subpart ii—improving coverage
A prior subpart 2, consisting of sections 300gg–4 to 300gg–7, related to other requirements, prior to repeal of the subpart designation and heading and transfer of sections 300gg–4 to 300gg–7 to 300gg–25 to 300gg–28, respectively, of this title by
Another prior subpart 2, consisting of sections 300gg–11 to 300gg–13, related to provisions applicable only to health insurance issuers, was redesignated subpart 3 of this part by
A prior subpart 3, consisting of sections 300gg–11 to 300gg–13, related to provisions applicable only to health insurance issuers, prior to repeal of the subpart designation and heading by
A prior subpart 4, consisting of sections 300gg–21 to 300gg–23, which related to exclusion of plans, enforcement, and preemption, was redesignated subpart 2 of this part by
§300gg–11. No lifetime or annual limits
(a) Prohibition
(1) In general
A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish—
(A) lifetime limits on the dollar value of benefits for any participant or beneficiary; or
(B) except as provided in paragraph (2), annual limits on the dollar value of benefits for any participant or beneficiary.
(2) Annual limits prior to 2014
With respect to plan years beginning prior to January 1, 2014, a group health plan and a health insurance issuer offering group or individual health insurance coverage may only establish a restricted annual limit on the dollar value of benefits for any participant or beneficiary with respect to the scope of benefits that are essential health benefits under
(b) Per beneficiary limits
Subsection (a) shall not be construed to prevent a group health plan or health insurance coverage from placing annual or lifetime per beneficiary limits on specific covered benefits that are not essential health benefits under
(July 1, 1944, ch. 373, title XXVII, §2711, as added and amended
Prior Provisions
A prior section 300gg–11, act July 1, 1944, ch. 373, title XXVII, §2711, as added
"(a)
"(1)
"(A) must accept every small employer (as defined in
"(B) must accept for enrollment under such coverage every eligible individual (as defined in paragraph (2)) who applies for enrollment during the period in which the individual first becomes eligible to enroll under the terms of the group health plan and may not place any restriction which is inconsistent with
"(2)
"(A) in accordance with the terms of such plan,
"(B) as provided by the issuer under rules of the issuer which are uniformly applicable in a State to small employers in the small group market, and
"(C) in accordance with all applicable State laws governing such issuer and such market.
"(b)
"(1)
"(A) the access of large employers to health insurance coverage in the State, and
"(B) the circumstances for lack of access (if any) of large employers (or one or more classes of such employers) in the State to such coverage.
"(2)
"(3) GAO
"(c)
"(1)
"(A) limit the employers that may apply for such coverage to those with eligible individuals who live, work, or reside in the service area for such network plan; and
"(B) within the service area of such plan, deny such coverage to such employers if the issuer has demonstrated, if required, to the applicable State authority that—
"(i) it will not have the capacity to deliver services adequately to enrollees of any additional groups because of its obligations to existing group contract holders and enrollees, and
"(ii) it is applying this paragraph uniformly to all employers without regard to the claims experience of those employers and their employees (and their dependents) or any health status-related factor relating to such employees and dependents.
"(2) 180
"(d)
"(1)
"(A) it does not have the financial reserves necessary to underwrite additional coverage; and
"(B) it is applying this paragraph uniformly to all employers in the small group market in the State consistent with applicable State law and without regard to the claims experience of those employers and their employees (and their dependents) or any health status-related factor relating to such employees and dependents.
"(2) 180
"(e)
"(1)
"(2)
"(A) the term 'employer contribution rule' means a requirement relating to the minimum level or amount of employer contribution toward the premium for enrollment of participants and beneficiaries; and
"(B) the term 'group participation rule' means a requirement relating to the minimum number of participants or beneficiaries that must be enrolled in relation to a specified percentage or number of eligible individuals or employees of an employer.
