162 
gaining agreements which are reached pursuant to 
collective bargaining described in section 8(d) of the 
National Labor Relations Act (29 U.S.C. 158(d)) or 
paragraph Fourth of section 2 of the Railway Labor 
Act (45 U.S.C. 152, paragraph Fourth) or which are 
reached pursuant to labor-management negotiations 
under similar provisions of State public employee re-
lations laws; or 
‘‘(3) being a plan or arrangement described in 
section 3(40)(A)(i), 
shall, upon conviction, be imprisoned not more than 5 
years, be fined under title 18, United States Code, or 
both.’’. 
(b) CEASE ACTIVITIES ORDERS.—Section 502 of the 
Employee Retirement Income Security Act of 1974 (29 
U.S.C. 1132) is amended by adding at the end the fol-
lowing new subsection: 
‘‘(n) ASSOCIATION HEALTH PLAN CEASE AND DE-
SIST ORDERS.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
upon application by the Secretary showing the oper-
ation, promotion, or marketing of an association 
health plan (or similar arrangement providing bene-
fits consisting of medical care (as defined in section 
733(a)(2))) that— 
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163 
‘‘(A) is not certified under part 8, is sub-
ject under section 514(b)(6) to the insurance 
laws of any State in which the plan or arrange-
ment offers or provides benefits, and is not li-
censed, registered, or otherwise approved under 
the insurance laws of such State; or 
‘‘(B) is an association health plan certified 
under part 8 and is not operating in accordance 
with the requirements under part 8 for such 
certification, 
a district court of the United States shall enter an 
order requiring that the plan or arrangement cease 
activities. 
‘‘(2) EXCEPTION.—Paragraph (1) shall not 
apply in the case of an association health plan or 
other arrangement if the plan or arrangement shows 
that— 
‘‘(A) all benefits under it referred to in 
paragraph (1) consist of health insurance cov-
erage; and 
‘‘(B) with respect to each State in which 
the plan or arrangement offers or provides ben-
efits, the plan or arrangement is operating in 
accordance with applicable State laws that are 
not superseded under section 514. 
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164 
‘‘(3) ADDITIONAL
EQUITABLE
RELIEF.—The 
court may grant such additional equitable relief, in-
cluding any relief available under this title, as it 
deems necessary to protect the interests of the pub-
lic and of persons having claims for benefits against 
the plan.’’. 
(c) RESPONSIBILITY
FOR CLAIMS PROCEDURE.— 
Section 503 of the Employee Retirement Income Security 
Act of 1974 (29 U.S.C. 1133) is amended by inserting 
‘‘(a) IN GENERAL.—’’ before ‘‘In accordance’’, and by 
adding at the end the following new subsection: 
‘‘(b) ASSOCIATION HEALTH PLANS.—The terms of 
each association health plan which is or has been certified 
under part 8 shall require the board of trustees or the 
named fiduciary (as applicable) to ensure that the require-
ments of this section are met in connection with claims 
filed under the plan.’’. 
SEC. 214. COOPERATION BETWEEN FEDERAL AND STATE 
AUTHORITIES. 
Section 506 of the Employee Retirement Income Se-
curity Act of 1974 (29 U.S.C. 1136) is amended by adding 
at the end the following new subsection: 
‘‘(d) CONSULTATION WITH STATES WITH RESPECT 
TO ASSOCIATION HEALTH PLANS.— 
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165 
‘‘(1) AGREEMENTS
WITH
STATES.—The Sec-
retary shall consult with the State recognized under 
paragraph (2) with respect to an association health 
plan regarding the exercise of— 
‘‘(A) the Secretary’s authority under sec-
tions 502 and 504 to enforce the requirements 
for certification under part 8; and 
‘‘(B) the Secretary’s authority to certify 
association health plans under part 8 in accord-
ance with regulations of the Secretary applica-
ble to certification under part 8. 
‘‘(2) RECOGNITION
OF
PRIMARY
DOMICILE 
STATE.—In carrying out paragraph (1), the Sec-
retary shall ensure that only one State will be recog-
nized, with respect to any particular association 
health plan, as the State with which consultation is 
required. In carrying out this paragraph— 
‘‘(A) in the case of a plan which provides 
health insurance coverage (as defined in section 
812(a)(3)), such State shall be the State with 
which filing and approval of a policy type of-
fered by the plan was initially obtained, and 
‘‘(B) in any other case, the Secretary shall 
take into account the places of residence of the 
participants and beneficiaries under the plan 
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166 
and the State in which the trust is main-
tained.’’. 
SEC. 215. EFFECTIVE DATE AND TRANSITIONAL AND 
OTHER RULES. 
(a) EFFECTIVE DATE.—The amendments made by 
this Act shall take effect 1 year after the date of the enact-
ment of this Act. The Secretary of Labor shall first issue 
all regulations necessary to carry out the amendments 
made by this Act within 1 year after the date of the enact-
ment of this Act. 
(b) TREATMENT
OF CERTAIN EXISTING HEALTH 
BENEFITS PROGRAMS.— 
(1) IN GENERAL.—In any case in which, as of 
the date of the enactment of this Act, an arrange-
ment is maintained in a State for the purpose of 
providing benefits consisting of medical care for the 
employees and beneficiaries of its participating em-
ployers, at least 200 participating employers make 
contributions to such arrangement, such arrange-
ment has been in existence for at least 10 years, and 
such arrangement is licensed under the laws of one 
or more States to provide such benefits to its par-
ticipating employers, upon the filing with the appli-
cable authority (as defined in section 812(a)(5) of 
the Employee Retirement Income Security Act of 
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167 
1974 (as amended by this Act)) by the arrangement 
of an application for certification of the arrangement 
under part 8 of subtitle B of title I of such Act— 
(A) such arrangement shall be deemed to 
be a group health plan for purposes of title I 
of such Act; 
(B) the requirements of sections 801(a) 
and 803(a) of the Employee Retirement Income 
Security Act of 1974 shall be deemed met with 
respect to such arrangement; 
(C) the requirements of section 803(b) of 
such Act shall be deemed met, if the arrange-
ment is operated by a board of directors 
which— 
(i) is elected by the participating em-
ployers, with each employer having one 
vote; and 
(ii) has complete fiscal control over 
the arrangement and which is responsible 
for all operations of the arrangement; 
(D) the requirements of section 804(a) of 
such Act shall be deemed met with respect to 
such arrangement; and 
(E) the arrangement may be certified by 
any applicable authority with respect to its op-
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168 
erations in any State only if it operates in such 
State on the date of certification. 
The provisions of this subsection shall cease to apply 
with respect to any such arrangement at such time 
after the date of the enactment of this Act as the 
applicable requirements of this subsection are not 
met with respect to such arrangement. 
