1.Short title; table of
contents
(a)This Act may be cited
as the Health Security for All
Americans Act of 2009
.
(b)The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
Title I—MEDICARE
Sec. 101. Medicare physician payment update reform.
Sec. 102. Medicare GPCI floors.
Sec. 103. Annual physical examinations under
Medicare.
Sec. 104. Medicare outreach campaign on availability of welcome
to Medicare physicals.
Sec. 105. Improvements to the medicare-dependent hospital (MDH)
program.
Sec. 106. Temporary improvements to the Medicare inpatient
hospital payment adjustment for low-volume hospitals.
Sec. 107. Ensuring proportional representation of interests of
rural areas on MedPAC.
Title II—SMALL BUSINESS HEALTH PLANS
Subtitle A—Enhanced Marketplace Pools
Sec. 201. Rules governing enhanced marketplace
pools.
Part 8—Rules governing enhanced marketplace pools
Sec. 801. Small business health plans.
Sec. 802. Alternative Market Pooling Organizations.
Sec. 803. Certification of small business health
plans.
Sec. 804. Requirements relating to sponsors and boards of
trustees.
Sec. 805. Participation and coverage requirements.
Sec. 806. Other requirements relating to plan documents,
contribution rates, and benefit options.
Sec. 807. Requirements for application and related
requirements.
Sec. 808. Notice requirements for voluntary
termination.
Sec. 809. Implementation and application authority by
Secretary.
Sec. 810. Definitions and rules of
construction.
Sec. 202. Cooperation between Federal and State
authorities.
Sec. 203. Effective date and transitional and other
rules.
Subtitle B—Market Relief
Sec. 211. Market relief.
Title XXXI—Health care insurance marketplace
modernization
Sec. 3101. General insurance definitions.
Sec. 3102. Implementation and application authority by
Secretary.
Subtitle A—Market relief
Part I—Rating requirements
Sec. 3111. Definitions.
Sec. 3112. Rating rules.
Sec. 3113. Application and preemption.
Sec. 3114. Civil actions and jurisdiction.
Sec. 3115. Ongoing review.
Part II—Affordable Plans
Sec. 3121. Definitions.
Sec. 3122. Offering affordable plans.
Sec. 3123. Application and preemption.
Sec. 3124. Civil actions and jurisdiction.
Sec. 3125. Rules of
construction.
Subtitle C—Harmonization of Health Insurance
Standards
Sec. 221. Health Insurance Standards
Harmonization.
Subtitle B—Standards Harmonization
Sec. 3131. Definitions.
Sec. 3132. Harmonized standards.
Sec. 3133. Application and preemption.
Sec. 3134. Civil actions and jurisdiction.
Sec. 3135. Authorization of appropriations; rule of
construction.
Title III—TAX-RELATED HEALTH INCENTIVES
Sec. 301. SECA tax deduction for health insurance
costs.
Sec. 302. Deduction for qualified health insurance costs of
individuals.
Title IV—INCREASING ACCESS TO VA HEALTH CARE
Sec. 401. Requirement for payments to facilities other than the
Department of Veterans Affairs for covered health services.
Sec. 402. Authority of Department of Veterans Affairs
pharmacies to dispense medications to veterans on prescriptions written by
private practitioners.
Title V—NURSING SHORTAGE
Sec. 501. Child care assistance for individuals pursuing
advanced nursing degrees.
Sec. 502. Nurse faculty program.
Part E—Nurse Faculty Project
Sec. 771. Purposes.
Sec. 772. Assistance authorized.
Sec. 773. Applications.
Sec. 774. Authorization of appropriations.
Sec. 775. Definition.
Sec. 503. Nurse Faculty Loan Repayment Program.
Sec. 504. Programs to increase the number of nurses within the
Armed Forces.
Title VI—RESERVE COMPONENTS OF THE ARMED FORCES
Sec. 601. Effective date of active duty for purposes of
entitlement to active duty health care of members of the reserve components of
the Armed Forces receiving alert order anticipating a call or order to active
duty in support of a contingency operation.
<enum>I</enum><header>MEDICARE</header>
<section id="H68EAB4C2DBAF4B9480DF3D6663BDDF65"><enum>101.</enum><header>Medicare
physician payment update reform</header>
<subsection id="H65F58C17E9174042A3330018EFBFC3B"><enum>(a)</enum><header>Substitution of
MEI Increase for SGR Adjustments</header><text>Section 1848(d) of the Social
Security Act (42 U.S.C. 1395w–4(d)) is amended—</text>
<paragraph id="H2767303F9228490A9FFACD40C300C3CE"><enum>(1)</enum><text>in paragraph
(1)(A), by inserting <quote>and before 2010</quote> after <quote>beginning with
2001</quote>;</text>
</paragraph><paragraph id="H17302B0D564B43E5B99E11E58DD1ED61"><enum>(2)</enum><text>in paragraph
(1)(A), by inserting before the period at the end the following: <quote>, and
for years beginning with 2010, multiplied by the update established under
paragraph (10) applicable to the year involved</quote>; and</text>
</paragraph><paragraph id="H1EB124F757BE4B17BED88661FECF4F82"><enum>(3)</enum><text>in paragraph
(4)—</text>
<subparagraph id="H45AEE623C3364705B40486F55BFF25B"><enum>(A)</enum><text>in the heading by
striking <quote><header-in-text level="paragraph" style="OLC">years beginning
with 2001</header-in-text></quote> and inserting <quote><header-in-text level="paragraph" style="OLC">2001, 2002, and 2003</header-in-text></quote>;
and</text>
</subparagraph><subparagraph id="H12DF4F15176F402D8300D71DAC832458"><enum>(B)</enum><text>in subparagraph
(A), by inserting <quote>and ending with 2003</quote> after <quote>beginning
with 2001</quote>; and</text>
</subparagraph></paragraph><paragraph id="H2A44F6C3DE644A7D93EEC2946696A2E6"><enum>(4)</enum><text>by adding at the
end the following new paragraph:</text>
<quoted-block id="H154186840FF34294B3C2E60013B2C162" style="OLC">
<paragraph id="H5A382DF0DC4A4450B427448115008DEA"><enum>(10)</enum><header>Update
beginning with 2010</header><text>The update to the single conversion factor
established in paragraph (1)(C) for 2010 and each succeeding year shall be the
percentage increase in the MEI (as defined in section 1842(i)(3)) for the year
involved minus 1 percentage
point.</text>
</paragraph><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></subsection><subsection id="H6AF6C371CE344B19A6F5B5E4F6F0806"><enum>(b)</enum><header>Ending
Application of Sustainable Growth Rate (SGR)</header><text>Section
1848(f)(1)(B) of such Act (42 U.S.C. 1395w–4(f)(1)(B)) is amended by inserting
<quote>(and before 2009)</quote> after <quote>each succeeding
year</quote>.</text>
</subsection><subsection id="H350AED04330C44B3A0E13B73D625A282"><enum>(c)</enum><header>Effective
Date</header><text>The amendments made by this section shall apply to payment
for services furnished on or after January 1, 2010.</text>
</subsection></section><section id="H3396EF26786549468128EFDD27850034"><enum>102.</enum><header>Medicare GPCI
floors</header><text display-inline="no-display-inline">Section 1848(e)(1) of
the Social Security Act (42 U.S.C. 1395w–4(e)(1)) is amended—</text>
<paragraph id="HD77ADA75F8884B4280695E7B1FFCEF86"><enum>(1)</enum><text>in subparagraph
(A), by striking <quote>and (G)</quote> and inserting <quote>(G), (H), and
(I)</quote>; and</text>
</paragraph><paragraph id="H4A2FC1E63B664A37B6003BA0902F5F14"><enum>(2)</enum><text>by adding at the
end the following new subparagraphs:</text>
<quoted-block id="HD11FCBE9BCF642E7BF3762759FE78B80" style="OLC">
<subparagraph id="H2CD8985726664074B98FFDEAC3D08F9"><enum>(H)</enum><header>Floor at 1.0 for
practice expense index</header><text>After calculating the practice expense
index in subparagraph (A)(ii), for purposes of payment for services furnished
on or after January 1, 2010, the Secretary shall increase the practice expense
geographic index to 1.00 for any locality for which such practice expense
geographic index is less than 1.00.</text>
</subparagraph><subparagraph id="H750EBDD0F6DB469AA3661459DE4C1267"><enum>(I)</enum><header>Floor at 1.0 for
work expenses index</header><text>After calculating the practice expense index
in subparagraph (A)(ii), for purposes of payment for services furnished on or
after January 1, 2010, the Secretary shall increase the practice expense
geographic index to 1.00 for any locality for which such practice expense
geographic index is less than
1.00.</text>
</subparagraph><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></section><section id="HADB38941AE324B62AB3137528E4BD4A3"><enum>103.</enum><header>Annual physical
examinations under Medicare</header>
<subsection id="H44AE4F86AE8A46EA9E844E0034A055FC"><enum>(a)</enum><header>In
General</header><text>Section 1861 of the Social Security Act (42 U.S.C. 1395x)
is amended—</text>
<paragraph id="H55F305A6819042A6BA0707977E943B9E"><enum>(1)</enum><text>in each of
subparagraphs (W) and (AA)(i) of subsection (s)(2), by striking
<quote>initial</quote> and inserting <quote>annual</quote>;</text>
</paragraph><paragraph id="H44AB04C49E6A4A5787C040F4E7787E9B"><enum>(2)</enum><text>in the heading of
subsection (ww), by striking <quote><header-in-text level="subsection" other-style="archaic" style="other">Initial</header-in-text></quote> and
inserting <quote><header-in-text level="subsection" other-style="archaic" style="other">Annual</header-in-text></quote>; and</text>
</paragraph><paragraph id="HC3FA36511FC6438FB6528B20C3E5EE21"><enum>(3)</enum><text>by amending
paragraph (1) of subsection (ww) to read as follows:</text>
<quoted-block id="H7A6DF722EA2045AEB7BCB41407C21923" style="OLC">
<paragraph id="H67A7D5735B134F1BBA17F3FB58F4ECF0"><enum>(1)</enum><text>The term
<term>annual preventive physical examination</term> means professional services
of a physician, or of a nurse practitioner or physician assistant which the
practitioner or assistant is authorized to provide under State law, consisting
of a physical examination (including, as medically appropriate, measurement of
height, weight, body mass index, and blood pressure) with the goal of health
promotion and disease detection and includes education, counseling, and
referral with respect to screening and other preventive services described in
paragraph (2) and end-of-life planning (as defined in paragraph (3)) upon the
agreement with the individual, as well as related clinical laboratory tests and
such other preventive services in connection with the same visit as the
Secretary may provide (taking into account services typically included in an
annual physical examination covered under private health benefit
plans).</text>
</paragraph><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></subsection><subsection id="HB2C6FC4E4E8F402BA2F363CE4890FAF0"><enum>(b)</enum><header>Modification of
Exclusions</header><text>Section 1862(a) of such Act (42 U.S.C. 1395y(a)) is
amended—</text>
<paragraph id="H90E4F8CC2FAD4AED98767F1EEFD4716D"><enum>(1)</enum><text>in paragraph (1),
by amending subparagraph (K) to read as follows:</text>
<quoted-block id="H97DD7147100F451B90E0B900F20696DB" style="OLC">
<subparagraph id="HB61A75F8BC654173B84094758B00A726"><enum>(K)</enum><text>in the case of an
annual preventive physical examination, which is performed for an individual
more frequently than once in any 12-month
period,</text>
</subparagraph><after-quoted-block>;
and</after-quoted-block></quoted-block>
</paragraph><paragraph id="HFB1ED4DA80CA4F90A4A4DDA12C22BC7"><enum>(2)</enum><text>in
paragraph (7), by inserting <quote>(other than annual preventive physical
examinations)</quote> after <quote>routine physical checkups</quote>.</text>
</paragraph></subsection><subsection id="HE5223C133CA44C8C93005F78AFE9A26E"><enum>(c)</enum><header>Conforming
amendment</header><text>Section 1833(b)(9) of such Act (42 U.S.C. 1395l(b)(9))
is amended by striking <quote>initial</quote> and inserting
<quote>annual</quote>.</text>
</subsection><subsection id="H31AF1FEA64734717A7128DEABA3E57F9"><enum>(d)</enum><header>Effective
Date</header><text>The amendments made by this section shall apply to services
furnished on or after January 1 of the first year beginning more than 60 days
after the date of the enactment of this Act.</text>
</subsection></section><section id="HACF0D5023E0444719652F613D894C9B3"><enum>104.</enum><header>Medicare
outreach campaign on availability of welcome to Medicare physicals</header>
<subsection id="HC7CACECC8B284B18B73CCDDF64F06945"><enum>(a)</enum><header>In
general</header><text display-inline="yes-display-inline">The Secretary of
Health and Human Services shall conduct a national campaign to provide
information to the public on the availability of an initial preventive physical
examination (as defined in section 1861(ww) of the Social Security Act (42
U.S.C. 1395x(ww))) for beneficiaries of the Medicare program under title XVIII
of the Social Security Act (42 U.S.C. 1395 et seq.).</text>
</subsection><subsection id="H92D261B51A6A45C6B8DAD200B27E33C0"><enum>(b)</enum><header>Authorization of
Appropriations</header><text display-inline="yes-display-inline">There is
authorized to be appropriated to carry out this section $1,000,000 for each of
fiscal years 2010 through 2014.</text>
</subsection></section><section display-inline="no-display-inline" id="HE2E1B586553C47038E9FB6F50054FD70" section-type="subsequent-section"><enum>105.</enum><header>Improvements to the
medicare-dependent hospital (MDH) program</header>
<subsection id="H7D3F3F321AEE4E51914D49AE04A1FA45"><enum>(a)</enum><header>Use of non-Wage
adjusted PPS rate</header><text>Section 1886(d)(5)(G) of the Social Security
Act (42 U.S.C. 1395ww(d)(5)(G)) is amended by adding at the end the following
new clause:</text>
<quoted-block display-inline="no-display-inline" id="HB9FA2822919A46E6A4FD9F4771250674" style="OLC">
<clause id="H58A6695DB2504923A5F0E32FBEC9C62" indent="up3"><enum>(v)</enum><text>In the case of discharges occurring
on or after October 1, 2010, and before October 1, 2012, in determining the
amount under paragraph (1)(A)(iii) for purposes of clauses (i) and (ii)(II),
such amount shall, if it results in greater payments to the hospital, be
determined without regard to any adjustment for different area wage levels
under paragraph
(3)(E).</text>
</clause><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="H8B03C1D33A864C7B833DDE4B0051E6DD"><enum>(b)</enum><header>Enhanced payment
for amount by which the target exceeds the PPS rate</header><text>Section
1886(d)(5)(G)(ii)(II) of the Social Security Act (42 U.S.C.
1395ww(d)(5)(G)(ii)(II)) is amended by inserting <quote>, and before October 1,
2010, or 85 percent in the case of discharges occurring on or after October 1,
2010, and before October 1, 2012</quote> after <quote>October 1,
2011</quote>.</text>
</subsection></section><section id="HB709270F498C4B289C3B6B6FBC2D7514"><enum>106.</enum><header>Temporary
improvements to the Medicare inpatient hospital payment adjustment for
low-volume hospitals</header><text display-inline="no-display-inline">Section
1886(d)(12) of the <act-name parsable-cite="SSA">Social Security Act</act-name>
(42 U.S.C. 1395ww(d)(12)) is amended—</text>
<paragraph id="H431B260E6D2540A09E75F48531296CB7"><enum>(1)</enum><text>in subparagraph
(A), by inserting <quote>or (D)</quote> after <quote>subparagraph
(B)</quote>;</text>
</paragraph><paragraph id="H95ABCF70BEDA4EEDBC92E68DB3F3A89F"><enum>(2)</enum><text>in subparagraph
(B), by striking <quote>The Secretary</quote> and inserting <quote>For
discharges occurring in fiscal years 2005 through 2010 and for discharges
occurring in fiscal year 2013 and subsequent fiscal years, the
Secretary</quote>;</text>
</paragraph><paragraph id="HB6BBE493A8C84DC98CD0CBF861008462"><enum>(3)</enum><text display-inline="yes-display-inline">in subparagraph (C)(i)—</text>
<subparagraph id="H9CA9F13FB5954EA2B9C7AFAAA269DE0"><enum>(A)</enum><text>by inserting
<quote>(or, with respect to fiscal years 2011 and 2012, 15 road miles)</quote>
after <quote>25 road miles</quote>; and</text>
</subparagraph><subparagraph id="H5CBB907A7F8A4FC4ACC1E216E1F6D2D9"><enum>(B)</enum><text display-inline="yes-display-inline">by inserting <quote>(or, with respect to
fiscal years 2011 and 2012, 2,000 discharges of individuals entitled to, or
enrolled for, benefits under part A)</quote> after <quote>800
discharges</quote>; and</text>
</subparagraph></paragraph><paragraph id="H52DDAC89E2134C8A900603D8AF34D471"><enum>(4)</enum><text>by adding at the
end the following new subparagraph:</text>
<quoted-block display-inline="no-display-inline" id="H1397BE7ACFA24EF695A4B211B3683F7B" style="OLC">
<subparagraph id="H480574A0229F4B059CC8238508BEF1BE"><enum>(D)</enum><header>Temporary
applicable percentage increase</header><text>For discharges occurring in fiscal
years 2011 or 2012, the Secretary shall determine an applicable percentage
increase for purposes of subparagraph (A) using a linear sliding scale ranging
from 25 percent for low-volume hospitals with fewer than an appropriate number
(as determined by the Secretary) of discharges of individuals entitled to, or
enrolled for, benefits under part A in the fiscal year to 0 percent for
low-volume hospitals with greater than 2,000 discharges of such individuals in
the fiscal
year.</text>
</subparagraph><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></section><section display-inline="no-display-inline" id="H6D6A481CFDF34C4FA2394C669B00F8A1" section-type="subsequent-section"><enum>107.</enum><header>Ensuring
proportional representation of interests of rural areas on MedPAC</header>
<subsection id="HE3AA4861D29948230046D7290DAA52B"><enum>(a)</enum><header>In
general</header><text>Section 1805(c)(2) of the Social Security Act (42 U.S.C.
