Senate File 2253 - Introduced SENATE FILE 2253 BY COMMITTEE ON COMMERCE (SUCCESSOR TO SF 2112) A BILL FOR An Act providing for the establishment of the Iowa health 1 insurance marketplace and including effective date 2 provisions. 3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 4 TLSB 5289SV (3) 85 rj/rj

S.F. 2253 DIVISION I 1 IOWA HEALTH INSURANCE MARKETPLACE ACT 2 Section 1. NEW SECTION . 514M.1 Title. 3 This chapter shall be known and may be cited as the “Iowa 4 Health Insurance Marketplace Act” . 5 Sec. 2. NEW SECTION . 514M.2 Purpose and intent. 6 The purpose of this chapter is to provide for the 7 establishment of a health insurance marketplace in this 8 state to facilitate the sale and purchase of qualified health 9 insurance plans by qualified individuals in the individual 10 market in this state and by qualified small employers in the 11 small group market in this state. The intent of authorizing 12 the establishment of a health insurance marketplace in this 13 state is to reduce the number of uninsured individuals in 14 this state, provide a transparent marketplace and consumer 15 education, and assist individuals with access to relevant 16 federal and state programs, premium assistance tax credits, and 17 cost-sharing reductions. 18 Sec. 3. NEW SECTION . 514M.3 Definitions. 19 As used in this chapter, unless the context otherwise 20 requires: 21 1. “Board” means the board of directors of the Iowa health 22 insurance marketplace as provided in section 514M.5. 23 2. “Commissioner” means the commissioner of insurance. 24 3. “Executive director” means the executive director of the 25 Iowa health insurance marketplace. 26 4. “Federal Act” means the federal Patient Protection and 27 Affordable Care Act, Pub. L. No. 111-148, as amended by the 28 federal Health Care and Education Reconciliation Act of 2010, 29 Pub. L. No. 111-152, and any amendments thereto, or regulations 30 or guidance issued under, those Acts. 31 5. “Health carrier” means an entity subject to the insurance 32 laws and rules of this state, or subject to the jurisdiction 33 of the commissioner, that contracts or offers to contract to 34 provide, deliver, arrange for, pay for, or reimburse any of 35 -1- LSB 5289SV (3) 85 rj/rj 1/ 31

S.F. 2253 the costs of health care services, including an insurance 1 company offering sickness and accident plans, a health 2 maintenance organization, a nonprofit hospital or health 3 service corporation, or any other entity providing a plan of 4 health insurance, health benefits, or health services. 5 6. a. “Health insurance plan” means a policy, contract, 6 certificate, or agreement offered or issued by a health carrier 7 to provide, deliver, arrange for, pay for, or reimburse any of 8 the costs of health care services. 9 b. “Health insurance plan” does not include any of the 10 following: 11 (1) Coverage only for accident, or disability income 12 insurance, or any combination thereof. 13 (2) Coverage issued as a supplement to liability insurance. 14 (3) Liability insurance, including general liability 15 insurance and automobile liability insurance. 16 (4) Workers’ compensation or similar insurance. 17 (5) Automobile medical payment insurance. 18 (6) Credit-only insurance. 19 (7) Coverage for on-site medical clinics. 20 (8) Other similar insurance coverage, specified in federal 21 regulations issued pursuant to Tit. XXVII of the federal Public 22 Health Service Act, as enacted by the federal Health Insurance 23 Portability and Accountability Act of 1996, Pub. L. No. 24 104-191, and amended by the federal Act, under which benefits 25 for health care services are secondary or incidental to other 26 insurance benefits. 27 c. “Health insurance plan” does not include any of the 28 following benefits if they are provided under a separate 29 policy, certificate, or contract of insurance or are otherwise 30 not an integral part of the plan: 31 (1) Limited scope dental or vision benefits. 32 (2) Benefits for long-term care, nursing home care, home 33 health care, community-based care, or any combination thereof. 34 (3) Other similar, limited benefits specified in federal 35 -2- LSB 5289SV (3) 85 rj/rj 2/ 31

