I 

116TH CONGRESS 

1ST SESSION H. R. 4159 

To amend the Health Insurance Portability and Accountability Act to ensure 

coverage for individuals with preexisting conditions, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

AUGUST 2, 2019 

Mr. RIGGLEMAN (for himself, Mrs. WAGNER, Mr. HUIZENGA, Mr. NEWHOUSE, 

and Ms. HERRERA BEUTLER) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to 

the Committees on Ways and Means, and Education and Labor, 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 Health Insurance Portability and Accountability Act to ensure coverage for individuals with preexisting conditions, 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 ‘‘Maintaining Protec5 tions for Patients with Preexisting Conditions Act of 

6 2019’’. 


kjohnson on DSK79L0C42 with BILLS
2 

•HR 4159 IH

1 SEC. 2. GUARANTEED AVAILABILITY OF COVERAGE; PRO2 HIBITING DISCRIMINATION. 

3 (a) IN GENERAL.—Subtitle C of title I of the Health 

4 Insurance Portability and Accountability Act of 1996 

5 (Public Law 104–191) is amended by adding at the end 

6 the following: 

7 ‘‘SEC. 196. GUARANTEED AVAILABILITY OF COVERAGE. 

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

9 INDIVIDUAL AND GROUP MARKET.—Subject to sub10 sections (b) through (d), each health insurance issuer that 

11 offers health insurance coverage in the individual or group 

12 market in a State must accept every employer and indi13 vidual in the State that applies for such coverage. 

14 ‘‘(b) ENROLLMENT.— 

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

16 described in subsection (a) may restrict enrollment 

17 in coverage described in such subsection to open or 

18 special enrollment periods. 

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

20 issuer described in subsection (a) shall, in accord21 ance with the regulations promulgated under para22 graph (3), establish special enrollment periods for 

23 qualifying events (under section 603 of the Em24 ployee Retirement Income Security Act of 1974). 


kjohnson on DSK79L0C42 with BILLS
3 

•HR 4159 IH

1 ‘‘(3) REGULATIONS.—The Secretary shall pro2 mulgate regulations with respect to enrollment peri3 ods under paragraphs (1) and (2). 

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

5 ‘‘(1) IN GENERAL.—In the case of a health in6 surance issuer that offers health insurance coverage 

7 in the group and individual market through a net8 work plan, the issuer may— 

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

10 for such coverage to those with eligible individ11 uals who live, work, or reside in the service area 

12 for such network plan; and 

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

14 deny such coverage to such employers and indi15 viduals if the issuer has demonstrated, if re16 quired, to the applicable State authority that— 

17 ‘‘(i) it will not have the capacity to de18 liver services adequately to enrollees of any 

19 additional groups or any additional individ20 uals because of its obligations to existing 

21 group contract holders and enrollees; and 

22 ‘‘(ii) it is applying this paragraph uni23 formly to all employers and individuals 

24 without regard to the claims experience of 

25 those individuals, employers and their emVerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159

kjohnson on DSK79L0C42 with BILLS
4 

•HR 4159 IH

1 ployees (and their dependents), or any 

2 health status-related factor relating to 

3 such individuals, employees, and depend4 ents. 

5 ‘‘(2) 180-DAY SUSPENSION UPON DENIAL OF

6 COVERAGE.—An issuer, upon denying health insur7 ance coverage in any service area in accordance with 

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

9 group or individual market within such service area 

10 for a period of 180 days after the date such cov11 erage is denied. 

12 ‘‘(d) APPLICATION OF FINANCIAL CAPACITY LIM13 ITS.— 

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

15 may deny health insurance coverage in the group or 

16 individual market if the issuer has demonstrated, if 

17 required, to the applicable State authority that— 

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

19 necessary to underwrite additional coverage; 

20 and 

21 ‘‘(B) it is applying this paragraph uni22 formly to all employers and individuals in the 

23 group or individual market in the State con24 sistent with applicable State law and without 

25 regard to the claims experience of those individVerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159

kjohnson on DSK79L0C42 with BILLS
5 

•HR 4159 IH

1 uals, employers and their employees (and their 

2 dependents) or any health status-related factor 

3 relating to such individuals, employees, and de4 pendents. 

5 ‘‘(2) 180-DAY SUSPENSION UPON DENIAL OF

6 COVERAGE.—A health insurance issuer upon denying 

7 health insurance coverage in connection with group 

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

9 State may not offer coverage in connection with 

10 group health plans in the group or individual market 

11 in the State for a period of 180 days after the date 

12 such coverage is denied or until the issuer has dem13 onstrated to the applicable State authority, if re14 quired under applicable State law, that the issuer 

15 has sufficient financial reserves to underwrite addi16 tional coverage, whichever is later. An applicable 

17 State authority may provide for the application of 

18 this subsection on a service-area-specific basis. 

19 ‘‘(e) DEFINITIONS.—In this section and in sections 

20 197 through 199A: 

21 ‘‘(1) The term ‘Secretary’ means the Secretary 

22 of Health and Human Services. 

23 ‘‘(2) The terms ‘genetic information’, ‘genetic 

24 test’, ‘group health plan’, ‘group market’, ‘health in25 surance coverage’, ‘health insurance issuer’, ‘group 


kjohnson on DSK79L0C42 with BILLS
6 

•HR 4159 IH

1 health insurance coverage’, ‘individual health insur2 ance coverage’, ‘individual market’, and ‘under3 writing purpose’ have the meanings given such terms 

4 in section 2791 of the Public Health Service Act. 

5 ‘‘SEC. 197. FAIR HEALTH INSURANCE PREMIUMS. 

6 ‘‘(a) PROHIBITING DISCRIMINATORY PREMIUM

7 RATES.— 

8 ‘‘(1) IN GENERAL.—With respect to the pre9 mium rate charged by a health insurance issuer for 

10 health insurance coverage offered in the individual 

11 or small group market— 

12 ‘‘(A) such rate shall vary with respect to 

13 the particular plan or coverage involved only 

14 by— 

15 ‘‘(i) whether such plan or coverage 

16 covers an individual or family; 

17 ‘‘(ii) rating area, as established in ac18 cordance with paragraph (2); 

19 ‘‘(iii) age, except that such rate shall 

20 not vary by more than 3 to 1 for adults; 

21 and 

22 ‘‘(iv) tobacco use, except that such 

23 rate shall not vary by more than 1.5 to 1; 

24 and 


kjohnson on DSK79L0C42 with BILLS
7 

•HR 4159 IH

1 ‘‘(B) such rate shall not vary with respect 

2 to the particular plan or coverage involved by 

3 any other factor not described in subparagraph 

4 (A). 

5 ‘‘(2) RATING AREA.— 

6 ‘‘(A) IN GENERAL.—Each State shall es7 tablish 1 or more rating areas within that State 

8 for purposes of applying the requirements of 

9 this title. 

10 ‘‘(B) SECRETARIAL REVIEW.—The Sec11 retary shall review the rating areas established 

12 by each State under subparagraph (A) to en13 sure the adequacy of such areas for purposes of 

14 carrying out the requirements of this title. If 

15 the Secretary determines a State’s rating areas 

16 are not adequate, or that a State does not es17 tablish such areas, the Secretary may establish 

18 rating areas for that State. 

19 ‘‘(3) PERMISSIBLE AGE BANDS.—The Sec20 retary, in consultation with the National Association 

21 of Insurance Commissioners, shall define the permis22 sible age bands for rating purposes under paragraph 

23 (1)(A)(iii). 

24 ‘‘(4) APPLICATION OF VARIATIONS BASED ON

25 AGE OR TOBACCO USE.—With respect to family covVerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159

kjohnson on DSK79L0C42 with BILLS
8 

•HR 4159 IH

1 erage under a group health plan or health insurance 

2 coverage, the rating variations permitted under 

3 clauses (iii) and (iv) of paragraph (1)(A) shall be 

4 applied based on the portion of the premium that is 

5 attributable to each family member covered under 

6 the plan or coverage. 

