,,ii #aae? ,,congress #a/ ,session ,s4 #bjba ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$ ,,/ates ,octob] #bf1 #bjag,mr4 ,cruz 7= himself & ,mr4 ,rubio7 introduc$ ! foll[+ bill2 :i* 0 read twice & ref]r$ to ! ,committee on ,f9ance ,a ,,bill ,to repeal title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act & to am5d ! ,public ,heal? ,s]vice ,act to provide = coop]ative gov]n+ ( individual heal? insurance cov]age (f]$ 9 int]/ate comm]ce4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,heal? ,c>e ,*oice ,act ( #bjag4 #b4 ,specification ( con/itutional au?ority = enactm5t ( law ,?is ,act is enact$ pursuant to ! p[] grant$ ,congress "u article ,i1 section #h1 clause #c1 ( ! ,unit$ ,/ates ,con/itution4 #c4 ,f9d+s ,congress f9ds ! foll[+3 7#a7 ,! application ( num]\s & significant v>iations 9 ,/ate law & ! implem5tation ( ! ,pati5t ,protection & ,af=dable ,c>e ,act impacts ! ability ( insur]s to (f]1 & individuals to obta91 af=dable individual heal? insurance cov]age1 !reby imp$+ comm]ce 9 individual heal? insurance cov]age4 7#b7 ,m&ates = heal? c>e cov]age e/abli%$ by title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act w significantly elevate heal? insurance co/s beyond ,/ate & ,f$]al ability to pay4 7#c7 ,individual heal? insurance cov]age is increas+ly (f]$ ?r\gh ! ,int]net1 o!r electronic means1 & by mail1 all ( :i* are inh]5tly "p ( int]/ate comm]ce4 7#d7 ,9 response to ^! issues1 x is appropriate to enc\rage increas$ effici5cy 9 ! (f]+ ( individual heal? insurance cov]age ?r\gh a collaborative approa* by ! ,/ates 9 regulat+ ?is cov]age4 7#e7 ,! e/abli%m5t ( risk-ret5tion gr\ps has provid$ a successful model = ! sale ( insurance across ,/ate l9es1 z ! acts e/abli%+ ^? gr\ps all[ insurance to be sold 9 multiple ,/ates b regulat$ by a s+le ,/ate4 #d4 ,repeal ( title ,i ( ,,ppaca ,effective z ( ! enactm5t ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh71 title ,i ( su* ,act is repeal$ 7& any am5dm5ts to su* title1 or to am5dm5ts made by su* title1 made by ! ,heal? ,c>e & ,education ,reconciliation ,act ( #bjaj 7,public ,law #aaa-aeb7 are repeal$71 & ! provisions ( law am5d$ or repeal$ by su* title 7or am5dm5ts7 are re/or$ or reviv$ z if su* title 7& am5dm5ts7 _h n be5 enact$4 #e4 ,coop]ative gov]n+ ( individual heal? insurance cov]age 7a7 ,9 ,g5]al ,title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq47 is am5d$ by add+ at ! end ! foll[+ new "p3 ,d ,coop]ative ,gov]n+ ( ,individual ,heal? ,insurance ,cov]age #bgie4 ,def9itions ,9 ?is "p3 7#a7 ,prim>y /ate ,! t]m prim>y ,/ate means1 ) respect to individual heal? insurance cov]age (f]$ by a heal? insurance issu]1 ! ,/ate designat$ by ! issu] z ! ,/ate ^: cov]$ laws %all gov]n ! heal? insurance issu] 9 ! sale ( su* cov]age "u ?is "p4 ,an issu]1 ) respect to a p>ticul> policy1 may only designate "o su* ,/ate z its prim>y ,/ate ) respect to all su* cov]age x (f]s4 ,su* an issu] may n *ange ! designat$ prim>y ,/ate ) respect to individual heal? insurance cov]age once ! policy is issu$1 except t su* a *ange may be made ^u r5ewal ( ! policy4 ,) respect to su* designat$ ,/ate1 ! issu] is deem$ to be do+ bus9ess 9 t ,/ate4 7#b7 ,second>y /ate ,! t]m second>y ,/ate means1 ) respect to individual heal? insurance cov]age (f]$ by a heal? insurance issu]1 any ,/ate t is n ! prim>y ,/ate4 ,9 ! case ( a heal? insurance