,,ii #aafth ,,congress #ast ,session ,s4 #abac ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,april #aa1 #bjai ,ms4 ,warren 7for herself1 ,mrs4 ,gillibrand1 ,ms4 ,harris1 ,ms4 ,baldwin1 ,ms4 ,klobuchar1 ,mr4 ,booker1 and ,mr4 ,blumenthal7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to provide health insurance reform1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,consumer ,health ,insurance ,protection ,act of #bjai4 #b4 ,table of contents ,the table of contents for this ,act is as follows3 ,sec4 #a4 ,short title4 ,sec4 #b4 ,table of contents4 ,,title ,i--,limiting insurer profits and preventing unreasonable premium increases ,sec4 #aja4 ,medical loss ratio4 ,sec4 #ajb4 ,ensuring that consumers get value for their dollars4 ,sec4 #ajc4 ,effective date4 ,,title ,,ii--,making health insurance coverage affordable ,sec4 #bja4 ,enhancement of premium assistance credit4 ,sec4 #bjb4 ,enhancements for reduced cost-sharing4 ,sec4 #bjc4 ,cap on prescription drug cost-sharing4 ,sec4 #bjd4 ,standardized options in the bronze1 silver1 and gold levels of coverage4 ,sec4 #bje4 ,deductible-exempt services for group health plans and group health insurance coverage4 ,sec4 #bjf4 ,clarification regarding determination of affordability of employer-sponsored minimum essential coverage4 ,,title ,,iii--,ensuring access to care ,sec4 #cja4 ,network adequacy requirements4 ,sec4 #cjb4 ,ensuring adequate coverage in areas with fewer than #c health insurance issuers offering qualified health plans on the ,state ,exchange4 ,sec4 #cjc4 ,enrollment in ,exchanges4 ,sec4 #cjd4 ,marketing and outreach for ,exchanges operated by the ,secretary4 ,sec4 #cje4 ,navigator program4 ,,title ,,iv--,strengthening consumer health insurance protections ,sec4 #dja4 ,prohibiting discriminatory premiums based on tobacco use4 ,sec4 #djb4 ,health insurance consumer information4 ,sec4 #djc4 ,patient protections4 ,sec4 #djd4 ,limitation on balance billing for emergency services4 ,sec4 #dje4 ,notification of provider terminations4 ,sec4 #djf4 ,short-term limited duration health insurance coverage4 ,sec4 #djg4 ,protecting essential health benefits and coverage of pediatric services4 ,sec4 #djh4 ,association health plans4 ,i ,limiting insurer profits and preventing unreasonable premium increases #aja4 ,medical loss ratio ,section #bgah7;b77#a77;,a77ii7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ah7;b77#a77;,a77ii77 is amended by striking #hj each place it appears and inserting #he4 #ajb4 ,ensuring that consumers get value for their dollars ,the first section #bgid of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#id71 added by section #ajjc of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 is amended-- 7#a7 in subsection 7a7-- 7,a7 in paragraph 7#a71 by striking subsection 7b77#b77;,a7 and inserting subsections 7b77#b77;,a7 and 7b77#c72 and 7,b7 in paragraph 7#b71 by adding at the end the following3 ,notwithstanding any other provision of law1 a health insurance issuer may not exclude from such disclosure information that is a trade secret or commercial or financial information described in section #eeb7;b77#d7 of title #e1 ,united ,states ,code42 7#b7 in subsection 7b7-- 7,a7 in paragraph 7#b77;,a71 by inserting and paragraph 7#c7 after subsection 7a77#b72 and 7,b7 by adding at the end the following3 7#c7 ,prohibiting unreasonable premium increases 7,a7 ,in general ,beginning with plan years beginning in #bjba1 the ,secretary1 or a ,state pursuant to an effective rate review program meeting the requirements under paragraph 7#d7-- 7i7 shall1 consistent with subsection 7a77#b7 and paragraph 7#b71 review increases in premiums for health insurance coverage that are subject to review pursuant to section #aed4bjj of title #de1 ,code of ,federal ,regulations 7or any successor regulation71 and determine whether such increases are unreasonable2 and 7ii7 may prohibit a health insurance issuer from implementing such an increase that is unreasonable4 7,b7 ,unreasonable increases ,in determining whether an increase in premiums for health insurance coverage is unreasonable under subparagraph 7,a77i7-- 7i7 the ,secretary shall consider whether the increase is excessive1 unjustified1 discriminatory1 or inadequate2 and 7ii7 the ,state1 pursuant to an effective rate review program meeting the requirements under paragraph 7#d71 shall apply applicable ,state law for making such determination4 7#d7 ,state effective rate review programs ,a ,state effective rate review program meets the requirements under this paragraph if-- 7,a7 the program carries out the reviews described in paragraph 7#c77;,a77i7 and ensures that such reviews are meaningful1 effective1 and timely reviews of the data and documentation 7including any contracts or documents described in subparagraph 7,e77 submitted by health insurance issuers in support of proposed increases in premiums for health insurance coverage2 7,b7 such reviews include an examination of-- 7i7 the affordability of proposed increases in premiums for health insurance coverage2 7ii7 the quality improvement activities carried out by health insurance issuers proposing the increases2 7iii7 the cost containment activities of health insurance issuers proposing the increases2 and 7iv7 the solvency of the health insurance coverage2 7,c7 the program establishes a mechanism for receiving public comments on proposed increases in premiums for health insurance coverage reviewed by the ,state2 7,d7 such reviews include a review of all public comments received under subparagraph 7,c72 7,e7 the program requires each health insurance issuer proposing an increase in premiums for health insurance coverage to submit to the ,state any provider contracts that may be affected1 including any documents incorporated by reference into such contracts2 and 7,f7 the program requires the ,state to provide the ,secretary its determination of whether each increase reviewed is unreasonable1 in a form and manner prescribed by the ,secretary4 2 and 7#c7 in subsection 7c7-- 7,a7 in paragraph 7#a7-- 7i7 in the heading1 by striking #bjaj through #bjad and inserting #bjba through #bjbe2 and 7ii7 in the matter preceding subparagraph 7,a71 by striking #bjaj and inserting #bjba2 and 7,b7 in paragraph 7#b77;,b71 by striking #bjad and inserting #bjbe4 #ajc4 ,effective date ,the amendments made by this title shall apply to plan years beginning after ,december #ca1 #bjbj4 ,,ii ,making health insurance coverage affordable #bja4 ,enhancement of premium assistance credit 7a7 ,use of gold level plan for benchmark 7#a7 ,in general ,clause 7i7 of section #cf;,b7b77#b77;,b7 of the ,internal ,revenue ,code of #aihf is amended by striking applicable second lowest cost silver plan and inserting applicable second lowest cost gold plan4 7#b7 ,conforming amendment related to affordability ,section #cf;,b7c77#d77;,c77i77,i7 of such ,code is amended by striking second lowest cost silver plan and inserting second lowest cost gold plan4 7#c7 ,other conforming amendments ,subparagraphs 7,b7 and 7,c7 of section #cf;,b7b77#c7 of such ,code are each amended by striking silver plan each place it appears in the text and the heading and inserting