On December 24, 2009, the Senate passed health reform legislation (the Patient Protection and Affordable Care Act, hereafter referred to as H.R. 3590 , or the Senate bill) that would, among other changes, make statutory changes affecting the regulation of and payment for certain types of private health insurance. On March 18, 2010, the House Rules Committee issued an amendment in the nature of a substitute to H.R. 4872 , the Health Care and Education Affordability Reconciliation Act of 2010 (hereafter referred to as the reconciliation bill). If passed, this reconciliation bill would amend H.R. 3590 . This report summarizes only the modifications in the reconciliation bill, as well as the affected provisions in Senate-passed H.R. 3590 . This report is a companion report to the one that describes all the private health insurance provisions in H.R. 3590 , CRS Report R40942, Private Health Insurance Provisions in Senate-Passed H.R. 3590, the Patient Protection and Affordable Care Act . On March 18, 2010, the Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) provided a preliminary estimate of the effect of the reconciliation bill. According to the CBO, the combined effect of H.R. 3590 and the changes from the reconciliation bill would reduce federal deficits by $138 billion over the 10-year period of 2010-2019, and by 2019 would insure 95% of the non-elderly, legally present U.S. population. In pointing out the provisions in the reconciliation bill with larger long-term fiscal impacts, the CBO said the following: Relative to H.R. 3590 , the reconciliation proposal would make a number of changes that would affect its longer-term impact on the budget. In particular, it would increase the subsidies offered in the new insurance exchanges and would reduce the impact of an excise tax on health insurance plans with premiums above certain thresholds. An important component of the longer-term analysis is that, beginning in 2019, the reconciliation proposal would change the annual indexing provisions so that the premium subsidies offered through the exchanges would grow more slowly; over time, the spending on exchange subsidies would therefore fall back toward the level under H.R. 3590 by itself. Senate-passed H.R. 3590 would implement several reforms to the individual and group markets prior to the start-up of the health insurance exchanges required by 2014. Among the immediate market reforms in H.R. 3590 are provisions that would do the following: Prohibit lifetime limits and restrict annual limits on essential health benefits by group health plans and health insurance issuers offering group or individual plans. Lifetime and annual limits refer to the establishment of a cap on the dollar value of benefits for any participant or beneficiary. This prohibition would not extend to covered benefits that are not essential health benefits under section 1302(b) of H.R. 3590 to the extent that such limits are otherwise permitted by federal and state law. The restriction on annual limits would be further defined by the Secretary, who would ensure that there is access to needed services available with minimal impact on premiums. Generally prohibit rescissions for a group health plan and a health insurance issuer offering group or individual health insurance coverage. A rescission generally refers to the practice of cancelling a health insurance policy after a plan member or policyholder has submitted medical claims. Rescissions would still be permitted in cases where the covered individual committed fraud or made an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage. Any cancellation of coverage in this case would require prior notice to the enrollee. Require a group health plan and a health insurance issuer offering coverage in the group or individual markets that provides dependent coverage of children to extend that coverage to unmarried adult children until the individual is 26 years old. A health plan or a health insurance issuer would not be required to make coverage available for a child of a child receiving dependent coverage. Under the reconciliation bill, the prohibition of lifetime limits, prohibition on rescissions, and the requirement to provide coverage for dependent children up to age 26 would also apply to the grandfathered plans starting six months after enactment. For adult dependent coverage, the requirement that the dependent not be married would be removed. There are also some amendments applicable specifically for grandfathered group health plans. The restriction on annual limits would begin six months after enactment. For coverage of dependent children prior to 2014, the requirement would be limited to those adult children without an employer offer of coverage. Under H.R. 3590 , most individuals would be required to maintain minimum essential coverage for themselves and their dependents. Minimum essential coverage includes coverage under public programs (e.g., Children's Health Insurance Program) and comprehensive coverage purchased from the private health insurance market, as specified in the bill. A person who is not in compliance with the individual mandate may be subject to a financial penalty based on either a percentage