issu] t is sell+ a policy 91 or to a resid5t (1 a second>y ,/ate1 ! issu] is deem$ to be do+ bus9ess 9 t second>y ,/ate4 7#c7 ,heal? insurance issu] ,! t]m heal? insurance issu] has ! mean+ giv5 su* t]m 9 section #bgia7;b77#b71 except t su* an issu] mu/ be lic5s$ 9 ! prim>y ,/ate & be qualifi$ to sell individual heal? insurance cov]age 9 t ,/ate4 7#d7 ,individual heal? insurance cov]age ,! t]m individual heal? insurance cov]age means heal? insurance cov]age (f]$ 9 ! individual m>ket1 z def9$ 9 section #bgia7;e77#a74 7#e7 ,applicable /ate au?ority ,! t]m applicable ,/ate au?ority means1 ) respect to a heal? insurance issu] 9 a ,/ate1 ! ,/ate insurance commission] or (ficial or (ficials designat$ by ! ,/ate to en=ce ! requirem5ts ( ?is title = ! ,/ate ) respect to ! issu]4 7#f7 ,haz>d\s f9ancial condition ,! t]m haz>d\s f9ancial condition means t1 bas$ on its pres5t or reasonably anticipat$ f9ancial condition1 a heal? insurance issu] is unlikely to be able-- 7,a7 to meet obligations to policyhold]s ) respect to kn[n claims & reasonably anticipat$ claims2 or 7,b7 to pay o!r obligations 9 ! normal c\rse ( bus9ess4 7#g7 ,cov]$ laws 7,a7 ,9 g5]al ,! t]m cov]$ laws means ! laws1 rules1 regulations1 agreem5ts1 & ord]s gov]n+ ! insurance bus9ess p]ta9+ to-- 7i7 individual heal? insurance cov]age issu$ by a heal? insurance issu]2 7ii7 ! (f]1 sale1 rat+ 7includ+ m$ical und]writ+71 r5ewal1 & issuance ( individual heal? insurance cov]age to an individual2 7iii7 ! provision to an individual 9 relation to individual heal? insurance cov]age ( heal? c>e & insurance relat$ s]vices2 7iv7 ! provision to an individual 9 relation to individual heal? insurance cov]age ( managem5t1 op]ations1 & inve/m5t activities ( a heal? insurance issu]2 & 7v7 ! provision to an individual 9 relation to individual heal? insurance cov]age ( loss control & claims adm9i/ration = a heal? insurance issu] ) respect to liability = :i* ! issu] provides insurance4 7,b7 ,exception ,su* t]m does n include any law1 rule1 regulation1 agreem5t1 or ord] gov]n+ ! use ( c>e or co/ managem5t te*niques1 includ+ any requirem5t relat$ to provid] contract+1 network access or adequacy1 heal? c>e data collection1 or quality assurance4 7#h7 ,/ate ,! t]m ,/ate means ! #ej ,/ates & includes ! ,di/rict ( ,columbia1 ,pu]to ,rico1 ! ,virg9 ,isl&s1 ,guam1 ,am]ican ,samoa1 & ! ,nor!rn ,m>iana ,isl&s4 7#i7 ,unfair claims settlem5t practices ,! t]m unfair claims settlem5t practices means only ! foll[+ practices3 7,a7 ,kn[+ly misrepres5t+ to claimants & insur$ individuals relevant facts or policy provisions relat+ to cov]age at issue4 7,b7 ,fail+ to ackn[l$ge ) reasonable promptness p]t95t communications ) respect to claims aris+ "u policies4 7,c7 ,fail+ to adopt & implem5t reasonable /&>ds = ! prompt inve/igation & settlem5t ( claims aris+ "u policies4 7,d7 ,fail+ to effectuate prompt1 fair1 & equitable settlem5t ( claims submitt$ 9 :i* liability has become reasonably cle>4 7,e7 ,refus+ to pay claims )\t conduct+ a reasonable inve/igation4 7,f7 ,fail+ to affirm or d5y cov]age ( claims )9 a reasonable p]iod ( "t aft] hav+ complet$ an inve/igation relat$ to ^? claims4 7,g7 ,a patt]n or practice ( compell+ insur$ individuals or _! b5efici>ies to in/itute suits to recov] am\nts due "u its policies by (f]+ sub/antially less ?an ! am\nts ultimately recov]$ 