Topic	Senate Year	House Year	Senate Bill HR 3590	House Bill HR 3962
High Risk Pool Pre Exchange	2010	2010	Temporary national insurance high-risk pool. Within 90 days of enactment a high risk insurance pool will be made available to people who have been uninsured for 6 months and have a preexisting condition. Ensures premium rate limits for the newly insured population. Those eligible, will pay monthly premiums. Appropriates up to $5 billion for the program, which terminates in 2014 when the Exchanges are operational. Establishes a transition to the Exchanges for eligible individuals. (Sec. 1101)	Temporary national insurance high risk pool program will be available to provide health benefits to "medically eligible" individuals who have been denied individual health insurance coverage because of a preexisting condition or who were offered limited coverage. Eligible individuals would be charged monthly premiums. Covered benefits would be consistent with the essential benefits package, and coverage under the program would be treated as credible coverage. Appropriates up to $5 billion for the program, which terminates in 2014 when the Exchanges are operational. Establishes a transition to the Exchanges for eligible individuals (Sec. 101)
Prohibition on Rescission	2010	2010	Prohibition on rescissions. Prohibits all plans from rescinding coverage except in instances of fraud or misrepresentation. (Sec 1001)	Ending health insurance rescission abuse. Prohibits health insurance companies from rescinding coverage except in instances of fraud and requires independent review of any rescission determination effective July 1, 2010. (sec 103)
Ensuring Value /Sunshine in Premium Increases / Medical Loss Ratios	2010	2010	Ensuring value for Premium dollars. For plan years beginning in 2010, the Secretary and States will establish a process for the annual review of increases in premiums for health insurance coverage. Requires States to make recommendations to their Exchanges about whether health insurance issuers should be excluded from participation in the Exchanges based on unjustified premium increases. Provides $250 million in funding to States from 2010 until 2014 to assist States in reviewing and, if appropriate under State law, approving premium increases for health insurance coverage and in providing information and recommendations to the Secretary. (Sec 1003) Bringing down the cost of health care coverage. Health insurance companies will be required to report publicly the percentage of total premium revenue that is expended on clinical services, and quality rather than administrative costs. Health insurance companies will be required to refund each enrollee by the amount by which premium revenue expended by the health insurer for non-claims costs exceeds 20 percent in the group market and 25 percent in the individual market. The requirement to provide a refund expires on December 31, 2013, but the requirement to report percentages continues. (Sec 1001) Special deduction for not for profit insurers. Requires that non-profit insurers have a medical loss ratio of 85 percent or higher in order to take advantage of the special tax benefits provided to them under IRC Section 833, including the deduction for 25 percent of claims and expenses and the 100 percent deduction for unearned premium reserves. (sec. 9016)	Ensuring value for Premium dollars - Medical Loss Ratio. Until the exchange is established in 2014, health insurance issuers in the small and large group market must meet a medical loss ratio of not less than 85%. The Secretary must require that plans in the individual market also meet a medical loss ratio of not less than 85% so long as it does not destabilize the existing individual market. If plans exceed that limit, rebates to enrollees are required. In determining the methodology for the medical loss ratio, the Secretary is to design it to ensure adequate participation by issuers, competition in the market, and value for consumers. ( Sec. 102) Sunshine on price gouging. Establishes an annual review process for increases in health insurance premiums by the Secretary of HHS in conjunction with the States that requires insurers to submit a justification for any premium increases prior to implementation. ( sec. 104)
Pre-existing Condition Limits- Pre Exchange		2010		Health Condition Discrimination Ban Pre Exchange. Prior to the bill’s complete prohibition on preexisting condition exclusions beginning in 2013, reduces the window that plans can look back for pre-existing conditions from 6 months to 30 days and shortens the period that plans may exclude coverage of certain benefits. It also prohibits insurers from limiting or denying coverage based on acts stemming from domestic violence (sec 106).
