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Restoring Equity, Saving Coverage, and Undoing Errors Act of 2015

H.R. 2650 · 114th Congress · Jun 4, 2015 · Lineage

A BILL

To restore equity, save coverage, and undo errors in the case of individuals who lose health insurance subsidies under King v. Burwell, and other individuals, and for other purposes.

Section 1 Short title; table of contents; contingency and limitation on application

(a)
Short title— This Act may be cited as the “Restoring Equity, Saving Coverage, and Undoing Errors Act of 2015” or as the “RESCUE America’s Health Care Act of 2015”.
(b)
Table of contents— The table of contents of this Act is as follows:
(c)
Contingency and limitation on application—
(1)
Dependent upon Supreme Court determination in King v. Burwell— The succeeding provisions of this Act (including the amendments made by this Act) shall only apply if the Supreme Court determines that the premium tax credit under section 36B of the Internal Revenue Code of 1986 is not available to individuals who are enrolled in a qualified health plan offered through the federally operated Exchange established pursuant to section 1321(c) of the Patient Protection and Affordable Care Act (42 U.S.C. 18041(c)).
(2)
Application in States without a State-operated Exchange— In the case of a State that has not established an Exchange under section 1311 of the Patient Protection and Affordable Care Act (42 U.S.C. 18031) for which a premium tax credit is available pursuant to section 36B(b)(1)(A) of the Internal Revenue Code of 1986, as interpreted by the Supreme Court, the succeeding provisions of this Act (including the amendments made by this Act) shall apply, subject to paragraphs (1) and (4), to the State and to individuals residing in the State as of the date on which such credit becomes no longer available to such individuals pursuant to the Supreme Court determination described in paragraph (1) (such date referred to in this Act as the “King v. Burwell effective date”) .
(3)
Option of application in States with a State-operated Exchange— In the case of a State that has established an Exchange under section 1311 of the Patient Protection and Affordable Care Act (42 U.S.C. 18031) for which a premium tax credit is available pursuant to section 36B(b)(1)(A) of the Internal Revenue Code of 1986, as interpreted by the Supreme Court—
(A)
the State may at any time terminate operation of such Exchange; and
(B)
if the State terminates operation of any such Exchange established under such section 1311, the provisions of this Act (including the amendments made by this Act) shall apply, subject to paragraphs (1) and (4), to the State and to individuals residing in the State as of the date on which the operation of such Exchange is terminated, but in no case shall such provisions and amendments apply earlier than the King v. Burwell effective date.
(4)
No application to States with an Exchange for which premium credit is available— The succeeding provisions of this Act (including the amendments made by this Act) shall not apply to a State and to individuals residing in a State so long as there is operating in the State an Exchange for which a premium tax credit is available pursuant to section 36B(b)(1)(A) of the Internal Revenue Code of 1986 to such individuals, as interpreted by the Supreme Court.

Sec. 2 Refundable tax credit for health insurance coverage

(a)
In general— Subpart C of part IV of subchapter A of chapter 1 of the Internal Revenue Code of 1986 is amended by inserting after section 36B the following new section:

“36C. Health insurance coverage

“(a) In general—In the case of an individual, there shall be allowed as a credit against the tax imposed by subtitle A the aggregate monthly credit amounts determined under subsection (b) with respect to the taxpayer and the taxpayer’s qualifying family members for eligible coverage months beginning during the taxable year.

“(b) Monthly credit amounts

“(1) In general—The monthly credit amount with respect to any individual for any eligible coverage month is 1/12 of—

“(A) $900 in the case of an individual who has not attained age 18 as of the beginning of such month,

“(B) $1,200 in the case of an individual who has so attained age 18 but who has not so attained age 35,

“(C) $2,100 in the case of an individual who has so attained age 35, but who has not so attained age 50, and

“(D) $3,000 in the case of an individual who has so attained age 50.