"(f)
Another prior section 2711 of act July 1, 1944, was successively renumbered by subsequent acts and transferred, see
Amendments
2010—
"(a)
"(1) lifetime limits on the dollar value of benefits for any participant or beneficiary; or
"(2) unreasonable annual limits (within the meaning of
"(b)
Effective Date
"(a)
"(b)
§300gg–12. Prohibition on rescissions
A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not rescind such plan or coverage with respect to an enrollee once the enrollee is covered under such plan or coverage involved, except that this section shall not apply to a covered individual who has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage. Such plan or coverage may not be cancelled except with prior notice to the enrollee, and only as permitted under section 300gg–2(b) 1 or 300gg–42(b) of this title.
(July 1, 1944, ch. 373, title XXVII, §2712, as added
References in Text
Prior Provisions
A prior section 300gg–12, act July 1, 1944, ch. 373, title XXVII, §2712, as added
"(a)
"(b)
"(1)
"(2)
"(3)
"(4)
"(5)
"(6)
"(c)
"(1)
"(A) the issuer provides notice to each plan sponsor provided coverage of this type in such market (and participants and beneficiaries covered under such coverage) of such discontinuation at least 90 days prior to the date of the discontinuation of such coverage;
"(B) the issuer offers to each plan sponsor provided coverage of this type in such market, the option to purchase all (or, in the case of the large group market, any) other health insurance coverage currently being offered by the issuer to a group health plan in such market; and
"(C) in exercising the option to discontinue coverage of this type and in offering the option of coverage under subparagraph (B), the issuer acts uniformly without regard to the claims experience of those sponsors or any health status-related factor relating to any participants or beneficiaries covered or new participants or beneficiaries who may become eligible for such coverage.
"(2)
"(A)
"(i) the issuer provides notice to the applicable State authority and to each plan sponsor (and participants and beneficiaries covered under such coverage) of such discontinuation at least 180 days prior to the date of the discontinuation of such coverage; and
"(ii) all health insurance issued or delivered for issuance in the State in such market (or markets) are discontinued and coverage under such health insurance coverage in such market (or markets) is not renewed.
"(B)
"(d)
"(1) in the large group market; or
"(2) in the small group market if, for coverage that is available in such market other than only through one or more bona fide associations, such modification is consistent with State law and effective on a uniform basis among group health plans with that product.
"(e)
Another prior section 2712 of act July 1, 1944, was successively renumbered by subsequent acts and transferred, see
Effective Date
Section effective for plan years beginning on or after the date that is 6 months after Mar. 23, 2010, see section 1004 of
1 See References in Text note below.
§300gg–13. Coverage of preventive health services
(a) In general
A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for—
(1) evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force;
(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and 1
(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.2
(4) with respect to women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph.2
(5) for the purposes of this chapter, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around November 2009.
Nothing in this subsection shall be construed to prohibit a plan or issuer from providing coverage for services in addition to those recommended by United States Preventive Services Task Force or to deny coverage for services that are not recommended by such Task Force.
(b) Interval
(1) In general
The Secretary shall establish a minimum interval between the date on which a recommendation described in subsection (a)(1) or (a)(2) or a guideline under subsection (a)(3) is issued and the plan year with respect to which the requirement described in subsection (a) is effective with respect to the service described in such recommendation or guideline.
(2) Minimum
The interval described in paragraph (1) shall not be less than 1 year.
(c) Value-based insurance design
The Secretary may develop guidelines to permit a group health plan and a health insurance issuer offering group or individual health insurance coverage to utilize value-based insurance designs.
(July 1, 1944, ch. 373, title XXVII, §2713, as added
Prior Provisions
A prior section 300gg–13, act July 1, 1944, ch. 373, title XXVII, §2713, as added
Another prior section 2713 of act July 1, 1944, was successively renumbered by subsequent acts and transferred, see
Effective Date
Section effective for plan years beginning on or after the date that is 6 months after Mar. 23, 2010, see section 1004 of
1 So in original. The word "and" probably should not appear.
2 So in original. The period probably should be a semicolon.
§300gg–14. Extension of dependent coverage
(a) In general
A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child until the child turns 26 years of age. Nothing in this section shall require a health plan or a health insurance issuer described in the preceding sentence to make coverage available for a child of a child receiving dependent coverage.
(b) Regulations
The Secretary shall promulgate regulations to define the dependents to which coverage shall be made available under subsection (a).
