II 

113TH CONGRESS 

2D SESSION H. R. 4414 

IN THE SENATE OF THE UNITED STATES 

APRIL 30, 2014 

Received 

AN ACT 

To clarify the treatment under the Patient Protection and 

Affordable Care Act of health plans in which expatriates 

are the primary enrollees, and for other purposes. 

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


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Expatriate Health Cov3 erage Clarification Act of 2014’’. 

4 SEC. 2. TREATMENT OF EXPATRIATE HEALTH PLANS 

5 UNDER ACA. 

6 (a) IN GENERAL.—Subject to subsection (b), the pro7 visions of (including any amendment made by) the Patient 

8 Protection and Affordable Care Act (Public Law 111– 

9 148) and of title I and subtitle B of title II of the Health 

10 Care and Education Reconciliation Act of 2010 (Public 

11 Law 111–152) shall not apply with respect to— 

12 (1) expatriate health plans; 

13 (2) employers with respect to any such plans 

14 for which such employers are acting as plan spon15 sors; or 

16 (3) expatriate health insurance issuers with re17 spect to coverage offered by such issuers under such 

18 plans. 

19 (b) MINIMUM ESSENTIAL COVERAGE AND ELIGIBLE

20 EMPLOYER-SPONSORED PLAN.—For purposes of section 

21 5000A(f) of the Internal Revenue Code of 1986, and any 

22 other section of the Internal Revenue Code of 1986 that 

23 incorporates the definition of minimum essential coverage 

24 provided under such section 5000A(f) by reference, cov25 erage under an expatriate health plan shall be deemed to 

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1 sponsored plan as defined in paragraph (2) of such sec2 tion. 

3 (c) QUALIFIED EXPATRIATES AND DEPENDENTS

4 NOT UNITED STATES HEALTH RISK.— 

5 (1) IN GENERAL.—For purposes of section 

6 9010 of the Patient Protection and Affordable Care 

7 Act (26 U.S.C. 4001 note prec.), for calendar years 

8 after 2014, a qualified expatriate (and any depend9 ent of such individual) enrolled in an expatriate 

10 health plan shall not be considered a United States 

11 health risk. 

12 (2) SPECIAL RULE FOR 2014.—The fee under 

13 section 9010 of such Act for calendar year 2014 

14 with respect to any expatriate health insurance 

15 issuer shall be the amount which bears the same 

16 ratio to the fee amount determined by the Secretary 

17 of the Treasury with respect to such issuer under 

18 such section for such year (determined without re19 gard to this paragraph) as— 

20 (A) the amount of premiums taken into ac21 count under such section with respect to such 

22 issuer for such year, less the amount of pre23 miums for expatriate health plans taken into 

24 account under such section with respect to such 

25 issuer for such year, bears to 


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1 (B) the amount of premiums taken into ac2 count under such section with respect to such 

3 issuer for such year. 

4 (d) DEFINITIONS.—In this section: 

5 (1) EXPATRIATE HEALTH INSURANCE

6 ISSUER.—The term ‘‘expatriate health insurance 

7 issuer’’ means a health insurance issuer that issues 

8 expatriate health plans. 

9 (2) EXPATRIATE HEALTH PLAN.—The term 

10 ‘‘expatriate health plan’’ means a group health plan, 

11 health insurance coverage offered in connection with 

12 a group health plan, or health insurance coverage of13 fered to a group of individuals described in para14 graph (3)(B) (which may include dependents of such 

15 individuals) that meets each of the following stand16 ards: 

17 (A) Substantially all of the primary enroll18 ees in such plan or coverage are qualified expa19 triates, with respect to such plan or coverage. 

20 In applying the previous sentence, an individual 

21 shall not be taken into account as a primary en22 rollee if the individual is not a national of the 

23 United States and resides in the country of 

24 which the individual is a citizen. 


