ticing physician or health professional, and another member would be an expert on children's health. Finally, at least 25% of the Com: mittee members would have to be health care practitioners who practiced in a rural area for at least the five years preceding the appointment. The Committee's recommendations to the Secretary on the essential benefits package (as defined in Section 122), cost-sharing levels for the enhanced plans and premium plans (as defined in Section 203), and periodic updates of the package would be required to incorporate innovation in health care. The Committee members would also be required to consider how the package would reduce health disparities, and would allow for public input as part of developing its recommendations. The Committee's initial benefit recommendations must be made to the Secretary within one year of enactment. In developing standards for the basic, enhanced and premium plans, the Committee would be required to calculate cost-sharing such that the enhanced plan would have benefits that are actuarially equivalent to about 85% of the actuarial value of the benefits provided in the essential benefits package, and the premium plans would have benefits that are actuarially equivalent to about 95% of the actuarial value of the benefits provided in the essential benefits package. Committee members would serve without pay, but would receive federal travel expenses, including per diem expenses. In addition, the Committee would be subject to the Federal Advisory Committee Act (which provides sunshine and transparency over advisory committee actions). The Secretary would be required to publish all recommendations developed pursuant to this Section in the Federal Register and on the HHS website. Sec. 124. Process for adoption of recommendations; adoption of benefit standards Current Law No provision. Proposed Law This section proposes a timeline under which the Secretary must choose whether to adopt the recommendations of the Committee established under section 123 of this bill. Within 45 days of receiving the Committee's recommendations regarding the essential benefits package, the Secretary would be required either to adopt the benefit standards as written or not adopt the benefit standards. If the Secretary does not wish to adopt the recommendations, the Secretary shall notify the Committee of the reasons for this decision, and provide an opportunity for the Committee to revise and resubmit its recommendations. The Secretary would be required to adopt an initial set of benefit standards within 18 months of enactment. The Secretary would be required to publish all determinations under this section in the Federal Register. The Secretary would be required to periodically update the benefit standards. However, an essential benefits pack age that does not meet the essential benefits requirements specified in section 122 could not be adopted. Sec. 125. Prohibition of discrimination in health care services based on religious or spiritual content Current Law No provision. Proposed Law The Commissioner and insurance issuers offering health insurance coverage through the Health Insurance Exchange shall not discriminate in approving or covering a health care service based on its religious or spiritual content if the services are deductible as an eligible medical expense, as defined in the Internal Revenue Code. Subtitle D-Additional Consumer Protections Sec. 131. Requiring fair marketing practices by health insurers Current Law States have established fair marketing standards to regulate insurers' marketing activities. Proposed Law This provision would require the Commissioner to establish uniform marketing standards for QHBPS. Sec. 132. Requiring fair grievance and appeals mechanisms Current Law ERISA does not require an employer to offer health benefits, but does mandate compliance to certain standards if an employer chooses to offer health benefits, such as procedures for appealing denied benefit claims. In addition, as of February 2008, 44 states and the District of Columbia mandate the independent review of benefit denials by an entity outside of the health plan (“external review"). Proposed Law This provision would require QHBPS to provide for timely grievance and appeals mechanisms as established by the Commissioner consistent with sections 139 through 139B. Sec. 133. Requiring information transparency and plan disclosure Current Law ERISA requires applicable health plans (as well as other "welfare benefit" plans) to disclose and report certain plan information to enrollees and regulators. For example, plan administrators must provide to enrollees a written summary plan description (SPD) that contains the terms of the plan and the benefits offered, including any material modifications, and the SPD must be written in a manner that can be understood by the average enrollee. Certain plans must file an annual report with the Department of Labor, con taining information about the operation, funding, assets, and investments of those plans. Proposed Law This provision would require QHBPs to comply with disclosure standards established by the Commissioner concerning plan terms and conditions, claims payment policies, plan finances, claims denials, and other information as determined appropriate by the Commissioner. The Commissioner would require such disclosure to be provided in plain language. QHBPs would be required to comply with standards established by the Commissioner to ensure transparency to a provider regarding reimbursements between the plan and such health care provider. A change in a QHBP could not be made without reasonable and timely advance notice to enrollees about the change. The purpose of the pharmacy benefit managers transparency provision is to provide the Commissioner and QHBPS additional information on several aspects of the performance of pharmacy benefit managers: the spread between the price PBMs pay to pharmacies and the ultimate cost to the PBM of drugs; the extent to which PBMs are successful at switching patients to less costly generic drugs; the extent and reasons for switching patients to more expensive drugs; and the ability of PBMS to obtain-and pass through to QHPBS-discounts, rebates, and price concessions from drug manufacturers. Under the provision, a QHBP would be allowed to contract with a pharmacy benefit manager (PBM) to manage prescription drug coverage offered under the health plan, or control costs related to such coverage, only if as a condition of the contract the PBM is required to annually