovery of costs in health care lawsuits 7a7 ,authorization of payment of future damages to claimants in health care lawsuits ,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 ,recovery of costs2 payment of award ,in any health care lawsuit1 the court may supervise the arrangements for payment of damages to protect against conflicts of interest that may have the effect of reducing the amount of damages awarded that are actually paid to claimants4 ,in particular1 in any health care lawsuit in which the attorney for a party claims a financial stake in the outcome by virtue of a contingent fee1 the court shall have the power to restrict the payment of a claimant's damage recovery to such attorney1 and to redirect such damages to the claimant based upon the interests of justice and principles of equity4 7c7 ,applicability ,this section applies to all actions which have not been first set for trial or retrial before the effective date of this title4 7d7 ,statute of limitations 7#a7 ,in general ,except in the case of a ,state law that provides for a shorter period of time1 the time for the commencement of a health care lawsuit shall be no more than #c years after the date of manifestation of injury or #a year after the claimant discovers1 or through the use of reasonable diligence should have discovered1 the injury1 whichever occurs first4 ,in no event shall the time for commencement of a health care lawsuit exceed #c years after the date of manifestation of injury unless tolled for any of the following-- 7,a7 upon proof of fraud2 7,b7 intentional concealment2 or 7,c7 the presence of a foreign body1 which has no therapeutic or diagnostic purpose or effect1 in the person of the injured person4 7#b7 ,cases involving minors ,except in the case of a ,state law that provides for a shorter period of time1 actions by a minor shall be commenced within #c years from the date of the alleged manifestation of injury except that actions by a minor under the full age of #f years shall be commenced within #c years of manifestation of injury or prior to the minor's #hth birthday1 whichever provides a longer period4 ,such time limitation shall be tolled for minors for any period during which a parent or guardian and a health care provider or health care organization have committed fraud or collusion in the failure to bring an action on behalf of the injured minor4 7e7 ,fair share rule ,in any health care lawsuit1 each party shall be liable for that party's several share of any damages only and not for the share of any other person4 ,each party shall be liable only for the amount of damages allocated to such party in direct proportion to such party's percentage of responsibility4 ,whenever a judgment of liability is rendered as to any party1 a separate judgment shall be rendered against each such party for the amount allocated to such party4 ,for purposes of this section1 the trier of fact shall determine the proportion of responsibility of each party for the claimant's harm4 7f7 ,apologies ,in any health care lawsuit1 if a claimant receives any expression of regret for any act pertaining to conduct giving rise to the health care lawsuit1 such expression of regret1 notwithstanding any applicable rule of evidence may not be admitted into evidence in the health care lawsuit4 #djd4 ,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 including 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 #dje4 ,effect on other laws 7a7 ,vaccine ,injury 7#a7 ,non-applicability of this title ,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 ,applicability of this title ,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 #djf4 ,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 ,v ,wellness and ,prevention #eja4 ,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 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 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 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 ,,vi ,transparency and ,insurance ,reform ,measures #fja4 ,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 #cj days after the date on which 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 ,internet ,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 #c-year 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 shall-- 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 in 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 shall 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 in subsection 7b77#c71 for the period described in 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 in 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 #aj days after the date on which 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 #ae days 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 ,,vii ,quality #gja4 ,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 7#ba ,u4,s4,c4 #cja et seq47 or the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bja et seq474 #gjb4 ,establishment of performance-based quality measures ,not later than ,january #a1 #bjag1 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 ,act 7#db ,u4,s4,c4 #acie et seq474 ,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 ,,viii ,state ,transparency ,plan ,portal #hja4 ,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 under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 or a ,state child health plan under the ,state ,children's ,health ,insurance ,program established under title ,,xxi of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;aa et seq474 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 ,act 7#db ,u4,s4,c4 #acif et seq474 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 ,,ix ,patient ,freedom of ,choice #ija4 ,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 subsections 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 #ijb4 ,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 #ijc4 ,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 #ijd4 ,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 ,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 #ije4 ,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 ,a group health plan 7as defined in section #bgia of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;g-#a774 7,b7 ,health insurance coverage 7as defined in section #bgia of such ,act 7#db ,u4,s4,c4 #cjj;g-#a774 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 ,act 7#db ,u4,s4,c4 #acif et seq472 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 ,x ,quality ,health ,care ,coalition #ajja4 ,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 ,state ,children's ,health ,insurance ,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