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Title III — Ensuring access to care

S. 1213 · 116th Congress · Apr 11, 2019 · Lineage

III Ensuring access to care

Sec. 301 Network adequacy requirements

(a)
In general— Section 1311(c) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)) is amended—
(1)
in paragraph (1)(B), by inserting “and paragraph (7) and in accordance with paragraph (8)” after “Public Health Service Act”; and
(2)
by adding at the end the following:

“(7) Network adequacy requirements

“(A) In general—A qualified health plan shall, to be certified under this subsection, meet the network adequacy standards established by the Secretary under subparagraph (B), except as provided in subparagraphs (B)(ii) and (C).

“(B) Federal standards and review

“(i) Standard

“(I) Establishment—The Secretary shall, in consultation with stakeholders including pediatric-specific stakeholders, establish a network adequacy standard based on access to in-network providers for qualified health plans, except for those plans described in subparagraph (C). Such standard shall—

“(aa) include requirements for the minimum number and type of in-network providers available, the geographical location of such providers, the average distance and travel time required for patients to visit such providers, and the average appointment wait times for services covered by the plan; and

“(bb) account for differences in the needs of children and adults.

“(II) Medicare Advantage organizations—The network adequacy standard established under subclause (I) shall, at a minimum, be equivalent to the requirements for access to services applicable to Medicare Advantage organizations offering Medicare Advantage plans under part C of title XVIII of the Social Security Act.

“(ii) Justification—A qualified health plan that fails to meet the standard established under clause (i) may satisfy the requirement under subparagraph (A) by providing the Secretary with a reasonable justification for the variance from such standard, based on factors such as the availability of providers and variables reflected in local patterns of health care.

“(iii) Review—The Secretary shall establish a process for reviewing the network adequacy of qualified health plans, except for those plans reviewed by the State in accordance with subparagraph (C)(ii).

“(C) State standard

“(i) In general—In the case of a qualified health plan offered in a State that has implemented a quantifiable network adequacy metric that the Secretary determines is an acceptable metric commonly used in the health insurance industry to measure network adequacy, such qualified health plan may, to be certified under this subsection, satisfy the requirement under subparagraph (A) by meeting the network adequacy standards of such State based on such metric.

“(ii) Review—A State with an acceptable metric described in clause (i) may review the network adequacy of qualified health plans offered in such State in a process established by the State.

“(8) Coverage of out-of-network essential health benefits

“(A) In general—A qualified health plan shall, to be certified under this subsection, provide to individuals enrolled in such plan coverage of any service provided by an out-of-network provider if—

“(i) coverage of such service would otherwise be provided by the plan if the service was provided by an in-network provider;

“(ii) the service is included in the essential health benefits package described in section 1302(a); and

“(iii) the service cannot be provided to the individual by an in-network provider within a reasonable timeframe or within a reasonable distance and travel time.

“(B) Cost-sharing—A qualified health plan that provides coverage of a service provided by an out-of-network provider under subparagraph (A) shall provide such coverage with the same cost-sharing requirements as if the service was provided by an in-network provider.”

(b)
Effective date— The amendments made by subsection (a) shall apply to plans beginning after December 31, 2020.
(c)
Grants for State network adequacy reviews—
(1)
In general— The Secretary of Health and Human Services shall carry out a program to award grants to States during the 5-year period beginning with fiscal year 2021 to assist such States in developing a metric to measure network adequacy as described in subparagraph (C)(i) of section 1311(c)(7) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)(7)) and to carry out the reviews described in subparagraph (C)(ii) of such section.
(2)
Authorization of appropriations— There are authorized to be appropriated for each of fiscal years 2021 through 2025 such sums as may be necessary to carry out the grant program under this subsection.
(d)
Report—
(1)
In general— Not later than December 31, 2022, the Secretary shall prepare, and submit to Congress, a report containing the analysis and recommendations described in paragraph (2).
(2)
Analysis and recommendations— The report under this subsection shall—
(A)
analyze how network adequacy and access to care has changed since the implementation of this section, including the amendments made by this section, including for children;
(B)
include information on the availability of providers that are essential community providers as described in section 1311(c)(1)(C) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)(1)(C)); and
(C)
provide recommendations for such legislation and administrative actions as the Secretary considers appropriate to improve network adequacy, including with respect to access to pediatric services and essential community providers.

Sec. 302 Ensuring adequate coverage in areas with fewer than 3 health insurance issuers offering qualified health plans on the State Exchange

(a)
Requirements for Medicare Advantage organizations—
(1)
In general— Section 1857(e) of the Social Security Act (42 U.S.C. 1395w–27(e)) is amended by adding at the end the following new paragraph:

“(6) Requirement for certain Medicare Advantage organizations that offer an MA plan in an applicable area to also offer qualified health plans in the applicable area

“(A) In general—A contract under this section with an MA organization described in subparagraph (B) shall require the organization to, in each applicable area in which the organization offers an MA plan, also offer, through the individual market in the Exchange operating in the State, at least one qualified health plan in the silver level of coverage and at least one qualified health plan in the gold level of coverage, as described in section 1302(d) of the Patient Protection and Affordable Care Act.

