,i #aafth ,,congress #ast ,session ,h4 ,r4 #daei ,,in ,,the ,,house ,,of ,,representatives ,august #b1 #bjai,mr4 ,riggleman 7for himself1 ,mrs4 ,wagner1 ,mr4 ,huizenga1 ,mr4 ,newhouse1 and ,ms4 ,herrera ,beutler7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committees on ,ways and ,means1 and ,education and ,labor1 for a period to be subsequently determined by the ,speaker1 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 ,accountability ,act to ensure coverage for individuals with preexisting conditions1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,maintaining ,protections for ,patients with ,preexisting ,conditions ,act of #bjai4 #b4 ,guaranteed availability of coverage2 prohibiting discrimination 7a7 ,in general ,subtitle ,c of title ,i of the ,health ,insurance ,portability and ,accountability ,act of #aiif 7,public ,law #ajd-aia7 is amended by adding at the end the following3 #aif4 ,guaranteed availability of coverage 7a7 ,guaranteed issuance of coverage in the individual and group market ,subject to subsections 7b7 through 7d71 each health insurance issuer that offers health insurance coverage in the individual or group market in a ,state must accept every employer and individual in the ,state that applies for such coverage4 7b7 ,enrollment 7#a7 ,restriction ,a health insurance issuer described in subsection 7a7 may restrict enrollment in coverage described in such subsection to open or special enrollment periods4 7#b7 ,establishment ,a health insurance issuer described in subsection 7a7 shall1 in accordance with the regulations promulgated under paragraph 7#c71 establish special enrollment periods for qualifying events 7under section #fjc of the ,employee ,retirement ,income ,security ,act of #aigd74 7#c7 ,regulations ,the ,secretary shall promulgate regulations with respect to enrollment periods under paragraphs 7#a7 and 7#b74 7c7 ,special rules for network plans 7#a7 ,in general ,in the case of a health insurance issuer that offers health insurance coverage in the group and individual market through a network plan1 the issuer may-- 7,a7 limit the employers that may apply for such coverage to those with eligible individuals who live1 work1 or reside in the service area for such network plan2 and 7,b7 within the service area of such plan1 deny such coverage to such employers and individuals if the issuer has demonstrated1 if required1 to the applicable ,state authority that-- 7i7 it will not have the capacity to deliver services adequately to enrollees of any additional groups or any additional individuals because of its obligations to existing group contract holders and enrollees2 and 7ii7 it is applying this paragraph uniformly to all employers and individuals without regard to the claims experience of those individuals1 employers and their employees 7and their dependents71 or any health status-related factor relating to such individuals1 employees1 and dependents4 7#b7 #ahj-;day suspension upon denial of coverage ,an issuer1 upon denying health insurance coverage in any service area in accordance with paragraph 7#a77;,b71 may not offer coverage in the group or individual market within such service area for a period of #ahj days after the date such coverage is denied4 7d7 ,application of financial capacity limits 7#a7 ,in general ,a health insurance issuer may deny health insurance coverage in the group or individual market if the issuer has demonstrated1 if required1 to the applicable ,state authority that-- 7,a7 it does not have the financial reserves necessary to underwrite additional coverage2 and 7,b7 it is applying this paragraph uniformly to all employers and individuals in the group or individual market in the ,state consistent with applicable ,state law and without regard to the claims experience of those individuals1 employers and their employees 7and their dependents7 or any health status-related factor relating to such individuals1 employees1 and dependents4 7#b7 #ahj-;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 7#a7 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 #ahj days after the date such coverage is denied or until the issuer has demonstrated to the applicable ,state authority1 if required under applicable ,state law1 that the issuer has sufficient financial reserves to underwrite additional coverage1 whichever is later4 ,an applicable ,state authority may provide for the application of this subsection on a service-area-specific basis4 7e7 ,definitions ,in this section and in sections #aig through #aii;,a3 7#a7 ,the term ,secretary means the ,secretary of ,health and ,human ,services4 7#b7 ,the terms genetic information1 genetic test1 group health plan1 group market1 health insurance coverage1 health insurance issuer1 group health insurance coverage1 individual health insurance coverage1 individual market1 and underwriting purpose have the meanings given such terms in section #bgia of the ,public ,health ,service ,act4 #aig4 ,fair health insurance premiums 7a7 ,prohibiting discriminatory premium rates 7#a7 ,in general ,with respect to the premium rate charged by a health insurance issuer for health insurance coverage offered in the individual or small group market-- 7,a7 such rate shall vary with respect to the particular plan or coverage involved only by-- 7i7 whether such plan or coverage covers an individual or family2 7ii7 rating area1 as established in accordance with paragraph 7#b72 7iii7 age1 except that such rate shall not vary by more than #c to #a for adults2 and 7iv7 tobacco use1 except that such rate shall not vary by more than #a4e to #a2 and 7,b7 such rate shall not vary with respect to the particular plan or coverage involved by any other factor not described in subparagraph 7,a74 7#b7 ,rating area 7,a7 ,in general ,each ,state shall establish #a or more rating areas within that ,state for purposes of applying the requirements of this title4 7,b7 ,secretarial review ,the ,secretary shall review the rating areas established by each ,state under subparagraph 7,a7 to ensure the adequacy of such areas for purposes of carrying out the requirements of this title4 ,if the ,secretary determines a ,state's rating areas are not adequate1 or that a ,state does not establish such areas1 the ,secretary may establish rating areas for that ,state4 7#c7 ,permissible age bands ,the ,secretary1 in consultation with the ,national ,association of ,insurance ,commissioners1 shall define the permissible age bands for rating purposes under