I 

113TH CONGRESS 

1ST SESSION H. R. 2165 

To amend the Public Health Service Act to provide individual and group 

market reforms to protect health insurance consumers, to make such 

reforms and protections contingent on the enactment of legislation repealing the Patient Protection and Affordable Care Act, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 23, 2013 

Mr. HECK of Nevada (for himself and Mr. FITZPATRICK) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and the Workforce, Ways and Means, and the Judiciary, 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 the Public Health Service Act to provide individual 

and group market reforms to protect health insurance 

consumers, to make such reforms and protections contingent on the enactment of legislation repealing the Patient 

Protection and Affordable Care Act, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 


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1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

2 (a) SHORT TITLE.—This Act may be cited as the 

3 ‘‘Ensuring Quality Health Care for All Americans Act of 

4 2013’’. 

5 (b) TABLE OF CONTENTS.—The table of contents for 

6 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Effective date contingent on repeal of PPACA. 

Sec. 3. Prohibiting discrimination based on health status. 

Sec. 4. Guaranteed renewability of coverage. 

Sec. 5. Prohibition of preexisting condition exclusions and other discrimination 

based on health status. 

Sec. 6. No lifetime or annual limits. 

Sec. 7. Prohibition on rescissions. 

Sec. 8. Extension of dependent coverage. 

Sec. 9. Application of group market reforms to ERISA and the Internal Revenue Code of 1986. 

Sec. 10. Catastrophic plan. 

Sec. 11. Grants for health insurance risk adjustment mechanisms. 

Sec. 12. Liability protections for health care providers. 

7 SEC. 2. EFFECTIVE DATE CONTINGENT ON REPEAL OF 

8 PPACA. 

9 (a) IN GENERAL.—This Act and the amendments 

10 made by this Act shall take effect upon the enactment of 

11 PPACA repeal legislation described in subsection (b) and 

12 this Act and the amendments made by this Act shall have 

13 no force or effect if such PPACA repeal legislation is not 

14 enacted. 

15 (b) PPACA REPEAL LEGISLATION DESCRIBED.— 

16 For purposes of subsection (a), PPACA repeal legislation 

17 described in this subsection is legislation that— 

18 (1) repeals Public Law 111–148, and restores 

19 or revives the provisions of law amended or repealed, 


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1 respectively, by such Act as if such Act had not been 

2 enacted and without further amendment to such 

3 provisions of law; and 

4 (2) repeals title I and subtitle B of title II of 

5 the Health Care and Education Reconciliation Act of 

6 2010 (Public Law 111–152), and restores or revives 

7 the provisions of law amended or repealed, respec8 tively, by such title or subtitle, respectively, as if 

9 such title and subtitle had not been enacted and 

10 without further amendment to such provisions of 

11 law. 

12 SEC. 3. PROHIBITING DISCRIMINATION BASED ON HEALTH 

13 STATUS. 

14 (a) GROUP MARKET.—Subpart 3 of part A of title 

15 XXVII of the Public Health Service Act is amended by 

16 striking section 2711 of such Act (42 U.S.C. 300gg–11) 

17 and inserting the following: 

18 ‘‘SEC. 2711. GUARANTEED AVAILABILITY OF COVERAGE. 

19 ‘‘(a) GUARANTEED ISSUANCE OF COVERAGE IN THE

20 GROUP MARKET.— 

21 ‘‘(1) IN GENERAL.—Subject to subsections (b) 

22 through (e), each health insurance issuer that offers 

23 health insurance coverage in the group market in a 

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1 vidual in a group in the State that applies for such 

2 coverage. 

3 ‘‘(2) SPECIAL RULE FOR ASSOCIATIONS.—An 

4 association shall be treated as an employer for pur5 poses of this section if such association seeks to pro6 vide group health insurance coverage to not less 

7 than 200 qualified individuals. 

8 ‘‘(b) ENROLLMENT.— 

9 ‘‘(1) RESTRICTION.—A health insurance issuer 

10 described in subsection (a) may restrict enrollment 

11 in coverage described in such subsection to open or 

12 special enrollment periods. 

13 ‘‘(2) ESTABLISHMENT.—A health insurance 

14 issuer described in subsection (a) shall, in accord15 ance with the regulations promulgated under para16 graph (3), establish special enrollment periods for 

17 qualifying events (as such term is defined in section 

18 603 of the Employee Retirement Income Security 

19 Act of 1974). 

20 ‘‘(3) SPECIAL RULES FOR ASSOCIATIONS.— 

21 ‘‘(A) QUALIFYING EVENTS.—For purposes 

22 of applying paragraph (2) to an association— 

23 ‘‘(i) the term ‘covered employee’ in 

24 section 603 of the Employee Retirement 

25 Income Security Act of 1974 shall include 


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1 a qualified individual (as such term is de2 fined in section 2701(d)(2)(D)); 

3 ‘‘(ii) the term ‘employer’ shall include 

4 an association (as such term is defined in 

5 section 2701(d)(2)(A)); and 

6 ‘‘(iii) the term ‘termination (other 

7 than by reason of such employee’s gross 

8 misconduct), or reduction of hours, of the 

9 covered employee’s employment’ shall in10 clude the termination of membership to the 

11 association. 

12 ‘‘(B) ENROLLMENT.—With respect to 

13 health insurance coverage provided to an asso14 ciation under subsection (a)(2), a health insur15 ance issuer shall permit a qualified individual 

16 who is eligible, but not enrolled (or a dependent 

17 of such individual if the dependent is eligible, 

18 but not enrolled) for such coverage to enroll for 

19 coverage under the terms of such coverage 

20 when any one of the following events occur: 

21 ‘‘(i) NEW MEMBERS AND EMPLOY22 EES.—A qualified individual, and any de23 pendent of such individual, may enroll dur24 ing the 30-day period following the end of 

25 the period described under section 


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1 2701(d)(2)(D) that applies to such indi2 vidual. 

