II 
113TH CONGRESS 
2D SESSION 
H. R. 4414 
IN THE SENATE OF THE UNITED STATES 
APRIL 30, 2014 
Received 
AN ACT 
To clarify the treatment under the Patient Protection and 
Affordable Care Act of health plans in which expatriates 
are the primary enrollees, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Expatriate Health Cov-
erage Clarification Act of 2014’’. 
SEC. 2. TREATMENT OF EXPATRIATE HEALTH PLANS 
UNDER ACA. 
(a) IN GENERAL.—Subject to subsection (b), the pro-
visions of (including any amendment made by) the Patient 
Protection and Affordable Care Act (Public Law 111– 
148) and of title I and subtitle B of title II of the Health 
Care and Education Reconciliation Act of 2010 (Public 
Law 111–152) shall not apply with respect to— 
(1) expatriate health plans; 
(2) employers with respect to any such plans 
for which such employers are acting as plan spon-
sors; or 
(3) expatriate health insurance issuers with re-
spect to coverage offered by such issuers under such 
plans. 
(b) MINIMUM ESSENTIAL COVERAGE AND ELIGIBLE 
EMPLOYER-SPONSORED PLAN.—For purposes of section 
5000A(f) of the Internal Revenue Code of 1986, and any 
other section of the Internal Revenue Code of 1986 that 
incorporates the definition of minimum essential coverage 
provided under such section 5000A(f) by reference, cov-
erage under an expatriate health plan shall be deemed to 
be minimum essential coverage under an eligible employer- 
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sponsored plan as defined in paragraph (2) of such sec-
tion. 
(c) QUALIFIED EXPATRIATES
AND DEPENDENTS 
NOT UNITED STATES HEALTH RISK.— 
(1) IN
GENERAL.—For purposes of section 
9010 of the Patient Protection and Affordable Care 
Act (26 U.S.C. 4001 note prec.), for calendar years 
after 2014, a qualified expatriate (and any depend-
ent of such individual) enrolled in an expatriate 
health plan shall not be considered a United States 
health risk. 
(2) SPECIAL RULE FOR 2014.—The fee under 
section 9010 of such Act for calendar year 2014 
with respect to any expatriate health insurance 
issuer shall be the amount which bears the same 
ratio to the fee amount determined by the Secretary 
of the Treasury with respect to such issuer under 
such section for such year (determined without re-
gard to this paragraph) as— 
(A) the amount of premiums taken into ac-
count under such section with respect to such 
issuer for such year, less the amount of pre-
miums for expatriate health plans taken into 
account under such section with respect to such 
issuer for such year, bears to 
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(B) the amount of premiums taken into ac-
count under such section with respect to such 
issuer for such year. 
(d) DEFINITIONS.—In this section: 
(1) 
EXPATRIATE
HEALTH
INSURANCE 
ISSUER.—The term ‘‘expatriate health insurance 
issuer’’ means a health insurance issuer that issues 
expatriate health plans. 
(2) EXPATRIATE
HEALTH
PLAN.—The term 
‘‘expatriate health plan’’ means a group health plan, 
health insurance coverage offered in connection with 
a group health plan, or health insurance coverage of-
fered to a group of individuals described in para-
graph (3)(B) (which may include dependents of such 
individuals) that meets each of the following stand-
ards: 
(A) Substantially all of the primary enroll-
ees in such plan or coverage are qualified expa-
triates, with respect to such plan or coverage. 
In applying the previous sentence, an individual 
shall not be taken into account as a primary en-
rollee if the individual is not a national of the 
United States and resides in the country of 
which the individual is a citizen. 
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(B) Substantially all of the benefits pro-
vided under the plan or coverage are not ex-
cepted benefits described in section 9832(c) of 
the Internal Revenue Code of 1986. 
(C) The plan or coverage provides benefits 
for items and services, in excess of emergency 
care, furnished by health care providers— 
(i) in the case of individuals described 
in paragraph (3)(A), in the country or 
countries in which the individual is present 
in connection with the individual’s employ-
ment, and such other country or countries 
as the Secretary of Health and Human 
Services, in consultation with the Secretary 
of the Treasury and the Secretary of 
Labor, may designate; or 
(ii) in the case of individuals described 
in paragraph (3)(B), in the country or 
countries as the Secretary of Health and 
Human Services, in consultation with the 
Secretary of the Treasury and the Sec-
retary of Labor, may designate. 
(D) In the case of an expatriate health 
plan that is a group health plan offered by a 
plan sponsor that— 
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(i) also offers a qualifying minimum 
value domestic group health plan, the plan 
sponsor reasonably believes that the bene-
fits provided by the expatriate health plan 
are actuarially similar to, or better than, 
the benefits provided under a qualifying 
minimum value domestic group health plan 
offered by that plan sponsor; or 
(ii) does not also offer a qualifying 
minimum value domestic group health 
plan, the plan sponsor reasonably believes 
that the benefits provided by the expatriate 
health plan are actuarially similar to, or 
better than, the benefits provided under a 
qualifying minimum value domestic group 
health plan. 
(E) If the plan or coverage provides de-
pendent coverage of children, the plan or cov-
erage makes such dependent coverage available 
for adult children until the adult child turns 26 
years of age, unless such individual is the child 
of a child receiving dependent coverage. 
