,i  #aaf? ,,congress  #a/ ,session  ,h4 
,r4 #daei  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,augu/ #b1 #bjai,mr4  
,riggleman 7= himself1 ,mrs4 ,wagn]1    
,mr4 ,huiz5ga1 ,mr4 ,ne:\se1 & ,ms4     
,h]r]a ,beutl]7 introduc$ ! foll[+ bill2
 :i* 0 ref]r$ to ! ,committee on ,en]gy 
& ,comm]ce1 & 9 addition to !           
,committees on ,ways & ,means1 &        
,education & ,labor1 = a p]iod to be    
subsequ5tly det]m9$ by ! ,speak]1 9 ea* 
case = consid]ation ( su* provisions z  
fall )9 ! jurisdiction ( ! committee    
conc]n$  ,a ,,bill  ,to am5d ! ,heal?   
,insurance ,portability & ,acc\ntability
 ,act to ensure cov]age = individuals ) 
preexi/+ conditions1 & = o!r purposes4  
#a4 ,%ort title ,?is ,act may be cit$ z 
! ,ma9ta9+ ,protections = ,pati5ts )    
,preexi/+ ,conditions ,act ( #bjai4  #b4
 ,gu>ante$ availability ( cov]age2      
prohibit+ discrim9ation  7a7 ,9 g5]al   
,subtitle ,c ( title ,i ( ! ,heal?      
,insurance ,portability & ,acc\ntability
 ,act ( #aiif 7,public ,law #ajd-aia7 is

 am5d$ by add+ at ! end ! foll[+3  #aif4
 ,gu>ante$ availability ( cov]age  7a7  
,gu>ante$ issuance ( cov]age 9 !        
individual & gr\p m>ket ,subject to     
subsections 7b7 ?r\gh 7d71 ea* heal?    
insurance issu] t (f]s heal? insurance  
cov]age 9 ! individual or gr\p m>ket 9 a
 ,/ate mu/ accept e employ] & individual
 9 ! ,/ate t applies = su* cov]age4  7b7
 ,enrollm5t  7#a7 ,re/riction ,a heal?  
insurance issu] describ$ 9 subsection   
7a7 may re/rict enrollm5t 9 cov]age     
describ$ 9 su* subsection to op5 or     
special enrollm5t p]iods4  7#b7         
,e/abli%m5t ,a heal? insurance issu]    
describ$ 9 subsection 7a7 %all1 9       
accordance ) ! regulations promulgat$ "u
 p>agraph 7#c71 e/abli% special         
enrollm5t p]iods = qualify+ ev5ts 7"u   
section #fjc ( ! ,employee ,retirem5t   
,income ,security ,act ( #aigd74  7#c7  
,regulations ,! ,secret>y %all          
promulgate regulations ) respect to     
enrollm5t p]iods "u p>agraphs 7#a7 &    
7#b74  7c7 ,special rules = network     

plans  7#a7 ,9 g5]al ,9 ! case ( a heal?
 insurance issu] t (f]s heal? insurance 
cov]age 9 ! gr\p & individual m>ket     
?r\gh a network plan1 ! issu] may-- 7,a7
 limit ! employ]s t may apply = su*     
cov]age to ^? ) eligible individuals :o 
live1 "w1 or reside 9 ! s]vice area =   
su* network plan2 &  7,b7 )9 ! s]vice   
area ( su* plan1 d5y su* cov]age to su* 
employ]s & individuals if ! issu] has   
demon/rat$1 if requir$1 to ! applicable 
,/ate au?ority t-- 7i7 x w n h !        
capacity to deliv] s]vices adequately to
 enrollees ( any additional gr\ps or any
 additional individuals because ( its   
obligations to exi/+ gr\p contract      
hold]s & enrollees2 &  7ii7 x is apply+ 
?is p>agraph uni=mly to all employ]s &  
individuals )\t reg>d to ! claims       
exp]i5ce ( ^? individuals1 employ]s & _!
 employees 7& _! dep5d5ts71 or any heal?
 /atus-relat$ factor relat+ to su*      
individuals1 employees1 & dep5d5ts4     
7#b7 #ahj-;day susp5sion ^u d5ial (     
cov]age ,an issu]1 ^u d5y+ heal?        

insurance cov]age 9 any s]vice area 9   
accordance ) p>agraph 7#a77;,b71 may n  
(f] cov]age 9 ! gr\p or individual m>ket
 )9 su* s]vice area = a p]iod ( #ahj    
days aft] ! date su* cov]age is d5i$4   
7d7 ,application ( f9ancial capacity    
limits  7#a7 ,9 g5]al ,a heal? insurance
 issu] may d5y heal? insurance cov]age 9
 ! gr\p or individual m>ket if ! issu]  
has demon/rat$1 if requir$1 to !        
applicable ,/ate au?ority t-- 7,a7 x    
does n h ! f9ancial res]ves necess>y to 
und]write additional cov]age2 &  7,b7 x 
is apply+ ?is p>agraph uni=mly to all   
employ]s & individuals 9 ! gr\p or      
individual m>ket 9 ! ,/ate consi/5t )   
applicable ,/ate law & )\t reg>d to !   
claims exp]i5ce ( ^? individuals1       
employ]s & _! employees 7& _! dep5d5ts7 
or any heal? /atus-relat$ factor relat+ 
to su* individuals1 employees1 &        
dep5d5ts4  7#b7 #ahj-;day susp5sion ^u  
d5ial ( cov]age ,a heal? insurance issu]
 ^u d5y+ heal? insurance cov]age 9      
connection ) gr\p heal? plans 9         

accordance ) p>agraph 7#a7 9 a ,/ate may
 n (f] cov]age 9 connection ) gr\p heal?
 plans 9 ! gr\p or individual m>ket 9 ! 
,/ate = a p]iod ( #ahj days aft] ! date 
su* cov]age is d5i$ or until ! issu] has
 demon/rat$ to ! applicable ,/ate       
au?ority1 if requir$ "u applicable ,/ate
 law1 t ! issu] has suffici5t f9ancial  
res]ves to und]write additional cov]age1
 :i*ev] is lat]4 ,an applicable ,/ate   
au?ority may provide = ! application (  
?is subsection on a s]vice-area-specific
 basis4  7e7 ,def9itions ,9 ?is section 
& 9 sections #aig ?r\gh #aii;,a3 7#a7 ,!
 t]m ,secret>y means ! ,secret>y (      
,heal? & ,human ,s]vices4  7#b7 ,! t]ms 
g5etic in=mation1 g5etic te/1 gr\p heal?
 plan1 gr\p m>ket1 heal? insurance      
cov]age1 heal? insurance issu]1 gr\p    
heal? insurance cov]age1 individual     
heal? insurance cov]age1 individual     
m>ket1 & und]writ+ purpose h ! mean+s   
giv5 su* t]ms 9 section #bgia ( !       
,public ,heal? ,s]vice ,act4  #aig4     
,fair heal? insurance premiums  7a7     

,prohibit+ discrim9atory premium rates  
7#a7 ,9 g5]al ,) respect to ! premium   
rate *>g$ by a heal? insurance issu] =  
heal? insurance cov]age (f]$ 9 !        
individual or small gr\p m>ket--  7,a7  
su* rate %all v>y ) respect to !        
p>ticul> plan or cov]age involv$ only   
by-- 7i7 :e!r su* plan or cov]age cov]s 
an individual or family2  7ii7 rat+     
area1 z e/abli%$ 9 accordance ) p>agraph
 7#b72  7iii7 age1 except t su* rate    
%all n v>y by m ?an #c to #a = adults2 &
  7iv7 tobacco use1 except t su* rate   
%all n v>y by m ?an #a4e to #a2 &  7,b7 
su* rate %all n v>y ) respect to !      
p>ticul> plan or cov]age involv$ by any 
o!r factor n describ$ 9 subp>agraph     
7,a74  7#b7 ,rat+ area  7,a7 ,9 g5]al   
,ea* ,/ate %all e/abli% #a or m rat+    
areas )9 t ,/ate = purposes ( apply+ !  
requirem5ts ( ?is title4  7,b7          
,secret>ial review ,! ,secret>y %all    
review ! rat+ areas e/abli%$ by ea*     
,/ate "u subp>agraph 7,a7 to ensure !   
adequacy ( su* areas = purposes ( c>ry+ 