provide to the Commissioner and QHBP, in a form and manner to be determined by the Commissioner, certain information on the performance of the PBM under the contract, including the volume of prescriptions filled; aggregate average payments made to pharmacists by the PBM, and paid to the PBM by the QHBP, per prescription for mail order and retail sales; discounts, rebates, and price concessions received from drug manufacturers; volume of generic drugs dispensed; number of instances when enrollees switched from a less expensive prescribed drug to a more expensive prescription and the rationale for such switches, and other information. Information disclosed by a PBM to the Commissioner and QHBP would be considered confidential, and the disclosure of information in a form which discloses the identity of a specific PBM or a specific retailer, manufacturer, or wholesaler would be prohibited from disclosure by the Commissioner or QHBP except for specified purposes. The intent of these confidentiality provisions is to provide the same general level of confidentiality for this information as is given to Medicaid drug rebate data reported by manufactures under Section 1927 of the Social Security Act. The Commissioner would be allowed to publish industry-wide aggregate or average information to be used by the Commissioner, by QHBPS, and by members of the public in assessing the overall impact of PBMs on prescription drug prices and spending. Sec. 134. Application to qualified health benefits plans not offered through the Health Insurance Exchange Current Law No provision. Proposed Law The previous disclosure and other standards would apply to QHBPS offered outside of the Exchange only to the extent specified by the Commissioner. Sec. 135. Timely payment of claims Current Law Under Medicare Advantage (MA), private health plans are paid a per-person amount to provide all Medicare-covered benefits (except hospice) to beneficiaries who enroll in their plans. MA plans include health maintenance organizations (HMOs) and private feefor-service (PFFS) plans, among other plan types. MA PFFS plans that generally do not currently contract with providers—are required to pay 95% of "clean claims" within 30 days of receipt. The Centers for Medicare and Medicaid Services (CMS) defines a clean claim as a claim that has no defect or impropriety, and is submitted with all the required documentation. The 30-day rule also applies to claims submitted to any MA organization by a provider who does not have a written contract with the plan. MA organizations are required to pay interest on clean claims that are not paid within 30 days. All other claims from non-contracted providers must be paid within 60 days. MA organizations that contract with providers (i.e., HMOs and PPOs) must include a prompt payment provision in their contracts. Proposed Law This provision would require QHBPS to comply with the prompt pay requirements applicable to Medicare Advantage plans. Sec. 136. Standardized rules for coordination and subrogation of benefits Current Law While there are no federal statutes specifying primary and secondary payment rules for multiple insurers in the private market, Section 1862(b) of the Social Security Act authorizes the Medicare Secondary Payer (MSP) program, which identifies specific conditions under which another party has primary responsibility for payment and Medicare is only responsible for qualified secondary payments. The statute authorizes several methods to identify cases when an insurer other than Medicare is the primary payer and to facilitate recoveries when incorrect Medicare payments have been made. Under certain conditions, the law makes Medicare the secondary payer to insurance plans and programs for beneficiaries covered through (1) a group health plan based on either their own or a spouse's current employment; (2) auto and other liability insurance; (3) no-fault liability insurance; and (4) workers' compensation situations, including the Black Lung program. Additionally, the Medicare statutes exclude Medicare coverage for items and services paid for directly or indirectly by a government entity, subject to certain limitations. This includes the Department of Veterans Affairs, among others. Proposed Law The Commissioner would establish standards for the coordination of benefits and reimbursement of payments in cases involving individual and multiple plan coverage. Sec. 137. Application of administrative simplification Current Law To support the growth of electronic record keeping and claims processing, HIPAA's Administrative Simplification provisions instructed the Secretary to adopt electronic format and data standards for several routine administrative and financial transactions between health care providers and health plans/payers. The standards apply to health care providers (who transmit any health information in electronic form in connection with a HIPAA-specified transaction), health plans, and health care clearinghouses. Proposed Law This provision would require QHBP-offering entities (as defined in the bill) to comply with existing and new administrative simplification standards under Title 11 of the Social Security Act and adopted under Section 163 (discussed below). Sec. 138. Information on end-of-life planning Current Law No provision. Proposed Law This provision would require QHBP offering entities to provide for the dissemination of information related to end-of-life planning to individuals seeking enrollment in Exchange-participating plans. The QHBP would be prohibited from promoting suicide, assisted suicide, or the active hastening of death. Moreover, the information presented would not presume the withdrawal of treatment and would be required to include end-of-life planning information that would maintain all or most medical interventions. Nothing in this provision would be construed to (1) require an individual to complete an advanced directive, physician's order for life sustaining treatment, or other end-of-life planning document; (2) require an individual to consent to restrictions on the amount, duration, or scope of medical benefits otherwise covered under a QHBP; or (3) encourage the hastening of death or the promotion of assisted suicide. An "advance directive" would be defined to include a living will, a comfort care order, or a durable power of attorney for health care. Sec. 139. Utilization review activities Current Law Section 503 of ERISA requires every employee benefit plan to "provide adequate notice in writing to every participant or bene |