gold plan4 7b7 ,expansion of eligibility for refundable credits for coverage under qualified health plans 7#a7 ,in general ,section #cf;,b7c77#a77;,a7 of the ,internal ,revenue ,code of #aihf is amended by striking but does not exceed #djj percent4 7#b7 ,conforming amendments relating to recapture of excess advanced payments ,clause 7i7 of section #cf;,b7f77#b77;,b7 of such ,code is amended-- 7,a7 by striking ,in the case of and all that follows through the amount of and inserting ,the amount of1 and 7,b7 by striking but less than #djj in the table therein4 7c7 ,determination of applicable percentage 7#a7 ,in general ,subparagraph 7,a7 of section #cf;,b7b77#c7 of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7,a7 ,applicable percentage ,the applicable percentage for any taxable year shall be the percentage such that the applicable percentage for any taxpayer whose household income is within an income tier specified in the following table shall increase1 on a sliding scale in a linear manner1 from the initial premium percentage to the final premium percentage specified in such table for such income tier3 ,in the case of householdincome 7expressed as a percent of poverty line7 within thefollowing income tier3,the initialpremiumpercentage is--,the finalpremiumpercentage is-- #ajj through #accja4j #acc through #aeja4jb4j #aej through #bjjb4jd4j #bjj through #bejd4jf4j #bej through #cjjf4jg4j #cjj through #djjg4jh4e ,over #djjh4eh4e 4 7#b7 ,conforming amendments ,subsections 7c77#b77;,c77iv7 and 7c77#d77;,f7 of section #cf;,b of the ,internal ,revenue ,code of #aihf are each amended by inserting 7as in effect before the date of the enactment of the ,consumer ,health ,insurance ,protection ,act of #bjai7 after subsection 7b77#c77;,a77ii74 7d7 ,reconciliation of premium assistance credit and advance credit for single-,parent households 7#a7 ,in general ,clause 7i7 of section #cf;,b7f77#b77;,b7 of the ,internal ,revenue ,code of #aihf is amended by striking section #a7;c7 and inserting subsection 7b7 or 7c7 of section #a4 7#b7 ,effective date ,the amendment made by this subsection shall apply to taxable years beginning after ,december #ca1 #bjai4 7e7 ,determination of premium assistance credit for disabled workers 7#a7 ,in general ,section #cf;,b7d77#b7 of the ,internal ,revenue ,code of #aihf is amended by inserting at the end the following new subparagraph3 7,c7 ,exclusion of certain amounts received as lump-sum payment ,for purposes of subparagraph 7,b71 such amount shall not include any portion of a lump-sum payment of disability insurance benefits under section #bbc of the ,social ,security ,act 7#db ,u4,s4,c4 #dbc7 which is-- 7i7 received during the taxable year1 and 7ii7 attributable to prior taxable years4 4 7#b7 ,effective date ,the amendment made by this subsection shall apply to taxable years beginning after ,december #ca1 #bjai4 7f7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjbj4 #bjb4 ,enhancements for reduced cost-sharing 7a7 ,modification of amount 7#a7 ,in general ,section #adjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjga7 is amended-- 7,a7 in subsection 7b77#a71 by striking silver and inserting gold2 7,b7 by amending subsection 7c77#a77;,b7 to read as follows3 7,b7 ,coordination with actuarial limits ,the ,secretary shall ensure the reduction under this paragraph shall not result in the plan's share of the total allowed costs of benefits provided under the plan becoming less than-- 7i7 #ie percent in the case of an eligible insured described in paragraph 7#b77;,a72 7ii7 #ij percent in the case of an eligible insured described in paragraph 7#b77;,b72 and 7iii7 #he percent in the case of an eligible insured described in paragraph 7#b77;,c74 2 and 7,c7 by amending subsection 7c77#b7 to read as follows3 7#b7 ,additional reduction ,the ,secretary shall establish procedures under which the issuer of a qualified health plan to which this section applies shall further reduce cost-sharing under the plan in a manner sufficient to-- 7,a7 in the case of an eligible insured whose household income is not less than #ajj percent but not more than #bjj percent of the poverty line for a family of the size involved1 increase the plan's share of the total allowed costs of benefits provided under the plan to #ie percent of such costs2 7,b7 in the case of an eligible insured whose household income is more than #bjj percent but not more than #cjj percent of the poverty line for a family of the size involved1 increase the plan's share of the total allowed costs of benefits provided under the plan to #ij percent of such costs2 and 7,c7 in the case of an eligible insured whose household income is more than #cjj percent but not more than #djj percent of the poverty line for a family of the size involved1 increase the plan's share of the total allowed costs of benefits provided under the plan to #he percent of such costs4 4 7#b7 ,effective date ,the amendments made by this subsection shall apply to plan years beginning after ,december #ca1 #bjbj4 7b7 ,funding ,section #adjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjga7 is amended by adding at the end the following new subsection3 7g7 ,funding ,out of any funds in the ,treasury not otherwise appropriated1 there are appropriated to the ,secretary such sums as may be necessary for payments under this section4 4 #bjc4 ,cap on prescription drug cost-sharing 7a7 ,qualified health plans ,section #acjb7;c7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7;c77 is amended-- 7#a7 in paragraph 7#c77;,a77i71 by inserting 1 including cost-sharing with respect to prescription drugs covered by the plan after charges2 and 7#b7 by adding at the end the following3 7#e7 ,prescription drug cost-sharing 7,a7 #bjba ,for plan years beginning in #bjba1 the cost-sharing incurred under a health plan with respect to prescription drugs covered by the plan shall not exceed #bej per month for each enrolled individual1 or #ejj for each family4 7,b7 #bjbb and later 7i7 ,in general ,in the case of any plan year beginning in a calendar year after #bjba1 the limitation under this paragraph shall be equal to the applicable dollar amount under subparagraph 7,a7 for plan years beginning in #bjba1 increased by an amount equal to the product of that amount and the medical care component of the consumer price index for all urban consumers 7as published by the ,bureau of ,labor ,statistics7 for that year4 7ii7 ,adjustment to amount ,if the amount of any increase under clause 7i7 is not a multiple of #e1 such increase shall be rounded to the next lowest multiple of #e4 4 7b7 ,group health plans ,section #bgjg7;b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#f7;b77 is amended-- 7#a7 by striking annual2 and 7#b7 by striking paragraph 7#a7 of section #acjb7;c7 and inserting paragraphs 7#a7 and 7#e7 of section #acjb7;c7 of the ,patient ,protection and ,affordable ,care ,act4 7c7 ,effective date ,the amendments made by subsections 7a7 and 7b7 shall take effect with respect to plans beginning after ,december #ca1 #bjbj4 #bjd4 ,standardized options in the bronze1 silver1 and gold levels of coverage 7a7 ,in general ,section #acja7;a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjba7;a77 is amended-- 7#a7 in paragraph 7#a77;,c7-- 7,a7 in clause 7iii71 by striking 2 and and inserting 22 7,b7 by redesignating clause 7iv7 as clause 7v72 and 7,c7 by inserting after clause 7iii7 the following3 7iv7 7,i7 agrees to offer the applicable standardized option under paragraph 7#e7 for each level of coverage offered by the issuer that is the bronze1 silver1 or gold level of coverage2 and 7,,ii7 with respect to offering coverage that is the bronze1 silver1 or gold level of coverage through an ,exchange that is operated by the ,secretary1 agrees to offer only the applicable standardized option under paragraph 7#e7 and not any other plan for such levels of coverage2 and 2 and 7#b7 by adding at the end the following3 7#e7 ,standardized options 7,a7 ,definition of standardized option ,in this section1 the term standardized option means a qualified health plan-- 7i7 with a standardized cost-sharing structure established by the applicable ,state1 or the ,secretary1 in accordance with this paragraph2 and 7ii7 that is offered through an ,exchange4 7,b7 ,establishment 7i7 ,state ,each ,state may establish a standardized option for the bronze1 silver1 and gold levels of coverage4 7ii7 ,secretary ,the ,secretary shall establish a standardized option in a ,state for any level of coverage described in clause 7i7 for which the ,state has not established a standardized option4 7iii7 ,updates ,the ,secretary shall annually update any standardized option established by the ,secretary under clause 7ii74 7,c7 ,deductible-exempt services 7i7 ,in general ,except as provided in clause 7ii71 each standardized option established by the ,secretary under subparagraph 7,b77ii7 shall provide coverage for and waive the application of a deductible for-- 7,i7 all primary care visits and specialist visits2 7,,ii7 all mental health and substance use disorder outpatient services2 7,,iii7 all drugs approved under section #eje7;j7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act and biological products licensed under section #cea7k7 of the ,public ,health ,service ,act2 and 7,,iv7 all urgent care services4 7ii7 ,bronze and silver levels of coverage ,the ,secretary may alter the services that shall be covered as deductible-exempt services under clause 7i7 for standardized options in the bronze and silver levels of coverage4 7,d7 ,display ,each ,exchange operated by a ,state shall preferentially display the standardized options offered in such ,state on the website of the ,exchange4 4 7b7 ,effective date ,the amendments made by this section shall apply to plans beginning after ,december #ca1 #bjbj4 #bje4 ,deductible-exempt services for group health plans and group health insurance coverage 7a7 ,in general ,section #bgac of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ac7 is amended by adding at the end the following3 7d7 ,deductible-,exempt services for group health plans and group health insurance coverage 7#a7 ,in general ,subject to paragraph 7#b71 a group health plan and a health insurance issuer offering group health insurance coverage shall1 in addition to the requirement under subsection 7a71 at a minimum provide coverage for and waive the application of a deductible for-- 7,a7 all primary care visits and specialist visits2 7,b7 all mental health and substance use disorder outpatient services2 7,c7 all drugs approved under section #eje7;j7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act and biological products licensed under section #cea7k7 of the ,public ,health ,service ,act2 and 7,d7 all urgent care services4 7#b7 ,regulations ,the ,secretary may issue regulations to-- 7,a7 assist group health plans and health insurance issuers offering group health insurance coverage in complying with paragraph 7#a72 and 7,b7 alter the services that shall be covered as deductible-exempt services under paragraph 7#a7 for group health plans and group health insurance coverage with levels of coverage that are designed to provide benefits that are actuarially equivalent to #fj or #gj percent of the full actuarial value of the benefits provided under the plan or coverage4 4 7b7 ,effective date ,the amendments made by this section shall apply to plans beginning after ,december #ca1 #bjbj4 #bjf4 ,clarification regarding determination of affordability of employer-sponsored minimum essential coverage 7a7 ,special rule for employer-,sponsored minimum essential coverage ,clause 7i7 of section #cf;,b7c77#b77;,c7 of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7i7 ,coverage must be affordable 7,i7 ,in general ,except as provided in clause 7iii71 an individual shall not be treated as eligible for minimum essential coverage if such coverage consists of an eligible employer-sponsored plan 7as defined in section #ejjj;,a7f77#b77 and the required contribution with respect to the plan exceeds #h4e percent of the applicable taxpayer's household income4 7,,ii7 ,required contribution with respect to employee ,in the case of the employee eligible to enroll in the plan1 the required contribution for purposes of subclause 7,i7 is the employee's required contribution 7within the meaning of section #ejjj;,a7e77#a77;,b77i77 with respect to the plan4 7,,iii7 ,required contribution with respect to family members ,in the case of an individual who is eligible to enroll in the plan by reason of a relationship the individual bears to the employee1 the required contribution for purposes of subclause 7,i7 is the employee's required contribution 7within the meaning of section #ejjj;,a7e77#a77;,b77i71 determined by substituting family for self-only7 with respect to the plan4 4 7b7 ,conforming amendments 7#a7 ,clause 7ii7 of section #cf;,b7c77#b77;,c7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following3 ,this clause shall also apply to an individual who is eligible to enroll in the plan by reason of a relationship the individual bears to the employee44 7#b7 ,clause 7iii7 of section #cf;,b7c77#b77;,c7 of such ,code is amended by striking the last sentence of clause 7i7 and inserting clause 7i77,,iii74 7#c7 ,clause 7iv7 of section #cf;,b7c77#b77;,c7 of such ,code is amended by striking clause 7i77,,ii7 and inserting clause 7i77,i74 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjbj4 ,,iii ,ensuring access to care #cja4 ,network adequacy requirements 7a7 ,in general ,section #acaa7;c7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjca7;c77 is amended-- 7#a7 in paragraph 7#a77;,b71 by inserting and paragraph 7#g7 and in accordance with paragraph 7#h7 after ,public ,health ,service ,act2 and 7#b7 by adding at the end the following3 7#g7 ,network adequacy requirements 7,a7 ,in general ,a qualified health plan shall1 to be certified under this subsection1 meet the network adequacy standards established by the ,secretary under subparagraph 7,b71 except as provided in subparagraphs 7,b77ii7 and 7,c74 7,b7 ,federal standards and review 7i7 ,standard 7,i7 ,establishment ,the ,secretary shall1 in consultation with stakeholders including pediatric-specific stakeholders1 establish a network adequacy standard based on access to in-network providers for qualified health plans1 except for