out ! requirem5ts ( ?is title4 ,if !    
,secret>y det]m9es a ,/ate's rat+ areas 
are n adequate1 or t a ,/ate does n     
e/abli% su* areas1 ! ,secret>y may      
e/abli% rat+ areas = t ,/ate4  7#c7     
,p]missible age b&s ,! ,secret>y1 9     
consultation ) ! ,national ,association 
( ,insurance ,commission]s1 %all def9e !
 p]missible age b&s = rat+ purposes "u  
p>agraph 7#a77;,a77iii74  7#d7          
,application ( v>iations bas$ on age or 
tobacco use ,) respect to family cov]age
 "u a gr\p heal? plan or heal? insurance
 cov]age1 ! rat+ v>iations p]mitt$ "u   
clauses 7iii7 & 7iv7 ( p>agraph         
7#a77;,a7 %all be appli$ bas$ on !      
portion ( ! premium t is attributable to
 ea* family memb] cov]$ "u ! plan or    
cov]age4  #aih4 ,prohibit+ discrim9ation
 aga9/ individual p>ticipants &         
b5efici>ies bas$ on heal? /atus  7a7 ,9 
g5]al ,a gr\p heal? plan & a heal?      
insurance issu] (f]+ gr\p or individual 
heal? insurance cov]age may n e/abli%   
rules = eligibility 7includ+ cont9u$    

eligibility7 ( any individual to enroll 
"u ! t]ms ( ! plan or cov]age bas$ on   
any ( ! foll[+ heal? /atus-relat$       
factors 9 relation to ! individual or a 
dep5d5t ( ! individual3 7#a7 ,heal?     
/atus4  7#b7 ,m$ical condition 7includ+ 
bo? physical & m5tal illnesses74  7#c7  
,claims exp]i5ce4  7#d7 ,receipt ( heal?
 c>e4  7#e7 ,m$ical hi/ory4  7#f7       
,g5etic in=mation4  7#g7 ,evid5ce (     
insurability 7includ+ conditions aris+  
out ( acts ( dome/ic viol5ce74  7#h7    
,disability4  7#i7 ,any o!r heal?       
/atus-relat$ factor det]m9$ appropriate 
by ! ,secret>y4  7b7 ,9 premium         
contributions  7#a7 ,9 g5]al ,a gr\p    
heal? plan1 & a heal? insurance issu]   
(f]+ gr\p or individual heal? insurance 
cov]age1 may n require any individual 7z
 a condition ( enrollm5t or cont9u$     
enrollm5t "u ! plan7 to pay a premium or
 contribution :i* is great] ?an su*     
premium or contribution = a simil>ly    
situat$ individual enroll$ 9 ! plan on !
 basis ( any heal? /atus-relat$ factor 9

 relation to ! individual or to an      
individual enroll$ "u ! plan z a dep5d5t
 ( ! individual4  7#b7 ,con/ruction     
,no?+ 9 p>agraph 7#a7 %all be con/ru$-- 
7,a7 to re/rict ! am\nt t an employ] or 
individual may be *>g$ = cov]age "u a   
gr\p heal? plan except z provid$ 9      
p>agraph 7#c7 or individual heal?       
cov]age1 z ! case may be2 or  7,b7 to   
prev5t a gr\p heal? plan1 & a heal?     
insurance issu] (f]+ gr\p heal?         
insurance cov]age1 f e/abli%+ premium   
disc\nts or rebates or modify+ o!rwise  
applicable copaym5ts or d$uctibles 9    
return = adh]5ce to programs ( heal?    
promotion & disease prev5tion4  7#c7 ,no
 gr\p-bas$ discrim9ation on basis (     
g5etic in=mation  7,a7 ,9 g5]al ,=      
purposes ( ?is section1 a gr\p heal?    
plan1 & heal? insurance issu] (f]+ gr\p 
heal? insurance cov]age 9 connection ) a
 gr\p heal? plan1 may n adju/ premium or
 contribution am\nts = ! gr\p cov]$ "u  
su* plan on ! basis ( g5etic in=mation4 
7,b7 ,rule ( con/ruction ,no?+ 9        

subp>agraph 7,a7 or 9 p>agraphs 7#a7 &  
7#b7 ( subsection 7d7 %all be con/ru$ to
 limit ! ability ( a heal? insurance    
issu] (f]+ gr\p or individual heal?     
insurance cov]age to increase ! premium 
= an employ] bas$ on ! manife/ation ( a 
disease or disord] ( an individual :o is
 enroll$ 9 ! plan4 ,9 su* case1 !       
manife/ation ( a disease or disord] 9 "o
 individual _c also be us$ z g5etic     
in=mation ab\t o!r gr\p memb]s & to     
fur!r increase ! premium = ! employ]4   
7c7 ,g5etic te/+  7#a7 ,limitation on   
reque/+ or requir+ g5etic te/+ ,a gr\p  
heal? plan1 & a heal? insurance issu]   
(f]+ heal? insurance cov]age 9          
connection ) a gr\p heal? plan1 %all n  
reque/ or require an individual or a    
family memb] ( su* individual to und]go 
a g5etic te/4  7#b7 ,rule ( con/ruction 
,p>agraph 7#a7 %all n be con/ru$ to     
limit ! au?ority ( a heal? c>e          
pr(essional :o is provid+ heal? c>e     
s]vices to an individual to reque/ t su*
 individual und]go a g5etic te/4  7#c7  

,rule ( con/ruction reg>d+ paym5t  7,a7 
,9 g5]al ,no?+ 9 p>agraph 7#a7 %all be  
con/ru$ to preclude a gr\p heal? plan1  
or a heal? insurance issu] (f]+ heal?   
insurance cov]age 9 connection ) a gr\p 
heal? plan1 f obta9+ & us+ ! results ( a
 g5etic te/ 9 mak+ a det]m9ation reg>d+ 
paym5t 7z su* t]m is def9$ = ! purposes 
( apply+ ! regulations promulgat$ by !  
,secret>y "u "p ,c ( title ,,xi ( !     
,social ,security ,act & section #bfd ( 
?is ,act1 z may be revis$ f "t to "t7   
consi/5t ) subsection 7a74  7,b7        
,limitation ,= purposes ( subp>agraph   
7,a71 a gr\p heal? plan1 or a heal?     
insurance issu] (f]+ heal? insurance    
cov]age 9 connection ) a gr\p heal?     
plan1 may reque/ only ! m9imum am\nt (  
in=mation necess>y to accompli% ! int5d$
 purpose4  7#d7 ,rese>* exception       
,not)/&+ p>agraph 7#a71 a gr\p heal?    
plan1 or a heal? insurance issu] (f]+   
heal? insurance cov]age 9 connection ) a
 gr\p heal? plan1 may reque/1 b n       
require1 t a p>ticipant or b5efici>y    

und]go a g5etic te/ if ea* ( ! foll[+   
conditions is met3 7,a7 ,! reque/ is    
made pursuant to rese>* t complies ) "p 
#df ( title #de1 ,code ( ,f$]al         
,regulations1 or equival5t ,f$]al       
regulations1 & any applicable ,/ate or  
local law or regulations = ! protection 
( human subjects 9 rese>*4  7,b7 ,! plan
 or issu] cle>ly indicates to ea*       
p>ticipant or b5efici>y1 or 9 ! case ( a
 m9or *ild1 to ! legal gu>dian ( su*    
b5efici>y1 to :om ! reque/ is made t--  
7i7 compliance ) ! reque/ is volunt>y2 &
  7ii7 noncompliance w h no effect on   
enrollm5t /atus or premium or           
contribution am\nts4  7,c7 ,no g5etic   
in=mation collect$ or acquir$ "u ?is    
p>agraph %all be us$ = und]writ+        
purposes4  7,d7 ,! plan or issu]        
notifies ! ,secret>y 9 writ+ t ! plan or
 issu] is conduct+ activities pursuant  
to ! exception provid$ = "u ?is         
p>agraph1 includ+ a description ( !     
activities conduct$4  7,e7 ,! plan or   
issu] complies ) su* o!r conditions z ! 