3 ‘‘(ii) ANNUAL ENROLLMENT.—A 

4 qualified individual, and any dependent of 

5 such individual, may enroll during the an6 nual enrollment period established under 

7 the terms of the coverage 

8 ‘‘(C) TERMINATION OF ENROLLMENT.— 

9 With respect to group health insurance cov10 erage provided by an association, a qualified in11 dividual or dependent who terminates enroll12 ment in such coverage may only re-enroll in 

13 such coverage during the annual enrollment pe14 riod described under subparagraph (B)(ii). 

15 ‘‘(D) DEFINITIONS.—For purposes of this 

16 section, the terms ‘association’ and ‘qualified 

17 individual’ have the meaning given such terms 

18 in section 2701(d)(2). 

19 ‘‘(4) REGULATIONS.—The Secretary shall pro20 mulgate regulations with respect to enrollment peri21 ods under this subsection. 

22 ‘‘(c) SPECIAL RULES FOR NETWORK PLANS.— 

23 ‘‘(1) IN GENERAL.—In the case of a health in24 surance issuer that offers health insurance coverage 


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1 in the group market in a State through a network 

2 plan, the issuer may— 

3 ‘‘(A) limit the employers that may apply 

4 for such coverage to those with eligible individ5 uals who live, work, or reside in the service area 

6 for such network plan; and 

7 ‘‘(B) within the service area of such plan, 

8 deny such coverage to such employers if the 

9 issuer has demonstrated, if required, to the ap10 plicable State authority that— 

11 ‘‘(i) it will not have the capacity to de12 liver services adequately to enrollees of any 

13 additional groups because of its obligations 

14 to existing group contract holders and en15 rollees; and 

16 ‘‘(ii) it is applying this paragraph uni17 formly to all employers without regard 

18 to— 

19 ‘‘(I) the claims experience of 

20 those employers and their employees 

21 (and their dependents); or 

22 ‘‘(II) any health-status-related 

23 factor relating to such employees and 

24 dependents. 


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1 ‘‘(2) 180-DAY SUSPENSION UPON DENIAL OF

2 COVERAGE.—An issuer, upon denying health insur3 ance coverage in any service area in accordance with 

4 paragraph (1)(B), may not offer coverage in the 

5 group market within such service area for a period 

6 of 180 days after the date such coverage is denied. 

7 ‘‘(d) APPLICATION OF FINANCIAL CAPACITY LIM8 ITS.— 

9 ‘‘(1) IN GENERAL.—A health insurance issuer 

10 may deny health insurance coverage in the group if 

11 the issuer has demonstrated, if required, to the ap12 plicable State authority that— 

13 ‘‘(A) it does not have the financial reserves 

14 necessary to underwrite additional coverage; 

15 and 

16 ‘‘(B) it is applying this paragraph uni17 formly to all employers and individuals in the 

18 group market in the State— 

19 ‘‘(i) in a manner that is consistent 

20 with applicable State law; and 

21 ‘‘(ii) without regard to— 

22 ‘‘(I) the claims experience of 

23 those individuals, employers, and their 

24 employees (and their dependents); or 


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1 ‘‘(II) any health-status-related 

2 factor relating to such individuals, 

3 employees, and dependents. 

4 ‘‘(2) 180-DAY SUSPENSION UPON DENIAL OF

5 COVERAGE.—A health insurance issuer upon denying 

6 health insurance coverage in connection with group 

7 health plans in accordance with paragraph (1) in a 

8 State may not offer coverage in connection with 

9 group health plans in the group market in the State 

10 for a period of 180 days after the date such cov11 erage is denied or until the issuer has demonstrated 

12 to the applicable State authority, if required under 

13 applicable State law, that the issuer has sufficient fi14 nancial reserves to underwrite additional coverage, 

15 whichever is later. An applicable State authority 

16 may provide for the application of this subsection on 

17 a service-area-specific basis.’’. 

18 (b) INDIVIDUAL MARKET.—Subpart 1 of part B of 

19 title XXVII of the Public Health Service Act is amended 

20 by striking section 2741 of such Act (42 U.S.C. 300gg– 

21 41) and inserting the following: 

22 ‘‘SEC. 2741. GUARANTEED AVAILABILITY OF COVERAGE. 

23 ‘‘The provisions of section 2711 (other than sub24 section (a)(2) and subsection (b)(3)) shall apply to health 

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1 surance issuer in the individual market in the same man2 ner as such provisions apply to health insurance coverage 

3 offered to employers by a health insurance issuer in con4 nection with health insurance coverage in the group mar5 ket. For purposes of this section, the Secretary shall treat 

6 any reference of the word ‘employer’ in such section as 

7 a reference to the term ‘individual’.’’. 

8 SEC. 4. GUARANTEED RENEWABILITY OF COVERAGE. 

9 Section 2712 of the Public Health Service Act (42 

10 U.S.C. 300gg–12) is amended— 

11 (1) in subsection (a)— 

12 (A) by inserting ‘‘, including coverage of13 fered’’ before ‘‘in connection with a group 

14 health plan’’; and 

15 (B) by inserting ‘‘employer or other’’ be16 fore ‘‘plan sponsor of the plan’’; 

17 (2) in subsection (b)— 

18 (A) in the matter before paragraph (1), by 

19 striking ‘‘health insurance coverage in connec20 tion with a group health plan in the small or 

21 large group market’’ and insert ‘‘such health in22 surance coverage’’; and 

23 (B) in paragraph (6) by striking ‘‘ one or 

24 more bona fide associations’’ and inserting ‘‘one 


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1 or more associations (as such term is defined in 

2 section 2701(d)(2)(A))’’; 

3 (3) in subsection (c)(1)(B), by striking ‘‘to a 

4 group health plan’’; 

5 (4) in subsection (d)— 

6 (A) in matter before paragraph (1), by 

7 striking ‘‘to a group health plan’’; and 

8 (B) in paragraph (2), by striking ‘‘bona 

9 fide associations’’ and inserting ‘‘associations 

10 (as such term is defined in section 

11 2701(d)(2)(A))’’; and 

12 (5) in subsection (e), by inserting ‘‘(as such 

13 term is defined in section 2701(d)(2)(A))’’ after 

14 ‘‘one or more associations’’. 