7 ‘‘SEC. 198. PROHIBITING DISCRIMINATION AGAINST INDI8 VIDUAL PARTICIPANTS AND BENEFICIARIES 

9 BASED ON HEALTH STATUS. 

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

11 insurance issuer offering group or individual health insur12 ance coverage may not establish rules for eligibility (in13 cluding continued eligibility) of any individual to enroll 

14 under the terms of the plan or coverage based on any of 

15 the following health status-related factors in relation to 

16 the individual or a dependent of the individual: 

17 ‘‘(1) Health status. 

18 ‘‘(2) Medical condition (including both physical 

19 and mental illnesses). 

20 ‘‘(3) Claims experience. 

21 ‘‘(4) Receipt of health care. 

22 ‘‘(5) Medical history. 

23 ‘‘(6) Genetic information. 

24 ‘‘(7) Evidence of insurability (including condi25 tions arising out of acts of domestic violence). 


kjohnson on DSK79L0C42 with BILLS
9 

•HR 4159 IH

1 ‘‘(8) Disability. 

2 ‘‘(9) Any other health status-related factor de3 termined appropriate by the Secretary. 

4 ‘‘(b) IN PREMIUM CONTRIBUTIONS.— 

5 ‘‘(1) IN GENERAL.—A group health plan, and a 

6 health insurance issuer offering group or individual 

7 health insurance coverage, may not require any indi8 vidual (as a condition of enrollment or continued en9 rollment under the plan) to pay a premium or con10 tribution which is greater than such premium or 

11 contribution for a similarly situated individual en12 rolled in the plan on the basis of any health status13 related factor in relation to the individual or to an 

14 individual enrolled under the plan as a dependent of 

15 the individual. 

16 ‘‘(2) CONSTRUCTION.—Nothing in paragraph 

17 (1) shall be construed— 

18 ‘‘(A) to restrict the amount that an em19 ployer or individual may be charged for cov20 erage under a group health plan except as pro21 vided in paragraph (3) or individual health cov22 erage, as the case may be; or 

23 ‘‘(B) to prevent a group health plan, and 

24 a health insurance issuer offering group health 

25 insurance coverage, from establishing premium 


kjohnson on DSK79L0C42 with BILLS
10 

•HR 4159 IH

1 discounts or rebates or modifying otherwise ap2 plicable copayments or deductibles in return for 

3 adherence to programs of health promotion and 

4 disease prevention. 

5 ‘‘(3) NO GROUP-BASED DISCRIMINATION ON

6 BASIS OF GENETIC INFORMATION.— 

7 ‘‘(A) IN GENERAL.—For purposes of this 

8 section, a group health plan, and health insur9 ance issuer offering group health insurance cov10 erage in connection with a group health plan, 

11 may not adjust premium or contribution 

12 amounts for the group covered under such plan 

13 on the basis of genetic information. 

14 ‘‘(B) RULE OF CONSTRUCTION.—Nothing 

15 in subparagraph (A) or in paragraphs (1) and 

16 (2) of subsection (d) shall be construed to limit 

17 the ability of a health insurance issuer offering 

18 group or individual health insurance coverage to 

19 increase the premium for an employer based on 

20 the manifestation of a disease or disorder of an 

21 individual who is enrolled in the plan. In such 

22 case, the manifestation of a disease or disorder 

23 in one individual cannot also be used as genetic 

24 information about other group members and to 

25 further increase the premium for the employer. 


kjohnson on DSK79L0C42 with BILLS
11 

•HR 4159 IH

1 ‘‘(c) GENETIC TESTING.— 

2 ‘‘(1) LIMITATION ON REQUESTING OR REQUIR3 ING GENETIC TESTING.—A group health plan, and a 

4 health insurance issuer offering health insurance 

5 coverage in connection with a group health plan, 

6 shall not request or require an individual or a family 

7 member of such individual to undergo a genetic test. 

8 ‘‘(2) RULE OF CONSTRUCTION.—Paragraph (1) 

9 shall not be construed to limit the authority of a 

10 health care professional who is providing health care 

11 services to an individual to request that such indi12 vidual undergo a genetic test. 

13 ‘‘(3) RULE OF CONSTRUCTION REGARDING PAY14 MENT.— 

15 ‘‘(A) IN GENERAL.—Nothing in paragraph 

16 (1) shall be construed to preclude a group 

17 health plan, or a health insurance issuer offer18 ing health insurance coverage in connection 

19 with a group health plan, from obtaining and 

20 using the results of a genetic test in making a 

21 determination regarding payment (as such term 

22 is defined for the purposes of applying the regu23 lations promulgated by the Secretary under 

24 part C of title XI of the Social Security Act and 


kjohnson on DSK79L0C42 with BILLS
12 

•HR 4159 IH

1 section 264 of this Act, as may be revised from 

2 time to time) consistent with subsection (a). 

3 ‘‘(B) LIMITATION.—For purposes of sub4 paragraph (A), a group health plan, or a health 

5 insurance issuer offering health insurance cov6 erage in connection with a group health plan, 

7 may request only the minimum amount of in8 formation necessary to accomplish the intended 

9 purpose. 

10 ‘‘(4) RESEARCH EXCEPTION.—Notwithstanding 

11 paragraph (1), a group health plan, or a health in12 surance issuer offering health insurance coverage in 

13 connection with a group health plan, may request, 

14 but not require, that a participant or beneficiary un15 dergo a genetic test if each of the following condi16 tions is met: 

17 ‘‘(A) The request is made pursuant to re18 search that complies with part 46 of title 45, 

19 Code of Federal Regulations, or equivalent Fed20 eral regulations, and any applicable State or 

21 local law or regulations for the protection of 

22 human subjects in research. 

23 ‘‘(B) The plan or issuer clearly indicates to 

24 each participant or beneficiary, or in the case of 


kjohnson on DSK79L0C42 with BILLS
13 

•HR 4159 IH

1 a minor child, to the legal guardian of such 

2 beneficiary, to whom the request is made that— 

3 ‘‘(i) compliance with the request is 

4 voluntary; and 

5 ‘‘(ii) noncompliance will have no effect 

6 on enrollment status or premium or con7 tribution amounts. 

8 ‘‘(C) No genetic information collected or 

9 acquired under this paragraph shall be used for 

10 underwriting purposes. 

11 ‘‘(D) The plan or issuer notifies the Sec12 retary in writing that the plan or issuer is con13 ducting activities pursuant to the exception pro14 vided for under this paragraph, including a de15 scription of the activities conducted. 

16 ‘‘(E) The plan or issuer complies with such 

17 other conditions as the Secretary may by regu18 lation require for activities conducted under this 

19 paragraph. 

20 ‘‘(d) PROHIBITION ON COLLECTION OF GENETIC IN21 FORMATION.— 

22 ‘‘(1) IN GENERAL.—A group health plan, and a 

23 health insurance issuer offering health insurance 

24 coverage in connection with a group health plan, 


kjohnson on DSK79L0C42 with BILLS
14 

•HR 4159 IH

1 shall not request, require, or purchase genetic infor2 mation for underwriting purposes. 

3 ‘‘(2) PROHIBITION ON COLLECTION OF GE4 NETIC INFORMATION PRIOR TO ENROLLMENT.—A 

5 group health plan, and a health insurance issuer of6 fering health insurance coverage in connection with 

7 a group health plan, shall not request, require, or 

8 purchase genetic information with respect to any in9 dividual prior to such individual’s enrollment under 

10 the plan or coverage in connection with such enroll11 ment. 

12 ‘‘(3) INCIDENTAL COLLECTION.—If a group 

13 health plan, or a health insurance issuer offering 

14 health insurance coverage in connection with a group 

15 health plan, obtains genetic information incidental to 

16 the requesting, requiring, or purchasing of other in17 formation concerning any individual, such request, 

18 requirement, or purchase shall not be considered a 

19 violation of paragraph (2) if such request, require20 ment, or purchase is not in violation of paragraph 

21 (1). 

