[Congressional Record Volume 155, Number 74 (Thursday, May 14, 2009)]
[Senate]
[Pages S5523-S5529]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. REID (for Mr. Rockefeller (for himself, Mr. Kohl, and Mr. 
        Levin)):
  S. 1050. A bill-amend title XXVII of the Public Health Service Act to 
establish Federal standards for health insurance forms, quality, fair 
marketing, and honesty in out-of-network coverage in the group and 
individual health insurance markets, to improve transparency and 
accountability in those markets, and to establish a Federal Office of 
Health Insurance Oversight to monitor performance in those markets, and 
for other purposes; to the Committee on Health, Education, Labor, and 
Pensions.
  Mr. ROCKEFELLER. Mr. President, I rise today--with my colleagues 
Congresswoman Rosa DeLauro and Congresswoman Alyson Schwartz--to 
introduce the Informed Consumer Choices in Health Care Act, legislation 
to hold insurance companies accountable by increasing transparency in 
insurance coverage and to provide consumers critical information about 
their health care so they can make informed decisions.
  All Americans deserve affordable, meaningful health care coverage 
that meets their needs when they need it. However, there is an 
unsettling trend in America that is growing at an alarming rate--
hardworking Americans are suffering from serious economic hardship 
because of medical bills. There countless consumers all across the 
country who thought they were safe because they had health insurance 
coverage. Health insurance is meant to protect against the risk that, 
if you get sick, severely injured or require extensive medical care for 
one reason or another, it would not bankrupt you. However, the exact 
opposite is happening. People who thought they had coverage for health 
care events--small and large--found out much too late that they were 
not protected at all. The lack of insurance transparency leads 
consumers to purchase coverage that actually does not meet their needs 
and leads to disaster for them financially.
  In June 2008, the Senate Finance Committee held a hearing on health 
insurance reform where we heard devastating testimony from Mrs. Lisa 
Kelly, who purchased a limited benefit plan that did not provide 
adequate coverage when she needed treatment for leukemia. Mrs. Kelly 
paid a monthly premium of $185 for AARP's Medical Advantage plan, 
underwritten by UnitedHealth Group, only to be told that she had to pay 
M.D. Anderson $105,000 up front, prior to starting her chemotherapy 
treatment. This situation left Ms. Kelly in the untenable situation of 
leaving her cancer untreated or finding a way to pay on a limited 
budget.
  Medical bills are the second highest cause of bankruptcy in our 
country. It is estimated that 50 percent of all bankruptcies are a 
result of medical expenses. Sixty-one percent of the 72 million adults 
under age 65 who had problems paying medical bills or were paying off 
medical debt in 2007 were insured at the time health care was provided. 
An additional 1.5 million families lose their homes every single year 
due to medical costs. This is simply unacceptable.
  This is not just a coincidence. Plans that provide bare-bones 
coverage may be fine if you live in a bubble, but that is not the 
reality most Americans live in. If we as a nation are serious about 
protecting all Americans from the devastating financial consequences of 
serious illness, then Congress must hold the insurance industry 
accountable by arming consumers with comprehensive information about 
the benefits covered and not covered under their health plan, the true 
cost of their coverage, and the cost-sharing they are responsible for. 
This information should not be shrouded in the legalese of health 
insurance companies, but in clear language that is easy for consumers 
to understand. As we seek to give consumers greater coverage choices, 
we should also give them the necessary tools to understand those 
choices.

  Another example of where the lack of insurance transparency has hurt 
consumers is in the experience of the Medicare prescription drug 
benefit. Seniors and individuals with disabilities have simply been 
overwhelmed by the number of prescription drug plans offered--without 
any meaningful way to decipher the differences between plans in terms 
of benefits covered or cost-sharing. Over the last recess, I held a 
health care roundtable discussion in Charleston, which has more than 50 
Medicare prescription drug plans for seniors and individuals with 
disabilities to choose from. I heard from countless West Virginians 
about the extreme difficulty they have wading through their 
prescription drug coverage options each and every plan year. The most 
compelling stories came from a retired chemical engineer and a retired 
attorney--both very smart individuals--who have had major problems 
determining what is and is not offered and how much they will have to 
pay out of their pockets for it.
  When consumers buy cars, computers, or even cereal, they generally 
know what they are buying and how much it will cost. But, when it comes 
to making choices about health care coverage, it is often very 
difficult for consumers to tell what is actually covered and how much 
they will have to pay out-of-pocket in case of a serious illness or 
injury. Consumers cannot make meaningful choices if details about 
coverage are obscure or if the definitions of key terms such as 
``hospitalization'', ``outpatient care'', or ``out-of-pocket limit'' 
vary from plan to plan.
  The lack of health insurance transparency also contributes to 
administrative waste and complexity. According to the American Medical 
Association, more than half of health insurers do not provide 
physicians with the transparency necessary for an efficient claims 
processing system. Physicians and hospitals must divert substantial 
resources away from patient care to accurately determine patient 
insurance eligibility and benefit structure.
  The black box in which insurers operate also provides them with the 
opportunity to use flawed payment structures, like the Ingenix 
database, to underpay patients who choose to get health care out of 
network. An investigation by the New York Attorney General and hearings 
conducted this spring by the Senate Commerce Committee revealed 
American consumers have been paying billions of dollars out of their 
own pockets for health care that the insurance companies should have 
been paying. The numbers the insurance industry relied on justify these 
under-payments came from a secretive health care data company called 
Ingenix. Insurers refused to tell patients or doctors how Ingenix came 
up with their payment amounts. And they didn't disclose that Ingenix 
was a wholly owned subsidiary of UnitedHealth Group, the Nation's 
second largest health insurance company. The Ingenix investigations 
show tat the health insurance industry is willing to go to great 
lengths to withhold accurate, objective health care payment information 
from American consumers. While they talk about transparency, they spent 
hundreds of millions of dollars

