I
118THCONGRESS
1
STSESSION H. R. 77
To amend the Public Health Service Act to provide for cooperative governing
of individual health insurance coverage.
IN THE HOUSE OF REPRESENTATIVES
JANUARY9, 2023
Mr. B
IGGSintroduced the following bill; which was referred to the Committee
on Energy and Commerce
A BILL
To amend the Public Health Service Act to provide for
cooperative governing of individual health insurance coverage.
Be it enacted by the Senate and House of Representa-1
tives of the United States of America in Congress assembled, 2
SECTION 1. COOPERATIVE GOVERNING OF INDIVIDUAL 3
HEALTH INSURANCE COVERAGE. 4
(a) I
NGENERAL.—Title XXVII of the Public Health 5
Service Act (42 U.S.C. 300gg et seq.) is amended by add-6
ing at the end the following new part: 7
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‘‘PART E—COOPERATIVE GOVERNING OF 1
INDIVIDUAL HEALTH INSURANCE COVERAGE 2
‘‘SEC. 2799E–1. DEFINITIONS. 3
‘‘In this part: 4
‘‘(1) P
RIMARY STATE.—The term ‘primary 5
State’ means, with respect to individual health insur-6
ance coverage offered by a health insurance issuer, 7
the State designated by the issuer as the State 8
whose covered laws shall govern the health insurance 9
issuer in the sale of such coverage under this part. 10
An issuer, with respect to a particular policy, may 11
only designate one such State as its primary State 12
with respect to all such coverage it offers. Such an 13
issuer may not change the designated primary State 14
with respect to individual health insurance coverage 15
once the policy is issued, except that such a change 16
may be made upon renewal of the policy. With re-17
spect to such designated State, the issuer is deemed 18
to be doing business in that State. 19
‘‘(2) S
ECONDARY STATE.—The term ‘secondary 20
State’ means, with respect to individual health insur-21
ance coverage offered by a health insurance issuer, 22
any State that is not the primary State. In the case 23
of a health insurance issuer that is selling a policy 24
in, or to a resident of, a secondary State, the issuer 25
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is deemed to be doing business in that secondary 1
State. 2
‘‘(3) H
EALTH INSURANCE ISSUER .—The term 3
‘health insurance issuer’ has the meaning given such 4
term in section 2791(b)(2), except that such an 5
issuer must be licensed in the primary State and be 6
qualified to sell individual health insurance coverage 7
in that State. 8
‘‘(4) I
NDIVIDUAL HEALTH INSURANCE COV -9
ERAGE.—The term ‘individual health insurance cov-10
erage’ means health insurance coverage offered in 11
the individual market, as defined in section 12
2791(e)(1). 13
‘‘(5) A
PPLICABLE STATE AUTHORITY .—The 14
term ‘applicable State authority’ means, with respect 15
to a health insurance issuer in a State, the State in-16
surance commissioner or official or officials des-17
ignated by the State to enforce the requirements of 18
this title for the State with respect to the issuer. 19
‘‘(6) H
AZARDOUS FINANCIAL CONDITION .—The 20
term ‘hazardous financial condition’ means that, 21
based on its present or reasonably anticipated finan-22
cial condition, a health insurance issuer is unlikely 23
to be able— 24
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‘‘(A) to meet obligations to policyholders 1
with respect to known claims and reasonably 2
anticipated claims; or 3
‘‘(B) to pay other obligations in the normal 4
course of business. 5
‘‘(7) C
OVERED LAWS.— 6
‘‘(A) I
N GENERAL.—The term ‘covered 7
laws’ means the laws, rules, regulations, agree-8
ments, and orders governing the insurance busi-9
ness pertaining to— 10
‘‘(i) individual health insurance cov-11
erage issued by a health insurance issuer; 12
‘‘(ii) the offer, sale, rating (including 13
medical underwriting), renewal, and 14
issuance of individual health insurance cov-15
erage to an individual; 16
‘‘(iii) the provision to an individual in 17
relation to individual health insurance cov-18
erage of health care and insurance related 19
services; 20
‘‘(iv) the provision to an individual in 21
relation to individual health insurance cov-22
erage of management, operations, and in-23
vestment activities of a health insurance 24
issuer; and 25
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‘‘(v) the provision to an individual in 1
relation to individual health insurance cov-2
erage of loss control and claims adminis-3
tration for a health insurance issuer with 4
respect to liability for which the issuer pro-5
vides insurance. 6
‘‘(B) E
XCEPTION.—Such term does not in-7
