,,ii ,calendar ,no4 #eed #aafth ,,congress #b;d ,session ,s4 #dfge ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,september #bc1 #bjbj,mr4 ,tillis introduced the following bill2 which was read the first time ,september #bd1 #bjbj,read the second time and placed on the calendar ,a ,,bill ,to amend the ,health ,insurance ,portability and ,accountability ,act4 #a4 ,short title ,this ,act may be cited as the ,protect ,act4 #b4 ,findings ,congress finds as follows3 7#a7 ,in ,president ,obama's last year in office1 ,obamacare's high costs exposed working ,americans to potential health insurance coverage loss1 the most extreme form of lacking pre-existing conditions protection4 ,that year1 there was a #bj percent decrease in enrollment in plans offered on the ,exchange among working ,americans who earned too much to receive a premium tax credit subsidy1 but not enough to cover the over #aje percent increases in premiums under ,obamacare4 7#b7 ,in #bjae1 nearly #hj percent of the households who paid the individual mandate tax earned less than #ej1jjj per year4 7#c7 ,recognizing this unfair burden1 in ,december #bjag1 ,congress acted to restore freedom and liberty to ,americans by eliminating the penalty for noncompliance with such individual mandate4 7#d7 ,obamacare is not the only way to protect ,americans with pre-existing conditions4 7#e7 ,obamacare's one-size-fits-all approach undermines ,states' ability to care for their populations and left many ,americans unable to afford any health insurance in the individual market4 7#f7 ,congress will protect individuals with preexisting conditions if the ,supreme ,court ultimately determines in ,texas v4 ,california that ,obamacare is unconstitutional4 #c4 ,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 ,prohibition of pre-existing condition exclusions 7a7 ,in general ,a group health plan and a health insurance issuer offering group or individual health insurance coverage may not impose any pre-existing condition exclusion with respect to such plan or coverage4 7b7 ,definitions ,for purposes of this section3 7#a7 ,pre-existing condition exclusion 7,a7 ,in general ,the term pre-existing 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 enrollment date 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 subparagraph 7,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 ,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 #aig4 ,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 basis 7e7 ,definitions ,in this section and in sections #aif and #aih3 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 4 #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 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 ,prohibition of pre-existing condition exclusions4,sec4 #aig4 ,guaranteed ,availability of ,coverage4,sec4 #aih4 ,prohibiting ,discrimination against individual participants and beneficiaries based on health status4 4 7c7 ,enforcement 7#a7 ,,phsa ,section #bgbc of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#bb7 is amended-- 7,a7 in subsection 7a7-- 7i7 in paragraph 7#a71 by inserting and sections #aif 1#aig1 and #aih of the ,health ,insurance ,portability and ,accountability ,act of #aiif after this part2 and 7ii7 in paragraph 7#b71 by inserting or section #aif1 #aig1 or #aih of the ,health ,insurance ,portability and ,accountability ,act of #aiif after this part2 and 7,b7 in subsection 7b71 by inserting or section #aif1 #aig1 or #aih of the ,health ,insurance ,portability and ,accountability ,act of #aiif after this part each place such term appears4 7#b7 ,,erisa ,section #gae of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahe;d7 is amended by adding at the end the following3 7c7 ,additional provisions ,section #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 #aif and #aih 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 section #aig with respect to health insurance issuers providing health insurance coverage in connection with group health plans or of such section #aif or #aih 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 #aif1 #aig1 and #aih1 as applicable1 shall apply4 4 7#c7 ,,irc ,section #ihae of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following3 7c7 ,additional provisions ,section #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 section #aif and #aih 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 section #aig with respect to health insurance issuers providing health insurance coverage in connection with group health plans or of such section #aif or #aih 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 #aif1 #aig1 and #aih1 as applicable1 shall apply4 4 7d7 ,effective date ,this amendments made by this section shall take effect one day after the date of enactment of this ,act4 ,september #bd1 #bjbj,read the second time and placed on the calendar