[[Page S5524]]

creating a reimbursement system that kept patients and doctors in the 
dark.
  The U.S. Department of Labor currently lacks the capacity to oversee 
insurance industry compliance with federal health insurance laws and to 
provide states with the technical assistance necessary to effectively 
enforce federal standards for health insurance. These federal standards 
include crucial protections like the Genetic Information and 
Nondiscrimination Act, GINA, the Health Insurance Portability and 
Accountability Act, HIPAA, the Newborns' and Mothers' Health Protection 
Act, the Women's Health and Cancer Rights Act of 1998, Michelle's Law, 
and mental health parity. As states continue to be overwhelmed by the 
increasing pressure of the recession and cost-cutting measures by 
insurers, state regulators are in desperate need for additional 
resources. In a 21st Century health system where there will be even 
greater health insurance choices, adequate federal oversight is 
absolutely critical.
  There is no excuse for limiting access to information that has such 
widespread consequences for consumers. The Informed Consumer Choices in 
Health Care Act is the type of transformative legislation we need to 
address the very significant issues stemming from the lack of health 
insurance transparency. First, this legislation promotes transparency 
in coverage by providing crucial data and assistance to consumers and 
health care providers. This includes new ``Coverage Facts'' labels for 
insurance, similar to nutrition labels, which accurately portray the 
financial obligations of patients in a given year under various medical 
scenarios. The legislation also requires the development of consistent 
standards for insurance, including standard definitions of key 
insurance terms to be used in descriptions of plan benefits, so that 
consumers can make ``apples to apples'' comparisons of coverage 
options. Lastly, it strengthens insurance accountability and oversight 
by creating a new Office of Health Insurance Oversight within the 
Department of Health and Human Services, and provides new resources for 
states to help enforce federal standards.
  In the most recent Presidential election, the voice of American 
voters was clear--they want medical care they can afford and health 
care coverage they can trust. The traditional role of insurers to hide 
or misrepresent insurance coverage options can longer be tolerated; 
therefore, I urge my colleagues to stand up for informed consumer 
decisions in health care and support this bill.
  Mr. President, I ask unanimous consent that the text of the bill and 
support material be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                S. 1050

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Informed 
     Consumer Choices in Health Care Act of 2009''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. New minimum Federal standards for health insurance forms, 
              quality, fair marketing, and honesty in out-of-network 
              coverage.
Sec. 4. Health Insurance accountability initiatives.
Sec. 5. Health insurance transparency initiatives.
Sec. 6. Office of Health Insurance Oversight.
Sec. 7. Standards and accountability and transparency initiatives for 
              group health plans through Departments of Labor and the 
              Treasury.

     SEC. 2. FINDINGS.