,secret>y may by regulation require =   
activities conduct$ "u ?is p>agraph4    
7d7 ,prohibition on collection ( g5etic 
in=mation  7#a7 ,9 g5]al ,a gr\p heal?  
plan1 & a heal? insurance issu] (f]+    
heal? insurance cov]age 9 connection ) a
 gr\p heal? plan1 %all n reque/1        
require1 or pur*ase g5etic in=mation =  
und]writ+ purposes4  7#b7 ,prohibition  
on collection ( g5etic in=mation prior  
to enrollm5t ,a gr\p heal? plan1 & a    
heal? insurance issu] (f]+ heal?        
insurance cov]age 9 connection ) a gr\p 
heal? plan1 %all n reque/1 require1 or  
pur*ase g5etic in=mation ) respect to   
any individual prior to su* individual's
 enrollm5t "u ! plan or cov]age 9       
connection ) su* enrollm5t4  7#c7       
,incid5tal collection ,if a gr\p heal?  
plan1 or a heal? insurance issu] (f]+   
heal? insurance cov]age 9 connection ) a
 gr\p heal? plan1 obta9s g5etic         
in=mation incid5tal to ! reque/+1       
requir+1 or pur*as+ ( o!r in=mation     
conc]n+ any individual1 su* reque/1     

requirem5t1 or pur*ase %all n be        
consid]$ a violation ( p>agraph 7#b7 if 
su* reque/1 requirem5t1 or pur*ase is n 
9 violation ( p>agraph 7#a74  7e7       
,g5etic in=mation ( a fetus or embryo   
,any ref]5ce 9 ?is "p to g5etic         
in=mation conc]n+ an individual or      
family memb] ( an individual %all--     
7#a7 ) respect to su* an individual or  
family memb] ( an individual :o is a    
pregnant woman1 include g5etic in=mation
 ( any fetus c>ri$ by su* pregnant      
woman2 &  7#b7 ) respect to an          
individual or family memb] utiliz+ an   
assi/$ reproductive te*nology1 include  
g5etic in=mation ( any embryo legally   
held by ! individual or family memb]4   
7f7 ,programs ( heal? promotion or      
disease prev5tion  7#a7 ,g5]al          
provisions  7,a7 ,g5]al rule ,= purposes
 ( subsection 7b77#b77;,b71 a program ( 
heal? promotion or disease prev5tion    
7ref]r$ to 9 ?is subsection z a wellness
 program7 %all be a program (f]$ by an  
employ] t is design$ to promote heal? or

 prev5t disease t meets ! applicable    
requirem5ts ( ?is subsection4  7,b7 ,no 
conditions bas$ on heal? /atus factor   
,if none ( ! conditions = obta9+ a      
premium disc\nt or rebate or o!r rew>d =
 p>ticipation 9 a wellness program is   
bas$ on an individual satisfy+ a /&>d t 
is relat$ to a heal? /atus factor1 su*  
wellness program %all n violate ?is     
section if p>ticipation 9 ! program is  
made available to all simil>ly situat$  
individuals & ! requirem5ts ( p>agraph  
7#b7 are compli$ )4  7,c7 ,conditions   
bas$ on heal? /atus factor ,if any ( !  
conditions = obta9+ a premium disc\nt or
 rebate or o!r rew>d = p>ticipation 9 a 
wellness program is bas$ on an          
individual satisfy+ a /&>d t is relat$  
to a heal? /atus factor1 su* wellness   
program %all n violate ?is section if ! 
requirem5ts ( p>agraph 7#c7 are compli$ 
)4  7#b7 ,wellness programs n subject to
 requirem5ts ,if none ( ! conditions =  
obta9+ a premium disc\nt or rebate or   
o!r rew>d "u a wellness program z       

describ$ 9 p>agraph 7#a77;,b7 are bas$  
on an individual satisfy+ a /&>d t is   
relat$ to a heal? /atus factor 7or if   
su* a wellness program does n provide   
su* a rew>d71 ! wellness program %all n 
violate ?is section if p>ticipation 9 ! 
program is made available to all        
simil>ly situat$ individuals4 ,! foll[+ 
programs %all n h to comply ) !         
requirem5ts ( p>agraph 7#c7 if          
p>ticipation 9 ! program is made        
available to all simil>ly situat$       
individuals3  7,a7 ,a program t         
reimburses all or "p ( ! co/ = memb]%ips
 9 a fitness c5t]4  7,b7 ,a diagno/ic   
te/+ program t provides a rew>d =       
p>ticipation & does n base any "p ( !   
rew>d on outcomes4  7,c7 ,a program t   
enc\rages prev5tive c>e relat$ to a     
heal? condition ?r\gh ! waiv] ( !       
copaym5t or d$uctible requirem5t "u gr\p
 heal? plan = ! co/s ( c]ta9 items or   
s]vices relat$ to a heal? condition 7su*
 z pr5atal c>e or well-baby visits74    
7,d7 ,a program t reimburses individuals

 = ! co/s ( smok+ cessation programs )\t
 reg>d to :e!r ! individual quits smok+4
  7,e7 ,a program t provides a rew>d to 
individuals = att5d+ a p]iodic heal?    
education sem9>4  7#c7 ,wellness        
programs subject to requirem5ts ,if any 
( ! conditions = obta9+ a premium       
disc\nt1 rebate1 or rew>d "u a wellness 
program z describ$ 9 p>agraph 7#a77;,c7 
is bas$ on an individual satisfy+ a /&>d
 t is relat$ to a heal? /atus factor1 ! 
wellness program %all n violate ?is     
section if ! foll[+ requirem5ts are     
compli$ )3  7,a7 ,! rew>d = ! wellness  
program1 toge!r ) ! rew>d = o!r wellness
 programs ) respect to ! plan t requires
 satisfaction ( a /&>d relat$ to a heal?
 /atus factor1 %all n exce$ #cj p]c5t ( 
! co/ ( employee-only cov]age "u ! plan4
 ,if1 9 addition to employees or        
individuals1 any class ( dep5d5ts 7su* z
 sp\ses or sp\ses & dep5d5t *ildr57 may 
p>ticipate fully 9 ! wellness program1  
su* rew>d %all n exce$ #cj p]c5t ( ! co/
 ( ! cov]age 9 :i* an employee or       

individual & any dep5d5ts are enroll$4  
,= purposes ( ?is p>agraph1 ! co/ (     
cov]age %all be det]m9$ bas$ on ! total 
am\nt ( employ] & employee contributions
 = ! b5efit package "u :i* ! employee is
 7or ! employee & any dep5d5ts are7     
receiv+ cov]age4 ,a rew>d may be 9 ! =m 
( a disc\nt or rebate ( a premium or    
contribution1 a waiv] ( all or "p ( a   
co/-%>+ me*anism 7su* z d$uctibles1     
copaym5ts1 or co9surance71 ! abs5ce ( a 
sur*>ge1 or ! value ( a b5efit t w\ld   
o!rwise n be provid$ "u ! plan4 ,!      
,secret>ies ( ,labor1 ,heal? & ,human   
,s]vices1 & ! ,treasury may increase !  
rew>d available "u ?is subp>agraph to up
 to #ej p]c5t ( ! co/ ( cov]age if !    
,secret>ies det]m9e t su* an increase is
 appropriate4  7,b7 ,! wellness program 
%all be reasonably design$ to promote   
heal? or prev5t disease4 ,a program     
complies ) ! prec$+ s5t5ce if ! program 
has a reasonable *ance ( improv+ ! heal?
 (1 or prev5t+ disease 91 p>ticipat+    
individuals & x is n ov]ly burd5some1 is

 n a subt]fuge = discrim9at+ bas$ on a  
heal? /atus factor1 & is n highly       
suspect 9 ! me?od *os5 to promote heal? 
or prev5t disease4  7,c7 ,! plan %all   
give individuals eligible = ! program ! 
opportunity to qualify = ! rew>d "u !   
program at lea/ once ea* ye>4  7,d7 ,!  
full rew>d "u ! wellness program %all be
 made available to all simil>ly situat$ 
individuals4 ,= su* purpose1 among o!r  
?+s3  7i7 ,! rew>d is n available to all
 simil>ly situat$ individuals = a p]iod 
unless ! wellness program all[s-- 7,i7 =
 a reasonable alt]native /&>d 7or waiv] 
( ! o!rwise applicable /&>d7 = obta9+ ! 
rew>d = any individual = :om1 = t p]iod1
 x is unreasonably difficult due to a   
m$ical condition to satisfy ! o!rwise   
applicable /&>d2 &  7,,ii7 = a          
reasonable alt]native /&>d 7or waiv] ( !
 o!rwise applicable /&>d7 = obta9+ !    
rew>d = any individual = :om1 = t p]iod1
 x is m$ically inadvisable to attempt to
 satisfy ! o!rwise applicable /&>d4     
7ii7 ,if reasonable "u ! circum/ances1 !

