I 
113TH CONGRESS 
1ST SESSION H. R. 2165 
To amend the Public Health Service Act to provide individual and group 
market reforms to protect health insurance consumers, to make such 
reforms and protections contingent on the enactment of legislation repeal-
ing the Patient Protection and Affordable Care Act, and for other pur-
poses. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 23, 2013 
Mr. HECK of Nevada (for himself and Mr. FITZPATRICK) introduced the fol-
lowing bill; which was referred to the Committee on Energy and Com-
merce, and in addition to the Committees on Education and the Work-
force, Ways and Means, and the Judiciary, for a period to be subse-
quently determined by the Speaker, in each case for consideration of such 
provisions as fall within the jurisdiction of the committee concerned 
A BILL 
To amend the Public Health Service Act to provide individual 
and group market reforms to protect health insurance 
consumers, to make such reforms and protections contin-
gent on the enactment of legislation repealing the Patient 
Protection and Affordable Care Act, and for other pur-
poses. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
VerDate Mar 15 2010 
03:21 Jun 01, 2013
Jkt 029200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Ensuring Quality Health Care for All Americans Act of 
2013’’. 
(b) TABLE OF CONTENTS.—The table of contents for 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
Sec. 2. Effective date contingent on repeal of PPACA. 
Sec. 3. Prohibiting discrimination based on health status. 
Sec. 4. Guaranteed renewability of coverage. 
Sec. 5. Prohibition of preexisting condition exclusions and other discrimination 
based on health status. 
Sec. 6. No lifetime or annual limits. 
Sec. 7. Prohibition on rescissions. 
Sec. 8. Extension of dependent coverage. 
Sec. 9. Application of group market reforms to ERISA and the Internal Rev-
enue Code of 1986. 
Sec. 10. Catastrophic plan. 
Sec. 11. Grants for health insurance risk adjustment mechanisms. 
Sec. 12. Liability protections for health care providers. 
SEC. 2. EFFECTIVE DATE CONTINGENT ON REPEAL OF 
PPACA. 
(a) IN GENERAL.—This Act and the amendments 
made by this Act shall take effect upon the enactment of 
PPACA repeal legislation described in subsection (b) and 
this Act and the amendments made by this Act shall have 
no force or effect if such PPACA repeal legislation is not 
enacted. 
(b) PPACA REPEAL LEGISLATION DESCRIBED.— 
For purposes of subsection (a), PPACA repeal legislation 
described in this subsection is legislation that— 
(1) repeals Public Law 111–148, and restores 
or revives the provisions of law amended or repealed, 
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
respectively, by such Act as if such Act had not been 
enacted and without further amendment to such 
provisions of law; and 
(2) repeals title I and subtitle B of title II of 
the Health Care and Education Reconciliation Act of 
2010 (Public Law 111–152), and restores or revives 
the provisions of law amended or repealed, respec-
tively, by such title or subtitle, respectively, as if 
such title and subtitle had not been enacted and 
without further amendment to such provisions of 
law. 
SEC. 3. PROHIBITING DISCRIMINATION BASED ON HEALTH 
STATUS. 
(a) GROUP MARKET.—Subpart 3 of part A of title 
XXVII of the Public Health Service Act is amended by 
striking section 2711 of such Act (42 U.S.C. 300gg–11) 
and inserting the following: 
‘‘SEC. 2711. GUARANTEED AVAILABILITY OF COVERAGE. 
‘‘(a) GUARANTEED ISSUANCE OF COVERAGE IN THE 
GROUP MARKET.— 
‘‘(1) IN GENERAL.—Subject to subsections (b) 
through (e), each health insurance issuer that offers 
health insurance coverage in the group market in a 
State shall accept every employer and every indi-
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
a qualified individual (as such term is de-
fined in section 2701(d)(2)(D)); 
‘‘(ii) the term ‘employer’ shall include 
an association (as such term is defined in 
section 2701(d)(2)(A)); and 
‘‘(iii) the term ‘termination (other 
than by reason of such employee’s gross 
misconduct), or reduction of hours, of the 
covered employee’s employment’ shall in-
clude the termination of membership to the 
association. 