(2) DEFINITIONS.—For purposes of this sub-
section, the terms ‘‘group health plan’’, ‘‘medical 
care’’, and ‘‘participating employer’’ shall have the 
meanings provided in section 812 of the Employee 
Retirement Income Security Act of 1974, except 
that the reference in paragraph (7) of such section 
to an ‘‘association health plan’’ shall be deemed a 
reference to an arrangement referred to in this sub-
section. 
(c) COORDINATION WITH EXISTING LAW.—Nothing 
in this Act shall require plans to become certified under 
section 802 of the Employee Retirement Income Security 
Act of 1974, as amended by this Act, or require plans 
that are not certified under such section to comply with 
the requirements under part 8 of such Act, except to the 
extent provided in section 809 of such Act. 
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169 
SEC. 216. SHORT-TERM LIMITED DURATION INSURANCE. 
(a) DEFINITION.—Section 2791(b) of the Public 
Health Service Act (42 U.S.C. 300gg–91(b)) is amended 
by adding at the end the following: 
‘‘(6) SHORT-TERM LIMITED DURATION INSUR-
ANCE.—The term ‘short-term limited duration insur-
ance’ means health insurance coverage provided pur-
suant to a contract with a health insurance issuer 
that has an expiration date specified in the contract 
(not taking into account any extensions that may be 
elected by the policyholder with or without the 
issuer’s consent) that is less than 12 months after 
the original effective date of the contract.’’. 
(b) GUARANTEED RENEWABILITY.—Section 2703 of 
the Public Health Service Act (42 U.S.C. 300gg–2) is 
amended— 
(1) in subsection (a), by inserting ‘‘or offers 
short-term limited duration insurance’’ after ‘‘group 
market’’; and 
(2) by adding at the end the following: 
‘‘(f) APPLICATION TO SHORT-TERM LIMITED DURA-
TION INSURANCE.— 
‘‘(1) IN GENERAL.—In applying this section in 
the case of short-term limited duration insurance— 
‘‘(A) a reference to ‘health insurance cov-
erage’ with respect to such coverage offered in 
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170 
the individual market shall be deemed to in-
clude short-term limited duration insurance; 
and 
‘‘(B) a reference to ‘health insurance 
issuer’ with respect to health insurance cov-
erage offered in the individual market shall be 
deemed to include an issuer of short-term lim-
ited duration insurance. 
‘‘(2) SPECIAL RULE FOR SHORT-TERM LIMITED 
DURATION INSURANCE.—In the case of short-term 
limited duration insurance, at the time of application 
for enrollment in such insurance coverage, an issuer 
of such insurance may offer renewability of such 
coverage, and an individual may decline renewability 
of such coverage in accordance with this section, and 
the contract between such individual and the health 
insurance issuer shall specify whether the individual 
opted for renewability or no renewability.’’. 
(c) APPLICABILITY.—The amendments made by sub-
sections (a) and (b) shall apply with respect to contracts 
for short-term limited duration insurance that take effect 
on or after January 1, 2021. 
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171 
Subtitle C—Improving Commercial 
Health Insurance 
SEC. 221. INVISIBLE GUARANTEED COVERAGE POOL REIN-
SURANCE PROGRAM; TAX ON EXCHANGE 
PLANS. 
(a) ESTABLISHMENT.—Not later than January 1, 
2021, the Secretary of Health and Human Services shall 
establish the Invisible Guaranteed Coverage Pool Reinsur-
ance Program (in this section referred to as the ‘‘IGCPR 
program’’). 
(b) STATE GRANTS.—Under the IGCPR program, 
the Secretary shall, from amounts appropriated under 
subsection (f) for a fiscal year, award grants to States for 
such fiscal year, in amounts determined in accordance 
with the allocation methodology specified under subsection 
(d). Such grants shall be used for the purpose of estab-
lishing or maintaining a qualifying Invisible Guaranteed 
Coverage Pool for the State. 
(c) FEDERAL DEFAULT.— 
(1) IN GENERAL.—In the case of a State that 
does not, by a date and in a manner specified by the 
Secretary, choose to be awarded a grant under sub-
section (b) for a fiscal year to operate a qualifying 
Invisible Guaranteed Coverage Pool for the State, 
the Secretary shall, from amounts appropriated 
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172 
under subsection (f) for such fiscal year, use the al-
location determined for the State under subsection 
(d) for participation of such State in the Federal de-
fault qualifying Invisible Guaranteed Coverage Pool 
described in paragraph (2). 
(2) FEDERAL DEFAULT QUALIFYING INVISIBLE 
GUARANTEED
COVERAGE
POOL.—The Federal de-
fault qualifying high risk pool is, with respect to 
each State that chooses not to be awarded a grant 
under subsection (b) with respect to a fiscal year for 
which funds are appropriated under subsection (f), 
an Invisible Guaranteed Coverage Pool under which 
health insurance issuers participating in the Ex-
change of such a State, with respect to designated 
individuals who are enrolled in health insurance cov-
erage and are expected to experience higher than av-
erage health costs as determined by the insurer, cede 
risk to the pool, without affecting the premium paid 
by the designated individuals or their terms of cov-
erage. With respect to such pool— 
(A) high-risk individuals designated for 
cession to the pool shall be designated by the 
ceding issuer; 
(B) the premium amount the ceding issuer 
shall pay to the reinsurance pool shall be 90 
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173 
percent of the premium paid to the issuer for 
the coverage; 
(C) the ceding issuer shall retain the same 
risk under the ceded policies as under any other 
policy of the issuer with respect to the first 
$10,000 of benefits for each ceded policy in-
volved and will not retain any risk under ceded 
policies after such first $10,000 of benefits; and 
(D) after a ceding issuer, with respect to 
a ceded policy, no longer retains risk under 
such policy pursuant to subparagraph (C), the 
negotiated rate under such policy for items and 
services shall be payable at the reimbursement 
rate under the Medicare program under title 
XVIII of the Social Security Act for such items 
and services, or in the case of items and serv-
ices for which payment is available under the 
policy but not the Medicare program, at a rate 
determined by the Secretary. 
(d) ALLOCATION METHODOLOGY.—Not later than 
June 30, 2021, the Secretary shall specify an allocation 
methodology for determining the amount of funds appro-
priated under subsection (f) for a fiscal year to be allo-
cated for each State for purposes of subsections (b) and 
(c). Such methodology shall be based on the number of 
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174 
residents of each State and the general health status of 
such residents. 