(c) Rule of construction
Nothing in this section shall be construed to modify the definition of "dependent" as used in title 26 with respect to the tax treatment of the cost of coverage.
(July 1, 1944, ch. 373, title XXVII, §2714, as added
Prior Provisions
A prior section 2714 of act July 1, 1944, was successively renumbered by subsequent acts and transferred, see
Amendments
2010—Subsec. (a).
Effective Date
Section effective for plan years beginning on or after the date that is 6 months after Mar. 23, 2010, see section 1004 of
§300gg–15. Development and utilization of uniform explanation of coverage documents and standardized definitions
(a) In general
Not later than 12 months after March 23, 2010, the Secretary shall develop standards for use by a group health plan and a health insurance issuer offering group or individual health insurance coverage, in compiling and providing to applicants, enrollees, and policyholders or certificate holders a summary of benefits and coverage explanation that accurately describes the benefits and coverage under the applicable plan or coverage. In developing such standards, the Secretary shall consult with the National Association of Insurance Commissioners (referred to in this section as the "NAIC"), a working group composed of representatives of health insurance-related consumer advocacy organizations, health insurance issuers, health care professionals, patient advocates including those representing individuals with limited English proficiency, and other qualified individuals.
(b) Requirements
The standards for the summary of benefits and coverage developed under subsection (a) shall provide for the following:
(1) Appearance
The standards shall ensure that the summary of benefits and coverage is presented in a uniform format that does not exceed 4 pages in length and does not include print smaller than 12-point font.
(2) Language
The standards shall ensure that the summary is presented in a culturally and linguistically appropriate manner and utilizes terminology understandable by the average plan enrollee.
(3) Contents
The standards shall ensure that the summary of benefits and coverage includes—
(A) uniform definitions of standard insurance terms and medical terms (consistent with subsection (g)) so that consumers may compare health insurance coverage and understand the terms of coverage (or exception to such coverage);
(B) a description of the coverage, including cost sharing for—
(i) each of the categories of the essential health benefits described in subparagraphs (A) through (J) of
(ii) other benefits, as identified by the Secretary;
(C) the exceptions, reductions, and limitations on coverage;
(D) the cost-sharing provisions, including deductible, coinsurance, and co-payment obligations;
(E) the renewability and continuation of coverage provisions;
(F) a coverage facts label that includes examples to illustrate common benefits scenarios, including pregnancy and serious or chronic medical conditions and related cost sharing, such scenarios to be based on recognized clinical practice guidelines;
(G) a statement of whether the plan or coverage—
(i) provides minimum essential coverage (as defined under
(ii) ensures that the plan or coverage share of the total allowed costs of benefits provided under the plan or coverage is not less than 60 percent of such costs;
(H) a statement that the outline is a summary of the policy or certificate and that the coverage document itself should be consulted to determine the governing contractual provisions; and
(I) a contact number for the consumer to call with additional questions and an Internet web address where a copy of the actual individual coverage policy or group certificate of coverage can be reviewed and obtained.
(c) Periodic review and updating
The Secretary shall periodically review and update, as appropriate, the standards developed under this section.
(d) Requirement to provide
(1) In general
Not later than 24 months after March 23, 2010, each entity described in paragraph (3) shall provide, prior to any enrollment restriction, a summary of benefits and coverage explanation pursuant to the standards developed by the Secretary under subsection (a) to—
(A) an applicant at the time of application;
(B) an enrollee prior to the time of enrollment or reenrollment, as applicable; and
(C) a policyholder or certificate holder at the time of issuance of the policy or delivery of the certificate.
(2) Compliance
An entity described in paragraph (3) is deemed to be in compliance with this section if the summary of benefits and coverage described in subsection (a) is provided in paper or electronic form.
(3) Entities in general
An entity described in this paragraph is—
(A) a health insurance issuer (including a group health plan that is not a self-insured plan) offering health insurance coverage within the United States; or
(B) in the case of a self-insured group health plan, the plan sponsor or designated administrator of the plan (as such terms are defined in
(4) Notice of modifications
If a group health plan or health insurance issuer makes any material modification in any of the terms of the plan or coverage involved (as defined for purposes of
(e) Preemption
The standards developed under subsection (a) shall preempt any related State standards that require a summary of benefits and coverage that provides less information to consumers than that required to be provided under this section, as determined by the Secretary.
