Title 1 Protections and standards for qualified health benefits plans
Section 101 Requirements Reforming Health Insurance Market Place
The purpose of this title is to establish standards to ensure that new health insurance coverage and employments based health plans that are offered meet standards guaranteeing access to affordable coverage, essential benefits, and other consumer protections.
Requirements for qualified health benefits plans
On or after the first day of Y1, a health benefit plan shall not be a qualified health benefits plan under this division unless the plan meets the applicable requirements of the following for the types of plan and plan year involved
Subtitle B- relating to affordable coverage
“ C- Relating to essential benefits
“ C- Relating to consumer protection
Protecting the choice to keep current coverage- grandfathered in if the following are met
1. Limitations on new enrollment
A. Except as provided in the paragraph insurance company offers coverage and does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1
B. B. Dependent coverage permitted not effect enrollment
2. Limits on changes in terms or conditions except as required under state law the issuer does not change including benefits, and cost sharing.
3. Restrictions on Premium Increases
b. Cannot vary the percentage increase in premiums for a risk group grandfathered in without changing premiums for all enrollees in the risk group at the same rate
1. Grace period of current employment based health plans
A. Grace Period beginning with Y1 for a 5-year period. Employment plan in operation the day of before the first day of Y1.
B. Exception for limited benefits plan shall not apply to employment based plans that coverage consists of
o American Recovery and Reinvestment Act of 2009
o Benefits from Employee Retirement Income Security Act of 1974
o Limitation supplied from insurance commissioner
Employee-based health in no case shall consist of only one or more of the coverage benefits, through the
The acts listed above.
2. Transitional treatment as acceptable coverage
Grace period specified above described, is treated as acceptable coverage.
C. Limitations on individual health insurance coverage
1. General
a. Coverage not grandfathered in may be offered on or after the first day of Y1 as an exchange participating health plan.
2 Separate, accepted coverage permitted
Nothing shall be permitted other than Para 1 other than the health insurance exchange, unless it is offered and priced separately from health insurance coverage.
2. Stand-alone dental and vision coverage
a. Does not prevent offering stand-alone plans
b. Benefits plans to such stand-alone plans offered and priced separately from the plan.
Standards guaranteeing access to affordable coverage
Prohibiting Preexisting Condition Exclusions
No preexisting condition exclusion or impose any limit or condition on coverage with respect to an individual or dependent.
Guaranteed Issue and Renewal for insured plans
Applies to individuals and employees in individual and group health plan, whether offered in the Health Insurance Exchange through employment, or otherwise, and apply to the public health insurance plan option. Coverage offered in the small group market except renewal, or discontinuation. The issuer provides the enrollee with notice of non-payment, and a grace period to correct nonpayment except in cases of fraud.
Insurance Rating Rules
Guaranteed availability and renewability of coverage applies to individuals and employers in all individual and group coverage weather offered through the health insurance exchange, employment based, or otherwise and apply to the public health insurance option, (except renewal or discontinuation of coverage). Coverage is only prohibited in cases of fraud.
A. a. Rates charged and coverage may not vary except:
1. Limited age variations
2. By area
3. By family enrollment
b Actuarial value of optional service coverage
1. Commissioner will estimate the basic per enrollee, per month cost; determine an average actuarial base, to include coverage under a basic plan.
2. Considerations
a. Take into account the impact of overall costs of inclusion of coverage, not any reduction of cost estimated with results from services, including prenatal, delivery, and postnatal care.
b. B estimate costs as if coverage for the entire population and
c. May not estimate cost at less than $1 per enrollee per month.
C Study and Reports
1 The commissioner and Secretary of HHS and Sec. Of labor, conduct a study of large group insured and self-insured employer care markets to examine
a. Types of employers by key characteristics: including size that purchase insured products v. self-insured.
b. Note similarities and differences between typical insured, and self-plans
c. Financial solvency and capital reserve levels of employers that self-insure by size
d. Risk of self-insured employers unable to pay, or become insolvent as a result.
e. Which rating rules likely to cause adverse selection in the large market or encourage small to midsize employers to self-insure
2 Reports
Not later than 18 months after the enactment of the Act, the study will be submitted to Congress and agencies
1. Including
a. Recommendations
b. Ensure the law does not provide incentives for small and mid-size employers to self-insure or create adverse selection in risk pools of large groups, and self-insured employers.
c. Not later than 18 months after the first day of Y1, for the Commissioner to submit to congress, and agencies
i. Any updated reports,
ii. Any updated recommendations
Sect. 114. Nondiscrimination in Benefits; Parity in Mental Health and Substance Abuse Disorder Benefits.