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1 (B) Substantially all of the benefits pro2 vided under the plan or coverage are not ex3 cepted benefits described in section 9832(c) of 

4 the Internal Revenue Code of 1986. 

5 (C) The plan or coverage provides benefits 

6 for items and services, in excess of emergency 

7 care, furnished by health care providers— 

8 (i) in the case of individuals described 

9 in paragraph (3)(A), in the country or 

10 countries in which the individual is present 

11 in connection with the individual’s employ12 ment, and such other country or countries 

13 as the Secretary of Health and Human 

14 Services, in consultation with the Secretary 

15 of the Treasury and the Secretary of 

16 Labor, may designate; or 

17 (ii) in the case of individuals described 

18 in paragraph (3)(B), in the country or 

19 countries as the Secretary of Health and 

20 Human Services, in consultation with the 

21 Secretary of the Treasury and the Sec22 retary of Labor, may designate. 

23 (D) In the case of an expatriate health 

24 plan that is a group health plan offered by a 

25 plan sponsor that— 


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1 (i) also offers a qualifying minimum 

2 value domestic group health plan, the plan 

3 sponsor reasonably believes that the bene4 fits provided by the expatriate health plan 

5 are actuarially similar to, or better than, 

6 the benefits provided under a qualifying 

7 minimum value domestic group health plan 

8 offered by that plan sponsor; or 

9 (ii) does not also offer a qualifying 

10 minimum value domestic group health 

11 plan, the plan sponsor reasonably believes 

12 that the benefits provided by the expatriate 

13 health plan are actuarially similar to, or 

14 better than, the benefits provided under a 

15 qualifying minimum value domestic group 

16 health plan. 

17 (E) If the plan or coverage provides de18 pendent coverage of children, the plan or cov19 erage makes such dependent coverage available 

20 for adult children until the adult child turns 26 

21 years of age, unless such individual is the child 

22 of a child receiving dependent coverage. 

23 (F) The plan or coverage— 

24 (i) is issued by an expatriate health 

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1 trator, that maintains, with respect to such 

2 plan or coverage— 

3 (I) network provider agreements 

4 with health care providers that are 

5 outside of the United States; and 

6 (II) call centers in more than one 

7 country and accepts calls from cus8 tomers in multiple languages; and 

9 (ii) offers reimbursements for items or 

10 services under such plan or coverage in 

11 more than two currencies. 

12 (G) The plan or coverage, and the plan 

13 sponsor or expatriate health insurance issuer 

14 with respect to such plan or coverage, satisfies 

15 the provisions of title XXVII of the Public 

16 Health Service Act (42 U.S.C. 300gg et seq.), 

17 chapter 100 of the Internal Revenue Code of 

18 1986, and part 7 of subtitle B of title I of the 

19 Employee Retirement Income Security Act of 

20 1974 (29 U.S.C. 1181 et seq.), which would 

21 otherwise apply to such a plan or coverage, and 

22 sponsor or issuer, if not for the enactment of 

23 the Patient Protection and Affordable Care Act 

24 and title I and subtitle B of title II of the 


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1 Health Care and Education Reconciliation Act 

2 of 2010. 

3 (3) QUALIFIED EXPATRIATE.—The term ‘‘quali4 fied expatriate’’ means any of the following individ5 uals: 

6 (A) WORKERS.—An individual who is a 

7 participant in a group health plan, who is an 

8 alien residing outside the United States, a na9 tional of the United States, lawful permanent 

10 resident, or nonimmigrant for whom there is a 

11 good faith expectation by the plan sponsor of 

12 the plan that, in connection with the individ13 ual’s employment, the individual is abroad for a 

14 total of not less than 180 days during any pe15 riod of 12 consecutive months. 

16 (B) OTHER INDIVIDUALS ABROAD.—An in17 dividual, such as a student or religious mis18 sionary, who is abroad, and who is a member 

19 of a group determined appropriate by the Sec20 retary of Health and Human Services, in con21 sultation with the Secretary of the Treasury 

22 and the Secretary of Labor. 

