Senate File 2042 - Introduced SENATE FILE 2042 BY HATCH A BILL FOR An Act providing for the establishment of the Iowa health 1 benefit marketplace and including effective date provisions. 2 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 3 TLSB 5007SS (8) 84 av/rj

S.F. 2042 Section 1. NEW SECTION . 514M.1 Title. 1 This Act shall be known and may be cited as the “Iowa Health 2 Benefit Marketplace Act” . 3 Sec. 2. NEW SECTION . 514M.2 Purpose and intent. 4 The purpose of this Act is to provide for the establishment 5 of a health benefit marketplace in this state to facilitate 6 the sale and purchase of qualified health benefit plans by 7 qualified individuals in the individual market in this state 8 and by qualified small employers in the small group market 9 in this state. The intent of authorizing the establishment 10 of a health benefit marketplace in this state is to reduce 11 the number of uninsured individuals in this state, provide a 12 transparent marketplace and consumer education, and assist 13 individuals with access to programs, premium assistance tax 14 credits, and cost-sharing reductions. 15 Sec. 3. NEW SECTION . 514M.3 Definitions. 16 As used in this chapter, unless the context otherwise 17 requires: 18 1. “Board” means the board of directors of the Iowa health 19 benefit marketplace as provided in section 514M.5. 20 2. “Commissioner” means the commissioner of insurance. 21 3. “Executive director” means the executive director of the 22 Iowa health benefit marketplace. 23 4. “Federal Act” means the federal Patient Protection and 24 Affordable Care Act, Pub. L. No. 111-148, as amended by the 25 federal Health Care and Education Reconciliation Act of 2010, 26 Pub. L. No. 111-152, and any amendments thereto, or regulations 27 or guidance issued under, those Acts. 28 5. a. “Health benefit plan” means a policy, contract, 29 certificate, or agreement offered or issued by a health carrier 30 to provide, deliver, arrange for, pay for, or reimburse any of 31 the costs of health care services. 32 b. “Health benefit plan” does not include any of the 33 following: 34 (1) Coverage only for accident, or disability income 35 -1- LSB 5007SS (8) 84 av/rj 1/ 29

S.F. 2042 insurance, or any combination thereof. 1 (2) Coverage issued as a supplement to liability insurance. 2 (3) Liability insurance, including general liability 3 insurance and automobile liability insurance. 4 (4) Workers’ compensation or similar insurance. 5 (5) Automobile medical payment insurance. 6 (6) Credit-only insurance. 7 (7) Coverage for on-site medical clinics. 8 (8) Other similar insurance coverage, specified in federal 9 regulations issued pursuant to Tit. XXVII of the federal Public 10 Health Service Act, as enacted by the federal Health Insurance 11 Portability and Accountability Act of 1996, Pub. L. No. 12 104-191, and amended by the federal Act, under which benefits 13 for health care services are secondary or incidental to other 14 insurance benefits. 15 c. “Health benefit plan” does not include any of the 16 following benefits if they are provided under a separate 17 policy, certificate, or contract of insurance or are otherwise 18 not an integral part of the plan: 19 (1) Limited scope dental or vision benefits. 20 (2) Benefits for long-term care, nursing home care, home 21 health care, community-based care, or any combination thereof. 22 (3) Other similar, limited benefits specified in federal 23 regulations issued pursuant to the federal Health Insurance 24 Portability and Accountability Act of 1996, Pub. L. No. 25 104-191. 26 d. “Health benefit plan” does not include any of the 27 following benefits if the benefits are provided under a 28 separate policy, certificate, or contract of insurance, there 29 is no coordination between the provision of the benefits and 30 any exclusion of benefits under any group health benefit plan 31 maintained by the same plan sponsor, and the benefits are paid 32 with respect to an event without regard to whether benefits are 33 provided with respect to such an event under any group health 34 benefit plan maintained by the same plan sponsor: 35 -2- LSB 5007SS (8) 84 av/rj 2/ 29

