I 
117TH CONGRESS 
2D SESSION 
H. R. 8588 
To address the high costs of health care services, prescription drugs, and 
health insurance coverage in the United States, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 28, 2022 
Mr. WESTERMAN (for himself and Mr. GONZALEZ of Ohio) introduced the fol-
lowing bill; which was referred to the Committee on Energy and Com-
merce, and in addition to the Committees on Ways and Means, Education 
and Labor, the Judiciary, Oversight and Reform, Rules, the Budget, 
Armed Services, and House Administration, 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 address the high costs of health care services, prescription 
drugs, and health insurance coverage in the United 
States, 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; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Fair Care Act of 2022’’. 
(b) TABLE OF CONTENTS.—The table of contents for 
this Act is as follows: 
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Sec. 1. Short title; table of contents. 
TITLE I—MODERNIZATION OF HEALTH SAVINGS ACCOUNTS 
Subtitle A—Modernization of Health Savings Accounts and Contributions 
Sec. 101. Modernization of health savings accounts. 
Sec. 102. Unused premium tax credits may be deposited in health savings ac-
counts. 
Sec. 103. Health Reimbursement Arrangements and Other Account-Based 
Group Health Plans. 
Sec. 104. Cost-sharing reduction payments as eligible contributions. 
Sec. 105. Direct primary care. 
Subtitle B—Assistance to Health Savings Accounts 
Sec. 111. One-time application of saver’s credit to contributions to health sav-
ings accounts. 
Sec. 112. Grants for health savings account assistance and outreach. 
Sec. 113. New corporations required to use health savings accounts. 
Sec. 114. Federal employee health benefits and health savings accounts. 
TITLE II—IMPROVING PRIVATE HEALTH INSURANCE 
Subtitle A—Maintaining Protections for Patients With Preexisting Conditions 
Sec. 201. Guaranteed availability of coverage; prohibiting discrimination. 
Subtitle B—Expanding Coverage Options 
Sec. 211. Definition of ‘‘employer’’ under ERISA with respect to group health 
plans. 
Sec. 212. Short-term limited duration insurance. 
Subtitle C—Improving Commercial Health Insurance 
Sec. 221. Invisible Guaranteed Coverage Pool Reinsurance Program; tax on ex-
change plans. 
Sec. 222. Employer health insurance mandate repeal. 
Sec. 223. Refundable credits for coverage under a qualified health plan for indi-
viduals offered employer-sponsored insurance. 
Sec. 224. Inclusion in income of certain costs of employer-provided coverage 
under health plans. 
Sec. 225. Change in permissible age variation in health insurance premium 
rates. 
Sec. 226. Premium assistance adjustment to reflect age. 
Sec. 227. Premium assistance. 
Sec. 228. Adding copper plans to Exchanges. 
Sec. 229. Copper and bronze plans. 
Sec. 230. Waivers for State innovation. 
Sec. 231. Enrollment periods. 
Sec. 232. State-operated Exchanges flexibility for open enrollment periods. 
Sec. 233. Promoting health plans that cover individuals in more than one State. 
TITLE III—COMPETITION, TRANSPARENCY AND ACCOUNTABILITY 
Subtitle A—Provider and Insurer Competition 
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Sec. 301. Hospital consolidation. 
Sec. 302. Authority of Federal Trade Commission over certain tax-exempt or-
ganizations. 
Sec. 303. Leveling the playing field between payers and providers. 
Sec. 304. Banning anticompetitive terms in facility and insurance contracts 
that limit access to higher quality, lower cost care. 
Sec. 305. Repealing eligibility of certain ACOs. 
Sec. 306. Repeal of health care reform provisions limiting Medicare exception 
to the prohibition on certain physician referrals for hospitals. 
Sec. 307. Alternative payment model for certain shoppable procedures. 
Subtitle B—Price Transparency 
Sec. 321. Price transparency requirements. 
Sec. 322. Ensuring enrollee access to cost-sharing information. 
Sec. 323. Access of individuals to protected health information. 
Sec. 324. Timely bills for patients. 
Sec. 325. Advisory group on reducing burden of hospital administrative require-
ments. 
Sec. 326. Data reporting to improve the transparency regarding how 340B hos-
pital covered entities provide care for patients. 
Sec. 327. Requiring 340B drug discount program reports by DSH hospital cov-
ered entities on low-income utilization rate of outpatient hos-
pital services. 
Sec. 328. Employer benefits reports. 
Sec. 329. Government Accountability Office study on profit- and revenue-shar-
ing in health care. 
Subtitle C—Prescription Drug Competition and Innovation 
Sec. 341. Expedited development and priority review for generic complex drug 
products. 
Sec. 342. Preventing blocking of generic drugs. 
Sec. 343. Ensuring timely access to generics. 
Sec. 344. Preemption of State barriers to the substitution of biosimilar prod-
ucts. 
Sec. 345. Increasing pharmaceutical options to treat an unmet medical need. 
Sec. 346. Provisional approval of new human drugs. 
Sec. 347. Consolidating exclusivity periods for drugs treating rare diseases and 
conditions. 
Sec. 348. Exclusivity period for brand name biological products. 
Sec. 349. Regulation of manufacturer-sponsored copay contributions. 
Sec. 350. Antitrust exemption for private health insurer issuers to negotiate 
wholesale acquisition prices of prescription drugs purchased 
from drug manufacturers. 
Sec. 351. Biological product innovation. 
Sec. 352. Prompt approval of drugs related to safety information. 
Sec. 353. Congressional review of the Food and Drug Administration rule-
making. 
Sec. 354. Government Accountability Office study of rules. 
Subtitle D—Prescription Drug and Pharmacy Benefit Manager Transparency 
Sec. 361. Patent disclosure requirements. 
Sec. 362. Requirements with respect to prescription drug benefits. 
Sec. 363. PBM transparency and elimination of DIR fees. 
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Sec. 364. Health plan oversight of pharmacy benefit manager services. 
Sec. 365. Study by Comptroller General of United States. 
Subtitle E—Medicare and Medicaid Prescription Drug Reforms 
Sec. 371. Medicare part D modernization redesign. 
Sec. 372. Maximum monthly cap on cost-sharing payments under prescription 
drug plans and MA–PD plans. 
Sec. 373. Medicare part B rebate by manufacturers for drugs or biologicals 
with prices increasing faster than inflation. 
Sec. 374. Market based part B pricing index. 
Sec. 375. Innovation model testing of Medicare drug payments. 
Sec. 376. Modification of maximum rebate amount under Medicaid drug rebate 
program. 
Subtitle F—Medical Malpractice Reform 
Sec. 381. Definitions. 
Sec. 382. Encouraging speedy resolution of claims. 
Sec. 383. Compensating patient injury. 
Sec. 384. Maximizing patient recovery. 
Sec. 385. Authorization of payment of future damages to claimants in health 
care lawsuits. 
Sec. 386. Product liability for health care providers. 
Sec. 387. Effect on other laws. 
Sec. 388. Limitation on expert witness testimony. 
Sec. 389. Expert witness qualifications. 
Sec. 390. Communications following unanticipated outcome. 
Sec. 391. Affidavit of merit. 
Sec. 392. Notice of intent to commence lawsuit. 
Sec. 393. Limitation on liability for volunteer health care professionals. 
Sec. 394. Rules of construction. 
Sec. 395. Effective date. 
TITLE IV—MEDICARE AND MEDICAID REFORMS 
Subtitle A—Medicaid Reforms 
Sec. 401. Medicaid payment reform. 
Sec. 402. Income limitations for refundable credits for coverage under a quali-
fied health plan. 
Sec. 403. Medicaid eligibility determinations. 
Sec. 404. Lowering safe harbor threshold with respect to State taxes on health 
care providers. 
Sec. 405. Providing for State approval and implementation of specified waivers 
under the Medicaid program. 
Sec. 406. Deduction for qualified charity care. 
Subtitle B—Medicare Reforms 
Sec. 411. Off-campus provider-based department Medicare site neutral pay-
ment. 
Sec. 412. Eliminating FEHBP eligibility for annuitants. 
Sec. 413. Elimination of Medicare eligibility for certain individuals. 
Sec. 414. Medicare part D tax deduction. 
Sec. 415. Repeal of net investment income tax. 
Sec. 416. Medicare coverage of bad debt. 
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Subtitle C—Medicare Choice and Competition 
Sec. 421. Competitive bidding and premiums under unified Medicare. 
Sec. 422. New unified eligibility and enrollment rules. 
Sec. 423. New benefit structure under unified Medicare. 
Sec. 424. Late enrollment penalty not to apply for months of any health cov-
erage. 
Sec. 425. Medigap reform. 
Sec. 426. ACO revision. 
Sec. 427. Primary care options. 
Sec. 428. General provisions; effective date. 
Subtitle D—Telehealth Improvements and Expansion 
Sec. 431. Expansion of coverage of telehealth services. 
Sec. 432. Expanding the use of telehealth through the waiver of certain re-
quirements. 
Sec. 433. Expanding the use of telehealth for mental health services. 
Sec. 434. Use of telehealth in emergency medical care. 
Sec. 435. Improvements to the process for adding telehealth services. 
Sec. 436. Rural health clinics and Federally qualified health centers. 
Sec. 437. Native American health facilities. 
Sec. 438. Waiver of telehealth restrictions during national emergencies. 
Sec. 439. Use of telehealth in recertification for hospice care. 
Sec. 440. Clarification for fraud and abuse laws regarding technologies pro-
vided to beneficiaries. 
Sec. 441. Study and report on increasing access to telehealth services in the 
home. 
Sec. 442. Analysis of telehealth waivers in alternative payment models. 
Sec. 443. Model to allow additional health professionals to furnish telehealth 
services. 
Sec. 444. Testing of models to examine the use of telehealth under the Medi-
care program. 
TITLE I—MODERNIZATION OF 
HEALTH SAVINGS ACCOUNTS 
Subtitle 
A—Modernization 
of 
Health Savings Accounts and 
Contributions 
SEC. 101. MODERNIZATION OF HEALTH SAVINGS AC-
COUNTS. 
(a) IN GENERAL.—Section 223 of the Internal Rev-
enue Code of 1986 is amended to read as follows: 
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‘‘SEC. 223. HEALTH SAVINGS ACCOUNTS. 
‘‘(a) DEDUCTION ALLOWED.—In the case of an indi-
vidual who is an eligible individual for any month during 
the taxable year, there shall be allowed as a deduction for 
the taxable year an amount equal to the aggregate amount 
paid in cash during such taxable year by or on behalf of 
such individual to a health savings account of such indi-
vidual. 
‘‘(b) LIMITATIONS.— 
‘‘(1) IN GENERAL.—The amount allowable as a 
deduction under subsection (a) with respect to any 
month is 1⁄12 of the dollar amount in effect under 
subsection (d)(2)(A) for the taxable year which in-
cluded such month. 
‘‘(2) DENIAL
OF
DEDUCTION
TO
DEPEND-
ENTS.—No deduction shall be allowed under this 
section to any individual with respect to whom a de-
duction under section 151 is allowable to another 
taxpayer for a taxable year beginning in the cal-
endar year in which such individual’s taxable year 
begins. 
‘‘(3) INCREASE IN LIMIT FOR INDIVIDUALS BE-
COMING ELIGIBLE INDIVIDUALS AFTER THE BEGIN-
NING OF THE YEAR.— 
‘‘(A) IN GENERAL.—For purposes of com-
puting the limitation under paragraph (1) for 
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any taxable year, an individual who is an eligi-
ble individual during the last month of such 
taxable year shall be treated— 
‘‘(i) as having been an eligible indi-
vidual during each of the months in such 
taxable year, and 
‘‘(ii) as having been enrolled, during 
each of the months such individual is 
treated as an eligible individual solely by 
reason of clause (i), in the same qualified 
plan in which the individual was enrolled 
for the last month of such taxable year. 
‘‘(B) FAILURE
TO
MAINTAIN
QUALIFIED 
PLAN COVERAGE.— 
‘‘(i) IN
GENERAL.—If, at any time 
during the testing period, the individual is 
not an eligible individual, then— 
‘‘(I) gross income of the indi-
vidual for the taxable year in which 
occurs the first month in the testing 
period for which such individual is not 
an eligible individual is increased by 
the aggregate amount of all contribu-
tions to the health savings account of 
the individual which could not have 
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been made but for subparagraph (A), 
and 
‘‘(II) the tax imposed by this 
chapter for any taxable year on the 
individual shall be increased by 10 
percent of the amount of such in-
crease. 
‘‘(ii) EXCEPTION FOR DISABILITY OR 
DEATH.—Subclauses (I) and (II) of clause 
(i) shall not apply if the individual ceased 
to be an eligible individual by reason of the 
death of the individual or the individual 
becoming disabled (within the meaning of 
section 72(m)(7)). 
‘‘(iii) TESTING
PERIOD.—The term 
‘testing period’ means the period beginning 
with the last month of the taxable year re-
ferred to in subparagraph (A) and ending 
on the last day of the 12th month fol-
lowing such month. 
‘‘(c) DEFINITIONS AND SPECIAL RULES.—For pur-
poses of this section— 
‘‘(1) ELIGIBLE INDIVIDUAL.—The term ‘eligible 
individual’ means, with respect to any month, any 
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individual if such individual is covered under a quali-
fied plan as of the 1st day of such month 
‘‘(2) QUALIFIED PLAN.— 
‘‘(A) IN
GENERAL.—The term ‘qualified 
health plan’ means any health plan, including 
employer plans, individual plans, short term 
plans, Medicare, Medicaid, VA health care, 
TRICARE, Indian health service, health care 
sharing ministries, and association health plans. 
‘‘(B) EXCLUSION
OF
CERTAIN
PLANS.— 
Such term does not include a health plan if 
substantially all of its coverage is— 
‘‘(i) coverage for any benefit provided 
by permitted insurance, or 
‘‘(ii) coverage (whether through insur-
ance or otherwise) for accidents, disability, 
dental care, vision care, or long-term care. 
‘‘(3) PERMITTED INSURANCE.—The term ‘per-
mitted insurance’ means— 
‘‘(A) insurance if substantially all of the 
coverage provided under such insurance relates 
to— 
‘‘(i) liabilities incurred under workers’ 
compensation laws, 
‘‘(ii) tort liabilities, 
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‘‘(iii) liabilities relating to ownership 
or use of property, or 
‘‘(iv) such other similar liabilities as 
the Secretary may specify by regulations, 
‘‘(B) insurance for a specified disease or 
illness, and 
‘‘(C) insurance paying a fixed amount per 
day (or other period) of hospitalization. 
‘‘(4) FAMILY
COVERAGE.—The term ‘family 
coverage’ means any coverage other than self-only 
coverage. 
‘‘(d) HEALTH SAVINGS ACCOUNT.—For purposes of 
this section— 
‘‘(1) IN GENERAL.—The term ‘health savings 
account’ means a trust created or organized in the 
United States as a health savings account exclusively 
for the purpose of paying the qualified medical ex-
penses of the account beneficiary, but only if the 
written governing instrument creating the trust 
meets the following requirements: 
‘‘(A) Except in the case of a rollover con-
tribution described in subsection (f)(5) or sec-
tion 220(f)(5), no contribution will be accept-
ed— 
‘‘(i) unless it is in cash, or 
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‘‘(ii) to the extent such contribution, 
when added to previous contributions to 
the trust for the calendar year, exceeds the 
limitation amount specified in paragraph 
(2)(A), or 
‘‘(iii) to the extent such contribution, 
when added to the balance of the account, 
exceeds the limitation amount specified in 
paragraph (2)(B). 
‘‘(B) The trustee is a bank (as defined in 
section 408(n)), an insurance company (as de-
fined in section 816), or another person who 
demonstrates to the satisfaction of the Sec-
retary that the manner in which such person 
will administer the trust will be consistent with 
the requirements of this section. 
‘‘(C) No part of the trust assets will be in-
vested in life insurance contracts. 
‘‘(D) The assets of the trust will not be 
commingled with other property except in a 
common trust fund or common investment 
fund. 
‘‘(E) The interest of an individual in the 
balance in his account is nonforfeitable. 
‘‘(2) LIMITATIONS.— 
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‘‘(A) ANNUAL LIMITATION.— 
‘‘(i) IN
GENERAL.—The limitation 
amount specified in this subparagraph is— 
‘‘(I) $5,000 in the case of a 
qualified health plan with an actuarial 
value of less than 40 percent, 
‘‘(II) $4,300 in the case of a 
qualified health plan with an actuarial 
value that is 40 percent or more and 
less than 75 percent, and 
‘‘(III) $3,600 in the case of a 
qualified health plan with an actuarial 
value that is 75 percent or more. 
‘‘(ii) ACTUARIAL
VALUE
OF
QUALI-
FIED
HEALTH
PLAN.—For purposes of 
clause (i), the actuarial value of a qualified 
health plan is the percentage of the total 
average costs of covered benefits under the 
health plan. 
‘‘(B) ACCOUNT
ACCUMULATION
LIMITA-
TION.—The limitation amount specified in this 
paragraph is $50,000. 
‘‘(C) INDEXING.— 
‘‘(i) IN GENERAL.—In the case of any 
taxable year beginning in a calendar year 
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after 2023, each dollar amount contained 
in subparagraphs (A)(i) and (B) shall be 
increased by the medical care cost adjust-
ment of such amount for such calendar 
year. 
‘‘(ii) MEDICAL
CARE
COST
ADJUST-
MENT.—For purposes of clause (i), the 
medical care cost adjustment for any cal-
endar year is the percentage (if any) by 
which— 
‘‘(I) the medical care component 
of the C–CPI–U (as defined in section 
1(f)(6)) for August of the preceding 
calendar year, exceeds 
‘‘(II) such component of the C– 
CPI–U (as so defined) for August of 
2022. 
‘‘(iii) ROUNDING.— 
‘‘(I) ANNUAL
LIMITATION.—If 
any increase in a dollar amount con-
tained in subparagraph (A)(i) deter-
mined under clause (i) is not a mul-
tiple of $100, such increase shall be 
rounded to the nearest multiple of 
$100. 
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‘‘(II) ACCOUNT LIMITATION.—If 
any increase in the dollar amount con-
tained in subparagraph (B) deter-
mined under clause (i) is not a mul-
tiple of $1,000, such increase shall be 
rounded to the nearest multiple of 
$1,000. 
‘‘(D) COORDINATION
WITH
OTHER
CON-
TRIBUTIONS.—The limitation which would (but 
for this paragraph) apply under subparagraphs 
(A) and (B) to an individual for any taxable 
year shall be reduced (but not below zero) by 
the sum of— 
‘‘(i) the aggregate amount contributed 
to health savings accounts of such indi-
vidual which is excludable from the tax-
payer’s gross income for such taxable year 
under section 106(d) (and such amount 
shall not be allowed as a deduction under 
subsection (a)), and 
‘‘(ii) the aggregate amount contrib-
uted to health savings accounts of such in-
dividual for such taxable year under sec-
tion 408(d)(9) (and such amount shall not 
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be allowed as a deduction under subsection 
(a)). 
‘‘(3) QUALIFIED MEDICAL EXPENSES.— 
‘‘(A) IN
GENERAL.—The term ‘qualified 
medical expenses’ means, with respect to an ac-
count beneficiary, amounts paid by such bene-
ficiary for medical care (as defined in section 
213(d)) for such individual, the spouse of such 
individual, and any dependent (as defined in 
section 152, determined without regard to sub-
sections (b)(1), (b)(2), and (d)(1)(B) thereof) 
of such individual, but only to the extent such 
amounts are not compensated for by insurance 
or otherwise. For purposes of this subpara-
graph, amounts paid for menstrual care prod-
ucts shall be treated as paid for medical care. 
‘‘(B) HEALTH
INSURANCE
MAY
NOT
BE 
PURCHASED FROM ACCOUNT.— 
‘‘(i) IN GENERAL.—Subparagraph (A) 
shall not apply to any payment for insur-
ance. 
‘‘(ii) EXCEPTIONS.—Clause (i) shall 
not apply to any expense for coverage 
under— 
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‘‘(I) a health plan during any pe-
riod of continuation coverage required 
under any Federal law, 
‘‘(II) a qualified long-term care 
insurance contract (as defined in sec-
tion 7702B(b)), 
‘‘(III) a health plan during a pe-
riod in which the individual is receiv-
ing 
unemployment 
compensation 
under any Federal or State law, or 
‘‘(IV) in the case of an account 
beneficiary who has attained the age 
specified in section 1811 of the Social 
Security Act, any health insurance 
other than a medicare supplemental 
policy (as defined in section 1882 of 
the Social Security Act). 
‘‘(iii) EXCEPTION
FOR
INTEGRATED 
HEALTH
PLANS.—Clause (i) shall not 
apply to any expense for coverage under an 
integration eligible health plan which is in-
tegrated with the health savings account 
within the meaning of section 106(d). 
‘‘(iv) EXCEPTION
FOR
DIRECT
PRI-
MARY CARE SERVICE ARRANGEMENTS.— 
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‘‘(I) IN GENERAL.—A direct pri-
mary care service arrangement shall 
not be treated as insurance for pur-
poses of clause (i). 
