Medical Loss Ratio Accountability Act of 2016

Medical Loss Ratio Accountability Act of 2016

This bill amends the Public Health Service Act to require the Department of Health and Human Services (HHS) to audit a statistically significant and representative selection of health insurers to verify that insurer reports on medical loss ratio are accurate.

This bill amends the Social Security Act to base determinations of the medical loss ratio of a Medicare Advantage plan on information from the HHS audit of the plan, if the plan was audited.

[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4801 Introduced in House (IH)]

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114th CONGRESS
  2d Session
                                H. R. 4801

To amend title XXVII of the Public Health Service Act, and title XVIII 
of the Social Security Act, to direct the Secretary of Health and Human 
 Services to conduct audits of medical loss ratio reports submitted by 
           health insurance issuers, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             March 17, 2016

     Ms. Michelle Lujan Grisham of New Mexico (for herself and Ms. 
 Schakowsky) introduced the following bill; which was referred to the 
 Committee on Energy and Commerce, and in addition to the Committee on 
   Ways and Means, for a period to be subsequently determined by the 
  Speaker, in each case for consideration of such provisions as fall 
           within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
To amend title XXVII of the Public Health Service Act, and title XVIII 
of the Social Security Act, to direct the Secretary of Health and Human 
 Services to conduct audits of medical loss ratio reports submitted by 
           health insurance issuers, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medical Loss Ratio Accountability 
Act of 2016''.

SEC. 2. AUDITS OF MEDICAL LOSS RATIO REPORTS SUBMITTED WITH RESPECT TO 
              GROUP OR INDIVIDUAL HEALTH INSURANCE COVERAGE.

    Section 2718 of the Public Health Service Act (42 U.S.C. 300gg-18) 
is amended--
            (1) in subsection (b)(3), by inserting ``, including with 
        respect to the submission of any information that, pursuant to 
        an audit conducted under subsection (f), is found to be 
        untruthful or inaccurate'' after ``penalties''; and
            (2) by adding at the end the following new subsection:
    ``(f) Audits.--
            ``(1) In general.--Beginning with the first plan year that 
        begins after the date of the enactment of the Medical Loss 
        Ratio Accountability Act of 2016, the Secretary shall, with 
        respect to a statistically significant percentage of the 
        reports submitted under this section by health insurance 
        issuers offering group or individual health insurance coverage 
        (including grandfathered health plans), conduct audits of the 
        books and records (or such other information as may be 
        necessary) of such health insurance issuers to verify that the 
        information contained in each such report is truthful and 
        accurate.
            ``(2) Selection of reports for audits.--In selecting 
        reports to be audited under paragraph (1), the Secretary shall 
        ensure that, for a plan year, the health insurance issuers 
        whose reports are selected for such audits are representative 
        of the health insurance issuers that submitted such reports for 
        such plan year.
            ``(3) Authority to enter into contracts or cooperative 
        agreements.--The Secretary may, for purposes of conducting 
        audits under paragraph (1), enter into a contract or 
        cooperative agreement with a private entity.
            ``(4) Report to congress.--Beginning 18 months after the 
        date of the enactment of the Medical Loss Ratio Accountability 
        Act of 2016 and each year thereafter, the Secretary shall 
        submit to Congress a report on the results of audits conducted 
        under this section with respect to the previous plan year.''.

SEC. 3. APPLICATION TO PARTS C AND D OF THE MEDICARE PROGRAM.

    Section 1857(e)(4) of the Social Security Act (42 U.S.C. 1395w-
27(e)(4)) is amended by adding at the end the following new flush 
sentence:
``In the case that audits have been conducted by the Secretary (such as 
the audits conducted under section 2718(f) of the Public Health Service 
Act) of the books and records (or of such other information as may be 
necessary) of an MA plan for a contract year that begins on or after 
the date of the enactment of the Medical Loss Ratio Accountability Act 
of 2016, a determination that is made under this paragraph for such MA 
plan for such contract year shall be based upon one or more reports (or 
other submissions of information) by the MA plan with respect to which 
the Secretary has verified, through such audits of such MA plan, that 
the information contained in such reports (or other submissions) is 
truthful and accurate.''.
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