S.F. 2253 regulations issued pursuant to the federal Health Insurance 1 Portability and Accountability Act of 1996, Pub. L. No. 2 104-191. 3 d. “Health insurance plan” does not include any of the 4 following benefits if the benefits are provided under a 5 separate policy, certificate, or contract of insurance, there 6 is no coordination between the provision of the benefits 7 and any exclusion of benefits under any group health plan 8 maintained by the same plan sponsor, and the benefits are paid 9 with respect to an event without regard to whether benefits are 10 provided with respect to such an event under any group health 11 plan maintained by the same plan sponsor: 12 (1) Coverage only for a specified disease or illness. 13 (2) Hospital indemnity or other fixed indemnity insurance. 14 e. “Health insurance plan” does not include any of the 15 following if offered as a separate policy, certificate, or 16 contract of insurance: 17 (1) Medicare supplemental health insurance as defined under 18 section 1882(g)(1) of the federal Social Security Act. 19 (2) Coverage supplemental to the coverage provided under 10 20 U.S.C. ch. 55, by the civilian health and medical program of 21 the uniformed services. 22 (3) Supplemental coverage similar to that provided under a 23 group health insurance plan. 24 7. “Insurance producer” means a person required to be 25 licensed under chapter 522B. 26 8. “Marketplace” means the Iowa health insurance marketplace 27 established pursuant to section 514M.4. 28 9. “Navigator” means a person selected, licensed, and 29 regulated by the marketplace in accordance with section 1311(i) 30 of the federal Act, standards developed by the secretary, and 31 chapter 522D. 32 10. “Qualified dental plan” means a limited scope dental 33 plan that has been certified in accordance with section 34 514M.10. 35 -3- LSB 5289SV (3) 85 rj/rj 3/ 31

S.F. 2253 11. “Qualified employer” means a small employer that elects 1 to make its full-time employees eligible for one or more 2 qualified health insurance plans offered through the small 3 business health options program of the marketplace, and at 4 the option of the employer, make some or all of its part-time 5 employees so eligible, provided that the employer does either 6 of the following: 7 a. Has its principal place of business in this state and 8 elects to provide coverage through the marketplace to all of 9 its eligible employees wherever employed. 10 b. Elects to provide coverage through the marketplace to all 11 of its eligible employees who are principally employed in this 12 state. 13 12. “Qualified health plan” means a health plan that has in 14 effect a certification as described in section 1311(c) of the 15 federal Act and section 514M.10. 16 13. “Qualified individual” means an individual, including a 17 minor, who is all of the following: 18 a. Is seeking to enroll in a qualified health plan offered 19 to individuals through the marketplace. 20 b. Is a resident of this state. 21 c. At the time of enrollment, is not incarcerated, other 22 than incarceration pending the disposition of charges. 23 d. Is, and is reasonably expected to be, for the entire 24 period for which enrollment is sought, a citizen or national of 25 the United States or an alien lawfully present in the United 26 States. 27 14. “Secretary” means the secretary of the United States 28 department of health and human services. 29 15. “Secretary of the board” means the secretary of the 30 board of directors of the Iowa health insurance marketplace. 31 16. “Small business health options program” means the small 32 business health options program component of the marketplace 33 established under section 514M.8. 34 17. a. “Small employer” means an employer that employed 35 -4- LSB 5289SV (3) 85 rj/rj 4/ 31

S.F. 2253 an average of at least one and not more than fifty employees 1 during the preceding calendar year. 2 b. For the purposes of this subsection: 3 (1) All persons treated as a single employer under 4 subsection (b), (c), (m), or (o) of section 414 of the Internal 5 Revenue Code of 1986 shall be treated as a single employer. 6 (2) An employer and any predecessor employer shall be 7 treated as a single employer. 8 (3) All employees shall be counted, including part-time 9 employees and employees who are not eligible for coverage 10 through the employer. 11 (4) If an employer was not in existence throughout the 12 preceding calendar year, the determination of whether that 13 employer is a small employer shall be based on the average 14 number of employees that the employer is reasonably expected to 15 employ on business days in the current calendar year. 16 (5) An employer that makes enrollment in qualified health 17 plans available to its employees through the small business 18 health options program component of the marketplace, and 19 would cease to be a small employer by reason of an increase 20 in the number of its employees, shall continue to be treated 21 as a small employer for purposes of this chapter as long as 22 the employer continuously makes enrollment through the small 23 business health options program component of the marketplace 24 available to its employees. 25 Sec. 4. NEW SECTION . 514M.4 Establishment of Iowa health 26 insurance marketplace. 27 1. The Iowa health insurance marketplace is established 28 as a nonprofit corporation. The marketplace shall be 29 established for the purpose of facilitating the sale and 30 purchase of qualified health plans by qualified individuals 31 in the individual market in this state and by qualified small 32 employers in the small group market in this state. 33 2. The powers and duties of the marketplace are vested in 34 and shall be exercised by a board of directors established 35 -5- LSB 5289SV (3) 85 rj/rj 5/ 31