‘‘(II) DIRECT
PRIMARY
CARE 
SERVICE
ARRANGEMENT
DEFINED.— 
For purposes of this clause, the term 
‘direct primary care service arrange-
ment’ means an arrangement under 
which an individual is provided med-
ical care (as defined in section 
213(d)(1), determined without regard 
to subparagraph (E) thereof) con-
sisting solely of primary care services 
provided by primary care practitioners 
(as defined in section 1833(x)(2)(A) 
of the Social Security Act, determined 
without regard to clause (ii) thereof), 
if the sole compensation for such care 
is a fixed periodic fee. 
‘‘(C) MENSTRUAL
CARE
PRODUCT.—For 
purposes of this paragraph, the term ‘menstrual 
care product’ means a tampon, pad, liner, cup, 
sponge, or similar product used by individuals 
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with respect to menstruation or other genital- 
tract secretions. 
‘‘(4) ACCOUNT
BENEFICIARY.—The term ‘ac-
count beneficiary’ means the individual on whose be-
half the health savings account was established. 
‘‘(5) CERTAIN RULES TO APPLY.—Rules similar 
to the following rules shall apply for purposes of this 
section: 
‘‘(A) Section 219(d)(2) (relating to no de-
duction for rollovers). 
‘‘(B) Section 219(f)(3) (relating to time 
when contributions deemed made). 
‘‘(C) Except as provided in section 106(d), 
section 219(f)(5) (relating to employer pay-
ments). 
‘‘(D) Section 408(g) (relating to commu-
nity property laws). 
‘‘(E) Section 408(h) (relating to custodial 
accounts). 
‘‘(e) TAX TREATMENT OF ACCOUNTS.— 
‘‘(1) IN GENERAL.—A health savings account is 
exempt from taxation under this subtitle unless such 
account has ceased to be a health savings account. 
Notwithstanding the preceding sentence, any such 
account is subject to the taxes imposed by section 
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511 (relating to imposition of tax on unrelated busi-
ness income of charitable, etc. organizations). 
‘‘(2) ACCOUNT TERMINATIONS.—Rules similar 
to the rules of paragraphs (2) and (4) of section 
408(e) shall apply to health savings accounts, and 
any amount treated as distributed under such rules 
shall be treated as not used to pay qualified medical 
expenses. 
‘‘(f) TAX TREATMENT OF DISTRIBUTIONS.— 
‘‘(1) AMOUNTS USED FOR QUALIFIED MEDICAL 
EXPENSES.—Any amount paid or distributed out of 
a health savings account which is used exclusively to 
pay qualified medical expenses of any account bene-
ficiary shall not be includible in gross income. 
‘‘(2) INCLUSION OF AMOUNTS NOT USED FOR 
QUALIFIED MEDICAL EXPENSES.—Any amount paid 
or distributed out of a health savings account which 
is not used exclusively to pay the qualified medical 
expenses of the account beneficiary shall be included 
in the gross income of such beneficiary. 
‘‘(3) EXCESS CONTRIBUTIONS RETURNED BE-
FORE DUE DATE OF RETURN.— 
‘‘(A) IN
GENERAL.—If any excess con-
tribution is contributed for a taxable year to 
any health savings account of an individual, 
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paragraph (2) shall not apply to distributions 
from the health savings accounts of such indi-
vidual (to the extent such distributions do not 
exceed the aggregate excess contributions to all 
such accounts of such individual for such year) 
if— 
‘‘(i) such distribution is received by 
the individual on or before the last day 
prescribed by law (including extensions of 
time) for filing such individual’s return for 
such taxable year, and 
‘‘(ii) such distribution is accompanied 
by the amount of net income attributable 
to such excess contribution. 
Any net income described in clause (ii) shall be 
included in the gross income of the individual 
for the taxable year in which it is received. 
‘‘(B) EXCESS
CONTRIBUTION.—For pur-
poses of subparagraph (A), the term ‘excess 
contribution’ means any contribution (other 
than a rollover contribution described in para-
graph (5) or section 220(f)(5)) which is neither 
excludable from gross income under section 
106(d) nor deductible under this section. 
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‘‘(4) ADDITIONAL TAX ON DISTRIBUTIONS NOT 
USED FOR QUALIFIED MEDICAL EXPENSES.— 
‘‘(A) IN GENERAL.—The tax imposed by 
this chapter on the account beneficiary for any 
taxable year in which there is a payment or dis-
tribution from a health savings account of such 
beneficiary which is includible in gross income 
under paragraph (2) shall be increased by 20 
percent of the amount which is so includible. 
‘‘(B) EXCEPTION
FOR
DISABILITY
OR 
DEATH.—Subparagraph (A) shall not apply if 
the payment or distribution is made after the 
account beneficiary becomes disabled within the 
meaning of section 72(m)(7) or dies. 
‘‘(C) 
EXCEPTION
FOR
DISTRIBUTIONS 
AFTER MEDICARE ELIGIBILITY.—Subparagraph 
(A) shall not apply to any payment or distribu-
tion after the date on which the account bene-
ficiary attains the age specified in section 1811 
of the Social Security Act. 
‘‘(5) ROLLOVER CONTRIBUTION.—An amount is 
described in this paragraph as a rollover contribu-
tion if it meets the requirements of subparagraphs 
(A) and (B). 
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‘‘(A) IN
GENERAL.—Paragraph (2) shall 
not apply to any amount paid or distributed 
from a health savings account to the account 
beneficiary to the extent the amount received is 
paid into a health savings account for the ben-
efit of such beneficiary not later than the 60th 
day after the day on which the beneficiary re-
ceives the payment or distribution. 
‘‘(B) LIMITATION.—This paragraph shall 
not apply to any amount described in subpara-
graph (A) received by an individual from a 
health savings account if, at any time during 
the 1-year period ending on the day of such re-
ceipt, such individual received any other amount 
described in subparagraph (A) from a health 
savings account which was not includible in the 
individual’s gross income because of the appli-
cation of this paragraph. 
‘‘(C) ROLLOVER FROM FSA, ARCHER MSA, 
AND HRA.—An amount is described in this sub-
paragraph for a calendar year as a rollover con-
tribution if the amount is the remaining balance 
in a health flexible spending account, Archer 
MSA, or health reimbursement arrangement 
that is contributed to the health savings ac-
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count for a taxable year ending on or before 
one year after the date of the enactment of this 
subparagraph. 
‘‘(6) COORDINATION WITH MEDICAL EXPENSE 
DEDUCTION.—For purposes of determining the 
amount of the deduction under section 213, any pay-
ment or distribution out of a health savings account 
for qualified medical expenses shall not be treated as 
an expense paid for medical care. 
‘‘(7) TRANSFER OF ACCOUNT INCIDENT TO DI-
VORCE.—The transfer of an individual’s interest in 
a health savings account to an individual’s spouse or 
former spouse under a divorce or separation instru-
ment described in clause (i) of section 121(d)(3)(C) 
shall not be considered a taxable transfer made by 
such individual notwithstanding any other provision 
of this subtitle, and such interest shall, after such 
transfer, be treated as a health savings account with 
respect to which such spouse is the account bene-
ficiary. 
‘‘(8) TREATMENT AFTER DEATH OF ACCOUNT 
BENEFICIARY.— 
‘‘(A) TREATMENT IF DESIGNATED BENE-
FICIARY
IS
SPOUSE.—If the account bene-
ficiary’s surviving spouse acquires such bene-
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ficiary’s interest in a health savings account by 
reason of being the designated beneficiary of 
such account at the death of the account bene-
ficiary, such health savings account shall be 
treated as if the spouse were the account bene-
ficiary. 
‘‘(B) OTHER CASES.— 
‘‘(i) IN GENERAL.—If, by reason of 
the death of the account beneficiary, any 
person acquires the account beneficiary’s 
interest in a health savings account in a 
case to which subparagraph (A) does not 
apply— 
‘‘(I) such account shall cease to 
be a health savings account as of the 
date of death, and 
‘‘(II) an amount equal to the fair 
market value of the assets in such ac-
count on such date shall be includible 
if such person is not the estate of 
such beneficiary, in such person’s 
gross income for the taxable year 
which includes such date, or if such 
person is the estate of such bene-
ficiary, in such beneficiary’s gross in-
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come for the last taxable year of such 
beneficiary. 
‘‘(ii) SPECIAL RULES.— 
‘‘(I) REDUCTION
OF
INCLUSION 
FOR
PREDEATH
EXPENSES.—The 
amount includible in gross income 
under clause (i) by any person (other 
than the estate) shall be reduced by 
the amount of qualified medical ex-
penses which were incurred by the de-
cedent before the date of the dece-
dent’s death and paid by such person 
within 1 year after such date. 
‘‘(II) DEDUCTION
FOR
ESTATE 
TAXES.—An 
appropriate 
deduction 
shall be allowed under section 691(c) 
to any person (other than the dece-
dent or the decedent’s spouse) with 
respect to amounts included in gross 
income under clause (i) by such per-
son. 
‘‘(g) COST-OF-LIVING ADJUSTMENT.— 
‘‘(1) IN GENERAL.—In the case of any taxable 
year beginning after December 31, 2023, each dollar 
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amount in paragraphs (2) and (3) of subsection (c) 
shall be increased by an amount equal to— 
‘‘(A) such dollar amount, multiplied by 
‘‘(B) the cost-of-living adjustment deter-
mined under section 1(f)(3) for the calendar 
year in which such taxable year begins deter-
mined by substituting ‘2022’ for ‘2016’ in sub-
paragraph (A)(ii) thereof. 
‘‘(2) ROUNDING.—If any increase under para-
graph (1) is not a multiple of $50, such increase 
shall be rounded to the nearest multiple of $50. 
‘‘(h) REPORTS.—The Secretary may require— 
‘‘(1) the trustee of a health savings account to 
make such reports regarding such account to the 
Secretary and to the account beneficiary with re-
spect to contributions, distributions, the return of 
excess contributions, and such other matters as the 
Secretary determines appropriate, and 
‘‘(2) any person who provides an individual with 
a qualified health plan to make such reports to the 
Secretary and to the account beneficiary with re-
spect to such plan as the Secretary determines ap-
propriate.’’. 
(b) EMPLOYER CONTRIBUTIONS TO HEALTH SAV-
INGS ACCOUNTS.— 
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(1) IN GENERAL.—Section 106(d) is amended 
to read as follows: 
‘‘(d) CONTRIBUTIONS
TO HEALTH SAVINGS AC-
COUNTS.— 
‘‘(1) IN GENERAL.—In the case of an employee 
who is an eligible individual, amounts contributed by 
such employee’s employer to any health savings ac-
count of such employee shall be treated as employer- 
provided coverage for medical expenses under an ac-
cident or health plan to the extent— 
‘‘(A) such amounts do not exceed twice the 
limitation in effect under section 223(b)(2) (de-
termined without regard to this subsection) 
which is applicable to such employee for such 
taxable year, 
‘‘(B) such amounts are contributed to an 
account which is integrated with an integration 
eligible health plan, 
‘‘(C) such employer does not offer such 
employee coverage under any other accident or 
health plan, 
‘‘(D) such employer offers such amounts 
only to members of a qualified class of employ-
ees and offers such amounts to all members of 
any such qualified class, 
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‘‘(E) such employer offers employees an 
opportunity to elect not to receive such amounts 
at least once per year and upon termination 
from employment, and 
‘‘(F) such employee is not covered under 
any health insurance offered by an employer of 
such employee’s spouse. 
‘‘(2) INTEGRATION ELIGIBLE HEALTH PLAN.— 
For purposes of this subsection, the term ‘integra-
tion eligible health plan’ means— 
‘‘(A) any bronze, silver, or gold plan of-
fered through an Exchange established under 
the Patient Protection and Affordable Care Act, 
‘‘(B) entitlement to benefits under part A 
of title XVIII of the Social Security Act and en-
rollment under part B of such title, including 
enrollment under a Medicare Advantage plan 
under part C of such title, 
‘‘(C) in the case of any individual who has 
not attained age 30 or is determined by the 
Secretary (after consultation with the Secretary 
of Health and Human Services) to have a hard-
ship, coverage under a catastrophic plan, and 
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‘‘(D) in the case of any student, coverage 
under a health plan which is conditioned on 
maintaining status as being such a student. 
‘‘(3) 
INTEGRATION
OF
PLANS
AND
AC-
COUNTS.—For purposes of this subsection, an ac-
count shall be treated as integrated with an integra-
tion eligible health plan (and such plan shall be 
treated as integrated with such account) for any 
month if— 
‘‘(A) the employee is the account bene-
ficiary of such account and such employee is 
covered under an integration eligible health 
plan for such month, 
‘‘(B) the employer verifies that the em-
ployee is so covered by requiring the submission 
of documentation to such employer, and 
‘‘(C) the employer makes contributions to 
such account for such month which are not less 
than the excess (if any) of— 
‘‘(i) the adjusted monthly premiums 
for the applicable second lowest cost silver 
plan with respect to the taxpayer, over 
‘‘(ii) 1⁄12 of 9.5 percent of the tax-
payer’s household income (within the 
meaning of section 36B). 
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‘‘(4) QUALIFIED CLASS.—For purposes of this 
subsection— 
‘‘(A) IN
GENERAL.—The term ‘qualified 
class’ means only the following: All employees; 
Full-time employees; Part-time employees; Sea-
sonal employees; Employees covered under a 
collective bargaining agreement; Employees in a 
waiting period; Foreign employees who work 
abroad; Employees working in the same geo-
graphic location (same insurance rating area, 
State, or multi-State region); Salaried workers; 
Non-Salaried workers (such as hourly workers); 
Temporary employees of staffing firms. 
‘‘(B) RULES RELATED TO CLASS SIZE.— 
‘‘(i) MINIMUM CLASS SIZE.—A class 
shall not be treated as a qualified class un-
less in consisting of at least the following 
number of employees: 
‘‘(I) In the case of an employer 
with fewer than 100 employees, the 
lesser of 10 employees or all employ-
ees of the employer. 
‘‘(II) In the case of an employer 
with at least 100 and not more than 
200 employees, 10 percent of the 
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number of such employees (if not a 
whole number, rounded down to the 
next lowest whole number). 
‘‘(III) In the case of an employer 
with more than 200 employees, 20 
employees. 
‘‘(ii) COMBINATION
OF
CLASSES.— 
Two or more qualified classes described in 
subparagraph (A) may be combined if each 
such class separately would not satisfy the 
requirement of clause (i). 
‘‘(C) 
PERMITTED
VARIATION
WITHIN 
QUALIFIED
CLASSES.—An employer shall not 
fail to meet the requirements of paragraph 
(1)(D) solely because the amounts offered to 
members of a qualified class vary on the basis 
of— 
‘‘(i) number of dependents, 
‘‘(ii) age, if such variation based on 
age does not exceed a ratio of 3:1, and 
‘‘(iii) chronic health condition, if such 
variation based on chronic health condition 
does not exceed a ratio of 1.2:1. 
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‘‘(6) NO CONSTRUCTIVE RECEIPT.—No amount 
shall be included in the gross income of any em-
ployee solely because the employee may choose be-
tween the contributions referred to in paragraph (1) 
and employer contributions to another health plan of 
the employer. 
‘‘(7) SPECIAL RULE FOR DEDUCTION OF EM-
PLOYER CONTRIBUTIONS.—Any employer contribu-
tion to a health savings account, if otherwise allow-
able as a deduction under this chapter, shall be al-
lowed only for the taxable year in which paid. 
‘‘(8) EMPLOYER
HEALTH
SAVINGS
ACCOUNT 
CONTRIBUTIONS REQUIRED TO BE SHOWN ON RE-
TURN.—Every individual required to file a return 
under section 6012 for the taxable year shall include 
on such return the aggregate amount contributed by 
employers to the health savings accounts of such in-
dividual or such individual’s spouse for such taxable 
year. 
‘‘(9) HEALTH
SAVINGS
ACCOUNT
CONTRIBU-
TIONS NOT PART OF COBRA COVERAGE.—Paragraph 
(1) shall not apply for purposes of section 4980B. 
‘‘(10) DEFINITIONS.—Terms used in this sub-
section which are also used in section 223 shall have 
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the same respective meanings as when used in such 
section. 
‘‘(11) 
REGULATIONS.—The 
Secretaries 
of 
Treasury, Labor, and Health and Human Services 
shall each issue such regulations or other guidance 
as may be necessary or appropriate to carry out the 
purposes of this subsection, including regulations or 
other guidance to— 
‘‘(A) prevent employers from offering plans 
integrated with health savings accounts selec-
tively to sicker workers, and 
‘‘(B) establish a safe harbor that helps em-
ployers determine whether contributions to 
health savings accounts with respect to which 
there is an integrated health plan comply with 
affordability requirements under the Patient 
Protection and Affordable Care Act and the 
amendments made by such Act. 
‘‘(12) CROSS REFERENCE.—For penalty on fail-
ure by employer to make comparable contributions 
to the health savings accounts of comparable em-
ployees, see section 4980G.’’. 
(2) NONAPPLICATION OF ERISA.—Contributions 
by an employer to a health savings account (as de-
fined in section 223 of the Internal Revenue Code of 
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1986), and an integration eligible health plan which 
is integrated with such account (within the meaning 
of such section), shall not be treated as a plan for 
purposes of the Employee Retirement Income Secu-
rity Act of 1974 if— 
(A) receipt of such contributions by the 
employee is voluntary, 
(B) the employer does not select or en-
dorse the integration eligible health plan which 
is integrated with such account, 
(C) no premiums, other than premiums for 
the integration eligible health plan which is in-
tegrated with such account, are paid from the 
account, 
(D) the employer receives no consideration 
(money or other benefit) in connection with the 
employee selecting or renewing a plan, and 
(E) each participant is notified annually 
that such contributions and such plan are not 
subject to the requirements of such Act. 
(c) TERMINATION
OF CERTAIN OTHER HEALTH 
CARE RELATED TAX BENEFITS.— 
(1) EXCLUSION
LIMITED
TO
SELF-FUNDED 
MAJOR
MEDICAL
PLAN
OF
EMPLOYERS.—Section 
105(b) of such Code is amended by striking ‘‘paid,’’ 
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and inserting ‘‘paid under a self-funded major med-
ical plan of the employer’’. 
(2) EXCLUSION NOT APPLICABLE TO HEALTH 
REIMBURSEMENT ARRANGEMENTS.—Section 105(h) 
of such Code is amended to read as follows: 
‘‘(h) EXCLUSION NOT APPLICABLE TO HEALTH RE-
IMBURSEMENT ARRANGEMENTS.—Subsection (b) shall 
not apply to health reimbursement arrangements.’’. 
(3) REPEAL OF EXCLUSIONS FROM INCOME FOR 
ARCHER MSAS AND FSAS.—Section 106 of such Code 
is amended by striking subsections (b), (e), and (g). 
(4) TERMINATION
OF
DEDUCTION
FOR
CON-
TRIBUTIONS TO ARCHER MSAS.—Section 220(a) of 
such Code is amended by adding at the end the fol-
lowing: ‘‘No amount shall be allowed as a deduction 
under the preceding sentence for any taxable year 
beginning after one year after the date of the enact-
ment of this sentence.’’. 
(d) BANKRUPTCY PROTECTIONS.—Section 522 of 
title 11, United States Code, is amended by adding at the 
end the following new subsection: 
‘‘(r) For purposes of this section, any health savings 
account (as described in section 223 of the Internal Rev-
enue Code of 1986) shall be treated in the same manner 
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as an individual retirement account described in section 
408 of such Code.’’. 
(e) ROLLOVER OF FSA, ARCHER MSA, HRA TO 
HEALTH SAVINGS ACCOUNT.—Notwithstanding any other 
provision of law, if the remaining balance in a health flexi-
ble spending arrangement, Archer MSA, or health reim-
bursement arrangement is transferred to a health savings 
account before the end of any taxable year ending on or 
before one year after the date of the enactment of this 
Act, such transfer shall be treated as a rollover to the 
health savings account under section 223(f)(5) of the In-
ternal Revenue Code of 1986 and the distribution from 
the health flexible spending arrangement, Archer MSA, or 
health reimbursement arrangement shall not be includible 
in gross income. 
(f) EFFECTIVE DATES.— 
(1) IN GENERAL.—The amendments made by 
subsections (a) and (b) shall apply to taxable years 
beginning after the date of the enactment of this 
Act. 
(2) TERMINATION OF CERTAIN OTHER HEALTH 
CARE RELATED TAX BENEFITS.—The amendments 
made by subsection (c) shall apply to taxable years 
beginning after the date which is 1 year after the 
date of the enactment of this Act. 
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(3) BANKRUPTCY PROTECTIONS.—The amend-
ment made by subsection (d) shall apply to cases 
commencing under title 11, United States Code, 
after the date of the enactment of this Act. 
SEC. 102. UNUSED PREMIUM TAX CREDITS MAY BE DEPOS-
ITED IN HEALTH SAVINGS ACCOUNTS. 