 plan or issu] may seek v]ification1 su*
 z a /atem5t f an individual's          
physician1 t a heal? /atus factor makes 
x unreasonably difficult or m$ically    
inadvisable = ! individual to satisfy or
 attempt to satisfy ! o!rwise applicable
 /&>d4  7,e7 ,! plan or issu] involv$   
%all disclose 9 all plan mat]ials       
describ+ ! t]ms ( ! wellness program !  
availability ( a reasonable alt]native  
/&>d 7or ! possibility ( waiv] ( !      
o!rwise applicable /&>d7 requir$ "u     
subp>agraph 7,d74 ,if plan mat]ials     
disclose t su* a program is available1  
)\t describ+ its t]ms1 ! disclosure "u  
?is subp>agraph %all n be requir$4      
#aii4 ,prohibition ( preexi/+ condition 
exclusions or o!r discrim9ation bas$ on 
heal? /atus  7a7 ,9 g5]al ,a gr\p heal? 
plan & a heal? insurance issu] (f]+ gr\p
 or individual heal? insurance cov]age  
may n impose any preexi/+ condition     
exclusion ) respect to su* plan or      
cov]age4  7b7 ,def9itions ,= purposes ( 
?is section-- 7#a7 ,preexi/+ condition  

exclusion  7,a7 ,9 g5]al ,! t]m preexi/+
 condition exclusion means1 ) respect to
 cov]age1 a limitation or exclusion (   
b5efits relat+ to a condition bas$ on ! 
fact t ! condition 0 pres5t be=e ! date 
( enrollm5t = su* cov]age1 :e!r or n any
 m$ical advice1 diagnosis1 c>e1 or      
treatm5t 0 recomm5d$ or receiv$ be=e su*
 date4  7,b7 ,treatm5t ( g5etic         
in=mation ,g5etic in=mation %all n be   
treat$ z a condition describ$ 9         
subsection 7a77#a7 9 ! abs5ce ( a       
diagnosis ( ! condition relat$ to su*   
in=mation4  7#b7 ,enrollm5t date ,! t]m 
enrollm5t date means1 ) respect to an   
individual cov]$ "u a gr\p heal? plan or
 heal? insurance cov]age1 ! date (      
enrollm5t ( ! individual 9 ! plan or    
cov]age or1 if e>li]1 ! fir/ day ( !    
wait+ p]iod = su* enrollm5t4  7#c7 ,late
 enrollee ,! t]m late enrollee means1 ) 
respect to cov]age "u a gr\p heal? plan1
 a p>ticipant or b5efici>y :o enrolls "u
 ! plan o!r ?an dur+-- 7,a7 ! fir/ p]iod
 9 :i* ! individual is eligible to      

enroll "u ! plan2 or  7,b7 a special    
enrollm5t p]iod "u subsection 7f74  7#d7
 ,wait+ p]iod ,! t]m wait+ p]iod means1 
) respect to a gr\p heal? plan & an     
individual :o is a pot5tial p>ticipant  
or b5efici>y 9 ! plan1 ! p]iod t mu/    
pass ) respect to ! individual be=e !   
individual is eligible to be cov]$ =    
b5efits "u ! t]ms ( ! plan4  7c7 ,rules 
relat+ to cr$it+ previ\s cov]age  7#a7  
,cr$itable cov]age def9$ ,= purposes (  
?is title1 ! t]m cr$itable cov]age      
means1 ) respect to an individual1      
cov]age ( ! individual "u any ( !       
foll[+3 7,a7 ,a gr\p heal? plan4  7,b7  
,heal? insurance cov]age4  7,c7 ,"p ,a  
or "p ,b ( title ,,xviii ( ! ,social    
,security ,act4  7,d7 ,title ,,xix ( !  
,social ,security ,act1 o!r ?an cov]age 
consi/+ solely ( b5efits "u section     
#aibh4  7,e7 ,*apt] #ee ( title #aj1    
,unit$ ,/ates ,code4  7,f7 ,a m$ical c>e
 program ( ! ,indian ,heal? ,s]vice or (
 a tribal organization4  7,g7 ,a ,/ate  
heal? b5efits risk pool4  7,h7 ,a heal? 

plan (f]$ "u *apt] #hi ( title #e1      
,unit$ ,/ates ,code4  7,i7 ,a public    
heal? plan 7z def9$ 9 regulations74     
7,j7 ,a heal? b5efit plan "u section    
#e7;e7 ( ! ,peace ,corps ,act 7#bb      
,u4,s4,c4 #bejd7;e774  ,su* t]m does n  
include cov]age consi/+ solely ( cov]age
 ( except$ b5efits 7z def9$ 9 section   
#bgia7;c774  7#b7 ,n c\nt+ p]iods be=e  
significant breaks 9 cov]age  7,a7 ,9   
g5]al ,a p]iod ( cr$itable cov]age %all 
n be c\nt$1 ) respect to enrollm5t ( an 
individual "u a gr\p or individual heal?
 plan1 if1 aft] su* p]iod & be=e !      
enrollm5t date1 !re 0 a #fc-;day p]iod  
dur+ all ( :i* ! individual 0 n cov]$ "u
 any cr$itable cov]age4  7,b7 ,wait+    
p]iod n treat$ z a break 9 cov]age ,=   
purposes ( subp>agraph 7,a7 & subsection
 7d77#d71 any p]iod t an individual is 9
 a wait+ p]iod = any cov]age "u a gr\p  
or individual heal? plan 7or = gr\p     
heal? insurance cov]age7 or is 9 an     
affiliation p]iod 7z def9$ 9 subsection 
7g77#b77 %all n be tak5 into acc\nt 9   

det]m9+ ! cont9u\s p]iod "u subp>agraph 
7,a74  7,c7 ,,taa-eligible individuals  
,9 ! case ( plan ye>s beg9n+ be=e       
,janu>y #a1 #bjad--  7i7 ,,taa          
pre-c]tification p]iod rule ,9 ! case ( 
a ,,taa-eligible individual1 ! p]iod    
beg9n+ on ! date ! individual has a     
,,taa-relat$ loss ( cov]age & end+ on ! 
date t is #g days aft] ! date ( !       
issuance by ! ,secret>y 7or by any p]son
 or entity designat$ by ! ,secret>y7 ( a
 qualifi$ heal? insurance co/s cr$it    
eligibility c]tificate = su* individual 
= purposes ( section #gebg ( ! ,int]nal 
,rev5ue ,code ( #aihf %all n be tak5    
into acc\nt 9 det]m9+ ! cont9u\s p]iod  
"u subp>agraph 7,a74  7ii7 ,def9itions  
,! t]ms ,,taa-eligible individual &     
,,taa-relat$ loss ( cov]age h ! mean+s  
giv5 su* t]ms 9 section #bbje7;b77#d74  
7#c7 ,me?od ( cr$it+ cov]age  7,a7 ,/&>d
 me?od ,except z o!rwise provid$ "u     
subp>agraph 7,b71 = purposes ( apply+   
subsection 7a77#c71 a gr\p heal? plan1 &
 a heal? insurance issu] (f]+ gr\p or   

individual heal? insurance cov]age1 %all
 c\nt a p]iod ( cr$itable cov]age )\t   
reg>d to ! specific b5efits cov]$ dur+ !
 p]iod4  7,b7 ,election ( alt]native    
me?od ,a gr\p heal? plan1 or a heal?    
insurance issu] (f]+ gr\p or individual 
heal? insurance1 may elect to apply     
subsection 7a77#c7 bas$ on cov]age (    
b5efits )9 ea* ( sev]al classes or      
categories ( b5efits specifi$ 9         
regulations r ?an z provid$ "u          
subp>agraph 7,a74 ,su* election %all be 
made on a uni=m basis = all p>ticipants 
& b5efici>ies4 ,"u su* election a gr\p  
or individual heal? plan or issu] %all  
c\nt a p]iod ( cr$itable cov]age )      
respect to any class or category (      
b5efits if any level ( b5efits is cov]$ 
)9 su* class or category4  7,c7 ,plan   
notice ,9 ! case ( an election ) respect
 to a gr\p heal? plan "u subp>agraph    
7,b7 7:e!r or n heal? insurance cov]age 
is provid$ 9 connection ) su* plan71 !  
plan %all-- 7i7 prom95tly /ate 9 any    
disclosure /atem5ts conc]n+ ! plan1 &   

/ate to ea* enrollee at ! "t ( enrollm5t
 "u ! plan1 t ! plan has made su*       
election2 &  7ii7 include 9 su* /atem5ts
 a description ( ! effect ( ?is         
election4  7,d7 ,issu] notice ,9 ! case 
( an election "u subp>agraph 7,b7 )     
respect to heal? insurance cov]age (f]$ 
by an issu] 9 ! individual or gr\p      
m>ket1 ! issu]--  7i7 %all prom95tly    
/ate 9 any disclosure /atem5ts conc]n+ !
 cov]age1 & to ea* employ] at ! "t ( !  
(f] or sale ( ! cov]age1 t ! issu] has  
made su* election2 &  7ii7 %all include 
9 su* /atem5ts a description ( ! effect 
( su* election4  7#d7 ,e/abli%m5t (     
p]iod ,p]iods ( cr$itable cov]age )     
respect to an individual %all be        
e/abli%$ ?r\gh pres5tation (            
c]tifications describ$ 9 subsection 7e7 
or 9 su* o!r mann] z may be specifi$ 9  
regulations4  7d7 ,exceptions  7#a7     
,exclusion n applicable to c]ta9        
newborns ,subject to p>agraph 7#d71 a   
gr\p heal? plan1 & a heal? insurance    
issu] (f]+ gr\p or individual heal?     

