II 

115TH CONGRESS 

2D SESSION S. 2582 

To provide health insurance reform, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

MARCH 21, 2018 

Ms. WARREN (for herself, Ms. HASSAN, Mr. SANDERS, Ms. HARRIS, Ms. 

BALDWIN, and Mrs. GILLIBRAND) introduced the following bill; which 

was read twice and referred to the Committee on Finance 

A BILL 

To provide health insurance reform, 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, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Consumer Health In5 surance Protection Act of 2018’’. 

6 SEC. 2. TABLE OF CONTENTS. 

7 The table of contents for this Act is as follows: 

Sec. 1. Short title. 

Sec. 2. Table of contents. 

TITLE I—LIMITING INSURER PROFITS AND PREVENTING 

UNREASONABLE PREMIUM INCREASES 

Sec. 101. Medical loss ratio. 

Sec. 102. Ensuring that consumers get value for their dollars. 

Sec. 103. Effective date. 


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TITLE II—MAKING HEALTH INSURANCE COVERAGE AFFORDABLE 

Sec. 201. Enhancement of premium assistance credit. 

Sec. 202. Enhancements for reduced cost-sharing. 

Sec. 203. Cap on prescription drug cost-sharing. 

Sec. 204. Standardized options in the bronze, silver, and gold levels of coverage. 

Sec. 205. Clarification regarding determination of affordability of employersponsored minimum essential coverage. 

TITLE III—ENSURING ACCESS TO CARE 

Sec. 301. Network adequacy requirements. 

Sec. 302. Ensuring adequate coverage in areas with fewer than 3 health insurance issuers offering qualified health plans on the State Exchange. 

Sec. 303. Enrollment in Exchanges. 

Sec. 304. Marketing and outreach for Exchanges operated by the Secretary. 

Sec. 305. Navigator program. 

TITLE IV—STRENGTHENING CONSUMER HEALTH INSURANCE 

PROTECTIONS 

Sec. 401. Prohibiting discriminatory premiums based on tobacco use. 

Sec. 402. Health insurance consumer information. 

Sec. 403. Patient protections. 

Sec. 404. Limitation on balance billing for emergency services. 

Sec. 405. Notification of provider terminations. 

Sec. 406. Short-term limited duration health insurance coverage. 

Sec. 407. Protecting essential health benefits. 

Sec. 408. Association health plans. 

1 TITLE I—LIMITING INSURER 

2 PROFITS AND PREVENTING 

3 UNREASONABLE PREMIUM 

4 INCREASES 

5 SEC. 101. MEDICAL LOSS RATIO. 

6 Section 2718(b)(1)(A)(ii) of the Public Health Serv7 ice Act (42 U.S.C. 300gg–18(b)(1)(A)(ii)) is amended by 

8 striking ‘‘80’’ each place it appears and inserting ‘‘85’’. 

9 SEC. 102. ENSURING THAT CONSUMERS GET VALUE FOR 

10 THEIR DOLLARS. 

11 Section 2794 of the Public Health Service Act (42 

12 U.S.C. 300gg–94) is amended— 


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1 (1) in subsection (a)— 

2 (A) in paragraph (1), by striking ‘‘sub3 section (b)(2)(A)’’ and inserting ‘‘subsections 

4 (b)(2)(A) and (b)(3)’’; and 

5 (B) in paragraph (2), by adding at the end 

6 the following: ‘‘Notwithstanding any other pro7 vision of law, a health insurance issuer may not 

8 exclude from such disclosure information that is 

9 a trade secret or commercial or financial infor10 mation described in section 552(b)(4) of title 5, 

11 United States Code.’’; 

12 (2) in subsection (b)— 

13 (A) in paragraph (2)(A), by inserting ‘‘and 

14 paragraph (3)’’ after ‘‘subsection (a)(2)’’; and 

15 (B) by adding at the end the following: 

16 ‘‘(3) PROHIBITING UNREASONABLE IN17 CREASES.— 

18 ‘‘(A) IN GENERAL.—Beginning with plan 

19 years beginning in 2020, the Secretary, or a 

20 State pursuant to an effective rate review pro21 gram meeting the requirements under para22 graph (4)— 

23 ‘‘(i) shall, consistent with subsection 

24 (a)(2) and paragraph (2), review increases 

25 in health insurance premiums that are subVerDate Sep 11 2014 04:38 Apr 03, 2018 Jkt 079200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S2582.IS S2582

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1 ject to review pursuant to section 154.200 

2 of title 45, Code of Federal Regulations (or 

3 any successor regulation), and determine 

4 whether such increases are unreasonable; 

5 and 

6 ‘‘(ii) may prohibit a health insurance 

7 issuer from implementing such an increase 

8 that is unreasonable. 

9 ‘‘(B) UNREASONABLE INCREASES.—In de10 termining whether an increase in health insur11 ance premiums is unreasonable under subpara12 graph (A)(i)— 

13 ‘‘(i) the Secretary shall consider 

14 whether the increase is excessive, unjusti15 fied, discriminatory, or inadequate; and 

16 ‘‘(ii) the State, pursuant to an effec17 tive rate review program meeting the re18 quirements under paragraph (4), shall 

19 apply applicable State law for making such 

20 determination. 

21 ‘‘(4) STATE EFFECTIVE RATE REVIEW PRO22 GRAMS.—A State effective rate review program 

23 meets the requirements under this paragraph if— 

24 ‘‘(A) the program carries out the reviews 

25 described in paragraph (3)(A)(i) and ensures 


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1 that such reviews are a meaningful, effective, 

2 and timely review of the data and documenta3 tion (including any contracts or documents de4 scribed in subparagraph (E)) submitted by 

5 health insurance issuers in support of proposed 

6 increases in health insurance premiums; 

7 ‘‘(B) such reviews include an examination 

8 of— 

9 ‘‘(i) the affordability of proposed in10 creases in health insurance premiums; 

11 ‘‘(ii) the quality improvement activi12 ties carried out by health insurance issuers 

13 proposing the increases; and 

14 ‘‘(iii) the cost containment activities 

15 of health insurance issuers proposing the 

16 increases; 

17 ‘‘(C) the program establishes a mechanism 

18 for receiving public comments on proposed in19 creases in health insurance premiums reviewed 

20 by the State; 

21 ‘‘(D) such reviews include a review of all 

22 public comments received under subparagraph 

23 (C); 

24 ‘‘(E) the program requires each health in25 surance issuer proposing an increase in health 


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1 insurance premiums to submit to the State any 

2 provider contracts that may be affected, includ3 ing any documents incorporated by reference 

4 into such contracts; and 

5 ‘‘(F) the program requires the State to 

6 provide the Secretary its determination of 

7 whether each increase reviewed is unreasonable, 

8 in a form and manner prescribed by the Sec9 retary.’’; and 

10 (3) in subsection (c)— 

11 (A) in paragraph (1)— 

12 (i) in the heading, by striking ‘‘2010

13 THROUGH 2014’’ and inserting ‘‘2020

14 THROUGH 2024’’; and 

15 (ii) in the matter preceding subpara16 graph (A), by striking ‘‘2010’’ and insert17 ing ‘‘2020’’; and 

18 (B) in paragraph (2)(B), by striking 

19 ‘‘2014’’ and inserting ‘‘2024’’. 

20 SEC. 103. EFFECTIVE DATE. 

21 The amendments made by this title shall apply to 

22 plan years beginning after December 31, 2019. 


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1 TITLE II—MAKING HEALTH IN2 SURANCE COVERAGE AF3 FORDABLE 

4 SEC. 201. ENHANCEMENT OF PREMIUM ASSISTANCE CRED5 IT. 

6 (a) USE OF GOLD LEVEL PLAN FOR BENCHMARK.— 

7 (1) IN GENERAL.—Clause (i) of section 

8 36B(b)(2)(B) of the Internal Revenue Code of 1986 

9 is amended by striking ‘‘applicable second lowest 

10 cost silver plan’’ and inserting ‘‘applicable second 

11 lowest cost gold plan’’. 