S.F. 2253 under section 514M.5. 1 3. The marketplace shall operate under a plan of operation 2 established and approved by the board of directors, in 3 consultation with the commissioner. The plan shall effectuate 4 the purposes of this chapter and assure the fair, reasonable, 5 and equitable administration of the marketplace. The board 6 shall do all of the following pursuant to the plan, including 7 but not limited to: 8 a. Plan, direct, coordinate, and execute the administrative 9 functions of the marketplace. 10 b. Employ professional and clerical staff as necessary. 11 c. Keep an accurate account of all activities, receipts, 12 and expenditures of the marketplace and annually submit a 13 report to the commissioner, governor, general assembly, and 14 the auditor of state concerning such accountings pursuant to 15 section 514M.14. 16 4. The marketplace shall be operated on a statewide basis. 17 5. The marketplace shall include separate marketplace 18 components which facilitate the sale and purchase of qualified 19 health plans to eligible individuals and to small employers as 20 described in this chapter and in the federal Act. 21 6. The marketplace may establish a reimbursement system for 22 health insurance plans issued in this state that all health 23 carriers and health care providers may join to facilitate fair 24 and reasonable payments for the cost of health care services 25 provided pursuant to a health insurance plan. 26 7. The marketplace shall do all of the following: 27 a. Facilitate the purchase and sale of qualified health 28 plans to qualified individuals and qualified employers as 29 described in this chapter and in the federal Act. 30 b. Establish rate schedules for commissions paid to 31 insurance producers by qualified health plans offered through 32 the marketplace. 33 c. Meet the requirements of this chapter and any rules 34 adopted pursuant to this chapter. 35 -6- LSB 5289SV (3) 85 rj/rj 6/ 31

S.F. 2253 8. a. A person who selects, purchases, or enrolls in a 1 qualified health plan offered through the marketplace shall be 2 enrolled in the plan by an insurance producer or may enroll in 3 the plan directly through the marketplace internet site. The 4 commission paid to an insurance producer who enrolls a person 5 in a plan offered through the marketplace shall be established 6 by the marketplace. 7 b. On the anniversary date of coverage obtained through 8 the marketplace, an enrollee may renew or enroll in coverage 9 offered through the marketplace through any insurance producer 10 of the enrollee’s choice or may enroll directly through the 11 marketplace internet site. A commission shall be paid to an 12 insurance producer who renews or enrolls a person in coverage 13 under this paragraph in the same manner as is provided in 14 paragraph “a” . 15 9. The marketplace may contract with an experienced and 16 reputable entity to develop and maintain the marketplace’s 17 internet site. The entity shall preferably have relevant 18 experience in developing and maintaining similar state health 19 insurance plan internet sites. 20 10. The marketplace may employ staff to carry out 21 the functions of the marketplace, but no employee of the 22 marketplace shall sell, solicit, or negotiate enrollment in a 23 health insurance plan or otherwise offer services for which 24 a license as an insurance producer is required pursuant to 25 chapter 522B. 26 11. The marketplace may contract with an eligible entity to 27 fulfill any of its specialized duties or responsibilities as 28 described in this chapter. An eligible entity includes but is 29 not limited to an entity that has experience in individual and 30 small group health insurance plans, benefit administration, or 31 other experience relevant to the responsibilities to be assumed 32 by the entity. However, a health carrier or an affiliate of a 33 health carrier is not an eligible entity for the purposes of 34 this subsection. 35 -7- LSB 5289SV (3) 85 rj/rj 7/ 31