insurance cov]age1 may n impose any     
preexi/+ condition exclusion 9 ! case ( 
an individual :o1 z ( ! la/ day ( !     
#cj-;day p]iod beg9n+ ) ! date ( bir?1  
is cov]$ "u cr$itable cov]age4  7#b7    
,exclusion n applicable to c]ta9 adopt$ 
*ildr5 ,subject to p>agraph 7#d71 a gr\p
 heal? plan1 & a heal? insurance issu]  
(f]+ gr\p or individual heal? insurance 
cov]age1 may n impose any preexi/+      
condition exclusion 9 ! case ( a *ild :o
 is adopt$ or plac$ = adoption be=e     
atta9+ #ah ye>s ( age & :o1 z ( ! la/   
day ( ! #cj-;day p]iod beg9n+ on ! date 
( ! adoption or placem5t = adoption1 is 
cov]$ "u cr$itable cov]age4 ,! previ\s  
s5t5ce %all n apply to cov]age be=e !   
date ( su* adoption or placem5t =       
adoption4  7#c7 ,exclusion n applicable 
to pregnancy ,a gr\p heal? plan1 & heal?
 insurance issu] (f]+ gr\p or individual
 heal? insurance cov]age1 may n impose  
any preexi/+ condition exclusion relat+ 
to pregnancy z a preexi/+ condition4    
7#d7 ,loss if break 9 cov]age ,p>agraphs

 7#a7 & 7#b7 %all no long] apply to an  
individual aft] ! end ( ! fir/ #fc-;day 
p]iod dur+ all ( :i* ! individual 0 n   
cov]$ "u any cr$itable cov]age4  7e7    
,c]tifications & disclosure ( cov]age   
7#a7 ,requirem5t = c]tification ( p]iod 
( cr$itable cov]age  7,a7 ,9 g5]al ,a   
gr\p heal? plan1 & a heal? insurance    
issu] (f]+ gr\p or individual heal?     
insurance cov]age1 %all provide !       
c]tification describ$ 9 subp>agraph     
7,b7--  7i7 at ! "t an individual ceases
 to be cov]$ "u ! plan or o!rwise       
becomes cov]$ "u a ,,cobra cont9uation  
provision2  7ii7 9 ! case ( an          
individual becom+ cov]$ "u su* a        
provision1 at ! "t ! individual ceases  
to be cov]$ "u su* provision2 &  7iii7  
on ! reque/ on behalf ( an individual   
made n lat] ?an #bd mon?s aft] ! date ( 
cessation ( ! cov]age describ$ 9 clause 
7i7 or 7ii71 :i*ev] is lat]4  ,!        
c]tification "u clause 7i7 may be       
provid$1 to ! ext5t practicable1 at a "t
 consi/5t ) notices requir$ "u any      

applicable ,,cobra cont9uation          
provision4  7,b7 ,c]tification ,!       
c]tification describ$ 9 ?is subp>agraph 
is a writt5 c]tification (--  7i7 !     
p]iod ( cr$itable cov]age ( ! individual
 "u su* plan & ! cov]age 7if any7 "u su*
 ,,cobra cont9uation provision2 &  7ii7 
! wait+ p]iod 7if any7 7& affiliation   
p]iod1 if applicable7 impos$ ) respect  
to ! individual = any cov]age "u su*    
plan4  7,c7 ,issu] compliance ,to !     
ext5t t m$ical c>e "u a gr\p heal? plan 
consi/s ( gr\p heal? insurance cov]age1 
! plan is deem$ to h satisfi$ !         
c]tification requirem5t "u ?is p>agraph 
if ! heal? insurance issu] (f]+ !       
cov]age provides = su* c]tification 9   
accordance ) ?is p>agraph4  7#b7        
,disclosure ( in=mation on previ\s      
b5efits ,9 ! case ( an election describ$
 9 subsection 7c77#c77;,b7 by a gr\p    
heal? plan or heal? insurance issu]1 if 
! plan or issu] enrolls an individual = 
cov]age "u ! plan & ! individual        
provides a c]tification ( cov]age ( !   

individual "u p>agraph 7#a7--  7,a7 ^u  
reque/ ( su* plan or issu]1 ! entity :i*
 issu$ ! c]tification provid$ by !      
individual %all promptly disclose to su*
 reque/+ plan or issu] in=mation on     
cov]age ( classes & categories ( heal?  
b5efits available "u su* entity's plan  
or cov]age2 &  7,b7 su* entity may *>ge 
! reque/+ plan or issu] = ! reasonable  
co/ ( disclos+ su* in=mation4  7#c7     
,regulations ,! ,secret>y %all e/abli%  
rules to prev5t an entity's failure to  
provide in=mation "u p>agraph 7#a7 or   
7#b7 ) respect to previ\s cov]age ( an  
individual f adv]sely affect+ any       
subsequ5t cov]age ( ! individual "u     
ano!r gr\p heal? plan or heal? insurance
 cov]age4  7f7 ,special enrollm5t p]iods
  7#a7 ,individuals los+ o!r cov]age ,a 
gr\p heal? plan1 & a heal? insurance    
issu] (f]+ gr\p heal? insurance cov]age 
9 connection ) a gr\p heal? plan1 %all  
p]mit an employee :o is eligible1 b n   
enroll$1 = cov]age "u ! t]ms ( ! plan   
7or a dep5d5t ( su* an employee if !    

dep5d5t is eligible1 b n enroll$1 =     
cov]age "u su* t]ms7 to enroll = cov]age
 "u ! t]ms ( ! plan if ea* ( ! foll[+   
conditions is met3  7,a7 ,! employee or 
dep5d5t 0 cov]$ "u a gr\p heal? plan or 
_h heal? insurance cov]age at ! "t      
cov]age 0 previ\sly (f]$ to ! employee  
or dep5d5t4  7,b7 ,! employee /at$ 9    
writ+ at su* "t t cov]age "u a gr\p     
heal? plan or heal? insurance cov]age 0 
! reason = decl9+ enrollm5t1 b only if !
 plan sponsor or issu] 7if applicable7  
requir$ su* a /atem5t at su* "t &       
provid$ ! employee ) notice ( su*       
requirem5t 7& ! consequ5ces ( su*       
requirem5t7 at su* "t4  7,c7 ,!         
employee's or dep5d5t's cov]age describ$
 9 subp>agraph 7,a7-- 7i7 0 "u a ,,cobra
 cont9uation provision & ! cov]age "u   
su* provision 0 exhau/$2 or  7ii7 0 n "u
 su* a provision & ei!r ! cov]age 0     
t]m9at$ z a result ( loss ( eligibility 
= ! cov]age 7includ+ z a result ( legal 
sep>ation1 divorce1 dea?1 t]m9ation (   
employm5t1 or r$uction 9 ! numb] ( h\rs 

( employm5t7 or employ] contributions   
t[>d su* cov]age 7 t]m9at$4  7,d7 ,"u ! 
t]ms ( ! plan1 ! employee reque/s su*   
enrollm5t n lat] ?an #cj days aft] !    
date ( exhau/ion ( cov]age describ$ 9   
subp>agraph 7,c77i7 or t]m9ation (      
cov]age or employ] contribution describ$
 9 subp>agraph 7,c77ii74  7#b7 ,=       
dep5d5t b5efici>ies  7,a7 ,9 g5]al ,if--
 7i7 a gr\p heal? plan makes cov]age    
available ) respect to a dep5d5t ( an   
individual2  7ii7 ! individual is a     
p>ticipant "u ! plan 7or has met any    
wait+ p]iod applicable to becom+ a      
p>ticipant "u ! plan & is eligible to be
 enroll$ "u ! plan b = a failure to     
enroll dur+ a previ\s enrollm5t p]iod72 
&  7iii7 a p]son becomes su* a dep5d5t (
 ! individual ?r\gh m>riage1 bir?1 or   
adoption or placem5t = adoption1  ! gr\p
 heal? plan %all provide = a dep5d5t    
special enrollm5t p]iod describ$ 9      
subp>agraph 7,b7 dur+ :i* ! p]son 7or1  
if n o!rwise enroll$1 ! individual7 may 
be enroll$ "u ! plan z a dep5d5t ( !    