15 SEC. 5. PROHIBITION OF PREEXISTING CONDITION EXCLU16 SIONS AND OTHER DISCRIMINATION BASED 

17 ON HEALTH STATUS. 

18 (a) GROUP MARKET.—Subpart 1 of part A of title 

19 XXVII of the Public Health Service Act (42 U.S.C. 300gg 

20 et seq.) is amended by striking section 2701 and inserting 

21 the following: 


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1 ‘‘SEC. 2701. PROHIBITION OF PREEXISTING CONDITION EX2 CLUSIONS AND OTHER DISCRIMINATION 

3 BASED ON HEALTH STATUS. 

4 ‘‘(a) IN GENERAL.—A group health plan or a health 

5 insurance issuer offering group health insurance coverage 

6 may not impose any preexisting condition exclusion with 

7 respect to such plan or coverage. 

8 ‘‘(b) DEFINITIONS.—For purposes of this part: 

9 ‘‘(1) PREEXISTING CONDITION EXCLUSION.— 

10 ‘‘(A) IN GENERAL.—The term ‘preexisting 

11 condition exclusion’ means, with respect to a 

12 group health plan or health insurance coverage, 

13 a limitation or exclusion of benefits relating to 

14 a condition based on the fact that the condition 

15 was present before the date of enrollment in 

16 such plan or for such coverage, whether or not 

17 any medical advice, diagnosis, care, or treat18 ment was recommended or received before such 

19 date. 

20 ‘‘(B) TREATMENT OF GENETIC INFORMA21 TION.—Genetic information shall not be treated 

22 as a preexisting condition in the absence of a 

23 diagnosis of the condition related to such infor24 mation. 

25 ‘‘(2) DATE OF ENROLLMENT.—The term ‘date 

26 of enrollment’ means, with respect to an individual 


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1 covered under a group health plan or health insur2 ance coverage, the date of enrollment of the indi3 vidual in the plan or coverage or, if earlier, the first 

4 day of the waiting period for such enrollment. 

5 ‘‘(3) WAITING PERIOD.—The term ‘waiting pe6 riod’ means, with respect to a group health plan and 

7 an individual who is a potential participant or bene8 ficiary in the plan, the period that must pass with 

9 respect to the individual before the individual is eli10 gible to be covered for benefits under the terms of 

11 the plan. 

12 ‘‘(c) SPECIAL ENROLLMENT PERIODS.— 

13 ‘‘(1) INDIVIDUALS LOSING OTHER COVERAGE.— 

14 A group health plan, and a health insurance issuer 

15 offering group health insurance coverage in connec16 tion with a group health plan, shall permit an em17 ployee who is eligible, but not enrolled, for coverage 

18 under the terms of the plan (or a dependent of such 

19 an employee if the dependent is eligible, but not en20 rolled, for coverage under such terms) to enroll for 

21 coverage under the terms of the plan if each of the 

22 following conditions is met: 

23 ‘‘(A) The employee or dependent was cov24 ered under a group health plan or had health 


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1 insurance coverage at the time coverage was 

2 previously offered to the employee or dependent. 

3 ‘‘(B) The employee stated in writing at 

4 such time that coverage under a group health 

5 plan or health insurance coverage was the rea6 son for declining enrollment, but only if the 

7 plan sponsor or issuer (if applicable) required 

8 such a statement at such time and provided the 

9 employee with notice of such requirement (and 

10 the consequences of such requirement) at such 

11 time. 

12 ‘‘(C) The employee’s or dependent’s cov13 erage described in subparagraph (A)— 

14 ‘‘(i) was under a COBRA continu15 ation provision and the coverage under 

16 such provision was exhausted; or 

17 ‘‘(ii) was not under such a provision 

18 and either the coverage was terminated as 

19 a result of loss of eligibility for the cov20 erage (including as a result of legal separa21 tion, divorce, death, termination of employ22 ment, or reduction in the number of hours 

23 of employment) or employer contributions 

24 toward such coverage were terminated. 


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1 ‘‘(D) Under the terms of the plan, the em2 ployee requests such enrollment not later than 

3 30 days after the date of exhaustion of coverage 

4 described in subparagraph (C)(i) or termination 

5 of coverage or employer contribution described 

6 in subparagraph (C)(ii). 

7 ‘‘(2) FOR DEPENDENT BENEFICIARIES.— 

8 ‘‘(A) IN GENERAL.—If— 

9 ‘‘(i) a group health plan makes cov10 erage available with respect to a dependent 

11 of an individual; 

12 ‘‘(ii) the individual is a participant 

13 under the plan (or has met any waiting pe14 riod applicable to becoming a participant 

15 under the plan and is eligible to be enrolled 

16 under the plan but for a failure to enroll 

17 during a previous enrollment period); and 

18 ‘‘(iii) a person becomes such a de19 pendent of the individual through mar20 riage, birth, or adoption or placement for 

21 adoption, 

22 the group health plan shall provide for a de23 pendent special enrollment period described in 

24 subparagraph (B) during which the person (or, 

25 if not otherwise enrolled, the individual) may be 


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1 enrolled under the plan as a dependent of the 

2 individual, and in the case of the birth or adop3 tion of a child, the spouse of the individual may 

4 be enrolled as a dependent of the individual if 

5 such spouse is otherwise eligible for coverage. 