“(2) Inflation adjustment—In the case of any taxable year beginning in a calendar year after 2016, each dollar amount contained in paragraph (1) shall be increased by an amount equal to—

“(A) such dollar amount, multiplied by

“(B) the cost-of-living adjustment determined under section 1(f)(3) for the calendar year in which the taxable year begins, determined by substituting “calendar year 2015” for “calendar year 1992” in subparagraph (B) thereof.

“(c) Eligible coverage month—For purposes of this section, the term eligible coverage month means, with respect to any individual, any month if, as of the first day of such month, the individual—

“(1) is covered by qualified health insurance,

“(2) does not have other specified coverage, and

“(3) is not imprisoned under Federal, State, or local authority.

“(d) Qualifying family member—For purposes of this section, the term qualifying family member means—

“(1) in the case of a joint return, the taxpayer’s spouse, and

“(2) any dependent of the taxpayer.

“(e) Qualified health insurance—For purposes of this section, the term qualified health insurance means health insurance coverage (other than excepted benefits as defined in section 9832(c)) which constitutes medical care.

“(f) Other specified coverage—For purposes of this section, an individual has other specified coverage for any month if, as of the first day of such month—

“(1) Coverage under Medicare, Medicaid, or SCHIP—Such individual—

“(A) is entitled to benefits under part A of title XVIII of the Social Security Act or is enrolled under part B of such title, or

“(B) is enrolled in the program under title XIX or XXI of such Act (other than under section 1928 of such Act).

“(2) Certain other coverage—Such individual—

“(A) is enrolled in a health benefits plan under chapter 89 of title 5, United States Code,

“(B) is entitled to receive benefits under chapter 55 of title 10, United States Code,

“(C) is entitled to receive benefits under chapter 17 of title 38, United States Code,

“(D) is enrolled in a group health plan (within the meaning of section 5000(b)(1)) which is subsidized by the employer, or

“(E) is a member of a health care sharing ministry.

“(3) Health care sharing ministry—For purposes of this subsection, the term health care sharing ministry means an organization—

“(A) which is described in section 501(c)(3) and is exempt from taxation under section 501(a),

“(B) members of which share a common set of ethical or religious beliefs and share medical expenses among members in accordance with those beliefs and without regard to the State in which a member resides or is employed,

“(C) members of which retain membership even after they develop a medical condition,

“(D) which (or a predecessor of which) has been in existence at all times since December 31, 1999, and medical expenses of its members have been shared continuously and without interruption since at least December 31, 1999, and

“(E) which conducts an annual audit which is performed by an independent certified public accounting firm in accordance with generally accepted accounting principles and which is made available to the public upon request.

“(g) Special rules

“(1) Credit in excess of premiums only payable to a health savings account

“(A) In general—If the credit allowed under subsection (a) (determined without regard to clause (ii)) for any taxable year exceeds the amount of premiums paid by the taxpayer for coverage of the taxpayer and the taxpayer’s qualifying family members under qualified health insurance for eligible coverage months beginning in the taxable year—

“(i) at the request of the taxpayer, the Secretary shall pay the amount of such excess to one or more health savings accounts of the taxpayer or of any qualifying family member of the taxpayer, and

“(ii) the credit allowed under subsection (a) for such taxable year shall not exceed the amount of such premiums.

“(B) Medical and health savings accounts—Amounts distributed from an Archer MSA (as defined in section 220(d)) or from a health savings account (as defined in section 223(d)) shall not be taken into account as premiums paid under subparagraph (A).

“(C) Insurance which covers other individuals—For purposes of this paragraph, rules similar to the rules of section 213(d)(6) shall apply with respect to any contract for qualified health insurance under which amounts are payable for coverage of an individual other than the taxpayer and qualifying family members.

“(D) Contributions treated as rollovers, etc

“(i) In general—Any amount paid the Secretary to a health savings account under this paragraph shall be treated for purposes of this title in the same manner as a rollover contribution described in section 223(f)(5).

“(ii) Coordination with limitation on rollovers—Any amount described in clause (i) shall not be taken into account in applying section 223(f)(5)(B) with respect to any other amount and the limitation of section 223(f)(5)(B) shall not apply with respect to the application of clause (i).

