Sec. 4. Pool reform for individual membership expansion
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/bill/114/hr/2650/ih/section-4A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
The Public Health Service Act is further amended by adding at the end the following: The purpose of this title is to provide, through the establishment of individual health pools (or IHPs), for the reform of, and expansion of enrollment in, health insurance coverage for individuals and small employers. For purposes of this title, the terms individual health pool and IHP mean a legal nonprofit entity that meets the following requirements: The IHP— has been formed and maintained in good faith for a purpose that includes the formation of a risk pool in order to offer health insurance coverage to its members; does not condition membership in the IHP on any health status-related factor relating to an individual (including an employee of an employer or a dependent of an employee); does not make health insurance coverage offered through the IHP available other than in connection with a member of the IHP; is not a health insurance issuer; and does not receive any consideration directly or indirectly from any health insurance issuer in connection with the enrollment of any individuals, or employees of employers, in any health insurance coverage, except in conjunction with services offered through the IHP.
The IHP, in conjunction with those health insurance issuers that offer health benefits coverage through the IHP, makes available health benefits coverage in the manner described in subsection
(b)to all members of the IHP and the dependents of such members (and, in the case of small employers, employees and their dependents) in the manner described in subsection (c)(2) at rates that are established by the health insurance issuer on a policy or product specific basis and that may vary for individuals covered through an IHP. Subject to clause (ii), the IHP may not offer health benefits coverage to a member of an IHP unless the same coverage is offered to all such members of the IHP. Nothing in this title shall be construed as requiring or permitting a health insurance issuer to provide coverage outside the service area of the issuer, as approved under State law, or preventing a health insurance issuer from underwriting or from excluding or limiting the coverage on any individual, subject to the requirement of section 2741 (relating to guaranteed availability of individual health insurance coverage to certain individuals with prior group coverage). The IHP provides health benefits coverage only through contracts with health insurance issuers and does not assume insurance risk with respect to such coverage. Nothing in this title shall be construed as preventing the establishment and operation of more than one IHP in a geographic area or as limiting the number of IHPs that may operate in any area. The IHP may provide administrative services for members. Such services may include accounting, billing, and enrollment information. Except as provided in section 3402, any health benefits coverage offered through an IHP— shall be issued by a health insurance issuer that meets all applicable State standards relating to consumer protection; shall be approved or otherwise permitted to be offered under State law; and may not impose any exclusion of a specific disease from such coverage. Nothing in this title shall be construed as precluding a health insurance issuer offering health benefits coverage through an IHP from establishing premium discounts or rebates for members or from modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention so long as such programs are agreed to in advance by the IHP and comply with all other provisions of this title and do not discriminate among similarly situated members. Under rules established to carry out this title, with respect to an individual or small employer who is a member of an IHP, the individual may enroll for health benefits coverage (including coverage for dependents of such individual) or employer may enroll employees for health benefits coverage (including coverage for dependents of such employees) offered by a health insurance issuer through the IHP. Nothing in this paragraph shall preclude an IHP from establishing rules of enrollment and reenrollment of members. Such rules shall be applied consistently to all members within the IHP and shall not be based in any manner on health status-related factors. The contract between an IHP and a health insurance issuer shall provide, with respect to a member enrolled with health benefits coverage offered by the issuer through the IHP, for the payment to the issuer of the premiums (if any) collected by the IHP for health insurance coverage offered by the issuer. Any State law or regulation relating to the composition or organization of an IHP is preempted to the extent the law or regulation is inconsistent with the provisions of this title. Subject to subparagraph (B), State laws are superseded, and shall not apply to health benefits coverage made available through an IHP, insofar as such laws impose benefit requirements for such coverage, including (but not limited to) requirements relating to coverage of specific providers, specific services or conditions, or the amount, duration, or scope of benefits. Subparagraph
(A)shall not apply to a requirement to the extent the requirement— implements title XXVII or other Federal law; or prohibits imposition of an exclusion of a specific disease from health benefits coverage. State laws are superseded, and shall not apply to health benefits coverage made available through an IHP, insofar as such laws impose any other requirements (including limitations on compensation arrangements) that, directly or indirectly, preclude (or have the effect of precluding) the offering of such coverage through an IHP, if the IHP meets the requirements of this title. State laws are superseded, and shall not apply to the premiums imposed for health benefits coverage made available through an IHP, insofar as such laws impose restrictions on the variation of premiums among such coverage offered to members of the IHP. For purposes of this title: The term dependent , as applied to health insurance coverage offered by a health insurance issuer licensed (or otherwise regulated) in a State, shall have the meaning applied to such term with respect to such coverage under the laws of the State relating to such coverage and such an issuer. Such term may include the spouse and children of the individual involved. The term health benefits coverage has the meaning given the term health insurance coverage in section 2791(b)(1), and does not include excepted benefits (as defined in section 2791(c)). The term health insurance issuer has the meaning given such term in section 2791(b)(2). The term health status-related factor has the meaning given such term in section 2791(d)(9). The term member means, with respect to an IHP, an individual or small employer who is a member of the legal entity described in section 3401(a)(1) to which the IHP is offering coverage. The term small employer has the meaning given such term in section 712(c)(1)(B) of the Employee Retirement and Income Security Act of 1974. .