Us Congress 2023-2024 Regular Session

Us Congress House Bill HB77 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	I
2	2	118THCONGRESS
3	3	1
4	4	STSESSION H. R. 77
5	5	To amend the Public Health Service Act to provide for cooperative governing
6	6	of individual health insurance coverage.
7	7	IN THE HOUSE OF REPRESENTATIVES
8	8	JANUARY9, 2023
9	9	Mr. B
10	10	IGGSintroduced the following bill; which was referred to the Committee
11	11	on Energy and Commerce
12	12	A BILL
13	13	To amend the Public Health Service Act to provide for
14	14	cooperative governing of individual health insurance coverage.
15	15	Be it enacted by the Senate and House of Representa-1
16	16	tives of the United States of America in Congress assembled, 2
17	17	SECTION 1. COOPERATIVE GOVERNING OF INDIVIDUAL 3
18	18	HEALTH INSURANCE COVERAGE. 4
19	19	(a) I
20	20	NGENERAL.—Title XXVII of the Public Health 5
21	21	Service Act (42 U.S.C. 300gg et seq.) is amended by add-6
22	22	ing at the end the following new part: 7
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26	26	‘‘PART E—COOPERATIVE GOVERNING OF 1
27	27	INDIVIDUAL HEALTH INSURANCE COVERAGE 2
28	28	‘‘SEC. 2799E–1. DEFINITIONS. 3
29	29	‘‘In this part: 4
30	30	‘‘(1) P
31	31	RIMARY STATE.—The term ‘primary 5
32	32	State’ means, with respect to individual health insur-6
33	33	ance coverage offered by a health insurance issuer, 7
34	34	the State designated by the issuer as the State 8
35	35	whose covered laws shall govern the health insurance 9
36	36	issuer in the sale of such coverage under this part. 10
37	37	An issuer, with respect to a particular policy, may 11
38	38	only designate one such State as its primary State 12
39	39	with respect to all such coverage it offers. Such an 13
40	40	issuer may not change the designated primary State 14
41	41	with respect to individual health insurance coverage 15
42	42	once the policy is issued, except that such a change 16
43	43	may be made upon renewal of the policy. With re-17
44	44	spect to such designated State, the issuer is deemed 18
45	45	to be doing business in that State. 19
46	46	‘‘(2) S
47	47	ECONDARY STATE.—The term ‘secondary 20
48	48	State’ means, with respect to individual health insur-21
49	49	ance coverage offered by a health insurance issuer, 22
50	50	any State that is not the primary State. In the case 23
51	51	of a health insurance issuer that is selling a policy 24
52	52	in, or to a resident of, a secondary State, the issuer 25
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55	55	•HR 77 IH
56	56	is deemed to be doing business in that secondary 1
57	57	State. 2
58	58	‘‘(3) H
59	59	EALTH INSURANCE ISSUER .—The term 3
60	60	‘health insurance issuer’ has the meaning given such 4
61	61	term in section 2791(b)(2), except that such an 5
62	62	issuer must be licensed in the primary State and be 6
63	63	qualified to sell individual health insurance coverage 7
64	64	in that State. 8
65	65	‘‘(4) I
66	66	NDIVIDUAL HEALTH INSURANCE COV -9
67	67	ERAGE.—The term ‘individual health insurance cov-10
68	68	erage’ means health insurance coverage offered in 11
69	69	the individual market, as defined in section 12
70	70	2791(e)(1). 13
71	71	‘‘(5) A
72	72	PPLICABLE STATE AUTHORITY .—The 14
73	73	term ‘applicable State authority’ means, with respect 15
74	74	to a health insurance issuer in a State, the State in-16
75	75	surance commissioner or official or officials des-17
76	76	ignated by the State to enforce the requirements of 18
77	77	this title for the State with respect to the issuer. 19
78	78	‘‘(6) H
79	79	AZARDOUS FINANCIAL CONDITION .—The 20
80	80	term ‘hazardous financial condition’ means that, 21
81	81	based on its present or reasonably anticipated finan-22
82	82	cial condition, a health insurance issuer is unlikely 23
83	83	to be able— 24
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86	86	•HR 77 IH
87	87	‘‘(A) to meet obligations to policyholders 1
88	88	with respect to known claims and reasonably 2
89	89	anticipated claims; or 3
90	90	‘‘(B) to pay other obligations in the normal 4
91	91	course of business. 5
92	92	‘‘(7) C
93	93	OVERED LAWS.— 6
94	94	‘‘(A) I
95	95	N GENERAL.—The term ‘covered 7
96	96	laws’ means the laws, rules, regulations, agree-8
97	97	ments, and orders governing the insurance busi-9
98	98	ness pertaining to— 10
99	99	‘‘(i) individual health insurance cov-11
100	100	erage issued by a health insurance issuer; 12
101	101	‘‘(ii) the offer, sale, rating (including 13
102	102	medical underwriting), renewal, and 14
103	103	issuance of individual health insurance cov-15
104	104	erage to an individual; 16
105	105	‘‘(iii) the provision to an individual in 17
106	106	relation to individual health insurance cov-18
107	107	erage of health care and insurance related 19
108	108	services; 20