those plans described in subparagraph 7,c74 ,such standard shall-- 7aa7 include requirements for the minimum number and type of in-network providers available1 the geographical location of such providers1 the average distance and travel time required for patients to visit such providers1 and the average appointment wait times for services covered by the plan2 and 7bb7 account for differences in the needs of children and adults4 7,,ii7 ,medicare ,advantage organizations ,the network adequacy standard established under subclause 7,i7 shall1 at a minimum1 be equivalent to the requirements for access to services applicable to ,medicare ,advantage organizations offering ,medicare ,advantage plans under part ,c of title ,,xviii of the ,social ,security ,act4 7ii7 ,justification ,a qualified health plan that fails to meet the standard established under clause 7i7 may satisfy the requirement under subparagraph 7,a7 by providing the ,secretary with a reasonable justification for the variance from such standard1 based on factors such as the availability of providers and variables reflected in local patterns of health care4 7iii7 ,review ,the ,secretary shall establish a process for reviewing the network adequacy of qualified health plans1 except for those plans reviewed by the ,state in accordance with subparagraph 7,c77ii74 7,c7 ,state standard 7i7 ,in general ,in the case of a qualified health plan offered in a ,state that has implemented a quantifiable network adequacy metric that the ,secretary determines is an acceptable metric commonly used in the health insurance industry to measure network adequacy1 such qualified health plan may1 to be certified under this subsection1 satisfy the requirement under subparagraph 7,a7 by meeting the network adequacy standards of such ,state based on such metric4 7ii7 ,review ,a ,state with an acceptable metric described in clause 7i7 may review the network adequacy of qualified health plans offered in such ,state in a process established by the ,state4 7#h7 ,coverage of out-of-network essential health benefits 7,a7 ,in general ,a qualified health plan shall1 to be certified under this subsection1 provide to individuals enrolled in such plan coverage of any service provided by an out-of-network provider if-- 7i7 coverage of such service would otherwise be provided by the plan if the service was provided by an in-network provider2 7ii7 the service is included in the essential health benefits package described in section #acjb7;a72 and 7iii7 the service cannot be provided to the individual by an in-network provider within a reasonable timeframe or within a reasonable distance and travel time4 7,b7 ,cost-sharing ,a qualified health plan that provides coverage of a service provided by an out-of-network provider under subparagraph 7,a7 shall provide such coverage with the same cost-sharing requirements as if the service was provided by an in-network provider4 4 7b7 ,effective date ,the amendments made by subsection 7a7 shall apply to plans beginning after ,december #ca1 #bjbj4 7c7 ,grants for ,state network adequacy reviews 7#a7 ,in general ,the ,secretary of ,health and ,human ,services shall carry out a program to award grants to ,states during the #e-year period beginning with fiscal year #bjba to assist such ,states in developing a metric to measure network adequacy as described in subparagraph 7,c77i7 of section #acaa7;c77#g7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjca7;c77#g77 and to carry out the reviews described in subparagraph 7,c77ii7 of such section4 7#b7 ,authorization of appropriations ,there are authorized to be appropriated for each of fiscal years #bjba through #bjbe such sums as may be necessary to carry out the grant program under this subsection4 7d7 ,report 7#a7 ,in general ,not later than ,december #ca1 #bjbb1 the ,secretary shall prepare1 and submit to ,congress1 a report containing the analysis and recommendations described in paragraph 7#b74 7#b7 ,analysis and recommendations ,the report under this subsection shall-- 7,a7 analyze how network adequacy and access to care has changed since the implementation of this section1 including the amendments made by this section1 including for children2 7,b7 include information on the availability of providers that are essential community providers as described in section #acaa7;c77#a77;,c7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjca7;c77#a77;,c772 and 7,c7 provide recommendations for such legislation and administrative actions as the ,secretary considers appropriate to improve network adequacy1 including with respect to access to pediatric services and essential community providers4 #cjb4 ,ensuring adequate coverage in areas with fewer than #c health insurance issuers offering qualified health plans on the ,state ,exchange 7a7 ,requirements for ,medicare ,advantage organizations 7#a7 ,in general ,section #aheg7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;e77 is amended by adding at the end the following new paragraph3 7#f7 ,requirement for certain ,medicare ,advantage organizations that offer an ,,ma plan in an applicable area to also offer qualified health plans in the applicable area 7,a7 ,in general ,a contract under this section with an ,,ma organization described in subparagraph 7,b7 shall require the organization to1 in each applicable area in which the organization offers an ,,ma plan1 also offer1 through the individual market in the ,exchange operating in the ,state1 at least one qualified health plan in the silver level of coverage and at least one qualified health plan in the gold level of coverage1 as described in section #acjb7;d7 of the ,patient ,protection and ,affordable ,care ,act4 7,b7 ,,ma organizations described ,an ,,ma organization described in this subparagraph is an ,,ma organization that1 in addition to offering an ,,ma plan in an applicable area1 offers health insurance coverage in the group market or individual market in the ,state but does not offer such coverage through the ,exchange operating in the ,state4 7,c7 ,notification ,the ,secretary1 or the ,state in the case of an ,,ma organization offering an ,,ma plan in an applicable area in a ,state with an ,exchange operated by the ,state1 shall notify each ,,ma organization that is required to offer a qualified health plan under subparagraph 7,a7 for a plan year of such requirement4 ,such notification shall be provided each year-- 7i7 beginning with respect to the requirement for plan years beginning after ,december #ca1 #bjbj2 and 7ii7 not less than #a year prior to the rate filing deadline for the plan year for the ,exchange operating in the ,state in which the ,,ma organization will be required to offer such plan4 7,d7 ,waiver ,the ,secretary1 or the ,state in the case of an ,,ma organization offering an ,,ma plan in an applicable area in a ,state with an ,exchange operated by the ,state1 may waive the requirement under subparagraph 7,a7 if-- 7i7 by the first day of the plan year following the determination1 the number of health insurance issuers offering a qualified health plan through the individual market in the ,exchange has increased such that the applicable area no longer has