Subject to paragraph 3 , information provided to meet the requirements of subsection a 2 shall not include advanced directives or other planning tools that list or describe as an option suicide, assisted suicide or the intentional hastening of death regardless of legality. Nothing in paragraph 1 shall be construed to apply to or affect any option to—. The requirements of subsection a shall not apply to any State that as of August 1, , requires the inclusion of information prohibited in such paragraph in advanced directives or other planning tools.
A qualified health benefits plan, and a QHBP offering entity that offers such plan, shall conduct utilization review activities in connection with the provision of benefits under such plan only in accordance with a utilization review program that meets the requirements of this section.
Nothing in this section shall be construed as preventing a qualified health benefits plan or QHBP offering entity from arranging through a contract or otherwise for persons or entities to conduct utilization review activities on behalf of the plan entity, so long as such activities are conducted in accordance with a utilization review program that meets the requirements of this section. For purposes of this section, the terms utilization review and utilization review activities mean procedures used to monitor or evaluate the use or coverage, clinical necessity, appropriateness, efficacy, or efficiency of health care services, procedures or settings, and includes prospective review, concurrent review, second opinions, case management, discharge planning, or retrospective review.
A utilization review program shall be conducted consistent with written policies and procedures that govern all aspects of the program. Such a program shall utilize written clinical review criteria developed with input from a range of appropriate actively practicing health care professionals, as determined by the plan, pursuant to the program.
Such criteria shall include written clinical review criteria that are based on valid clinical evidence where available and that are directed specifically at meeting the needs of at-risk populations and covered individuals with chronic conditions or severe illnesses, including gender-specific criteria and pediatric-specific criteria where available and appropriate.
If a health care service has been specifically pre-authorized or approved for an enrollee under such a program, the program shall not, pursuant to retrospective review, revise or modify the specific standards, criteria, or procedures used for the utilization review for procedures, treatment, and services delivered to the enrollee during the same course of treatment. Such a program shall provide for an evaluation of the clinical appropriateness of at least a sample of denials of claims for benefits.
A utilization review program shall be administered by qualified health care professionals who shall oversee review decisions. A utilization review program shall provide for the conduct of utilization review activities only through personnel who are qualified and have received appropriate training in the conduct of such activities under the program.
Such a program shall not, with respect to utilization review activities, permit or provide compensation or anything of value to its employees, agents, or contractors in a manner that encourages denials of claims for benefits. Such a program shall not permit a health care professional who is providing health care services to an individual to perform utilization review activities in connection with the health care services being provided to the individual.
Such a program shall provide that appropriate personnel performing utilization review activities under the program, including the utilization review administrator, are reasonably accessible by toll-free telephone during normal business hours to discuss patient care and allow response to telephone requests, and that appropriate provision is made to receive and respond promptly to calls received during other hours. Such a program shall not provide for the performance of utilization review activities with respect to a class of services furnished to an individual more frequently than is reasonably required to assess whether the services under review are medically necessary or appropriate.
Subject to clauses ii , iii , and iv , the deadline specified in this subparagraph is 14 days after the date of receipt of the request for prior authorization, but in no event later than 3 business days after the date of receipt of information that is reasonably necessary to make such determination.
In the case of a situation described in section A c 1 A , the deadline specified in this subparagraph is 72 hours after the time of the request for prior authorization. No prior approval shall be required in the case of emergency services provided by a hospital. Such notice shall include, with respect to ongoing health care items and services, the number of ongoing services approved, the new total of approved services, the date of onset of services, and the next review date, if any, as well as a statement of the individual"s rights to further appeal.
Subparagraph A shall not be interpreted as requiring plans or issuers to provide coverage of care that would exceed the coverage limitations for such care. In a case in which a qualified health benefits plan or QHBP offering entity fails to make a determination on a claim for benefit under paragraph 1 , 2 A , or 3 by the applicable deadline established under the respective paragraph, the failure shall be treated under this subtitle as a denial of the claim as of the date of the deadline.