109	109	‘‘(iv) the provision to an individual in 21
110	110	relation to individual health insurance cov-22
111	111	erage of management, operations, and in-23
112	112	vestment activities of a health insurance 24
113	113	issuer; and 25
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116	116	•HR 77 IH
117	117	‘‘(v) the provision to an individual in 1
118	118	relation to individual health insurance cov-2
119	119	erage of loss control and claims adminis-3
120	120	tration for a health insurance issuer with 4
121	121	respect to liability for which the issuer pro-5
122	122	vides insurance. 6
123	123	‘‘(B) E
124	124	XCEPTION.—Such term does not in-7
125	125	clude any law, rule, regulation, agreement, or 8
126	126	order governing the use of care or cost manage-9
127	127	ment techniques, including any requirement re-10
128	128	lated to provider contracting, network access or 11
129	129	adequacy, health care data collection, or quality 12
130	130	assurance. 13
131	131	‘‘(8) S
132	132	TATE.—The term ‘State’ means the 50 14
133	133	States and includes the District of Columbia, Puerto 15
134	134	Rico, the Virgin Islands, Guam, American Samoa, 16
135	135	and the Northern Mariana Islands. 17
136	136	‘‘(9) U
137	137	NFAIR CLAIMS SETTLEMENT PRAC -18
138	138	TICES.—The term ‘unfair claims settlement prac-19
139	139	tices’ means only the following practices: 20
140	140	‘‘(A) Knowingly misrepresenting to claim-21
141	141	ants and insured individuals relevant facts or 22
142	142	policy provisions relating to coverage at issue. 23
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146	146	‘‘(B) Failing to acknowledge with reason-1
147	147	able promptness pertinent communications with 2
148	148	respect to claims arising under policies. 3
149	149	‘‘(C) Failing to adopt and implement rea-4
150	150	sonable standards for the prompt investigation 5
151	151	and settlement of claims arising under policies. 6
152	152	‘‘(D) Failing to effectuate prompt, fair, 7
153	153	and equitable settlement of claims submitted in 8
154	154	which liability has become reasonably clear. 9
155	155	‘‘(E) Refusing to pay claims without con-10
156	156	ducting a reasonable investigation. 11
157	157	‘‘(F) Failing to affirm or deny coverage of 12
158	158	claims within a reasonable period of time after 13
159	159	having completed an investigation related to 14
160	160	those claims. 15
161	161	‘‘(G) A pattern or practice of compelling 16
162	162	insured individuals or their beneficiaries to in-17
163	163	stitute suits to recover amounts due under its 18
164	164	policies by offering substantially less than the 19
165	165	amounts ultimately recovered in suits brought 20
166	166	by them. 21
167	167	‘‘(H) A pattern or practice of attempting 22
168	168	to settle or settling claims for less than the 23
169	169	amount that a reasonable person would believe 24
170	170	the insured individual or his or her beneficiary 25
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173	173	•HR 77 IH
174	174	was entitled by reference to written or printed 1
175	175	advertising material accompanying or made 2
176	176	part of an application. 3
177	177	‘‘(I) Attempting to settle or settling claims 4
178	178	on the basis of an application that was materi-5
179	179	ally altered without notice to, or knowledge or 6
180	180	consent of, the insured. 7
181	181	‘‘(J) Failing to provide forms necessary to 8
182	182	present claims within 15 calendar days of a re-9
183	183	quest with reasonable explanations regarding 10
184	184	their use. 11
185	185	‘‘(K) Attempting to cancel a policy in less 12
186	186	time than that prescribed in the policy or by the 13
187	187	law of the primary State. 14
188	188	‘‘(10) F
189	189	RAUD AND ABUSE .—The term ‘fraud 15
190	190	and abuse’ means an act or omission committed by 16
191	191	a person who, knowingly and with intent to defraud, 17
192	192	commits, or conceals any material information con-18
193	193	cerning, one or more of the following: 19
194	194	‘‘(A) Presenting, causing to be presented 20
195	195	or preparing with knowledge or belief that it 21
196	196	will be presented to or by an insurer, a rein-22
197	197	surer, broker or its agent, false information as 23
198	198	part of, in support of or concerning a fact ma-24
199	199	terial to one or more of the following: 25
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202	202	•HR 77 IH
203	203	‘‘(i) An application for the issuance or 1
204	204	renewal of an insurance policy or reinsur-2
205	205	ance contract. 3
206	206	‘‘(ii) The rating of an insurance policy 4
207	207	or reinsurance contract. 5
208	208	‘‘(iii) A claim for payment or benefit 6
209	209	pursuant to an insurance policy or reinsur-7
210	210	ance contract. 8
211	211	‘‘(iv) Premiums paid on an insurance 9
212	212	policy or reinsurance contract. 10
