I 
112TH CONGRESS 
2D SESSION 
H. R. 6283 
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 
AUGUST 2, 2012 
Mr. BURGESS (for himself, Mr. SESSIONS, Mr. BARTON of Texas, and Mr. 
DANIEL E. LUNGREN of California) introduced the following bill; which 
was referred to the Committee on Energy and Commerce, and in addition 
to the Committees on Ways and Means and Education and the Work-
force, for a period to be subsequently determined by the Speaker, in each 
case for consideration of such provisions as fall within the jurisdiction of 
the committee concerned 
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 2012’’. 
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SEC. 2. REPEAL OF CERTAIN HEALTH INSURANCE RE-
QUIREMENTS. 
Title I and subtitle A of title X of the Patient Protec-
tion and Affordable Care Act and section 2301 of the 
Health Care and Education Reconciliation Act of 2010 are 
repealed, and the provisions of law amended or repealed 
by such title, subtitle, and section, respectively, are re-
stored or revived as if such Acts had not been enacted. 
SEC. 3. ENSURING AFFORDABILITY OF HEALTH COVERAGE 
THROUGH HIGH RISK POOLS, REINSURANCE 
PROGRAMS, AND OTHER INNOVATIVE METH-
ODS. 
(a) TREATMENT OF QUALIFIED STATE REINSUR-
ANCE PROGRAM AS AN ALTERNATIVE MECHANISM.—Sec-
tion 2744 of the Public Health Service Act (42 U.S.C. 
300gg–44) is amended— 
(1) in subsection (a)(1)(D)— 
(A) by striking ‘‘or’’ at the end of clause 
(ii); 
(B) by striking the period at the end of 
clause (iii) and inserting a comma; and 
(C) by adding at the end the following: 
‘‘(iv) a qualified reinsurance program 
described in subsection (c)(4), or 
‘‘(v) an innovative method described 
in subsection (c)(5).’’; and 
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(2) in subsection (c), by adding at the end the 
following: 
‘‘(4) QUALIFIED REINSURANCE PROGRAM.—For 
purposes of subsection (a)(1)(D)(iv), a ‘qualified re-
insurance program’ described in this paragraph is a 
program that— 
‘‘(A) is operated by a State (directly, or 
through a contract with an entity that provides 
reinsurance for health insurance coverage of-
fered in the individual market, the small group 
market, or in both such markets); and 
‘‘(B) is designed to make reinsurance pay-
ments to, or otherwise limit the risk of, health 
insurance issuers that provide health insurance 
coverage to eligible individuals in the individual 
market in the State. 
‘‘(5) INNOVATIVE METHOD.—For purposes of 
subsection (a)(1)(D)(v), the term ‘innovative meth-
od’ has the meaning given such term in section 
2745(g).’’. 
(b) SEED GRANTS TO STATES.—Section 2745(a) of 
the Public Health Service Act (42 U.S.C. 300gg–45(a)) 
is amended to read as follows: 
‘‘(a) SEED GRANTS TO STATES.— 
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‘‘(1) IN GENERAL.—The Secretary shall provide 
from the funds appropriated under subsection 
(d)(1)(A) a grant of up to $5,000,000 to a State de-
scribed in paragraph (2) for the State’s costs for the 
creation and initial operation of a qualified high risk 
pool, a qualified reinsurance program, or an innova-
tive method. 
‘‘(2) STATE DESCRIBED.—A State described in 
this paragraph is a State that, as of the date of en-
actment of the Guaranteed Access to Health Insur-
ance Act of 2012, has not created any of the fol-
lowing: 
‘‘(A) A qualified high risk pool. 
‘‘(B) A qualified reinsurance program. 
‘‘(C) An innovative method. 
‘‘(3) LIMITATIONS ON SEED GRANTS.— 
‘‘(A) ONE GRANT PER STATE.—After the 
date of enactment of the Guaranteed Access to 
Health Insurance Act of 2012, a State may re-
ceive only one grant under paragraph (1). 
‘‘(B) ONE YEAR TO SPEND.—The funds 
made available to a State under a grant under 
paragraph (1) shall not be available for obliga-
tion after the end of the 12-month period begin-
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ning on the date that the State receives such 
grant. 
