II 

116TH CONGRESS 

1ST SESSION S. 1213 

To provide health insurance reform, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

APRIL 11, 2019 

Ms. WARREN (for herself, Mrs. GILLIBRAND, Ms. HARRIS, Ms. BALDWIN, Ms. 

KLOBUCHAR, Mr. BOOKER, and Mr. BLUMENTHAL) 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 2019’’. 

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. 


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Sec. 103. Effective date. 

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. Deductible-exempt services for group health plans and group health 

insurance coverage. 

Sec. 206. 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 and coverage of pediatric services. 

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’’. 


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1 SEC. 102. ENSURING THAT CONSUMERS GET VALUE FOR 

2 THEIR DOLLARS. 

3 The first section 2794 of the Public Health Service 

4 Act (42 U.S.C. 300gg–94), added by section 1003 of the 

5 Patient Protection and Affordable Care Act (Public Law 

6 111–148), is amended— 

7 (1) in subsection (a)— 

8 (A) in paragraph (1), by striking ‘‘sub9 section (b)(2)(A)’’ and inserting ‘‘subsections 

10 (b)(2)(A) and (b)(3)’’; and 

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

12 the following: ‘‘Notwithstanding any other pro13 vision of law, a health insurance issuer may not 

14 exclude from such disclosure information that is 

15 a trade secret or commercial or financial infor16 mation described in section 552(b)(4) of title 5, 

17 United States Code.’’; 

18 (2) in subsection (b)— 

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

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

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

22 ‘‘(3) PROHIBITING UNREASONABLE PREMIUM

23 INCREASES.— 

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

25 years beginning in 2021, the Secretary, or a 

26 State pursuant to an effective rate review proVerDate Sep 11 2014 01:51 Apr 24, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S1213.IS S1213

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1 gram meeting the requirements under para2 graph (4)— 

3 ‘‘(i) shall, consistent with subsection 

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

5 in premiums for health insurance coverage 

6 that are subject to review pursuant to sec7 tion 154.200 of title 45, Code of Federal 

8 Regulations (or any successor regulation), 

9 and determine whether such increases are 

10 unreasonable; and 

11 ‘‘(ii) may prohibit a health insurance 

12 issuer from implementing such an increase 

13 that is unreasonable. 

14 ‘‘(B) UNREASONABLE INCREASES.—In de15 termining whether an increase in premiums for 

16 health insurance coverage is unreasonable 

17 under subparagraph (A)(i)— 

18 ‘‘(i) the Secretary shall consider 

19 whether the increase is excessive, unjusti20 fied, discriminatory, or inadequate; and 

21 ‘‘(ii) the State, pursuant to an effec22 tive rate review program meeting the re23 quirements under paragraph (4), shall 

24 apply applicable State law for making such 

25 determination. 


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1 ‘‘(4) STATE EFFECTIVE RATE REVIEW PRO2 GRAMS.—A State effective rate review program 

3 meets the requirements under this paragraph if— 

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

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

6 that such reviews are meaningful, effective, and 

7 timely reviews of the data and documentation 

8 (including any contracts or documents described 

9 in subparagraph (E)) submitted by health in10 surance issuers in support of proposed increases 

11 in premiums for health insurance coverage; 

12 ‘‘(B) such reviews include an examination 

13 of— 

14 ‘‘(i) the affordability of proposed in15 creases in premiums for health insurance 

16 coverage; 

17 ‘‘(ii) the quality improvement activi18 ties carried out by health insurance issuers 

19 proposing the increases; 

20 ‘‘(iii) the cost containment activities 

21 of health insurance issuers proposing the 

22 increases; and 

23 ‘‘(iv) the solvency of the health insur24 ance coverage; 


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1 ‘‘(C) the program establishes a mechanism 

2 for receiving public comments on proposed in3 creases in premiums for health insurance cov4 erage reviewed by the State; 

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

6 public comments received under subparagraph 

7 (C); 

8 ‘‘(E) the program requires each health in9 surance issuer proposing an increase in pre10 miums for health insurance coverage to submit 

11 to the State any provider contracts that may be 

12 affected, including any documents incorporated 

13 by reference into such contracts; and 

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

15 provide the Secretary its determination of 

16 whether each increase reviewed is unreasonable, 

17 in a form and manner prescribed by the Sec18 retary.’’; and 

19 (3) in subsection (c)— 

20 (A) in paragraph (1)— 

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

22 THROUGH 2014’’ and inserting ‘‘2021

23 THROUGH 2025’’; and 


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1 (ii) in the matter preceding subpara2 graph (A), by striking ‘‘2010’’ and insert3 ing ‘‘2021’’; and 

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

5 ‘‘2014’’ and inserting ‘‘2025’’. 

6 SEC. 103. EFFECTIVE DATE. 

7 The amendments made by this title shall apply to 

8 plan years beginning after December 31, 2020. 

9 TITLE II—MAKING HEALTH IN10 SURANCE COVERAGE AF11 FORDABLE 

12 SEC. 201. ENHANCEMENT OF PREMIUM ASSISTANCE CRED13 IT. 

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

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

16 36B(b)(2)(B) of the Internal Revenue Code of 1986 

17 is amended by striking ‘‘applicable second lowest 

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

19 lowest cost gold plan’’. 

20 (2) CONFORMING AMENDMENT RELATED TO

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

22 such Code is amended by striking ‘‘second lowest 

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

24 gold plan’’. 


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1 (3) OTHER CONFORMING AMENDMENTS.—Sub2 paragraphs (B) and (C) of section 36B(b)(3) of such 

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

4 each place it appears in the text and the heading 

5 and inserting ‘‘gold plan’’. 

6 (b) EXPANSION OF ELIGIBILITY FOR REFUNDABLE

7 CREDITS FOR COVERAGE UNDER QUALIFIED HEALTH

8 PLANS.— 

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

10 Internal Revenue Code of 1986 is amended by strik11 ing ‘‘but does not exceed 400 percent’’. 

12 (2) CONFORMING AMENDMENTS RELATING TO

13 RECAPTURE OF EXCESS ADVANCED PAYMENTS.— 

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

15 amended— 

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

17 that follows through ‘‘the amount of’’ and in18 serting ‘‘The amount of’’, and 

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

20 the table therein. 

21 (c) DETERMINATION OF APPLICABLE PERCENT22 AGE.— 

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

24 36B(b)(3) of the Internal Revenue Code of 1986 is 

25 amended to read as follows: 


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1 ‘‘(A) APPLICABLE PERCENTAGE.—The ap2 plicable percentage for any taxable year shall be 

3 the percentage such that the applicable percent4 age for any taxpayer whose household income is 

5 within an income tier specified in the following 

6 table shall increase, on a sliding scale in a lin7 ear manner, from the initial premium percent8 age to the final premium percentage specified in 

9 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% 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%’’. 