       Congress finds the following:
       (1) Effective competition in private health insurance 
     markets requires that consumers must have extensive and 
     meaningful information about what health insurance covers, 
     what it costs, and how it works.
       (2) Based on the information currently provided by health 
     insurers, patients are unable to predict what their health 
     insurance coverage limits or out-of-pocket costs would be if 
     they had a serious illness. 72 million adults under age 65 
     had problems paying medical bills or were paying off medical 
     debt in 2007, and 61 percent of those were insured at the 
     time care was provided.
       (3) It is difficult to impossible for consumers to obtain a 
     copy of a health insurance policy from an insurance company 
     before they purchase it.
       (4) Consumers often find it difficult to navigate and 
     evaluate their choices in today's health insurance markets 
     and many select a sub-optimal plan as a result.
       (5) The Institute of Medicine of the National Academy of 
     Sciences has estimated that nearly half of all American 
     adults--90 million people--have difficulty understanding and 
     using health information.
       (6) The Office of Disease Prevention and Health Promotion 
     in the Department of Health and Human Services reports that 
     only 12 percent of the population using a table can calculate 
     an employee's share of health insurance costs for a year.
       (7) A RAND Corporation study found that making it easier to 
     get information about insurance products and simplifying the 
     applications process would increase purchase rates as much as 
     modest subsidies would, and all these reports prove the need 
     for a fundamental improvement in the way insurance choices 
     are made available to consumers.
       (8) Insurance forms provided to patients and providers are 
     often confusing, difficult to reconcile with medical bills, 
     and vary widely from insurer to insurer, thereby adding 
     complexity and administrative waste to the health care 
     system.
       (9) Research indicates that physicians divert substantial 
     resources, as much as 14 percent of their total revenue, to 
     ensure accurate insurance payments for their services. 
     Hospitals spend as much as 11 percent of their total revenue 
     on billing and insurance-related costs. These include time 
     spent determining patient insurance eligibility and benefit 
     structure. One study found that paperwork adds at least 30 
     minutes to every hour of patient care.
       (10) According to the American Medical Association, there 
     is wide variation in how often health insurers pay nothing in 
     response to a physician claim and in how they explain the 
     reason for the denial. There is no consistency in the 
     application of codes used to explain the denials, making it 
     extremely expensive for physician practices to determine how 
     to respond.
       (11) According to the American Medical Association, more 
     than half of health insurers in a recent study did not 
     provide physicians with the transparency necessary for an 
     efficient claims processing system.
       (12) According to the American Medical Association, payers 
     vary widely on how often they use proprietary rather than 
     public claims edits to reduce payments (ranging from zero to 
     as high as nearly 72 percent). The use of undisclosed 
     proprietary edits inhibits the flow of transparent 
     information to physicians, adding additional administrative 
     costs to reconcile claims.
       (13) The Federal government currently lacks capacity to 
     carry out responsibility for oversight and enforcement of 
     current law requirements on health insurance issuers and to 
     provide States with technical assistance in effectively 
     enforcing Federal minimum standards for health insurance.
       (14) In order to improve the functioning of the private 
     health insurance market, assure the application of existing 
     requirements to health insurance coverage, and reduce 
     administrative hassles for patients and providers, there is a 
     need for periodic examinations and audits of such coverage, 
     for greater disclosure of information regarding the terms and 
     conditions of such coverage, and for the establishment of a 
     Federal oversight office to ensure enforcement of standards.

     SEC. 3. NEW MINIMUM FEDERAL STANDARDS FOR HEALTH INSURANCE 
                   FORMS, QUALITY, FAIR MARKETING, AND HONESTY IN 
                   OUT-OF-NETWORK COVERAGE.

       (a) Group Health Insurance.--Title XXVII of the Public 
     Health Service Act is amended by inserting after section 2707 
     the following new section:

     ``SEC. 2708. STANDARDS FOR HEALTH INSURANCE FORMS, QUALITY, 
                   FAIR MARKETING, AND HONESTY IN OUT-OF-NETWORK 
                   COVERAGE.

       ``(a) Defining Insurance Terms; Standardizing Insurance 
     Forms.--
       ``(1) In general.--The Secretary shall provide for the 
     development of standards for the information that health 
     insurance issuers are required to provide to group health 
     plans to promote informed choice of health insurance coverage 
     by such plans.
       ``(2) Standard definitions of insurance and medical 
     terms.--
       ``(A) In general.--The Secretary shall provide for the 
     development of standards for the definitions of terms used in 
     group health insurance coverage, including insurance-related 
     terms (including the insurance-related terms described in 
     subparagraph (B)) and medical terms (including the medical 
     terms described in subparagraph (C)).
       ``(B) Insurance-related terms.--The insurance-related terms 
     described in this subparagraph are premium, deductible, co-
     insurance, co-payment, out-of-pocket limit, preferred 
     provider, non-preferred provider, out-of-network co-payments, 
     UCR (usual, customary and reasonable) fees, excluded 
     services, grievance and appeals, and such other terms as the 
     Secretary determines are important to define so that 
     consumers may compare health insurance coverage and 
     understand the terms of their coverage.
       ``(C) Medical terms.--The medical terms described in this 
     subparagraph are hospitalization, hospital outpatient care, 
     emergency room care, physician services, prescription drug 
     coverage, durable medical equipment, home health care, 
     skilled nursing care, rehabilitation services, hospice

[[Page S5525]]

