H.R. 3200/Division A

. PURPOSE; TABLE OF CONTENTS OF DIVISION; GENERAL DEFINITIONS.

 * PURPOSE—
 * (1) IN GENERAL—
 * The purpose of this division is to provide affordable, quality health care for all Americans and reduce the growth in health care spending.
 * (2) BUILDING ON CURRENT SYSTEM—
 * This division achieves this purpose by building on what works in today's health care system, while repairing the aspects that are broken.
 * (3) INSURANCE REFORMS—
 * This division—
 * (A) enacts strong insurance market reforms;
 * (B) creates a new Health Insurance Exchange, with a public health insurance option alongside private plans;
 * (C) includes sliding scale affordability credits; and
 * (D) initiates shared responsibility among workers, employers, and the government;
 * so that all Americans have coverage of essential health benefits.
 * (4) HEALTH DELIVERY REFORM—
 * This division institutes health delivery system reforms both to increase quality and to reduce growth in health spending so that health care becomes more affordable for businesses, families, and government.


 * TABLE OF CONTENTS OF DIVISION—
 * The table of contents of this division is as follows:


 * Sec. 100. Purpose; table of contents of division; general definitions.

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TITLE I—PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS
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 * Subtitle A—General Standards
 * Sec. 101. Requirements Reforming Health Insurance Marketplace.
 * Sec. 102. Protecting the Choice to Keep Current Coverage.


 * Subtitle B—Standards Guaranteeing Access to Affordable Coverage
 * Sec. 111. Prohibiting Pre-existing Condition Exclusions.
 * Sec. 112. Guaranteed Issue and Renewal for Insured Plans.
 * Sec. 113. Insurance Rating Rules.
 * Sec. 114. Nondiscrimination in Benefits; Parity in Mental Health and Substance Abuse Disorder Benefits.
 * Sec. 115. Ensuring Adequacy of Provider Networks.
 * Sec. 116. Ensuring Value and Lower Premiums.


 * Subtitle C—Standards Guaranteeing Access to Essential Benefits
 * Sec. 121. Coverage of Essential Benefits Package.
 * Sec. 122. Essential Benefits Package Defined.
 * Sec. 123. Health Benefits Advisory Committee.
 * Sec. 124. Process for Adoption of Recommendations; Adoption of Benefit Standards.


 * Subtitle D—Additional Consumer Protections
 * Sec. 131. Requiring Fair Marketing Practices by Health Insurers.
 * Sec. 132. Requiring Fair Grievance and Appeals Mechanisms.
 * Sec. 133. Requiring Information Transparency and Plan Disclosure.
 * Sec. 134. Application to Qualified Health Benefits Plans Not Offered Through the Health Insurance Exchange.
 * Sec. 135. Timely Payment of Claims.
 * Sec. 136. Standardized Rules for Coordination and Subrogation of Benefits.
 * Sec. 137. Application of Administrative Simplification.


 * Subtitle E—Governance
 * Sec. 141. Health Choices Administration; Health Choices Commissioner.
 * Sec. 142. Duties and Authority of Commissioner.
 * Sec. 143. Consultation and Coordination.
 * Sec. 144. Health Insurance Ombudsman.


 * Subtitle F—Relation to Other Requirements; Miscellaneous
 * Sec. 151. Relation to Other Requirements.
 * Sec. 152. Prohibiting Discrimination in Health Care.
 * Sec. 153. Whistleblower Protection.
 * Sec. 154. Construction Regarding Collective Bargaining.
 * Sec. 155. Severability.


 * Subtitle G—Early Investments
 * Sec. 161. Ensuring Value and Lower Premiums.
 * Sec. 162. Ending Health Insurance Rescission Abuse.
 * Sec. 163. Administrative Simplification.
 * Sec. 164. Reinsurance Program for Retirees.

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TITLE II—HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS
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 * Subtitle A—Health Insurance Exchange
 * Sec. 201. Establishment of Health Insurance Exchange; Outline of Duties; Definitions.
 * Sec. 202. Exchange-Eligible Individuals and Employers.
 * Sec. 203. Benefits Package Levels.
 * Sec. 204. Contracts for the Offering of Exchange-Participating Health Benefits Plans.
 * Sec. 205. Outreach and Enrollment of Exchange-Eligible Individuals & Employers in Exchange-Participating Health Benefits Plan.
 * Sec. 206. Other Functions.
 * Sec. 207. Health Insurance Exchange Trust Fund.
 * Sec. 208. Optional Operation of State-Based Health Insurance Exchanges.