10 (2) CONFORMING AMENDMENTS.—Subsections 

11 (c)(2)(C)(iv) and (c)(4)(F) of section 36B of the In12 ternal Revenue Code of 1986 are each amended by 

13 inserting ‘‘(as in effect before the date of the enact14 ment of the Consumer Health Insurance Protection 

15 Act of 2019)’’ after ‘‘subsection (b)(3)(A)(ii)’’. 

16 (d) RECONCILIATION OF PREMIUM ASSISTANCE

17 CREDIT AND ADVANCE CREDIT FOR SINGLE-PARENT

18 HOUSEHOLDS.— 

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

20 36B(f)(2)(B) of the Internal Revenue Code of 1986 


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1 is amended by striking ‘‘section 1(c)’’ and inserting 

2 ‘‘subsection (b) or (c) of section 1’’. 

3 (2) EFFECTIVE DATE.—The amendment made 

4 by this subsection shall apply to taxable years begin5 ning after December 31, 2019. 

6 (e) DETERMINATION OF PREMIUM ASSISTANCE

7 CREDIT FOR DISABLED WORKERS.— 

8 (1) IN GENERAL.—Section 36B(d)(2) of the In9 ternal Revenue Code of 1986 is amended by insert10 ing at the end the following new subparagraph: 

11 ‘‘(C) EXCLUSION OF CERTAIN AMOUNTS

12 RECEIVED AS LUMP-SUM PAYMENT.—For pur13 poses of subparagraph (B), such amount shall 

14 not include any portion of a lump-sum payment 

15 of disability insurance benefits under section 

16 223 of the Social Security Act (42 U.S.C. 423) 

17 which is— 

18 ‘‘(i) received during the taxable year, 

19 and 

20 ‘‘(ii) attributable to prior taxable 

21 years.’’. 

22 (2) EFFECTIVE DATE.—The amendment made 

23 by this subsection shall apply to taxable years begin24 ning after December 31, 2019. 


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1 (f) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to taxable years beginning after 

3 December 31, 2020. 

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

5 (a) MODIFICATION OF AMOUNT.— 

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

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

8 18071) is amended— 

9 (A) in subsection (b)(1), by striking ‘‘sil10 ver’’ and inserting ‘‘gold’’; 

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

12 read as follows: 

13 ‘‘(B) COORDINATION WITH ACTUARIAL

14 LIMITS.—The Secretary shall ensure the reduc15 tion under this paragraph shall not result in the 

16 plan’s share of the total allowed costs of bene17 fits provided under the plan becoming less 

18 than— 

19 ‘‘(i) 95 percent in the case of an eligi20 ble insured described in paragraph (2)(A); 

21 ‘‘(ii) 90 percent in the case of an eli22 gible insured described in paragraph 

23 (2)(B); and 


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1 ‘‘(iii) 85 percent in the case of an eli2 gible insured described in paragraph 

3 (2)(C).’’; and 

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

5 as follows: 

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

7 shall establish procedures under which the issuer of 

8 a qualified health plan to which this section applies 

9 shall further reduce cost-sharing under the plan in 

10 a manner sufficient to— 

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

12 whose household income is not less than 100 

13 percent but not more than 200 percent of the 

14 poverty 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 95 

17 percent of such costs; 

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

19 whose household income is more than 200 per20 cent but not more than 300 percent of the pov21 erty line for a family of the size involved, in22 crease the plan’s share of the total allowed 

23 costs of benefits provided under the plan to 90 

24 percent of such costs; and 


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

2 whose household income is more than 300 per3 cent but not more than 400 percent of the pov4 erty line for a family of the size involved, in5 crease the plan’s share of the total allowed 

6 costs of benefits provided under the plan to 85 

7 percent of such costs.’’. 

8 (2) EFFECTIVE DATE.—The amendments made 

9 by this subsection shall apply to plan years begin10 ning after December 31, 2020. 

11 (b) FUNDING.—Section 1402 of the Patient Protec12 tion and Affordable Care Act (42 U.S.C. 18071) is amend13 ed by adding at the end the following new subsection: 

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

15 not otherwise appropriated, there are appropriated to the 

16 Secretary such sums as may be necessary for payments 

17 under this section.’’. 

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

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

20 the Patient Protection and Affordable Care Act (42 

21 U.S.C. 18022(c)) is amended— 

22 (1) in paragraph (3)(A)(i), by inserting ‘‘, in23 cluding cost-sharing with respect to prescription 

24 drugs covered by the plan’’ after ‘‘charges’’; and 

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


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

2 ‘‘(A) 2021.—For plan years beginning in 

3 2021, the cost-sharing incurred under a health 

4 plan with respect to prescription drugs covered 

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

6 each enrolled individual, or $500 for each fam7 ily. 

8 ‘‘(B) 2022 AND LATER.— 

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

10 plan year beginning in a calendar year 

11 after 2021, the limitation under this para12 graph shall be equal to the applicable dol13 lar amount under subparagraph (A) for 

14 plan years beginning in 2021, increased by 

15 an amount equal to the product of that 

16 amount and the medical care component of 

17 the consumer price index for all urban con18 sumers (as published by the Bureau of 

19 Labor Statistics) for that year. 

20 ‘‘(ii) ADJUSTMENT TO AMOUNT.—If 

21 the amount of any increase under clause 

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

23 shall be rounded to the next lowest mul24 tiple of $5.’’. 


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

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

3 amended— 

4 (1) by striking ‘‘annual’’; and 

5 (2) by striking ‘‘paragraph (1) of section 

6 1302(c)’’ and inserting ‘‘paragraphs (1) and (5) of 

7 section 1302(c) of the Patient Protection and Af8 fordable Care Act’’. 

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

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

11 plans beginning after December 31, 2020. 

12 SEC. 204. STANDARDIZED OPTIONS IN THE BRONZE, SIL13 VER, AND GOLD LEVELS OF COVERAGE. 

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

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

16 is amended— 

17 (1) in paragraph (1)(C)— 

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

19 inserting ‘‘;’’; 

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

21 (v); and 

22 (C) by inserting after clause (iii) the fol23 lowing: 

24 ‘‘(iv)(I) agrees to offer the applicable 

25 standardized option under paragraph (5) 


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1 for each level of coverage offered by the 

2 issuer that is the bronze, silver, or gold 

3 level of coverage; and 

4 ‘‘(II) with respect to offering coverage 

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

6 coverage through an Exchange that is op7 erated by the Secretary, agrees to offer 

8 only the applicable standardized option 

9 under paragraph (5) and not any other 

10 plan for such levels of coverage; and’’; and 

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

12 ‘‘(5) STANDARDIZED OPTIONS.— 

13 ‘‘(A) DEFINITION OF STANDARDIZED OP14 TION.—In this section, the term ‘standardized 

15 option’ means a qualified health plan— 

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

17 structure established by the applicable 

18 State, or the Secretary, in accordance with 

19 this paragraph; and 

20 ‘‘(ii) that is offered through an Ex21 change. 