fewer than #c health insurance issuers offering a qualified health plan through the individual market in the ,exchange operating in the ,state2 or 7ii7 the ,secretary1 or the ,state in such a case1 determines that the requirement under subparagraph 7,a7 would cause the ,,ma organization to become insolvent4 7,e7 ,definitions ,in this paragraph3 7i7 ,applicable area ,the term applicable area means an area in which1 at the time the ,secretary or the ,state sends the notification under subparagraph 7,c71 fewer than #c health insurance issuers offer a qualified health plan through the individual market in the ,exchange operating in the ,state4 7ii7 ,exchange ,the term ,exchange means an ,american ,health ,benefit ,exchange established under section #acaa or section #acba of the ,patient ,protection and ,affordable ,care ,act4 7iii7 ,group market ,the term group market has the meaning given such term in section #acjd of the ,patient ,protection and ,affordable ,care ,act4 7iv7 ,health insurance coverage ,the term health insurance coverage has the meaning given the term in section #bgia7;b7 of the ,public ,health ,service ,act4 7v7 ,individual market ,the term individual market has the meaning given such term in section #acjd of the ,patient ,protection and ,affordable ,care ,act4 7vi7 ,qualified health plan ,the term qualified health plan has the meaning given that term in section #acja7;a7 of the ,patient ,protection and ,affordable ,care ,act4 4 7#b7 ,effective date ,the amendment made by this subsection shall apply to contracts entered into or renewed after ,december #ca1 #bjbj4 7b7 ,requirements for medicaid managed care organizations 7#a7 ,in general ,section #aijc7m77#b77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7m77#b77;,a77 is amended-- 7,a7 in clause 7xii71 by striking 2 and and inserting a semicolon2 7,b7 by realigning the left margin of clause 7xiii7 to align with the left margin of clause 7xii72 7,c7 in clause 7xiii71 by striking the period at the end and inserting 2 and2 and 7,d7 by inserting after clause 7xiii7 the following3 7xiv7 such contract requires that the entity meets the requirements described in section #aheg7;e77#f7 in the same manner as such requirements apply to an ,,ma organization4 4 7#b7 ,effective date ,the amendments made by this subsection shall apply to contracts entered into or renewed after ,december #ca1 #bjbj4 #cjc4 ,enrollment in ,exchanges 7a7 ,open enrollment and special enrollment periods ,section #acaa7;c77#f7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjca7;c77#f77 is amended-- 7#a7 in subparagraph 7,b71 by inserting that are not less than #h weeks after open enrollment periods2 7#b7 in subparagraph 7,c71 by striking 2 and and inserting 22 7#c7 in subparagraph 7,d71 by striking the period and inserting 22 and 7#d7 by adding at the end the following3 7,e7 a special enrollment period for qualified individuals enrolled in a plan that makes significant provider terminations during the plan year1 as determined in accordance with regulations promulgated by the ,secretary2 and 7,f7 a special enrollment period-- 7i7 for each qualified individual who-- 7,i7 is determined by the ,exchange to be eligible for a premium assistance credit under section #cf;,b of the ,internal ,revenue ,code of #aihf2 and 7,,ii7 has a household income not in excess of #cjj percent of the poverty line for the size of the family involved2 and 7ii7 which shall begin on the date on which the individual is determined by the ,exchange to be eligible for a premium assistance credit under such section #cf;,b4 4 7b7 ,consumer protections regarding automatic re-,enrollment ,part #b of subtitle ,d of title ,i of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjca et seq47 is amended by adding at the end the following3 #acad4 ,consumer protections regarding automatic re-enrollment 7a7 ,consent ,to avoid automatic re-,enrollment for individuals losing eligibility for premium assistance credits ,the ,secretary shall establish a process to allow an individual1 who is enrolling in a qualified health plan through an ,exchange and whom the ,exchange estimates is eligible to receive a premium assistance credit under section #cf;,b of the ,internal ,revenue ,code of #aihf1 to provide consent to the ,exchange to not automatically re-enroll the individual in such qualified health plan 7or a comparable qualified health plan in a case described in subsection 7b77 for the following plan year if during the plan year the ,exchange estimates that the individual has become no longer eligible to receive such credit4 7b7 ,notice regarding discontinued plans ,in the case of an individual who is enrolled in a qualified health plan through an ,exchange for a plan year that will not be offered through such ,exchange for the following plan year1 the ,exchange through which such plan is offered shall1 prior to the open enrollment period for the following plan year1 send the individual a notice stating-- 7#a7 that the qualified health plan in which the individual is enrolled will not be offered through such ,exchange for the following plan year2 7#b7 that unless the individual takes action1 the individual will be enrolled in a comparable qualified health plan for the following plan year2 7#c7 the estimated amount of premiums for such comparable qualified health plan2 and 7#d7 clear information on the eligibility of the individual for a special enrollment period4 7c7 ,notice regarding automatic re-,enrollment ,any notice regarding automatic re-enrollment sent by an ,exchange to an individual enrolled in a qualified health plan shall be provided to the individual in the language that the individual has indicated to the ,exchange as the preferred language of the individual4 7d7 ,retroactive termination 7#a7 ,in general ,the ,secretary shall establish a process to allow an individual who is automatically re-enrolled in a qualified health plan for a plan year and who has enrolled in other creditable coverage for that plan year to retroactively terminate such qualified health plan for such plan year4 7#b7 ,creditable coverage ,in this subsection1 the term creditable coverage has the meaning given the term in section #bgjd7;c77#a7 of the ,public ,health ,service ,act4 4 7c7 ,effective date ,the amendments made by this section shall apply to plan years beginning after the date of enactment of this ,act4 7d7 ,study ,the ,secretary shall conduct a study that examines the practices used by the ,exchanges for notifying consumers of automatic re-enrollment in qualified health plans and identifies strategies for-- 7#a7 improving automatic re-enrollment and renewal notifications2 7#b7 improving the ability to reach consumers in providing such notices2 7#c7 increasing consumer comprehension of such notices2 and 7#d7 encouraging consumers to-- 7,a7 update information that will affect eligibility for premium assistance credits under section #cf;,b of the ,internal ,revenue ,code of #aihf and the amount of such credits2 and 7,b7 shop for qualified health plans that will best meet their needs through the ,exchange operating in their ,state4 #cjd4 ,marketing and outreach for ,exchanges operated by the ,secretary ,part #b of subtitle ,d of title ,i of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjca et seq471 as amended by section #cjc7;b71 is further amended by adding at the end the following3 #acae4 ,marketing and outreach for ,exchanges operated by the ,secretary 7a7 ,in general ,out of the funds appropriated under subsection 7b71 the ,secretary shall conduct a marketing and outreach program with respect to qualified health plans offered through ,exchanges operated by the ,secretary in order to encourage enrollment in such plans4 7b7 ,appropriations 7#a7 ,encouraging enrollment for plan year #bjbj ,there is appropriated to the ,secretary1 out of any moneys in the ,treasury not otherwise appropriated1 #dhj1jjj1jjj to carry out the marketing and outreach program under subsection 7a7 with respect to encouraging enrollment for qualified health plans that begin in calendar year #bjbj4 7#b7 ,encouraging enrollment for subsequent plan years ,to carry out the marketing and outreach program under subsection 7a7 with respect to encouraging enrollment for qualified health plans that begin in each of calendar years #bjba through #bjbe1 there is appropriated to the ,secretary prior to each such calendar year1 out of any moneys in the ,treasury not otherwise appropriated1 an amount equal to the amount appropriated under this subsection for the prior calendar year increased by #d percent for each such calendar year4 7#c7 ,availability ,the amounts appropriated under paragraphs 7#a7 and 7#b7 shall remain available until expended4 4 #cje4 ,navigator program ,section #acaa7;i7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjca7;i77 is amended-- 7#a7 in paragraph 7#b7-- 7,a7 in subparagraph 7,b71 by striking and other entities and inserting and other entities 7such as ,indian tribes1 tribal organizations1 urban ,indian organizations1 and ,state or local human service agencies72 and 7,b7 by adding at the end the following3 7,c7 ,preference ,an ,exchange shall ensure that1 each year1 it awards a grant under paragraph 7#a7 to-- 7i7 at least one entity described in this paragraph that is a community and consumer-focused nonprofit group2 and 7ii7 at least one entity described in subparagraph 7,b71 which may include another community and consumer-focused nonprofit group4 2 7#b7 in paragraph 7#c7-- 7,a7 in subparagraph 7,d71 by striking 2 and and inserting 22 7,b7 in subparagraph 7,e71 by striking the period and inserting 2 and2 and 7,c7 by adding at the end the following3 7,f7 provide targeted assistance to individuals likely to qualify for a special enrollment period under subparagraph 7,c71 7,d71 or 7,e7 of subsection 7c77#f74 2 and 7#c7 in paragraph 7#d77;,a7-- 7,a7 in the matter preceding clause 7i71 by striking not2 7,b7 in clause 7i7-- 7i7 by inserting not before be2 and 7ii7 by striking 2 or and inserting 22 7,c7 in clause 7ii7-- 7i7 by inserting not before receive2 and 7ii7 by striking the period and inserting 22 and 7,d7 by adding at the end the following3 7iii7 maintain physical presence in the ,state of the ,exchange so as to allow in-person assistance to consumers2 and 7iv7 not provide compensation to an employee employed by the navigator based on the number of individuals the employee assists in enrolling in qualified health plans4 4 ,,iv ,strengthening consumer health insurance protections #dja4 ,prohibiting discriminatory premiums based on tobacco use 7a7 ,in general ,section #bgja7;a77#a77;,a7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg7a77#a77;,a77 is amended-- 7#a7 in clause 7ii71 by inserting and after the semicolon2 and 7#b7 by striking clause 7iv74 7b7 ,effective date ,the amendments made by this section shall apply to plan years beginning after ,december #ca1 #bjbj4 #djb4 ,health insurance consumer information ,section #bgic of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ic7 is amended-- 7#a7 in subsection 7d7-- 7,a7 in the second sentence1 by striking and shall share and inserting 1 shall share2 and 7,b7 by striking the period at the end of second sentence and inserting 1 and 7not later than #b years after the date of enactment of the ,consumer ,health ,insurance ,protection ,act of #bjai7 shall make such data available to the public in a searchable format on an internet website established by the ,secretary42 and 7#b7 in subsection 7e7-- 7,a7 in paragraph 7#a71 by striking #cj1jjj1jjj for the first fiscal year for which this section applies and inserting #ej1jjj1jjj for each of fiscal years #bjba through #bjbe2 and 7,b7 in paragraph 7#b71 by striking each fiscal year following the fiscal year described in paragraph 7#a7 and inserting fiscal year #bjbf and each fiscal year thereafter4 #djc4 ,patient protections 7a7 ,in general ,section #bgai;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 is amended-- 7#a7 in subsection 7b7-- 7,a7 in paragraph 7#a71 in the matter preceding subparagraph 7,a71 by striking paragraph 7#b77;,b7 and inserting paragraph 7#c77;,b72 7,b7 by redesignating paragraph 7#b7 as paragraph 7#c72 7,c7 by inserting after paragraph 7#a7 the following3 7#b7 ,reimbursement ,a group health plan or health insurance issuer offering group or individual health insurance coverage shall reimburse an out-of-network provider providing emergency services to an individual who is a participant1 beneficiary1 or enrollee of such plan or coverage at an amount equal to the greatest of-- 7,a7 the median amount negotiated with in-network providers for the emergency service2 7,b7 the amount for the emergency service calculated using the same method the plan or issuer uses to determine payments for out-of-network services that are not emergency services2 or 7,c7 the amount that would be paid to a provider of services or supplier with respect to the furnishing of such service under title ,,xviii of the ,social ,security ,act4 2 and 7,d7 in paragraph 7#c77;,b71 as so redesignated-- 7i7 clause 7i71 by inserting 1 including ambulance services provided by ground or air transportation before 1 and at the end2 and 7ii7 in clause 7ii71 by striking the period at the end and inserting 1 including ambulance services provided by ground or air transportation42 and 7#b7 by adding at the end the following3 7e7 ,coverage of services by out-of-,network providers based on plan or issuer error 7#a7 ,in general ,a group health plan or health insurance issuer offering group or individual health insurance coverage shall provide coverage of a service provided by an out-of-network provider to an individual who is a participant1 beneficiary1 or enrollee of such plan or coverage if-- 7,a7 the plan or issuer would have provided coverage of the service if the service was provided by an in-network provider2 and 7,b7 in choosing such provider1 the individual reasonably relied on a materially inaccurate1 incomplete1 or misleading statement of information contained in a directory of in-network providers compiled by the plan or issuer4 7#b7 ,cost-sharing ,a group health plan or health insurance issuer that provides coverage of a service provided by an out-of-network provider under paragraph 7#a7 shall provide such coverage with the same cost-sharing requirement that would apply if the services