individual1 & 9 ! case ( ! bir? or      
adoption ( a *ild1 ! sp\se ( !          
individual may be enroll$ z a dep5d5t ( 
! individual if su* sp\se is o!rwise    
eligible = cov]age4  7,b7 ,dep5d5t      
special enrollm5t p]iod ,a dep5d5t      
special enrollm5t p]iod "u ?is          
subp>agraph %all be a p]iod ( n less ?an
 #cj days & %all beg9 on ! lat] (-- 7i7 
! date dep5d5t cov]age is made          
available2 or  7ii7 ! date ( ! m>riage1 
bir?1 or adoption or placem5t = adoption
 7z ! case may be7 describ$ 9           
subp>agraph 7,a77iii74  7,c7 ,no wait+  
p]iod ,if an individual seeks to enroll 
a dep5d5t dur+ ! fir/ #cj days ( su* a  
dep5d5t special enrollm5t p]iod1 !      
cov]age ( ! dep5d5t %all become         
effective--  7i7 9 ! case ( m>riage1 n  
lat] ?an ! fir/ day ( ! fir/ mon? beg9n+
 aft] ! date ! complet$ reque/ =        
enrollm5t is receiv$2  7ii7 9 ! case ( a
 dep5d5t's bir?1 z ( ! date ( su* bir?2 
or  7iii7 9 ! case ( a dep5d5t's        
adoption or placem5t = adoption1 ! date 

( su* adoption or placem5t = adoption4  
7#c7 ,special rules = application 9 case
 ( ,m$icaid & ,,*ip  7,a7 ,9 g5]al ,a   
gr\p heal? plan1 & a heal? insurance    
issu] (f]+ gr\p heal? insurance cov]age 
9 connection ) a gr\p heal? plan1 %all  
p]mit an employee :o is eligible1 b n   
enroll$1 = cov]age "u ! t]ms ( ! plan   
7or a dep5d5t ( su* an employee if !    
dep5d5t is eligible1 b n enroll$1 =     
cov]age "u su* t]ms7 to enroll = cov]age
 "u ! t]ms ( ! plan if ei!r ( ! foll[+  
conditions is met3  7i7 ,t]m9ation (    
,m$icaid or ,,*ip cov]age ,! employee or
 dep5d5t is cov]$ "u a ,m$icaid plan "u 
title ,,xix ( ! ,social ,security ,act  
or "u a ,/ate *ild heal? plan "u title  
,,xxi ( su* ,act & cov]age ( ! employee 
or dep5d5t "u su* a plan is t]m9at$ z a 
result ( loss ( eligibility = su*       
cov]age & ! employee reque/s cov]age "u 
! gr\p heal? plan 7or heal? insurance   
cov]age7 n lat] ?an #fj days aft] ! date
 ( t]m9ation ( su* cov]age4  7ii7       
,eligibility = employm5t assi/ance "u   

,m$icaid or ,,*ip ,! employee or dep5d5t
 becomes eligible = assi/ance1 ) respect
 to cov]age "u ! gr\p heal? plan or     
heal? insurance cov]age1 "u su* ,m$icaid
 plan or ,/ate *ild heal? plan 7includ+ 
"u any waiv] or demon/ration project    
conduct$ "u or 9 relation to su* a      
plan71 if ! employee reque/s cov]age "u 
! gr\p heal? plan or heal? insurance    
cov]age n lat] ?an #fj days aft] ! date 
! employee or dep5d5t is det]m9$ to be  
eligible = su* assi/ance4  7,b7         
,coord9ation ) ,m$icaid & ,,*ip  7i7    
,outrea* to employees reg>d+            
availability ( ,m$icaid & ,,*ip cov]age 
7,i7 ,9 g5]al ,ea* employ] t ma9ta9s a  
gr\p heal? plan 9 a ,/ate t provides    
m$ical assi/ance "u a ,/ate ,m$icaid    
plan "u title ,,xix ( ! ,social         
,security ,act1 or *ild heal? assi/ance 
"u a ,/ate *ild heal? plan "u title     
,,xxi ( su* ,act1 9 ! =m ( premium      
assi/ance = ! pur*ase ( cov]age "u a    
gr\p heal? plan1 %all provide to ea*    
employee a writt5 notice in=m+ !        

employee ( pot5tial opportunities !n    
curr5tly available 9 ! ,/ate 9 :i* !    
employee resides = premium assi/ance "u 
su* plans = heal? cov]age ( ! employee  
or ! employee's dep5d5ts4 ,= purposes ( 
compliance ) ?is subclause1 ! employ]   
may use any ,/ate-specific model notice 
develop$ 9 accordance ) section         
#gja7;f77#c77;,b77i77,,ii7 ( ! ,employee
 ,retirem5t ,income ,security ,act (    
#aigd 7#bi ,u4,s4,c4                    
#aaha7;f77#c77;,b77i77,,ii774  7,,ii7   
,option to provide concurr5t ) provision
 ( plan mat]ials to employee ,an employ]
 may provide ! model notice applicable  
to ! ,/ate 9 :i* an employee resides    
concurr5t ) ! furni%+ ( mat]ials notify+
 ! employee ( heal? plan eligibility1   
concurr5t ) mat]ials provid$ to !       
employee 9 connection ) an op5 season or
 election process conduct$ "u ! plan1 or
 concurr5t ) ! furni%+ ( ! summ>y plan  
description z provid$ 9 section #ajd7;b7
 ( ! ,employee ,retirem5t ,income       
,security ,act ( #aigd4  7ii7           

,disclosure ab\t gr\p heal? plan b5efits
 to ,/ates = m$icaid & *ip eligible     
individuals ,9 ! case ( an enrollee 9 a 
gr\p heal? plan :o is cov]$ "u a        
,m$icaid plan ( a ,/ate "u title ,,xix (
 ! ,social ,security ,act or "u a ,/ate 
*ild heal? plan "u title ,,xxi ( su*    
,act1 ! plan adm9i/rator ( ! gr\p heal? 
plan %all disclose to ! ,/ate1 ^u       
reque/1 in=mation ab\t ! b5efits        
available "u ! gr\p heal? plan 9        
suffici5t specificity1 z det]m9$ "u     
regulations ( ! ,secret>y ( ,heal? &    
,human ,s]vices 9 consultation ) !      
,secret>y t require use ( ! model       
cov]age coord9ation disclosure =m       
develop$ "u section #caa7;b77#a77;,c7 ( 
! ,*ildr5's ,heal? ,insurance           
,reau?orization ,act ( #bjji1 s z to    
p]mit ! ,/ate to make a det]m9ation 7"u 
p>agraph 7#b77;,b71 7#c71 or 7#aj7 (    
section #baje7;c7 ( ! ,social ,security 
,act or o!rwise7 conc]n+ !              
co/-effectiv5ess ( ! ,/ate provid+      
m$ical or *ild heal? assi/ance ?r\gh    

premium assi/ance = ! pur*ase ( cov]age 
"u su* gr\p heal? plan & 9 ord] = !     
,/ate to provide supplem5tal b5efits    
requir$ "u p>agraph 7#aj77;,e7 ( su*    
section or o!r au?ority4  7g7 ,use (    
,affiliation ,p]iod by ,h,m,os z        
,alt]native to ,preexi/+ ,condition     
,exclusion  7#a7 ,9 g5]al ,a heal?      
ma9t5ance organization :i* (f]s heal?   
insurance cov]age 9 connection ) a gr\p 
heal? plan & :i* does n impose any      
preexi/+ condition exclusion all[$ "u   
subsection 7a7 ) respect to any p>ticul>
 cov]age option may impose an           
affiliation p]iod = su* cov]age option1 
b only if--  7,a7 su* p]iod is appli$   
uni=mly )\t reg>d to any heal?          
/atus-relat$ factors2 &  7,b7 su* p]iod 
does n exce$ #b mon?s 7or #c mon?s 9 !  
case ( a late enrollee74  7#b7          
,affiliation p]iod  7,a7 ,def9$ ,=      
purposes ( ?is title1 ! t]m affiliation 
p]iod means a p]iod :i*1 "u ! t]ms ( !  
heal? insurance cov]age (f]$ by ! heal? 
ma9t5ance organization1 mu/ expire be=e 

