United States. Congress

“ HEALTH BENEFITS- The term `health benefits' means medical, surgical, hospital, prescription drug, and such other benefits as shall be determined by the Secretary, whether self-funded, or delivered through the purchase of insurance or otherwise. ”

“ IN GENERAL- A participating employment-based plan shall submit claims for reimbursement to the Secretary which shall contain documentation of the actual costs of the items and services for which each claim is being submitted. (B) BASIS FOR CLAIMS- Claims submitted under subparagraph (A) shall be based on the actual amount expended by the participating employment-based plan involved within the plan year for the health benefits provided to an early retiree or the spouse, surviving spouse, or dependent of such retiree. ”

“ IN GENERAL- The Secretary shall establish criteria for determining whether health insurance issuers and employment-based health plans have discouraged an individual from remaining enrolled in prior coverage based on that individual's health status. ”

“ CERTIFICATION BY OUTSIDE ENTITY- The Secretary may designate independent, outside entities to certify that a health plan has complied with the requirements under this subsection, provided that the certification standards employed by such entities are in accordance with any standards or operating rules issued by the Secretary. ”

“ Such operating rules shall be consensus-based and reflect the necessary business rules affecting health plans and health care providers and the manner in which they operate pursuant to standards issued under Health Insurance Portability and Accountability Act of 1996. ` (2) OPERATING RULES DEVELOPMENT- In adopting operating rules under this subsection, the Secretary shall consider recommendations for operating rules developed by a qualified nonprofit entity that meets the following requirements: ` (A) The entity focuses its mission on administrative simplification. ”

“ Health insurance coverage offered by health insurance issuers, other than coverage that provides reimbursement only for the treatment or mitigation of-- (i) a single disease or condition; or (ii) an unreasonably limited set of diseases or conditions (as determined by the Secretary) ; (B) Medicaid coverage under title XIX of the Social Security Act. (C) Coverage under title XXI of the Social Security Act. (D) A State health benefits high risk pool, to the extent that such high risk pool is offered in such State; and (E) Coverage under a high risk pool under section 1101. ”

“ The entity demonstrates a multi-stakeholder and consensus-based process for development of operating rules, including representation by or participation from health plans, health care providers, vendors, relevant Federal agencies, and other standard development organizations. ` (C) The entity has a public set of guiding principles that ensure the operating rules and process are open and transparent, and supports nondiscrimination and conflict of interest policies that demonstrate a commitment to open, fair, and nondiscriminatory practices. ”

“ ELECTRONIC FUNDS TRANSFERS AND HEALTH CARE PAYMENT AND REMITTANCE ADVICE- The set of operating rules for electronic funds transfers and health care payment and remittance advice transactions shall-- ` (I) allow for automated reconciliation of the electronic payment with the remittance advice ”