12 (2) CONFORMING AMENDMENT RELATED TO

13 AFFORDABILITY.—Section 36B(c)(4)(C)(i)(I) of 

14 such Code is amended by striking ‘‘second lowest 

15 cost silver plan’’ and inserting ‘‘second lowest cost 

16 gold plan’’. 

17 (3) OTHER CONFORMING AMENDMENTS.—Sub18 paragraphs (B) and (C) of section 36B(b)(3) of such 

19 Code are each amended by striking ‘‘silver plan’’ 

20 each place it appears in the text and the heading 

21 and inserting ‘‘gold plan’’. 

22 (b) EXPANSION OF ELIGIBILITY FOR REFUNDABLE

23 CREDITS FOR COVERAGE UNDER QUALIFIED HEALTH

24 PLANS.— 


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1 (1) IN GENERAL.—Section 36B(c)(1)(A) of the 

2 Internal Revenue Code of 1986 is amended by strik3 ing ‘‘but does not exceed 400 percent’’. 

4 (2) CONFORMING AMENDMENTS RELATING TO

5 RECAPTURE OF EXCESS ADVANCED PAYMENTS.— 

6 Clause (i) of section 36B(f)(2)(B) of such Code is 

7 amended— 

8 (A) by striking ‘‘In the case of’’ and all 

9 that follows through ‘‘the amount of’’ and in10 serting ‘‘The amount of’’; and 

11 (B) by striking ‘‘but less than 400%’’ in 

12 the table therein. 

13 (c) DETERMINATION OF APPLICABLE PERCENT14 AGE.— 

15 (1) IN GENERAL.—Subparagraph (A) of section 

16 36B(b)(3) of the Internal Revenue Code of 1986 is 

17 amended to read as follows: 

18 ‘‘(A) APPLICABLE PERCENTAGE.—The ap19 plicable percentage for any taxable year shall be 

20 the percentage such that the applicable percent21 age for any taxpayer whose household income is 

22 within an income tier specified in the following 

23 table shall increase, on a sliding scale in a lin24 ear manner, from the initial premium percentVerDate Sep 11 2014 04:38 Apr 03, 2018 Jkt 079200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S2582.IS S2582

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1 age to the final premium percentage specified in 

2 such table for such income tier: 

‘‘In the case of household 

income (expressed as a 

percent of poverty line) within 

the following income tier: 

The initial 

premium 

percentage is— 

The final 

premium 

percentage is— 

100% through 133% ..................... 0.0% 1.0%

133% through 150% ..................... 1.0% 2.0%

150% through 200% ..................... 2.0% 4.0%

200% through 250% ..................... 4.0% 6.0%

250% through 300% ..................... 6.0% 7.0%

300% through 400% ..................... 7.0% 8.5%

Over 400% ..................................... 8.5% 8.5%’’. 

3 (2) CONFORMING AMENDMENTS.—Subsections 

4 (c)(2)(C)(iv) and (c)(4)(F) of section 36B of the In5 ternal Revenue Code of 1986 are each amended by 

6 inserting ‘‘(as in effect before the date of the enact7 ment of the Consumer Health Insurance Protection 

8 Act of 2018)’’ after ‘‘subsection (b)(3)(A)(ii)’’. 

9 (d) EFFECTIVE DATE.—The amendments made by 

10 this section shall apply to taxable years beginning after 

11 December 31, 2019. 

12 SEC. 202. ENHANCEMENTS FOR REDUCED COST-SHARING. 

13 (a) MODIFICATION OF AMOUNT.— 

14 (1) IN GENERAL.—Section 1402 of the Patient 

15 Protection and Affordable Care Act (42 U.S.C. 

16 18071) is amended— 

17 (A) in subsection (b)(1), by striking ‘‘sil18 ver’’ and inserting ‘‘gold’’; 

19 (B) by amending subsection (c)(1)(B) to 

20 read as follows: 


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1 ‘‘(B) COORDINATION WITH ACTUARIAL

2 LIMITS.—The Secretary shall ensure the reduc3 tion under this paragraph shall not result in the 

4 plan’s share of the total allowed costs of bene5 fits provided under the plan becoming less 

6 than— 

7 ‘‘(i) 95 percent in the case of an eligi8 ble insured described in paragraph (2)(A); 

9 ‘‘(ii) 90 percent in the case of an eli10 gible insured described in paragraph 

11 (2)(B); and 

12 ‘‘(iii) 85 percent in the case of an eli13 gible insured described in paragraph 

14 (2)(C).’’; and 

15 (C) by amending subsection (c)(2) to read 

16 as follows: 

17 ‘‘(2) ADDITIONAL REDUCTION.—The Secretary 

18 shall establish procedures under which the issuer of 

19 a qualified health plan to which this section applies 

20 shall further reduce cost-sharing under the plan in 

21 a manner sufficient to— 

22 ‘‘(A) in the case of an eligible insured 

23 whose household income is not less than 100 

24 percent but not more than 200 percent of the 

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1 crease the plan’s share of the total allowed 

2 costs of benefits provided under the plan to 95 

3 percent of such costs; 

4 ‘‘(B) in the case of an eligible insured 

5 whose household income is more than 200 per6 cent but not more than 300 percent of the pov7 erty line for a family of the size involved, in8 crease the plan’s share of the total allowed 

9 costs of benefits provided under the plan to 90 

10 percent of such costs; and 

11 ‘‘(C) in the case of an eligible insured 

12 whose household income is more than 300 per13 cent but not more than 400 percent of the pov14 erty line for a family of the size involved, in15 crease the plan’s share of the total allowed 

16 costs of benefits provided under the plan to 85 

17 percent of such costs.’’. 

18 (2) EFFECTIVE DATE.—The amendments made 

19 by this subsection shall apply to plan years begin20 ning after December 31, 2019. 

21 (b) FUNDING.—Section 1402 of the Patient Protec22 tion and Affordable Care Act (42 U.S.C. 18071) is amend23 ed by adding at the end the following new subsection: 

24 ‘‘(g) FUNDING.—Out of any funds in the Treasury 

25 not otherwise appropriated, there are appropriated to the 


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1 Secretary such sums as may be necessary for payments 

2 under this section.’’. 

3 SEC. 203. CAP ON PRESCRIPTION DRUG COST-SHARING. 

4 (a) QUALIFIED HEALTH PLANS.—Section 1302(c) of 

5 the Patient Protection and Affordable Care Act (42 

6 U.S.C. 18022(c)) is amended— 

7 (1) in paragraph (3)(A)(i), by inserting ‘‘(in8 cluding cost-sharing with respect to prescription 

9 drugs covered by the plan)’’ after ‘‘copayments’’; 

10 and 

11 (2) by adding at the end the following: 

12 ‘‘(5) PRESCRIPTION DRUG COST-SHARING.— 

13 ‘‘(A) 2020.—For plan years beginning in 

14 2020, the cost-sharing incurred under a health 

15 plan with respect to prescription drugs covered 

16 by the plan shall not exceed $250 per month for 

17 each enrolled individual, or $500 for each fam18 ily. 

19 ‘‘(B) 2021 AND LATER.— 

20 ‘‘(i) IN GENERAL.—In the case of any 

21 plan year beginning in a calendar year 

22 after 2020, the limitation under this para23 graph shall be equal to the applicable dol24 lar amount under subparagraph (A) for 

25 plan years beginning in 2020, increased by 


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1 an amount equal to the product of that 

2 amount and the medical care component of 

3 the consumer price index for all urban con4 sumers (as published by the Bureau of 

5 Labor Statistics) for that year. 

6 ‘‘(ii) ADJUSTMENT TO AMOUNT.—If 

7 the amount of any increase under clause 

8 (i) is not a multiple of $5, such increase 

9 shall be rounded to the next lowest mul10 tiple of $5.’’. 