! heal? insurance cov]age becomes       
effective4 ,! organization is n requir$ 
to provide heal? c>e s]vices or b5efits 
dur+ su* p]iod & no premium %all be *>g$
 to ! p>ticipant or b5efici>y = any     
cov]age dur+ ! p]iod4  7,b7 ,beg9n+ ,su*
 p]iod %all beg9 on ! enrollm5t date4   
7,c7 ,runs concurr5tly ) wait+ p]iods   
,an affiliation p]iod "u a plan %all run
 concurr5tly ) any wait+ p]iod "u !     
plan4  7#c7 ,alt]native me?ods ,a heal? 
ma9t5ance organization describ$ 9       
p>agraph 7#a7 may use alt]native me?ods1
 f ^? describ$ 9 su* p>agraph1 to       
address adv]se selection z approv$ by ! 
,/ate insurance commission] or (ficial  
or (ficials designat$ by ! ,/ate to     
en=ce ! requirem5ts ( ?is "p = ! ,/ate  
involv$ ) respect to su* issu]4         
#aii;,a4 ,en=cem5t ( c]ta9 heal?        
insurance requirem5ts  7a7 ,/ate        
,en=cem5t  7#a7 ,/ate au?ority ,ea*     
,/ate may require t heal? insurance     
issu]s t issue1 sell1 r5ew1 or (f] heal?
 insurance cov]age 9 ! ,/ate 9 !        

individual or gr\p m>ket meet !         
requirem5ts ( ?is "p ) respect to su*   
issu]s4  7#b7 ,failure to implem5t      
provisions ,9 ! case ( a det]m9ation by 
! ,secret>y t a ,/ate has fail$ to      
sub/antially en=ce a provision 7or      
provisions7 ( sections #aif ?r\gh #aii )
 respect to heal? insurance issu]s 9 !  
,/ate1 ! ,secret>y %all en=ce su*       
provision 7or provisions7 "u subsection 
7b7 ins(> z !y relate to ! issuance1    
sale1 r5ewal1 & (f]+ ( heal? insurance  
cov]age 9 connection ) gr\p heal? plans 
or individual heal? insurance cov]age 9 
su* ,/ate4  7b7 ,secret>ial ,en=cem5t   
,au?ority  7#a7 ,limitation ,!          
provisions ( ?is subsection %all apply  
to en=cem5t ( a provision 7or           
provisions7 describ$ 9 subsection       
7a77#b7 only-- 7,a7 z provid$ "u su*    
subsection2 &  7,b7 ) respect to        
individual heal? insurance cov]age or   
gr\p heal? plans t are non-,f$]al       
gov]nm5tal plans4  7#b7 ,imposition (   
p5alties ,9 ! cases describ$ 9 p>agraph 

7#a7--  7,a7 ,9 g5]al ,subject to !     
succe$+ provisions ( ?is subsection1 any
 non-,f$]al gov]nm5tal plan t is a gr\p 
heal? plan & any heal? insurance issu] t
 fails to meet a provision ( ?is "p     
applicable to su* plan or issu] is      
subject to a civil money p5alty "u ?is  
subsection4  7,b7 ,liability = p5alty ,9
 ! case ( a failure by--  7i7 a heal?   
insurance issu]1 ! issu] is liable = su*
 p5alty2 or  7ii7 a gr\p heal? plan t is
 a non-,f$]al gov]nm5tal plan :i* is--  
7,i7 sponsor$ by #b or m employ]s1 !    
plan is liable = su* p5alty2 or  7,,ii7 
n s sponsor$1 ! employ] is liable = su* 
p5alty4  7,c7 ,am\nt ( p5alty  7i7 ,9   
g5]al ,! maximum am\nt ( p5alty impos$  
"u ?is p>agraph is #ajj = ea* day = ea* 
individual ) respect to :i* su* a       
failure occurs4  7ii7 ,consid]ations 9  
imposition ,9 det]m9+ ! am\nt ( any     
p5alty to be assess$ "u ?is p>agraph1 ! 
,secret>y %all take into acc\nt !       
previ\s record ( compliance ( ! entity  
be+ assess$ ) ! applicable provisions ( 

?is "p & ! gravity ( ! violation4  7iii7
 ,limitations  7,i7 ,p5alty n to apply  
:]e failure n discov]$ ex]cis+          
reasonable dilig5ce ,no civil money     
p5alty %all be impos$ "u ?is p>agraph on
 any failure dur+ any p]iod = :i* x is  
e/abli%$ to ! satisfaction ( ! ,secret>y
 t none ( ! entities aga9/ :om ! p5alty 
w\ld be impos$ knew1 or ex]cis+         
reasonable dilig5ce w\ld h kn[n1 t su*  
failure exi/$4  7,,ii7 ,p5alty n to     
apply to failures correct$ )9 #cj days  
,no civil money p5alty %all be impos$ "u
 ?is p>agraph on any failure if su*     
failure 0 due to reasonable cause & n to
 willful neglect1 & su* failure is      
correct$ dur+ ! #cj-;day p]iod beg9n+ on
 ! fir/ day any ( ! entities aga9/ :om !
 p5alty w\ld be impos$ knew1 or ex]cis+ 
reasonable dilig5ce w\ld h kn[n1 t su*  
failure exi/$4  7,d7 ,adm9i/rative      
review  7i7 ,opportunity = he>+ ,!      
entity assess$ %all be af=d$ an         
opportunity = he>+ by ! ,secret>y ^u    
reque/ made )9 #cj days aft] ! date ( ! 

issuance ( a notice ( assessm5t4 ,9 su* 
he>+ ! decision %all be made on ! record
 pursuant to section #eed ( title #e1   
,unit$ ,/ates ,code4 ,if no he>+ is     
reque/$1 ! assessm5t %all con/itute a   
f9al & unappealable ord]4  7ii7 ,he>+   
proc$ure ,if a he>+ is reque/$1 !       
initial ag5cy decision %all be made by  
an adm9i/rative law judge1 & su*        
decision %all become ! f9al ord] unless 
! ,secret>y modifies or vacates !       
decision4 ,notice ( int5t to modify or  
vacate ! decision ( ! adm9i/rative law  
judge %all be issu$ to ! p>ties )9 #cj  
days aft] ! date ( ! decision ( ! judge4
 ,a f9al ord] :i* takes effect "u ?is   
p>agraph %all be subject to review only 
z provid$ "u subp>agraph 7,e74  7,e7    
,judicial review  7i7 ,fil+ ( action =  
review ,any entity aga9/ :om an ord]    
impos+ a civil money p5alty has be5     
ent]$ aft] an ag5cy he>+ "u ?is p>agraph
 may obta9 review by ! ,unit$ ,/ates    
di/rict c\rt = any di/rict 9 :i* su*    
entity is locat$ or ! ,unit$ ,/ates     

,di/rict ,c\rt = ! ,di/rict ( ,columbia 
by fil+ a notice ( appeal 9 su* c\rt )9 
#cj days f ! date ( su* ord]1 &         
simultane\sly s5d+ a copy ( su* notice  
by regi/]$ mail to ! ,secret>y4  7ii7   
,c]tification ( adm9i/rative record ,!  
,secret>y %all promptly c]tify & file 9 
su* c\rt ! record ^u :i* ! p5alty 0     
impos$4  7iii7 ,/&>d = review ,! f9d+s (
 ! ,secret>y %all be set aside only if  
f\nd to be unsupport$ by sub/antial     
evid5ce z provid$ by section            
#gjf7b77;,e7 ( title #e1 ,unit$ ,/ates  
,code4  7iv7 ,appeal ,any f9al decision1
 ord]1 or judgm5t ( ! di/rict c\rt      
conc]n+ su* review %all be subject to   
appeal z provid$ 9 *apt] #hc ( title #bh
 ( su* ,code4  7,f7 ,failure to pay     
assessm5t2 ma9t5ance ( action  7i7      
,failure to pay assessm5t ,if any entity
 fails to pay an assessm5t aft] x has   
become a f9al & unappealable ord]1 or   
aft] ! c\rt has ent]$ f9al judgm5t 9    
favor ( ! ,secret>y1 ! ,secret>y %all   
ref] ! matt] to ! ,attorney ,g5]al :o   

