H.F. 349 Section 1. NEW SECTION . 507B.5A Discrimination in health 1 benefit plan design prohibited. 2 1. A carrier that offers a policy, contract, or plan that 3 covers the essential health benefits as required pursuant 4 to section 1302 of the federal Patient Protection and 5 Affordable Care Act, Pub. L. No. 111-148, and its implementing 6 regulations, shall not use a plan benefit design or a manner of 7 implementing a plan benefit design for providing the essential 8 health benefits that discriminates against an enrollee based 9 on the enrollee’s age, expected length of life, race, color, 10 national origin, sex, gender identity, sexual orientation, 11 present or predicted disability, degree of medical dependency, 12 quality of life, or present or predicted diagnosis, disease, or 13 health condition. The commissioner may adopt rules pursuant to 14 chapter 17A to administer this section. 15 2. For purposes of this section, unless the context 16 otherwise requires, “carrier” means the same as defined in 17 section 513B.2. 18 Sec. 2. NEW SECTION . 514K.2 Health carrier disclosures —— 19 public internet sites. 20 1. A carrier that provides small group health coverage 21 pursuant to chapter 513B or individual health coverage pursuant 22 to chapter 513C and that offers for sale a policy, contract, 23 or plan that covers the essential health benefits required 24 pursuant to section 1302 of the federal Patient Protection and 25 Affordable Care Act, Pub. L. No. 111-148, and its implementing 26 regulations, shall provide to each of its enrollees at the 27 time of enrollment, and shall make available to prospective 28 enrollees and enrollees, insurance producers licensed under 29 chapter 522B, and the general public, on the carrier’s 30 internet site, all of the following information in a clear and 31 understandable form for use in comparing policies, contracts, 32 and plans, and coverage and premiums: 33 a. Any exclusions from coverage and any restrictions on 34 the use or quantity of covered items and services in each 35 -1- LSB 2239YH (5) 86 av/nh 1/ 5

H.F. 349 category of benefits, including prescription drugs and drugs 1 administered by a physician or clinic. 2 b. Any items or services, including prescription drugs, that 3 have a coinsurance requirement where the cost-sharing required 4 depends on the cost of the item or service. 5 c. The specific prescription drugs available on the 6 carrier’s formulary, the specific prescription drugs covered 7 when furnished by a physician or clinic, and any clinical 8 prerequisites or prior authorization requirements for coverage 9 of the drugs. 10 d. The specific types of specialists available in the 11 carrier’s network and the specific physicians included in the 12 carrier’s network. 13 e. The process for an enrollee to appeal a carrier’s denial 14 of coverage of an item or service prescribed or ordered by the 15 enrollee’s treating physician. 16 f. How medications will specifically be included in or 17 excluded from the deductible, including a description of all 18 out-of-pocket costs that may not apply to the deductible for a 19 prescription drug. 20 2. The commissioner may adopt rules pursuant to chapter 17A 21 to administer this section. 22 3. The commissioner may impose any of the sanctions provided 23 under chapter 507B for a violation of this section. 24 Sec. 3. NEW SECTION . 514K.3 Health care plan internal 25 appeals process —— disclosure requirements. 26 1. A carrier that provides small group health coverage 27 pursuant to chapter 513B or individual health coverage pursuant 28 to chapter 513C through the issuance of nongrandfathered 29 health plans as defined in section 1251 of the federal Patient 30 Protection and Affordable Care Act, Pub. L. No. 111-148, and 31 in 45 C.F.R. §147.140, shall implement and maintain procedures 32 for carrying out an effective internal claims and appeals 33 process that meets the requirements established pursuant to 34 section 2719 of the federal Public Health Service Act, 42 35 -2- LSB 2239YH (5) 86 av/nh 2/ 5