“(B) MA organizations described—An MA organization described in this subparagraph is an MA organization that, in addition to offering an MA plan in an applicable area, offers health insurance coverage in the group market or individual market in the State but does not offer such coverage through the Exchange operating in the State.

“(C) Notification—The Secretary, or the State in the case of an MA organization offering an MA plan in an applicable area in a State with an Exchange operated by the State, shall notify each MA organization that is required to offer a qualified health plan under subparagraph (A) for a plan year of such requirement. Such notification shall be provided each year—

“(i) beginning with respect to the requirement for plan years beginning after December 31, 2020; and

“(ii) not less than 1 year prior to the rate filing deadline for the plan year for the Exchange operating in the State in which the MA organization will be required to offer such plan.

“(D) Waiver—The Secretary, or the State in the case of an MA organization offering an MA plan in an applicable area in a State with an Exchange operated by the State, may waive the requirement under subparagraph (A) if—

“(i) by the first day of the plan year following the determination, the number of health insurance issuers offering a qualified health plan through the individual market in the Exchange has increased such that the applicable area no longer has fewer than 3 health insurance issuers offering a qualified health plan through the individual market in the Exchange operating in the State; or

“(ii) the Secretary, or the State in such a case, determines that the requirement under subparagraph (A) would cause the MA organization to become insolvent.

“(E) Definitions—In this paragraph:

“(i) Applicable area—The term “applicable area” means an area in which, at the time the Secretary or the State sends the notification under subparagraph (C), fewer than 3 health insurance issuers offer a qualified health plan through the individual market in the Exchange operating in the State.

“(ii) Exchange—The term “Exchange” means an American Health Benefit Exchange established under section 1311 or section 1321 of the Patient Protection and Affordable Care Act.

“(iii) Group market—The term group market has the meaning given such term in section 1304 of the Patient Protection and Affordable Care Act.

“(iv) Health insurance coverage—The term health insurance coverage has the meaning given the term in section 2791(b) of the Public Health Service Act.

“(v) Individual market—The term individual market has the meaning given such term in section 1304 of the Patient Protection and Affordable Care Act.

“(vi) Qualified health plan—The term “qualified health plan” has the meaning given that term in section 1301(a) of the Patient Protection and Affordable Care Act.”

(2)
Effective date— The amendment made by this subsection shall apply to contracts entered into or renewed after December 31, 2020.
(b)
Requirements for medicaid managed care organizations—
(1)
In general— Section 1903(m)(2)(A) of the Social Security Act (42 U.S.C. 1396b(m)(2)(A)) is amended—
(A)
in clause (xii), by striking “; and” and inserting a semicolon;
(B)
by realigning the left margin of clause (xiii) to align with the left margin of clause (xii);
(C)
in clause (xiii), by striking the period at the end and inserting “; and”; and
(D)
by inserting after clause (xiii) the following:

“(xiv) such contract requires that the entity meets the requirements described in section 1857(e)(6) in the same manner as such requirements apply to an MA organization.”

(2)
Effective date— The amendments made by this subsection shall apply to contracts entered into or renewed after December 31, 2020.

Sec. 303 Enrollment in Exchanges

(a)
Open enrollment and special enrollment periods— Section 1311(c)(6) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)(6)) is amended—
(1)
in subparagraph (B), by inserting “that are not less than 8 weeks” after “open enrollment periods”;
(2)
in subparagraph (C), by striking “; and” and inserting “;”;
(3)
in subparagraph (D), by striking the period and inserting “;”; and
(4)
by adding at the end the following:

“(E) a special enrollment period for qualified individuals enrolled in a plan that makes significant provider terminations during the plan year, as determined in accordance with regulations promulgated by the Secretary; and

“(F) a special enrollment period—

“(i) for each qualified individual who—

“(I) is determined by the Exchange to be eligible for a premium assistance credit under section 36B of the Internal Revenue Code of 1986; and

“(II) has a household income not in excess of 300 percent of the poverty line for the size of the family involved; and

“(ii) which shall begin on the date on which the individual is determined by the Exchange to be eligible for a premium assistance credit under such section 36B.”

(b)
Consumer protections regarding automatic re-Enrollment— Part 2 of subtitle D of title I of the Patient Protection and Affordable Care Act (42 U.S.C. 18031 et seq.) is amended by adding at the end the following:

“1314. Consumer protections regarding automatic re-enrollment

“(a) Consent To avoid automatic re-Enrollment for individuals losing eligibility for premium assistance credits—The Secretary shall establish a process to allow an individual, who is enrolling in a qualified health plan through an Exchange and whom the Exchange estimates is eligible to receive a premium assistance credit under section 36B of the Internal Revenue Code of 1986, to provide consent to the Exchange to not automatically re-enroll the individual in such qualified health plan (or a comparable qualified health plan in a case described in subsection (b)) for the following plan year if during the plan year the Exchange estimates that the individual has become no longer eligible to receive such credit.