(a) IN GENERAL.—Section 36B is amended by redes-
ignating subsection (h) as subsection (i) and by inserting 
after subsection (g) the following new subsection: 
‘‘(h) EXCESS CREDIT MAY BE DEPOSITED INTO A 
HEALTH SAVINGS ACCOUNT.— 
‘‘(1) IN GENERAL.—If the amount described in 
subparagraph (B) of subsection (b)(2) exceeds the 
amount described in subparagraph (A) of such sub-
section with respect to any coverage month and an 
election under paragraph (2) is in effect with respect 
to the applicable taxpayer, the Secretary shall de-
posit such excess into a health savings account of 
such taxpayer. 
‘‘(2) ELECTION
TO
DEPOSIT
EXCESS
CREDIT 
INTO
A
HEALTH
SAVINGS
ACCOUNT.—A taxpayer 
may elect (at such time and in such manner as the 
Secretary may provide) to have the Secretary deposit 
the excess described in paragraph (1) into a health 
savings account of the taxpayer. Any such election 
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shall only be treated as being in effect if the tax-
payer provides the Secretary with such information 
as the Secretary may require to allow the Secretary 
to make such deposit. 
‘‘(3) COORDINATION
WITH
HEALTH
SAVINGS 
ACCOUNT
RULES.—Any amount deposited in a 
health savings account by the Secretary under this 
subsection shall— 
‘‘(A) be includible in the gross income of 
the applicable taxpayer, and 
‘‘(B) be taken into account as an amount 
paid to such account for purposes of this sec-
tion. 
‘‘(4) TREATMENT OF DEPOSITS.—For purposes 
of section 1324 of title 31, United States Code, any 
deposit made under this subsection shall be treated 
as a credit allowed under this section.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
the date of the enactment of this Act. 
SEC. 103. HEALTH REIMBURSEMENT ARRANGEMENTS AND 
OTHER 
ACCOUNT-BASED 
GROUP 
HEALTH 
PLANS. 
The rule published by the Internal Revenue Service, 
the Employee Benefits Security Administration, and the 
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Health and Human Services Department relating to 
‘‘Health Reimbursement Arrangements and Other Ac-
count-Based Group Health Plans’’ (June 20, 2019) shall 
have the force and effect of law. Health Reimbursement 
Arrangements as described in this rule are subject to all 
sections in this title. 
SEC. 104. COST-SHARING REDUCTION PAYMENTS AS ELIGI-
BLE CONTRIBUTIONS. 
(a) ALTERNATIVE WAIVER
FOR STATE INNOVA-
TION.—Section 1332 of the Patient Protection and Af-
fordable Care Act (42 U.S.C. 18052) is amended by add-
ing at the end the following new subsection: 
‘‘(f) ALTERNATIVE WAIVER
FOR STATE INNOVA-
TION.— 
‘‘(1) IN GENERAL.—Notwithstanding any pre-
ceding provision of this section, a State may apply 
to the Secretary for the waiver of any requirement 
of subsection (a)(2) with respect to health insurance 
coverage within that State for plan years beginning 
on or after January 1, 2023, if instead of complying 
with section 1402 the State provides for the dis-
tribution of funding received under paragraph (2) to 
health savings accounts of qualifying individuals 
with respect to such State. Such application shall be 
filed at such time and in such manner as the Sec-
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retary may require, and shall include such informa-
tion as the Secretary may require (including a 10- 
year budget plan for such plan that is budget neu-
tral for the Federal Government). 
‘‘(2) PASS-THROUGH FUNDING.—With respect 
to a State waiver under paragraph (1), under which, 
due to the structure of such waiver, individuals in 
the State would not qualify for cost-sharing reduc-
tions under section 1402 for which they would other-
wise be eligible, the Secretary shall provide for an al-
ternative means by which an amount is transferred 
to the State equal to the aggregate amount of such 
reductions that would have been paid on behalf of 
the participants in the Exchanges established under 
this title— 
‘‘(A) had the State not received such waiv-
er; 
‘‘(B) had references to ‘eligible insureds’ 
under section 1402 referred to ‘qualifying in-
sureds (as defined in section 1332(f))’; 
‘‘(C) had, after application of clause (ii), in 
the case of a qualifying insured enrolled in the 
bronze level of coverage— 
‘‘(i) the percentages specified in sub-
clauses (I), (II), and (III) of section 
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1402(c)(1)(B) were references to 84 per-
cent, 77 percent, and 63 percent, respec-
tively; and 
‘‘(ii) the references in subparagraphs 
(A), (B), and (C) of section 1402(c)(2) to 
94 percent, 87 percent, and 73 percent, re-
spectively, were references to 84 percent, 
77 percent, and 63 percent, respectively; 
and 
‘‘(D) had, after application of clause (ii), 
in the case of a qualifying insured enrolled in 
the copper level of coverage— 
‘‘(i) the percentages specified in sub-
clauses (I), (II), and (III) of section 
1402(c)(1)(B) were references to 74 per-
cent, 67 percent, and 53 percent, respec-
tively; and 
‘‘(ii) the references in subparagraphs 
(A), (B), and (C) of section 1402(c)(2) to 
94 percent, 87 percent, and 73 percent, re-
spectively, were references to 74 percent, 
67 percent, and 53 percent, respectively. 
The amount transferred pursuant to the previous 
sentence shall be determined annually by the Sec-
retary, taking into consideration the experience of 
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other States with respect to participation in an Ex-
change and reductions provided under such provi-
sions to residents of the other States, and shall be 
paid to the State for purposes of implementing such 
waiver. 
‘‘(3) WAIVER
CONSIDERATION
AND
TRANS-
PARENCY.—The provisions of paragraph (4) of sub-
section (a) shall apply to an application for a waiver 
under paragraph (1) in the same manner as such 
provisions apply with respect to an application for a 
waiver under subsection (a)(1), except that, for pur-
poses of this paragraph, the provisions of subsection 
(a)(4)(B)(ii) shall not apply. 
‘‘(4) DETERMINATIONS; TERM
OF
WAIVER.— 
The provisions of subsections (d) and (e) shall apply 
with respect to a determination with respect to an 
application under paragraph (1), and with respect to 
the term of a waiver under such paragraph, in the 
same manner as such provisions apply with respect 
to a determination with respect to an application 
under subsection (a)(1), and with respect to the 
term of a waiver under such subsection. 
‘‘(5) DEFINITIONS.—For purposes of this sub-
section: 
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‘‘(A) HEALTH
SAVINGS
ACCOUNT.—The 
term ‘health savings account’ has the meaning 
given such term in section 223 of the Internal 
Revenue Code of 1986. 
‘‘(B) QUALIFYING
INSURED.—The term 
‘qualifying insured’ means, with respect to a 
State and a year, an individual— 
‘‘(i) who is enrolled in a health sav-
ings account; 
‘‘(ii) who is enrolled for such year in 
a silver, bronze, or copper level coverage 
offered through an Exchange; and 
‘‘(iii) whose household income is not 
more than 250 percent of the Federal pov-
erty line for a family of the size involved.’’. 
(b) ADDITIONAL AMENDMENTS.—Section 1402 of 
the Patient Protection and Affordable Care Act (42 
U.S.C. 18071) is amended by striking ‘‘not less than 100 
percent but’’ and ‘‘exceeds 100 percent but’’ and ‘‘more 
than 100 percent but’’ each place such phrases appear. 
(c) CONFORMING AMENDMENTS.—Section 1332 of 
the Patient Protection and Affordable Care Act (42 
U.S.C. 18052), as amended by subsection (a), is further 
amended in subsection (a)(4)— 
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(1) in subparagraph (A) by striking the period 
and inserting ‘‘, except in the case of a waiver de-
scribed in subsection (f).’’; and 
(2) in subparagraph (B)(ii) by inserting after 
‘‘an application’’ the following: ‘‘(except in the case 
of a waiver described in subsection (f))’’. 
(d) APPROPRIATION
FOR
COST-SHARING
PAY-
MENTS.—Section 1402 of the Patient Protection and Af-
fordable Care Act (42 U.S.C. 18071) is amended by add-
ing at the end the following new subsection: 
‘‘(g) FUNDING.— 
‘‘(1) APPROPRIATIONS.—Out of any funds in 
the Treasury not otherwise appropriated, there is 
appropriated such sums as may be necessary to, 
subject to paragraph (2), provide health benefits 
coverage through payment to issuers (under this sec-
tion or through advance payment by the Secretary 
of the Treasury under section 1412(c)(3)) of the 
amounts computed under this section for each of 
plan years 2023 through 2027. 
‘‘(2) 
ADJUSTMENTS.—Notwithstanding 
any 
other provision of law, payments and other actions 
for adjustments to obligations incurred prior to De-
cember 31, 2023, may be made through December 
31, 2023. 
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‘‘(3) 
LIMITATION.—Amounts 
appropriated 
under paragraph (1) for each of plan years 2023 
through 2027 are subject to the requirements and 
limitations under sections 506 and 507 of division H 
of Public Law 115–31 in the same manner and to 
the same extent as if such amounts for each such 
year were appropriated under such division.’’. 
SEC. 105. DIRECT PRIMARY CARE. 
(a) IN GENERAL.—Section 223(c)(1) of the Internal 
Revenue Code of 1986 is amended by adding at the end 
the following new subparagraph: 
‘‘(D) TREATMENT
OF
DIRECT
PRIMARY 
CARE SERVICE ARRANGEMENTS.— 
‘‘(i) IN GENERAL.—A direct primary 
care service arrangement shall not be 
treated as a health plan for purposes of 
subparagraph (A)(ii). 
‘‘(ii) DIRECT PRIMARY CARE SERVICE 
ARRANGEMENT.—For purposes of this 
paragraph— 
‘‘(I) IN GENERAL.—The term ‘di-
rect primary care service arrange-
ment’ means, with respect to any indi-
vidual, an arrangement under which 
such individual is provided medical 
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care (as defined in section 213(d)) 
consisting solely of primary care serv-
ices provided by primary care practi-
tioners 
(as 
defined 
in 
section 
1833(x)(2)(A) of the Social Security 
Act, determined without regard to 
clause (ii) thereof), if the sole com-
pensation for such care is a fixed peri-
odic fee. 
‘‘(II) LIMITATION.—With respect 
to any individual for any month, such 
term shall not include any arrange-
ment if the aggregate fees for all di-
rect primary care service arrange-
ments (determined without regard to 
this subclause) with respect to such 
individual for such month exceed 
$150 (twice such dollar amount in the 
case of an individual with any direct 
primary care service arrangement (as 
so determined) that covers more than 
one individual). 
‘‘(iii) CERTAIN
SERVICES
SPECIFI-
CALLY
EXCLUDED
FROM
TREATMENT
AS 
PRIMARY
CARE
SERVICES.—For purposes 
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of this paragraph, the term ‘primary care 
services’ shall not include— 
‘‘(I) procedures that require the 
use of general anesthesia, and 
‘‘(II) laboratory services not typi-
cally administered in an ambulatory 
primary care setting. 
The Secretary, after consultation with the 
Secretary of Health and Human Services, 
shall issue regulations or other guidance 
regarding the application of this clause.’’. 
(b) DIRECT PRIMARY CARE SERVICE ARRANGEMENT 
FEES
TREATED
AS
MEDICAL
EXPENSES.—Section 
223(d)(2)(C) is amended by striking ‘‘or’’ at the end of 
clause (iii), by striking the period at the end of clause (iv) 
and inserting ‘‘, or’’, and by adding at the end the fol-
lowing new clause: 
‘‘(v) any direct primary care service arrangement.’’. 
(c) INFLATION ADJUSTMENT.—Section 223(g)(1) of 
such Code is amended— 
(1) by inserting ‘‘, (c)(1)(D)(ii)(II),’’ after 
‘‘(b)(2),’’ each place such term appears, and 
(2) in subparagraph (B), by inserting ‘‘and 
(iii)’’ after ‘‘clause (ii)’’ in clause (i), by striking 
‘‘and’’ at the end of clause (i), by striking the period 
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at the end of clause (ii) and inserting ‘‘, and’’, and 
by inserting after clause (ii) the following new 
clause: 
‘‘(iii) in the case of the dollar amount 
in subsection (c)(1)(D)(ii)(II) for taxable 
years beginning in calendar years after 
2020, calendar year 2019.’’. 
(d) REPORTING OF DIRECT PRIMARY CARE SERVICE 
ARRANGEMENT FEES ON W–2.—Section 6051(a) of such 
Code is amended by striking ‘‘and’’ at the end of para-
graph (16), by striking the period at the end of paragraph 
(17) and inserting ‘‘, and’’, and by inserting after para-
graph (17) the following new paragraph: 
‘‘(18) in the case of a direct primary care serv-
ice 
arrangement 
(as 
defined 
in 
section 
223(c)(1)(D)(ii)) which is provided in connection 
with employment, the aggregate fees for such ar-
rangement for such employee.’’. 
(e) EFFECTIVE DATE.—The amendments made by 
this section shall apply to months beginning after Decem-
ber 31, 2022, in taxable years ending after such date. 
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Subtitle B—Assistance to Health 
Savings Accounts 
SEC. 111. ONE-TIME APPLICATION OF SAVER’S CREDIT TO 
CONTRIBUTIONS TO HEALTH SAVINGS AC-
COUNTS. 
(a) IN GENERAL.—In the case of an applicable tax-
able year, contributions to any health savings account of 
the taxpayer during such taxable year shall be treated as 
a qualified retirement savings contribution for purposes 
of section 25B of the Internal Revenue Code of 1986. 
(b) APPLICABLE TAXABLE YEAR.—For purposes of 
this section, the term ‘‘applicable taxable year’’ means any 
taxable year elected by the taxpayer (at such time and 
in such manner as the Secretary of the Treasury may pro-
vide) which begins after during the 3-year period begin-
ning 1 year after the date of the enactment of this Act. 
A taxpayer may not elect not more than 1 applicable tax-
able year under this subsection. 
SEC. 112. GRANTS FOR HEALTH SAVINGS ACCOUNT ASSIST-
ANCE AND OUTREACH. 
(a) IN GENERAL.—The Administrator shall establish 
a grant program to provide assistance to eligible entities 
to carry out the activities described in subsection (c). 
(b) APPLICATION.—An eligible entity shall submit an 
application to the Administrator in such time and in such 
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manner as the Administrator may require, providing that 
such application requires a demonstration of the existence 
of a relationship with, or the ability to establish a relation-
ship with, an employer, employee, self-employed indi-
vidual, or consumer eligible to enroll in a health savings 
account. 
(c) USE OF FUNDS.—An eligible entity receiving a 
grant under this section shall use such funds to— 
(1) distribute fair and impartial information to 
consumers about health savings accounts, including 
the availability of such accounts and how such ac-
counts may be utilized; 
(2) conduct activities to raise public awareness 
of health savings accounts; 
(3) facilitate enrollment in health savings ac-
counts; and 
(4) refer individuals enrolled in a health savings 
account to the appropriate official, organization, or 
State agency for the purpose of addressing a com-
plaint, grievance, or other question with respect to 
such health savings account. 
(d) AMOUNT.—The Administrator may distribute up 
to $5,000,000 annually to be divided among grant recipi-
ents under this section. 
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(e) REPORT.—Not later than one year after the date 
on which the last of the grant periods awarded under this 
section ends, the Administrator shall submit a report to 
the Congress on the effectiveness of the grants provided 
under this section. 
(f) DEFINITIONS.—In this section: 
(1) ADMINISTRATOR.—The term ‘‘Adminis-
trator’’ means the Administrator of the Centers for 
Medicare & Medicaid Services. 
(2) CONSUMER.—The term ‘‘consumer’’ means 
an individual enrolled in, or seeking to enroll in, a 
health savings account. 
(3) ELIGIBLE ENTITY.—The term ‘‘eligible enti-
ty’’ includes the following: 
(A) A State. 
(B) Trade. 
(C) Industry. 
(D) Professional associations. 
(E) Commercial fishing industry organiza-
tions. 
(F) Ranching and farming organizations. 
(G) Community and consumer-focused 
nonprofit groups. 
(H) Chambers of commerce. 
(I) Unions. 
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(J) Small business development centers (as 
defined in section 21 of the Small Business Act 
(15 U.S.C. 648)). 
(K) Other entities capable of carrying out 
the activities described under subsection (b). 
(4) HEALTH
SAVINGS
ACCOUNT.—The term 
‘‘health savings account’’ has the meaning given 
such term in section 223 of the Internal Revenue 
Code of 1986. 
(5) STATE.—The term ‘‘State’’ means each of 
the several States, the District of Columbia, each 
territory and possession of the United States, and 
each federally recognized Indian Tribe. 
SEC. 113. NEW CORPORATIONS REQUIRED TO USE HEALTH 
SAVINGS ACCOUNTS. 
Notwithstanding any other provision of law, a cor-
poration incorporated after December 31, 2022, may not 
receive tax benefits for offering employees health insur-
ance. The previous sentence shall not apply to health sav-
ings account contributions offered by such a corporation. 
SEC. 114. FEDERAL EMPLOYEE HEALTH BENEFITS AND 
HEALTH SAVINGS ACCOUNTS. 
(a) IN GENERAL.—Section 1312(d)(3)(D) of the Pa-
tient Protection and Affordable Care Act (42 U.S.C. 
18032(d)(3)(D)) is amended— 
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(1) in the subparagraph heading, by striking 
‘‘MEMBERS OF CONGRESS’’ and inserting ‘‘PRESI-
DENT, VICE PRESIDENT, MEMBERS OF CONGRESS, 
AND FEDERAL EMPLOYEES’’; 
(2) in clause (i), in the matter preceding sub-
clause (I)— 
(A) by striking ‘‘Members of Congress and 
congressional staff’’ and inserting ‘‘the Presi-
dent, Vice President, Members of Congress, and 
Federal employees’’; and 
(B) by striking ‘‘a Member of Congress or 
congressional staff’’ and inserting ‘‘the Presi-
dent, the Vice President, a Member of Con-
gress, or a Federal employee’’; and 
(3) in clause (ii), by amending subclause (II) to 
read as follows: 
‘‘(II) FEDERAL EMPLOYEE.—The 
term ‘Federal employee’ means— 
‘‘(aa) an ‘employee’, as such 
term is defined in section 2105 of 
title 5, United States Code; and 
‘‘(bb) includes an individual 
to whom subsection (c) or (f) of 
such 
section 
2105 
pertains 
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(whether or not such individual 
satisfies item (aa)).’’. 
(b) CONVERSION TO HEALTH SAVINGS ACCOUNTS.— 
Each plan offered under chapter 89 of title 5, United 
States Code, shall be converted into a health savings ac-
count deposit and funded at the level of the second-least 
expensive silver plan available through the Exchange 
where the applicable individual resides. 
TITLE II—IMPROVING PRIVATE 
HEALTH INSURANCE 
Subtitle 
A—Maintaining 
Protec-
tions for Patients With Pre-
existing Conditions 
SEC. 201. GUARANTEED AVAILABILITY OF COVERAGE; PRO-
HIBITING DISCRIMINATION. 
(a) IN GENERAL.—Subtitle C of title I of the Health 
Insurance Portability and Accountability Act of 1996 
(Public Law 104–191) is amended by adding at the end 
the following: 
‘‘SEC. 196. GUARANTEED AVAILABILITY OF COVERAGE. 
‘‘(a) GUARANTEED ISSUANCE OF COVERAGE IN THE 
INDIVIDUAL
AND GROUP MARKET.—Subject to sub-
sections (b) through (d), each health insurance issuer that 
offers health insurance coverage in the individual or group 
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market in a State must accept every employer and indi-
vidual in the State that applies for such coverage. 
‘‘(b) ENROLLMENT.— 
‘‘(1) RESTRICTION.—A health insurance issuer 
described in subsection (a) may restrict enrollment 
in coverage described in such subsection to open or 
special enrollment periods. 
‘‘(2) ESTABLISHMENT.—A health insurance 
issuer described in subsection (a) shall, in accord-
ance with the regulations promulgated under para-
graph (3), establish special enrollment periods for 
qualifying events (under section 603 of the Em-
ployee Retirement Income Security Act of 1974). 
‘‘(3) REGULATIONS.—The Secretary shall pro-
mulgate regulations with respect to enrollment peri-
ods under paragraphs (1) and (2). 
‘‘(c) SPECIAL RULES FOR NETWORK PLANS.— 
‘‘(1) IN GENERAL.—In the case of a health in-
surance issuer that offers health insurance coverage 
in the group and individual market through a net-
work 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 
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‘‘(B) within the service area of such plan, 
deny such coverage to such employers and indi-
viduals if the issuer has demonstrated, if re-
quired, to the applicable State authority that— 
‘‘(i) it will not have the capacity to de-
liver services adequately to enrollees of any 
additional groups or any additional individ-
uals because of its obligations to existing 
group contract holders and enrollees; and 
‘‘(ii) it is applying this paragraph uni-
formly to all employers and individuals 
without regard to the claims experience of 
those individuals, employers and their em-
ployees (and their dependents), or any 
health status-related factor relating to 
such individuals, employees, and depend-
ents. 
‘‘(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 or individual market within such service area 
for a period of 180 days after the date such cov-
erage is denied. 
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‘‘(d) APPLICATION OF FINANCIAL CAPACITY LIM-
ITS.— 
‘‘(1) IN GENERAL.—A health insurance issuer 
may deny health insurance coverage in the group or 
individual market if the issuer has demonstrated, if 
required, to the applicable 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 or individual market in the State con-
sistent with applicable State law and without 
regard to the claims experience of those individ-
uals, employers and their employees (and their 
dependents) or any health status-related factor 
relating to such individuals, employees, and de-
pendents. 