(e) QUALIFYING INVISIBLE GUARANTEED COVERAGE 
POOL.—For purposes of this section, the term ‘‘qualifying 
Invisible Guaranteed Coverage Pool’’ means, with respect 
to a State, a method of designation under which health 
insurance issuers identify individuals who experience high-
er than average health costs as determined by the State 
and are enrolled in health insurance coverage offered in 
the individual market, and cede the risk of spending more 
than $10,000 on health care services for a single indi-
vidual to the pool without affecting the premium paid by 
the designated individuals or their terms of coverage. With 
respect to such pool, the State, or an entity operating the 
pool on behalf of the State, shall establish— 
(1) the premium amount the ceding issuer shall 
pay to the reinsurance pool; 
(2) the applicable attachment points or coinsur-
ance percentages if the ceding issuer retains any 
portion of the risk under ceded policies, except that 
the provisions of subparagraphs (C) and (D) of sub-
section (c)(2) shall apply to such high risk pool in 
the same manner as such clauses apply to the Fed-
eral default high risk pool; and 
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(3) the mechanism by which high-risk individ-
uals are designated for cession to the pool, which 
may include a list of designated high-cost health 
conditions. 
(f) APPROPRIATIONS.—There is appropriated to the 
Secretary 
of 
Health 
and 
Human 
Services 
$200,000,000,000 to carry out this section for the period 
of fiscal year 2021 through fiscal year 2029. 
(g) TAX ON HEALTH INSURANCE PLANS SOLD ON 
EXCHANGES.— 
(1) IN GENERAL.—Chapter 34 of the Internal 
Revenue Code of 1986 is amended by adding at the 
end the following new subchapter: 
‘‘Subchapter C—Additional Tax on Health In-
surance Plans Sold by Insurers Offering 
Plans on Exchanges 
‘‘Sec. 4401. Additional tax on health insurance plans sold by insurers offering 
plans on exchanges. 
‘‘SEC. 4401. ADDITIONAL TAX ON HEALTH INSURANCE 
PLANS SOLD BY INSURERS OFFERING PLANS 
ON EXCHANGES. 
‘‘(a) IMPOSITION OF TAX.—There is imposed a tax 
of $4 for each policy month of each health insurance policy 
sold by insurers offering plans through an Exchange es-
tablished under the Patient Protection and Affordable 
Care Act. 
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‘‘(b) LIABILITY.—The tax imposed by subsection (a) 
shall be paid by the plan sponsor.’’. 
(2) CONFORMING AMENDMENT.—The table of 
subchapters for chapter 34 of the Internal Revenue 
Code of 1986 is amended by adding at the end the 
following item: 
‘‘SUBCHAPTER C—ADDITIONAL TAX ON HEALTH INSURANCE PLANS SOLD BY 
INSURERS OFFERING PLANS ON EXCHANGES’’. 
(3) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply with respect to months 
beginning after the date of enactment of this Act. 
(h) REPORT.—The Secretary of Health and Human 
Services, in collaboration with the Comptroller General of 
the United States, shall submit to Congress, not later than 
January 1, 2026, and again 5 years thereafter, a report 
on the status of reinsurance pool funding, along with any 
recommendations with respect to future allocations or 
funding methods for such pool. 
SEC. 222. EMPLOYER HEALTH INSURANCE MANDATE RE-
PEAL. 
(a) IN GENERAL.—Chapter 43 of the Internal Rev-
enue Code of 1986 is amended by striking section 4980H. 
(b) REPEAL
OF RELATED REPORTING REQUIRE-
MENTS.—Subpart D of part III of subchapter A of chap-
ter 61 of such Code is amended by striking section 6056. 
(c) CONFORMING AMENDMENTS.— 
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(1) Section 6724(d)(1)(B) of such Code is 
amended by inserting ‘‘or’’ at the end of clause 
(xxiii), by striking ‘‘or’’ at the end of clause (xxiv), 
and by striking clause (xxv). 
(2) Section 6724(d)(2) of such Code is amend-
ed by inserting ‘‘or’’ at the end of subparagraph 
(GG) and by striking subparagraph (HH). 
(3) The table of sections for chapter 43 of such 
Code is amended by striking the item relating to sec-
tion 4980H. 
(4) The table of sections for subpart D of part 
III of subchapter A of chapter 61 of such Code is 
amended by striking the item relating to section 
6056. 
(5) Section 1513 of the Patient Protection and 
Affordable Care Act is amended by striking sub-
section (c). 
(d) EFFECTIVE DATE.— 
(1) IN
GENERAL.—Except as otherwise pro-
vided in this subsection, the amendments made by 
this section shall apply to months and other periods 
beginning after December 31, 2021. 
(2) REPEAL
OF
STUDY
AND
REPORT.—The 
amendment made by subsection (c)(5) shall take ef-
fect on the date of the enactment of this Act. 
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178 
SEC. 223. REFUNDABLE CREDITS FOR COVERAGE UNDER A 
QUALIFIED HEALTH PLAN FOR INDIVIDUALS 
OFFERED 
EMPLOYER-SPONSORED 
INSUR-
ANCE. 
(a) IN GENERAL.—Section 36B(c)(2) of the Internal 
Revenue Code of 1986 is amended— 
(1) in subparagraph (B)(i), by inserting ‘‘or 
section 5000A(f)(1)(B)’’, and 
(2) by striking subparagraph (C). 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
the date of the enactment of this Act. 
SEC. 224. INCLUSION IN INCOME OF CERTAIN COSTS OF 
EMPLOYER-PROVIDED 
COVERAGE 
UNDER 
HEALTH PLANS. 
(a) IN GENERAL.—Section 106 of the Internal Rev-
enue Code of 1986 is amended by adding at the end the 
following new subsection: 
‘‘(h) LIMITATION.— 
‘‘(1) IN
GENERAL.—Subsection (a) shall not 
apply to the extent that employer-provided coverage 
under health plans for an employee for a taxable 
year exceeds— 
‘‘(A) $10,200 for self-only coverage, and 
‘‘(B) $27,500 for all other coverage. 
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‘‘(2) IN GENERAL.—In the case of any calendar 
year after 2021, the dollar amounts in paragraph 
(1) shall each be increased by an amount equal to— 
‘‘(A) such dollar amount, multiplied by— 
‘‘(B) the cost-of-living adjustment deter-
mined under section 1(f)(3) for such calendar 
year, determined 
‘‘(i) by substituting ‘calendar year 
2021’ for ‘calendar year 2016’ in subpara-
graph (A)(ii) thereof, and 
‘‘(ii) by substituting for the C–CPI–U 
referred to in section 1(f)(3)(A) the 
amount that such CPI would have been if 
the annual percentage increase in CPI with 
respect to each year after 2021 and before 
2031 had been one percentage point great-
er. 
