TITLE I—ASSOCIATION HEALTH 
PLANS ACT 
SEC. 101. SHORT TITLE. 
This title may be cited as the ‘‘Association Health 
Plans Act’’. 
SEC. 102. TREATMENT OF GROUP OR ASSOCIATION OF EM-
PLOYERS. 
(a) IN GENERAL.—Section 3(5) of the Employee Re-
tirement Income Security Act of 1974 (29 U.S.C. 
1002(5)) is amended— 
(1) by striking ‘‘The term’’ and inserting ‘‘(A) 
The term’’; and 
(2) by adding at the end the following: 
‘‘(B) For purposes of subparagraph (A), a group or 
association of employers shall be treated as an ‘employer’, 
regardless of whether the employers composing such group 
or association are in the same industry, trade, or profes-
sion, if such group or association— 
‘‘(i)(I) has established and maintains an em-
ployee welfare benefit plan that is a group health 
plan (as defined in section 733(a)(1)); 
‘‘(II) provides coverage under such plan to at 
least 51 employees after all of the employees em-
ployed by all of the employer members of such group
or association have been aggregated and counted to-
gether as described in subparagraph (D); 
‘‘(III) has been actively in existence for at least 
2 years prior to establishing and maintaining an em-
ployer welfare benefit plan that is a group health 
plan (as defined in section 733(a)(1)); 
‘‘(IV) has been formed and maintained in good 
faith for purposes other than providing medical care 
(as defined in section 733(a)(2)) through the pur-
chase of insurance or otherwise; 
‘‘(V) does not condition membership in the 
group or association on any health status-related 
factor (as described in section 702(a)(1)) relating to 
any individual; 
‘‘(VI) makes coverage under such plan available 
to all employer members of such group or associa-
tion regardless of any health status-related factor 
(as described in section 702(a)(1)) relating to such 
employer members; 
‘‘(VII) does not provide coverage under such 
plan to any individual other than an employee of an 
employer member of such group or association; 
‘‘(VIII) has established a governing board with 
by-laws or other similar indications of formality to 
manage and operate such plan in both form and
substance, of which at least 75 percent of the board 
members shall be made up of employer members of 
such group or association participating in the plan 
that are duly elected by each participating employer 
member casting 1 vote during a scheduled election; 
‘‘(IX) is not a health insurance issuer (as de-
fined in section 733(b)(2)), and is not owned or con-
trolled by such a health insurance issuer or by a 
subsidiary or affiliate of such a health insurance 
issuer, other than to the extent such a health insur-
ance issuer— 
‘‘(aa) may participate in the group or asso-
ciation as a member; and 
‘‘(bb) may provide services such as assist-
ance with plan development, marketing, and ad-
ministrative services to such group or associa-
tion; 
‘‘(ii) meets any set of criteria to qualify for 
such treatment in an advisory opinion issued by the 
Secretary prior to the date of enactment of the As-
sociation Health Plans Act; or 
‘‘(iii) meets any other set of criteria to qualify 
for such treatment that the Secretary by regulation 
may provide.
‘‘(C)(i) For purposes of subparagraph (B), a self-em-
ployed individual shall be treated as— 
‘‘(I) an employer who may become a member of 
a group or association of employers; 
‘‘(II) an employee who may participate in an 
employee welfare benefit plan established and main-
tained by such group or association; and 
‘‘(III) a participant of such plan subject to the 
eligibility determination and monitoring require-
ments set forth in clause (iii). 
‘‘(ii) For purposes of this subparagraph, the term 
‘self-employed individual’ means an individual who— 
‘‘(I) does not have any common law employees; 
‘‘(II) has an ownership right in a trade or busi-
ness, regardless of whether such trade or business is 
incorporated or unincorporated; 
‘‘(III) earns wages (as defined in section 
3121(a) of the Internal Revenue Code of 1986) or 
self-employment income (as defined in section 
1402(b) of such Code) from such trade or business; 
and 
‘‘(IV) works at least 10 hours per week or 40 
hours per month providing personal services to such 
trade or business.
