I 

113TH CONGRESS 

2D SESSION H. R. 4496 

To establish universal access programs to improve high risk pools and reinsurance markets to ensure coverage for individuals with pre-existing conditions, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

APRIL 28, 2014 

Mr. GARDNER introduced the following bill; which was referred to the 

Committee on Energy and Commerce 

A BILL 

To establish universal access programs to improve high risk 

pools and reinsurance markets to ensure coverage for 

individuals with pre-existing 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 ‘‘Covering People With 

5 Pre-Existing Conditions Act of 2014’’. 


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1 SEC. 2. ESTABLISHING UNIVERSAL ACCESS PROGRAMS TO 

2 IMPROVE HIGH RISK POOLS AND REINSUR3 ANCE MARKETS FOR INDIVIDUALS WITH PRE4 EXISTING CONDITIONS. 

5 (a) STATE REQUIREMENT.— 

6 (1) IN GENERAL.—Not later than January 1, 

7 2015, each State shall— 

8 (A) subject to paragraph (3), operate— 

9 (i) a qualified State reinsurance pro10 gram described in subsection (b); or 

11 (ii) qualifying State high risk pool de12 scribed in subsection (c)(1); and 

13 (B) subject to paragraph (3), apply to the 

14 operation of such a program from State funds 

15 an amount equivalent to the portion of State 

16 funds derived from State premium assessments 

17 (as defined by the Secretary) that are not oth18 erwise used on State health care programs. 

19 (2) RELATION TO CURRENT QUALIFIED HIGH

20 RISK POOL PROGRAM.— 

21 (A) STATES NOT OPERATING A QUALIFIED

22 HIGH RISK POOL.—In the case of a State that 

23 is not operating a current section 2745 quali24 fied high risk pool as of the date of the enact25 ment of this Act— 


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1 (i) the State may only meet the re2 quirement of paragraph (1) through the 

3 operation of a qualified State reinsurance 

4 program described in subsection (b); and 

5 (ii) the State’s operation of such a re6 insurance program shall be treated, for 

7 purposes of section 2745 of the Public 

8 Health Service Act, as the operation of a 

9 qualified high risk pool described in such 

10 section. 

11 (B) STATE OPERATING A QUALIFIED HIGH

12 RISK POOL.—In the case of a State that is op13 erating a current section 2745 qualified high 

14 risk pool as of the date of the enactment of this 

15 Act— 

16 (i) as of January 1, 2015, such a pool 

17 shall not be treated as a qualified high risk 

18 pool under section 2745 of the Public 

19 Health Service Act unless the pool is a 

20 qualifying State high risk pool described in 

21 subsection (c)(1); and 

22 (ii) the State may use premium as23 sessment funds described in paragraph 

24 (1)(B) to transition from operation of such 

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1 insurance program described in subsection 

2 (b). 

3 (3) APPLICATION OF FUNDS.—If the program 

4 or pool operated under paragraph (1)(A) is in strong 

5 fiscal health, as determined in accordance with 

6 standards established by the National Association of 

7 Insurance Commissioners and as approved by the 

8 State Insurance Commissioner involved, the require9 ment of paragraph (1)(B) shall be deemed to be 

10 met. 

11 (b) QUALIFIED STATE REINSURANCE PROGRAM.— 

12 (1) IN GENERAL.—For purposes of this section, 

13 a ‘‘qualified State reinsurance program’’ means a 

14 program operated by a State program that provides 

15 reinsurance for health insurance coverage offered in 

16 the small group market in accordance with the 

17 model for such a program established (as of the date 

18 of the enactment of this Act). 

19 (2) FORM OF PROGRAM.—A qualified State re20 insurance program may provide reinsurance— 

21 (A) on a prospective or retrospective basis; 

22 and 

23 (B) on a basis that protects health insur24 ance issuers against the annual aggregate 


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1 spending of their enrollees as well as purchase 

2 protection against individual catastrophic costs. 

3 (3) SATISFACTION OF HIPAA REQUIREMENT.— 

4 A qualified State reinsurance program shall be 

5 deemed, for purposes of section 2745 of the Public 

6 Health Service Act, to be a qualified high risk pool 

7 under such section. 