‘‘(B) 
ENROLLMENT.—With 
respect 
to 
health insurance coverage provided to an asso-
ciation under subsection (a)(2), a health insur-
ance issuer shall permit a qualified individual 
who is eligible, but not enrolled (or a dependent 
of such individual if the dependent is eligible, 
but not enrolled) for such coverage to enroll for 
coverage under the terms of such coverage 
when any one of the following events occur: 
‘‘(i) NEW
MEMBERS
AND
EMPLOY-
EES.—A qualified individual, and any de-
pendent of such individual, may enroll dur-
ing the 30-day period following the end of 
the 
period 
described 
under 
section 
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
2701(d)(2)(D) that applies to such indi-
vidual. 
‘‘(ii) 
ANNUAL
ENROLLMENT.—A 
qualified individual, and any dependent of 
such individual, may enroll during the an-
nual enrollment period established under 
the terms of the coverage 
‘‘(C) TERMINATION
OF
ENROLLMENT.— 
With respect to group health insurance cov-
erage provided by an association, a qualified in-
dividual or dependent who terminates enroll-
ment in such coverage may only re-enroll in 
such coverage during the annual enrollment pe-
riod described under subparagraph (B)(ii). 
‘‘(D) DEFINITIONS.—For purposes of this 
section, the terms ‘association’ and ‘qualified 
individual’ have the meaning given such terms 
in section 2701(d)(2). 
‘‘(4) REGULATIONS.—The Secretary shall pro-
mulgate regulations with respect to enrollment peri-
ods under this subsection. 
‘‘(c) SPECIAL RULES FOR NETWORK PLANS.— 
‘‘(1) IN GENERAL.—In the case of a health in-
surance issuer that offers health insurance coverage 
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
in the group market in a State through a network 
plan, the issuer may— 
‘‘(A) limit the employers that may apply 
for such coverage to those with eligible individ-
uals who live, work, or reside in the service area 
for such network plan; and 
‘‘(B) within the service area of such plan, 
deny such coverage to such employers if the 
issuer has demonstrated, if required, to the ap-
plicable State authority that— 
‘‘(i) it will not have the capacity to de-
liver services adequately to enrollees of any 
additional groups because of its obligations 
to existing group contract holders and en-
rollees; and 
‘‘(ii) it is applying this paragraph uni-
formly to all employers without regard 
to— 
‘‘(I) the claims experience of 
those employers and their employees 
(and their dependents); or 
‘‘(II) any health-status-related 
factor relating to such employees and 
dependents. 
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
‘‘(2) 180-DAY
SUSPENSION
UPON
DENIAL
OF 
COVERAGE.—An issuer, upon denying health insur-
ance coverage in any service area in accordance with 
paragraph (1)(B), may not offer coverage in the 
group market within such service area for a period 
of 180 days after the date such coverage is denied. 
‘‘(d) APPLICATION OF FINANCIAL CAPACITY LIM-
ITS.— 
‘‘(1) IN GENERAL.—A health insurance issuer 
may deny health insurance coverage in the group if 
the issuer has demonstrated, if required, to the ap-
plicable State authority that— 
‘‘(A) it does not have the financial reserves 
necessary to underwrite additional coverage; 
and 
‘‘(B) it is applying this paragraph uni-
formly to all employers and individuals in the 
group market in the State— 
‘‘(i) in a manner that is consistent 
with applicable State law; and 
‘‘(ii) without regard to— 
‘‘(I) the claims experience of 
those individuals, employers, and their 
employees (and their dependents); or 
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
‘‘(II) any health-status-related 
factor relating to such individuals, 
employees, and dependents. 
‘‘(2) 180-DAY
SUSPENSION
UPON
DENIAL
OF 
COVERAGE.—A health insurance issuer upon denying 
health insurance coverage in connection with group 
health plans in accordance with paragraph (1) in a 
State may not offer coverage in connection with 
group health plans in the group market in the State 
for a period of 180 days after the date such cov-
erage is denied or until the issuer has demonstrated 
to the applicable State authority, if required under 
applicable State law, that the issuer has sufficient fi-
nancial reserves to underwrite additional coverage, 
whichever is later. An applicable State authority 
may provide for the application of this subsection on 
a service-area-specific basis.’’. 
(b) INDIVIDUAL MARKET.—Subpart 1 of part B of 
title XXVII of the Public Health Service Act is amended 
by striking section 2741 of such Act (42 U.S.C. 300gg– 
41) and inserting the following: 
‘‘SEC. 2741. GUARANTEED AVAILABILITY OF COVERAGE. 