S.F. 2253 12. The marketplace may enter into information-sharing 1 agreements with federal and state agencies to carry out 2 its responsibilities under this chapter provided such 3 agreements include adequate protections with respect to the 4 confidentiality of the information to be shared and comply with 5 all state laws and rules and federal laws and regulations. 6 13. Each qualified health plan offered through the 7 marketplace shall be assigned a rating by the marketplace in 8 accordance with criteria developed by the secretary under 9 section 1311(c)(3) of the federal Act, and the marketplace 10 shall determine the level of coverage of each qualified health 11 plan in accordance with regulations issued by the secretary 12 under section 1302(d)(2)(A) of the federal Act and applicable 13 state law. 14 14. If a qualified health plan offered through the 15 marketplace meets or exceeds the criteria for a qualified 16 health plan set forth by the secretary, the plan shall be 17 reviewed and assigned a rating by the marketplace. 18 Sec. 5. NEW SECTION . 514M.5 Board of directors —— executive 19 director —— secretary. 20 1. The board of directors of the Iowa health insurance 21 marketplace shall effectuate the powers and duties of the 22 marketplace as set forth in this chapter. 23 2. a. The board shall consist of seven members. The 24 members shall be appointed by the governor, subject to 25 confirmation by the senate. The members of the board shall 26 annually elect one member as chairperson and one member as vice 27 chairperson. 28 b. The members shall be appointed by the governor as 29 follows: 30 (1) Two persons who represent the interests of small 31 business from nominations made to the governor by nationally 32 recognized groups that represent the interests of small 33 business. 34 (2) Three persons who represent the interests of consumers 35 -8- LSB 5289SV (3) 85 rj/rj 8/ 31

S.F. 2253 from nominations made to the governor by nationally recognized 1 groups that represent the interests of consumers. 2 (3) One person who is an insurance producer licensed under 3 chapter 522B. 4 (4) One person who is a health care provider. 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 members of 10 the board shall be in compliance with sections 69.16, 69.16A, 11 and 69.16C. 12 5. The members of the board shall be appointed for staggered 13 terms of three years as provided in section 69.19. The initial 14 terms of the members of the board shall be staggered at the 15 discretion of the governor. A member of the board is eligible 16 for reappointment. The governor shall fill a vacancy on the 17 board in the same manner as the original appointment for the 18 remainder of the term. A member of the board may be removed 19 by the governor for misfeasance, malfeasance, willful neglect 20 of duty, failure to actively participate in the affairs of the 21 board, or other cause after notice and a public hearing unless 22 the notice and hearing are waived by the member in writing. 23 6. A member of the board shall not be an employee of, 24 a consultant to, a member of the board of directors of, 25 affiliated with, have an ownership interest in, or otherwise 26 be a representative of any health carrier, insurance producer 27 agency, insurance consultant organization, trade association of 28 insurers, or association offering health insurance plans to its 29 members, while serving on the board. 30 7. Members of the board shall be reimbursed from the moneys 31 of the marketplace for all actual and necessary expenses 32 incurred in the performance of their duties as members, and 33 shall receive per diem at the rate of fifty dollars per day for 34 their services. 35 -9- LSB 5289SV (3) 85 rj/rj 9/ 31

S.F. 2253 8. A majority of the members of the board constitutes a 1 quorum. The affirmative vote of a majority of the members is 2 necessary for any action taken by the board. The majority 3 shall not include a member who has a conflict of interest and a 4 statement by a member of a conflict of interest is conclusive 5 for this purpose. A vacancy in the membership of the board 6 does not impair the right of a quorum to exercise the rights 7 and perform the duties of the board. An action taken by the 8 board under this chapter may be authorized by resolution at 9 a regular or special meeting and each resolution shall take 10 effect immediately and need not be published or posted. 11 9. The members of the board shall give bond as required for 12 public officers by chapter 64. 13 10. The members of the board are subject to and are 14 officials within the meaning of chapter 68B. 15 11. The board shall meet at the call of the chairperson, 16 or in the absence of the chairperson, at the call of the vice 17 chairperson, or when any four members of the board file a 18 written request with the chairperson for a meeting. Written 19 notice of the time and place of each meeting shall be given to 20 each member of the board. 21 12. a. The members of the board shall appoint an executive 22 director, subject to confirmation by the senate, to supervise 23 the administrative affairs and general management and 24 operations of the marketplace. 25 b. The members of the board may appoint other officers as 26 the members of the board determine. The officers shall not be 27 members of the board and shall serve at the pleasure of the 28 members of the board, and shall receive compensation as fixed 29 by the board. 30 c. The board may employ other staff to carry out the 31 functions of the marketplace, but no employee of the 32 marketplace shall sell, solicit, or negotiate enrollment in a 33 health insurance plan or otherwise offer services for which 34 a license as an insurance producer is required pursuant to 35 -10- LSB 5289SV (3) 85 rj/rj 10/ 31