Lifetime Limits	2010	2010	No lifetime limits. Prohibits all plans from establishing lifetime limits. Sec 1001	Elimination of lifetime aggregate limits. Prohibits health insurers from utilizing lifetime limits on benefits for plan years beginning January 1, 2010. Sec 109
Annual Limits	2010		Ban on annual limits. After 2014, annual limits are banned. Before 2014, annual limits must be restricted to the "essential" benefits outlined in the bill. The Secretary shall ensure accesses to needed services with minimal impact on premiums. Sec 10101 of Manager’s Amendment
Preventative Services	2010	2013	Coverage of preventive health services. Requires all plans to cover preventive services and immunizations recommended by the U.S. Preventive Services Task Force and the CDC, and certain child preventive services recommended by the Health Resources and Services Administration, without any cost-sharing. Sec 1001	Coverage Requirements outlines basic requirements of essential benefits package including a prohibition on cost sharing for preventative services. Sec 222
Extension of Dependent Coverage	2010	2010	Extension of Dependent Coverage: Requires any group health plan or plan in the individual market that provides dependent coverage for children to continue to make that coverage available until the child turns 26 years of age. This takes effect for plan years beginning on or after the date that is six months after enactment. (Sec 1001)	Extension of Dependent Coverage until age 27: Allows those under age 27 not otherwise covered to remain on their parents’ policies at their parents’ discretion. (Sec 105)
Reinsurance for early retirees	2010	2010	Reinsurance for early retirees. Establishes a temporary reinsurance program to provide reimbursement to participating employment-based plans for part of the cost of providing health benefits to retirees (age 55-64) and their families. The program reimburses participating employment-based plans for 80 percent of the cost of benefits provided per enrollee in excess of $15,000 and below $90,000. The plans are required to use the funds to lower costs borne directly by participants and beneficiaries, and the program incentivizes plans to implement programs and procedures to better manage chronic conditions. The act appropriates $5 billion for this fund and funds are available until expended.(Sec 1102)	Reinsurance program for retirees. Establishes a temporary reinsurance program to provide reimbursement to participating employment‐based plans for part of the cost of providing health benefits to retirees (age 55‐64) and their families. The program reimburses participating employment‐based plans for 80% of the cost of benefits provided per enrollee in excess of $15,000 and below $90,000. The plans are required to use the funds to lower costs borne directly by participants and beneficiaries. The act appropriates $10 billion for this fund and those funds are available until expended. (Sec 111)
Small Business Tax Credit	2010	2013	Small Business Tax Credit: In 2010 the first phase of the small business tax credit for qualified small employers for contributions to purchase health insurance for its employees. The bill provides a sliding scale tax credit to small employers with fewer than 25 employees and average annual wages of less than $50,000 that purchase health insurance for their employees. The full credit will be available to employers with 10 or fewer employees and average annual wages of less than $25,000. To be eligible for a tax credit, the employer must contribute at least 50 percent of the total premium cost or 50 percent of a benchmark premium. In 2011 through 2013, eligible employers can receive a small business tax credit for up to 35 percent of their contribution toward the employee’s health insurance premium. Tax-exempt small businesses meeting the above requirements are eligible for tax credits of up to 25 percent of their contribution. In 2014 and beyond, eligible employers who purchase coverage through the State Exchange can receive a tax credit for two years of up to 50 percent of their contribution. Tax-exempt small businesses meeting the above requirements are eligible for tax credits of up to 35 percent of their contribution. (Sec 1421) CBO projects $ 40 B in cost	Small Business Tax Credit: Provide small employers with fewer than 25 employees and average wages of less than $40,000 with a health coverage tax credit for up to two years. The full credit of 50% of premium costs paid by employers is available to employers with 10 or fewer employees and average annual wages of $20,000 or less. The credit phases-out as firm size and average wage increases and is not permitted for employees earning more than $80,000 per year. (Section 512) CBO projects $ 25 B in costs
Small Business Tax Credit Eligibility			Small Business Tax Credit Eligibility Sole Proprietors are excluded from the tax credit Credits are non refundable (Section 1421)	Small Business Tax Credit Eligibility Sole Proprietorships are excluded from tax credit unless they hire an employee. If they do, then the owner may be counted as an employee. Credits are non refundable(Section 521 which amends the IRS statutes)
