H. R. 3590—790 
‘‘(C) The requirement, together with the other provi-
sions of this Act, will add millions of new consumers to 
the health insurance market, increasing the supply of, and 
demand for, health care services, and will increase the 
number and share of Americans who are insured. 
‘‘(D) The requirement achieves near-universal coverage 
by building upon and strengthening the private employer- 
based health insurance system, which covers 176,000,000 
Americans nationwide. In Massachusetts, a similar require-
ment has strengthened private employer-based coverage: 
despite the economic downturn, the number of workers 
offered employer-based coverage has actually increased. 
‘‘(E) The economy loses up to $207,000,000,000 a year 
because of the poorer health and shorter lifespan of the 
uninsured. By significantly reducing the number of the 
uninsured, the requirement, together with the other provi-
sions of this Act, will significantly reduce this economic 
cost. 
‘‘(F) The cost of providing uncompensated care to the 
uninsured was $43,000,000,000 in 2008. To pay for this 
cost, health care providers pass on the cost to private 
insurers, which pass on the cost to families. This cost- 
shifting increases family premiums by on average over 
$1,000 a year. By significantly reducing the number of 
the uninsured, the requirement, together with the other 
provisions of this Act, will lower health insurance pre-
miums. 
‘‘(G) 62 percent of all personal bankruptcies are caused 
in part by medical expenses. By significantly increasing 
health insurance coverage, the requirement, together with 
the other provisions of this Act, will improve financial 
security for families. 
‘‘(H) Under the Employee Retirement Income Security 
Act of 1974 (29 U.S.C. 1001 et seq.), the Public Health 
Service Act (42 U.S.C. 201 et seq.), and this Act, the Federal 
Government has a significant role in regulating health 
insurance. The requirement is an essential part of this 
larger regulation of economic activity, and the absence 
of the requirement would undercut Federal regulation of 
the health insurance market. 
‘‘(I) Under sections 2704 and 2705 of the Public Health 
Service Act (as added by section 1201 of this Act), if there 
were no requirement, many individuals would wait to pur-
chase health insurance until they needed care. By signifi-
cantly increasing health insurance coverage, the require-
ment, together with the other provisions of this Act, will 
minimize this adverse selection and broaden the health 
insurance risk pool to include healthy individuals, which 
will lower health insurance premiums. The requirement 
is essential to creating effective health insurance markets 
in which improved health insurance products that are 
guaranteed issue and do not exclude coverage of pre- 
existing conditions can be sold. 
‘‘(J) Administrative costs for private health insurance, 
which were $90,000,000,000 in 2006, are 26 to 30 percent 
of premiums in the current individual and small group
H. R. 3590—791 
markets. By significantly increasing health insurance cov-
erage and the size of purchasing pools, which will increase 
economies of scale, the requirement, together with the other 
provisions of this Act, will significantly reduce administra-
tive costs and lower health insurance premiums. The 
requirement is essential to creating effective health insur-
ance markets that do not require underwriting and elimi-
nate its associated administrative costs.’’. 
(b)(1) Section 5000A(b)(1) of the Internal Revenue Code of 1986, 
as added by section 1501(b) of this Act, is amended to read as 
follows: 
‘‘(1) IN GENERAL.—If a taxpayer who is an applicable indi-
vidual, or an applicable individual for whom the taxpayer is 
liable under paragraph (3), fails to meet the requirement of 
subsection (a) for 1 or more months, then, except as provided 
in subsection (e), there is hereby imposed on the taxpayer 
a penalty with respect to such failures in the amount deter-
mined under subsection (c).’’. 
(2) Paragraphs (1) and (2) of section 5000A(c) of the 
Internal Revenue Code of 1986, as so added, are amended 
to read as follows: 
‘‘(1) IN GENERAL.—The amount of the penalty imposed by 
this section on any taxpayer for any taxable year with respect 
to failures described in subsection (b)(1) shall be equal to the 
lesser of— 
‘‘(A) the sum of the monthly penalty amounts deter-
mined under paragraph (2) for months in the taxable year 
during which 1 or more such failures occurred, or 
‘‘(B) an amount equal to the national average premium 
for qualified health plans which have a bronze level of 
coverage, provide coverage for the applicable family size 
involved, and are offered through Exchanges for plan years 
beginning in the calendar year with or within which the 
taxable year ends. 
‘‘(2) MONTHLY PENALTY AMOUNTS.—For purposes of para-
graph (1)(A), the monthly penalty amount with respect to any 
taxpayer for any month during which any failure described 
in subsection (b)(1) occurred is an amount equal to 1⁄12 of 
the greater of the following amounts: 
‘‘(A) FLAT DOLLAR AMOUNT.—An amount equal to the 
lesser of— 
‘‘(i) the sum of the applicable dollar amounts for 
all individuals with respect to whom such failure 
occurred during such month, or 
‘‘(ii) 300 percent of the applicable dollar amount 
(determined without regard to paragraph (3)(C)) for 
the calendar year with or within which the taxable 
year ends. 
‘‘(B) PERCENTAGE
OF
INCOME.—An amount equal to 
the following percentage of the taxpayer’s household income 
for the taxable year: 
‘‘(i) 0.5 percent for taxable years beginning in 2014. 
‘‘(ii) 1.0 percent for taxable years beginning in 
2015. 
‘‘(iii) 2.0 percent for taxable years beginning after 
2015.’’.
H. R. 3590—792 
(3) Section 5000A(c)(3) of the Internal Revenue Code of 1986, 
as added by section 1501(b) of this Act, is amended by striking 
‘‘$350’’ and inserting ‘‘$495’’. 