1395b–6(c)(2)) is amended—</text>
<paragraph id="H17D32963857347D9A4943E0059EA00B7"><enum>(1)</enum><text>in subparagraph
(A), by inserting <quote>consistent with subparagraph (E)</quote> after
<quote>rural representatives</quote>; and</text>
</paragraph><paragraph id="H6FDAAF2A72F9447088FF5BD38515F9E3"><enum>(2)</enum><text>by adding at the
end the following new subparagraph:</text>
<quoted-block display-inline="no-display-inline" id="HBEEBFF77E0F3426200831DC9CEBBD1C" style="OLC">
<subparagraph id="HD4293F2DA4E54DEB896FAB996EC8EF9D"><enum>(E)</enum><header>Proportional
representation of interests of rural areas</header><text display-inline="yes-display-inline">In order to provide a balance between urban
and rural representatives under subparagraph (A), the proportion of members of
the Commission who represent the interests of health care providers and
Medicare beneficiaries located in rural areas shall be no less than the
proportion of the total number of Medicare beneficiaries who reside in rural
areas.</text>
</subparagraph><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></subsection><subsection id="H8CC881B90CD7497497E3ECC3CC2BF9D8"><enum>(b)</enum><header>Effective
date</header><text>The amendments made by subsection (a) shall apply to
appointments to the Medicare Payment Advisory Commission made after the date of
enactment of this Act.</text>
</subsection></section><enum>II</enum><header>SMALL BUSINESS
HEALTH PLANS </header>
<subtitle id="H1A8FC60C5DB54245B1A4C991BB76E3C3"><enum>A</enum><header>Enhanced
Marketplace Pools</header>
<section id="H10583681477843378EBE5D4CB69B3954"><enum>201.</enum><header>Rules governing
enhanced marketplace pools</header>
<subsection id="H0C3A9B4AC04B41EE883089A42F181EC9"><enum>(a)</enum><header>In
general</header><text>Subtitle B of title I of the
<act-name parsable-cite="ERISA">Employee Retirement Income Security Act of
1974</act-name> is amended by adding after part 7 the following new
part:</text>
<quoted-block act-name="Employee Retirement Income Security Act of 1974" id="HEB29218D8FEC42AB92901563B59B01ED">
<part id="H6BF94ECEFBB54A068CC276335BB7E6F5"><enum>8</enum><header>Rules governing
enhanced marketplace pools</header>
<section id="H17CDDF1630FB49208620D365198E7E55"><enum>801.</enum><header>Small business
health plans</header>
<subsection id="H09F3C47AFE3C436E911D257492C3929B"><enum>(a)</enum><header>In
general</header><text>For purposes of this part, the term <term>small business
health plan</term> means a fully insured group health plan whose sponsor is (or
is deemed under this part to be) described in subsection (b).</text>
</subsection><subsection id="H9631DE6963B84D5CB6537FEE8BCD32DF"><enum>(b)</enum><header>Sponsorship</header><text>The
sponsor of a group health plan is described in this subsection if such
sponsor—</text>
<paragraph id="H53F07483E23843C2AE8EF241D0661BA6"><enum>(1)</enum><text>is organized and
maintained in good faith, with a constitution and bylaws specifically stating
its purpose and providing for periodic meetings on at least an annual basis, as
a bona fide trade association, a bona fide industry association (including a
rural electric cooperative association or a rural telephone cooperative
association), a bona fide professional association, or a bona fide chamber of
commerce (or similar bona fide business association, including a corporation or
similar organization that operates on a cooperative basis (within the meaning
of section 1381 of the Internal Revenue Code of 1986)), for substantial
purposes other than that of obtaining medical care;</text>
</paragraph><paragraph id="H5096F0582482479181B2A359B2001F29"><enum>(2)</enum><text>is established as
a permanent entity which receives the active support of its members and
requires for membership payment on a periodic basis of dues or payments
necessary to maintain eligibility for membership;</text>
</paragraph><paragraph id="HFC032C9EB29F469F0051A51FE852A156"><enum>(3)</enum><text>does not condition
membership, such dues or payments, or coverage under the plan on the basis of
health status-related factors with respect to the employees of its members (or
affiliated members), or the dependents of such employees, and does not
condition such dues or payments on the basis of group health plan
participation; and</text>
</paragraph><paragraph id="HBECC3FBC2D764E2F892346DEF3F6E146"><enum>(4)</enum><text>does not condition
membership on the basis of a minimum group size.</text>
</paragraph><continuation-text continuation-text-level="subsection">Any
sponsor consisting of an association of entities which meet the requirements of
paragraphs (1), (2), (3), and (4) shall be deemed to be a sponsor described in
this subsection.</continuation-text></subsection></section><section id="H6D352074F584413B00B5DE618C006F21"><enum>802.</enum><header>Alternative
Market Pooling Organizations</header>
<subsection id="H05C63BD221E8422F904F6F86DDDCA6DD"><enum>(a)</enum><header>In
general</header><text>The Secretary, not later than 1 year after the date of
enactment of this part, shall promulgate regulations that apply the rules and
standards of this part, as necessary, to circumstances in which a pooling
entity other (hereinafter <quote>Alternative Market Pooling
Organizations</quote>) is not made up principally of employers and their
employees, or not a professional organization or such small business health
plan entity identified in section 801.</text>
</subsection><subsection id="HABB08ED0F57D4CB5BA5BAC8D46FE842B"><enum>(b)</enum><header>Adaption of
standards</header><text>In developing and promulgating regulations pursuant to
subsection (a), the Secretary, in consultation with the Secretary of Health and
Human Services, small business health plans, small and large employers, large
and small insurance issuers, consumer representatives, and state insurance
commissioners, shall—</text>
<paragraph id="H1C8C33F9F5EF416884E03BD8D4206563"><enum>(1)</enum><text>adapt the
standards of this part, to the maximum degree practicable, to assure balanced
and comparable oversight standards for both small business health plans and
alternative market pooling organizations;</text>
</paragraph><paragraph id="HD6E1EA4F4CB34CE5847F15A9026FE871"><enum>(2)</enum><text>permit the
participation as alternative market pooling organizations unions, churches and
other faith-based organizations, or other organizations composed of individuals
and groups which may have little or no association with employment, provided
however, that such alternative market pooling organizations meet, and continue
meeting on an ongoing basis, to satisfy standards, rules, and requirements
materially equivalent to those set forth in this part with respect to small
business health plans;</text>
</paragraph><paragraph id="H0D908A5E259D4FCEADC0EB90E42F1B03"><enum>(3)</enum><text>conduct periodic
verification of such compliance by alternative market pooling organizations, in
consultation with the Secretary of Health and Human Services and the National
Association of Insurance Commissioners, except that such periodic verification
shall not materially impede market entry or participation as pooling entities
comparable to that of small business health plans;</text>
</paragraph><paragraph id="H5DF5E887FB784A1E0029305218EB1435"><enum>(4)</enum><text>assure that
consistent, clear, and regularly monitored standards are applied with respect
to alternative market pooling organizations to avert material risk-selection
within or among the composition of such organizations;</text>
</paragraph><paragraph id="H7924D643B2A14EDEA4001600AE463E26"><enum>(5)</enum><text>the expedited and
deemed certification procedures provided in section 805(d) shall not apply to
alternative market pooling organizations until sooner of the promulgation of
regulations under this subsection or the expiration of one year following
enactment of this Act; and</text>
</paragraph><paragraph id="H44CB2D8BB59F400C9D04FD6D3E37DDB8"><enum>(6)</enum><text>make such other
appropriate adjustments to the requirements of this part as the Secretary may
reasonably deem appropriate to fit the circumstances of an individual
alternative market pooling organization or category of such organization,
including but not limited to the application of the membership payment
requirements of section 801(b)(2) to alternative market pooling organizations
composed primarily of church- or faith-based membership.</text>
</paragraph></subsection></section><section id="H96187A65471341899161EF5CC2004F86"><enum>803.</enum><header>Certification
of small business health plans</header>
<subsection id="HFAE60966534248CF911DD612A91E3542"><enum>(a)</enum><header>In
general</header><text>Not later than 6 months after the date of enactment of
this part, the applicable authority shall prescribe by interim final rule a
procedure under which the applicable authority shall certify small business
health plans which apply for certification as meeting the requirements of this
part.</text>
</subsection><subsection id="H6A506A7FB976450BAFEF646FE84BBE42"><enum>(b)</enum><header>Requirements
applicable to certified plans</header><text>A small business health plan with
respect to which certification under this part is in effect shall meet the
applicable requirements of this part, effective on the date of certification
(or, if later, on the date on which the plan is to commence operations).</text>
</subsection><subsection id="H8D8144A8A7F8487C98DADAAD2F4618"><enum>(c)</enum><header>Requirements for
continued certification</header><text>The applicable authority may provide by
regulation for continued certification of small business health plans under
this part. Such regulation shall provide for the revocation of a certification
if the applicable authority finds that the small business health plan involved
is failing to comply with the requirements of this part.</text>
</subsection><subsection id="H8910AF9528904EE6B5A79020BC7427A1"><enum>(d)</enum><header>Expedited and
deemed certification</header>
<paragraph id="H17100AECAC0B4FCAB5405FE1BCD3F97"><enum>(1)</enum><header>In
general</header><text>If the Secretary fails to act on an application for
certification under this section within 90 days of receipt of such application,
the applying small business health plan shall be deemed certified until such
time as the Secretary may deny for cause the application for
certification.</text>
</paragraph><paragraph id="H0B92B11EAEB842A9A1432866B010ED34"><enum>(2)</enum><header>Civil
penalty</header><text>The Secretary may assess a civil penalty against the
board of trustees and plan sponsor (jointly and severally) of a small business
health plan that is deemed certified under paragraph (1) of up to $500,000 in
the event the Secretary determines that the application for certification of
such small business health plan was willfully or with gross negligence
incomplete or inaccurate.</text>
</paragraph></subsection></section><section id="HB1F0D7D6F7C94CAB8422D8ACAA16E478"><enum>804.</enum><header>Requirements
relating to sponsors and boards of trustees</header>
<subsection id="HB1C503EC42FC40B6ADB3AB656C7CE6F0"><enum>(a)</enum><header>Sponsor</header><text>The
requirements of this subsection are met with respect to a small business health
plan if the sponsor has met (or is deemed under this part to have met) the
requirements of section 801(b) for a continuous period of not less than 3 years
ending with the date of the application for certification under this
part.</text>
</subsection><subsection id="H153037983C684AE2AD91E8E6E76B20D2"><enum>(b)</enum><header>Board of
trustees</header><text>The requirements of this subsection are met with respect
to a small business health plan if the following requirements are met:</text>
<paragraph id="H23F15D5A15D845A6931B3BEC27A0E6B4"><enum>(1)</enum><header>Fiscal
control</header><text>The plan is operated, pursuant to a plan document, by a
board of trustees which pursuant to a trust agreement has complete fiscal
control over the plan and which is responsible for all operations of the
plan.</text>
</paragraph><paragraph id="H6BBB39DCCB1E408BB4B100FF011922BF"><enum>(2)</enum><header>Rules of
operation and financial controls</header><text>The board of trustees has in
effect rules of operation and financial controls, based on a 3-year plan of
operation, adequate to carry out the terms of the plan and to meet all
requirements of this title applicable to the plan.</text>
</paragraph><paragraph id="H1392FB69B7764B218BB4EE88FDD312E9"><enum>(3)</enum><header>Rules governing
relationship to participating employers and to contractors</header>
<subparagraph id="H1C0259364C09464AA38FA8456D5FC0AB"><enum>(A)</enum><header>Board
membership</header>
<clause id="H25B699530C4D4EB0881EFCA5136300B4"><enum>(i)</enum><header>In
general</header><text>Except as provided in clauses (ii) and (iii), the members
of the board of trustees are individuals selected from individuals who are the
owners, officers, directors, or employees of the participating employers or who
are partners in the participating employers and actively participate in the
business.</text>
</clause><clause commented="no" id="HD0E4EFAA436D4E3295B142CB283B43"><enum>(ii)</enum><header>Limitation</header>
<subclause commented="no" id="H45F7C1C5EEC447D7BF2E2538BA2EFB9E"><enum>(I)</enum><header>General
rule</header><text>Except as provided in subclauses (II) and (III), no such
member is an owner, officer, director, or employee of, or partner in, a
contract administrator or other service provider to the plan.</text>
</subclause><subclause commented="no" id="H3608B62273814FFB8F604968BDBFF01B"><enum>(II)</enum><header>Limited
exception for providers of services solely on behalf of the
sponsor</header><text>Officers or employees of a sponsor which is a service
provider (other than a contract administrator) to the plan may be members of
the board if they constitute not more than 25 percent of the membership of the
board and they do not provide services to the plan other than on behalf of the
sponsor.</text>
</subclause><subclause commented="no" id="H6CFC6C64BF614D49A055F9B2DDFB71D"><enum>(III)</enum><header>Treatment of
providers of medical care</header><text>In the case of a sponsor which is an
association whose membership consists primarily of providers of medical care,
subclause (I) shall not apply in the case of any service provider described in
subclause (I) who is a provider of medical care under the plan.</text>
</subclause></clause><clause commented="no" id="H98A4EB857F9041CEBC08E804FC08BEE9"><enum>(iii)</enum><header>Certain plans
excluded</header><text>Clause (i) shall not apply to a small business health
plan which is in existence on the date of the enactment of this part.</text>
</clause></subparagraph><subparagraph id="H8805C3AC30F54617842B3F9B8943735C"><enum>(B)</enum><header>Sole
authority</header><text>The board has sole authority under the plan to approve
applications for participation in the plan and to contract with
insurers.</text>
</subparagraph></paragraph></subsection><subsection id="H71ED01ADB2974DA6B7C30337FD61B3EE"><enum>(c)</enum><header>Treatment of
franchises</header><text>In the case of a group health plan which is
established and maintained by a franchiser for a franchisor or for its
franchisees—</text>
<paragraph id="H1240C4CA7FB04302A65835DC6900CAD3"><enum>(1)</enum><text>the requirements
of subsection (a) and section 801(a) shall be deemed met if such requirements
would otherwise be met if the franchisor were deemed to be the sponsor referred
to in section 801(b) and each franchisee were deemed to be a member (of the
sponsor) referred to in section 801(b); and</text>
</paragraph><paragraph id="H4D3A57CB051F442797B1259FD8E0F2E6"><enum>(2)</enum><text>the requirements
of section 804(a)(1) shall be deemed met.</text>
</paragraph><continuation-text continuation-text-level="subsection">For
purposes of this subsection the terms <term>franchisor</term> and
<term>franchisee</term> shall have the meanings given such terms for purposes
of sections 436.2(a) through 436.2(c) of title 16, Code of Federal Regulations
(including any such amendments to such regulation after the date of enactment
of this part).</continuation-text></subsection></section><section id="HD2BC680B771C4D2585D2F9B6BA185E6E"><enum>805.</enum><header>Participation
and coverage requirements</header>
<subsection id="HBE47779647F04B979E43356CD8F3FE91"><enum>(a)</enum><header>Covered
employers and individuals</header><text>The requirements of this subsection are
met with respect to a small business health plan if, under the terms of the
plan—</text>
<paragraph id="H13C1E49C35E449ED87CC769208F94D94"><enum>(1)</enum><text>each participating
employer must be—</text>
<subparagraph id="H7450CC62B68A4D8D9FDEDEA1A6FC70F"><enum>(A)</enum><text>a member of the
sponsor;</text>
</subparagraph><subparagraph id="HF2A71176272A413F81911994815C09B6"><enum>(B)</enum><text>the sponsor;
or</text>
</subparagraph><subparagraph id="H6D95A60803CC4A1888CF0236E5609568"><enum>(C)</enum><text>an affiliated
member of the sponsor, except that, in the case of a sponsor which is a
professional association or other individual-based association, if at least one
of the officers, directors, or employees of an employer, or at least one of the
individuals who are partners in an employer and who actively participates in
the business, is a member or such an affiliated member of the sponsor,
participating employers may also include such employer; and</text>
</subparagraph></paragraph><paragraph id="H3B3C6DAC07C149168610D2DDFFE46B93"><enum>(2)</enum><text>all individuals
commencing coverage under the plan after certification under this part must
be—</text>
<subparagraph id="H55C0C8E1BD684E938CE05C4675DA00E1"><enum>(A)</enum><text>active or retired
owners (including self-employed individuals), officers, directors, or employees
of, or partners in, participating employers; or</text>
</subparagraph><subparagraph id="HC3EC12952D2D452C856CDB29828806E2"><enum>(B)</enum><text>the dependents of
individuals described in subparagraph (A).</text>
</subparagraph></paragraph></subsection><subsection id="H0AF80DD7CCC042F0BF5B3600A694624F"><enum>(b)</enum><header>Individual
market unaffected</header><text>The requirements of this subsection are met
with respect to a small business health plan if, under the terms of the plan,
no participating employer may provide health insurance coverage in the
individual market for any employee not covered under the plan which is similar
to the coverage contemporaneously provided to employees of the employer under
the plan, if such exclusion of the employee from coverage under the plan is
based on a health status-related factor with respect to the employee and such
employee would, but for such exclusion on such basis, be eligible for coverage
under the plan.</text>
</subsection><subsection id="H773BF798AE8C40BC9402018B5555E800"><enum>(c)</enum><header>Prohibition of
discrimination against employers and employees eligible To
participate</header><text>The requirements of this subsection are met with
respect to a small business health plan if—</text>
<paragraph id="H20C9204FC9BB4AFB8C1DD2C7C0312049"><enum>(1)</enum><text>under the terms of
the plan, all employers meeting the preceding requirements of this section are
eligible to qualify as participating employers for all geographically available
coverage options, unless, in the case of any such employer, participation or
contribution requirements of the type referred to in section 2711 of the
<act-name parsable-cite="PHSA">Public Health Service Act</act-name> are not
met;</text>
</paragraph><paragraph id="H8BE8E61138774907BC2076EEB6BE2EEA"><enum>(2)</enum><text>information
regarding all coverage options available under the plan is made readily
available to any employer eligible to participate; and</text>
</paragraph><paragraph id="HB636F3CBEF46404AB8E596E3C2F058BC"><enum>(3)</enum><text>the applicable
requirements of sections 701, 702, and 703 are met with respect to the
plan.</text>
</paragraph></subsection></section><section id="HD886CEDE4F0D45248BD8180490F658F5"><enum>806.</enum><header>Other
requirements relating to plan documents, contribution rates, and benefit
options</header>
<subsection id="H82A86FD6928D496898EBFADFF805A849"><enum>(a)</enum><header>In
general</header><text>The requirements of this section are met with respect to
a small business health plan if the following requirements are met:</text>
<paragraph id="H005DF54359764E7CA6D01693DEBC83A3"><enum>(1)</enum><header>Contents of
governing instruments</header>
<subparagraph id="HF56F5D6154DC41DF91B800B3FC1C6E00"><enum>(A)</enum><header>In
general</header><text>The instruments governing the plan include a written
instrument, meeting the requirements of an instrument required under section
402(a)(1), which—</text>
<clause id="H6A1DBF30C2E44FFE005319F582B67A8"><enum>(i)</enum><text>provides that the
board of trustees serves as the named fiduciary required for plans under
section 402(a)(1) and serves in the capacity of a plan administrator (referred
to in section 3(16)(A)); and</text>
</clause><clause id="H2B1E4F7C63994ED5826E0096EB471992"><enum>(ii)</enum><text>provides that the
sponsor of the plan is to serve as plan sponsor (referred to in section
3(16)(B)).</text>
</clause></subparagraph><subparagraph id="HA3B26A71D8FB4EEA92465BABC1DF16CA"><enum>(B)</enum><header>Description of
material provisions</header><text>The terms of the health insurance coverage
(including the terms of any individual certificates that may be offered to
individuals in connection with such coverage) describe the material benefit and
rating, and other provisions set forth in this section and such material
provisions are included in the summary plan description.</text>
</subparagraph></paragraph><paragraph id="H10ED4F7E4F3E46CB8D7B844B697B00B7"><enum>(2)</enum><header>Contribution
rates must be nondiscriminatory</header>
<subparagraph id="H3991E23053964F5FA8F8745101095D1F"><enum>(A)</enum><header>In
general</header><text>The contribution rates for any participating small
employer shall not vary on the basis of any health status-related factor in
relation to employees of such employer or their beneficiaries and shall not
vary on the basis of the type of business or industry in which such employer is
engaged, subject to subparagraph (B) and the terms of this title.</text>
</subparagraph><subparagraph id="HC6BA648ACEB54272AC4C2FC16C87EAEE"><enum>(B)</enum><header>Effect of
title</header><text>Nothing in this title or any other provision of law shall
be construed to preclude a health insurance issuer offering health insurance
coverage in connection with a small business health plan that meets the
requirements of this part, and at the request of such small business health
plan, from—</text>
<clause id="HA36D0F25209F46AE80992C00E4A6707E"><enum>(i)</enum><text>setting
contribution rates for the small business health plan based on the claims
experience of the small business health plan so long as any variation in such
rates for participating small employers complies with the requirements of
clause (ii), except that small business health plans shall not be subject, in
nonadopting States, to subparagraphs (A)(ii) and (C) of section 2912(a)(2) of
the Public Health Service Act, and in adopting States, to any State law that
would have the effect of imposing requirements as outlined in such
subparagraphs (A)(ii) and (C); or</text>
</clause><clause id="HF2FDAACAA5D244E284D5172446E659FE"><enum>(ii)</enum><text display-inline="yes-display-inline">varying contribution rates for
participating small employers in a small business health plan in a State to the
extent that such rates could vary using the same methodology employed in such
State for regulating small group premium rates, subject to the terms of part I
of subtitle A of title XXXI of the Public Health Service Act (relating to
rating requirements), as added by subtitle B of title II of the Health Security
for All Americans Act of 2009.</text>
</clause></subparagraph></paragraph><paragraph id="H44FEF125C2FB4CE5B467F4EAB552C8C3"><enum>(3)</enum><header>Exceptions
regarding self-employed and large employers</header>
<subparagraph id="H1AF7239861C549CA82D700967D98B300"><enum>(A)</enum><header>Self-employed</header>
<clause id="HBE70657CDB37493CACDAC4E183D640CA"><enum>(i)</enum><header>In
general</header><text>Small business health plans with participating employers
who are self-employed individuals (and their dependents) shall enroll such
self-employed participating employers in accordance with rating rules that do
not violate the rating rules for self-employed individuals in the State in
which such self-employed participating employers are located.</text>
</clause><clause id="H00A79554BD814B19A2350010599900B0"><enum>(ii)</enum><header>Guarantee
issue</header><text>Small business health plans with participating employers
who are self-employed individuals (and their dependents) may decline to
guarantee issue to such participating employers in States in which guarantee
issue is not otherwise required for the self-employed in that State.</text>
</clause></subparagraph><subparagraph id="HB482534795A245E790E111ED2FF683B5"><enum>(B)</enum><header>Large
employers</header><text>Small business health plans with participating
employers that are larger than small employers (as defined in section
808(a)(10)) shall enroll such large participating employers in accordance with
rating rules that do not violate the rating rules for large employers in the
State in which such large participating employers are located.</text>
</subparagraph></paragraph><paragraph id="H1282A658602C4D4C8B5D974828BAD331"><enum>(4)</enum><header>Regulatory
requirements</header><text>Such other requirements as the applicable authority
determines are necessary to carry out the purposes of this part, which shall be
prescribed by the applicable authority by regulation.</text>