S.F. 2253 chapter 522B. All employees of the marketplace are exempt from 1 chapter 8A, subchapter IV, and chapter 97B. 2 13. a. The members of the board shall appoint a secretary 3 of the board who shall keep a record of the proceedings of the 4 board, and shall be the custodian of all books, documents, and 5 papers filed with the board, including information filed in an 6 electronic format, and the minute book or journal of the board. 7 b. The secretary of the board shall serve at the pleasure 8 of the board, and shall receive compensation as fixed by the 9 board. 10 14. Members of the board, or persons acting on behalf of 11 the marketplace, while acting in the scope of their agency or 12 employment, are not subject to personal liability resulting 13 from carrying out the powers and duties in this chapter. 14 Sec. 6. NEW SECTION . 514M.6 General powers. 15 1. The marketplace has any and all powers necessary and 16 convenient to carry out its purposes and duties and exercise 17 its specific powers, including but not limited to the power to: 18 a. Sue and be sued in its own name. 19 b. Have and alter a corporate seal. 20 c. Make and alter bylaws for its management consistent with 21 the provisions of this chapter. 22 d. Make and execute agreements, contracts, and other 23 instruments of any and all types on such terms and conditions 24 as the marketplace may find necessary or convenient to the 25 purpose of the marketplace, with any public or private entity, 26 including but not limited to contracts for goods and services. 27 All political subdivisions, other public agencies, and state 28 departments and agencies may enter into contracts and otherwise 29 cooperate with the marketplace. 30 e. Adopt procedures relating to competitive bidding, 31 including the identification of those circumstances under 32 which competitive bidding by the marketplace, either 33 formally or informally, shall be required. In any bidding 34 process, the marketplace may administer its own bidding and 35 -11- LSB 5289SV (3) 85 rj/rj 11/ 31

S.F. 2253 procurement or may utilize the services of the department of 1 administrative services or any other agency. Except when such 2 rules apply, the marketplace and all contracts entered into 3 by the marketplace in carrying out its public and essential 4 governmental functions with respect to any of its purposes 5 shall be exempt from the provisions and requirements of all 6 laws or rules of the state which require competitive bids in 7 connection with the letting of such contracts. 8 f. Acquire, hold, improve, mortgage, lease, and dispose of 9 real and personal property, including but not limited to the 10 power to sell at public or private sale, with or without public 11 bidding, any such property, or other obligation held by it. 12 g. Procure insurance against any loss in connection with its 13 operations and property interests. 14 h. Accept appropriations, gifts, grants, loans, or other 15 aid from public or private entities. A record of all gifts or 16 grants, stating the type, amount, and donor, shall be clearly 17 set out in the marketplace’s annual report along with the 18 record of other receipts. 19 i. Provide to public and private entities technical 20 assistance and counseling related to the marketplace’s 21 purposes. 22 j. In cooperation with other local, state, or federal 23 governmental agencies, conduct research studies, develop 24 estimates of unmet health insurance needs, gather and compile 25 data useful to facilitating decision making, and enter into 26 agreements to carry out programs within or without the state 27 which the marketplace finds to be consistent with the goals of 28 the marketplace. 29 k. Enter into agreements with the federal government, 30 tribes, and other states to facilitate the sale or purchase of 31 qualified health plans by qualified individuals and qualified 32 small employers in this state. 33 l. Own or acquire intellectual property rights including 34 but not limited to copyrights, trademarks, service marks, and 35 -12- LSB 5289SV (3) 85 rj/rj 12/ 31