‘‘(iii) The board of a group or association of employ-
ers shall— 
‘‘(I) initially determine whether an individual 
meets the requirements under clause (ii) to be con-
sidered a self-employed individual for the purposes 
of being treated as an— 
‘‘(aa) employer member of such group or 
association (in accordance with clause (i)(I)); 
and 
‘‘(bb) employee who may participate in the 
employee welfare benefit plan established and 
maintained by such group or association (in ac-
cordance with clause (i)(II)); 
‘‘(II) through reasonable monitoring proce-
dures, periodically determine whether the individual 
continues to meet such requirements; and 
‘‘(III) if the board determines that an indi-
vidual no longer meets such requirements, not make 
such plan coverage available to such individual (or 
dependents thereof) for any plan year following the 
plan year during which the board makes such deter-
mination. If, subsequent to a determination that an 
individual no longer meets such requirements, such 
individual furnishes evidence of satisfying such re-
quirements, such individual (and dependents thereof) 
shall be eligible to receive plan coverage. 
‘‘(D) For purposes of subparagraph (B), all of the 
employees (including self-employed individuals) employed 
by all of the employer members (including self-employed 
individuals) of a group or association of employers shall 
be— 
‘‘(i) treated as employed by a single employer; 
and 
‘‘(ii) aggregated and counted together for pur-
poses of any regulation of an employee welfare ben-
efit plan established and maintained by such group 
or association.’’. 
(b) DETERMINATION OF EMPLOYER OR JOINT EM-
PLOYER STATUS.—The provision of employee welfare ben-
efit plan coverage by a group or association of employers 
shall not be construed as evidence for establishing an em-
ployer or joint employer relationship under any Federal 
or State law. 
SEC. 103. RULES APPLICABLE TO GROUP HEALTH PLANS 
ESTABLISHED AND MAINTAINED BY A GROUP 
OR ASSOCIATION OF EMPLOYERS. 
Part 7 of subtitle B of title I of the Employee Retire-
ment Income Security Act of 1974 (29 U.S.C. 1181, et 
seq.) is amended by adding at the end the following:
‘‘SEC. 736. RULES APPLICABLE TO GROUP HEALTH PLANS 
ESTABLISHED AND MAINTAINED BY A GROUP 
OR ASSOCIATION OF EMPLOYERS. 
‘‘(a) PREMIUM RATES FOR A GROUP OR ASSOCIA-
TION OF EMPLOYERS.— 
‘‘(1)(A) In the case of a group health plan es-
tablished and maintained by a group or association 
of employers described in section 3(5)(B), such plan 
may— 
‘‘(i) establish base premium rates formed 
on an actuarially sound, modified community 
rating methodology that considers the pooling 
of all plan participant claims; and 
‘‘(ii) utilize the specific risk profile of each 
employer member of such group or association 
to determine contribution rates for each such 
employer member’s share of a premium by ac-
tuarially adjusting above or below the estab-
lished base premium rates. 
‘‘(B) For purposes of paragraph (1), the term 
‘employer member’ means— 
‘‘(i) an employer who is a member of such 
group or association of employers and employs 
at least 1 common law employee; or 
‘‘(ii) a group made up solely of self-em-
ployed individuals, within which all of the self-
employed individual members of such group or 
association are aggregated together as a single 
employer member group, provided the group in-
cludes at least 20 self-employed individual 
members. 
‘‘(2) In the event a group or association is 
made up solely of self-employed individuals (and no 
employers with at least 1 common law employee are 
members of such group or association), the group 
health plan established by such group or association 
shall— 
‘‘(A) treat all self-employed individuals 
who are members of such group or association 
as a single risk pool; 
‘‘(B) pool all plan participant claims; and 
‘‘(C) charge each plan participant the 
same premium rate. 