213	213	‘‘(v) Payments made in accordance 11
214	214	with the terms of an insurance policy or 12
215	215	reinsurance contract. 13
216	216	‘‘(vi) A document filed with the com-14
217	217	missioner or the chief insurance regulatory 15
218	218	official of another jurisdiction. 16
219	219	‘‘(vii) The financial condition of an in-17
220	220	surer or reinsurer. 18
221	221	‘‘(viii) The formation, acquisition, 19
222	222	merger, reconsolidation, dissolution or 20
223	223	withdrawal from one or more lines of in-21
224	224	surance or reinsurance in all or part of a 22
225	225	State by an insurer or reinsurer. 23
226	226	‘‘(ix) The issuance of written evidence 24
227	227	of insurance. 25
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230	230	•HR 77 IH
231	231	‘‘(x) The reinstatement of an insur-1
232	232	ance policy. 2
233	233	‘‘(B) Solicitation or acceptance of new or 3
234	234	renewal insurance risks on behalf of an insurer, 4
235	235	reinsurer, or other person engaged in the busi-5
236	236	ness of insurance by a person who knows or 6
237	237	should know that the insurer or other person 7
238	238	responsible for the risk is insolvent at the time 8
239	239	of the transaction. 9
240	240	‘‘(C) Transaction of the business of insur-10
241	241	ance in violation of laws requiring a license, cer-11
242	242	tificate of authority or other legal authority for 12
243	243	the transaction of the business of insurance. 13
244	244	‘‘(D) Attempt to commit, aiding or abet-14
245	245	ting in the commission of, or conspiracy to com-15
246	246	mit the acts or omissions specified in this para-16
247	247	graph. 17
248	248	‘‘SEC. 2799E–2. APPLICATION OF LAW. 18
249	249	‘‘(a) I
250	250	NGENERAL.—The covered laws of the primary 19
251	251	State shall apply to individual health insurance coverage 20
252	252	offered by a health insurance issuer in the primary State 21
253	253	and in any secondary State, but only if the coverage and 22
254	254	issuer comply with the conditions of this section with re-23
255	255	spect to the offering of coverage in any secondary State. 24
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258	258	•HR 77 IH
259	259	‘‘(b) EXEMPTIONSFROMCOVEREDLAWS IN ASEC-1
260	260	ONDARYSTATE.—Except as provided in this section, a 2
261	261	health insurance issuer with respect to its offer, sale, rat-3
262	262	ing (including medical underwriting), renewal, and 4
263	263	issuance of individual health insurance coverage in any 5
264	264	secondary State is exempt from any covered laws of the 6
265	265	secondary State (and any rules, regulations, agreements, 7
266	266	or orders sought or issued by such State under or related 8
267	267	to such covered laws) to the extent that such laws would— 9
268	268	‘‘(1) make unlawful, or regulate, directly or in-10
269	269	directly, the operation of the health insurance issuer 11
270	270	operating in the secondary State, except that any 12
271	271	secondary State may require such an issuer— 13
272	272	‘‘(A) to pay, on a nondiscriminatory basis, 14
273	273	applicable premium and other taxes (including 15
274	274	high risk pool assessments) which are levied on 16
275	275	insurers and surplus lines insurers, brokers, or 17
276	276	policyholders under the laws of the State; 18
277	277	‘‘(B) to register with and designate the 19
278	278	State insurance commissioner as its agent solely 20
279	279	for the purpose of receiving service of legal doc-21
280	280	uments or process; 22
281	281	‘‘(C) to submit to an examination of its fi-23
282	282	nancial condition by the State insurance com-24
283	283	missioner in any State in which the issuer is 25
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286	286	•HR 77 IH
287	287	doing business to determine the issuer’s finan-1
288	288	cial condition, if— 2
289	289	‘‘(i) the State insurance commissioner 3
290	290	of the primary State has not done an ex-4
291	291	amination within the period recommended 5
292	292	by the National Association of Insurance 6
293	293	Commissioners; and 7
294	294	‘‘(ii) any such examination is con-8
295	295	ducted in accordance with the examiners’ 9
296	296	handbook of the National Association of 10
297	297	Insurance Commissioners and is coordi-11
298	298	nated to avoid unjustified duplication and 12
299	299	unjustified repetition; 13
300	300	‘‘(D) to comply with a lawful order 14
301	301	issued— 15
302	302	‘‘(i) in a delinquency proceeding com-16
303	303	menced by the State insurance commis-17
304	304	sioner if there has been a finding of finan-18
305	305	cial impairment under subparagraph (C); 19
306	306	or 20
307	307	‘‘(ii) in a voluntary dissolution pro-21
308	308	ceeding; 22
309	309	‘‘(E) to comply with an injunction issued 23
310	310	by a court of competent jurisdiction, upon a pe-24
