certified plan under this section may not change
such enrollment.
‘‘(3) SURCHARGE.—
‘‘(A) IN GENERAL.—Except as provided in
paragraph (4), with respect to an eligible indi-
vidual who does not enroll in a certified plan
during, or who elects to change the plan in
which such individual is enrolled outside of, the
national open enrollment period, the participat-
ing State involved may assess a late enrollment
surcharge in an amount determined appropriate
by the State.
‘‘(B) WAIVER.—A State may grant a waiv-
er of any enrollment surcharges if the applicant
or applicant’s family can demonstrate that the
applicant or was out-of-State during the open
enrollment period or for other unavoidable and
legitimate reasons as determined appropriate by
the State, including sudden loss of health cov-
erage due to unemployment, divorce, and finan-
cial crisis.
‘‘(4) ENROLLMENT OF NEWBORNS.—A partici-
pating State shall provide a family with the oppor-
tunity to enroll the newborn children of such family
in a certified plan prior to or at the time of the de-
livery (through the hospital or birthing center) of
such children. To avoid a surcharge under para-
graph (2), a newborn must be enrolled in a certified
plan prior to birth or within 30 days after birth or
during the open enrollment period.
‘‘(f) PLAN CHOICE AND TERMINATION OF ENROLL-
MENT.—
‘‘(1) PLAN CHOICE.—As part of an enrollment
application, the family shall indicate the choice of
certified plan. A family with a child enrolled in a
certified plan may at any time elect to change enroll-
ment in plans and such new enrollment shall become
effective on the first day of the next open enrollment
period. A family that desires to change certified
plans at a time that is not within the open enroll-
ment period may do so but shall be subject to a sub-
stantial surcharge to be imposed by the State. An
enrolled pregnant woman who elects to change plans
shall be subject to a similar surcharge. The State
shall not impose a surcharge on a family with an en-
rolled child or on a pregnant woman if the change
of certified plans is due to the family moving to an-
other area not served by the current plan, in the
case of a plan withdrawing from a market area, or
for other justifiable and legitimate reasons as deter-
mined by the State.
‘‘(2) PERIOD
OF
ENROLLMENT.—The period
during which enrollment in a certified plan shall be
effective shall—
‘‘(A) in the case of an eligible child, not be
less than 1 year; and
‘‘(B) in the case of a pregnant woman, be
for the duration of the pregnancy and eligible
post-partum period.
‘‘(3) PROHIBITION
ON
WAITING
PERIODS.—A
certified plan may not impose a waiting period with
respect to the provision of covered health services
under the plan. Access to such services shall be ef-
fective immediately upon the date on which the en-
rollment application is submitted.
‘‘(4) PROVISION OF SERVICES.—Upon the sub-
mission of an application for enrollment during an
initial point-of-service visit, a certified plan shall
provide covered health services to the applicant indi-
vidual if the individual declares that such individual
is not otherwise enrolled in a certified plan under
this title and the individual reasonably appears to be
of an eligible age. The provision of such services
shall continue until such time as the State has noti-
fied the plan that the applicant is not eligible under
this title. The State shall impose a surcharge, in an
amount to be determined appropriate by the State,
for enrollment at the point-of-service outside of the
open enrollment period. A State may elect to directly
compensate a certified plan for services provided to
individuals who are subsequently determined to be
ineligible, or permit such plans to factor in the esti-
mated costs of providing services to such individuals
in their rate negotiations with the State.
‘‘SEC. 2816. TRANSITION FROM ELIGIBILITY.
‘‘(a) ELIGIBLE CHILD.—
‘‘(1) TERMINATION
OF
SUBSIDIES.—With re-
spect to an eligible child enrolled in a certified plan
who attains the age of seven years during the term
of enrollment under the plan, premium subsidies
under this title for such plan shall terminate on the
date on which the term of enrollment terminates.
The plan in which the child is enrolled shall continue
to provide coverage for such child for an indefinite
period if the full unsubsidized premium and copay-
ments for such plan are paid.
‘‘(2) PREEXISTING CONDITIONS.—With respect
to an eligible child, a certified plan may not exclude
coverage for preexisting conditions. If an eligible
child elects to terminate coverage under a certified
plan after the seventh birthday of the child and en-
roll in another health plan or in an employer-pro-
vided health plan that provides similar benefits to
employee dependents, the plan or employer shall ac-
cept the child into the plan and may not exclude cov-
erage for any preexisting conditions.
‘‘(b) ELIGIBLE PREGNANT WOMAN.—With respect to
an eligible pregnant woman enrolled in a certified plan,
coverage for health benefits under the plan shall terminate
on the date that is 2 months after the date of the end
of the pregnancy. If the woman was covered under a
health plan or employer-based health plan (without preg-
nancy-related benefits) immediately prior to enrollment in
the certified plan under the State program, the previous
health plan or employer shall readmit the woman into the
plan with no exclusions for preexisting or pregnancy-relat-
ed conditions at a cost comparable to the cost paid prior
to enrollment in the certified plan.’’.
SEC. 202. COMPREHENSIVE HEALTH BENEFITS AND COST
SHARING REQUIREMENTS.
Title XXVIII of the Public Health Service Act (as
added by section 201) is amended by adding at the end
thereof the following new part:
‘‘PART C—COMPREHENSIVE HEALTH BENEFITS AND
COST SHARING REQUIREMENTS
‘‘SUBPART 1—COMPREHENSIVE HEALTH BENEFITS
‘‘SEC. 2821. COMPREHENSIVE HEALTH BENEFITS PACKAGE.
‘‘(a) DEVELOPMENT OF PACKAGE.—
‘‘(1) IN GENERAL.—Not later than 180 days
after the date of enactment of this title, the Sec-
retary, in consultation with health care professionals
and health-related organizations determined appro-
priate by the Secretary and in accordance with para-
graph (2), shall develop a comprehensive benefits
package for both children and pregnant women.
Such benefits packages shall be based on the general
categories of benefits described in section 2822.
‘‘(2) CONSULTATION.—In developing a com-
prehensive benefits package under paragraph (1),
the Secretary shall, at a minimum, consult with—
‘‘(A) in the case of a benefits package for
children, the American Academy of Pediatrics,
the Association of Maternal and Child Health
Programs, and the American Dental Associa-
tion; and
‘‘(B) in the case of a benefits package for
pregnant women, the American College of Ob-
stetricians and Gynecologists and the Associa-
tion of Maternal and Child Health Programs.
‘‘(3) PERIODICITY SCHEDULES.—To the extent
practicable, the comprehensive benefits packages de-
veloped under paragraph (1) shall contain periodicity
schedules for preventive services.
‘‘(b) LIMITATIONS.—In developing the comprehensive
benefits packages under subsection (a), the Secretary shall
ensure that such packages are consistent with the follow-
ing:
‘‘(1) The actuarial equivalent of the specific
comprehensive benefits packages shall exceed the av-
erage actuarial equivalent of all health benefits of-
fered to children and pregnant women by all States
under the program under title XIX of the Social Se-
curity Act on the date of enactment of this title.
‘‘(2) The actuarial equivalent of the specific
comprehensive benefits packages shall not exceed the
actuarial equivalent of health benefits offered to chil-
dren and pregnant women in the State or States
providing the most generous benefits package under
title XIX of the Social Security Act for such popu-
lations on the date of enactment of this title.
‘‘(c) COPAYMENTS.—In addition to developing the
comprehensive benefits package under subsection (a), the