     services, emergency medical transportation, and such other 
     terms as the Secretary determines are important to define so 
     that consumers may compare the medical benefits offered by 
     insurance health insurance and understand the extent of those 
     medical benefits (or exceptions to those benefits).
       ``(3) Standardization of insurance forms.--The Secretary 
     shall provide for the development of standards for the forms 
     used in connection with group health insurance coverage, 
     including for--
       ``(A) applications for health insurance coverage;
       ``(B) explanations of benefits for such coverage;
       ``(C) filing of complaints, grievances, and appeals 
     respecting such coverage; and
       ``(D) other common functions relating to such coverage as 
     the Secretary deems appropriate.
       ``(4) Coverage facts labels for patient claims scenarios.--
     The Secretary shall develop standards for coverage facts 
     labels based on the patient claims scenarios described in 
     section 2794(b)(4), which include information on estimated 
     out-of-pocket cost-sharing and significant exclusions or 
     benefit limits for such scenarios.
       ``(5) Personalized statement.--The Secretary shall develop 
     standards for an annual personalized statement that 
     summarizes use of health care services and payment of claims 
     with respect to an enrollee (and covered dependents) under 
     group health insurance coverage in the preceding year.
       ``(6) Application of standards.--No group health insurance 
     coverage may be offered for sale after the date that is two 
     years after date of the enactment of this section unless--
       ``(A) the benefits and other terms of coverage are 
     consistent with the definitional standards developed under 
     paragraph (2);
       ``(B) the application and form of coverage and related 
     forms are consistent with the standardized forms developed 
     under paragraph (3); and
       ``(C) there is provided coverage facts labels described in 
     paragraph (4) with respect to the coverage.
       ``(7) Periodic review and updating.--The Secretary shall 
     periodically review and update, as appropriate, the standards 
     developed under this subsection.
       ``(8) Evaluation of information resources.--In developing, 
     reviewing, and updating standards under this subsection, the 
     Secretary shall provide for testing and evaluation of 
     information resources in general and to specific audiences 
     including those with low literacy skills.
       ``(9) Consultation.--In developing reviewing, and updating 
     standards under this subsection, the Secretary shall consult 
     with, among others, the National Association of Insurance 
     Commissioners, health care professionals, researchers, health 
     insurance issuers, group health plans, patient advocates, and 
     literacy experts.
       ``(b) Quality Assurances for Health Insurance.--
       ``(1) In general.--The Secretary shall provide for the 
     development of standards to assure the quality of benefits 
     under group health insurance coverage. Such standards shall 
     include standards relating to at least--
       ``(A) network adequacy and stability;
       ``(B) guaranteed coverage for one year of contracted 
     benefits;
       ``(C) adequacy and stability of prescription drug networks;
       ``(D) utilization control systems; and
       ``(E) grievances and appeals.
       ``(2) Application of provisions.--The provisions of 
     paragraphs (5) through (9) of subsection (a) apply to 
     standards developed under this subsection in the same manner 
     as such provisions apply to standards developed under 
     subsection (a).
       ``(c) Marketing.--
       ``(1) In general.--The Secretary shall provide for the 
     development of standards for the marketing of group health 
     insurance coverage. Such standards shall include standards 
     for at least--
       ``(A) marketing materials; and
       ``(B) sales commissions.
       ``(2) Nondiscrimination.--No group health insurance 
     coverage may be offered for sale after the date that is two 
     years after date of the enactment of this section unless the 
     issuer provides the Secretary with a written certification 
     that all marketing materials, seminars, and other outreach 
     efforts in connection with the offering of such coverage do 
     not discriminate on the basis of income, race, gender, 
     ethnicity, or other demographic factors as determined by the 
     Secretary.
       ``(3) Application of provisions.--The provisions of 
     paragraphs (7) through (9) of subsection (a) apply to 
     standards developed under this subsection in the same manner 
     as such provisions apply to standards developed under 
     subsection (a).
       ``(d) Honesty in Coverage of Out-of-Network Providers.--The 
     Secretary shall provide for the development of standards for 
     the accuracy and clarity of coverage for out-of-network 
     providers, including cost sharing and payments to such 
     providers, for health insurance issuers in group health 
     insurance coverage that provide such coverage.''.
       (b) Application in the Individual Market.--Such title is 
     further amended by inserting after section 2745 the following 
     new section:

     ``SEC. 2746. STANDARDS FOR HEALTH INSURANCE INSURANCE FORMS, 
                   QUALITY, FAIR MARKETING, AND HONESTY IN OUT-OF-
                   NETWORK COVERAGE.

       ``The provisions of section 2708 shall apply under this 
     part to individual health insurance coverage and enrollees in 
     such coverage in the same manner as such provisions apply 
     under part A in the case of group health insurance coverage 
     and group health plans and participants and beneficiaries.''.
       (c) Application to the Medicare Advantage Program and the 
     Medicare Prescription Drug Program.--
       (1) Medicare advantage program.--Section 1852 of the Social 
     Security Act (42 U.S.C. 1395w-22) is amended by adding at the 
     end the following new subsection:
       ``(m) Standards for Health Insurance Forms, Quality, Fair 
     Marketing, and Honesty in Out-of-Network Coverage.--The 
     provisions of section 2708(a) of the Public Health Service 
     Act shall apply to Medicare Advantage organizations, Medicare 
     Advantage plans, and enrollees in such plans in the same 
     manner as such provisions apply under such section to group 
     health insurance coverage and group health plans and 
     participants and beneficiaries.''.
       (2) Medicare prescription drug program.--Section 1860D-4 of 
     the Social Security Act (42 U.S.C. 1395w-104) is amended by 
     adding at the end the following new subsection:
       ``(m) Standards for Health Insurance Forms, Quality, Fair 
     Marketing, and Honesty in Out-of-Network Coverage.--The 
     provisions of section 2708(a) of the Public Health Service 
     Act shall apply to PDP sponsors, prescription drug plans, and 
     enrollees in such plans in the same manner as such provisions 
     apply under such section to group health insurance coverage 
     and group health plans and participants and beneficiaries.''.
       (3) Effective date.--The amendments made by this subsection 
     shall apply to plan years beginning after the date that is 2 
     years after the date of the enactment of this Act.
       (d) Application to FEHBP.--The provisions of section 
     2708(a) of the Public Health Service Act shall apply to the 
     Federal Employees Health Benefits Program under chapter 89 of 
     title 5, United States Code, and to contractors, health 
     plans, and enrollees in such plans in the same manner as such 
     provisions apply under such section to group health insurance 
     coverage and group health plans and participants and 
     beneficiaries.