‘‘(C) UNEXPENDED
FUNDS
AVAILABLE 
FOR ALLOTMENT.—Any funds made available 
under a grant under this subsection that are 
not expended in the period under subparagraph 
(B) shall be made available for purpose of allot-
ment under subsection (b).’’. 
(c) GRANTS FOR OPERATIONAL LOSSES.— 
(1) IN
GENERAL.—Paragraph (1) of section 
2745(b) of the Public Health Service Act (42 U.S.C. 
300gg–45(b)(1)) is amended to read as follows: 
‘‘(1) IN GENERAL.— 
‘‘(A) GRANTS FOR POOLS, REINSURANCE 
PROGRAMS, AND
INNOVATIVE
METHODS.—In 
the case of a State that has established a quali-
fied high risk pool described in subparagraph 
(B), a qualified reinsurance program, or an in-
novative method the Secretary shall provide, 
from funds allotted to the State under para-
graph (2), a grant for the losses incurred by the 
State in connection with the operation of the 
qualified high risk pool, qualified reinsurance 
program, or innovative method. 
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‘‘(B) QUALIFIED
HIGH
RISK
POOL
DE-
SCRIBED.—A qualified high risk pool described 
in this subparagraph is a qualified high risk 
pool (as such term is defined in subsection 
(g)(1)) that has in effect a mechanism reason-
ably designed to ensure continued funding of 
losses incurred by the State in connection with 
operation of the pool after the end of the last 
fiscal year for which a grant is provided under 
this paragraph.’’. 
(2) ALLOTMENT.—Paragraph (2) of section 
2745(b) the Public Health Service Act (42 U.S.C. 
300gg–45(b)(2)) is amended— 
(A) in the matter preceding subparagraph 
(A)— 
(i) by striking ‘‘appropriated under 
paragraphs (1)(B)(i) and (2)(A) of sub-
section (d) for a fiscal year’’ and inserting 
‘‘allocated for a fiscal year under sub-
section (d)(2)(A)’’; and 
(ii) by inserting ‘‘, reinsurance pro-
gram, or innovative method’’ after ‘‘oper-
ate the high risk pool’’; 
(B) in subparagraph (A)— 
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(i) by striking ‘‘40’’ and inserting 
‘‘30’’; and 
(ii) by striking ‘‘appropriated’’ and in-
serting ‘‘allocated’’; 
(C) in subparagraph (B), by striking each 
instance of ‘‘appropriated’’ and inserting ‘‘allo-
cated’’; 
(D) in subparagraph (C)— 
(i) by striking each instance of ‘‘ap-
propriated’’ and inserting ‘‘allocated’’; and 
(ii) by striking ‘‘as the number of in-
dividuals’’ and all that follows through the 
end of the subparagraph and inserting the 
following: ‘‘as— 
‘‘(i) the sum of— 
‘‘(I) the number of individuals 
enrolled 
in 
health 
care 
coverage 
through the qualified high risk pool of 
the State; and 
‘‘(II) the number of individuals 
whose health care coverage is covered 
by the qualified reinsurance program 
or innovative method of the State; 
bears to 
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‘‘(ii) the total number of individuals in 
all qualifying States that so apply that are 
so enrolled or so covered (as determined by 
the Secretary).’’; and 
(E) by adding at the end the following new 
subparagraph: 
‘‘(D) An amount equal to 10 percent of 
such allocated amount for the fiscal year shall 
be allotted among qualifying States that apply 
for such a grant so that the amount allotted to 
a State bears the same ratio to such allocated 
amount as— 
‘‘(i) the amount of funds contributed 
to the operation of any qualified high risk 
pool, qualified reinsurance program, or in-
novative method of the State by funding 
sources other than grants under this sub-
section; bears to 
‘‘(ii) the total of the amount described 
in clause (i) for all States.’’. 
(3) CONSISTENT
PREMIUM
RULES.—Section 
2745(b) the Public Health Service Act (42 U.S.C. 
300gg–45(b)) is amended— 
(A) by striking paragraph (3); and 
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(B) by redesignating paragraph (4) as 
paragraph (3). 
(d) PREFERENCE POLICY; NO BONUS GRANTS.— 
Section 2745 of the Public Health Service Act (42 U.S.C. 