22 ‘‘(e) GENETIC INFORMATION OF A FETUS OR EM23 BRYO.—Any reference in this part to genetic information 

24 concerning an individual or family member of an indi25 vidual shall— 


kjohnson on DSK79L0C42 with BILLS
15 

•HR 4159 IH

1 ‘‘(1) with respect to such an individual or fam2 ily member of an individual who is a pregnant 

3 woman, include genetic information of any fetus car4 ried by such pregnant woman; and 

5 ‘‘(2) with respect to an individual or family 

6 member utilizing an assisted reproductive tech7 nology, include genetic information of any embryo le8 gally held by the individual or family member. 

9 ‘‘(f) PROGRAMS OF HEALTH PROMOTION OR DIS10 EASE PREVENTION.— 

11 ‘‘(1) GENERAL PROVISIONS.— 

12 ‘‘(A) GENERAL RULE.—For purposes of 

13 subsection (b)(2)(B), a program of health pro14 motion or disease prevention (referred to in this 

15 subsection as a ‘wellness program’) shall be a 

16 program offered by an employer that is de17 signed to promote health or prevent disease 

18 that meets the applicable requirements of this 

19 subsection. 

20 ‘‘(B) NO CONDITIONS BASED ON HEALTH

21 STATUS FACTOR.—If none of the conditions for 

22 obtaining a premium discount or rebate or 

23 other reward for participation in a wellness pro24 gram is based on an individual satisfying a 

25 standard that is related to a health status facVerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159

kjohnson on DSK79L0C42 with BILLS
16 

•HR 4159 IH

1 tor, such wellness program shall not violate this 

2 section if participation in the program is made 

3 available to all similarly situated individuals 

4 and the requirements of paragraph (2) are com5 plied with. 

6 ‘‘(C) CONDITIONS BASED ON HEALTH STA7 TUS FACTOR.—If any of the conditions for ob8 taining a premium discount or rebate or other 

9 reward for participation in a wellness program 

10 is based on an individual satisfying a standard 

11 that is related to a health status factor, such 

12 wellness program shall not violate this section if 

13 the requirements of paragraph (3) are complied 

14 with. 

15 ‘‘(2) WELLNESS PROGRAMS NOT SUBJECT TO

16 REQUIREMENTS.—If none of the conditions for ob17 taining a premium discount or rebate or other re18 ward under a wellness program as described in para19 graph (1)(B) are based on an individual satisfying 

20 a standard that is related to a health status factor 

21 (or if such a wellness program does not provide such 

22 a reward), the wellness program shall not violate 

23 this section if participation in the program is made 

24 available to all similarly situated individuals. The 

25 following programs shall not have to comply with the 


kjohnson on DSK79L0C42 with BILLS
17 

•HR 4159 IH

1 requirements of paragraph (3) if participation in the 

2 program is made available to all similarly situated 

3 individuals: 

4 ‘‘(A) A program that reimburses all or 

5 part of the cost for memberships in a fitness 

6 center. 

7 ‘‘(B) A diagnostic testing program that 

8 provides a reward for participation and does 

9 not base any part of the reward on outcomes. 

10 ‘‘(C) A program that encourages preven11 tive care related to a health condition through 

12 the waiver of the copayment or deductible re13 quirement under group health plan for the costs 

14 of certain items or services related to a health 

15 condition (such as prenatal care or well-baby 

16 visits). 

17 ‘‘(D) A program that reimburses individ18 uals for the costs of smoking cessation pro19 grams without regard to whether the individual 

20 quits smoking. 

21 ‘‘(E) A program that provides a reward to 

22 individuals for attending a periodic health edu23 cation seminar. 

24 ‘‘(3) WELLNESS PROGRAMS SUBJECT TO RE25 QUIREMENTS.—If any of the conditions for obtaining 


kjohnson on DSK79L0C42 with BILLS
18 

•HR 4159 IH

1 a premium discount, rebate, or reward under a 

2 wellness program as described in paragraph (1)(C) 

3 is based on an individual satisfying a standard that 

4 is related to a health status factor, the wellness pro5 gram shall not violate this section if the following re6 quirements are complied with: 

7 ‘‘(A) The reward for the wellness program, 

8 together with the reward for other wellness pro9 grams with respect to the plan that requires 

10 satisfaction of a standard related to a health 

11 status factor, shall not exceed 30 percent of the 

12 cost of employee-only coverage under the plan. 

13 If, in addition to employees or individuals, any 

14 class of dependents (such as spouses or spouses 

15 and dependent children) may participate fully 

16 in the wellness program, such reward shall not 

17 exceed 30 percent of the cost of the coverage in 

18 which an employee or individual and any de19 pendents are enrolled. For purposes of this 

20 paragraph, the cost of coverage shall be deter21 mined based on the total amount of employer 

22 and employee contributions for the benefit 

23 package under which the employee is (or the 

24 employee and any dependents are) receiving 

25 coverage. A reward may be in the form of a disVerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00018 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159

kjohnson on DSK79L0C42 with BILLS
19 

•HR 4159 IH

1 count or rebate of a premium or contribution, 

2 a waiver of all or part of a cost-sharing mecha3 nism (such as deductibles, copayments, or coin4 surance), the absence of a surcharge, or the 

5 value of a benefit that would otherwise not be 

6 provided under the plan. The Secretaries of 

7 Labor, Health and Human Services, and the 

8 Treasury may increase the reward available 

9 under this subparagraph to up to 50 percent of 

10 the cost of coverage if the Secretaries determine 

11 that such an increase is appropriate. 

12 ‘‘(B) The wellness program shall be rea13 sonably designed to promote health or prevent 

14 disease. A program complies with the preceding 

15 sentence if the program has a reasonable 

16 chance of improving the health of, or preventing 

17 disease in, participating individuals and it is 

18 not overly burdensome, is not a subterfuge for 

19 discriminating based on a health status factor, 

20 and is not highly suspect in the method chosen 

21 to promote health or prevent disease. 

22 ‘‘(C) The plan shall give individuals eligible 

23 for the program the opportunity to qualify for 

24 the reward under the program at least once 

25 each year. 


kjohnson on DSK79L0C42 with BILLS
20 

•HR 4159 IH

1 ‘‘(D) The full reward under the wellness 

2 program shall be made available to all similarly 

3 situated individuals. For such purpose, among 

4 other things: 

5 ‘‘(i) The reward is not available to all 

6 similarly situated individuals for a period 

7 unless the wellness program allows— 

8 ‘‘(I) for a reasonable alternative 

9 standard (or waiver of the otherwise 

10 applicable standard) for obtaining the 

11 reward for any individual for whom, 

12 for that period, it is unreasonably dif13 ficult due to a medical condition to 

14 satisfy the otherwise applicable stand15 ard; and 

16 ‘‘(II) for a reasonable alternative 

17 standard (or waiver of the otherwise 

18 applicable standard) for obtaining the 

19 reward for any individual for whom, 

20 for that period, it is medically inadvis21 able to attempt to satisfy the other22 wise applicable standard. 

23 ‘‘(ii) If reasonable under the cir24 cumstances, the plan or issuer may seek 

25 verification, such as a statement from an 


kjohnson on DSK79L0C42 with BILLS
21 

•HR 4159 IH

1 individual’s physician, that a health status 

2 factor makes it unreasonably difficult or 

3 medically inadvisable for the individual to 

4 satisfy or attempt to satisfy the otherwise 

5 applicable standard. 

6 ‘‘(E) The plan or issuer involved shall dis7 close in all plan materials describing the terms 

8 of the wellness program the availability of a 

9 reasonable alternative standard (or the possi10 bility of waiver of the otherwise applicable 

11 standard) required under subparagraph (D). If 

12 plan materials disclose that such a program is 

13 available, without describing its terms, the dis14 closure under this subparagraph shall not be re15 quired. 

16 ‘‘SEC. 199. PROHIBITION OF PREEXISTING CONDITION EX17 CLUSIONS OR OTHER DISCRIMINATION 

18 BASED ON HEALTH STATUS. 

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

20 insurance issuer offering group or individual health insur21 ance coverage may not impose any preexisting condition 

22 exclusion with respect to such plan or coverage. 