‘‘(b) DISCRIMINATION
AND PRE-EXISTING CONDI-
TION PROTECTIONS.—A group health plan established 
and maintained by a group or association of employers de-
scribed in section 3(5)(B) shall be prohibited from— 
‘‘(1) establishing any rule for eligibility (includ-
ing continued eligibility) of any individual (including 
an employee of an employer member or a self-em-
ployed individual, or a dependent of such employee
or self-employed individual) to enroll for benefits 
under the terms of the plan that discriminates based 
on any health status-related factor that relates to 
such individual (consistent with the rules under sec-
tion 702(a)(1)); 
‘‘(2) requiring an individual (including an em-
ployee of an employer member or a self-employed in-
dividual, or a dependent of such employee or self- 
employed individual), as a condition of enrollment or 
continued enrollment under the plan, to pay a pre-
mium or contribution that is greater than the pre-
mium or contribution for a similarly situated indi-
vidual enrolled in the plan based on any health sta-
tus-related factor that relates to such individual 
(consistent with the rules under section 702(b)(1)); 
and 
‘‘(3) denying coverage under such plan on the 
basis of a pre-existing condition (consistent with the 
rules under section 2704 of the Public Health Serv-
ice Act).’’. 
SEC. 104. RULE OF CONSTRUCTION. 
Nothing in this title shall be construed to exempt a 
group health plan which is an employee welfare benefit 
plan offered through a group or association of employers 
from the requirements of part 7 of subtitle B of title I
of the Employee Retirement Income Security Act of 1974 
(29 U.S.C. 1181 et. seq.), including the provisions of part 
A of title XXVII of the Public Health Service Act as incor-
porated by reference into this Act through section 715. 
TITLE II—CHOICE 
ARRANGEMENT ACT 
SEC. 201. SHORT TITLE. 
This title may be cited as the ‘‘Custom Health Option 
and Individual Care Expense Arrangement Act’’ or the 
‘‘CHOICE Arrangement Act’’. 
SEC. 202. TREATMENT OF HEALTH REIMBURSEMENT AR-
RANGEMENTS 
INTEGRATED 
WITH 
INDI-
VIDUAL MARKET COVERAGE. 
(a) IN GENERAL.—Section 9815(b) of the Internal 
Revenue Code of 1986 is amended— 
(1) by striking ‘‘EXCEPTION.—Notwithstanding 
subsection (a)’’ and inserting the following: ‘‘EXCEP-
TIONS.— 
‘‘(1) SELF-INSURED GROUP HEALTH PLANS.— 
Notwithstanding subsection (a)’’, and 
(2) by adding at the end the following new 
paragraph: 
‘‘(2) CUSTOM HEALTH OPTION AND INDIVIDUAL 
CARE EXPENSE ARRANGEMENTS.—
‘‘(A) IN GENERAL.—For purposes of this 
subchapter, a custom health option and indi-
vidual care expense arrangement shall be treat-
ed as meeting the requirements of sections 
2711 and 2713 of title XXVII of the Public 
Health Service Act. 
‘‘(B) CUSTOM HEALTH OPTION AND INDI-
VIDUAL
CARE
EXPENSE
ARRANGEMENTS
DE-
FINED.—For purposes of this section, the term 
‘custom health option and individual care ex-
pense arrangement’ means a health reimburse-
ment arrangement— 
‘‘(i) which is an employer-provided 
group health plan funded solely by em-
ployer contributions to provide payments 
or reimbursements for medical care subject 
to a maximum fixed dollar amount for a 
period, 
‘‘(ii) under which such payments or 
reimbursements may only be made for 
medical care provided during periods dur-
ing which the individual is covered— 
‘‘(I) under individual health in-
surance coverage (other than coverage
that consists solely of excepted bene-
fits), or 
‘‘(II) under part A and B of title 
XVIII of the Social Security Act or 
part C of such title, 
‘‘(iii) which meets the nondiscrimina-
tion requirements of subparagraph (C), 
‘‘(iv) which meets the substantiation 
requirements of subparagraph (D), and 
‘‘(v) which meets the notice require-
ments of subparagraph (E). 
