,,ii  #aaeth ,,congress  #ast ,session  
,s4 #bjba  ,,in ,,the ,,senate ,,of     
,,the ,,united ,,states  ,october #bf1  
#bjag,mr4 ,cruz 7for himself and ,mr4   
,rubio7 introduced the following bill2  
which was read twice and referred to the
 ,committee on ,finance  ,a ,,bill  ,to 
repeal title ,i of the ,patient         
,protection and ,affordable ,care ,act  
and to amend the ,public ,health        
,service ,act to provide for cooperative
 governing of individual health         
insurance coverage offered in interstate
 commerce4  #a4 ,short title ,this ,act 
may be cited as the ,health ,care       
,choice ,act of #bjag4  #b4             
,specification of constitutional        
authority for enactment of law ,this    
,act is enacted pursuant to the power   
granted ,congress under article ,i1     
section #h1 clause #c1 of the ,united   
,states ,constitution4  #c4 ,findings   
,congress finds the following3 7#a7 ,the
 application of numerous and significant
 variations in ,state law and the       

implementation of the ,patient          
,protection and ,affordable ,care ,act  
impacts the ability of insurers to      
offer1 and individuals to obtain1       
affordable individual health insurance  
coverage1 thereby impeding commerce in  
individual health insurance coverage4   
7#b7 ,mandates for health care coverage 
established by title ,i of the ,patient 
,protection and ,affordable ,care ,act  
will significantly elevate health       
insurance costs beyond ,state and       
,federal ability to pay4  7#c7          
,individual health insurance coverage is
 increasingly offered through the       
,internet1 other electronic means1 and  
by mail1 all of which are inherently    
part of interstate commerce4  7#d7 ,in  
response to these issues1 it is         
appropriate to encourage increased      
efficiency in the offering of individual
 health insurance coverage through a    
collaborative approach by the ,states in
 regulating this coverage4  7#e7 ,the   
establishment of risk-retention groups  

has provided a successful model for the 
sale of insurance across ,state lines1  
as the acts establishing those groups   
allow insurance to be sold in multiple  
,states but regulated by a single       
,state4  #d4 ,repeal of title ,i of     
,,ppaca ,effective as of the enactment  
of the ,patient ,protection and         
,affordable ,care ,act 7,public ,law    
#aaa-adh71 title ,i of such ,act is     
repealed 7and any amendments to such    
title1 or to amendments made by such    
title1 made by the ,health ,care and    
,education ,reconciliation ,act of #bjaj
 7,public ,law #aaa-aeb7 are repealed71 
and the provisions of law amended or    
repealed by such title 7or amendments7  
are restored or revived as if such title
 7and amendments7 had not been enacted4 
#e4 ,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 seq47 is amended by adding at
 the end the following new part3  ,d    

,cooperative ,governing of ,individual  
,health ,insurance ,coverage  #bgie4    
,definitions ,in this part3  7#a7       
,primary state ,the term primary ,state 
means1 with respect to individual health
 insurance coverage offered by a health 
insurance issuer1 the ,state designated 
by the issuer as the ,state whose       
covered laws shall govern the health    
insurance issuer in the sale of such    
coverage under this part4 ,an issuer1   
with respect to a particular policy1 may
 only designate one such ,state as its  
primary ,state with respect to all such 
coverage it offers4 ,such an issuer may 
not change the designated primary ,state
 with respect to individual health      
insurance coverage once the policy is   
issued1 except that such a change may be
 made upon renewal of the policy4 ,with 
respect to such designated ,state1 the  
issuer is deemed to be doing business in
 that ,state4  7#b7 ,secondary state    
,the term secondary ,state means1 with  
respect to individual health insurance  

coverage offered by a health insurance  
issuer1 any ,state that is not the      
primary ,state4 ,in the case of a health
 insurance issuer that is selling a     
policy in1 or to a resident of1 a       
secondary ,state1 the issuer is deemed  
to be doing business in that secondary  
,state4  7#c7 ,health insurance issuer  
,the term health insurance issuer has   
the meaning given such term in section  
#bgia7;b77#b71 except that such an      
issuer must be licensed in the primary  
,state and be qualified to sell         
individual health insurance coverage in 
that ,state4  7#d7 ,individual health   
insurance coverage ,the term individual 
health insurance coverage means health  
insurance coverage offered in the       
individual market1 as defined in section
 #bgia7;e77#a74  7#e7 ,applicable state 
authority ,the term applicable ,state   
authority means1 with respect to a      
health insurance issuer in a ,state1 the
 ,state insurance commissioner or       
official or officials designated by the 