23 ‘‘(b) DEFINITIONS.—For purposes of this section— 

24 ‘‘(1) PREEXISTING CONDITION EXCLUSION.— 


kjohnson on DSK79L0C42 with BILLS
22 

•HR 4159 IH

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

2 condition exclusion’ means, with respect to cov3 erage, a limitation or exclusion of benefits relat4 ing to a condition based on the fact that the 

5 condition was present before the date of enroll6 ment for such coverage, whether or not any 

7 medical advice, diagnosis, care, or treatment 

8 was recommended or received before such date. 

9 ‘‘(B) TREATMENT OF GENETIC INFORMA10 TION.—Genetic information shall not be treated 

11 as a condition described in subsection (a)(1) in 

12 the absence of a diagnosis of the condition re13 lated to such information. 

14 ‘‘(2) ENROLLMENT DATE.—The term ‘enroll15 ment date’ means, with respect to an individual cov16 ered under a group health plan or health insurance 

17 coverage, the date of enrollment of the individual in 

18 the plan or coverage or, if earlier, the first day of 

19 the waiting period for such enrollment. 

20 ‘‘(3) LATE ENROLLEE.—The term ‘late en21 rollee’ means, with respect to coverage under a 

22 group health plan, a participant or beneficiary who 

23 enrolls under the plan other than during— 

24 ‘‘(A) the first period in which the indi25 vidual is eligible to enroll under the plan; or 


kjohnson on DSK79L0C42 with BILLS
23 

•HR 4159 IH

1 ‘‘(B) a special enrollment period under 

2 subsection (f). 

3 ‘‘(4) WAITING PERIOD.—The term ‘waiting pe4 riod’ means, with respect to a group health plan and 

5 an individual who is a potential participant or bene6 ficiary in the plan, the period that must pass with 

7 respect to the individual before the individual is eli8 gible to be covered for benefits under the terms of 

9 the plan. 

10 ‘‘(c) RULES RELATING TO CREDITING PREVIOUS

11 COVERAGE.— 

12 ‘‘(1) CREDITABLE COVERAGE DEFINED.—For 

13 purposes of this title, the term ‘creditable coverage’ 

14 means, with respect to an individual, coverage of the 

15 individual under any of the following: 

16 ‘‘(A) A group health plan. 

17 ‘‘(B) Health insurance coverage. 

18 ‘‘(C) Part A or part B of title XVIII of the 

19 Social Security Act. 

20 ‘‘(D) Title XIX of the Social Security Act, 

21 other than coverage consisting solely of benefits 

22 under section 1928. 

23 ‘‘(E) Chapter 55 of title 10, United States 

24 Code. 


kjohnson on DSK79L0C42 with BILLS
24 

•HR 4159 IH

1 ‘‘(F) A medical care program of the Indian 

2 Health Service or of a tribal organization. 

3 ‘‘(G) A State health benefits risk pool. 

4 ‘‘(H) A health plan offered under chapter 

5 89 of title 5, United States Code. 

6 ‘‘(I) A public health plan (as defined in 

7 regulations). 

8 ‘‘(J) A health benefit plan under section 

9 5(e) of the Peace Corps Act (22 U.S.C. 

10 2504(e)). 

11 Such term does not include coverage consisting sole12 ly of coverage of excepted benefits (as defined in sec13 tion 2791(c)). 

14 ‘‘(2) NOT COUNTING PERIODS BEFORE SIGNIFI15 CANT BREAKS IN COVERAGE.— 

16 ‘‘(A) IN GENERAL.—A period of creditable 

17 coverage shall not be counted, with respect to 

18 enrollment of an individual under a group or in19 dividual health plan, if, after such period and 

20 before the enrollment date, there was a 63-day 

21 period during all of which the individual was 

22 not covered under any creditable coverage. 

23 ‘‘(B) WAITING PERIOD NOT TREATED AS A

24 BREAK IN COVERAGE.—For purposes of sub25 paragraph (A) and subsection (d)(4), any peVerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00024 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159

kjohnson on DSK79L0C42 with BILLS
25 

•HR 4159 IH

1 riod that an individual is in a waiting period for 

2 any coverage under a group or individual health 

3 plan (or for group health insurance coverage) or 

4 is in an affiliation period (as defined in sub5 section (g)(2)) shall not be taken into account 

6 in determining the continuous period under 

7 subparagraph (A). 

8 ‘‘(C) TAA-ELIGIBLE INDIVIDUALS.—In the 

9 case of plan years beginning before January 1, 

10 2014— 

11 ‘‘(i) TAA PRE-CERTIFICATION PERIOD

12 RULE.—In the case of a TAA-eligible indi13 vidual, the period beginning on the date 

14 the individual has a TAA-related loss of 

15 coverage and ending on the date that is 7 

16 days after the date of the issuance by the 

17 Secretary (or by any person or entity des18 ignated by the Secretary) of a qualified 

19 health insurance costs credit eligibility cer20 tificate for such individual for purposes of 

21 section 7527 of the Internal Revenue Code 

22 of 1986 shall not be taken into account in 

23 determining the continuous period under 

24 subparagraph (A). 


kjohnson on DSK79L0C42 with BILLS
26 

•HR 4159 IH

1 ‘‘(ii) DEFINITIONS.—The terms ‘TAA2 eligible individual’ and ‘TAA-related loss of 

3 coverage’ have the meanings given such 

4 terms in section 2205(b)(4). 

5 ‘‘(3) METHOD OF CREDITING COVERAGE.— 

6 ‘‘(A) STANDARD METHOD.—Except as oth7 erwise provided under subparagraph (B), for 

8 purposes of applying subsection (a)(3), a group 

9 health plan, and a health insurance issuer offer10 ing group or individual health insurance cov11 erage, shall count a period of creditable cov12 erage without regard to the specific benefits 

13 covered during the period. 

14 ‘‘(B) ELECTION OF ALTERNATIVE METH15 OD.—A group health plan, or a health insur16 ance issuer offering group or individual health 

17 insurance, may elect to apply subsection (a)(3) 

18 based on coverage of benefits within each of 

19 several classes or categories of benefits specified 

20 in regulations rather than as provided under 

21 subparagraph (A). Such election shall be made 

22 on a uniform basis for all participants and 

23 beneficiaries. Under such election a group or in24 dividual health plan or issuer shall count a pe25 riod of creditable coverage with respect to any 


kjohnson on DSK79L0C42 with BILLS
27 

•HR 4159 IH

1 class or category of benefits if any level of bene2 fits is covered within such class or category. 

3 ‘‘(C) PLAN NOTICE.—In the case of an 

4 election with respect to a group health plan 

5 under subparagraph (B) (whether or not health 

6 insurance coverage is provided in connection 

7 with such plan), the plan shall— 

8 ‘‘(i) prominently state in any disclo9 sure statements concerning the plan, and 

10 state to each enrollee at the time of enroll11 ment under the plan, that the plan has 

12 made such election; and 

13 ‘‘(ii) include in such statements a de14 scription of the effect of this election. 

15 ‘‘(D) ISSUER NOTICE.—In the case of an 

16 election under subparagraph (B) with respect to 

17 health insurance coverage offered by an issuer 

18 in the individual or group market, the issuer— 

19 ‘‘(i) shall prominently state in any dis20 closure statements concerning the cov21 erage, and to each employer at the time of 

22 the offer or sale of the coverage, that the 

23 issuer has made such election; and 

24 ‘‘(ii) shall include in such statements 

25 a description of the effect of such election. 


kjohnson on DSK79L0C42 with BILLS
28 

•HR 4159 IH

1 ‘‘(4) ESTABLISHMENT OF PERIOD.—Periods of 

2 creditable coverage with respect to an individual 

3 shall be established through presentation of certifi4 cations described in subsection (e) or in such other 

5 manner as may be specified in regulations. 