300gg–45) is amended by striking subsection (c) and in-
serting the following: 
‘‘(c) PREFERENCE POLICY.—Beginning 3 years after 
the date of the enactment of the Guaranteed Access to 
Health Insurance Act of 2012, for the purpose of pro-
viding access to health insurance for high risk individuals 
in a State, the Secretary, in awarding any competitive 
grant for Federal funding for which the only eligible enti-
ties are States, shall give preference to any State that has 
received a grant under this section in the year during 
which such grant is awarded.’’. 
(e) FUNDING.—Section 2745(d) of the Public Health 
Service Act (42 U.S.C. 300gg–45(d)) is amended— 
(1) by striking paragraphs (1), (2), (3), and (4) 
and inserting the following: 
‘‘(1) APPROPRIATIONS FOR FISCAL YEAR 2013 
AND SUBSEQUENT YEARS.—Out of any funds in the 
Treasury not otherwise appropriated, on October 1, 
2012, there is appropriated to the Secretary, 
$25,000,000,000, to remain available until ex-
pended, to carry out this section, of which— 
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‘‘(A) $35,000,000 is to carry out sub-
section (a); and 
‘‘(B) $22,965,000,000 subject to para-
graph (2), shall be made available for allot-
ments under subsection (b)(2). 
‘‘(2) ALLOTMENTS.— 
‘‘(A) ANNUAL AMOUNT.— 
‘‘(i) IN
GENERAL.—For each fiscal 
year, the Secretary shall determine, from 
the amount available under paragraph 
(1)(B), the amount to allocate to such fis-
cal year for purposes of allotments under 
subsection (b)(2) for such fiscal year. 
‘‘(ii) CRITERIA.—In determining the 
amount for a fiscal year under clause (i), 
the Secretary shall ensure that an ade-
quate, but not excessive, amount of fund-
ing is made available to support qualified 
high risk pools, qualified reinsurance pro-
grams, and innovative methods in the 
States. 
‘‘(B) REALLOTMENT.—If, on June 30 of 
each fiscal year for which the Secretary made 
funds available for allotment under subpara-
graph (A), the Secretary determines that all the 
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amounts made available for allotment for such 
fiscal year are not allotted or otherwise made 
available to States, such remaining amounts 
shall be allotted and made available under sub-
section (b) among States receiving grants under 
subsection (b) for the fiscal year based upon the 
allotment formula specified in such sub-
section.’’; and 
(2) by redesignating paragraph (5) as para-
graph (3). 
(f) DEFINITIONS.— 
(1) QUALIFIED
HIGH
RISK
POOL.—Section 
2745(g)(1) of the Public Health Service Act (42 
U.S.C. 300gg–45(g)(1)) is amended— 
(A) in subparagraph (A)— 
(i) by striking ‘‘has the meaning given 
such term in section 2744(c)(2)’’ and in-
serting ‘‘means a ‘qualified high risk pool’ 
(as such term is described in section 
2744(c)(2)) that meets the requirements of 
subparagraph (B)’’; 
(ii) by striking ‘‘subparagraph (A) of 
such section’’ and inserting ‘‘subparagraph 
(A) of section 2744(c)(2)’’; and 
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(iii) by adding at the end the fol-
lowing: 
‘‘(B) REQUIREMENTS FOR CONSUMER PRO-
TECTIONS.—The requirements under this sub-
paragraph for consumer protections for a quali-
fied high risk pool are the following: 
‘‘(i) CHOICE
OF
COVERAGE.—The 
high risk pool provides all eligible individ-
uals with a choice of health insurance cov-
erage that includes at least one policy form 
that is a high deductible health plan that 
is combined with a health savings account. 
‘‘(ii) LIFETIME
LIMITS.—The high 
risk pool provides to all eligible individuals 
health insurance coverage that does not 
impose any lifetime limit on the dollar 
value of benefits for any participant or 
beneficiary of such coverage. 
‘‘(iii) GUARANTEED
AVAILABILITY.— 
The high risk pool shall provide health in-
surance coverage to all eligible individuals 
who— 
‘‘(I) seek such coverage; and 
‘‘(II) pay any applicable pre-
miums. 