6 ‘‘(B) DEPENDENT SPECIAL ENROLLMENT

7 PERIOD.—A dependent special enrollment pe8 riod under this subparagraph shall be a period 

9 of not less than 30 days and shall begin on the 

10 later of— 

11 ‘‘(i) the date dependent coverage is 

12 made available; or 

13 ‘‘(ii) the date of the marriage, birth, 

14 or adoption or placement for adoption (as 

15 the case may be) described in subpara16 graph (A)(iii). 

17 ‘‘(C) NO WAITING PERIOD.—If an indi18 vidual seeks to enroll a dependent during the 

19 first 30 days of such a dependent special enroll20 ment period, the coverage of the dependent 

21 shall become effective— 

22 ‘‘(i) in the case of marriage, not later 

23 than the first day of the first month begin24 ning after the date the completed request 

25 for enrollment is received; 


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1 ‘‘(ii) in the case of a dependent’s 

2 birth, as of the date of such birth; or 

3 ‘‘(iii) in the case of a dependent’s 

4 adoption or placement for adoption, the 

5 date of such adoption or placement for 

6 adoption. 

7 ‘‘(3) SPECIAL RULES FOR APPLICATION IN CASE

8 OF MEDICAID AND CHIP.— 

9 ‘‘(A) IN GENERAL.—A group health plan, 

10 and a health insurance issuer offering group 

11 health insurance coverage in connection with a 

12 group health plan, shall permit an employee 

13 who is eligible, but not enrolled, for coverage 

14 under the terms of the plan (or a dependent of 

15 such an employee if the dependent is eligible, 

16 but not enrolled, for coverage under such 

17 terms) to enroll for coverage under the terms of 

18 the plan or coverage if either of the following 

19 conditions is met: 

20 ‘‘(i) TERMINATION OF MEDICAID OR

21 CHIP COVERAGE.—The employee or de22 pendent is covered under a Medicaid plan 

23 under title XIX of the Social Security Act 

24 or under a State child health plan under 

25 title XXI of such Act and coverage of the 


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1 employee or dependent under such a plan 

2 is terminated as a result of loss of eligi3 bility for such coverage and the employee 

4 requests coverage under the group health 

5 plan (or health insurance coverage) not 

6 later than 60 days after the date of termi7 nation of such coverage. 

8 ‘‘(ii) ELIGIBILITY FOR EMPLOYMENT

9 ASSISTANCE UNDER MEDICAID OR CHIP.— 

10 The employee or dependent becomes eligi11 ble for assistance, with respect to coverage 

12 under the group health plan or health in13 surance coverage, under such Medicaid 

14 plan or State child health plan (including 

15 under any waiver or demonstration project 

16 conducted under or in relation to such a 

17 plan), if the employee requests coverage 

18 under the group health plan or health in19 surance coverage not later than 60 days 

20 after the date the employee or dependent is 

21 determined to be eligible for such assist22 ance. 

23 ‘‘(B) COORDINATION WITH MEDICAID AND

24 CHIP.— 


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1 ‘‘(i) OUTREACH TO EMPLOYEES RE2 GARDING AVAILABILITY OF MEDICAID AND

3 CHIP COVERAGE.— 

4 ‘‘(I) IN GENERAL.—Each em5 ployer that maintains a group health 

6 plan in a State that provides medical 

7 assistance under a State Medicaid 

8 plan under title XIX of the Social Se9 curity Act, or child health assistance 

10 under a State child health plan under 

11 title XXI of such Act, in the form of 

12 premium assistance for the purchase 

13 of coverage under a group health 

14 plan, shall provide to each employee a 

15 written notice informing the employee 

16 of potential opportunities then cur17 rently available in the State in which 

18 the employee resides for premium as19 sistance under such plans for health 

20 coverage of the employee or the em21 ployee’s dependents. For purposes of 

22 compliance with this subclause, the 

23 employer may use any State-specific 

24 model notice developed in accordance 

25 with section 701(f)(3)(B)(i)(II) of the 


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1 Employee Retirement Income Security 

2 Act of 1974 (29 U.S.C. 

3 1181(f)(3)(B)(i)(II)). 

4 ‘‘(II) OPTION TO PROVIDE CON5 CURRENT WITH PROVISION OF PLAN

6 MATERIALS TO EMPLOYEE.—An em7 ployer may provide the model notice 

8 applicable to the State in which an 

9 employee resides concurrent with the 

10 furnishing of materials notifying the 

11 employee of health plan eligibility, 

12 concurrent with materials provided to 

13 the employee in connection with an 

14 open season or election process con15 ducted under the plan, or concurrent 

16 with the furnishing of the summary 

17 plan description as provided in section 

18 104(b) of the Employee Retirement 

19 Income Security Act of 1974. 

20 ‘‘(ii) DISCLOSURE ABOUT GROUP

21 HEALTH PLAN BENEFITS TO STATES FOR

22 MEDICAID- AND CHIP-ELIGIBLE INDIVID23 UALS.—In the case of an enrollee in a 

24 group health plan who is covered under a 

25 Medicaid plan of a State under title XIX 


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1 of the Social Security Act or under a State 

2 child health plan under title XXI of such 

3 Act, the plan administrator of the group 

4 health plan shall disclose to the State, 

5 upon request, information about the bene6 fits available under the group health plan 

7 in sufficient specificity, as determined 

8 under regulations of the Secretary of 

9 Health and Human Services in consulta10 tion with the Secretary that require use of 

11 the model coverage coordination disclosure 

12 form developed under section 311(b)(1)(C) 

13 of the Children’s Health Insurance Reau14 thorization Act of 2009, so as to permit 

15 the State to establish (under paragraph 

16 (2)(B), (3), or (10) of section 2105(c) of 

17 the Social Security Act or otherwise) the 

18 cost effectiveness of the State providing 

19 medical or child health assistance through 

20 premium assistance for the purchase of 

21 coverage under such group health plan and 

22 in order for the State to provide supple23 mental benefits required under paragraph 

24 (10)(E) of such section or other authority. 