‘‘(C) NONDISCRIMINATION.— 
‘‘(i) IN
GENERAL.—An arrangement 
meets the requirements of this subpara-
graph if an employer offering such ar-
rangement to an employee within a speci-
fied class of employee— 
‘‘(I) offers such arrangement to 
all employees within such specified 
class on the same terms, and 
‘‘(II) does not offer any other 
group health plan to any employees 
within such specified class. 
‘‘(ii) 
SPECIFIED
CLASS
OF
EM-
PLOYEE.—For purposes of this subpara-
graph, any of the following may be des-
ignated as a specified class of employee: 
‘‘(I) Full-time employees. 
‘‘(II) Part-time employees. 
‘‘(III) Salaried employees. 
‘‘(IV) Non-salaried employees. 
‘‘(V) Employees whose primary 
site of employment is in the same rat-
ing area. 
‘‘(VI) Employees who are in-
cluded in a unit of employees covered 
under a collective bargaining agree-
ment to which the employer is subject 
(determined under rules similar to the 
rules of section 105(h)). 
‘‘(VII) Employees who have not 
met a group health plan, or health in-
surance issuer offering group health 
insurance coverage, waiting period re-
quirement that satisfies the of section 
2708 of the Public Health Service 
Act. 
‘‘(VIII) Seasonal employees. 
‘‘(IX) Employees who are non-
resident aliens and who receive no
earned income (within the meaning of 
section 911(d)(2)) from the employer 
which constitutes income from sources 
within the United States (within the 
meaning of section 861(a)(3)). 
‘‘(X) Such other classes of em-
ployees as the Secretary may des-
ignate. 
An employer may designate (in such man-
ner as is prescribed by the Secretary) two 
or more of the classes described in the pre-
ceding subclauses as the specified class of 
employees to which the arrangement is of-
fered for purposes of applying this sub-
paragraph. 
‘‘(iii) 
SPECIAL
RULE
FOR
NEW 
HIRES.—An employer may designate pro-
spectively so much of a specified class of 
employees as are hired after a date set by 
the employer. Such subclass of employees 
shall be treated as the specified class for 
purposes of applying clause (i). 
‘‘(iv) RULES FOR DETERMINING TYPE 
OF EMPLOYEE.—For purposes for clause 
(ii), any determination of full-time, part-
time, or seasonal employment status shall 
be made under rules similar to the rules of 
section 105(h) or 4980H, whichever the 
employer elects for the plan year. Such 
election shall apply with respect to all em-
ployees of the employer for the plan year. 
‘‘(v) 
PERMITTED
VARIATION.—For 
purposes of clause (i)(I), an arrangement 
shall not fail to be treated as provided on 
the same terms within a specified class 
merely 
because 
the 
maximum 
dollar 
amount of payments and reimbursements 
which may be made under the terms of the 
arrangement for the year with respect to 
each employee within such class— 
‘‘(I) increases as additional de-
pendents of the employee are covered 
under the arrangement, and 
‘‘(II) increases with respect to a 
participant as the age of the partici-
pant increases, but not in excess of an 
amount equal to 300 percent the low-
est maximum dollar amount with re-
spect to such a participant determined 
without regard to age.
‘‘(D) SUBSTANTIATION REQUIREMENTS.— 
An arrangement meets the requirements of this 
subparagraph if the arrangement has reason-
able procedures to substantiate— 
‘‘(i) that the participant is, or will be, 
enrolled in coverage described in subpara-
graph (B)(ii) as of the beginning of the 
plan year of the arrangement (or as of the 
beginning of coverage under the arrange-
ment in the case of an employee who first 
becomes eligible to participate in the ar-
rangement after the date notice is given 
with respect to the plan under subpara-
graph (E) (determined without regard to 
clause (iii) thereof), and 
‘‘(ii) any requests made for payment 
or reimbursement of medical care under 
the arrangement and that the participant 
remains so enrolled. 