</paragraph></subsection><subsection id="HC7C0188E4FDC4B4081E9D588B268F39"><enum>(b)</enum><header>Ability of small
business health plans To design benefit options</header><text display-inline="yes-display-inline">Nothing in this part or any provision of
State law (as defined in section 514(c)(1)) shall be construed to preclude a
small business health plan or a health insurance issuer offering health
insurance coverage in connection with a small business health plan from
exercising its sole discretion in selecting the specific benefits and services
consisting of medical care to be included as benefits under such plan or
coverage, except that such benefits and services must meet the terms and
specifications of part II of subtitle A of title XXXI of the Public Health
Service Act (relating to lower cost plans), as added by subtitle B of title II
of the Health Security for All Americans Act of 2009.</text>
</subsection><subsection id="HBE25BE8159854DAF969F6392C9EE27E1"><enum>(c)</enum><header>Domicile and
non-domicile States</header>
<paragraph id="H1419910338204400B060ADC4BFC384EB"><enum>(1)</enum><header>Domicile
state</header><text>Coverage shall be issued to a small business health plan in
the State in which the sponsor's principal place of business is located.</text>
</paragraph><paragraph id="HA28E4F11F7354F62AE0083C6FE964B76"><enum>(2)</enum><header>Non-domicile
states</header><text>With respect to a State (other than the domicile State) in
which participating employers of a small business health plan are located but
in which the insurer of the small business health plan in the domicile State is
not yet licensed, the following shall apply:</text>
<subparagraph id="HD0788171F86F4B3484EFC4DEAF7BA1E1"><enum>(A)</enum><header>Temporary
preemption</header><text>If, upon the expiration of the 90-day period following
the submission of a licensure application by such insurer (that includes a
certified copy of an approved licensure application as submitted by such
insurer in the domicile State) to such State, such State has not approved or
denied such application, such State's health insurance licensure laws shall be
temporarily preempted and the insurer shall be permitted to operate in such
State, subject to the following terms:</text>
<clause id="H4EA1451FF75340BABE0165CD5DBC6F34"><enum>(i)</enum><header>Application of
non-domicile State law</header><text display-inline="yes-display-inline">Except
with respect to licensure and with respect to the terms of subtitle A of title
XXXI of the Public Health Service Act (relating to rating and benefits as added
by subtitle B of title II of the Health Security for All Americans Act of
2009), the laws and authority of the non-domicile State shall remain in full
force and effect.</text>
</clause><clause id="HEE5FF91F7C6945E486BF2315494E0017"><enum>(ii)</enum><header>Revocation of
preemption</header><text>The preemption of a non-domicile State's health
insurance licensure laws pursuant to this subparagraph, shall be terminated
upon the occurrence of either of the following:</text>
<subclause id="H51C431E9C39344379B851076FAA4EEBA"><enum>(I)</enum><header>Approval or
denial of application</header><text>The approval of denial of an insurer's
licensure application, following the laws and regulations of the non-domicile
State with respect to licensure.</text>
</subclause><subclause id="H8736904876134670A444696F9F2185BA"><enum>(II)</enum><header>Determination
of material violation</header><text display-inline="yes-display-inline">A
determination by a non-domicile State that an insurer operating in a
non-domicile State pursuant to the preemption provided for in this subparagraph
is in material violation of the insurance laws (other than licensure and with
respect to the terms of subtitle A of title XXXI of the Public Health Service
Act (relating to rating and benefits added by subtitle B of title II of the
Health Security for All Americans Act of 2009)) of such State.</text>
</subclause></clause></subparagraph><subparagraph id="H262C0D62CB9540BB93909FF0CFDD9FE3"><enum>(B)</enum><header>No prohibition
on promotion</header><text>Nothing in this paragraph shall be construed to
prohibit a small business health plan or an insurer from promoting coverage
prior to the expiration of the 90-day period provided for in subparagraph (A),
except that no enrollment or collection of contributions shall occur before the
expiration of such 90-day period.</text>
</subparagraph><subparagraph id="H5AAC79B3C79948998E83C06500713E46"><enum>(C)</enum><header>licensure</header><text>Except
with respect to the application of the temporary preemption provision of this
paragraph, nothing in this part shall be construed to limit the requirement
that insurers issuing coverage to small business health plans shall be licensed
in each State in which the small business health plans operate.</text>
</subparagraph><subparagraph id="H701E87EFF5DE445F00C04E8922444408"><enum>(D)</enum><header>Servicing by
licensed insurers</header><text>Notwithstanding subparagraph (C), the
requirements of this subsection may also be satisfied if the participating
employers of a small business health plan are serviced by a licensed insurer in
that State, even where such insurer is not the insurer of such small business
health plan in the State in which such small business health plan is
domiciled.</text>
</subparagraph></paragraph></subsection></section><section id="H892C5CD2ED044CAEA929D1F4C0D4BFF2"><enum>807.</enum><header>Requirements
for application and related requirements</header>
<subsection id="HA8263B9CA88241F5837E75BCD2A1AD1D"><enum>(a)</enum><header>Filing
fee</header><text>Under the procedure prescribed pursuant to section 802(a), a
small business health plan shall pay to the applicable authority at the time of
filing an application for certification under this part a filing fee in the
amount of $5,000, which shall be available in the case of the Secretary, to the
extent provided in appropriation Acts, for the sole purpose of administering
the certification procedures applicable with respect to small business health
plans.</text>
</subsection><subsection id="H6248F047442C44F68EF24CE9F00CE94"><enum>(b)</enum><header>Information To be
included in application for certification</header><text>An application for
certification under this part meets the requirements of this section only if it
includes, in a manner and form which shall be prescribed by the applicable
authority by regulation, at least the following information:</text>
<paragraph id="HC3778AE7493E47578E0999D3E1C97E08"><enum>(1)</enum><header>Identifying
information</header><text>The names and addresses of—</text>
<subparagraph id="HFAA1D504703B4712B1F51FB4B67EE264"><enum>(A)</enum><text>the sponsor;
and</text>
</subparagraph><subparagraph id="H54B8A747FB0F4A8EBFADDFE5F13164DE"><enum>(B)</enum><text>the members of the
board of trustees of the plan.</text>
</subparagraph></paragraph><paragraph id="H61BFD87312F2480C817DE659FA49B24D"><enum>(2)</enum><header>States in which
plan intends to do business</header><text>The States in which participants and
beneficiaries under the plan are to be located and the number of them expected
to be located in each such State.</text>
</paragraph><paragraph id="H66297B1CBBA7466BB9E3003E9B06F642"><enum>(3)</enum><header>Bonding
requirements</header><text>Evidence provided by the board of trustees that the
bonding requirements of section 412 will be met as of the date of the
application or (if later) commencement of operations.</text>
</paragraph><paragraph id="H31A6E238F8A74ED8A449CC8747B92543"><enum>(4)</enum><header>Plan
documents</header><text>A copy of the documents governing the plan (including
any bylaws and trust agreements), the summary plan description, and other
material describing the benefits that will be provided to participants and
beneficiaries under the plan.</text>
</paragraph><paragraph id="H6CB8E49D1FBF4D4598D6F6811B426B61"><enum>(5)</enum><header>Agreements with
service providers</header><text>A copy of any agreements between the plan,
health insurance issuer, and contract administrators and other service
providers.</text>
</paragraph></subsection><subsection id="H17372EB3A0D74011AE7F35B066084561"><enum>(c)</enum><header>Filing notice of
certification with States</header><text>A certification granted under this part
to a small business health plan shall not be effective unless written notice of
such certification is filed with the applicable State authority of each State
in which the small business health plans operate.</text>
</subsection><subsection id="H7DB4CC7A7FDB4B3481E9794CD6EB0E7"><enum>(d)</enum><header>Notice of
material changes</header><text>In the case of any small business health plan
certified under this part, descriptions of material changes in any information
which was required to be submitted with the application for the certification
under this part shall be filed in such form and manner as shall be prescribed
by the applicable authority by regulation. The applicable authority may require
by regulation prior notice of material changes with respect to specified
matters which might serve as the basis for suspension or revocation of the
certification.</text>
</subsection></section><section commented="no" id="HF7F4FDF27CEF43E59647AF961D849B00"><enum>808.</enum><header>Notice
requirements for voluntary termination</header><text display-inline="no-display-inline">A small business health plan which is or has
been certified under this part may terminate (upon or at any time after
cessation of accruals in benefit liabilities) only if the board of trustees,
not less than 60 days before the proposed termination date—</text>
<paragraph commented="no" id="H5CD193BAFA774F4CB9C0CF5BFBA295E5"><enum>(1)</enum><text>provides to the
participants and beneficiaries a written notice of intent to terminate stating
that such termination is intended and the proposed termination date;</text>
</paragraph><paragraph commented="no" id="H47431D11B235412D9E68E2C6D5790235"><enum>(2)</enum><text>develops a plan
for winding up the affairs of the plan in connection with such termination in a
manner which will result in timely payment of all benefits for which the plan
is obligated; and</text>
</paragraph><paragraph commented="no" id="H5E47094E6BF3409499199C3B1FE48575"><enum>(3)</enum><text>submits such plan
in writing to the applicable authority.</text>
</paragraph><continuation-text commented="no" continuation-text-level="section">Actions required under this section
shall be taken in such form and manner as may be prescribed by the applicable
authority by regulation.</continuation-text></section><section id="H17176947967C4B77A223C1F5D65DEB27"><enum>809.</enum><header>Implementation
and application authority by Secretary</header><text display-inline="no-display-inline">The Secretary shall, through promulgation
and implementation of such regulations as the Secretary may reasonably
determine necessary or appropriate, and in consultation with a balanced
spectrum of effected entities and persons, modify the implementation and
application of this part to accommodate with minimum disruption such changes to
State or Federal law provided in this part and the (and the amendments made by
such Act) or in regulations issued thereto.</text>
</section><section id="H9314849F277C4FD8A981F1E700F35816"><enum>810.</enum><header>Definitions and
rules of construction</header>
<subsection id="H866668C30E5A40449B198D89D9BCB0A0"><enum>(a)</enum><header>Definitions</header><text>For
purposes of this part—</text>
<paragraph id="HBD0915A6213D4C8B87981EA546AC4711"><enum>(1)</enum><header>Affiliated
member</header><text>The term <term>affiliated member</term> means, in
connection with a sponsor—</text>
<subparagraph id="H79258A7B1FA246D986348BFD769B6116"><enum>(A)</enum><text>a person who is
otherwise eligible to be a member of the sponsor but who elects an affiliated
status with the sponsor, or</text>
</subparagraph><subparagraph id="HD28740301BE245B3B73B6F3484F73F63"><enum>(B)</enum><text>in the case of a
sponsor with members which consist of associations, a person who is a member or
employee of any such association and elects an affiliated status with the
sponsor.</text>
</subparagraph></paragraph><paragraph id="HF8BE1570A675406EB39818A1B8F6F0ED"><enum>(2)</enum><header>Applicable
authority</header><text>The term <term>applicable authority</term> means the
Secretary of Labor, except that, in connection with any exercise of the
Secretary's authority with respect to which the Secretary is required under
section 506(d) to consult with a State, such term means the Secretary, in
consultation with such State.</text>
</paragraph><paragraph id="H6D224359C5B64E35A0F8C2E259F9C8C0"><enum>(3)</enum><header>Applicable State
authority</header><text>The term <term>applicable State authority</term> means,
with respect to a health insurance issuer in a State, the State insurance
commissioner or official or officials designated by the State to enforce the
requirements of title XXVII of the <act-name parsable-cite="PHSA">Public Health
Service Act</act-name> for the State involved with respect to such
issuer.</text>
</paragraph><paragraph id="H33E213181EFE43709CE07F231771E2F0"><enum>(4)</enum><header>Group health
plan</header><text>The term <term>group health plan</term> has the meaning
provided in section 733(a)(1) (after applying subsection (b) of this
section).</text>
</paragraph><paragraph id="HF10103597F9B473EA1BC6CBCEE64EDC0"><enum>(5)</enum><header>Health insurance
coverage</header><text>The term <term>health insurance coverage</term> has the
meaning provided in section 733(b)(1), except that such term shall not include
excepted benefits (as defined in section 733(c)).</text>
</paragraph><paragraph id="HADE0365096E849AA84C8FEB8204B862"><enum>(6)</enum><header>Health insurance
issuer</header><text>The term <term>health insurance issuer</term> has the
meaning provided in section 733(b)(2).</text>
</paragraph><paragraph id="H96FC805AA53143A4806D93A2B31D5391"><enum>(7)</enum><header>Individual
market</header>
<subparagraph id="HACC67592FA62400F00C87316CEAC3EE"><enum>(A)</enum><header>In
general</header><text>The term <term>individual market</term> means the market
for health insurance coverage offered to individuals other than in connection
with a group health plan.</text>
</subparagraph><subparagraph id="H2547CCB4AAD0491482FE9F7B5E94BCA"><enum>(B)</enum><header>Treatment of very
small groups</header>
<clause id="H3E0627BFCF72442585E9785325032DA"><enum>(i)</enum><header>In
general</header><text>Subject to clause (ii), such term includes coverage
offered in connection with a group health plan that has fewer than 2
participants as current employees or participants described in section
732(d)(3) on the first day of the plan year.</text>
</clause><clause id="H5BE02B60815D41C5AD2497DD54CEFB4F"><enum>(ii)</enum><header>State
exception</header><text>Clause (i) shall not apply in the case of health
insurance coverage offered in a State if such State regulates the coverage
described in such clause in the same manner and to the same extent as coverage
in the small group market (as defined in section 2791(e)(5) of the
<act-name parsable-cite="PHSA">Public Health Service Act</act-name>) is
regulated by such State.</text>
</clause></subparagraph></paragraph><paragraph id="HCB47039EEA544E8C9F641FE1C08FBB2D"><enum>(8)</enum><header>Medical
care</header><text>The term <term>medical care</term> has the meaning provided
in section 733(a)(2).</text>
</paragraph><paragraph id="H037FE7FEF0E6483D863929DA1214C34D"><enum>(9)</enum><header>Participating
employer</header><text>The term <term>participating employer</term> means, in
connection with a small business health plan, any employer, if any individual
who is an employee of such employer, a partner in such employer, or a
self-employed individual who is such employer (or any dependent, as defined
under the terms of the plan, of such individual) is or was covered under such
plan in connection with the status of such individual as such an employee,
partner, or self-employed individual in relation to the plan.</text>
</paragraph><paragraph id="HED5040F82E3B48628FE3C6BE1332523B"><enum>(10)</enum><header>Small
employer</header><text>The term <term>small employer</term> means, in
connection with a group health plan with respect to a plan year, a small
employer as defined in section 2791(e)(4).</text>
</paragraph><paragraph id="H87BB755DD0D74197AB6BB8748FD59F"><enum>(11)</enum><header>Trade association
and professional association</header><text>The terms <term>trade
association</term> and <term>professional association</term> mean an entity
that meets the requirements of section 1.501(c)(6)–1 of title 26, Code of
Federal Regulations (as in effect on the date of enactment of this Act).</text>
</paragraph></subsection><subsection id="H60AAC9D333B842A400347868DDA839D5"><enum>(b)</enum><header>Rule of
construction</header><text>For purposes of determining whether a plan, fund, or
program is an employee welfare benefit plan which is a small business health
plan, and for purposes of applying this title in connection with such plan,
fund, or program so determined to be such an employee welfare benefit
plan—</text>
<paragraph id="HD37A892FCB3A47E488AB1D02A655DAA0"><enum>(1)</enum><text>in the case of a
partnership, the term <term>employer</term> (as defined in section 3(5))
includes the partnership in relation to the partners, and the term
<term>employee</term> (as defined in section 3(6)) includes any partner in
relation to the partnership; and</text>
</paragraph><paragraph id="H19C5BAAD69F64B2ABCCA6F7D5BD95DAC"><enum>(2)</enum><text>in the case of a
self-employed individual, the term <term>employer</term> (as defined in section
3(5)) and the term <term>employee</term> (as defined in section 3(6)) shall
include such individual.</text>
</paragraph></subsection><subsection id="H7053A962191644E9B73EA607051BFD5C"><enum>(c)</enum><header>Renewal</header><text>Notwithstanding
any provision of law to the contrary, a participating employer in a small
business health plan shall not be deemed to be a plan sponsor in applying
requirements relating to coverage renewal.</text>
</subsection><subsection commented="no" display-inline="no-display-inline" id="H5FB4B21D98BD49C0A3BCA07C2447D164"><enum>(d)</enum><header>Health savings
accounts</header><text display-inline="yes-display-inline">Nothing in this part
shall be construed to create any mandates for coverage of benefits for
HSA-qualified health plans that would require reimbursements in violation of
section 223(c)(2) of the Internal Revenue Code of
1986.</text>
</subsection></section></part><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection commented="no" id="H924D52C467754138848E029459D96968"><enum>(b)</enum><header>Conforming
amendments to preemption rules</header>
<paragraph commented="no" id="HA93179999AF14DEBB10974A22F95863C"><enum>(1)</enum><text>Section 514(b)(6)
of such Act (29 U.S.C. 1144(b)(6)) is amended by adding at the end the
following new subparagraph:</text>
<quoted-block id="H674E4438B18443F4B77B751319093B4E">
<subparagraph commented="no" id="HA71DCD7B7E70438DAACA50E1D5FFE28E" indent="up2"><enum>(E)</enum><text>The preceding subparagraphs of this
paragraph do not apply with respect to any State law in the case of a small
business health plan which is certified under part
8.</text>
</subparagraph><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph><paragraph commented="no" id="H7730D2A0C5A94894A46280D58D3E5B00"><enum>(2)</enum><text>Section 514 of
such Act (29 U.S.C. 1144) is amended—</text>
<subparagraph commented="no" id="HDFF31742002B403EAC3600F3D1FCCA10"><enum>(A)</enum><text>in subsection
(b)(4), by striking <quote>Subsection (a)</quote> and inserting
<quote>Subsections (a) and (d)</quote>;</text>
</subparagraph><subparagraph commented="no" id="HC93D807AA90A427B8F7C1F6741D8F2FA"><enum>(B)</enum><text>in subsection
(b)(5), by striking <quote>subsection (a)</quote> in subparagraph (A) and
inserting <quote>subsection (a) of this section and subsections (a)(2)(B) and
(b) of section 805</quote>, and by striking <quote>subsection (a)</quote> in
subparagraph (B) and inserting <quote>subsection (a) of this section or
subsection (a)(2)(B) or (b) of section 805</quote>;</text>
</subparagraph><subparagraph commented="no" id="H58743334C8B7403199C9401E454204E0"><enum>(C)</enum><text>by redesignating
subsection (d) as subsection (e); and</text>
</subparagraph><subparagraph commented="no" id="HB4DFF9C1D1F244B1B20616E06100FCDC"><enum>(D)</enum><text>by inserting after
subsection (c) the following new subsection:</text>
<quoted-block id="HC0F90DD3428F4C6BA9A04F5FC30011">
<subsection commented="no" id="H51EF8BD0D3144A1C97B916D1D610C881"><enum>(d)</enum><paragraph commented="no" display-inline="yes-display-inline" id="HFC293BE403AD4E21003D7F001C53A84E"><enum>(1)</enum><text>Except as provided in
subsection (b)(4), the provisions of this title shall supersede any and all
State laws insofar as they may now or hereafter preclude a health insurance
issuer from offering health insurance coverage in connection with a small
business health plan which is certified under part 8.</text>
</paragraph><paragraph commented="no" id="HF94C9138F8BB4669B73F9D5D57B67D33" indent="up1"><enum>(2)</enum><text display-inline="yes-display-inline">In any case in which health insurance
coverage of any policy type is offered under a small business health plan
certified under part 8 to a participating employer operating in such State, the
provisions of this title shall supersede any and all laws of such State insofar
as they may establish rating and benefit requirements that would otherwise
apply to such coverage, provided the requirements of subtitle A of title XXXI
of the Public Health Service Act (as added by title II of the Health Security
for All Americans Act of 2009) (concerning health plan rating and benefits) are
met.</text>
</paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block>
</subparagraph></paragraph></subsection><subsection commented="no" id="H6B92ECA5277B46B99775AFE058C53D63"><enum>(c)</enum><header>Plan
sponsor</header><text>Section 3(16)(B) of such Act (29 U.S.C. 102(16)(B)) is
amended by adding at the end the following new sentence: <quote>Such term also
includes a person serving as the sponsor of a small business health plan under
part 8.</quote>.</text>
</subsection><subsection commented="no" id="HC28694549D7F4E0B9585F982D59D00EA"><enum>(d)</enum><header>Savings
clause</header><text>Section 731(c) of such Act is amended by inserting
<quote>or part 8</quote> after <quote>this part</quote>.</text>
</subsection><subsection id="H1E5C3903D7FE4846BE34CF565B20ADCC"><enum>(e)</enum><header>Clerical
amendment</header><text>The table of contents in section 1 of the
<act-name parsable-cite="ERISA">Employee Retirement Income Security Act of
1974</act-name> is amended by inserting after the item relating to section 734
the following new items:</text>
<quoted-block act-name="Employee Retirement Income Security Act of 1974" id="HDB8295925E6E4E5C924C84D44F294B9F" style="USC">
<toc regeneration="no-regeneration">
<toc-entry level="part">Part 8—Rules governing small business health
plans</toc-entry>
<toc-entry level="section">801. Small business health
plans.</toc-entry>
<toc-entry bold="off" level="section">802. Alternative market pooling
organizations.</toc-entry>
<toc-entry level="section">803. Certification of small business
health plans.</toc-entry>
<toc-entry level="section">804. Requirements relating to sponsors and
boards of trustees.</toc-entry>
<toc-entry level="section">805. Participation and coverage
requirements.</toc-entry>
<toc-entry level="section">806. Other requirements relating to plan
documents, contribution rates, and benefit options.</toc-entry>
<toc-entry level="section">807. Requirements for application and
related requirements.</toc-entry>
<toc-entry level="section">808. Notice requirements for voluntary
termination.</toc-entry>
<toc-entry bold="off" level="section">809. Implementation and
application authority by Secretary.</toc-entry>
<toc-entry level="section">810. Definitions and rules of
construction.</toc-entry>
</toc>
<after-quoted-block>.</after-quoted-block></quoted-block>
</subsection></section><section id="HA25FB20F9D19499EBF84B116203C5241"><enum>202.</enum><header>Cooperation
between Federal and State authorities</header><text display-inline="no-display-inline">Section 506 of the
<act-name parsable-cite="ERISA">Employee Retirement Income Security Act of
1974</act-name> (29 U.S.C. 1136) is amended by adding at the end the following
new subsection:</text>
<quoted-block act-name="Employee Retirement Income Security Act of 1974" id="H6FA3C29E01124FB885AFF374305C1B43">
<subsection id="H7BEDAA29E48041D3A5EFC473D3CC19F7"><enum>(d)</enum><header>Consultation
with States with respect to small business health plans</header>
<paragraph id="H80A2F4225A864BFE80D25F4C768D13B8"><enum>(1)</enum><header>Agreements with
States</header><text>The Secretary shall consult with the State recognized
under paragraph (2) with respect to a small business health plan regarding the
exercise of—</text>
<subparagraph id="H31CBB3EEC17C4803AC42B5EC3645EB1D"><enum>(A)</enum><text>the Secretary’s
authority under sections 502 and 504 to enforce the requirements for
certification under part 8; and</text>
</subparagraph><subparagraph id="H9BEB724D323048FEAD84CA912210D1C"><enum>(B)</enum><text>the Secretary’s
authority to certify small business health plans under part 8 in accordance
with regulations of the Secretary applicable to certification under part
8.</text>
</subparagraph></paragraph><paragraph id="HEECF2807BE8047FD8F2E66451FABA5F4"><enum>(2)</enum><header>Recognition of
domicile State</header><text>In carrying out paragraph (1), the Secretary shall
ensure that only one State will be recognized, with respect to any particular
small business health plan, as the State with which consultation is required.
