Page:United States Statutes at Large Volume 124.djvu/913

 124 STAT. 887 PUBLIC LAW 111–148—MAR. 23, 2010 premium revenue for each of the previous 3 years for the plan. ‘‘(2) CONSIDERATION IN SETTING PERCENTAGES.—In deter- mining 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) ENFORCEMENT.—The Secretary shall promulgate regu- lations for enforcing the provisions of this section and may provide for appropriate penalties. ‘‘(c) DEFINITIONS.—Not later than December 31, 2010, and sub- ject to the certification of the Secretary, the National Association of Insurance Commissioners shall establish uniform definitions of the activities reported under subsection (a) and standardized meth- odologies for calculating measures of such activities, including definitions of which activities, and in what regard such activities, constitute activities described in subsection (a)(2). Such methodolo- gies shall be designed to take into account the special circumstances of smaller plans, different types of plans, and newer plans. ‘‘(d) ADJUSTMENTS.—The Secretary may adjust the rates described in subsection (b) if the Secretary determines appropriate on account of the volatility of the individual market due to the establishment of State Exchanges. ‘‘(e) 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.’’. (g) Section 2719 of the Public Health Service Act, as added by section 1001(4) of this Act, is amended to read as follows: ‘‘SEC. 2719. APPEALS PROCESS. ‘‘(a) INTERNAL CLAIMS APPEALS.— ‘‘(1) IN GENERAL.—A group health plan and a health insur- ance issuer offering group or individual health insurance cov- erage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum— ‘‘(A) have in effect an internal claims appeal process; ‘‘(B) 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; and ‘‘(C) 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. ‘‘(2) ESTABLISHED PROCESSES.—To comply with paragraph (1)— ‘‘(A) a group health plan and a health insurance issuer offering group health coverage shall provide an internal claims and appeals process that initially incorporates the 42 USC 300gg–19. Deadline. Certification. Regulations.