Maintaining Protections for Patients with Preexisting Conditions Act of 2019

I 116TH CONGRESS 1ST SESSION H. R. 4159 To amend the Health Insurance Portability and Accountability Act to ensure coverage for individuals with preexisting conditions, and for other purposes. IN THE HOUSE OF REPRESENTATIVES AUGUST 2, 2019 Mr. RIGGLEMAN (for himself, Mrs. WAGNER, Mr. HUIZENGA, Mr. NEWHOUSE, and Ms. HERRERA BEUTLER) introduced the following bill; which was re- ferred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Labor, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the com- mittee concerned A BILL To amend the Health Insurance Portability and Account- ability Act to ensure coverage for individuals with pre- existing conditions, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘Maintaining Protec- 4 tions for Patients with Preexisting Conditions Act of 5 2019’’. 6 VerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159 kjohnson on DSK79L0C42 with BILLS 2 •HR 4159 IH SEC. 2. GUARANTEED AVAILABILITY OF COVERAGE; PRO- 1 HIBITING DISCRIMINATION. 2 (a) IN GENERAL.—Subtitle C of title I of the Health 3 Insurance Portability and Accountability Act of 1996 4 (Public Law 104–191) is amended by adding at the end 5 the following: 6 ‘‘SEC. 196. GUARANTEED AVAILABILITY OF COVERAGE. 7 ‘‘(a) GUARANTEED ISSUANCE OF COVERAGE IN THE 8 INDIVIDUAL AND GROUP MARKET.—Subject to sub- 9 sections (b) through (d), each health insurance issuer that 10 offers health insurance coverage in the individual or group 11 market in a State must accept every employer and indi- 12 vidual in the State that applies for such coverage. 13 ‘‘(b) ENROLLMENT.— 14 ‘‘(1) RESTRICTION.—A health insurance issuer 15 described in subsection (a) may restrict enrollment 16 in coverage described in such subsection to open or 17 special enrollment periods. 18 ‘‘(2) ESTABLISHMENT.—A health insurance 19 issuer described in subsection (a) shall, in accord- 20 ance with the regulations promulgated under para- 21 graph (3), establish special enrollment periods for 22 qualifying events (under section 603 of the Em- 23 ployee Retirement Income Security Act of 1974). 24 VerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159 kjohnson on DSK79L0C42 with BILLS 3 •HR 4159 IH ‘‘(3) REGULATIONS.—The Secretary shall pro- 1 mulgate regulations with respect to enrollment peri- 2 ods under paragraphs (1) and (2). 3 ‘‘(c) SPECIAL RULES FOR NETWORK PLANS.— 4 ‘‘(1) IN GENERAL.—In the case of a health in- 5 surance issuer that offers health insurance coverage 6 in the group and individual market through a net- 7 work plan, the issuer may— 8 ‘‘(A) limit the employers that may apply 9 for such coverage to those with eligible individ- 10 uals who live, work, or reside in the service area 11 for such network plan; and 12 ‘‘(B) within the service area of such plan, 13 deny such coverage to such employers and indi- 14 viduals if the issuer has demonstrated, if re- 15 quired, to the applicable State authority that— 16 ‘‘(i) it will not have the capacity to de- 17 liver services adequately to enrollees of any 18 additional groups or any additional individ- 19 uals because of its obligations to existing 20 group contract holders and enrollees; and 21 ‘‘(ii) it is applying this paragraph uni- 22 formly to all employers and individuals 23 without regard to the claims experience of 24 those individuals, employers and their em- 25 VerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159 kjohnson on DSK79L0C42 with BILLS 4 •HR 4159 IH ployees (and their dependents), or any 1 health status-related factor relating to 2 such individuals, employees, and depend- 3 ents. 4 ‘‘(2) 180-DAY SUSPENSION UPON DENIAL OF 5 COVERAGE.—An issuer, upon denying health insur- 6 ance coverage in any service area in accordance with 7 paragraph (1)(B), may not offer coverage in the 8 group or individual market within such service area 9 for a period of 180 days after the date such cov- 10 erage is denied. 11 ‘‘(d) APPLICATION OF FINANCIAL CAPACITY LIM- 12 ITS.— 13 ‘‘(1) IN GENERAL.—A health insurance issuer 14 may deny health insurance coverage in the group or 15 individual market if the issuer has demonstrated, if 16 required, to the applicable State authority that— 17 ‘‘(A) it does not have the financial reserves 18 necessary to underwrite additional coverage; 19 and 20 ‘‘(B) it is applying this paragraph uni- 21 formly to all employers and individuals in the 22 group or individual market in the State con- 23 sistent with applicable State law and without 24 regard to the claims experience of those individ- 25 VerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159 kjohnson on DSK79L0C42 with BILLS 5 •HR 4159 IH uals, employers and their employees (and their 1 dependents) or any health status-related factor 2 relating to such individuals, employees, and de- 3 pendents. 