were provided in-network4 7f7 ,coverage for enrollees in active course of treatment 7#a7 ,in general ,a group health plan or health insurance issuer offering group or individual health insurance coverage shall1 at the request of an individual who is a participant1 beneficiary1 or enrollee of such plan or coverage and in accordance with paragraphs 7#d7 and 7#e71 provide to such individual coverage of services for an active course of treatment provided by a provider that is an out-of-network provider with respect to such plan or coverage if-- 7,a7 coverage of such services would be provided under the group health plan or health insurance coverage if the services were provided by an in-network provider2 and 7,b7 a circumstance described in paragraph 7#c7 applies4 7#b7 ,cost-sharing ,a group health plan or health insurance issuer offering group or individual health insurance coverage shall ensure that any cost-sharing requirements for coverage of services for an active course of treatment provided by an out-of-network provider under paragraph 7#a7 are the same requirements as if such services were provided by an in-network provider4 7#c7 ,circumstance ,a circumstance described in this paragraph is a circumstance in which-- 7,a7 with respect to a health insurance issuer offering group or individual health insurance coverage-- 7i7 the individual was receiving services for the active course of treatment described in paragraph 7#a7 from the out-of-network provider described in such paragraph during the prior plan year when-- 7,i7 the individual was a participant1 beneficiary1 or enrollee of a different health insurance coverage offered by such health insurance issuer2 and 7,,ii7 such provider was an in-network provider with respect to such different health insurance coverage2 and 7ii7 the health insurance issuer decided to cancel or discontinue offering such different health insurance coverage for the plan year for which the individual makes the request1 including a case in which such different health insurance coverage is withdrawn from the market for such plan year2 and 7,b7 the individual was receiving services for the active course of treatment described in paragraph 7#a7 from the out-of-network provider described in such paragraph while the provider was an in-network provider for the group health plan or health insurance coverage for the plan year1 and1 during such plan year1 the provider became a terminated provider with respect to such plan or coverage for the remainder of such plan year4 7#d7 ,duration ,a group health plan or health insurance issuer offering group or individual health insurance coverage shall provide coverage of services for an active course of treatment under paragraph 7#a7 until the earlier of-- 7,a7 the date on which the treatment is complete2 or 7,b7 the date that is #ahj days following the first date on which the provider described in paragraph 7#a7 is no longer an in-network provider of the plan or coverage in providing such services to the individual4 7#e7 ,request for continuity of care ,a request made under paragraph 7#a7 shall be subject to any internal or external grievance or appeals process of the group health plan or health insurance issuer1 in accordance with any applicable ,state or ,federal law4 7#f7 ,definitions ,for purposes of this subsection3 7,a7 ,active course of treatment ,the term active course of treatment means any of the following3 7i7 ,an ongoing course of treatment for-- 7,i7 a life-threatening condition2 7,,ii7 a serious1 acute condition2 or 7,,iii7 a serious1 chronic condition4 7ii7 ,care provided with respect to pregnancy1 including until the completion of postpartum care directly related to the delivery4 7iii7 ,an ongoing course of treatment for a child between birth and #cf months4 7iv7 ,the performance of a surgery or other procedure that1 as documented prior to the time the provider became an out-of-network provider with respect to the group health plan or health insurance coverage-- 7,i7 the plan or issuer offering such coverage authorized as part of a course of treatment for the individual2 and 7,,ii7 the provider recommended for such individual4 7,b7 ,terminated provider ,the term terminated provider-- 7i7 means a provider that had a contract with a group health plan or health insurance issuer offering group or individual health insurance coverage to provide services as an in-network provider with respect to such plan or coverage for a plan year1 and1 during such plan year1 the plan or issuer terminated such contract or did not renew such contract for the remainder of the plan year2 and 7ii7 does not include-- 7,i7 any provider that voluntarily terminated or did not renew such contract for the remainder of the plan year2 and 7,,ii7 any provider whose contract with the plan or issuer terminated1 or was not renewed1 for the remainder of the plan year for reasons relating to a medical disciplinary cause1 fraud1 or other criminal activity4 7g7 ,limitations on changes in coverage of prescription drugs 7#a7 ,in general ,a group health plan or health insurance issuer offering group or individual health insurance coverage shall not1 during a plan year1 take any of the following actions with respect to coverage for such plan year3 7,a7 ,remove a prescription drug from a formulary of prescription drugs covered by such plan or coverage1 except as provided in paragraph 7#b77;,c74 7,b7 ,increase the obligation of a participant1 beneficiary1 or enrollee with respect to cost-sharing1 as defined in section #acjb7;c77#c7 of the ,patient ,protection and ,affordable ,care ,act1 for a prescription drug covered under such plan or coverage4 7#b7 ,rule of construction ,nothing in this subsection shall prohibit a group health plan or health insurance issuer offering group or individual health insurance coverage from1 during a plan year1 taking any of the following actions with respect to coverage under the plan or health insurance coverage for such plan year3 7,a7 ,changing the policy of the plan or health insurance coverage to require a participant1 beneficiary1 or enrollee to use a generic substitution for a branded prescription drug4 7,b7 ,adding a new prescription drug to a formulary of prescription drugs covered by such plan or health insurance coverage4 7,c7 ,removing a prescription drug from such a formulary due to patient safety concerns1 or a prescription drug recall1 or removing a prescription drug from interstate commerce as determined necessary by the ,secretary4 4 7b7 ,effective date ,the amendments made by this section shall apply to plan years beginning after ,december #ca1 #bjbj4 #djd4 ,limitation on balance billing for emergency services 7a7 ,in general ,a health care provider that provides any emergency service to an individual that is a participant1 beneficiary1 or enrollee of a group health plan1 group health insurance coverage1 or individual health insurance coverage and that is not an in-network provider of such plan or coverage shall not impose a charge on such individual for such emergency service1 other than any cost-sharing that would otherwise be applicable if the health care provider was an in-network provider of such