‘‘(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 or individual market 
in the State for a period of 180 days after the date 
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such coverage is denied or until the issuer has dem-
onstrated to the applicable State authority, if re-
quired under applicable State law, that the issuer 
has sufficient financial reserves to underwrite addi-
tional coverage, whichever is later. An applicable 
State authority may provide for the application of 
this subsection on a service-area-specific basis. 
‘‘(e) DEFINITIONS.—In this section and in sections 
197 through 199A: 
‘‘(1) The term ‘Secretary’ means the Secretary 
of Health and Human Services. 
‘‘(2) The terms ‘genetic information’, ‘genetic 
test’, ‘group health plan’, ‘group market’, ‘health in-
surance coverage’, ‘health insurance issuer’, ‘group 
health insurance coverage’, ‘individual health insur-
ance coverage’, ‘individual market’, and ‘under-
writing purpose’ have the meanings given such terms 
in section 2791 of the Public Health Service Act. 
‘‘SEC. 197. FAIR HEALTH INSURANCE PREMIUMS. 
‘‘(a) 
PROHIBITING
DISCRIMINATORY
PREMIUM 
RATES.— 
‘‘(1) IN GENERAL.—With respect to the pre-
mium rate charged by a health insurance issuer for 
health insurance coverage offered in the individual 
or small group market— 
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‘‘(A) such rate shall vary with respect to 
the particular plan or coverage involved only 
by— 
‘‘(i) whether such plan or coverage 
covers an individual or family; 
‘‘(ii) rating area, as established in ac-
cordance with paragraph (2); 
‘‘(iii) age, except that such rate shall 
not vary by more than 5 to 1 for adults; 
and 
‘‘(iv) tobacco use, except that such 
rate shall not vary by more than 1.5 to 1; 
and 
‘‘(B) such rate shall not vary with respect 
to the particular plan or coverage involved by 
any other factor not described in subparagraph 
(A). 
‘‘(2) RATING AREA.— 
‘‘(A) IN GENERAL.—Each State shall es-
tablish 1 or more rating areas within that State 
for purposes of applying the requirements of 
this title. 
‘‘(B) SECRETARIAL
REVIEW.—The Sec-
retary shall review the rating areas established 
by each State under subparagraph (A) to en-
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sure the adequacy of such areas for purposes of 
carrying out the requirements of this title. If 
the Secretary determines a State’s rating areas 
are not adequate, or that a State does not es-
tablish such areas, the Secretary may establish 
rating areas for that State. 
‘‘(3) PERMISSIBLE
AGE
BANDS.—The Sec-
retary, in consultation with the National Association 
of Insurance Commissioners, shall define the permis-
sible age bands for rating purposes under paragraph 
(1)(A)(iii). 
‘‘(4) APPLICATION OF VARIATIONS BASED ON 
AGE OR TOBACCO USE.—With respect to family cov-
erage under a group health plan or health insurance 
coverage, the rating variations permitted under 
clauses (iii) and (iv) of paragraph (1)(A) shall be 
applied based on the portion of the premium that is 
attributable to each family member covered under 
the plan or coverage. 
‘‘SEC. 198. PROHIBITING DISCRIMINATION AGAINST INDI-
VIDUAL PARTICIPANTS AND BENEFICIARIES 
BASED ON HEALTH STATUS. 
‘‘(a) IN GENERAL.—A group health plan and a health 
insurance issuer offering group or individual health insur-
ance coverage may not establish rules for eligibility (in-
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cluding continued eligibility) of any individual to enroll 
under the terms of the plan or coverage based on any of 
the following health status-related factors in relation to 
the individual or a dependent of the individual: 
‘‘(1) Health status. 
‘‘(2) Medical condition (including both physical 
and mental illnesses). 
‘‘(3) Claims experience. 
‘‘(4) Receipt of health care. 
‘‘(5) Medical history. 
‘‘(6) Genetic information. 
‘‘(7) Evidence of insurability (including condi-
tions arising out of acts of domestic violence). 
‘‘(8) Disability. 
‘‘(9) Any other health status-related factor de-
termined appropriate by the Secretary. 
‘‘(b) IN PREMIUM CONTRIBUTIONS.— 
‘‘(1) IN GENERAL.—A group health plan, and a 
health insurance issuer offering group or individual 
health insurance coverage, may not require any indi-
vidual (as a condition of enrollment or continued en-
rollment under the plan) to pay a premium or con-
tribution which is greater than such premium or 
contribution for a similarly situated individual en-
rolled in the plan on the basis of any health status- 
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related factor in relation to the individual or to an 
individual enrolled under the plan as a dependent of 
the individual. 
‘‘(2) CONSTRUCTION.—Nothing in paragraph 
(1) shall be construed— 
‘‘(A) to restrict the amount that an em-
ployer or individual may be charged for cov-
erage under a group health plan except as pro-
vided in paragraph (3) or individual health cov-
erage, as the case may be; or 
‘‘(B) to prevent a group health plan, and 
a health insurance issuer offering group health 
insurance coverage, from establishing premium 
discounts or rebates or modifying otherwise ap-
plicable copayments or deductibles in return for 
adherence to programs of health promotion and 
disease prevention. 
‘‘(3) NO
GROUP-BASED
DISCRIMINATION
ON 
BASIS OF GENETIC INFORMATION.— 
‘‘(A) IN GENERAL.—For purposes of this 
section, a group health plan, and health insur-
ance issuer offering group health insurance cov-
erage in connection with a group health plan, 
may not adjust premium or contribution 
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amounts for the group covered under such plan 
on the basis of genetic information. 
‘‘(B) RULE OF CONSTRUCTION.—Nothing 
in subparagraph (A) or in paragraphs (1) and 
(2) of subsection (d) shall be construed to limit 
the ability of a health insurance issuer offering 
group or individual health insurance coverage to 
increase the premium for an employer based on 
the manifestation of a disease or disorder of an 
individual who is enrolled in the plan. In such 
case, the manifestation of a disease or disorder 
in one individual cannot also be used as genetic 
information about other group members and to 
further increase the premium for the employer. 
‘‘(c) GENETIC TESTING.— 
‘‘(1) LIMITATION ON REQUESTING OR REQUIR-
ING GENETIC TESTING.—A group health plan, and a 
health insurance issuer offering health insurance 
coverage in connection with a group health plan, 
shall not request or require an individual or a family 
member of such individual to undergo a genetic test. 
‘‘(2) RULE OF CONSTRUCTION.—Paragraph (1) 
shall not be construed to limit the authority of a 
health care professional who is providing health care 
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services to an individual to request that such indi-
vidual undergo a genetic test. 
‘‘(3) RULE OF CONSTRUCTION REGARDING PAY-
MENT.— 
‘‘(A) IN GENERAL.—Nothing in paragraph 
(1) shall be construed to preclude a group 
health plan, or a health insurance issuer offer-
ing health insurance coverage in connection 
with a group health plan, from obtaining and 
using the results of a genetic test in making a 
determination regarding payment (as such term 
is defined for the purposes of applying the regu-
lations promulgated by the Secretary under 
part C of title XI of the Social Security Act and 
section 264 of this Act, as may be revised from 
time to time) consistent with subsection (a). 
‘‘(B) LIMITATION.—For purposes of sub-
paragraph (A), a group health plan, or a health 
insurance issuer offering health insurance cov-
erage in connection with a group health plan, 
may request only the minimum amount of in-
formation necessary to accomplish the intended 
purpose. 
‘‘(4) RESEARCH EXCEPTION.—Notwithstanding 
paragraph (1), a group health plan, or a health in-
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surance issuer offering health insurance coverage in 
connection with a group health plan, may request, 
but not require, that a participant or beneficiary un-
dergo a genetic test if each of the following condi-
tions is met: 
‘‘(A) The request is made pursuant to re-
search that complies with part 46 of title 45, 
Code of Federal Regulations, or equivalent Fed-
eral regulations, and any applicable State or 
local law or regulations for the protection of 
human subjects in research. 
‘‘(B) The plan or issuer clearly indicates to 
each participant or beneficiary, or in the case of 
a minor child, to the legal guardian of such 
beneficiary, to whom the request is made that— 
‘‘(i) compliance with the request is 
voluntary; and 
‘‘(ii) noncompliance will have no effect 
on enrollment status or premium or con-
tribution amounts. 
‘‘(C) No genetic information collected or 
acquired under this paragraph shall be used for 
underwriting purposes. 
‘‘(D) The plan or issuer notifies the Sec-
retary in writing that the plan or issuer is con-
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ducting activities pursuant to the exception pro-
vided for under this paragraph, including a de-
scription of the activities conducted. 
‘‘(E) The plan or issuer complies with such 
other conditions as the Secretary may by regu-
lation require for activities conducted under this 
paragraph. 
‘‘(d) PROHIBITION ON COLLECTION OF GENETIC IN-
FORMATION.— 
‘‘(1) IN GENERAL.—A group health plan, and a 
health insurance issuer offering health insurance 
coverage in connection with a group health plan, 
shall not request, require, or purchase genetic infor-
mation for underwriting purposes. 
‘‘(2) PROHIBITION
ON
COLLECTION
OF
GE-
NETIC
INFORMATION
PRIOR
TO
ENROLLMENT.—A 
group health plan, and a health insurance issuer of-
fering health insurance coverage in connection with 
a group health plan, shall not request, require, or 
purchase genetic information with respect to any in-
dividual prior to such individual’s enrollment under 
the plan or coverage in connection with such enroll-
ment. 
‘‘(3) INCIDENTAL
COLLECTION.—If a group 
health plan, or a health insurance issuer offering 
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health insurance coverage in connection with a group 
health plan, obtains genetic information incidental to 
the requesting, requiring, or purchasing of other in-
formation concerning any individual, such request, 
requirement, or purchase shall not be considered a 
violation of paragraph (2) if such request, require-
ment, or purchase is not in violation of paragraph 
(1). 
‘‘(e) GENETIC INFORMATION OF A FETUS OR EM-
BRYO.—Any reference in this part to genetic information 
concerning an individual or family member of an indi-
vidual shall— 
‘‘(1) with respect to such an individual or fam-
ily member of an individual who is a pregnant 
woman, include genetic information of any fetus car-
ried by such pregnant woman; and 
‘‘(2) with respect to an individual or family 
member utilizing an assisted reproductive tech-
nology, include genetic information of any embryo le-
gally held by the individual or family member. 
‘‘(f) PROGRAMS OF HEALTH PROMOTION OR DIS-
EASE PREVENTION.— 
‘‘(1) GENERAL PROVISIONS.— 
‘‘(A) GENERAL
RULE.—For purposes of 
subsection (b)(2)(B), a program of health pro-
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the requirements of paragraph (3) are complied 
with. 
‘‘(2) WELLNESS PROGRAMS NOT SUBJECT TO 
REQUIREMENTS.—If none of the conditions for ob-
taining a premium discount or rebate or other re-
ward under a wellness program as described in para-
graph (1)(B) are based on an individual satisfying 
a standard that is related to a health status factor 
(or if such a wellness program does not provide such 
a reward), the wellness program shall not violate 
this section if participation in the program is made 
available to all similarly situated individuals. The 
following programs shall not have to comply with the 
requirements of paragraph (3) if participation in the 
program is made available to all similarly situated 
individuals: 
‘‘(A) A program that reimburses all or 
part of the cost for memberships in a fitness 
center. 
‘‘(B) A diagnostic testing program that 
provides a reward for participation and does 
not base any part of the reward on outcomes. 
‘‘(C) A program that encourages preven-
tive care related to a health condition through 
the waiver of the copayment or deductible re-
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quirement under group health plan for the costs 
of certain items or services related to a health 
condition (such as prenatal care or well-baby 
visits). 
‘‘(D) A program that reimburses individ-
uals for the costs of smoking cessation pro-
grams without regard to whether the individual 
quits smoking. 
‘‘(E) A program that provides a reward to 
individuals for attending a periodic health edu-
cation seminar. 
‘‘(3) WELLNESS
PROGRAMS
SUBJECT
TO
RE-
QUIREMENTS.—If any of the conditions for obtaining 
a premium discount, rebate, or reward under a 
wellness program as described in paragraph (1)(C) 
is based on an individual satisfying a standard that 
is related to a health status factor, the wellness pro-
gram shall not violate this section if the following re-
quirements are complied with: 
‘‘(A) The reward for the wellness program, 
together with the reward for other wellness pro-
grams with respect to the plan that requires 
satisfaction of a standard related to a health 
status factor, shall not exceed 30 percent of the 
cost of employee-only coverage under the plan. 
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If, in addition to employees or individuals, any 
class of dependents (such as spouses or spouses 
and dependent children) may participate fully 
in the wellness program, such reward shall not 
exceed 30 percent of the cost of the coverage in 
which an employee or individual and any de-
pendents are enrolled. For purposes of this 
paragraph, the cost of coverage shall be deter-
mined based on the total amount of employer 
and employee contributions for the benefit 
package under which the employee is (or the 
employee and any dependents are) receiving 
coverage. A reward may be in the form of a dis-
count or rebate of a premium or contribution, 
a waiver of all or part of a cost-sharing mecha-
nism (such as deductibles, copayments, or coin-
surance), the absence of a surcharge, or the 
value of a benefit that would otherwise not be 
provided under the plan. The Secretaries of 
Labor, Health and Human Services, and the 
Treasury may increase the reward available 
under this subparagraph to up to 50 percent of 
the cost of coverage if the Secretaries determine 
that such an increase is appropriate. 
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‘‘(B) The wellness program shall be rea-
sonably designed to promote health or prevent 
disease. A program complies with the preceding 
sentence if the program has a reasonable 
chance of improving the health of, or preventing 
disease in, participating individuals and it is 
not overly burdensome, is not a subterfuge for 
discriminating based on a health status factor, 
and is not highly suspect in the method chosen 
to promote health or prevent disease. 
‘‘(C) The plan shall give individuals eligible 
for the program the opportunity to qualify for 
the reward under the program at least once 
each year. 
‘‘(D) The full reward under the wellness 
program shall be made available to all similarly 
situated individuals. For such purpose, among 
other things: 
‘‘(i) The reward is not available to all 
similarly situated individuals for a period 
unless the wellness program allows— 
‘‘(I) for a reasonable alternative 
standard (or waiver of the otherwise 
applicable standard) for obtaining the 
reward for any individual for whom, 
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for that period, it is unreasonably dif-
ficult due to a medical condition to 
satisfy the otherwise applicable stand-
ard; and 
‘‘(II) for a reasonable alternative 
standard (or waiver of the otherwise 
applicable standard) for obtaining the 
reward for any individual for whom, 
for that period, it is medically inadvis-
able to attempt to satisfy the other-
wise applicable standard. 
‘‘(ii) If reasonable under the cir-
cumstances, the plan or issuer may seek 
verification, such as a statement from an 
individual’s physician, that a health status 
factor makes it unreasonably difficult or 
medically inadvisable for the individual to 
satisfy or attempt to satisfy the otherwise 
applicable standard. 
‘‘(E) The plan or issuer involved shall dis-
close in all plan materials describing the terms 
of the wellness program the availability of a 
reasonable alternative standard (or the possi-
bility of waiver of the otherwise applicable 
standard) required under subparagraph (D). If 
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plan materials disclose that such a program is 
available, without describing its terms, the dis-
closure under this subparagraph shall not be re-
quired. 
‘‘SEC. 199. PROHIBITION OF PREEXISTING CONDITION EX-
CLUSIONS 
OR 
OTHER 
DISCRIMINATION 
BASED ON HEALTH STATUS. 
‘‘(a) IN GENERAL.—A group health plan and a health 
insurance issuer offering group or individual health insur-
ance coverage may not impose any preexisting condition 
exclusion with respect to such plan or coverage. 
‘‘(b) DEFINITIONS.—For purposes of this section— 
‘‘(1) PREEXISTING CONDITION EXCLUSION.— 
‘‘(A) IN GENERAL.—The term ‘preexisting 
condition exclusion’ means, with respect to cov-
erage, a limitation or exclusion of benefits relat-
ing to a condition based on the fact that the 
condition was present before the date of enroll-
ment for such coverage, whether or not any 
medical advice, diagnosis, care, or treatment 
was recommended or received before such date. 
‘‘(B) TREATMENT OF GENETIC INFORMA-
TION.—Genetic information shall not be treated 
as a condition described in subsection (a)(1) in 
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the absence of a diagnosis of the condition re-
lated to such information. 
‘‘(2) ENROLLMENT
DATE.—The term ‘enroll-
ment date’ means, with respect to an individual cov-
ered under a group health plan or health insurance 
coverage, the date of enrollment of the individual in 
the plan or coverage or, if earlier, the first day of 
the waiting period for such enrollment. 
‘‘(3) LATE
ENROLLEE.—The term ‘late en-
rollee’ means, with respect to coverage under a 
group health plan, a participant or beneficiary who 
enrolls under the plan other than during— 
‘‘(A) the first period in which the indi-
vidual is eligible to enroll under the plan; or 
‘‘(B) a special enrollment period under 
subsection (f). 
‘‘(4) 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) RULES RELATING
TO CREDITING PREVIOUS 
COVERAGE.— 
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‘‘(1) CREDITABLE
COVERAGE
DEFINED.—For 
purposes of this title, the term ‘creditable coverage’ 
means, with respect to an individual, coverage of the 
individual under any of the following: 
‘‘(A) A group health plan. 
‘‘(B) Health insurance coverage. 
‘‘(C) Part A or part B of title XVIII of the 
Social Security Act. 
‘‘(D) Title XIX of the Social Security Act, 
other than coverage consisting solely of benefits 
under section 1928. 
‘‘(E) Chapter 55 of title 10, United States 
Code. 
‘‘(F) A medical care program of the Indian 
Health Service or of a tribal organization. 
‘‘(G) A State health benefits risk pool. 
‘‘(H) A health plan offered under chapter 
89 of title 5, United States Code. 
‘‘(I) A public health plan (as defined in 
regulations). 
‘‘(J) A health benefit plan under section 
5(e) of the Peace Corps Act (22 U.S.C. 
2504(e)). 
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Such term does not include coverage consisting sole-
ly of coverage of excepted benefits (as defined in sec-
tion 2791(c)). 
‘‘(2) NOT COUNTING PERIODS BEFORE SIGNIFI-
CANT BREAKS IN COVERAGE.— 
‘‘(A) IN GENERAL.—A period of creditable 
coverage shall not be counted, with respect to 
enrollment of an individual under a group or in-
dividual health plan, if, after such period and 
before the enrollment date, there was a 63-day 
period during all of which the individual was 
not covered under any creditable coverage. 
‘‘(B) WAITING PERIOD NOT TREATED AS A 
BREAK IN COVERAGE.—For purposes of sub-
paragraph (A) and subsection (d)(4), any pe-
riod that an individual is in a waiting period for 
any coverage under a group or individual health 
plan (or for group health insurance coverage) or 
is in an affiliation period (as defined in sub-
section (g)(2)) shall not be taken into account 
in determining the continuous period under 
subparagraph (A). 
‘‘(C) TAA-ELIGIBLE INDIVIDUALS.—In the 
case of plan years beginning before January 1, 
2014— 
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‘‘(i) TAA PRE-CERTIFICATION PERIOD 
RULE.—In the case of a TAA-eligible indi-
vidual, the period beginning on the date 
the individual has a TAA-related loss of 
coverage and ending on the date that is 7 
days after the date of the issuance by the 
Secretary (or by any person or entity des-
ignated by the Secretary) of a qualified 
health insurance costs credit eligibility cer-
tificate for such individual for purposes of 
section 7527 of the Internal Revenue Code 
of 1986 shall not be taken into account in 
determining the continuous period under 
subparagraph (A). 
‘‘(ii) DEFINITIONS.—The terms ‘TAA- 
eligible individual’ and ‘TAA-related loss of 
coverage’ have the meanings given such 
terms in section 2205(b)(4). 
‘‘(3) METHOD OF CREDITING COVERAGE.— 
‘‘(A) STANDARD METHOD.—Except as oth-
erwise provided under subparagraph (B), for 
purposes of applying subsection (a)(3), a group 
health plan, and a health insurance issuer offer-
ing group or individual health insurance cov-
erage, shall count a period of creditable cov-
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erage without regard to the specific benefits 
covered during the period. 
‘‘(B) ELECTION OF ALTERNATIVE METH-
OD.—A group health plan, or a health insur-
ance issuer offering group or individual health 
insurance, may elect to apply subsection (a)(3) 
based on coverage of benefits within each of 
several classes or categories of benefits specified 
in regulations rather than as provided under 
subparagraph (A). Such election shall be made 
on a uniform basis for all participants and 
beneficiaries. Under such election a group or in-
dividual health plan or issuer shall count a pe-
riod of creditable coverage with respect to any 
class or category of benefits if any level of bene-
fits is covered within such class or category. 