(F) The plan or coverage— 
(i) is issued by an expatriate health 
plan issuer, or administered by an adminis-
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trator, that maintains, with respect to such 
plan or coverage— 
(I) network provider agreements 
with health care providers that are 
outside of the United States; and 
(II) call centers in more than one 
country and accepts calls from cus-
tomers in multiple languages; and 
(ii) offers reimbursements for items or 
services under such plan or coverage in 
more than two currencies. 
(G) The plan or coverage, and the plan 
sponsor or expatriate health insurance issuer 
with respect to such plan or coverage, satisfies 
the provisions of title XXVII of the Public 
Health Service Act (42 U.S.C. 300gg et seq.), 
chapter 100 of the Internal Revenue Code of 
1986, and part 7 of subtitle B of title I of the 
Employee Retirement Income Security Act of 
1974 (29 U.S.C. 1181 et seq.), which would 
otherwise apply to such a plan or coverage, and 
sponsor or issuer, if not for the enactment of 
the Patient Protection and Affordable Care Act 
and title I and subtitle B of title II of the 
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Health Care and Education Reconciliation Act 
of 2010. 
(3) QUALIFIED EXPATRIATE.—The term ‘‘quali-
fied expatriate’’ means any of the following individ-
uals: 
(A) WORKERS.—An individual who is a 
participant in a group health plan, who is an 
alien residing outside the United States, a na-
tional of the United States, lawful permanent 
resident, or nonimmigrant for whom there is a 
good faith expectation by the plan sponsor of 
the plan that, in connection with the individ-
ual’s employment, the individual is abroad for a 
total of not less than 180 days during any pe-
riod of 12 consecutive months. 
(B) OTHER INDIVIDUALS ABROAD.—An in-
dividual, such as a student or religious mis-
sionary, who is abroad, and who is a member 
of a group determined appropriate by the Sec-
retary of Health and Human Services, in con-
sultation with the Secretary of the Treasury 
and the Secretary of Labor. 
(4) QUALIFYING
MINIMUM
VALUE
DOMESTIC 
GROUP HEALTH PLAN.—The term ‘‘qualifying min-
imum value domestic group health plan’’ means a 
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group health plan that is offered in the United 
States that meets the following requirements: 
(A) Substantially all of the primary enroll-
ees in the plan are not qualified expatriates, 
with respect to such plan. 
(B) Substantially all of the benefits pro-
vided under the plan are not excepted benefits 
described in section 9832(c) of the Internal 
Revenue Code of 1986. 
(C) 
The 
application 
of 
section 
36B(c)(2)(C)(ii) of such Code to such plan 
would not prevent an employee eligible for cov-
erage under such plan from being treated as eli-
gible for minimum essential coverage for pur-
poses of section 36B(c)(2)(B) of such Code. 
(5) ABROAD.— 
(A) UNITED STATES NATIONALS.— 
(i) IN GENERAL.—Except as provided 
in clause (ii), for purposes of applying 
paragraph (3) to a national of the United 
States, the term ‘‘abroad’’ means outside 
the 50 States, the District of Columbia, 
and Puerto Rico. 
(ii) SPECIAL RULE.—For purposes of 
applying paragraph (3) to a national of the 
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United States who resides in the United 
States Virgin Islands, the Commonwealth 
of the Northern Mariana Islands, Amer-
ican Samoa, or Guam, the term ‘‘abroad’’ 
means outside of the 50 States, the Dis-
trict of Columbia, Puerto Rico, and such 
territory or possession. 
(B) FOREIGN CITIZENS.—For purposes of 
applying paragraph (3) to an individual who is 
not a national of the United States, the term 
‘‘abroad’’ means outside of the country of which 
that individual is a citizen. 
(6) 
UNITED
STATES.—The 
term 
‘‘United 
States’’ means the 50 States, the District of Colum-
bia, Puerto Rico, the United States Virgin Islands, 
the Commonwealth of the Northern Mariana Is-
lands, American Samoa, and Guam. 
(7) MISCELLANEOUS TERMS.— 
(A) GROUP
HEALTH
PLAN; HEALTH
IN-
SURANCE
COVERAGE; 
HEALTH
INSURANCE 
ISSUER; PLAN
SPONSOR.—The terms ‘‘group 
health plan’’, ‘‘health insurance coverage’’, 
‘‘health insurance issuer’’, and ‘‘plan sponsor’’ 
have the meanings given those terms in section 
2791 of the Public Health Service Act (42 
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U.S.C. 300gg–91), except that in applying such 
terms under this section the term ‘‘health in-
surance issuer’’ includes a foreign corporation 
which is predominantly engaged in an insurance 
business and which would be subject to tax 
under subchapter L of chapter 1 of the Internal 
Revenue Code of 1986 if it were a domestic cor-
poration. 
(B) FOREIGN STATE; NATIONAL OF THE 
UNITED STATES; NONIMMIGRANT; RESIDE; LAW-
FUL PERMANENT RESIDENT.—The terms ‘‘na-
tional of the United States’’, and ‘‘non-
immigrant’’ have the meaning given such terms 
in section 101(a) of the Immigration and Na-
tionality Act (8 U.S.C. 1101(a)), the term ‘‘re-
side’’ means having a residence (within the 
meaning of such term in such section), and the 
term ‘‘lawful permanent resident’’ means an 
alien lawfully admitted for permanent residence 
(as defined in such section). 
Passed the House of Representatives April 29, 2014. 
Attest: 
KAREN L. HAAS, 
Clerk. 
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