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Sec. 115. Ensuring adequacy of provider networks

Current Law

HIPAA established special rules for plans that develop a network of providers. It allows small group issuers to (1) limit the employers that apply for coverage to those firms with eligible individuals who live or work in the network service area, and (2) deny coverage to small employers if the issuer demonstrates (if required) to the state that it has limited provider capacity due to obligations to existing enrollees and it is applying this decision uniformly without regard to claims experience or health status-related factors. HIPAA also prohibits a small group issuer that has denied coverage in any service area to offer small group coverage in that area for 180 days after the denial.

Proposed Law

This provision would require QHBPs that use provider networks to meet provider network standards that may be established by the Commissioner to ensure the adequacy of networks, and transparency in the cost-sharing differences between in- and out-of-network coverage. The term "provider network" means the providers with respect to covered benefits, treatments, and services available under a health benefit plan.

Sec. 116. Ensuring value and lower premiums

Current Law

Medical loss ratio is the share of total premium revenue spent on medical claims. Medigap insurance policies are private supplemental health care policies that Medicare beneficiaries can purchase to help cover some items, services, and cost sharing not covered under Medicare. Medigap plans are required to have a minimum medical loss ratio of 65% for individual policies and 75% for group policies. In addition, some states impose medical loss ratios or related requirements on insurers in the individual and/or small group health insurance markets. As of June 2008, minimum ratios required by states ranged from 55% to 80%.

Proposed Law

This provision would require QHBPS to comply with a medical loss ratio standard to be determined by the Commissioner. For any QHBP that does not meet such a standard, it would be required to provide rebates to enrollees, in a manner specified by the Commissioner, in sufficient amounts to meet such a loss ratio. To establish the medical loss ratio standard, the Commissioner would build on the definition and methodology, developed by the HHS Secretary under Section 161, for determining how to calculate such a ratio. The methodology would set the highest ratio possible to ensure adequate QHBP participation, competition both in and out of the Exchange, and value for consumers so that their premium payments are used predominately for medical claims.

Subtitle C-Standards Guaranteeing Access to Essential Benefits Sec. 121. Coverage of essential benefits package

Current Law

There are very limited federal benefit mandates for health insurance. These standards were added to HIPAA and are described in the discussion of Section 122. There are more than 2,000 state-level benefit mandates that vary across the country.

Proposed Law

This provision would require a QHBP to cover at least an "essential benefit package." QHBPs could be offered in or outside of an Exchange. QHBPs offered outside of an Exchange would be allowed to offer additional benefits beyond those specified in the essential benefits package. For QHBPs offered through the Exchange, a plan offering a premium-plus level of benefits (established under Section 203) could also provide additional benefits.

The requirements under Division A would not affect the offering of limited-purpose or "excepted" benefit plans, including policies covering dental or vision treatment, long-term care, workers' compensation, and other similar benefits, if such benefit plans are offered under a separate policy, contract, or certificate of insurance. A QHBP would not be allowed to impose coverage restrictions (except cost sharing) unrelated to the clinical appropriateness of the health care items and services.

Sec. 122. Essential benefit package defined

Current Law

There are very few federally mandated benefits. The laws that provide guidance are found in the Employee Retirement Income Security Act (ERISA covers employer-sponsored plans), the Public Health Service Act (PHSA covers insurance plans and state and local government plans), and the Internal Revenue Code (IRC_covers church plans in certain circumstances). There is no federal requirement that employers offer health insurance, or that any plans that are offered cover any specific benefits. However, the mandates that do exist require that if a plan (governed by ERISA, PHSA, or IRC) covers a particular service that is addressed in the statutes, then that benefit must be designed in a certain way. Those mandates include:

• The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPA) (P.L. 110-343) requires a large group health plan to offer parity in mental health and substance use disorder benefits and medical and surgical benefits with regard to annual and lifetime limits, financial requirements and treatment limitations, but does not require a plan to cover mental health benefits.

• The Newborns' and Mothers' Health Protection Act of 1996 (NMHPA) (P.L. 104–204) requires plans that offer maternity coverage to pay for at least a 48-hour hospital stay following childbirth (96-hour stay in the case of a cesarean section).

• The Women's Health and Cancer Rights Act of 1998 (P.L. 105– 277) contains protections for patients who elect breast reconstruction in connection with a mastectomy. For plan participants and

beneficiaries receiving benefits in connection with a mastectomy, plans offering coverage for a mastectomy must also cover reconstructive surgery and other benefits related to a mastectomy.

• The Genetic Information Nondiscrimination Act of 2008 (GINA) (P.L. 110-233) prohibits discrimination based on genetic information by health insurers and employers. Broadly, GINA prohibits health insurers from engaging in three practices: (1) using genetic information about an individual to adjust a group plan's premiums, or, in the case of individual plans, to deny coverage, adjust premiums, or impose a pre-existing condition exclusion; (2) requiring or requesting genetic testing; and (3) requesting, requiring, or purchasing genetic information for underwriting purposes. It also prohibits employers from making hiring or firing decisions based on genetic information.

• Michelle's Law (P.L. 110-381) ensures that dependent post secondary education students who take a medically necessary leave of absence do not lose health insurance coverage. The law provides that a group health plan may not terminate a college student's health coverage simply because the student takes a medically necessary leave of absence from school or changes to part-time status. The leave of absence must be medically necessary, begin while the student is suffering from a serious illness or injury and would otherwise result in a loss of coverage.

