I 
111TH CONGRESS 
1ST SESSION H. R. 4020 
To enable States to establish reinsurance programs or high risk pools to 
ensure that high risk individuals are able to access health insurance. 
IN THE HOUSE OF REPRESENTATIVES 
NOVEMBER 4, 2009 
Mr. BURGESS (for himself, Mr. DEAL of Georgia, Mr. PITTS, Mr. BUYER, and 
Mr. BLUNT) introduced the following bill; which was referred to the Com-
mittee on Energy and Commerce 
A BILL 
To enable States to establish reinsurance programs or high 
risk pools to ensure that high risk individuals are able 
to access health insurance. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Guaranteed Access to 
Health Insurance Act of 2009’’. 
SEC. 2. ENSURING AFFORDABILITY FOR ALL THROUGH 
SPECIAL POOLING OF THE COST OF HIGH 
RISK INDIVIDUALS. 
(a) STATE REQUIREMENT.— 
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(1) IN GENERAL.—Not later than 2 years after 
the date of the enactment of this Act, each State is 
encouraged to ensure that an adequate financial 
backstop exists to mitigate the cost of high risk indi-
viduals in the State, through establishing either— 
(A) a qualified State reinsurance program 
described in subsection (b); or 
(B) a qualifying State high risk pool de-
scribed in subsection (c)(1). 
(2) PREFERENCE.—Beginning 3 years after the 
date of the enactment of this Act, in the case of a 
competitive grant for which the only eligible entities 
are States, the Secretary, in awarding such grant to 
a State, shall give preference to any State with a 
program that meets the requirements of paragraph 
(1)(A). 
(b) QUALIFIED STATE REINSURANCE PROGRAM.— 
(1) IN GENERAL.—For purposes of this section, 
the term ‘‘qualified State reinsurance program’’ 
means a program operated by a State or a State au-
thorized program that provides reinsurance for 
health insurance coverage offered in the individual, 
small group market, or in both markets. 
(2) FORM OF PROGRAM.—A qualified State re-
insurance program may provide reinsurance— 
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(A) on a prospective or retrospective basis; 
(B) that protects health insurance issuers 
against the annual aggregate spending of their 
enrollees; and 
(C) that provides purchase protection 
against individual catastrophic costs. 
(c) QUALIFYING STATE HIGH RISK POOL.— 
(1) IN GENERAL.—A qualifying State high risk 
pool described in this subsection means a section 
2745 qualified high risk pool that meets the fol-
lowing requirements: 
(A) The high risk pool does not have a life-
time coverage cap. 
(B) The high risk pool incorporates appli-
cable Federal or State programs (such as cov-
erage under title XIX of the Social Security 
Act) for eligible low-income individuals. 
(C) The high risk pool provides a variety 
of types of coverage, including at least one high 
deductible health plan that is combined with a 
health savings account. 
(D) The high risk pool eliminates any 
waiting list and pre-existing condition exclu-
sionary periods so that all eligible residents who 
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are seeking coverage through the pool can re-
ceive coverage through the pool. 
(E) The high risk pool allows for coverage 
of individuals who, but for the 24-month dis-
ability waiting period under section 226(b) of 
the Social Security Act, would be eligible for 
Medicare during the period of such waiting pe-
riod. 
(F) The high risk pool must not charge 
participants more than 150 percent of the aver-
age premium in the individual market for 
health insurance coverage in that State. 
(G) The high risk pool conducts education 
and outreach initiatives so that residents and 
insurance brokers understand that the pool is 
available to eligible residents. 
(2) USE OF FUNDS FOR THE TRANSITION.—A 
State may use any funding sources available to it as 
of the date of the enactment of this Act to transition 
from operating a section 2745 high risk pool, to op-
erating a qualified State reinsurance program de-
scribed in paragraph (1). 
(3) FUNDING SOURCE.—The high risk pool de-
scribed in this subsection is also encouraged to have 
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‘‘(B) UPDATED
DEFINITION.—Beginning 
on the last day of the 2-year period beginning 
in the date of the enactment of the Guaranteed 
Access to Health Insurance Act of 2009, the 
term ‘qualified high risk pool’ means— 
‘‘(i) a pool that meets the require-
ments of subparagraph (A) of this para-
graph and the requirements of section 
2(c)(1) of such Act; or 
‘‘(ii) a qualified State reinsurance pro-
gram as such term is defined in section 
2(b) of such Act.’’. 
(e) WAIVERS.— 
(1) IN
GENERAL.—In order to accommodate 
new and innovative programs, the Secretary may 
waive such requirements of this section for qualified 
State reinsurance programs and for qualifying State 
high risk pools as the Secretary deems appropriate. 
(2) COVERAGE OF HIGH RISK INDIVIDUALS.— 
The Secretary may waive the requirement under 
subsection (a)(1) in the case of a State that dem-
onstrates, to the satisfaction of the Secretary, that 
the State has provided an adequate financial back-
stop to mitigate the cost of high risk individuals in 
the State in a manner that is better than, as deter-
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mined by the Secretary, the requirements under 
such subsection. 
(f) SEED GRANTS TO STATES.—The Secretary shall 
provide, from the funds appropriated, a grant of up to 
$5,000,000 to each State that has not created a qualified 
high risk pool as of the date of enactment of this Act. 
Such grants shall be made in the same manner, for the 
same purpose, but are in addition to, grants to States 
made under Section 2745(a) of the Public Health Service 
Act. 
(g) VERIFICATION OF CITIZENSHIP OR ALIEN QUALI-
FICATION.— 
(1) IN GENERAL.—Only citizens and nationals 
of the United States shall be eligible to participate 
in a qualifying State high risk pool or qualifying 
State reinsurance program receiving funding under 
this section. 
(2) GRANT CONDITIONS.—As a condition of re-
ceiving grants under this section, the Secretary shall 
require any State that applies to receive grant fund-
ing under this section to certify to the satisfaction 
of the Secretary that such State requires all appli-
cants for coverage in a qualifying State high risk to 
pool or a qualifying State reinsurance program to 
provide satisfactory documentation of such citizen-
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ship or nationality and identity in a manner con-
sistent with section 1903(x) of the Social Security 
Act. The Secretary shall keep sufficient records such 
that a determination of citizenship or nationality has 
to be made once for any individual. 
(h) DEFINITIONS.—In this section: 
(1) The terms ‘‘health insurance coverage’’ and 
‘‘health insurance issuer’’ have the meanings given 
such terms in section 2791 of the Public Health 
Service Act. 
(2) The term ‘‘section 2745 qualified high risk 
pool’’ has the meaning given the term ‘‘qualified 
high risk pool’’ under section 2745(g)(1) of the Pub-
lic Health Service Act as such section is in effect on 
the date of the enactment of this Act. 
(3) The term ‘‘Secretary’’ means Secretary of 
Health and Human Services. 
(4) The term ‘‘State’’ has the meaning given 
such term for purposes of title XIX of the Social Se-
curity Act. 
(i) AUTHORIZATION OF APPROPRIATIONS.—For the 
purposes of carrying out section 2745 of the Public Health 
Service Act and this section, in addition to any other 
amounts authorized to be appropriated, there is author-
ized to be appropriated, $20,000,000,000 beginning with 
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2010. Any funds that are authorized under this subsection 
that are used for purposes of carrying out section 2745 
of the Public Health Service Act shall be allocated to the 
allotments under such section in the proportions required 
under subsection (d)(2) of such section. 
Æ 
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