 * Subtitle B—Public Health Insurance Option
 * Sec. 221. Establishment and Administration of a Public Health Insurance Option as an Exchange-Qualified Health Benefits Plan.
 * Sec. 222. Premiums and Financing.
 * Sec. 223. Payment Rates for Items and Services.
 * Sec. 224. Modernized Payment Initiatives and Delivery System Reform.
 * Sec. 225. Provider Participation.
 * Sec. 226. Application of Fraud and Abuse Provisions.


 * Subtitle C—Individual Affordability Credits
 * Sec. 241. Availability Through Health Insurance Exchange.
 * Sec. 242. Affordable Credit Eligible Individual.
 * Sec. 243. Affordable Premium Credit.
 * Sec. 244. Affordability Cost-Sharing Credit.
 * Sec. 245. Income Determinations.
 * Sec. 246. No Federal Payment for Undocumented Aliens.

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TITLE III—SHARED RESPONSIBILITY
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 * Subtitle A—Individual Responsibility
 * Sec. 301. Individual Responsibility.


 * Subtitle B—Employer Responsibility
 * /Title III/Subtitle B/Part 1
 * Sec. 311. Health Coverage Participation Requirements.
 * Sec. 312. Employer Responsibility to Contribute Towards Employee and Dependent Coverage.
 * Sec. 313. Employer Contributions in Lieu of Coverage.
 * Sec. 314. Authority Related to Improper Steering.


 * /Title III/Subtitle B/Part 2
 * Sec. 321. Satisfaction of Health Coverage Participation Requirements Under the Employee Retirement Income Security Act of 1974.
 * Sec. 322. Satisfaction of Health Coverage Participation Requirements Under the Internal Revenue Code of 1986.
 * Sec. 323. Satisfaction of Health Coverage Participation Requirements Under the Public Health Service Act.
 * Sec. 324. Additional Rules Relating to Health Coverage Participation Requirements.

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TITLE IV—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986
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 * Subtitle A—Shared Responsibility
 * /Title IV/Subtitle A/Part 1
 * Sec. 401. Tax On Individuals Without Acceptable Health Care Coverage.


 * /Title IV/Subtitle A/Part 2
 * Sec. 411. Election to Satisfy Health Coverage Participation Requirements.
 * Sec. 412. Responsibilities of Nonelecting Employers.


 * Subtitle B—Credit for Small Business Employee Health Coverage Expenses
 * Sec. 421. Credit for Small Business Employee Health Coverage Expenses.


 * Subtitle C—Disclosures To Carry Out Health Insurance Exchange Subsidies
 * Sec. 431. Disclosures to Carry Out Health Insurance Exchange Subsidies.


 * Subtitle D—Other Revenue Provisions
 * /Title IV/Subtitle D/Part 1
 * Sec. 441. Surcharge on High Income Individuals.
 * Sec. 442. Delay in Application of Worldwide Allocation of Interest.


 * /Title IV/Subtitle D/Part 2
 * Sec. 451. Limitation on Treaty Benefits for Certain Deductible Payments.
 * Sec. 452. Codification of Economic Substance Doctrine.
 * Sec. 453. Penalties for Underpayments.