11 (b) GROUP HEALTH PLANS.—Section 2707(b) of the 

12 Public Health Service Act (42 U.S.C. 300gg–6(b)) is 

13 amended by striking ‘‘paragraph (1) of section 1302(c)’’ 

14 and inserting ‘‘paragraphs (1) and (5) of section 1302(c) 

15 of the Patient Protection and Affordable Care Act’’. 

16 (c) EFFECTIVE DATE.—The amendments made by 

17 subsections (a) and (b) shall take effect with respect to 

18 plans beginning after December 31, 2019. 

19 SEC. 204. STANDARDIZED OPTIONS IN THE BRONZE, SIL20 VER, AND GOLD LEVELS OF COVERAGE. 

21 (a) IN GENERAL.—Section 1301(a) of the Patient 

22 Protection and Affordable Care Act (42 U.S.C. 18021(a)) 

23 is amended— 

24 (1) in paragraph (1)(C)— 


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1 (A) in clause (iii), by striking ‘‘; and’’ and 

2 inserting ‘‘;’’; 

3 (B) by redesignating clause (iv) as clause 

4 (v); and 

5 (C) by inserting after clause (iii) the fol6 lowing: 

7 ‘‘(iv)(I) agrees to offer the standard8 ized option established for the State under 

9 paragraph (5) for each level of coverage of10 fered by the issuer that is the bronze, sil11 ver, or gold level of coverage; and 

12 ‘‘(II) with respect to offering coverage 

13 that is the bronze, silver, or gold level of 

14 coverage on an Exchange that is operated 

15 by the Secretary, agrees to offer only 

16 standardized options established for the 

17 State under paragraph (5) and not any 

18 other plan for such levels of coverage; 

19 and’’; and 

20 (2) by adding at the end the following: 

21 ‘‘(5) STANDARDIZED OPTIONS.— 

22 ‘‘(A) DEFINITION OF STANDARDIZED OP23 TION.—In this section, the term ‘standardized 

24 option’ means a qualified health plan— 


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1 ‘‘(i) with a standardized cost-sharing 

2 structure established by the applicable 

3 State, or the Secretary, in accordance with 

4 this paragraph; and 

5 ‘‘(ii) that is offered on an Exchange. 

6 ‘‘(B) ESTABLISHMENT.— 

7 ‘‘(i) STATE.—Each State may estab8 lish a standardized option for the bronze, 

9 silver, and gold levels of coverage. 

10 ‘‘(ii) SECRETARY.—The Secretary 

11 shall establish a standardized option in a 

12 State for any level of coverage described in 

13 clause (i) for which the State has not es14 tablished a standardized option. 

15 ‘‘(iii) UPDATES.—The Secretary shall 

16 annually update any standardized option 

17 established by the Secretary under clause 

18 (ii). 

19 ‘‘(C) DEDUCTIBLE-EXEMPT SERVICES.— 

20 ‘‘(i) IN GENERAL.—Except as pro21 vided in clause (ii), each standardized op22 tion established by the Secretary under 

23 subparagraph (B)(ii) shall include coverage 

24 of each of the following as deductible-ex25 empt services: 


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1 ‘‘(I) All primary care visits and 

2 specialist visits. 

3 ‘‘(II) All mental health and sub4 stance use disorder outpatient serv5 ices. 

6 ‘‘(III) All drugs approved under 

7 section 505(j) of the Federal Food, 

8 Drug, and Cosmetic Act and biological 

9 products licensed under section 

10 351(k) of the Public Health Service 

11 Act. 

12 ‘‘(IV) All urgent care services. 

13 ‘‘(ii) BRONZE AND SILVER LEVELS OF

14 COVERAGE.—The Secretary may alter the 

15 services that shall be covered as deductible16 exempt services under clause (i) for stand17 ardized options in the bronze and silver 

18 levels of coverage. 

19 ‘‘(D) DISPLAY.—Each Exchange operated 

20 by a State shall preferentially display the stand21 ardized options offered in such State on the 

22 website of the Exchange.’’. 

23 (b) EFFECTIVE DATE.—The amendments made by 

24 this section shall apply to plans beginning after December 

25 31, 2019. 


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1 SEC. 205. CLARIFICATION REGARDING DETERMINATION OF 

2 AFFORDABILITY OF EMPLOYER-SPONSORED 

3 MINIMUM ESSENTIAL COVERAGE. 

4 (a) SPECIAL RULE FOR EMPLOYER-SPONSORED

5 MINIMUM ESSENTIAL COVERAGE.—Clause (i) of section 

6 36B(c)(2)(C) of the Internal Revenue Code of 1986 is 

7 amended to read as follows: 

8 ‘‘(i) COVERAGE MUST BE AFFORD9 ABLE.— 

10 ‘‘(I) IN GENERAL.—Except as 

11 provided in clause (iii), an individual 

12 shall not be treated as eligible for 

13 minimum essential coverage if such 

14 coverage consists of an eligible em15 ployer-sponsored plan (as defined in 

16 section 5000A(f)(2)) and the required 

17 contribution with respect to the plan 

18 exceeds 8.5 percent of the applicable 

19 taxpayer’s household income. 

20 ‘‘(II) REQUIRED CONTRIBUTION

21 WITH RESPECT TO EMPLOYEE.—In 

22 the case of the employee eligible to en23 roll in the plan, the required contribu24 tion for purposes of subclause (I) is 

25 the employee’s required contribution 

26 (within the meaning of section 


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1 5000A(e)(1)(B)(i)) with respect to the 

2 plan. 

3 ‘‘(III) REQUIRED CONTRIBUTION

4 WITH RESPECT TO FAMILY MEM5 BERS.—In the case of an individual 

6 who is eligible to enroll in the plan by 

7 reason of a relationship the individual 

8 bears to the employee, the required 

9 contribution for purposes of subclause 

10 (I) is the employee’s required con11 tribution (within the meaning of sec12 tion 5000A(e)(1)(B)(i), determined by 

13 substituting ‘family’ for ‘self-only’) 

14 with respect to the plan.’’. 

15 (b) CONFORMING AMENDMENTS.— 

16 (1) Clause (ii) of section 36B(c)(2)(C) of the 

17 Internal Revenue Code of 1986 is amended by add18 ing at the end the following: ‘‘This clause shall also 

19 apply to an individual who is eligible to enroll in the 

20 plan by reason of a relationship the individual bears 

21 to the employee.’’. 

22 (2) Clause (iii) of section 36B(c)(2)(C) of such 

23 Code is amended by striking ‘‘the last sentence of 

24 clause (i)’’ and inserting ‘‘clause (i)(III)’’. 


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1 (3) Clause (iv) of section 36B(c)(2)(C) of such 

2 Code is amended by striking ‘‘clause (i)(II)’’ and in3 serting ‘‘clause (i)(I)’’. 

4 (c) EFFECTIVE DATE.—The amendments made by 

5 this section shall apply to taxable years beginning after 

6 December 31, 2019. 

7 TITLE III—ENSURING ACCESS 

8 TO CARE 

9 SEC. 301. NETWORK ADEQUACY REQUIREMENTS. 

10 (a) IN GENERAL.—Section 1311(c) of the Patient 

11 Protection and Affordable Care Act (42 U.S.C. 18031(c)) 

12 is amended— 

13 (1) in paragraph (1)(B), by inserting ‘‘and 

14 paragraph (7) and in accordance with paragraph 

15 (8)’’ after ‘‘Public Health Service Act’’; and 

16 (2) by adding at the end the following: 

17 ‘‘(7) NETWORK ADEQUACY REQUIREMENTS.— 

18 ‘‘(A) IN GENERAL.—A qualified health 

19 plan shall meet the network adequacy standards 

20 established by the Secretary under subpara21 graph (B), except as provided in subparagraphs 

22 (B)(ii) and (C). 