25 ‘‘(d) APPLICATION TO ASSOCIATION PLANS.— 


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1 ‘‘(1) IN GENERAL.—A group health plan or 

2 health insurance issuer that provides coverage to an 

3 association as required under section 2711(a)(2) 

4 shall accept every qualified individual that the asso5 ciation seeks health insurance coverage for, without 

6 regard to the health status of such individual. 

7 ‘‘(2) DEFINITIONS RELATED TO ASSOCIA8 TIONS.—For purposes of this subsection: 

9 ‘‘(A) ASSOCIATION.—The term ‘associa10 tion’ means an association that— 

11 ‘‘(i) has a constitution and bylaws; 

12 ‘‘(ii) is determined by the Secretary to 

13 be an association which is operating in 

14 good faith for a primary purpose other 

15 than that of obtaining insurance; and 

16 ‘‘(iii) has been in existence for a pe17 riod of at least 5 years. 

18 ‘‘(B) DEPENDENT.—The term ‘dependent’, 

19 with respect to a qualified individual, has the 

20 meaning given such term in section 2714, with 

21 respect to a policy holder. 

22 ‘‘(C) QUALIFIED ACTUARY.—The term 

23 ‘qualified actuary’ means a member in good 

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1 aries, or a successor organization approved by 

2 the Secretary. 

3 ‘‘(D) QUALIFIED INDIVIDUALS.—The term 

4 ‘qualified individual’ means, with respect to an 

5 association, an individual who meets any of the 

6 following: 

7 ‘‘(i) A member of the association who 

8 has been such a member for a period of at 

9 least 30 days. 

10 ‘‘(ii) An employee of such member 

11 who has been employed by such member 

12 for a period of at least 30 days. 

13 ‘‘(iii) An employee of the association 

14 who has been employed by the association 

15 for a period of at least 30 days.’’. 

16 (b) INDIVIDUAL MARKET.—Subpart 1 of part B of 

17 title XXVII of the Public Health Service Act (42 U.S.C. 

18 300gg–41 et seq.) is amended by adding at the end the 

19 following: 

20 ‘‘SEC. 2746. PROHIBITION OF PREEXISTING CONDITION EX21 CLUSIONS OR OTHER DISCRIMINATION 

22 BASED ON HEALTH STATUS. 

23 ‘‘The provisions of section 2701 (other than subpara24 graphs (A)(ii) and (B) of subsection (c)(3)) shall apply 

25 to health insurance coverage offered to individuals by a 


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1 health insurance issuer in the individual market in the 

2 same manner as it applies to health insurance coverage 

3 offered by a health insurance issuer in the group market.’’. 

4 SEC. 6. NO LIFETIME OR ANNUAL LIMITS. 

5 (a) GROUP MARKET.—Subpart 2 of part A of title 

6 XXVII of the Public Health Service Act (42 U.S.C. 

7 300gg–4 et seq.) is amended by adding at the end the 

8 following: 

9 ‘‘SEC. 2708. NO LIFETIME OR ANNUAL LIMITS. 

10 ‘‘(a) IN GENERAL.—A group health plan and a health 

11 insurance issuer offering group health insurance coverage 

12 may not establish— 

13 ‘‘(1) lifetime limits on the dollar value of bene14 fits for any participant or beneficiary; or 

15 ‘‘(2) unreasonable annual limits (within the 

16 meaning of section 223 of the Internal Revenue 

17 Code of 1986) on the dollar value of benefits for any 

18 participant or beneficiary. 

19 ‘‘(b) PER BENEFICIARY LIMITS.—A group health 

20 plan or health insurance coverage may not place annual 

21 or lifetime per beneficiary limits on specific covered bene22 fits unless such limits are otherwise permitted under Fed23 eral or State law.’’. 

24 (b) INDIVIDUAL MARKET.—Subpart 2 of part B of 

25 title XXVII of the Public Health Service Act (42 U.S.C. 


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1 300gg–51 et seq.) is amended by adding at the end the 

2 following: 

3 ‘‘SEC. 2754. NO LIFETIME OR ANNUAL LIMITS. 

4 ‘‘The provisions of section 2708 shall apply to health 

5 insurance coverage offered to individuals by a health in6 surance issuer in the individual market in the same man7 ner as it applies to health insurance coverage offered by 

8 a health insurance issuer in the group market.’’. 

9 SEC. 7. PROHIBITION ON RESCISSIONS. 

10 (a) GROUP MARKET.—Subpart 1 of part A of title 

11 XXVII of the Public Health Service Act (42 U.S.C. 300gg 

12 et seq.) is amended by adding at the end the following: 

13 ‘‘SEC. 2703. PROHIBITION ON RESCISSIONS. 

14 ‘‘A group health plan and a health insurance issuer 

15 offering group health insurance coverage shall not rescind 

16 such plan or coverage with respect to an enrollee once the 

17 enrollee is covered under such plan or coverage involved, 

18 except that this section shall not apply to a covered indi19 vidual who has performed an act or practice that con20 stitutes fraud or makes an intentional misrepresentation 

21 of material fact as prohibited by the terms of the plan 

22 or coverage. Such plan or coverage may not be cancelled 

23 except with prior notice to the enrollee, and only as per24 mitted under section 2712(b).’’. 