‘‘The provisions of section 2711 (other than sub-
section (a)(2) and subsection (b)(3)) shall apply to health 
insurance coverage offered to individuals by a health in-
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
surance issuer in the individual market in the same man-
ner as such provisions apply to health insurance coverage 
offered to employers by a health insurance issuer in con-
nection with health insurance coverage in the group mar-
ket. For purposes of this section, the Secretary shall treat 
any reference of the word ‘employer’ in such section as 
a reference to the term ‘individual’.’’. 
SEC. 4. GUARANTEED RENEWABILITY OF COVERAGE. 
Section 2712 of the Public Health Service Act (42 
U.S.C. 300gg–12) is amended— 
(1) in subsection (a)— 
(A) by inserting ‘‘, including coverage of-
fered’’ before ‘‘in connection with a group 
health plan’’; and 
(B) by inserting ‘‘employer or other’’ be-
fore ‘‘plan sponsor of the plan’’; 
(2) in subsection (b)— 
(A) in the matter before paragraph (1), by 
striking ‘‘health insurance coverage in connec-
tion with a group health plan in the small or 
large group market’’ and insert ‘‘such health in-
surance coverage’’; and 
(B) in paragraph (6) by striking ‘‘ one or 
more bona fide associations’’ and inserting ‘‘one 
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
‘‘SEC. 2701. PROHIBITION OF PREEXISTING CONDITION EX-
CLUSIONS 
AND 
OTHER 
DISCRIMINATION 
BASED ON HEALTH STATUS. 
‘‘(a) IN GENERAL.—A group health plan or a health 
insurance issuer offering group health insurance coverage 
may not impose any preexisting condition exclusion with 
respect to such plan or coverage. 
‘‘(b) DEFINITIONS.—For purposes of this part: 
‘‘(1) PREEXISTING CONDITION EXCLUSION.— 
‘‘(A) IN GENERAL.—The term ‘preexisting 
condition exclusion’ means, with respect to a 
group health plan or health insurance coverage, 
a limitation or exclusion of benefits relating to 
a condition based on the fact that the condition 
was present before the date of enrollment in 
such plan or for such coverage, whether or not 
any medical advice, diagnosis, care, or treat-
ment was recommended or received before such 
date. 
‘‘(B) TREATMENT OF GENETIC INFORMA-
TION.—Genetic information shall not be treated 
as a preexisting condition in the absence of a 
diagnosis of the condition related to such infor-
mation. 
‘‘(2) DATE OF ENROLLMENT.—The term ‘date 
of enrollment’ means, with respect to an individual 
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00012
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
covered under a group health plan or health insur-
ance coverage, the date of enrollment of the indi-
vidual in the plan or coverage or, if earlier, the first 
day of the waiting period for such enrollment. 
‘‘(3) WAITING PERIOD.—The term ‘waiting pe-
riod’ means, with respect to a group health plan and 
an individual who is a potential participant or bene-
ficiary in the plan, the period that must pass with 
respect to the individual before the individual is eli-
gible to be covered for benefits under the terms of 
the plan. 
‘‘(c) SPECIAL ENROLLMENT PERIODS.— 
‘‘(1) INDIVIDUALS LOSING OTHER COVERAGE.— 
A group health plan, and a health insurance issuer 
offering group health insurance coverage in connec-
tion with a group health plan, shall permit an em-
ployee who is eligible, but not enrolled, for coverage 
under the terms of the plan (or a dependent of such 
an employee if the dependent is eligible, but not en-
rolled, for coverage under such terms) to enroll for 
coverage under the terms of the plan if each of the 
following conditions is met: 
‘‘(A) The employee or dependent was cov-
ered under a group health plan or had health 
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00013
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
insurance coverage at the time coverage was 
previously offered to the employee or dependent. 
‘‘(B) The employee stated in writing at 
such time that coverage under a group health 
plan or health insurance coverage was the rea-
son for declining enrollment, but only if the 
plan sponsor or issuer (if applicable) required 
such a statement at such time and provided the 
employee with notice of such requirement (and 
the consequences of such requirement) at such 
time. 
‘‘(C) The employee’s or dependent’s cov-
erage described in subparagraph (A)— 
‘‘(i) was under a COBRA continu-
ation provision and the coverage under 
such provision was exhausted; or 
‘‘(ii) was not under such a provision 
and either the coverage was terminated as 
a result of loss of eligibility for the cov-
erage (including as a result of legal separa-
tion, divorce, death, termination of employ-
ment, or reduction in the number of hours 
of employment) or employer contributions 
toward such coverage were terminated. 