6 ‘‘(d) EXCEPTIONS.— 

7 ‘‘(1) EXCLUSION NOT APPLICABLE TO CERTAIN

8 NEWBORNS.—Subject to paragraph (4), a group 

9 health plan, and a health insurance issuer offering 

10 group or individual health insurance coverage, may 

11 not impose any preexisting condition exclusion in the 

12 case of an individual who, as of the last day of the 

13 30-day period beginning with the date of birth, is 

14 covered under creditable coverage. 

15 ‘‘(2) EXCLUSION NOT APPLICABLE TO CERTAIN

16 ADOPTED CHILDREN.—Subject to paragraph (4), a 

17 group health plan, and a health insurance issuer of18 fering group or individual health insurance coverage, 

19 may not impose any preexisting condition exclusion 

20 in the case of a child who is adopted or placed for 

21 adoption before attaining 18 years of age and who, 

22 as of the last day of the 30-day period beginning on 

23 the date of the adoption or placement for adoption, 

24 is covered under creditable coverage. The previous 


kjohnson on DSK79L0C42 with BILLS
29 

•HR 4159 IH

1 sentence shall not apply to coverage before the date 

2 of such adoption or placement for adoption. 

3 ‘‘(3) EXCLUSION NOT APPLICABLE TO PREG4 NANCY.—A group health plan, and health insurance 

5 issuer offering group or individual health insurance 

6 coverage, may not impose any preexisting condition 

7 exclusion relating to pregnancy as a preexisting con8 dition. 

9 ‘‘(4) LOSS IF BREAK IN COVERAGE.—Para10 graphs (1) and (2) shall no longer apply to an indi11 vidual after the end of the first 63-day period during 

12 all of which the individual was not covered under 

13 any creditable coverage. 

14 ‘‘(e) CERTIFICATIONS AND DISCLOSURE OF COV15 ERAGE.— 

16 ‘‘(1) REQUIREMENT FOR CERTIFICATION OF

17 PERIOD OF CREDITABLE COVERAGE.— 

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

19 and a health insurance issuer offering group or 

20 individual health insurance coverage, shall pro21 vide the certification described in subparagraph 

22 (B)— 

23 ‘‘(i) at the time an individual ceases 

24 to be covered under the plan or otherwise 


kjohnson on DSK79L0C42 with BILLS
30 

•HR 4159 IH

1 becomes covered under a COBRA continu2 ation provision; 

3 ‘‘(ii) in the case of an individual be4 coming covered under such a provision, at 

5 the time the individual ceases to be covered 

6 under such provision; and 

7 ‘‘(iii) on the request on behalf of an 

8 individual made not later than 24 months 

9 after the date of cessation of the coverage 

10 described in clause (i) or (ii), whichever is 

11 later. 

12 The certification under clause (i) may be pro13 vided, to the extent practicable, at a time con14 sistent with notices required under any applica15 ble COBRA continuation provision. 

16 ‘‘(B) CERTIFICATION.—The certification 

17 described in this subparagraph is a written cer18 tification of— 

19 ‘‘(i) the period of creditable coverage 

20 of the individual under such plan and the 

21 coverage (if any) under such COBRA con22 tinuation provision; and 

23 ‘‘(ii) the waiting period (if any) (and 

24 affiliation period, if applicable) imposed 


kjohnson on DSK79L0C42 with BILLS
31 

•HR 4159 IH

1 with respect to the individual for any cov2 erage under such plan. 

3 ‘‘(C) ISSUER COMPLIANCE.—To the extent 

4 that medical care under a group health plan 

5 consists of group health insurance coverage, the 

6 plan is deemed to have satisfied the certification 

7 requirement under this paragraph if the health 

8 insurance issuer offering the coverage provides 

9 for such certification in accordance with this 

10 paragraph. 

11 ‘‘(2) DISCLOSURE OF INFORMATION ON PRE12 VIOUS BENEFITS.—In the case of an election de13 scribed in subsection (c)(3)(B) by a group health 

14 plan or health insurance issuer, if the plan or issuer 

15 enrolls an individual for coverage under the plan and 

16 the individual provides a certification of coverage of 

17 the individual under paragraph (1)— 

18 ‘‘(A) upon request of such plan or issuer, 

19 the entity which issued the certification pro20 vided by the individual shall promptly disclose 

21 to such requesting plan or issuer information 

22 on coverage of classes and categories of health 

23 benefits available under such entity’s plan or 

24 coverage; and 


kjohnson on DSK79L0C42 with BILLS
32 

•HR 4159 IH

1 ‘‘(B) such entity may charge the request2 ing plan or issuer for the reasonable cost of dis3 closing such information. 

4 ‘‘(3) REGULATIONS.—The Secretary shall es5 tablish rules to prevent an entity’s failure to provide 

6 information under paragraph (1) or (2) with respect 

7 to previous coverage of an individual from adversely 

8 affecting any subsequent coverage of the individual 

9 under another group health plan or health insurance 

10 coverage. 

11 ‘‘(f) SPECIAL ENROLLMENT PERIODS.— 

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

13 A group health plan, and a health insurance issuer 

14 offering group health insurance coverage in connec15 tion with a group health plan, shall permit an em16 ployee who is eligible, but not enrolled, for coverage 

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

18 an employee if the dependent is eligible, but not en19 rolled, for coverage under such terms) to enroll for 

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

21 following conditions is met: 

22 ‘‘(A) The employee or dependent was cov23 ered under a group health plan or had health 

24 insurance coverage at the time coverage was 

25 previously offered to the employee or dependent. 


kjohnson on DSK79L0C42 with BILLS
33 

•HR 4159 IH

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

2 such time that coverage under a group health 

3 plan or health insurance coverage was the rea4 son for declining enrollment, but only if the 

5 plan sponsor or issuer (if applicable) required 

6 such a statement at such time and provided the 

7 employee with notice of such requirement (and 

8 the consequences of such requirement) at such 

9 time. 

10 ‘‘(C) The employee’s or dependent’s cov11 erage described in subparagraph (A)— 

12 ‘‘(i) was under a COBRA continu13 ation provision and the coverage under 

14 such provision was exhausted; or 

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

16 and either the coverage was terminated as 

17 a result of loss of eligibility for the cov18 erage (including as a result of legal separa19 tion, divorce, death, termination of employ20 ment, or reduction in the number of hours 

21 of employment) or employer contributions 

22 toward such coverage were terminated. 

23 ‘‘(D) Under the terms of the plan, the em24 ployee requests such enrollment not later than 

25 30 days after the date of exhaustion of coverage 


kjohnson on DSK79L0C42 with BILLS
34 

•HR 4159 IH

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

2 of coverage or employer contribution described 

3 in subparagraph (C)(ii). 

4 ‘‘(2) FOR DEPENDENT BENEFICIARIES.— 

5 ‘‘(A) IN GENERAL.—If— 

6 ‘‘(i) a group health plan makes cov7 erage available with respect to a dependent 

8 of an individual; 

9 ‘‘(ii) the individual is a participant 

10 under the plan (or has met any waiting pe11 riod applicable to becoming a participant 

12 under the plan and is eligible to be enrolled 

13 under the plan but for a failure to enroll 

14 during a previous enrollment period); and 

15 ‘‘(iii) a person becomes such a de16 pendent of the individual through mar17 riage, birth, or adoption or placement for 

18 adoption, 

19 the group health plan shall provide for a de20 pendent special enrollment period described in 

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

22 if not otherwise enrolled, the individual) may be 

23 enrolled under the plan as a dependent of the 

24 individual, and in the case of the birth or adop25 tion of a child, the spouse of the individual may 


kjohnson on DSK79L0C42 with BILLS
35 

•HR 4159 IH

1 be enrolled as a dependent of the individual if 

2 such spouse is otherwise eligible for coverage. 

3 ‘‘(B) DEPENDENT SPECIAL ENROLLMENT

4 PERIOD.—A dependent special enrollment pe5 riod under this subparagraph shall be a period 

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

7 later of— 

8 ‘‘(i) the date dependent coverage is 

9 made available; or 

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

11 or adoption or placement for adoption (as 

12 the case may be) described in subpara13 graph (A)(iii). 