,state to enforce the requirements of   
this title for the ,state with respect  
to the issuer4  7#f7 ,hazardous         
financial condition ,the term hazardous 
financial condition means that1 based on
 its present or reasonably anticipated  
financial condition1 a health insurance 
issuer is unlikely to be able--  7,a7 to
 meet obligations to policyholders with 
respect to known claims and reasonably  
anticipated claims2 or  7,b7 to pay     
other obligations in the normal course  
of business4  7#g7 ,covered laws  7,a7  
,in general ,the term covered laws means
 the laws1 rules1 regulations1          
agreements1 and orders governing the    
insurance business pertaining to--  7i7 
individual health insurance coverage    
issued by a health insurance issuer2    
7ii7 the offer1 sale1 rating 7including 
medical underwriting71 renewal1 and     
issuance of individual health insurance 
coverage to an individual2  7iii7 the   
provision to an individual in relation  
to individual health insurance coverage 

of health care and insurance related    
services2  7iv7 the provision to an     
individual in relation to individual    
health insurance coverage of management1
 operations1 and investment activities  
of a health insurance issuer2 and  7v7  
the provision to an individual in       
relation to individual health insurance 
coverage of loss control and claims     
administration for a health insurance   
issuer with respect to liability for    
which the issuer provides insurance4    
7,b7 ,exception ,such term does not     
include any law1 rule1 regulation1      
agreement1 or order governing the use of
 care or cost management techniques1    
including any requirement related to    
provider contracting1 network access or 
adequacy1 health care data collection1  
or quality assurance4  7#h7 ,state ,the 
term ,state means the #ej ,states and   
includes the ,district of ,columbia1    
,puerto ,rico1 the ,virgin ,islands1    
,guam1 ,american ,samoa1 and the        
,northern ,mariana ,islands4  7#i7      

,unfair claims settlement practices ,the
 term unfair claims settlement practices
 means only the following practices3    
7,a7 ,knowingly misrepresenting to      
claimants and insured individuals       
relevant facts or policy provisions     
relating to coverage at issue4  7,b7    
,failing to acknowledge with reasonable 
promptness pertinent communications with
 respect to claims arising under        
policies4  7,c7 ,failing to adopt and   
implement reasonable standards for the  
prompt investigation and settlement of  
claims arising under policies4  7,d7    
,failing to effectuate prompt1 fair1 and
 equitable settlement of claims         
submitted in which liability has become 
reasonably clear4  7,e7 ,refusing to pay
 claims without conducting a reasonable 
investigation4  7,f7 ,failing to affirm 
or deny coverage of claims within a     
reasonable period of time after having  
completed an investigation related to   
those claims4  7,g7 ,a pattern or       
practice of compelling insured          

individuals or their beneficiaries to   
institute suits to recover amounts due  
under its policies by offering          
substantially less than the amounts     
ultimately recovered in suits brought by
 them4  7,h7 ,a pattern or practice of  
attempting to settle or settling claims 
for less than the amount that a         
reasonable person would believe the     
insured individual or his or her        
beneficiary was entitled by reference to
 written or printed advertising material
 accompanying or made part of an        
application4  7,i7 ,attempting to settle
 or settling claims on the basis of an  
application that was materially altered 
without notice to1 or knowledge or      
consent of1 the insured4  7,j7 ,failing 
to provide forms necessary to present   
claims within #ae calendar days of a    
requests with reasonable explanations   
regarding their use4  7,k7 ,attempting  
to cancel a policy in less time than    
that prescribed in the policy or by the 
law of the primary ,state4  7#aj7 ,fraud