Notice of a denial of claims for benefits under a utilization review program shall be provided in printed form and written in a manner calculated to be understood by the participant, beneficiary, or enrollee and shall include—. Such a notice shall also specify what if any additional necessary information must be provided to, or obtained by, the person making the denial in order to make a decision on such an appeal. The term claim for benefits means any request for coverage including authorization of coverage , for eligibility, or for payment in whole or in part, for an item or service under a qualified health benefits plan.
The term denial means, with respect to a claim for benefits, means a denial, or a failure to act on a timely basis upon, in whole or in part, the claim for benefits and includes a failure to provide benefits including items and services required to be provided under this title.
Each qualified health benefits plan, and each QHBP offering entity offering such plan—. The request for review under paragraph 1 B may be made orally, but, in the case of an oral request, shall be followed by a request in writing.
A review of a denial of claim under this section shall be made by an individual who—. For purposes of subparagraph A , the term limited scope coverage means a qualified health benefits plan the only benefits under which are for benefits described in section c 2 A of the Public Health Service Act 42 U.
Having received such a request for review of a denial of claim, the QHBP offering entity offering a qualified health benefits plan, in accordance with the medical exigencies of the case but not later than the deadline specified in subparagraph B , complete the review on the denial and transmit to the participant, beneficiary, enrollee, or other person involved a decision that affirms, reverses, or modifies the denial.
If the decision does not reverse the denial, the plan or issuer shall transmit, in printed form, a notice that sets forth the grounds for such decision and that includes a description of rights to any further appeal. Such decision shall be treated as the final decision of the plan. Failure to issue such a decision by such deadline shall be treated as a final decision affirming the denial of claim.
Subject to clauses ii and iii , the deadline specified in this subparagraph is 14 days after the date of receipt of the request for internal review. If a qualified health benefits plan of QHBP offering entity—. In the case of a situation described in subsection c 1 A , the deadline specified in this subparagraph is 72 hours after the time of the request for review.
A qualified health benefits plan, and a QHBP offering entity, shall establish procedures in writing for the expedited consideration of requests for review under subsection b in situations—. The decision on the expedited review must be made and communicated to the parties as soon as possible in accordance with the medical exigencies of the case, and in no event later than 72 hours after the time of receipt of the request for expedited review, except that in a case described in paragraph 1 B , the decision must be made before the end of the approved period of care.
A plan or entity may waive its rights for an internal review under subsection b. In such case the participant, beneficiary, or enrollee involved and any designee or provider involved shall be relieved of any obligation to complete the review involved and may, at the option of such participant, beneficiary, enrollee, designee, or provider, proceed directly to seek further appeal through any applicable external appeals process.
The appropriate Secretary shall establish standards to carry out such requirements. For purposes of this section, the term externally appealable decision means a denial of claim for benefits as defined in section f 2 —. Such term also includes a failure to meet an applicable deadline for internal review under section A. Except as provided under section A d , a plan or entity may condition the use of an external appeal process in the case of an externally appealable decision upon a final decision in an internal review under section , but only if the decision is made in a timely basis consistent with the deadlines provided under this subtitle.
The plan or issuer may not require payment of the filing fee in the case of an individual participant, beneficiary, or enrollee who certifies in a form and manner specified in guidelines established by the Secretary of Health and Human Services that the individual is indigent as defined in such guidelines.
The plan or entity shall refund payment of the filing fee under this paragraph if the recommendation of the external appeal entity is to reverse or modify the denial of a claim for benefits which is the subject of the appeal. Except as provided in subparagraph D , the external appeal process under this section of a plan or entity shall be conducted under a contract between the plan or issuer and one or more qualified external appeal entities as defined in subsection c. The applicable authority shall implement procedures—.
The terms and conditions of a contract under this paragraph shall be consistent with the standards the appropriate Secretary shall establish to assure there is no real or apparent conflict of interest in the conduct of external appeal activities. Such contract shall provide that all costs of the process except those incurred by the participant, beneficiary, enrollee, or treating professional in support of the appeal shall be paid by the plan or entity, and not by the participant, beneficiary, or enrollee.