23 ‘‘(B) FEDERAL STANDARDS AND RE24 VIEW.— 

25 ‘‘(i) STANDARD.— 


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1 ‘‘(I) ESTABLISHMENT.—The Sec2 retary shall establish a network ade3 quacy standard based on access to in4 network providers for qualified health 

5 plans, except for those plans described 

6 in subparagraph (C). Such standard 

7 shall include requirements for the 

8 minimum number and type of in-net9 work providers available, the geo10 graphical location of such providers, 

11 the average distance and travel time 

12 required for patients to visit such pro13 viders, and the average appointment 

14 wait times for services covered by the 

15 plan. 

16 ‘‘(II) MEDICARE ADVANTAGE OR17 GANIZATIONS.—The network ade18 quacy standard established under sub19 clause (I) shall, at a minimum, be 

20 equivalent to the requirements for ac21 cess to services applicable to Medicare 

22 Advantage organizations offering 

23 Medicare Advantage plans under part 

24 C of title XVIII of the Social Security 

25 Act. 


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1 ‘‘(ii) JUSTIFICATION.—A qualified 

2 health plan that fails to meet the standard 

3 established under clause (i) may satisfy the 

4 requirement under subparagraph (A) by 

5 providing the Secretary with a reasonable 

6 justification for the variance from such 

7 standard, based on factors such as the 

8 availability of providers and variables re9 flected in local patterns of health care. 

10 ‘‘(iii) REVIEW.—The Secretary shall 

11 establish a process for reviewing the net12 work adequacy of qualified health plans, 

13 except for those plans reviewed by the 

14 State in accordance with subparagraph 

15 (C)(ii). 

16 ‘‘(C) STATE STANDARD.— 

17 ‘‘(i) IN GENERAL.—In the case of a 

18 qualified health plan offered in a State 

19 that has implemented a quantifiable net20 work adequacy metric that the Secretary 

21 determines is an acceptable metric com22 monly used in the health insurance indus23 try to measure network adequacy, such 

24 qualified health plan may satisfy the re25 quirement under subparagraph (A) by 


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1 meeting the network adequacy standards 

2 of such State based on such metric. 

3 ‘‘(ii) REVIEW.—A State with an ac4 ceptable metric described in clause (i) may 

5 review the network adequacy of qualified 

6 health plans offered in such State in a 

7 process established by the State. 

8 ‘‘(8) COVERAGE OF OUT-OF-NETWORK ESSEN9 TIAL HEALTH BENEFITS.— 

10 ‘‘(A) IN GENERAL.—A qualified health 

11 plan shall provide, to an individual enrolled in 

12 such plan, coverage of any service provided by 

13 an out-of-network provider if— 

14 ‘‘(i) coverage of such service would 

15 otherwise be provided by the plan if the 

16 service was provided by an in-network pro17 vider; 

18 ‘‘(ii) the service is included in the es19 sential health benefits package described in 

20 section 1302(a); and 

21 ‘‘(iii) the service cannot be provided to 

22 the individual by an in-network provider 

23 within a reasonable timeframe or within a 

24 reasonable distance and travel time. 


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1 ‘‘(B) COST-SHARING.—A qualified health 

2 plan that provides coverage of a service pro3 vided by an out-of-network provider under sub4 paragraph (A) shall provide such coverage with 

5 the same cost-sharing requirements as if the 

6 service was provided by an in-network pro7 vider.’’. 

8 (b) EFFECTIVE DATE.—The amendments made by 

9 subsection (a) shall apply to plans beginning after Decem10 ber 31, 2019. 

11 (c) GRANTS FOR STATE NETWORK ADEQUACY RE12 VIEWS.— 

13 (1) IN GENERAL.—The Secretary of Health and 

14 Human Services shall carry out a program to award 

15 grants to States during the 5-year period beginning 

16 with fiscal year 2020 to assist such States in devel17 oping a metric to measure network adequacy as de18 scribed in subparagraph (C)(i) of section 1311(c)(7) 

19 of the Patient Protection and Affordable Care Act 

20 (42 U.S.C. 18031(c)(7)) and to carry out the re21 views described in subparagraph (C)(ii) of such sec22 tion. 

23 (2) AUTHORIZATION OF APPROPRIATIONS.— 

24 There are authorized to be appropriated for fiscal 

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1 essary to carry out the grant program under this 

2 subsection. 

3 SEC. 302. ENSURING ADEQUATE COVERAGE IN AREAS WITH 

4 FEWER THAN 3 HEALTH INSURANCE ISSUERS 

5 OFFERING QUALIFIED HEALTH PLANS ON 

6 THE STATE EXCHANGE. 

7 (a) REQUIREMENTS FOR MEDICARE ADVANTAGE OR8 GANIZATIONS.— 

9 (1) IN GENERAL.—Section 1857(e) of the So10 cial Security Act (42 U.S.C. 1395w–27(e)) is 

11 amended by adding at the end the following new 

12 paragraph: 

13 ‘‘(5) REQUIREMENT FOR CERTAIN MEDICARE

14 ADVANTAGE ORGANIZATIONS THAT OFFER AN MA

15 PLAN IN AN APPLICABLE AREA TO ALSO OFFER

16 QUALIFIED HEALTH PLANS IN THE APPLICABLE

17 AREA.— 

18 ‘‘(A) IN GENERAL.—A contract under this 

19 section with an MA organization described in 

20 subparagraph (B) shall require the organization 

21 to, in each applicable area in which the organi22 zation offers an MA plan, also offer, through 

23 the individual market in the Exchange oper24 ating in the State, at least one qualified health 

25 plan in the silver level of coverage and at least 


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1 one qualified health plan in the gold level of 

2 coverage, as described in section 1302(d) of the 

3 Patient Protection and Affordable Care Act. 

4 ‘‘(B) MA ORGANIZATIONS DESCRIBED.— 

5 An MA organization described in this subpara6 graph is an MA organization that, in addition 

7 to offering an MA plan in an applicable area, 

8 offers health insurance coverage in the group 

9 market or individual market in the State but 

10 does not offer such coverage through the Ex11 change operating in the State. 

12 ‘‘(C) NOTIFICATION.—The Secretary, or 

13 the State in the case of an MA organization of14 fering an MA plan in an applicable area in a 

15 State with an Exchange operated by the State, 

16 shall notify each MA organization that is re17 quired to offer a qualified health plan under 

18 subparagraph (A) for a plan year of such re19 quirement. Such notification shall be provided 

20 each year— 

21 ‘‘(i) beginning with respect to the re22 quirement for plan years beginning after 

23 December 31, 2019; and 

24 ‘‘(ii) not less than 1 year prior to the 

25 rate filing deadline for the plan year for 


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1 the Exchange operating in the State in 

2 which the MA organization will be required 

3 to offer such plan. 

4 ‘‘(D) WAIVER.—The Secretary, or the 

5 State in the case of an MA organization offer6 ing an MA plan in an applicable area in a State 

7 with an Exchange operated by the State, may 

8 waive the requirement under subparagraph (A) 

9 if— 

10 ‘‘(i) by the first day of the plan year, 

11 the number of health insurance issuers of12 fering a qualified health plan through the 

13 individual market in the Exchange has in14 creased such that the applicable area no 

15 longer has fewer than 3 health insurance 

16 issuers offering a qualified health plan 

17 through the individual market in the Ex18 change operating in the State; or 

19 ‘‘(ii) the Secretary, or the State in 

20 such a case, determines that the require21 ment under subparagraph (A) would cause 

22 the MA organization to become insolvent. 

23 ‘‘(E) DEFINITIONS.—In this paragraph: 

24 ‘‘(i) APPLICABLE AREA.—The term 

25 ‘applicable area’ means an area in which, 


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1 at the time the Secretary or the State 

2 sends the notification under subparagraph 

3 (C), fewer than 3 health insurance issuers 

4 offer a qualified health plan through the 

5 individual market in the Exchange oper6 ating in the State. 

