SEC. 204. CONTRACTS FOR THE OFFERING OF EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS.

[a] Contracting Duties- In carrying out section 201[b][1] and consistent with this subtitle:

[1] OFFERING ENTITY AND PLAN STANDARDS- The Commissioner shall--

[A] establish standards necessary to implement the requirements of this title and title I for--

[i] QHBP offering entities for the offering of an Exchange-participating health benefits plan; and

[ii] for Exchange-participating health benefits plans; and

[B] certify QHBP offering entities and qualified health benefits plans as meeting such standards and requirements of this title and title I for purposes of this subtitle.

[2] SOLICITING AND NEGOTIATING BIDS; CONTRACTS- The Commissioner shall--

[A] solicit bids from QHBP offering entities for the offering of Exchange-participating health benefits plans;

[B] based upon a review of such bids, negotiate with such entities for the offering of such plans; and

[C] enter into contracts with such entities for the offering of such plans through the Health Insurance Exchange under terms [consistent with this title] negotiated between the Commissioner and such entities.

[3] FAR NOT APPLICABLE- The provisions of the Federal Acquisition Regulation shall not apply to contracts between the Commissioner and QHBP offering entities for the offering of Exchange-participating health benefits plans under this title.

[b] Standards for QHBP Offering Entities To Offer Exchange-Participating Health Benefits Plans- The standards established under subsection [a][1][A] shall require that, in order for a QHBP offering entity to offer an Exchange-participating health benefits plan, the entity must meet the following requirements:

[1] LICENSED- The entity shall be licensed to offer health insurance coverage under State law for each State in which it is offering such coverage.

[2] DATA REPORTING- The entity shall provide for the reporting of such information as the Commissioner may specify, including information necessary to administer the risk pooling mechanism described in section 206[b] and information to address disparities in health and health care.

[3] IMPLEMENTING AFFORDABILITY CREDITS- The entity shall provide for implementation of the affordability credits provided for enrollees under subtitle C, including the reduction in cost-sharing under section 244[c].

[4] ENROLLMENT- The entity shall accept all enrollments under this subtitle, subject to such exceptions [such as capacity limitations] in accordance with the requirements under title I for a qualified health benefits plan. The entity shall notify the Commissioner if the entity projects or anticipates reaching such a capacity limitation that would result in a limitation in enrollment.

[5] RISK POOLING PARTICIPATION- The entity shall participate in such risk pooling mechanism as the Commissioner establishes under section 206[b].

[6] ESSENTIAL COMMUNITY PROVIDERS- With respect to the basic plan offered by the entity, the entity shall contract for outpatient services with covered entities [as defined in section 340B[a][4] of the Public Health Service Act, as in effect as of July 1, 2009]. The Commissioner shall specify the extent to which and manner in which the previous sentence shall apply in the case of a basic plan with respect to which the Commissioner determines provides substantially all benefits through a health maintenance organization, as defined in section 2791[b][3] of the Public Health Service Act.

[7] CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES AND COMMUNICATIONS- The entity shall provide for culturally and linguistically appropriate communication and health services.

[8] ADDITIONAL REQUIREMENTS- The entity shall comply with other applicable requirements of this title, as specified by the Commissioner, which shall include standards regarding billing and collection practices for premiums and related grace periods and which may include standards to ensure that the entity does not use coercive practices to force providers not to contract with other entities offering coverage through the Health Insurance Exchange.

[c] Contracts-

[1] BID APPLICATION- To be eligible to enter into a contract under this section, a QHBP offering entity shall submit to the Commissioner a bid at such time, in such manner, and containing such information as the Commissioner may require.

[2] TERM- Each contract with a QHBP offering entity under this section shall be for a term of not less than one year, but may be made automatically renewable from term to term in the absence of notice of termination by either party.

[3] ENFORCEMENT OF NETWORK ADEQUACY- In the case of a health benefits plan of a QHBP offering entity that uses a provider network, the contract under this section with the entity shall provide that if--

[A] the Commissioner determines that such provider network does not meet such standards as the Commissioner shall establish under section 115; and

[B] an individual enrolled in such plan receives an item or service from a provider that is not within such network; then any cost-sharing for such item or service shall be equal to the amount of such cost-sharing that would be imposed if such item or service was furnished by a provider within such network.

[4] OVERSIGHT AND ENFORCEMENT RESPONSIBILITIES- The Commissioner shall establish processes, in coordination with State insurance regulators, to oversee, monitor, and enforce applicable requirements of this title with respect to QHBP offering entities offering Exchange-participating health benefits plans and such plans, including the marketing of such plans. Such processes shall include the following:

[A] GRIEVANCE AND COMPLAINT MECHANISMS- The Commissioner shall establish, in coordination with State insurance regulators, a process under which Exchange-eligible individuals and employers may file complaints concerning violations of such standards.

[B] ENFORCEMENT- In carrying out authorities under this division relating to the Health Insurance Exchange, the Commissioner may impose one or more of the intermediate sanctions described in section 142[c].

[C] TERMINATION-

[i] IN GENERAL- The Commissioner may terminate a contract with a QHBP offering entity under this section for the offering of an Exchange-participating health benefits plan if such entity fails to comply with the applicable requirements of this title. Any determination by the Commissioner to terminate a contract shall be made in accordance with formal investigation and compliance procedures established by the Commissioner under which--

[I] the Commissioner provides the entity with the reasonable opportunity to develop and implement a corrective action plan to correct the deficiencies that were the basis of the Commissioner's determination; and

[II] the Commissioner provides the entity with reasonable notice and opportunity for hearing [including the right to appeal an initial decision] before terminating the contract.

[ii] EXCEPTION FOR IMMINENT AND SERIOUS RISK TO HEALTH- Clause [i] shall not apply if the Commissioner determines that a delay in termination, resulting from compliance with the procedures specified in such clause prior to termination, would pose an imminent and serious risk to the health of individuals enrolled under the qualified health benefits plan of the QHBP offering entity.

[D] CONSTRUCTION- Nothing in this subsection shall be construed as preventing the application of other sanctions under subtitle E of title I with respect to an entity for a violation of such a requirement.