I 
115TH CONGRESS 
2D SESSION 
H. R. 6898 
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 
SEPTEMBER 26, 2018 
Mr. KNIGHT (for himself, Mr. HUIZENGA, Mr. CURTIS, Mr. DENHAM, Mrs. 
MIMI WALTERS of California, Mrs. WAGNER, Mr. BLUM, Mr. VALADAO, 
Ms. HERRERA BEUTLER, Mr. POLIQUIN, and Mr. RENACCI) introduced 
the following bill; which was referred to the Committee on Energy and 
Commerce, and in addition to the Committees on Ways and Means, and 
Education and the Workforce, 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 committee 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 
2018’’. 
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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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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 
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— 
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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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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 
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.— 
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‘‘(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 
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 
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‘‘(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.— 
‘‘(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. 
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‘‘(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)). 
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-
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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— 
‘‘(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). 
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‘‘(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-
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 
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‘‘(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 
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 
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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 
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 
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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. 
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 
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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-
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 
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‘‘(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 
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. 
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‘‘(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)— 
‘‘(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 
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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 
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 
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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 
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 
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‘‘(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 
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-
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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 
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.— 
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‘‘(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 
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)). 
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‘‘(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 
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 
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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 
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.— 
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