7 ‘‘(ii) EXCHANGE.—The term ‘Ex8 change’ means an American Health Ben9 efit Exchange established under section 

10 1311 or section 1321 of the Patient Pro11 tection and Affordable Care Act. 

12 ‘‘(iii) GROUP MARKET.—The term 

13 ‘group market’ has the meaning given such 

14 term in section 1304 of the Patient Protec15 tion and Affordable Care Act. 

16 ‘‘(iv) HEALTH INSURANCE COV17 ERAGE.—The term ‘health insurance cov18 erage’ has the meaning given the term in 

19 section 2791(b) of the Public Health Serv20 ice Act. 

21 ‘‘(v) INDIVIDUAL MARKET.—The term 

22 ‘individual market’ has the meaning given 

23 such term in section 1304 of the Patient 

24 Protection and Affordable Care Act. 


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1 ‘‘(vi) QUALIFIED HEALTH PLAN.— 

2 The term ‘qualified health plan’ has the 

3 meaning given that term in section 

4 1301(a) of the Patient Protection and Af5 fordable Care Act.’’. 

6 (2) EFFECTIVE DATE.—The amendment made 

7 by this subsection shall apply to contracts entered 

8 into or renewed after December 31, 2019. 

9 (b) REQUIREMENTS FOR MEDICAID MANAGED CARE

10 ORGANIZATIONS.— 

11 (1) IN GENERAL.—Section 1903(m)(2)(A) of 

12 the Social Security Act (42 U.S.C. 1396b(m)(2)(A)) 

13 is amended— 

14 (A) in clause (xii), by striking ‘‘; and’’ and 

15 inserting a semicolon; 

16 (B) by realigning the left margin of clause 

17 (xiii) to align with the left margin of clause 

18 (xii); 

19 (C) in clause (xiii), by striking the period 

20 at the end and inserting ‘‘; and’’; and 

21 (D) by inserting after clause (xiii) the fol22 lowing: 

23 ‘‘(xiv) such contract requires that the enti24 ty meets the requirements described in section 


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1 1857(e)(5) in the same manner as such require2 ments apply to an MA organization.’’. 

3 (2) EFFECTIVE DATE.—The amendments made 

4 by this subsection shall apply to contracts entered 

5 into or renewed after December 31, 2019. 

6 SEC. 303. ENROLLMENT IN EXCHANGES. 

7 (a) OPEN ENROLLMENT AND SPECIAL ENROLLMENT

8 PERIODS.—Section 1311(c)(6) of the Patient Protection 

9 and Affordable Care Act (42 U.S.C. 18031(c)(6)) is 

10 amended— 

11 (1) in subparagraph (B), by inserting ‘‘that are 

12 not less than 8 weeks’’ after ‘‘open enrollment peri13 ods’’; 

14 (2) in subparagraph (C), by striking ‘‘; and’’ 

15 and inserting ‘‘;’’; 

16 (3) in subparagraph (D), by striking the period 

17 and inserting ‘‘; and’’; and 

18 (4) by adding at the end the following: 

19 ‘‘(E) a special enrollment period for indi20 viduals enrolled in a plan that makes significant 

21 provider terminations during the plan year, as 

22 determined in accordance with regulations pro23 mulgated by the Secretary.’’. 

24 (b) CONSUMER PROTECTIONS REGARDING AUTO25 MATIC RE-ENROLLMENT.—Part 2 of subtitle D of title I 


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1 of the Patient Protection and Affordable Care Act (42 

2 U.S.C. 18031 et seq.) is amended by adding at the end 

3 the following: 

4 ‘‘SEC. 1314. CONSUMER PROTECTIONS REGARDING AUTO5 MATIC RE-ENROLLMENT. 

6 ‘‘(a) CONSENT TO AVOID AUTOMATIC RE-ENROLL7 MENT FOR INDIVIDUALS LOSING ELIGIBILITY FOR PRE8 MIUM TAX CREDITS.—The Secretary shall establish a 

9 process to allow an individual, who is enrolling in a quali10 fied health plan through an Exchange and whom the Ex11 change estimates is eligible to receive a premium tax credit 

12 under section 36B of the Internal Revenue Code of 1986, 

13 to provide consent to the Exchange to not automatically 

14 re-enroll the individual in such qualified health plan (or 

15 a comparable qualified health plan in a case described in 

16 subsection (b)) for the following plan year if during the 

17 plan year the Exchange estimates that the individual has 

18 become no longer eligible to receive such credit. 

19 ‘‘(b) NOTICE REGARDING DISCONTINUED PLANS.— 

20 In the case of an individual who is enrolled in a qualified 

21 health plan through an Exchange for a plan year that will 

22 not be offered through such Exchange for the following 

23 plan year, the Exchange through which such plan is of24 fered shall, prior to the open enrollment period for the 

25 following plan year, send the individual a notice stating— 


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1 ‘‘(1) that the qualified health plan in which the 

2 individual is enrolled will not be offered through 

3 such Exchange for the following plan year; 

4 ‘‘(2) that unless the individual takes action, the 

5 individual will be enrolled in a comparable qualified 

6 health plan for the following plan year; 

7 ‘‘(3) the estimated amount of premiums for 

8 such comparable qualified health plan; and 

9 ‘‘(4) clear information on the eligibility of the 

10 individual for a special enrollment period. 

11 ‘‘(c) NOTICE REGARDING AUTOMATIC RE-ENROLL12 MENT.—Any notice regarding automatic re-enrollment 

13 sent by an Exchange to an individual enrolled in a quali14 fied health plan shall be provided to the individual in the 

15 language that the individual has indicated to the Ex16 change as the preferred language of the individual.’’. 

17 (c) EFFECTIVE DATE.—The amendments made by 

18 this section shall apply to plan years beginning after the 

19 date of enactment of this Act. 

20 (d) STUDY.—The Secretary shall conduct a study 

21 that examines the practices used by the Exchanges for no22 tifying consumers of automatic re-enrollment in qualified 

23 health plans and identifies strategies for— 

24 (1) improving automatic re-enrollment and re25 newal notifications; 


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1 (2) improving the ability to reach consumers in 

2 providing such notices; 

3 (3) increasing consumer comprehension of such 

4 notices; and 

5 (4) encouraging consumers to— 

6 (A) update information that will affect eli7 gibility for premium tax credits under section 

8 36B of the Internal Revenue Code of 1986 and 

9 the amount of such credits; and 

10 (B) shop for qualified health plans that 

11 will best meet their needs through the Ex12 change operating in their State. 

13 SEC. 304. MARKETING AND OUTREACH FOR EXCHANGES 

14 OPERATED BY THE SECRETARY. 

15 Part 2 of subtitle D of title I of the Patient Protec16 tion and Affordable Care Act (42 U.S.C. 18031 et seq.), 

17 as amended by section 303(b), is further amended by add18 ing at the end the following: 

19 ‘‘SEC. 1315. MARKETING AND OUTREACH FOR EXCHANGES 

20 OPERATED BY THE SECRETARY. 

21 ‘‘(a) IN GENERAL.—Out of the funds appropriated 

22 under subsection (b), the Secretary shall conduct a mar23 keting and outreach program with respect to qualified 

24 health plans offered in Exchanges operated by the Sec25 retary in order to encourage enrollment in such plans. 


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1 ‘‘(b) APPROPRIATION.— 

2 ‘‘(1) ENCOURAGING ENROLLMENT FOR PLAN

3 YEAR 2019.—There is appropriated to the Secretary, 

4 out of any moneys in the Treasury not otherwise ap5 propriated, $480,000,000 to carry out the marketing 

6 and outreach program under subsection (a) with re7 spect to encouraging enrollment for qualified health 

8 plans that begin in calendar year 2019. 