clude any law, rule, regulation, agreement, or 8
order governing the use of care or cost manage-9
ment techniques, including any requirement re-10
lated to provider contracting, network access or 11
adequacy, health care data collection, or quality 12
assurance. 13
‘‘(8) S
TATE.—The term ‘State’ means the 50 14
States and includes the District of Columbia, Puerto 15
Rico, the Virgin Islands, Guam, American Samoa, 16
and the Northern Mariana Islands. 17
‘‘(9) U
NFAIR CLAIMS SETTLEMENT PRAC -18
TICES.—The term ‘unfair claims settlement prac-19
tices’ means only the following practices: 20
‘‘(A) Knowingly misrepresenting to claim-21
ants and insured individuals relevant facts or 22
policy provisions relating to coverage at issue. 23
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‘‘(B) Failing to acknowledge with reason-1
able promptness pertinent communications with 2
respect to claims arising under policies. 3
‘‘(C) Failing to adopt and implement rea-4
sonable standards for the prompt investigation 5
and settlement of claims arising under policies. 6
‘‘(D) Failing to effectuate prompt, fair, 7
and equitable settlement of claims submitted in 8
which liability has become reasonably clear. 9
‘‘(E) Refusing to pay claims without con-10
ducting a reasonable investigation. 11
‘‘(F) Failing to affirm or deny coverage of 12
claims within a reasonable period of time after 13
having completed an investigation related to 14
those claims. 15
‘‘(G) A pattern or practice of compelling 16
insured individuals or their beneficiaries to in-17
stitute suits to recover amounts due under its 18
policies by offering substantially less than the 19
amounts ultimately recovered in suits brought 20
by them. 21
‘‘(H) A pattern or practice of attempting 22
to settle or settling claims for less than the 23
amount that a reasonable person would believe 24
the insured individual or his or her beneficiary 25
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was entitled by reference to written or printed 1
advertising material accompanying or made 2
part of an application. 3
‘‘(I) Attempting to settle or settling claims 4
on the basis of an application that was materi-5
ally altered without notice to, or knowledge or 6
consent of, the insured. 7
‘‘(J) Failing to provide forms necessary to 8
present claims within 15 calendar days of a re-9
quest with reasonable explanations regarding 10
their use. 11
‘‘(K) Attempting to cancel a policy in less 12
time than that prescribed in the policy or by the 13
law of the primary State. 14
‘‘(10) F
RAUD AND ABUSE .—The term ‘fraud 15
and abuse’ means an act or omission committed by 16
a person who, knowingly and with intent to defraud, 17
commits, or conceals any material information con-18
cerning, one or more of the following: 19
‘‘(A) Presenting, causing to be presented 20
or preparing with knowledge or belief that it 21
will be presented to or by an insurer, a rein-22
surer, broker or its agent, false information as 23
part of, in support of or concerning a fact ma-24
terial to one or more of the following: 25
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‘‘(i) An application for the issuance or 1
renewal of an insurance policy or reinsur-2
ance contract. 3
‘‘(ii) The rating of an insurance policy 4
or reinsurance contract. 5
‘‘(iii) A claim for payment or benefit 6
pursuant to an insurance policy or reinsur-7
ance contract. 8
‘‘(iv) Premiums paid on an insurance 9
policy or reinsurance contract. 10
‘‘(v) Payments made in accordance 11
with the terms of an insurance policy or 12
reinsurance contract. 13
‘‘(vi) A document filed with the com-14
missioner or the chief insurance regulatory 15
official of another jurisdiction. 16
‘‘(vii) The financial condition of an in-17
surer or reinsurer. 18
‘‘(viii) The formation, acquisition, 19
merger, reconsolidation, dissolution or 20
withdrawal from one or more lines of in-21
surance or reinsurance in all or part of a 22
State by an insurer or reinsurer. 23
‘‘(ix) The issuance of written evidence 24
of insurance. 25
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‘‘(x) The reinstatement of an insur-1
ance policy. 2
‘‘(B) Solicitation or acceptance of new or 3
renewal insurance risks on behalf of an insurer, 4
reinsurer, or other person engaged in the busi-5
ness of insurance by a person who knows or 6
should know that the insurer or other person 7
responsible for the risk is insolvent at the time 8
of the transaction. 9
‘‘(C) Transaction of the business of insur-10
ance in violation of laws requiring a license, cer-11