 and abuse ,the term fraud and abuse    
means an act or omission committed by a 
person who1 knowingly and with intent to
 defraud1 commits1 or conceals any      
material information concerning1 one or 
more of the following3  7,a7            
,presenting1 causing to be presented or 
preparing with knowledge or belief that 
it will be presented to or by an        
insurer1 a reinsurer1 broker or its     
agent1 false information as part of1 in 
support of or concerning a fact material
 to one or more of the following3  7i7  
,an application for the issuance or     
renewal of an insurance policy or       
reinsurance contract4  7ii7 ,the rating 
of an insurance policy or reinsurance   
contract4  7iii7 ,a claim for payment or
 benefit pursuant to an insurance policy
 or reinsurance contract4  7iv7         
,premiums paid on an insurance policy or
 reinsurance contract4  7v7 ,payments   
made in accordance with the terms of an 
insurance policy or reinsurance         
contract4  7vi7 ,a document filed with  

the commissioner or the chief insurance 
regulatory official of another          
jurisdiction4  7vii7 ,the financial     
condition of an insurer or reinsurer4   
7viii7 ,the formation1 acquisition1     
merger1 reconsolidation1 dissolution or 
withdrawal from one or more lines of    
insurance or reinsurance in all or part 
of a ,state by an insurer or reinsurer4 
7ix7 ,the issuance of written evidence  
of insurance4  7x7 ,the reinstatement of
 an insurance policy4  7,b7             
,solicitation or acceptance of new or   
renewal insurance risks on behalf of an 
insurer reinsurer or other person       
engaged in the business of insurance by 
a person who knows or should know that  
the insurer or other person responsible 
for the risk is insolvent at the time of
 the transaction4  7,c7 ,transaction of 
the business of insurance in violation  
of laws requiring a license1 certificate
 of authority or other legal authority  
for the transaction of the business of  
insurance4  7,d7 ,attempt to commit1    

aiding or abetting in the commission of1
 or conspiracy to commit the acts or    
omissions specified in this paragraph4  
#bgif4 ,application of law  7a7 ,in     
,general ,the covered laws of the       
primary ,state shall apply to individual
 health insurance coverage offered by a 
health insurance issuer in the primary  
,state and in any secondary ,state1 but 
only if the coverage and issuer comply  
with the conditions of this section with
 respect to the offering of coverage in 
any secondary ,state4  7b7 ,exemptions  
,from ,covered ,laws in a ,secondary    
,state ,except as provided in this      
section1 a health insurance issuer with 
respect to its offer1 sale1 rating      
7including medical underwriting71       
renewal1 and issuance of individual     
health insurance coverage in any        
secondary ,state is exempt from any     
covered laws of the secondary ,state    
7and any rules1 regulations1 agreements1
 or orders sought or issued by such     
,state under or related to such covered 

laws7 to the extent that such laws      
would--  7#a7 make unlawful1 or         
regulate1 directly or indirectly1 the   
operation of the health insurance issuer
 operating in the secondary ,state1     
except that any secondary ,state may    
require such an issuer--  7,a7 to pay1  
on a nondiscriminatory basis1 applicable
 premium and other taxes 7including high
 risk pool assessments7 which are levied
 on insurers and surplus lines insurers1
 brokers1 or policyholders under the    
laws of the ,state2  7,b7 to register   
with and designate the ,state insurance 
commissioner as its agent solely for the
 purpose of receiving service of legal  
documents or process2  7,c7 to submit to
 an examination of its financial        
condition by the ,state insurance       
commissioner in any ,state in which the 
issuer is doing business to determine   
the issuer's financial condition1 if--  
7i7 the ,state insurance commissioner of
 the primary ,state has not done an     
examination within the period           

recommended by the ,national            
,association of ,insurance              
,commissioners2 and  7ii7 any such      
examination is conducted in accordance  
with the examiners' handbook of the     
,national ,association of ,insurance    
,commissioners and is coordinated to    
avoid unjustified duplication and       
unjustified repetition2  7,d7 to comply 
with a lawful order issued-- 7i7 in a   
delinquency proceeding commenced by the 
,state insurance commissioner if there  
has been a finding of financial         
impairment under subparagraph 7,c72 or  
7ii7 in a voluntary dissolution         
proceeding2  7,e7 to comply with an     
injunction issued by a court of         
competent jurisdiction1 upon a petition 
by the ,state insurance commissioner    
alleging that the issuer is in hazardous
 financial condition2  7,f7 to          
participate1 on a nondiscriminatory     
basis1 in any insurance insolvency      
guaranty association or similar         
association to which a health insurance 