22 ‘‘(B) ESTABLISHMENT.— 

23 ‘‘(i) STATE.—Each State may estab24 lish a standardized option for the bronze, 

25 silver, and gold levels of coverage. 


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1 ‘‘(ii) SECRETARY.—The Secretary 

2 shall establish a standardized option in a 

3 State for any level of coverage described in 

4 clause (i) for which the State has not es5 tablished a standardized option. 

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

7 annually update any standardized option 

8 established by the Secretary under clause 

9 (ii). 

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

11 ‘‘(i) IN GENERAL.—Except as pro12 vided in clause (ii), each standardized op13 tion established by the Secretary under 

14 subparagraph (B)(ii) shall provide coverage 

15 for and waive the application of a deduct16 ible for— 

17 ‘‘(I) all primary care visits and 

18 specialist visits; 

19 ‘‘(II) all mental health and sub20 stance use disorder outpatient serv21 ices; 

22 ‘‘(III) all drugs approved under 

23 section 505(j) of the Federal Food, 

24 Drug, and Cosmetic Act and biological 

25 products licensed under section 


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1 351(k) of the Public Health Service 

2 Act; and 

3 ‘‘(IV) all urgent care services. 

4 ‘‘(ii) BRONZE AND SILVER LEVELS OF

5 COVERAGE.—The Secretary may alter the 

6 services that shall be covered as deductible7 exempt services under clause (i) for stand8 ardized options in the bronze and silver 

9 levels of coverage. 

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

11 by a State shall preferentially display the stand12 ardized options offered in such State on the 

13 website of the Exchange.’’. 

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

15 this section shall apply to plans beginning after December 

16 31, 2020. 

17 SEC. 205. DEDUCTIBLE-EXEMPT SERVICES FOR GROUP 

18 HEALTH PLANS AND GROUP HEALTH INSUR19 ANCE COVERAGE. 

20 (a) IN GENERAL.—Section 2713 of the Public Health 

21 Service Act (42 U.S.C. 300gg–13) is amended by adding 

22 at the end the following: 

23 ‘‘(d) DEDUCTIBLE-EXEMPT SERVICES FOR GROUP

24 HEALTH PLANS AND GROUP HEALTH INSURANCE COV25 ERAGE.— 


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1 ‘‘(1) IN GENERAL.—Subject to paragraph (2), a 

2 group health plan and a health insurance issuer of3 fering group health insurance coverage shall, in ad4 dition to the requirement under subsection (a), at a 

5 minimum provide coverage for and waive the appli6 cation of a deductible for— 

7 ‘‘(A) all primary care visits and specialist 

8 visits; 

9 ‘‘(B) all mental health and substance use 

10 disorder outpatient services; 

11 ‘‘(C) all drugs approved under section 

12 505(j) of the Federal Food, Drug, and Cos13 metic Act and biological products licensed 

14 under section 351(k) of the Public Health Serv15 ice Act; and 

16 ‘‘(D) all urgent care services. 

17 ‘‘(2) REGULATIONS.—The Secretary may issue 

18 regulations to— 

19 ‘‘(A) assist group health plans and health 

20 insurance issuers offering group health insur21 ance coverage in complying with paragraph (1); 

22 and 

23 ‘‘(B) alter the services that shall be cov24 ered as deductible-exempt services under para25 graph (1) for group health plans and group 


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1 health insurance coverage with levels of cov2 erage that are designed to provide benefits that 

3 are actuarially equivalent to 60 or 70 percent of 

4 the full actuarial value of the benefits provided 

5 under the plan or coverage.’’. 

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

7 this section shall apply to plans beginning after December 

8 31, 2020. 

9 SEC. 206. CLARIFICATION REGARDING DETERMINATION OF 

10 AFFORDABILITY OF EMPLOYER-SPONSORED 

11 MINIMUM ESSENTIAL COVERAGE. 

12 (a) SPECIAL RULE FOR EMPLOYER-SPONSORED

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

14 36B(c)(2)(C) of the Internal Revenue Code of 1986 is 

15 amended to read as follows: 

16 ‘‘(i) COVERAGE MUST BE AFFORD17 ABLE.— 

18 ‘‘(I) IN GENERAL.—Except as 

19 provided in clause (iii), an individual 

20 shall not be treated as eligible for 

21 minimum essential coverage if such 

22 coverage consists of an eligible em23 ployer-sponsored plan (as defined in 

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

25 contribution with respect to the plan 


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1 exceeds 8.5 percent of the applicable 

2 taxpayer’s household income. 

3 ‘‘(II) REQUIRED CONTRIBUTION

4 WITH RESPECT TO EMPLOYEE.—In 

5 the case of the employee eligible to en6 roll in the plan, the required contribu7 tion for purposes of subclause (I) is 

8 the employee’s required contribution 

9 (within the meaning of section 

10 5000A(e)(1)(B)(i)) with respect to the 

11 plan. 

12 ‘‘(III) REQUIRED CONTRIBUTION

13 WITH RESPECT TO FAMILY MEM14 BERS.—In the case of an individual 

15 who is eligible to enroll in the plan by 

16 reason of a relationship the individual 

17 bears to the employee, the required 

18 contribution for purposes of subclause 

19 (I) is the employee’s required con20 tribution (within the meaning of sec21 tion 5000A(e)(1)(B)(i), determined by 

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

23 with respect to the plan.’’. 

24 (b) CONFORMING AMENDMENTS.— 


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

2 Internal Revenue Code of 1986 is amended by add3 ing at the end the following: ‘‘This clause shall also 

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

5 plan by reason of a relationship the individual bears 

6 to the employee.’’. 

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

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

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

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

11 Code is amended by striking ‘‘clause (i)(II)’’ and in12 serting ‘‘clause (i)(I)’’. 

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

14 this section shall apply to taxable years beginning after 

15 December 31, 2020. 

16 TITLE III—ENSURING ACCESS 

17 TO CARE 

18 SEC. 301. NETWORK ADEQUACY REQUIREMENTS. 

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

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

21 is amended— 

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

23 paragraph (7) and in accordance with paragraph 

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

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


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1 ‘‘(7) NETWORK ADEQUACY REQUIREMENTS.— 

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

3 plan shall, to be certified under this subsection, 

4 meet the network adequacy standards estab5 lished by the Secretary under subparagraph 

6 (B), except as provided in subparagraphs 

7 (B)(ii) and (C). 

