a) Definitions.

i) “Carrier”  means an entity that provides health insurance in this [STATE] including an insurance company, health service corporation, managed care organization and any other entity subject to state insurance regulation for health insurance. The term also includes any third-party administrator or other entity that adjusts, administers, or settles claims in connection with health insurance.

ii) “Commissioner”  means the State Insurance Commissioner [or equivalent].

iii) “Department”  means State Department of Insurance [or equivalent].

iv) “Dependent” as defined in 26 U.S.C. § 152(f)(1).

v) “Essential benefits” means the minimum benefits that must be included in a health insurance policy under this Act which includes:

1) Ambulatory patient services 

2) Emergency services

3) Hospitalization 

4) Pregnancy, maternity, and newborn care 

5) Mental health and substance use disorder services, including behavioral health treatment 

6) Prescription drugs

7) Rehabilitative and habilitative services and devices 

8) Laboratory services

9) Preventative and wellness services and chronic disease management

10) Pediatric services, including oral and vision care

vi) “Health insurance policy” means a policy, subscriber contract, certificate or plan issued by a carrier that provides medical or healthcare coverage. The term does not include:

1) An accident only policy; 

2) A credit only policy; 

3) A long-term care or disability income policy; 

4) A specified disease policy; 

5) A medicare supplement policy; 

6) A fixed indemnity policy; 

7) A dental only policy; 

8) A vision only policy; 

9) A workers’ compensation policy; 

10) An automobile medical payment policy; 

11) A policy under which benefits are provided by the Federal Government to active or former military personnel and their dependents; 

12) A hospital indemnity policy; or

13) Any other similar policies providing for limited benefits.

vi) “Preexisting condition exclusion” means a limitation or exclusion of benefits, including denial of coverage, based on the fact that the condition was present before the effective date of coverage under a group health plan or group or individual health insurance coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that day.

vii) “Protected class” as defined in 45 CFR 92 and implementing rules and regulations as in effect January 1, 2025, or [STATE law defining protected classes].

b) Authority.

i) The Commissioner shall ensure that a health insurance policy offered to, or in use by the residents of [STATE] includes at a minimum the benefits required by this Act. 

ii) The Department shall promulgate regulations as necessary to implement and administer this Act.

c) Coverage requirements.

i) A carrier offering a health insurance policy in [STATE] shall not impose any preexisting condition exclusion with respect to coverage under the plan.

ii) Each carrier that offers health insurance coverage in the individual or group market in the state shall accept every individual, including eligible dependents, in the state that applies for such coverage who is eligible to apply.

d) Limitations on premium rates.

i) A carrier shall apply the rating variations permitted under this subsection based on the portion of the premium that is attributable to each family member covered under the plan in accordance with regulations promulgated by the Department.

1) Premiums may only be adjusted annually, except that the carrier may change the premium rates to reflect:

(a) Changes to the family composition of the policyholder or employee;

(b) Changes in geographic rating area of the policyholder or tobacco use;

(c) Changes to the health insurance policy requested by the policyholder; or,

(d) Other changes required by federal law or regulations or otherwise expressly permitted by [STATE] law or regulation.

e) Annual and lifetime limits. A carrier offering, issuing, or renewing a health insurance policy in [STATE] shall not establish, on an annual or lifetime basis, a limit on the dollar value of any essential benefit for a covered individual, whether provided by an in-network or out-of-network provider.

f) Coverage for dependents until age twenty-six.

i) A carrier offering, issuing, or renewing a health insurance policy in [STATE] that includes coverage of dependents shall continue to make such coverage available for an adult dependent who has not attained the age of twenty-six prior to the date of issuance of renewal.

ii) With respect to a dependent who has not attained the age of twenty-six, a health insurance policy:

1) Shall not deny or restrict coverage based on:

(a) The presence or absence of financial dependency; 

(b) The residency of the dependent; 

(c) The marital status of the dependent; 

(d) The enrollment of the dependent in an educational institution; or 

(e) The employment status of the dependent.

2) Shall not vary terms of dependent children on the basis of age.

g) Preventative care.

i) Each health insurance policy offered in [STATE] shall include coverage of preventative services from in-network providers without copayments, deductibles, coinsurance, or other cost sharing, as described in 42 U.S.C. Sec. 300gg-12 and related regulations and guidance as of January 1, 2025, as well as any additional covered services added thereafter.

ii) The Department shall promulgate regulations determining preventative services which shall be included in health insurance policies under this section.

iii) The Department shall maintain a list of preventative services on the Department’s publicly accessible internet website.

h) Nondiscrimination in health insurance policies.

i) A carrier shall not, on the basis of an individual’s actual or perceived membership in a protected class, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any health insurance policy issued or delivered in this state.

ii) A carrier shall not in offering, providing, or administering a health insurance policy do any of the following:

1) Deny, cancel, limit or refuse to issue or renew a health plan or other health-related coverage;

2) Deny or limit coverage of a claim or impose additional cost sharing or other limitations or restrictions on coverage on the basis of actual or perceived membership in a protected class; or 

3) Implement or maintain marketing practices or benefit designs that discriminate on the basis of actual or perceived membership in a protected class.

i) Enforcement.

i) In addition to any other penalty provided by law, a violation of this Act may be punished by any of the following at the Commissioner’s discretion:

1) Suspension or revocation of the license of the offending carrier or other person;

2) Refusal, for a period not to exceed one year, to issue a new license to the offending carrier or other person;

3) A fine of not more than $5,000 for each violation of this Act;

4) A fine of not more than $10,000 for each willful violation of this Act.

5) Fines imposed against an individual carrier under this Act may not exceed $500,000 in the aggregate during a single calendar year.

6) Fines imposed against any other person under this Act may not exceed $100,000 in the aggregate during a single calendar year.

ii) Commencing [ONE YEAR AFTER ENACTMENT], and every year thereafter, the penalty amounts specified in this section shall be adjusted based on whichever is the higher of:

1) The average rate of change in premium rates for the individual and small group markets, weighted by enrollment since the previous adjustment; or

2) Adjustment based on inflation.

j) Severability: The provisions of this Act are severable. If any provision of this Act or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application.

k) Data Privacy and Aggregation: [STATE] has a compelling interest in protecting privacy and personal information. The Department shall only request data necessary to administer this Act and retain it only as required to administer and achieve the purposes of the Act. Any personal information or data collected or obtained in the course of administering this Act shall be shared only in a manner that has been deidentified and aggregated to the greatest extent allowable while still in compliance with federal eligibility requirements and every allowable effort shall be made to revoke access to such data should the need for access expire. Personal information or data collected or obtained in the course of administering this Act shall not be otherwise disclosed without the informed consent of the individual, a warrant signed by a [STATE] judge or federal judge, lawful court order administered within [STATE] or a lawful federal court order, or subpoena administered within [STATE] or federal subpoena, or unless otherwise required by federal or state statute. Personal information or data may be considered deidentified if it cannot reasonably be used to infer information about, or otherwise be linked to, a particular individual or household.