(f) Failure to provide
An entity described in subsection (d)(3) that willfully fails to provide the information required under this section shall be subject to a fine of not more than $1,000 for each such failure. Such failure with respect to each enrollee shall constitute a separate offense for purposes of this subsection.
(g) Development of standard definitions
(1) In general
The Secretary shall, by regulation, provide for the development of standards for the definitions of terms used in health insurance coverage, including the insurance-related terms described in paragraph (2) and the medical terms described in paragraph (3).
(2) Insurance-related terms
The insurance-related terms described in this paragraph 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.
(3) Medical terms
The medical terms described in this paragraph 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 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 health insurance and understand the extent of those medical benefits (or exceptions to those benefits).
(July 1, 1944, ch. 373, title XXVII, §2715, as added and amended
Amendments
2010—Subsec. (a).
Effective Date
Section effective for plan years beginning on or after the date that is 6 months after Mar. 23, 2010, see section 1004 of
§300gg–15a. Provision of additional information
A group health plan and a health insurance issuer offering group or individual health insurance coverage shall comply with the provisions of
(July 1, 1944, ch. 373, title XXVII, §2715A, as added
§300gg–16. Prohibition on discrimination in favor of highly compensated individuals
(a) In general
A group health plan (other than a self-insured plan) shall satisfy the requirements of
(b) Rules and definitions
For purposes of this section—
(1) Certain rules to apply
Rules similar to the rules contained in paragraphs (3), (4), and (8) of
(2) Highly compensated individual
The term "highly compensated individual" has the meaning given such term by
(July 1, 1944, ch. 373, title XXVII, §2716, as added and amended
Amendments
2010—
"(a)
"(b)
Effective Date
Section effective for plan years beginning on or after the date that is 6 months after Mar. 23, 2010, see section 1004 of
§300gg–17. Ensuring the quality of care
(a) Quality reporting
(1) In general
Not later than 2 years after March 23, 2010, the Secretary, in consultation with experts in health care quality and stakeholders, shall develop reporting requirements for use by a group health plan, and a health insurance issuer offering group or individual health insurance coverage, with respect to plan or coverage benefits and health care provider reimbursement structures that—
(A) improve health outcomes through the implementation of activities such as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives, including through the use of the medical homes model as defined for purposes of section 3602 1 of the Patient Protection and Affordable Care Act, for treatment or services under the plan or coverage;
(B) implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional;
(C) implement activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage; and
(D) implement wellness and health promotion activities.
(2) Reporting requirements
(A) In general
A group health plan and a health insurance issuer offering group or individual health insurance coverage shall annually submit to the Secretary, and to enrollees under the plan or coverage, a report on whether the benefits under the plan or coverage satisfy the elements described in subparagraphs (A) through (D) of paragraph (1).
(B) Timing of reports
A report under subparagraph (A) shall be made available to an enrollee under the plan or coverage during each open enrollment period.
(C) Availability of reports
The Secretary shall make reports submitted under subparagraph (A) available to the public through an Internet website.
(D) Penalties
In developing the reporting requirements under paragraph (1), the Secretary may develop and impose appropriate penalties for non-compliance with such requirements.
(E) Exceptions
In developing the reporting requirements under paragraph (1), the Secretary may provide for exceptions to such requirements for group health plans and health insurance issuers that substantially meet the goals of this section.
(b) Wellness and prevention programs
For purposes of subsection (a)(1)(D), wellness and health promotion activities may include personalized wellness and prevention services, which are coordinated, maintained or delivered by a health care provider, a wellness and prevention plan manager, or a health, wellness or prevention services organization that conducts health risk assessments or offers ongoing face-to-face, telephonic or web-based intervention efforts for each of the program's participants, and which may include the following wellness and prevention efforts:
(1) Smoking cessation.
(2) Weight management.
(3) Stress management.