311	311	tition by the State insurance commissioner al-25
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314	314	•HR 77 IH
315	315	leging that the issuer is in hazardous financial 1
316	316	condition; 2
317	317	‘‘(F) to participate, on a nondiscriminatory 3
318	318	basis, in any insurance insolvency guaranty as-4
319	319	sociation or similar association to which a 5
320	320	health insurance issuer in the State is required 6
321	321	to belong; 7
322	322	‘‘(G) to comply with any State law regard-8
323	323	ing fraud and abuse (as defined in section 9
324	324	2799E–1(10)), except that if the State seeks an 10
325	325	injunction regarding the conduct described in 11
326	326	this subparagraph, such injunction must be ob-12
327	327	tained from a court of competent jurisdiction; 13
328	328	‘‘(H) to comply with any State law regard-14
329	329	ing unfair claims settlement practices (as de-15
330	330	fined in section 2799E–1(9)); or 16
331	331	‘‘(I) to comply with the applicable require-17
332	332	ments for independent review under section 18
333	333	2799E–4 with respect to coverage offered in the 19
334	334	State; 20
335	335	‘‘(2) require any individual health insurance 21
336	336	coverage issued by the issuer to be countersigned by 22
337	337	an insurance agent or broker residing in that Sec-23
338	338	ondary State; or 24
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341	341	•HR 77 IH
342	342	‘‘(3) otherwise discriminate against the issuer 1
343	343	issuing insurance in both the primary State and in 2
344	344	any secondary State. 3
345	345	‘‘(c) C
346	346	LEAR AND CONSPICUOUSDISCLOSURE.—A 4
347	347	health insurance issuer shall provide the following notice, 5
348	348	in 12-point bold type, in any insurance coverage offered 6
349	349	in a secondary State under this part by such a health in-7
350	350	surance issuer and at renewal of the policy, with the 5 8
351	351	blank spaces therein being appropriately filled with the 9
352	352	name of the health insurance issuer, the name of the pri-10
353	353	mary State, the name of the secondary State, the name 11
354	354	of the secondary State, and the name of the secondary 12
355	355	State, respectively, for the coverage concerned: 13
356	356	‘‘‘N
357	357	OTICE 14
358	358	‘‘‘This policy is issued by lllll and is gov-15
359	359	erned by the laws and regulations of the State of 16
360	360	lllll , and it has met all the laws of that State as 17
361	361	determined by that State’s Department of Insurance. This 18
362	362	policy may be less expensive than others because it is not 19
363	363	subject to all of the insurance laws and regulations of the 20
364	364	State of lllll , including coverage of some services 21
365	365	or benefits mandated by the law of the State of 22
366	366	lllll . Additionally, this policy is not subject to all 23
367	367	of the consumer protection laws or restrictions on rate 24
368	368	changes of the State of lllll . As with all insurance 25
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371	371	•HR 77 IH
372	372	products, before purchasing this policy, you should care-1
373	373	fully review the policy and determine what health care 2
374	374	services the policy covers and what benefits it provides, 3
375	375	including any exclusions, limitations, or conditions for 4
376	376	such services or benefits.’.’’. 5
377	377	‘‘(d) P
378	378	ROHIBITION ONCERTAINRECLASSIFICATIONS 6
379	379	ANDPREMIUMINCREASES.— 7
380	380	‘‘(1) I
381	381	N GENERAL.—For purposes of this sec-8
382	382	tion, a health insurance issuer that provides indi-9
383	383	vidual health insurance coverage to an individual 10
384	384	under this part in a primary or secondary State may 11
385	385	not upon renewal— 12
386	386	‘‘(A) move or reclassify the individual in-13
387	387	sured under the health insurance coverage from 14
388	388	the class such individual is in at the time of 15
389	389	issue of the contract based on the health status- 16
390	390	related factors of the individual; or 17
391	391	‘‘(B) increase the premiums assessed the 18
392	392	individual for such coverage based on a health 19
393	393	status-related factor or change of a health sta-20
394	394	tus-related factor or the past or prospective 21
395	395	claim experience of the insured individual. 22
396	396	‘‘(2) C
397	397	ONSTRUCTION.—Nothing in paragraph 23
398	398	(1) shall be construed to prohibit a health insurance 24
399	399	issuer— 25
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402	402	•HR 77 IH
403	403	‘‘(A) from terminating or discontinuing 1
404	404	coverage or a class of coverage in accordance 2
405	405	with subsections (b) and (c) of section 2742; 3
406	406	‘‘(B) from raising premium rates for all 4
407	407	policyholders within a class based on claims ex-5
408	408	perience; 6