8 ‘‘(B) FEDERAL STANDARDS AND RE9 VIEW.— 

10 ‘‘(i) STANDARD.— 

11 ‘‘(I) ESTABLISHMENT.—The Sec12 retary shall, in consultation with 

13 stakeholders including pediatric-spe14 cific stakeholders, establish a network 

15 adequacy standard based on access to 

16 in-network providers for qualified 

17 health plans, except for those plans 

18 described in subparagraph (C). Such 

19 standard shall— 

20 ‘‘(aa) include requirements 

21 for the minimum number and 

22 type of in-network providers 

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1 quired for patients to visit such 

2 providers, and the average ap3 pointment wait times for services 

4 covered by the plan; and 

5 ‘‘(bb) account for differences 

6 in the needs of children and 

7 adults. 

8 ‘‘(II) MEDICARE ADVANTAGE OR9 GANIZATIONS.—The network ade10 quacy standard established under sub11 clause (I) shall, at a minimum, be 

12 equivalent to the requirements for ac13 cess to services applicable to Medicare 

14 Advantage organizations offering 

15 Medicare Advantage plans under part 

16 C of title XVIII of the Social Security 

17 Act. 

18 ‘‘(ii) JUSTIFICATION.—A qualified 

19 health plan that fails to meet the standard 

20 established under clause (i) may satisfy the 

21 requirement under subparagraph (A) by 

22 providing the Secretary with a reasonable 

23 justification for the variance from such 

24 standard, based on factors such as the 


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1 availability of providers and variables re2 flected in local patterns of health care. 

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

4 establish a process for reviewing the net5 work adequacy of qualified health plans, 

6 except for those plans reviewed by the 

7 State in accordance with subparagraph 

8 (C)(ii). 

9 ‘‘(C) STATE STANDARD.— 

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

11 qualified health plan offered in a State 

12 that has implemented a quantifiable net13 work adequacy metric that the Secretary 

14 determines is an acceptable metric com15 monly used in the health insurance indus16 try to measure network adequacy, such 

17 qualified health plan may, to be certified 

18 under this subsection, satisfy the require19 ment under subparagraph (A) by meeting 

20 the network adequacy standards of such 

21 State based on such metric. 

22 ‘‘(ii) REVIEW.—A State with an ac23 ceptable metric described in clause (i) may 

24 review the network adequacy of qualified 


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1 health plans offered in such State in a 

2 process established by the State. 

3 ‘‘(8) COVERAGE OF OUT-OF-NETWORK ESSEN4 TIAL HEALTH BENEFITS.— 

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

6 plan shall, to be certified under this subsection, 

7 provide to individuals enrolled in such plan cov8 erage of any service provided by an out-of-net9 work provider if— 

10 ‘‘(i) coverage of such service would 

11 otherwise be provided by the plan if the 

12 service was provided by an in-network pro13 vider; 

14 ‘‘(ii) the service is included in the es15 sential health benefits package described in 

16 section 1302(a); and 

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

18 the individual by an in-network provider 

19 within a reasonable timeframe or within a 

20 reasonable distance and travel time. 

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

22 plan that provides coverage of a service pro23 vided by an out-of-network provider under sub24 paragraph (A) shall provide such coverage with 

25 the same cost-sharing requirements as if the 


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1 service was provided by an in-network pro2 vider.’’. 

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

4 subsection (a) shall apply to plans beginning after Decem5 ber 31, 2020. 

6 (c) GRANTS FOR STATE NETWORK ADEQUACY RE7 VIEWS.— 

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

9 Human Services shall carry out a program to award 

10 grants to States during the 5-year period beginning 

11 with fiscal year 2021 to assist such States in devel12 oping a metric to measure network adequacy as de13 scribed in subparagraph (C)(i) of section 1311(c)(7) 

14 of the Patient Protection and Affordable Care Act 

15 (42 U.S.C. 18031(c)(7)) and to carry out the re16 views described in subparagraph (C)(ii) of such sec17 tion. 

18 (2) AUTHORIZATION OF APPROPRIATIONS.— 

19 There are authorized to be appropriated for each of 

20 fiscal years 2021 through 2025 such sums as may 

21 be necessary to carry out the grant program under 

22 this subsection. 

23 (d) REPORT.— 

24 (1) IN GENERAL.—Not later than December 31, 

25 2022, the Secretary shall prepare, and submit to 


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1 Congress, a report containing the analysis and rec2 ommendations described in paragraph (2). 

3 (2) ANALYSIS AND RECOMMENDATIONS.—The 

4 report under this subsection shall— 

5 (A) analyze how network adequacy and ac6 cess to care has changed since the implementa7 tion of this section, including the amendments 

8 made by this section, including for children; 

9 (B) include information on the availability 

10 of providers that are essential community pro11 viders as described in section 1311(c)(1)(C) of 

12 the Patient Protection and Affordable Care Act 

13 (42 U.S.C. 18031(c)(1)(C)); and 

14 (C) provide recommendations for such leg15 islation and administrative actions as the Sec16 retary considers appropriate to improve network 

17 adequacy, including with respect to access to 

18 pediatric services and essential community pro19 viders. 

20 SEC. 302. ENSURING ADEQUATE COVERAGE IN AREAS WITH 

21 FEWER THAN 3 HEALTH INSURANCE ISSUERS 

22 OFFERING QUALIFIED HEALTH PLANS ON 

23 THE STATE EXCHANGE. 

24 (a) REQUIREMENTS FOR MEDICARE ADVANTAGE OR25 GANIZATIONS.— 


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1 (1) IN GENERAL.—Section 1857(e) of the So2 cial Security Act (42 U.S.C. 1395w–27(e)) is 

3 amended by adding at the end the following new 

4 paragraph: 

5 ‘‘(6) REQUIREMENT FOR CERTAIN MEDICARE

6 ADVANTAGE ORGANIZATIONS THAT OFFER AN MA

7 PLAN IN AN APPLICABLE AREA TO ALSO OFFER

8 QUALIFIED HEALTH PLANS IN THE APPLICABLE

9 AREA.— 

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

11 section with an MA organization described in 

12 subparagraph (B) shall require the organization 

13 to, in each applicable area in which the organi14 zation offers an MA plan, also offer, through 

15 the individual market in the Exchange oper16 ating in the State, at least one qualified health 

17 plan in the silver level of coverage and at least 

18 one qualified health plan in the gold level of 

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

20 Patient Protection and Affordable Care Act. 

21 ‘‘(B) MA ORGANIZATIONS DESCRIBED.— 

22 An MA organization described in this subpara23 graph is an MA organization that, in addition 

24 to offering an MA plan in an applicable area, 

25 offers health insurance coverage in the group 


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1 market or individual market in the State but 

2 does not offer such coverage through the Ex3 change operating in the State. 

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

5 the State in the case of an MA organization of6 fering an MA plan in an applicable area in a 

7 State with an Exchange operated by the State, 

8 shall notify each MA organization that is re9 quired to offer a qualified health plan under 

10 subparagraph (A) for a plan year of such re11 quirement. Such notification shall be provided 

12 each year— 

13 ‘‘(i) beginning with respect to the re14 quirement for plan years beginning after 

15 December 31, 2020; and 

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

17 rate filing deadline for the plan year for 

18 the Exchange operating in the State in 

19 which the MA organization will be required 

20 to offer such plan. 

