respect to each plan year, submit to the Secretary a report concerning the percentage of total premium revenue that such coverage expends "(1) on reimbursement for clinical services provided to enrollees under such coverage; "(2) for activities that improve health care quality; and "(3) on all other non-claims costs, including an explanation of the nature of such costs, and excluding State taxes and licensing or regulatory fees. The Secretary shall make reports received under this section available to the public on the Internet website of the Department of Health and Human Services. "(b) ENSURING THAT CONSUMERS RECEIVE VALUE FOR THEIR PREMIUM PAYMENTS. "(1) REQUIREMENT TO PROVIDE VALUE FOR PREMIUM PAYMENTS.-A health insurance issuer offering group or individual health insurance coverage shall, with respect to each plan year, provide an annual rebate to each enrollee under such coverage, on a pro rata basis, in an amount that is equal to the amount by which premium revenue expended by the issuer on activities described in subsection (a)(3) exceeds "(A) with respect to a health insurance issuer offering coverage in the group market, 20 percent, or such lower percentage as a State may by regulation determine; or "(B) with respect to a health insurance issuer offering coverage in the individual market, 25 percent, or such lower percentage as a State may by regulation determine, except that such percentage shall be adjusted to the extent the Secretary determines that the application of such percentage with a State may destabilize the existing individual market in such State. "(2) CONSIDERATION IN SETTING PERCENTAGES.-In determining the percentages under paragraph (1), a State shall seek to ensure adequate participation by health insurance issuers, competition in the health insurance market in the State, and value for consumers so that premiums are used for clinical services and quality improvements. "(3) TERMINATION.-The provisions of this subsection shall have no force or effect after December 31, 2013. "(c) STANDARD HOSPITAL CHARGES.-Each hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital's standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act. "(d) DEFINITIONS.-The Secretary, in consultation with the National Association of Insurance Commissions, shall establish uniform definitions for the activities reported under subsection (a). "SEC. 2719. APPEALS PROCESS. "A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum"(1) have in effect an internal claims appeal process; Public information. Web posting. 42 USC 300gg-19. Notification. 42 USC 300gg-93. Grants. "(2) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 2793 to assist such enrollees with the appeals processes; "(3) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process; and "(4) provide an external review process for such plans and issuers that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners and is binding on such plans.". SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION. Part C of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-91 et seq.) is amended by adding at the end the following: "SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION. "(a) IN GENERAL.-The Secretary shall award grants to States to enable such States (or the Exchanges operating in such States) to establish, expand, or provide support for "(1) offices of health insurance consumer assistance; or "(2) health insurance ombudsman programs. "(b) ELIGIBILITY.— "(1) IN GENERAL.-To be eligible to receive a grant, a State shall designate an independent office of health insurance consumer assistance, or an ombudsman, that, directly or in coordination with State health insurance regulators and consumer assistance organizations, receives and responds to inquiries and complaints concerning health insurance coverage with respect to Federal health insurance requirements and under State law. “(2) CRITERIA.-A State that receives a grant under this section shall comply with criteria established by the Secretary for carrying out activities under such grant. "(c) DUTIES.-The office of health insurance consumer assistance or health insurance ombudsman shall— "(1) assist with the filing of complaints and appeals, including filing appeals with the internal appeal or grievance process of the group health plan or health insurance issuer involved and providing information about the external appeal process; "(2) collect, track, and quantify problems and inquiries encountered by consumers; “(3) educate consumers on their rights and responsibilities with respect to group health plans and health insurance coverage; "(4) assist consumers with enrollment in a group health plan or health insurance coverage by providing information, referral, and assistance; and "(5) resolve problems with obtaining premium tax credits under section 36B of the Internal Revenue Code of 1986. "(d) DATA COLLECTION.-As a condition of receiving a grant under subsection (a), an office of health insurance consumer assistance or ombudsman program shall be required to collect and report data to the Secretary on the types of problems and inquiries encountered by consumers. The Secretary shall utilize such data to identify areas where more enforcement action is necessary and shall share such information with State insurance regulators, the Secretary of Labor, and the Secretary of the Treasury for use in the enforcement activities of such agencies. "(e) FUNDING. “(1) INITIAL FUNDING.-There is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $30,000,000 for the first fiscal year for which this section applies to carry out this section. Such amount shall remain available without fiscal year limitation. "(2) AUTHORIZATION FOR SUBSEQUENT YEARS.-There is authorized to be appropriated to the Secretary for each fiscal year following the fiscal year described in paragraph (1), such sums as may be necessary to carry out this section.". SEC. 1003. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOL- Part C of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-91 et seq.), as amended by section 1002, is further amended by adding at the end the following: "SEC. 2794. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOLLARS. "(a) INITIAL PREMIUM REVIEW PROCESS.— 42 USC 300gg-94. with Effective date. "(1) IN GENERAL.-The Secretary, in conjunction with States, shall establish a process for the annual review, beginning with the 2010 plan year and subject to subsection (b)(2)(A), of unreasonable increases in premiums for health insurance coverage. "(2) JUSTIFICATION AND DISCLOSURE.