I 
113TH CONGRESS 
2D SESSION 
H. R. 4496 
To establish universal access programs to improve high risk pools and reinsur-
ance markets to ensure coverage for individuals with pre-existing condi-
tions, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
APRIL 28, 2014 
Mr. GARDNER introduced the following bill; which was referred to the 
Committee on Energy and Commerce 
A BILL 
To establish universal access programs to improve high risk 
pools and reinsurance markets to ensure coverage for 
individuals with pre-existing conditions, and for other 
purposes. 
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 ‘‘Covering People With 
Pre-Existing Conditions Act of 2014’’. 
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SEC. 2. ESTABLISHING UNIVERSAL ACCESS PROGRAMS TO 
IMPROVE HIGH RISK POOLS AND REINSUR-
ANCE MARKETS FOR INDIVIDUALS WITH PRE- 
EXISTING CONDITIONS. 
(a) STATE REQUIREMENT.— 
(1) IN GENERAL.—Not later than January 1, 
2015, each State shall— 
(A) subject to paragraph (3), operate— 
(i) a qualified State reinsurance pro-
gram described in subsection (b); or 
(ii) qualifying State high risk pool de-
scribed in subsection (c)(1); and 
(B) subject to paragraph (3), apply to the 
operation of such a program from State funds 
an amount equivalent to the portion of State 
funds derived from State premium assessments 
(as defined by the Secretary) that are not oth-
erwise used on State health care programs. 
(2) RELATION TO CURRENT QUALIFIED HIGH 
RISK POOL PROGRAM.— 
(A) STATES NOT OPERATING A QUALIFIED 
HIGH RISK POOL.—In the case of a State that 
is not operating a current section 2745 quali-
fied high risk pool as of the date of the enact-
ment of this Act— 
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(i) the State may only meet the re-
quirement of paragraph (1) through the 
operation of a qualified State reinsurance 
program described in subsection (b); and 
(ii) the State’s operation of such a re-
insurance program shall be treated, for 
purposes of section 2745 of the Public 
Health Service Act, as the operation of a 
qualified high risk pool described in such 
section. 
(B) STATE OPERATING A QUALIFIED HIGH 
RISK POOL.—In the case of a State that is op-
erating a current section 2745 qualified high 
risk pool as of the date of the enactment of this 
Act— 
(i) as of January 1, 2015, such a pool 
shall not be treated as a qualified high risk 
pool under section 2745 of the Public 
Health Service Act unless the pool is a 
qualifying State high risk pool described in 
subsection (c)(1); and 
(ii) the State may use premium as-
sessment funds described in paragraph 
(1)(B) to transition from operation of such 
a pool to operation of a qualified State re-
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insurance program described in subsection 
(b). 
(3) APPLICATION OF FUNDS.—If the program 
or pool operated under paragraph (1)(A) is in strong 
fiscal health, as determined in accordance with 
standards established by the National Association of 
Insurance Commissioners and as approved by the 
State Insurance Commissioner involved, the require-
ment of paragraph (1)(B) shall be deemed to be 
met. 
(b) QUALIFIED STATE REINSURANCE PROGRAM.— 
(1) IN GENERAL.—For purposes of this section, 
a ‘‘qualified State reinsurance program’’ means a 
program operated by a State program that provides 
reinsurance for health insurance coverage offered in 
the small group market in accordance with the 
model for such a program established (as of the date 
of the enactment of this Act). 
(2) FORM OF PROGRAM.—A qualified State re-
insurance program may provide reinsurance— 
(A) on a prospective or retrospective basis; 
and 
(B) on a basis that protects health insur-
ance issuers against the annual aggregate 
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spending of their enrollees as well as purchase 
protection against individual catastrophic costs. 
(3) SATISFACTION OF HIPAA REQUIREMENT.— 
A qualified State reinsurance program shall be 
deemed, for purposes of section 2745 of the Public 
Health Service Act, to be a qualified high risk pool 
under such section. 