Full Time Employer Definition for Tax Credit	2010	2013	The number of full time employees is determined by dividing the total number of hours for which wages were paid by 2080. Hours worked by any individual in excess of 2080 are not counted. Hours worked by seasonal workers not counted unless that individual worked for more than 120 days. Sec1421	Workers paid $5,000 or more per year are considered employees for purposes of the small business tax credit Sec 521
Exchange(s) / Marketplace Creation	2014	2013	Create state-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges, administered by a governmental agency or non-profit organization, through which individuals and small businesses with up to 100 employees can purchase qualified coverage. Small Businesses will be grouped in the SHOP exchange and individuals in the American Health Benefit Exchanges. A health insurance issuer shall consider all enrollees in all health plans offered by such issuer in the individual market, including those enrollees who do not enroll in such plans through the Exchange, to be members of a single risk pool. A health insurance issuer shall consider all enrollees in all health plans (other than grandfathered health plans) offered by such issuer in the small group market, including those enrollees who do not enroll in such plans through the Exchange, to be members of a single risk pool. State law may limit participation to small businesses with up to 50 employees. Permits states to allow businesses with more than 100 employees to purchase coverage in the SHOP Exchange beginning in 2017. States may form regional Exchanges or allow more than one Exchange to operate in a state as long as each Exchange serves a distinct geographic area. Employers eligible for the exchange can offer their employees the option to choose from any plan within the benefit level determined by the employer. Small businesses that prosper and grow beyond the 100 employee limit after enrolling in the SHOP will be allowed to continue shopping in the exchanges (Sec 1311,1312 et seq.)	Create a National Health Insurance Exchange, through which individuals and employers (phasing-in eligibility for employers starting with smallest employers) can purchase qualified insurance, including from private health plans and the public health insurance option In year one, individuals not enrolled in other acceptable coverage are allowed into the Exchange as well as small employers with 25 or fewer employees. In year two, employers with 50 and fewer employees are allowed into the Exchange. In year three, the Commissioner is, at a minimum, required to open the Exchange to employers with 100 and fewer employees, but is permitted from this year forward to expand employer participation as appropriate, with the goal of allowing all employers access to the Exchange. (Sec 301, et seq) Employers eligible for the exchange may offer it to their employees who then have the option of choosing any plan at any level within the exchange but the employer is responsible for the minimum contribution of the average of the three lowest cost basic plans. (Sec 412 and 343(c)) States may form regional exchanges or offer their own exchange provided that the state(s) perform all of the duties of the federal Exchange as approved by the Health Choices Commissioner. The Commissioner has authority to terminate state exchanges if they are not meeting their obligations. Presumes that any State operating an Exchange prior to 2010 is allowed to continue doing so. Sec 308 Interstate health insurance compacts. Effective January 1, 2015, would allow 2 or more States to form Health Care Choice Compacts to facilitate the purchase of individual health insurance across State lines. Ensures that such compacts require licensure in each state and maintains authority of the State in which a covered individual resides to protect the individual. Allows States to apply for grants from the Secretary of HHS to help implement such compacts. Sec 309
Public Option		2013		Public Option: Create a new public health insurance option to be offered through the Health Insurance Exchange that must meet the same requirements as private plans regarding benefit levels, provider networks, consumer protections, and cost-sharing. Require the public plan to offer basic, enhanced, and premium plans, and permit it to offer premium plus plans. Prohibit the public plan from providing coverage for abortions beyond those permitted by federal law (to save the life of the woman and in cases of rape and incest). Finance the costs of the public plan through revenues from premiums. Require the public health insurance option to negotiate rates with providers so that the rates are not lower than Medicare rates and not higher than the average rates paid by other qualified health benefit plan offering entities. Health care providers participating in Medicare are considered participating providers in the public plan unless they opt out. Permit the public plan to develop innovative payment mechanisms, including medical home and other care management payments, value-based purchasing, bundling of services, differential payment rates, performance based payments, or partial capitation and modify cost-sharing and payment rates to encourage use of high-value services.(Section 321 et seq