paragraph 7#a77;,a77iii74 7#d7 ,application of variations based on age or tobacco use ,with respect to family coverage under a group health plan or health insurance coverage1 the rating variations permitted under clauses 7iii7 and 7iv7 of paragraph 7#a77;,a7 shall be applied based on the portion of the premium that is attributable to each family member covered under the plan or coverage4 #aih4 ,prohibiting discrimination against individual participants and beneficiaries based on health status 7a7 ,in general ,a group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish rules for eligibility 7including continued eligibility7 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 individual3 7#a7 ,health status4 7#b7 ,medical condition 7including both physical and mental illnesses74 7#c7 ,claims experience4 7#d7 ,receipt of health care4 7#e7 ,medical history4 7#f7 ,genetic information4 7#g7 ,evidence of insurability 7including conditions arising out of acts of domestic violence74 7#h7 ,disability4 7#i7 ,any other health status-related factor determined appropriate by the ,secretary4 7b7 ,in premium contributions 7#a7 ,in general ,a group health plan1 and a health insurance issuer offering group or individual health insurance coverage1 may not require any individual 7as a condition of enrollment or continued enrollment under the plan7 to pay a premium or contribution which is greater than such premium or contribution for a similarly situated individual enrolled 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 individual4 7#b7 ,construction ,nothing in paragraph 7#a7 shall be construed-- 7,a7 to restrict the amount that an employer or individual may be charged for coverage under a group health plan except as provided in paragraph 7#c7 or individual health coverage1 as the case may be2 or 7,b7 to prevent a group health plan1 and a health insurance issuer offering group health insurance coverage1 from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention4 7#c7 ,no group-based discrimination on basis of genetic information 7,a7 ,in general ,for purposes of this section1 a group health plan1 and health insurance issuer offering group health insurance coverage in connection with a group health plan1 may not adjust premium or contribution amounts for the group covered under such plan on the basis of genetic information4 7,b7 ,rule of construction ,nothing in subparagraph 7,a7 or in paragraphs 7#a7 and 7#b7 of subsection 7d7 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 plan4 ,in such case1 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 employer4 7c7 ,genetic testing 7#a7 ,limitation on requesting or requiring genetic testing ,a group health plan1 and a health insurance issuer offering health insurance coverage in connection with a group health plan1 shall not request or require an individual or a family member of such individual to undergo a genetic test4 7#b7 ,rule of construction ,paragraph 7#a7 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 individual undergo a genetic test4 7#c7 ,rule of construction regarding payment 7,a7 ,in general ,nothing in paragraph 7#a7 shall be construed to preclude a group health plan1 or a health insurance issuer offering health insurance coverage in connection with a group health plan1 from obtaining and using the results of a genetic test in making a determination regarding payment 7as such term is defined for the purposes of applying the regulations promulgated by the ,secretary under part ,c of title ,,xi of the ,social ,security ,act and section #bfd of this ,act1 as may be revised from time to time7 consistent with subsection 7a74 7,b7 ,limitation ,for purposes of subparagraph 7,a71 a group health plan1 or a health insurance issuer offering health insurance coverage in connection with a group health plan1 may request only the minimum amount of information necessary to accomplish the intended purpose4 7#d7 ,research exception ,notwithstanding paragraph 7#a71 a group health plan1 or a health insurance issuer offering health insurance coverage in connection with a group health plan1 may request1 but not require1 that a participant or beneficiary undergo a genetic test if each of the following conditions is met3 7,a7 ,the request is made pursuant to research that complies with part #df of title #de1 ,code of ,federal ,regulations1 or equivalent ,federal regulations1 and any applicable ,state or local law or regulations for the protection of human subjects in research4 7,b7 ,the plan or issuer clearly indicates to each participant or beneficiary1 or in the case of a minor child1 to the legal guardian of such beneficiary1 to whom the request is made that-- 7i7 compliance with the request is voluntary2 and 7ii7 noncompliance will have no effect on enrollment status or premium or contribution amounts4 7,c7 ,no genetic information collected or acquired under this paragraph shall be used for underwriting purposes4 7,d7 ,the plan or issuer notifies the ,secretary in writing that the plan or issuer is conducting activities pursuant to the exception provided for under this paragraph1 including a description of the activities conducted4 7,e7 ,the plan or issuer complies with such other conditions as the ,secretary may by regulation require for activities conducted under this paragraph4 7d7 ,prohibition on collection of genetic information 7#a7 ,in general ,a group health plan1 and a health insurance issuer offering health insurance coverage in connection with a group health plan1 shall not request1 require1 or purchase genetic information for underwriting purposes4 7#b7 ,prohibition on collection of genetic information prior to enrollment ,a group health plan1 and a health insurance issuer offering health insurance coverage in connection with a group health plan1 shall not request1 require1 or purchase genetic information with respect to any individual prior to such individual's enrollment under the plan or coverage in connection with such enrollment4 7#c7 ,incidental collection ,if a group health plan1 or a health insurance issuer offering health insurance coverage in connection with a group health plan1 obtains genetic information incidental to the requesting1 requiring1 or purchasing of other information concerning any individual1 such request1 requirement1 or purchase shall not be considered a violation of paragraph 7#b7 if such request1 requirement1 or purchase is not in violation of paragraph 7#a74 7e7 ,genetic information of a fetus or embryo ,any