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‘‘(iv) NO WAIT LIST.—The high risk 
pool may not— 
‘‘(I) apply any waiting period for 
health 
insurance 
coverage 
offered 
through the pool; 
‘‘(II) maintain any waiting list 
for access to such coverage; or 
‘‘(III) otherwise require an eligi-
ble individual to wait for access to 
such coverage. 
‘‘(v) PREMIUMS.—The high risk pool 
may not charge any participant or bene-
ficiary of coverage under such pool a pre-
mium for such coverage that is greater 
than 150 percent of the average premium 
in the individual market for health insur-
ance coverage in that State. 
‘‘(vi) OUTREACH AND EDUCATION.— 
The high risk pool conducts education and 
outreach to residents of the State and in-
surance brokers in the State to ensure that 
such residents and brokers understand 
that the high risk pool is available to eligi-
ble individuals.’’. 
(2) ELIGIBLE INDIVIDUAL.— 
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(A) IN GENERAL.—Section 2745(g) of the 
Public Health Service Act (42 U.S.C. 300gg– 
45(g)), as amended by paragraph (1), is further 
amended by striking paragraph (2) and insert-
ing the following: 
‘‘(2) ELIGIBLE INDIVIDUAL.—The term ‘eligible 
individual’ means an individual who— 
‘‘(A) is an eligible individual (as such term 
is defined in section 2741(b)); or 
‘‘(B) would be eligible for Medicare under 
title XVIII of the Social Security Act, except 
that such individual is subject to a 24-month 
disability waiting period under section 226(b) of 
the Social Security Act, during such period.’’. 
(B) CONFORMING
AMENDMENT.—Section 
2741(b) of the Public Health Service Act (42 
U.S.C. 300gg–41(b)) is amended by inserting 
‘‘(except, for purposes of section 2745)’’ after 
‘‘In this part’’. 
(3) QUALIFIED
REINSURANCE
PROGRAM
AND 
INNOVATIVE METHOD.—Section 2745(g) of the Pub-
lic Health Service Act (42 U.S.C. 300gg–45(g)), as 
amended by paragraph (2), is further amended by 
adding at the end the following: 
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‘‘(4) QUALIFIED REINSURANCE PROGRAM.—The 
term ‘qualified reinsurance program’ means a ‘quali-
fied reinsurance program’, as such term is defined in 
section 2744(c)(4), that does not require any waiting 
period for health insurance coverage offered to eligi-
ble individuals in connection with such qualified re-
insurance program. 
‘‘(5) INNOVATIVE METHOD.—The term ‘innova-
tive method’ means a method implemented by a 
State, to provide access to health insurance coverage 
for eligible individuals in the State, that the Sec-
retary determines will— 
‘‘(A) mitigate the cost of providing health 
insurance coverage to eligible individuals in the 
State in a manner that is better than, as deter-
mined by the Secretary, the provision of such 
coverage through a qualified high risk pool; and 
‘‘(B) that ensures that such individuals re-
ceive consumer protections that are similar to 
the consumer protections required under para-
graph (1)(B) for a qualified high risk pool.’’. 
(g) PROTECTION AGAINST DUMPING.—Section 2745 
of the Public Health Service Act (42 U.S.C. 300gg–45) 
is amended by adding at the end the following: 
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‘‘(h) PROTECTION AGAINST DUMPING RISK BY IN-
SURERS.— 
‘‘(1) IN GENERAL.—Subject to the criteria es-
tablished by the Secretary under paragraph (1) of 
section 2746(d), a State operating a qualified high 
risk pool, qualified reinsurance program, or innova-
tive method under this section may enforce sanctions 
against health insurance issuers in the State that 
are similar to the sanctions described in paragraph 
(2) of such section. 
‘‘(2) RULE
OF
CONSTRUCTION.—The rule of 
construction under paragraph (3) of section 2746(d) 
shall apply to this subsection in the same manner 
that 
such 
paragraph 
(3) 
applies 
to 
section 
2746(d).’’. 
(h) EFFECTIVE DATE.—The amendments made by 
this section shall take effect on October 1, 2012. 
SEC. 4. FEDERAL FALLBACK HIGH RISK POOL. 
(a) IN GENERAL.—Subpart 1 of part B of title 
XXVII of the Public Health Service Act (42 U.S.C. 