9 suits br\ght by !m4 7,h7 ,a patt]n or practice ( attempt+ to settle or settl+ claims = less ?an ! am\nt t a reasonable p]son w\ld believe ! insur$ individual or 8 or h] b5efici>y 0 entitl$ by ref]5ce to writt5 or pr9t$ adv]tis+ mat]ial accompany+ or made "p ( an application4 7,i7 ,attempt+ to settle or settl+ claims on ! basis ( an application t 0 mat]ially alt]$ )\t notice to1 or k or cons5t (1 ! insur$4 7,j7 ,fail+ to provide =ms necess>y to pres5t claims )9 #ae cal5d> days ( a reque/s ) reasonable explanations reg>d+ _! use4 7,k7 ,attempt+ to cancel a policy 9 less "t ?an t prescrib$ 9 ! policy or by ! law ( ! prim>y ,/ate4 7#aj7 ,fraud & abuse ,! t]m fraud & abuse means an act or omission committ$ by a p]son :o1 kn[+ly & ) int5t to defraud1 commits1 or conceals any mat]ial in=mation conc]n+1 "o or m ( ! foll[+3 7,a7 ,pres5t+1 caus+ to be pres5t$ or prep>+ ) k or belief t x w be pres5t$ to or by an insur]1 a re9sur]1 brok] or its ag5t1 false in=mation z "p (1 9 support ( or conc]n+ a fact mat]ial to "o or m ( ! foll[+3 7i7 ,an application = ! issuance or r5ewal ( an insurance policy or re9surance contract4 7ii7 ,! rat+ ( an insurance policy or re9surance contract4 7iii7 ,a claim = paym5t or b5efit pursuant to an insurance policy or re9surance contract4 7iv7 ,premiums paid on an insurance policy or re9surance contract4 7v7 ,paym5ts made 9 accordance ) ! t]ms ( an insurance policy or re9surance contract4 7vi7 ,a docum5t fil$ ) ! commission] or ! *ief insurance regulatory (ficial ( ano!r jurisdiction4 7vii7 ,! f9ancial condition ( an insur] or re9sur]4 7viii7 ,! =mation1 acquisition1 m]g]1 reconsolidation1 dissolution or )drawal f "o or m l9es ( insurance or re9surance 9 all or "p ( a ,/ate by an insur] or re9sur]4 7ix7 ,! issuance ( writt5 evid5ce ( insurance4 7x7 ,! re9/atem5t ( an insurance policy4 7,b7 ,solicitation or acceptance ( new or r5ewal insurance risks on behalf ( an insur] re9sur] or o!r p]son engag$ 9 ! bus9ess ( insurance by a p]son :o kn[s or %\ld "k t ! insur] or o!r p]son responsible = ! risk is insolv5t at ! "t ( ! transaction4 7,c7 ,transaction ( ! bus9ess ( insurance 9 violation ( laws requir+ a lic5se1 c]tificate ( au?ority or o!r legal au?ority = ! transaction ( ! bus9ess ( insurance4 7,d7 ,attempt to commit1 aid+ or abett+ 9 ! commission (1 or conspiracy to commit ! acts or omissions specifi$ 9 ?is p>agraph4 #bgif4 ,application ( law 7a7 ,9 ,g5]al ,! cov]$ laws ( ! prim>y ,/ate %all apply to individual heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! prim>y ,/ate & 9 any second>y ,/ate1 b only if ! cov]age & issu] comply ) ! conditions ( ?is section ) respect to ! (f]+ ( cov]age 9 any second>y ,/ate4 7b7 ,exemptions ,f ,cov]$ ,laws 9 a ,second>y ,/ate ,except z provid$ 9 ?is section1 a heal? insurance issu] ) respect to its (f]1 sale1 rat+ 7includ+ m$ical und]writ+71 r5ewal1 & issuance ( individual heal? insurance cov]age 9 any second>y ,/ate is exempt f any cov]$ laws ( ! second>y ,/ate 7& any rules1 regulations1 agreem5ts1 or ord]s s\ght or issu$ by su* ,/ate "u or relat$ to su* cov]$ laws7 to ! ext5t t su* laws w\ld-- 7#a7 make unlawful1 or regulate1 directly or indirectly1 ! op]ation ( ! heal? insurance issu] op]at+ 9 ! second>y ,/ate1 except t any second>y ,/ate may require su* an issu]-- 7,a7 to pay1 on a nondiscrim9atory basis1 applicable premium & o!r taxes 7includ+ high risk pool assessm5ts7 :i* are levi$ on insur]s & surplus l9es insur]s1 brok]s1 or policyhold]s "u ! laws ( ! ,/ate2 7,b7 to regi/] ) & designate ! ,/ate insurance commission] z its ag5t solely = ! purpose ( receiv+ s]vice ( legal docum5ts or process2 7,c7 to submit to an exam9ation ( its f9ancial condition by ! ,/ate insurance commission] 9 any ,/ate 9 :i* ! issu] is do+ bus9ess to det]m9e ! issu]'s f9ancial condition1 if-- 7i7 ! ,/ate insurance commission] ( ! prim>y ,/ate has n done an exam9ation )9 ! p]iod recomm5d$ by ! ,national ,association ( ,insurance ,commission]s2 & 7ii7 any su* exam9ation is conduct$ 9 accordance ) ! exam9]s' h&book ( ! ,national ,association ( ,insurance ,commission]s & is coord9at$ to avoid unju/ifi$ duplication & unju/ifi$ repetition2 7,d7 to comply ) a lawful ord] issu$-- 7i7 9 a del9qu5cy proce$+ comm5c$ by ! ,/ate insurance commission] if !re has be5 a f9d+ ( f9ancial impairm5t "u subp>agraph 7,c72 or 7ii7 9 a volunt>y dissolution proce$+2 7,e7 to comply ) an injunction issu$ by a c\rt ( compet5t jurisdiction1 ^u a petition by ! ,/ate insurance commission] alleg+ t ! issu] is 9 haz>d\s f9ancial condition2 7,f7 to p>ticipate1 on a nondiscrim9atory basis1 9 any insurance insolv5cy gu>anty association or simil> association to :i* a heal? insurance issu] 9 ! ,/ate is requir$ to belong2 7,g7 to comply ) any ,/ate law reg>d+ fraud & abuse 7z def9$ 9 section #bgie7aj771 except t if ! ,/ate seeks an injunction reg>d+ ! conduct describ$ 9 ?is subp>agraph1 su* injunction mu/ be obta9$ f a c\rt ( compet5t jurisdiction2 7,h7 to comply ) any ,/ate law reg>d+ unfair claims settlem5t practices 7z def9$ 9 section #bgie7i772 or 7,i7 to comply ) ! applicable requirem5ts = indep5d5t review "u section #bgih ) respect to cov]age (f]$ 9 ! ,/ate2 7#b7 require any individual heal? insurance cov]age issu$ by ! issu] to be c\nt]sign$ by an insurance ag5t or brok] resid+ 9 t second>y ,/ate2 or 7#c7 o!rwise discrim9ate aga9/ ! issu] issu+ insurance 9 bo? ! prim>y ,/ate & 9 any second>y ,/ate4 7c7 ,cle> & ,conspicu\s ,disclosure ,a heal? insurance issu] %all provide ! foll[+ notice1 9 #ab-po9t bold type1 9 any insurance cov]age (f]$ 9 a second>y ,/ate "u ?is "p by su* a heal? insurance issu] & at r5ewal ( ! policy1 ) ! #e blank spaces !re9 be+ appropriately fill$ ) ! "n ( ! heal? insurance issu]1 ! "n ( ! prim>y ,/ate1 ! "n ( ! second>y ,/ate1 ! "n ( ! second>y ,/ate1 & ! "n ( ! second>y ,/ate1 respectively1 = ! cov]age conc]n$3 ,notice ,?is policy is issu$ by & is gov]n$ by ! laws & regulations ( ! ,/ate ( 1 & x has met all ! laws ( t ,/ate z det]m9$ by t ,/ate's ,dep>tm5t ( ,insurance4 ,?is policy may be less exp5sive ?an o!rs because x is n subject to all ( ! insurance laws & regulations ( ! ,/ate ( 1 includ+ cov]age ( "s s]vices or b5efits m&at$ by ! law ( ! ,/ate ( 4 ,additionally1 ?is policy is n subject to all ( ! consum] protection laws or re/rictions on rate *anges ( ! ,/ate ( 4 ,z ) all insurance products1 be=e pur*as+ ?is policy1 y %\ld c>efully review ! policy & det]m9e :at heal? c>e s]vices ! policy cov]s & :at b5efits x provides1 includ+ any exclusions1 limitations1 or conditions = su* s]vices or b5efits4 4 7d7 ,prohibition on ,c]ta9 ,reclassifications & ,premium ,increases 7#a7 ,9 g5]al ,= purposes ( ?is section1 a heal? insurance issu] t