‘‘(C) PLAN
NOTICE.—In the case of an 
election with respect to a group health plan 
under subparagraph (B) (whether or not health 
insurance coverage is provided in connection 
with such plan), the plan shall— 
‘‘(i) prominently state in any disclo-
sure statements concerning the plan, and 
state to each enrollee at the time of enroll-
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ment under the plan, that the plan has 
made such election; and 
‘‘(ii) include in such statements a de-
scription of the effect of this election. 
‘‘(D) ISSUER NOTICE.—In the case of an 
election under subparagraph (B) with respect to 
health insurance coverage offered by an issuer 
in the individual or group market, the issuer— 
‘‘(i) shall prominently state in any dis-
closure statements concerning the cov-
erage, and to each employer at the time of 
the offer or sale of the coverage, that the 
issuer has made such election; and 
‘‘(ii) shall include in such statements 
a description of the effect of such election. 
‘‘(4) ESTABLISHMENT OF PERIOD.—Periods of 
creditable coverage with respect to an individual 
shall be established through presentation of certifi-
cations described in subsection (e) or in such other 
manner as may be specified in regulations. 
‘‘(d) EXCEPTIONS.— 
‘‘(1) EXCLUSION NOT APPLICABLE TO CERTAIN 
NEWBORNS.—Subject to paragraph (4), a group 
health plan, and a health insurance issuer offering 
group or individual health insurance coverage, may 
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not impose any preexisting condition exclusion in the 
case of an individual who, as of the last day of the 
30-day period beginning with the date of birth, is 
covered under creditable coverage. 
‘‘(2) EXCLUSION NOT APPLICABLE TO CERTAIN 
ADOPTED CHILDREN.—Subject to paragraph (4), a 
group health plan, and a health insurance issuer of-
fering group or individual health insurance coverage, 
may not impose any preexisting condition exclusion 
in the case of a child who is adopted or placed for 
adoption before attaining 18 years of age and who, 
as of the last day of the 30-day period beginning on 
the date of the adoption or placement for adoption, 
is covered under creditable coverage. The previous 
sentence shall not apply to coverage before the date 
of such adoption or placement for adoption. 
‘‘(3) EXCLUSION NOT APPLICABLE TO PREG-
NANCY.—A group health plan, and health insurance 
issuer offering group or individual health insurance 
coverage, may not impose any preexisting condition 
exclusion relating to pregnancy as a preexisting con-
dition. 
‘‘(4) LOSS
IF
BREAK
IN
COVERAGE.—Para-
graphs (1) and (2) shall no longer apply to an indi-
vidual after the end of the first 63-day period during 
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all of which the individual was not covered under 
any creditable coverage. 
‘‘(e) CERTIFICATIONS
AND DISCLOSURE
OF COV-
ERAGE.— 
‘‘(1) REQUIREMENT
FOR
CERTIFICATION
OF 
PERIOD OF CREDITABLE COVERAGE.— 
‘‘(A) IN GENERAL.—A group health plan, 
and a health insurance issuer offering group or 
individual health insurance coverage, shall pro-
vide the certification described in subparagraph 
(B)— 
‘‘(i) at the time an individual ceases 
to be covered under the plan or otherwise 
becomes covered under a COBRA continu-
ation provision; 
‘‘(ii) in the case of an individual be-
coming covered under such a provision, at 
the time the individual ceases to be covered 
under such provision; and 
‘‘(iii) on the request on behalf of an 
individual made not later than 24 months 
after the date of cessation of the coverage 
described in clause (i) or (ii), whichever is 
later. 
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The certification under clause (i) may be pro-
vided, to the extent practicable, at a time con-
sistent with notices required under any applica-
ble COBRA continuation provision. 
‘‘(B) CERTIFICATION.—The certification 
described in this subparagraph is a written cer-
tification of— 
‘‘(i) the period of creditable coverage 
of the individual under such plan and the 
coverage (if any) under such COBRA con-
tinuation provision; and 
‘‘(ii) the waiting period (if any) (and 
affiliation period, if applicable) imposed 
with respect to the individual for any cov-
erage under such plan. 
‘‘(C) ISSUER COMPLIANCE.—To the extent 
that medical care under a group health plan 
consists of group health insurance coverage, the 
plan is deemed to have satisfied the certification 
requirement under this paragraph if the health 
insurance issuer offering the coverage provides 
for such certification in accordance with this 
paragraph. 
‘‘(2) DISCLOSURE OF INFORMATION ON PRE-
VIOUS BENEFITS.—In the case of an election de-
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scribed in subsection (c)(3)(B) by a group health 
plan or health insurance issuer, if the plan or issuer 
enrolls an individual for coverage under the plan and 
the individual provides a certification of coverage of 
the individual under paragraph (1)— 
‘‘(A) upon request of such plan or issuer, 
the entity which issued the certification pro-
vided by the individual shall promptly disclose 
to such requesting plan or issuer information 
on coverage of classes and categories of health 
benefits available under such entity’s plan or 
coverage; and 
‘‘(B) such entity may charge the request-
ing plan or issuer for the reasonable cost of dis-
closing such information. 
‘‘(3) REGULATIONS.—The Secretary shall es-
tablish rules to prevent an entity’s failure to provide 
information under paragraph (1) or (2) with respect 
to previous coverage of an individual from adversely 
affecting any subsequent coverage of the individual 
under another group health plan or health insurance 
coverage. 
‘‘(f) SPECIAL ENROLLMENT PERIODS.— 
‘‘(1) INDIVIDUALS LOSING OTHER COVERAGE.— 
A group health plan, and a health insurance issuer 
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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 
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)— 
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‘‘(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. 
‘‘(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 
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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 
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 
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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; 
‘‘(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 
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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 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 
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 
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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.— 
‘‘(i) OUTREACH TO EMPLOYEES RE-
GARDING AVAILABILITY OF MEDICAID AND 
CHIP COVERAGE.— 
‘‘(I) IN
GENERAL.—Each em-
ployer that maintains a group health 
plan in a State that provides medical 
assistance under a State Medicaid 
plan under title XIX of the Social Se-
curity Act, or child health assistance 
under a State child health plan under 
title XXI of such Act, in the form of 
premium assistance for the purchase 
of coverage under a group health 
plan, shall provide to each employee a 
written notice informing the employee 
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of potential opportunities then cur-
rently available in the State in which 
the employee resides for premium as-
sistance under such plans for health 
coverage of the employee or the em-
ployee’s dependents. For purposes of 
compliance with this subclause, the 
employer may use any State-specific 
model notice developed in accordance 
with section 701(f)(3)(B)(i)(II) of the 
Employee Retirement Income Security 
Act 
of 
1974 
(29 
U.S.C. 
1181(f)(3)(B)(i)(II)). 
‘‘(II) OPTION TO PROVIDE CON-
CURRENT WITH PROVISION OF PLAN 
MATERIALS
TO
EMPLOYEE.—An em-
ployer may provide the model notice 
applicable to the State in which an 
employee resides concurrent with the 
furnishing of materials notifying the 
employee of health plan eligibility, 
concurrent with materials provided to 
the employee in connection with an 
open season or election process con-
ducted under the plan, or concurrent 
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with the furnishing of the summary 
plan description as provided in section 
104(b) of the Employee Retirement 
Income Security Act of 1974. 
‘‘(ii) 
DISCLOSURE
ABOUT
GROUP 
HEALTH PLAN BENEFITS TO STATES FOR 
MEDICAID
AND
CHIP
ELIGIBLE
INDIVID-
UALS.—In the case of an enrollee in a 
group health plan who is covered under a 
Medicaid plan of a State under title XIX 
of the Social Security Act or under a State 
child health plan under title XXI of such 
Act, the plan administrator of the group 
health plan shall disclose to the State, 
upon request, information about the bene-
fits available under the group health plan 
in sufficient specificity, as determined 
under regulations of the Secretary of 
Health and Human Services in consulta-
tion with the Secretary that require use of 
the model coverage coordination disclosure 
form developed under section 311(b)(1)(C) 
of the Children’s Health Insurance Reau-
thorization Act of 2009, so as to permit 
the State to make a determination (under 
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paragraph (2)(B), (3), or (10) of section 
2105(c) of the Social Security Act or oth-
erwise) concerning the cost-effectiveness of 
the State providing medical or child health 
assistance through premium assistance for 
the purchase of coverage under such group 
health plan and in order for the State to 
provide supplemental benefits required 
under paragraph (10)(E) of such section 
or other authority. 
‘‘(g) USE OF AFFILIATION PERIOD BY HMOS AS AL-
TERNATIVE TO PREEXISTING CONDITION EXCLUSION.— 
‘‘(1) IN GENERAL.—A health maintenance orga-
nization which offers health insurance coverage in 
connection with a group health plan and which does 
not impose any preexisting condition exclusion al-
lowed under subsection (a) with respect to any par-
ticular coverage option may impose an affiliation pe-
riod for such coverage option, but only if— 
‘‘(A) such period is applied uniformly with-
out regard to any health status-related factors; 
and 
‘‘(B) such period does not exceed 2 months 
(or 3 months in the case of a late enrollee). 
‘‘(2) AFFILIATION PERIOD.— 
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‘‘(A) DEFINED.—For purposes of this 
title, the term ‘affiliation period’ means a pe-
riod which, under the terms of the health insur-
ance coverage offered by the health mainte-
nance organization, must expire before the 
health insurance coverage becomes effective. 
The organization is not required to provide 
health care services or benefits during such pe-
riod and no premium shall be charged to the 
participant or beneficiary for any coverage dur-
ing the period. 
‘‘(B) BEGINNING.—Such period shall begin 
on the enrollment date. 
‘‘(C) RUNS CONCURRENTLY WITH WAITING 
PERIODS.—An affiliation period under a plan 
shall run concurrently with any waiting period 
under the plan. 
‘‘(3) ALTERNATIVE METHODS.—A health main-
tenance organization described in paragraph (1) may 
use alternative methods, from those described in 
such paragraph, to address adverse selection as ap-
proved by the State insurance commissioner or offi-
cial or officials designated by the State to enforce 
the requirements of this part for the State involved 
with respect to such issuer. 
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‘‘SEC. 199A. EXTENSION OF DEPENDENT COVERAGE. 
‘‘(a) IN GENERAL.—A group health plan and a health 
insurance issuer offering group or individual health insur-
ance coverage that provides dependent coverage of chil-
dren shall continue to make such coverage available for 
an adult child (who is not married) until the child turns 
26 years of age. Nothing in this section shall require a 
health plan or a health insurance issuer described in the 
preceding sentence to make coverage available for a child 
of a child receiving dependent coverage. 
‘‘(b) REGULATIONS.—The Secretary shall promul-
gate regulations to define the dependents to which cov-
erage shall be made available under subsection (a). 
‘‘(c) RULE OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed to modify the definition of ‘depend-
ent’ as used in the Internal Revenue Code of 1986 with 
respect to the tax treatment of the cost of coverage. 
‘‘SEC. 199B. ANNUAL LIMITATION ON COST-SHARING. 
‘‘(a) IN GENERAL.— 
‘‘(1) 2014.—The cost-sharing incurred under a 
group health plan or group or individual health in-
surance coverage with respect to self-only coverage 
or coverage other than self-only coverage for a plan 
year beginning in 2014 shall not exceed the dollar 
amounts in effect under section 223(c)(2)(A)(ii) of 
the Internal Revenue Code of 1986 for self-only and 
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family coverage, respectively, for taxable years begin-
ning in 2014. 
‘‘(2) 2015 AND
LATER.—In the case of any 
plan year beginning in a calendar year after 2014, 
the limitation under this paragraph shall— 
‘‘(A) in the case of self-only coverage, be 
equal to the dollar amount under paragraph (1) 
for self-only coverage for plan years beginning 
in 2014, increased by an amount equal to the 
product of that amount and the premium ad-
justment percentage under subsection (c) for 
the calendar year; and 
‘‘(B) in the case of other coverage, twice 
the amount in effect under subparagraph (A). 
If the amount of any increase under subparagraph 
(A) is not a multiple of $50, such increase shall be 
rounded to the next lowest multiple of $50. 
‘‘(b) COST-SHARING.—In this section: 
‘‘(1) IN GENERAL.—The term ‘cost-sharing’ in-
cludes— 
‘‘(A) deductibles, coinsurance, copayments, 
or similar charges; and 
‘‘(B) any other expenditure required of an 
insured individual which is a qualified medical 
expense 
(within 
the 
meaning 
of 
section 
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223(d)(2) of the Internal Revenue Code of 
1986) with respect to essential health benefits 
covered under the plan. 
‘‘(2) EXCEPTIONS.—Such term does not include 
premiums, balance billing amounts for non-network 
providers, or spending for non-covered services. 
‘‘(c) PREMIUM ADJUSTMENT PERCENTAGE.—For 
purposes of subsection (a)(2)(A), the premium adjustment 
percentage for any calendar year is the percentage (if any) 
by which the average per capita premium for health insur-
ance coverage in the United States for the preceding cal-
endar year (as estimated by the Secretary no later than 
October 1 of such preceding calendar year) exceeds such 
average per capita premium for 2013 (as determined by 
the Secretary). 
‘‘SEC. 199C. ENFORCEMENT OF CERTAIN HEALTH INSUR-
ANCE REQUIREMENTS. 
‘‘(a) STATE ENFORCEMENT.— 
‘‘(1) STATE AUTHORITY.—Each State may re-
quire that health insurance issuers that issue, sell, 
renew, or offer health insurance coverage in the 
State in the individual or group market meet the re-
quirements of this part with respect to such issuers. 
‘‘(2) FAILURE TO IMPLEMENT PROVISIONS.—In 
the case of a determination by the Secretary that a 
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State has failed to substantially enforce a provision 
(or provisions) of sections 196 through 199A with 
respect to health insurance issuers in the State, the 
Secretary shall enforce such provision (or provisions) 
under subsection (b) insofar as they relate to the 
issuance, sale, renewal, and offering of health insur-
ance coverage in connection with group health plans 
or individual health insurance coverage in such 
State. 
‘‘(b) SECRETARIAL ENFORCEMENT AUTHORITY.— 
‘‘(1) LIMITATION.—The provisions of this sub-
section shall apply to enforcement of a provision (or 
provisions) described in subsection (a)(2) only— 
‘‘(A) as provided under such subsection; 
and 
‘‘(B) with respect to individual health in-
surance coverage or group health plans that are 
non-Federal governmental plans. 
‘‘(2) IMPOSITION OF PENALTIES.—In the cases 
described in paragraph (1)— 
‘‘(A) IN
GENERAL.—Subject to the suc-
ceeding provisions of this subsection, any non- 
Federal governmental plan that is a group 
health plan and any health insurance issuer 
that fails to meet a provision of this part appli-
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100 
cable to such plan or issuer is subject to a civil 
money penalty under this subsection. 
‘‘(B) LIABILITY
FOR
PENALTY.—In the 
case of a failure by— 
‘‘(i) a health insurance issuer, the 
issuer is liable for such penalty; or 
‘‘(ii) a group health plan that is a 
non-Federal governmental plan which is— 
‘‘(I) sponsored by 2 or more em-
ployers, the plan is liable for such 
penalty; or 
‘‘(II) not so sponsored, the em-
ployer is liable for such penalty. 
‘‘(C) AMOUNT OF PENALTY.— 
‘‘(i) IN
GENERAL.—The maximum 
amount of penalty imposed under this 
paragraph is $100 for each day for each 
individual with respect to which such a 
failure occurs. 
‘‘(ii) CONSIDERATIONS
IN
IMPOSI-
TION.—In determining the amount of any 
penalty to be assessed under this para-
graph, the Secretary shall take into ac-
count the previous record of compliance of 
the entity being assessed with the applica-
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101 
ble provisions of this part and the gravity 
of the violation. 
‘‘(iii) LIMITATIONS.— 
‘‘(I) PENALTY
NOT
TO
APPLY 
WHERE
FAILURE
NOT
DISCOVERED 
EXERCISING
REASONABLE
DILI-
GENCE.—No civil money penalty shall 
be imposed under this paragraph on 
any failure during any period for 
which it is established to the satisfac-
tion of the Secretary that none of the 
entities against whom the penalty 
would be imposed knew, or exercising 
reasonable 
diligence 
would 
have 
known, that such failure existed. 
‘‘(II) PENALTY
NOT
TO
APPLY 
TO FAILURES CORRECTED WITHIN 30 
DAYS.—No civil money penalty shall 
be imposed under this paragraph on 
any failure if such failure was due to 
reasonable cause and not to willful ne-
glect, and such failure is corrected 
during the 30-day period beginning on 
the first day any of the entities 
against whom the penalty would be 
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102 
imposed knew, or exercising reason-
able diligence would have known, that 
such failure existed. 
‘‘(D) ADMINISTRATIVE REVIEW.— 
‘‘(i) OPPORTUNITY
FOR
HEARING.— 
The entity assessed shall be afforded an 
opportunity for hearing by the Secretary 
upon request made within 30 days after 
the date of the issuance of a notice of as-
sessment. In such hearing the decision 
shall be made on the record pursuant to 
section 554 of title 5, United States Code. 
If no hearing is requested, the assessment 
shall constitute a final and unappealable 
order. 
‘‘(ii) HEARING
PROCEDURE.—If a 
hearing is requested, the initial agency de-
cision shall be made by an administrative 
law judge, and such decision shall become 
the final order unless the Secretary modi-
fies or vacates the decision. Notice of in-
tent to modify or vacate the decision of the 
administrative law judge shall be issued to 
the parties within 30 days after the date of 
the decision of the judge. A final order 
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103 
which takes effect under this paragraph 
shall be subject to review only as provided 
under subparagraph (E). 
‘‘(E) JUDICIAL REVIEW.— 
‘‘(i) FILING
OF
ACTION
FOR
RE-
VIEW.—Any entity against whom an order 
imposing a civil money penalty has been 
entered after an agency hearing under this 
paragraph may obtain review by the 
United States district court for any district 
in which such entity is located or the 
United States District Court for the Dis-
trict of Columbia by filing a notice of ap-
peal in such court within 30 days from the 
date of such order, and simultaneously 
sending a copy of such notice by registered 
mail to the Secretary. 
‘‘(ii) CERTIFICATION OF ADMINISTRA-
TIVE
RECORD.—The 
Secretary 
shall 
promptly certify and file in such court the 
record upon which the penalty was im-
posed. 
‘‘(iii) STANDARD FOR REVIEW.—The 
findings of the Secretary shall be set aside 
only if found to be unsupported by sub-
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104 
stantial evidence as provided by section 
706(2)(E) of title 5, United States Code. 
‘‘(iv) APPEAL.—Any final decision, 
order, or judgment of the district court 
concerning such review shall be subject to 
appeal as provided in chapter 83 of title 28 
of such Code. 
‘‘(F) FAILURE TO PAY ASSESSMENT; MAIN-
TENANCE OF ACTION.— 
‘‘(i) FAILURE TO PAY ASSESSMENT.— 
If any entity fails to pay an assessment 
after 
it 
has 
become 
a 
final 
and 
unappealable order, or after the court has 
entered final judgment in favor of the Sec-
retary, the Secretary shall refer the matter 
to the Attorney General who shall recover 
the amount assessed by action in the ap-
propriate United States district court. 
‘‘(ii) NONREVIEWABILITY.—In such 
action the validity and appropriateness of 
the final order imposing the penalty shall 
not be subject to review. 
‘‘(G) PAYMENT OF PENALTIES.—Except as 
otherwise provided, penalties collected under 
this paragraph shall be paid to the Secretary 
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105 
(or other officer) imposing the penalty and shall 
be available without appropriation and until ex-
pended for the purpose of enforcing the provi-
sions with respect to which the penalty was im-
posed. 
‘‘(3) ENFORCEMENT AUTHORITY RELATING TO 
GENETIC DISCRIMINATION.— 
‘‘(A) GENERAL RULE.—In the cases de-
scribed in paragraph (1), notwithstanding the 
provisions of paragraph (2)(C), the succeeding 
subparagraphs of this paragraph shall apply 
with respect to an action under this subsection 
by the Secretary with respect to any failure of 
a health insurance issuer in connection with a 
group health plan, to meet the requirements of 
subsection (a)(1)(F), (b)(3), (c), or (d) of sec-
tion 196 or section 197 or 196(b)(1) with re-
spect to genetic information in connection with 
the plan. 
‘‘(B) AMOUNT.— 
‘‘(i) IN
GENERAL.—The amount of 
the penalty imposed under this paragraph 
shall be $100 for each day in the non-
compliance period with respect to each par-
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106 
ticipant or beneficiary to whom such fail-
ure relates. 
‘‘(ii) NONCOMPLIANCE PERIOD.—For 
purposes of this paragraph, the term ‘non-
compliance period’ means, with respect to 
any failure, the period— 
‘‘(I) beginning on the date such 
failure first occurs; and 
‘‘(II) ending on the date the fail-
ure is corrected. 
‘‘(C) MINIMUM PENALTIES WHERE FAIL-
URE DISCOVERED.—Notwithstanding clauses (i) 
and (ii) of subparagraph (D): 
‘‘(i) IN GENERAL.—In the case of 1 or 
more failures with respect to an indi-
vidual— 
‘‘(I) which are not corrected be-
fore the date on which the plan re-
ceives a notice from the Secretary of 
such violation; and 
‘‘(II) which occurred or continued 
during the period involved, 
the amount of penalty imposed by subpara-
graph (A) by reason of such failures with 
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107 
respect to such individual shall not be less 
than $2,500. 
