II 113th CONGRESS 2d Session H. R. 4414 IN THE SENATE OF THE UNITED STATES April 30, 2014 Received AN ACT To clarify the treatment under the Patient Protection and Affordable Care Act of health plans in which expatriates are the primary enrollees, and for other purposes.

1. Short title This Act may be cited as the Expatriate Health Coverage Clarification Act of 2014 . 2. Treatment of expatriate health plans under ACA (a) In general Subject to subsection (b), the provisions of (including any amendment made by) the Patient Protection and Affordable Care Act ( Public Law 111–148 ) and of title I and subtitle B of title II of the Health Care and Education Reconciliation Act of 2010 ( Public Law 111–152 ) shall not apply with respect to— (1) expatriate health plans; (2) employers with respect to any such plans for which such employers are acting as plan sponsors; or (3) expatriate health insurance issuers with respect to coverage offered by such issuers under such plans. (b) Minimum essential coverage and eligible employer-Sponsored plan For purposes of section 5000A(f) of the Internal Revenue Code of 1986, and any other section of the Internal Revenue Code of 1986 that incorporates the definition of minimum essential coverage provided under such section 5000A(f) by reference, coverage under an expatriate health plan shall be deemed to be minimum essential coverage under an eligible employer-sponsored plan as defined in paragraph (2) of such section. (c) Qualified expatriates and dependents not United States health risk (1) In general For purposes of section 9010 of the Patient Protection and Affordable Care Act ( 26 U.S.C. 4001 note prec.), for calendar years after 2014, a qualified expatriate (and any dependent of such individual) enrolled in an expatriate health plan shall not be considered a United States health risk. (2) Special rule for 2014 The fee under section 9010 of such Act for calendar year 2014 with respect to any expatriate health insurance issuer shall be the amount which bears the same ratio to the fee amount determined by the Secretary of the Treasury with respect to such issuer under such section for such year (determined without regard to this paragraph) as— (A) the amount of premiums taken into account under such section with respect to such issuer for such year, less the amount of premiums for expatriate health plans taken into account under such section with respect to such issuer for such year, bears to (B) the amount of premiums taken into account under such section with respect to such issuer for such year. (d) Definitions In this section: (1) Expatriate health insurance issuer The term expatriate health insurance issuer means a health insurance issuer that issues expatriate health plans. (2) Expatriate health plan The term expatriate health plan means a group health plan, health insurance coverage offered in connection with a group health plan, or health insurance coverage offered to a group of individuals described in paragraph (3)(B) (which may include dependents of such individuals) that meets each of the following standards: (A) Substantially all of the primary enrollees in such plan or coverage are qualified expatriates, with respect to such plan or coverage. In applying the previous sentence, an individual shall not be taken into account as a primary enrollee if the individual is not a national of the United States and resides in the country of which the individual is a citizen. (B) Substantially all of the benefits provided under the plan or coverage are not excepted benefits described in section 9832(c) of the Internal Revenue Code of 1986. (C) The plan or coverage provides benefits for items and services, in excess of emergency care, furnished by health care providers— (i) in the case of individuals described in paragraph (3)(A), in the country or countries in which the individual is present in connection with the individual’s employment, and such other country or countries as the Secretary of Health and Human Services, in consultation with the Secretary of the Treasury and the Secretary of Labor, may designate; or (ii) in the case of individuals described in paragraph (3)(B), in the country or countries as the Secretary of Health and Human Services, in consultation with the Secretary of the Treasury and the Secretary of Labor, may designate. (D) In the case of an expatriate health plan that is a group health plan offered by a plan sponsor that— (i) also offers a qualifying minimum value domestic group health plan, the plan sponsor reasonably believes that the benefits provided by the expatriate health plan are actuarially similar to, or better than, the benefits provided under a qualifying minimum value domestic group health plan offered by that plan sponsor; or (ii) does not also offer a qualifying minimum value domestic group health plan, the plan sponsor reasonably believes that the benefits provided by the expatriate health plan are actuarially similar to, or better than, the benefits provided under a qualifying minimum value domestic group health plan. (E) If