issuer in the ,state is required to     
belong2  7,g7 to comply with any ,state 
law regarding fraud and abuse 7as       
defined in section #bgie7aj771 except   
that if the ,state seeks an injunction  
regarding the conduct described in this 
subparagraph1 such injunction must be   
obtained from a court of competent      
jurisdiction2  7,h7 to comply with any  
,state law regarding unfair claims      
settlement practices 7as defined in     
section #bgie7i772 or  7,i7 to comply   
with the applicable requirements for    
independent review under section #bgih  
with respect to coverage offered in the 
,state2  7#b7 require any individual    
health insurance coverage issued by the 
issuer to be countersigned by an        
insurance agent or broker residing in   
that secondary ,state2 or  7#c7         
otherwise discriminate against the      
issuer issuing insurance in both the    
primary ,state and in any secondary     
,state4  7c7 ,clear and ,conspicuous    
,disclosure ,a health insurance issuer  

shall provide the following notice1 in  
#ab-point bold type1 in any insurance   
coverage offered in a secondary ,state  
under this part by such a health        
insurance issuer and at renewal of the  
policy1 with the #e blank spaces therein
 being appropriately filled with the    
name of the health insurance issuer1 the
 name of the 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  ,notice ,this      
policy is issued by  and is governed by 
the laws and regulations of the ,state  
of 1 and it has met all the laws of that
 ,state as determined by that ,state's  
,department of ,insurance4 ,this policy 
may be less expensive than others       
because it is not subject to all of the 
insurance laws and regulations of the   
,state of 1 including coverage of some  
services or benefits mandated by the law
 of the ,state of 4 ,additionally1 this 
policy is not subject to all of the     

consumer protection laws or restrictions
 on rate changes of the ,state of 4 ,as 
with all insurance products1 before     
purchasing this policy1 you should      
carefully review the policy and         
determine what health care services the 
policy covers and what benefits it      
provides1 including any exclusions1     
limitations1 or conditions for such     
services or benefits4 4  7d7            
,prohibition on ,certain                
,reclassifications and ,premium         
,increases  7#a7 ,in general ,for       
purposes of this section1 a health      
insurance issuer that provides          
individual health insurance coverage to 
an individual under this part in a      
primary or secondary ,state may not upon
 renewal--  7,a7 move or reclassify the 
individual insured under the health     
insurance coverage from the class such  
individual is in at the time of issue of
 the contract based on the health       
status-related factors of the           
individual2 or  7,b7 increase the       

premiums assessed the individual for    
such coverage based on a health         
status-related factor or change of a    
health status-related factor or the past
 or prospective claim experience of the 
insured individual4  7#b7 ,construction 
,nothing in paragraph 7#a7 shall be     
construed to prohibit a health insurance
 issuer-- 7,a7 from terminating or      
discontinuing coverage or a class of    
coverage in accordance with subsections 
7b7 and 7c7 of section #bgdb2  7,b7 from
 raising premium rates for all policy   
holders within a class based on claims  
experience2  7,c7 from changing premiums
 or offering discounted premiums to     
individuals who engage in wellness      
activities at intervals prescribed by   
the issuer1 if such premium changes or  
incentives--  7i7 are disclosed to the  
consumer in the insurance contract2     
7ii7 are based on specific wellness     
activities that are not applicable to   
all individuals2 and  7iii7 are not     
obtainable by all individuals to whom   

coverage is offered2  7,d7 from         
reinstating lapsed coverage2 or  7,e7   
from retroactively adjusting the rates  
charged an insured individual if the    
initial rates were set based on material
 misrepresentation by the individual at 
the time of issue4  7e7 ,prior ,offering
 of ,policy in ,primary ,state ,a health
 insurance issuer may not offer for sale
 individual health insurance coverage in
 a secondary ,state unless that coverage
 is currently offered for sale in the   
primary ,state4  7f7 ,licensing of      
,agents or ,brokers for ,health         
,insurance ,issuers ,any ,state may     
require that a person acting1 or        
offering to act1 as an agent or broker  
for a health insurance issuer with      
respect to the offering of individual   
health insurance coverage obtain a      
license from that ,state1 with          
commissions or other compensation       
subject to the provisions of the laws of
 that ,state1 except that a ,state may  
not impose any qualification or         