The previous sentence shall not be construed as applying to the imposition of a filing fee under subsection a 4. State authority with respect to qualified external appeal entity for health insurance issuers. With respect to QHBP offering entities offering qualified health benefits plans in a State, the State may provide for external review activities to be conducted by a qualified external appeal entity that is designated by the State or that is selected by the State in a manner determined by the State to assure an unbiased determination.
An external appeal process shall be conducted consistent with standards established by the appropriate Secretary that include at least the following:. The process shall provide for a fair, de novo determination.
However, nothing in this paragraph shall be construed as providing for coverage of items and services for which benefits are specifically excluded under the plan. If the entity determines the decision is in accordance with such needs, the entity shall affirm the decision and to the extent that the entity determines the decision is not in accordance with such needs, the entity shall reverse or modify the decision.
In making such determination, the external appeal entity shall consider but not be bound by any language in the plan or coverage document relating to the definitions of the terms medical necessity, medically necessary or appropriate, or experimental, investigational, or related terms. An external appeal entity shall include, among the evidence taken into consideration—.
Such external appeal entity may also take into consideration but not be limited to the following evidence to the extent available :. The results of studies that meet professionally recognized standards of validity and replicability or that have been published in peer-reviewed journals.
The results of professional consensus conferences conducted or financed in whole or in part by one or more government agencies. Practice and treatment guidelines prepared or financed in whole or in part by government agencies.
Government-issued coverage and treatment policies. Community standard of care and generally accepted principles of professional medical practice. To the extent that the entity determines it to be free of any conflict of interest, the opinions of individuals who are qualified as experts in one or more fields of health care which are directly related to the matters under appeal.
To the extent that the entity determines it to be free of any conflict of interest, the results of peer reviews conducted by the plan involved. A qualified external appeal entity shall determine—. Each party to an externally appealable decision may submit evidence related to the issues in dispute. The plan or issuer involved shall provide timely access to the external appeal entity to information and to provisions of the plan relating to the matter of the externally appealable decision, as determined by the entity.
A determination by the external appeal entity on the decision shall—. If the external appeal entity reverses or modifies the denial of a claim for benefits, the plan shall—. For purposes of this section, the term qualified external appeal entity means, in relation to a plan or issuer, an entity that is certified under paragraph 2 as meeting the following requirements:. The entity meets the independence requirements of paragraph 3.
The entity conducts external appeal activities through a panel of not fewer than 3 clinical peers. The entity has sufficient medical, legal, and other expertise and sufficient staffing to conduct external appeal activities for the plan on a timely basis consistent with subsection b 2 G. The entity meets such other requirements as the appropriate Secretary may impose. In order to be treated as a qualified external appeal entity with respect to—. The appropriate Secretary shall develop standards for the recertification of external appeal entities.
Such standards shall include a review of—. For purposes of subparagraph A i III , the Secretary of Labor may provide for a process for certification and periodic recertification of qualified private standard-setting organizations which provide for certification of external review entities. Such an organization shall only be certified if the organization does not certify an external review entity unless it meets standards required for certification of such an entity by such Secretary under subparagraph A i I.
For purposes of subparagraph A ii II , the Secretary of Health and Human Services may provide for a process for certification and periodic recertification of qualified private standard-setting organizations which provide for certification of external review entities. Such an organization shall only be certified if the organization does not certify an external review entity unless it meets standards required for certification of such an entity by such Secretary under subparagraph A ii II.
A clinical peer or other entity meets the independence requirements of this paragraph if—. For purposes of this paragraph, the term related party means—. No qualified external appeal entity having a contract with a qualified health benefits plan under this part and no person who is employed by any such entity or who furnishes professional services to such entity, shall be held by reason of the performance of any duty, function, or activity required or authorized pursuant to this section, to have violated any criminal law, or to be civilly liable under any law of the United States or of any State or political subdivision thereof if due care was exercised in the performance of such duty, function, or activity and there was no actual malice or gross misconduct in the performance of such duty, function, or activity.