‘‘(E) NOTICE.— 
‘‘(i) IN
GENERAL.—Except as pro-
vided in clause (iii), an arrangement meets 
the requirements of this subparagraph if, 
under the arrangement, each employee eli-
gible to participate is, not later than 90
days before the beginning of the plan year, 
given written notice of the employee’s 
rights and obligations under the arrange-
ment which— 
‘‘(I) is sufficiently accurate and 
comprehensive to appraise the em-
ployee of such rights and obligations, 
and 
‘‘(II) is written in a manner cal-
culated to be understood by the aver-
age employee eligible to participate. 
‘‘(ii) NOTICE
REQUIREMENTS.—Such 
notice shall include such information as the 
Secretary may by regulation prescribe. 
‘‘(iii) NOTICE
DEADLINE
FOR
CER-
TAIN EMPLOYEES.—In the case of an em-
ployee— 
‘‘(I) who first becomes eligible to 
participate in the arrangement after 
the date notice is given with respect 
to the plan under clause (i) (deter-
mined without regard to this clause), 
or 
‘‘(II) whose employer is first es-
tablished fewer than 120 days before
the beginning of the first plan year of 
the arrangement, 
the requirements of this subparagraph 
shall be treated as met if the notice re-
quired under clause (i) is provided not 
later than the date the arrangement may 
take effect with respect to such em-
ployee.’’. 
(b) NO INFERENCE.—To the extent not inconsistent 
with the amendments made by this section— 
(1) no inference shall be made from such 
amendments with respect to the rules prescribed in 
the Federal Register on June 20, 2019, (84 Fed. 
Reg. 28888) relating to health reimbursement ar-
rangements and other account-based group health 
plans, and 
(2) any reference to custom health option and 
individual care expense arrangements shall for pur-
poses of such rules be treated as including a ref-
erence to individual coverage health reimbursement 
arrangements. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to plan years beginning after De-
cember 31, 2023.
TITLE III—SELF-INSURANCE 
PROTECTION ACT 
SEC. 301. SHORT TITLE. 
This title may be cited as the ‘‘Self-Insurance Protec-
tion Act’’. 
SEC. 302. FINDINGS. 
Congress finds the following: 
(1) Small and large employers offer health ben-
efit plan coverage to employees in self-funded ar-
rangements using company assets or a fund, or by 
paying premiums to purchase fully-insured coverage 
from a health insurance company. 
(2) Employers that self-fund health benefit 
plans will often purchase stop-loss insurance as a fi-
nancial risk management tool to protect against ex-
cess or unexpected catastrophic health plan claims 
losses that arise above projected costs paid out of 
company assets. 
(3) Stop-loss coverage insures the employer 
sponsoring the health benefit plan against unfore-
seen health plan claims, does not insure the em-
ployee health benefit plan itself, and does not pay 
health care providers for medical services provided to 
the employees.
(4) Employer-sponsored health benefit plans are 
regulated under the Employee Retirement Income 
Security Act of 1974, however, States regulate the 
availability and the coverage terms of stop-loss in-
surance coverage that employers purchase to protect 
company assets and to protect a fund against excess 
or unexpected claims losses. 
(5) Both large and small employers that choose 
to self-fund must also be able to protect company as-
sets or a fund against excess or unexpected claims 
losses and States must reasonably regulate stop-loss 
insurance to assure its availability to both large and 
small employers. 
SEC. 303. CERTAIN MEDICAL STOP-LOSS INSURANCE OB-
TAINED BY CERTAIN PLAN SPONSORS OF 
GROUP 
HEALTH 
PLANS 
NOT 
INCLUDED 
UNDER THE DEFINITION OF HEALTH INSUR-
ANCE COVERAGE. 
Section 733(b)(1) of the Employee Retirement In-
come Security Act of 1974 (29 U.S.C. 1191b(b)(1)) is 
amended by adding at the end the following sentence: 
‘‘Such term shall not include a stop-loss policy obtained 
by a self-insured group health plan or a plan sponsor of 
a group health plan that self-insures the health risks of 
its plan participants to reimburse the plan or sponsor for
losses that the plan or sponsor incurs in providing health 
or medical benefits to such plan participants in excess of 
a predetermined level set forth in the stop-loss policy ob-
tained by such plan or sponsor.’’. 