14 ‘‘(C) NO WAITING PERIOD.—If an indi15 vidual seeks to enroll a dependent during the 

16 first 30 days of such a dependent special enroll17 ment period, the coverage of the dependent 

18 shall become effective— 

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

20 than the first day of the first month begin21 ning after the date the completed request 

22 for enrollment is received; 

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

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


kjohnson on DSK79L0C42 with BILLS
36 

•HR 4159 IH

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

2 adoption or placement for adoption, the 

3 date of such adoption or placement for 

4 adoption. 

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

6 OF MEDICAID AND CHIP.— 

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

8 and a health insurance issuer offering group 

9 health insurance coverage in connection with a 

10 group health plan, shall permit an employee 

11 who is eligible, but not enrolled, for coverage 

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

13 such an employee if the dependent is eligible, 

14 but not enrolled, for coverage under such 

15 terms) to enroll for coverage under the terms of 

16 the plan if either of the following conditions is 

17 met: 

18 ‘‘(i) TERMINATION OF MEDICAID OR

19 CHIP COVERAGE.—The employee or de20 pendent is covered under a Medicaid plan 

21 under title XIX of the Social Security Act 

22 or under a State child health plan under 

23 title XXI of such Act and coverage of the 

24 employee or dependent under such a plan 

25 is terminated as a result of loss of eligiVerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00036 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159

kjohnson on DSK79L0C42 with BILLS
37 

•HR 4159 IH

1 bility for such coverage and the employee 

2 requests coverage under the group health 

3 plan (or health insurance coverage) not 

4 later than 60 days after the date of termi5 nation of such coverage. 

6 ‘‘(ii) ELIGIBILITY FOR EMPLOYMENT

7 ASSISTANCE UNDER MEDICAID OR CHIP.— 

8 The employee or dependent becomes eligi9 ble for assistance, with respect to coverage 

10 under the group health plan or health in11 surance coverage, under such Medicaid 

12 plan or State child health plan (including 

13 under any waiver or demonstration project 

14 conducted under or in relation to such a 

15 plan), if the employee requests coverage 

16 under the group health plan or health in17 surance coverage not later than 60 days 

18 after the date the employee or dependent is 

19 determined to be eligible for such assist20 ance. 

21 ‘‘(B) COORDINATION WITH MEDICAID AND

22 CHIP.— 

23 ‘‘(i) OUTREACH TO EMPLOYEES RE24 GARDING AVAILABILITY OF MEDICAID AND

25 CHIP COVERAGE.— 


kjohnson on DSK79L0C42 with BILLS
38 

•HR 4159 IH

1 ‘‘(I) IN GENERAL.—Each em2 ployer that maintains a group health 

3 plan in a State that provides medical 

4 assistance under a State Medicaid 

5 plan under title XIX of the Social Se6 curity Act, or child health assistance 

7 under a State child health plan under 

8 title XXI of such Act, in the form of 

9 premium assistance for the purchase 

10 of coverage under a group health 

11 plan, shall provide to each employee a 

12 written notice informing the employee 

13 of potential opportunities then cur14 rently available in the State in which 

15 the employee resides for premium as16 sistance under such plans for health 

17 coverage of the employee or the em18 ployee’s dependents. For purposes of 

19 compliance with this subclause, the 

20 employer may use any State-specific 

21 model notice developed in accordance 

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

23 Employee Retirement Income Security 

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

25 1181(f)(3)(B)(i)(II)). 


kjohnson on DSK79L0C42 with BILLS
39 

•HR 4159 IH

1 ‘‘(II) OPTION TO PROVIDE CON2 CURRENT WITH PROVISION OF PLAN

3 MATERIALS TO EMPLOYEE.—An em4 ployer may provide the model notice 

5 applicable to the State in which an 

6 employee resides concurrent with the 

7 furnishing of materials notifying the 

8 employee of health plan eligibility, 

9 concurrent with materials provided to 

10 the employee in connection with an 

11 open season or election process con12 ducted under the plan, or concurrent 

13 with the furnishing of the summary 

14 plan description as provided in section 

15 104(b) of the Employee Retirement 

16 Income Security Act of 1974. 

17 ‘‘(ii) DISCLOSURE ABOUT GROUP

18 HEALTH PLAN BENEFITS TO STATES FOR

19 MEDICAID AND CHIP ELIGIBLE INDIVID20 UALS.—In the case of an enrollee in a 

21 group health plan who is covered under a 

22 Medicaid plan of a State under title XIX 

23 of the Social Security Act or under a State 

24 child health plan under title XXI of such 

25 Act, the plan administrator of the group 


kjohnson on DSK79L0C42 with BILLS
40 

•HR 4159 IH

1 health plan shall disclose to the State, 

2 upon request, information about the bene3 fits available under the group health plan 

4 in sufficient specificity, as determined 

5 under regulations of the Secretary of 

6 Health and Human Services in consulta7 tion with the Secretary that require use of 

8 the model coverage coordination disclosure 

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

10 of the Children’s Health Insurance Reau11 thorization Act of 2009, so as to permit 

12 the State to make a determination (under 

13 paragraph (2)(B), (3), or (10) of section 

14 2105(c) of the Social Security Act or oth15 erwise) concerning the cost-effectiveness of 

16 the State providing medical or child health 

17 assistance through premium assistance for 

18 the purchase of coverage under such group 

19 health plan and in order for the State to 

20 provide supplemental benefits required 

21 under paragraph (10)(E) of such section 

22 or other authority. 

23 ‘‘(g) USE OF AFFILIATION PERIOD BY HMOS AS AL24 TERNATIVE TO PREEXISTING CONDITION EXCLUSION.— 


kjohnson on DSK79L0C42 with BILLS
41 

•HR 4159 IH

1 ‘‘(1) IN GENERAL.—A health maintenance orga2 nization which offers health insurance coverage in 

3 connection with a group health plan and which does 

4 not impose any preexisting condition exclusion al5 lowed under subsection (a) with respect to any par6 ticular coverage option may impose an affiliation pe7 riod for such coverage option, but only if— 

8 ‘‘(A) such period is applied uniformly with9 out regard to any health status-related factors; 

10 and 

11 ‘‘(B) such period does not exceed 2 months 

12 (or 3 months in the case of a late enrollee). 

13 ‘‘(2) AFFILIATION PERIOD.— 

14 ‘‘(A) DEFINED.—For purposes of this 

15 title, the term ‘affiliation period’ means a pe16 riod which, under the terms of the health insur17 ance coverage offered by the health mainte18 nance organization, must expire before the 

19 health insurance coverage becomes effective. 

20 The organization is not required to provide 

21 health care services or benefits during such pe22 riod and no premium shall be charged to the 

23 participant or beneficiary for any coverage dur24 ing the period. 


kjohnson on DSK79L0C42 with BILLS
42 

•HR 4159 IH

1 ‘‘(B) BEGINNING.—Such period shall begin 

2 on the enrollment date. 

3 ‘‘(C) RUNS CONCURRENTLY WITH WAITING

4 PERIODS.—An affiliation period under a plan 

5 shall run concurrently with any waiting period 

6 under the plan. 

7 ‘‘(3) ALTERNATIVE METHODS.—A health main8 tenance organization described in paragraph (1) may 

9 use alternative methods, from those described in 

10 such paragraph, to address adverse selection as ap11 proved by the State insurance commissioner or offi12 cial or officials designated by the State to enforce 

13 the requirements of this part for the State involved 

14 with respect to such issuer. 

15 ‘‘SEC. 199A. ENFORCEMENT OF CERTAIN HEALTH INSUR16 ANCE REQUIREMENTS. 