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1 (b) INDIVIDUAL MARKET.—Subpart 1 of part B of 

2 title XXVII of the Public Health Service Act (42 U.S.C. 

3 300gg–41 et seq.) is amended by adding at the end the 

4 following: 

5 ‘‘SEC. 2747. PROHIBITION ON RESCISSIONS. 

6 ‘‘The provisions of section 2703 shall apply to health 

7 insurance coverage offered to individuals by a health in8 surance issuer in the individual market in the same man9 ner as it applies to health insurance coverage offered by 

10 a health insurance issuer in the group market.’’. 

11 SEC. 8. EXTENSION OF DEPENDENT COVERAGE. 

12 (a) GROUP MARKET.— 

13 (1) IN GENERAL.—Subpart 1 of part A of title 

14 XXVII of the Public Health Service Act (42 U.S.C. 

15 300gg et seq.) is amended by adding at the end: 

16 ‘‘SEC. 2703A. EXTENSION OF DEPENDENT COVERAGE. 

17 ‘‘(a) IN GENERAL.—A group health plan and a health 

18 insurance issuer offering group health insurance coverage 

19 that provides dependent coverage of children shall con20 tinue to make such coverage available for such a depend21 ent after such dependent turns 18 years of age until the 

22 first of the following events occurs: 

23 ‘‘(1) The dependent turns 26 years of age. 

24 ‘‘(2) The dependent marries. 


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1 ‘‘(3) Subject to subsection (c), the dependent no 

2 longer resides in the home of— 

3 ‘‘(A) the policy holder through which such 

4 dependent is eligible for dependent coverage; or 

5 ‘‘(B) in the case that the policy holder 

6 through which such dependent is eligible for de7 pendent coverage provides such coverage subject 

8 to an order to provide child support, the de9 pendent’s parent or legal guardian. 

10 ‘‘(b) EXCEPTION FOR COLLEGE STUDENTS.—Para11 graph (3) of subsection (a) shall not apply to a dependent 

12 for any period of time during which such dependent is en13 rolled as a full-time student at a postsecondary edu14 cational institution (including an institution of higher edu15 cation as defined in section 102 of the Higher Education 

16 Act of 1965). 

17 ‘‘(c) LIMITATION.—Nothing in this section shall re18 quire a plan or an issuer described in subsection (a) to 

19 make coverage available for a child of an individual receiv20 ing dependent coverage pursuant to this section. 

21 ‘‘(d) RULE OF CONSTRUCTION.—Nothing in this sec22 tion shall be construed to modify the definition of ‘depend23 ent’ as used in the Internal Revenue Code of 1986 with 

24 respect to the tax treatment of the cost of coverage.’’. 


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1 (2) REGULATIONS.—The Secretary shall pro2 mulgate regulations to define the dependents to 

3 which coverage shall be made available under section 

4 2703A of the Public Health Service Act, as added 

5 by paragraph (1). 

6 (b) INDIVIDUAL MARKET.—Subpart 1 of part B of 

7 title XXVII of the Public Health Service Act (42 U.S.C. 

8 300gg–41 et seq.) is amended by adding at the end the 

9 following: 

10 ‘‘SEC. 2748. EXTENSION OF DEPENDENT COVERAGE. 

11 ‘‘The provisions of section 2703A shall apply to 

12 health insurance coverage offered to individuals by a 

13 health insurance issuer in the individual market in the 

14 same manner as it applies to health insurance coverage 

15 offered by a health insurance issuer in the group market.’’. 

16 SEC. 9. APPLICATION OF GROUP MARKET REFORMS TO 

17 ERISA AND THE INTERNAL REVENUE CODE 

18 OF 1986. 

19 (a) ERISA.— 

20 (1) IN GENERAL.—Subpart A of title VII of the 

21 Employee Retirement Income Security Act of 1974 

22 (29 U.S.C. 1181 et seq.) is amended— 

23 (A) by striking sections 701 and 703; and 

24 (B) by inserting before section 702 the fol25 lowing: 


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1 ‘‘SEC. 701. APPLICATION OF CERTAIN PHSA REQUIRE2 MENTS. 

3 ‘‘(a) IN GENERAL.—Sections 2701, 2703, 2703A, 

4 2708, 2711, and 2712 of the Public Health Service Act 

5 shall apply to group health plans, and health insurance 

6 issuers providing health insurance coverage in connection 

7 with group health plans, as if included in this subpart. 

8 ‘‘(b) CONFLICT.—To the extent that any provision of 

9 this part conflicts with a provision of any section of the 

10 Public Health Service Act listed in subsection (a) with re11 spect to group health plans, or health insurance issuers 

12 providing health insurance coverage in connection with 

13 group health plans, the provisions of such sections shall 

14 apply.’’. 

15 (2) CONFORMING AMENDMENT.—The table of 

16 contents in section 1 of such Act (29 U.S.C. 1001 

17 note) is amended— 

18 (A) by striking the item related to section 

19 701 and inserting ‘‘Sec. 701. Application of cer20 tain PHSA requirements.’’; and 

21 (B) by striking the item related to section 

22 703. 

23 (b) INTERNAL REVENUE CODE OF 1986.—Sub24 chapter A of chapter 100 of the Internal Revenue Code 

25 of 1986 (relating to group health plan requirements) is 

26 amended— 


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1 (1) by striking sections 9801 and 9803; and 

2 (2) by inserting before section 9802 the fol3 lowing: 

4 ‘‘SEC. 9801. APPLICATION OF CERTAIN PHSA REQUIRE5 MENTS. 