tificate of authority or other legal authority for 12
the transaction of the business of insurance. 13
‘‘(D) Attempt to commit, aiding or abet-14
ting in the commission of, or conspiracy to com-15
mit the acts or omissions specified in this para-16
graph. 17
‘‘SEC. 2799E–2. APPLICATION OF LAW. 18
‘‘(a) I
NGENERAL.—The covered laws of the primary 19
State shall apply to individual health insurance coverage 20
offered by a health insurance issuer in the primary State 21
and in any secondary State, but only if the coverage and 22
issuer comply with the conditions of this section with re-23
spect to the offering of coverage in any secondary State. 24
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‘‘(b) EXEMPTIONSFROMCOVEREDLAWS IN ASEC-1
ONDARYSTATE.—Except as provided in this section, a 2
health insurance issuer with respect to its offer, sale, rat-3
ing (including medical underwriting), renewal, and 4
issuance of individual health insurance coverage in any 5
secondary State is exempt from any covered laws of the 6
secondary State (and any rules, regulations, agreements, 7
or orders sought or issued by such State under or related 8
to such covered laws) to the extent that such laws would— 9
‘‘(1) make unlawful, or regulate, directly or in-10
directly, the operation of the health insurance issuer 11
operating in the secondary State, except that any 12
secondary State may require such an issuer— 13
‘‘(A) to pay, on a nondiscriminatory basis, 14
applicable premium and other taxes (including 15
high risk pool assessments) which are levied on 16
insurers and surplus lines insurers, brokers, or 17
policyholders under the laws of the State; 18
‘‘(B) to register with and designate the 19
State insurance commissioner as its agent solely 20
for the purpose of receiving service of legal doc-21
uments or process; 22
‘‘(C) to submit to an examination of its fi-23
nancial condition by the State insurance com-24
missioner in any State in which the issuer is 25
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doing business to determine the issuer’s finan-1
cial condition, if— 2
‘‘(i) the State insurance commissioner 3
of the primary State has not done an ex-4
amination within the period recommended 5
by the National Association of Insurance 6
Commissioners; and 7
‘‘(ii) any such examination is con-8
ducted in accordance with the examiners’ 9
handbook of the National Association of 10
Insurance Commissioners and is coordi-11
nated to avoid unjustified duplication and 12
unjustified repetition; 13
‘‘(D) to comply with a lawful order 14
issued— 15
‘‘(i) in a delinquency proceeding com-16
menced by the State insurance commis-17
sioner if there has been a finding of finan-18
cial impairment under subparagraph (C); 19
or 20
‘‘(ii) in a voluntary dissolution pro-21
ceeding; 22
‘‘(E) to comply with an injunction issued 23
by a court of competent jurisdiction, upon a pe-24
tition by the State insurance commissioner al-25
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leging that the issuer is in hazardous financial 1
condition; 2
‘‘(F) to participate, on a nondiscriminatory 3
basis, in any insurance insolvency guaranty as-4
sociation or similar association to which a 5
health insurance issuer in the State is required 6
to belong; 7
‘‘(G) to comply with any State law regard-8
ing fraud and abuse (as defined in section 9
2799E–1(10)), except that if the State seeks an 10
injunction regarding the conduct described in 11
this subparagraph, such injunction must be ob-12
tained from a court of competent jurisdiction; 13
‘‘(H) to comply with any State law regard-14
ing unfair claims settlement practices (as de-15
fined in section 2799E–1(9)); or 16
‘‘(I) to comply with the applicable require-17
ments for independent review under section 18
2799E–4 with respect to coverage offered in the 19
State; 20
‘‘(2) require any individual health insurance 21
coverage issued by the issuer to be countersigned by 22
an insurance agent or broker residing in that Sec-23
ondary State; or 24
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‘‘(3) otherwise discriminate against the issuer 1
issuing insurance in both the primary State and in 2
any secondary State. 3
‘‘(c) C
LEAR AND CONSPICUOUSDISCLOSURE.—A 4
health insurance issuer shall provide the following notice, 5
in 12-point bold type, in any insurance coverage offered 6
in a secondary State under this part by such a health in-7
surance issuer and at renewal of the policy, with the 5 8
blank spaces therein being appropriately filled with the 9
name of the health insurance issuer, the name of the pri-10