17 ‘‘(a) STATE ENFORCEMENT.— 

18 ‘‘(1) STATE AUTHORITY.—Each State may re19 quire that health insurance issuers that issue, sell, 

20 renew, or offer health insurance coverage in the 

21 State in the individual or group market meet the re22 quirements of this part with respect to such issuers. 

23 ‘‘(2) FAILURE TO IMPLEMENT PROVISIONS.—In 

24 the case of a determination by the Secretary that a 

25 State has failed to substantially enforce a provision 


kjohnson on DSK79L0C42 with BILLS
43 

•HR 4159 IH

1 (or provisions) of sections 196 through 199 with re2 spect to health insurance issuers in the State, the 

3 Secretary shall enforce such provision (or provisions) 

4 under subsection (b) insofar as they relate to the 

5 issuance, sale, renewal, and offering of health insur6 ance coverage in connection with group health plans 

7 or individual health insurance coverage in such 

8 State. 

9 ‘‘(b) SECRETARIAL ENFORCEMENT AUTHORITY.— 

10 ‘‘(1) LIMITATION.—The provisions of this sub11 section shall apply to enforcement of a provision (or 

12 provisions) described in subsection (a)(2) only— 

13 ‘‘(A) as provided under such subsection; 

14 and 

15 ‘‘(B) with respect to individual health in16 surance coverage or group health plans that are 

17 non-Federal governmental plans. 

18 ‘‘(2) IMPOSITION OF PENALTIES.—In the cases 

19 described in paragraph (1)— 

20 ‘‘(A) IN GENERAL.—Subject to the suc21 ceeding provisions of this subsection, any non22 Federal governmental plan that is a group 

23 health plan and any health insurance issuer 

24 that fails to meet a provision of this part appliVerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00043 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159

kjohnson on DSK79L0C42 with BILLS
44 

•HR 4159 IH

1 cable to such plan or issuer is subject to a civil 

2 money penalty under this subsection. 

3 ‘‘(B) LIABILITY FOR PENALTY.—In the 

4 case of a failure by— 

5 ‘‘(i) a health insurance issuer, the 

6 issuer is liable for such penalty; or 

7 ‘‘(ii) a group health plan that is a 

8 non-Federal governmental plan which is— 

9 ‘‘(I) sponsored by 2 or more em10 ployers, the plan is liable for such 

11 penalty; or 

12 ‘‘(II) not so sponsored, the em13 ployer is liable for such penalty. 

14 ‘‘(C) AMOUNT OF PENALTY.— 

15 ‘‘(i) IN GENERAL.—The maximum 

16 amount of penalty imposed under this 

17 paragraph is $100 for each day for each 

18 individual with respect to which such a 

19 failure occurs. 

20 ‘‘(ii) CONSIDERATIONS IN IMPOSI21 TION.—In determining the amount of any 

22 penalty to be assessed under this para23 graph, the Secretary shall take into ac24 count the previous record of compliance of 

25 the entity being assessed with the applicaVerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00044 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159

kjohnson on DSK79L0C42 with BILLS
45 

•HR 4159 IH

1 ble provisions of this part and the gravity 

2 of the violation. 

3 ‘‘(iii) LIMITATIONS.— 

4 ‘‘(I) PENALTY NOT TO APPLY

5 WHERE FAILURE NOT DISCOVERED

6 EXERCISING REASONABLE DILI7 GENCE.—No civil money penalty shall 

8 be imposed under this paragraph on 

9 any failure during any period for 

10 which it is established to the satisfac11 tion of the Secretary that none of the 

12 entities against whom the penalty 

13 would be imposed knew, or exercising 

14 reasonable diligence would have 

15 known, that such failure existed. 

16 ‘‘(II) PENALTY NOT TO APPLY

17 TO FAILURES CORRECTED WITHIN 30

18 DAYS.—No civil money penalty shall 

19 be imposed under this paragraph on 

20 any failure if such failure was due to 

21 reasonable cause and not to willful ne22 glect, and such failure is corrected 

23 during the 30-day period beginning on 

24 the first day any of the entities 

25 against whom the penalty would be 


kjohnson on DSK79L0C42 with BILLS
46 

•HR 4159 IH

1 imposed knew, or exercising reason2 able diligence would have known, that 

3 such failure existed. 

4 ‘‘(D) ADMINISTRATIVE REVIEW.— 

5 ‘‘(i) OPPORTUNITY FOR HEARING.— 

6 The entity assessed shall be afforded an 

7 opportunity for hearing by the Secretary 

8 upon request made within 30 days after 

9 the date of the issuance of a notice of as10 sessment. In such hearing the decision 

11 shall be made on the record pursuant to 

12 section 554 of title 5, United States Code. 

13 If no hearing is requested, the assessment 

14 shall constitute a final and unappealable 

15 order. 

16 ‘‘(ii) HEARING PROCEDURE.—If a 

17 hearing is requested, the initial agency de18 cision shall be made by an administrative 

19 law judge, and such decision shall become 

20 the final order unless the Secretary modi21 fies or vacates the decision. Notice of in22 tent to modify or vacate the decision of the 

23 administrative law judge shall be issued to 

24 the parties within 30 days after the date of 

25 the decision of the judge. A final order 


kjohnson on DSK79L0C42 with BILLS
47 

•HR 4159 IH

1 which takes effect under this paragraph 

2 shall be subject to review only as provided 

3 under subparagraph (E). 

4 ‘‘(E) JUDICIAL REVIEW.— 

5 ‘‘(i) FILING OF ACTION FOR RE6 VIEW.—Any entity against whom an order 

7 imposing a civil money penalty has been 

8 entered after an agency hearing under this 

9 paragraph may obtain review by the 

10 United States district court for any district 

11 in which such entity is located or the 

12 United States District Court for the Dis13 trict of Columbia by filing a notice of ap14 peal in such court within 30 days from the 

15 date of such order, and simultaneously 

16 sending a copy of such notice by registered 

17 mail to the Secretary. 

18 ‘‘(ii) CERTIFICATION OF ADMINISTRA19 TIVE RECORD.—The Secretary shall 

20 promptly certify and file in such court the 

21 record upon which the penalty was im22 posed. 

23 ‘‘(iii) STANDARD FOR REVIEW.—The 

24 findings of the Secretary shall be set aside 

25 only if found to be unsupported by subVerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00047 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159

kjohnson on DSK79L0C42 with BILLS
48 

•HR 4159 IH

1 stantial evidence as provided by section 

2 706(2)(E) of title 5, United States Code. 

3 ‘‘(iv) APPEAL.—Any final decision, 

4 order, or judgment of the district court 

5 concerning such review shall be subject to 

6 appeal as provided in chapter 83 of title 28 

7 of such Code. 

8 ‘‘(F) FAILURE TO PAY ASSESSMENT; MAIN9 TENANCE OF ACTION.— 

10 ‘‘(i) FAILURE TO PAY ASSESSMENT.— 

11 If any entity fails to pay an assessment 

12 after it has become a final and 

13 unappealable order, or after the court has 

14 entered final judgment in favor of the Sec15 retary, the Secretary shall refer the matter 

16 to the Attorney General who shall recover 

17 the amount assessed by action in the ap18 propriate United States district court. 

19 ‘‘(ii) NONREVIEWABILITY.—In such 

20 action the validity and appropriateness of 

21 the final order imposing the penalty shall 

22 not be subject to review. 

23 ‘‘(G) PAYMENT OF PENALTIES.—Except as 

24 otherwise provided, penalties collected under 

25 this paragraph shall be paid to the Secretary 


kjohnson on DSK79L0C42 with BILLS
49 

•HR 4159 IH

1 (or other officer) imposing the penalty and shall 

2 be available without appropriation and until ex3 pended for the purpose of enforcing the provi4 sions with respect to which the penalty was im5 posed. 

6 ‘‘(3) ENFORCEMENT AUTHORITY RELATING TO

7 GENETIC DISCRIMINATION.— 

8 ‘‘(A) GENERAL RULE.—In the cases de9 scribed in paragraph (1), notwithstanding the 

10 provisions of paragraph (2)(C), the succeeding 

11 subparagraphs of this paragraph shall apply 

12 with respect to an action under this subsection 

13 by the Secretary with respect to any failure of 

14 a health insurance issuer in connection with a 

15 group health plan, to meet the requirements of 

16 subsection (a)(1)(F), (b)(3), (c), or (d) of sec17 tion 196 or section 197 or 196(b)(1) with re18 spect to genetic information in connection with 

19 the plan. 