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

22 State in the case of an MA organization offer23 ing an MA plan in an applicable area in a State 

24 with an Exchange operated by the State, may 


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1 waive the requirement under subparagraph (A) 

2 if— 

3 ‘‘(i) by the first day of the plan year 

4 following the determination, the number of 

5 health insurance issuers offering a quali6 fied health plan through the individual 

7 market in the Exchange has increased 

8 such that the applicable area no longer has 

9 fewer than 3 health insurance issuers of10 fering a qualified health plan through the 

11 individual market in the Exchange oper12 ating in the State; or 

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

14 such a case, determines that the require15 ment under subparagraph (A) would cause 

16 the MA organization to become insolvent. 

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

18 ‘‘(i) APPLICABLE AREA.—The term 

19 ‘applicable area’ means an area in which, 

20 at the time the Secretary or the State 

21 sends the notification under subparagraph 

22 (C), fewer than 3 health insurance issuers 

23 offer a qualified health plan through the 

24 individual market in the Exchange oper25 ating in the State. 


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1 ‘‘(ii) EXCHANGE.—The term ‘Ex2 change’ means an American Health Ben3 efit Exchange established under section 

4 1311 or section 1321 of the Patient Pro5 tection and Affordable Care Act. 

6 ‘‘(iii) GROUP MARKET.—The term 

7 ‘group market’ has the meaning given such 

8 term in section 1304 of the Patient Protec9 tion and Affordable Care Act. 

10 ‘‘(iv) HEALTH INSURANCE COV11 ERAGE.—The term ‘health insurance cov12 erage’ has the meaning given the term in 

13 section 2791(b) of the Public Health Serv14 ice Act. 

15 ‘‘(v) INDIVIDUAL MARKET.—The term 

16 ‘individual market’ has the meaning given 

17 such term in section 1304 of the Patient 

18 Protection and Affordable Care Act. 

19 ‘‘(vi) QUALIFIED HEALTH PLAN.— 

20 The term ‘qualified health plan’ has the 

21 meaning given that term in section 

22 1301(a) of the Patient Protection and Af23 fordable Care Act.’’. 


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1 (2) EFFECTIVE DATE.—The amendment made 

2 by this subsection shall apply to contracts entered 

3 into or renewed after December 31, 2020. 

4 (b) REQUIREMENTS FOR MEDICAID MANAGED CARE

5 ORGANIZATIONS.— 

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

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

8 is amended— 

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

10 inserting a semicolon; 

11 (B) by realigning the left margin of clause 

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

13 (xii); 

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

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

16 (D) by inserting after clause (xiii) the fol17 lowing: 

18 ‘‘(xiv) such contract requires that the enti19 ty meets the requirements described in section 

20 1857(e)(6) in the same manner as such require21 ments apply to an MA organization.’’. 

22 (2) EFFECTIVE DATE.—The amendments made 

23 by this subsection shall apply to contracts entered 

24 into or renewed after December 31, 2020. 


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1 SEC. 303. ENROLLMENT IN EXCHANGES. 

2 (a) OPEN ENROLLMENT AND SPECIAL ENROLLMENT

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

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

5 amended— 

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

7 not less than 8 weeks’’ after ‘‘open enrollment peri8 ods’’; 

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

10 and inserting ‘‘;’’; 

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

12 and inserting ‘‘;’’; and 

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

14 ‘‘(E) a special enrollment period for quali15 fied individuals enrolled in a plan that makes 

16 significant provider terminations during the 

17 plan year, as determined in accordance with 

18 regulations promulgated by the Secretary; and 

19 ‘‘(F) a special enrollment period— 

20 ‘‘(i) for each qualified individual 

21 who— 

22 ‘‘(I) is determined by the Ex23 change to be eligible for a premium 

24 assistance credit under section 36B of 

25 the Internal Revenue Code of 1986; 

26 and 


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1 ‘‘(II) has a household income not 

2 in excess of 300 percent of the pov3 erty line for the size of the family in4 volved; and 

5 ‘‘(ii) which shall begin on the date on 

6 which the individual is determined by the 

7 Exchange to be eligible for a premium as8 sistance credit under such section 36B.’’. 

9 (b) CONSUMER PROTECTIONS REGARDING AUTO10 MATIC RE-ENROLLMENT.—Part 2 of subtitle D of title I 

11 of the Patient Protection and Affordable Care Act (42 

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

13 the following: 

14 ‘‘SEC. 1314. CONSUMER PROTECTIONS REGARDING AUTO15 MATIC RE-ENROLLMENT. 

16 ‘‘(a) CONSENT TO AVOID AUTOMATIC RE-ENROLL17 MENT FOR INDIVIDUALS LOSING ELIGIBILITY FOR PRE18 MIUM ASSISTANCE CREDITS.—The Secretary shall estab19 lish a process to allow an individual, who is enrolling in 

20 a qualified health plan through an Exchange and whom 

21 the Exchange estimates is eligible to receive a premium 

22 assistance credit under section 36B of the Internal Rev23 enue Code of 1986, to provide consent to the Exchange 

24 to not automatically re-enroll the individual in such quali25 fied health plan (or a comparable qualified health plan in 


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1 a case described in subsection (b)) for the following plan 

2 year if during the plan year the Exchange estimates that 

3 the individual has become no longer eligible to receive such 

4 credit. 

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

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

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

8 not be offered through such Exchange for the following 

9 plan year, the Exchange through which such plan is of10 fered shall, prior to the open enrollment period for the 

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

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

13 individual is enrolled will not be offered through 

14 such Exchange for the following plan year; 

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

16 individual will be enrolled in a comparable qualified 

17 health plan for the following plan year; 

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

19 such comparable qualified health plan; and 

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

21 individual for a special enrollment period. 

22 ‘‘(c) NOTICE REGARDING AUTOMATIC RE-ENROLL23 MENT.—Any notice regarding automatic re-enrollment 

24 sent by an Exchange to an individual enrolled in a quali25 fied health plan shall be provided to the individual in the 


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1 language that the individual has indicated to the Ex2 change as the preferred language of the individual. 

3 ‘‘(d) RETROACTIVE TERMINATION.— 

4 ‘‘(1) IN GENERAL.—The Secretary shall estab5 lish a process to allow an individual who is automati6 cally re-enrolled in a qualified health plan for a plan 

7 year and who has enrolled in other creditable cov8 erage for that plan year to retroactively terminate 

9 such qualified health plan for such plan year. 

10 ‘‘(2) CREDITABLE COVERAGE.—In this sub11 section, the term ‘creditable coverage’ has the mean12 ing given the term in section 2704(c)(1) of the Pub13 lic Health Service Act.’’. 

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

15 this section shall apply to plan years beginning after the 

16 date of enactment of this Act. 