“(iii) Establishment of HSAs—Nothing in any provision of law shall be construed—

“(I) to prevent an individual from establishing a health savings account (as defined in section 223(d)) merely because such individual is not an eligible individual (as defined in section 223(c)), or

“(II) to prevent such an account from being treated as a health savings account merely because all or a substantial portion of the contributions to such account are described in this paragraph.

“(2) Coordination with advance payments of credit—With respect to any taxable year—

“(A) the amount which would (but for this subsection) be allowed as a credit to the taxpayer under subsection (a) shall be reduced (but not below zero) by the aggregate amount paid on behalf of such taxpayer under section 7529 for months beginning in such taxable year, and

“(B) the tax imposed by section 1 for such taxable year shall be increased by the excess (if any) of—

“(i) the aggregate amount paid on behalf of such taxpayer under section 7529 for months beginning in such taxable year, over

“(ii) the amount which would (but for this subsection) be allowed as a credit to the taxpayer under subsection (a).

“(3) Coordination with other provisions—For purposes of any deduction allowed under section 162(l), 213, or 224, and any credit allowed under section 35, any health insurance premiums which would (but for this paragraph) be taken into account shall be reduced (but not below zero) by the amount of the credit allowed under this section (determined without regard to paragraphs (1) and (2) of this subsection).

“(4) Denial of credit to dependents and nonpermanent resident alien individuals—No credit shall be allowed under this section to any individual who is—

“(A) not a citizen or lawful permanent resident of the United States for the calendar year in which the taxable year begins, or

“(B) a dependent with respect to another taxpayer for a taxable year beginning in the calendar year in which such individual’s taxable year begins.

“(5) Regulations—The Secretary may prescribe such regulations and other guidance as may be necessary or appropriate to carry out this section, section 6050W, and section 7529.”

(b)
Advance payment of credit—
(1)
In general— Chapter 77 of the Internal Revenue Code of 1986 (relating to miscellaneous provisions) is amended by adding at the end the following:

“7529. Advance payment of credit for health insurance coverage

“(a) General rule—Not later than January 1, 2016, the Secretary shall establish a program for making payments to providers of qualified health insurance (as defined in section 36C(e)) on behalf of taxpayers eligible for the credit under section 36C.

“(b) Limitation—The aggregate payments made under this section with respect to any taxpayer, determined as of any time during any calendar year, shall not exceed the monthly credit amounts determined with respect to such taxpayer under section 36C for months during such calendar year which have ended as of such time.

“(c) Application of rule that credits in excess of premiums only payable to a health savings account—Under rules similar to the rules of section 36C(g)(1), any amount otherwise payable on behalf of the taxpayer under subsection (a) with respect to any eligible coverage month which is in excess of the amount of premiums paid by the taxpayer for coverage of the taxpayer and the taxpayer’s qualifying family members under qualified health insurance for such month shall be payable only to one or more health savings accounts of the taxpayer or of any qualifying family member of the taxpayer.

“(d) Certification process and proof of coverage—The Secretary shall establish a process under which individuals are certified as eligible for payment under this section. Such process shall include an initial application by the taxpayer to determine eligibility and thereafter continued eligibility shall be determined, to the maximum extent feasible, by the Secretary on the basis of information provided under section 6050X.

“(e) Definitions—For purposes of this section, terms used in this section which are also used in section 36C shall have the same meaning as when used in section 36C.”

(2)
Information reporting—
(A)
In general— Subpart B of part III of subchapter A of chapter 61 of such Code (relating to information concerning transactions with other persons) is amended by adding at the end the following new section:

“6050X. Returns relating to credit for health insurance coverage

“(a) Requirement of reporting—Every person who provides qualified health insurance for any month of any calendar year with respect to any individual shall, at such time as the Secretary may prescribe, make the return described in subsection (b) with respect to each such individual. With respect to any individual with respect to whom payments under section 7529 are made by the Secretary, the Secretary may require that reporting under subsection (b) be made on a monthly basis.