reference in this part to genetic information concerning an individual or family member of an individual shall-- 7#a7 with respect to such an individual or family member of an individual who is a pregnant woman1 include genetic information of any fetus carried by such pregnant woman2 and 7#b7 with respect to an individual or family member utilizing an assisted reproductive technology1 include genetic information of any embryo legally held by the individual or family member4 7f7 ,programs of health promotion or disease prevention 7#a7 ,general provisions 7,a7 ,general rule ,for purposes of subsection 7b77#b77;,b71 a program of health promotion or disease prevention 7referred to in this subsection as a wellness program7 shall be a program offered by an employer that is designed to promote health or prevent disease that meets the applicable requirements of this subsection4 7,b7 ,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 program is based on an individual satisfying a standard that is related to a health status factor1 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 7#b7 are complied with4 7,c7 ,conditions based on health status factor ,if any of the conditions for obtaining 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 factor1 such wellness program shall not violate this section if the requirements of paragraph 7#c7 are complied with4 7#b7 ,wellness programs not subject to requirements ,if none of the conditions for obtaining a premium discount or rebate or other reward under a wellness program as described in paragraph 7#a77;,b7 are based on an individual satisfying a standard that is related to a health status factor 7or if such a wellness program does not provide such a reward71 the wellness program shall not violate this section if participation in the program is made available to all similarly situated individuals4 ,the following programs shall not have to comply with the requirements of paragraph 7#c7 if participation in the program is made available to all similarly situated individuals3 7,a7 ,a program that reimburses all or part of the cost for memberships in a fitness center4 7,b7 ,a diagnostic testing program that provides a reward for participation and does not base any part of the reward on outcomes4 7,c7 ,a program that encourages preventive care related to a health condition through the waiver of the copayment or deductible requirement under group health plan for the costs of certain items or services related to a health condition 7such as prenatal care or well-baby visits74 7,d7 ,a program that reimburses individuals for the costs of smoking cessation programs without regard to whether the individual quits smoking4 7,e7 ,a program that provides a reward to individuals for attending a periodic health education seminar4 7#c7 ,wellness programs subject to requirements ,if any of the conditions for obtaining a premium discount1 rebate1 or reward under a wellness program as described in paragraph 7#a77;,c7 is based on an individual satisfying a standard that is related to a health status factor1 the wellness program shall not violate this section if the following requirements are complied with3 7,a7 ,the reward for the wellness program1 together with the reward for other wellness programs with respect to the plan that requires satisfaction of a standard related to a health status factor1 shall not exceed #cj percent of the cost of employee-only coverage under the plan4 ,if1 in addition to employees or individuals1 any class of dependents 7such as spouses or spouses and dependent children7 may participate fully in the wellness program1 such reward shall not exceed #cj percent of the cost of the coverage in which an employee or individual and any dependents are enrolled4 ,for purposes of this paragraph1 the cost of coverage shall be determined based on the total amount of employer and employee contributions for the benefit package under which the employee is 7or the employee and any dependents are7 receiving coverage4 ,a reward may be in the form of a discount or rebate of a premium or contribution1 a waiver of all or part of a cost-sharing mechanism 7such as deductibles1 copayments1 or coinsurance71 the absence of a surcharge1 or the value of a benefit that would otherwise not be provided under the plan4 ,the ,secretaries of ,labor1 ,health and ,human ,services1 and the ,treasury may increase the reward available under this subparagraph to up to #ej percent of the cost of coverage if the ,secretaries determine that such an increase is appropriate4 7,b7 ,the wellness program shall be reasonably designed to promote health or prevent disease4 ,a program complies with the preceding sentence if the program has a reasonable chance of improving the health of1 or preventing disease in1 participating individuals and it is not overly burdensome1 is not a subterfuge for discriminating based on a health status factor1 and is not highly suspect in the method chosen to promote health or prevent disease4 7,c7 ,the plan shall give individuals eligible for the program the opportunity to qualify for the reward under the program at least once each year4 7,d7 ,the full reward under the wellness program shall be made available to all similarly situated individuals4 ,for such purpose1 among other things3 7i7 ,the reward is not available to all similarly situated individuals for a period unless the wellness program allows-- 7,i7 for a reasonable alternative standard 7or waiver of the otherwise applicable standard7 for obtaining the reward for any individual for whom1 for that period1 it is unreasonably difficult due to a medical condition to satisfy the otherwise applicable standard2 and 7,,ii7 for a reasonable alternative standard 7or waiver of the otherwise applicable standard7 for obtaining the reward for any individual for whom1 for that period1 it is medically inadvisable to attempt to satisfy the otherwise applicable standard4 7ii7 ,if reasonable under the circumstances1 the plan or issuer may seek verification1 such as a statement from an individual's physician1 that a health status factor makes it unreasonably difficult or medically inadvisable for the individual to satisfy or attempt to satisfy the otherwise applicable standard4 7,e7 ,the plan or issuer involved shall disclose in all plan materials describing the terms of the wellness program the availability of a reasonable alternative standard 7or the possibility of waiver of the otherwise applicable standard7 required under