‘‘(3) TERMS RELATED TO CPI.— 
‘‘(A) ANNUAL PERCENTAGE INCREASE.— 
For purposes of subparagraph (B)(ii)(II), the 
term ‘annual percentage increase’ means the 
percentage (if any) by which C–CPI–U for any 
year exceeds the C–CPI–U for the prior year. 
‘‘(B) OTHER TERMS.—Terms used in this 
paragraph which are also used in section 
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180 
1(f)(3) shall have the same meanings as when 
used in such section.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to taxable years begin-
ning after December 31, 2021. 
SEC. 225. CHANGE IN PERMISSIBLE AGE VARIATION IN 
HEALTH INSURANCE PREMIUM RATES. 
Section 2701(a)(1)(A)(iii) of the Public Health Serv-
ice Act (42 U.S.C. 300gg(a)(1)(A)(iii)) is amended by in-
serting after ‘‘(consistent with section 2707(c))’’ the fol-
lowing: ‘‘or, for plan years beginning on or after January 
1, 2021, as the Secretary may implement through interim 
final regulation, 5 to 1 for adults (consistent with section 
2707(c))’’. 
SEC. 226. PREMIUM ASSISTANCE ADJUSTMENT TO RE-
FLECT AGE. 
(a) MODIFICATION OF APPLICABLE PERCENTAGE.— 
Section 36B(b)(3)(A) of the Internal Revenue Code of 
1986 is amended to read as follows: 
‘‘(A) APPLICABLE PERCENTAGE.— 
‘‘(i) IN
GENERAL.—The applicable 
percentage for any taxable year shall be 
the percentage such that the applicable 
percentage for any taxpayer whose house-
hold income is within an income tier speci-
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fied in the following table shall increase, on 
a sliding scale in a linear manner, from the 
initial percentage to the final percentage 
specified in such table for such income tier 
with respect to a taxpayer of the age in-
volved: 
‘‘In the case of 
household income 
(expressed as a 
percent of the 
poverty line) 
within the 
following 
income tier: 
Up to Age 29 
Age 30–39 
Age 40–49 
Age 50–59 
Over Age 59 
Initial 
% 
Final 
% 
Initial 
% 
Final 
% 
Initial 
% 
Final 
% 
Initial 
% 
Final 
% 
Initial 
% 
Final 
% 
Up to 100% 
100%–133% 
133%–150% 
4.3 
4.3 
4.3 
4.3 
4.3 
150%–200% 
4.3 
6.7 
4.3 
6.7 
4.3 
6.7 
4.3 
6.7 
4.3 
6.7 
200%–250% 
6.7 
6.7 
6.7 
7.6 
6.7 
8.5 
6.7 
8.5 
6.7 
8.5 
250%–300% 
6.7 
6.7 
7.6 
7.6 
8.3 
9.8 
8.3 
9.8 
8.3 
9.8 
300%–400% 
6.7 
7.6 
9.8 
9.8 
9.8 
400%-600% 
‘‘(ii) AGE DETERMINATIONS.— 
‘‘(I) IN GENERAL.—For purposes 
of clause (i), the age of the taxpayer 
taken into account under clause (i) 
with respect to any taxable year is the 
age attained by such taxpayer before 
the close of such taxable year. 
‘‘(II) JOINT
RETURNS.—In the 
case of a joint return, the age of the 
older spouse shall be taken into ac-
count under clause (i). 
‘‘(iii) INDEXING.—In the case of any 
taxable year beginning after calendar year 
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2021, the initial and final percentages con-
tained in clause (i) shall be adjusted to re-
flect— 
‘‘(I) the excess (if any) of the 
rate of premium growth for the period 
beginning with calendar year 2013 
and ending with calendar year 2021, 
over the rate of income growth for 
such period, and 
‘‘(II) in addition to any adjust-
ment under subclause (I), the excess 
(if any) of the rate of premium 
growth for calendar year 2021, over 
the rate of growth in the consumer 
price index for calendar year 2021. 
‘‘(iv) FAILSAFE.—Clause (iii)(II) shall 
apply only if the aggregate amount of pre-
mium tax credits under this section and 
cost-sharing reductions under section 1402 
of the Patient Protection and Affordable 
Care Act for the preceding calendar year 
exceeds an amount equal to 0.504 percent 
of the gross domestic product for such cal-
endar year.’’. 
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(b) EXPANSION OF ELIGIBILITY.—Section 36B of the 
Internal Revenue Code of 1986 is amended— 
(1) in subsection (c)(1)(A), by striking ‘‘400’’ 
and inserting ‘‘600’’; and 
(2) in subsection (f)(2)(B)(i), by striking ‘‘400’’ 
each place such reference appears and inserting 
‘‘600’’ in each such place. 
(c) EFFECTIVE DATE.—The amendment made by 
this section shall apply to taxable years beginning after 
December 31, 2021. 
SEC. 227. PREMIUM ASSISTANCE. 
Notwithstanding any other provision of law, the Sec-
retary of the Treasury shall calculate the credit allowable 
under section 36B of the Internal Revenue Code of 1986 
based on the taxpayer’s prior year tax return and the Sec-
retary of Health and Human Services shall provide for 
open enrollment periods that end on April 15. 
SEC. 228. ADDING COPPER PLANS TO EXCHANGES. 
(a) IN GENERAL.—Section 1302 of the Patient Pro-
tection and Affordable Care Act (42 U.S.C. 18022) is 
amended— 
(1) in subsection (a)(3), by inserting ‘‘copper,’’ 
after ‘‘either the’’; 
(2) in subsection (c), by adding at the end the 
following new paragraph: 
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‘‘(5) SPECIAL RULE FOR COPPER PLANS.—A 
health plan in the copper level of coverage (as de-
scribed in subsection (d)(1)(E)) shall be deemed to 
meet the requirements of this subsection.’’; 
(3) in subsection (d)— 
(A) in paragraph (1), by adding at the end 
the following new subparagraph: 
‘‘(E) COPPER LEVEL.—A plan in the cop-
per level shall provide a level of coverage that 
is designed to provide benefits that are actuari-
ally equivalent to 50 percent of the full actu-
arial value of the benefits provided under the 
plan and will have out-of-pocket limits that are 
30 percent higher than bronze plans.’’; and 
(B) in paragraph (4)— 
(i) by inserting ‘‘copper,’’ after ‘‘any 
reference to a’’; and 
(ii) by inserting ‘‘copper,’’ after ‘‘pro-
viding a’’; and 
(4) in subsection (e)(1), by inserting ‘‘copper,’’ 
after ‘‘not providing a’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to plan years begin-
ning on or after January 1, 2021. 
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SEC. 229. COPPER AND BRONZE PLANS. 