“(b) Form and manner of returns—A return is described in this subsection if such return—

“(1) is in such form as the Secretary may prescribe, and

“(2) contains, with respect to each policy of qualified health insurance—

“(A) the name, address, and TIN of each individual covered under such policy,

“(B) the premiums paid with respect to such policy, and

“(C) such other information as the Secretary may prescribe.

“(c) Statements To Be Furnished to Individuals With Respect to Whom Information Is Required—Every person required to make a return under subsection (a) shall furnish to each individual whose name is required to be set forth in such return a written statement showing—

“(1) the name and address of the person required to make such return and the phone number of the information contact for such person, and

“(2) the information required to be shown on the return with respect to such individual.

“(d) Definitions—For purposes of this section, terms used in this section which are also used in section 36C shall have the same meaning as when used in section 36C.”

(B)
Assessable penalties—
(i)
Subparagraph (B) of section 6724(d)(1) of such Code is amended by striking “or” at the end of clause (xxiv), by striking “and” at the end of clause (xxv) and inserting “or”, and by inserting after clause (xxv) the following new clause:

“(xxvi) section 6050X (relating to returns relating to credit for health insurance coverage), and”

(ii)
Paragraph (2) of section 6724(d) of such Code is amended by striking “or” at the end of subparagraph (GG), by striking the period at the end of subparagraph (HH) and inserting “, or”, and by adding after subparagraph (HH) the following new subparagraph:

“(II) section 6050X (relating to returns relating to credit for health insurance coverage).”

(3)
Disclosure of return information for purposes of advance payment of credit as premiums for qualified health insurance—
(A)
In general— Subsection (l) of section 6103 of such Code is amended by adding at the end the following new paragraph:

“(23) Disclosure of return information related to payments of the health insurance coverage credit—The Secretary may, on behalf of taxpayers eligible for the credit under section 36C, disclose to a provider of qualified health insurance (as defined in section 36(e)) or a trustee of a health savings account (and persons acting on behalf of such provider or such trustee), return information with respect to any such taxpayer only to the extent necessary (as prescribed by regulations issued by the Secretary) to carry out sections 36C(g)(1) (relating to credit in excess of premiums only payable to a health savings account) and 7529 (relating to advance payment of credit for health insurance coverage).”

(B)
Confidentiality of information— Paragraph (3) of section 6103(a) of such Code is amended by striking “or (21)” and inserting “(21), or (22)”.
(C)
Unauthorized disclosure— Paragraph (2) of section 7213(a) of such Code is amended by striking “or (21)” and inserting “(21), or (22)”.
(4)
Effective date— Subject to section 1(c), the amendments made by this section shall take effect on the date of the enactment of this Act.
(c)
Conforming amendments—
(1)
Paragraph (2) of section 1324(b) of title 31, United States Code, is amended by inserting “36C,” after “36B,”.
(2)
The table of sections for subpart C of part IV of subchapter A of chapter 1 of the Internal Revenue Code of 1986 is amended by inserting after the item relating to section 36B the following new item:
(3)
The table of sections for subpart B of part III of subchapter A of chapter 61 of such Code is amended by adding at the end the following new item:
(4)
The table of sections for chapter 77 of such Code is amended by adding at the end the following new item:
(d)
Effective date— Subject to section 1(c), the amendments made by this section shall apply with respect to coverage months beginning on or after the King v. Burwell effective date.

Sec. 3 Restoring to States the freedom and flexibility to regulate health insurance markets