S.F. 2042 (1) Coverage only for a specified disease or illness. 1 (2) Hospital indemnity or other fixed indemnity insurance. 2 e. “Health benefit plan” does not include any of the 3 following if offered as a separate policy, certificate, or 4 contract of insurance: 5 (1) Medicare supplemental health insurance as defined under 6 section 1882(g)(1) of the federal Social Security Act. 7 (2) Coverage supplemental to the coverage provided under 10 8 U.S.C. ch. 55, by the civilian health and medical program of 9 the uniformed services. 10 (3) Supplemental coverage similar to that provided under a 11 group health benefit plan. 12 6. “Health carrier” means an entity subject to the insurance 13 laws and rules of this state, or subject to the jurisdiction 14 of the commissioner, that contracts or offers to contract to 15 provide, deliver, arrange for, pay for, or reimburse any of 16 the costs of health care services, including an insurance 17 company offering sickness and accident plans, a health 18 maintenance organization, a nonprofit hospital or health 19 service corporation, or any other entity providing a plan of 20 health insurance, health benefits, or health services. 21 7. “Insurance producer” means a person required to be 22 licensed under chapter 522B. 23 8. “Marketplace” means the Iowa health benefit marketplace 24 established pursuant to section 514M.4. 25 9. “Navigator” means a person selected and regulated by the 26 marketplace in accordance with section 1311(i) of the federal 27 Act, standards developed by the secretary, and section 514M.9. 28 10. “Qualified dental plan” means a limited scope dental 29 plan that has been certified in accordance with section 30 514M.10. 31 11. “Qualified employer” means a small employer that 32 elects to make its full-time employees eligible for one or 33 more qualified health benefit plans offered through the small 34 business health options program of the marketplace, and at the 35 -3- LSB 5007SS (8) 84 av/rj 3/ 29

S.F. 2042 option of the employer, some or all of its part-time employees, 1 provided that the employer does either of the following: 2 a. Has its principal place of business in this state and 3 elects to provide coverage through the marketplace to all of 4 its eligible employees wherever employed. 5 b. Elects to provide coverage through the marketplace to all 6 of its eligible employees who are principally employed in this 7 state. 8 12. “Qualified health benefit plan” means a health benefit 9 plan that has in effect a certification as described in section 10 1311(c) of the federal Act and section 514M.10. 11 13. “Qualified individual” means an individual, including a 12 minor, who is all of the following: 13 a. Is seeking to enroll in a qualified health benefit plan 14 offered to individuals through the marketplace. 15 b. Is a resident of this state. 16 c. At the time of enrollment, is not incarcerated, other 17 than incarceration pending the disposition of charges. 18 d. Is, and is reasonably expected to be, for the entire 19 period for which enrollment is sought, a citizen or national of 20 the United States or an alien lawfully present in the United 21 States. 22 14. “Secretary” means the secretary of the United States 23 department of health and human services. 24 15. “Secretary of the board” means the secretary of the 25 board of directors of the Iowa health benefit marketplace. 26 16. “Small business health options program” means the small 27 business health options program component of the marketplace 28 established under section 514M.8. 29 17. a. “Small employer” means an employer that employed an 30 average of one to fifty employees during the preceding calendar 31 year. 32 b. For the purposes of this subsection: 33 (1) All persons treated as a single employer under 34 subsection (b), (c), (m), or (o) of section 414 of the Internal 35 -4- LSB 5007SS (8) 84 av/rj 4/ 29

S.F. 2042 Revenue Code of 1986 shall be treated as a single employer. 1 (2) An employer and any predecessor employer shall be 2 treated as a single employer. 3 (3) All employees shall be counted, including part-time 4 employees and employees who are not eligible for coverage 5 through the employer. 6 (4) If an employer was not in existence throughout the 7 preceding calendar year, the determination of whether that 8 employer is a small employer shall be based on the average 9 number of employees that the employer is reasonably expected to 10 employ on business days in the current calendar year. 11 (5) An employer that makes enrollment in qualified health 12 benefit plans available to its employees through the small 13 business health options program component of the marketplace, 14 and would cease to be a small employer by reason of an increase 15 in the number of its employees, shall continue to be treated 16 as a small employer for purposes of this chapter as long as 17 the employer continuously makes enrollment through the small 18 business health options program component of the marketplace 19 available to its employees. 20 Sec. 4. NEW SECTION . 514M.4 Establishment of Iowa health 21 benefit marketplace. 22 1. The Iowa health benefit marketplace is established as a 23 nonprofit corporation. The marketplace shall be established 24 for the purpose of facilitating the sale and purchase of 25 qualified health benefit plans by qualified individuals in 26 the individual market in this state and by qualified small 27 employers in the small group market in this state. 28 2. The powers and duties of the marketplace are vested in 29 and shall be exercised by a board of directors established 30 under section 514M.5. 31 3. The marketplace shall operate under a plan of operation 32 established and approved by the board of directors, in 33 consultation with the commissioner. The plan shall effectuate 34 the purposes of this chapter and assure the fair, reasonable, 35 -5- LSB 5007SS (8) 84 av/rj 5/ 29