     SEC. 4. HEALTH INSURANCE ACCOUNTABILITY INITIATIVES.

       (a) Improved Health Insurance Accountability.--Title XXVII 
     of the Public Health Service Act is amended by adding at the 
     end the following new section:

     ``SEC. 2793. ACCOUNTABILITY INITIATIVES.

       ``(a) In General.--The Secretary, acting through the Office 
     of Health Insurance Oversight established under section 2795, 
     shall undertake activities in accordance with this section to 
     promote accountability of health insurance issuers in meeting 
     Federal health insurance requirements, regardless of whether 
     this relates to health insurance in the individual or group 
     market.
       ``(b) Compliance Examinations and Audits.--
       ``(1) In general.--Without regard to whether or not there 
     is a determination under section 2722(a)(2) or 2761(a)(2) 
     with respect to a health insurance issuer, in carrying out 
     this section, the Secretary shall conduct independent market 
     conduct examinations and audits to monitor and verify the 
     compliance of an health insurance issuer with Federal health 
     insurance requirements. Such audits may include random 
     compliance audits and targeted audits in response to 
     complaints or other suspected non-compliance.
       ``(2) Recoupment of costs.--In connection with such 
     examinations and audits, the Secretary is authorized to 
     recoup from health insurance issuers reimbursement for the 
     costs of such examinations and audits of such issuers.
       ``(3) Relation to other authority.--The authorities under 
     this section are in addition to any authorities of the 
     Secretary, including authorities under sections 2722(b) and 
     2761(b).
       ``(c) Data Collection and Review.--
       ``(1) In general.--The Secretary shall collect and review 
     data from health insurance issuers on health insurance 
     coverage to monitor compliance with Federal health insurance 
     requirements applicable to such issuers and coverage. Upon 
     request by the Secretary, such issuers shall provide such 
     data to the Secretary on a timely basis.
       ``(2) Elements to review.--In carrying out this subsection, 
     the Secretary shall review at least the following:
       ``(A) Underwriting guidelines to ensure compliance with 
     applicable Federal health insurance requirements.
       ``(B) Rating practices to ensure compliance with such 
     requirements.
       ``(C) Enrollment and disenrollment data, including 
     information the Secretary may need to detect patterns of 
     discrimination against individuals based on health status or 
     other characteristics, to ensure compliance with such 
     requirements (including nondiscrimination in group coverage, 
     guaranteed issue, guaranteed renewability requirements 
     applicable in all markets).
       ``(D) Post-claims underwriting and rescission practices to 
     ensure compliance with such requirements relating to 
     guaranteed renewability.
       ``(E) Marketing materials and agent guidelines to ensure 
     compliance with applicable Federal health insurance 
     requirements.
       ``(F) Data on the imposition of pre-existing condition 
     exclusion periods and claims subjected to such exclusion 
     periods.

[[Page S5526]]