A. Plan shall prohibit discrimination, or benefit structure for plans from :
• Employee Retirement Income Security Act of 1974
• The Public Health Service Act, and
• IRS code of 1986.
B. Parity in mental health and substance abuse disorder benefits
a. Provisions are not superseded by or inconsistent with subtitle C, the provisions of section 2715, of the Public Health Service Act will apply to plans regardless of it being offered in individual or group market, such provisions apply coverage in the large group market.
Sec 115. Ensuring Adequacy of Provider Networks
a. Qualified health benefits plan that uses a network for items and services meet standards the Commissioner established for adequate networks with enrollee access to such items and services and transparency in the cost sharing differentials between in and out of network coverage.
b. Provider network defined
a) Means the provider which covered benefits treatments, and services are available under the plan
Sec, 116 Ensuring value, and lower premiums
a. Plans must meet a medical loss ratio. For any plan year in which the plan does not meet the medical loss ratio the entity shall provide rebates to enrollees of payment sufficient to meet the loss.
b. Building on Interims Rules
a. Building on the HHS the Commissioner will define and develop methodologies to determine how to calculate the medical loss ratio. Methodology will be set at the highest level medical loss ratio possible that is designed to ensure adequate participation by qualify health benefits plan (QHBP) offering entities, competition in the insurance market in and out of the Exchange, and value for consumers so premiums are used for services.
Subtitle C- Standards Guaranteeing Access to Essential Benefits
Section 121 Coverage of Essential Benefits Package
a. meets the standards adopted under section 124 for the essential benefits package described in section 122 for the plan year
b. Choice of Coverage
1. Non exchange participating Health Benefits plans-
2. A plan not in an exchange participating plan, this type of plan may offer coverage in addition to the essential package.
3. Continuation of Offering of Separate excepted benefits coverage- Nothing in this section will affect the offering of benefits as excepted benefits, if offered under a separate policy, contract, or certificate of insurance.
c. No Restrictions on Coverage Unrelated to clinical appropriateness- plan may not impose restrictions unrelated to clinical appropriateness on care of items and services
Sect. 122 Essential benefits package defined
a) Essential benefits package means health benefits coverage, consistent with standards adopted to ensure quality care, and financial security, that-
1. Provides payment for items and services
b) Within the standards of care or practice
2. Limits cost sharing
3. Prohibits annual or lifetime limits on coverage
4. Complies with section 115 and
5. Is equivalent to the average employee sponsored coverage
b. Minimum Services to be Covered-subject to subsection (d), the items, and services described are:
1. Hospitalization
2. Outpatient hospital and outpatient clinic, services, including emergency department services
3. Professional services of physicians and other health professionals
4. Services, equipment, and supplies incident to the services of a physician’s or a health professional’s delivery of care in institutional settings, dr. offices patient homes, place of residence or other settings as appropriated.
5. Prescription Drugs
6. Rehabilitative and habilitative services
7. Mental Health and substance use disorder services, including behavior health treatment.
8. Preventive services including services a, or b by the task force on clinical preventive services and vaccines recommended by the CDC
9. Maternity care
10. Well baby and well childcare; treatment of congenital or developmental deformity, disease or injury; oral health, and hearing services, equipment and supplies for children under 21.
c. Requirements relating to Cost-Sharing and Minimum Actuarial value
1. No cost sharing for preventive services.
No cost sharing for essential benefits package for preventive items and services including well baby and well childcare.
2. Annual Limitation
A does not exceed the applicable level specified under subparagraph b.
B applicable Level
Applicable level is for Y1 is $5,000 for an individual and $10,000 for a family. Such levels shall be increase in $100 increments for each subsequent year by annual percentage increase in the Consumer Price Index applicable to the year.