S.F. 2042 and equitable administration of the marketplace. The board 1 shall do all of the following pursuant to the plan, including 2 but not limited to: 3 a. Plan, direct, coordinate, and execute the administrative 4 functions of the marketplace. 5 b. Employ professional and clerical staff as necessary. 6 c. Keep an accurate account of all activities, receipts, 7 and expenditures of the marketplace and annually submit a 8 report to the commissioner, governor, general assembly, and 9 the auditor of state concerning such accountings pursuant to 10 section 514M.14. 11 4. The marketplace shall be operated on a statewide basis. 12 5. The marketplace shall include separate marketplace 13 components which facilitate the sale and purchase of qualified 14 health benefit plans to eligible individuals and to small 15 employers as described in this chapter and in the federal Act. 16 6. The marketplace may establish a reimbursement system 17 for health benefit plans issued in this state that all health 18 carriers and health providers may join to facilitate fair 19 and reasonable payments for the cost of health care services 20 provided pursuant to a health benefit plan. 21 7. The marketplace shall do all of the following: 22 a. Facilitate the purchase and sale of qualified health 23 benefit plans to qualified individuals and qualified employers 24 as described in this chapter and in the federal Act. 25 b. Establish rate schedules for commissions paid to 26 insurance producers by qualified health benefit plans offered 27 through the marketplace. 28 c. Meet the requirements of this chapter and any rules 29 adopted pursuant to this chapter. 30 8. a. A person who selects, purchases, or enrolls in a 31 qualified health benefit plan offered through the marketplace 32 shall be enrolled in the plan by an insurance producer or may 33 enroll in the plan directly through the marketplace internet 34 site. The commission paid to an insurance producer who enrolls 35 -6- LSB 5007SS (8) 84 av/rj 6/ 29

S.F. 2042 a person in a plan offered through the marketplace shall be 1 established by the marketplace. 2 b. On the anniversary date of coverage obtained through 3 the marketplace, an enrollee may renew or enroll in coverage 4 offered through the marketplace through any insurance producer 5 of the enrollee’s choice or may enroll directly through the 6 marketplace internet site. A commission shall be paid to an 7 insurance producer who renews or enrolls a person in coverage 8 under this paragraph in the same manner as is provided in 9 paragraph “a” . 10 9. The marketplace may employ staff to carry out the 11 functions of the marketplace, but no employee of the 12 marketplace shall sell, solicit, or negotiate enrollment in 13 a health benefit plan or otherwise offer services for which 14 a license as an insurance producer is required pursuant to 15 chapter 522B. 16 10. The marketplace may contract with an eligible entity to 17 fulfill any of its specialized duties or responsibilities as 18 described in this chapter. An eligible entity includes but is 19 not limited to an entity that has experience in individual and 20 small group health benefit plans, benefit administration, or 21 other experience relevant to the responsibilities to be assumed 22 by the entity. However, a health carrier or an affiliate of a 23 health carrier is not an eligible entity for the purposes of 24 this subsection. 25 11. The marketplace may enter into information-sharing 26 agreements with federal and state agencies to carry out 27 its responsibilities under this chapter provided such 28 agreements include adequate protections with respect to the 29 confidentiality of the information to be shared and comply with 30 all state and federal laws and regulations. 31 12. Each qualified health benefit plan offered through 32 the marketplace shall be assigned a rating by the marketplace 33 in accordance with criteria developed by the secretary under 34 section 1311(c)(3) of the federal Act, and the marketplace 35 -7- LSB 5007SS (8) 84 av/rj 7/ 29