6 ‘‘(a) IN GENERAL.—Sections 2701, 2703, 2703A, 

7 2708, 2711, and 2712 of the Public Health Service Act 

8 shall apply to group health plans, and health insurance 

9 issuers providing health insurance coverage in connection 

10 with group health plans, as if included in this subchapter. 

11 ‘‘(b) CONFLICT.—To the extent that any provision of 

12 this subchapter conflicts with a provision of any section 

13 of the Public Health Service Act listed in subsection (a) 

14 with respect to group health plans, or health insurance 

15 issuers providing health insurance coverage in connection 

16 with group health plans, the provisions of such sections 

17 shall apply.’’. 

18 SEC. 10. CATASTROPHIC PLAN. 

19 Subpart 1 of part B of title XXVII of the Public 

20 Health Service Act (42 U.S.C. 300gg–41 et seq.) is 

21 amended by adding at the end the following: 

22 ‘‘SEC. 2749. CATASTROPHIC PLAN. 

23 ‘‘(a) IN GENERAL.—Each health insurance issuer 

24 that offers health insurance coverage in the individual 


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1 market in a State shall offer a catastrophic plan in such 

2 State in such market. 

3 ‘‘(b) COVERAGE REQUIREMENTS.—To meet the re4 quirements of this section, a catastrophic plan must pro5 vide for the essential health benefits, as defined by the 

6 Secretary under subsection (c). 

7 ‘‘(c) ESSENTIAL HEALTH BENEFITS.—The Sec8 retary shall define the essential health benefits, except 

9 that such benefits shall include— 

10 ‘‘(1) coverage for at least three primary care 

11 visits during a plan year; and 

12 ‘‘(2) at least the following general categories 

13 and the items and services covered within the cat14 egories: 

15 ‘‘(A) Ambulatory patient services. 

16 ‘‘(B) Emergency services. 

17 ‘‘(C) Hospitalization. 

18 ‘‘(D) Maternity and newborn care. 

19 ‘‘(E) Mental health and substance use dis20 order services, including behavioral health treat21 ment. 

22 ‘‘(F) Prescription drugs. 

23 ‘‘(G) Rehabilitative and habilitative serv24 ices and devices. 

25 ‘‘(H) Laboratory services. 


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1 ‘‘(I) Preventive and wellness services and 

2 chronic disease management. 

3 ‘‘(J) Pediatric services, including oral and 

4 vision care. 

5 ‘‘(d) RESTRICTION TO INDIVIDUAL MARKET.—If a 

6 health insurance issuer offers a health plan described in 

7 this section, the issuer may only offer the plan in the indi8 vidual market.’’. 

9 SEC. 11. GRANTS FOR HEALTH INSURANCE RISK ADJUST10 MENT MECHANISMS. 

11 (a) IN GENERAL.—The Secretary of Health and 

12 Human Services shall make grants to States for planning 

13 for the establishment and implementation of health insur14 ance risk adjustment mechanisms. 

15 (b) AMOUNT.— 

16 (1) IN GENERAL.—The Secretary shall deter17 mine the amount of a grant made to a State under 

18 this section pursuant to a formula, issued by rule 

19 not later than one year after the date of the enact20 ment of the PPACA repeal legislation described in 

21 section 2(b), that takes into account the number of 

22 high-risk individuals in such State. 

23 (2) LIMITATION.—The amount of a grant made 

24 to a State under this section shall not exceed 

25 $1,000,000 for any fiscal year. 


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1 (c) USE OF FUNDS.—The grant funds made available 

2 to a State under this section may only be used by a State 

3 for the cost associated with planning for the establishment 

4 and implementation of health insurance risk adjustment 

5 mechanisms. Such funds may not be used for costs related 

6 to administering such mechanisms. 

7 (d) DEFINITIONS.—For purposes of this section: 

8 (1) HIGH-RISK INDIVIDUAL.—The term ‘‘high9 risk individual’’ means an individual who— 

10 (A) is a citizen or national of the United 

11 States or is lawfully present in the United 

12 States; 

13 (B) has not been covered under creditable 

14 coverage (as defined in section 2701(c)(1) of 

15 the Public Health Service Act as in effect on 

16 March 22, 2010) during the previous 6-month 

17 period; and 

18 (C) has a preexisting condition, as deter19 mined in a manner consistent with guidance 

20 issued by the Secretary. 

21 (2) HEALTH INSURANCE RISK-ADJUSTMENT

22 MECHANISMS.— 

23 (A) IN GENERAL.—With respect to a 

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1 ment mechanism’’ shall be a mechanism that 

2 applies to— 

3 (i) all health insurance issuers who 

4 offer health insurance coverage in such 

5 State; and 

6 (ii) all covered lives for health insur7 ance coverage offered in such State that is 

8 subject to the requirements of section 2711 

9 or section 2741 of the Public Health Serv10 ice Act, as added by section 3 of this Act. 

11 (B) FURTHER DEFINITION.—With respect 

12 to a State, any further definition of such term 

13 shall be determined by the State insurance com14 missioner, acting in cooperation with health in15 surance issuers who offer health insurance cov16 erage in such State. 

17 (3) STATE.—The term ‘‘State’’ means each of 

18 the 50 States and the District of Columbia. 

19 (e) SUNSET DATE.—The Secretary may not make 

20 any grants under this section after the date that is 2 years 

21 after the date of the enactment of the PPACA repeal legis22 lation described in section 2(b). 


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1 SEC. 12. LIABILITY PROTECTIONS FOR HEALTH CARE PRO2 VIDERS. 

