Sec. 221. Requirements for individual health insurance

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Section 2741 of the Public Health Service Act ( 42 U.S.C. 300gg–41 ), as restored and revived by section 2 of this Act, is amended— in subsection (a)— in the heading, by striking to certain individuals with prior group coverage ; in paragraph (1), by striking and section 2744 ; in paragraph (1)(B), by inserting unless such exclusion complies with paragraph

(2)before the period; and by striking paragraph

(2)and inserting the following new paragraphs: A health insurance issuer offering health insurance coverage in the individual market may not, with respect to an enrollee in such coverage, impose any preexisting condition exclusion if such enrollee has at least 18 months of continuous creditable coverage (as defined in section 2701(c)(1)) immediately preceding the enrollment date. Notwithstanding paragraph (1)(B), a health insurance issuer offering health insurance coverage in the individual market may, with respect to an enrollee in such coverage who is not described in subparagraph (A), impose a preexisting condition exclusion only if— such exclusion relates to a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on the enrollment date; such exclusion extends for a period of not more than 18 months after the enrollment date; and the period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage (if any, as defined in section 2701(c)(1)) applicable to the enrollee as of the enrollment date. Notwithstanding paragraph (6), with respect to an enrollee described in subparagraph (B), a health insurance issuer may charge a premium for the coverage involved that does not exceed 150 percent of the applicable standard rate, for not to exceed 24 months (or 36 months if the health insurance issuer does not impose any preexisting condition exclusion with respect to such enrollee), reduced by the aggregate of the periods of creditable coverage (if any, as defined in section 2701(c)(1)) applicable to the enrollee as of the enrollment date. For purposes of this subsection, the term applicable standard rate means the standard premium rate that the issuer charges for the coverage involved with respect to an individual described in subparagraph

(A)with the same rating characteristics or rating factors as the enrollee described in subparagraph (B), provided that any variations in standard premium rates are based on the uniform application of rating characteristics or rating factors that are permitted by State law and are not otherwise prohibited by paragraph (6). Notwithstanding paragraph (2), and subject to subparagraph (D), a health insurance issuer offering health insurance coverage in the individual market, may not impose any of the following preexisting condition exclusion: In the case of an individual who, as of the last day of the 30-day period beginning with the date of birth, is a dependent of an enrollee in such coverage. In the case of a child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period beginning on the date of the adoption or placement for adoption, is a dependent of an enrollee in such coverage. The previous sentence shall not apply to coverage before the date of such adoption or placement for adoption. Relating to pregnancy as a preexisting condition. Subparagraphs

(A)and

(B)shall no longer apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any creditable coverage. A health insurance issuer offering health insurance coverage in the individual market may limit the applicability of the provisions of paragraph

(1)to scheduled open enrollment periods, provided that— any such open enrollment period shall not be less than 30 days; any period between scheduled open enrollment periods shall not exceed 24 months; and such limitation shall not apply to any individual who qualifies for a special enrollment period under paragraph (5). Subject to subparagraphs

(E)and (F), a health insurance issuer offering health insurance coverage in the individual market shall permit an individual who is an eligible individual or a dependent to enroll in coverage during a special enrollment period if the individual experiences any of the following qualifying events: The individual becomes, by reason of marriage, birth, adoption or placement for adoption, a dependent of an individual enrolled in a plan offered by the health insurance issuer and such individual otherwise qualifies, under the terms of the plan, as eligible for coverage as a dependent of such enrollee. The individual loses coverage under a group health plan as a result of— loss of eligibility for the coverage (including as a result of legal separation, divorce, death, attaining an age at which eligibility terminates, termination of employment, or reduction in the number of hours of employment); or termination of the coverage by the plan sponsor. The individual loses individual market coverage as a result of— discontinuation of a plan as a result of a health insurance issuer ceasing to offer coverage in the individual market in accordance with section 2742(c)(2) ( 42 U.S.C. 300gg–42(c)(2) ) of this title; expiration of COBRA, or other, continuation coverage; ceasing to qualify, under the terms of the coverage, as a dependent (including as a result of legal separation, divorce, death, or attaining an age at which eligibility terminates); and permanently moving outside the State in which the coverage was issued, or in the case of a network plan, outside the plan’s service area. The individual loses coverage by ceasing to be eligible for coverage under any of the following: Part A or part B of title XVIII of the Social Security Act ( 42 U.S.C. 1395c et seq. , 1395j et seq.). Title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq. ), other than coverage consisting solely of benefits under section 1928 ( 42 U.S.C. 1396s ). Title XXI of the Social Security Act ( 42 U.S.C. 1397aa et seq. ). Chapter 55 of title 10. Chapter 89 of title 5. A State health benefits risk pool. For purposes of this paragraph, loss of coverage shall not include any of the following: Voluntary termination of coverage by an individual, except if such termination is the result of circumstances described in subparagraph (C)(iv). Termination of coverage by the issuer or the plan sponsor of the coverage for any reason described in paragraphs

(1)or

(2)of section 2742(b) (300gg–42(b)) of this title. Loss of any coverage that consists solely of coverage of excepted benefits (as defined in section 300gg–91(c) of this title). Any special enrollment period shall not be less than 60 days and shall begin on the date of the qualifying event. With respect to the premium rate charged by a health insurance issuer for health insurance coverage offered in the individual market, such rate, with respect to the particular plan or coverage involved, shall not vary based on any of the following health status-related factors in relation to an eligible individual or dependent: Health status. Medical condition (including both physical and mental illnesses). Claims experience. Receipt of health care. Medical history. Genetic information. Evidence of insurability (including conditions arising out of acts of domestic violence). Disability. ; by amending subsection

(b)to read as follows: For purposes of this section: The term eligible individual means an individual who is eligible under applicable State law to purchase individual health insurance coverage in the State. The term dependent means an individual who, under the terms of the coverage and applicable State law, qualifies to enroll in such coverage as a dependent of an individual described in paragraph (1). ; and by striking subsection

(c)and redesignating subsection

(d)and the first subsection

(e)as subsections

(c)and (d), respectively. Section 2744 of the Public Health Service Act ( 42 U.S.C. 300gg–44 ), as restored and revived by section 2 of this Act, is repealed. The amendments made by this section shall apply with respect to health insurance coverage offered for plan years beginning after the date of the enactment of this Act.

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