S.F. 2042 shall determine the level of coverage of each qualified health 1 benefit plan in accordance with regulations issued by the 2 secretary under section 1302(d)(2)(A) of the federal Act and 3 applicable state law. 4 13. If a qualified health benefit plan offered through 5 the marketplace meets or exceeds the criteria for a qualified 6 health benefit plan set forth by the secretary, the plan shall 7 be reviewed and assigned a rating by the marketplace. 8 Sec. 5. NEW SECTION . 514M.5 Board of directors —— executive 9 director —— secretary. 10 1. The board of directors of the Iowa health benefit 11 marketplace shall effectuate the powers and duties of the 12 marketplace as set forth in this chapter. 13 2. The board shall consist of seven voting members and 14 five ex officio, nonvoting members. The voting members shall 15 be appointed by the governor, subject to confirmation by the 16 senate. The voting members of the board shall annually elect 17 one voting member as chairperson and one voting member as vice 18 chairperson. 19 a. The voting members shall be appointed by the governor as 20 follows: 21 (1) Two persons who represent the interests of small 22 business from nominations made to the governor by nationally 23 recognized groups that represent the interests of small 24 business. 25 (2) Three persons who represent the interests of consumers 26 from nominations made to the governor by nationally recognized 27 groups that represent the interests of consumers. 28 (3) One person who is an insurance producer licensed under 29 chapter 522B. 30 (4) One person who is a health care provider. 31 b. The ex officio, nonvoting members of the board are as 32 follows: 33 (1) Four members of the general assembly, one appointed 34 by the speaker of the house of representatives, one appointed 35 -8- LSB 5007SS (8) 84 av/rj 8/ 29

S.F. 2042 by the minority leader of the house of representatives, 1 one appointed by the majority leader of the senate, and one 2 appointed by the minority leader of the senate. 3 (2) A person who shall serve as the secretary of the board, 4 appointed by the board. 5 3. The governor shall not appoint to the board any person 6 who is either the spouse or a relative within the first degree 7 of consanguinity of a serving member of the board. 8 4. Each member of the board appointed by the governor shall 9 be a resident of this state and the composition of voting 10 members of the board shall be in compliance with sections 11 69.16, 69.16A, and 69.16C. 12 5. The voting members of the board shall be appointed for 13 staggered terms of three years within sixty days after the 14 effective date of this Act and by December 15 of each year 15 thereafter. The initial terms of the voting members of the 16 board shall be staggered at the discretion of the governor. A 17 voting member of the board is eligible for reappointment. The 18 governor shall fill a vacancy on the board in the same manner 19 as the original appointment for the remainder of the term. A 20 voting member of the board may be removed by the governor for 21 misfeasance, malfeasance, willful neglect of duty, failure to 22 actively participate in the affairs of the board, or other 23 cause after notice and a public hearing unless the notice and 24 hearing are waived by the member in writing. 25 6. A voting member of the board shall not be an employee 26 of, a consultant to, a member of the board of directors of, 27 affiliated with, have an ownership interest in, or otherwise 28 be a representative of any health carrier, insurance producer 29 agency, insurance consultant organization, trade association of 30 insurers, or association offering health benefit plans to its 31 members, while serving on the board. 32 7. Voting members of the board shall be reimbursed from the 33 moneys of the marketplace for all actual and necessary expenses 34 incurred in the performance of their duties as members, and 35 -9- LSB 5007SS (8) 84 av/rj 9/ 29

S.F. 2042 shall receive per diem at the rate of fifty dollars per day for 1 their services. 2 8. A majority of the voting members of the board constitutes 3 a quorum. The affirmative vote of a majority of the voting 4 members is necessary for any action taken by the board. The 5 majority shall not include a member who has a conflict of 6 interest and a statement by a member of a conflict of interest 7 is conclusive for this purpose. A vacancy in the membership of 8 the board does not impair the right of a quorum to exercise the 9 rights and perform the duties of the board. An action taken by 10 the board under this chapter may be authorized by resolution 11 at a regular or special meeting and each resolution shall take 12 effect immediately and need not be published or posted. 13 9. The voting members of the board shall give bond as 14 required for public officers by chapter 64. 15 10. The voting members of the board are subject to and are 16 officials within the meaning of chapter 68B. 17 11. The board shall meet at the call of the chairperson, 18 or in the absence of the chairperson, at the call of the vice 19 chairperson, or when any four voting members of the board file 20 a written request with the chairperson for a meeting. Written 21 notice of the time and place of each meeting shall be given to 22 each member of the board. 23 12. a. The voting members of the board shall appoint an 24 executive director, subject to confirmation by the senate, to 25 supervise the administrative affairs and general management and 26 operations of the marketplace. 27 b. The voting members of the board may appoint other 28 officers as the members of the board determine. The officers 29 shall not be members of the board, with the exception of the 30 secretary of the board, and shall serve at the pleasure of the 31 voting members of the board, and shall receive compensation as 32 fixed by the board. 33 c. The board may employ other staff to carry out the 34 functions of the marketplace, but no employee of the 35 -10- LSB 5007SS (8) 84 av/rj 10/ 29