8 (c) QUALIFYING STATE HIGH RISK POOL.— 

9 (1) IN GENERAL.—A qualifying State high risk 

10 pool described in this subsection means a current 

11 section 2745 qualified high risk pool that meets the 

12 following requirements: 

13 (A) The pool must provide at least two 

14 coverage options, one of which must be a high 

15 deductible health plan coupled with a health 

16 savings account. 

17 (B) The pool must be funded with a stable 

18 funding source. 

19 (C) The pool must eliminate any waiting 

20 lists so that all eligible residents who are seek21 ing coverage through the pool should be allowed 

22 to receive coverage through the pool. 

23 (D) The pool must allow for coverage of 

24 individuals who, but for the 24-month disability 

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1 cial Security Act, would be eligible for Medicare 

2 during the period of such waiting period. 

3 (E) The pool must limit the pool premiums 

4 to no more than 150 percent of the average 

5 premium for applicable standard risk rates in 

6 that State. 

7 (F) The pool must conduct education and 

8 outreach initiatives so that residents and bro9 kers understand that the pool is available to eli10 gible residents. 

11 (G) The pool must provide coverage for 

12 preventive services and disease management for 

13 chronic diseases. 

14 (2) VERIFICATION OF CITIZENSHIP OR ALIEN

15 QUALIFICATION.— 

16 (A) IN GENERAL.—Notwithstanding any 

17 other provision of law, only citizens and nation18 als of the United States shall be eligible to par19 ticipate in a qualifying State high risk pool that 

20 receives funds under section 2745 of the Public 

21 Health Service Act or this section. 

22 (B) CONDITION OF PARTICIPATION.—As a 

23 condition of a State receiving such funds, the 

24 Secretary shall require the State to certify, to 

25 the satisfaction of the Secretary, that such 


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1 State requires all applicants for coverage in the 

2 qualifying State high risk pool to provide satis3 factory documentation of citizenship or nation4 ality in a manner consistent with section 

5 1903(x) of the Social Security Act. 

6 (C) RECORDS.—The Secretary shall keep 

7 sufficient records such that a determination of 

8 citizenship or nationality only has to be made 

9 once for any individual under this paragraph. 

10 (3) RELATION TO SECTION 2745.—As of Janu11 ary 1, 2015, a pool shall not qualify as qualified 

12 high risk pool under section 2745 of the Public 

13 Health Service Act unless the pool is a qualifying 

14 State high risk pool described in paragraph (1). 

15 (d) WAIVERS.—In order to accommodate new and in16 novative programs, the Secretary may waive such require17 ments of this section for qualified State reinsurance pro18 grams and for qualifying State high risk pools as the Sec19 retary deems appropriate. 

20 (e) FUNDING.—In addition to any other amounts ap21 propriated, there is appropriated to carry out section 2745 

22 of the Public Health Service Act (including through a pro23 gram or pool described in subsection (a)(1))— 

24 (1) $15,000,000,000 for the period of fiscal 

25 years 2015 through 2024; and 


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1 (2) an additional $10,000,000,000 for the pe2 riod of fiscal years 2020 through 2024. 

3 (f) DEFINITIONS.—In this section: 

4 (1) HEALTH INSURANCE COVERAGE; HEALTH

5 INSURANCE ISSUER.—The terms ‘‘health insurance 

6 coverage’’ and ‘‘health insurance issuer’’ have the 

7 meanings given such terms in section 2791 of the 

8 Public Health Service Act. 

9 (2) CURRENT SECTION 2745 QUALIFIED HIGH

10 RISK POOL.—The term ‘‘current section 2745 quali11 fied high risk pool’’ has the meaning given the term 

12 ‘‘qualified high risk pool’’ under section 2745(g) of 

13 the Public Health Service Act as in effect as of the 

14 date of the enactment of this Act. 

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

16 the Secretary of Health and Human Services. 

17 (4) STANDARD RISK RATE.—The term ‘‘stand18 ard risk rate’’ means a rate that— 

19 (A) is determined under the State high 

20 risk pool by considering the premium rates 

21 charged by other health insurance issuers offer22 ing health insurance coverage to individuals in 

23 the insurance market served; 

24 (B) is established using reasonable actu25 arial techniques; and 


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1 (C) reflects anticipated claims experience 

2 and expenses for the coverage involved. 

3 (5) STATE.—The term ‘‘State’’ means any of 

4 the 50 States or the District of Columbia. 

Æ 


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