9 ‘‘(2) ENCOURAGING ENROLLMENT FOR SUBSE10 QUENT PLAN YEARS.—To carry out the marketing 

11 and outreach program under subsection (a) with re12 spect to encouraging enrollment for qualified health 

13 plans that begin in each of calendar years 2020 

14 through 2024, there is appropriated to the Secretary 

15 prior to each such calendar year, out of any moneys 

16 in the Treasury not otherwise appropriated, an 

17 amount equal to the amount appropriated under this 

18 subsection for the prior calendar year increased by 

19 4 percent for each such calendar year. 

20 ‘‘(3) AVAILABILITY.—The amounts appro21 priated under paragraphs (1) and (2) shall remain 

22 available until expended.’’. 

23 SEC. 305. NAVIGATOR PROGRAM. 

24 Section 1311(i) of the Patient Protection and Afford25 able Care Act (42 U.S.C. 18031(i)) is amended— 


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1 (1) in paragraph (2)— 

2 (A) in subparagraph (B), by striking ‘‘and 

3 other entities’’ and inserting ‘‘and other entities 

4 (such as Indian tribes, tribal organizations, 

5 urban Indian organizations, and State or local 

6 human service agencies)’’; and 

7 (B) by adding at the end the following: 

8 ‘‘(C) PREFERENCE.—An Exchange shall 

9 ensure that, each year, it awards a grant under 

10 paragraph (1) to— 

11 ‘‘(i) at least one entity described in 

12 this paragraph that is a community and 

13 consumer-focused nonprofit group; and 

14 ‘‘(ii) at least one entity described in 

15 subparagraph (B), which may include an16 other community and consumer-focused 

17 nonprofit group.’’; 

18 (2) in paragraph (3)— 

19 (A) in subparagraph (D), by striking ‘‘; 

20 and’’ and inserting ‘‘;’’; 

21 (B) in subparagraph (E), by striking the 

22 period and inserting ‘‘; and’’; and 

23 (C) by adding at the end the following: 

24 ‘‘(F) provide targeted assistance to individ25 uals likely to qualify for a special enrollment 


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1 period under subparagraph (C), (D), or (E) of 

2 subsection (c)(6).’’; and 

3 (3) in paragraph (4)(A)— 

4 (A) in the matter preceding clause (i), by 

5 striking ‘‘not’’; 

6 (B) in clause (i)— 

7 (i) by inserting ‘‘not’’ before ‘‘be’’; 

8 and 

9 (ii) by striking ‘‘; or’’ and inserting 

10 ‘‘;’’; 

11 (C) in clause (ii)— 

12 (i) by inserting ‘‘not’’ before ‘‘re13 ceive’’; and 

14 (ii) by striking the period and insert15 ing ‘‘;’’; and 

16 (D) by adding at the end the following: 

17 ‘‘(iii) maintain physical presence in 

18 the State of the Exchange so as to allow 

19 in-person assistance to consumers; and 

20 ‘‘(iv) not provide compensation to an 

21 employee employed by the navigator based 

22 on the number of individuals the employee 

23 assists in enrolling in qualified health 

24 plans.’’. 


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1 TITLE IV—STRENGTHENING 

2 CONSUMER HEALTH INSUR3 ANCE PROTECTIONS 

4 SEC. 401. PROHIBITING DISCRIMINATORY PREMIUMS 

5 BASED ON TOBACCO USE. 

6 (a) IN GENERAL.—Section 2701(a)(1)(A) of the 

7 Public Health Service Act (42 U.S.C. 300gg(a)(1)(A)) is 

8 amended— 

9 (1) in clause (ii), by inserting ‘‘and’’ after the 

10 semicolon; and 

11 (2) by striking clause (iv). 

12 (b) EFFECTIVE DATE.—The amendments made by 

13 this section shall apply to plan years beginning after De14 cember 31, 2019. 

15 SEC. 402. HEALTH INSURANCE CONSUMER INFORMATION. 

16 Section 2793 of the Public Health Service Act (42 

17 U.S.C. 300gg–93) is amended— 

18 (1) in subsection (d)— 

19 (A) in the second sentence, by striking 

20 ‘‘and shall share’’ and inserting ‘‘, shall share’’; 

21 and 

22 (B) by striking the period at the end of 

23 second sentence and inserting ‘‘, and (not later 

24 than 2 years after the date of enactment of the 

25 Consumer Health Insurance Protection Act of 


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1 2018) shall make such data available to the 

2 public in a searchable format on an internet 

3 website established by the Secretary.’’; and 

4 (2) in subsection (e)— 

5 (A) in paragraph (1), by striking 

6 ‘‘$30,000,000 for the first fiscal year for which 

7 this section applies’’ and inserting 

8 ‘‘$50,000,000 for each of fiscal years 2020 

9 through 2024’’; and 

10 (B) in paragraph (2), by striking ‘‘each 

11 fiscal year following the fiscal year described in 

12 paragraph (1)’’ and inserting ‘‘fiscal year 2025 

13 and each fiscal year thereafter’’. 

14 SEC. 403. PATIENT PROTECTIONS. 

15 (a) IN GENERAL.—Section 2719A of the Public 

16 Health Service Act (42 U.S.C. 300gg–19a) is amended— 

17 (1) in subsection (b)— 

18 (A) in paragraph (1), by striking ‘‘para19 graph (2)(B)’’ and inserting ‘‘paragraph 

20 (3)(B)’’; 

21 (B) by redesignating paragraph (2) as 

22 paragraph (3); and 

23 (C) by inserting after paragraph (1) the 

24 following: 


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1 ‘‘(2) REIMBURSEMENT.—A group health plan 

2 or health insurance issuer offering group or indi3 vidual health insurance coverage shall reimburse an 

4 out-of-network provider providing emergency services 

5 to an individual enrolled in such plan or coverage at 

6 an amount equal to the greatest of— 

7 ‘‘(A) the median amount negotiated with 

8 in-network providers for the emergency service; 

9 ‘‘(B) the amount for the emergency service 

10 calculated using the same method the plan or 

11 issuer generally uses to determine payments for 

12 out-of-network services; or 

13 ‘‘(C) the amount that would be paid to a 

14 provider of services or supplier with respect to 

15 the furnishing of such service under title XVIII 

16 of the Social Security Act.’’; and 

17 (2) by adding at the end the following: 

18 ‘‘(e) COVERAGE OF SERVICES BY OUT-OF-NETWORK

19 PROVIDERS BASED ON PLAN OR ISSUER ERROR.— 

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

21 health insurance issuer offering group or individual 

22 health insurance coverage shall provide coverage of 

23 a service provided by an out-of-network provider to 

24 an individual enrolled in such plan or coverage if— 


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1 ‘‘(A) the plan or issuer would have pro2 vided coverage for the service if the service was 

3 provided by an in-network provider; and 

4 ‘‘(B) in choosing such provider, the indi5 vidual reasonably relied on a materially inac6 curate, incomplete, or misleading statement of 

7 information contained in a directory, compiled 

8 by the plan or issuer, of in-network providers. 

9 ‘‘(2) COST-SHARING.—A group health plan or 

10 health insurance issuer that provides coverage of a 

11 service provided by an out-of-network provider under 

12 paragraph (1) shall provide such coverage with the 

13 same cost-sharing requirements as if the service was 

14 provided by an in-network provider. 