requirement which discriminates against 
a nonresident agent or broker4  7g7     
,documents for ,submission to ,state    
,insurance ,commissioner ,each health   
insurance issuer issuing individual     
health insurance coverage in both       
primary and secondary ,states shall     
submit--  7#a7 to the insurance         
commissioner of each ,state in which it 
intends to offer such coverage1 before  
it may offer individual health insurance
 coverage in such ,state--  7,a7 a copy 
of the plan of operation or feasibility 
study or any similar statement of the   
policy being offered and its coverage   
7which shall include the name of its    
primary ,state and its principal place  
of business72  7,b7 written notice of   
any change in its designation of its    
primary ,state2 and  7,c7 written notice
 from the issuer of the issuer's        
compliance with all the laws of the     
primary ,state2 and  7#b7 to the        
insurance commissioner of each secondary
 ,state in which it offers individual   

health insurance coverage1 a copy of the
 issuer's quarterly financial statement 
submitted to the primary ,state1 which  
statement shall be certified by an      
independent public accountant and       
contain a statement of opinion on loss  
and loss adjustment expense reserves    
made by--  7,a7 a member of the         
,american ,academy of ,actuaries2 or    
7,b7 a qualified loss reserve           
specialist4  7h7 ,power of ,courts ,to  
,enjoin ,conduct ,nothing in this       
section shall be construed to affect the
 authority of any ,federal or ,state    
court to enjoin--  7#a7 the solicitation
 or sale of individual health insurance 
coverage by a health insurance issuer to
 any person or group who is not eligible
 for such insurance2 or  7#b7 the       
solicitation or sale of individual      
health insurance coverage that violates 
the requirements of the law of a        
secondary ,state which are described in 
subparagraphs 7,a7 through 7,h7 of      
section #bgif7;b77#a74  7i7 ,power of   

,secondary ,states ,to ,take            
,administrative ,action ,nothing in this
 section shall be construed to affect   
the authority of any ,state to enjoin   
conduct in violation of that ,state's   
laws described in section #bgif7;b77#a74
  7j7 ,state ,powers ,to ,enforce ,state
 ,laws  7#a7 ,in general ,subject to the
 provisions of subsection 7b77#a77;,g7  
7relating to injunctions7 and paragraph 
7#b71 nothing in this section shall be  
construed to affect the authority of any
 ,state to make use of any of its powers
 to enforce the laws of such ,state with
 respect to which a health insurance    
issuer is not exempt under subsection   
7b74  7#b7 ,courts of competent         
jurisdiction ,if a ,state seeks an      
injunction regarding the conduct        
described in paragraphs 7#a7 and 7#b7 of
 subsection 7h71 such injunction must be
 obtained from a ,federal or ,state     
court of competent jurisdiction4  7k7   
,states' ,authority ,to ,sue ,nothing in
 this section shall affect the authority

 of any ,state to bring action in any   
,federal or ,state court4  7l7          
,generally ,applicable ,laws ,nothing in
 this section shall be construed to     
affect the applicability of ,state laws 
generally applicable to persons or      
corporations4  7m7 ,guaranteed          
,availability of ,coverage to ,,hipaa   
,eligible ,individuals ,to the extent   
that a health insurance issuer is       
offering coverage in a primary ,state   
that does not accommodate residents of  
secondary ,states or does not provide a 
working mechanism for residents of a    
secondary ,state1 and the issuer is     
offering coverage under this part in    
such secondary ,state which has not     
adopted a qualified high risk pool as   
its acceptable alternative mechanism 7as
 defined in section #bgdd7;c77#b771 the 
issuer shall1 with respect to any       
individual health insurance coverage    
offered in a secondary ,state under this
 part1 comply with the guaranteed       
availability requirements for eligible  