subparagraph 7,d74 ,if plan materials disclose that such a program is available1 without describing its terms1 the disclosure under this subparagraph shall not be required4 #aii4 ,prohibition of preexisting condition exclusions or other discrimination based on health status 7a7 ,in general ,a group health plan and a health insurance issuer offering group or individual health insurance coverage may not impose any preexisting condition exclusion with respect to such plan or coverage4 7b7 ,definitions ,for purposes of this section-- 7#a7 ,preexisting condition exclusion 7,a7 ,in general ,the term preexisting condition exclusion means1 with respect to coverage1 a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage1 whether or not any medical advice1 diagnosis1 care1 or treatment was recommended or received before such date4 7,b7 ,treatment of genetic information ,genetic information shall not be treated as a condition described in subsection 7a77#a7 in the absence of a diagnosis of the condition related to such information4 7#b7 ,enrollment date ,the term enrollment date means1 with respect to an individual covered under a group health plan or health insurance coverage1 the date of enrollment of the individual in the plan or coverage or1 if earlier1 the first day of the waiting period for such enrollment4 7#c7 ,late enrollee ,the term late enrollee means1 with respect to coverage under a group health plan1 a participant or beneficiary who enrolls under the plan other than during-- 7,a7 the first period in which the individual is eligible to enroll under the plan2 or 7,b7 a special enrollment period under subsection 7f74 7#d7 ,waiting period ,the term waiting period means1 with respect to a group health plan and an individual who is a potential participant or beneficiary in the plan1 the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan4 7c7 ,rules relating to crediting previous coverage 7#a7 ,creditable coverage defined ,for purposes of this title1 the term creditable coverage means1 with respect to an individual1 coverage of the individual under any of the following3 7,a7 ,a group health plan4 7,b7 ,health insurance coverage4 7,c7 ,part ,a or part ,b of title ,,xviii of the ,social ,security ,act4 7,d7 ,title ,,xix of the ,social ,security ,act1 other than coverage consisting solely of benefits under section #aibh4 7,e7 ,chapter #ee of title #aj1 ,united ,states ,code4 7,f7 ,a medical care program of the ,indian ,health ,service or of a tribal organization4 7,g7 ,a ,state health benefits risk pool4 7,h7 ,a health plan offered under chapter #hi of title #e1 ,united ,states ,code4 7,i7 ,a public health plan 7as defined in regulations74 7,j7 ,a health benefit plan under section #e7;e7 of the ,peace ,corps ,act 7#bb ,u4,s4,c4 #bejd7;e774 ,such term does not include coverage consisting solely of coverage of excepted benefits 7as defined in section #bgia7;c774 7#b7 ,not counting periods before significant breaks in coverage 7,a7 ,in general ,a period of creditable coverage shall not be counted1 with respect to enrollment of an individual under a group or individual health plan1 if1 after such period and before the enrollment date1 there was a #fc-;day period during all of which the individual was not covered under any creditable coverage4 7,b7 ,waiting period not treated as a break in coverage ,for purposes of subparagraph 7,a7 and subsection 7d77#d71 any period that an individual is in a waiting period for any coverage under a group or individual health plan 7or for group health insurance coverage7 or is in an affiliation period 7as defined in subsection 7g77#b77 shall not be taken into account in determining the continuous period under subparagraph 7,a74 7,c7 ,,taa-eligible individuals ,in the case of plan years beginning before ,january #a1 #bjad-- 7i7 ,,taa pre-certification period rule ,in the case of a ,,taa-eligible individual1 the period beginning on the date the individual has a ,,taa-related loss of coverage and ending on the date that is #g days after the date of the issuance by the ,secretary 7or by any person or entity designated by the ,secretary7 of a qualified health insurance costs credit eligibility certificate for such individual for purposes of section #gebg of the ,internal ,revenue ,code of #aihf shall not be taken into account in determining the continuous period under subparagraph 7,a74 7ii7 ,definitions ,the terms ,,taa-eligible individual and ,,taa-related loss of coverage have the meanings given such terms in section #bbje7;b77#d74 7#c7 ,method of crediting coverage 7,a7 ,standard method ,except as otherwise provided under subparagraph 7,b71 for purposes of applying subsection 7a77#c71 a group health plan1 and a health insurance issuer offering group or individual health insurance coverage1 shall count a period of creditable coverage without regard to the specific benefits covered during the period4 7,b7 ,election of alternative method ,a group health plan1 or a health insurance issuer offering group or individual health insurance1 may elect to apply subsection 7a77#c7 based on coverage of benefits within each of several classes or categories of benefits specified in regulations rather than as provided under subparagraph 7,a74 ,such election shall be made on a uniform basis for all participants and beneficiaries4 ,under such election a group or individual health plan or issuer shall count a period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within such class or category4 7,c7 ,plan notice ,in the case of an election with respect to a group health plan under subparagraph 7,b7 7whether or not health insurance coverage is provided in connection with such plan71 the plan shall-- 7i7 prominently state in any disclosure statements concerning the plan1 and state to each enrollee at the time of enrollment under the plan1 that the plan has made such election2 and 7ii7 include in such statements a description of the effect of this election4 7,d7 ,issuer notice ,in the case of an election under subparagraph 7,b7 with respect to health insurance coverage offered by an issuer in the individual or group market1 the issuer-- 7i7 shall prominently state in any disclosure statements concerning the coverage1 and to each employer at the time of the offer or sale of the coverage1 that the issuer has made such election2 and 7ii7 shall include in such statements a description of the effect of such election4 7#d7 ,establishment of period ,periods of creditable coverage with respect to an