The determination by an external appeal entity under this section is binding on the plan involved in the determination. Penalties against authorized officials for refusing to authorize the determination of an external review entity.
In any action described in paragraph 1 brought by a participant, beneficiary, or enrollee with respect to a qualified health benefits plan, in which a plaintiff alleges that a person referred to in such paragraph has taken an action resulting in a refusal of a benefit determined by an external appeal entity in violation of such terms of the plan, coverage, or this subtitle, or has failed to take an action for which such person is responsible under the plan or this title and which is necessary under the plan or coverage for authorizing a benefit, the court shall cause to be served on the defendant an order requiring the defendant—.
In addition to any penalty imposed under paragraph 1 or 2 , the appropriate Secretary may assess a civil penalty against a person acting in the capacity of authorizing a benefit determined by an external review entity for one or more qualified health benefits plans, for—. Such penalty shall be payable only upon proof by clear and convincing evidence of such pattern or practice and shall be in an amount not to exceed the lesser of—.
Any person acting in the capacity of authorizing benefits who has engaged in any such pattern or practice described in paragraph 3 A with respect to a plan or coverage, upon the petition of the appropriate Secretary, may be removed by the court from such position, and from any other involvement, with respect to such a plan or coverage, and may be precluded from returning to any such position or involvement for a period determined by the court.
Nothing in this subtitle shall be construed as altering or eliminating any cause of action or legal rights or remedies of participants, beneficiaries, enrollees, and others under State or Federal law including sections and of the Employee Retirement Income Security Act of , including the right to file judicial actions to enforce actions. The provisions of this section shall apply with respect to all acceptable coverage in the same manner as such provisions apply with respect to qualified health benefits plans under this section.
There is hereby established, as an independent agency in the executive branch of the Government, a Health Choices Administration in this division referred to as the Administration. The Administration shall be headed by a Health Choices Commissioner in this division referred to as the Commissioner who shall be appointed by the President, by and with the advice and consent of the Senate. The provisions of paragraphs 2 , 5 , and 7 of subsection a relating to compensation, terms, general powers, rulemaking, and delegation of section of the Social Security Act 42 U.
The Commissioner is responsible for carrying out the following functions under this division:. The establishment of qualified health benefits plan standards under this title, including the enforcement of such standards in coordination with State insurance regulators and the Secretaries of Labor and the Treasury.
The administration of individual affordability credits under subtitle C of title II, including determination of eligibility for such credits. Such additional functions as may be specified in this division. The Commissioner shall undertake activities in accordance with this subtitle to promote accountability of QHBP offering entities in meeting Federal health insurance requirements, regardless of whether such accountability is with respect to qualified health benefits plans offered through the Health Insurance Exchange or outside of such Exchange.
The commissioner shall, in coordination with States, conduct audits of qualified health benefits plan compliance with Federal requirements. Such audits may include random compliance audits and targeted audits in response to complaints or other suspected non-compliance.
The Commissioner is authorized to recoup from qualified health benefits plans reimbursement for the costs of such examinations and audit of such QHBP offering entities. In the case that the Commissioner determines that a QHBP offering entity violates a requirement of this title, the Commissioner may, in coordination with State insurance regulators and the Secretary of Labor, provide, in addition to any other remedies authorized by law, for any of the remedies described in paragraph 2.
The remedies described in this paragraph, with respect to a qualified health benefits plan offered by a QHBP offering entity, are—. The Commissioner shall provide for the development of standards for the definitions of terms used in health insurance coverage, including insurance-related terms.
The Commissioner shall issue regulations for the effective and efficient administration of the Health Insurance Exchange and affordability credits under subtitle C, including, with respect to the determination of eligibility for affordability credits, the use of personnel who are employed in accordance with the requirements of title 5, United States Code, to carry out the duties of the Commissioner or, in the case of sections and b 2 , the use of State personnel who are employed in accordance with standards prescribed by the Office of Personnel Management pursuant to section of the Intergovernmental Personnel Act of 42 U.