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00014
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
‘‘(D) Under the terms of the plan, the em-
ployee requests such enrollment not later than 
30 days after the date of exhaustion of coverage 
described in subparagraph (C)(i) or termination 
of coverage or employer contribution described 
in subparagraph (C)(ii). 
‘‘(2) FOR DEPENDENT BENEFICIARIES.— 
‘‘(A) IN GENERAL.—If— 
‘‘(i) a group health plan makes cov-
erage available with respect to a dependent 
of an individual; 
‘‘(ii) the individual is a participant 
under the plan (or has met any waiting pe-
riod applicable to becoming a participant 
under the plan and is eligible to be enrolled 
under the plan but for a failure to enroll 
during a previous enrollment period); and 
‘‘(iii) a person becomes such a de-
pendent of the individual through mar-
riage, birth, or adoption or placement for 
adoption, 
the group health plan shall provide for a de-
pendent special enrollment period described in 
subparagraph (B) during which the person (or, 
if not otherwise enrolled, the individual) may be 
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00015
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
enrolled under the plan as a dependent of the 
individual, and in the case of the birth or adop-
tion of a child, the spouse of the individual may 
be enrolled as a dependent of the individual if 
such spouse is otherwise eligible for coverage. 
‘‘(B) DEPENDENT SPECIAL ENROLLMENT 
PERIOD.—A dependent special enrollment pe-
riod under this subparagraph shall be a period 
of not less than 30 days and shall begin on the 
later of— 
‘‘(i) the date dependent coverage is 
made available; or 
‘‘(ii) the date of the marriage, birth, 
or adoption or placement for adoption (as 
the case may be) described in subpara-
graph (A)(iii). 
‘‘(C) NO
WAITING
PERIOD.—If an indi-
vidual seeks to enroll a dependent during the 
first 30 days of such a dependent special enroll-
ment period, the coverage of the dependent 
shall become effective— 
‘‘(i) in the case of marriage, not later 
than the first day of the first month begin-
ning after the date the completed request 
for enrollment is received; 
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00016
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
‘‘(ii) in the case of a dependent’s 
birth, as of the date of such birth; or 
‘‘(iii) in the case of a dependent’s 
adoption or placement for adoption, the 
date of such adoption or placement for 
adoption. 
‘‘(3) SPECIAL RULES FOR APPLICATION IN CASE 
OF MEDICAID AND CHIP.— 
‘‘(A) IN GENERAL.—A group health plan, 
and a health insurance issuer offering group 
health insurance coverage in connection with a 
group health plan, shall permit an employee 
who is eligible, but not enrolled, for coverage 
under the terms of the plan (or a dependent of 
such an employee if the dependent is eligible, 
but not enrolled, for coverage under such 
terms) to enroll for coverage under the terms of 
the plan or coverage if either of the following 
conditions is met: 
‘‘(i) TERMINATION OF MEDICAID OR 
CHIP
COVERAGE.—The employee or de-
pendent is covered under a Medicaid plan 
under title XIX of the Social Security Act 
or under a State child health plan under 
title XXI of such Act and coverage of the 
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00017
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS
employee or dependent under such a plan 
is terminated as a result of loss of eligi-
bility for such coverage and the employee 
requests coverage under the group health 
plan (or health insurance coverage) not 
later than 60 days after the date of termi-
nation of such coverage. 
‘‘(ii) ELIGIBILITY FOR EMPLOYMENT 
ASSISTANCE UNDER MEDICAID OR CHIP.— 
The employee or dependent becomes eligi-
ble for assistance, with respect to coverage 
under the group health plan or health in-
surance coverage, under such Medicaid 
plan or State child health plan (including 
under any waiver or demonstration project 
conducted under or in relation to such a 
plan), if the employee requests coverage 
under the group health plan or health in-
surance coverage not later than 60 days 
after the date the employee or dependent is 
determined to be eligible for such assist-
ance. 
‘‘(B) COORDINATION WITH MEDICAID AND 
CHIP.— 
VerDate Mar 15 2010 
23:00 May 31, 2013
Jkt 029200
PO 00000
Frm 00018
Fmt 6652
Sfmt 6201
E:\BILLS\H2165.IH
H2165
tjames on DSK6SPTVN1PROD with BILLS