S.F. 2253 patents, and enforce the rights of the marketplace with respect 1 to such intellectual property rights. 2 m. Form committees or panels as necessary to facilitate the 3 marketplace’s duties. Committees or panels formed pursuant to 4 this paragraph shall be subject to the provisions of chapters 5 21 and 22. 6 n. Establish one or more funds within the state treasury 7 under the control of the marketplace. Notwithstanding section 8 8.33 or 12C.7, or any other provision to the contrary, moneys 9 invested by the treasurer of state pursuant to this paragraph 10 shall not revert to the general fund of the state and interest 11 accrued on the moneys shall be moneys of the marketplace and 12 shall not be credited to the general fund of the state. The 13 nonreversion of moneys allowed under this paragraph does not 14 apply to moneys appropriated to the marketplace by the general 15 assembly. 16 o. Exercise generally all powers typically exercised by 17 private enterprises engaged in business pursuits unless the 18 exercise of such a power would violate the terms of this 19 chapter or the Constitution of the State of Iowa. 20 2. Notwithstanding any other provision of law, any purchase 21 or lease of real property, other than on a temporary basis, 22 when necessary in order to implement the purposes of the 23 marketplace or protect the investments of the marketplace, 24 shall require written notice from the marketplace to the 25 government oversight committees of the general assembly or 26 their successor committees and the prior approval of the 27 executive council. 28 3. The powers enumerated in this section are cumulative of 29 and in addition to those powers enumerated elsewhere in this 30 chapter and such powers do not limit or restrict any other 31 powers of the marketplace. 32 Sec. 7. NEW SECTION . 514M.7 Specific powers. 33 1. In addition to the general powers described in section 34 514M.6, the marketplace shall have all powers convenient and 35 -13- LSB 5289SV (3) 85 rj/rj 13/ 31

S.F. 2253 necessary to carry out the purpose and intent of this chapter. 1 2. The marketplace established pursuant to section 514M.4 2 shall make qualified health plans that are effective on January 3 1, 2016, available to qualified individuals and qualified 4 employers in this state. 5 3. At such time as applications for waivers from the 6 requirements of the federal Act are accepted by the secretary, 7 the marketplace may request such waivers from the secretary. 8 4. The marketplace shall allow a health carrier to offer a 9 plan that provides limited scope dental benefits meeting the 10 requirements of section 9832(c)(2)(A) of the Internal Revenue 11 Code of 1986 through the marketplace, either separately or in 12 conjunction with a qualified health plan, if the plan provides 13 pediatric dental benefits meeting the requirements of section 14 1302(b)(1)(J) of the federal Act. 15 5. The marketplace or a health carrier offering qualified 16 health plans through the marketplace shall not charge an 17 individual a fee or penalty for termination of coverage if 18 the individual enrolls in another type of minimum essential 19 coverage because the individual has become newly eligible for 20 that coverage or because the individual’s employer-sponsored 21 coverage has become affordable using the standards of the 22 federal Act, as codified at section 36B(c)(2)(C) of the 23 Internal Revenue Code of 1986. 24 Sec. 8. NEW SECTION . 514M.8 Duties of the marketplace. 25 The marketplace shall do all of the following: 26 1. Implement procedures for the certification, 27 recertification, and decertification of health insurance plans 28 as qualified health plans, consistent with guidelines developed 29 by the secretary under section 1311(c) of the federal Act and 30 applicable state law. 31 2. Provide for the operation of an internet site, a 32 toll-free telephone hotline, and in-person support staff 33 available in selected locations in the state to respond to 34 requests for assistance. 35 -14- LSB 5289SV (3) 85 rj/rj 14/ 31

S.F. 2253 3. Provide for enrollment periods, as determined by the 1 secretary under section 1311(c)(6) of the federal Act and 2 applicable state law. 3 4. Utilize a standardized format for presenting health 4 insurance plan options in the marketplace, including the use of 5 the uniform outline of coverage established under section 2715 6 of the Public Health Service Act and applicable state law. 7 5. In accordance with section 1413 of the federal Act 8 and applicable state law, inform individuals of eligibility 9 requirements for the Medicaid program under Tit. XIX of the 10 federal Social Security Act, the children’s health insurance 11 program under Tit. XXI of the federal Social Security Act, 12 or any applicable state or local public program, screen 13 any application received by the marketplace, and assist 14 the department of human services in enrolling any eligible 15 individual for any such program. 16 6. Establish and make available by electronic means a 17 calculator to determine the actual cost of coverage after 18 application of any premium tax credit for which an individual 19 is eligible using the standards of the federal Act as codified 20 at section 36B(c)(2)(C) of the Internal Revenue Code of 1986 21 and any cost-sharing reductions under section 1402 of the 22 federal Act. 23 7. Establish a small business health options program 24 component of the marketplace through which individuals 25 employed by a qualified employer may enroll in any qualified 26 health plan offered through the small business health options 27 program at the level of coverage specified by the employer. 28 In establishing a small business health options program 29 marketplace component, the marketplace shall do all of the 30 following: 31 a. Provide consolidated billing and premium payment 32 by qualified employers including detailed information to 33 those employers about health insurance plans chosen by their 34 employees and the cost of those plans. 35 -15- LSB 5289SV (3) 85 rj/rj 15/ 31

