11 So in original. No subsec. (b) has been enacted. Prohibiting discriminatory premium rates
(1)
In general
With respect to the premium rate charged by a health insurance issuer for health insurance coverage offered in the individual or small group market—
(A)
such rate shall vary with respect to the particular plan or coverage involved only by—
(i)
whether such plan or coverage covers an individual or family;
(ii)
rating area, as established in accordance with paragraph (2);
(iii)
section 300gg–6(c) of this title age, except that such rate shall not vary by more than 3 to 1 for adults (consistent with ); and
(iv)
tobacco use, except that such rate shall not vary by more than 1.5 to 1; and
(B)
such rate shall not vary with respect to the particular plan or coverage involved by any other factor not described in subparagraph (A).
(2)
Rating area
(A)
In general
Each State shall establish 1 or more rating areas within that State for purposes of applying the requirements of this subchapter.
(B)
Secretarial review
The Secretary shall review the rating areas established by each State under subparagraph (A) to ensure the adequacy of such areas for purposes of carrying out the requirements of this subchapter. If the Secretary determines a State’s rating areas are not adequate, or that a State does not establish such areas, the Secretary may establish rating areas for that State.
(3)
Permissible age bands
The Secretary, in consultation with the National Association of Insurance Commissioners, shall define the permissible age bands for rating purposes under paragraph (1)(A)(iii).
(4)
Application of variations based on age or tobacco use
With respect to family coverage under a group health plan or health insurance coverage, the rating variations permitted under clauses (iii) and (iv) of paragraph (1)(A) shall be applied based on the portion of the premium that is attributable to each family member covered under the plan or coverage.
(5)
Special rule for large group market
section 18032(f)(2)(B) of this titleIf a State permits health insurance issuers that offer coverage in the large group market in the State to offer such coverage through the State Exchange (as provided for under ), the provisions of this subsection shall apply to all coverage offered in such market (other than self-insured group health plans offered in such market) in the State.
Pub. L. 111–148section 300gg of this titlesection 300gg–3 of this title“This subtitle [subtitle C (§§ 1201–1255) of title I of , enacting subchapter II of chapter 157 of this title and sections 300gg to 300gg–2 and 300gg–4 to 300gg–7 of this title, and amending sections 300gg–1 and 300gg–4 of this title and transferring former to ] (and the amendments made by this subtitle) shall become effective for plan years beginning on or after , except that—“(1)
section 18011 of this title section 1251 [enacting ] shall take effect on the date of enactment of this Act []; and
“(2)
42 U.S.C. 300gg–3 the provisions of section 2704 of the Public Health Service Act [] (as amended by section 1201), as they apply to enrollees who are under 19 years of age, shall become effective for plan years beginning on or after the date that is 6 months after the date of enactment of this Act [].. [sic]”
42 U.S.C. 300ggExcept as provided in this subsection, part A of title XXVII of the Public Health Service Act [ et seq.] (as added by subsection (a)) shall apply with respect to group health plans, and health insurance coverage offered in connection with group health plans, for plan years beginning after .
“(2)
Determination of creditable coverage.—
“(A)
Period of coverage.—
“(i)
In general .—
42 U.S.C. 300ggSubject to clause (ii), no period before , shall be taken into account under part A of title XXVII of the Public Health Service Act [ et seq.] (as added by this section) in determining creditable coverage.
“(ii)
Special rule for certain periods .—
42 U.S.C. 300gg–92The Secretary of Health and Human Services, consistent with section 104 [ note], shall provide for a process whereby individuals who need to establish creditable coverage for periods before , and who would have such coverage credited but for clause (i) may be given credit for creditable coverage for such periods through the presentation of documents or other means.
“(B)
Certifications, etc.—
“(i)
In general .—
42 U.S.C. 300gg–3(e)Subject to clauses (ii) and (iii), subsection (e) of section 2701 [now 2704] of the Public Health Service Act [] (as added by this section) shall apply to events occurring after .
“(ii)
No certification required to be provided before .—
In no case is a certification required to be provided under such subsection before .
“(iii)
Certification only on written request for events occurring before .—
In the case of an event occurring after , and before , a certification is not required to be provided under such subsection unless an individual (with respect to whom the certification is otherwise required to be made) requests such certification in writing.