       ``(G) Information on issuance of certificates of creditable 
     coverage.
       ``(H) Information on cost-sharing and payments with respect 
     to any out-of-network coverage.
       ``(I) Such other information as the Secretary may determine 
     to be necessary to verify compliance with requirements of 
     this title.
       ``(J) The application to issuers of penalties for violation 
     of such requirements, including the failure to produce 
     requested information.
       ``(3) Treatment of proprietary information.--The Secretary 
     may request under this subsection information that is 
     proprietary or that reveals a trade secret, but such 
     information shall not be subject to further disclosure to the 
     general public in a manner that reveals proprietary 
     information or a trade secret.
       ``(4) Form and manner of information.--Information under 
     paragraph (1) shall be provided--
       ``(A) in a form and manner specified by the Secretary; and
       ``(B) within 30 days of the date of receipt of the request 
     for the information, or within such longer time period as the 
     Secretary deems appropriate.
       ``(5) Enforcement.--The Secretary shall have the same 
     authority in relation to enforcement of requests for data 
     under paragraph (1) as the Secretary has under section 
     2722(b).
       ``(6) Coordination with states.--
       ``(A) In general.--The Secretary shall coordinate with 
     State insurance regulators so that data with respect to 
     health insurance issuers and coverage are collected and 
     reported in a common format.
       ``(B) Clearinghouse.--The Secretary shall establish a 
     clearinghouse for the sharing of data reported by health 
     insurance issuers and for the findings from audits and 
     investigations. Such clearinghouse may be established in 
     conjunction with the National Association of Insurance 
     Commissioners.
       ``(7) Coordination with departments of labor and 
     treasury.--The Secretary shall coordinate with the 
     Secretaries of Labor and Treasury with respect to 
     requirements to report data that affect health insurance 
     coverage sold in connection with group health plans.
       ``(d) Health Insurance Accountability Grants to States.--
       ``(1) In general.--The Secretary shall provide for grants 
     to Departments of Insurance in States to strengthen their 
     enforcement of Federal health insurance requirements with 
     respect to health insurance issuers operating in such States. 
     Such a grant shall only be made pursuant to an application 
     made to the Secretary.
       ``(2) Funding.--
       ``(A) In general.--Of the funds appropriated under 
     subparagraph (B) for grants under this subsection, the 
     Secretary shall provide a grant to each State with an 
     application approved under paragraph (1).
       ``(B) Allocation.--Funds so appropriated for any fiscal 
     year shall be apportioned among the States in accordance with 
     a formula determined by the Secretary that takes into account 
     the scope of health insurance subject to regulation under 
     this title in each State and such other factors as the 
     Secretary may specify.
       ``(C) Appropriations and authorizations.--There is hereby 
     appropriated, out of any funds in the Treasury not otherwise 
     appropriated for the first fiscal year in which this section 
     is in effect, $10,000,000 for grants under this subsection, 
     to be available until expended. For each subsequent fiscal 
     year there is authorized to be appropriated such sums as may 
     be necessary for such grants.
       ``(e) Federal Health Insurance Requirements Defined.--In 
     this part, the term `Federal health insurance requirements' 
     means the requirements under this title insofar as they 
     relate to health insurance issuers and health insurance 
     coverage, whether in the individual or group market, and 
     includes other requirements imposed under Federal law 
     specifically in relation to the offering of health insurance 
     coverage by health insurance issuers.''.

     SEC. 5. HEALTH INSURANCE TRANSPARENCY INITIATIVES.

       (a) In General.--Title XXVII of the Public Health Service 
     Act, as amended by section 3, is further amended by adding at 
     the end the following new section:

     ``SEC. 2794. TRANSPARENCY INITIATIVES.