S.F. 2042 marketplace shall sell, solicit, or negotiate enrollment in 1 a health benefit plan or otherwise offer services for which 2 a license as an insurance producer is required pursuant to 3 chapter 522B. All employees of the marketplace are exempt from 4 chapter 8A, subchapter IV, and chapter 97B. 5 13. a. The voting members of the board shall appoint a 6 secretary of the board who shall be an ex officio member of the 7 board, shall keep a record of the proceedings of the board, 8 and shall be the custodian of all books, documents, and papers 9 filed with the board, and the minute book or journal of the 10 board. 11 b. The secretary of the board shall serve at the pleasure 12 of the board, and shall receive compensation as fixed by the 13 board. 14 14. Members of the board, or persons acting on behalf of 15 the marketplace, while acting in the scope of their agency or 16 employment, are not subject to personal liability resulting 17 from carrying out the powers and duties in this chapter. 18 Sec. 6. NEW SECTION . 514M.6 General powers. 19 1. The marketplace has any and all powers necessary and 20 convenient to carry out its purposes and duties and exercise 21 its specific powers, including but not limited to the power to: 22 a. Sue and be sued in its own name. 23 b. Have and alter a corporate seal. 24 c. Make and alter bylaws for its management consistent with 25 the provisions of this chapter. 26 d. Make and execute agreements, contracts, and other 27 instruments of any and all types on such terms and conditions 28 as the marketplace may find necessary or convenient to the 29 purpose of the marketplace, with any public or private entity, 30 including but not limited to contracts for goods and services. 31 All political subdivisions, other public agencies, and state 32 departments and agencies may enter into contracts and otherwise 33 cooperate with the marketplace. 34 e. Adopt procedures relating to competitive bidding, 35 -11- LSB 5007SS (8) 84 av/rj 11/ 29

S.F. 2042 including the identification of those circumstances under which 1 competitive bidding by the marketplace, either formally or 2 informally, shall be required. In any bidding process, the 3 marketplace may administer its own bidding and procurement or 4 may utilize the services of the department of administrative 5 services or any other agency. Except when such rules apply, 6 the marketplace and all contracts made by it in carrying out 7 its public and essential governmental functions with respect 8 to any of its purposes shall be exempt from the provisions 9 and requirements of all laws or rules of the state which 10 require competitive bids in connection with the letting of such 11 contracts. 12 f. Acquire, hold, improve, mortgage, lease, and dispose of 13 real and personal property, including but not limited to the 14 power to sell at public or private sale, with or without public 15 bidding, any such property, or other obligation held by it. 16 g. Procure insurance against any loss in connection with its 17 operations and property interests. 18 h. Accept appropriations, gifts, grants, loans, or other 19 aid from public or private entities. A record of all gifts or 20 grants, stating the type, amount, and donor, shall be clearly 21 set out in the marketplace’s annual report along with the 22 record of other receipts. 23 i. Provide to public and private entities technical 24 assistance and counseling related to the marketplace’s 25 purposes. 26 j. In cooperation with other local, state, or federal 27 governmental agencies, conduct research studies, develop 28 estimates of unmet health insurance needs, gather and compile 29 data useful to facilitating decision making, and enter into 30 agreements to carry out programs within or without the state 31 which the marketplace finds to be consistent with the goals of 32 the marketplace. 33 k. Enter into agreements with the federal government, 34 tribes, and other states to facilitate the sale or purchase of 35 -12- LSB 5007SS (8) 84 av/rj 12/ 29