“(b) Notice regarding discontinued plans—In the case of an individual who is enrolled in a qualified health plan through an Exchange for a plan year that will not be offered through such Exchange for the following plan year, the Exchange through which such plan is offered shall, prior to the open enrollment period for the following plan year, send the individual a notice stating—

“(1) that the qualified health plan in which the individual is enrolled will not be offered through such Exchange for the following plan year;

“(2) that unless the individual takes action, the individual will be enrolled in a comparable qualified health plan for the following plan year;

“(3) the estimated amount of premiums for such comparable qualified health plan; and

“(4) clear information on the eligibility of the individual for a special enrollment period.

“(c) Notice regarding automatic re-Enrollment—Any notice regarding automatic re-enrollment sent by an Exchange to an individual enrolled in a qualified health plan shall be provided to the individual in the language that the individual has indicated to the Exchange as the preferred language of the individual.

“(d) Retroactive termination

“(1) In general—The Secretary shall establish a process to allow an individual who is automatically re-enrolled in a qualified health plan for a plan year and who has enrolled in other creditable coverage for that plan year to retroactively terminate such qualified health plan for such plan year.

“(2) Creditable coverage—In this subsection, the term creditable coverage has the meaning given the term in section 2704(c)(1) of the Public Health Service Act.”

(c)
Effective date— The amendments made by this section shall apply to plan years beginning after the date of enactment of this Act.
(d)
Study— The Secretary shall conduct a study that examines the practices used by the Exchanges for notifying consumers of automatic re-enrollment in qualified health plans and identifies strategies for—
(1)
improving automatic re-enrollment and renewal notifications;
(2)
improving the ability to reach consumers in providing such notices;
(3)
increasing consumer comprehension of such notices; and
(4)
encouraging consumers to—
(A)
update information that will affect eligibility for premium assistance credits under section 36B of the Internal Revenue Code of 1986 and the amount of such credits; and
(B)
shop for qualified health plans that will best meet their needs through the Exchange operating in their State.

Sec. 304 Marketing and outreach for Exchanges operated by the Secretary

Part 2 of subtitle D of title I of the Patient Protection and Affordable Care Act (42 U.S.C. 18031 et seq.), as amended by section 303(b), is further amended by adding at the end the following:

“1315. Marketing and outreach for Exchanges operated by the Secretary

“(a) In general—Out of the funds appropriated under subsection (b), the Secretary shall conduct a marketing and outreach program with respect to qualified health plans offered through Exchanges operated by the Secretary in order to encourage enrollment in such plans.

“(b) Appropriations

“(1) Encouraging enrollment for plan year 2020—There is appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, $480,000,000 to carry out the marketing and outreach program under subsection (a) with respect to encouraging enrollment for qualified health plans that begin in calendar year 2020.

“(2) Encouraging enrollment for subsequent plan years—To carry out the marketing and outreach program under subsection (a) with respect to encouraging enrollment for qualified health plans that begin in each of calendar years 2021 through 2025, there is appropriated to the Secretary prior to each such calendar year, out of any moneys in the Treasury not otherwise appropriated, an amount equal to the amount appropriated under this subsection for the prior calendar year increased by 4 percent for each such calendar year.

“(3) Availability—The amounts appropriated under paragraphs (1) and (2) shall remain available until expended.”

Sec. 305 Navigator program

Section 1311(i) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(i)) is amended—
(1)
in paragraph (2)—
(A)
in subparagraph (B), by striking “and other entities” and inserting “and other entities (such as Indian tribes, tribal organizations, urban Indian organizations, and State or local human service agencies)”; and
(B)
by adding at the end the following:

“(C) Preference—An Exchange shall ensure that, each year, it awards a grant under paragraph (1) to—

“(i) at least one entity described in this paragraph that is a community and consumer-focused nonprofit group; and

“(ii) at least one entity described in subparagraph (B), which may include another community and consumer-focused nonprofit group.”

(2)
in paragraph (3)—
(A)
in subparagraph (D), by striking “; and” and inserting “;”;
(B)
in subparagraph (E), by striking the period and inserting “; and”; and
(C)
by adding at the end the following:

“(F) provide targeted assistance to individuals likely to qualify for a special enrollment period under subparagraph (C), (D), or (E) of subsection (c)(6).”

(3)
in paragraph (4)(A)—
(A)
in the matter preceding clause (i), by striking “not”;
(B)
in clause (i)—
(i)
by inserting “not” before “be”; and
(ii)
by striking “; or” and inserting “;”;
(C)
in clause (ii)—
(i)
by inserting “not” before “receive”; and
(ii)
by striking the period and inserting “;”; and
(D)
by adding at the end the following:

“(iii) maintain physical presence in the State of the Exchange so as to allow in-person assistance to consumers; and

“(iv) not provide compensation to an employee employed by the navigator based on the number of individuals the employee assists in enrolling in qualified health plans.”