(4) Physical fitness.
(5) Nutrition.
(6) Heart disease prevention.
(7) Healthy lifestyle support.
(8) Diabetes prevention.
(c) Protection of Second Amendment gun rights
(1) Wellness and prevention programs
A wellness and health promotion activity implemented under subsection (a)(1)(D) may not require the disclosure or collection of any information relating to—
(A) the presence or storage of a lawfully-possessed firearm or ammunition in the residence or on the property of an individual; or
(B) the lawful use, possession, or storage of a firearm or ammunition by an individual.
(2) Limitation on data collection
None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used for the collection of any information relating to—
(A) the lawful ownership or possession of a firearm or ammunition;
(B) the lawful use of a firearm or ammunition; or
(C) the lawful storage of a firearm or ammunition.
(3) Limitation on databases or data banks
None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used to maintain records of individual ownership or possession of a firearm or ammunition.
(4) Limitation on determination of premium rates or eligibility for health insurance
A premium rate may not be increased, health insurance coverage may not be denied, and a discount, rebate, or reward offered for participation in a wellness program may not be reduced or withheld under any health benefit plan issued pursuant to or in accordance with the Patient Protection and Affordable Care Act or an amendment made by that Act on the basis of, or on reliance upon—
(A) the lawful ownership or possession of a firearm or ammunition; or
(B) the lawful use or storage of a firearm or ammunition.
(5) Limitation on data collection requirements for individuals
No individual shall be required to disclose any information under any data collection activity authorized under the Patient Protection and Affordable Care Act or an amendment made by that Act relating to—
(A) the lawful ownership or possession of a firearm or ammunition; or
(B) the lawful use, possession, or storage of a firearm or ammunition.
(d) Regulations
Not later than 2 years after March 23, 2010, the Secretary shall promulgate regulations that provide criteria for determining whether a reimbursement structure is described in subsection (a).
(e) Study and report
Not later than 180 days after the date on which regulations are promulgated under subsection (c),2 the Government Accountability Office shall review such regulations and conduct a study and submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives a report regarding the impact the activities under this section have had on the quality and cost of health care.
(July 1, 1944, ch. 373, title XXVII, §2717, as added and amended
References in Text
Section 3602 of the Patient Protection and Affordable Care Act, referred to in subsec. (a)(1)(A), is section 3602 of
The Patient Protection and Affordable Care Act, referred to in subsec. (c), is
Amendments
2010—Subsecs. (c) to (e).
Effective Date
Section effective for plan years beginning on or after the date that is 6 months after Mar. 23, 2010, see section 1004 of
1 See References in Text note below.
2 So in original. Probably should be "subsection (d),".
§300gg–18. Bringing down the cost of health care coverage
(a) Clear accounting for costs
A health insurance issuer offering group or individual health insurance coverage (including a grandfathered health plan) shall, with respect to each plan year, submit to the Secretary a report concerning the ratio of the incurred loss (or incurred claims) plus the loss adjustment expense (or change in contract reserves) to earned premiums. Such report shall include the percentage of total premium revenue, after accounting for collections or receipts for risk adjustment and risk corridors and payments of reinsurance, that such coverage expends—
(1) on reimbursement for clinical services provided to enrollees under such coverage;
(2) for activities that improve health care quality; and
(3) on all other non-claims costs, including an explanation of the nature of such costs, and excluding Federal and State taxes and licensing or regulatory fees.
The Secretary shall make reports received under this section available to the public on the Internet website of the Department of Health and Human Services.
(b) Ensuring that consumers receive value for their premium payments
(1) Requirement to provide value for premium payments
(A) Requirement
Beginning not later than January 1, 2011, a health insurance issuer offering group or individual health insurance coverage (including a grandfathered health plan) shall, with respect to each plan year, provide an annual rebate to each enrollee under such coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the issuer on costs described in paragraphs (1) and (2) of subsection (a) to the total amount of premium revenue (excluding Federal and State taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance under
(i) with respect to a health insurance issuer offering coverage in the large group market, 85 percent, or such higher percentage as a State may by regulation determine; or
(ii) with respect to a health insurance issuer offering coverage in the small group market or in the individual market, 80 percent, or such higher percentage as a State may by regulation determine, except that the Secretary may adjust such percentage with respect to a State if the Secretary determines that the application of such 80 percent may destabilize the individual market in such State.