Notwithstanding any other provision of law, refund-
able credits for coverage under a qualified health plan and 
cost-sharing reductions may be used to purchase bronze 
and copper plans. 
SEC. 230. WAIVERS FOR STATE INNOVATION. 
(a) STREAMLINING THE STATE APPLICATION PROC-
ESS.—Section 1332 of the Patient Protection and Afford-
able Care Act (42 U.S.C. 18052) is amended— 
(1) in subsection (a)(1)(C), by striking ‘‘the 
law’’ and inserting ‘‘a law or has in effect a certifi-
cation’’; and 
(2) in subsection (b)(2)— 
(A) in the paragraph heading, by inserting 
‘‘OR CERTIFY’’ after ‘‘LAW’’; 
(B) in subparagraph (A)— 
(i) by striking ‘‘A law’’ and inserting 
the following: 
‘‘(i) LAWS.—A law’’; and 
(ii) by adding at the end the fol-
lowing: 
‘‘(ii) 
CERTIFICATIONS.—A 
certifi-
cation described in this paragraph is a doc-
ument, signed by the Governor of the 
State, that certifies that such Governor 
has the authority under existing Federal 
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and State law to take action under this 
section, including implementation of the 
State plan under subsection (a)(1)(B).’’; 
and 
(C) in subparagraph (B)— 
(i) in the subparagraph heading, by 
striking ‘‘OF OPT OUT’’; and 
(ii) by striking ‘‘may repeal a law’’ 
and all that follows through the period at 
the end and inserting the following: ‘‘may 
terminate the authority provided under the 
waiver with respect to the State by— 
‘‘(i) repealing a law described in sub-
paragraph (A)(i); or 
‘‘(ii) terminating a certification de-
scribed in subparagraph (A)(ii), through a 
certification for such termination signed by 
the Governor of the State.’’. 
(b) PROVIDING EXPEDITED APPROVAL OF STATE 
WAIVERS.—Section 1332(d) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18052(d)) is amended— 
(1) in paragraph (1) by striking ‘‘180’’ and in-
serting ‘‘90’’; and 
(2) by adding at the end the following: 
‘‘(3) EXPEDITED DETERMINATION.— 
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‘‘(A) IN GENERAL.—With respect to any 
application under subsection (a)(1) submitted 
on or after the date of this paragraph or any 
such application submitted prior to such date of 
enactment and under review by the Secretary 
on such date of enactment, the Secretary shall 
make a determination on such application, 
using the criteria for approval otherwise appli-
cable under this section, not later than 45 days 
after the receipt of such application, and shall 
allow the public notice and comment at the 
State and Federal levels described under sub-
section (a)(4) to occur concurrently if such 
State application— 
‘‘(i) is submitted in response to an ur-
gent situation, with respect to areas in the 
State that the Secretary determines are at 
risk for excessive premium increases or 
having no health plans offered in the appli-
cable health insurance market for the cur-
rent or following plan year; or 
‘‘(ii) is for a waiver that is the same 
or substantially similar to a waiver that 
the Secretary already has approved for an-
other State. 
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‘‘(B) APPROVAL.— 
‘‘(i) URGENT SITUATIONS.— 
‘‘(I) PROVISIONAL APPROVAL.—A 
waiver approved under the expedited 
determination process under subpara-
graph (A)(i) shall be in effect for a 
period of 3 years, unless the State re-
quests a shorter duration. 
‘‘(II) FULL APPROVAL.—Subject 
to the requirements for approval oth-
erwise applicable under this section, 
not later than 1 year before the expi-
ration of a provisional waiver period 
described in subclause (I) with respect 
to an application described in sub-
paragraph (A)(i), the Secretary shall 
make a determination on whether to 
extend the approval of such waiver for 
the full term of the waiver requested 
by the State, for a total approval pe-
riod not to exceed 6 years. The Sec-
retary may request additional infor-
mation as the Secretary determines 
appropriate to make such determina-
tion. 
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‘‘(ii) APPROVAL OF SAME OR SIMILAR 
APPLICATIONS.—An approval of a waiver 
under subparagraph (A)(ii) shall be subject 
to the terms of subsection (e). 
‘‘(C) GAO STUDY.—Not later than 5 years 
after the date of enactment of this paragraph, 
the Comptroller General of the United States 
shall conduct a review of all waivers approved 
pursuant to an application under subparagraph 
(A)(ii) to evaluate whether such waivers met 
the requirements of subsection (b)(1) and 
whether the applications should have qualified 
for such expedited process.’’. 
(c) PROVIDING CERTAINTY FOR STATE-BASED RE-
FORMS.—Section 1332(e) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18052(e)) is amended by 
striking ‘‘No waiver’’ and all that follows through the pe-
riod at the end and inserting the following: ‘‘A waiver 
under this section— 
‘‘(1) shall be in effect for a period of 6 years 
unless the State requests a shorter duration; 
‘‘(2) may be renewed, subject to the State meet-
ing the criteria for approval otherwise applicable 
under this section, for unlimited additional 6-year 
periods upon application by the State; and 
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‘‘(3) may not be suspended or terminated, in 
whole or in part, by the Secretary at any time before 
the date of expiration of the waiver period (including 
any renewal period under paragraph (2)), unless the 
Secretary determines that the State materially failed 
to comply with the terms and conditions of the waiv-
er.’’. 
(d) ENSURING PATIENT ACCESS TO MORE FLEXIBLE 
HEALTH PLANS.—Section 1332(b)(1)(B) of the Patient 
Protection 
and 
Affordable 
Care 
Act 
(42 
U.S.C. 
18052(b)(1)(B)) is amended by striking ‘‘at least as af-
fordable’’ and inserting ‘‘of comparable affordability, in-
cluding for low-income individuals, individuals with serious 
health needs, and other vulnerable populations,’’. 
(e) APPLICABILITY.—The amendments made by this 
Act to section 1332 of the Patient Protection and Afford-
able Care Act (42 U.S.C. 18052)— 
(1) with respect to applications for waivers 
under such section 1332 submitted after the date of 
enactment of this Act and applications for such 
waivers submitted prior to such date of enactment 
and under review by the Secretary on the date of en-
actment, shall take effect on the date of enactment 
of this Act; and 
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(2) with respect to applications for waivers ap-
proved under such section 1332 before the date of 
enactment of this Act, shall not require reconsider-
ation of whether such applications meet the require-
ments of such section 1332, except that, at the re-
quest of a State, the Secretary shall recalculate the 
amount of funding provided under subsection (a)(3) 
of such section. 
SEC. 231. ENROLLMENT PERIODS. 