15 ‘‘(f) COVERAGE FOR ENROLLEES IN ACTIVE COURSE

16 OF TREATMENT.— 

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

18 health insurance issuer offering group or individual 

19 health insurance coverage shall, at the request of an 

20 individual enrolled in such plan or coverage and sub21 ject to paragraph (3), provide covered services (as 

22 defined in paragraph (4)) by an out-of-network pro23 vider for such individual in accordance with para24 graph (2) if— 


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1 ‘‘(A) the individual is receiving an active 

2 course of treatment from such out-of-network 

3 provider that was occurring while the individual 

4 was enrolled in a different health plan offered 

5 by such plan or issuer for the prior plan year 

6 that has been discontinued by such plan or 

7 issuer, including a case where such plan is with8 drawn from the market, and such provider was 

9 an in-network provider under such different 

10 health plan; or 

11 ‘‘(B) the individual is receiving an active 

12 course of treatment from such out-of-network 

13 provider for a plan year in which the provider 

14 was an in-network provider of the plan or issuer 

15 but became a terminated provider with respect 

16 to such plan or issuer for such plan year. 

17 ‘‘(2) DURATION AND RATES OF COVERAGE.— 

18 ‘‘(A) DURATION.—The coverage for an ac19 tive course of treatment described in paragraph 

20 (1) shall be continued until the earlier of— 

21 ‘‘(i) the date on which the treatment 

22 is complete; or 

23 ‘‘(ii) the date that is 180 days fol24 lowing the date on which— 


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1 ‘‘(I) in the case of an individual 

2 described in subparagraph (A) of 

3 paragraph (1), the individual enrolls 

4 in such group health plan or health 

5 insurance coverage; or 

6 ‘‘(II) in the case of an individual 

7 described in subparagraph (B) of 

8 paragraph (1), the contract of the ter9 minated provider with the group 

10 health plan or health insurance issuer 

11 is no longer in effect. 

12 ‘‘(B) COST-SHARING.—The coverage for an 

13 active course of treatment provided by an out14 of-network provider as described in paragraph 

15 (1) shall be provided with cost-sharing require16 ments that are the same as if such coverage 

17 was provided by an in-network provider. 

18 ‘‘(3) REQUEST FOR CONTINUITY OF CARE.— 

19 Any request made under paragraph (1) shall be sub20 ject to any internal or external grievance or appeals 

21 process of the plan or issuer, in accordance with any 

22 applicable State or Federal law. 

23 ‘‘(4) DEFINITIONS.—For purposes of this sub24 section: 


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1 ‘‘(A) ACTIVE COURSE OF TREATMENT.— 

2 The term ‘active course of treatment’ means 

3 any of the following that is occurring on the 

4 first day on which, with respect to an individual 

5 described in paragraph (1)(A), the individual’s 

6 prior health plan described in such paragraph 

7 has been discontinued by the plan or issuer or, 

8 with respect to an individual described in para9 graph (1)(B), the provider providing the treat10 ment becomes a terminated provider: 

11 ‘‘(i) An ongoing course of treatment 

12 for a life-threatening condition, serious 

13 acute condition, or serious chronic condi14 tion. 

15 ‘‘(ii) Services provided with respect to 

16 pregnancy, including until the completion 

17 of postpartum care directly related to the 

18 delivery. 

19 ‘‘(iii) An ongoing course of treatment 

20 for a child between birth and 36 months. 

21 ‘‘(iv) The performance of a surgery or 

22 other procedure that, prior to the applica23 ble time described in this subparagraph, 

24 has been authorized by the plan or cov25 erage as part of a documented course of 


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1 treatment for such individual and has been 

2 recommended and documented by the pro3 vider for such individual. 

4 ‘‘(B) COVERED SERVICES.—The term ‘cov5 ered services’ means services that— 

6 ‘‘(i) would be covered by the group 

7 health plan or health insurance issuer of8 fering group or individual health insurance 

9 coverage if such services were provided by 

10 an in-network provider; and 

11 ‘‘(ii) are for an active course of treat12 ment. 

13 ‘‘(C) TERMINATED PROVIDER.—The term 

14 ‘terminated provider’ means a provider that had 

15 a contract for participation with the plan or 

16 coverage during a plan year while the individual 

17 was enrolled in such plan or coverage and re18 ceiving covered services from such provider and, 

19 during such plan year, the plan or issuer termi20 nates such contract or does not renew such con21 tract for the remainder of the plan year. Such 

22 term does not include— 

23 ‘‘(i) any provider that voluntarily ter24 minates or does not renew such contract 

25 for the remainder of the plan year; and 


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1 ‘‘(ii) any provider whose contract with 

2 the plan or issuer has terminated, or was 

3 not renewed, for the remainder of the plan 

4 year for reasons relating to a medical dis5 ciplinary cause or fraud or other criminal 

6 activity. 

7 ‘‘(g) LIMITATIONS ON CHANGES IN COVERAGE OF

8 PRESCRIPTION DRUGS.— 

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

10 health insurance issuer offering group or individual 

11 health insurance coverage shall not, during a plan 

12 year, take any of the following actions with respect 

13 to coverage for such plan year: 

14 ‘‘(A) Removing a prescription drug from a 

15 formulary of prescription drugs covered by such 

16 plan or issuer, except as provided in paragraph 

17 (2)(C). 

18 ‘‘(B) Increasing the obligation of an en19 rollee with respect to cost-sharing, as defined in 

20 section 1302(c)(3) of the Patient Protection 

21 and Affordable Care Act, required for a pre22 scription drug covered by such plan or issuer. 

23 ‘‘(2) RULE OF CONSTRUCTION.—Nothing in 

24 this subsection shall prohibit a group health plan or 

25 health insurance issuer offering group or individual 


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1 health insurance coverage from, during a plan year, 

2 taking any of the following actions with respect to 

3 coverage for such plan year: 

4 ‘‘(A) Changing the policy of the plan or 

5 issuer to require an enrollee to use a generic 

6 substitution for a branded prescription drug. 

7 ‘‘(B) Adding a new prescription drug to a 

8 formulary of prescription drugs covered by such 

9 plan or issuer. 

10 ‘‘(C) Removing a prescription drug from 

11 such a formulary due to patient safety con12 cerns, a prescription drug recall, or the removal 

13 of a prescription drug from interstate commerce 

14 as determined necessary by the Secretary.’’. 

15 (b) EFFECTIVE DATE.—The amendments made by 

16 this section shall apply to plan years beginning after De17 cember 31, 2019. 

18 SEC. 404. LIMITATION ON BALANCE BILLING FOR EMER19 GENCY SERVICES. 

20 (a) IN GENERAL.—A health care provider that pro21 vides any emergency service to an individual enrolled in 

22 a group health plan, group health insurance coverage, or 

23 individual health insurance coverage and that is not an 

24 in-network provider of such plan or coverage shall not im25 pose a charge on such individual for such emergency servVerDate Sep 11 2014 04:38 Apr 03, 2018 Jkt 079200 PO 00000 Frm 00045 Fmt 6652 Sfmt 6201 E:\BILLS\S2582.IS S2582

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1 ice, other than any cost-sharing that would otherwise be 

2 applicable if the physician was an in-network provider of 

3 such plan or coverage. 

4 (b) ENFORCEMENT.—The Secretary may impose a 

5 civil monetary penalty, in the same manner as such pen6 alties are authorized under section 1128A of the Social 

7 Security Act (42 U.S.C. 1320a–7a) for violations of bal8 ance billing prohibitions under part B of title XVIII of 

9 such Act (42 U.S.C. 1395j et seq.), on any provider that 

10 violates the requirement under subsection (a). 