C Use of copayments
Use copayments not coinsurance
3. Minimum Actuarial Value
a. provide a level of coverage designed to provide benefits that are equivalent to approx. 70% of the full actuarial value of the benefits.
b. Reference benefits package described
is essential benefits package if there were no cost sharing imposed.
d. Abortion coverage prohibited as part of the Minimal, Benefits package
2. voluntary choice of coverage by plan.
Plan is not required to provide coverage of services for paragraph 4a, or 4b and shall determine whether coverage is provided.
3. coverage under public health insurance option
Provide coverage for services described in 4 b. Nothing shall be construed as preventing the public health insurance option from providing for or prohibiting coverage of services described in 4a.
4. Abortion Services
A Abortions for which public funding is prohibited. Based on the law as in effect as of the date that is six months before the beginning of the plan year involved.
B. Abortions for which public funding is allowed. The services for abortions which the expenditure of Federal funds appropriated for the DHH is permitted based on the law in effect as of the plan year involved.
e. standalone coverage
1. No application to adult coverage- Nothing in this subtitle shall be construed as requiring an individual 21 or older to be provided stand-alone dental only or vision only coverage.
2. Treatment of combined coverage-The combination of stand-alone coverage described in paragraph 1 and a benefits plan without coverage of such oral and vision services shall be treated as satisfying the essential benefits package under this division.
Sec. 123. Health Benefits Advisory Committee.
A Establishment
1. establish a private-public advisory committee shall be a panel of medical and other experts to be known as the Health Benefits Advisory Committee to recommend covered benefits, and essential, enhanced, and premium plans.
2. Chair- The Surgeon General shall be a Chair of the Health Benefits Advisory Committee.
3. Membership- The Health Benefits Advisory Committee shall be composed of the following members in addition to the surgeon general:
a- Nine members who are not Federal employees or officers and who are appointed by the President.
B nine members who are not federal employees or officers and who are appointed by the Comptroller General of the United States in a manner similar to the manner in which the Comptroller General appoints members to the Medicare Payment Advisory Commission under the Social Security Act.
C. Such even number of members who are federal employees and officers as the President may appoint, not to exceed 8.
Such initial appointments shall be made no later than 60 days after the date of the enactment of this Act.
4. Terms- Each member of the Committee shall serve a 3-year term on the Committee, except that the terms of the initial members shall be adjusted in order to provide for staggered tem of appointment for all such members.
5. Participation – The membership of the Committee shall at least reflect providers, consumer representatives, employers, labor, health insurance issuers, experts in health care financing and delivery, experts in racial and ethnic disparities, experts in care for those with disabilities representatives of relevant governmental agencies, and at least one practicing physicians or other health professional and an expert on children’s health and shall represent a balance among various sectors of the health care system so that no single sector unduly influences the recommendation of such Committee. Not less than 25 percent of the members of the Committee shall be practicing health care practitioners, who as of the date of their appointment, practice in a rural area and who have practiced in a rural area for at least the 5-year period preceding such date.
B Duties
1. Recommendations on benefits standards. The Health Benefits Advisory Committee shall recommend to the SHH benefit standard (4), and periodic updates to such standards. In developing such recommendations, the Committee shall take into account innovation in health care and consider how such standards could reduce health disparities.
2. Deadline- The Health Benefits Advisory Committee shall recommend initial benefits standards to the Secretary not later than 1 year after the date of the enactment of this Act.
3. Public Input- The Committee shall allow for public input when developing recommendations.
4. Benefit standards defined
A the essential benefits package described in section 122, including treatment, items, and services within benefit classes, and cost-sharing consistent with (d) and
B The cost sharing levels for enhanced plans and premium plans.
5. Levels of cost sharing for enhanced and Premium Plans
A enhanced plan- the level of cost sharing for enhanced plans shall be designed so the plans have benefits that are actuarially equivalent to approximately 85% of the actuarial value of the benefits provided under the reference benefits package described in section 122© (3)(B)
B. Premium Plan- The level of cost sharing for this plan is designed to have benefits that are actuarially equivalent approximately 95% of the actuarial value of the benefits provided under the reference benefits package.