%all recov] ! am\nt assess$ by action 9 
! appropriate ,unit$ ,/ates di/rict     
c\rt4  7ii7 ,nonreviewability ,9 su*    
action ! validity & appropriat5ess ( !  
f9al ord] impos+ ! p5alty %all n be     
subject to review4  7,g7 ,paym5t (      
p5alties ,except z o!rwise provid$1     
p5alties collect$ "u ?is p>agraph %all  
be paid to ! ,secret>y 7or o!r (fic]7   
impos+ ! p5alty & %all be available )\t 
appropriation & until exp5d$ = ! purpose
 ( en=c+ ! provisions ) respect to :i* !
 p5alty 0 impos$4  7#c7 ,en=cem5t       
au?ority relat+ to g5etic discrim9ation 
7,a7 ,g5]al rule ,9 ! cases describ$ 9  
p>agraph 7#a71 not)/&+ ! provisions (   
p>agraph 7#b77;,c71 ! succe$+           
subp>agraphs ( ?is p>agraph %all apply )
 respect to an action "u ?is subsection 
by ! ,secret>y ) respect to any failure 
( a heal? insurance issu] 9 connection )
 a gr\p heal? plan1 to meet !           
requirem5ts ( subsection 7a77#a77;,f71  
7b77#c71 7c71 or 7d7 ( section #aif or  
section #aig or #aif7;b77#a7 ) respect  

to g5etic in=mation 9 connection ) !    
plan4  7,b7 ,am\nt  7i7 ,9 g5]al ,!     
am\nt ( ! p5alty impos$ "u ?is p>agraph 
%all be #ajj = ea* day 9 ! noncompliance
 p]iod ) respect to ea* p>ticipant or   
b5efici>y to :om su* failure relates4   
7ii7 ,noncompliance p]iod ,= purposes ( 
?is p>agraph1 ! t]m noncompliance p]iod 
means1 ) respect to any failure1 !      
p]iod--  7,i7 beg9n+ on ! date su*      
failure fir/ occurs2 &  7,,ii7 end+ on !
 date ! failure is correct$4  7,c7      
,m9imum p5alties :]e failure discov]$   
,not)/&+ clauses 7i7 & 7ii7 (           
subp>agraph 7,d73 7i7 ,9 g5]al ,9 ! case
 ( #a or m failures ) respect to an     
individual--  7,i7 :i* are n correct$   
be=e ! date on :i* ! plan receives a    
notice f ! ,secret>y ( su* violation2 & 
7,,ii7 :i* occurr$ or cont9u$ dur+ !    
p]iod involv$2  ! am\nt ( p5alty impos$ 
by subp>agraph 7,a7 by reason ( su*     
failures ) respect to su* individual    
%all n be less ?an #b1ejj4  7ii7 ,high] 
m9imum p5alty :]e violations are m ?an  

de m9imis ,to ! ext5t violations = :i*  
any p]son is liable "u ?is p>agraph =   
any ye> are m ?an de m9imis1 clause 7i7 
%all be appli$ by sub/itut+ #ae1jjj =   
#b1ejj ) respect to su* p]son4  7,d7    
,limitations  7i7 ,p5alty n to apply :]e
 failure n discov]$ ex]cis+ reasonable  
dilig5ce ,no p5alty %all be impos$ by   
subp>agraph 7,a7 on any failure dur+ any
 p]iod = :i* x is e/abli%$ to !         
satisfaction ( ! ,secret>y t ! p]son    
o!rwise liable = su* p5alty did n "k1 & 
ex]cis+ reasonable dilig5ce w\ld n h    
kn[n1 t su* failure exi/$4  7ii7 ,p5alty
 n to apply to failures correct$ )9     
c]ta9 p]iods ,no p5alty %all be impos$  
by subp>agraph 7,a7 on any failure if-- 
7,i7 su* failure 0 due to reasonable    
cause & n to willful neglect2 &  7,,ii7 
su* failure is correct$ dur+ ! #cj-;day 
p]iod beg9n+ on ! fir/ date ! p]son     
o!rwise liable = su* p5alty knew1 or    
ex]cis+ reasonable dilig5ce w\ld h kn[n1
 t su* failure exi/$4  7iii7 ,ov]all    
limitation = un9t5tional failures ,9 !  

case ( failures :i* are due to          
reasonable cause & n to willful neglect1
 ! p5alty impos$ by subp>agraph 7,a7 =  
failures %all n exce$ ! am\nt equal to !
 less] (--  7,i7 #aj p]c5t ( ! aggregate
 am\nt paid or incurr$ by ! employ] 7or 
pr$ecessor employ]7 dur+ ! prec$+       
taxable ye> = gr\p heal? plans2 or      
7,,ii7 #ejj1jjj4  7,e7 ,waiv] by        
,secret>y ,9 ! case ( a failure :i* is  
due to reasonable cause & n to willful  
neglect1 ! ,secret>y may waive "p or all
 ( ! p5alty impos$ by subp>agraph 7,a7  
to ! ext5t t ! paym5t ( su* p5alty w\ld 
be excessive relative to ! failure      
involv$4  7c7 ,def9itions ,= purposes ( 
?is section3  7#a7 ,gov]nm5tal plan ,!  
t]m gov]nm5tal plan has ! mean+ giv5 su*
 t]m "u section #c7cb7 ( ! ,employee    
,retirem5t ,income ,security ,act (     
#aigd & any ,f$]al gov]nm5tal plan4     
7#b7 ,f$]al gov]nm5tal plan ,! t]m      
#8,f$]al gov]nm5tal plan' means a       
gov]nm5tal plan e/abli%$ or ma9ta9$ =   
its employees by ! ,gov]nm5t ( ! ,unit$ 

,/ates or by any ag5cy or in/rum5tality 
( su* ,gov]nm5t4  7#c7 ,non-,f$]al      
gov]nm5tal plan ,! t]m non-,f$]al       
gov]nm5tal plan means a gov]nm5tal plan 
t is n a ,f$]al gov]nm5tal plan4  4  7b7
 ,con=m+ am5dm5t ,! table ( cont5ts "u  
section #a7;b7 ( ! ,heal? ,insurance    
,portability & ,acc\ntability ,act (    
#aiif 7,public ,law #ajd-aia7 is am5d$  
by ins]t+ aft] ! item relat+ to section 
#aie ! foll[+3  ,sec4 #aif4 ,gu>ante$   
availability ( cov]age4 ,sec4 #aig4     
,fair heal? insurance premiums4 ,sec4   
#aih4 ,prohibit+ discrim9ation aga9/    
individual p>ticipants & b5efici>ies    
bas$ on heal? /atus4 ,sec4 #aii4        
,prohibition ( preexi/+ condition       
exclusions or o!r discrim9ation bas$ on 
heal? /atus4 ,sec4 #aii;,a4 ,en=cem5t ( 
c]ta9 heal? insurance requirem5ts4  4   
7c7 ,,erisa & ,,irc ,en=cem5t  7#a7     
,,erisa ,subp>t ,b ( "p #g ( title ,i ( 
! ,employee ,retirem5t ,income ,security
 ,act ( #aigd 7#bi ,u4,s4,c4 #aahe et   
seq47 is am5d$ by add+ at ! end ! foll[+

 new section3  #gaf4 ,o!r m>ket re=ms   
,sections #aif & #aig ( ! ,heal?        
,insurance ,portability & ,acc\ntability
 ,act ( #aiif %all apply to heal?       
insurance issu]s provid+ heal? insurance
 cov]age 9 connection ) gr\p heal?      
plans1 & sections #aih ?r\gh #aii ( su* 
,act %all apply to gr\p heal? plans &   
heal? insurance issu]s provid+ heal?    
insurance cov]age 9 connection ) gr\p   
heal? plans1 z if includ$ 9 ?is subp>t1 
& to ! ext5t t any provision ( ?is "p   
conflicts ) a provision ( su* sections  
#aif or #aig ) respect to heal?         
insurance issu]s provid+ heal? insurance
 cov]age 9 connection ) gr\p heal? plans
 or ( su* sections #aih or #aii )       
respect to gr\p heal? plans or heal?    
insurance issu]s provid+ heal? insurance
 cov]age 9 connection ) gr\p heal?      
plans1 ! provisions ( su* sections #aif 
?r\gh #aii %all apply4  4  7#b7 ,,irc   
,sub*apt] ,b ( *apt] #ajj ( subtitle ,k 
( title #bf ( ! ,int]nal ,rev5ue ,code (
 #aihf is am5d$ by add+ at ! end !      

foll[+ new section3  #ihaf4 ,o!r m>ket  
re=ms ,sections #aif & #aig ( ! ,heal?  
,insurance ,portability & ,acc\ntability
 ,act ( #aiif %all apply to heal?       
insurance issu]s provid+ heal? insurance
 cov]age 9 connection ) gr\p heal?      
plans1 & sections #aih ?r\gh #aii ( su* 
,act %all apply to gr\p heal? plans &   
heal? insurance issu]s provid+ heal?    
insurance cov]age 9 connection ) gr\p   
heal? plans1 z if includ$ 9 ?is         
sub*apt]1 & to ! ext5t t any provision (
 ?is *apt] conflicts ) a provision ( su*
 sections #aif or #aig ) respect to     
heal? insurance issu]s provid+ heal?    
insurance cov]age 9 connection ) gr\p   
heal? plans or ( su* sections #aih or   
#aii ) respect to gr\p heal? plans or   
heal? insurance issu]s provid+ heal?    
insurance cov]age 9 connection ) gr\p   
heal? plans1 ! provisions ( su* sections
 #aif ?r\gh #aii %all apply4  4