 * GENERAL DEFINITIONS—
 * Except as otherwise provided, in this division:
 * (1) ACCEPTABLE COVERAGE—
 * The term `acceptable coverage' has the meaning given such term in section 202(d)(2).
 * (2) BASIC PLAN—
 * The term `basic plan' has the meaning given such term in section 203(c).
 * (3) COMMISSIONER—
 * The term `Commissioner' means the Health Choices Commissioner established under section 141.
 * (4) COST-SHARING—
 * The term `cost-sharing' includes deductibles, coinsurance, copayments, and similar charges but does not include premiums or any network payment differential for covered services or spending for non-covered services.
 * (5) DEPENDENT—
 * The term `dependent' has the meaning given such term by the Commissioner and includes a spouse.
 * (6) EMPLOYMENT-BASED HEALTH PLAN—
 * The term `employment-based health plan'—
 * (A) means a group health plan (as defined in section 733(a)(1) of the Employee Retirement Income Security Act of 1974); and
 * (B) includes such a plan that is the following:
 * (i) FEDERAL, STATE, AND TRIBAL GOVERNMENTAL PLANS—
 * A governmental plan (as defined in section 3(32) of the Employee Retirement Income Security Act of 1974), including a health benefits plan offered under chapter 89 of title 5, United States Code.
 * (ii) CHURCH PLANS—
 * A church plan (as defined in section 3(33) of the Employee Retirement Income Security Act of 1974).
 * (7) ENHANCED PLAN—
 * The term `enhanced plan' has the meaning given such term in section 203(c).
 * (8) ESSENTIAL BENEFITS PACKAGE—
 * The term `essential benefits package' is defined in section 122(a).
 * (9) FAMILY—
 * The term `family' means an individual and includes the individual's dependents.
 * (10) FEDERAL POVERTY LEVEL; FPL—
 * The terms `Federal poverty level' and `FPL' have the meaning given the term `poverty line' in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section.
 * (11) HEALTH BENEFITS PLAN—
 * The terms `health benefits plan' means health insurance coverage and an employment-based health plan and includes the public health insurance option.
 * (12) HEALTH INSURANCE COVERAGE; HEALTH INSURANCE ISSUER—
 * The terms `health insurance coverage' and `health insurance issuer' have the meanings given such terms in section 2791 of the Public Health Service Act.
 * (13) HEALTH INSURANCE EXCHANGE—
 * The term `Health Insurance Exchange' means the Health Insurance Exchange established under section 201.
 * (14) MEDICAID—
 * The term `Medicaid' means a State plan under title XIX of the Social Security Act (whether or not the plan is operating under a waiver under section 1115 of such Act).
 * (15) MEDICARE—
 * The term `Medicare' means the health insurance programs under title XVIII of the Social Security Act.
 * (16) PLAN SPONSOR—
 * The term `plan sponsor' has the meaning given such term in section 3(16)(B) of the Employee Retirement Income Security Act of 1974.
 * (17) PLAN YEAR—
 * The term `plan year' means—
 * (A) with respect to an employment-based health plan, a plan year as specified under such plan; or
 * (B) with respect to a health benefits plan other than an employment-based health plan, a 12-month period as specified by the Commissioner.
 * (18) PREMIUM PLAN; PREMIUM-PLUS PLAN—
 * The terms `premium plan' and `premium-plus plan' have the meanings given such terms in section 203(c).
 * (19) QHBP OFFERING ENTITY—
 * The terms `QHBP offering entity' means, with respect to a health benefits plan that is—
 * (A) a group health plan (as defined, subject to subsection (d), in section 733(a)(1) of the Employee Retirement Income Security Act of 1974), the plan sponsor in relation to such group health plan, except that, in the case of a plan maintained jointly by 1 or more employers and 1 or more employee organizations and with respect to which an employer is the primary source of financing, such term means such employer;
 * (B) health insurance coverage, the health insurance issuer offering the coverage;
 * (C) the public health insurance option, the Secretary of Health and Human Services;
 * (D) a non-Federal governmental plan (as defined in section 2791(d) of the Public Health Service Act), the State or political subdivision of a State (or agency or instrumentality of such State or subdivision) which establishes or maintains such plan; or
 * (E) a Federal governmental plan (as defined in section 2791(d) of the Public Health Service Act), the appropriate Federal official.
 * (20) QUALIFIED HEALTH BENEFITS PLAN—
 * The term `qualified health benefits plan' means a health benefits plan that meets the requirements for such a plan under title I and includes the public health insurance option.
 * (21) PUBLIC HEALTH INSURANCE OPTION—
 * The term `public health insurance option' means the public health insurance option as provided under subtitle B of title II.
 * (22) SERVICE AREA; PREMIUM RATING AREA—
 * The terms `service area' and `premium rating area' mean with respect to health insurance coverage—
 * (A) offered other than through the Health Insurance Exchange, such an area as established by the QHBP offering entity of such coverage in accordance with applicable State law; and
 * (B) offered through the Health Insurance Exchange, such an area as established by such entity in accordance with applicable State law and applicable rules of the Commissioner for Exchange-participating health benefits plans.
 * (23) STATE—
 * The term `State' means the 50 States and the District of Columbia.
 * (24) STATE MEDICAID AGENCY—
 * The term `State Medicaid agency' means, with respect to a Medicaid plan, the single State agency responsible for administering such plan under title XIX of the Social Security Act.
 * (25) Y1, Y2, ETC—
 * The terms `Y1', `Y2', `Y3', `Y4', `Y5', and similar subsequently numbered terms, mean 2013 and subsequent years, respectively.