individuals in section #bgda4  #bgig4   
,primary ,state must meet ,federal floor
 before issuer may sell into secondary  
,states ,a health insurance issuer may  
not offer1 sell1 or issue individual    
health insurance coverage in a secondary
 ,state if the ,state insurance         
commissioner does not use a risk-based  
capital formula for the determination of
 capital and surplus requirements for   
all health insurance issuers4  #bgih4   
,independent external appeals procedures
  7a7 ,right to ,external ,appeal ,a    
health insurance issuer may not offer1  
sell1 or issue individual health        
insurance coverage in a secondary ,state
 under the provisions of this title     
unless--  7#a7 both the secondary ,state
 and the primary ,state have legislation
 or regulations in place establishing an
 independent review process for         
individuals who are covered by          
individual health insurance coverage2 or
  7#b7 in any case in which the         
requirements of subparagraph 7,a7 are   

not met with respect to the either of   
such ,states1 the issuer provides an    
independent review mechanism            
substantially identical 7as determined  
by the applicable ,state authority of   
such ,state7 to that prescribed in the  
,health ,carrier ,external ,review      
,model ,act of the ,national            
,association of ,insurance              
,commissioners for all individuals who  
purchase insurance coverage under the   
terms of this part1 except that1 under  
such mechanism1 the review is conducted 
by an independent medical reviewer1 or a
 panel of such reviewers1 with respect  
to whom the requirements of subsection  
7b7 are met4  7b7 ,qualifications of    
,independent ,medical ,reviewers ,in the
 case of any independent review         
mechanism referred to in subsection     
7a77#b7-- 7#a7 ,in general ,in referring
 a denial of a claim to an independent  
medical reviewer1 or to any panel of    
such reviewers1 to conduct independent  
medical review1 the issuer shall ensure 

that--  7,a7 each independent medical   
reviewer meets the qualifications       
described in paragraphs 7#b7 and 7#c72  
7,b7 with respect to each review1 each  
reviewer meets the requirements of      
paragraph 7#d7 and the reviewer1 or at  
least #a reviewer on the panel1 meets   
the requirements described in paragraph 
7#e72 and  7,c7 compensation provided by
 the issuer to each reviewer is         
consistent with paragraph 7#f74  7#b7   
,licensure and expertise ,each          
independent medical reviewer shall be a 
physician 7allopathic or osteopathic7 or
 health care professional who--  7,a7 is
 appropriately credentialed or licensed 
in #a or more ,states to deliver health 
care services2 and  7,b7 typically      
treats the condition1 makes the         
diagnosis1 or provides the type of      
treatment under review4  7#c7           
,independence  7,a7 ,in general ,subject
 to subparagraph 7,b71 each independent 
medical reviewer in a case shall-- 7i7  
not be a related party 7as defined in   

paragraph 7#g772  7ii7 not have a       
material familial1 financial1 or        
professional relationship with such a   
party2 and  7iii7 not otherwise have a  
conflict of interest with such a party  
7as determined under regulations74  7,b7
 ,exception ,nothing in subparagraph    
7,a7 shall be construed to-- 7i7        
prohibit an individual1 solely on the   
basis of affiliation with the issuer1   
from serving as an independent medical  
reviewer if--  7,i7 a non-affiliated    
individual is not reasonably available2 
7,,ii7 the affiliated individual is not 
involved in the provision of items or   
services in the case under review2      
7,,iii7 the fact of such an affiliation 
is disclosed to the issuer and the      
enrollee 7or authorized representative7 
and neither party objects2 and  7,,iv7  
the affiliated individual is not an     
employee of the issuer and does not     
provide services exclusively or         
primarily to or on behalf of the issuer2
  7ii7 prohibit an individual who has   

staff privileges at the institution     
where the treatment involved takes place
 from serving as an independent medical 
reviewer merely on the basis of such    
affiliation if the affiliation is       
disclosed to the issuer and the enrollee
 7or authorized representative71 and    
neither party objects2 or  7iii7        
prohibit receipt of compensation by an  
independent medical reviewer from an    
entity if the compensation is provided  
consistent with paragraph 7#f74  7#d7   
,practicing health care professional in 
same field  7,a7 ,in general ,in a case 
involving treatment1 or the provision of
 items or services-- 7i7 by a physician1
 a reviewer shall be a practicing       
physician 7allopathic or osteopathic7 of
 the same or similar specialty1 as a    
physician who1 acting within the        
appropriate scope of practice within the
 ,state in which the service is provided
 or rendered1 typically treats the      
condition1 makes the diagnosis1 or      
provides the type of treatment under    