In carrying out this paragraph such State shall be the domicile State, as
defined in section
805(c).</text>
</paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block>
</section><section id="HC4E9BB0DAF114A54B3108F4D6CFD7075"><enum>203.</enum><header>Effective date
and transitional and other rules</header>
<subsection commented="no" id="H6CD8B1E78BBF4DE3B9E3D600C25CFE1E"><enum>(a)</enum><header>Effective
date</header><text>The amendments made by this subtitle shall take effect 12
months after the date of the enactment of this Act. The Secretary of Labor
shall first issue all regulations necessary to carry out the amendments made by
this subtitle within 6 months after the date of the enactment of this
Act.</text>
</subsection><subsection id="HDF04C655406C42BEB1335FAD39FAE28F"><enum>(b)</enum><header>Treatment of
certain existing health benefits programs</header>
<paragraph id="H1E82975141E04532008FE395E192AE18"><enum>(1)</enum><header>In
general</header><text>In any case in which, as of the date of the enactment of
this Act, an arrangement is maintained in a State for the purpose of providing
benefits consisting of medical care for the employees and beneficiaries of its
participating employers, at least 200 participating employers make
contributions to such arrangement, such arrangement has been in existence for
at least 10 years, and such arrangement is licensed under the laws of one or
more States to provide such benefits to its participating employers, upon the
filing with the applicable authority (as defined in section 808(a)(2) of the
<act-name parsable-cite="ERISA">Employee Retirement Income Security Act of
1974</act-name> (as amended by this subtitle)) by the arrangement of an
application for certification of the arrangement under part 8 of subtitle B of
title I of such Act—</text>
<subparagraph id="H0AB9B33E4503441BBD93E34641739C3D"><enum>(A)</enum><text>such arrangement
shall be deemed to be a group health plan for purposes of title I of such
Act;</text>
</subparagraph><subparagraph id="H4BB7FECDA7A74EC99DD7E3001D3C6DAD"><enum>(B)</enum><text>the requirements
of sections 801(a) and 803(a) of the <act-name parsable-cite="ERISA">Employee
Retirement Income Security Act of 1974</act-name> shall be deemed met with
respect to such arrangement;</text>
</subparagraph><subparagraph id="H4F783950A891403C801F55E492D998F7"><enum>(C)</enum><text>the requirements
of section 803(b) of such Act shall be deemed met, if the arrangement is
operated by a board of trustees which has control over the arrangement;</text>
</subparagraph><subparagraph id="HA245DEA46B4B4A938954D90D9892DCB"><enum>(D)</enum><text>the requirements of
section 804(a) of such Act shall be deemed met with respect to such
arrangement; and</text>
</subparagraph><subparagraph id="H8F1960F4CC9842FDBE96E3D8C4855548"><enum>(E)</enum><text>the arrangement
may be certified by any applicable authority with respect to its operations in
any State only if it operates in such State on the date of
certification.</text>
</subparagraph><continuation-text continuation-text-level="paragraph">The
provisions of this subsection shall cease to apply with respect to any such
arrangement at such time after the date of the enactment of this Act as the
applicable requirements of this subsection are not met with respect to such
arrangement or at such time that the arrangement provides coverage to
participants and beneficiaries in any State other than the States in which
coverage is provided on such date of enactment.</continuation-text></paragraph><paragraph commented="no" display-inline="no-display-inline" id="HDD40FD18066B4B56A909F7F7D1F1C86"><enum>(2)</enum><header>Definitions</header><text>For
purposes of this subsection, the terms <term>group health plan</term>,
<term>medical care</term>, and <term>participating employer</term> shall have
the meanings provided in section 808 of the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of
1974</act-name>, except that the reference in paragraph (7) of such section to
an <quote>small business health plan</quote> shall be deemed a reference to an
arrangement referred to in this subsection.</text>
</paragraph></subsection></section></subtitle><subtitle id="HA86DEB0C5AC5409B992038638DF3BB3"><enum>B</enum><header>Market
Relief</header>
<section id="H34FF1ED5790C4BDAAF4ED9AC66E7ED55"><enum>211.</enum><header>Market
relief</header><text display-inline="no-display-inline">The Public Health
Service Act (42 U.S.C. 201 et seq.) is amended by adding at the end the
following:</text>
<quoted-block display-inline="no-display-inline" id="HC0645A5B27A643AEAB3138C37AFD6CC" style="OLC">
<title id="H6C4E69A201184EE480055E75988900F6"><enum>XXXI</enum><header>Health care
insurance marketplace modernization</header>
<section id="H08219981730E46CBB9B57467611BB953"><enum>3101.</enum><header>General
insurance definitions</header><text display-inline="no-display-inline">In this
title, the terms <term>health insurance coverage</term>, <term>health insurance
issuer</term>, <term>group health plan</term>, and <term>individual health
insurance</term> shall have the meanings given such terms in section
2791.</text>
</section><section id="H1FE735F11CA247EB985EAD3648E5D3FB"><enum>3102.</enum><header>Implementation
and application authority by Secretary</header><text display-inline="no-display-inline">The Secretary shall, through promulgation
and implementation of such regulations as the Secretary may reasonably
determine necessary or appropriate, and in consultation with a balanced
spectrum of effected entities and persons, modify the implementation and
application of this title to accommodate with minimum disruption such changes
to State or Federal law provided in this title and the (and the amendments made
by such Act) or in regulations issued thereto.</text>
</section><subtitle id="HD8B234D303A14917BF2E2F90AF055144"><enum>A</enum><header>Market
relief</header>
<part id="H29183B81723148DD89332F5BD629AEF8"><enum>I</enum><header>Rating
requirements</header>
<section id="H61B0B268E33B40CE8415A793DC006818"><enum>3111.</enum><header>Definitions</header><text display-inline="no-display-inline">In this part:</text>
<paragraph id="HC8EB59C3FD8E47DD86D6698DB459B71"><enum>(1)</enum><header>Adopting
state</header><text>The term <term>adopting State</term> means a State that,
with respect to the small group market, has enacted small group rating rules
that meet the minimum standards set forth in section 3112(a)(1) or, as
applicable, transitional small group rating rules set forth in section
3112(b).</text>
</paragraph><paragraph id="HA4B0F8AA2A934521B0DCE7BCC1354D5"><enum>(2)</enum><header>Applicable State
authority</header><text>The term <term>applicable State authority</term> means,
with respect to a health insurance issuer in a State, the State insurance
commissioner or official or officials designated by the State to enforce the
insurance laws of such State.</text>
</paragraph><paragraph id="HB13B4DA44F39443293EAC6BF55070644"><enum>(3)</enum><header>Base premium
rate</header><text>The term <term>base premium rate</term> means, for each
class of business with respect to a rating period, the lowest premium rate
charged or that could have been charged under a rating system for that class of
business by the small employer carrier to small employers with similar case
characteristics for health benefit plans with the same or similar
coverage.</text>
</paragraph><paragraph id="H8848025566B743AE91419EE41D45B1B0"><enum>(4)</enum><header>Eligible
insurer</header><text>The term <term>eligible insurer</term> means a health
insurance issuer that is licensed in a State and that—</text>
<subparagraph id="HBD7294D604AB4707B4B26CC300C6919E"><enum>(A)</enum><text>notifies the
Secretary, not later than 30 days prior to the offering of coverage described
in this subparagraph, that the issuer intends to offer health insurance
coverage consistent with the Model Small Group Rating Rules or, as applicable,
transitional small group rating rules in a State;</text>
</subparagraph><subparagraph id="HF14AAC0533F747AEAAB363E732344600"><enum>(B)</enum><text>notifies the
insurance department of a nonadopting State (or other State agency), not later
than 30 days prior to the offering of coverage described in this subparagraph,
that the issuer intends to offer small group health insurance coverage in that
State consistent with the Model Small Group Rating Rules, and provides with
such notice a copy of any insurance policy that it intends to offer in the
State, its most recent annual and quarterly financial reports, and any other
information required to be filed with the insurance department of the State (or
other State agency); and</text>
</subparagraph><subparagraph id="H218208B27270414294FF76F3FA121EFB"><enum>(C)</enum><text>includes in the
terms of the health insurance coverage offered in nonadopting States (including
in the terms of any individual certificates that may be offered to individuals
in connection with such group health coverage) and filed with the State
pursuant to subparagraph (B), a description in the insurer's contract of the
Model Small Group Rating Rules and an affirmation that such Rules are included
in the terms of such contract.</text>
</subparagraph></paragraph><paragraph id="H793248DEA5DE45269F75A13B98852C42"><enum>(5)</enum><header>Health insurance
coverage</header><text>The term <term>health insurance coverage</term> means
any coverage issued in the small group health insurance market, except that
such term shall not include excepted benefits (as defined in section
2791(c)).</text>
</paragraph><paragraph id="H68FCF0E47DB04B25871412A9A1AAB29"><enum>(6)</enum><header>Index
rate</header><text>The term <term>index rate</term> means for each class of
business with respect to the rating period for small employers with similar
case characteristics, the arithmetic average of the applicable base premium
rate and the corresponding highest premium rate.</text>
</paragraph><paragraph id="H9053B57266AB4E3096FFC5603270EB90"><enum>(7)</enum><header> Model Small
Group Rating Rules</header><text>The term <term>Model Small Group Rating
Rules</term> means the rules set forth in section 3112(a)(2).</text>
</paragraph><paragraph id="H19E8DE4A7E624880BCDD953FBCE35E27"><enum>(8)</enum><header>Nonadopting
state</header><text>The term <term>nonadopting State</term> means a State that
is not an adopting State.</text>
</paragraph><paragraph id="H88B5EA83D2B143A9A57696DD44561721"><enum>(9)</enum><header>Small group
insurance market</header><text>The term <term>small group insurance
market</term> shall have the meaning given the term <term>small group
market</term> in section 2791(e)(5).</text>
</paragraph><paragraph id="HEA6F589325164F7CA6CE9F13B2AE4310"><enum>(10)</enum><header>State
law</header><text>The term <term>State law</term> means all laws, decisions,
rules, regulations, or other State actions (including actions by a State
agency) having the effect of law, of any State.</text>
</paragraph><paragraph id="HA8819FD602DA4060B6B27B5D498A4A5"><enum>(11)</enum><header>Variation
limits</header>
<subparagraph id="H3F73027441A54668999CE8508B69FC85"><enum>(A)</enum><header>Composite
variation limit</header>
<clause id="H1AB829697034498E8527B5F36B571573"><enum>(i)</enum><header>In
general</header><text>The term <term>composite variation limit</term> means the
total variation in premium rates charged by a health insurance issuer in the
small group market as permitted under applicable State law based on the
following factors or case characteristics:</text>
<subclause id="H4855119F29B74763B48F85A190C64140"><enum>(I)</enum><text>Age.</text>
</subclause><subclause id="H92EC266BD2C940C78F626FD1F33B9288"><enum>(II)</enum><text>Duration of
coverage.</text>
</subclause><subclause id="HEDF1BAC670A740ACA0AAC6457BB6E7B0"><enum>(III)</enum><text>Claims
experience.</text>
</subclause><subclause id="H6A4D0EDB7B8C4CC08D20007000F6C922"><enum>(IV)</enum><text>Health
status.</text>
</subclause></clause><clause id="H34EB914EB9DC463C807E00288E36EF09"><enum>(ii)</enum><header>Use of
factors</header><text>With respect to the use of the factors described in
clause (i) in setting premium rates, a health insurance issuer shall use one or
both of the factors described in subclauses (I) or (IV) of such clause and may
use the factors described in subclauses (II) or (III) of such clause.</text>
</clause></subparagraph><subparagraph id="H16A5E7F51A704FD497992C9F9D0017DA"><enum>(B)</enum><header>Total variation
limit</header><text>The term <term>total variation limit</term> means the total
variation in premium rates charged by a health insurance issuer in the small
group market as permitted under applicable State law based on all factors and
case characteristics (as described in section 3112(a)(1)).</text>
</subparagraph></paragraph></section><section id="H65FC10B29DF3417CB18FAFFFA0089327"><enum>3112.</enum><header>Rating
rules</header>
<subsection id="HEA0B409402934B16AAF113D8843BB4CB"><enum>(a)</enum><header>Establishment of
minimum standards for premium variations and model small group rating
rules</header><text>Not later than 6 months after the date of enactment of this
title, the Secretary shall promulgate regulations establishing the following
Minimum Standards and Model Small Group Rating Rules:</text>
<paragraph id="H49332DF73E734963B79DC079D7968FEB"><enum>(1)</enum><header>Minimum
standards for premium variations</header>
<subparagraph id="H638FD5B7EB61425A84F0E435E4848742"><enum>(A)</enum><header>Composite
variation limit</header><text>The composite variation limit shall not be less
than 3:1.</text>
</subparagraph><subparagraph id="HEBA4AB1FCEA8454CB708F96F00724B65"><enum>(B)</enum><header>Total variation
limit</header><text>The total variation limit shall not be less than
5:1.</text>
</subparagraph><subparagraph commented="no" id="H351AC18DA7F941CDB02855AC72CBC603"><enum>(C)</enum><header>Prohibition on
use of certain case characteristics</header><text>For purposes of this
paragraph, in calculating the total variation limit, the State shall not use
case characteristics other than those used in calculating the composite
variation limit and industry, geographic area, group size, participation rate,
class of business, and participation in wellness programs.</text>
</subparagraph></paragraph><paragraph id="H284A22E26E2F4A24A12BAC77A819BF87"><enum>(2)</enum><header>Model Small
Group Rating Rules</header><text>The following apply to an eligible insurer in
a nonadopting State:</text>
<subparagraph id="HFFBFC370C8B44A70BDA6BA788099C1F9"><enum>(A)</enum><header>Premium
rates</header><text>Premium rates for small group health benefit plans to which
this title applies shall comply with the following provisions relating to
premiums, except as provided for under subsection (b):</text>
<clause id="HFCD2604ED0444E85B2C568F16B2461F9"><enum>(i)</enum><header>Variation in
premium rates</header><text>The plan may not vary premium rates by more than
the minimum standards provided for under paragraph (1).</text>
</clause><clause id="H4305C2EBC19A44ABB1B64DF8CF9F3209"><enum>(ii)</enum><header>Index
rate</header><text>The index rate for a rating period for any class of business
shall not exceed the index rate for any other class of business by more than 20
percent, excluding those classes of business related to association groups
under this title.</text>
</clause><clause id="HB0A11348C60748C2AAF21F6635A037F8"><enum>(iii)</enum><header>Class of
businesses</header><text>With respect to a class of business, the premium rates
charged during a rating period to small employers with similar case
characteristics for the same or similar coverage or the rates that could be
charged to such employers under the rating system for that class of business,
shall not vary from the index rate by more than 25 percent of the index rate
under clause (ii).</text>
</clause><clause id="H32B87670652647F2AACD6D116C06D800"><enum>(iv)</enum><header>Increases for
new rating periods</header><text>The percentage increase in the premium rate
charged to a small employer for a new rating period may not exceed the sum of
the following:</text>
<subclause id="H11FBAC3077A74200001BD1805C672C1C"><enum>(I)</enum><text>The percentage
change in the new business premium rate measured from the first day of the
prior rating period to the first day of the new rating period. In the case of a
health benefit plan into which the small employer carrier is no longer
enrolling new small employers, the small employer carrier shall use the
percentage change in the base premium rate, except that such change shall not
exceed, on a percentage basis, the change in the new business premium rate for
the most similar health benefit plan into which the small employer carrier is
actively enrolling new small employers.</text>
</subclause><subclause id="H0AC43974BAC24BD0ADE5BECAB57000DE"><enum>(II)</enum><text>Any adjustment,
not to exceed 15 percent annually and adjusted pro rata for rating periods of
less then 1 year, due to the claim experience, health status or duration of
coverage of the employees or dependents of the small employer as determined
from the small employer carrier's rate manual for the class of business
involved.</text>
</subclause><subclause id="H4BE9C7DF647348A4B7081243F7119CEA"><enum>(III)</enum><text>Any adjustment
due to change in coverage or change in the case characteristics of the small
employer as determined from the small employer carrier's rate manual for the
class of business.</text>
</subclause></clause><clause id="H165DC6ED96074C308813D7A2003D6989"><enum>(v)</enum><header>Uniform
application of adjustments</header><text>Adjustments in premium rates for claim
experience, health status, or duration of coverage shall not be charged to
individual employees or dependents. Any such adjustment shall be applied
uniformly to the rates charged for all employees and dependents of the small
employer.</text>
</clause><clause commented="no" id="H9AAFA97B3D5B4D5EBB74964DD4908276"><enum>(vi)</enum><header>Prohibition on
use of certain case characteristic</header><text>A small employer carrier shall
not utilize case characteristics, other than those permitted under paragraph
(1)(C), without the prior approval of the applicable State authority.</text>
</clause><clause id="H3BAFBD0B814C453D8713E47B791E18D5"><enum>(vii)</enum><header>Consistent
application of factors</header><text>Small employer carriers shall apply rating
factors, including case characteristics, consistently with respect to all small
employers in a class of business. Rating factors shall produce premiums for
identical groups which differ only by the amounts attributable to plan design
and do not reflect differences due to the nature of the groups assumed to
select particular health benefit plans.</text>
</clause><clause id="H5263D3486C9D458BA81629BDFC6FA098"><enum>(viii)</enum><header>Treatment of
plans as having same rating period</header><text>A small employer carrier shall
treat all health benefit plans issued or renewed in the same calendar month as
having the same rating period.</text>
</clause><clause id="H5FD7AC7D2A704AF4AC2D6F49CD43CCC0"><enum>(ix)</enum><header>Require
compliance</header><text>Premium rates for small business health benefit plans
shall comply with the requirements of this subsection notwithstanding any
assessments paid or payable by a small employer carrier as required by a
State's small employer carrier reinsurance program.</text>
</clause></subparagraph><subparagraph id="H25FBD97B09874288A1A3947CDF844D94"><enum>(B)</enum><header>Establishment of
separate class of business</header><text>Subject to subparagraph (C), a small
employer carrier may establish a separate class of business only to reflect
substantial differences in expected claims experience or administrative costs
related to the following:</text>
<clause id="H17934CD25778482FA5D5E71600B6CDAE"><enum>(i)</enum><text>The small employer
carrier uses more than one type of system for the marketing and sale of health
benefit plans to small employers.</text>
</clause><clause id="HE4FC964ABF6F4113B2C802D42401C3CF"><enum>(ii)</enum><text>The small
employer carrier has acquired a class of business from another small employer
carrier.</text>
</clause><clause id="H7BE115DCD08F46EE831E3E9115B9549C"><enum>(iii)</enum><text>The small
employer carrier provides coverage to one or more association groups that meet
the requirements of this title.</text>
</clause></subparagraph><subparagraph id="HD8C2F11A357D41998630C57BB75E9E15"><enum>(C)</enum><header>Limitation</header><text>A
small employer carrier may establish up to 9 separate classes of business under
subparagraph (B), excluding those classes of business related to association
groups under this title.</text>
</subparagraph><subparagraph id="HDB87EF63EE424069ADE5F9981060515C"><enum>(D)</enum><header>Limitation on
transfers</header><text>A small employer carrier shall not transfer a small
employer involuntarily into or out of a class of business. A small employer
carrier shall not offer to transfer a small employer into or out of a class of
business unless such offer is made to transfer all small employers in the class
of business without regard to case characteristics, claim experience, health
status or duration of coverage since issue.</text>
</subparagraph></paragraph></subsection><subsection id="H72EF50FF79DF48B5BAE8F9413FE2544E"><enum>(b)</enum><header>Transitional
Model Small Group Rating Rules</header>
<paragraph id="H837B6CCD803647A6B9D7C5B49ED200AE"><enum>(1)</enum><header>In
general</header><text>Not later than 6 months after the date of enactment of
this title and to the extent necessary to provide for a graduated transition to
the minimum standards for premium variation as provided for in subsection
(a)(1), the Secretary, in consultation with the National Association of
Insurance Commissioners (NAIC), shall promulgate State-specific transitional
small group rating rules in accordance with this subsection, which shall be
applicable with respect to nonadopting States and eligible insurers operating
in such States for a period of not to exceed 3 years from the date of the
promulgation of the minimum standards for premium variation pursuant to
subsection (a).</text>
</paragraph><paragraph id="H8639C1A09FD3474DADB1000344F46BDA"><enum>(2)</enum><header>Compliance with
transitional model small group rating rules</header><text>During the transition
period described in paragraph (1), a State that, on the date of enactment of
this title, has in effect a small group rating rules methodology that allows
for a variation that is less than the variation provided for under subsection
(a)(1) (concerning minimum standards for premium variation), shall be deemed to
be an adopting State if the State complies with the transitional small group
rating rules as promulgated by the Secretary pursuant to paragraph (1).</text>
</paragraph><paragraph id="H357FD3B79C154A898745139F21005E06"><enum>(3)</enum><header>Transitioning of
old business</header>
<subparagraph id="HA1B03D2AF5F4469D8DF0D555A4A40088"><enum>(A)</enum><header>In
general</header><text>In developing the transitional small group rating rules
under paragraph (1), the Secretary shall, after consultation with the National
Association of Insurance Commissioners and representatives of insurers
operating in the small group health insurance market in nonadopting States,
promulgate special transition standards with respect to independent rating
classes for old and new business, to the extent reasonably necessary to protect
health insurance consumers and to ensure a stable and fair transition for old