S.F. 2042 qualified health benefit plans by qualified individuals and 1 qualified small employers in the state of Iowa. 2 l. Own or acquire intellectual property rights including 3 but not limited to copyrights, trademarks, service marks, and 4 patents, and enforce the rights of the marketplace with respect 5 to such intellectual property rights. 6 m. Form committees or panels as necessary to facilitate the 7 marketplace’s duties. Committees or panels formed pursuant to 8 this paragraph shall be subject to the provisions of chapters 9 21 and 22. 10 n. Establish one or more funds within the state treasury 11 under the control of the marketplace. Notwithstanding section 12 8.33 or 12C.7, or any other provision to the contrary, moneys 13 invested by the treasurer of state pursuant to this paragraph 14 shall not revert to the general fund of the state and interest 15 accrued on the moneys shall be moneys of the marketplace and 16 shall not be credited to the general fund of the state. The 17 nonreversion of moneys allowed under this paragraph does not 18 apply to moneys appropriated to the marketplace by the general 19 assembly. 20 o. Exercise generally all powers typically exercised by 21 private enterprises engaged in business pursuits unless the 22 exercise of such a power would violate the terms of this 23 chapter or the Constitution of the State of Iowa. 24 2. Notwithstanding any other provision of law, any purchase 25 or lease of real property, other than on a temporary basis, 26 when necessary in order to implement the purposes of the 27 marketplace or protect the investments of the marketplace, 28 shall require written notice from the marketplace to the 29 government oversight committees of the general assembly or 30 their successor committees and the prior approval of the 31 executive council. 32 3. The powers enumerated in this section are cumulative of 33 and in addition to those powers enumerated elsewhere in this 34 chapter and such powers do not limit or restrict any other 35 -13- LSB 5007SS (8) 84 av/rj 13/ 29

S.F. 2042 powers of the marketplace. 1 Sec. 7. NEW SECTION . 514M.7 Specific powers. 2 1. In addition to the general powers described in section 3 514M.6, the marketplace shall have all powers convenient and 4 necessary to carry out the purpose and intent of this chapter. 5 2. The marketplace established pursuant to section 514M.4 6 shall make qualified health benefit plans that are effective on 7 or before January 1, 2014, available to qualified individuals 8 and qualified employers in this state. 9 3. At such time as applications for waivers from the 10 requirements of the federal Act are accepted by the secretary, 11 the marketplace may request such waivers from the secretary. 12 4. The marketplace shall allow a health carrier to offer a 13 plan that provides limited scope dental benefits meeting the 14 requirements of section 9832(c)(2)(A) of the Internal Revenue 15 Code of 1986 through the marketplace, either separately or in 16 conjunction with a qualified health benefit plan, if the plan 17 provides pediatric dental benefits meeting the requirements of 18 section 1302(b)(1)(J) of the federal Act. 19 5. The marketplace or a health carrier offering qualified 20 health benefit plans through the marketplace shall not charge 21 an individual a fee or penalty for termination of coverage if 22 the individual enrolls in another type of minimum essential 23 coverage because the individual has become newly eligible for 24 that coverage or because the individual’s employer-sponsored 25 coverage has become affordable using the standards of the 26 federal Act, as codified at section 36B(c)(2)(C) of the 27 Internal Revenue Code of 1986. 28 Sec. 8. NEW SECTION . 514M.8 Duties of the marketplace. 29 The marketplace shall do all of the following: 30 1. Implement procedures for the certification, 31 recertification, and decertification of health benefit plans 32 as qualified health benefit plans, consistent with guidelines 33 developed by the secretary under section 1311(c) of the federal 34 Act and applicable state law. 35 -14- LSB 5007SS (8) 84 av/rj 14/ 29

S.F. 2042 2. Provide for the operation of a toll-free telephone 1 hotline to respond to requests for assistance. 2 3. Provide for enrollment periods, as determined by the 3 secretary under section 1311(c)(6) of the federal Act and 4 applicable state law. 5 4. Utilize a standardized format for presenting health 6 benefit plan options in the marketplace, including the use of 7 the uniform outline of coverage established under section 2715 8 of the Public Health Service Act and applicable state law. 9 5. In accordance with section 1413 of the federal Act 10 and applicable state law, inform individuals of eligibility 11 requirements for the Medicaid program under Tit. XIX of the 12 federal Social Security Act, the children’s health insurance 13 program under Tit. XXI of the federal Social Security Act, or 14 any applicable state or local public program and, if through 15 screening of an application by the marketplace, the marketplace 16 determines that any individual is eligible for any such 17 program, enroll that individual in that program. 18 6. Establish and make available by electronic means a 19 calculator to determine the actual cost of coverage after 20 application of any premium tax credit for which an individual 21 is eligible using the standards of the federal Act as codified 22 at section 36B(c)(2)(C) of the Internal Revenue Code of 1986 23 and any cost-sharing reductions under section 1402 of the 24 federal Act. 25 7. Establish a small business health options program 26 component of the marketplace through which individuals employed 27 by a qualified employer may enroll in any qualified health 28 benefit plan offered through the small business health options 29 program at the level of coverage specified by the employer. 30 In establishing a small business health options program 31 marketplace component, the marketplace shall do all of the 32 following: 33 a. Provide consolidated billing and premium payment by 34 qualified employers including detailed information to those 35 -15- LSB 5007SS (8) 84 av/rj 15/ 29