review2 or  7ii7 by a non-physician     
health care professional1 the reviewer1 
or at least #a member of the review     
panel1 shall be a practicing            
non-physician health care professional  
of the same or similar specialty as the 
non-physician health care professional  
who1 acting within the appropriate scope
 of practice within the ,state in which 
the service is provided or rendered1    
typically treats the condition1 makes   
the diagnosis1 or provides the type of  
treatment under review4  7,b7           
,practicing defined ,for purposes of    
this paragraph1 the term practicing     
means1 with respect to an individual who
 is a physician or other health care    
professional1 that the individual       
provides health care services to        
individual patients on average at least 
#b days per week4  7#e7 ,pediatric      
expertise ,in the case of an external   
review relating to a child1 a reviewer  
shall have expertise under paragraph    
7#b7 in pediatrics4  7#f7 ,limitations  

on reviewer compensation ,compensation  
provided by the issuer to an independent
 medical reviewer in connection with a  
review under this section shall--  7,a7 
not exceed a reasonable level2 and  7,b7
 not be contingent on the decision      
rendered by the reviewer4  7#g7 ,related
 party defined ,for purposes of this    
section1 the term related party means1  
with respect to a denial of a claim     
under a coverage relating to an         
enrollee1 any of the following3  7,a7   
,the issuer involved1 or any fiduciary1 
officer1 director1 or employee of the   
issuer4  7,b7 ,the enrollee 7or         
authorized representative74  7,c7 ,the  
health care professional that provides  
the items or services involved in the   
denial4  7,d7 ,the institution at which 
the items or services 7or treatment7    
involved in the denial are provided4    
7,e7 ,the manufacturer of any drug or   
other item that is included in the items
 or services involved in the denial4    
7,f7 ,any other party determined under  

any regulations to have a substantial   
interest in the denial involved4  7#h7  
,definitions ,for purposes of this      
subsection-- 7,a7 ,enrollee ,the term   
enrollee means1 with respect to health  
insurance coverage offered by a health  
insurance issuer1 an individual enrolled
 with the issuer to receive such        
coverage4  7,b7 ,health care            
professional ,the term health care      
professional means an individual who is 
licensed1 accredited1 or certified under
 ,state law to provide specified health 
care services and who is operating      
within the scope of such licensure1     
accreditation1 or certification4  #bgii4
 ,enforcement  7a7 ,in ,general ,subject
 to subsection 7b71 with respect to     
specific individual health insurance    
coverage the primary ,state for such    
coverage has sole jurisdiction to       
enforce the primary ,state's covered    
laws in the primary ,state and any      
secondary ,state4  7b7 ,secondary       
,state's ,authority ,nothing in         

subsection 7a7 shall be construed to    
affect the authority of a secondary     
,state to enforce its laws as set forth 
in the exception specified in section   
#bgif7;b77#a74  7c7 ,court              
,interpretation ,in reviewing action    
initiated by the applicable secondary   
,state authority1 the court of competent
 jurisdiction shall apply the covered   
laws of the primary ,state4  7d7 ,notice
 of ,compliance ,failure ,in the case of
 individual health insurance coverage   
offered in a secondary ,state that fails
 to comply with the covered laws of the 
primary ,state1 the applicable ,state   
authority of the secondary ,state may   
notify the applicable ,state authority  
of the primary ,state4  4  7b7          
,effective ,date ,the amendment made by 
subsection 7a7 shall apply to individual
 health insurance coverage offered1     
issued1 or sold after the date that is  
one year after the date of the enactment
 of this ,act4  7c7 ,,gao ,ongoing      
,study and ,reports  7#a7 ,study ,the   

,comptroller ,general of the ,united    
,states shall conduct an ongoing study  
concerning the effect of the amendment  
made by subsection 7a7 on--  7,a7 the   
number of uninsured and underinsured2   
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  #f4 ,severability ,if any       
provision of the ,act or the application

 of such provision to any person or     
circumstance is held to be              
unconstitutional1 the remainder of this 
,act and the application of the         
provisions of such to any other person  
or circumstance shall not be affected4