       ``(a) In General.--The Secretary, acting through the Office 
     of Health Insurance Oversight established under section 2795, 
     shall undertake activities in accordance with this section to 
     promote transparency in costs, market practices, and other 
     factors for health insurance coverage, regardless of whether 
     the coverage is offered or in effect in the individual or 
     group market.
       ``(b) Development and Disclosure of Standardized 
     Information.--
       ``(1) In general.--In carrying out this section, the 
     Secretary shall provide for the development of--
       ``(A) standards for information about health insurance 
     issuers, their health insurance policies, and their market 
     practices with respect to such policies; and
       ``(B) standards for the disclosure of such information in a 
     timely, consistent, and accurate manner by health insurance 
     issuers about each health insurance policy marketed and in 
     force.
       ``(2) Information to be disclosed.--
       ``(A) In general.--In carrying out this section, the 
     Secretary shall require health insurance issuers to disclose 
     to enrollees, potential enrollees, in-network health care 
     providers, and others through a publicly available Internet 
     website and other appropriate means at least the following 
     concerning each policy of health insurance coverage marketed 
     or in force, in such standardized manner as the Secretary 
     specifies:
       ``(i) Full policy contract language.
       ``(ii) A summary of the information described in paragraph 
     (3).
       ``(iii) For each of the scenarios developed under paragraph 
     (4), the coverage facts label information developed under 
     section 2709(a)(4).
       ``(B) Personalized statement.--In carrying out this 
     section, the Secretary shall require health insurance issuers 
     to disclose to enrollees, in such standardized manner as the 
     Secretary specifies, an annual personalized statement 
     described in section 2708(a)(5).
       ``(3) Information to be disclosed.--The information 
     described in this paragraph is at least the following:
       ``(A) Data on the price of each new policy of health 
     insurance coverage and renewal rating practices.
       ``(B) Information on claims payment policies and practices, 
     including how many and how quickly claims were paid.
       ``(C) Information on provider fee schedules and usual, 
     customary, and reasonable fees (for both network and out-of-
     network providers).
       ``(D) Information on provider participation and provider 
     directories.
       ``(E) Information on loss ratios, including detailed 
     information about amount and type of non-claims expenses.
       ``(F) Information on covered benefits, cost-sharing, and 
     amount of payment provided toward each type of service 
     identified as a covered benefit, including preventive care 
     services recommended by the United States Preventive Services 
     Task Force.
       ``(G) Information on civil or criminal actions successfully 
     concluded against the issuer by any governmental entity.
       ``(H) Benefit exclusions and limits.
       ``(4) Development of patient claims scenarios.--
       ``(A) In general.--In order to improve the ability of 
     individuals and group health plans to compare the coverage 
     and value provided under different health insurance coverage, 
     the Secretary shall develop a series of patient claims 
     scenarios under which benefits (including out-of-pocket 
     costs) under such coverage can be simulated for certain 
     common or expensive conditions or courses of treatment, such 
     as maternity care, breast cancer, heart disease, diabetes 
     management, and well-child visits.
       ``(B) Consultation and basis.--The Secretary shall develop 
     the scenarios under this paragraph--
       ``(i) in consultation with the National Institutes of 
     Health, the Centers for Disease Control and Prevention, the 
     Agency for Healthcare Research and Quality, health 
     professional societies, patient advocates, and others as 
     deemed necessary by the Secretary; and
       ``(ii) based upon recognized clinical practice guidelines.
       ``(5) Manner of disclosure.--
       ``(A) In general.--The standards under paragraph (1)(B) 
     shall provide for health insurance issuers to disclose the 
     information under this subsection--
       ``(i) with all marketing materials;
       ``(ii) on the web site of the issuer; and
       ``(iii) at other times upon request.
       ``(B) Contract language.--Such standards also shall require 
     the disclosure of full policy contract language in printed 
     form upon request.
       ``(c) Application of Enforcement Provisions.--The 
     provisions of sections 2722 and 2671 shall apply to 
     enforcement of the requirements of this section in the same 
     manner as such provisions apply to the provisions of part A 
     or part B, respectively. Under such provisions the States 
     shall have initial (and primary) enforcement authority with 
     respect to such requirements, except that the Secretary under 
     section 2793 may directly monitor compliance with such 
     provisions as well.''.
       (b) Conforming Amendments Regarding Disclosure of 
     Information.--
       (1) Reference in the group market.--Section 2713 of the 
     Public Health Service Act (42 U.S.C. 300gg-13)) is amended by 
     adding at the end the following new subsection:
       ``(c) Reference to Disclosure of Information.--For 
     provision requiring disclosure of information by health 
     insurance issuers, see section 2794(d).''.
       (2) Reference in the individual market.--Section 2761 of 
     the Public Health Service Act is amended by adding at the end 
     the following new subsection:
       ``(c) Reference to Disclosure of Information.--For 
     provision requiring disclosure of information by health 
     insurance issuers, see section 2794(d).''.

     SEC. 6. OFFICE OF HEALTH INSURANCE OVERSIGHT.

       (a) In General.--Title XXVII of the Public Health Service 
     Act, as amended by sections 3 and 4, is amended by adding at 
     the end of part C the following new section:

     ``SEC. 2795. OFFICE OF HEALTH INSURANCE OVERSIGHT.

       ``(a) Establishment.--There is established within the 
     Department of Health and Human Services an Office of Health 
     Insurance Oversight (referred to in this section as the 
     `Office'). The Office shall be headed by a Director of Health 
     Insurance Oversight (referred

[[Page S5527]]