the plan or coverage provides dependent coverage of children, the plan or coverage makes such dependent coverage available for adult children until the adult child turns 26 years of age, unless such individual is the child of a child receiving dependent coverage. (F) The plan or coverage— (i) is issued by an expatriate health plan issuer, or administered by an administrator, that maintains, with respect to such plan or coverage— (I) network provider agreements with health care providers that are outside of the United States; and (II) call centers in more than one country and accepts calls from customers in multiple languages; and (ii) offers reimbursements for items or services under such plan or coverage in more than two currencies. (G) The plan or coverage, and the plan sponsor or expatriate health insurance issuer with respect to such plan or coverage, satisfies the provisions of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg et seq. ), chapter 100 of the Internal Revenue Code of 1986, and part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1181 et seq. ), which would otherwise apply to such a plan or coverage, and sponsor or issuer, if not for the enactment of the Patient Protection and Affordable Care Act and title I and subtitle B of title II of the Health Care and Education Reconciliation Act of 2010. (3) Qualified expatriate The term qualified expatriate means any of the following individuals: (A) Workers An individual who is a participant in a group health plan, who is an alien residing outside the United States, a national of the United States, lawful permanent resident, or nonimmigrant for whom there is a good faith expectation by the plan sponsor of the plan that, in connection with the individual’s employment, the individual is abroad for a total of not less than 180 days during any period of 12 consecutive months. (B) Other individuals abroad An individual, such as a student or religious missionary, who is abroad, and who is a member of a group determined appropriate by the Secretary of Health and Human Services, in consultation with the Secretary of the Treasury and the Secretary of Labor. (4) Qualifying minimum value domestic group health plan The term qualifying minimum value domestic group health plan means a group health plan that is offered in the United States that meets the following requirements: (A) Substantially all of the primary enrollees in the plan are not qualified expatriates, with respect to such plan. (B) Substantially all of the benefits provided under the plan are not excepted benefits described in section 9832(c) of the Internal Revenue Code of 1986. (C) The application of section 36B(c)(2)(C)(ii) of such Code to such plan would not prevent an employee eligible for coverage under such plan from being treated as eligible for minimum essential coverage for purposes of section 36B(c)(2)(B) of such Code. (5) Abroad (A) United States Nationals (i) In general Except as provided in clause (ii), for purposes of applying paragraph (3) to a national of the United States, the term abroad means outside the 50 States, the District of Columbia, and Puerto Rico. (ii) Special rule For purposes of applying paragraph (3) to a national of the United States who resides in the United States Virgin Islands, the Commonwealth of the Northern Mariana Islands, American Samoa, or Guam, the term abroad means outside of the 50 States, the District of Columbia, Puerto Rico, and such territory or possession. (B) Foreign citizens For purposes of applying paragraph (3) to an individual who is not a national of the United States, the term abroad means outside of the country of which that individual is a citizen. (6) United States The term United States means the 50 States, the District of Columbia, Puerto Rico, the United States Virgin Islands, the Commonwealth of the Northern Mariana Islands, American Samoa, and Guam. (7) Miscellaneous terms (A) Group health plan; health insurance coverage; health insurance issuer; plan sponsor The terms group health plan , health insurance coverage , health insurance issuer , and plan sponsor have the meanings given those terms in section 2791 of the Public Health Service Act (42 U.S.C. 300gg–91), except that in applying such terms under this section the term health insurance issuer includes a foreign corporation which is predominantly engaged in an insurance business and which would be subject to tax under subchapter L of chapter 1 of the Internal Revenue Code of 1986 if it were a domestic corporation. (B) Foreign state; national of the United States; nonimmigrant; reside; lawful permanent resident The terms national of the United States , and nonimmigrant have the meaning given such terms in section 101(a) of the Immigration and Nationality Act (8 U.S.C. 1101(a)), the term reside means having a residence (within the meaning of such term in such section), and the term lawful permanent resident means an alien lawfully admitted for permanent residence (as defined in such section).

Passed the House of Representatives April 29, 2014. Karen L. Haas, Clerk