409	409	‘‘(C) from changing premiums or offering 7
410	410	discounted premiums to individuals who engage 8
411	411	in wellness activities at intervals prescribed by 9
412	412	the issuer, if such premium changes or incen-10
413	413	tives— 11
414	414	‘‘(i) are disclosed to the consumer in 12
415	415	the insurance contract; 13
416	416	‘‘(ii) are based on specific wellness ac-14
417	417	tivities that are not applicable to all indi-15
418	418	viduals; and 16
419	419	‘‘(iii) are not obtainable by all individ-17
420	420	uals to whom coverage is offered; 18
421	421	‘‘(D) from reinstating lapsed coverage; or 19
422	422	‘‘(E) from retroactively adjusting the rates 20
423	423	charged an insured individual if the initial rates 21
424	424	were set based on material misrepresentation by 22
425	425	the individual at the time of issue. 23
426	426	‘‘(e) P
427	427	RIOROFFERING OF POLICY INPRIMARY 24
428	428	S
429	429	TATE.—A health insurance issuer may not offer for sale 25
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432	432	•HR 77 IH
433	433	individual health insurance coverage in a secondary State 1
434	434	unless that coverage is currently offered for sale in the 2
435	435	primary State. 3
436	436	‘‘(f) L
437	437	ICENSING OF AGENTS OR BROKERS FOR 4
438	438	H
439	439	EALTHINSURANCEISSUERS.—Any State may require 5
440	440	that a person acting, or offering to act, as an agent or 6
441	441	broker for a health insurance issuer with respect to the 7
442	442	offering of individual health insurance coverage obtain a 8
443	443	license from that State, with commissions or other com-9
444	444	pensation subject to the provisions of the laws of that 10
445	445	State, except that a State may not impose any qualifica-11
446	446	tion or requirement which discriminates against a non-12
447	447	resident agent or broker. 13
448	448	‘‘(g) D
449	449	OCUMENTS FOR SUBMISSION TOSTATEIN-14
450	450	SURANCECOMMISSIONER.—Each health insurance issuer 15
451	451	issuing individual health insurance coverage in both pri-16
452	452	mary and secondary States shall submit— 17
453	453	‘‘(1) to the insurance commissioner of each 18
454	454	State in which it intends to offer such coverage, be-19
455	455	fore it may offer individual health insurance cov-20
456	456	erage in such State— 21
457	457	‘‘(A) a copy of the plan of operation or fea-22
458	458	sibility study or any similar statement of the 23
459	459	policy being offered and its coverage (which 24
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462	462	•HR 77 IH
463	463	shall include the name of its primary State and 1
464	464	its principal place of business); 2
465	465	‘‘(B) written notice of any change in its 3
466	466	designation of its primary State; and 4
467	467	‘‘(C) written notice from the issuer of the 5
468	468	issuer’s compliance with all the laws of the pri-6
469	469	mary State; and 7
470	470	‘‘(2) to the insurance commissioner of each sec-8
471	471	ondary State in which it offers individual health in-9
472	472	surance coverage, a copy of the issuer’s quarterly fi-10
473	473	nancial statement submitted to the primary State, 11
474	474	which statement shall be certified by an independent 12
475	475	public accountant and contain a statement of opin-13
476	476	ion on loss and loss adjustment expense reserves 14
477	477	made by— 15
478	478	‘‘(A) a member of the American Academy 16
479	479	of Actuaries; or 17
480	480	‘‘(B) a qualified loss reserve specialist. 18
481	481	‘‘(h) P
482	482	OWER OFCOURTSTOENJOINCONDUCT.— 19
483	483	Nothing in this section shall be construed to affect the 20
484	484	authority of any Federal or State court to enjoin— 21
485	485	‘‘(1) the solicitation or sale of individual health 22
486	486	insurance coverage by a health insurance issuer to 23
487	487	any person or group who is not eligible for such in-24
488	488	surance; or 25
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491	491	•HR 77 IH
492	492	‘‘(2) the solicitation or sale of individual health 1
493	493	insurance coverage that violates the requirements of 2
494	494	the law of a secondary State which are described in 3
495	495	subparagraphs (A) through (H) of section 4
496	496	2796(b)(1). 5
497	497	‘‘(i) P
498	498	OWER OFSECONDARYSTATESTOTAKEAD-6
499	499	MINISTRATIVEACTION.—Nothing in this section shall be 7
500	500	construed to affect the authority of any State to enjoin 8
501	501	conduct in violation of that State’s laws described in sub-9
502	502	section (b)(1). 10
503	503	‘‘(j) S
504	504	TATEPOWERSTOENFORCESTATELAWS.— 11
505	505	‘‘(1) I
506	506	N GENERAL.—Subject to the provisions of 12
507	507	subsection (b)(1)(G) (relating to injunctions) and 13
508	508	paragraph (2), nothing in this section shall be con-14
509	509	strued to affect the authority of any State to make 15
510	510	use of any of its powers to enforce the laws of such 16