Although current federal law provides only a limited number of service and coverage mandates, it does provide some guidance toward the definition of preventive services for use by public programs and private insurance. The U.S. Preventive Services Task Force (USPSTF), administered by the Agency for Healthcare Research and Quality (AHRQ), reviews scientific evidence and makes recommendations to the health care community regarding the use of clinical preventive services, based on evidence of effectiveness and any harm associated with specific services. The USPSTF grades services as "A" through "D," or notes that there is insufficient evidence to support a recommendation. Clinical services graded "A" or "B" by the USPSTF are recommended for use in clinical practice.

Similarly, the Advisory Committee on Immunization Practices (ACIP), administered by the Centers for Disease Control and Prevention (CDC), reviews scientific evidence and makes recommendations to the Secretary and the CDC Director for the routine administration of vaccines to children, adolescents, and adults in the U.S. civilian population. The ACIP is not explicitly authorized; rather, it is based in general authorities of the Secretary in Titles II and III of the PHSA.

"Actuarial value" is a summary measure of a health insurance plan's benefit generosity. It is expressed as the percentage of medical expenses estimated to be paid by the insurer for a standard population and set of allowed charges. Two plans that have the same actuarial value are "actuarially equivalent." Because these are summary measures, two plans that are actuarially equivalent may not provide the same benefits for any two individuals. State health insurance regulations may include requirements expressed in terms of actuarial value.

Proposed Law

This provision would require the essential benefits package to cover specified items and services, limit cost sharing, prohibit annual and lifetime limits on covered services, ensure the adequacy of provider networks, and be equivalent (as certified by the Office of the Actuary of the Centers for Medicare and Medicaid Services) to the average prevailing employer-sponsored coverage.

The essential benefits package would be required to cover the following items and services:

• Hospitalization;

Outpatient hospital and clinic services, including emergency department services;

• Services of physicians and other health professionals;

Services, equipment, and supplies incident to the services of a physician or health professional in appropriate settings; • Prescription drugs;

• Rehabilitative and "habilitative" services (i.e., services to maintain or prevent the deterioration of the physical, intellectual, emotional, and social functioning of developmentally delayed individuals);

• Mental health and substance use disorder services, including behavioral health treatments;

• Preventive services, include those graded "A" or "B" by the Task Force on Clinical and Preventive Services, as established by this Act, and those vaccines recommended by the Director of the CDC;

• Maternity care; and

• Well-baby and well-child care; treatment of a congenital or developmental deformity, disease, or injury; and oral health, vision, and hearing services, equipment, and supplies for those under age 21.

A qualified health benefits plan offering entity has the option of subcontracting with other entities to provide select benefits as is often the case currently, such as dental, vision, and mental health benefits.

Mental health and substance use disorder services include medically necessary and appropriate treatments, items and services for disorders and conditions listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association.

Services recommended with a grade A or B grade by the Task Force on Clinical Preventive Services (formerly the U.S. Preventive Services Task Force) and vaccines recommended for use by the Director of the Centers for Disease Control and Prevention constitute a floor for preventive services in the essential benefits package. The Health Benefits Advisory Committee has discretion to also consider recommendations of specialty medical associations, patient advocacy groups, and scientific societies in making recommendations to the Secretary of covered treatments, items and services within the essential benefits package.

The essential benefits package would be subject to various requirements concerning cost-sharing. The package would be required to provide preventive items and services without cost-sharing (including well-baby and well-child care). The annual out-ofpocket limit in Y1 would be $5,000 for an individual and $10,000

for a family. These limits would be annually adjusted for inflation using the Consumer Price Index for all Urban Consumers (CPI-U). The Secretary could consider establishing a lower limit on costsharing for prescription drugs that would be included within the global cost-sharing cap. All out-of-pocket spending on prescription drugs would count toward both the lower, drug-specific limit and the global limit on all cost-sharing. The drug-specific cap could be helpful for chronically ill patients that rely on medications to remain healthy and avoid hospitalizations and other acute health care services. The Secretary in setting a drug-specific limit could do so at a level that will support medication adherence.

To the extent possible, the Benefits Advisory Committee and the Secretary of HHS would establish cost-sharing levels using copayments (a flat dollar fee) and not coinsurance (a percentage fee). Cost-sharing for the Essential Benefits Package would result in coverage equal to approximately 70% of the actuarial value of the benefits if there were no cost-sharing imposed.

This provision would also prohibit the requirement of abortion services as a minimum benefit in any plan. Each plan is to decide voluntarily on whether abortion is a covered benefit; in the case of the public option, the Secretary is to make that decision. This provision is discussed in detail below in the section titled "AbortionRelated Language in Division A."

Adults 21 and over would not be required to receive separately priced stand-alone vision-only or dental-only coverage (as defined in Section 102(c)(3)).

Sec. 123. Health Benefits Advisory Committee

Current Law

No provision.

Proposed Law

A Health Benefits Advisory Committee would be established to recommend covered benefits and cost-sharing parameters and the essential, enhanced, and premium plans. The Committee would be chaired by the Surgeon General. The Committee membership would be comprised of:

• Nine members, appointed by the President, who are neither federal employees nor officers;

• Nine members, appointed by the Comptroller General, who are neither federal employees nor officers; and

• An even number, up to eight members, appointed by the President, who are federal employees and officers.

The initial appointments would be made within 60 days of enactment. Each Committee member would serve a three-year term, except the terms of the initial appointments would be adjusted to provide for staggered years of appointment. The members would reflect the interests of the many diverse groups of stakeholders so that no single interest would unduly influence the Committee's recommendations. At a minimum, Committee membership would reflect physicians and other health care providers, consumer representatives, employers, labor, health insurance issuers, experts in health care delivery, and experts in health disparities, and government agencies. At least one Committee member would be a prac

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