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

18 that examines the practices used by the Exchanges for no19 tifying consumers of automatic re-enrollment in qualified 

20 health plans and identifies strategies for— 

21 (1) improving automatic re-enrollment and re22 newal notifications; 

23 (2) improving the ability to reach consumers in 

24 providing such notices; 


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1 (3) increasing consumer comprehension of such 

2 notices; and 

3 (4) encouraging consumers to— 

4 (A) update information that will affect eli5 gibility for premium assistance credits under 

6 section 36B of the Internal Revenue Code of 

7 1986 and the amount of such credits; and 

8 (B) shop for qualified health plans that 

9 will best meet their needs through the Ex10 change operating in their State. 

11 SEC. 304. MARKETING AND OUTREACH FOR EXCHANGES 

12 OPERATED BY THE SECRETARY. 

13 Part 2 of subtitle D of title I of the Patient Protec14 tion and Affordable Care Act (42 U.S.C. 18031 et seq.), 

15 as amended by section 303(b), is further amended by add16 ing at the end the following: 

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

18 OPERATED BY THE SECRETARY. 

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

20 under subsection (b), the Secretary shall conduct a mar21 keting and outreach program with respect to qualified 

22 health plans offered through Exchanges operated by the 

23 Secretary in order to encourage enrollment in such plans. 

24 ‘‘(b) APPROPRIATIONS.— 


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1 ‘‘(1) ENCOURAGING ENROLLMENT FOR PLAN

2 YEAR 2020.—There is appropriated to the Secretary, 

3 out of any moneys in the Treasury not otherwise ap4 propriated, $480,000,000 to carry out the marketing 

5 and outreach program under subsection (a) with re6 spect to encouraging enrollment for qualified health 

7 plans that begin in calendar year 2020. 

8 ‘‘(2) ENCOURAGING ENROLLMENT FOR SUBSE9 QUENT PLAN YEARS.—To carry out the marketing 

10 and outreach program under subsection (a) with re11 spect to encouraging enrollment for qualified health 

12 plans that begin in each of calendar years 2021 

13 through 2025, there is appropriated to the Secretary 

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

15 in the Treasury not otherwise appropriated, an 

16 amount equal to the amount appropriated under this 

17 subsection for the prior calendar year increased by 

18 4 percent for each such calendar year. 

19 ‘‘(3) AVAILABILITY.—The amounts appro20 priated under paragraphs (1) and (2) shall remain 

21 available until expended.’’. 

22 SEC. 305. NAVIGATOR PROGRAM. 

23 Section 1311(i) of the Patient Protection and Afford24 able Care Act (42 U.S.C. 18031(i)) is amended— 

25 (1) in paragraph (2)— 


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

2 other entities’’ and inserting ‘‘and other entities 

3 (such as Indian tribes, tribal organizations, 

4 urban Indian organizations, and State or local 

5 human service agencies)’’; and 

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

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

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

9 paragraph (1) to— 

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

11 this paragraph that is a community and 

12 consumer-focused nonprofit group; and 

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

14 subparagraph (B), which may include an15 other community and consumer-focused 

16 nonprofit group.’’; 

17 (2) in paragraph (3)— 

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

19 and’’ and inserting ‘‘;’’; 

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

21 period and inserting ‘‘; and’’; and 

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

23 ‘‘(F) provide targeted assistance to individ24 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, 2020. 

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 2019) 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 2021 

9 through 2025’’; 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 2026 

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), in the matter pre19 ceding subparagraph (A), by striking ‘‘para20 graph (2)(B)’’ and inserting ‘‘paragraph 

21 (3)(B)’’; 

22 (B) by redesignating paragraph (2) as 

23 paragraph (3); 

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

25 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 who is a participant, beneficiary, or 

6 enrollee of such plan or coverage at an amount equal 

7 to the greatest of— 

8 ‘‘(A) the median amount negotiated with 

9 in-network providers for the emergency service; 

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

11 calculated using the same method the plan or 

12 issuer uses to determine payments for out-of13 network services that are not emergency serv14 ices; or 

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

16 provider of services or supplier with respect to 

17 the furnishing of such service under title XVIII 

18 of the Social Security Act.’’; and 

19 (D) in paragraph (3)(B), as so redesig20 nated— 

21 (i) clause (i), by inserting ‘‘, including 

22 ambulance services provided by ground or 

23 air transportation’’ before ‘‘, and’’ at the 

24 end; and 


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1 (ii) in clause (ii), by striking the pe2 riod at the end and inserting ‘‘, including 

3 ambulance services provided by ground or 

4 air transportation.’’; and 

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

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

7 PROVIDERS BASED ON PLAN OR ISSUER ERROR.— 

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

9 health insurance issuer offering group or individual 

10 health insurance coverage shall provide coverage of 

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

12 an individual who is a participant, beneficiary, or en13 rollee of such plan or coverage if— 

14 ‘‘(A) the plan or issuer would have pro15 vided coverage of the service if the service was 

16 provided by an in-network provider; and 

17 ‘‘(B) in choosing such provider, the indi18 vidual reasonably relied on a materially inac19 curate, incomplete, or misleading statement of 

20 information contained in a directory of in-net21 work providers compiled by the plan or issuer. 

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

23 health insurance issuer that provides coverage of a 

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

25 paragraph (1) shall provide such coverage with the 


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1 same cost-sharing requirement that would apply if 

2 the services were provided in-network. 

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

4 OF TREATMENT.— 

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

6 health insurance issuer offering group or individual 

7 health insurance coverage shall, at the request of an 

8 individual who is a participant, beneficiary, or en9 rollee of such plan or coverage and in accordance 

10 with paragraphs (4) and (5), provide to such indi11 vidual coverage of services for an active course of 

12 treatment provided by a provider that is an out-of13 network provider with respect to such plan or cov14 erage if— 

15 ‘‘(A) coverage of such services would be 

16 provided under the group health plan or health 

17 insurance coverage if the services were provided 

18 by an in-network provider; and 

19 ‘‘(B) a circumstance described in para20 graph (3) applies. 

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

22 health insurance issuer offering group or individual 

23 health insurance coverage shall ensure that any cost24 sharing requirements for coverage of services for an 

25 active course of treatment provided by an out-of-netVerDate Sep 11 2014 20:26 Apr 25, 2019 Jkt 089200 PO 00000 Frm 00046 Fmt 6652 Sfmt 6201 E:\BILLS\S1213.IS S1213

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1 work provider under paragraph (1) are the same re2 quirements as if such services were provided by an 

3 in-network provider. 