mary State, the name of the secondary State, the name 11
of the secondary State, and the name of the secondary 12
State, respectively, for the coverage concerned: 13
‘‘‘N
OTICE 14
‘‘‘This policy is issued by lllll and is gov-15
erned by the laws and regulations of the State of 16
lllll , and it has met all the laws of that State as 17
determined by that State’s Department of Insurance. This 18
policy may be less expensive than others because it is not 19
subject to all of the insurance laws and regulations of the 20
State of lllll , including coverage of some services 21
or benefits mandated by the law of the State of 22
lllll . Additionally, this policy is not subject to all 23
of the consumer protection laws or restrictions on rate 24
changes of the State of lllll . As with all insurance 25
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products, before purchasing this policy, you should care-1
fully review the policy and determine what health care 2
services the policy covers and what benefits it provides, 3
including any exclusions, limitations, or conditions for 4
such services or benefits.’.’’. 5
‘‘(d) P
ROHIBITION ONCERTAINRECLASSIFICATIONS 6
ANDPREMIUMINCREASES.— 7
‘‘(1) I
N GENERAL.—For purposes of this sec-8
tion, a health insurance issuer that provides indi-9
vidual health insurance coverage to an individual 10
under this part in a primary or secondary State may 11
not upon renewal— 12
‘‘(A) move or reclassify the individual in-13
sured under the health insurance coverage from 14
the class such individual is in at the time of 15
issue of the contract based on the health status- 16
related factors of the individual; or 17
‘‘(B) increase the premiums assessed the 18
individual for such coverage based on a health 19
status-related factor or change of a health sta-20
tus-related factor or the past or prospective 21
claim experience of the insured individual. 22
‘‘(2) C
ONSTRUCTION.—Nothing in paragraph 23
(1) shall be construed to prohibit a health insurance 24
issuer— 25
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‘‘(A) from terminating or discontinuing 1
coverage or a class of coverage in accordance 2
with subsections (b) and (c) of section 2742; 3
‘‘(B) from raising premium rates for all 4
policyholders within a class based on claims ex-5
perience; 6
‘‘(C) from changing premiums or offering 7
discounted premiums to individuals who engage 8
in wellness activities at intervals prescribed by 9
the issuer, if such premium changes or incen-10
tives— 11
‘‘(i) are disclosed to the consumer in 12
the insurance contract; 13
‘‘(ii) are based on specific wellness ac-14
tivities that are not applicable to all indi-15
viduals; and 16
‘‘(iii) are not obtainable by all individ-17
uals to whom coverage is offered; 18
‘‘(D) from reinstating lapsed coverage; or 19
‘‘(E) from retroactively adjusting the rates 20
charged an insured individual if the initial rates 21
were set based on material misrepresentation by 22
the individual at the time of issue. 23
‘‘(e) P
RIOROFFERING OF POLICY INPRIMARY 24
S
TATE.—A health insurance issuer may not offer for sale 25
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individual health insurance coverage in a secondary State 1
unless that coverage is currently offered for sale in the 2
primary State. 3
‘‘(f) L
ICENSING OF AGENTS OR BROKERS FOR 4
H
EALTHINSURANCEISSUERS.—Any State may require 5
that a person acting, or offering to act, as an agent or 6
broker for a health insurance issuer with respect to the 7
offering of individual health insurance coverage obtain a 8
license from that State, with commissions or other com-9
pensation subject to the provisions of the laws of that 10
State, except that a State may not impose any qualifica-11
tion or requirement which discriminates against a non-12
resident agent or broker. 13
‘‘(g) D
OCUMENTS FOR SUBMISSION TOSTATEIN-14
SURANCECOMMISSIONER.—Each health insurance issuer 15
issuing individual health insurance coverage in both pri-16
mary and secondary States shall submit— 17
‘‘(1) to the insurance commissioner of each 18
State in which it intends to offer such coverage, be-19
fore it may offer individual health insurance cov-20
erage in such State— 21
‘‘(A) a copy of the plan of operation or fea-22
sibility study or any similar statement of the 23
policy being offered and its coverage (which 24
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shall include the name of its primary State and 1
its principal place of business); 2
‘‘(B) written notice of any change in its 3