     to in this section as the `Director') who shall be appointed 
     by and report directly to the Secretary.
       ``(b) Duties.--
       ``(1) Promotion of accountability in health insurance.--
       ``(A) In general.--The Director shall implement 
     accountability initiatives under section 2793.
       ``(B) Clearinghouse.--The Director shall provide, in 
     consultation with the National Association of Insurance 
     Commissioners, for a clearinghouse for State health insurance 
     regulators to share information concerning, and help them to 
     enact and enforce, Federal health insurance requirements.
       ``(2) Promote transparency in health insurance.--The 
     Director shall implement transparency initiatives under 
     section 2794.
       ``(3) Consumer information, assistance.--
       ``(A) In general.--The Director shall provide for consumer 
     information assistance on health insurance coverage, and 
     Federal health insurance consumer protections under this 
     title, including through carrying out activities under this 
     paragraph.
       ``(B) Information resources.--The Director shall develop 
     health insurance information resources for consumers, 
     including coverage facts labels for patient claims scenarios 
     developed under section 2794(b)(4) and web-based information 
     on average price ranges for out-of-network services based on 
     geography.
       ``(C) Service.--The Director shall establish a consumer 
     assistance service that, directly or in coordination with 
     State health insurance regulators and consumer assistance 
     organizations, receives and responds to inquiries and 
     complaints concerning health insurance coverage with respect 
     to Federal health insurance requirements and under State law.
       ``(4) Health insurance consumer assistance grants.--
       ``(A) In general.--The Director shall provide for grants to 
     public, private or not-for-profit consumer assistance 
     organizations to develop, support, and evaluate consumer 
     assistance programs related to selecting and navigating 
     health care coverage. Such a grant shall only be made 
     pursuant to an application made to the Director. In making 
     such grants, the Director shall attempt to ensure regional 
     and geographic equity.
       ``(B) Grant requirement.--As a condition of receiving such 
     a grant, an organization shall be required to collect and 
     report data to the Director on the types of problems and 
     inquiries encountered by consumers they serve. Data shall be 
     used by the Director to inform enforcement activities and be 
     shared with State insurance regulators, the Department of 
     Labor, and the Secretary of the Treasury.
       ``(C) Appropriations and authorizations.--There is hereby 
     appropriated, out of any funds in the Treasury not otherwise 
     appropriated for the first fiscal year in which this section 
     is in effect, $30,000,000 for grants under this paragraph, to 
     be available until expended. For each subsequent fiscal year 
     there are authorized to be appropriated such sums as may be 
     necessary for such grants.
       ``(5) Administration of high risk pool.--The Director shall 
     administer the high risk pool program under section 2745.
       ``(6) Administration of grants to state insurance 
     departments.--The Director shall administer the program of 
     grants to State insurance departments under section 2793(d).
       ``(c) Periodic Reports.--The Director shall submit periodic 
     reports to Congress on the Office's activities.
       ``(d) Coordination.--
       ``(1) Federal officials.--The Director shall coordinate, 
     with the Secretaries of Labor and Treasury, activities under 
     this section with respect to requirements that affect health 
     insurance coverage offered in connection with group health 
     plans, including coordination in --
       ``(A) development and dissemination of information; and
       ``(B) consumer inquiries and complaints relating to Federal 
     health insurance requirements.
       ``(2) State health insurance regulators.--In carrying out 
     the Office's activities, the Director shall--
       ``(A) coordinate with State health insurance regulators 
     regarding data collection and disclosure and audit and 
     enforcement activities in order to avoid duplication and to 
     use regulatory resources most efficiently;
       ``(B) monitor State efforts to implement and enforce 
     consumer protections consistent with Federal health insurance 
     requirements;
       ``(C) provide technical assistance to States seeking to 
     implement and enforce consumer protections consistent with 
     such requirements; and
       ``(D) provide for regular communication with such 
     regulators to coordinate enforcement efforts and sharing of 
     information
       ``(e) Transfer of Personnel and Resources.--The Secretary 
     shall provide for the transfer to the Office of those 
     personnel and resources within the Department of Health and 
     Human Services that, as of the date of the enactment of this 
     section, relate directly to the responsibilities of the 
     Director under this section.
       ``(f) Authorization of Appropriations.--In addition to 
     amounts made available under subsection (b)(4)(C), there are 
     authorized to be appropriated to carry out this section 
     $20,000,000 for the first fiscal year beginning after the 
     date of the enactment of this section and such sums as may be 
     necessary for subsequent fiscal years.''.
       (b) Conforming Amendments Regarding Additional Authority.--
       (1) Group market.--Section 2722 of such Act (42 U.S.C. 
     300gg-22) is amended by adding at the end the following new 
     subsection:
       ``(c) Reference to Additional Authority.--For additional 
     Secretarial authorities with respect to requirements under 
     this part, see sections 2793 and 2794.''.
       (2) Individual market.--Section 2761 of such Act (42 U.S.C. 
     300gg-61) is amended by adding at the end the following new 
     subsection:
       ``(c) Reference to Additional Authority.--For additional 
     Secretarial authorities with respect to requirements under 
     this part, see sections 2793 and 2794.''.

     SEC. 7. STANDARDS AND ACCOUNTABILITY AND TRANSPARENCY 
                   INITIATIVES FOR GROUP HEALTH PLANS THROUGH 
                   DEPARTMENTS OF LABOR AND THE TREASURY.

       (a) Standards.--In coordination with the Secretary of 
     Health and Human Services, the Secretaries of Labor and the 
     Treasury shall establish for group health plans standards 
     comparable to the standards developed by the Secretary of 
     Health and Human Services for group health insurance coverage 
     under section 2708 of the Public Health Service Act, as added 
     by section 3(a), in order to promote quality, fair marketing, 
     and honesty in out-of-network coverage under such plans and 
     to permit participants to make an informed decision in cases 
     where they are offered a choice of coverage under such a 
     plan.
       (b) Accountability and Transparency Initiatives.--In 
     coordination with the Secretary of Health and Human Services, 
     the Secretaries of Labor and the Treasury shall jointly 
     undertake accountability and transparency initiatives with 
     respect to group health plans similar to those undertaken by 
     the Secretary of Health and Human Services with respect to 
     group and individual health insurance coverage under sections 
     2793 and 2794 of the Public Health Service Act, as added by 
     sections 4 and 5 of this Act.
       (c) Group Health Plan Defined.--In this section, with 
     respect to the Secretary of Labor and the Secretary of the 
     Treasury, the term ``group health plan'' has the meaning such 
     term for purposes of part 7 of subtitle B of title I of the 
     Employee Retirement Income Security Act of 1974 and chapter 
     100 of the Internal Revenue Code of 1986, respectively.
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