(a)
Elimination of PPACA restrictions on the insurance market— Any provision of title I of the Patient Protection and Affordable Care Act (Public Law 111–148) or of the Health Care and Education Reconciliation Act of 2010 (Public Law 111–152) amending title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.), or amending the Internal Revenue Code of 1986 or the Employee Retirement Income Security Act of 1974 in order to incorporate or apply such an amendment to such title XXVII, is repealed and the provisions of law amended by such provisions of title I of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 are restored or revived as if such title and Act had not been enacted.
(b)
HSAs and FSAs— Any provision of, or amendment made by, the Patient Protection and Affordable Care Act (Public Law 111–148) or the Health Care and Education Reconciliation Act of 2010 (Public Law 111–152) applying a requirement or restriction on a health savings account (within the meaning of section 223(d) of the Internal Revenue Code of 1986) or a health flexible spending arrangement (within the meaning of section 106(c) of the Internal Revenue Code of 1986) is repealed and the provisions of law amended by such provisions of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 are restored or revived as if such Acts had not been enacted.
(c)
Expanded Health Plan Selection—
(1)
In general— Section 1301(a)(1) of the Patient Protection and Affordable Care Act (42 U.S.C. 18021(a)(1)) is amended by striking “a health plan that” and all that follows through the period at the end and inserting “any health plan (as defined in subsection (b)).”.
(2)
Direct primary care medical home plans— Section 1301(a)(3) of such Act (42 U.S.C. 18021(a)(3)) is amended by striking “medical home plan that meets criteria” and all that follows through the period at the end and inserting “medical home plan.” .
(3)
Stand-alone dental benefits— Section 1311(d)(2)(B)(ii) of such Act (42 U.S.C. 18031(d)(2)(B)(ii)) is amended by striking “health plan) if the plan” and all that follows through the period at the end and inserting “health plan).” .
(4)
Conforming amendments— The following provisions of the Patient Protection and Affordable Care Act (Public Law 111–148) shall have no force or effect after the date of the enactment of this Act:
(A)
Section 1301(b)(1)(B) of such Act (42 U.S.C. 18021(b)(1)(B)).
(B)
Paragraphs (1), (2), and (6) of section 1311(c) of such Act (42 U.S.C. 18031(c)).
(C)
Section 1311(d)(4)(A) of such Act (42 U.S.C. 18031(d)(4)(A)).
(D)
Section 1311(e) of such Act (42 U.S.C. 18031(e)).
(E)
Section 1311(j) of such Act (42 U.S.C. 18031(j)).
(F)
Subparagraphs (B) and (D) of section 1321(a)(1) of such Act (42 U.S.C. 18041(a)(1)).

Sec. 4 Pool reform for individual membership expansion

The Public Health Service Act is further amended by adding at the end the following:

“XXXIV Pool Reform for Individual Membership Expansion

“3400. Purpose

“The purpose of this title is to provide, through the establishment of individual health pools (or IHPs), for the reform of, and expansion of enrollment in, health insurance coverage for individuals and small employers.

“3401. Definition of individual health pool (IHP)

“(a) In general—For purposes of this title, the terms individual health pool and IHP mean a legal nonprofit entity that meets the following requirements:

“(1) Organization—The IHP—

“(A) has been formed and maintained in good faith for a purpose that includes the formation of a risk pool in order to offer health insurance coverage to its members;

“(B) does not condition membership in the IHP on any health status-related factor relating to an individual (including an employee of an employer or a dependent of an employee);

“(C) does not make health insurance coverage offered through the IHP available other than in connection with a member of the IHP;

“(D) is not a health insurance issuer; and

“(E) does not receive any consideration directly or indirectly from any health insurance issuer in connection with the enrollment of any individuals, or employees of employers, in any health insurance coverage, except in conjunction with services offered through the IHP.

“(2) Offering health benefits coverage

“(A) Different groups—The IHP, in conjunction with those health insurance issuers that offer health benefits coverage through the IHP, makes available health benefits coverage in the manner described in subsection (b) to all members of the IHP and the dependents of such members (and, in the case of small employers, employees and their dependents) in the manner described in subsection (c)(2) at rates that are established by the health insurance issuer on a policy or product specific basis and that may vary for individuals covered through an IHP.

“(B) Nondiscrimination in coverage offered

“(i) In general—Subject to clause (ii), the IHP may not offer health benefits coverage to a member of an IHP unless the same coverage is offered to all such members of the IHP.

“(ii) Construction—Nothing in this title shall be construed as requiring or permitting a health insurance issuer to provide coverage outside the service area of the issuer, as approved under State law, or preventing a health insurance issuer from underwriting or from excluding or limiting the coverage on any individual, subject to the requirement of section 2741 (relating to guaranteed availability of individual health insurance coverage to certain individuals with prior group coverage).

