H.R. 3200/Division A/Title I/Subtitle D

SUBTITLE D — ADDITIONAL CONSUMER PROTECTIONS

Sec. 131. Requiring Fair Marketing Practices by Health Insurers.

The Commissioner shall establish uniform marketing standards that all insured QHBP offering entities shall meet.

Sec. 132. Requiring Fair Grievance and Appeals Mechanisms.

(a) In General.—

A QHBP offering entity shall provide for timely grievance and appeals mechanisms that the Commissioner shall establish.

(b) Internal Claims and Appeals Process.—

Under a qualified health benefits plan the QHBP offering entity 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 FR 70246) and shall update such process in accordance with any standards that the Commissioner may establish.

(c) External Review Process.—

(1) In General.—

The Commissioner shall establish an external review process (including procedures for expedited reviews of urgent claims) that provides for an impartial, independent, and de novo review of denied claims under this division.

(2) Requiring Fair Grievance and Appeals Mechanisms.—

A determination made, with respect to a qualified health benefits plan offered by a QHBP offering entity, under the external review process established under this subsection shall be binding on the plan and the entity.

(d) Construction.—

Nothing in this section shall be construed as affecting the availability of judicial review under State law for adverse decisions under subsection (b) or (c), subject to section 151.

Sec. 133. Requiring Information Transparency and Plan Disclosure.

(a) Accurate and Timely Disclosure.—

(1) In General.—

A qualified health benefits plan shall comply with standards established by the Commissioner for the accurate and timely disclosure of plan documents, plan terms and conditions, claims payment policies and practices, periodic financial disclosure, data on enrollment, data on disenrollment, data on the number of claims denials, data on rating practices, information on cost-sharing and payments with respect to any out-of-network coverage, and other information as determined appropriate by the Commissioner. The Commissioner shall require that such disclosure be provided in plain language.

(2) Plain Language.—

In this subsection, the term “plain language” means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is clean, concise, well-organized, and follows other best practices of plain language writing.

(3) Guidance.—

The Commissioner shall develop and issue guidance on best practices of plain language writing.

(b) Contracting Reimbursement.—

A qualified health benefits plan shall comply with standards established by the Commissioner to ensure transparency to each health care provider relating to reimbursement arrangements between such plan and such provider.

(c) Advance Notice of Plan Cchanges.—

A change in a qualified health benefits plan shall not be made without such reasonable and timely advance notice to enrollees of such change.

Sec. 134. Application to Qualified Health Benefits Plans Not Offered Through the Health Insurance Exchange.

The requirements of the previous provisions of this subtitle shall apply to qualified health benefits plans that are not being offered through the Health Insurance Exchange only to the extent specified by the Commissioner.

Sec. 135. Timely Payment of Claims.

A QHBP offering entity shall comply with the requirements of section 1857(f) of the Social Security Act with respect to a qualified health benefits plan it offers in the same manner an Medicare Advantage organization is required to comply with such requirements with respect to a Medicare Advantage plan it offers under part C of Medicare.

Sec. 136. Standardized Rules for Coordination and Subrogation of Benefits.

The Commissioner shall establish standards for the coordination and subrogation of benefits and reimbursement of payments in cases involving individuals and multiple plan coverage.

Sec. 137. Application of Administrative Simplification.

A QHBP offering entity is required to comply with standards for electronic financial and administrative transactions under section 1173A of the Social Security Act, added by section 163(a).