Subtitle C - Standards Guaranteeing Access to Essential Benefits
Sec. 121: Coverage of Essential Benefits Package
A qualified health plan must meet benefit standards with a certain benefits package for the plan year. If a qualified health plan is not part of the exchange market, it can offer additional benefits beyond the standard benefit package. If a plan is part of the exchange market, it must offer specific levels of benefits, or more if it is a premium-plus plan. These standards do not apply to excepted benefits as long as those are offered as a separate policy. Qualified health benefits may not have restrictions, other than cost-sharing, unrelated to clinical appropriateness regarding health care items and services.
Sec. 122: Essential Benefits Package Defined
Essential benefits means coverage that pays for items and services that meet accepted standards of medical, clinical, or professional practice, limits cost-sharing for such items and services appropriately, offers before-mentioned standards of provider network adequacy, and is equivalent to the average employer-sponsored coverage.
The minimum services must be covered; this includes hospitalization, outpatient services, professional services, services, equipment, and supplies necessary for delivery of care, prescription drugs, rehabilitative/habilitative services, mental health/substance abuse disorder services, preventive services, maternity care, and baby/child medical care up to 21 years old.
Cost-sharing is prohibited regarding preventive services. Cost-sharing may not exceed $5,000 per individual per year and $10,000 per family per year. These limits will increase every year by the annual percentage increase determined by the Consumer Price Index. To determine cost-sharing levels for basic, enhanced, and premium plans, co-payments will be used as much as possible. Cost-sharing will provide a level of benefits equal to 70% of the full actuarial value of the essential benefits packaged descibed above.
Sec. 123: Health Benefits Advisory Committee
This will be a private/public committee to recommend covered benefits, and what makes a plan essential, enhanced, or premium. The Surgeon General will chair this committee. Nine members will be non-Federal employees appointed by the President. Nine will be non-Federal employees appointed by the Comptroller General in a method similar to the appointment of members to the Medicare Payment Advisory Commission. Two, four, six, or eight members may be Federal employees and officers appointed by the President.
Each member will serve a three-year term. These terms will be staggered. Membership will reflect providers, consumers, employers, labor, health insurance companies, health care finance and delivery experts, racial/ethnic disparity experts, disabled care experts, relevant government agencies, and at least one practicing physician or health professional and an expert on children's health.
The committee is tasked with recommending and updating benefits standards, the first of which must come before one year after enactment of this bill. The committee will allow for public input as part of making recommendations. An essential plan will have benefits equal to 70% of the actuarial value of the benefits described above. An enhanced plan will have benefits actuarially equal to 85% of the value, and a premium plan will have benefits actuarially equal to 95%.
The committee will recieve coverage for travel expenses and a per diem. They will otherwise not be paid. They will not be considered Federal employees. The committee will adhere to the Federal Advisory Committee Act, and issue an online publication of all its recommendations.
Sec. 124: Process for Adoption of Recommendations; Adoption of Benefit Standards
The Secretary of Health and Human Services will review the committee's recommendations and decide whether or not to adopt those standards within 45 days of receipt. If not accepted, the Secretary must notify the committee of their reasons in writing and provide opportunity for the committee to make changes and resubmit. Standards will be adopted if the Secretary cannot come to a decision within 45 days. Standards will be published in the Federal Register.
The initial set of standards will be adopted no later than 18 months after the enactment of this bill. Adopted standards may not be inconsistent with the guidelines already mentioned in sections 122 and 123.
Section D - Additional Consumer Protections
Sec. 131: Requiring Fair Marketing Practices by Health Insurers
Uniform standards will be established that all entities offering qualified health benefit plans must meet.
Sec. 132: Requiring Fair Grievance and Appeals Mechanisms
Timely grievance and appeals mechanisms will be established. All entities offering qualified health benefit plans must provide an internal claims and appeals process that incorporates the procedures established in the Code of Federal Regulation, as well as any the standards determined by the commission. An external review board will establish a process for expedited review of urgent claims and for a review denied claims. Determinations made by this review board will be binding. All decisions of both internal and external boards are subject to the possibility of judicial review under state law regarding adverse decisions.
Sec. 133: Requiring Information Transparancy and Plan Disclosure
Qualified health benefits providers will disclose plan documents, terms, conditions, claims payment policies and practices, and periodic financial disclosure in an accurate and timely manner. Providers will also disclose data on enrollment and disenrollment, number of claims denials, rating practices, information on cost-sharing and payments regarding out-of-network coverage, and any other information deemed appropriate by the commission. This information will be provided in plain language that even individuals with limited English proficiency can readily understand. It will be clean, concise, and well-organized.
Standards will be established to ensure transparancy regarding reimbursement between a health care plan and provider.
Changes in qualified plans will not be made without reasonable and timely advance notice to enrollees.
Sec. 134: Application to Qualified Health Benefits Plans Not Offered Through the Health Insurance Exchange
Qualified health benefits plans not offered through the exchange will be subject to the same standards previously mentioned to an extent determined by the commission.
Sec. 135: Timely Payment of Claims
Qualified providers will be subject to the same payment rules that Medicare Advantage organizations are required to comply with regarding Medicare Part C, as determined by the Social Security Act.
Sec. 136: Standardized Rules for Coordination and Subrogation of Benefits
The commission will establish standards for coordination and subrogation of benefits and reimbursement of payments in cases involving individuals and multiple plan coverages.
Sec. 137: Application of Administrative Simplification
Qualified providers are subject to electronic financial and administrative transaction standards as defined in the Social Security Act.
Subtitles E and F tomorrow.
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