of household income or a flat dollar amount, whichever is greater. The penalty amount based on household income would be the product of household income multiplied by 0.5% in 2014, 1.0% in 2015, and 2% for each year thereafter. The annual flat dollar amount would be phased in—$95 in 2014, $495 in 2015, $750 in 2016 (adjusted for inflation thereafter), assessed for each taxpayer and any dependents. Other penalty rules would apply in the case of any dependents under the age of 18, and a family's penalty would be capped as specified in the bill. No penalty would be imposed on certain individuals if they meet specified criteria. One such individual would be a person whose household income does not exceed the federal poverty level (FPL). The reconciliation bill would make certain changes to the calculation of the penalties imposed on persons who are not in compliance with the individual mandate, and would modify a rule regarding the exemption from the individual mandate. For the non-compliance penalty based on percentage of income, the reconciliation bill would change the base income amount and percentages depending on the year. The base income amount would be the amount of household income that exceeds the personal exemption amount for the applicable tax year. The applicable percentages would be 1% in 2014, 2% in 2015, and 2.5% for each year thereafter. For the non-compliance penalty based on a flat dollar amount, the reconciliation bill changes the penalty amounts for 2015 and 2016: $325 and $695, respectively. This penalty would be adjusted for inflation (based on the 2016 amount) thereafter. The reconciliation bill would strike the exception to the non-compliance penalty for persons with income below the poverty line included in H.R. 3590 . Instead, the reconciliation bill would except from the non-compliance penalty individuals whose household income is less than the personal exemption amount for the applicable tax year. Under H.R. 3590 , all employers with more than 50 full-time employees (defined as employees working on average at least 30 hours per week and excluding seasonal workers) who did not provide coverage could be required to pay a penalty for certain employees, as well as employers who did provide access to coverage but fail to meet certain requirements. For applicable employers who (1) did not offer coverage and (2) had a full-time employee receive a premium credit for enrollment in an exchange plan, such employers would be assessed a penalty equal to the number of full-time employees times one-twelfth of $750, for any applicable month in 2014. After that year, the applicable payment amount would be indexed. For applicable employers who did offer coverage but had a full-time employee decline that coverage and instead receive a premium credit for enrollment in an exchange plan, such employers would be assessed an annual penalty equal to $3,000 ($250 per month) for each such employee in 2014. The penalty amounts would be indexed after 2014. The total annual penalty for an employer who did offer coverage would be limited to the total number of the firm's full-time employees times $750 ($62.50 per month). In addition, a fee would be imposed on applicable large employers that required extended waiting periods (over 60 days) before employees could enroll in a minimum essential coverage under an employer-sponsored plan. The reconciliation bill would make changes to how the employer penalties would be calculated, creating more similarity in penalties among employers who do offer coverage and those that do not offer coverage. The reconciliation bill also would include full-time equivalents in the counting of full-time employees, and strike the employer fee based on extended waiting periods. Solely for calculating either (1) the penalty for an employer who does not offer coverage with at least one full-time employee who received a premium credit, or (2) the overall limit on the total penalty imposed on an employer who offers coverage with at least one full-time employee who received a premium credit, the number of full-time employees would be reduced by 30 under the reconciliation bill. This reduction would apply only once under (1) or (2) for persons who are treated as 1 employer under the federal tax code. Furthermore, the reconciliation bill would remove the special rule for the construction industry, for purposes of determining whether or not they are a large employer. Under the reconciliation bill, those in the construction industry would be treated the same as other employers. Under the reconciliation bill, the monthly employer penalty in 2014 for an applicable employer who does not offer coverage with at least one full-time employee who received a premium credit would be the product of the number of full-time employees (minus 30 as described above) times one-twelfth of $2,000. The monthly penalty in 2014 for an applicable employer who offers coverage with at least one full-time employee who received a premium credit would be the product of the number of full-time employees who received such credits times one-twelfth of $3,000. Moreover, the reconciliation bill would limit the total penalty imposed on such an employer.