H.R. 4496 — Introduced in House

I 113th CONGRESS 2d Session H. R. 4496 IN THE HOUSE OF REPRESENTATIVES April 28, 2014 Mr. Gardner introduced the following bill; which was referred to the Committee on Energy and Commerce A BILL To establish universal access programs to improve high risk pools and reinsurance markets to ensure coverage for individuals with pre-existing conditions, and for other purposes. 1. Short title This Act may be cited as the Covering People With Pre-Existing Conditions Act of 2014. 2. Establishing universal access programs to improve high risk pools and reinsurance markets for individuals with pre-existing conditions (a) State requirement (1) In general Not later than January 1, 2015, each State shall— (A) subject to paragraph (3), operate— (i) a qualified State reinsurance program described in subsection (b); or (ii) qualifying State high risk pool described in subsection (c)(1); and (B) subject to paragraph (3), apply to the operation of such a program from State funds an amount equivalent to the portion of State funds derived from State premium assessments (as defined by the Secretary) that are not otherwise used on State health care programs. (2) Relation to current qualified high risk pool program (A) States not operating a qualified high risk pool In the case of a State that is not operating a current section 2745 qualified high risk pool as of the date of the enactment of this Act— (i) the State may only meet the requirement of paragraph (1) through the operation of a qualified State reinsurance program described in subsection (b); and (ii) the State’s operation of such a reinsurance program shall be treated, for purposes of section 2745 of the Public Health Service Act, as the operation of a qualified high risk pool described in such section. (B) State operating a qualified high risk pool In the case of a State that is operating a current section 2745 qualified high risk pool as of the date of the enactment of this Act— (i) as of January 1, 2015, such a pool shall not be treated as a qualified high risk pool under section 2745 of the Public Health Service Act unless the pool is a qualifying State high risk pool described in subsection (c)(1); and (ii) the State may use premium assessment funds described in paragraph (1)(B) to transition from operation of such a pool to operation of a qualified State reinsurance program described in subsection (b). (3) Application of funds If the program or pool operated under paragraph (1)(A) is in strong fiscal health, as determined in accordance with standards established by the National Association of Insurance Commissioners and as approved by the State Insurance Commissioner involved, the requirement of paragraph (1)(B) shall be deemed to be met. (b) Qualified state reinsurance program (1) In general For purposes of this section, a qualified State reinsurance program means a program operated by a State program that provides reinsurance for health insurance coverage offered in the small group market in accordance with the model for such a program established (as of the date of the enactment of this Act). (2) Form of program A qualified State reinsurance program may provide reinsurance— (A) on a prospective or retrospective basis; and (B) on a basis that protects health insurance issuers against the annual aggregate spending of their enrollees as well as purchase protection against individual catastrophic costs. (3) Satisfaction of HIPAA requirement A qualified State reinsurance program shall be deemed, for purposes of section 2745 of the Public Health Service Act, to be a qualified high risk pool under such section. (c) Qualifying State high risk pool (1) In general A qualifying State high risk pool described in this subsection means a current section 2745 qualified high risk pool that meets the following requirements: (A) The pool must provide at least two coverage options, one of which must be a high deductible health plan coupled with a health savings account. (B) The pool must be funded with a stable funding source. (C) The pool must eliminate any waiting lists so that all eligible residents who are seeking coverage through the pool should be allowed to receive coverage through the pool. (D) The pool must allow for coverage of individuals who, but for the 24-month disability waiting period under section 226(b) of the Social Security Act, would be eligible for Medicare during the period of such waiting period. (E) The pool must limit the pool premiums to no more than 150 percent of the average premium for applicable standard risk rates in that State. (F) The pool must conduct education and outreach initiatives so that residents and brokers understand that the pool is available to eligible residents. (G) The pool must provide coverage for preventive services and disease management for chronic diseases. (2) Verification of citizenship or alien qualification (A) In general Notwithstanding any other provision of law, only citizens and nationals of the United States shall be eligible to participate in a qualifying State high risk pool that receives funds under section 2745 of the Public Health Service Act or this section. (B) Condition of participation As a condition of a State receiving such funds, the Secretary shall require the State to certify, to the satisfaction of the Secretary, that such State requires all applicants for coverage in the qualifying State high risk pool to provide satisfactory documentation of citizenship or nationality in a manner consistent with section 1903(x) of the Social Security Act. (C) Records The Secretary shall keep sufficient records such that a determination of citizenship or nationality only has to be made once for any individual under this paragraph. (3) Relation to section 2745 As of January 1, 2015, a pool shall not qualify as qualified high risk pool under section 2745 of the Public Health Service Act unless the pool is a qualifying State high risk pool described in paragraph (1). (d) Waivers In order to accommodate new and innovative programs, the Secretary may waive such requirements of this section for qualified State reinsurance programs and for qualifying State high risk pools as the Secretary deems appropriate. (e) Funding In addition to any other amounts appropriated, there is appropriated to carry out section 2745 of the Public Health Service Act (including through a program or pool described in subsection (a)(1))— (1) $15,000,000,000 for the period of fiscal years 2015 through 2024; and (2) an additional $10,000,000,000 for the period of fiscal years 2020 through 2024. (f) Definitions In this section: (1) Health insurance coverage; health insurance issuer The terms health insurance coverage and health insurance issuer have the meanings given such terms in section 2791 of the Public Health Service Act. (2) Current section 2745 qualified high risk pool The term current section 2745 qualified high risk pool has the meaning given the term qualified high risk pool under section 2745(g) of the Public Health Service Act as in effect as of the date of the enactment of this Act. (3) Secretary The term Secretary means the Secretary of Health and Human Services. (4) Standard risk rate The term standard risk rate means a rate that— (A) is determined under the State high risk pool by considering the premium rates charged by other health insurance issuers offering health insurance coverage to individuals in the insurance market served; (B) is established using reasonable actuarial techniques; and (C) reflects anticipated claims experience and expenses for the coverage involved. (5) State The term State means any of the 50 States or the District of Columbia.