and new market entrants.</text>
</subparagraph><subparagraph commented="no" id="HA1CB8EEBE6524412AF512FE63E720539"><enum>(B)</enum><header>Period for
operation of independent rating classes</header><text>In developing the special
transition standards pursuant to subparagraph (A), the Secretary shall permit a
carrier in a nonadopting State, at its option, to maintain independent rating
classes for old and new business for a period of up to 5 years, with the
commencement of such 5-year period to begin at such time, but not later than
the date that is 3 years after the date of enactment of this title, as the
carrier offers a book of business meeting the minimum standards for premium
variation provided for in subsection (a)(1) or the transitional small group
rating rules under paragraph (1).</text>
</subparagraph></paragraph><paragraph id="H272D33EE375647E78745B9914D932E51"><enum>(4)</enum><header>Other
transitional authority</header><text>In developing the transitional small group
rating rules under paragraph (1), the Secretary shall provide for the
application of the transitional small group rating rules in transition States
as the Secretary may determine necessary for a an effective transition.</text>
</paragraph></subsection><subsection id="H2C61B456ABE04B3694C4137B56DDD7CC"><enum>(c)</enum><header>Market
re-entry</header>
<paragraph id="H079614BC33B944B68DB1193690565267"><enum>(1)</enum><header>In
general</header><text>Notwithstanding any other provision of law, a health
insurance issuer that has voluntarily withdrawn from providing coverage in the
small group market prior to the date of enactment of this title shall not be
excluded from re-entering such market on a date that is more than 180 days
after such date of enactment.</text>
</paragraph><paragraph id="H17CDE8329C594BD78C71115B36E0461E"><enum>(2)</enum><header>Termination</header><text>The
provision of this subsection shall terminate on the date that is 24 months
after the date of enactment of this title.</text>
</paragraph></subsection></section><section id="HFADD617BC01D42578DF4E0931470DD01"><enum>3113.</enum><header>Application
and preemption</header>
<subsection id="H9138643C4211432C80B2C2ED993A300"><enum>(a)</enum><header>Superseding of
state law</header>
<paragraph id="HF0999FA5C3C54FE8A64036CB44DD00A0"><enum>(1)</enum><header>In
general</header><text>This part shall supersede any and all State laws of a
nonadopting State insofar as such State laws (whether enacted prior to or after
the date of enactment of this subtitle) relate to rating in the small group
insurance market as applied to an eligible insurer, or small group health
insurance coverage issued by an eligible insurer, including with respect to
coverage issued to a small employer through a small business health plan, in a
State.</text>
</paragraph><paragraph id="H8039A93B4F6445AE954D2555873B7F2B"><enum>(2)</enum><header>Nonadopting
states</header><text>This part shall supersede any and all State laws of a
nonadopting State insofar as such State laws (whether enacted prior to or after
the date of enactment of this subtitle)—</text>
<subparagraph id="H5E823A2E9FDE4C8390FD317D14FCCA41"><enum>(A)</enum><text>prohibit an
eligible insurer from offering, marketing, or implementing small group health
insurance coverage consistent with the Model Small Group Rating Rules or
transitional model small group rating rules; or</text>
</subparagraph><subparagraph id="H0CBF540D7E684CB498951CD296727E5D"><enum>(B)</enum><text>have the effect of
retaliating against or otherwise punishing in any respect an eligible insurer
for offering, marketing, or implementing small group health insurance coverage
consistent with the Model Small Group Rating Rules or transitional model small
group rating rules.</text>
</subparagraph></paragraph></subsection><subsection id="H3F3A2BA111144FD3BE5CC2825D4E7CB9"><enum>(b)</enum><header>Savings clause
and construction</header>
<paragraph id="HA15A6DA8476E44BABEA8D9D8C53746E"><enum>(1)</enum><header>Nonapplication to
adopting states</header><text>Subsection (a) shall not apply with respect to
adopting states.</text>
</paragraph><paragraph id="HE0567CC31DBA400C9D2298D8FDCB4ED"><enum>(2)</enum><header>Nonapplication to
certain insurers</header><text>Subsection (a) shall not apply with respect to
insurers that do not qualify as eligible insurers that offer small group health
insurance coverage in a nonadopting State.</text>
</paragraph><paragraph id="HCC5D0B3C72C7406F8C1D9CBB88EB4D2F"><enum>(3)</enum><header>Nonapplication
where obtaining relief under state law</header><text>Subsection (a)(1) shall
not supercede any State law in a nonadopting State to the extent necessary to
permit individuals or the insurance department of the State (or other State
agency) to obtain relief under State law to require an eligible insurer to
comply with the Model Small Group Rating Rules or transitional model small
group rating rules.</text>
</paragraph><paragraph id="HE930A8D0970343B891351BE6363B1019"><enum>(4)</enum><header>No effect on
preemption</header><text>In no case shall this part be construed to limit or
affect in any manner the preemptive scope of sections 502 and 514 of the
Employee Retirement Income Security Act of 1974. In no case shall this part be
construed to create any cause of action under Federal or State law or enlarge
or affect any remedy available under the Employee Retirement Income Security
Act of 1974.</text>
</paragraph><paragraph id="HFDA07EF69DF94B80B260CC288456BCA9"><enum>(5)</enum><header>Preemption
limited to rating</header><text>Subsection (a) shall not preempt any State law
that does not have a reference to or a connection with State rating rules that
would otherwise apply to eligible insurers.</text>
</paragraph></subsection><subsection id="H39C886EE0D364FF50088075757FE00AD"><enum>(c)</enum><header>Effective
date</header><text>This section shall apply, at the election of the eligible
insurer, beginning in the first plan year or the first calendar year following
the issuance of the final rules by the Secretary under the Model Small Group
Rating Rules or, as applicable, the Transitional Model Small Group Rating
Rules, but in no event earlier than the date that is 12 months after the date
of enactment of this title.</text>
</subsection></section><section id="H82C28639B33F42B4BA4B8BEA567CFF12"><enum>3114.</enum><header>Civil actions
and jurisdiction</header>
<subsection id="HAEEEE52836CF497BB9DFB4DB5DBB0018"><enum>(a)</enum><header>In
general</header><text>The courts of the United States shall have exclusive
jurisdiction over civil actions involving the interpretation of this
part.</text>
</subsection><subsection id="H7B1398B14635442FA3B87DFA3E6B9EDC"><enum>(b)</enum><header>Actions</header><text>An
eligible insurer may bring an action in the district courts of the United
States for injunctive or other equitable relief against any officials or agents
of a nonadopting State in connection with any conduct or action, or proposed
conduct or action, by such officials or agents which violates, or which would
if undertaken violate, section 3113.</text>
</subsection><subsection id="HC59921BA23164094A4FA6C76D4F627C1"><enum>(c)</enum><header>Direct filing in
Court of Appeals</header><text>At the election of the eligible insurer, an
action may be brought under subsection (b) directly in the United States Court
of Appeals for the circuit in which the nonadopting State is located by the
filing of a petition for review in such Court.</text>
</subsection><subsection id="H26728E8D71AB4216A0E916F26C4C148"><enum>(d)</enum><header>Expedited
review</header>
<paragraph id="HD01CB0AC78244850B59EF8B2EAFB06F"><enum>(1)</enum><header>District
court</header><text>In the case of an action brought in a district court of the
United States under subsection (b), such court shall complete such action,
including the issuance of a judgment, prior to the end of the 120-day period
beginning on the date on which such action is filed, unless all parties to such
proceeding agree to an extension of such period.</text>
</paragraph><paragraph id="H444D25ADFE004743B74B2888A7F52E62"><enum>(2)</enum><header>Court of
Appeals</header><text>In the case of an action brought directly in a United
States Court of Appeal under subsection (c), or in the case of an appeal of an
action brought in a district court under subsection (b), such Court shall
complete all action on the petition, including the issuance of a judgment,
prior to the end of the 60-day period beginning on the date on which such
petition is filed with the Court, unless all parties to such proceeding agree
to an extension of such period.</text>
</paragraph></subsection><subsection id="H24332F84B14942DC82D255EC7F637288"><enum>(e)</enum><header>Standard of
review</header><text>A court in an action filed under this section, shall
render a judgment based on a review of the merits of all questions presented in
such action and shall not defer to any conduct or action, or proposed conduct
or action, of a nonadopting State.</text>
</subsection></section><section id="H0ACA12AB1A6E424595A5C7B8AB6F5BF7"><enum>3115.</enum><header>Ongoing
review</header><text display-inline="no-display-inline">Not later than 5 years
after the date on which the Model Small Group Rating Rules are issued under
this part, and every 5 years thereafter, the Secretary, in consultation with
the National Association of Insurance Commissioners, shall prepare and submit
to the appropriate committees of Congress a report that assesses the effect of
the Model Small Group Rating Rules on access, cost, and market functioning in
the small group market. Such report may, if the Secretary, in consultation with
the National Association of Insurance Commissioners, determines such is
appropriate for improving access, costs, and market functioning, contain
legislative proposals for recommended modification to such Model Small Group
Rating Rules.</text>
</section></part><part id="HD3890FAE4EE74E209E5730B094C0FBD0"><enum>II</enum><header>Affordable
Plans</header>
<section id="H51429DC5FA774F46A9078425B895E43D"><enum>3121.</enum><header>Definitions</header><text display-inline="no-display-inline">In this part:</text>
<paragraph id="HC90A51E7ACA54A308EC76C8B50D57ED5"><enum>(1)</enum><header>Adopting
state</header><text>The term <term>adopting State</term> means a State that has
enacted a law providing that small group, individual, and large group health
insurers in such State may offer and sell products in accordance with the List
of Required Benefits and the Terms of Application as provided for in section
3122(b).</text>
</paragraph><paragraph id="H9A2F3D4AC7F3478D88C91BCE5415756B"><enum>(2)</enum><header>Eligible
insurer</header><text>The term <term>eligible insurer</term> means a health
insurance issuer that is licensed in a nonadopting State and that—</text>
<subparagraph id="H59CD0875E6C34C34B3009E346D2E611D"><enum>(A)</enum><text>notifies the
Secretary, not later than 30 days prior to the offering of coverage described
in this subparagraph, that the issuer intends to offer health insurance
coverage consistent with the List of Required Benefits and Terms of Application
in a nonadopting State;</text>
</subparagraph><subparagraph id="H32EF12B399EF4703BDEC1E901631D1F7"><enum>(B)</enum><text>notifies the
insurance department of a nonadopting State (or other applicable State agency),
not later than 30 days prior to the offering of coverage described in this
subparagraph, that the issuer intends to offer health insurance coverage in
that State consistent with the List of Required Benefits and Terms of
Application, and provides with such notice a copy of any insurance policy that
it intends to offer in the State, its most recent annual and quarterly
financial reports, and any other information required to be filed with the
insurance department of the State (or other State agency) by the Secretary in
regulations; and</text>
</subparagraph><subparagraph id="H6732CE3810504047BCC3A98284A8E978"><enum>(C)</enum><text>includes in the
terms of the health insurance coverage offered in nonadopting States (including
in the terms of any individual certificates that may be offered to individuals
in connection with such group health coverage) and filed with the State
pursuant to subparagraph (B), a description in the insurer's contract of the
List of Required Benefits and a description of the Terms of Application,
including a description of the benefits to be provided, and that adherence to
such standards is included as a term of such contract.</text>
</subparagraph></paragraph><paragraph id="HCC3DADA739A3401199CE1597EFB31300"><enum>(3)</enum><header>Health insurance
coverage</header><text>The term <term>health insurance coverage</term> means
any coverage issued in the small group, individual, or large group health
insurance markets, including with respect to small business health plans,
except that such term shall not include excepted benefits (as defined in
section 2791(c)).</text>
</paragraph><paragraph id="H31EF805A3CB443BEA04E02D00007F47"><enum>(4)</enum><header>List of Required
Benefits</header><text>The term <term>List of Required Benefits</term> means
the list issued under section 3122(a).</text>
</paragraph><paragraph id="H7BB2C0189D42445C9EB8B495F0E9F1F"><enum>(5)</enum><header>Nonadopting
state</header><text>The term <term>nonadopting State</term> means a State that
is not an adopting State.</text>
</paragraph><paragraph id="HA7DD198D92854BD192FB7B7215139300"><enum>(6)</enum><header>State
law</header><text>The term <term>State law</term> means all laws, decisions,
rules, regulations, or other State actions (including actions by a State
agency) having the effect of law, of any State.</text>
</paragraph><paragraph id="H9A046F6FC6164CAAB3C9FB8F003CE023"><enum>(7)</enum><header>State Provider
Freedom of Choice Law</header><text>The term <term>State Provider Freedom of
Choice Law</term> means a State law requiring that a health insurance issuer,
with respect to health insurance coverage, not discriminate with respect to
participation, reimbursement, or indemnification as to any provider who is
acting within the scope of the provider's license or certification under
applicable State law.</text>
</paragraph><paragraph id="H86A802AFCCA64C4300C7A69491F96671"><enum>(8)</enum><header>Terms of
Application</header><text>The term <term>Terms of Application</term> means
terms provided under section 3122(a).</text>
</paragraph></section><section commented="no" display-inline="no-display-inline" id="H654D0DFEF75840BDBEF66B3B8421E2B7" section-type="subsequent-section"><enum>3122.</enum><header>Offering affordable
plans</header>
<subsection id="HB7E5208D5F27400785ACCB878FF058C1"><enum>(a)</enum><header>List of Required
Benefits</header><text>Not later than 3 months after the date of enactment of
this title, the Secretary, in consultation with the National Association of
Insurance Commissioners, shall issue by interim final rule a list (to be known
as the <quote>List of Required Benefits</quote>) of covered benefits, services,
or categories of providers that are required to be provided by health insurance
issuers, in each of the small group, individual, and large group markets, in at
least 26 States as a result of the application of State covered benefit,
service, and category of provider mandate laws. With respect to plans sold to
or through small business health plans, the List of Required Benefits
applicable to the small group market shall apply.</text>
</subsection><subsection id="H039312892C504368A1F4886B58847D44"><enum>(b)</enum><header>Terms of
Application</header>
<paragraph id="HC60A443ED8E145E7BBB30099B549BEB5"><enum>(1)</enum><header>State with
mandates</header><text>With respect to a State that has a covered benefit,
service, or category of provider mandate in effect that is covered under the
List of Required Benefits under subsection (a), such State mandate shall,
subject to paragraph (3) (concerning uniform application), apply to a coverage
plan or plan in, as applicable, the small group, individual, or large group
market or through a small business health plan in such State.</text>
</paragraph><paragraph id="HC759BE0A865D462384138507DFD2C26D"><enum>(2)</enum><header>States without
mandates</header><text>With respect to a State that does not have a covered
benefit, service, or category of provider mandate in effect that is covered
under the List of Required Benefits under subsection (a), such mandate shall
not apply, as applicable, to a coverage plan or plan in the small group,
individual, or large group market or through a small business health plan in
such State.</text>
</paragraph><paragraph id="H0BDB49E190814CDA895FCCA4F431623F"><enum>(3)</enum><header>Uniform
application of laws</header>
<subparagraph id="HEF805FEF489843C4A400BC571148342D"><enum>(A)</enum><header>In
general</header><text>With respect to a State described in paragraph (1), in
applying a covered benefit, service, or category of provider mandate that is on
the List of Required Benefits under subsection (a) the State shall permit a
coverage plan or plan offered in the small group, individual, or large group
market or through a small business health plan in such State to apply such
benefit, service, or category of provider coverage in a manner consistent with
the manner in which such coverage is applied under one of the three most
heavily subscribed national health plans offered under the Federal Employee
Health Benefits Program under chapter 89 of title 5, United States Code (as
determined by the Secretary in consultation with the Director of the Office of
Personnel Management), and consistent with the Publication of Benefit
Applications under subsection (c). In the event a covered benefit, service, or
category of provider appearing in the List of Required Benefits is not offered
in one of the three most heavily subscribed national health plans offered under
the Federal Employees Health Benefits Program, such covered benefit, service,
or category of provider requirement shall be applied in a manner consistent
with the manner in which such coverage is offered in the remaining most heavily
subscribed plan of the remaining Federal Employees Health Benefits Program
plans, as determined by the Secretary, in consultation with the Director of the
Office of Personnel Management.</text>
</subparagraph><subparagraph id="H5955B380152E41468161EA61544F9874"><enum>(B)</enum><header>Exception
regarding State provider freedom of choice laws</header><text>Notwithstanding
subparagraph (A), in the event a category of provider mandate is included in
the List of Covered Benefits, any State Provider Freedom of Choice Law (as
defined in section 3121(7)) that is in effect in any State in which such
category of provider mandate is in effect shall not be preempted, with respect
to that category of provider, by this part.</text>
</subparagraph></paragraph></subsection><subsection id="H77AA39EFB688401BAAC8F4D2E9CFA657"><enum>(c)</enum><header>Publication of
benefit applications</header><text>Not later than 3 months after the date of
enactment of this title, and on the first day of every calendar year
thereafter, the Secretary, in consultation with the Director of the Office of
Personnel Management, shall publish in the Federal Register a description of
such covered benefits, services, and categories of providers covered in that
calendar year by each of the three most heavily subscribed nationally available
Federal Employee Health Benefits Plan options which are also included on the
List of Required Benefits.</text>
</subsection><subsection id="H64EA145814A84A1BB4D6F7DC933AB1D"><enum>(d)</enum><header>Effective
dates</header>
<paragraph id="HCE84982CA96049D184692E72912CDB5"><enum>(1)</enum><header>Small business
health plans</header><text>With respect to health insurance provided to
participating employers of small business health plans, the requirements of
this part (concerning lower cost plans) shall apply beginning on the date that
is 12 months after the date of enactment of this title.</text>
</paragraph><paragraph id="HB67600B59F444C099B4D28667FA4BD89"><enum>(2)</enum><header>Non-association
coverage</header><text>With respect to health insurance provided to groups or
individuals other than participating employers of small business health plans,
the requirements of this part shall apply beginning on the date that is 15
months after the date of enactment of this title.</text>
</paragraph></subsection><subsection id="H704B8E93D58D4BAE894443EDB94F22D8"><enum>(e)</enum><header>Updating of list
of required benefits</header><text>Not later than 2 years after the date on
which the List of Required Benefits is issued under subsection (a), and every 2
years thereafter, the Secretary, in consultation with the National Association
of Insurance Commissioners, shall update the list based on changes in the laws
and regulations of the States. The Secretary shall issue the updated list by
regulation, and such updated list shall be effective upon the first plan year
following the issuance of such regulation.</text>
</subsection></section><section id="H605D5CD1281243B987F4D8EADAFF73D"><enum>3123.</enum><header>Application and
preemption</header>
<subsection id="H48126D50985C460AB65422EADCEB90ED"><enum>(a)</enum><header>Superceding of
state law</header>
<paragraph id="HB45A6406E46642F1917F85A9B769BF3"><enum>(1)</enum><header>In
general</header><text>This part shall supersede any and all State laws insofar
as such laws relate to mandates relating to covered benefits, services, or
categories of provider in the health insurance market as applied to an eligible
insurer, or health insurance coverage issued by an eligible insurer, including
with respect to coverage issued to a small business health plan, in a
nonadopting State.</text>
</paragraph><paragraph id="H434BEA0523BC49A8A5B838A0E5F62271"><enum>(2)</enum><header>Nonadopting
states</header><text>This part shall supersede any and all State laws of a
nonadopting State (whether enacted prior to or after the date of enactment of
this title) insofar as such laws—</text>
<subparagraph id="HFE8CA91475DA4551B8346428F58C6BCB"><enum>(A)</enum><text>prohibit an
eligible insurer from offering, marketing, or implementing health insurance
coverage consistent with the Benefit Choice Standards, as provided for in
section 3122(a); or</text>
</subparagraph><subparagraph id="H322EAE5A4D7A4D7782F565D41E7FE74E"><enum>(B)</enum><text>have the effect of
retaliating against or otherwise punishing in any respect an eligible insurer
for offering, marketing, or implementing health insurance coverage consistent
with the Benefit Choice Standards.</text>
</subparagraph></paragraph></subsection><subsection id="H9E0BA0CCC56A4DAFBAA300A889F0084"><enum>(b)</enum><header>Savings clause
and construction</header>
<paragraph id="H2A4A79217EDB460AAC54CDD7B8BEBC4"><enum>(1)</enum><header>Nonapplication to
adopting states</header><text>Subsection (a) shall not apply with respect to
adopting States.</text>
</paragraph><paragraph id="H293B43748A13480D8611D700C6999500"><enum>(2)</enum><header>Nonapplication
to certain insurers</header><text>Subsection (a) shall not apply with respect
to insurers that do not qualify as eligible insurers who offer health insurance
coverage in a nonadopting State.</text>
</paragraph><paragraph id="H1305ED5D1A1D47C681E06E7BFFD54B82"><enum>(3)</enum><header>Nonapplication
where obtaining relief under state law</header><text>Subsection (a)(1) shall
not supercede any State law of a nonadopting State to the extent necessary to