‘‘(ii) 
HIGHER
MINIMUM
PENALTY 
WHERE VIOLATIONS ARE MORE THAN DE 
MINIMIS.—To the extent violations for 
which any person is liable under this para-
graph for any year are more than de mini-
mis, clause (i) shall be applied by sub-
stituting ‘$15,000’ for ‘$2,500’ with re-
spect to such person. 
‘‘(D) LIMITATIONS.— 
‘‘(i) PENALTY NOT TO APPLY WHERE 
FAILURE
NOT
DISCOVERED
EXERCISING 
REASONABLE
DILIGENCE.—No 
penalty 
shall be imposed by subparagraph (A) on 
any failure during any period for which it 
is established to the satisfaction of the 
Secretary that the person otherwise liable 
for such penalty did not know, and exer-
cising reasonable diligence would not have 
known, that such failure existed. 
‘‘(ii) PENALTY
NOT
TO
APPLY
TO 
FAILURES
CORRECTED
WITHIN
CERTAIN 
PERIODS.—No penalty shall be imposed by 
subparagraph (A) on any failure if— 
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108 
‘‘(I) such failure was due to rea-
sonable cause and not to willful ne-
glect; and 
‘‘(II) such failure is corrected 
during the 30-day period beginning on 
the first date the person otherwise lia-
ble for such penalty knew, or exer-
cising reasonable diligence would have 
known, that such failure existed. 
‘‘(iii) OVERALL LIMITATION FOR UN-
INTENTIONAL FAILURES.—In the case of 
failures which are due to reasonable cause 
and not to willful neglect, the penalty im-
posed by subparagraph (A) for failures 
shall not exceed the amount equal to the 
lesser of— 
‘‘(I) 10 percent of the aggregate 
amount paid or incurred by the em-
ployer (or predecessor employer) dur-
ing the preceding taxable year for 
group health plans; or 
‘‘(II) $500,000. 
‘‘(E) WAIVER BY SECRETARY.—In the case 
of a failure which is due to reasonable cause 
and not to willful neglect, the Secretary may 
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109 
waive part or all of the penalty imposed by sub-
paragraph (A) to the extent that the payment 
of such penalty would be excessive relative to 
the failure involved. 
‘‘(c) DEFINITIONS.—For purposes of this section: 
‘‘(1) GOVERNMENTAL PLAN.—The term ‘gov-
ernmental plan’ has the meaning given such term 
under section 3(32) of the Employee Retirement In-
come Security Act of 1974 and any Federal govern-
mental plan. 
‘‘(2) FEDERAL
GOVERNMENTAL
PLAN.—The 
term ‘‘Federal governmental plan’’ means a govern-
mental plan established or maintained for its em-
ployees by the Government of the United States or 
by any agency or instrumentality of such Govern-
ment. 
‘‘(3) NON-FEDERAL
GOVERNMENTAL
PLAN.— 
The term ‘non-Federal governmental plan’ means a 
governmental plan that is not a Federal govern-
mental plan.’’. 
(b) CONFORMING AMENDMENT.—The table of con-
tents under section 1(b) of the Health Insurance Port-
ability and Accountability Act of 1996 (Public Law 104– 
191) is amended by inserting after the item relating to 
section 195 the following: 
‘‘Sec. 196. Guaranteed availability of coverage. 
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110 
‘‘Sec. 197. Fair health insurance premiums. 
‘‘Sec. 198. Prohibiting discrimination against individual participants and bene-
ficiaries based on health status. 
‘‘Sec. 199. Prohibition of preexisting condition exclusions or other discrimina-
tion based on health status. 
‘‘Sec. 199A. Extension of dependent coverage. 
‘‘Sec. 199B. Annual limitation on cost-sharing. 
‘‘Sec. 199C. Enforcement of certain health insurance requirements.’’. 
(c) ERISA AND IRC ENFORCEMENT.— 
(1) ERISA.—Subpart B of part 7 of title I of 
the Employee Retirement Income Security Act of 
1974 (29 U.S.C. 1185 et seq.) is amended by adding 
at the end the following new section: 
‘‘SEC. 716. OTHER MARKET REFORMS. 
‘‘Sections 196 and 197 of the Health Insurance Port-
ability and Accountability Act of 1996 shall apply to 
health insurance issuers providing health insurance cov-
erage in connection with group health plans, and sections 
198 through 199B of such Act shall apply to group health 
plans and health insurance issuers providing health insur-
ance coverage in connection with group health plans, as 
if included in this subpart, and to the extent that any pro-
vision of this part conflicts with a provision of such section 
196 or 197 with respect to health insurance issuers pro-
viding health insurance coverage in connection with group 
health plans or of such section 198, 199, 199A, or 199B 
with respect to group health plans or health insurance 
issuers providing health insurance coverage in connection 
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111 
with group health plans, the provisions of such sections 
196 through 199B shall apply.’’. 
(2) IRC.—Subchapter B of chapter 100 of sub-
title K of title 26 of the Internal Revenue Code of 
1986 is amended by adding at the end the following 
new section: 
‘‘SEC. 9816. OTHER MARKET REFORMS. 
‘‘Sections 196 and 197 of the Health Insurance Port-
ability and Accountability Act of 1996 shall apply to 
health insurance issuers providing health insurance cov-
erage in connection with group health plans, and sections 
198 through 199B of such Act shall apply to group health 
plans and health insurance issuers providing health insur-
ance coverage in connection with group health plans, as 
if included in this subchapter, and to the extent that any 
provision of this chapter conflicts with a provision of such 
section 196 or 197 with respect to health insurance issuers 
providing health insurance coverage in connection with 
group health plans or of such section 198, 199, 199A, or 
199B with respect to group health plans or health insur-
ance issuers providing health insurance coverage in con-
nection with group health plans, the provisions of such 
sections 196 through 199B shall apply.’’. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall take effect on the date on which the Su-
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112 
preme Court of the United States issues a decision strik-
ing down the Patient Protection and Affordable Care Act 
(Public Law 111–148) in its entirety. 
Subtitle B—Expanding Coverage 
Options 
SEC. 211. DEFINITION OF ‘‘EMPLOYER’’ UNDER ERISA WITH 
RESPECT TO GROUP HEALTH PLANS. 
(a) DEFINITION OF EMPLOYER.—Section 3(5) of the 
Employee Retirement Income Security Act of 1974 (29 
U.S.C. 1002(5)) is amended by striking the period and 
inserting ‘‘(which, with respect to a group health plan, 
shall be determined in accordance with criteria that in-
cludes the criteria under section 735).’’. 
(b) GROUP HEALTH PLANS.—Part 7 of subtitle B 
of title I of the Employee Retirement Income Security Act 
of 1974 (29 U.S.C. 1181 et seq.) is amended by adding 
at the end the following: 
‘‘SEC. 735. DEFINITION OF ‘EMPLOYER’ WITH RESPECT TO 
GROUP HEALTH PLANS. 
‘‘(a) IN GENERAL.—A group or association of em-
ployers that meets the criteria under subsection (b) shall 
be considered an employer under section 3(5) for purposes 
of sponsoring a group health plan. 
‘‘(b) REQUIREMENTS.—The requirements under this 
subsection are each of the following: 
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114 
‘‘(5) The employer members shall have a com-
monality of interest as described in subsection (d). 
‘‘(6)(A) The group or association shall not 
make health coverage through the group health plan 
available other than to— 
‘‘(i) an employee of a current employer 
member of the group or association; 
‘‘(ii) a former employee of a current em-
ployer member of the group or association who 
became eligible for coverage under the group 
health plan when the former employee was an 
employee of the employer; and 
‘‘(iii) a beneficiary of an individual de-
scribed in clause (i) or (ii), such as a spouse or 
dependent child. 
‘‘(B) Notwithstanding subparagraph (A), the 
group or association shall not make health coverage 
through the group health plan available to any indi-
vidual (or beneficiaries of the individual) for any 
plan year following the plan year in which the plan 
determines pursuant to reasonable monitoring proce-
dures described in subsection (f)(2)(C) that the indi-
vidual ceases to meet the conditions described in 
subsection (f)(2) for being a working owner (unless 
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115 
the individual again meets those conditions), except 
as may be required by section 601. 
‘‘(7) The group or association, and any health 
coverage offered by the group or association, shall 
comply with the nondiscrimination provisions under 
subsection (e). 
‘‘(8) The group or association shall not be a 
health insurance issuer, or owned or controlled by 
such a health insurance issuer or by a subsidiary or 
affiliate of such a health insurance issuer, other 
than to the extent such entities participate in the 
group or association in their capacity as employer 
members of the group or association. 
‘‘(c) SUBSTANTIAL BUSINESS PURPOSE.— 
‘‘(1) IN GENERAL.—For purposes of subsection 
(b)(1), a substantial business purpose shall exist if 
the group or association would be a viable entity in 
the absence of sponsoring an employee benefit plan. 
‘‘(2) BUSINESS
PURPOSE.—For purposes of 
subsection (b)(1) and paragraph (1), a business pur-
pose shall— 
‘‘(A) include promoting common business 
interests of the members of the group or asso-
ciation or the common economic interests in a 
given trade or employer community; and 
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116 
‘‘(B) not be required to be a for-profit ac-
tivity. 
‘‘(d) COMMONALITY OF INTEREST.— 
‘‘(1) IN GENERAL.—Subject to paragraph (3), 
employer members of the group or association shall 
be treated as having a commonality of interest for 
purposes of subsection (b)(5) if— 
‘‘(A) the employers are in the same trade, 
industry, line of business, or profession; or 
‘‘(B) each employer has a principal place 
of business in the same region that does not ex-
ceed the boundaries of a single State or a met-
ropolitan area (even if the metropolitan area in-
cludes more than 1 State). 
‘‘(2) SAME
TRADE, INDUSTRY, OR
LINE
OF 
BUSINESS.—In the case of a group or association 
that is sponsoring a group health plan under this 
section and that is itself an employer member of the 
group or association, the group or association shall 
be deemed for purposes of paragraph (1)(A) to be 
in the same trade, industry, line of business, or pro-
fession, as applicable, as the other employer mem-
bers of the group or association. 
‘‘(3) 
NONDISCRIMINATION.—The 
standards 
under paragraph (1) shall not be implemented in a 
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117 
manner that is subterfuge for discrimination as is 
prohibited under subsection (e). 
‘‘(e) NONDISCRIMINATION.— 
‘‘(1) IN GENERAL.—A group or association of 
employers sponsoring a group health plan under this 
section, and any health coverage sponsored by such 
group or association, shall comply with each of the 
following: 
‘‘(A) The group or association shall not 
condition employer membership in the group or 
association on any health factor of any indi-
vidual who is or may become eligible to partici-
pate in the group health plan sponsored by the 
group or association. 
‘‘(B) The group health plan sponsored by 
the group or association shall comply with the 
rules under section 2590.702(b) of title 29, 
Code of Federal Regulations (as in effect on 
June 21, 2018), with respect to nondiscrimina-
tion in rules for eligibility for benefits, subject 
to subparagraph (D). 
‘‘(C) The group health plan sponsored by 
the group or association shall comply with the 
rules under section 2590.702(c) of title 29, 
Code of Federal Regulations (as in effect on 
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118 
June 21, 2018), with respect to nondiscrimina-
tion in premiums or contributions required by 
any participant or beneficiary for coverage 
under the plan, subject to subparagraph (D). 
‘‘(D) In applying subparagraphs (B) and 
(C), the group or association may not treat the 
employees of different employer members of the 
group or association as distinct groups of simi-
larly-situated individuals based on a health fac-
tor of 1 or more individuals. 
‘‘(2) DEFINITION
OF
HEALTH
FACTOR.—For 
purposes of this subsection, the term ‘health factor’ 
has the meaning given such term in section 
2590.702(a) of title 29, Code of Federal Regulations 
(as in effect on June 21, 2018). 
‘‘(f) DUAL TREATMENT OF WORKING OWNERS AS 
EMPLOYERS AND EMPLOYEES.— 
‘‘(1) IN GENERAL.—A person determined in ac-
cordance with paragraph (2) to be a working owner 
of a trade or business may qualify as both an em-
ployer and as an employee of the trade or business 
for purposes of the requirements under subsection 
(b), including the requirements under paragraphs 
(2) and (6) of such subsection. 
‘‘(2) WORKING OWNER.— 
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119 
‘‘(A) ELIGIBILITY.—A person shall qualify 
as a ‘working owner’ if a responsible fiduciary 
of the group health plan reasonably determines 
that the person— 
‘‘(i) does not have any common law 
employees; 
‘‘(ii) has an ownership right of any 
nature in a trade or business, whether in-
corporated or unincorporated, including a 
partner and other self-employed individual; 
‘‘(iii) is earning wages or self-employ-
ment income from the trade or business 
for providing personal services to the trade 
or business; and 
‘‘(iv) either— 
‘‘(I) works on average at least 20 
hours per week, or at least 80 hours 
per month, providing personal services 
to the person’s trade or business; or 
‘‘(II) has wages or self-employ-
ment income from such trade or busi-
ness that at least equals the person’s 
cost of coverage for participation by 
the person, and any covered bene-
ficiaries, in the group health plan 
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120 
sponsored by the group or association 
in which the person is participating. 
‘‘(B) DETERMINATION.—The determina-
tion under subparagraph (A) shall be made 
when the person first becomes eligible for cov-
erage under the group health plan. 
‘‘(C) REASONABLE
MONITORING
PROCE-
DURES.—A responsible fiduciary of the group 
health plan shall, through reasonable moni-
toring procedures, periodically confirm the con-
tinued eligibility of a person to qualify as a 
working owner under subparagraph (A) for pur-
poses of meeting the requirements under sub-
section (b) for the group health plan sponsored 
under this section. 
‘‘(g) APPLICABILITY.— 
‘‘(1) FULLY INSURED.—This section shall apply 
beginning on September 1, 2018, with respect to a 
group or association of employers sponsoring a 
group health plan that is fully insured. 
‘‘(2) PLANS EXPANDING TO INCLUDE BROADER 
GROUP.—This section shall apply beginning on Jan-
uary 1, 2019, with respect to a group or association 
of employers sponsoring a group health plan that— 
‘‘(A) is not fully insured; 
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121 
‘‘(B) is in existence on June 21, 2018; 
‘‘(C) meets the requirements that applied 
with respect to such plan before June 21, 2018; 
and 
‘‘(D) chooses to be a plan sponsored under 
this section (and subject to the requirements 
under subsections (b) through (f)). 
‘‘(3) OTHER
ASSOCIATION
HEALTH
PLANS.— 
This section shall apply beginning on April 1, 2019, 
with respect to any other group or association of em-
ployers sponsoring a group health plan. 
‘‘(4) OTHER
CRITERIA
IN
ADVISORY
OPIN-
IONS.—The criteria under this section shall not in-
validate any criteria provided in an advisory opinion, 
in effect on or after the date of enactment of the 
Fair Care Act of 2022, that the Secretary may use 
to determine if a group or association of employers 
is an employer under section 3(5) for purposes of 
sponsoring a group health plan. 
‘‘(h) DETERMINATION OF EMPLOYER OR JOINT EM-
PLOYER STATUS.— 
‘‘(1) IN GENERAL.—Participating in or facili-
tating a group health plan sponsored by a bona fide 
group or association of employers pursuant to sub-
section (a) shall not be construed as establishing an 
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122 
employer or joint employer relationship under any 
Federal or State law. 
‘‘(2) APPLICATION OF PROVISION.—Paragraph 
(1) shall apply to a group health plan sponsored or 
facilitated by a franchisor and any franchisee, by 
multiple franchisors for the benefit of the employees 
of such franchisors and their franchisees, by mul-
tiple franchisees for the benefit of the employees of 
such franchisees, by a franchisor whose franchisee or 
franchisees participate or participates in the plan, or 
by a person or entity that contracts with any indi-
vidual as an independent contractor for whom the 
plan benefits. 
‘‘(i) RULE OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed as repealing or otherwise limiting 
the application of this Act (including section 712 relating 
to mental health parity) to group health plans and em-
ployee welfare benefit plans.’’. 
SEC. 212. SHORT-TERM LIMITED DURATION INSURANCE. 
(a) DEFINITION.—Section 2791(b) of the Public 
Health Service Act (42 U.S.C. 300gg–91(b)) is amended 
by adding at the end the following: 
‘‘(6) SHORT-TERM LIMITED DURATION INSUR-
ANCE.—The term ‘short-term limited duration insur-
ance’ means health insurance coverage provided pur-
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123 
suant to a contract with a health insurance issuer 
that has an expiration date specified in the contract 
(not taking into account any extensions that may be 
elected by the policyholder with or without the 
issuer’s consent) that is less than 12 months after 
the original effective date of the contract.’’. 
(b) GUARANTEED RENEWABILITY.—Section 2703 of 
the Public Health Service Act (42 U.S.C. 300gg–2) is 
amended— 
(1) in subsection (a), by inserting ‘‘or offers 
short-term limited duration insurance’’ after ‘‘group 
market’’; and 
(2) by adding at the end the following: 
‘‘(f) APPLICATION TO SHORT-TERM LIMITED DURA-
TION INSURANCE.— 
‘‘(1) IN GENERAL.—In applying this section in 
the case of short-term limited duration insurance— 
‘‘(A) a reference to ‘health insurance cov-
erage’ with respect to such coverage offered in 
the individual market shall be deemed to in-
clude short-term limited duration insurance; 
and 
‘‘(B) a reference to ‘health insurance 
issuer’ with respect to health insurance cov-
erage offered in the individual market shall be 
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124 
deemed to include an issuer of short-term lim-
ited duration insurance. 
‘‘(2) SPECIAL RULE FOR SHORT-TERM LIMITED 
DURATION INSURANCE.—In the case of short-term 
limited duration insurance, at the time of application 
for enrollment in such insurance coverage, an issuer 
of such insurance may offer renewability of such 
coverage, and an individual may decline renewability 
of such coverage in accordance with this section, and 
the contract between such individual and the health 
insurance issuer shall specify whether the individual 
opted for renewability or no renewability.’’. 
(c) APPLICABILITY.—The amendments made by sub-
sections (a) and (b) shall apply with respect to contracts 
for short-term limited duration insurance that take effect 
on or after January 1, 2023. 
Subtitle C—Improving Commercial 
Health Insurance 
SEC. 221. INVISIBLE GUARANTEED COVERAGE POOL REIN-
SURANCE PROGRAM; TAX ON EXCHANGE 
PLANS. 
(a) ESTABLISHMENT.—Not later than 2 years after 
the date of enactment of this Act, the Secretary of Health 
and Human Services shall establish the Invisible Guaran-
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teed Coverage Pool Reinsurance Program (in this section 
referred to as the ‘‘IGCPR program’’). 
(b) STATE GRANTS.—Under the IGCPR program, 
the Secretary shall, from amounts appropriated under 
subsection (f) for a fiscal year, award grants to States for 
such fiscal year, in amounts determined in accordance 
with the allocation methodology specified under subsection 
(d). Such grants shall be used for the purpose of estab-
lishing or maintaining a qualifying Invisible Guaranteed 
Coverage Pool for the State. 
(c) FEDERAL DEFAULT.— 
(1) IN GENERAL.—In the case of a State that 
does not, by a date and in a manner specified by the 
Secretary, choose to be awarded a grant under sub-
section (b) for a fiscal year to operate a qualifying 
Invisible Guaranteed Coverage Pool for the State, 
the Secretary shall, from amounts appropriated 
under subsection (f) for such fiscal year, use the al-
location determined for the State under subsection 
(d) for participation of such State in the Federal de-
fault qualifying Invisible Guaranteed Coverage Pool 
described in paragraph (2). 
(2) FEDERAL DEFAULT QUALIFYING INVISIBLE 
GUARANTEED
COVERAGE
POOL.—The Federal de-
fault qualifying high risk pool is, with respect to 
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each State that chooses not to be awarded a grant 
under subsection (b) with respect to a fiscal year for 
which funds are appropriated under subsection (f), 
an Invisible Guaranteed Coverage Pool under which 
health insurance issuers participating in the Ex-
change of such a State, with respect to designated 
individuals who are enrolled in health insurance cov-
erage and are expected to experience higher than av-
erage health costs as determined by the insurer, cede 
risk to the pool, without affecting the premium paid 
by the designated individuals or their terms of cov-
erage. With respect to such pool— 
(A) high-risk individuals designated for 
cession to the pool shall be designated by the 
ceding issuer; 
(B) the premium amount the ceding issuer 
shall pay to the reinsurance pool shall be 90 
percent of the premium paid to the issuer for 
the coverage; 
(C) the ceding issuer shall retain the same 
risk under the ceded policies as under any other 
policy of the issuer with respect to the first 
$10,000 of benefits for each ceded policy in-
volved and will not retain any risk under ceded 
policies after such first $10,000 of benefits; and 
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127 
(D) after a ceding issuer, with respect to 
a ceded policy, no longer retains risk under 
such policy pursuant to subparagraph (C), the 
negotiated rate under such policy for items and 
services shall be payable at the reimbursement 
rate under the Medicare program under title 
XVIII of the Social Security Act for such items 
and services, or in the case of items and serv-
ices for which payment is available under the 
policy but not the Medicare program, at a rate 
determined by the Secretary. 