S.F. 2042 employers about health benefit plans chosen by their employees 1 and the cost of those plans. 2 b. Establish an electronic interface and facilitate the flow 3 of funds between health carriers, employers, and employees, 4 including subsidiaries. 5 c. Provide for the dissemination of health benefit plan 6 enrollment information to employers. 7 8. Establish an individual health options marketplace 8 component through which individuals may enroll in any qualified 9 health benefit plan for individuals. 10 9. Select entities qualified to serve as navigators in 11 accordance with section 1311(i) of the federal Act, standards 12 developed by the secretary, and applicable state law and award 13 grants to facilitate the function of navigators as provided in 14 section 514M.9. 15 10. Encourage and review the development of cafeteria plans 16 pursuant to section 125 of the Internal Revenue Code of 1986, 17 for use by employers participating in the marketplace. 18 11. Maintain an internet site through which enrollees, 19 employers, and prospective enrollees of qualified health 20 benefit plans, at a minimum, may obtain standardized 21 comparative information on qualified health benefit plans 22 and health benefit plans that are not offered through the 23 marketplace. In developing the electronic clearinghouse, 24 the marketplace may require health carriers participating in 25 the marketplace to make available and regularly update an 26 electronic directory of contracting health care providers so 27 individuals seeking coverage through the marketplace can search 28 by health care provider name to determine which qualified 29 health benefit plans in the marketplace include that health 30 care provider in their network, and whether that health care 31 provider is accepting new patients for that particular health 32 benefit plan. 33 12. Consult with stakeholders who are relevant to carrying 34 out the activities required under this chapter. 35 -16- LSB 5007SS (8) 84 av/rj 16/ 29

S.F. 2042 13. Assist in the implementation of reinsurance and risk 1 adjustment mechanisms, as required by state and federal law. 2 14. Establish guidelines for determining qualifications for 3 marketplace employees and entities or persons who are selected 4 as navigators. 5 15. Subject to section 1411 of the federal Act and 6 applicable state law, grant a certification attesting that, for 7 purposes of the individual responsibility penalty under the 8 standards of the federal Act, as codified at section 5000A of 9 the Internal Revenue Code of 1986, an individual is exempt from 10 the individual responsibility requirement or from the penalty 11 imposed by that section because of any of the following: 12 a. There is no affordable qualified health benefit plan 13 available through the marketplace, or the individual’s 14 employer, covering the individual. 15 b. The individual meets the requirements for any other such 16 exemption from the individual responsibility requirement or 17 penalty. 18 16. Transfer to the United States secretary of the treasury 19 all of the following: 20 a. A list of the individuals who are issued a certification 21 under subsection 15, paragraph “a” , including the name and 22 taxpayer identification number of each individual. 23 b. The name and taxpayer identification number of each 24 individual who was an employee of an employer but who was 25 determined to be eligible for the premium tax credit using 26 the standards of the federal Act as codified at section 27 36B(c)(2)(C) of the Internal Revenue Code of 1986, because of 28 either of the following: 29 (1) The employer did not provide minimum essential health 30 benefits coverage. 31 (2) The employer provided minimum essential health benefits 32 coverage, but it was determined using the standards of the 33 federal Act, as codified at section 36B(c)(2)(C) of the 34 Internal Revenue Code of 1986, to either be unaffordable to 35 -17- LSB 5007SS (8) 84 av/rj 17/ 29