designation of its primary State; and 4
‘‘(C) written notice from the issuer of the 5
issuer’s compliance with all the laws of the pri-6
mary State; and 7
‘‘(2) to the insurance commissioner of each sec-8
ondary State in which it offers individual health in-9
surance coverage, a copy of the issuer’s quarterly fi-10
nancial statement submitted to the primary State, 11
which statement shall be certified by an independent 12
public accountant and contain a statement of opin-13
ion on loss and loss adjustment expense reserves 14
made by— 15
‘‘(A) a member of the American Academy 16
of Actuaries; or 17
‘‘(B) a qualified loss reserve specialist. 18
‘‘(h) P
OWER OFCOURTSTOENJOINCONDUCT.— 19
Nothing in this section shall be construed to affect the 20
authority of any Federal or State court to enjoin— 21
‘‘(1) the solicitation or sale of individual health 22
insurance coverage by a health insurance issuer to 23
any person or group who is not eligible for such in-24
surance; or 25
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‘‘(2) the solicitation or sale of individual health 1
insurance coverage that violates the requirements of 2
the law of a secondary State which are described in 3
subparagraphs (A) through (H) of section 4
2796(b)(1). 5
‘‘(i) P
OWER OFSECONDARYSTATESTOTAKEAD-6
MINISTRATIVEACTION.—Nothing in this section shall be 7
construed to affect the authority of any State to enjoin 8
conduct in violation of that State’s laws described in sub-9
section (b)(1). 10
‘‘(j) S
TATEPOWERSTOENFORCESTATELAWS.— 11
‘‘(1) I
N GENERAL.—Subject to the provisions of 12
subsection (b)(1)(G) (relating to injunctions) and 13
paragraph (2), nothing in this section shall be con-14
strued to affect the authority of any State to make 15
use of any of its powers to enforce the laws of such 16
State with respect to which a health insurance issuer 17
is not exempt under subsection (b). 18
‘‘(2) C
OURTS OF COMPETENT JURISDICTION .— 19
If a State seeks an injunction regarding the conduct 20
described in paragraphs (1) and (2) of subsection 21
(h), such injunction must be obtained from a Fed-22
eral or State court of competent jurisdiction. 23
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‘‘(k) STATES’ AUTHORITYTOSUE.—Nothing in this 1
section shall affect the authority of any State to bring ac-2
tion in any Federal or State court. 3
‘‘(l) G
ENERALLYAPPLICABLELAWS.—Nothing in 4
this section shall be construed to affect the applicability 5
of State laws generally applicable to persons or corpora-6
tions. 7
‘‘(m) G
UARANTEEDAVAILABILITY OFCOVERAGE TO 8
HIPAA E
LIGIBLEINDIVIDUALS.—To the extent that a 9
health insurance issuer is offering coverage in a primary 10
State that does not accommodate residents of secondary 11
States or does not provide a working mechanism for resi-12
dents of a secondary State, and the issuer is offering cov-13
erage under this part in such secondary State which has 14
not adopted a qualified high risk pool as its acceptable 15
alternative mechanism (as defined in section 2744(c)(2)), 16
the issuer shall, with respect to any individual health in-17
surance coverage offered in a secondary State under this 18
part, comply with the guaranteed availability requirements 19
for eligible individuals in section 2741. 20
‘‘SEC. 2799E–3. PRIMARY STATE MUST MEET FEDERAL 21
FLOOR BEFORE ISSUER MAY SELL INTO SEC-22
ONDARY STATES. 23
‘‘A health insurance issuer may not offer, sell, or 24
issue individual health insurance coverage in a secondary 25
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State if the State insurance commissioner does not use 1
a risk-based capital formula for the determination of cap-2
ital and surplus requirements for all health insurance 3
issuers. 4
‘‘SEC. 2799E–4. INDEPENDENT EXTERNAL APPEALS PROCE-5
DURES. 6
‘‘(a) R
IGHT TOEXTERNALAPPEAL.—A health insur-7
ance issuer may not offer, sell, or issue individual health 8
insurance coverage in a secondary State under the provi-9
sions of this title unless— 10
‘‘(1) both the secondary State and the primary 11
State have legislation or regulations in place estab-12
lishing an independent review process for individuals 13
who are covered by individual health insurance cov-14
erage; or 15
‘‘(2) in any case in which the requirements of 16
subparagraph (A) are not met with respect to either 17
of such States, the issuer provides an independent 18
review mechanism substantially identical (as deter-19
mined by the applicable State authority of such 20
State) to that prescribed in the ‘Health Carrier Ex-21