23 (4) QUALIFYING MINIMUM VALUE DOMESTIC

24 GROUP HEALTH PLAN.—The term ‘‘qualifying min25 imum value domestic group health plan’’ means a 


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1 group health plan that is offered in the United 

2 States that meets the following requirements: 

3 (A) Substantially all of the primary enroll4 ees in the plan are not qualified expatriates, 

5 with respect to such plan. 

6 (B) Substantially all of the benefits pro7 vided under the plan are not excepted benefits 

8 described in section 9832(c) of the Internal 

9 Revenue Code of 1986. 

10 (C) The application of section 

11 36B(c)(2)(C)(ii) of such Code to such plan 

12 would not prevent an employee eligible for cov13 erage under such plan from being treated as eli14 gible for minimum essential coverage for pur15 poses of section 36B(c)(2)(B) of such Code. 

16 (5) ABROAD.— 

17 (A) UNITED STATES NATIONALS.— 

18 (i) IN GENERAL.—Except as provided 

19 in clause (ii), for purposes of applying 

20 paragraph (3) to a national of the United 

21 States, the term ‘‘abroad’’ means outside 

22 the 50 States, the District of Columbia, 

23 and Puerto Rico. 

24 (ii) SPECIAL RULE.—For purposes of 

25 applying paragraph (3) to a national of the 


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1 United States who resides in the United 

2 States Virgin Islands, the Commonwealth 

3 of the Northern Mariana Islands, Amer4 ican Samoa, or Guam, the term ‘‘abroad’’ 

5 means outside of the 50 States, the Dis6 trict of Columbia, Puerto Rico, and such 

7 territory or possession. 

8 (B) FOREIGN CITIZENS.—For purposes of 

9 applying paragraph (3) to an individual who is 

10 not a national of the United States, the term 

11 ‘‘abroad’’ means outside of the country of which 

12 that individual is a citizen. 

13 (6) UNITED STATES.—The term ‘‘United 

14 States’’ means the 50 States, the District of Colum15 bia, Puerto Rico, the United States Virgin Islands, 

16 the Commonwealth of the Northern Mariana Is17 lands, American Samoa, and Guam. 

18 (7) MISCELLANEOUS TERMS.— 

19 (A) GROUP HEALTH PLAN; HEALTH IN20 SURANCE COVERAGE; HEALTH INSURANCE

21 ISSUER; PLAN SPONSOR.—The terms ‘‘group 

22 health plan’’, ‘‘health insurance coverage’’, 

23 ‘‘health insurance issuer’’, and ‘‘plan sponsor’’ 

24 have the meanings given those terms in section 

25 2791 of the Public Health Service Act (42 


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1 U.S.C. 300gg–91), except that in applying such 

2 terms under this section the term ‘‘health in3 surance issuer’’ includes a foreign corporation 

4 which is predominantly engaged in an insurance 

5 business and which would be subject to tax 

6 under subchapter L of chapter 1 of the Internal 

7 Revenue Code of 1986 if it were a domestic cor8 poration. 

9 (B) FOREIGN STATE; NATIONAL OF THE

10 UNITED STATES; NONIMMIGRANT; RESIDE; LAW11 FUL PERMANENT RESIDENT.—The terms ‘‘na12 tional of the United States’’, and ‘‘non13 immigrant’’ have the meaning given such terms 

14 in section 101(a) of the Immigration and Na15 tionality Act (8 U.S.C. 1101(a)), the term ‘‘re16 side’’ means having a residence (within the 

17 meaning of such term in such section), and the 

18 term ‘‘lawful permanent resident’’ means an 

19 alien lawfully admitted for permanent residence 

20 (as defined in such section). 

Passed the House of Representatives April 29, 2014. 

Attest: KAREN L. HAAS, 

Clerk. 


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