-The process established under paragraph (1) shall require health insurance issuers to submit to the Secretary and the relevant State a justification for an unreasonable premium increase prior to the implementation of the increase. Such issuers shall promi- Web posting. nently post such information on their Internet websites. The Secretary shall ensure the public disclosure of information on such increases and justifications for all health insurance issuers. "(b) CONTINUING PREMIUM REVIEW PROCESS. "(1) INFORMING SECRETARY OF PREMIUM INCREASE PATTERNS.-As a condition of receiving a grant under subsection (c)(1), a State, through its Commissioner of Insurance, shall— "(A) provide the Secretary with information about trends in premium increases in health insurance coverage in premium rating areas in the State; and "(B) make recommendations, as appropriate, to the State Exchange about whether particular health insurance issuers should be excluded from participation in the Exchange based on a pattern or practice of excessive or unjustified premium increases. "(2) MONITORING BY SECRETARY OF PREMIUM INCREASES.— "(A) IN GENERAL.-Beginning with plan years begin- Effective date. ning in 2014, the Secretary, in conjunction with the States 42 USC 300gg-11 note. and consistent with the provisions of subsection (a)(2), shall monitor premium increases of health insurance coverage offered through an Exchange and outside of an Exchange. "(B) CONSIDERATION IN OPENING EXCHANGE.-In determining under section 1312(f)(2)(B) of the Patient Protection and Affordable Care Act whether to offer qualified health plans in the large group market through an Exchange, the State shall take into account any excess of premium growth outside of the Exchange as compared to the rate of such growth inside the Exchange. "(c) GRANTS IN SUPPORT OF PROCESS.— "(1) PREMIUM REVIEW GRANTS DURING 2010 THROUGH 2014.The Secretary shall carry out a program to award grants to States during the 5-year period beginning with fiscal year 2010 to assist such States in carrying out subsection (a), including“(A) in reviewing and, if appropriate under State law, approving premium increases for health insurance coverage; and "(B) in providing information and recommendations to the Secretary under subsection (b)(1). "(2) FUNDING. "(A) IN GENERAL.-Out of all funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary $250,000,000, to be available for expenditure for grants under paragraph (1) and subparagraph (B). "(B) FURTHER AVAILABILITY FOR INSURANCE REFORM AND CONSUMER PROTECTION.-If the amounts appropriated under subparagraph (A) are not fully obligated under grants under paragraph (1) by the end of fiscal year 2014, any remaining funds shall remain available to the Secretary for grants to States for planning and implementing the insurance reforms and consumer protections under part A. "(C) ALLOCATION.-The Secretary shall establish a formula for determining the amount of any grant to a State under this subsection. Under such formula "(i) the Secretary shall consider the number of plans of health insurance coverage offered in each State and the population of the State; and "(ii) no State qualifying for a grant under paragraph (1) shall receive less than $1,000,000, or more than $5,000,000 for a grant year.". SEC. 1004. EFFECTIVE DATES. (a) IN GENERAL.-Except as provided for in subsection (b), this subtitle (and the amendments made by this subtitle) shall become effective for plan years beginning on or after the date that is 6 months after the date of enactment of this Act, except that the amendments made by sections 1002 and 1003 shall become effective for fiscal years beginning with fiscal year 2010. (b) SPECIAL RULE.-The amendments made by sections 1002 and 1003 shall take effect on the date of enactment of this Act. Subtitle B-Immediate Actions to Preserve and Expand Coverage SEC. 1101. IMMEDIATE ACCESS TO INSURANCE FOR UNINSURED 42 USC 18001. INDIVIDUALS WITH A PREEXISTING CONDITION. (a) IN GENERAL.-Not later than 90 days after the date of enactment of this Act, the Secretary shall establish a temporary high risk health insurance pool program to provide health insurance coverage for eligible individuals during the period beginning on the date on which such program is established and ending on January 1, 2014. (b) ADMINISTRATION. (1) IN GENERAL.-The Secretary may carry out the program under this section directly or through contracts to eligible entities. (2) ELIGIBLE ENTITIES.-To be eligible for a contract under paragraph (1), an entity shall (A) be a State or nonprofit private entity; (B) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require; and (C) agree to utilize contract funding to establish and administer a qualified high risk pool for eligible individuals. (3) MAINTENANCE OF EFFORT.-To be eligible to enter into a contract with the Secretary under this subsection, a State shall agree not to reduce the annual amount the State expended for the operation of one or more State high risk pools during the year preceding the year in which such contract is entered into. (c) QUALIFIED HIGH RISK POOL. (1) IN GENERAL.-Amounts made available under this section shall be used to establish a qualified high risk pool that meets the requirements of paragraph (2). (2) REQUIREMENTS.-A qualified high risk pool meets the requirements of this paragraph if such pool— (A) provides to all eligible individuals health insurance coverage that does not impose any preexisting condition exclusion with respect to such coverage; (B) provides health insurance coverage (i) in which the issuer's share of the total allowed costs of benefits provided under such coverage is not less than 65 percent of such costs; and (ii) that has an out of pocket limit not greater than the applicable amount described in section 223(c)(2) of the Internal Revenue Code of 1986 for the year involved, except that the Secretary may modify such limit if necessary to ensure the pool meets the actuarial value limit under clause (i); (C) ensures that with respect to the premium rate charged for health insurance coverage offered to eligible individuals through the high risk pool, such rate shall— (i) except as provided in clause (ii), vary only as provided for under section 2701 of the Public Health Service Act (as amended by this Act and notwithstanding the date on which such amendments take effect); Deadline. |