511	511	State with respect to which a health insurance issuer 17
512	512	is not exempt under subsection (b). 18
513	513	‘‘(2) C
514	514	OURTS OF COMPETENT JURISDICTION .— 19
515	515	If a State seeks an injunction regarding the conduct 20
516	516	described in paragraphs (1) and (2) of subsection 21
517	517	(h), such injunction must be obtained from a Fed-22
518	518	eral or State court of competent jurisdiction. 23
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521	521	•HR 77 IH
522	522	‘‘(k) STATES’ AUTHORITYTOSUE.—Nothing in this 1
523	523	section shall affect the authority of any State to bring ac-2
524	524	tion in any Federal or State court. 3
525	525	‘‘(l) G
526	526	ENERALLYAPPLICABLELAWS.—Nothing in 4
527	527	this section shall be construed to affect the applicability 5
528	528	of State laws generally applicable to persons or corpora-6
529	529	tions. 7
530	530	‘‘(m) G
531	531	UARANTEEDAVAILABILITY OFCOVERAGE TO 8
532	532	HIPAA E
533	533	LIGIBLEINDIVIDUALS.—To the extent that a 9
534	534	health insurance issuer is offering coverage in a primary 10
535	535	State that does not accommodate residents of secondary 11
536	536	States or does not provide a working mechanism for resi-12
537	537	dents of a secondary State, and the issuer is offering cov-13
538	538	erage under this part in such secondary State which has 14
539	539	not adopted a qualified high risk pool as its acceptable 15
540	540	alternative mechanism (as defined in section 2744(c)(2)), 16
541	541	the issuer shall, with respect to any individual health in-17
542	542	surance coverage offered in a secondary State under this 18
543	543	part, comply with the guaranteed availability requirements 19
544	544	for eligible individuals in section 2741. 20
545	545	‘‘SEC. 2799E–3. PRIMARY STATE MUST MEET FEDERAL 21
546	546	FLOOR BEFORE ISSUER MAY SELL INTO SEC-22
547	547	ONDARY STATES. 23
548	548	‘‘A health insurance issuer may not offer, sell, or 24
549	549	issue individual health insurance coverage in a secondary 25
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552	552	•HR 77 IH
553	553	State if the State insurance commissioner does not use 1
554	554	a risk-based capital formula for the determination of cap-2
555	555	ital and surplus requirements for all health insurance 3
556	556	issuers. 4
557	557	‘‘SEC. 2799E–4. INDEPENDENT EXTERNAL APPEALS PROCE-5
558	558	DURES. 6
559	559	‘‘(a) R
560	560	IGHT TOEXTERNALAPPEAL.—A health insur-7
561	561	ance issuer may not offer, sell, or issue individual health 8
562	562	insurance coverage in a secondary State under the provi-9
563	563	sions of this title unless— 10
564	564	‘‘(1) both the secondary State and the primary 11
565	565	State have legislation or regulations in place estab-12
566	566	lishing an independent review process for individuals 13
567	567	who are covered by individual health insurance cov-14
568	568	erage; or 15
569	569	‘‘(2) in any case in which the requirements of 16
570	570	subparagraph (A) are not met with respect to either 17
571	571	of such States, the issuer provides an independent 18
572	572	review mechanism substantially identical (as deter-19
573	573	mined by the applicable State authority of such 20
574	574	State) to that prescribed in the ‘Health Carrier Ex-21
575	575	ternal Review Model Act’ of the National Association 22
576	576	of Insurance Commissioners for all individuals who 23
577	577	purchase insurance coverage under the terms of this 24
578	578	part, except that, under such mechanism, the review 25
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581	581	•HR 77 IH
582	582	is conducted by an independent medical reviewer, or 1
583	583	a panel of such reviewers, with respect to whom the 2
584	584	requirements of subsection (b) are met. 3
585	585	‘‘(b) Q
586	586	UALIFICATIONS OF INDEPENDENT MEDICAL 4
587	587	R
588	588	EVIEWERS.—In the case of any independent review 5
589	589	mechanism referred to in subsection (a)(2)— 6
590	590	‘‘(1) I
591	591	N GENERAL.—In referring a denial of a 7
592	592	claim to an independent medical reviewer, or to any 8
593	593	panel of such reviewers, to conduct independent 9
594	594	medical review, the issuer shall ensure that— 10
595	595	‘‘(A) each independent medical reviewer 11
596	596	meets the qualifications described in paragraphs 12
597	597	(2) and (3); 13
598	598	‘‘(B) with respect to each review, each re-14
599	599	viewer meets the requirements of paragraph (4) 15
600	600	and the reviewer, or at least 1 reviewer on the 16
601	601	panel, meets the requirements described in 17
602	602	paragraph (5); and 18
603	603	‘‘(C) compensation provided by the issuer 19
604	604	to each reviewer is consistent with paragraph 20
605	605	(6). 21
606	606	‘‘(2) L
607	607	ICENSURE AND EXPERTISE .—Each inde-22