(B) Rebate amount
(i) Calculation of amount
The total amount of an annual rebate required under this paragraph shall be in an amount equal to the product of—
(I) the amount by which the percentage described in clause (i) or (ii) of subparagraph (A) exceeds the ratio described in such subparagraph; and
(II) the total amount of premium revenue (excluding Federal and State taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance under
(ii) Calculation based on average ratio
Beginning on January 1, 2014, the determination made under subparagraph (A) for the year involved shall be based on the averages of the premiums expended on the costs described in such subparagraph and total premium revenue for each of the previous 3 years for the plan.
(2) Consideration in setting percentages
In determining the percentages under paragraph (1), a State shall seek to ensure adequate participation by health insurance issuers, competition in the health insurance market in the State, and value for consumers so that premiums are used for clinical services and quality improvements.
(3) Enforcement
The Secretary shall promulgate regulations for enforcing the provisions of this section and may provide for appropriate penalties.
(c) Definitions
Not later than December 31, 2010, and subject to the certification of the Secretary, the National Association of Insurance Commissioners shall establish uniform definitions of the activities reported under subsection (a) and standardized methodologies for calculating measures of such activities, including definitions of which activities, and in what regard such activities, constitute activities described in subsection (a)(2). Such methodologies shall be designed to take into account the special circumstances of smaller plans, different types of plans, and newer plans.
(d) Adjustments
The Secretary may adjust the rates described in subsection (b) if the Secretary determines appropriate on account of the volatility of the individual market due to the establishment of State Exchanges.
(e) Standard hospital charges
Each hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital's standard charges for items and services provided by the hospital, including for diagnosis-related groups established under
(July 1, 1944, ch. 373, title XXVII, §2718, as added and amended
Amendments
2010—
Effective Date
Section effective for plan years beginning on or after the date that is 6 months after Mar. 23, 2010, see section 1004 of
§300gg–19. Appeals process
(a) Internal claims appeals
(1) In general
A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum—
(A) have in effect an internal claims appeal process;
(B) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under
(C) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process.
(2) Established processes
To comply with paragraph (1)—
(A) a group health plan and a health insurance issuer offering group health coverage shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503–1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70256), and shall update such process in accordance with any standards established by the Secretary of Labor for such plans and issuers; and
(B) a health insurance issuer offering individual health coverage, and any other issuer not subject to subparagraph (A), shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures set forth under applicable law (as in existence on March 23, 2010), and shall update such process in accordance with any standards established by the Secretary of Health and Human Services for such issuers.
(b) External review
A group health plan and a health insurance issuer offering group or individual health insurance coverage—
(1) shall comply with the applicable State external review process for such plans and issuers that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners and is binding on such plans; or
(2) shall implement an effective external review process that meets minimum standards established by the Secretary through guidance and that is similar to the process described under paragraph (1)—
(A) if the applicable State has not established an external review process that meets the requirements of paragraph (1); or
(B) if the plan is a self-insured plan that is not subject to State insurance regulation (including a State law that establishes an external review process described in paragraph (1)).
(c) Secretary authority
The Secretary may deem the external review process of a group health plan or health insurance issuer, in operation as of the date of enactment of this section, to be in compliance with the applicable process established under subsection (b), as determined appropriate by the Secretary.
(July 1, 1944, ch. 373, title XXVII, §2719, as added and amended
Amendments
2010—
Effective Date
Section effective for plan years beginning on or after the date that is 6 months after Mar. 23, 2010, see section 1004 of
§300gg–19a. Patient protections
(a) Choice of health care professional
If a group health plan, or a health insurance issuer offering group or individual health insurance coverage, requires or provides for designation by a participant, beneficiary, or enrollee of a participating primary care provider, then the plan or issuer shall permit each participant, beneficiary, and enrollee to designate any participating primary care provider who is available to accept such individual.