(a) EXCHANGES.—Paragraph (7) of section 1311(c) 
of the Patient Protection and Affordable Care Act (42 
U.S.C. 18031(c)), as added by section 106, is amended 
by adding at the end the following new subparagraph: 
‘‘(B) ENROLLMENTS OTHER THAN DURING 
INITIAL, OPEN, AND SPECIAL ENROLLMENT PE-
RIODS.—Beginning with plan year 2021, an Ex-
change may provide for enrollments during pe-
riods in addition to open enrollment periods de-
scribed in subparagraph (A) or paragraph (6) 
and special enrollment periods described in 
paragraph (6).’’. 
(b) HEALTH PLANS.—Subpart I of part A of title 
XXVII of the Public Health Service Act is amended by 
adding at the end the following new section: 
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‘‘SEC. 2710. ENROLLMENT OUTSIDE OF INITIAL, OPEN, AND 
SPECIAL ENROLLMENT PERIOD. 
‘‘Beginning with plan year 2021, a group health plan 
and a health insurance issuer offering group or individual 
health insurance coverage may provide for enrollment in 
such plan or coverage during periods in addition to initial, 
open, or special enrollment periods. In the case that an 
individual enrolls in such plan or coverage during a period 
pursuant to the previous sentence, the plan or issuer may 
charge the individual a one-time enrollment fee.’’. 
SEC. 232. STATE-OPERATED EXCHANGES FLEXIBILITY FOR 
OPEN ENROLLMENT PERIODS. 
Section 1311(c) of the Patient Protection and Afford-
able Care Act (42 U.S.C. 18031(c)) is amended— 
(1) in paragraph (6), by striking ‘‘The Sec-
retary’’ and inserting ‘‘Subject to paragraph (7), the 
Secretary’’; and 
(2) by adding at the end the following new 
paragraph: 
‘‘(7) FLEXIBILITY
FOR
ENROLLMENT
PERI-
ODS.— 
‘‘(A) STATE-OPERATED EXCHANGES OPEN 
ENROLLMENT PERIODS.—In the case of an Ex-
change operated by a State, beginning with 
plan year 2021, the Exchange may provide for 
open enrollment periods (after the initial enroll-
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ment period) every 12, 24, or 36 months, as de-
termined by the State.’’. 
SEC. 233. PROMOTING HEALTH PLANS THAT COVER INDI-
VIDUALS IN MORE THAN ONE STATE. 
There are appropriated, out of amounts in the Treas-
ury not otherwise appropriated, $10,000,000 to be made 
available by December 31, 2021, to the Center for Medi-
care & Medicaid Innovation to fund new research or pilot 
programs dedicated to pursuing viable methods of enroll-
ing individuals in health insurance programs that cross 
State lines. 
TITLE 
III—COMPETITION, 
TRANSPARENCY 
AND 
AC-
COUNTABILITY 
Subtitle A—Provider and Insurer 
Competition 
SEC. 301. HOSPITAL CONSOLIDATION. 
(a) AUTHORIZATION OF APPROPRIATIONS.—There is 
authorized to be appropriated $160,000,000 to the Fed-
eral Trade Commission to hire staff to investigate, as con-
sistent with the Sherman Antitrust Act and other relevant 
Federal laws, anti-competitive mergers and practices 
under such laws to the extent such mergers and practices 
relate to providers of inpatient and outpatient health care 
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services, as defined by the Secretary of Health and 
Human Services. 
(b) MEDICARE ADVANTAGE RATES APPLIED TO CER-
TAIN HHI HOSPITALS.— 
(1) IN GENERAL.—Section 1866(a) of the So-
cial Security Act (42 U.S.C. 1395cc(a)) is amend-
ed— 
(A) in paragraph (1)— 
(i) in subparagraph (X), by striking 
‘‘and’’ at the end; 
(ii) in subparagraph (Y), by striking 
the period at the end and inserting ‘‘; 
and’’; and 
(iii) by inserting after subparagraph 
(Y) the following new subparagraph: 
‘‘(Z) subject to paragraph (4), in the case 
of a hospital located in a county whose popu-
lation density is above the median population 
density for all counties in the United States 
with respect to which there is a Herfindahl- 
Hirschman Index (HHI) of greater than 4,000, 
to apply the average reimbursement rate with 
respect to individuals (regardless of whether 
such an individual is entitled to or eligible for 
benefits under this title, but excluding individ-
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uals eligible for medical assistance under a 
State plan under title XIX) furnished items and 
services at such hospital that would be billable 
under this title for such items and services if 
furnished by such hospital to an individual en-
rolled under part C.’’; and 
(B) by adding at the end the following new 
paragraph: 
‘‘(4)(A) The requirement under paragraph 
(1)(Z) shall not apply in the case of a hospital in a 
hospital referral region if— 
‘‘(i) the HRR market share of such hos-
pital (as determined under subparagraph (B)) 
is less than 0.15; or 
‘‘(ii) the hospital is located in a rural area 
(as defined in section 1886(d)(2)(D)). 
‘‘(B) For purposes of subparagraph (A), the 
HRR market share of a hospital in a hospital refer-
ral region is equal to— 
‘‘(i) the total revenue of the hospital, di-
vided by 
‘‘(ii) the total revenue of all hospital in the 
hospital referral region.’’. 
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(2) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply with respect to items 
and services furnished on or after January 1, 2021. 
(c) GRANTS FOR HOSPITAL INFRASTRUCTURE IM-
PROVEMENT.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services shall carry out a grant program 
under which the Secretary shall provide grants to el-
igible States, in accordance with this subsection. 
(2) USES.—An eligible State receiving a grant 
under this subsection may use such grant to improve 
the State hospital infrastructure and to supplement 
any other funds provided for a purpose authorized 
under a State or local hospital grant program under 
State law. 
(3) ELIGIBILITY.— 
(A) IN GENERAL.—An eligible State may 
receive not more than one grant under this sub-
section with respect to each qualifying criterion 
described in subparagraph (B) that is met by 
the State. 
(B) ELIGIBLE
STATE.—For purposes of 
this subsection, the term ‘‘eligible State’’ means 
a State that meets any one or more of the fol-
lowing qualifying criteria: 
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(i) The State does not have in effect 
any State certificate of need law that re-
quires a health care provider to provide to 
a regulatory body a certification that the 
community needs the services provided by 
the health care provider. 
(ii) The State has in effect State 
scope of practice laws that— 
(I) allow advanced practice pro-
viders (such as nurse practitioners, 
advanced practice registered nurses, 
clinical nurse specialists, and physi-
cian assistants) to evaluate patients; 
diagnose, order, and interpret diag-
nostic tests; and initiate and manage 
treatments; or 
(II) provide that the only jus-
tification for limiting the scope of 
practice of a health care provider is 
safety to the public. 