H.F. 349 U.S.C. §300gg-19, and 45 C.F.R. §147.136. The procedures shall 1 include but are not limited to all of the following: 2 a. Expedited notification to enrollees of benefit 3 determinations involving urgent care. 4 b. Full and fair internal review of claims and appeals. 5 c. Avoidance of conflicts of interest. 6 d. Sufficient notice to enrollees, including a description 7 of available internal claims and appeals procedures, as well 8 as information about how to initiate an appeal of a denial of 9 coverage. 10 2. a. A carrier that provides health coverage as described 11 in subsection 1 shall maintain written records of all requests 12 for internal claims and appeals that are received and for which 13 internal review was performed during each calendar year. Such 14 records shall be maintained for at least three years. 15 b. A carrier that provides health coverage as described in 16 subsection 1 shall submit to the commissioner, upon request, a 17 report that includes all of the following: 18 (1) The total number of requests for internal review of 19 claims and appeals that are received by the carrier each year. 20 (2) The average length of time for resolution of each 21 request for internal review of a claim or appeal. 22 (3) A summary of the types of coverage or cases for which 23 internal review of a claim or appeal was requested. 24 (4) Any other information required by the commissioner in a 25 format specified by rule. 26 3. A carrier that provides health coverage as described 27 in subsection 1 shall make available to consumers written 28 notice of the carrier’s internal claims and appeals and 29 internal review procedures and shall maintain a toll-free 30 consumer-assistance telephone helpline that offers consumers 31 assistance with the carrier’s internal claims and appeals 32 and internal review procedures, including how to initiate, 33 complete, or submit a claim or appeal. 34 4. The commissioner may adopt rules pursuant to chapter 17A 35 -3- LSB 2239YH (5) 86 av/nh 3/ 5

H.F. 349 to administer this section. 1 Sec. 4. APPLICABILITY. This Act is applicable to health 2 insurance policies, contracts, or plans that are delivered, 3 issued for delivery, continued, or renewed on or after January 4 1, 2016. 5 EXPLANATION 6 The inclusion of this explanation does not constitute agreement with 7 the explanation’s substance by the members of the general assembly. 8 This bill relates to certain health coverage offered in this 9 state that covers the essential health benefits required by the 10 federal Patient Protection and Affordable Care Act and includes 11 applicability and penalty provisions. 12 New Code section 507B.5A prohibits a health carrier that 13 offers such coverage from using a plan benefit design that 14 discriminates against an enrollee on specified bases. The 15 commissioner of insurance may adopt rules to administer the 16 provision. A person who violates the new Code section is 17 subject to the enforcement provisions of Code chapter 507B 18 including cease and desist orders and civil penalties. 19 New Code section 514K.2 requires health carriers that 20 provide small group or individual health coverage that covers 21 the essential health benefits to make information available 22 to prospective enrollees and enrollees, insurance producers, 23 and the general public on the carrier’s internet site that can 24 be used to compare policies, contracts, and plans and coverage 25 and premiums. The bill specifies what information must be 26 included. The commissioner may adopt rules to administer the 27 new Code section. The commissioner may impose any of the 28 sanctions available under Code chapter 507B for a violation of 29 the new Code section. 30 New Code section 514K.3 requires health carriers that 31 provide small group or individual health coverage that covers 32 the essential health benefits to implement and maintain 33 procedures for carrying out effective internal claims and 34 appeals and specifies what these procedures must include. The 35 -4- LSB 2239YH (5) 86 av/nh 4/ 5

H.F. 349 provision also requires a health carrier to maintain written 1 records concerning internal claims and appeals received and 2 to submit a report to the commissioner, upon request, with 3 specified information about the internal claims and appeals. A 4 health carrier is also required to make available to consumers 5 written notice about the carrier’s internal claims and appeals 6 procedures and to maintain a toll-free consumer-assistance 7 telephone helpline that offers consumers assistance with 8 these procedures, including how to initiate, complete, or 9 submit a claim or appeal. The commissioner may adopt rules to 10 administer the new Code section. 11 The bill is applicable to health insurance policies, 12 contracts, or plans that are delivered, issued for delivery, 13 continued, or renewed on or after January 1, 2016. 14 -5- LSB 2239YH (5) 86 av/nh 5/ 5