4 ‘‘(2) 180-DAY SUSPENSION UPON DENIAL OF 5 COVERAGE.—A health insurance issuer upon denying 6 health insurance coverage in connection with group 7 health plans in accordance with paragraph (1) in a 8 State may not offer coverage in connection with 9 group health plans in the group or individual market 10 in the State for a period of 180 days after the date 11 such coverage is denied or until the issuer has dem- 12 onstrated to the applicable State authority, if re- 13 quired under applicable State law, that the issuer 14 has sufficient financial reserves to underwrite addi- 15 tional coverage, whichever is later. An applicable 16 State authority may provide for the application of 17 this subsection on a service-area-specific basis. 18 ‘‘(e) DEFINITIONS.—In this section and in sections 19 197 through 199A: 20 ‘‘(1) The term ‘Secretary’ means the Secretary 21 of Health and Human Services. 22 ‘‘(2) The terms ‘genetic information’, ‘genetic 23 test’, ‘group health plan’, ‘group market’, ‘health in- 24 surance coverage’, ‘health insurance issuer’, ‘group 25 VerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159 kjohnson on DSK79L0C42 with BILLS 6 •HR 4159 IH health insurance coverage’, ‘individual health insur- 1 ance coverage’, ‘individual market’, and ‘under- 2 writing purpose’ have the meanings given such terms 3 in section 2791 of the Public Health Service Act. 4 ‘‘SEC. 197. FAIR HEALTH INSURANCE PREMIUMS. 5 ‘‘(a) PROHIBITING DISCRIMINATORY PREMIUM 6 RATES.— 7 ‘‘(1) IN GENERAL.—With respect to the pre- 8 mium rate charged by a health insurance issuer for 9 health insurance coverage offered in the individual 10 or small group market— 11 ‘‘(A) such rate shall vary with respect to 12 the particular plan or coverage involved only 13 by— 14 ‘‘(i) whether such plan or coverage 15 covers an individual or family; 16 ‘‘(ii) rating area, as established in ac- 17 cordance with paragraph (2); 18 ‘‘(iii) age, except that such rate shall 19 not vary by more than 3 to 1 for adults; 20 and 21 ‘‘(iv) tobacco use, except that such 22 rate shall not vary by more than 1.5 to 1; 23 and 24 VerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159 kjohnson on DSK79L0C42 with BILLS 7 •HR 4159 IH ‘‘(B) such rate shall not vary with respect 1 to the particular plan or coverage involved by 2 any other factor not described in subparagraph 3 (A). 4 ‘‘(2) RATING AREA.— 5 ‘‘(A) IN GENERAL.—Each State shall es- 6 tablish 1 or more rating areas within that State 7 for purposes of applying the requirements of 8 this title. 9 ‘‘(B) SECRETARIAL REVIEW.—The Sec- 10 retary shall review the rating areas established 11 by each State under subparagraph (A) to en- 12 sure the adequacy of such areas for purposes of 13 carrying out the requirements of this title. If 14 the Secretary determines a State’s rating areas 15 are not adequate, or that a State does not es- 16 tablish such areas, the Secretary may establish 17 rating areas for that State. 18 ‘‘(3) PERMISSIBLE AGE BANDS.—The Sec- 19 retary, in consultation with the National Association 20 of Insurance Commissioners, shall define the permis- 21 sible age bands for rating purposes under paragraph 22 (1)(A)(iii). 23 ‘‘(4) APPLICATION OF VARIATIONS BASED ON 24 AGE OR TOBACCO USE.—With respect to family cov- 25 VerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159 kjohnson on DSK79L0C42 with BILLS 8 •HR 4159 IH erage under a group health plan or health insurance 1 coverage, the rating variations permitted under 2 clauses (iii) and (iv) of paragraph (1)(A) shall be 3 applied based on the portion of the premium that is 4 attributable to each family member covered under 5 the plan or coverage. 6 ‘‘SEC. 198. PROHIBITING DISCRIMINATION AGAINST INDI- 7 VIDUAL PARTICIPANTS AND BENEFICIARIES 8 BASED ON HEALTH STATUS. 9 ‘‘(a) IN GENERAL.—A group health plan and a health 10 insurance issuer offering group or individual health insur- 11 ance coverage may not establish rules for eligibility (in- 12 cluding continued eligibility) of any individual to enroll 13 under the terms of the plan or coverage based on any of 14 the following health status-related factors in relation to 15 the individual or a dependent of the individual: 16 ‘‘(1) Health status. 17 ‘‘(2) Medical condition (including both physical 18 and mental illnesses). 19 ‘‘(3) Claims experience. 20 ‘‘(4) Receipt of health care. 21 ‘‘(5) Medical history. 22 ‘‘(6) Genetic information. 23 ‘‘(7) Evidence of insurability (including condi- 24 tions arising out of acts of domestic violence). 