,i  #aai? ,,congress  #b;d ,session  ,h4
 ,r4 #hddb  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,april #bb1 #bjbf,ms4 
,craig 7= h]self & ,mr4 ,ryan7 introduc$
 ! foll[+ bill2 :i* 0 ref]r$ to !       
,committee on ,en]gy & ,comm]ce  ,a     
,,bill  ,to am5d title ,,xxvii ( !      
,public ,heal? ,s]vice ,act to e/abli%  
civil liability = heal? insurance issu]s
 ) high levels ( claims d5ials4  #a4    
,%ort title  ,?is ,act may be cit$ z !  
,pati5t ,refunds = ,bad ,d5ials ,act (  
#bjbf4  #b4 ,e/abli%+ civil liability = 
heal? insurance issu]s ) high levels (  
claims d5ials  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  ,f  
,claims d5ials  #bgii;,c-#a4 ,civil     
liability = high rates ( claims d5ials  
7a7 ,9 g5]al ,! ,secret>y may impose on 
ea* heal? insurance issu] (f]+ gr\p or  
individual heal? insurance cov]age = a  
plan ye> beg9n+ on or aft] ,janu>y #a1  
#bjbg1 a civil monet>y p5alty n to exce$

 ! am\nt specifi$ 9 subsection 7e7 if ! 
,secret>y f9ds t any su* cov]age (f]$ by
 su* issu] dur+ su* plan ye> _h an      
claims d5ial p]c5tage ( #be p]c5t 7or   
su* l[] p]c5t z ! ,secret>y may specify7
 or great]4  7b7 ,claims d5ial p]c5tage 
7#a7 ,9 g5]al ,= purposes ( ?is section1
 ! t]m claims d5ial p]c5tage means1 )   
respect to gr\p or individual heal?     
insurance cov]age & a plan ye>1 !       
p]c5tage ( claims = items & s]vices     
furni%$ dur+ su* plan ye> t ! ,secret>y 
det]m9es1 pursuant to audits conduct$ "u
 subsection 7c71 7 d5i$4  7#b7          
,exclusion ( c]ta9 claims ,a claim d5i$ 
on ! basis ( fraud or lack ( m$ical     
necessity t ! ,secret>y det]m9es1       
pursuant to audits conduct$ "u          
subsection 7c71 7 correctly d5i$ %all n 
be treat$ z a d5i$ claim = purposes (   
clause 7i74  7#c7 ,evaluations ( d5i$   
claims ,9 assess+ :e!r a claim t 0 d5i$ 
by a heal? insurance issu] (f]+ gr\p or 
individual heal? insurance cov]age on ! 
basis ( fraud 0 correctly d5i$ =        

purposes ( det]m9+ ! claims d5ial       
p]c5tage ( su* cov]age1 ! ,secret>y %all
 f9d su* claim to h be5 correctly d5i$  
only if su* issu] provides suffici5t    
in=mation to ! ,secret>y to demon/rate t
 su* claim 0 fraudul5t4  7c7 ,audits ,! 
,secret>y may conduct su* audits ( gr\p 
& individual heal? insurance cov]age z !
 ,secret>y det]m9es appropriate =       
purposes ( asc]ta9+ ! claims d5ial      
p]c5tage ( su* cov]age4  7d7            
,di/ribution ( am\nts ,! ,secret>y %all 
di/ribute on a pro rata basis to        
individuals enroll$ dur+ a plan ye> 9   
gr\p or individual heal? insurance      
cov]age (f]$ by a heal? insurance issu] 
:i* is subject to a civil monet>y p5alty
 impos$ "u ?is section ) respect to su* 
plan ye> an am\nt equal to am\nts       
collect$ "u ?is section = su* p5alties s
 impos$4  7e7 ,am\nt specifi$  7#a7 ,9  
g5]al ,= purposes ( subsection 7a71 !   
am\nt specifi$ 9 ?is subsection is1 )   
respect to a heal? insurance issu]--    
7,a7 #aj1jjj1jjj2 plus  7,b7 an         

additional #b1jjj1jjj = e p]c5tage po9t 
by :i* ! claims d5ial p]c5tage ( su*    
issu] exce$s #be p]c5t4  7#b7 ,inflation
 adju/m5ts ,! ,secret>y may adju/ !     
am\nts specifi$ 9 ?is subsection = #bjbh
 & ea* subsequ5t ye> to acc\nt = ! *ange
 9 ! consum] price index = all urban    
consum]s ov] ! prec$+ ye>4  7#c7        
,consid]ations 9 imposition ,9 det]m9+ !
 am\nt ( a civil monet>y p5alty "u ?is  
section1 ! ,secret>y may take into      
acc\nt any ef=ts made by ! heal?        
insurance issu] to r$uce ! claims d5ial 
p]c5tage ( heal? insurance cov]age (f]$ 
by su* issu]4  4  7b7 ,consum]          
protections  7#a7 ,9 g5]al ,subp>t ,,ii 
( "p ,a ( title ,,xxvii ( ! ,public     
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;gg-#aa et seq47 is am5d$ by add+ at
 ! end ! foll[+ new section3  #bgcj4    
,transp>5cy ( in=mation  7a7 ,9 g5]al ,a
 heal? insurance issu] (f]+ gr\p or     
individual heal? insurance cov]age %all1
 9 ! case su* issu] d5ies a claim = an  
item or s]vice furni%$ to an individual 

on ! basis t su* item or s]vice 0 n     
m$ically necess>y1 provide to su*       
individual a notice conta9+--  7#a7 !   
issu]'s m$ical necessity /&>ds = su*    
item or s]vice2 &  7#b7 an explanation (
 :y su* item or s]vice s furni%$ fail$  
to meet su* /&>ds4  7b7 ,base claims    
d5ial rate ,a heal? insurance issu] (f]+
 gr\p or individual heal? insurance     
cov]age %all = ea* plan ye> submit to ! 
,secret>y ! p]c5tage ( claims t 7 d5i$  
"u su* cov]age = any reason4  4  7#b7   
,effective date ,! am5dm5t made by ?is  
subsection %all apply ) respect to plan 
ye>s beg9n+ on or aft] ,janu>y #a1      
#bjbg4