C Operations-
1. Per Diem Pay
Each member shall receive travel expenses, including per diem in accordance with applicable provisions under subchapter I of chapter 57 of title 5, US Code and shall otherwise serve without additional pay.
2. Members not treated as Federal Employees.
Members shall not be considered employees of the federal government by reason of any service on the committee.
3. Application of FACA
The Federal Advisory Committee Act other than section 14 shall apply to the committee.
d. Publication
The secretary will provide in the Federal Register and post on the website of DHHS of all recommendations made.
Sec. 124 Process for adoption of Recommendation
Adoption of Benefit Standards.
(a) Process for Adoption of Recommendations.-
1. Review of Recommended Standards.-
Not later than 45 days after the date of receipt of benefits of such standards as modified under (2) (b), The Secretary will review standards and determine to propose adoption of as a package.
2. Determination to Adopt Standards If the Secretary determines-
A to propose adoption of standards so recommended as a package, the Secretary shall propose adoption such standards or
B not to propose adoption of such standards as a package, the Secretary shall notify the Committee in writing the determination and reasons for not proposing the recommendation and provide the Committee with opportunities to modify the recommendation and resubmit on a timely basis.
3. Contingency- If because the application of paragraph (2)(b), the Secretary would otherwise be unable to propose initial adoption of such recommended standards by the deadline The Secretary will propose adoption of the initial standards by such deadline.
4. Publication- In the Federal Register by the Secretary
B adoption of Standards
1. Initial Standards not later than 18 months after the enactment date. The secretary through rule making process adopt an initial set of standards.
2. Periodic Updating Standards Under subsection a secretary will provide periodic updating the standards previously adoption.
3. Requirement-
The Secretary may not adopt any standards for essential benefits or for level of cost sharing that are inconsistent with the requirements.
Sec. 124. Process For Adoption of Benefit Standards
A process for adoption of Recommendations
1 Review of recommended standards
Not later than 45 days after the date of receipt of standards recommended under section of 123, the Secretary will review, and determine to propose adoption of standards as a package.
2. Determination to adopt standards If the secretary determines-
A to propose adoption of standards as a package propose adoption or
B not to propose adoption, the secretary shall notify the Committee of the determination and reasons. The secretary will provide an opportunity to modify and resubmit.
3. Contingency- If the application of (2) (B) the secretary would otherwise be unable to propose initial adoption of such recommended standards by the deadline
4. Publication- Secretary will publish in the Federal Register
B Adoption of standards
1 initial standards not later than 18 months after the date of enactment, the secretary through rulemaking, adopt an initial set of standards
2. Periodic Updating Standards- the secretary will provide for periodic updating of the standards previously adopted.
3. Requirement- The secretary may not adopt any standards for an essential benefits package or for level of cost sharing that are inconsistent with the requirements for such a packs or level.
Sec. 125 Prohibition of Discrimination In Health Care Services Based on Religious or Spiritual Content
Neither the commissioner nor issuer discriminate in approving covering health care services on the basis of its religious or spiritual content if expenditures for such care are allowable as a deduction.
Subtitle D- Additional Consumer Protections
Sec. 131 Requiring Fair marketing practices by insurers.
132 Requiring fair grievance and appeals mechanism
Section 133 Requiring information Transparency and Plan Disclosure
A accurate and timely disclosure
1. plans shall comply with standards by the commissioner for the accurate and timely disclosure of plan documents, plan terms, and conditions, claims payment policies and practices, periodic financial disclosure, data on enrollment, data on disenrollment’s, data on the number of claims denials, data on rating practices, information on cost-sharing and payments with respect to any out of network coverage, and other info. As determined appropriate by the Commissioner, who shall require such disclosure be provided in plain language.
2. Plain Language-
Means nonprofessionals language
3. Guidance – development and issue guidance on best practice in plain language.
B Contracting Reimbursement- a qualified plan shall comply with standards by the commissioner to ensure transparency to each healthcare provider relating to reimbursement arrangements between such plan and such provider
C Advance notice of plan changes-
Shall not be made without reasonable notification and timely.
D Pharmacy Benefit Managers Transparency Requirements pg44
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