4 ‘‘(3) CIRCUMSTANCE.—A circumstance de5 scribed in this paragraph is a circumstance in 

6 which— 

7 ‘‘(A) with respect to a health insurance 

8 issuer offering group or individual health insur9 ance coverage— 

10 ‘‘(i) the individual was receiving serv11 ices for the active course of treatment de12 scribed in paragraph (1) from the out-of13 network provider described in such para14 graph during the prior plan year when— 

15 ‘‘(I) the individual was a partici16 pant, beneficiary, or enrollee of a dif17 ferent health insurance coverage of18 fered by such health insurance issuer; 

19 and 

20 ‘‘(II) such provider was an in21 network provider with respect to such 

22 different health insurance coverage; 

23 and 

24 ‘‘(ii) the health insurance issuer de25 cided to cancel or discontinue offering such 


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1 different health insurance coverage for the 

2 plan year for which the individual makes 

3 the request, including a case in which such 

4 different health insurance coverage is with5 drawn from the market for such plan year; 

6 and 

7 ‘‘(B) the individual was receiving services 

8 for the active course of treatment described in 

9 paragraph (1) from the out-of-network provider 

10 described in such paragraph while the provider 

11 was an in-network provider for the group health 

12 plan or health insurance coverage for the plan 

13 year, and, during such plan year, the provider 

14 became a terminated provider with respect to 

15 such plan or coverage for the remainder of such 

16 plan year. 

17 ‘‘(4) DURATION.—A group health plan or 

18 health insurance issuer offering group or individual 

19 health insurance coverage shall provide coverage of 

20 services for an active course of treatment under 

21 paragraph (1) until the earlier of— 

22 ‘‘(A) the date on which the treatment is 

23 complete; or 

24 ‘‘(B) the date that is 180 days following 

25 the first date on which the provider described in 


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1 paragraph (1) is no longer an in-network pro2 vider of the plan or coverage in providing such 

3 services to the individual. 

4 ‘‘(5) REQUEST FOR CONTINUITY OF CARE.—A 

5 request made under paragraph (1) shall be subject 

6 to any internal or external grievance or appeals 

7 process of the group health plan or health insurance 

8 issuer, in accordance with any applicable State or 

9 Federal law. 

10 ‘‘(6) DEFINITIONS.—For purposes of this sub11 section: 

12 ‘‘(A) ACTIVE COURSE OF TREATMENT.— 

13 The term ‘active course of treatment’ means 

14 any of the following: 

15 ‘‘(i) An ongoing course of treatment 

16 for— 

17 ‘‘(I) a life-threatening condition; 

18 ‘‘(II) a serious, acute condition; 

19 or 

20 ‘‘(III) a serious, chronic condi21 tion. 

22 ‘‘(ii) Care provided with respect to 

23 pregnancy, including until the completion 

24 of postpartum care directly related to the 

25 delivery. 


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1 ‘‘(iii) An ongoing course of treatment 

2 for a child between birth and 36 months. 

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

4 other procedure that, as documented prior 

5 to the time the provider became an out-of6 network provider with respect to the group 

7 health plan or health insurance coverage— 

8 ‘‘(I) the plan or issuer offering 

9 such coverage authorized as part of a 

10 course of treatment for the individual; 

11 and 

12 ‘‘(II) the provider recommended 

13 for such individual. 

14 ‘‘(B) TERMINATED PROVIDER.—The term 

15 ‘terminated provider’— 

16 ‘‘(i) means a provider that had a con17 tract with a group health plan or health in18 surance issuer offering group or individual 

19 health insurance coverage to provide serv20 ices as an in-network provider with respect 

21 to such plan or coverage for a plan year, 

22 and, during such plan year, the plan or 

23 issuer terminated such contract or did not 

24 renew such contract for the remainder of 

25 the plan year; and 


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1 ‘‘(ii) does not include— 

2 ‘‘(I) any provider that voluntarily 

3 terminated or did not renew such con4 tract for the remainder of the plan 

5 year; and 

6 ‘‘(II) any provider whose contract 

7 with the plan or issuer terminated, or 

8 was not renewed, for the remainder of 

9 the plan year for reasons relating to a 

10 medical disciplinary cause, fraud, or 

11 other criminal activity. 

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

13 PRESCRIPTION DRUGS.— 

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

15 health insurance issuer offering group or individual 

16 health insurance coverage shall not, during a plan 

17 year, take any of the following actions with respect 

18 to coverage for such plan year: 

19 ‘‘(A) Remove a prescription drug from a 

20 formulary of prescription drugs covered by such 

21 plan or coverage, except as provided in para22 graph (2)(C). 

23 ‘‘(B) Increase the obligation of a partici24 pant, beneficiary, or enrollee with respect to 

25 cost-sharing, as defined in section 1302(c)(3) of 


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1 the Patient Protection and Affordable Care Act, 

2 for a prescription drug covered under such plan 

3 or coverage. 

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

5 this subsection shall prohibit a group health plan or 

6 health insurance issuer offering group or individual 

7 health insurance coverage from, during a plan year, 

8 taking any of the following actions with respect to 

9 coverage under the plan or health insurance cov10 erage for such plan year: 

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

12 health insurance coverage to require a partici13 pant, beneficiary, or enrollee to use a generic 

14 substitution for a branded prescription drug. 

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

16 formulary of prescription drugs covered by such 

17 plan or health insurance coverage. 

18 ‘‘(C) Removing a prescription drug from 

19 such a formulary due to patient safety con20 cerns, or a prescription drug recall, or removing 

21 a prescription drug from interstate commerce 

22 as determined necessary by the Secretary.’’. 

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

24 this section shall apply to plan years beginning after De25 cember 31, 2020. 


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1 SEC. 404. LIMITATION ON BALANCE BILLING FOR EMER2 GENCY SERVICES. 

3 (a) IN GENERAL.—A health care provider that pro4 vides any emergency service to an individual that is a par5 ticipant, beneficiary, or enrollee of a group health plan, 

6 group health insurance coverage, or individual health in7 surance coverage and that is not an in-network provider 

8 of such plan or coverage shall not impose a charge on such 

9 individual for such emergency service, other than any cost10 sharing that would otherwise be applicable if the health 

11 care provider was an in-network provider of such plan or 

12 health insurance coverage. 

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

14 civil monetary penalty, in the same manner as such pen15 alties are authorized under section 1128A of the Social 

16 Security Act (42 U.S.C. 1320a–7a) for violations of bal17 ance billing prohibitions under part B of title XVIII of 

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

19 violates the requirement under subsection (a). 

20 (c) DEFINITIONS.—In this section: 

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

22 has the meaning given the term in section 

23 1302(c)(3) of the Patient Protection and Affordable 

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

25 (2) EMERGENCY SERVICE.—The term ‘‘emer26 gency service’’ has the meaning given such term in 


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1 paragraph (3)(B) of section 2719A(b) of the Public 

2 Health Service Act (42 U.S.C. 300gg–19a(b)), as 

3 amended by section 403(a). 