The National Association of Insurance Commissioners, State attorneys general, and State insurance regulators, including concerning the standards for insured qualified health benefits plans under this title and enforcement of such standards. Appropriate State agencies, specifically concerning the administration of individual affordability credits under subtitle C of title II and the offering of Exchange-participating health benefits plans, to Medicaid eligible individuals under subtitle A of such title.
The National Association of Insurance Commissioners for purposes of using model guidelines established by such association for purposes of subtitles B and D. In carrying out the functions of the Commissioner, including with respect to the enforcement of the provisions of this division, the Commissioner shall work in coordination with existing Federal and State entities to the maximum extent feasible consistent with this division and in a manner that prevents conflicts of interest in duties and ensures effective enforcement.
The Commissioner, in coordination with such entities, shall seek to achieve uniform standards that adequately protect consumers in a manner that does not unreasonably affect employers and insurers.
The Commissioner shall appoint within the Health Choices Administration a Qualified Health Benefits Plan Ombudsman who shall have expertise and experience in the fields of health care and education of and assistance to individuals. The Ombudsman shall not serve as an advocate for any increases in payments or new coverage of services, but may identify issues and problems in payment or coverage policies.
In the case of health insurance coverage not offered through the Health Insurance Exchange whether or not offered in connection with an employment-based health plan , and in the case of employment-based health plans, the requirements of this title do not supercede any requirements applicable under titles XXII and XXVII of the Public Health Service Act, parts 6 and 7 of subtitle B of title I of the Employee Retirement Income Security Act of , or State law, except insofar as such requirements prevent the application of a requirement of this division, as determined by the Commissioner.
Nothing in paragraph 1 shall be construed as affecting the application of section of the Employee Retirement Income Security Act of In the case of health insurance coverage offered through the Health Insurance Exchange—.
In the case of coverage described in paragraph 1 , nothing in such paragraph shall be construed as preventing the application of rights and remedies under State laws with respect to any requirement referred to in paragraph 1 A.
Except as otherwise explicitly permitted by this Act and by subsequent regulations consistent with this Act, all health care and related services including insurance coverage and public health activities covered by this Act shall be provided without regard to personal characteristics extraneous to the provision of high quality health care or related services. To implement the requirement set forth in subsection a , the Secretary of Health and Human Services shall, not later than 18 months after the date of the enactment of this Act, promulgate such regulations as are necessary or appropriate to insure that all health care and related services including insurance coverage and public health activities covered by this Act are provided whether directly or through contractual, licensing, or other arrangements without regard to personal characteristics extraneous to the provision of high quality health care or related services.
No employer may discharge any employee or otherwise discriminate against any employee with respect to his compensation, terms, conditions, or other privileges of employment because the employee or any person acting pursuant to a request of the employee —. An employee covered by this section who alleges discrimination by an employer in violation of subsection a may bring an action governed by the rules, procedures, legal burdens of proof, and remedies set forth in section 40 b of the Consumer Product Safety Act 15 U.
As used in this section, the term employer means any person including one or more individuals, partnerships, associations, corporations, trusts, professional membership organization including a certification, disciplinary, or other professional body, unincorporated organizations, nongovernmental organizations, or trustees engaged in profit or nonprofit business or industry whose activities are governed by this Act, and any agent, contractor, subcontractor, grantee, or consultant of such person.
The rule of construction set forth in section h of title 49, United States Code, shall also apply to this section. Nothing in this division shall be construed to alter of supercede any statutory or other obligation to engage in collective bargaining over the terms and conditions of employment related to health care. If any provision of this Act, or any application of such provision to any person or circumstance, is held to be unconstitutional, the remainder of the provisions of this Act and the application of the provision to any other person or circumstance shall not be affected.
Nothing in this Act shall be construed to preempt or otherwise have any effect on State laws regarding the prohibition of or requirement of coverage, funding, or procedural requirements on abortions, including parental notification or consent for the performance of an abortion on a minor.