(d) ALLOCATION METHODOLOGY.—Not later than six 
months after the establishment of the IGCPR program, 
the Secretary shall specify an allocation methodology for 
determining the amount of funds appropriated under sub-
section (f) for a fiscal year to be allocated for each State 
for purposes of subsections (b) and (c). Such methodology 
shall be based on the number of residents of each State 
and the general health status of such residents. 
(e) QUALIFYING INVISIBLE GUARANTEED COVERAGE 
POOL.—For purposes of this section, the term ‘‘qualifying 
Invisible Guaranteed Coverage Pool’’ means, with respect 
to a State, a method of designation under which health 
insurance issuers identify individuals who experience high-
er than average health costs as determined by the State 
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128 
and are enrolled in health insurance coverage offered in 
the individual market, and cede the risk of spending more 
than $10,000 on health care services for a single indi-
vidual to the pool without affecting the premium paid by 
the designated individuals or their terms of coverage. With 
respect to such pool, the State, or an entity operating the 
pool on behalf of the State, shall establish— 
(1) the premium amount the ceding issuer shall 
pay to the reinsurance pool; 
(2) the applicable attachment points or coinsur-
ance percentages if the ceding issuer retains any 
portion of the risk under ceded policies, except that 
the provisions of subparagraphs (C) and (D) of sub-
section (c)(2) shall apply to such high risk pool in 
the same manner as such clauses apply to the Fed-
eral default high risk pool; and 
(3) the mechanism by which high-risk individ-
uals are designated for cession to the pool, which 
may include a list of designated high-cost health 
conditions. 
(f) APPROPRIATIONS.—There is appropriated to the 
Secretary 
of 
Health 
and 
Human 
Services 
$200,000,000,000 to carry out this section for the period 
of the first 10 years after the establishment of the IGCPR 
program. 
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129 
(g) TAX ON HEALTH INSURANCE PLANS SOLD ON 
EXCHANGES.— 
(1) IN GENERAL.—Chapter 34 of the Internal 
Revenue Code of 1986 is amended by adding at the 
end the following new subchapter: 
‘‘Subchapter C—Additional Tax on Health In-
surance Plans Sold by Insurers Offering 
Plans on Exchanges 
‘‘Sec. 4401. Additional tax on health insurance plans sold by insurers offering 
plans on exchanges. 
‘‘SEC. 4401. ADDITIONAL TAX ON HEALTH INSURANCE 
PLANS SOLD BY INSURERS OFFERING PLANS 
ON EXCHANGES. 
‘‘(a) IMPOSITION OF TAX.—There is imposed a tax 
of $4 for each policy month of each health insurance policy 
sold by insurers offering plans through an Exchange es-
tablished under the Patient Protection and Affordable 
Care Act. 
‘‘(b) LIABILITY.—The tax imposed by subsection (a) 
shall be paid by the plan sponsor.’’. 
(2) CONFORMING AMENDMENT.—The table of 
subchapters for chapter 34 of the Internal Revenue 
Code of 1986 is amended by adding at the end the 
following item: 
‘‘SUBCHAPTER C—ADDITIONAL TAX ON HEALTH INSURANCE PLANS SOLD BY 
INSURERS OFFERING PLANS ON EXCHANGES’’. 
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130 
(3) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply with respect to months 
beginning after the date of enactment of this Act. 
(h) REPORT.—The Secretary of Health and Human 
Services, in collaboration with the Comptroller General of 
the United States, shall submit to Congress, not later than 
5 years after the date of enactment of this Act, and again 
5 years thereafter, a report on the status of reinsurance 
pool funding, along with any recommendations with re-
spect to future allocations or funding methods for such 
pool. 
SEC. 222. EMPLOYER HEALTH INSURANCE MANDATE RE-
PEAL. 
(a) IN GENERAL.—Chapter 43 of the Internal Rev-
enue Code of 1986 is amended by striking section 4980H. 
(b) REPEAL
OF RELATED REPORTING REQUIRE-
MENTS.—Subpart D of part III of subchapter A of chap-
ter 61 of such Code is amended by striking section 6056. 
(c) CONFORMING AMENDMENTS.— 
(1) Section 6724(d)(1)(B) of such Code is 
amended by inserting ‘‘or’’ at the end of clause 
(xxiii), by striking ‘‘or’’ at the end of clause (xxiv), 
and by striking clause (xxv). 
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131 
(2) Section 6724(d)(2) of such Code is amend-
ed by inserting ‘‘or’’ at the end of subparagraph 
(GG) and by striking subparagraph (HH). 
(3) The table of sections for chapter 43 of such 
Code is amended by striking the item relating to sec-
tion 4980H. 
(4) The table of sections for subpart D of part 
III of subchapter A of chapter 61 of such Code is 
amended by striking the item relating to section 
6056. 
(5) Section 1513 of the Patient Protection and 
Affordable Care Act is amended by striking sub-
section (c). 
(d) EFFECTIVE DATE.— 
(1) IN
GENERAL.—Except as otherwise pro-
vided in this subsection, the amendments made by 
this section shall apply to months and other periods 
beginning after December 31, 2023. 
(2) REPEAL
OF
STUDY
AND
REPORT.—The 
amendment made by subsection (c)(5) shall take ef-
fect on the date of the enactment of this Act. 
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132 
SEC. 223. REFUNDABLE CREDITS FOR COVERAGE UNDER A 
QUALIFIED HEALTH PLAN FOR INDIVIDUALS 
OFFERED 
EMPLOYER-SPONSORED 
INSUR-
ANCE. 
(a) IN GENERAL.—Section 36B(c)(2) of the Internal 
Revenue Code of 1986 is amended— 
(1) in subparagraph (B)(i), by inserting ‘‘or 
section 5000A(f)(1)(B)’’, and 
(2) by striking subparagraph (C). 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
the date of the enactment of this Act. 
SEC. 224. INCLUSION IN INCOME OF CERTAIN COSTS OF 
EMPLOYER-PROVIDED 
COVERAGE 
UNDER 
HEALTH PLANS. 
(a) IN GENERAL.—Section 106 of the Internal Rev-
enue Code of 1986 is amended by adding at the end the 
following new subsection: 
‘‘(h) LIMITATION.— 
‘‘(1) IN
GENERAL.—Subsection (a) shall not 
apply to the extent that employer-provided coverage 
under health plans for an employee for a taxable 
year exceeds— 
‘‘(A) $10,200 for self-only coverage, and 
‘‘(B) $27,500 for all other coverage. 
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133 
‘‘(2) IN GENERAL.—In the case of any calendar 
year after 2023, the dollar amounts in paragraph 
(1) shall each be increased by an amount equal to— 
‘‘(A) such dollar amount, multiplied by— 
‘‘(B) the cost-of-living adjustment deter-
mined under section 1(f)(3) for such calendar 
year, determined— 
‘‘(i) by substituting ‘calendar year 
2023’ for ‘calendar year 2018’ in subpara-
graph (A)(ii) thereof, and 
‘‘(ii) by substituting for the C–CPI–U 
referred to in section 1(f)(3)(A) the 
amount that such CPI would have been if 
the annual percentage increase in CPI with 
respect to each year after 2023 and before 
2033 had been one percentage point great-
er. 
‘‘(3) TERMS RELATED TO CPI.— 
‘‘(A) ANNUAL PERCENTAGE INCREASE.— 
For purposes of subparagraph (B)(ii)(II), the 
term ‘annual percentage increase’ means the 
percentage (if any) by which C–CPI–U for any 
year exceeds the C–CPI–U for the prior year. 
‘‘(B) OTHER TERMS.—Terms used in this 
paragraph which are also used in section 
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134 
1(f)(3) shall have the same meanings as when 
used in such section.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to taxable years begin-
ning after December 31, 2023. 
SEC. 225. CHANGE IN PERMISSIBLE AGE VARIATION IN 
HEALTH INSURANCE PREMIUM RATES. 
Section 2701(a)(1)(A)(iii) of the Public Health Serv-
ice Act (42 U.S.C. 300gg(a)(1)(A)(iii)) is amended by in-
serting after ‘‘(consistent with section 2707(c))’’ the fol-
lowing: ‘‘or, for plan years beginning on or after January 
1, 2023, as the Secretary may implement through interim 
final regulation, 5 to 1 for adults (consistent with section 
2707(c))’’. 
SEC. 226. PREMIUM ASSISTANCE ADJUSTMENT TO RE-
FLECT AGE. 
(a) MODIFICATION OF APPLICABLE PERCENTAGE.— 
Section 36B(b)(3)(A) of the Internal Revenue Code of 
1986 is amended to read as follows: 
‘‘(A) APPLICABLE PERCENTAGE.— 
‘‘(i) IN
GENERAL.—The applicable 
percentage for any taxable year shall be 
the percentage such that the applicable 
percentage for any taxpayer whose house-
hold income is within an income tier speci-
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135 
fied in the following table shall increase, on 
a sliding scale in a linear manner, from the 
initial percentage to the final percentage 
specified in such table for such income tier 
with respect to a taxpayer of the age in-
volved: 
‘‘In the case of 
household income 
(expressed as a 
percent of the 
poverty line) 
within the 
following 
income tier: 
Up to Age 29 
Age 30–39 
Age 40–49 
Age 50–59 
Over Age 59 
Initial 
% 
Final 
% 
Initial 
% 
Final 
% 
Initial 
% 
Final 
% 
Initial 
% 
Final 
% 
Initial 
% 
Final 
% 
Up to 100% 
100%–133% 
133%–150% 
4.3 
4.3 
4.3 
4.3 
4.3 
150%–200% 
4.3 
6.7 
4.3 
6.7 
4.3 
6.7 
4.3 
6.7 
4.3 
6.7 
200%–250% 
6.7 
6.7 
6.7 
7.6 
6.7 
8.3 
6.7 
8.3 
6.7 
8.3 
250%–300% 
6.7 
6.7 
7.6 
7.6 
8.3 
9.8 
8.3 
9.8 
8.3 
9.8 
300%–400% 
6.7 
7.6 
9.8 
9.8 
9.8 
400%-600% 
‘‘(ii) AGE DETERMINATIONS.— 
‘‘(I) IN GENERAL.—For purposes 
of clause (i), the age of the taxpayer 
taken into account under clause (i) 
with respect to any taxable year is the 
age attained by such taxpayer before 
the close of such taxable year. 
‘‘(II) JOINT
RETURNS.—In the 
case of a joint return, the age of the 
older spouse shall be taken into ac-
count under clause (i). 
‘‘(iii) INDEXING.—In the case of any 
taxable year beginning after calendar year 
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136 
2023, the initial and final percentages con-
tained in clause (i) shall be adjusted to re-
flect— 
‘‘(I) the excess (if any) of the 
rate of premium growth for the period 
beginning with calendar year 2013 
and ending with calendar year 2023, 
over the rate of income growth for 
such period, and 
‘‘(II) in addition to any adjust-
ment under subclause (I), the excess 
(if any) of the rate of premium 
growth for calendar year 2023, over 
the rate of growth in the consumer 
price index for calendar year 2023. 
‘‘(iv) FAILSAFE.—Clause (iii)(II) shall 
apply only if the aggregate amount of pre-
mium tax credits under this section and 
cost-sharing reductions under section 1402 
of the Patient Protection and Affordable 
Care Act for the preceding calendar year 
exceeds an amount equal to 0.504 percent 
of the gross domestic product for such cal-
endar year.’’. 
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137 
(b) EXPANSION OF ELIGIBILITY.—Section 36B of the 
Internal Revenue Code of 1986 is amended— 
(1) in subsection (c)(1)(A), by striking ‘‘400’’ 
and inserting ‘‘600’’; and 
(2) in subsection (f)(2)(B)(i), by striking ‘‘400’’ 
each place such reference appears and inserting 
‘‘600’’ in each such place. 
(c) EFFECTIVE DATE.—The amendment made by 
this section shall apply to taxable years beginning after 
December 31, 2023. 
SEC. 227. PREMIUM ASSISTANCE. 
Notwithstanding any other provision of law, the Sec-
retary of the Treasury shall calculate the credit allowable 
under section 36B of the Internal Revenue Code of 1986 
based on the taxpayer’s prior year tax return and the Sec-
retary of Health and Human Services shall provide for 
open enrollment periods that end on April 15. 
SEC. 228. ADDING COPPER PLANS TO EXCHANGES. 
(a) IN GENERAL.—Section 1302 of the Patient Pro-
tection and Affordable Care Act (42 U.S.C. 18022) is 
amended— 
(1) in subsection (a)(3), by inserting ‘‘copper,’’ 
after ‘‘either the’’; 
(2) in subsection (c), by adding at the end the 
following new paragraph: 
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138 
‘‘(5) SPECIAL RULE FOR COPPER PLANS.—A 
health plan in the copper level of coverage (as de-
scribed in subsection (d)(1)(E)) shall be deemed to 
meet the requirements of this subsection.’’; 
(3) in subsection (d)— 
(A) in paragraph (1), by adding at the end 
the following new subparagraph: 
‘‘(E) COPPER LEVEL.—A plan in the cop-
per level shall provide a level of coverage that 
is designed to provide benefits that are actuari-
ally equivalent to 50 percent of the full actu-
arial value of the benefits provided under the 
plan and will have out-of-pocket limits that are 
30 percent higher than bronze plans.’’; and 
(B) in paragraph (4)— 
(i) by inserting ‘‘copper,’’ after ‘‘any 
reference to a’’; and 
(ii) by inserting ‘‘copper,’’ after ‘‘pro-
viding a’’; and 
(4) in subsection (e)(1), by inserting ‘‘copper,’’ 
after ‘‘not providing a’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to plan years begin-
ning on or after January 1, 2023. 
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139 
SEC. 229. COPPER AND BRONZE PLANS. 
Notwithstanding any other provision of law, refund-
able credits for coverage under a qualified health plan and 
cost-sharing reductions may be used to purchase bronze 
and copper plans. 
SEC. 230. WAIVERS FOR STATE INNOVATION. 
(a) STREAMLINING THE STATE APPLICATION PROC-
ESS.—Section 1332 of the Patient Protection and Afford-
able Care Act (42 U.S.C. 18052) is amended— 
(1) in subsection (a)(1)(C), by striking ‘‘the 
law’’ and inserting ‘‘a law or has in effect a certifi-
cation’’; and 
(2) in subsection (b)(2)— 
(A) in the paragraph heading, by inserting 
‘‘OR CERTIFY’’ after ‘‘LAW’’; 
(B) in subparagraph (A)— 
(i) by striking ‘‘A law’’ and inserting 
the following: 
‘‘(i) LAWS.—A law’’; and 
(ii) by adding at the end the fol-
lowing: 
‘‘(ii) 
CERTIFICATIONS.—A 
certifi-
cation described in this paragraph is a doc-
ument, signed by the Governor of the 
State, that certifies that such Governor 
has the authority under existing Federal 
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140 
and State law to take action under this 
section, including implementation of the 
State plan under subsection (a)(1)(B).’’; 
and 
(C) in subparagraph (B)— 
(i) in the subparagraph heading, by 
striking ‘‘OF OPT OUT’’; and 
(ii) by striking ‘‘may repeal a law’’ 
and all that follows through the period at 
the end and inserting the following: ‘‘may 
terminate the authority provided under the 
waiver with respect to the State by— 
‘‘(i) repealing a law described in sub-
paragraph (A)(i); or 
‘‘(ii) terminating a certification de-
scribed in subparagraph (A)(ii), through a 
certification for such termination signed by 
the Governor of the State.’’. 
(b) PROVIDING EXPEDITED APPROVAL OF STATE 
WAIVERS.—Section 1332(d) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18052(d)) is amended— 
(1) in paragraph (1) by striking ‘‘180’’ and in-
serting ‘‘90’’; and 
(2) by adding at the end the following: 
‘‘(3) EXPEDITED DETERMINATION.— 
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141 
‘‘(A) IN GENERAL.—With respect to any 
application under subsection (a)(1) submitted 
on or after the date of this paragraph or any 
such application submitted prior to such date of 
enactment and under review by the Secretary 
on such date of enactment, the Secretary shall 
make a determination on such application, 
using the criteria for approval otherwise appli-
cable under this section, not later than 45 days 
after the receipt of such application, and shall 
allow the public notice and comment at the 
State and Federal levels described under sub-
section (a)(4) to occur concurrently if such 
State application— 
‘‘(i) is submitted in response to an ur-
gent situation, with respect to areas in the 
State that the Secretary determines are at 
risk for excessive premium increases or 
having no health plans offered in the appli-
cable health insurance market for the cur-
rent or following plan year; or 
‘‘(ii) is for a waiver that is the same 
or substantially similar to a waiver that 
the Secretary already has approved for an-
other State. 
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142 
‘‘(B) APPROVAL.— 
‘‘(i) URGENT SITUATIONS.— 
‘‘(I) PROVISIONAL APPROVAL.—A 
waiver approved under the expedited 
determination process under subpara-
graph (A)(i) shall be in effect for a 
period of 3 years, unless the State re-
quests a shorter duration. 
‘‘(II) FULL APPROVAL.—Subject 
to the requirements for approval oth-
erwise applicable under this section, 
not later than 1 year before the expi-
ration of a provisional waiver period 
described in subclause (I) with respect 
to an application described in sub-
paragraph (A)(i), the Secretary shall 
make a determination on whether to 
extend the approval of such waiver for 
the full term of the waiver requested 
by the State, for a total approval pe-
riod not to exceed 6 years. The Sec-
retary may request additional infor-
mation as the Secretary determines 
appropriate to make such determina-
tion. 
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143 
‘‘(ii) APPROVAL OF SAME OR SIMILAR 
APPLICATIONS.—An approval of a waiver 
under subparagraph (A)(ii) shall be subject 
to the terms of subsection (e). 
‘‘(C) GAO STUDY.—Not later than 5 years 
after the date of enactment of this paragraph, 
the Comptroller General of the United States 
shall conduct a review of all waivers approved 
pursuant to an application under subparagraph 
(A)(ii) to evaluate whether such waivers met 
the requirements of subsection (b)(1) and 
whether the applications should have qualified 
for such expedited process.’’. 
(c) PROVIDING CERTAINTY FOR STATE-BASED RE-
FORMS.—Section 1332(e) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18052(e)) is amended by 
striking ‘‘No waiver’’ and all that follows through the pe-
riod at the end and inserting the following: ‘‘A waiver 
under this section— 
‘‘(1) shall be in effect for a period of 6 years 
unless the State requests a shorter duration; 
‘‘(2) may be renewed, subject to the State meet-
ing the criteria for approval otherwise applicable 
under this section, for unlimited additional 6-year 
periods upon application by the State; and 
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144 
‘‘(3) may not be suspended or terminated, in 
whole or in part, by the Secretary at any time before 
the date of expiration of the waiver period (including 
any renewal period under paragraph (2)), unless the 
Secretary determines that the State materially failed 
to comply with the terms and conditions of the waiv-
er.’’. 
(d) ENSURING PATIENT ACCESS TO MORE FLEXIBLE 
HEALTH PLANS.—Section 1332(b)(1)(B) of the Patient 
Protection 
and 
Affordable 
Care 
Act 
(42 
U.S.C. 
18052(b)(1)(B)) is amended by striking ‘‘at least as af-
fordable’’ and inserting ‘‘of comparable affordability, in-
cluding for low-income individuals, individuals with serious 
health needs, and other vulnerable populations,’’. 
(e) APPLICABILITY.—The amendments made by this 
Act to section 1332 of the Patient Protection and Afford-
able Care Act (42 U.S.C. 18052)— 
(1) with respect to applications for waivers 
under such section 1332 submitted after the date of 
enactment of this Act and applications for such 
waivers submitted prior to such date of enactment 
and under review by the Secretary on the date of en-
actment, shall take effect on the date of enactment 
of this Act; and 
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145 
(2) with respect to applications for waivers ap-
proved under such section 1332 before the date of 
enactment of this Act, shall not require reconsider-
ation of whether such applications meet the require-
ments of such section 1332, except that, at the re-
quest of a State, the Secretary shall recalculate the 
amount of funding provided under subsection (a)(3) 
of such section. 
SEC. 231. ENROLLMENT PERIODS. 
(a) EXCHANGES.—Paragraph (7) of section 1311(c) 
of the Patient Protection and Affordable Care Act (42 
U.S.C. 18031(c)), as added by section 106, is amended 
by adding at the end the following new subparagraph: 
‘‘(B) ENROLLMENTS OTHER THAN DURING 
INITIAL, OPEN, AND SPECIAL ENROLLMENT PE-
RIODS.—Beginning with plan year 2023, an Ex-
change may provide for enrollments during pe-
riods in addition to open enrollment periods de-
scribed in subparagraph (A) or paragraph (6) 
and special enrollment periods described in 
paragraph (6).’’. 
(b) HEALTH PLANS.—Subpart I of part A of title 
XXVII of the Public Health Service Act is amended by 
adding at the end the following new section: 
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146 
‘‘SEC. 2710. ENROLLMENT OUTSIDE OF INITIAL, OPEN, AND 
SPECIAL ENROLLMENT PERIOD. 