11 (c) DEFINITIONS.—In this section: 

12 (1) COST-SHARING.—The term ‘‘cost-sharing’’ 

13 has the meaning given the term in section 

14 1302(c)(3) of the Patient Protection and Affordable 

15 Care Act (42 U.S.C. 18022(c)(3)). 

16 (2) EMERGENCY SERVICE.—The term ‘‘emer17 gency service’’ has the meaning given such term in 

18 section 2719A(b)(3)(B) of the Public Health Service 

19 Act (42 U.S.C. 300gg–19a(b)(3)(B)). 

20 (3) GROUP HEALTH PLAN, GROUP HEALTH IN21 SURANCE COVERAGE, AND INDIVIDUAL HEALTH IN22 SURANCE COVERAGE.—The terms ‘‘group health 

23 plan’’, ‘‘group health insurance coverage’’, and ‘‘in24 dividual health insurance coverage’’ have the meanVerDate Sep 11 2014 04:38 Apr 03, 2018 Jkt 079200 PO 00000 Frm 00046 Fmt 6652 Sfmt 6201 E:\BILLS\S2582.IS S2582

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1 ings given such terms in section 2791 of the Public 

2 Health Service Act (42 U.S.C. 300gg–91). 

3 (4) SECRETARY.—The term ‘‘Secretary’’ means 

4 the Secretary of Health and Human Services. 

5 (d) EFFECTIVE DATE.—This section shall apply to 

6 plan years beginning after December 31, 2019. 

7 SEC. 405. NOTIFICATION OF PROVIDER TERMINATIONS. 

8 Title XXVII of the Public Health Service Act (42 

9 U.S.C. 300gg et seq.) is amended by inserting after sec10 tion 2728 (42 U.S.C. 300gg–28) the following: 

11 ‘‘SEC. 2729. NOTIFICATION OF PROVIDER TERMINATIONS. 

12 ‘‘(a) IN GENERAL.—Beginning January 1, 2019, a 

13 group health plan or health insurance issuer offering 

14 group or individual health insurance coverage shall inform 

15 individuals enrolled in such plan or coverage, who are de16 scribed in subsection (b), of the termination of any pro17 vider as an in-network provider under the plan or cov18 erage. Such notice shall be provided not later than 30 days 

19 prior to the termination. 

20 ‘‘(b) INDIVIDUALS.—The individuals described in this 

21 subsection are any patients who have seen a provider de22 scribed in subsection (a) on a regular basis or who have 

23 received primary care from the provider.’’. 


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1 SEC. 406. SHORT-TERM LIMITED DURATION HEALTH INSUR2 ANCE COVERAGE. 

3 (a) IN GENERAL.—Section 2791(b)(5) of the Public 

4 Health Service Act (42 U.S.C. 300gg–91(b)(5)) is amend5 ed by striking ‘‘but does not include’’ and inserting ‘‘in6 cluding’’. 

7 (b) EFFECTIVE DATE.—The amendment made by 

8 this section shall apply to plan years beginning after De9 cember 31, 2019. 

10 SEC. 407. PROTECTING ESSENTIAL HEALTH BENEFITS. 

11 Section 1302(b) of the Patient Protection and Af12 fordable Care Act (42 U.S.C. 18022(b)) is amended— 

13 (1) in paragraph (2)(B) and paragraph (3), by 

14 striking ‘‘(4)(H)’’ each place it appears and insert15 ing ‘‘(4)(I)’’; and 

16 (2) in paragraph (4)— 

17 (A) in subparagraph (A), by inserting 

18 ‘‘and coverage in every category is included’’ be19 fore the semicolon; 

20 (B) by redesignating subparagraphs (E) 

21 through (H) as subparagraphs (F) through (I), 

22 respectively; and 

23 (C) by inserting after subparagraph (D) 

24 the following: 

25 ‘‘(E) ensure that, to be treated as pro26 viding coverage for the essential health benefits 


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1 described in paragraph (1), a qualified health 

2 plan— 

3 ‘‘(i) shall not substitute benefits 

4 across the various categories described in 

5 paragraph (1); 

6 ‘‘(ii) shall provide a wide variety of 

7 classes of prescription drugs on the pre8 scription drug formulary of such plan; 

9 ‘‘(iii) shall, if a medically necessary 

10 drug is not on the prescription drug for11 mulary of such plan, allow individuals en12 rolled in such plan to have access to the 

13 drug through an exceptions process estab14 lished by the plan; and 

15 ‘‘(iv) shall provide coverage of 

16 habilitative services at parity with rehabili17 tative services, in accordance with regula18 tions promulgated by the Secretary.’’. 

19 SEC. 408. ASSOCIATION HEALTH PLANS. 

20 (a) TREATMENT OF ASSOCIATION HEALTH PLANS.— 

21 (1) ASSOCIATION HEALTH PLAN DEFINED.— 

22 For purposes of this subsection, the term ‘‘associa23 tion health plan’’ means any health insurance cov24 erage that is provided to an association, but not reVerDate Sep 11 2014 04:38 Apr 03, 2018 Jkt 079200 PO 00000 Frm 00049 Fmt 6652 Sfmt 6201 E:\BILLS\S2582.IS S2582

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1 lated to employment, and sold to individuals through 

2 such association. 

3 (2) TREATMENT AS INDIVIDUAL HEALTH IN4 SURANCE COVERAGE.—For purposes of title XXVII 

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

6 et seq.), part 7 of subtitle B of title I of the Em7 ployee Retirement Income Security Act of 1974 (29 

8 U.S.C. 1181 et seq.), chapter 100 of the Internal 

9 Revenue Code of 1986, and title I of the Patient 

10 Protection and Affordable Care Act (Public Law 

11 111–148), health insurance coverage offered through 

12 an association health plan shall be treated as indi13 vidual health insurance coverage if— 

14 (A) the coverage is offered to a member of 

15 the association other than in connection with a 

16 group health plan; or 

17 (B) the coverage is offered to a member of 

18 the association that is an employer maintaining 

19 a group health plan that has fewer than 2 par20 ticipants who are employees on the first day of 

21 the plan year. 

22 (3) TREATMENT AS HEALTH INSURANCE COV23 ERAGE IN THE SMALL GROUP MARKET.—For pur24 poses of title XXVII of the Public Health Service 

25 Act (42 U.S.C. 300gg et seq.), part 7 of subtitle B 


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1 of title I of the Employee Retirement Income Secu2 rity Act of 1974 (29 U.S.C. 1181 et seq.), chapter 

3 100 of the Internal Revenue Code of 1986, and title 

4 I of the Patient Protection and Affordable Care Act 

5 (Public Law 111–148), health insurance coverage of6 fered through an association health plan shall, sub7 ject to paragraph (2)(B), be treated as health insur8 ance coverage in the small group market if the cov9 erage is offered to a member of the association in 

10 connection with a group health plan offered to em11 ployers that are small employers, as defined in such 

12 applicable Act or Code. 

13 (4) PREEMPTION.—An association health plan 

14 shall be treated as individual health insurance cov15 erage in accordance with paragraph (2) or health in16 surance coverage in the small group market in ac17 cordance with paragraph (3) notwithstanding any 

18 applicable State law. 

19 (5) EFFECTIVE DATE.—This subsection shall 

20 apply to plan years beginning after December 31, 

21 2019. 

22 (b) PROPOSED RULE REGARDING THE DEFINITION

23 OF ‘‘EMPLOYER’’ UNDER ERISA.— 

24 (1) DEFINITION OF ‘‘JANUARY 5, 2018, PRO25 POSED RULE’’.—In this subsection, the term ‘‘JanuVerDate Sep 11 2014 04:38 Apr 03, 2018 Jkt 079200 PO 00000 Frm 00051 Fmt 6652 Sfmt 6201 E:\BILLS\S2582.IS S2582

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1 ary 5, 2018, proposed rule’’ means the proposed rule 

2 of the Department of Labor entitled ‘‘Definition of 

3 ‘Employer’ Under Section 3(5) of ERISA—Associa4 tion Health Plans’’ (83 Fed. Reg. 614), or any final 

5 rule promulgated with respect to such proposed rule. 

6 (2) ENFORCEMENT.—Beginning on the date of 

7 enactment of this Act, the January 5, 2018, pro8 posed rule shall cease to have any force or effect. In 

9 the case that the January 5, 2018, proposed rule is 

10 a final rule on the date of enactment of this Act, the 

11 Secretary of Labor shall cease to enforce such final 

12 rule. 

Æ 


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