300gg–41 et seq.) is amended by adding at the end the 
following: 
‘‘SEC. 2746. FEDERAL FALLBACK HIGH RISK POOL. 
‘‘(a) ESTABLISHMENT AND APPLICATION OF FED-
ERAL FALLBACK HIGH RISK POOL.— 
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‘‘(1) FOR STATES WITH NO HISTORY OF PRO-
VIDING SUPPORT FOR ELIGIBLE INDIVIDUALS.—If, 
by October 1, 2015, a State has not established a 
qualified high risk pool, qualified reinsurance pro-
gram, or innovative method at any point in the 5- 
year period before such date, the Secretary shall es-
tablish a Federal fallback high risk pool program to 
provide health insurance coverage for eligible indi-
viduals in such State. 
‘‘(2) FOR STATES THAT DISCONTINUE STATE 
HIGH RISK POOLS.—Beginning October 1, 2015, if a 
State that operated a qualified high risk pool, a 
qualified reinsurance program, or innovative method 
under section 2745 before such date fails to operate 
a qualified high risk pool, qualified reinsurance pro-
gram, or innovative method for any period of 2 con-
secutive years after such date, the Secretary shall, at 
the end of such 2-year period, establish a Federal 
fallback high risk pool to provide health insurance 
coverage for eligible individuals in such State. 
‘‘(b) ADMINISTRATION.— 
‘‘(1) IN GENERAL.—The Secretary may carry 
out the program under this section directly or 
through contracts to eligible entities. 
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‘‘(2) ELIGIBLE ENTITIES.—To be eligible for a 
contract under paragraph (1), an entity shall— 
‘‘(A) be a nonprofit private entity; 
‘‘(B) submit to the Secretary an applica-
tion at such time, in such manner, and con-
taining such information as the Secretary may 
require; and 
‘‘(C) agree to utilize contract funding to 
establish and administer a Federal fallback 
high risk pool for eligible individuals. 
‘‘(c) USE
OF FUNDS.—Amounts made available 
under this section shall be used to establish and operate 
a Federal fallback high risk pool that is a qualified high 
risk pool, as such term is defined in section 2744(c)(2), 
that meets the requirements of section 2745(g)(1)(B) of 
such Act, with respect to each State in which such Federal 
fallback high risk pool applies. 
‘‘(d) PROTECTION AGAINST DUMPING RISK BY IN-
SURERS.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish criteria for determining whether health insur-
ance issuers and employment-based health plans 
have discouraged an individual from remaining en-
rolled in prior coverage based on that individual’s 
health status. 
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‘‘(2) SANCTIONS.—An health insurance issuer 
or employment-based health plan shall be responsible 
for reimbursing the Federal fallback high risk pool 
under this section for the medical expenses incurred 
by the Federal fallback high risk pool for an indi-
vidual who, based on criteria established by the Sec-
retary, the Secretary finds was encouraged by the 
health insurance issuer to disenroll from health ben-
efits coverage prior to enrolling in coverage through 
the Federal fallback high risk. The criteria shall in-
clude at least the following circumstances: 
‘‘(A) In the case of prior coverage obtained 
through an employer, the provision by the em-
ployer, group health plan, or the health insur-
ance issuer of money or other financial consid-
eration for disenrolling from the coverage. 
‘‘(B) In the case of prior coverage obtained 
directly from a health insurance issuer or under 
an employment-based health plan— 
‘‘(i) the provision by the health insur-
ance issuer or plan of money or other fi-
nancial consideration for disenrolling from 
the coverage; or 
‘‘(ii) in the case of an individual 
whose premium for the prior coverage ex-
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ceeded the premium required by the pro-
gram (adjusted based on the age factors 
applied to the prior coverage)— 
‘‘(I) the prior coverage is a policy 
that is no longer being actively mar-
keted (as defined by the Secretary) by 
the health insurance issuer; or 
‘‘(II) the prior coverage is a pol-
icy for which duration of coverage 
form issue or health status are factors 
that can be considered in determining 
premiums at renewal. 