ternal Review Model Act’ of the National Association 22
of Insurance Commissioners for all individuals who 23
purchase insurance coverage under the terms of this 24
part, except that, under such mechanism, the review 25
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is conducted by an independent medical reviewer, or 1
a panel of such reviewers, with respect to whom the 2
requirements of subsection (b) are met. 3
‘‘(b) Q
UALIFICATIONS OF INDEPENDENT MEDICAL 4
R
EVIEWERS.—In the case of any independent review 5
mechanism referred to in subsection (a)(2)— 6
‘‘(1) I
N GENERAL.—In referring a denial of a 7
claim to an independent medical reviewer, or to any 8
panel of such reviewers, to conduct independent 9
medical review, the issuer shall ensure that— 10
‘‘(A) each independent medical reviewer 11
meets the qualifications described in paragraphs 12
(2) and (3); 13
‘‘(B) with respect to each review, each re-14
viewer meets the requirements of paragraph (4) 15
and the reviewer, or at least 1 reviewer on the 16
panel, meets the requirements described in 17
paragraph (5); and 18
‘‘(C) compensation provided by the issuer 19
to each reviewer is consistent with paragraph 20
(6). 21
‘‘(2) L
ICENSURE AND EXPERTISE .—Each inde-22
pendent medical reviewer shall be a physician 23
(allopathic or osteopathic) or health care profes-24
sional who— 25
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‘‘(A) is appropriately credentialed or li-1
censed in one or more States to deliver health 2
care services; and 3
‘‘(B) typically treats the condition, makes 4
the diagnosis, or provides the type of treatment 5
under review. 6
‘‘(3) I
NDEPENDENCE.— 7
‘‘(A) I
N GENERAL.—Subject to subpara-8
graph (B), each independent medical reviewer 9
in a case shall— 10
‘‘(i) not be a related party (as defined 11
in paragraph (7)); 12
‘‘(ii) not have a material familial, fi-13
nancial, or professional relationship with 14
such a party; and 15
‘‘(iii) not otherwise have a conflict of 16
interest with such a party (as determined 17
under regulations). 18
‘‘(B) E
XCEPTION.—Nothing in subpara-19
graph (A) shall be construed to— 20
‘‘(i) prohibit an individual, solely on 21
the basis of affiliation with the issuer, 22
from serving as an independent medical re-23
viewer if— 24
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‘‘(I) a non-affiliated individual is 1
not reasonably available; 2
‘‘(II) the affiliated individual is 3
not involved in the provision of items 4
or services in the case under review; 5
‘‘(III) the fact of such an affili-6
ation is disclosed to the issuer and the 7
enrollee (or authorized representative) 8
and neither party objects; and 9
‘‘(IV) the affiliated individual is 10
not an employee of the issuer and 11
does not provide services exclusively or 12
primarily to or on behalf of the issuer; 13
‘‘(ii) prohibit an individual who has 14
staff privileges at the institution where the 15
treatment involved takes place from serv-16
ing as an independent medical reviewer 17
merely on the basis of such affiliation if 18
the affiliation is disclosed to the issuer and 19
the enrollee (or authorized representative), 20
and neither party objects; or 21
‘‘(iii) prohibit receipt of compensation 22
by an independent medical reviewer from 23
an entity if the compensation is provided 24
consistent with paragraph (6). 25
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‘‘(4) PRACTICING HEALTH CARE PROFESSIONAL 1
IN SAME FIELD.— 2
‘‘(A) I
N GENERAL.—In a case involving 3
treatment, or the provision of items or serv-4
ices— 5
‘‘(i) by a physician, a reviewer shall be 6
a practicing physician (allopathic or osteo-7
pathic) of the same or similar specialty, as 8
a physician who, acting within the appro-9
priate scope of practice within the State in 10
which the service is provided or rendered, 11
typically treats the condition, makes the 12
diagnosis, or provides the type of treat-13
ment under review; or 14
‘‘(ii) by a non-physician health care 15
professional, the reviewer, or at least 1 16
member of the review panel, shall be a 17
practicing non-physician health care pro-18
fessional of the same or similar specialty 19
as the non-physician health care profes-20
sional who, acting within the appropriate 21
scope of practice within the State in which 22
the service is provided or rendered, typi-23
cally treats the condition, makes the diag-24
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•HR 77 IH
nosis, or provides the type of treatment 1
under review. 2
‘‘(B) P
RACTICING DEFINED .—For pur-3