S.F. 2253 b. Establish an electronic interface and facilitate the flow 1 of funds between health carriers, employers, and employees, 2 including subsidiaries. 3 c. Provide for the dissemination of health insurance plan 4 enrollment information to employers. 5 8. Establish an individual health options marketplace 6 component through which individuals may enroll in any qualified 7 health plan for individuals. 8 9. Establish and operate a program to engage both certified 9 application counselors and navigators to facilitate the 10 enrollment of applicants in qualified health plans offered 11 through the marketplace or in health insurance plans offered 12 outside the marketplace. 13 10. Select entities qualified and licensed to serve as 14 navigators in accordance with section 1311(i) of the federal 15 Act, standards developed by the secretary, section 514M.9, and 16 chapter 522D, and award grants to facilitate the function of 17 navigators as provided in section 514M.9. 18 11. Encourage and review the development of cafeteria plans 19 pursuant to section 125 of the Internal Revenue Code of 1986, 20 for use by employers participating in the marketplace. 21 12. Maintain an internet site through which enrollees, 22 employers, and prospective enrollees of qualified health 23 plans, at a minimum, may obtain standardized comparative 24 information on qualified health plans and health plans that 25 are not offered through the marketplace. In developing the 26 electronic clearinghouse, the marketplace may require health 27 carriers participating in the marketplace to make available 28 and regularly update an electronic directory of contracting 29 health care providers so individuals seeking coverage through 30 the marketplace can search by health care provider name to 31 determine which qualified health plans in the marketplace 32 include that health care provider in their network, and whether 33 that health care provider is accepting new patients for that 34 particular health plan. 35 -16- LSB 5289SV (3) 85 rj/rj 16/ 31

S.F. 2253 13. Consult with stakeholders who are relevant to carrying 1 out the activities required under this chapter. 2 14. Assist in the implementation of reinsurance and risk 3 adjustment mechanisms, as required by state and federal law. 4 15. Establish guidelines for determining qualifications for 5 marketplace employees and entities or persons who are licensed 6 and selected as navigators. 7 16. Subject to section 1411 of the federal Act and 8 applicable state law, grant a certification attesting that, for 9 purposes of the individual responsibility penalty under the 10 standards of the federal Act, as codified at section 5000A of 11 the Internal Revenue Code of 1986, an individual is exempt from 12 the individual responsibility requirement or from the penalty 13 imposed by that section because of any of the following: 14 a. There is no affordable qualified health plan available 15 through the marketplace, or the individual’s employer, covering 16 the individual. 17 b. The individual meets the requirements for any other such 18 exemption from the individual responsibility requirement or 19 penalty. 20 17. Transfer to the United States secretary of the treasury 21 all of the following: 22 a. A list of the individuals who are issued a certification 23 under subsection 16, paragraph “a” , including the name and 24 taxpayer identification number of each individual. 25 b. The name and taxpayer identification number of each 26 individual who was an employee of an employer but who was 27 determined to be eligible for the premium tax credit using 28 the standards of the federal Act as codified at section 29 36B(c)(2)(C) of the Internal Revenue Code of 1986, because of 30 either of the following: 31 (1) The employer did not provide minimum essential health 32 benefits coverage. 33 (2) The employer provided minimum essential health benefits 34 coverage, but it was determined using the standards of the 35 -17- LSB 5289SV (3) 85 rj/rj 17/ 31

