PPACA Sec. 1001

 
SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.

Part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended—

(1) by striking the part heading and inserting the following:

‘‘PART A—INDIVIDUAL AND GROUP MARKET REFORMS’’;

(2) by redesignating sections 2704 through 2707 as sections 2725 through 2728, respectively;

(3) by redesignating sections 2711 through 2713 as sections 2731 through 2733, respectively;

(4) by redesignating sections 2721 through 2723 as sections 2735 through 2737, respectively; and

(5) by inserting after section 2702, the following:
 

‘‘Subpart II—Improving Coverage

‘‘SEC. 2711. NO LIFETIME OR ANNUAL LIMITS. (See PPACA 10101 for Reconciliation Changes)

‘‘(a) IN GENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish—

‘‘(1) lifetime limits on the dollar value of benefits for any participant or beneficiary; or

‘‘(2) unreasonable annual limits (within the meaning of section 223 of the Internal Revenue Code of 1986) on the dollar value of benefits for any participant or beneficiary.

‘‘(b) PER BENEFICIARY LIMITS.—Subsection (a) shall not be construed to prevent a group health plan or health insurance coverage that is not required to provide essential health benefits under section 1302`(b) of the Patient Protection and Affordable Care Act from placing annual or lifetime per beneficiary limits on specific

covered benefits to the extent that such limits are otherwise permitted under Federal or State law.

 
 ‘‘ SEC. 2712. 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 2702(c) or 2742(b).

 
‘‘ SEC. 2713. 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 (ACIP/CDC Immunization website)

with respect to the individual involved; and

‘‘(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.

‘‘(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 HealthResources and Services Administration for purposes of this paragraph.

‘‘(5) for the purposes of this Act, 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.

 

‘‘ SEC. 2714. 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 (who is not married) 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 the Internal Revenue Code of 1986 with respect to the tax treatment of the cost of coverage.
 

‘‘SEC. 2717. ENSURING THE QUALITY OF CARE.

‘‘(a) QUALITY REPORTING.—

‘‘(1) IN GENERAL.—Not later than 2 years after the date of enactment of the Patient Protection and Affordable Care Act, 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 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) REGULATIONS.—Not later than 2 years after the date of enactment of the Patient Protection and Affordable Care Act, the

Secretary shall promulgate regulations that provide criteria for determining whether a reimbursement structure is described in subsection (a).

‘‘(d) STUDY AND REPORT.—Not later than 180 days after the date on which regulations are promulgated under subsection (c),

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.

 

‘‘ SEC. 2719. APPEALS PROCESS.  (See PPACA 10101 for Reconciliation Changes)

‘‘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—

‘‘(1) have in effect an internal claims appeal process;

‘‘(2) 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 section 2793 to assist such enrollees with the appeals processes;

‘‘(3) 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; and

‘‘(4) provide an 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.’’.

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