provides individual heal? insurance cov]age to an individual "u ?is "p 9 a prim>y or second>y ,/ate may n ^u r5ewal-- 7,a7 move or reclassify ! individual insur$ "u ! heal? insurance cov]age f ! class su* individual is 9 at ! "t ( issue ( ! contract bas$ on ! heal? /atus-relat$ factors ( ! individual2 or 7,b7 increase ! premiums assess$ ! individual = su* cov]age bas$ on a heal? /atus-relat$ factor or *ange ( a heal? /atus-relat$ factor or ! pa/ or prospective claim exp]i5ce ( ! insur$ individual4 7#b7 ,con/ruction ,no?+ 9 p>agraph 7#a7 %all be con/ru$ to prohibit a heal? insurance issu]-- 7,a7 f t]m9at+ or discont9u+ cov]age or a class ( cov]age 9 accordance ) subsections 7b7 & 7c7 ( section #bgdb2 7,b7 f rais+ premium rates = all policy hold]s )9 a class bas$ on claims exp]i5ce2 7,c7 f *ang+ premiums or (f]+ disc\nt$ premiums to individuals :o engage 9 wellness activities at int]vals prescrib$ by ! issu]1 if su* premium *anges or inc5tives-- 7i7 are disclos$ to ! consum] 9 ! insurance contract2 7ii7 are bas$ on specific wellness activities t are n applicable to all individuals2 & 7iii7 are n obta9able by all individuals to :om cov]age is (f]$2 7,d7 f re9/at+ laps$ cov]age2 or 7,e7 f retroactively adju/+ ! rates *>g$ an insur$ individual if ! initial rates 7 set bas$ on mat]ial misrepres5tation by ! individual at ! "t ( issue4 7e7 ,prior ,(f]+ ( ,policy 9 ,prim>y ,/ate ,a heal? insurance issu] may n (f] = sale individual heal? insurance cov]age 9 a second>y ,/ate unless t cov]age is curr5tly (f]$ = sale 9 ! prim>y ,/ate4 7f7 ,lic5s+ ( ,ag5ts or ,brok]s = ,heal? ,insurance ,issu]s ,any ,/ate may require t a p]son act+1 or (f]+ to act1 z an ag5t or brok] = a heal? insurance issu] ) respect to ! (f]+ ( individual heal? insurance cov]age obta9 a lic5se f t ,/ate1 ) commissions or o!r comp5sation subject to ! provisions ( ! laws ( t ,/ate1 except t a ,/ate may n impose any qualification or requirem5t :i* discrim9ates aga9/ a nonresid5t ag5t or brok]4 7g7 ,docum5ts = ,submission to ,/ate ,insurance ,commission] ,ea* heal? insurance issu] issu+ individual heal? insurance cov]age 9 bo? prim>y & second>y ,/ates %all submit-- 7#a7 to ! insurance commission] ( ea* ,/ate 9 :i* x int5ds to (f] su* cov]age1 be=e x may (f] individual heal? insurance cov]age 9 su* ,/ate-- 7,a7 a copy ( ! plan ( op]ation or feasibility /udy or any simil> /atem5t ( ! policy be+ (f]$ & its cov]age 7:i* %all include ! "n ( its prim>y ,/ate & its pr9cipal place ( bus9ess72 7,b7 writt5 notice ( any *ange 9 its designation ( its prim>y ,/ate2 & 7,c7 writt5 notice f ! issu] ( ! issu]'s compliance ) all ! laws ( ! prim>y ,/ate2 & 7#b7 to ! insurance commission] ( ea* second>y ,/ate 9 :i* x (f]s individual heal? insurance cov]age1 a copy ( ! issu]'s qu>t]ly f9ancial /atem5t submitt$ to ! prim>y ,/ate1 :i* /atem5t %all be c]tifi$ by an indep5d5t public acc\ntant & conta9 a /atem5t ( op9ion on loss & loss adju/m5t exp5se res]ves made by-- 7,a7 a memb] ( ! ,am]ican ,academy ( ,actu>ies2 or 7,b7 a qualifi$ loss res]ve speciali/4 7h7 ,p[] ( ,c\rts ,to ,enjo9 ,conduct ,no?+ 9 ?is section %all be con/ru$ to affect ! au?ority ( any ,f$]al or ,/ate c\rt to enjo9-- 7#a7 ! solicitation or sale ( individual heal? insurance cov]age by a heal? insurance issu] to any p]son or gr\p :o is n eligible = su* insurance2 or 7#b7 ! solicitation or sale ( individual heal? insurance cov]age t violates ! requirem5ts ( ! law ( a second>y ,/ate :i* are describ$ 9 subp>agraphs 7,a7 ?r\gh 7,h7 ( section #bgif7;b77#a74 7i7 ,p[] ( ,second>y ,/ates ,to ,take ,adm9i/rative ,action ,no?