‘‘(3) CONSTRUCTION.—Nothing in this sub-
section shall be construed as constituting exclusive 
remedies for violations of criteria established under 
paragraph (1) or as preventing States from applying 
or enforcing such paragraph or other provisions 
under law with respect to health insurance issuers. 
‘‘(e) OVERSIGHT.—The Secretary shall establish— 
‘‘(1) an appeals process to enable individuals to 
appeal a determination under this section; and 
‘‘(2) procedures to protect against waste, fraud, 
and abuse. 
‘‘(f) FUNDING; TERMINATION OF AUTHORITY.— 
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‘‘(1) IN GENERAL.—There are authorized to be 
appropriated to the Secretary $2,500,000,000 for 
the 3-fiscal-year period beginning on October 1, 
2015, to pay claims against (and the administrative 
costs of) the Federal fallback high risk pool under 
this section that are in excess of the amount of pre-
miums collected from eligible individuals enrolled in 
the Federal fallback high risk pool. 
‘‘(2) INSUFFICIENT FUNDS.—If the Secretary 
estimates for any fiscal year that the aggregate 
amounts available for the payment of the expenses 
of the Federal fallback high risk pool will be less 
than the actual amount of such expenses, the Sec-
retary shall make such adjustments as are necessary 
to eliminate such deficit. 
‘‘(3) RELATIONSHIP
TO
STATE
HIGH
RISK 
POOLS.— 
‘‘(A) TERMINATION
OF
FEDERAL
COV-
ERAGE.—Subject to subparagraph (B), if a 
State establishes a qualified high risk pool, 
qualified reinsurance program, or innovative 
method under section 2745, coverage of an eli-
gible individual in such State under a Federal 
fallback high risk pool shall terminate on the 
date that— 
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‘‘(i) is the last day of the plan year 
that applies to such individual under such 
Federal fallback high risk pool; and 
‘‘(ii) that occurs after the date on 
which the State establishes such a quali-
fied high risk pool, qualified reinsurance 
program, or innovative method. 
‘‘(B) TRANSITION
TO
STATE
HIGH
RISK 
POOLS.—The Secretary shall develop proce-
dures to provide for the transition of eligible in-
dividuals in a State enrolled in health insurance 
coverage offered through a Federal fallback 
high risk pool established under this section 
into a qualified high risk pool in such State. 
Such procedures shall ensure that there is no 
lapse in coverage with respect to the individual 
and may extend coverage after the applicable 
termination date under subparagraph (A) of the 
Federal fallback risk pool involved, if the Sec-
retary determines necessary to avoid such a 
lapse. 
‘‘(C) NO
NEW
ENROLLMENT.—The Fed-
eral fallback high risk pool in a State shall not 
enroll any individual in the State for coverage 
under such a Federal fallback high risk pool at 
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any time that the State is operating such a 
qualified high risk pool, qualified reinsurance 
program, or innovative method under section 
2745. 
‘‘(4) LIMITATIONS.—The Secretary has the au-
thority to stop taking applications for participation 
in the Federal fallback high risk pool under this sec-
tion to comply with paragraph (2). 
‘‘(5) RELATION TO STATE LAWS.—The stand-
ards established under this section shall supersede 
any State law or regulation (other than State licens-
ing laws or State laws relating to plan solvency) with 
respect to any Federal fallback high risk pool which 
is established in accordance with this section. 
‘‘(g) DEFINITIONS.—For purposes of this section— 
‘‘(1) TERMS FROM SECTION 2745.—Except as 
otherwise provided in this section, the terms ‘eligible 
individual’, ‘innovative method’, ‘qualified high risk 
pool’, and ‘qualified reinsurance program’ have the 
meanings given such terms in section 2745(g). 
‘‘(2) EMPLOYMENT-BASED
HEALTH
PLAN.— 
The term ‘employment-based health plan’ shall have 
the meaning given such term by the Secretary, con-
sistent with the meaning given such term under sec-
tion 1101 of Public Law 111–148.’’. 
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(b) CONFORMING AMENDMENT.—Section 2741(b) of 
the Public Health Service Act (42 U.S.C. 300gg–41(b)), 
as amended by section 3(f)(2)(B), is further amended, in 
the matter before paragraph (1), by inserting ‘‘and section 
2746’’ after ‘‘for purposes of section 2745’’. 
Æ 
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