25 VerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159 kjohnson on DSK79L0C42 with BILLS 9 •HR 4159 IH ‘‘(8) Disability. 1 ‘‘(9) Any other health status-related factor de- 2 termined appropriate by the Secretary. 3 ‘‘(b) IN PREMIUM CONTRIBUTIONS.— 4 ‘‘(1) IN GENERAL.—A group health plan, and a 5 health insurance issuer offering group or individual 6 health insurance coverage, may not require any indi- 7 vidual (as a condition of enrollment or continued en- 8 rollment under the plan) to pay a premium or con- 9 tribution which is greater than such premium or 10 contribution for a similarly situated individual en- 11 rolled in the plan on the basis of any health status- 12 related factor in relation to the individual or to an 13 individual enrolled under the plan as a dependent of 14 the individual. 15 ‘‘(2) CONSTRUCTION.—Nothing in paragraph 16 (1) shall be construed— 17 ‘‘(A) to restrict the amount that an em- 18 ployer or individual may be charged for cov- 19 erage under a group health plan except as pro- 20 vided in paragraph (3) or individual health cov- 21 erage, as the case may be; or 22 ‘‘(B) to prevent a group health plan, and 23 a health insurance issuer offering group health 24 insurance coverage, from establishing premium 25 VerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159 kjohnson on DSK79L0C42 with BILLS 10 •HR 4159 IH discounts or rebates or modifying otherwise ap- 1 plicable copayments or deductibles in return for 2 adherence to programs of health promotion and 3 disease prevention. 4 ‘‘(3) NO GROUP-BASED DISCRIMINATION ON 5 BASIS OF GENETIC INFORMATION.— 6 ‘‘(A) IN GENERAL.—For purposes of this 7 section, a group health plan, and health insur- 8 ance issuer offering group health insurance cov- 9 erage in connection with a group health plan, 10 may not adjust premium or contribution 11 amounts for the group covered under such plan 12 on the basis of genetic information. 13 ‘‘(B) RULE OF CONSTRUCTION.—Nothing 14 in subparagraph (A) or in paragraphs (1) and 15 (2) of subsection (d) shall be construed to limit 16 the ability of a health insurance issuer offering 17 group or individual health insurance coverage to 18 increase the premium for an employer based on 19 the manifestation of a disease or disorder of an 20 individual who is enrolled in the plan. In such 21 case, the manifestation of a disease or disorder 22 in one individual cannot also be used as genetic 23 information about other group members and to 24 further increase the premium for the employer. 25 VerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159 kjohnson on DSK79L0C42 with BILLS 11 •HR 4159 IH ‘‘(c) GENETIC TESTING.— 1 ‘‘(1) LIMITATION ON REQUESTING OR REQUIR- 2 ING GENETIC TESTING.—A group health plan, and a 3 health insurance issuer offering health insurance 4 coverage in connection with a group health plan, 5 shall not request or require an individual or a family 6 member of such individual to undergo a genetic test. 7 ‘‘(2) RULE OF CONSTRUCTION.—Paragraph (1) 8 shall not be construed to limit the authority of a 9 health care professional who is providing health care 10 services to an individual to request that such indi- 11 vidual undergo a genetic test. 12 ‘‘(3) RULE OF CONSTRUCTION REGARDING PAY- 13 MENT.— 14 ‘‘(A) IN GENERAL.—Nothing in paragraph 15 (1) shall be construed to preclude a group 16 health plan, or a health insurance issuer offer- 17 ing health insurance coverage in connection 18 with a group health plan, from obtaining and 19 using the results of a genetic test in making a 20 determination regarding payment (as such term 21 is defined for the purposes of applying the regu- 22 lations promulgated by the Secretary under 23 part C of title XI of the Social Security Act and 24 VerDate Sep 11 2014 23:32 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H4159.IH H4159 kjohnson on DSK79L0C42 with BILLS 12 •HR 4159 IH section 264 of this Act, as may be revised from 1 time to time) consistent with subsection (a). 2 ‘‘(B) LIMITATION.—For purposes of sub- 3 paragraph (A), a group health plan, or a health 4 insurance issuer offering health insurance cov- 5 erage in connection with a group health plan, 6 may request only the minimum amount of in- 7 formation necessary to accomplish the intended 8 purpose. 9 ‘‘(4) RESEARCH EXCEPTION.—Notwithstanding 10 paragraph (1), a group health plan, or a health in- 11 surance issuer offering health insurance coverage in 12 connection with a group health plan, may request, 13 but not require, that a participant or beneficiary un- 14 dergo a genetic test if each of [Text truncated for display. 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