608	608	pendent medical reviewer shall be a physician 23
609	609	(allopathic or osteopathic) or health care profes-24
610	610	sional who— 25
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613	613	•HR 77 IH
614	614	‘‘(A) is appropriately credentialed or li-1
615	615	censed in one or more States to deliver health 2
616	616	care services; and 3
617	617	‘‘(B) typically treats the condition, makes 4
618	618	the diagnosis, or provides the type of treatment 5
619	619	under review. 6
620	620	‘‘(3) I
621	621	NDEPENDENCE.— 7
622	622	‘‘(A) I
623	623	N GENERAL.—Subject to subpara-8
624	624	graph (B), each independent medical reviewer 9
625	625	in a case shall— 10
626	626	‘‘(i) not be a related party (as defined 11
627	627	in paragraph (7)); 12
628	628	‘‘(ii) not have a material familial, fi-13
629	629	nancial, or professional relationship with 14
630	630	such a party; and 15
631	631	‘‘(iii) not otherwise have a conflict of 16
632	632	interest with such a party (as determined 17
633	633	under regulations). 18
634	634	‘‘(B) E
635	635	XCEPTION.—Nothing in subpara-19
636	636	graph (A) shall be construed to— 20
637	637	‘‘(i) prohibit an individual, solely on 21
638	638	the basis of affiliation with the issuer, 22
639	639	from serving as an independent medical re-23
640	640	viewer if— 24
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643	643	•HR 77 IH
644	644	‘‘(I) a non-affiliated individual is 1
645	645	not reasonably available; 2
646	646	‘‘(II) the affiliated individual is 3
647	647	not involved in the provision of items 4
648	648	or services in the case under review; 5
649	649	‘‘(III) the fact of such an affili-6
650	650	ation is disclosed to the issuer and the 7
651	651	enrollee (or authorized representative) 8
652	652	and neither party objects; and 9
653	653	‘‘(IV) the affiliated individual is 10
654	654	not an employee of the issuer and 11
655	655	does not provide services exclusively or 12
656	656	primarily to or on behalf of the issuer; 13
657	657	‘‘(ii) prohibit an individual who has 14
658	658	staff privileges at the institution where the 15
659	659	treatment involved takes place from serv-16
660	660	ing as an independent medical reviewer 17
661	661	merely on the basis of such affiliation if 18
662	662	the affiliation is disclosed to the issuer and 19
663	663	the enrollee (or authorized representative), 20
664	664	and neither party objects; or 21
665	665	‘‘(iii) prohibit receipt of compensation 22
666	666	by an independent medical reviewer from 23
667	667	an entity if the compensation is provided 24
668	668	consistent with paragraph (6). 25
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671	671	•HR 77 IH
672	672	‘‘(4) PRACTICING HEALTH CARE PROFESSIONAL 1
673	673	IN SAME FIELD.— 2
674	674	‘‘(A) I
675	675	N GENERAL.—In a case involving 3
676	676	treatment, or the provision of items or serv-4
677	677	ices— 5
678	678	‘‘(i) by a physician, a reviewer shall be 6
679	679	a practicing physician (allopathic or osteo-7
680	680	pathic) of the same or similar specialty, as 8
681	681	a physician who, acting within the appro-9
682	682	priate scope of practice within the State in 10
683	683	which the service is provided or rendered, 11
684	684	typically treats the condition, makes the 12
685	685	diagnosis, or provides the type of treat-13
686	686	ment under review; or 14
687	687	‘‘(ii) by a non-physician health care 15
688	688	professional, the reviewer, or at least 1 16
689	689	member of the review panel, shall be a 17
690	690	practicing non-physician health care pro-18
691	691	fessional of the same or similar specialty 19
692	692	as the non-physician health care profes-20
693	693	sional who, acting within the appropriate 21
694	694	scope of practice within the State in which 22
695	695	the service is provided or rendered, typi-23
696	696	cally treats the condition, makes the diag-24
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699	699	•HR 77 IH
700	700	nosis, or provides the type of treatment 1
701	701	under review. 2
702	702	‘‘(B) P
703	703	RACTICING DEFINED .—For pur-3
704	704	poses of this paragraph, the term ‘practicing’ 4
705	705	means, with respect to an individual who is a 5
706	706	physician or other health care professional, that 6
707	707	the individual provides health care services to 7
708	708	individual patients on average at least 2 days 8
709	709	per week. 9
710	710	‘‘(5) P
711	711	EDIATRIC EXPERTISE.—In the case of an 10
712	712	external review relating to a child, a reviewer shall 11
713	713	have expertise under paragraph (2) in pediatrics. 12
714	714	‘‘(6) L
715	715	IMITATIONS ON REVIEWER COMPENSA -13
716	716	TION.—Compensation provided by the issuer to an 14
717	717	independent medical reviewer in connection with a 15
718	718	review under this section shall— 16