“(C) No assumption of insurance risk by IHP—The IHP provides health benefits coverage only through contracts with health insurance issuers and does not assume insurance risk with respect to such coverage.

“(3) Geographic areas—Nothing in this title shall be construed as preventing the establishment and operation of more than one IHP in a geographic area or as limiting the number of IHPs that may operate in any area.

“(4) Provision of administrative services to purchasers—The IHP may provide administrative services for members. Such services may include accounting, billing, and enrollment information.

“(b) Health benefits coverage requirements

“(1) Compliance with consumer protection requirements—Except as provided in section 3402, any health benefits coverage offered through an IHP—

“(A) shall be issued by a health insurance issuer that meets all applicable State standards relating to consumer protection;

“(B) shall be approved or otherwise permitted to be offered under State law; and

“(C) may not impose any exclusion of a specific disease from such coverage.

“(2) Wellness bonuses for health promotion—Nothing in this title shall be construed as precluding a health insurance issuer offering health benefits coverage through an IHP from establishing premium discounts or rebates for members or from modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention so long as such programs are agreed to in advance by the IHP and comply with all other provisions of this title and do not discriminate among similarly situated members.

“(c) Members; health insurance issuers

“(1) Members

“(A) In general—Under rules established to carry out this title, with respect to an individual or small employer who is a member of an IHP, the individual may enroll for health benefits coverage (including coverage for dependents of such individual) or employer may enroll employees for health benefits coverage (including coverage for dependents of such employees) offered by a health insurance issuer through the IHP.

“(B) Rules for enrollment—Nothing in this paragraph shall preclude an IHP from establishing rules of enrollment and reenrollment of members. Such rules shall be applied consistently to all members within the IHP and shall not be based in any manner on health status-related factors.

“(2) Health insurance issuers—The contract between an IHP and a health insurance issuer shall provide, with respect to a member enrolled with health benefits coverage offered by the issuer through the IHP, for the payment to the issuer of the premiums (if any) collected by the IHP for health insurance coverage offered by the issuer.

“3402. Application of certain laws and requirements

“(a) Preemption of State laws restricting formation of IHPs—Any State law or regulation relating to the composition or organization of an IHP is preempted to the extent the law or regulation is inconsistent with the provisions of this title.

“(b) Preemption of State requirements relating to health benefit coverage

“(1) Benefit requirements

“(A) In general—Subject to subparagraph (B), State laws are superseded, and shall not apply to health benefits coverage made available through an IHP, insofar as such laws impose benefit requirements for such coverage, including (but not limited to) requirements relating to coverage of specific providers, specific services or conditions, or the amount, duration, or scope of benefits.

“(B) Exception for federally imposed requirements and for requirements prohibiting disease-specific exclusions—Subparagraph (A) shall not apply to a requirement to the extent the requirement—

“(i) implements title XXVII or other Federal law; or

“(ii) prohibits imposition of an exclusion of a specific disease from health benefits coverage.

“(2) Other requirements preventing offering of coverage through an IHP—State laws are superseded, and shall not apply to health benefits coverage made available through an IHP, insofar as such laws impose any other requirements (including limitations on compensation arrangements) that, directly or indirectly, preclude (or have the effect of precluding) the offering of such coverage through an IHP, if the IHP meets the requirements of this title.

“(c) Preemption of State premium rating requirements—State laws are superseded, and shall not apply to the premiums imposed for health benefits coverage made available through an IHP, insofar as such laws impose restrictions on the variation of premiums among such coverage offered to members of the IHP.

“3403. Definitions

“For purposes of this title:

“(1) Dependent—The term dependent, as applied to health insurance coverage offered by a health insurance issuer licensed (or otherwise regulated) in a State, shall have the meaning applied to such term with respect to such coverage under the laws of the State relating to such coverage and such an issuer. Such term may include the spouse and children of the individual involved.