CO-OP	2013	2010	Create the Consumer Operated and Oriented Plan (CO-OP) program to foster the creation of non-profit, member-run health insurance companies in all 50 states and District of Columbia to offer qualified health plans. To be eligible to receive funds, an organization must not be an existing health insurer or sponsored by a state or local government, substantially all of its activities must consist of the issuance of qualified health benefit plans in each state in which it is licensed, governance of the organization must be subject to a majority vote of its members, must operate with a strong consumer focus, and any profits must be used to lower premiums, improve benefits, or improve the quality of health care delivered to its members. (Appropriate $6 billion to finance the program and award loans and grants to establish CO-OPs by July 1, 2013) (Section 1322)	Create a Consumer Operated and Oriented Program (CO-OP) to facilitate the establishment of non-profit, member-run health insurance cooperatives to provide insurance through the Exchange. (Sec 310)
Other Choice Provisions	2014		Requires the Office of Personnel Management (OPM) to contract with health insurers to offer at least two multi-state qualified health plans (at least one non-profit) through Exchanges in each State. Requires OPM to negotiate contracts in a manner similar to the manner in which it negotiates contracts for Federal Employees Health Benefits Program (FEHBP), and allows OPM to prohibit multi-state plans that do not meet standards for medical loss ratios, profit margins, and premiums. Requires multi-state plans to cover essential health benefits and meet all of the requirements of a qualified health plan; States may require multi-state plans to offer additional benefits, but must pay for the additional cost. Multi-state plans must comply with 3:1 age rating, except States may require more protective age rating. Multi-state plans must comply with the minimum standards and requirements of FEHBP. Guarantees that FEHBP will maintain a separate risk pool and remain a separate program(Section 1303(q)
Cafeteria plans	2011		Establishment of simple cafeteria plans for small businesses. Establishes Simple Cafeteria Plans that ease participation restrictions so that small businesses can provide tax-free benefits to their employees. Under this provision, self-employed individuals are included as qualified employees. The provision also exempts employers who make contributions for employees under a simple cafeteria plan from pension plan nondiscrimination requirements applicable to highly compensated and key employees.(Sec 9022)
Individual Requirements	2014	2013	Individual Mandate: Require U.S. citizens and legal residents to have qualifying health coverage. Individuals who do not purchase coverage will pay the greater of $95 in 2014, $495 in 2015 and $750 in 2016, or up to two percent of income by 2016, up to a cap of the national average bronze plan premium. Families will pay half the amount for children up to a cap of $2,250 for the entire family. After 2016, dollar amounts will increase by the annual cost of living adjustment. (Sec 10106 Manager’s amendment) Exemptions will be granted for financial hardship, religious objections, American Indians, those without coverage for less than three months, undocumented immigrants, incarcerated individuals, if the lowest cost plan option exceeds 8% of an individual’s income, and if the individual has income below 100% of the poverty level. (Sec 1501)	Individual Mandate: Require individuals to have "acceptable health coverage". Those without coverage pay a penalty of 2.5% of their adjusted income above the filing threshold up to the cost of the average national premium for self-only or family coverage under a basic plan in the Health Insurance Exchange. Exceptions granted for those with incomes below the filing threshold (in 2009 the threshold for taxpayers under age 65 is $9,350 for singles and $18,700 for couples), religious objections and financial hardship (Sec 401)
Minimum Acceptable Coverage Levels	2014	2013	Coverage of essential benefit package Create four benefit categories of plans plus a separate catastrophic plan to be offered through the Exchange, and in the individual and small group markets: · Bronze plan represents minimum creditable coverage and provides the essential health benefits, cover 60% of the benefit costs of the plan, with an out-of-pocket limit equal to the Health Savings Account (HSA) current law limit ($5,950 for individuals and $11,900 for families in 2010); · Silver plan provides the essential health benefits, covers 70% of the benefit costs of the plan, with the HSA out-of-pocket limits; · Gold plan provides the essential health benefits, covers 80% of the benefit costs of the plan, with the HSA out-of-pocket limits; · Platinum plan provides the essential health benefits, covers 90% of the benefit costs of the plan, with the HSA out-of-pocket limits; · Catastrophic plan available to those up to age 30 or to those who are exempt from the mandate to purchase coverage and provides catastrophic coverage only with the coverage level set at the HSA current law levels except that prevention benefits and coverage for three