“(C)
Transitional rule .—
In the case of an individual who seeks to establish creditable coverage for any period for which certification is not required because it relates to an event occurring before —
“(i)
the individual may present other credible evidence of such coverage in order to establish the period of creditable coverage; and
“(ii)
a group health plan and a health insurance issuer shall not be subject to any penalty or enforcement action with respect to the plan’s or issuer’s crediting (or not crediting) such coverage if the plan or issuer has sought to comply in good faith with the applicable requirements under the amendments made by this section [enacting this section and sections 300gg–1, 300gg–11 to 300gg–13, 300gg–21 to 300gg–23, 300gg–91, and 300gg–92 of this title and amending sections 300e and 300bb–8 of this title].
“(3)
Special rule for collective bargaining agreements .—
42 U.S.C. 300gg42 U.S.C. 300gg–3(e)Except as provided in paragraph (2)(B), in the case of a group health plan maintained pursuant to 1 or more collective bargaining agreements between employee representatives and one or more employers ratified before the date of the enactment of this Act [], part A of title XXVII of the Public Health Service Act [ et seq.] (other than section 2701(e) [now 2704(e)] thereof []) shall not apply to plan years beginning before the later of—
“(A)
the date on which the last of the collective bargaining agreements relating to the plan terminates (determined without regard to any extension thereof agreed to after the date of the enactment of this Act), or
“(B)
.
For purposes of subparagraph (A), any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement of such part shall not be treated as a termination of such collective bargaining agreement.
“(4)
Timely regulations .—
42 U.S.C. 300gg–92The Secretary of Health and Human Services, consistent with section 104 [ note], shall first issue by not later than , such regulations as may be necessary to carry out the amendments made by this section [enacting this section and sections 300gg–1, 300gg–11 to 300gg–13, 300gg–21 to 300gg–23, 300gg–91, and 300gg–92 of this title and amending sections 300e and 300bb–8 of this title] and section 111 [enacting sections 300gg–41 to 300gg–44 and 300gg–61 to 300gg–63 of this title].
“(5)
Limitation on actions .—
No enforcement action shall be taken, pursuant to the amendments made by this section, against a group health plan or health insurance issuer with respect to a violation of a requirement imposed by such amendments before , or, if later, the date of issuance of regulations referred to in paragraph (4), if the plan or issuer has sought to comply in good faith with such requirements.”
, , , provided that:
Congressional Findings Relating to Exercise of Commerce Clause Authority; Severability
Findings Relating to Exercise of Commerce Clause Authority .—
section 300gg–92 of this titlesection 1181 of Title 29Congress finds the following in relation to the provisions of this title [enacting this subchapter and sections 1181 to 1183 and 1191 to 1191c of Title 29, Labor, amending sections 233, 300e, and 300bb–8 of this title and sections 1003, 1021, 1022, 1024, 1132, 1136, and 1144 of Title 29, and enacting provisions set out as notes under this section, , and ]:
“(1)
Provisions in group health plans and health insurance coverage that impose certain preexisting condition exclusions impact the ability of employees to seek employment in interstate commerce, thereby impeding such commerce.
“(2)
Health insurance coverage is commercial in nature and is in and affects interstate commerce.
“(3)
It is a necessary and proper exercise of Congressional authority to impose requirements under this title on group health plans and health insurance coverage (including coverage offered to individuals previously covered under group health plans) in order to promote commerce among the States.
“(4)
29 U.S.C. 1001 Congress, however, intends to defer to States, to the maximum extent practicable, in carrying out such requirements with respect to insurers and health maintenance organizations that are subject to State regulation, consistent with the provisions of the Employee Retirement Income Security Act of 1974 [ et seq.].
“(b)
Severability .—
If any provision of this title or the application of such provision to any person or circumstance is held to be unconstitutional, the remainder of this title and the application of the provisions of such to any person or circumstance shall not be affected thereby.”
, , , provided that:
Health Coverage Availability Studies
Pub. L. 104–191, title I, § 191110 Stat. 1987Pub. L. 104–191, , , directed the Secretary of Health and Human Services to provide for a study on the effectiveness of the provisions of title I of and the various State laws, in ensuring the availability of reasonably priced health coverage to employers and individuals and a study on access to, and choice of, health care providers and the cost and cost-effectiveness to health insurance issuers of providing access to out-of-network providers, and the potential impact of providing such access on the cost and quality of health insurance coverage, and to report to the appropriate committees of Congress on each of such studies not later than .