“(2) Health benefits coverage—The term health benefits coverage has the meaning given the term health insurance coverage in section 2791(b)(1), and does not include excepted benefits (as defined in section 2791(c)).

“(3) Health insurance issuer—The term health insurance issuer has the meaning given such term in section 2791(b)(2).

“(4) Health status-related factor—The term health status-related factor has the meaning given such term in section 2791(d)(9).

“(5) Member—The term member means, with respect to an IHP, an individual or small employer who is a member of the legal entity described in section 3401(a)(1) to which the IHP is offering coverage.

“(6) Small employer—The term small employer has the meaning given such term in section 712(c)(1)(B) of the Employee Retirement and Income Security Act of 1974.”

Sec. 5 Requirements for individual health insurance

(a)
In general— Section 2741 of the Public Health Service Act (42 U.S.C. 300gg–41), as restored and revived by section 3 of this Act, is amended—
(1)
in subsection (a)—
(A)
in the heading, by striking “to certain individuals with prior group coverage”;
(B)
in paragraph (1), by striking “and section 2744”;
(C)
in paragraph (1)(B), by inserting “unless such exclusion complies with paragraph (2)” before the period; and
(D)
by striking paragraph (2) and inserting the following new paragraphs:

“(2) Limitation on preexisting condition exclusion period

“(A) Limitation—A health insurance issuer offering health insurance coverage in the individual market may not, with respect to an enrollee in such coverage, impose any preexisting condition exclusion if such enrollee has at least 18 months of continuous creditable coverage (as defined in section 2701(c)(1)) immediately preceding the enrollment date.

“(B) Imposition of exclusion—Notwithstanding paragraph (1)(B), a health insurance issuer offering health insurance coverage in the individual market may, with respect to an enrollee in such coverage who is not described in subparagraph (A), impose a preexisting condition exclusion only if—

“(i) such exclusion relates to a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on the enrollment date;

“(ii) such exclusion extends for a period of not more than 18 months after the enrollment date; and

“(iii) the period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage (if any, as defined in section 2701(c)(1)) applicable to the enrollee as of the enrollment date.

“(C) Premium surcharge—Notwithstanding paragraph (6), with respect to an enrollee described in subparagraph (B), a health insurance issuer may charge a premium for the coverage involved that does not exceed 150 percent of the applicable standard rate, for not to exceed 24 months (or 36 months if the health insurance issuer does not impose any preexisting condition exclusion with respect to such enrollee), reduced by the aggregate of the periods of creditable coverage (if any, as defined in section 2701(c)(1)) applicable to the enrollee as of the enrollment date. For purposes of this subsection, the term applicable standard rate means the standard premium rate that the issuer charges for the coverage involved with respect to an individual described in subparagraph (A) with the same rating characteristics or rating factors as the enrollee described in subparagraph (B), provided that any variations in standard premium rates are based on the uniform application of rating characteristics or rating factors that are permitted by State law and are not otherwise prohibited by paragraph (6).

“(3) Exceptions—Notwithstanding paragraph (2), and subject to subparagraph (D), a health insurance issuer offering health insurance coverage in the individual market, may not impose any of the following preexisting condition exclusions:

“(A) Exclusion not applicable to certain newborns—In the case of an individual who, as of the last day of the 30-day period beginning with the date of birth, is a dependent of an enrollee in such coverage.

“(B) Exclusion not applicable to certain adopted children—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 a dependent of an enrollee in such coverage. The previous sentence shall not apply to coverage before the date of such adoption or placement for adoption.

“(C) Exclusion not applicable to pregnancy—Relating to pregnancy as a preexisting condition.

“(D) Loss if break in coverage—Subparagraphs (A) and (B) shall no longer apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any creditable coverage.

“(4) Open enrollment periods—A health insurance issuer offering health insurance coverage in the individual market may limit the applicability of the provisions of paragraph (1) to scheduled open enrollment periods, provided that—

“(A) any such open enrollment period shall not be less than 30 days;

“(B) any period between scheduled open enrollment periods shall not exceed 24 months; and

“(C) such limitation shall not apply to any individual who qualifies for a special enrollment period under paragraph (5).