permit individuals or the insurance department of the State (or other State
agency) to obtain relief under State law to require an eligible insurer to
comply with the Benefit Choice Standards.</text>
</paragraph><paragraph id="H06E041ECD256408E957905F92DD778E1"><enum>(4)</enum><header>No effect on
preemption</header><text>In no case shall this part be construed to limit or
affect in any manner the preemptive scope of sections 502 and 514 of the
Employee Retirement Income Security Act of 1974. In no case shall this part be
construed to create any cause of action under Federal or State law or enlarge
or affect any remedy available under the Employee Retirement Income Security
Act of 1974.</text>
</paragraph><paragraph id="H595B650B83684BB88CE1C5FB4B948417"><enum>(5)</enum><header>Preemption
limited to benefits</header><text>Subsection (a) shall not preempt any State
law that does not have a reference to or a connection with State mandates
regarding covered benefits, services, or categories of providers that would
otherwise apply to eligible insurers.</text>
</paragraph></subsection></section><section id="H5C985D8438AE4B4C851E1B0072628580"><enum>3124.</enum><header>Civil actions
and jurisdiction</header>
<subsection id="HC0BD6B72060E4D04A61DD0A930B6CD6D"><enum>(a)</enum><header>In
general</header><text>The courts of the United States shall have exclusive
jurisdiction over civil actions involving the interpretation of this
part.</text>
</subsection><subsection id="HAFCA9DE172004A2D9400EBEB3CF8E5A6"><enum>(b)</enum><header>Actions</header><text>An
eligible insurer may bring an action in the district courts of the United
States for injunctive or other equitable relief against any officials or agents
of a nonadopting State in connection with any conduct or action, or proposed
conduct or action, by such officials or agents which violates, or which would
if undertaken violate, section 3123.</text>
</subsection><subsection id="HFBED6A8E8FEA4827A354C3C7A1D0DF83"><enum>(c)</enum><header>Direct filing in
Court of Appeals</header><text>At the election of the eligible insurer, an
action may be brought under subsection (b) directly in the United States Court
of Appeals for the circuit in which the nonadopting State is located by the
filing of a petition for review in such Court.</text>
</subsection><subsection id="H93B12AD933624FA6BFCA386CFCA6C7A3"><enum>(d)</enum><header>Expedited
review</header>
<paragraph id="HFD36785262E74EC79D0429F6009654E7"><enum>(1)</enum><header>District
court</header><text>In the case of an action brought in a district court of the
United States under subsection (b), such court shall complete such action,
including the issuance of a judgment, prior to the end of the 120-day period
beginning on the date on which such action is filed, unless all parties to such
proceeding agree to an extension of such period.</text>
</paragraph><paragraph id="HA305818C4D9A43E89F2B97C89F242B86"><enum>(2)</enum><header>Court of
Appeals</header><text>In the case of an action brought directly in a United
States Court of Appeal under subsection (c), or in the case of an appeal of an
action brought in a district court under subsection (b), such Court shall
complete all action on the petition, including the issuance of a judgment,
prior to the end of the 60-day period beginning on the date on which such
petition is filed with the Court, unless all parties to such proceeding agree
to an extension of such period.</text>
</paragraph></subsection><subsection id="HBEDF1622BF974CD688DE005E98FF9190"><enum>(e)</enum><header>Standard of
review</header><text>A court in an action filed under this section, shall
render a judgment based on a review of the merits of all questions presented in
such action and shall not defer to any conduct or action, or proposed conduct
or action, of a nonadopting State.</text>
</subsection></section><section commented="no" id="H0DF4DB35C81940E480B1EFABC2461F5D"><enum>3125.</enum><header>Rules of
construction</header>
<subsection commented="no" id="HADF00C64AA664E5582CFDE243384775C"><enum>(a)</enum><header>In
general</header><text display-inline="yes-display-inline">Notwithstanding any
other provision of Federal or State law, a health insurance issuer in an
adopting State or an eligible insurer in a nonadopting State may amend its
existing policies to be consistent with the terms of this subtitle (concerning
rating and benefits).</text>
</subsection><subsection commented="no" id="H7415ED0250554B52BC04CF6E2BB957BA"><enum>(b)</enum><header>Health savings
accounts</header><text display-inline="yes-display-inline">Nothing in this
subtitle shall be construed to create any mandates for coverage of benefits for
HSA-qualified health plans that would require reimbursements in violation of
section 223(c)(2) of the Internal Revenue Code of
1986.</text>
</subsection></section></part></subtitle>.
CHarmonization of
Health Insurance Standards
221.Health
Insurance Standards HarmonizationTitle XXXI of the Public Health Service Act
(as added by section 211) is amended by adding at the end the following:
B
3131.In this subtitle:
(1)The term adopting State means a State that has
enacted the harmonized standards adopted under this subtitle in their entirety
and as the exclusive laws of the State that relate to the harmonized
standards.
(2)The term eligible insurer means a health
insurance issuer that is licensed in a nonadopting State and that—
(A)notifies the
Secretary, not later than 30 days prior to the offering of coverage described
in this subparagraph, that the issuer intends to offer health insurance
coverage consistent with the harmonized standards in a nonadopting
State;
(B)notifies the
insurance department of a nonadopting State (or other State agency), not later
than 30 days prior to the offering of coverage described in this subparagraph,
that the issuer intends to offer health insurance coverage in that State
consistent with the harmonized standards published pursuant to section 3133(d),
and provides with such notice a copy of any insurance policy that it intends to
offer in the State, its most recent annual and quarterly financial reports, and
any other information required to be filed with the insurance department of the
State (or other State agency) by the Secretary in regulations; and
(C)includes in the
terms of the health insurance coverage offered in nonadopting States (including
in the terms of any individual certificates that may be offered to individuals
in connection with such health coverage) and filed with the State pursuant to
subparagraph (B), a description of the harmonized standards published pursuant
to section 3133(g)(2) and an affirmation that such standards are a term of the
contract.
(3)The term harmonized standards means the
standards certified by the Secretary under section 3133(d).
(4)Health insurance
coverageThe term health insurance coverage means
any coverage issued in the health insurance market, except that such term shall
not include excepted benefits (as defined in section 2791(c).
(5)The term nonadopting State means a State that
fails to enact, within 18 months of the date on which the Secretary certifies
the harmonized standards under this subtitle, the harmonized standards in their
entirety and as the exclusive laws of the State that relate to the harmonized
standards.
(6)The term State law means all laws, decisions,
rules, regulations, or other State actions (including actions by a State
agency) having the effect of law, of any State.
3132.
(a)
(1)Not
later than 3 months after the date of enactment of this title, the Secretary,
in consultation with the NAIC, shall establish the Health Insurance Consensus
Standards Board (referred to in this subtitle as the Board
) to
develop recommendations that harmonize inconsistent State health insurance laws
in accordance with the procedures described in subsection (b).
(2)
(A)The Board shall be composed of the following voting
members to be appointed by the Secretary after considering the recommendations
of professional organizations representing the entities and constituencies
described in this paragraph:
(i)Four State
insurance commissioners as recommended by the National Association of Insurance
Commissioners, of which two shall be Democrats and two shall be Republicans,
and of which one shall be designated as the chairperson and one shall be
designated as the vice chairperson.
(ii)Four
representatives of State government, two of which shall be governors of States
and two of which shall be State legislators, and two of which shall be
Democrats and two of which shall be Republicans.
(iii)Four
representatives of health insurers, of which one shall represent insurers that
offer coverage in the small group market, one shall represent insurers that
offer coverage in the large group market, one shall represent insurers that
offer coverage in the individual market, and one shall represent carriers
operating in a regional market.
(iv)Two
representatives of insurance agents and brokers.
(v)Two independent
representatives of the American Academy of Actuaries who have familiarity with
the actuarial methods applicable to health insurance.
(B)A representative of the Secretary shall serve as an ex
officio member of the Board.
(3)The Secretary shall establish an advisory panel to provide
advice to the Board, and shall appoint its members after considering the
recommendations of professional organizations representing the entities and
constituencies identified in this paragraph:
(A)Two
representatives of small business health plans.
(B)Two representatives
of employers, of which one shall represent small employers and one shall
represent large employers.
(C)Two
representatives of consumer organizations.
(D)Two
representatives of health care providers.
(4)The
membership of the Board shall include individuals with national recognition for
their expertise in health finance and economics, actuarial science, health
plans, providers of health services, and other related fields, who provide a
mix of different professionals, broad geographic representation, and a balance
between urban and rural representatives.
(5)The Secretary shall establish a system for public
disclosure by members of the Board of financial and other potential conflicts
of interest relating to such members. Members of the Board shall be treated as
employees of Congress for purposes of applying title I of the Ethics in
Government Act of 1978 (Public Law 95–521).
(6)Subject to such review as the Secretary deems necessary to
assure the efficient administration of the Board, the chair and vice-chair of
the Board may—
(A)employ and fix the
compensation of an Executive Director (subject to the approval of the
Comptroller General) and such other personnel as may be necessary to carry out
its duties (without regard to the provisions of title 5, United States Code,
governing appointments in the competitive service);
(B)seek such
assistance and support as may be required in the performance of its duties from
appropriate Federal departments and agencies;
(C)enter into
contracts or make other arrangements, as may be necessary for the conduct of
the work of the Board (without regard to section 3709 of the Revised Statutes
(41 U.S.C. 5));
(D)make advance,
progress, and other payments which relate to the work of the Board;
(E)provide
transportation and subsistence for persons serving without compensation;
and
(F)prescribe such
rules as it deems necessary with respect to the internal organization and
operation of the Board.
(7)The
members of the Board shall serve for the duration of the Board. Vacancies in
the Board shall be filled as needed in a manner consistent with the composition
described in paragraph (2).
(b)Development of
harmonized standards
(1)In accordance with the process described in subsection
(c), the Board shall identify and recommend nationally harmonized standards for
each of the following process categories:
(A)Form filing and
rate filingForm and rate filing standards shall be established
which promote speed to market and include the following defined areas for
States that require such filings:
(i)Procedures for
form and rate filing pursuant to a streamlined administrative filing
process.
(ii)Timeframes for
filings to be reviewed by a State if review is required before they are deemed
approved.
(iii)Timeframes for an
eligible insurer to respond to State requests following its review.
(iv)A
process for an eligible insurer to self-certify.
(v)State development
of form and rate filing templates that include only non-preempted State law and
Federal law requirements for eligible insurers with timely updates.
(vi)Procedures for
the resubmission of forms and rates.
(vii)Disapproval
rationale of a form or rate filing based on material omissions or violations of
non-preempted State law or Federal law with violations cited and
explained.
(viii)For States that
may require a hearing, a rationale for hearings based on violations of
non-preempted State law or insurer requests.
(B)Market conduct review standards shall be developed which
provide for the following:
(i)Mandatory
participation in national databases.
(ii)The
confidentiality of examination materials.
(iii)The
identification of the State agency with primary responsibility for
examinations.
(iv)Consultation and
verification of complaint data with the eligible insurer prior to State
actions.
(v)Consistency of
reporting requirements with the recordkeeping and administrative practices of
the eligible insurer.
(vi)Examinations that
seek to correct material errors and harmful business practices rather than
infrequent errors.
(vii)Transparency and
publishing of the State's examination standards.
(viii)Coordination of
market conduct analysis.
(ix)Coordination and
nonduplication between State examinations of the same eligible insurer.
(x)Rationale and
protocols to be met before a full examination is conducted.
(xi)Requirements on
examiners prior to beginning examinations such as budget planning and work
plans.
(xii)Consideration of
methods to limit examiners' fees such as caps, competitive bidding, or other
alternatives.
(xiii)Reasonable
fines and penalties for material errors and harmful business practices.
(C)The Board shall establish prompt payment standards for
eligible insurers based on standards similar to those applicable to the Social
Security Act as set forth in section 1842(c)(2) of such Act (42 U.S.C.
1395u(c)(2)). Such prompt payment standards shall be consistent with the timing
and notice requirements of the claims procedure rules to be specified under
subparagraph (D), and shall include appropriate exceptions such as for fraud,
nonpayment of premiums, or late submission of claims.
(D)The Board shall establish standards for claims procedures
for eligible insurers that are consistent with the requirements relating to
initial claims for benefits and appeals of claims for benefits under the
Employee Retirement Income Security Act of 1974 as set forth in section 503 of
such Act (29 U.S.C. 1133) and the regulations thereunder.
(2)The
Board shall recommend harmonized standards for each element of the categories
described in subparagraph (A) through (D) of paragraph (1) within each such
market. Notwithstanding the previous sentence, the Board shall not recommend
any harmonized standards that disrupt, expand, or duplicate the benefit,
service, or provider mandate standards provided in the Benefit Choice Standards
pursuant to section 3122(a).
(c)Process for
identifying harmonized standards
(1)The Board shall develop recommendations to harmonize
inconsistent State insurance laws with respect to each of the process
categories described in subparagraphs (A) through (D) of subsection
(b)(1).
(2)In
adopting standards under this section, the Board shall consider the
following:
(A)Any model acts or
regulations of the National Association of Insurance Commissioners in each of
the process categories described in subparagraphs (A) through (D) of subsection
(b)(1).
(B)Substantially
similar standards followed by a plurality of States, as reflected in existing
State laws, relating to the specific process categories described in
subparagraphs (A) through (D) of subsection (b)(1).
(C)Any Federal law
requirement related to specific process categories described in subparagraphs
(A) through (D) of subsection (b)(1).
(D)In the case of the
adoption of any standard that differs substantially from those referred to in
subparagraphs (A), (B), or (C), the Board shall provide evidence to the
Secretary that such standard is necessary to protect health insurance consumers
or promote speed to market or administrative efficiency.
(E)The criteria
specified in clauses (i) through (iii) of subsection (d)(2)(B).
(d)Recommendations
and certification by Secretary
(1)Not
later than 18 months after the date on which all members of the Board are
selected under subsection (a), the Board shall recommend to the Secretary the
certification of the harmonized standards identified pursuant to subsection
(c).
(2)
(A)Not later than 120 days after receipt of the Board's
recommendations under paragraph (1), the Secretary shall certify the
recommended harmonized standards as provided for in subparagraph (B), and issue
such standards in the form of an interim final regulation.
(B)The Secretary shall establish a process for certifying
the recommended harmonized standard, by category, as recommended by the Board
under this section. Such process shall—
(i)ensure that the
certified standards for a particular process area achieve regulatory
harmonization with respect to health plans on a national basis;
(ii)ensure that the
approved standards are the minimum necessary, with regard to substance and
quantity of requirements, to protect health insurance consumers and maintain a
competitive regulatory environment; and
(iii)ensure that the
approved standards will not limit the range of group health plan designs and
insurance products, such as catastrophic coverage only plans, health savings
accounts, and health maintenance organizations, that might otherwise be
available to consumers.
(3)Application and
effective dateThe standards certified by the Secretary under
paragraph (2) shall apply and become effective on the date that is 18 months
after the date on which the Secretary certifies the harmonized
standards.
(e)The
Board shall terminate and be dissolved after making the recommendations to the
Secretary pursuant to subsection (d)(1).
(f)Not earlier than 3 years after the termination of the
Board under subsection (e), and not earlier than every 3 years thereafter, the
Secretary, in consultation with the National Association of Insurance
Commissioners and the entities and constituencies represented on the Board and
the Advisory Panel, shall prepare and submit to the appropriate committees of
Congress a report that assesses the effect of the harmonized standards applied
under this section on access, cost, and health insurance market functioning.
The Secretary may, based on such report and applying the process established
for certification under subsection (d)(2)(B), in consultation with the National
Association of Insurance Commissioners and the entities and constituencies
represented on the Board and the Advisory Panel, update the harmonized
standards through notice and comment rulemaking.
(g)
(1)The
Secretary shall maintain an up to date listing of all harmonized standards
certified under this section on the Internet website of the Department of
Health and Human Services.
(2)The Secretary shall publish on the Internet website of
the Department of Health and Human Services sample contract language that
incorporates the harmonized standards certified under this section, which may
be used by insurers seeking to qualify as an eligible insurer. The types of
harmonized standards that shall be included in sample contract language are the
standards that are relevant to the contractual bargain between the insurer and
insured.
(h)State adoption
and enforcementNot later than 18 months after the certification
by the Secretary of harmonized standards under this section, the States may
adopt such harmonized standards (and become an adopting State) and, in which
case, shall enforce the harmonized standards pursuant to State law.
3133.Application
and preemption
(a)
(1)The harmonized standards certified under this subtitle
and applied as provided for in section 3133(d)(3), shall supersede any and all
State laws of a nonadopting State insofar as such State laws relate to the
areas of harmonized standards as applied to an eligible insurer, or health
insurance coverage issued by a eligible insurer, including with respect to
coverage issued to a small business health plan, in a nonadopting State.
(2)This subtitle shall supersede any and all State laws of a
nonadopting State (whether enacted prior to or after the date of enactment of
this title) insofar as they may—
(A)prohibit an
eligible insurer from offering, marketing, or implementing health insurance
coverage consistent with the harmonized standards; or
(B)have the effect of
retaliating against or otherwise punishing in any respect an eligible insurer
for offering, marketing, or implementing health insurance coverage consistent
with the harmonized standards under this subtitle.
(b)Savings clause
and construction
(1)Nonapplication
to adopting statesSubsection (a) shall not apply with respect to
adopting States.
(2)Nonapplication
to certain insurersSubsection (a) shall not apply with respect
to insurers that do not qualify as eligible insurers who offer health insurance
coverage in a nonadopting State.
(3)Nonapplication
where obtaining relief under state lawSubsection (a)(1) shall
not supercede any State law of a nonadopting State to the extent necessary to
permit individuals or the insurance department of the State (or other State
agency) to obtain relief under State law to require an eligible insurer to
comply with the harmonized standards under this subtitle.
(4)In no case shall this subtitle be construed to limit
or affect in any manner the preemptive scope of sections 502 and 514 of the
Employee Retirement Income Security Act of 1974. In no case shall this subtitle
be construed to create any cause of action under Federal or State law or
enlarge or affect any remedy available under the Employee Retirement Income
Security Act of 1974.
(c)This section shall apply beginning on the date that is 18
months after the date on harmonized standards are certified by the Secretary
under this subtitle.
3134.Civil actions
and jurisdiction
(a)The district courts of the United States shall have
exclusive jurisdiction over civil actions involving the interpretation of this
subtitle.
(b)An
eligible insurer may bring an action in the district courts of the United
States for injunctive or other equitable relief against any officials or agents
of a nonadopting State in connection with any conduct or action, or proposed
conduct or action, by such officials or agents which violates, or which would
if undertaken violate, section 3133.
(c)Direct filing in
Court of AppealsAt the election of the eligible insurer, an
action may be brought under subsection (b) directly in the United States Court
of Appeals for the circuit in which the nonadopting State is located by the
filing of a petition for review in such Court.
(d)
(1)In the case of an action brought in a district court of the
United States under subsection (b), such court shall complete such action,
including the issuance of a judgment, prior to the end of the 120-day period
beginning on the date on which such action is filed, unless all parties to such
proceeding agree to an extension of such period.