(c) Section 5000A(d)(2)(A) of the Internal Revenue Code of 
1986, as added by section 1501(b) of this Act, is amended to read 
as follows: 
‘‘(A) RELIGIOUS
CONSCIENCE
EXEMPTION.—Such term 
shall not include any individual for any month if such 
individual has in effect an exemption under section 
1311(d)(4)(H) of the Patient Protection and Affordable Care 
Act which certifies that such individual is— 
‘‘(i) a member of a recognized religious sect or 
division 
thereof 
which 
is 
described 
in 
section 
1402(g)(1), and 
‘‘(ii) an adherent of established tenets or teachings 
of such sect or division as described in such section.’’. 
(d) Section 5000A(e)(1)(C) of the Internal Revenue Code of 
1986, as added by section 1501(b) of this Act, is amended to read 
as follows: 
‘‘(C) SPECIAL
RULES
FOR
INDIVIDUALS
RELATED
TO 
EMPLOYEES.—For purposes of subparagraph (B)(i), if an 
applicable individual is eligible for minimum essential cov-
erage through an employer by reason of a relationship 
to an employee, the determination under subparagraph 
(A) shall be made by reference to required contribution 
of the employee.’’. 
(e) Section 4980H(b) of the Internal Revenue Code of 1986, 
as added by section 1513(a) of this Act, is amended to read as 
follows: 
‘‘(b) LARGE EMPLOYERS WITH WAITING PERIODS EXCEEDING 60 
DAYS.— 
‘‘(1) IN
GENERAL.—In the case of any applicable large 
employer which requires an extended waiting period to enroll 
in any minimum essential coverage under an employer-spon-
sored plan (as defined in section 5000A(f)(2)), there is hereby 
imposed on the employer an assessable payment of $600 for 
each full-time employee of the employer to whom the extended 
waiting period applies. 
‘‘(2) EXTENDED
WAITING
PERIOD.—The term ‘extended 
waiting period’ means any waiting period (as defined in section 
2701(b)(4) of the Public Health Service Act) which exceeds 
60 days.’’. 
(f)(1) Subparagraph (A) of section 4980H(d)(4) of the Internal 
Revenue Code of 1986, as added by section 1513(a) of this Act, 
is amended by inserting ‘‘, with respect to any month,’’ after 
‘‘means’’. 
(2) Section 4980H(d)(2) of the Internal Revenue Code of 1986, 
as added by section 1513(a) of this Act, is amended by adding 
at the end the following: 
‘‘(D) 
APPLICATION
TO
CONSTRUCTION
INDUSTRY 
EMPLOYERS.—In the case of any employer the substantial 
annual gross receipts of which are attributable to the 
construction industry— 
‘‘(i) subparagraph (A) shall be applied by sub-
stituting ‘who employed an average of at least 5 full- 
time employees on business days during the preceding 
calendar year and whose annual payroll expenses
H. R. 3590—793 
exceed $250,000 for such preceding calendar year’ for 
‘who employed an average of at least 50 full-time 
employees on business days during the preceding cal-
endar year’, and 
‘‘(ii) subparagraph (B) shall be applied by sub-
stituting ‘5’ for ‘50’.’’. 
(3) The amendment made by paragraph (2) shall apply to 
months beginning after December 31, 2013. 
(g) Section 6056(b) of the Internal Revenue Code of 1986, as 
added by section 1514(a) of the Act, is amended by adding at 
the end the following new flush sentence: 
‘‘The Secretary shall have the authority to review the accuracy 
of the information provided under this subsection, including the 
applicable large employer’s share under paragraph (2)(C)(iv).’’. 
SEC. 10107. AMENDMENTS TO SUBTITLE G. 
(a) Section 1562 of this Act is amended, in the amendment 
made by subsection (a)(2)(B)(iii), by striking ‘‘subpart 1’’ and 
inserting ‘‘subparts I and II’’; and 
(b) Subtitle G of title I of this Act is amended— 
(1) by redesignating section 1562 (as amended) as section 
1563; and 
(2) by inserting after section 1561 the following: 
‘‘SEC. 1562. GAO STUDY REGARDING THE RATE OF DENIAL OF COV-
ERAGE AND ENROLLMENT BY HEALTH INSURANCE 
ISSUERS AND GROUP HEALTH PLANS. 
‘‘(a) IN GENERAL.—The Comptroller General of the United 
States (referred to in this section as the ‘Comptroller General’) 
shall conduct a study of the incidence of denials of coverage for 
medical services and denials of applications to enroll in health 
insurance plans, as described in subsection (b), by group health 
plans and health insurance issuers. 
‘‘(b) DATA.— 
‘‘(1) IN GENERAL.—In conducting the study described in 
subsection (a), the Comptroller General shall consider samples 
of data concerning the following: 
‘‘(A)(i) denials of coverage for medical services to a 
plan enrollees, by the types of services for which such 
coverage was denied; and 
‘‘(ii) the reasons such coverage was denied; and 
‘‘(B)(i) incidents in which group health plans and health 
insurance issuers deny the application of an individual 
to enroll in a health insurance plan offered by such group 
health plan or issuer; and 
‘‘(ii) the reasons such applications are denied. 
‘‘(2) SCOPE OF DATA.— 
‘‘(A) FAVORABLY RESOLVED DISPUTES.—The data that 
the Comptroller General considers under paragraph (1) 
shall include data concerning denials of coverage for med-
ical services and denials of applications for enrollment in 
a plan by a group health plan or health insurance issuer, 
where such group health plan or health insurance issuer 
later approves such coverage or application. 
‘‘(B) ALL HEALTH PLANS.—The study under this section 
shall consider data from varied group health plans and 
health insurance plans offered by health insurance issuers,