(iii) The State does not have in effect 
any State laws that require managed care 
plans to accept into the network of such 
plan any qualified provider who is willing 
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198 
to accept the terms and conditions of the 
managed care plan. 
(iv) The State does not have in effect 
any Certificate of Public Advantage laws 
that clearly articulate the State’s intent to 
displace competition in favor of regulation 
or that violate State or Federal antitrust 
laws. 
(v) The State does not have in effect 
any network adequacy laws regulating a 
health plan’s ability to deliver benefits by 
providing reasonable access to a sufficient 
number of in-network primary care and 
specialty physicians, as well as all health 
care services included under the terms of 
an insuree’s contract with a health insurer. 
(4) FUNDING.—There is authorized to be ap-
propriated 
to 
carry 
out 
this 
subsection 
$1,000,000,000 for each of the fiscal years 2019 
through 2028. Funds appropriated under this para-
graph shall remain available until expended. 
(d) CRITICAL ACCESS HOSPITAL REIMBURSEMENT 
RATES.— 
(1) PART A.—Section 1814(l)(1) of the Social 
Security Act (42 U.S.C. 1395f(l)(1)) is amended by 
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199 
inserting ‘‘(or, for 2021, 102, plus 1 percentage 
point for each subsequent year through 2029, and 
110 for each subsequent year thereafter)’’ after 
‘‘101’’. 
(2) PART B.—Section 1834(g)(1) of such Act 
(42 U.S.C. 1395m(g)(1)) is amended by inserting 
‘‘(or, for 2021, 102, plus 1 percentage point for each 
subsequent year through 2029, and 110 for each 
subsequent year thereafter)’’ after ‘‘101’’. 
SEC. 302. AUTHORITY OF FEDERAL TRADE COMMISSION 
OVER 
CERTAIN 
TAX-EXEMPT 
ORGANIZA-
TIONS. 
Section 4 of the Federal Trade Commission Act (15 
U.S.C. 44) is amended, in the undesignated paragraph re-
lating to the definition of the term ‘‘Corporation’’— 
(1) by striking ‘‘, and any’’ and inserting ‘‘, 
any’’; and 
(2) by inserting before the period at the end the 
following: ‘‘, and any organization described in sec-
tion 501(c)(3) of the Internal Revenue Code of 1986 
that is exempt from taxation under section 501(a) of 
such Code’’. 
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200 
SEC. 303. RESTORING THE APPLICATION OF ANTITRUST 
LAWS TO THE BUSINESS OF HEALTH INSUR-
ANCE. 
(a) AMENDMENT TO MCCARRAN-FERGUSON ACT.— 
Section 3 of the Act of March 9, 1945 (15 U.S.C. 1013), 
commonly known as the McCarran-Ferguson Act, is 
amended by adding at the end the following: 
‘‘(c)(1) Nothing contained in this Act shall modify, 
impair, or supersede the operation of any of the antitrust 
laws with respect to the business of health insurance (in-
cluding the business of dental insurance and limited-scope 
dental benefits). 
‘‘(2) Paragraph (1) shall not apply with respect to 
making a contract, or engaging in a combination or con-
spiracy— 
‘‘(A) to collect, compile, or disseminate histor-
ical loss data; 
‘‘(B) to determine a loss development factor ap-
plicable to historical loss data; 
‘‘(C) to perform actuarial services if such con-
tract, combination, or conspiracy does not involve a 
restraint of trade; or 
‘‘(D) to develop or disseminate a standard in-
surance policy form (including a standard addendum 
to an insurance policy form and standard termi-
nology in an insurance policy form) if such contract, 
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201 
combination, or conspiracy is not to adhere to such 
standard form or require adherence to such standard 
form. 
‘‘(3) For purposes of this subsection— 
‘‘(A) the term ‘antitrust laws’ has the meaning 
given it in subsection (a) of the first section of the 
Clayton Act (15 U.S.C. 12), except that such term 
includes section 5 of the Federal Trade Commission 
Act (15 U.S.C. 45) to the extent that such section 
5 applies to unfair methods of competition; 
‘‘(B) the term ‘business of health insurance (in-
cluding the business of dental insurance and limited- 
scope dental benefits)’ does not include— 
‘‘(i) the business of life insurance (includ-
ing annuities); or 
‘‘(ii) the business of property or casualty 
insurance, including but not limited to— 
‘‘(I) any insurance or benefits defined 
as ‘excepted benefits’ under paragraph (1), 
subparagraph (B) or (C) of paragraph (2), 
or paragraph (3) of section 9832(c) of the 
Internal Revenue Code of 1986 (26 U.S.C. 
9832(c)) whether offered separately or in 
combination with insurance or benefits de-
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scribed in paragraph (2)(A) of such sec-
tion; and 
‘‘(II) any other line of insurance that 
is classified as property or casualty insur-
ance under State law; 
‘‘(C) the term ‘historical loss data’ means infor-
mation respecting claims paid, or reserves held for 
claims reported, by any person engaged in the busi-
ness of insurance; and 
‘‘(D) the term ‘loss development factor’ means 
an adjustment to be made to reserves held for losses 
incurred for claims reported by any person engaged 
in the business of insurance, for the purpose of 
bringing such reserves to an ultimate paid basis.’’. 
(b) RELATED PROVISION.—For purposes of section 
5 of the Federal Trade Commission Act (15 U.S.C. 45) 
to the extent such section applies to unfair methods of 
competition, section 3(c) of the McCarran-Ferguson Act 
shall apply with respect to the business of health insurance 
without regard to whether such business is carried on for 
profit, notwithstanding the definition of ‘‘Corporation’’ 
contained in section 4 of the Federal Trade Commission 
Act. 
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203 
SEC. 304. LEVELING THE PLAYING FIELD BETWEEN PAYERS 
AND PROVIDERS. 
(a) EXEMPTION.—It shall not be a violation of the 
antitrust laws for one or more private health insurer 
issuers or their designated agents to jointly negotiate 
prices of particular hospital services with a hospital pro-
vider with regards to the reimbursement policies of the 
insurers for those services. 
(b) DEFINITIONS.—For purposes of this section: 
(1) ANTITRUST
LAWS.—The term ‘‘antitrust 
laws’’ has the meaning given it in subsection (a) of 
the 1st section of the Clayton Act (15 U.S.C. 12(a)), 
except that such term includes section 5 of the Fed-
eral Trade Commission Act (15 U.S.C. 45) to the 
extent such section 5 applies to unfair methods of 
competition. 