(2)In the case of an action brought directly in a United
States Court of Appeal under subsection (c), or in the case of an appeal of an
action brought in a district court under subsection (b), such Court shall
complete all action on the petition, including the issuance of a judgment,
prior to the end of the 60-day period beginning on the date on which such
petition is filed with the Court, unless all parties to such proceeding agree
to an extension of such period.
(e)A court in an action filed under this section, shall
render a judgment based on a review of the merits of all questions presented in
such action and shall not defer to any conduct or action, or proposed conduct
or action, of a nonadopting State.
3135.Authorization of
appropriations; rule of construction
(a)Authorization of
appropriationsThere are
authorized to be appropriated such sums as may be necessary to carry out this
subtitle.
(b)Nothing in this subtitle shall be construed to create
any mandates for coverage of any benefits below the deductible levels set for
any health savings account-qualified health plan pursuant to section 223 of the
Internal Revenue Code of
1986.
.
<enum>III</enum><header>TAX-RELATED
HEALTH INCENTIVES</header>
<section id="HCCF911E76C0545A79E605E90DC692F67"><enum>301.</enum><header>SECA tax
deduction for health insurance costs</header>
<subsection id="H896FBE8849EA45F3AA55BA7C20FFC5F"><enum>(a)</enum><header>In
General</header><text>Subsection (l) of section 162 of the Internal Revenue
Code of 1986 (relating to special rules for health insurance costs of
self-employed individuals) is amended by striking paragraph (4) and by
redesignating paragraph (5) as paragraph (4).</text>
</subsection><subsection id="H4A4648D977B04FEF95789745F77E5568"><enum>(b)</enum><header>Effective
Date</header><text display-inline="yes-display-inline">The amendment made by
this section shall apply to taxable years beginning after December 31,
2009.</text>
</subsection></section><section id="H230822683CA34ED4AF8FCAB4E03285D"><enum>302.</enum><header>Deduction for
qualified health insurance costs of individuals</header>
<subsection id="H72BF3A8A79BE4F0490BA3008448ECB46"><enum>(a)</enum><header>In
General</header><text>Part VII of subchapter B of chapter 1 of the Internal
Revenue Code of 1986 (relating to additional itemized deductions for
individuals) is amended by redesignating section 224 as section 225 and by
inserting after section 223 the following new section:</text>
<quoted-block id="H1F53C50D5B304E04B25C370044F30448" style="OLC">
<section id="H14934254F7DE499A8B83FAE900E499F9"><enum>224.</enum><header>Costs of
qualified health insurance</header>
<subsection id="HB8DC7C837CF74AAB9DC3C6271B47EDE5"><enum>(a)</enum><header>In
General</header><text>In the case of an individual, there shall be allowed as a
deduction an amount equal to the amount paid during the taxable year for
coverage for the taxpayer, his spouse, and dependents under qualified health
insurance.</text>
</subsection><subsection id="HCE652E43543D4412A4C3AA4FF45FAF6E"><enum>(b)</enum><header>Qualified Health
Insurance</header><text>For purposes of this section, the term <term>qualified
health insurance</term> means insurance which constitutes medical care, other
than insurance substantially all of the coverage of which is of excepted
benefits described in section 9832(c).</text>
</subsection><subsection id="HF461913144BB4E72AA47D19EFDD3F21E"><enum>(c)</enum><header>Special
Rules</header>
<paragraph id="H5B6C3464E32B4380A89D00FB74881D26"><enum>(1)</enum><header>Coordination
with medical deduction, etc</header><text>Any amount paid by a taxpayer for
insurance to which subsection (a) applies shall not be taken into account in
computing the amount allowable to the taxpayer as a deduction under section
162(l) or 213(a). Any amount taken into account in determining the credit
allowed under section 35 shall not be taken into account for purposes of this
section.</text>
</paragraph><paragraph id="HBC7838D67B774FA5A75E80DE42C5428"><enum>(2)</enum><header>Deduction not
allowed for self-employment tax purposes</header><text>The deduction allowable
by reason of this section shall not be taken into account in determining an
individual’s net earnings from self-employment (within the meaning of section
1402(a)) for purposes of chapter
2.</text>
</paragraph></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="HECAC9424C7784E548FEDF500B1D9E134"><enum>(b)</enum><header>Deduction
Allowed in Computing Adjusted Gross Income</header><text>Subsection (a) of
section 62 of such Code is amended by inserting before the last sentence the
following new paragraph:</text>
<quoted-block id="H4689CEFB1A7546CDBC87D6826183F6F0" style="OLC">
<paragraph id="H4B2C365F342B4979937D5E863D7FDB1E"><enum>(22)</enum><header>Costs of
qualified health insurance</header><text>The deduction allowed by section
224.</text>
</paragraph><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="H9E19FBCF64E94E469120AFCB274075B4"><enum>(c)</enum><header>Clerical
Amendment</header><text>The table of sections for part VII of subchapter B of
chapter 1 of such Code is amended by redesignating the item relating to section
224 as an item relating to section 225 and inserting before such item the
following new item:</text>
<quoted-block display-inline="no-display-inline" id="H47EC7721C20548CC8D3B00BD50F81154" style="OLC">
<toc regeneration="no-regeneration">
<toc-entry level="section">Sec. 224. Costs of qualified health
insurance.</toc-entry>
</toc>
<after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="HCB423AE03F7A44019788C82EF5E8785B"><enum>(d)</enum><header>Effective
Date</header><text>The amendments made by this section shall apply to taxable
years beginning after December 31, 2009.</text>
</subsection></section><enum>IV</enum><header>INCREASING ACCESS
TO VA HEALTH CARE </header>
<section id="H240B978085C7404DA7C51752C7FC578C"><enum>401.</enum><header>Requirement for
payments to facilities other than the Department of Veterans Affairs for
covered health services</header>
<subsection id="HD5085DD41872445D91FBD7DE9BC24010"><enum>(a)</enum><header>Requirement To
Authorize Receipt of Covered Health Services at Non-Department Facilities
Pursuant to Contracts With Such Facilities</header><text>Subsection (a) of
section 1703 of title 38, United States Code, is amended to read as
follows:</text>
<quoted-block id="H0B0FBE7A703B48AE90C9C07621BE5902" style="OLC">
<subsection id="HAE74D969B9904CC58FE9375810AEF8B"><enum>(a)</enum><text>An enrolled veteran
may elect to receive covered health services through a non-Department facility.
Such an election shall be made by submission to the Secretary of an application
in accordance with such regulations as the Secretary prescribes. The Secretary
shall authorize such services to be furnished to such veteran pursuant to
contracting with such a facility to furnish such services to such a veteran, as
authorized in section 1710 of this
title.</text>
</subsection><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="H74C5DD5027A540C6840042992E8EF2EB"><enum>(b)</enum><header>Descriptions of
Covered Health Services and Enrolled Veterans</header><text>Such section is
further amended by adding at the end the following new subsection:</text>
<quoted-block id="H5B63AF432A024BA39828C2256CBA614" style="OLC">
<subsection id="H88CD7E3B7CE845ADB4746B7989B1EE46"><enum>(e)</enum><text>For purposes of
subsection (a)—</text>
<paragraph id="H5A3B1E75B4194FA9A578C899DD3D7599"><enum>(1)</enum><text>a covered health
service is any hospital care, medical service, rehabilitative service, or
preventative health service for which the veteran described in such subsection
is eligible under this title; and</text>
</paragraph><paragraph id="H0A3225B21FBC4DE7B6923D2C00B90890"><enum>(2)</enum><text>an enrolled
veteran is a veteran who is enrolled in the system of patient enrollment
established under section 1705(a) of this
title.</text>
</paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="HA0D8B5CB71AF417690E8093FAFDE0048"><enum>(c)</enum><header>Effective
Date</header><text>The Secretary of Veterans Affairs shall implement the
amendments made by subsections (a) and (b) in order for enrolled veterans
described in section 1703(e)(2) of title 38, United States Code, as added by
subsection (b), to receive covered health services in accordance with section
1703(a) of such title, as amended by subsection (a), not later than 180 days
after the date of the enactment of this Act.</text>
</subsection></section><section id="H6F6E816C671F44A2B45C121735BBD9F1"><enum>402.</enum><header>Authority of
Department of Veterans Affairs pharmacies to dispense medications to veterans
on prescriptions written by private practitioners</header><text display-inline="no-display-inline">Section 1712 of title 38, United States
Code, is amended by adding at the end the following new subsection:</text>
<quoted-block id="HB4A4592304794286B5EE1C5416B86644" style="OLC">
<subsection id="H4F92EEADBC9E40C39F1F02FF78B2DC65"><enum>(f)</enum><text>Subject to section
1722A of this title, the Secretary shall furnish to a veteran, through a
Department health care facility, such drugs and medicines as may be ordered on
prescription of a duly licensed physician in the treatment of any illness or
injury of the veteran provided pursuant to the authority to contract with a
non-Department facility for such treatment under section 1703 of this
title.</text>
</subsection><after-quoted-block>.</after-quoted-block></quoted-block>
</section><enum>V</enum><header>NURSING
SHORTAGE</header>
<section id="HD33D9B1425854D57AF3B50F2745B9F13"><enum>501.</enum><header>Child care
assistance for individuals pursuing advanced nursing degrees</header><text display-inline="no-display-inline">Part E of title VIII of the Public Health
Service Act (42 U.S.C. 297a et seq.) is amended—</text>
<paragraph id="HB3EEFDB8FDFD41738411BD72E506E7A9"><enum>(1)</enum><text>by redesignating
section 810 (relating to a prohibition against discrimination by schools) as
section 846B; and</text>
</paragraph><paragraph id="H14B5F37ADC4F4823AC132E442CA1E6C"><enum>(2)</enum><text>by
adding at the end the following:</text>
<quoted-block display-inline="no-display-inline" id="H812326FCF2AF476890527BF9CA7CFB62" style="OLC">
<section id="H4C88AACF47064D08922EAD99A5BFF663"><enum>846C.</enum><header>Child care
assistance for individuals pursuing advanced nursing degrees</header>
<subsection id="H5AC32B6AB7DA401DA8B7688657FE1C52"><enum>(a)</enum><header>In
general</header><text display-inline="yes-display-inline">The Secretary may
carry out a program of entering into contracts with eligible individuals under
which—</text>
<paragraph id="H8B712F2F99AC423EA969A54E5DCEF21C"><enum>(1)</enum><text display-inline="yes-display-inline">the Secretary agrees to provide child care
vouchers to the eligible individual for each month during which the individual
is a student in an advanced nursing degree program; and</text>
</paragraph><paragraph id="H5D936FF4BA1B4606B76059512D3FF1F9"><enum>(2)</enum><text>the eligible
individual agrees to serve, at the completion of such program, as a faculty
member at a school of nursing for a period of 4 years.</text>
</paragraph></subsection><subsection id="H923F206BB2C34F2391B7A6859818CF53"><enum>(b)</enum><header>Vouchers</header><text display-inline="yes-display-inline">Vouchers provided to an eligible individual
under this section—</text>
<paragraph id="HEBE69D8A14714C6C84BACA465E4743C8"><enum>(1)</enum><text display-inline="yes-display-inline">shall be for child care expenses;
and</text>
</paragraph><paragraph id="H3C5E44F269BE41E8923B52D4D73EE05"><enum>(2)</enum><text>shall be for not
more than $500 per month.</text>
</paragraph></subsection><subsection id="H154303E7E1E54D81A600BD97A4E5FC51"><enum>(c)</enum><header>Definition</header><text display-inline="yes-display-inline">In this section, the term <term>eligible
individual</term> means an individual who is enrolled or accepted for
enrollment as a full-time student in an advanced nursing degree program.</text>
</subsection><subsection id="H340526114E714B9994E8DE24038076CF"><enum>(d)</enum><header>Authorization of
appropriations</header><text>To carry out this section, there are authorized to
be appropriated such sums as may be necessary for each of fiscal years 2010
through
2014.</text>
</subsection></section><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></section><section display-inline="no-display-inline" id="H3F0420ADD5324E169054A8ABDBD4E731"><enum>502.</enum><header>Nurse faculty
program</header><text display-inline="no-display-inline">Title VII of the
Higher Education Act of 1965 (20 U.S.C. 1133 et seq.) is amended by adding at
the end the following new part:</text>
<quoted-block display-inline="no-display-inline" id="H9E14FDF4C33949FAA127834FB4911F1C" style="OLC">
<part id="HF6292CC8E0BC4612899C0001F5753E9D"><enum>E</enum><header>Nurse Faculty
Project</header>
<section id="H33DAE6427AD74BF382A9124493445856"><enum>771.</enum><header>Purposes</header><text display-inline="no-display-inline">The purposes of this part are to create a
program—</text>
<paragraph id="HA7DAFF24296C48DB83528F1448E578A5"><enum>(1)</enum><text>to provide
scholarships to qualified nurses in pursuit of an advanced degree with the goal
of becoming faculty members in an accredited nursing program; and</text>
</paragraph><paragraph id="H96AFE1EFF3CF49CD007BD39658D3879C"><enum>(2)</enum><text display-inline="yes-display-inline">to provide grants to partnerships between
accredited schools of nursing and hospitals or health facilities to fund
release time for qualified nurse employees, so that those employees can earn a
salary while obtaining an advanced degree in nursing with the goal of becoming
nurse faculty.</text>
</paragraph></section><section id="HFCE1FF9CE2E2424BAE5614CDD388C570"><enum>772.</enum><header>Assistance
authorized</header>
<subsection id="HD9ABFC763AB7439AB0B9E5B92609ECC4"><enum>(a)</enum><header>Competitive
grants authorized</header><text display-inline="yes-display-inline">The
Secretary may, on a competitive basis, award grants to, and enter into
contracts and cooperative agreements with, partnerships composed of an
accredited school of nursing at an institution of higher education and a
hospital or health facility to establish projects to enable such hospital or
health facility to retain its staff of experienced nurses while providing a
mechanism to have these individuals become, through an accelerated nursing
education program, faculty members of an accredited school of nursing.</text>
</subsection><subsection id="HA64E4BFD9B90450E965FE62E565989"><enum>(b)</enum><header>Duration;
evaluation and dissemination</header>
<paragraph id="H3B2FC8AFBF79412C822D0034D6E3C233"><enum>(1)</enum><header>Duration</header><text>Grants
under this part shall be awarded for a period of 3 to 5 years.</text>
</paragraph><paragraph id="H2D35F90065674F4A806C3FD800321B4C"><enum>(2)</enum><header>Mandatory
evaluation and dissemination</header><text>Grants under this part shall be
primarily used for evaluation, and dissemination to other institutions of
higher education, of the information obtained through the activities described
in
<internal-xref idref="H96AFE1EFF3CF49CD007BD39658D3879C" legis-path="771.(2)">section 771(2)</internal-xref>.</text>
</paragraph></subsection><subsection id="HCEE2CAE3824447018F5F85E45EE6B639"><enum>(c)</enum><header>Considerations
in Making Awards</header><text display-inline="yes-display-inline">In awarding
grants and entering into contracts and cooperative agreements under this
section, the Secretary shall consider the following:</text>
<paragraph id="HC6A0D657459F4DE8AAD3563E8B59B4C2"><enum>(1)</enum><header>Geographic
distribution</header><text>Providing an equitable geographic distribution of
such grants.</text>
</paragraph><paragraph id="H88AB074489CA4BD5A404D2E71CC0955"><enum>(2)</enum><header>Rural and urban
areas</header><text>Distributing such grants to urban and rural areas.</text>
</paragraph><paragraph id="H73BC5D4A5A5C4128005EAE2140C980A1"><enum>(3)</enum><header>Range and type
of institution</header><text>Ensuring that the activities to be assisted are
developed for a range of types and sizes of institutions of higher
education.</text>
</paragraph><paragraph id="HED40D22A13D64EA7BAC6CD2622AF4F53"><enum>(4)</enum><header>Prior experience
or exceptional programs</header><text display-inline="yes-display-inline">Institutions of higher education with
demonstrated prior experience in providing advanced nursing education programs
to prepare nurses interested in pursuing a faculty role.</text>
</paragraph></subsection><subsection id="H060F3C58EBB64EEE86E5196992E165B9"><enum>(d)</enum><header>Uses of
funds</header><text>Funds made available by grant, contract, or cooperative
agreement under this part may be used—</text>
<paragraph id="H865672C3CE0C40409277A612E79EF1C"><enum>(1)</enum><text display-inline="yes-display-inline">to develop a new national demonstration
initiative to align nursing education with the emerging challenges of health
care delivery; and</text>
</paragraph><paragraph id="H8AECC45E46344ADF80D5961D6EB4A5F6"><enum>(2)</enum><text>for any one or
more of the following innovations in educational programs:</text>
<subparagraph id="H70C0892C210840DAB2A74CB3D52DAF5E"><enum>(A)</enum><text display-inline="yes-display-inline">to develop a clinical simulation laboratory
in a hospital, health facility, or accredited school of nursing;</text>
</subparagraph><subparagraph id="HF776358B80E646C182F9A2757027AAC"><enum>(B)</enum><text>to purchase
distance learning technologies;</text>
</subparagraph><subparagraph id="HD8B891049B2F4CBF8BEE8D07DAA0A9A7"><enum>(C)</enum><text>to fund release
time for qualified nurses enrolled in the graduate nursing program;</text>
</subparagraph><subparagraph id="HCD5D7D1D9BDE4CD1B994FB5EA0A4CD03"><enum>(D)</enum><text>to provide for
faculty salaries; and</text>
</subparagraph><subparagraph id="H636440E7236A4420B0EEE34ADED496D"><enum>(E)</enum><text>to collect and
analyze data on educational outcomes.</text>
</subparagraph></paragraph></subsection></section><section id="HAB1A546C162B45A3948F66F3EFC97F30"><enum>773.</enum><header>Applications</header><text display-inline="no-display-inline">Each partnership desiring to receive a
grant, contract, or cooperative agreement under this part shall submit an
application to the Secretary at such time, in such manner, and accompanied by
such information as the Secretary may require. Each application shall include
assurances that—</text>
<paragraph id="HD5D654240FF244F4B5A64472D45BF32C"><enum>(1)</enum><text display-inline="yes-display-inline">the individuals enrolled in the program
will be qualified nurses in pursuit of a master’s or doctoral degree in nursing
and have a contractual obligation with the hospital or health facility that is
in partnership with the institution of higher education;</text>
</paragraph><paragraph id="H6B740245576E4C2A9C706276CC41D1A"><enum>(2)</enum><text display-inline="yes-display-inline">the hospital or health facility of
employment would be the clinical site for the accredited school of nursing
program;</text>
</paragraph><paragraph id="H26C2897E588A462EB96CA32033616234"><enum>(3)</enum><text display-inline="yes-display-inline">individuals will also maintain their
employment on a part-time basis to the hospital or health facility that allowed
them to participate in the program, and will receive an income from the
hospital or health facility, as a part-time employee, and release times or
flexible schedules to accommodate their class schedule; and</text>
</paragraph><paragraph id="H1F3E822DC32E45699204DF7E1894FC7D"><enum>(4)</enum><text display-inline="yes-display-inline">upon completion of the program, individuals
agree to teach for 2 years in an accredited school of nursing for each year of
support the individual received under this program.</text>
</paragraph></section><section id="HEF2181CD51DF4E54B990CCCF3EFB8F2"><enum>774.</enum><header>Authorization of
appropriations</header><text display-inline="no-display-inline">There are
authorized to be appropriated for this part not more than $10,000,000 for
fiscal year 2009 and such sums as may be necessary for each of the 4 succeeding
fiscal years.</text>
</section><section id="H19914FF6018C426F9147EE8732752E5D"><enum>775.</enum><header>Definition</header><text display-inline="no-display-inline">For purposes of this part, the term
<term>health facility</term> means an Indian Health Service health service
center, a Native Hawaiian health center, a hospital, a federally qualified
health center, a rural health clinic, a nursing home, a home health agency, a
hospice program, a public health clinic, a State or local department of public
health, a skilled nursing facility, or ambulatory surgical
center.</text>
</section></part><after-quoted-block>.</after-quoted-block></quoted-block>
</section><section display-inline="no-display-inline" id="HC0629FA85C5E4093859136D302FB315F"><enum>503.</enum><header>Nurse Faculty
Loan Repayment Program</header><text display-inline="no-display-inline">Part E
of title VIII of the Public Health Service Act (42 U.S.C. 297a et seq.) is
amended by inserting after section 846C, as added by section 501, the following
new section:</text>
<quoted-block display-inline="no-display-inline" id="HB4F5C73BCEBB44F6009CFE8CB200318E" style="OLC">
<section id="HE4D36CF5E3FF4BB5A43E5FBC234F4320"><enum>846D.</enum><header>Nurse Faculty
Loan Repayment Program</header>
<subsection id="HBF5E428DEAAA4E01841CCDBE3744F3D2"><enum>(a)</enum><header>Establishment</header><text display-inline="yes-display-inline">The Secretary, acting through the
Administrator of the Health Resources and Services Administration, may enter
into an agreement with eligible individuals for the repayment of education
loans, in accordance with this section, to increase the number of qualified
nursing faculty.</text>