(c) QUALIFYING STATE HIGH RISK POOL.— 
(1) IN GENERAL.—A qualifying State high risk 
pool described in this subsection means a current 
section 2745 qualified high risk pool that meets the 
following requirements: 
(A) The pool must provide at least two 
coverage options, one of which must be a high 
deductible health plan coupled with a health 
savings account. 
(B) The pool must be funded with a stable 
funding source. 
(C) The pool must eliminate any waiting 
lists so that all eligible residents who are seek-
ing coverage through the pool should be allowed 
to receive coverage through the pool. 
(D) The pool must allow for coverage of 
individuals who, but for the 24-month disability 
waiting period under section 226(b) of the So-
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cial Security Act, would be eligible for Medicare 
during the period of such waiting period. 
(E) The pool must limit the pool premiums 
to no more than 150 percent of the average 
premium for applicable standard risk rates in 
that State. 
(F) The pool must conduct education and 
outreach initiatives so that residents and bro-
kers understand that the pool is available to eli-
gible residents. 
(G) The pool must provide coverage for 
preventive services and disease management for 
chronic diseases. 
(2) VERIFICATION OF CITIZENSHIP OR ALIEN 
QUALIFICATION.— 
(A) IN
GENERAL.—Notwithstanding any 
other provision of law, only citizens and nation-
als of the United States shall be eligible to par-
ticipate in a qualifying State high risk pool that 
receives funds under section 2745 of the Public 
Health Service Act or this section. 
(B) CONDITION OF PARTICIPATION.—As a 
condition of a State receiving such funds, the 
Secretary shall require the State to certify, to 
the satisfaction of the Secretary, that such 
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State requires all applicants for coverage in the 
qualifying State high risk pool to provide satis-
factory documentation of citizenship or nation-
ality in a manner consistent with section 
1903(x) of the Social Security Act. 
(C) RECORDS.—The Secretary shall keep 
sufficient records such that a determination of 
citizenship or nationality only has to be made 
once for any individual under this paragraph. 
(3) RELATION TO SECTION 2745.—As of Janu-
ary 1, 2015, a pool shall not qualify as qualified 
high risk pool under section 2745 of the Public 
Health Service Act unless the pool is a qualifying 
State high risk pool described in paragraph (1). 
(d) WAIVERS.—In order to accommodate new and in-
novative programs, the Secretary may waive such require-
ments of this section for qualified State reinsurance pro-
grams and for qualifying State high risk pools as the Sec-
retary deems appropriate. 
(e) FUNDING.—In addition to any other amounts ap-
propriated, there is appropriated to carry out section 2745 
of the Public Health Service Act (including through a pro-
gram or pool described in subsection (a)(1))— 
(1) $15,000,000,000 for the period of fiscal 
years 2015 through 2024; and 
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(2) an additional $10,000,000,000 for the pe-
riod of fiscal years 2020 through 2024. 
(f) DEFINITIONS.—In this section: 
(1) HEALTH INSURANCE COVERAGE; HEALTH 
INSURANCE ISSUER.—The terms ‘‘health insurance 
coverage’’ and ‘‘health insurance issuer’’ have the 
meanings given such terms in section 2791 of the 
Public Health Service Act. 
(2) CURRENT SECTION 2745 QUALIFIED HIGH 
RISK POOL.—The term ‘‘current section 2745 quali-
fied high risk pool’’ has the meaning given the term 
‘‘qualified high risk pool’’ under section 2745(g) of 
the Public Health Service Act as in effect as of the 
date of the enactment of this Act. 
(3) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
(4) STANDARD RISK RATE.—The term ‘‘stand-
ard risk rate’’ means a rate that— 
(A) is determined under the State high 
risk pool by considering the premium rates 
charged by other health insurance issuers offer-
ing health insurance coverage to individuals in 
the insurance market served; 
(B) is established using reasonable actu-
arial techniques; and 
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(C) reflects anticipated claims experience 
and expenses for the coverage involved. 
(5) STATE.—The term ‘‘State’’ means any of 
the 50 States or the District of Columbia. 
Æ 
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