4 (3) GROUP HEALTH PLAN, GROUP HEALTH IN5 SURANCE COVERAGE, AND INDIVIDUAL HEALTH IN6 SURANCE COVERAGE.—The terms ‘‘group health 

7 plan’’, ‘‘group health insurance coverage’’, and ‘‘in8 dividual health insurance coverage’’ have the mean9 ings given such terms in section 2791 of the Public 

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

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

12 the Secretary of Health and Human Services. 

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

14 plan years beginning after December 31, 2020. 

15 SEC. 405. NOTIFICATION OF PROVIDER TERMINATIONS. 

16 Subpart II of part A of title XXVII of the Public 

17 Health Service Act (42 U.S.C. 300gg–11 et seq.) is 

18 amended by adding at the end the following: 

19 ‘‘SEC. 2730. NOTIFICATION OF PROVIDER TERMINATIONS. 

20 ‘‘(a) IN GENERAL.—Beginning January 1, 2020, a 

21 group health plan or health insurance issuer offering 

22 group or individual health insurance coverage shall inform 

23 individuals described in subsection (b) of the termination 

24 of any provider as an in-network provider under the plan 


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1 or health insurance coverage. Such notice shall be provided 

2 not later than 30 days prior to the termination. 

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

4 subsection are any individuals enrolled in the group health 

5 plan or health insurance coverage described in subsection 

6 (a) who have seen the provider described in such sub7 section on a regular basis or who have received primary 

8 care from such provider.’’. 

9 SEC. 406. SHORT-TERM LIMITED DURATION HEALTH INSUR10 ANCE COVERAGE. 

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

12 Health Service Act (42 U.S.C. 300gg–91(b)(5)) is amend13 ed by striking ‘‘but does not include’’ and inserting ‘‘in14 cluding’’. 

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

16 this section shall apply to plan years beginning after De17 cember 31, 2020. 

18 SEC. 407. PROTECTING ESSENTIAL HEALTH BENEFITS AND 

19 COVERAGE OF PEDIATRIC SERVICES. 

20 (a) PROTECTING ESSENTIAL HEALTH BENEFITS.— 

21 Section 1302(b) of the Patient Protection and Affordable 

22 Care Act (42 U.S.C. 18022(b)) is amended— 

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

24 striking ‘‘(4)(H)’’ each place it appears and insert25 ing ‘‘(4)(I)’’; and 


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1 (2) in paragraph (4)— 

2 (A) in subparagraph (A)— 

3 (i) by striking ‘‘such subsection’’ and 

4 inserting ‘‘such paragraph’’; and 

5 (ii) by inserting ‘‘and coverage in 

6 every category is included’’ before the 

7 semicolon; 

8 (B) by redesignating subparagraphs (E) 

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

10 respectively; and 

11 (C) by inserting after subparagraph (D) 

12 the following: 

13 ‘‘(E) ensure that, to be treated as pro14 viding coverage for the essential health benefits 

15 described in paragraph (1), a qualified health 

16 plan— 

17 ‘‘(i) shall not substitute benefits be18 tween categories described such paragraph, 

19 as described in section 156.115(b)(2)(ii) of 

20 title 45, Code of Federal Regulations, as in 

21 effect on the day before the date of enact22 ment of the Consumer Health Insurance 

23 Protection Act of 2019; 


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

2 classes of prescription drugs on the pre3 scription drug formulary of such plan; 

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

5 drug is not on the prescription drug for6 mulary of such plan, allow individuals en7 rolled in such plan to have access to the 

8 drug through an exceptions process estab9 lished by the plan; and 

10 ‘‘(iv) shall not impose limits on cov11 erage of habilitative services and devices 

12 that are less favorable than any such limits 

13 imposed on coverage of rehabilitative serv14 ices and devices.’’. 

15 (b) COVERAGE OF PEDIATRIC SERVICES.—The Sec16 retary of Health and Human Services, in consultation with 

17 pediatric service providers, shall promulgate a series of 

18 recommendations for group health plans and health insur19 ance issuers offering group or individual health insurance 

20 coverage to improve coverage of pediatric services. 

21 SEC. 408. ASSOCIATION HEALTH PLANS. 

22 (a) TREATMENT OF ASSOCIATION HEALTH PLANS.— 

23 (1) ASSOCIATION HEALTH PLAN DEFINED.— 

24 For purposes of this subsection, the term ‘‘associa25 tion health plan’’ means any health insurance covVerDate Sep 11 2014 01:51 Apr 24, 2019 Jkt 089200 PO 00000 Frm 00057 Fmt 6652 Sfmt 6201 E:\BILLS\S1213.IS S1213

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1 erage that is provided to an association, but not re2 lated to employment, and sold to individuals through 

3 such association. 

4 (2) TREATMENT AS INDIVIDUAL HEALTH IN5 SURANCE COVERAGE.—For purposes of title XXVII 

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

7 et seq.), part 7 of subtitle B of title I of the Em8 ployee Retirement Income Security Act of 1974 (29 

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

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

11 Protection and Affordable Care Act (Public Law 

12 111–148), health insurance coverage offered through 

13 an association health plan shall be treated as indi14 vidual health insurance coverage if— 

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

16 the association other than in connection with a 

17 group health plan; or 

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

19 the association that is an employer maintaining 

20 a group health plan that has fewer than 2 par21 ticipants who are employees on the first day of 

22 the plan year. 

23 (3) TREATMENT AS HEALTH INSURANCE COV24 ERAGE IN THE SMALL GROUP MARKET.—For pur25 poses of title XXVII of the Public Health Service 


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

2 of title I of the Employee Retirement Income Secu3 rity Act of 1974 (29 U.S.C. 1181 et seq.), chapter 

4 100 of the Internal Revenue Code of 1986, and title 

5 I of the Patient Protection and Affordable Care Act 

6 (Public Law 111–148), health insurance coverage of7 fered through an association health plan shall, sub8 ject to paragraph (2)(B), be treated as health insur9 ance coverage in the small group market if the cov10 erage is offered to a member of the association in 

11 connection with a group health plan offered to em12 ployers that are small employers, as defined in such 

13 applicable Act or Code. 

14 (4) PREEMPTION.—An association health plan 

15 shall be treated as individual health insurance cov16 erage in accordance with paragraph (2) or health in17 surance coverage in the small group market in ac18 cordance with paragraph (3) notwithstanding any 

19 applicable State law. 

20 (5) EFFECTIVE DATE.—This subsection shall 

21 apply to plan years beginning after December 31, 

22 2020. 

23 (b) DEPARTMENT OF LABOR RULE REGARDING THE

24 DEFINITION OF ‘‘EMPLOYER’’ UNDER ERISA.—Begin25 ning with respect to plan years beginning after December 


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1 31, 2020, the final rule of the Department of Labor enti2 tled ‘‘Definition of ‘Employer’ Under Section 3(5) of 

3 ERISA—Association Health Plans’’ (83 Fed. Reg. 28912 

4 (June 21, 2018)) shall have no force or effect. 

Æ 


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