plan or health insurance coverage4 7b7 ,enforcement ,the ,secretary may impose a civil monetary penalty1 in the same manner as such penalties are authorized under section #aabh;,a of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;a7 for violations of balance billing prohibitions under part ,b of title ,,xviii of such ,act 7#db ,u4,s4,c4 #acie;j et seq471 on any provider that violates the requirement under subsection 7a74 7c7 ,definitions ,in this section3 7#a7 ,cost-sharing ,the term cost-sharing has the meaning given the term in section #acjb7;c77#c7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7;c77#c774 7#b7 ,emergency service ,the term emergency service has the meaning given such term in paragraph 7#c77;,b7 of section #bgai;,a7b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7b771 as amended by section #djc7;a74 7#c7 ,group health plan1 group health insurance coverage1 and individual health insurance coverage ,the terms group health plan1 group health insurance coverage1 and individual health insurance coverage have the meanings given such terms in section #bgia of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ia74 7#d7 ,secretary ,the term ,secretary means the ,secretary of ,health and ,human ,services4 7d7 ,effective date ,this section shall apply to plan years beginning after ,december #ca1 #bjbj4 #dje4 ,notification of provider terminations ,subpart ,,ii of part ,a of title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#aa et seq47 is amended by adding at the end the following3 #bgcj4 ,notification of provider terminations 7a7 ,in general ,beginning ,january #a1 #bjbj1 a group health plan or health insurance issuer offering group or individual health insurance coverage shall inform individuals described in subsection 7b7 of the termination of any provider as an in-network provider under the plan or health insurance coverage4 ,such notice shall be provided not later than #cj days prior to the termination4 7b7 ,individuals ,the individuals described in this subsection are any individuals enrolled in the group health plan or health insurance coverage described in subsection 7a7 who have seen the provider described in such subsection on a regular basis or who have received primary care from such provider4 4 #djf4 ,short-term limited duration health insurance coverage 7a7 ,in general ,section #bgia7;b77#e7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ia7;b77#e77 is amended by striking but does not include and inserting including4 7b7 ,effective date ,the amendment made by this section shall apply to plan years beginning after ,december #ca1 #bjbj4 #djg4 ,protecting essential health benefits and coverage of pediatric services 7a7 ,protecting essential health benefits ,section #acjb7;b7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7;b77 is amended-- 7#a7 in paragraph 7#b77;,b7 and paragraph 7#c71 by striking 7#d77;,h7 each place it appears and inserting 7#d77;,i72 and 7#b7 in paragraph 7#d7-- 7,a7 in subparagraph 7,a7-- 7i7 by striking such subsection and inserting such paragraph2 and 7ii7 by inserting and coverage in every category is included before the semicolon2 7,b7 by redesignating subparagraphs 7,e7 through 7,h7 as subparagraphs 7,f7 through 7,i71 respectively2 and 7,c7 by inserting after subparagraph 7,d7 the following3 7,e7 ensure that1 to be treated as providing coverage for the essential health benefits described in paragraph 7#a71 a qualified health plan-- 7i7 shall not substitute benefits between categories described such paragraph1 as described in section #aef4aae7;b77#b77;ii7 of title #de1 ,code of ,federal ,regulations1 as in effect on the day before the date of enactment of the ,consumer ,health ,insurance ,protection ,act of #bjai2 7ii7 shall provide a wide variety of classes of prescription drugs on the prescription drug formulary of such plan2 7iii7 shall1 if a medically necessary drug is not on the prescription drug formulary of such plan1 allow individuals enrolled in such plan to have access to the drug through an exceptions process established by the plan2 and 7iv7 shall not impose limits on coverage of habilitative services and devices that are less favorable than any such limits imposed on coverage of rehabilitative services and devices4 4 7b7 ,coverage of pediatric services ,the ,secretary of ,health and ,human ,services1 in consultation with pediatric service providers1 shall promulgate a series of recommendations for group health plans and health insurance issuers offering group or individual health insurance coverage to improve coverage of pediatric services4 #djh4 ,association health plans 7a7 ,treatment of association health plans 7#a7 ,association health plan defined ,for purposes of this subsection1 the term association health plan means any health insurance coverage that is provided to an association1 but not related to employment1 and sold to individuals through such association4 7#b7 ,treatment as individual health insurance coverage ,for purposes of title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg et seq471 part #g of subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aaha et seq471 chapter #ajj of the ,internal ,revenue ,code of #aihf1 and title ,i of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 health insurance coverage offered through an association health plan shall be treated as individual health insurance coverage if-- 7,a7 the coverage is offered to a member of the association other than in connection with a group health plan2 or 7,b7 the coverage is offered to a member of the association that is an employer maintaining a group health plan that has fewer than #b participants who are employees on the first day of the plan year4 7#c7 ,treatment as health insurance coverage in the small group market ,for purposes of title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg et seq471 part #g of subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aaha et seq471 chapter #ajj of the ,internal ,revenue ,code of #aihf1 and title ,i of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 health insurance coverage offered through an association health plan shall1 subject to paragraph 7#b77;,b71 be treated as health insurance coverage in the small group market if the coverage is offered to a member of the association in connection with a group health plan offered to employers that are small employers1 as defined in such applicable ,act or ,code4 7#d7 ,preemption ,an association health plan shall be treated as individual health insurance coverage in accordance with paragraph 7#b7 or health insurance coverage in the small group market in accordance with paragraph 7#c7 notwithstanding any applicable ,state law4 7#e7 ,effective date ,this subsection shall apply to plan years beginning after ,december #ca1 #bjbj4 7b7 ,department of ,labor rule regarding the definition of employer under ,,erisa ,beginning with respect to plan years beginning after ,december #ca1 #bjbj1 the final rule of the ,department of ,labor entitled ,definition of ,employer ,under ,section #c7e7 of ,,erisa--,association ,health ,plans 7#hc ,fed4 ,reg4 #bhiab 7,june #ba1 #bjah77 shall have no force or effect4