+ 9 ?is section %all be con/ru$ to affect ! au?ority ( any ,/ate to enjo9 conduct 9 violation ( t ,/ate's laws describ$ 9 section #bgif7;b77#a74 7j7 ,/ate ,p[]s ,to ,en=ce ,/ate ,laws 7#a7 ,9 g5]al ,subject to ! provisions ( subsection 7b77#a77;,g7 7relat+ to injunctions7 & p>agraph 7#b71 no?+ 9 ?is section %all be con/ru$ to affect ! au?ority ( any ,/ate to make use ( any ( its p[]s to en=ce ! laws ( su* ,/ate ) respect to :i* a heal? insurance issu] is n exempt "u subsection 7b74 7#b7 ,c\rts ( compet5t jurisdiction ,if a ,/ate seeks an injunction reg>d+ ! conduct describ$ 9 p>agraphs 7#a7 & 7#b7 ( subsection 7h71 su* injunction mu/ be obta9$ f a ,f$]al or ,/ate c\rt ( compet5t jurisdiction4 7k7 ,/ates' ,au?ority ,to ,sue ,no?+ 9 ?is section %all affect ! au?ority ( any ,/ate to br+ action 9 any ,f$]al or ,/ate c\rt4 7l7 ,g5]ally ,applicable ,laws ,no?+ 9 ?is section %all be con/ru$ to affect ! applicability ( ,/ate laws g5]ally applicable to p]sons or corporations4 7m7 ,gu>ante$ ,availability ( ,cov]age to ,,hipaa ,eligible ,individuals ,to ! ext5t t a heal? insurance issu] is (f]+ cov]age 9 a prim>y ,/ate t does n accommodate resid5ts ( second>y ,/ates or does n provide a work+ me*anism = resid5ts ( a second>y ,/ate1 & ! issu] is (f]+ cov]age "u ?is "p 9 su* second>y ,/ate :i* has n adopt$ a qualifi$ high risk pool z its acceptable alt]native me*anism 7z def9$ 9 section #bgdd7;c77#b771 ! issu] %all1 ) respect to any individual heal? insurance cov]age (f]$ 9 a second>y ,/ate "u ?is "p1 comply ) ! gu>ante$ availability requirem5ts = eligible individuals 9 section #bgda4 #bgig4 ,prim>y ,/ate mu/ meet ,f$]al floor be=e issu] may sell into second>y ,/ates ,a heal? insurance issu] may n (f]1 sell1 or issue individual heal? insurance cov]age 9 a second>y ,/ate if ! ,/ate insurance commission] does n use a risk-bas$ capital =mula = ! det]m9ation ( capital & surplus requirem5ts = all heal? insurance issu]s4 #bgih4 ,indep5d5t ext]nal appeals proc$ures 7a7 ,"r to ,ext]nal ,appeal ,a heal? insurance issu] may n (f]1 sell1 or issue individual heal? insurance cov]age 9 a second>y ,/ate "u ! provisions ( ?is title unless-- 7#a7 bo? ! second>y ,/ate & ! prim>y ,/ate h legislation or regulations 9 place e/abli%+ an indep5d5t review process = individuals :o are cov]$ by individual heal? insurance cov]age2 or 7#b7 9 any case 9 :i* ! requirem5ts ( subp>agraph 7,a7 are n met ) respect to ! ei!r ( su* ,/ates1 ! issu] provides an indep5d5t review me*anism sub/antially id5tical 7z det]m9$ by ! applicable ,/ate au?ority ( su* ,/ate7 to t prescrib$ 9 ! ,heal? ,c>ri] ,ext]nal ,review ,model ,act ( ! ,national ,association ( ,insurance ,commission]s = all individuals :o pur*ase insurance cov]age "u ! t]ms ( ?is "p1 except t1 "u su* me*anism1 ! review is conduct$ by an indep5d5t m$ical review]1 or a panel ( su* review]s1 ) respect to :om ! requirem5ts ( subsection 7b7 are met4 7b7 ,qualifications ( ,indep5d5t ,m$ical ,review]s ,9 ! case ( any indep5d5t review me*anism ref]r$ to 9 subsection 7a77#b7-- 7#a7 ,9 g5]al ,9 ref]r+ a d5ial ( a claim to an indep5d5t m$ical review]1 or to any panel ( su* review]s1 to conduct indep5d5t m$ical review1 ! issu] %all ensure t-- 7,a7 ea* indep5d5t m$ical review] meets ! qualifications describ$ 9 p>agraphs 7#b7 & 7#c72 7,b7 ) respect to ea* review1 ea* review] meets ! requirem5ts ( p>agraph 7#d7 & ! review]1 or at lea/ #a review] on ! panel1 meets ! requirem5ts describ$ 9 p>agraph 7#e72 & 7,c7 comp5sation provid$ by ! issu] to ea* review] is consi/5t ) p>agraph 7#f74 7#b7 ,lic5sure & exp]tise ,ea* indep5d5t m$ical review] %all be a physician 7allopa?ic or o/eopa?ic7 or heal? c>e pr(essional :o-- 7,a7 is appropriately cr$5tial$ or lic5s$ 9 #a or m ,/ates to deliv] heal? c>e s]vices2 & 7,b7 typically treats ! condition1 makes ! diagnosis1 or provides ! type ( treatm5t "u review4 7#c7 ,indep5d5ce 7,a7 ,9 g5]al ,subject to subp>agraph 7,b71 ea* indep5d5t m$ical review] 9 a case %all-- 7i7 n be a relat$ p>ty 7z def9$ 9 p>agraph 7#g772 7ii7 n h a mat]ial familial1 f9ancial1 or pr(essional relation%ip ) su* a p>ty2 & 7iii7 n o!rwise h a conflict ( int]e/ ) su* a p>ty 7z det]m9$ "u regulations74 7,b7 ,exception ,no?+ 9 subp>agraph 7,a7 %all be con/ru$ to-- 7i7 prohibit an individual1 solely on ! basis ( affiliation ) ! issu]1 f s]v+ z an indep5d5t m$ical review] if-- 7,i7 a non-affiliat$ individual is n reasonably available2 7,,ii7 ! affiliat$ individual is n involv$ 9 ! provision ( items or s]vices 9 ! case "u review2 7,,iii7 ! fact ( su* an affiliation is disclos$ to ! issu] & ! enrollee 7or au?oriz$ repres5tative7 & nei!r p>ty objects2 & 7,,iv7 ! affiliat$ individual is n an employee ( ! issu] & does n provide s]vices exclusively or prim>ily to or on behalf ( ! issu]2 7ii7 prohibit an individual :o has /aff privileges at ! in/itution :]e ! treatm5t involv$ takes place f s]v+ z an indep5d5t m$ical review] m]ely on ! basis ( su* affiliation if ! affiliation is disclos$ to ! issu] & ! enrollee 7or au?oriz$ repres5tative71 & nei!r p>ty objects2 or 7iii7 prohibit receipt ( comp5sation by an indep5d5t m$ical review] f an entity if ! comp5sation is provid$ consi/5t ) p>agraph 7#f74 7#d7 ,practic+ heal? c>e pr(essional 9 same field 7,a7 ,9 g5]al ,9 a case involv+ treatm5t1 or ! provision ( items or s]vices-- 7i7 by a physician1 a review] %all be a practic+ physician 7allopa?ic or o/eopa?ic7 ( ! same or simil> specialty1 z a physician :o1 act+ )9 ! appropriate scope ( practice )9 ! ,/ate 9 :i* ! s]vice is provid$ or r5d]$1 typically treats ! condition1 makes ! diagnosis1 or provides ! type ( treatm5t "u review2 or 7ii7 by a non-physician heal? c>e pr(essional1 ! review]1 or at lea/ #a memb] ( ! review panel1 %all be a practic+ non-physician heal? c>e pr(essional ( ! same or simil> specialty z ! non-physician heal? c>e pr(essional :o1 act+ )9 ! appropriate scope ( practice )9 ! ,/ate 9 :i* ! s]vice is provid$ or r5d]$1 typically treats ! condition1 makes ! diagnosis1 or provides ! type ( treatm5t "u review4 7,b7 ,practic+ def9$ ,= purposes ( ?is p>agraph1 ! t]m practic+ means1 ) respect to an individual :o is a physician or o!r heal? c>e pr(essional1 t ! individual provides heal? c>e s]vices to individual pati5ts on av]age at lea/ #b days p] week4 7#e7 ,p$iatric exp]tise ,9 ! case ( an ext]nal review relat+ to a *ild1 a review] %all h exp]tise "u p>agraph 7#b7 9 p$iatrics4 7#f7 ,limitations on review] comp5sation ,comp5sation provid$ by ! issu] to an