20 ‘‘(B) AMOUNT.— 

21 ‘‘(i) IN GENERAL.—The amount of 

22 the penalty imposed under this paragraph 

23 shall be $100 for each day in the non24 compliance period with respect to each parVerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00049 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159

kjohnson on DSK79L0C42 with BILLS
50 

•HR 4159 IH

1 ticipant or beneficiary to whom such fail2 ure relates. 

3 ‘‘(ii) NONCOMPLIANCE PERIOD.—For 

4 purposes of this paragraph, the term ‘non5 compliance period’ means, with respect to 

6 any failure, the period— 

7 ‘‘(I) beginning on the date such 

8 failure first occurs; and 

9 ‘‘(II) ending on the date the fail10 ure is corrected. 

11 ‘‘(C) MINIMUM PENALTIES WHERE FAIL12 URE DISCOVERED.—Notwithstanding clauses (i) 

13 and (ii) of subparagraph (D): 

14 ‘‘(i) IN GENERAL.—In the case of 1 or 

15 more failures with respect to an indi16 vidual— 

17 ‘‘(I) which are not corrected be18 fore the date on which the plan re19 ceives a notice from the Secretary of 

20 such violation; and 

21 ‘‘(II) which occurred or continued 

22 during the period involved; 

23 the amount of penalty imposed by subpara24 graph (A) by reason of such failures with 


kjohnson on DSK79L0C42 with BILLS
51 

•HR 4159 IH

1 respect to such individual shall not be less 

2 than $2,500. 

3 ‘‘(ii) HIGHER MINIMUM PENALTY

4 WHERE VIOLATIONS ARE MORE THAN DE

5 MINIMIS.—To the extent violations for 

6 which any person is liable under this para7 graph for any year are more than de mini8 mis, clause (i) shall be applied by sub9 stituting ‘$15,000’ for ‘$2,500’ with re10 spect to such person. 

11 ‘‘(D) LIMITATIONS.— 

12 ‘‘(i) PENALTY NOT TO APPLY WHERE

13 FAILURE NOT DISCOVERED EXERCISING

14 REASONABLE DILIGENCE.—No penalty 

15 shall be imposed by subparagraph (A) on 

16 any failure during any period for which it 

17 is established to the satisfaction of the 

18 Secretary that the person otherwise liable 

19 for such penalty did not know, and exer20 cising reasonable diligence would not have 

21 known, that such failure existed. 

22 ‘‘(ii) PENALTY NOT TO APPLY TO

23 FAILURES CORRECTED WITHIN CERTAIN

24 PERIODS.—No penalty shall be imposed by 

25 subparagraph (A) on any failure if— 


kjohnson on DSK79L0C42 with BILLS
52 

•HR 4159 IH

1 ‘‘(I) such failure was due to rea2 sonable cause and not to willful ne3 glect; and 

4 ‘‘(II) such failure is corrected 

5 during the 30-day period beginning on 

6 the first date the person otherwise lia7 ble for such penalty knew, or exer8 cising reasonable diligence would have 

9 known, that such failure existed. 

10 ‘‘(iii) OVERALL LIMITATION FOR UN11 INTENTIONAL FAILURES.—In the case of 

12 failures which are due to reasonable cause 

13 and not to willful neglect, the penalty im14 posed by subparagraph (A) for failures 

15 shall not exceed the amount equal to the 

16 lesser of— 

17 ‘‘(I) 10 percent of the aggregate 

18 amount paid or incurred by the em19 ployer (or predecessor employer) dur20 ing the preceding taxable year for 

21 group health plans; or 

22 ‘‘(II) $500,000. 

23 ‘‘(E) WAIVER BY SECRETARY.—In the case 

24 of a failure which is due to reasonable cause 

25 and not to willful neglect, the Secretary may 


kjohnson on DSK79L0C42 with BILLS
53 

•HR 4159 IH

1 waive part or all of the penalty imposed by sub2 paragraph (A) to the extent that the payment 

3 of such penalty would be excessive relative to 

4 the failure involved. 

5 ‘‘(c) DEFINITIONS.—For purposes of this section: 

6 ‘‘(1) GOVERNMENTAL PLAN.—The term ‘gov7 ernmental plan’ has the meaning given such term 

8 under section 3(32) of the Employee Retirement In9 come Security Act of 1974 and any Federal govern10 mental plan. 

11 ‘‘(2) FEDERAL GOVERNMENTAL PLAN.—The 

12 term ‘‘Federal governmental plan’’ means a govern13 mental plan established or maintained for its em14 ployees by the Government of the United States or 

15 by any agency or instrumentality of such Govern16 ment. 

17 ‘‘(3) NON-FEDERAL GOVERNMENTAL PLAN.— 

18 The term ‘non-Federal governmental plan’ means a 

19 governmental plan that is not a Federal govern20 mental plan.’’. 

21 (b) CONFORMING AMENDMENT.—The table of con22 tents under section 1(b) of the Health Insurance Port23 ability and Accountability Act of 1996 (Public Law 104– 

24 191) is amended by inserting after the item relating to 

25 section 195 the following: 

‘‘Sec. 196. Guaranteed availability of coverage. 


kjohnson on DSK79L0C42 with BILLS
54 

•HR 4159 IH

‘‘Sec. 197. Fair health insurance premiums. 

‘‘Sec. 198. Prohibiting discrimination against individual participants and beneficiaries based on health status. 

‘‘Sec. 199. Prohibition of preexisting condition exclusions or other discrimination based on health status. 

‘‘Sec. 199A. Enforcement of certain health insurance requirements.’’. 

1 (c) ERISA AND IRC ENFORCEMENT.— 

2 (1) ERISA.—Subpart B of part 7 of title I of 

3 the Employee Retirement Income Security Act of 

4 1974 (29 U.S.C. 1185 et seq.) is amended by adding 

5 at the end the following new section: 

6 ‘‘SEC. 716. OTHER MARKET REFORMS. 

7 ‘‘Sections 196 and 197 of the Health Insurance Port8 ability and Accountability Act of 1996 shall apply to 

9 health insurance issuers providing health insurance cov10 erage in connection with group health plans, and sections 

11 198 through 199 of such Act shall apply to group health 

12 plans and health insurance issuers providing health insur13 ance coverage in connection with group health plans, as 

14 if included in this subpart, and to the extent that any pro15 vision of this part conflicts with a provision of such sec16 tions 196 or 197 with respect to health insurance issuers 

17 providing health insurance coverage in connection with 

18 group health plans or of such sections 198 or 199 with 

19 respect to group health plans or health insurance issuers 

20 providing health insurance coverage in connection with 

21 group health plans, the provisions of such sections 196 

22 through 199 shall apply.’’. 


kjohnson on DSK79L0C42 with BILLS
55 

•HR 4159 IH

1 (2) IRC.—Subchapter B of chapter 100 of sub2 title K of title 26 of the Internal Revenue Code of 

3 1986 is amended by adding at the end the following 

4 new section: 

5 ‘‘SEC. 9816. OTHER MARKET REFORMS. 

6 ‘‘Sections 196 and 197 of the Health Insurance Port7 ability and Accountability Act of 1996 shall apply to 

8 health insurance issuers providing health insurance cov9 erage in connection with group health plans, and sections 

10 198 through 199 of such Act shall apply to group health 

11 plans and health insurance issuers providing health insur12 ance coverage in connection with group health plans, as 

13 if included in this subchapter, and to the extent that any 

14 provision of this chapter conflicts with a provision of such 

15 sections 196 or 197 with respect to health insurance 

16 issuers providing health insurance coverage in connection 

17 with group health plans or of such sections 198 or 199 

18 with respect to group health plans or health insurance 

19 issuers providing health insurance coverage in connection 

20 with group health plans, the provisions of such sections 

21 196 through 199 shall apply.’’. 

Æ 


kjohnson on DSK79L0C42 with BILLS