719	719	‘‘(A) not exceed a reasonable level; and 17
720	720	‘‘(B) not be contingent on the decision ren-18
721	721	dered by the reviewer. 19
722	722	‘‘(7) R
723	723	ELATED PARTY DEFINED .—For purposes 20
724	724	of this section, the term ‘related party’ means, with 21
725	725	respect to a denial of a claim under a coverage relat-22
726	726	ing to an enrollee, any of the following: 23
727	727	‘‘(A) The issuer involved, or any fiduciary, 24
728	728	officer, director, or employee of the issuer. 25
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731	731	•HR 77 IH
732	732	‘‘(B) The enrollee (or authorized represent-1
733	733	ative). 2
734	734	‘‘(C) The health care professional that pro-3
735	735	vides the items or services involved in the de-4
736	736	nial. 5
737	737	‘‘(D) The institution at which the items or 6
738	738	services (or treatment) involved in the denial 7
739	739	are provided. 8
740	740	‘‘(E) The manufacturer of any drug or 9
741	741	other item that is included in the items or serv-10
742	742	ices involved in the denial. 11
743	743	‘‘(F) Any other party determined under 12
744	744	any regulations to have a substantial interest in 13
745	745	the denial involved. 14
746	746	‘‘(8) D
747	747	EFINITIONS.—For purposes of this sub-15
748	748	section: 16
749	749	‘‘(A) E
750	750	NROLLEE.—The term ‘enrollee’ 17
751	751	means, with respect to health insurance cov-18
752	752	erage offered by a health insurance issuer, an 19
753	753	individual enrolled with the issuer to receive 20
754	754	such coverage. 21
755	755	‘‘(B) H
756	756	EALTH CARE PROFESSIONAL .—The 22
757	757	term ‘health care professional’ means an indi-23
758	758	vidual who is licensed, accredited, or certified 24
759	759	under State law to provide specified health care 25
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762	762	•HR 77 IH
763	763	services and who is operating within the scope 1
764	764	of such licensure, accreditation, or certification. 2
765	765	‘‘SEC. 2799E–5. ENFORCEMENT. 3
766	766	‘‘(a) I
767	767	NGENERAL.—Subject to subsection (b), with 4
768	768	respect to specific individual health insurance coverage, 5
769	769	the primary State for such coverage has sole jurisdiction 6
770	770	to enforce the primary State’s covered laws in the primary 7
771	771	State and any secondary State. 8
772	772	‘‘(b) S
773	773	ECONDARYSTATE’SAUTHORITY.—Nothing in 9
774	774	subsection (a) shall be construed to affect the authority 10
775	775	of a secondary State to enforce its laws as set forth in 11
776	776	the exception specified in section 2796(b)(1). 12
777	777	‘‘(c) C
778	778	OURTINTERPRETATION.—In reviewing action 13
779	779	initiated by the applicable secondary State authority, the 14
780	780	court of competent jurisdiction shall apply the covered 15
781	781	laws of the primary State. 16
782	782	‘‘(d) N
783	783	OTICE OFCOMPLIANCEFAILURE.—In the case 17
784	784	of individual health insurance coverage offered in a sec-18
785	785	ondary State that fails to comply with the covered laws 19
786	786	of the primary State, the applicable State authority of the 20
787	787	secondary State may notify the applicable State authority 21
788	788	of the primary State.’’. 22
789	789	(b) E
790	790	FFECTIVEDATE.—The amendment made by 23
791	791	subsection (a) shall apply to individual health insurance 24
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794	794	•HR 77 IH
795	795	coverage offered, issued, or sold on or after October 1, 1
796	796	2023. 2
797	797	(c) GAO O
798	798	NGOINGSTUDY ANDREPORTS.— 3
799	799	(1) S
800	800	TUDY.—The Comptroller General of the 4
801	801	United States shall conduct an ongoing study con-5
802	802	cerning the effect of the amendment made by sub-6
803	803	section (a) on— 7
804	804	(A) the number of uninsured and under-in-8
805	805	sured; 9
806	806	(B) the availability and cost of health in-10
807	807	surance policies for individuals with pre-existing 11
808	808	medical conditions; 12
809	809	(C) the availability and cost of health in-13
810	810	surance policies generally; 14
811	811	(D) the elimination or reduction of dif-15
812	812	ferent types of benefits under health insurance 16
813	813	policies offered in different States; and 17
814	814	(E) cases of fraud or abuse relating to 18
815	815	health insurance coverage offered under such 19
816	816	amendment and the resolution of such cases. 20
817	817	(2) A
818	818	NNUAL REPORTS.—The Comptroller Gen-21
819	819	eral shall submit to Congress an annual report, after 22
820	820	the end of each of the 5 years following the effective 23
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823	823	•HR 77 IH
824	824	date of the amendment made by subsection (a), on 1
825	825	the ongoing study conducted under paragraph (1). 2
826	826	Æ
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