indep5d5t m$ical review] 9 connection ) a review "u ?is section %all-- 7,a7 n exce$ a reasonable level2 & 7,b7 n be cont+5t on ! decision r5d]$ by ! review]4 7#g7 ,relat$ p>ty def9$ ,= purposes ( ?is section1 ! t]m relat$ p>ty means1 ) respect to a d5ial ( a claim "u a cov]age relat+ to an enrollee1 any ( ! foll[+3 7,a7 ,! issu] involv$1 or any fiduci>y1 (fic]1 director1 or employee ( ! issu]4 7,b7 ,! enrollee 7or au?oriz$ repres5tative74 7,c7 ,! heal? c>e pr(essional t provides ! items or s]vices involv$ 9 ! d5ial4 7,d7 ,! in/itution at :i* ! items or s]vices 7or treatm5t7 involv$ 9 ! d5ial are provid$4 7,e7 ,! manufactur] ( any drug or o!r item t is includ$ 9 ! items or s]vices involv$ 9 ! d5ial4 7,f7 ,any o!r p>ty det]m9$ "u any regulations to h a sub/antial int]e/ 9 ! d5ial involv$4 7#h7 ,def9itions ,= purposes ( ?is subsection-- 7,a7 ,enrollee ,! t]m enrollee means1 ) respect to heal? insurance cov]age (f]$ by a heal? insurance issu]1 an individual enroll$ ) ! issu] to receive su* cov]age4 7,b7 ,heal? c>e pr(essional ,! t]m heal? c>e pr(essional means an individual :o is lic5s$1 accr$it$1 or c]tifi$ "u ,/ate law to provide specifi$ heal? c>e s]vices & :o is op]at+ )9 ! scope ( su* lic5sure1 accr$itation1 or c]tification4 #bgii4 ,en=cem5t 7a7 ,9 ,g5]al ,subject to subsection 7b71 ) respect to specific individual heal? insurance cov]age ! prim>y ,/ate = su* cov]age has sole jurisdiction to en=ce ! prim>y ,/ate's cov]$ laws 9 ! prim>y ,/ate & any second>y ,/ate4 7b7 ,second>y ,/ate's ,au?ority ,no?+ 9 subsection 7a7 %all be con/ru$ to affect ! au?ority ( a second>y ,/ate to en=ce its laws z set =? 9 ! exception specifi$ 9 section #bgif7;b77#a74 7c7 ,c\rt ,int]pretation ,9 review+ action initiat$ by ! applicable second>y ,/ate au?ority1 ! c\rt ( compet5t jurisdiction %all apply ! cov]$ laws ( ! prim>y ,/ate4 7d7 ,notice ( ,compliance ,failure ,9 ! case ( individual heal? insurance cov]age (f]$ 9 a second>y ,/ate t fails to comply ) ! cov]$ laws ( ! prim>y ,/ate1 ! applicable ,/ate au?ority ( ! second>y ,/ate may notify ! applicable ,/ate au?ority ( ! prim>y ,/ate4 4 7b7 ,effective ,date ,! am5dm5t made by subsection 7a7 %all apply to individual heal? insurance cov]age (f]$1 issu$1 or sold aft] ! date t is "o ye> aft] ! date ( ! enactm5t ( ?is ,act4 7c7 ,,gao ,ongo+ ,/udy & ,reports 7#a7 ,/udy ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all conduct an ongo+ /udy conc]n+ ! effect ( ! am5dm5t made by subsection 7a7 on-- 7,a7 ! numb] ( un9sur$ & und]9sur$2 7,b7 ! availability & co/ ( heal? insurance policies = individuals ) pre-exi/+ m$ical conditions2 7,c7 ! availability & co/ ( heal? insurance policies g5]ally2 7,d7 ! elim9ation or r$uction ( diff]5t types ( b5efits "u heal? insurance policies (f]$ 9 diff]5t ,/ates2 & 7,e7 cases ( fraud or abuse relat+ to heal? insurance cov]age (f]$ "u su* am5dm5t & ! resolution ( su* cases4 7#b7 ,annual reports ,! ,comptroll] ,g5]al %all submit to ,congress an annual report1 aft] ! end ( ea* ( ! #e ye>s foll[+ ! effective date ( ! am5dm5t made by subsection 7a71 on ! ongo+ /udy conduct$ "u p>agraph 7#a74 #f4 ,sev]ability ,if any provision ( ! ,act or ! application ( su* provision to any p]son or circum/ance is held to be uncon/itutional1 ! rema9d] ( ?is ,act & ! application ( ! provisions ( su* to any o!r p]son or circum/ance %all n be affect$4