individual shall be established through presentation of certifications described in subsection 7e7 or in such other manner as may be specified in regulations4 7d7 ,exceptions 7#a7 ,exclusion not applicable to certain newborns ,subject to paragraph 7#d71 a group health plan1 and a health insurance issuer offering group or individual health insurance coverage1 may not impose any preexisting condition exclusion in the case of an individual who1 as of the last day of the #cj-;day period beginning with the date of birth1 is covered under creditable coverage4 7#b7 ,exclusion not applicable to certain adopted children ,subject to paragraph 7#d71 a group health plan1 and a health insurance issuer offering group or individual health insurance coverage1 may not impose any preexisting condition exclusion in the case of a child who is adopted or placed for adoption before attaining #ah years of age and who1 as of the last day of the #cj-;day period beginning on the date of the adoption or placement for adoption1 is covered under creditable coverage4 ,the previous sentence shall not apply to coverage before the date of such adoption or placement for adoption4 7#c7 ,exclusion not applicable to pregnancy ,a group health plan1 and health insurance issuer offering group or individual health insurance coverage1 may not impose any preexisting condition exclusion relating to pregnancy as a preexisting condition4 7#d7 ,loss if break in coverage ,paragraphs 7#a7 and 7#b7 shall no longer apply to an individual after the end of the first #fc-;day period during all of which the individual was not covered under any creditable coverage4 7e7 ,certifications and disclosure of coverage 7#a7 ,requirement for certification of period of creditable coverage 7,a7 ,in general ,a group health plan1 and a health insurance issuer offering group or individual health insurance coverage1 shall provide the certification described in subparagraph 7,b7-- 7i7 at the time an individual ceases to be covered under the plan or otherwise becomes covered under a ,,cobra continuation provision2 7ii7 in the case of an individual becoming covered under such a provision1 at the time the individual ceases to be covered under such provision2 and 7iii7 on the request on behalf of an individual made not later than #bd months after the date of cessation of the coverage described in clause 7i7 or 7ii71 whichever is later4 ,the certification under clause 7i7 may be provided1 to the extent practicable1 at a time consistent with notices required under any applicable ,,cobra continuation provision4 7,b7 ,certification ,the certification described in this subparagraph is a written certification of-- 7i7 the period of creditable coverage of the individual under such plan and the coverage 7if any7 under such ,,cobra continuation provision2 and 7ii7 the waiting period 7if any7 7and affiliation period1 if applicable7 imposed with respect to the individual for any coverage under such plan4 7,c7 ,issuer compliance ,to the extent that medical care under a group health plan consists of group health insurance coverage1 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 paragraph4 7#b7 ,disclosure of information on previous benefits ,in the case of an election described in subsection 7c77#c77;,b7 by a group health plan or health insurance issuer1 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 7#a7-- 7,a7 upon request of such plan or issuer1 the entity which issued the certification provided 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 coverage2 and 7,b7 such entity may charge the requesting plan or issuer for the reasonable cost of disclosing such information4 7#c7 ,regulations ,the ,secretary shall establish rules to prevent an entity's failure to provide information under paragraph 7#a7 or 7#b7 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 coverage4 7f7 ,special enrollment periods 7#a7 ,individuals losing other coverage ,a group health plan1 and a health insurance issuer offering group health insurance coverage in connection with a group health plan1 shall permit an employee who is eligible1 but not enrolled1 for coverage under the terms of the plan 7or a dependent of such an employee if the dependent is eligible1 but not enrolled1 for coverage under such terms7 to enroll for coverage under the terms of the plan if each of the following conditions is met3 7,a7 ,the employee or dependent was covered under a group health plan or had health insurance coverage at the time coverage was previously offered to the employee or dependent4 7,b7 ,the employee stated in writing at such time that coverage under a group health plan or health insurance coverage was the reason for declining enrollment1 but only if the plan sponsor or issuer 7if applicable7 required such a statement at such time and provided the employee with notice of such requirement 7and the consequences of such requirement7 at such time4 7,c7 ,the employee's or dependent's coverage described in subparagraph 7,a7-- 7i7 was under a ,,cobra continuation provision and the coverage under such provision was exhausted2 or 7ii7 was not under such a provision and either the coverage was terminated as a result of loss of eligibility for the coverage 7including as a result of legal separation1 divorce1 death1 termination of employment1 or reduction in the number of hours of employment7 or employer contributions toward such coverage were terminated4 7,d7 ,under the terms of the plan1 the employee requests such enrollment not later than #cj days after the date of exhaustion of coverage described in subparagraph 7,c77i7 or termination of coverage or employer contribution described in subparagraph 7,c77ii74 7#b7 ,for dependent beneficiaries 7,a7 ,in general ,if-- 7i7 a group health plan makes coverage available with respect to a dependent of an individual2 7ii7 the individual is a participant under the plan 7or has met any waiting period 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 period72 and 7iii7 a person becomes such a dependent of the individual through marriage1 birth1 or adoption or placement for adoption1 the group health plan shall provide for a dependent special enrollment period described in subparagraph 7,b7 during which the person 7or1 if not otherwise enrolled1 the individual7 may be enrolled under the plan as a dependent of the individual1 and in the case of the birth or adoption of a child1 the spouse of the individual may be enrolled as a dependent of the individual if such spouse