(2) HEALTH
INSURANCE
ISSUER.—The term 
‘‘health insurance issuer’’ means an insurance com-
pany, insurance service, or insurance organization 
(including a health maintenance organization, as de-
fined in subparagraph (C)) which is licensed to en-
gage in the business of insurance in a State and 
which is subject to State law which regulates insur-
ance (within the meaning of section 514(b)(2) of the 
Employee Retirement Income Security Act of 1974 
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204 
(29 U.S.C. 1144(b)(2)). Such term does not include 
a group health plan. 
(3) HEALTH MAINTENANCE ORGANIZATION.— 
The 
term 
‘‘health 
maintenance 
organization’’ 
means— 
(A) a Federally qualified health mainte-
nance organization (as defined in section 
300e(a) of title 42 of the United States Code), 
(B) an organization recognized under State 
law as a health maintenance organization, or 
(C) a similar organization regulated under 
State law for solvency in the same manner and 
to the same extent as such a health mainte-
nance organization. 
(c) EFFECTIVE DATE.—This section shall take effect 
on the date of the enactment of this Act but shall not 
apply with respect to conduct that occurs before such date. 
SEC. 305. INCREASING TRANSPARENCY BY REMOVING GAG 
CLAUSES ON PRICE AND QUALITY INFORMA-
TION. 
Subpart II of part A of title XXVII of the Public 
Health Service Act (42 U.S.C. 300gg–11 et seq.), as 
amended by the preceding sections, is amended by adding 
at the end the following: 
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205 
‘‘SEC. 2729B. INCREASING TRANSPARENCY BY REMOVING 
GAG CLAUSES ON PRICE AND QUALITY IN-
FORMATION. 
‘‘(a) INCREASING
PRICE
AND
QUALITY
TRANS-
PARENCY FOR PLAN SPONSORS AND GROUP AND INDI-
VIDUAL MARKET AND CONSUMERS.— 
‘‘(1) GROUP HEALTH PLANS.—A group health 
plan or health insurance issuer offering group health 
insurance coverage may not enter into an agreement 
with a health care provider, network or association 
of providers, third-party administrator, or other 
service provider offering access to a network of pro-
viders that would directly or indirectly restrict a 
group health plan or health insurance issuer from— 
‘‘(A) providing provider-specific cost or 
quality of care information, through a consumer 
engagement tool or any other means, to refer-
ring providers, the plan sponsor, enrollees, or 
eligible enrollees of the plan or coverage; 
‘‘(B) electronically accessing de-identified 
claims and encounter data for each enrollee in 
the plan or coverage, upon request and con-
sistent with the privacy regulations promul-
gated pursuant to section 264(c) of the Health 
Insurance Portability and Accountability Act, 
the amendments to this Act made by the Ge-
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206 
netic Information Nondiscrimination Act of 
2008, and the Americans with Disabilities Act 
of 1990, with respect to the applicable health 
plan or health insurance coverage, including, on 
a per claim basis— 
‘‘(i) financial information, such as the 
allowed amount, or any other claim-related 
financial obligations included in the pro-
vider contract; 
‘‘(ii) provider information, including 
name and clinical designation; 
‘‘(iii) service codes; or 
‘‘(iv) any other data element normally 
included in claim or encounter transactions 
when received by a plan or issuer; or 
‘‘(C) sharing data described in subpara-
graph (A) or (B) with a business associate as 
defined in section 160.103 of title 45, Code of 
Federal Regulations (or successor regulations), 
consistent with the privacy regulations promul-
gated pursuant to section 264(c) of the Health 
Insurance Portability and Accountability Act, 
the amendments to this Act made by the Ge-
netic Information Nondiscrimination Act of 
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207 
2008, and the Americans with Disabilities Act 
of 1990. 
‘‘(2) INDIVIDUAL
HEALTH
INSURANCE
COV-
ERAGE.—A health insurance issuer offering indi-
vidual health insurance coverage may not enter into 
an agreement with a health care provider, network 
or association of providers, or other service provider 
offering access to a network of providers that would 
directly or indirectly restrict the health insurance 
issuer from— 
‘‘(A) providing provider-specific price or 
quality of care information, through a consumer 
engagement tool or any other means, to refer-
ring providers, enrollees, or eligible enrollees of 
the plan or coverage; or 
‘‘(B) sharing, for plan design, plan admin-
istration, and plan, financial, legal, and quality 
improvement activities, data described in sub-
paragraph (A) with a business associate as de-
fined in section 160.103 of title 45, Code of 
Federal Regulations (or successor regulations), 
consistent with the privacy regulations promul-
gated pursuant to section 264(c) of the Health 
Insurance Portability and Accountability Act, 
the amendments to this Act made by the Ge-
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208 
netic Information Nondiscrimination Act of 
2008, and the Americans with Disabilities Act 
of 1990. 
‘‘(3) CLARIFICATION REGARDING PUBLIC DIS-
CLOSURE OF INFORMATION.—Nothing in paragraph 
(1)(A) or (2)(A) prevents a health care provider, 
network or association of providers, or other service 
provider from placing reasonable restrictions on the 
public disclosure of the information described in 
such paragraphs (1) and (2). 
‘‘(4) ATTESTATION.—A group health plan or a 
health insurance issuer offering group or individual 
health insurance coverage shall annually submit to, 
as applicable, the applicable authority described in 
section 2723 or the Secretary of Labor, an attesta-
tion that such plan or issuer is in compliance with 
the requirements of this subsection. 
‘‘(5) RULE
OF
CONSTRUCTION.—Nothing in 
this section shall be construed to otherwise limit 
group health plan, plan sponsor, or health insurance 
issuer access to data currently permitted under the 
privacy regulations promulgated pursuant to section 
264(c) of the Health Insurance Portability and Ac-
countability Act, the amendments to this Act made 
by the Genetic Information Nondiscrimination Act of 
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225 
‘‘(ii) authorized users, including em-
ployers, employee organizations, providers, 
group health plans, health insurance 
issuers, researchers, and policymakers, 
subject to subsection (e). 
‘‘(2) PRIVACY AND SECURITY; BREACH NOTIFI-
CATIONS.— 
‘‘(A) REGULATIONS.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall issue regulations prescribing the ex-
tent to which, and the manner in which, 
the following rules (and any successors of 
such rules) shall apply to the activities 
under this section of an entity receiving a 
contract under subsection (a): 
‘‘(I) The Privacy Rule under part 
160 and subparts A and E of part 
164 of title 45, Code of Federal Regu-
lations (or any successor regulations). 
‘‘(II) The Security Rule under 
part 160 and subparts A and C of 
part 164 of such title 45 (or any suc-
cessor regulations). 
‘‘(III) The Breach Notification 
Rule under part 160 and subparts A 
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