“(5) Special enrollment periods—Subject to subparagraphs (E) and (F), a health insurance issuer offering health insurance coverage in the individual market shall permit an individual who is an eligible individual or a dependent to enroll in coverage during a special enrollment period if the individual experiences any of the following qualifying events:

“(A) For dependent beneficiaries—The individual becomes, by reason of marriage, birth, adoption or placement for adoption, a dependent of an individual enrolled in a plan offered by the health insurance issuer and such individual otherwise qualifies, under the terms of the plan, as eligible for coverage as a dependent of such enrollee.

“(B) Loss of group coverage—The individual loses coverage under a group health plan as a result of—

“(i) loss of eligibility for the coverage (including as a result of legal separation, divorce, death, attaining an age at which eligibility terminates, termination of employment, or reduction in the number of hours of employment); or

“(ii) termination of the coverage by the plan sponsor.

“(C) Loss of individual coverage—The individual loses individual market coverage as a result of—

“(i) discontinuation of a plan as a result of a health insurance issuer ceasing to offer coverage in the individual market in accordance with section 2742(c)(2) (42 U.S.C. 300gg–42(c)(2)) of this title;

“(ii) expiration of COBRA, or other, continuation coverage;

“(iii) ceasing to qualify, under the terms of the coverage, as a dependent (including as a result of legal separation, divorce, death, or attaining an age at which eligibility terminates); and

“(iv) permanently moving outside the State in which the coverage was issued, or in the case of a network plan, outside the plan’s service area.

“(D) Loss of eligibility for a government coverage program—The individual loses coverage by ceasing to be eligible for coverage under any of the following:

“(i) Part A or part B of title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.; 1395j et seq.).

“(ii) Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), other than coverage consisting solely of benefits under section 1928 (42 U.S.C. 1396s).

“(iii) Title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.).

“(iv) Chapter 55 of title 10.

“(v) Chapter 89 of title 5.

“(vi) A State health benefits risk pool.

“(E) Loss of coverage described—For purposes of this paragraph, loss of coverage shall not include any of the following:

“(i) Voluntary termination of coverage by an individual, except if such termination is the result of circumstances described in subparagraph (C)(iv).

“(ii) Termination of coverage by the issuer or the plan sponsor of the coverage for any reason described in paragraph (1) or (2) of section 2742(b) (300gg–42(b)) of this title.

“(iii) Loss of any coverage that consists solely of coverage of excepted benefits (as defined in section 300gg–91(c) of this title).

“(F) Limitation on special enrollment period—Any special enrollment period shall not be less than 60 days and shall begin on the date of the qualifying event.

“(6) Standard premium rates—With respect to the premium rate charged by a health insurance issuer for health insurance coverage offered in the individual market, such rate, with respect to the particular plan or coverage involved, shall not vary based on any of the following health status-related factors in relation to an eligible individual or dependent:

“(A) Health status.

“(B) Medical condition (including both physical and mental illnesses).

“(C) Claims experience.

“(D) Receipt of health care.

“(E) Medical history.

“(F) Genetic information.

“(G) Evidence of insurability (including conditions arising out of acts of domestic violence).

“(H) Disability.”

(2)
by amending subsection (b) to read as follows:

“(b) Definitions—For purposes of this section:

“(1) Eligible individual—The term eligible individual means an individual who is eligible under applicable State law to purchase individual health insurance coverage in the State.

“(2) Dependent—The term dependent means an individual who, under the terms of the coverage and applicable State law, qualifies to enroll in such coverage as a dependent of an individual described in paragraph (1).”

(3)
by striking subsection (c) and redesignating subsection (d) and the first subsection (e) as subsections (c) and (d), respectively.
(b)
Conforming amendment— Section 2744 of the Public Health Service Act (42 U.S.C. 300gg–44), as restored and revived by section 3 of this Act, is repealed.
(c)
Effective date— Subject to section 1(c), the amendments made by this section shall apply with respect to health insurance coverage offered for plan years beginning on or after the King v. Burwell effective date.