is otherwise eligible for coverage4 7,b7 ,dependent special enrollment period ,a dependent special enrollment period under this subparagraph shall be a period of not less than #cj days and shall begin on the later of-- 7i7 the date dependent coverage is made available2 or 7ii7 the date of the marriage1 birth1 or adoption or placement for adoption 7as the case may be7 described in subparagraph 7,a77iii74 7,c7 ,no waiting period ,if an individual seeks to enroll a dependent during the first #cj days of such a dependent special enrollment period1 the coverage of the dependent shall become effective-- 7i7 in the case of marriage1 not later than the first day of the first month beginning after the date the completed request for enrollment is received2 7ii7 in the case of a dependent's birth1 as of the date of such birth2 or 7iii7 in the case of a dependent's adoption or placement for adoption1 the date of such adoption or placement for adoption4 7#c7 ,special rules for application in case of ,medicaid and ,,chip 7,a7 ,in general ,a group health plan1 and a health insurance issuer offering group health insurance coverage in connection with a group health plan1 shall permit an employee who is eligible1 but not enrolled1 for coverage under the terms of the plan 7or a dependent of such an employee if the dependent is eligible1 but not enrolled1 for coverage under such terms7 to enroll for coverage under the terms of the plan if either of the following conditions is met3 7i7 ,termination of ,medicaid or ,,chip coverage ,the employee or dependent 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 eligibility for such coverage and the employee requests coverage under the group health plan 7or health insurance coverage7 not later than #fj days after the date of termination of such coverage4 7ii7 ,eligibility for employment assistance under ,medicaid or ,,chip ,the employee or dependent becomes eligible for assistance1 with respect to coverage under the group health plan or health insurance coverage1 under such ,medicaid plan or ,state child health plan 7including under any waiver or demonstration project conducted under or in relation to such a plan71 if the employee requests coverage under the group health plan or health insurance coverage not later than #fj days after the date the employee or dependent is determined to be eligible for such assistance4 7,b7 ,coordination with ,medicaid and ,,chip 7i7 ,outreach to employees regarding availability of ,medicaid and ,,chip coverage 7,i7 ,in general ,each employer that maintains a group health plan in a ,state that provides medical assistance under a ,state ,medicaid plan under title ,,xix of the ,social ,security ,act1 or child health assistance under a ,state child health plan under title ,,xxi of such ,act1 in the form of premium assistance for the purchase of coverage under a group health plan1 shall provide to each employee a written notice informing the employee of potential opportunities then currently available in the ,state in which the employee resides for premium assistance under such plans for health coverage of the employee or the employee's dependents4 ,for purposes of compliance with this subclause1 the employer may use any ,state-specific model notice developed in accordance with section #gja7;f77#c77;,b77i77,,ii7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aaha7;f77#c77;,b77i77,,ii774 7,,ii7 ,option to provide concurrent with provision of plan materials to employee ,an employer 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 eligibility1 concurrent with materials provided to the employee in connection with an open season or election process conducted under the plan1 or concurrent with the furnishing of the summary plan description as provided in section #ajd7;b7 of the ,employee ,retirement ,income ,security ,act of #aigd4 7ii7 ,disclosure about group health plan benefits to ,states for medicaid and chip eligible individuals ,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 ,act1 the plan administrator of the group health plan shall disclose to the ,state1 upon request1 information about the benefits available under the group health plan in sufficient specificity1 as determined under regulations of the ,secretary of ,health and ,human ,services in consultation with the ,secretary that require use of the model coverage coordination disclosure form developed under section #caa7;b77#a77;,c7 of the ,children's ,health ,insurance ,reauthorization ,act of #bjji1 so as to permit the ,state to make a determination 7under paragraph 7#b77;,b71 7#c71 or 7#aj7 of section #baje7;c7 of the ,social ,security ,act or otherwise7 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 7#aj77;,e7 of such section or other authority4 7g7 ,use of ,affiliation ,period by ,h,m,os as ,alternative to ,preexisting ,condition ,exclusion 7#a7 ,in general ,a health maintenance organization which offers health insurance coverage in connection with a group health plan and which does not impose any preexisting condition exclusion allowed under subsection 7a7 with respect to any particular coverage option may impose an affiliation period for such coverage option1 but only if-- 7,a7 such period is applied uniformly without regard to any health status-related factors2 and 7,b7 such period does not exceed #b months 7or #c months in the case of a late enrollee74 7#b7 ,affiliation period 7,a7 ,defined ,for purposes of this title1 the term affiliation period means a period which1 under the terms of the health insurance coverage offered by the health maintenance organization1 must expire before the health insurance coverage becomes effective4 ,the organization is not required to provide health care services or benefits during such period and no premium shall be charged to the participant or beneficiary for any coverage during the period4 7,b7 ,beginning ,such period shall begin on the enrollment date4 7,c7 ,runs concurrently with waiting periods ,an affiliation period under a plan shall run concurrently with any waiting period under the plan4 7#c7 ,alternative methods ,a health maintenance organization described in paragraph 7#a7 may use alternative methods1 from those described in such paragraph1 to address adverse selection as approved by the ,state insurance commissioner or official or officials designated by the ,state to enforce the requirements of this part for the ,state involved with respect to such issuer4 #aii;,a4 ,enforcement of certain health insurance