SEC. 304. EFFECT ON OTHER LAWS. 
Section 514(b) of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. 1144(b)) is amended by 
adding at the end the following: 
‘‘(10) The provisions of this title (including part 7 
relating to group health plans) shall preempt State laws 
insofar as they may now or hereafter prevent an employee 
benefit plan that is a group health plan from insuring 
against the risk of excess or unexpected health plan claims 
losses.’’. 
TITLE IV—SMALL BUSINESS 
FLEXIBILITY ACT 
SEC. 401. SHORT TITLE. 
This title may be cited as the ‘‘Small Business Flexi-
bility Act’’. 
SEC. 402. NOTIFICATION OF FLEXIBLE HEALTH INSURANCE 
BENEFITS. 
(a) IN GENERAL.—Subchapter C of chapter 100 of 
the Internal Revenue Code of 1986 is amended by adding 
at the end the following new section:
‘‘SEC. 9835. NOTIFICATION OF FLEXIBLE HEALTH INSUR-
ANCE BENEFITS. 
‘‘(a) IN GENERAL.—Not later than 1 year after the 
date of enactment of this section, the Secretary shall no-
tify employers of the availability of tax-advantaged flexible 
health insurance benefits, with an initial focus on small 
businesses, particularly in rural areas (as defined in sec-
tion 1393(a)(2)). 
‘‘(b) DEFINITIONS.—In this section: 
‘‘(1) EMPLOYER.—The term ‘employer’ has the 
meaning given such term in section 3(5) of the Em-
ployee Retirement Income Security Act (29 U.S.C. 
1002(5)). 
‘‘(2) FLEXIBLE
HEALTH
INSURANCE
BENE-
FITS.—The term ‘flexible health insurance benefits’ 
means— 
‘‘(A) an individual contribution health re-
imbursement arrangement (as described in the 
rule entitled ‘Health Reimbursement Arrange-
ments and Other Account-Based Group Health 
Plans’ (84 Fed. Reg. 28888 (June 20, 2019)); 
‘‘(B) a qualified small employer health re-
imbursement arrangement (as defined in sec-
tion 9831(d)(2)); and 
‘‘(C) the small employer health insurance 
credit determined under section 45R.’’.
(b) CLERICAL AMENDMENT.—The table of sections 
for subchapter C of chapter 100 of such Code is amended 
by adding at the end the following new item: 
‘‘Sec. 9835. Notification of flexible health insurance benefits.’’. 
TITLE V—RESCISSIONS 
SEC. 501. PREVENTION AND PUBLIC HEALTH FUND. 
Section 4002(b)(7) of the Patient Protection and Af-
fordable Care Act (42 U.S.C. 300u–11(b)(7)) is amended 
by striking ‘‘for each of fiscal years 2024 and 2025, 
$1,300,000,000’’ and inserting ‘‘for fiscal year 2024, 
$1,055,000,000, 
and 
for 
fiscal 
year 
2025, 
$1,300,000,000’’. 
TITLE VI—SENSE OF CONGRESS 
THAT 
AMERICANS 
SHALL 
HAVE 
HEALTHCARE 
FREE-
DOM 
SEC. 601. SENSE OF CONGRESS THAT HEALTHCARE FREE-
DOM IS THE FUTURE. 
It is the sense of Congress that— 
(1) the future of healthcare lies in healthcare 
freedom, not in socialized medicine; 
(2) Congress should take steps to address the 
broken healthcare system by restoring free market 
practices to lower costs;
(3) coverage is not care, and expanding direct 
access to healthcare should be prioritized over ex-
panding access to coverage; and 
(4) patients and doctors, not government bu-
reaucrats or insurance bureaucrats, should make 
healthcare decisions. 
Passed the House of Representatives June 21, 2023. 
Attest: 
Clerk.
118TH CONGRESS 
1ST SESSION 
H. R. 3799 
AN ACT 
To amend the Internal Revenue Code of 1986 to 
provide for health reimbursement arrangements 
integrated with individual health insurance cov-
erage.