3 (a) HEALTH CARE PROVIDERS PROTECTED.—The li4 ability protections in subsection (c) shall apply in any civil 

5 action, including an action before any court of any State, 

6 against a health care provider, arising from health care 

7 goods or services that— 

8 (1) were provided by a health care provider in 

9 a hospital to which the requirements of section 1867 

10 of the Social Security Act (42 U.S.C. 1395dd) apply; 

11 and 

12 (2) were provided only because they were re13 quired under section 1867 of the Social Security Act 

14 (42 U.S.C. 1395dd). 

15 (b) BURDEN OF PROOF.—In any proceeding under 

16 subsection (a), the burden of proof shall be on the defend17 ant to establish the elements in paragraphs (1) and (2) 

18 of subsection (a). 

19 (c) LIABILITY PROTECTIONS.— 

20 (1) CAP ON NONECONOMIC DAMAGES.—The 

21 amount of noneconomic damages, if available, shall 

22 not exceed $250,000, regardless of the number of 

23 parties against whom the action is brought with re24 spect to the same injury. An award for noneconomic 

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1 ther before entry of the order granting judgment, or 

2 by amendment of such order. 

3 (2) INSTALLMENT PAYMENTS.—If the award 

4 for damages exceeds $50,000, the defendant may 

5 pay such damages in installments, as determined by 

6 the court. 

7 (3) ATTORNEY FEES.—Any contingent fee for a 

8 party’s attorney shall not exceed— 

9 (A) 40 percent of the portion of the award 

10 amount that does not exceed $50,000; 

(B) 331 11 ⁄3 percent of the portion of the 

12 award amount that exceeds $50,000 but does 

13 not exceed $100,000; 

14 (C) 25 percent of the portion of the award 

15 amount that exceeds $100,000 but does not ex16 ceed $600,000; and 

17 (D) 15 percent of the portion of the award 

18 amount that exceeds $600,000. 

19 (4) DISCLOSURE OF COLLATERAL SOURCE BEN20 EFITS.—Any person bringing a civil action described 

21 in subsection (a) shall, and any party may, disclose 

22 or introduce evidence of collateral source benefits. 

23 (5) PREEMPTION.— 

24 (A) IN GENERAL.—The provisions of this 

25 Act preempt, subject to subparagraphs (B) and 


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1 (C), State law to the extent that State law pre2 vents the application of any provisions of law 

3 established by or under this Act. The provisions 

4 governing an action described in subsection (a) 

5 set forth in this Act supersede chapter 171 of 

6 title 28, United States Code, to the extent that 

7 such chapter— 

8 (i) provides for a greater amount of 

9 damages or contingent fees, a longer pe10 riod in which a health care lawsuit may be 

11 commenced, or a reduced applicability or 

12 scope of periodic payment of future dam13 ages, than provided in this Act; or 

14 (ii) prohibits the introduction of evi15 dence regarding collateral source benefits, 

16 or mandates or permits subrogation or a 

17 lien on collateral source benefits. 

18 (B) GREATER PROTECTIONS PRE19 SERVED.—This Act shall not preempt or super20 sede any State or Federal law that imposes 

21 greater procedural or substantive protections 

22 for health care providers from liability, loss, or 

23 damages than those provided by this Act or cre24 ate a cause of action. 


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1 (C) RULE OF CONSTRUCTION.—No provi2 sion of this Act shall be construed to preempt— 

3 (i) any State law (whether effective 

4 before, on, or after the date of the enact5 ment of this Act) that specifies a par6 ticular monetary amount of compensatory 

7 or punitive damages (or the total amount 

8 of damages) that may be awarded in an 

9 action described in subsection (a), regard10 less of whether such monetary amount is 

11 greater or lesser than is provided for under 

12 this Act; or 

13 (ii) any defense available to a party in 

14 an action described in subsection (a) under 

15 any other provision of State or Federal 

16 law. 

17 (6) DEFINITIONS.— 

18 (A) COLLATERAL SOURCE BENEFITS.—As 

19 used in this section, the term ‘‘collateral source 

20 benefits’’ means any amount paid or reasonably 

21 likely to be paid in the future to or on behalf 

22 of the claimant, or any service, product, or 

23 other benefit provided or reasonably likely to be 

24 provided in the future to or on behalf of the 


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1 claimant, as a result of the personal harm, pur2 suant to— 

3 (i) any State or Federal health, sick4 ness, income-disability, accident, or work5 ers’ compensation law; 

6 (ii) any health, sickness, income-dis7 ability, or accident insurance that provides 

8 health benefits or income-disability cov9 erage; 

10 (iii) any contract or agreement of any 

11 group, organization, partnership, or cor12 poration to provide, pay for, or reimburse 

13 the cost of medical, hospital, dental, or in14 come-disability benefits; and 

15 (iv) any other publicly or privately 

16 funded program. 

17 (B) NONECONOMIC DAMAGES.—As used in 

18 this section, the term ‘‘noneconomic damages’’ 

19 means damages for physical and emotional 

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1 utation, and all other nonpecuniary losses of 

2 any kind or nature. 

3 (C) HEALTH CARE PROVIDER.—As used in 

4 this section, the term ‘‘health care provider’’ 

5 means any person or entity required by State or 

6 Federal laws or regulations to be licensed, reg7 istered, or certified to provide health care serv8 ices, and being either so licensed, registered, or 

9 certified, or exempted from such requirement by 

10 other statute. 

11 (D) HEALTH CARE GOODS OR SERVICES.— 

12 As used in this section, the term ‘‘health care 

13 goods or services’’ means any goods or services 

14 provided by a health care organization, pro15 vider, or by any individual working under the 

16 supervision of a health care provider, that re17 lates to the diagnosis, prevention, or treatment 

18 of any human disease or impairment, or the as19 sessment or care of the health of human beings. 

Æ 


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