requirements 7a7 ,state ,enforcement 7#a7 ,state authority ,each ,state may require that health insurance issuers that issue1 sell1 renew1 or offer health insurance coverage in the ,state in the individual or group market meet the requirements of this part with respect to such issuers4 7#b7 ,failure to implement provisions ,in the case of a determination by the ,secretary that a ,state has failed to substantially enforce a provision 7or provisions7 of sections #aif through #aii with respect to health insurance issuers in the ,state1 the ,secretary shall enforce such provision 7or provisions7 under subsection 7b7 insofar as they relate to the issuance1 sale1 renewal1 and offering of health insurance coverage in connection with group health plans or individual health insurance coverage in such ,state4 7b7 ,secretarial ,enforcement ,authority 7#a7 ,limitation ,the provisions of this subsection shall apply to enforcement of a provision 7or provisions7 described in subsection 7a77#b7 only-- 7,a7 as provided under such subsection2 and 7,b7 with respect to individual health insurance coverage or group health plans that are non-,federal governmental plans4 7#b7 ,imposition of penalties ,in the cases described in paragraph 7#a7-- 7,a7 ,in general ,subject to the succeeding provisions of this subsection1 any non-,federal governmental plan that is a group health plan and any health insurance issuer that fails to meet a provision of this part applicable to such plan or issuer is subject to a civil money penalty under this subsection4 7,b7 ,liability for penalty ,in the case of a failure by-- 7i7 a health insurance issuer1 the issuer is liable for such penalty2 or 7ii7 a group health plan that is a non-,federal governmental plan which is-- 7,i7 sponsored by #b or more employers1 the plan is liable for such penalty2 or 7,,ii7 not so sponsored1 the employer is liable for such penalty4 7,c7 ,amount of penalty 7i7 ,in general ,the maximum amount of penalty imposed under this paragraph is #ajj for each day for each individual with respect to which such a failure occurs4 7ii7 ,considerations in imposition ,in determining the amount of any penalty to be assessed under this paragraph1 the ,secretary shall take into account the previous record of compliance of the entity being assessed with the applicable provisions of this part and the gravity of the violation4 7iii7 ,limitations 7,i7 ,penalty not to apply where failure not discovered exercising reasonable diligence ,no civil money penalty shall be imposed under this paragraph on any failure during any period for which it is established to the satisfaction of the ,secretary that none of the entities against whom the penalty would be imposed knew1 or exercising reasonable diligence would have known1 that such failure existed4 7,,ii7 ,penalty not to apply to failures corrected within #cj days ,no civil money penalty shall be imposed under this paragraph on any failure if such failure was due to reasonable cause and not to willful neglect1 and such failure is corrected during the #cj-;day period beginning on the first day any of the entities against whom the penalty would be imposed knew1 or exercising reasonable diligence would have known1 that such failure existed4 7,d7 ,administrative review 7i7 ,opportunity for hearing ,the entity assessed shall be afforded an opportunity for hearing by the ,secretary upon request made within #cj days after the date of the issuance of a notice of assessment4 ,in such hearing the decision shall be made on the record pursuant to section #eed of title #e1 ,united ,states ,code4 ,if no hearing is requested1 the assessment shall constitute a final and unappealable order4 7ii7 ,hearing procedure ,if a hearing is requested1 the initial agency decision shall be made by an administrative law judge1 and such decision shall become the final order unless the ,secretary modifies or vacates the decision4 ,notice of intent to modify or vacate the decision of the administrative law judge shall be issued to the parties within #cj days after the date of the decision of the judge4 ,a final order which takes effect under this paragraph shall be subject to review only as provided under subparagraph 7,e74 7,e7 ,judicial review 7i7 ,filing of action for review ,any entity against whom an order imposing a civil money penalty has been entered after an agency hearing under this paragraph may obtain review by the ,united ,states district court for any district in which such entity is located or the ,united ,states ,district ,court for the ,district of ,columbia by filing a notice of appeal in such court within #cj days from the date of such order1 and simultaneously sending a copy of such notice by registered mail to the ,secretary4 7ii7 ,certification of administrative record ,the ,secretary shall promptly certify and file in such court the record upon which the penalty was imposed4 7iii7 ,standard for review ,the findings of the ,secretary shall be set aside only if found to be unsupported by substantial evidence as provided by section #gjf7b77;,e7 of title #e1 ,united ,states ,code4 7iv7 ,appeal ,any final decision1 order1 or judgment of the district court concerning such review shall be subject to appeal as provided in chapter #hc of title #bh of such ,code4 7,f7 ,failure to pay assessment2 maintenance of action 7i7 ,failure to pay assessment ,if any entity fails to pay an assessment after it has become a final and unappealable order1 or after the court has entered final judgment in favor of the ,secretary1 the ,secretary shall refer the matter to the ,attorney ,general who shall recover the amount assessed by action in the appropriate ,united ,states district court4 7ii7 ,nonreviewability ,in such action the validity and appropriateness of the final order imposing the penalty shall not be subject to review4 7,g7 ,payment of penalties ,except as otherwise provided1 penalties collected under this paragraph shall be paid to the ,secretary 7or other officer7 imposing the penalty and shall be available without appropriation and until expended for the purpose of enforcing the provisions with respect to which the penalty was imposed4 7#c7 ,enforcement authority relating to genetic discrimination 7,a7 ,general rule ,in the cases described in paragraph 7#a71 notwithstanding the provisions of paragraph 7#b77;,c71 the succeeding subparagraphs of this paragraph shall apply with respect to an action under this subsection by the ,secretary with respect to any failure of a