‘‘Beginning with plan year 2023, a group health plan 
and a health insurance issuer offering group or individual 
health insurance coverage may provide for enrollment in 
such plan or coverage during periods in addition to initial, 
open, or special enrollment periods. In the case that an 
individual enrolls in such plan or coverage during a period 
pursuant to the previous sentence, the plan or issuer may 
charge the individual a one-time enrollment fee.’’. 
SEC. 232. STATE-OPERATED EXCHANGES FLEXIBILITY FOR 
OPEN ENROLLMENT PERIODS. 
Section 1311(c) of the Patient Protection and Afford-
able Care Act (42 U.S.C. 18031(c)) is amended— 
(1) in paragraph (6), by striking ‘‘The Sec-
retary’’ and inserting ‘‘Subject to paragraph (7), the 
Secretary’’; and 
(2) by adding at the end the following new 
paragraph: 
‘‘(7) FLEXIBILITY
FOR
ENROLLMENT
PERI-
ODS.— 
‘‘(A) STATE-OPERATED EXCHANGES OPEN 
ENROLLMENT PERIODS.—In the case of an Ex-
change operated by a State, beginning with 
plan years of 1 year after the date of enactment 
of this Act, the Exchange may provide for open 
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enrollment periods (after the initial enrollment 
period) every 12, 24, or 36 months, as deter-
mined by the State.’’. 
SEC. 233. PROMOTING HEALTH PLANS THAT COVER INDI-
VIDUALS IN MORE THAN ONE STATE. 
There are appropriated, out of amounts in the Treas-
ury not otherwise appropriated, $10,000,000 to be made 
available by no later than 1 year after the date of enact-
ment of this Act, to the Center for Medicare & Medicaid 
Innovation to fund new research or pilot programs dedi-
cated to pursuing viable methods of enrolling individuals 
in health insurance programs that cross State lines. 
TITLE 
III—COMPETITION, 
TRANSPARENCY 
AND 
AC-
COUNTABILITY 
Subtitle A—Provider and Insurer 
Competition 
SEC. 301. HOSPITAL CONSOLIDATION. 
(a) AUTHORIZATION OF APPROPRIATIONS.—There is 
authorized to be appropriated $160,000,000 to the Fed-
eral Trade Commission to hire staff to investigate, as con-
sistent with the Sherman Antitrust Act and other relevant 
Federal laws, anti-competitive mergers and practices 
under such laws to the extent such mergers and practices 
relate to providers of inpatient and outpatient health care 
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services, as defined by the Secretary of Health and 
Human Services. 
(b) MEDICARE ADVANTAGE RATES APPLIED TO CER-
TAIN HHI HOSPITALS.— 
(1) IN GENERAL.—Section 1866(a) of the So-
cial Security Act (42 U.S.C. 1395cc(a)) is amend-
ed— 
(A) in paragraph (1)— 
(i) in subparagraph (X), by striking 
‘‘and’’ at the end; 
(ii) in subparagraph (Y), by striking 
the period at the end and inserting ‘‘; 
and’’; and 
(iii) by inserting after subparagraph 
(Y) the following new subparagraph: 
‘‘(Z) subject to paragraph (4), in the case 
of a hospital located in a county whose popu-
lation density is above the median population 
density for all counties in the United States 
with respect to which there is a Herfindahl- 
Hirschman Index (HHI) of greater than 4,000, 
to apply the average reimbursement rate with 
respect to individuals (regardless of whether 
such an individual is entitled to or eligible for 
benefits under this title, but excluding individ-
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uals eligible for medical assistance under a 
State plan under title XIX) furnished items and 
services at such hospital that would be billable 
under this title for such items and services if 
furnished by such hospital to an individual en-
rolled under part C.’’; and 
(B) by adding at the end the following new 
paragraph: 
‘‘(4)(A) The requirement under paragraph 
(1)(Z) shall not apply in the case of a hospital in a 
hospital referral region if— 
‘‘(i) the HRR market share of such hos-
pital (as determined under subparagraph (B)) 
is less than 0.15; or 
‘‘(ii) the hospital is located in a rural area 
(as defined in section 1886(d)(2)(D)). 
‘‘(B) For purposes of subparagraph (A), the 
HRR market share of a hospital in a hospital refer-
ral region is equal to— 
‘‘(i) the total revenue of the hospital, di-
vided by 
‘‘(ii) the total revenue of all hospital in the 
hospital referral region.’’. 
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(2) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply with respect to items 
and services furnished on or after January 1, 2023. 
(c) GRANTS FOR HOSPITAL INFRASTRUCTURE IM-
PROVEMENT.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services shall carry out a grant program 
under which the Secretary shall provide grants to el-
igible States, in accordance with this subsection. 
(2) USES.—An eligible State receiving a grant 
under this subsection may use such grant to improve 
the State hospital infrastructure and to supplement 
any other funds provided for a purpose authorized 
under a State or local hospital grant program under 
State law. 
(3) ELIGIBILITY.— 
(A) IN GENERAL.—An eligible State may 
receive not more than one grant under this sub-
section with respect to each qualifying criterion 
described in subparagraph (B) that is met by 
the State. 
(B) ELIGIBLE
STATE.—For purposes of 
this subsection, the term ‘‘eligible State’’ means 
a State that meets any one or more of the fol-
lowing qualifying criteria: 
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151 
(i) The State does not have in effect 
any State certificate of need law that re-
quires a health care provider to provide to 
a regulatory body a certification that the 
community needs the services provided by 
the health care provider. 
(ii) The State has in effect State 
scope of practice laws that— 
(I) allow advanced practice pro-
viders (such as nurse practitioners, 
advanced practice registered nurses, 
clinical nurse specialists, and physi-
cian assistants) to evaluate patients; 
diagnose, order, and interpret diag-
nostic tests; and initiate and manage 
treatments; or 
(II) provide that the only jus-
tification for limiting the scope of 
practice of a health care provider is 
safety to the public. 
(iii) The State does not have in effect 
any State laws that require managed care 
plans to accept into the network of such 
plan any qualified provider who is willing 
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152 
to accept the terms and conditions of the 
managed care plan. 
(iv) The State does not have in effect 
any Certificate of Public Advantage laws 
that clearly articulate the State’s intent to 
displace competition in favor of regulation 
or that violate State or Federal antitrust 
laws. 
(v) The State does not have in effect 
any network adequacy laws regulating a 
health plan’s ability to deliver benefits by 
providing reasonable access to a sufficient 
number of in-network primary care and 
specialty physicians, as well as all health 
care services included under the terms of 
an insuree’s contract with a health insurer. 
(4) FUNDING.—There is authorized to be ap-
propriated 
to 
carry 
out 
this 
subsection 
$1,000,000,000 for each of the fiscal years 2022 
through 2031. Funds appropriated under this para-
graph shall remain available until expended. 
(d) CRITICAL ACCESS HOSPITAL REIMBURSEMENT 
RATES.— 
(1) PART A.—Section 1814(l)(1) of the Social 
Security Act (42 U.S.C. 1395f(l)(1)) is amended by 
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153 
inserting ‘‘(or, for 2023, 102, plus 1 percentage 
point for each subsequent year through 2031, and 
110 for each subsequent year thereafter)’’ after 
‘‘101’’. 
(2) PART B.—Section 1834(g)(1) of such Act 
(42 U.S.C. 1395m(g)(1)) is amended by inserting 
‘‘(or, for 2023, 102, plus 1 percentage point for each 
subsequent year through 2031, and 110 for each 
subsequent year thereafter)’’ after ‘‘101’’. 
SEC. 302. AUTHORITY OF FEDERAL TRADE COMMISSION 
OVER 
CERTAIN 
TAX-EXEMPT 
ORGANIZA-
TIONS. 
Section 4 of the Federal Trade Commission Act (15 
U.S.C. 44) is amended, in the undesignated paragraph re-
lating to the definition of the term ‘‘Corporation’’— 
(1) by striking ‘‘, and any’’ and inserting ‘‘, 
any’’; and 
(2) by inserting before the period at the end the 
following: ‘‘, and any organization described in sec-
tion 501(c)(3) of the Internal Revenue Code of 1986 
that is exempt from taxation under section 501(a) of 
such Code’’. 
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154 
SEC. 303. LEVELING THE PLAYING FIELD BETWEEN PAYERS 
AND PROVIDERS. 
(a) EXEMPTION.—It shall not be a violation of the 
antitrust laws for one or more private health insurer 
issuers or their designated agents to jointly negotiate 
prices of particular hospital services with a hospital pro-
vider with regards to the reimbursement policies of the 
insurers for those services. 
(b) DEFINITIONS.—For purposes of this section: 
(1) ANTITRUST
LAWS.—The term ‘‘antitrust 
laws’’ has the meaning given it in subsection (a) of 
the 1st section of the Clayton Act (15 U.S.C. 12(a)), 
except that such term includes section 5 of the Fed-
eral Trade Commission Act (15 U.S.C. 45) to the 
extent such section 5 applies to unfair methods of 
competition. 
(2) HEALTH
INSURANCE
ISSUER.—The term 
‘‘health insurance issuer’’ means an insurance com-
pany, insurance service, or insurance organization 
(including a health maintenance organization, as de-
fined in subparagraph (C)) which is licensed to en-
gage in the business of insurance in a State and 
which is subject to State law which regulates insur-
ance (within the meaning of section 514(b)(2) of the 
Employee Retirement Income Security Act of 1974 
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155 
(29 U.S.C. 1144(b)(2))). Such term does not include 
a group health plan. 
(3) HEALTH MAINTENANCE ORGANIZATION.— 
The 
term 
‘‘health 
maintenance 
organization’’ 
means— 
(A) a Federally qualified health mainte-
nance organization (as defined in section 
300e(a) of title 42 of the United States Code), 
(B) an organization recognized under State 
law as a health maintenance organization, or 
(C) a similar organization regulated under 
State law for solvency in the same manner and 
to the same extent as such a health mainte-
nance organization. 
(c) EFFECTIVE DATE.—This section shall take effect 
on the date of the enactment of this Act but shall not 
apply with respect to conduct that occurs before such date. 
SEC. 304. BANNING ANTICOMPETITIVE TERMS IN FACILITY 
AND INSURANCE CONTRACTS THAT LIMIT AC-
CESS TO HIGHER QUALITY, LOWER COST 
CARE. 
(a) IN GENERAL.—Section 2729B of the Public 
Health Service Act, as added by section 301, is amended 
by adding at the end the following: 
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156 
‘‘(b) PROTECTING HEALTH PLANS NETWORK DE-
SIGN FLEXIBILITY.— 
‘‘(1) IN GENERAL.—A group health plan or a 
health insurance issuer offering group or individual 
health insurance coverage shall not enter into an 
agreement with a provider, network or association of 
providers, or other service provider offering access to 
a network of service providers if such agreement, di-
rectly or indirectly— 
‘‘(A) restricts the group health plan or 
health insurance issuer from— 
‘‘(i) directing or steering enrollees to 
other health care providers; or 
‘‘(ii) offering incentives to encourage 
enrollees to utilize specific health care pro-
viders; 
‘‘(B) requires the group health plan or 
health insurance issuer to enter into any addi-
tional contract with an affiliate of the provider, 
such as an affiliate of the provider, as a condi-
tion of entering into a contract with such pro-
vider; 
‘‘(C) requires the group health plan or 
health insurance issuer to agree to payment 
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157 
rates or other terms for any affiliate not party 
to the contract of the provider involved; or 
‘‘(D) restricts other group health plans or 
health insurance issuers not party to the con-
tract from paying a lower rate for items or 
services than the contracting plan or issuer 
pays for such items or services. 
‘‘(2) ADDITIONAL REQUIREMENT FOR SELF-IN-
SURED
PLANS.—A self-insured group health plan 
shall not enter into an agreement with a provider, 
network or association of providers, third-party ad-
ministrator, or other service provider offering access 
to a network of providers if such agreement directly 
or indirectly requires the group health plan to cer-
tify, attest, or otherwise confirm in writing that the 
group health plan is bound by restrictive contracting 
terms between the service provider and a third-party 
administrator that the group health plan is not 
party to, without a disclosure that such terms exist. 
‘‘(3) EXCEPTION FOR CERTAIN GROUP MODEL 
ISSUERS.—Paragraph (1)(A) shall not apply to a 
group health plan or health insurance issuer offering 
group or individual health insurance coverage with 
respect to— 
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158 
‘‘(A) a health maintenance organization 
(as defined in section 2791(b)(3)), if such 
health maintenance organization operates pri-
marily through exclusive contracts with multi- 
specialty physician groups, nor to any arrange-
ment between such a health maintenance orga-
nization and its affiliates; or 
‘‘(B) a value-based network arrangement, 
such as an exclusive provider network, account-
able care organization, center of excellence, a 
provider sponsored health insurance issuer that 
operates primarily through aligned multi-spe-
cialty physician group practices or integrated 
health systems, or such other similar network 
arrangements as determined by the Secretary 
through rulemaking. 
‘‘(4) ATTESTATION.—A group health plan or 
health insurance issuer offering group or individual 
health insurance coverage shall annually submit to, 
as applicable, the applicable authority described in 
section 2723 or the Secretary of Labor, an attesta-
tion that such plan or issuer is in compliance with 
the requirements of this subsection. 
‘‘(c) MAINTENANCE OF EXISTING HIPAA, GINA, 
AND ADA PROTECTIONS.—Nothing in this section shall 
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159 
modify, reduce, or eliminate the existing privacy protec-
tions and standards provided by reason of State and Fed-
eral law, including the requirements of parts 160 and 164 
of title 45, Code of Federal Regulations (or any successor 
regulations). 
‘‘(d) REGULATIONS.—The Secretary, not later than 
1 year after the date of enactment of the Fair Care Act 
of 2022, shall promulgate regulations to carry out this sec-
tion. 
‘‘(e) RULE OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed to limit network design or cost or 
quality initiatives by a group health plan or health insur-
ance issuer, including accountable care organizations, ex-
clusive provider organizations, networks that tier providers 
by cost or quality or steer enrollees to centers of excel-
lence, or other pay-for-performance programs. 
‘‘(f) CLARIFICATION WITH RESPECT TO ANTITRUST 
LAWS.—Compliance with this section does not constitute 
compliance with the antitrust laws, as defined in sub-
section (a) of the first section of the Clayton Act (15 
U.S.C. 12(a)).’’. 
(b) EFFECTIVE DATE.—Section 2729B of the Public 
Health Service Act (as added by section 301 and amended 
by subsection (a)) shall apply with respect to any contract 
entered into on or after the date that is 18 months after 
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160 
the date of enactment of this Act. With respect to an ap-
plicable contract that is in effect on the date of enactment 
of this Act, such section 2729B shall apply on the earlier 
of the date of renewal of such contract or 3 years after 
such date of enactment. 
SEC. 305. REPEALING ELIGIBILITY OF CERTAIN ACOS. 
(a) IN GENERAL.—Section 1899(b)(1) of the Social 
Security Act (42 U.S.C. 1395jjj(b)(1)) is amended by 
striking subparagraphs (C) through (E). 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall take effect on January 1, 2023. 
SEC. 306. REPEAL OF HEALTH CARE REFORM PROVISIONS 
LIMITING MEDICARE EXCEPTION TO THE 
PROHIBITION ON CERTAIN PHYSICIAN RE-
FERRALS FOR HOSPITALS. 
Sections 6001 and 10601 of the Patient Protection 
and Affordable Care Act (Public Law 111–148; 124 Stat. 
684, 1005) and section 1106 of the Health Care and Edu-
cation Reconciliation Act of 2010 (Public Law 111–152; 
124 Stat. 1049) are repealed and the provisions of law 
amended by such sections are restored as if such sections 
had never been enacted. 
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161 
SEC. 307. ALTERNATIVE PAYMENT MODEL FOR CERTAIN 
SHOPPABLE PROCEDURES. 
(a) IN GENERAL.—A group health plan and a health 
insurance issuer offering group or individual health insur-
ance coverage (as such terms are defined in section 2791 
of the Public Health Service Act (42 U.S.C. 300gg–91)) 
may elect, with respect to a plan year, to provide a set 
payment amount to an enrollee under such plan or cov-
erage for certain shoppable procedures (as defined in sub-
section (b)) in accordance with the provisions of this sec-
tion in lieu of otherwise providing coverage for such a pro-
cedure under such plan or coverage, but only if the en-
rollee so agrees to such set payment amount. 
(b) DEFINITION.—For purposes of this section, the 
term ‘‘shoppable procedure’’ means a procedure specified 
by the Secretary of Health and Human Services (in this 
section referred to as the ‘‘Secretary’’) with respect to 
which individuals may be expected to compare prices for 
such procedure of health care providers and facilities, in-
cluding primary and preventive services, prenatal care and 
childbirth, common surgeries that can be scheduled, and 
other similar services. 
(c) SET PAYMENT RULES.—A set payment described 
in subsection (a) under a group health plan or group or 
individual health insurance coverage offered by a health 
insurance issuer shall— 
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162 
(1) be disclosed prior to beginning of each plan 
year such payment is in effect and shall not vary 
during such plan year; 
(2) be the same amount with respect to the 
same shoppable procedure furnished in a geographic 
area (as defined by the Secretary); 
(3) not be less than the median negotiated rate 
for all group health plans and health insurance cov-
erage offered in such area for such procedure; 
(4) be made available to an enrolled under such 
plan or such coverage regardless of the provider or 
facility furnishing the shoppable procedure; 
(5) represent the entirety of the payment obli-
gation of such plan or such issuer with respect to 
such procedure; and 
(6) may be retained by such enrollee to the ex-
tent that the amount of such payment exceeds the 
amount charged by such provider or facility for such 
procedure. 
(d) PROVISION
OF
PRICE
INFORMATION.—Each 
health care provider and facility that may furnish a 
shoppable procedure during a year shall post in a public 
area a notice containing the prices that will be charged 
by such provider of facility with respect to each such pro-
cedure to individuals making payment for such services 
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163 
pursuant to a set payment amount described in subsection 
(a). 
(e) EHB WAIVER AUTHORITY.—The Secretary may 
waive such provisions of section 1302(b) of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18022(b)) 
with respect to a group health plan, health insurance 
issuer offering group or individual health insurance cov-
erage, and a plan year as the Secretary determines nec-
essary to allow for the provision of set payment amounts 
described in subsection (a). 
Subtitle B—Price Transparency 
SEC. 321. PRICE TRANSPARENCY REQUIREMENTS. 
(a) HOSPITALS.—Section 2718(e) of the Public 
Health Service Act (42 U.S.C. 300gg–18(e)) is amend-
ed— 
(1) by striking ‘‘Each hospital’’ and inserting 
the following: 
‘‘(1) IN GENERAL.—Each hospital’’; 
(2) by inserting ‘‘, in a machine-readable for-
mat, via open application program interfaces 
(APIs)’’ after ‘‘a list’’; 
(3) by inserting ‘‘, along with such additional 
information as the Secretary may require with re-
spect to such charges for purposes of promoting 
public awareness of hospital pricing in advance of 
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164 
receiving a hospital item or service’’ before the pe-
riod; and 
(4) by adding at the end the following: 
‘‘(2) DEFINITION
OF
STANDARD
CHARGES.— 
Notwithstanding any other provision of law, for pur-
poses of paragraph (1), the term ‘standard charges’ 
means the rates hospitals, including providers or en-
tities that contract with or practice at a hospital, 
charge for all items and services at a minimum, 
chargemaster rates, rates that hospitals negotiate 
with third party payers across all plans, including 
those related to a patient’s specific plan, discounted 
cash prices, and other rates determined by the Sec-
retary. 
‘‘(3) ENFORCEMENT.—In addition to any other 
enforcement actions or penalties that may apply 
under subsection (b)(3) or another provision of law, 
a hospital that fails to provide the information re-
quired by this subsection and has not completed a 
corrective action plan to comply with the require-
ments of such subsection shall be subject to a civil 
monetary penalty of an amount not to exceed $300 
per day that the violation is ongoing as determined 
by the Secretary. Such penalty shall be imposed and 
collected in the same manner as civil money pen-
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165 
alties under subsection (a) of section 1128A of the 
Social Security Act are imposed and collected.’’. 
(b) 
TRANSPARENCY
IN
COVERAGE.—Section 
1311(e)(3) of the Patient Protection and Affordable Care 
Act (42 U.S.C. 18031(e)(3)) is amended— 
(1) in subparagraph (A)— 
(A) in clause (vii), by inserting before the 
period the following: ‘‘, including, for all items 
and services covered under the plan, aggregate 
information on specific payments the plan has 
made to out-of-network health care providers on 
behalf of plan enrollees’’; 
(B) by designating clause (ix) as clause 
(x); and 
(C) by inserting after clause (viii), the fol-
lowing: 
‘‘(ix) Information on the specific nego-
tiated payment rates between the plan and 
health care providers for all items and 
services covered under the plan.’’; 
(2) in subparagraph (B)— 
(A) in the heading, by striking ‘‘USE’’ and 
inserting ‘‘DELIVERY METHODS AND USE’’; 
(B) by inserting ‘‘, as applicable,’’ after 
‘‘English proficiency’’; and 
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