S.F. 2042 the employee or not to provide the required minimum actuarial 1 value. 2 c. The name and taxpayer identification number of all of the 3 following: 4 (1) Each individual who notifies the marketplace under 5 section 1411(b)(4) of the federal Act that the individual has 6 changed employers. 7 (2) Each individual who ceases coverage under a qualified 8 health benefit plan during a plan year and the effective date 9 of that cessation. 10 17. Provide to each employer the name of each employee of 11 the employer described in subsection 16, paragraph “b” , who 12 ceases coverage under a qualified health benefit plan during a 13 plan year and the effective date of the cessation. 14 18. Perform duties required of, or delegated to, the 15 marketplace by the secretary, the United States secretary 16 of the treasury, or the commissioner related to determining 17 eligibility for premium tax credits, reduced cost-sharing, or 18 individual responsibility requirement exemptions. 19 19. In consultation with the commissioner, review the 20 rate of premium growth of health benefit plans within the 21 marketplace and outside the marketplace, and consider the 22 information obtained in developing recommendations on whether 23 to continue limiting qualified employer status to small 24 employers. 25 Sec. 9. NEW SECTION . 514M.9 Navigators. 26 1. The marketplace may select entities qualified to serve as 27 navigators in accordance with section 1311(i) of the federal 28 Act, standards developed by the secretary, and applicable state 29 law, and award grants to enable navigators to do all of the 30 following: 31 a. Conduct public education activities to raise awareness of 32 the availability of qualified health benefit plans through the 33 marketplace. 34 b. Distribute fair and impartial information concerning 35 -18- LSB 5007SS (8) 84 av/rj 18/ 29

S.F. 2042 enrollment in qualified health benefit plans, and the 1 availability of premium tax credits for which an individual 2 may be eligible using the standards of the federal Act, as 3 codified at section 36B(c)(2)(C) of the Internal Revenue Code 4 of 1986, and any cost-sharing reductions under section 1402 of 5 the federal Act. 6 c. Facilitate enrollment in qualified health benefit plans 7 offered through the marketplace or in health benefit plans 8 offered outside the marketplace by referring consumers to 9 insurance producers and to the marketplace internet site for 10 enrollment. 11 d. Provide referrals to the office of health insurance 12 consumer assistance established under the federal Act pursuant 13 to section 2793 of the federal Public Health Service Act 14 and the office of the commissioner or any other appropriate 15 state agency, for any enrollee with a grievance, complaint, 16 or question regarding the enrollee’s health benefit plan or 17 coverage, or a determination under that plan or coverage. 18 e. Provide information in a manner that is culturally and 19 linguistically appropriate to the needs of the population being 20 served by the marketplace. 21 2. An entity selected as a navigator shall not engage in 22 any activities that require licensure as an insurance producer 23 under chapter 522B. 24 Sec. 10. NEW SECTION . 514M.10 Health benefit plan 25 certification. 26 1. The marketplace may certify a health benefit plan as 27 a qualified health benefit plan if the plan meets all of the 28 following criteria: 29 a. The plan provides the essential health benefit package 30 described in section 1302(a) of the federal Act, except that 31 the plan is not required to provide essential benefits that 32 duplicate the minimum benefits of qualified dental plans as 33 provided in subsection 6 if all of the following occur: 34 (1) The marketplace determines that at least one qualified 35 -19- LSB 5007SS (8) 84 av/rj 19/ 29

S.F. 2042 dental plan is available to supplement the plan’s coverage. 1 (2) The health carrier makes a prominent disclosure at the 2 time it offers the plan, in a form approved by the marketplace, 3 that the plan does not provide the full range of essential 4 pediatric benefits and that qualified dental plans providing 5 those benefits and other dental benefits not covered by the 6 plan are offered through the marketplace. 7 b. The premium rates and contract language have been 8 approved by the commissioner. 9 c. The plan provides at least a bronze level of coverage, 10 as that level is defined by the federal Act, unless the plan 11 is certified as a qualified catastrophic plan, meets the 12 requirements of the federal Act for catastrophic plans, and 13 will only be offered to individuals eligible for catastrophic 14 coverage. 15 d. The plan’s cost-sharing requirements do not exceed the 16 limits established under section 1302(c)(1) of the federal Act, 17 and if the plan is offered through the small business health 18 options program component of the marketplace that offers plans 19 to small employers, the plan’s deductible does not exceed the 20 limits established under section 1302(c)(2) of the federal Act. 21 e. The plan offers wellness programs. 22 f. The health carrier offering the plan provides greater 23 transparency and disclosure of information about the plan 24 benefits, provider networks, claim payment practices, and 25 solvency ratings, and establishes a process for consumers to 26 compare features of health benefit plans offered through the 27 marketplace. 28 g. The health carrier offering the plan meets all of the 29 following criteria: 30 (1) Is licensed and in good standing to offer health 31 insurance coverage in this state. 32 (2) Offers at least one qualified health benefit plan in the 33 silver level and at least one qualified health benefit plan in 34 the gold level, as those levels are defined in the federal Act, 35 -20- LSB 5007SS (8) 84 av/rj 20/ 29