</subsection><subsection id="H040F0BE3B0D74BF3840832D8EDDD8200"><enum>(b)</enum><header>Agreements</header><text display-inline="yes-display-inline">Each agreement entered into under
subsection (a) shall require that the eligible individual shall serve as a
full-time member of the faculty of an accredited school of nursing for a total
period, in the aggregate, of at least four years during the six-year period
beginning on the later of—</text>
<paragraph id="HFEF32A3A3D314B9DA2F922A1E2CC9FF0"><enum>(1)</enum><text>the date on which
the individual receives a master’s or doctorate nursing degree from an
accredited school of nursing; or</text>
</paragraph><paragraph id="H7D715282597C4EFF9377C6C39B67023"><enum>(2)</enum><text>the date on which
the individual enters into an agreement under subsection (a).</text>
</paragraph></subsection><subsection id="HBB675C31401440329DC99134F3AE119F"><enum>(c)</enum><header>Agreement
provisions</header><text>Agreements entered into pursuant to subsection (a)
shall be entered into on such terms and conditions as the Secretary may
determine, except that—</text>
<paragraph id="H26B3584747F441EF82BFE50003CD532"><enum>(1)</enum><text display-inline="yes-display-inline">not more than ten months after the date on
which the six-year period described under subsection (b) begins, but in no case
before the individual starts as a full-time member of the faculty of an
accredited school of nursing, the Secretary shall begin making payments, for
and on behalf of that individual, on the outstanding principal of, and interest
on, any loan of that individual obtained to pay for such degree;</text>
</paragraph><paragraph id="H78CF60C0CE1842BB80C98E4E25254D49"><enum>(2)</enum><text display-inline="yes-display-inline">for an individual who has completed a
master’s degree in nursing—</text>
<subparagraph id="H1EB279A3EE9D47DEA67052AD86780059"><enum>(A)</enum><text>payments may not
exceed $10,000 per calendar year; and</text>
</subparagraph><subparagraph id="H67D1601F4F994D9A9E4CA39327949821"><enum>(B)</enum><text>total payments may
not exceed $40,000; and</text>
</subparagraph></paragraph><paragraph id="H48C54E8AE4F547D4BB441FFFC1FA3183"><enum>(3)</enum><text display-inline="yes-display-inline">for an individual who has completed a
doctorate degree in nursing—</text>
<subparagraph id="H618006EA02CF4B9B83BB1200906EB926"><enum>(A)</enum><text>payments may not
exceed $20,000 per calendar year; and</text>
</subparagraph><subparagraph id="H4449D3AC09524489BF06E408B00D114"><enum>(B)</enum><text>total payments may
not exceed $80,000.</text>
</subparagraph></paragraph></subsection><subsection id="HEB0C2239CA524DC19F8F97D210F629F"><enum>(d)</enum><header>Breach of
agreement</header>
<paragraph id="H5F59BFC553254B098812C295D029B423"><enum>(1)</enum><header>In
general</header><text display-inline="yes-display-inline">In the case of any
agreement made under subsection (a), the individual is liable to the Federal
Government for the total amount paid by the Secretary under such agreement, and
for interest on such amount at the maximum legal prevailing rate, if the
individual fails to meet the agreement terms required under subsection
(b).</text>
</paragraph><paragraph id="HE46320F8BB7041BA80C283E52F08581D"><enum>(2)</enum><header>Waiver or
suspension of liability</header><text display-inline="yes-display-inline">In
the case of an individual making an agreement for purposes of paragraph (1),
the Secretary shall provide for the waiver or suspension of liability under
such paragraph if compliance by the individual with the agreement involved is
impossible or would involve extreme hardship to the individual or if
enforcement of the agreement with respect to the individual would be
unconscionable.</text>
</paragraph><paragraph id="H6C3B9F66D46D4BB49BB87EA239F5292F"><enum>(3)</enum><header>Date certain for
recovery</header><text>Subject to paragraph (2), any amount that the Federal
Government is entitled to recover under paragraph (1) shall be paid to the
United States not later than the expiration of the 3-year period beginning on
the date the United States becomes so entitled.</text>
</paragraph><paragraph id="H4CD391B818464EBDBE7C6F11738F3368"><enum>(4)</enum><header>Availability</header><text>Amounts
recovered under paragraph (1) shall be available to the Secretary for making
loan repayments under this section and shall remain available for such purpose
until expended.</text>
</paragraph></subsection><subsection display-inline="no-display-inline" id="H9FA4BE90904C41508F2DAB89FFCB8894"><enum>(e)</enum><header>Eligible
individual defined</header><text>For purposes of this section, the term
<term>eligible individual</term> means an individual who—</text>
<paragraph id="H30AA9A8C29FE4E789F5578405FC8EBAC"><enum>(1)</enum><text>is a United States
citizen, national, or lawful permanent resident;</text>
</paragraph><paragraph id="HB9E1723256B2401BA942E36B95687EEA"><enum>(2)</enum><text>holds an
unencumbered license as a registered nurse; and</text>
</paragraph><paragraph id="HC792C5F9DD43404FB1CB31A29538D2F9"><enum>(3)</enum><text display-inline="yes-display-inline">has either already completed a master’s or
doctorate nursing program at an accredited school of nursing or is currently
enrolled on a full-time or part-time basis in such a program.</text>
</paragraph></subsection><subsection id="H6B8B5B89E6E44BE4AAF3A60131557D44"><enum>(f)</enum><header>Authorization of
appropriations</header><text display-inline="yes-display-inline">There are
authorized to be appropriated to the Secretary such sums as may be necessary
for each of fiscal years 2010 through 2014 to carry out this Act. Such sums
shall remain available until
expended.</text>
</subsection></section><after-quoted-block>.</after-quoted-block></quoted-block>
</section><section id="H8D2938A1C790447098B9FCF2F25EC816"><enum>504.</enum><header>Programs to
increase the number of nurses within the Armed Forces</header>
<subsection id="HF305B41C237240B1905C9752040628A"><enum>(a)</enum><header>In
general</header><text>The Secretary of Defense may provide for the carrying out
of each of the programs described in subsections (b) through (f).</text>
</subsection><subsection id="HE5A081B7AA7A4F429BBCD56687DC3E52"><enum>(b)</enum><header>Service of Nurse
Officers as Faculty in Exchange for Commitment to Additional Service in the
Armed Forces</header>
<paragraph id="HD562DE14388E4022AD234E10B3040541"><enum>(1)</enum><header>In
general</header><text>One of the programs under this section may be a program
in which covered commissioned officers with a graduate degree in nursing or a
related field who are in the nurse corps of the Armed Force concerned serve a
tour of duty of two years as a full-time faculty member of an accredited school
of nursing.</text>
</paragraph><paragraph id="H4AB57201DB8E4FD8BD7E3F587801777E"><enum>(2)</enum><header>Covered
officers</header><text>A commissioned officer of the nurse corps of the Armed
Forces described in this paragraph is a nurse officer on active duty who has
served for more than nine years on active duty in the Armed Forces as an
officer of the nurse corps at the time of the commencement of the tour of duty
described in paragraph (1).</text>
</paragraph><paragraph id="H9021FF165267444894891EDD679B2814"><enum>(3)</enum><header>Benefits and
privileges</header><text>An officer serving on the faculty of an accredited
school or nursing under this subsection shall be accorded all the benefits,
privileges, and responsibilities (other than compensation and
compensation-related benefits) of any other comparably situated individual
serving a full-time faculty member of such school.</text>
</paragraph><paragraph id="H3D48658B73AE4959A395D6386F35EDF9"><enum>(4)</enum><header>Agreement for
additional service</header><text>Each officer who serves a tour of duty on the
faculty of a school of nursing under this subsection shall enter into an
agreement with the Secretary to serve upon the completion of such tour of duty
for a period of four years for such tour of duty as a member of the nurse corps
of the Armed Force concerned. Any service agreed to by an officer under this
paragraph is in addition to any other service required of the officer under
law.</text>
</paragraph></subsection><subsection id="HAB3693978A7A435EA49E3EF809F3249B"><enum>(c)</enum><header>Service of Nurse
Officers as Faculty in Exchange for Scholarships for Nurse Officer
Candidates</header>
<paragraph id="HD3D3993F957144F58B04E8181B6C9522"><enum>(1)</enum><header>In
general</header><text>One of the programs under this section may be a program
in which commissioned officers with a graduate degree in nursing or a related
field who are in the nurse corps of the Armed Force concerned serve while on
active duty a tour of duty of two years as a full-time faculty member of an
accredited school of nursing.</text>
</paragraph><paragraph id="HD08BF85D828741238712A6C219A0558C"><enum>(2)</enum><header>Benefits and
privileges</header><text>An officer serving on the faculty of an accredited
school of nursing under this subsection shall be accorded all the benefits,
privileges, and responsibilities (other than compensation and
compensation-related benefits) of any other comparably situated individual
serving as a full-time faculty member of such school.</text>
</paragraph><paragraph id="H7CDECB3A50734776BC014F468FA07583"><enum>(3)</enum><header>Scholarships for
nurse officer candidates</header><subparagraph commented="no" display-inline="yes-display-inline" id="H46BC5BB023C14F9DB5C740E8D888BEF1"><enum>(A)</enum><text>Each accredited school
of nursing at which an officer serves on the faculty under this subsection
shall provide scholarships to individuals undertaking an educational program at
such school leading to a degree in nursing who agree, upon completion of such
program, to accept a commission as an officer in the nurse corps of the Armed
Forces.</text>
</subparagraph><subparagraph id="H02B798F67BB44263A1888757E8F1C32B" indent="up1"><enum>(B)</enum><text>The total amount of funds made
available for scholarships by an accredited school of nursing under
subparagraph (A) for each officer serving on the faculty of that school under
this subsection shall be not less than the amount equal to an entry-level
full-time faculty member of that school for each year that such officer so
serves on the faculty of that school.</text>
</subparagraph><subparagraph id="H910154193CA14B2287C7136355BE71AE" indent="up1"><enum>(C)</enum><text>The total number of scholarships
provided by an accredited school of nursing under subparagraph (A) for each
officer serving on the faculty of that school under this subsection shall be
such number as the Secretary of Defense shall specify for purposes of this
subsection.</text>
</subparagraph></paragraph></subsection><subsection id="H5D62AFBB85454F1B8DF7CAA5D6F351A9"><enum>(d)</enum><header>Scholarships for
Certain Nurse Officers for Education as Nurses</header>
<paragraph id="H2B819AC92BF74C4C9438D6C21E45243D"><enum>(1)</enum><header>In
general</header><text>One of the programs under this section may be a program
in which the Secretary provides scholarships to commissioned officers of the
nurse corps of the Armed Force concerned described in paragraph (2) who enter
into an agreement described in paragraph (4) for the participation of such
officers in an educational program of an accredited school of nursing leading
to a graduate degree in nursing.</text>
</paragraph><paragraph id="HF581090392D64FBB8147AAA90084844B"><enum>(2)</enum><header>Covered nurse
officers</header><text>A commissioned officer of the nurse corps of the Armed
Forces described in this paragraph is a nurse officer who has served not less
than 20 years on active duty in the Armed Forces and is otherwise eligible for
retirement from the Armed Forces.</text>
</paragraph><paragraph id="HF829902DDBC54EE2A700728D0009B4F"><enum>(3)</enum><header>Scope of
scholarships</header><text>Amounts in a scholarship provided a nurse officer
under this subsection may be utilized by the officer to pay the costs of
tuition, fees, and other educational expenses of the officer in participating
in an educational program described in paragraph (1).</text>
</paragraph><paragraph id="H9278868EA5EA4CBFAE6B7F5B88615FAD"><enum>(4)</enum><header>Agreement</header><text>An
agreement of a nurse officer described in this paragraph is the agreement of
the officer—</text>
<subparagraph id="HCA61182A1975457A8EE5006572204095"><enum>(A)</enum><text>to participate in
an educational program described in paragraph (1); and</text>
</subparagraph><subparagraph id="H122D792EA8CA4DE0AC53E7A1E7443676"><enum>(B)</enum><text>upon graduation
from such educational program—</text>
<clause id="HA36C2D3AEA254F6D9DB9BA3BC414232B"><enum>(i)</enum><text>to
serve not less than two years as a full-time faculty member of an accredited
school of nursing; and</text>
</clause><clause id="H512980B1DF7847269710CDA3B89E5900"><enum>(ii)</enum><text>to
undertake such activities as the Secretary considers appropriate to encourage
current and prospective nurses to pursue service in the nurse corps of the
Armed Forces.</text>
</clause></subparagraph></paragraph></subsection><subsection id="HA54B1EB792C74D9A81CFF701ACE32183"><enum>(e)</enum><header>Transition
Assistance for Retiring Nurse Officers Qualified as Faculty</header>
<paragraph id="H9D6A2980886A4426894352007FC67017"><enum>(1)</enum><header>In
general</header><text>One of the programs under this section may be a program
in which the Secretary provides to commissioned officers of the nurse corps of
the Armed Force concerned described in paragraph (2) the assistance described
in paragraph (3) to assist such officers in obtaining and fulfilling positions
as full-time faculty members of an accredited school of nursing after
retirement from the Armed Forces.</text>
</paragraph><paragraph id="H7E18B373B90E44E1B8DEFF4F00D30630"><enum>(2)</enum><header>Covered nurse
officers</header><text>A commissioned officer of the nurse corps of the Armed
Forces described in this paragraph is a nurse officer who—</text>
<subparagraph id="H303AD267666A441794C29F32C51EB145"><enum>(A)</enum><text>has served an
aggregate of at least 20 years on active duty or in reserve active status in
the Armed Forces;</text>
</subparagraph><subparagraph id="H54C9D7329DF04B8CBEA97E4E90E759CD"><enum>(B)</enum><text>is eligible for
retirement from the Armed Forces; and</text>
</subparagraph><subparagraph id="HFE7602E9970049B2BED9FCD5FB762833"><enum>(C)</enum><text>possesses a
doctoral or master degree in nursing or a related field which qualifies the
nurse officer to discharge the position of nurse instructor at an accredited
school of nursing.</text>
</subparagraph></paragraph><paragraph id="H0ACEBE6AF46641E58DB2FD7D92DEE42B"><enum>(3)</enum><header>Assistance</header><text>The
assistance described in this paragraph is assistance as follows:</text>
<subparagraph id="H6E67DF025FA34B269749FC98C6D00074"><enum>(A)</enum><text>Career placement
assistance.</text>
</subparagraph><subparagraph id="H23CC6E7B626E48FEB1B18EE784B61C45"><enum>(B)</enum><text>Continuing
education.</text>
</subparagraph><subparagraph id="HC9BE4A4A9417427CB2C3A1A05E48CB43"><enum>(C)</enum><text>Stipends (in an
amount specified by the Secretary).</text>
</subparagraph></paragraph><paragraph id="H12DC72D7D20840CE9D6E8886257C48B"><enum>(4)</enum><header>Agreement</header><text>A
nurse officer provided assistance under this subsection shall enter into an
agreement with the Secretary to serve as a full-time faculty member of an
accredited school of nursing for such period as the Secretary shall provide in
the agreement.</text>
</paragraph></subsection><subsection id="H4712B3208FD34E96A5FFB2B9B6F12730"><enum>(f)</enum><header>Benefits for
Retired Nurse Officers Accepting Appointment as Faculty</header>
<paragraph id="HC04BEC8D90964F9AB8A2B07EB6854268"><enum>(1)</enum><header>In
general</header><text>One of the programs under this section may be a program
in which the Secretary provides to any individual described in paragraph (2)
the benefits specified in paragraph (3).</text>
</paragraph><paragraph id="HE8DE7781A85E4A0D9B3C412EFA5B34EC"><enum>(2)</enum><header>Covered
individuals</header><text>An individual described in this paragraph is an
individual who—</text>
<subparagraph id="H903B12DD28A245ACA1C9562F4574132"><enum>(A)</enum><text>is retired from the
Armed Forces after service as a commissioned officer in the nurse corps of the
Armed Forces;</text>
</subparagraph><subparagraph id="H101089DC4AFE45B2AAE6B3016555A11B"><enum>(B)</enum><text>holds a graduate
degree in nursing; and</text>
</subparagraph><subparagraph id="H6CDFA6C314BB46EBA08BEAF17109F142"><enum>(C)</enum><text>serves as a
full-time faculty member of an accredited school of nursing.</text>
</subparagraph></paragraph><paragraph id="HB141124C2C8845BB8427AA33ECC8CAAA"><enum>(3)</enum><header>Benefits</header><text>The
benefits specified in this paragraph shall include the following:</text>
<subparagraph id="HA8E1CBD3474C4E9192879CC8EC10A400"><enum>(A)</enum><text>Payment of retired
or retirement pay without reduction based on receipt of pay or other
compensation from the institution of higher education concerned.</text>
</subparagraph><subparagraph id="HC92B15A6230143E6BC7204E6C5984F47"><enum>(B)</enum><text>Payment by the
institution of higher education concerned of a salary and other compensation to
which other similarly situated faculty members of the institution of higher
education would be entitled.</text>
</subparagraph><subparagraph id="H70496B1F65EB462AACF78749912031F4"><enum>(C)</enum><text>If the amount of
pay and other compensation payable by the institution of higher education
concerned for service as an associate full-time faculty member is less than the
basic pay to which the individual was entitled immediately before retirement
from the Armed Forces, payment of an amount equal to the difference between
such basic pay and such payment and other compensation.</text>
</subparagraph></paragraph></subsection><subsection id="HFABCDDAB89214BB7822191DC0460EAC9"><enum>(g)</enum><header>Administration
and Duration of Programs</header>
<paragraph id="HEF599CFDF0FA4120BA6294C60402ACF3"><enum>(1)</enum><header>In
general</header><text>The Secretary shall establish requirements and procedures
for the administration of the programs authorized by this section. Such
requirements and procedures shall include procedures for selecting
participating schools of nursing.</text>
</paragraph><paragraph id="H02AA9F86A0C047F89B94D87CDDF84200"><enum>(2)</enum><header>Duration</header><text>Any
program carried out under this section shall continue for not less than two
years.</text>
</paragraph><paragraph id="HBB62678C43AA4C9FA4E7DD9B2EA1CA48"><enum>(3)</enum><header>Assessment</header><text>Not
later than two years after commencing any program under this section, the
Secretary shall assess the results of such program and determine whether or not
to continue such program. The assessment of any program shall be based on
measurable criteria, information concerning results, and such other matters as
the Secretary considers appropriate.</text>
</paragraph><paragraph id="H23F332ED9AEC46C0BEC45C35015826FA"><enum>(4)</enum><header>Continuation</header><text>The
Secretary may continue carrying out any program under this section that the
Secretary determines, pursuant to an assessment under paragraph (3), to
continue to carry out. In continuing to carry out a program, the Secretary may
modify the terms of the program within the scope of this section. The
continuation of any program may include its expansion to include additional
participating schools of nursing.</text>
</paragraph></subsection><subsection id="H1EDF199A97EE4270B1F5CCA128E7C90"><enum>(h)</enum><header>Definitions</header><text>In
this section, the terms <term>school of nursing</term> and
<term>accredited</term> have the meaning given those terms in section 801 of
the Public Health Service Act (42 U.S.C. 296).</text>
</subsection></section><enum>VI</enum><header>RESERVE
COMPONENTS OF THE ARMED FORCES</header>
<section id="HF88A53794709445C956B9E18F44408AD"><enum>601.</enum><header>Effective date
of active duty for purposes of entitlement to active duty health care of
members of the reserve components of the Armed Forces receiving alert order
anticipating a call or order to active duty in support of a contingency
operation</header><text display-inline="no-display-inline">Subsection (d) of
section 1074 of title 10, United States Code, is amended to read as
follows:</text>
<quoted-block id="HBBBCA569A0DA4E958D48FAA0097BDEFF" style="OLC">
<subsection id="H470944D59BE6420488B84F7A19200B3"><enum>(d)</enum><paragraph commented="no" display-inline="yes-display-inline" id="HF6727B920AFC48CDBFFA43225E4DCEDF"><enum>(1)</enum><text>For purposes of this
chapter, a member of a reserve component of the Armed Forces shall be treated
as a member of the Armed Forces on active duty as follows:</text>
<subparagraph id="HAE813ECC23554538AF78E194F3D406AC" indent="up1"><enum>(A)</enum><text>On the date of the issuance of the
alert order for the member’s unit in anticipation of the mobilization of the
unit for service for a period of more than 30 days in support of a contingency
operation.</text>
</subparagraph><subparagraph id="H0D8B593BC6CB42329CB467B85C429EDA" indent="up1"><enum>(B)</enum><text>On the date of the issuance of the
order providing for the assignment or attachment of the member to a unit
subject to an alert order described in paragraph (1).</text>
</subparagraph></paragraph><paragraph id="H90EC841E2AFD4B3486D0FBADB90267B9" indent="up1"><enum>(2)</enum><text>If the alert order for a member’s
unit (or the unit to which the member is assigned or attached) is rescinded,
the member shall cease to be treated on active duty for purposes of this
chapter as of the date of the issuance of the order rescinding such alert
order.</text>
</paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block>
</section>