health insurance issuer in connection with a group health plan1 to meet the requirements of subsection 7a77#a77;,f71 7b77#c71 7c71 or 7d7 of section #aif or section #aig or #aif7;b77#a7 with respect to genetic information in connection with the plan4 7,b7 ,amount 7i7 ,in general ,the amount of the penalty imposed under this paragraph shall be #ajj for each day in the noncompliance period with respect to each participant or beneficiary to whom such failure relates4 7ii7 ,noncompliance period ,for purposes of this paragraph1 the term noncompliance period means1 with respect to any failure1 the period-- 7,i7 beginning on the date such failure first occurs2 and 7,,ii7 ending on the date the failure is corrected4 7,c7 ,minimum penalties where failure discovered ,notwithstanding clauses 7i7 and 7ii7 of subparagraph 7,d73 7i7 ,in general ,in the case of #a or more failures with respect to an individual-- 7,i7 which are not corrected before the date on which the plan receives a notice from the ,secretary of such violation2 and 7,,ii7 which occurred or continued during the period involved2 the amount of penalty imposed by subparagraph 7,a7 by reason of such failures with respect to such individual shall not be less than #b1ejj4 7ii7 ,higher minimum penalty where violations are more than de minimis ,to the extent violations for which any person is liable under this paragraph for any year are more than de minimis1 clause 7i7 shall be applied by substituting #ae1jjj for #b1ejj with respect to such person4 7,d7 ,limitations 7i7 ,penalty not to apply where failure not discovered exercising reasonable diligence ,no penalty shall be imposed by subparagraph 7,a7 on any failure during any period for which it is established to the satisfaction of the ,secretary that the person otherwise liable for such penalty did not know1 and exercising reasonable diligence would not have known1 that such failure existed4 7ii7 ,penalty not to apply to failures corrected within certain periods ,no penalty shall be imposed by subparagraph 7,a7 on any failure if-- 7,i7 such failure was due to reasonable cause and not to willful neglect2 and 7,,ii7 such failure is corrected during the #cj-;day period beginning on the first date the person otherwise liable for such penalty knew1 or exercising reasonable diligence would have known1 that such failure existed4 7iii7 ,overall limitation for unintentional failures ,in the case of failures which are due to reasonable cause and not to willful neglect1 the penalty imposed by subparagraph 7,a7 for failures shall not exceed the amount equal to the lesser of-- 7,i7 #aj percent of the aggregate amount paid or incurred by the employer 7or predecessor employer7 during the preceding taxable year for group health plans2 or 7,,ii7 #ejj1jjj4 7,e7 ,waiver by ,secretary ,in the case of a failure which is due to reasonable cause and not to willful neglect1 the ,secretary may waive part or all of the penalty imposed by subparagraph 7,a7 to the extent that the payment of such penalty would be excessive relative to the failure involved4 7c7 ,definitions ,for purposes of this section3 7#a7 ,governmental plan ,the term governmental plan has the meaning given such term under section #c7cb7 of the ,employee ,retirement ,income ,security ,act of #aigd and any ,federal governmental plan4 7#b7 ,federal governmental plan ,the term #8,federal governmental plan' means a governmental plan established or maintained for its employees by the ,government of the ,united ,states or by any agency or instrumentality of such ,government4 7#c7 ,non-,federal governmental plan ,the term non-,federal governmental plan means a governmental plan that is not a ,federal governmental plan4 4 7b7 ,conforming amendment ,the table of contents under section #a7;b7 of the ,health ,insurance ,portability and ,accountability ,act of #aiif 7,public ,law #ajd-aia7 is amended by inserting after the item relating to section #aie the following3 ,sec4 #aif4 ,guaranteed availability of coverage4 ,sec4 #aig4 ,fair health insurance premiums4 ,sec4 #aih4 ,prohibiting discrimination against individual participants and beneficiaries based on health status4 ,sec4 #aii4 ,prohibition of preexisting condition exclusions or other discrimination based on health status4 ,sec4 #aii;,a4 ,enforcement of certain health insurance requirements4 4 7c7 ,,erisa and ,,irc ,enforcement 7#a7 ,,erisa ,subpart ,b of part #g of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahe et seq47 is amended by adding at the end the following new section3 #gaf4 ,other market reforms ,sections #aif and #aig of the ,health ,insurance ,portability and ,accountability ,act of #aiif shall apply to health insurance issuers providing health insurance coverage in connection with group health plans1 and sections #aih through #aii of such ,act shall apply to group health plans and health insurance issuers providing health insurance coverage in connection with group health plans1 as if included in this subpart1 and to the extent that any provision of this part conflicts with a provision of such sections #aif or #aig with respect to health insurance issuers providing health insurance coverage in connection with group health plans or of such sections #aih or #aii with respect to group health plans or health insurance issuers providing health insurance coverage in connection with group health plans1 the provisions of such sections #aif through #aii shall apply4 4 7#b7 ,,irc ,subchapter ,b of chapter #ajj of subtitle ,k of title #bf of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new section3 #ihaf4 ,other market reforms ,sections #aif and #aig of the ,health ,insurance ,portability and ,accountability ,act of #aiif shall apply to health insurance issuers providing health insurance coverage in connection with group health plans1 and sections #aih through #aii of such ,act shall apply to group health plans and health insurance issuers providing health insurance coverage in connection with group health plans1 as if included in this subchapter1 and to the extent that any provision of this chapter conflicts with a provision of such sections #aif or #aig with respect to health insurance issuers providing health insurance coverage in connection with group health plans or of such sections #aih or #aii with respect to group health plans or health insurance issuers providing health insurance coverage in connection with group health plans1 the provisions of such sections #aif through #aii shall apply4 4