I 
116TH CONGRESS 
1ST SESSION H. R. 4159 
To amend the Health Insurance Portability and Accountability Act to ensure 
coverage for individuals with preexisting conditions, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
AUGUST 2, 2019 
Mr. RIGGLEMAN (for himself, Mrs. WAGNER, Mr. HUIZENGA, Mr. NEWHOUSE, 
and Ms. HERRERA BEUTLER) introduced the following bill; which was re-
ferred to the Committee on Energy and Commerce, and in addition to 
the Committees on Ways and Means, and Education and Labor, for a 
period to be subsequently determined by the Speaker, in each case for 
consideration of such provisions as fall within the jurisdiction of the com-
mittee concerned 
A BILL 
To amend the Health Insurance Portability and Account-
ability Act to ensure coverage for individuals with pre-
existing conditions, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Maintaining Protec-
tions for Patients with Preexisting Conditions Act of 
2019’’. 
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SEC. 2. 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 
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). 
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‘‘(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 
‘‘(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-
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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. 
‘‘(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-
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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 
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 
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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— 
‘‘(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 3 to 1 for adults; 
and 
‘‘(iv) tobacco use, except that such 
rate shall not vary by more than 1.5 to 1; 
and 
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‘‘(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-
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-
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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-
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). 
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‘‘(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- 
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 
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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 
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. 
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‘‘(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 
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 
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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-
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 
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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-
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, 
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‘‘(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-
motion or disease prevention (referred to in this 
subsection as a ‘wellness program’) shall be a 
program offered by an employer that is de-
signed to promote health or prevent disease 
that meets the applicable requirements of this 
subsection. 
‘‘(B) NO CONDITIONS BASED ON HEALTH 
STATUS FACTOR.—If none of the conditions for 
obtaining a premium discount or rebate or 
other reward for participation in a wellness pro-
gram is based on an individual satisfying a 
standard that is related to a health status fac-
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tor, such wellness program shall not violate this 
section if participation in the program is made 
available to all similarly situated individuals 
and the requirements of paragraph (2) are com-
plied with. 
‘‘(C) CONDITIONS BASED ON HEALTH STA-
TUS FACTOR.—If any of the conditions for ob-
taining a premium discount or rebate or other 
reward for participation in a wellness program 
is based on an individual satisfying a standard 
that is related to a health status factor, such 
wellness program shall not violate this section if 
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 
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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-
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 
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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. 
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-
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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. 
‘‘(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. 
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‘‘(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, 
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 
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