(b) Coverage of emergency services
(1) In general
If a group health plan, or a health insurance issuer offering group or individual health insurance issuer,1 provides or covers any benefits with respect to services in an emergency department of a hospital, the plan or issuer shall cover emergency services (as defined in paragraph (2)(B))—
(A) without the need for any prior authorization determination;
(B) whether the health care provider furnishing such services is a participating provider with respect to such services;
(C) in a manner so that, if such services are provided to a participant, beneficiary, or enrollee—
(i) by a nonparticipating health care provider with or without prior authorization; or
(ii)(I) such services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the providing of services that is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan; and
(II) if such services are provided out-of-network, the cost-sharing requirement (expressed as a copayment amount or coinsurance rate) is the same requirement that would apply if such services were provided in-network; 2
(D) without regard to any other term or condition of such coverage (other than exclusion or coordination of benefits, or an affiliation or waiting period, permitted under section 2701 3 of this Act,
(2) Definitions
In this subsection:
(A) Emergency medical condition
The term "emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition described in clause (i), (ii), or (iii) of
(B) Emergency services
The term "emergency services" means, with respect to an emergency medical condition—
(i) a medical screening examination (as required under
(ii) within the capabilities of the staff and facilities available at the hospital, such further medical examination and treatment as are required under
(C) Stabilize
The term "to stabilize", with respect to an emergency medical condition (as defined in subparagraph (A)), has the meaning give 4 in
(c) Access to pediatric care
(1) Pediatric care
In the case of a person who has a child who is a participant, beneficiary, or enrollee under a group health plan, or health insurance coverage offered by a health insurance issuer in the group or individual market, if the plan or issuer requires or provides for the designation of a participating primary care provider for the child, the plan or issuer shall permit such person to designate a physician (allopathic or osteopathic) who specializes in pediatrics as the child's primary care provider if such provider participates in the network of the plan or issuer.
(2) Construction
Nothing in paragraph (1) shall be construed to waive any exclusions of coverage under the terms and conditions of the plan or health insurance coverage with respect to coverage of pediatric care.
(d) Patient access to obstetrical and gynecological care
(1) General rights
(A) Direct access
A group health plan, or health insurance issuer offering group or individual health insurance coverage, described in paragraph (2) may not require authorization or referral by the plan, issuer, or any person (including a primary care provider described in paragraph (2)(B)) in the case of a female participant, beneficiary, or enrollee who seeks coverage for obstetrical or gynecological care provided by a participating health care professional who specializes in obstetrics or gynecology. Such professional shall agree to otherwise adhere to such plan's or issuer's policies and procedures, including procedures regarding referrals and obtaining prior authorization and providing services pursuant to a treatment plan (if any) approved by the plan or issuer.
(B) Obstetrical and gynecological care
A group health plan or health insurance issuer described in paragraph (2) shall treat the provision of obstetrical and gynecological care, and the ordering of related obstetrical and gynecological items and services, pursuant to the direct access described under subparagraph (A), by a participating health care professional who specializes in obstetrics or gynecology as the authorization of the primary care provider.
(2) Application of paragraph
A group health plan, or health insurance issuer offering group or individual health insurance coverage, described in this paragraph is a group health plan or coverage that—
(A) provides coverage for obstetric or gynecologic care; and
(B) requires the designation by a participant, beneficiary, or enrollee of a participating primary care provider.
(3) Construction
Nothing in paragraph (1) shall be construed to—
(A) waive any exclusions of coverage under the terms and conditions of the plan or health insurance coverage with respect to coverage of obstetrical or gynecological care; or
(B) preclude the group health plan or health insurance issuer involved from requiring that the obstetrical or gynecological provider notify the primary care health care professional or the plan or issuer of treatment decisions.
(July 1, 1944, ch. 373, title XXVII, §2719A, as added
References in Text
Section 2701 of this Act, referred to in subsec. (b)(1)(D), is a reference to section 2701 of act July 1, 1944. Section 2701, which was classified to
Codification
1 So in original. Probably should be "coverage,".
2 So in original. The word "and" probably should appear.