poses of this paragraph, the term ‘practicing’ 4
means, with respect to an individual who is a 5
physician or other health care professional, that 6
the individual provides health care services to 7
individual patients on average at least 2 days 8
per week. 9
‘‘(5) P
EDIATRIC EXPERTISE.—In the case of an 10
external review relating to a child, a reviewer shall 11
have expertise under paragraph (2) in pediatrics. 12
‘‘(6) L
IMITATIONS ON REVIEWER COMPENSA -13
TION.—Compensation provided by the issuer to an 14
independent medical reviewer in connection with a 15
review under this section shall— 16
‘‘(A) not exceed a reasonable level; and 17
‘‘(B) not be contingent on the decision ren-18
dered by the reviewer. 19
‘‘(7) R
ELATED PARTY DEFINED .—For purposes 20
of this section, the term ‘related party’ means, with 21
respect to a denial of a claim under a coverage relat-22
ing to an enrollee, any of the following: 23
‘‘(A) The issuer involved, or any fiduciary, 24
officer, director, or employee of the issuer. 25
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•HR 77 IH
‘‘(B) The enrollee (or authorized represent-1
ative). 2
‘‘(C) The health care professional that pro-3
vides the items or services involved in the de-4
nial. 5
‘‘(D) The institution at which the items or 6
services (or treatment) involved in the denial 7
are provided. 8
‘‘(E) The manufacturer of any drug or 9
other item that is included in the items or serv-10
ices involved in the denial. 11
‘‘(F) Any other party determined under 12
any regulations to have a substantial interest in 13
the denial involved. 14
‘‘(8) D
EFINITIONS.—For purposes of this sub-15
section: 16
‘‘(A) E
NROLLEE.—The term ‘enrollee’ 17
means, with respect to health insurance cov-18
erage offered by a health insurance issuer, an 19
individual enrolled with the issuer to receive 20
such coverage. 21
‘‘(B) H
EALTH CARE PROFESSIONAL .—The 22
term ‘health care professional’ means an indi-23
vidual who is licensed, accredited, or certified 24
under State law to provide specified health care 25
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•HR 77 IH
services and who is operating within the scope 1
of such licensure, accreditation, or certification. 2
‘‘SEC. 2799E–5. ENFORCEMENT. 3
‘‘(a) I
NGENERAL.—Subject to subsection (b), with 4
respect to specific individual health insurance coverage, 5
the primary State for such coverage has sole jurisdiction 6
to enforce the primary State’s covered laws in the primary 7
State and any secondary State. 8
‘‘(b) S
ECONDARYSTATE’SAUTHORITY.—Nothing in 9
subsection (a) shall be construed to affect the authority 10
of a secondary State to enforce its laws as set forth in 11
the exception specified in section 2796(b)(1). 12
‘‘(c) C
OURTINTERPRETATION.—In reviewing action 13
initiated by the applicable secondary State authority, the 14
court of competent jurisdiction shall apply the covered 15
laws of the primary State. 16
‘‘(d) N
OTICE OFCOMPLIANCEFAILURE.—In the case 17
of individual health insurance coverage offered in a sec-18
ondary State that fails to comply with the covered laws 19
of the primary State, the applicable State authority of the 20
secondary State may notify the applicable State authority 21
of the primary State.’’. 22
(b) E
FFECTIVEDATE.—The amendment made by 23
subsection (a) shall apply to individual health insurance 24
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coverage offered, issued, or sold on or after October 1, 1
2023. 2
(c) GAO O
NGOINGSTUDY ANDREPORTS.— 3
(1) S
TUDY.—The Comptroller General of the 4
United States shall conduct an ongoing study con-5
cerning the effect of the amendment made by sub-6
section (a) on— 7
(A) the number of uninsured and under-in-8
sured; 9
(B) the availability and cost of health in-10
surance policies for individuals with pre-existing 11
medical conditions; 12
(C) the availability and cost of health in-13
surance policies generally; 14
(D) the elimination or reduction of dif-15
ferent types of benefits under health insurance 16
policies offered in different States; and 17
(E) cases of fraud or abuse relating to 18
health insurance coverage offered under such 19
amendment and the resolution of such cases. 20
(2) A
NNUAL REPORTS.—The Comptroller Gen-21
eral shall submit to Congress an annual report, after 22
the end of each of the 5 years following the effective 23
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•HR 77 IH
date of the amendment made by subsection (a), on 1
the ongoing study conducted under paragraph (1). 2
Æ
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