Nothing in this Act shall be construed to have any effect on Federal laws regarding—. Nothing in this section shall alter the rights and obligations of employees and employers under title VII of the Civil Rights Act of A Federal agency or program, and any State or local government that receives Federal financial assistance under this Act or an amendment made by this Act , may not—.
In this section, the term health care entity includes an individual physician or other health care professional, a hospital, a provider-sponsored organization, a health maintenance organization, a health insurance plan, or any other kind of health care facility, organization, or plan.
The Office for Civil Rights of the Department of Health and Human Services is designated to receive complaints of discrimination based on this section, and coordinate the investigation of such complaints. Each health insurance issuer that offers health insurance coverage in the small or large group market shall provide that for any plan year in which the coverage has a medical loss ratio below a level specified by the Secretary, the issuer shall provide in a manner specified by the Secretary for rebates to enrollees of payment sufficient to meet such loss ratio.
Such methodology shall be set at the highest level medical loss ratio possible that is designed to ensure adequate participation by issuers, competition in the health insurance market, and value for consumers so that their premiums are used for services. The Secretary shall establish a uniform definition of medical loss ratio and methodology for determining how to calculate the medical loss ratio.
Such methodology shall be designed to take into account the special circumstances of smaller plans, different types of plans, and newer plans. Such title is further amended by inserting after section the following new section:. The provisions of section shall apply to health insurance coverage offered in the individual market in the same manner as such provisions apply to health insurance coverage offered in the small or large group market.
The amendments made by this section shall apply in the group and individual market for plan years beginning on or after January 1, Clarification regarding application of guaranteed renewability of individual health insurance coverage.
Section of such Act 42 U. A health insurance issuer may rescind health insurance coverage only upon clear and convincing evidence of fraud described in subsection b 2. The Secretary, no later than July 1, , shall issue guidance implementing this requirement, including procedures for independent, external third party review.
If a health insurance issuer determines to rescind health insurance coverage for an individual in the individual market, before such rescission may take effect the issuer shall provide the individual with notice of such proposed rescission and an opportunity for a review of such determination by an independent, external third party under procedures specified by the Secretary under section f.
They can deactivate it at any time if they find you suspicious or not loyal to their government or go against them or their system and you will lose everything you ever had. Soon this device will be made common just like they did credit cards. Turning paper money into digital money means nothing is physically in your hand. It will be made a must for every citizen with time according to their plan, and then they will spread it outside America so they can monitor and control as many people as they can and turn them into slaves with their digital technologies.
Here is an example of a version of the rumor from over 5 years after the law was passed. Everything hindering the rapture has been removed. Gospel has been preached almost everywhere, all the prophecies have been fulfilled.
The devil is working very hard to occupy Christians with the things of this world so that the day will catch them unaware. Please be prepared, there is no more time. This is also a source of evangelism, souls are dying. God bless you! The implementation would commence soon.
The device will be implemented on the forehead or on the arm. The rapture is near! Revelations 13 is being played out right before us. Many are still unaware. Why is the chip being implanted exactly where the Bible says it would be. Why on the hand and forehead. Why not anywhere else? Why is it being connected to your bank account? I hope that you will take time to read for yourself the issue before making up your mind.
It is a five page section and will take about 20 minutes of your time to read. Click the link to read the text of SEC. Foot pain is no laughing matter. Studies show that 75 percent of Americans will experience….
Skip to content. August 3, Health Care Team. Share this article on your favorite social media:. Share on facebook Facebook. Share on twitter Twitter. Share on linkedin LinkedIn. It needs to be pushed:. Now that is a food fight I would love to see.
Attorneys would be working 24 hours a day filing lawsuits to stop the Zero and his minions. Even lawyers tell lawyer jokes about getting rid of 10, lawyers is a good start. Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.
Keep going over these Orwellian dictates written by Lord-knows-whom! The slumbering giant is stirring. Geewhiz Cripes, thats the place where people who don't believe in Gosh think they aint going.
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