S.F. 2253 federal Act, as codified at section 36B(c)(2)(C) of the 1 Internal Revenue Code of 1986, to either be unaffordable to 2 the employee or not to provide the required minimum actuarial 3 value. 4 c. The name and taxpayer identification number of all of the 5 following: 6 (1) Each individual who notifies the marketplace under 7 section 1411(b)(4) of the federal Act that the individual has 8 changed employers. 9 (2) Each individual who ceases coverage under a qualified 10 health plan during a plan year and the effective date of that 11 cessation. 12 18. Provide to each employer the name of each employee of 13 the employer described in subsection 17, paragraph “b” , who 14 ceases coverage under a qualified health plan during a plan 15 year and the effective date of the cessation. 16 19. Perform duties required of, or delegated to, the 17 marketplace by the secretary, the United States secretary 18 of the treasury, or the commissioner related to determining 19 eligibility for premium tax credits, reduced cost-sharing, or 20 individual responsibility requirement exemptions. 21 20. In consultation with the commissioner, review the 22 rate of premium growth of health insurance plans within the 23 marketplace and outside the marketplace, and consider the 24 information obtained in developing recommendations on whether 25 to continue limiting qualified employer status to small 26 employers. 27 Sec. 9. NEW SECTION . 514M.9 Navigators. 28 1. The marketplace may select entities qualified and 29 licensed to serve as navigators in accordance with section 30 1311(i) of the federal Act, standards developed by the 31 secretary, and applicable state law including chapter 522D, and 32 award grants to enable navigators to do all of the following: 33 a. Conduct public education activities to raise awareness 34 of the availability of qualified health plans through the 35 -18- LSB 5289SV (3) 85 rj/rj 18/ 31

S.F. 2253 marketplace. 1 b. Distribute fair and impartial information concerning 2 enrollment in qualified health plans, and the availability of 3 premium tax credits for which an individual may be eligible 4 using the standards of the federal Act, as codified at section 5 36B(c)(2)(C) of the Internal Revenue Code of 1986, and any 6 cost-sharing reductions under section 1402 of the federal Act. 7 c. Facilitate enrollment in qualified health plans offered 8 through the marketplace or in health insurance plans offered 9 outside the marketplace by referring consumers to insurance 10 producers and to the marketplace internet site for 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 insurance 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 and licensed as a navigator shall not 22 engage in any activities that require licensure as an insurance 23 producer under chapter 522B unless the entity is also licensed 24 as an insurance producer. 25 Sec. 10. NEW SECTION . 514M.10 Health insurance plan 26 certification. 27 1. The marketplace may certify a health insurance plan as a 28 qualified health plan if the plan meets all of the following 29 criteria: 30 a. The plan provides the essential health benefit package 31 described in section 1302(a) of the federal Act, except that 32 the plan is not required to provide essential benefits that 33 duplicate the minimum benefits of qualified dental plans as 34 provided in subsection 6 if all of the following occur: 35 -19- LSB 5289SV (3) 85 rj/rj 19/ 31

S.F. 2253 (1) The marketplace determines that at least one qualified 1 dental plan is available to supplement the plan’s coverage. 2 (2) The health carrier makes a prominent disclosure at the 3 time it offers the plan, in a form approved by the marketplace, 4 that the plan does not provide the full range of essential 5 pediatric benefits and that qualified dental plans providing 6 those benefits and other dental benefits not covered by the 7 plan are offered through the marketplace. 8 b. The premium rates and contract language have been 9 approved by the commissioner. 10 c. The plan provides at least a bronze level of coverage, 11 as that level is defined by the federal Act, unless the plan 12 is certified as a qualified catastrophic plan, meets the 13 requirements of the federal Act for catastrophic plans, and 14 will only be offered to individuals eligible for catastrophic 15 coverage. 16 d. The plan’s cost-sharing requirements do not exceed the 17 limits established under section 1302(c)(1) of the federal Act, 18 and if the plan is offered through the small business health 19 options program component of the marketplace that offers plans 20 to small employers, the plan’s deductible does not exceed the 21 limits established under section 1302(c)(2) of the federal Act. 22 e. The plan offers wellness programs. 23 f. The health carrier offering the plan provides greater 24 transparency and disclosure of information about the plan 25 benefits, provider networks, claim payment practices, and 26 solvency ratings, and establishes a process for consumers to 27 compare features of health insurance plans offered through the 28 marketplace. 29 g. The health carrier offering the plan meets all of the 30 following criteria: 31 (1) Is licensed and in good standing to offer health 32 insurance coverage in this state. 33 (2) Offers at least one qualified health plan in the silver 34 level and at least one qualified health plan in the gold level, 35 -20- LSB 5289SV (3) 85 rj/rj 20/ 31