The Truth About Obamacare, Part IV: Queen Kathleen

Kathleen Sebelius is now the Queen of HHS, not the Secretary.  Just read this brief excerpt from part 2 of the PPACA.

PART 2—CONSUMER CHOICES AND INSUR- 

ANCE COMPETITION THROUGH HEALTH 

BENEFIT EXCHANGES 

SEC. 1311 ø42 U.S.C. 13031¿. AFFORDABLE CHOICES OF HEALTH BEN- 

EFIT PLANS. 

(a) ASSISTANCETOSTATES TOESTABLISHAMERICANHEALTH 

BENEFITEXCHANGES.— 

(1) PLANNINGANDESTABLISHMENT GRANTS.—There shall 

be appropriated to the Secretary, out of any moneys in the 

Treasury not otherwise appropriated, an amount necessary to 

enable the Secretary to make awards, not later than 1 year 

after the date of enactment of this Act, to States in the amount 

specified in paragraph (2) for the uses described in paragraph 

(3). 

(2) AMOUNTSPECIFIED.—For each fiscal year, the Secretary 

shall determine the total amount that the Secretary will make 

available to each State for grants under this subsection. 

(3) USEOFFUNDS.—A State shall use amounts awarded 

under this subsection for activities (including planning activi- 

ties) related to establishing an American Health Benefit Ex- 

change, as described in subsection (b). 

(4) RENEWABILITYOFGRANT.— 

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70 

Sec. 1311 PPACA (Consolidated) 

(A) INGENERAL.—Subject to subsection (d)(4), the Sec- 

retary may renew a grant awarded under paragraph (1) if 

the State recipient of such grant— 

(i) is making progress, as determined by the Sec- 

retary, toward— 

(I) establishing an Exchange; and 

(II) implementing the reforms described in 

subtitles A and C (and the amendments made by 

such subtitles); and 

(ii) is meeting such other benchmarks as the Sec- 

retary may establish. 

(B) LIMITATION.—No grant shall be awarded under 

this subsection after January 1, 2015. 

(5) TECHNICALASSISTANCETOFACILITATEPARTICIPATIONIN 

SHOP EXCHANGES.—The Secretary shall provide technical as- 

sistance to States to facilitate the participation of qualified 

small businesses in such States in SHOP Exchanges. 

(b) AMERICANHEALTHBENEFITEXCHANGES.— 

(1) INGENERAL.—Each State shall, not later than January 

1, 2014, establish an American Health Benefit Exchange (re- 

ferred to in this title as an ‘‘Exchange’’) for the State that— 

(A) facilitates the purchase of qualified health plans; 

(B) provides for the establishment of a Small Business 

Health Options Program (in this title referred to as a 

‘‘SHOP Exchange’’) that is designed to assist qualified em- 

ployers in the State who are small employers in facili- 

tating the enrollment of their employees in qualified 

health plans offered in the small group market in the 

State; and 

(C) meets the requirements of subsection (d). 

(2) MERGEROFINDIVIDUALANDSHOPEXCHANGES.—A State 

may elect to provide only one Exchange in the State for pro- 

viding both Exchange and SHOP Exchange services to both 

qualified individuals and qualified small employers, but only if 

the Exchange has adequate resources to assist such individuals 

and employers. 

(c) RESPONSIBILITIESOFTHESECRETARY.— 

(1) INGENERAL.—The Secretary shall, by regulation, estab- 

lish criteria for the certification of health plans as qualified 

health plans. Such criteria shall require that, to be certified, 

a plan shall, at a minimum— 

(A) meet marketing requirements, and not employ 

marketing practices or benefit designs that have the effect 

of discouraging the enrollment in such plan by individuals 

with significant health needs; 

(B) ensure a sufficient choice of providers (in a manner 

consistent with applicable network adequacy provisions 

under section 2702(c) of the Public Health Service Act), 

and provide information to enrollees and prospective en- 

rollees on the availability of in-network and out-of-network 

providers; 

(C) include within health insurance plan networks 

those essential community providers, where available, that 

serve predominately low-income, medically-underserved in- 

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71 Sec. 1311 

PPACA (Consolidated) 

dividuals, such as health care providers defined in section 

340B(a)(4) of the Public Health Service Act and providers 

described in section 1927(c)(1)(D)(i)(IV) of the Social Secu- 

rity Act as set forth by section 221 of Public Law 111–8, 

except that nothing in this subparagraph shall be con- 

strued to require any health plan to provide coverage for 

any specific medical procedure; 

(D)(i) be accredited with respect to local performance 

on clinical quality measures such as the Healthcare Effec- 

tiveness Data and Information Set, patient experience rat- 

ings on a standardized Consumer Assessment of 

Healthcare Providers and Systems survey, as well as con- 

sumer access, utilization management, quality assurance, 

provider credentialing, complaints and appeals, network 

adequacy and access, and patient information programs by 

any entity recognized by the Secretary for the accredita- 

tion of health insurance issuers or plans (so long as any 

such entity has transparent and rigorous methodological 

and scoring criteria); or 

(ii) receive such accreditation within a period estab- 

lished by an Exchange for such accreditation that is appli- 

cable to all qualified health plans; 

(E) implement a quality improvement strategy de- 

scribed in subsection (g)(1); 

(F) utilize a uniform enrollment form that qualified in- 

dividuals and qualified employers may use (either elec- 

tronically or on paper) in enrolling in qualified health 

plans offered through such Exchange, and that takes into 

account criteria that the National Association of Insurance 

Commissioners develops and submits to the Secretary; 

(G) utilize the standard format established for pre- 

senting health benefits plan options; 

(H) provide information to enrollees and prospective 

enrollees, and to each Exchange in which the plan is of- 

fered, on any quality measures for health plan perform- 

ance endorsed under section 399JJ of the Public Health 

Service Act, as applicable; and 

(I) report to the Secretary at least annually and in 

such manner as the Secretary shall require, pediatric qual- 

ity reporting measures consistent with the pediatric qual- 

ity reporting measures established under section 1139A of 

the Social Security Act. øAs added by section 10203(a)¿ 

(2) RULEOFCONSTRUCTION.—Nothing in paragraph (1)(C) 

shall be construed to require a qualified health plan to contract 

with a provider described in such paragraph if such provider 

refuses to accept the generally applicable payment rates of 

such plan. 

(3) RATINGSYSTEM.—The Secretary shall develop a rating 

system that would rate qualified health plans offered through 

an Exchange in each benefits level on the basis of the relative 

quality and price. The Exchange shall include the quality rat- 

ing in the information provided to individuals and employers 

through the Internet portal established under paragraph (4).