primary care visits would be exempt from the deductible. This plan is only available in the individual market. (sec 1302)	Essential benefits package defined. Create four benefit categories of plans to be offered through the Exchange: · Basic plan includes essential benefits package and covers 70% of the benefit costs of the plan; · Enhanced plan includes essential benefits package, reduced cost-sharing compared to the basic plan, and covers 85% of benefit costs of the plan; · Premium plan includes essential benefits package with reduced cost-sharing compared to the enhanced plan and covers 95% of the benefit costs of the plan; Premium plus plan is a premium plan that provides additional benefits, such as oral health and vision care Outlines the broad categories of benefits required to be included in the essential benefits package, prohibits any cost‐sharing for preventive benefits (including well child and well baby care), and limits annual out‐of‐pocket spending in the essential benefits package to $5,000 for an individual and $10,000 (indexed to CPI) for a family. Defines the initial essential benefit package as being actuarially equivalent to 70% of the package if there were no cost‐sharing imposed. Requires the Secretary to assess adding counseling for domestic violence as part of the behavioral health or primary care visit. Prohibits abortion services from being made part of essential benefits package. Prohibits federal funds from being used to pay for abortion (except in cases of rape, incest, and to save life of the woman). Only private premium dollars can be used to provide abortion coverage. Where abortion coverage is provided, funds for this purpose must be segregated from other funds, including affordability credits. Includes a report regarding the need and cost of providing oral health care to adults as part of the essential benefits package. In the developing the essential benefit package, the Secretary shall support the need for assessment and counseling for domestic violence as part of the behavioral health assessment or primary care visit. Sec 222 Coverage of essential benefits package. Requires qualified plans to meet the benefit standards recommended by the Benefits Advisory Committee and adopted by the Secretary of HHS. Plans outside the Exchange must offer at least the essential benefits and others as they choose. Plans within the Exchange must meet the specified benefit packages, including being able to offer additional benefits in a specified tier. Allows for the continued offering of separate excepted benefits packages, as in current law, outside of the Exchange. Sec 221
Affordability Credits	2014	2013	Affordability Credits Note that those whose premiums are between 8 and 9.8% of their income are not eligible for affordability credits but may be exempt from the individual mandate and therefore may choose to forego coverage (Assuming they don’t qualify for Medicaid) Provide refundable and advanceable premium and cost sharing credits to individuals and families with incomes between 100-400% FPL to purchase insurance through the Exchanges. The credits will be tied to the second lowest-cost silver plan in the area and will be set on a sliding scale such that the premium contributions are limited to 2.8% of income for those at 100% FPL to 9.8% of income for those between 300-400% FPL, except that for those with incomes between 100 and 133% FPL, the premium contribution is limited to 2% of income. (These are the provisions as drafted; however, individuals with incomes less than 133% FPL are intended to get their coverage through Medicaid.) Increase the premium contributions for those receiving subsidies annually by the rate of premium growth from the preceding year. Provide cost-sharing subsidies to eligible individuals and families with incomes between 100-200% FPL. For those with incomes between 100-150% FPL, the cost-sharing subsidies will result in coverage for 90% of the benefit costs of the plan. For those with incomes between 150-200%, the cost-sharing subsidies will result in coverage for 80% of the benefit costs of the plan. American Indians with income less than 300% FPL will not be subject to any cost-sharing requirements. Limit availability of premium credits and cost-sharing subsidies through the Exchanges to U.S. citizens and legal immigrants who meet income limits. Employees who are offered coverage by an employer are not eligible for premium credits unless the employer plan does not have an actuarial value of at least 60% or if the employee share of the premium exceeds 9.8% of income. Legal immigrants who are barred from enrolling in Medicaid during their first five years in the U.S. will be eligible for premium credits. Require verification of both income and citizenship status in determining eligibility for the federal premium credits. Ensure that federal premium or cost-sharing subsidies are not used to purchase coverage for abortion if coverage extends beyond saving the life of the woman or in cases of rape or incest. If an individual who receives federal assistance purchases coverage in a plan that chooses to cover abortion services beyond those for which federal funds are permitted, those federal subsidy funds (for premiums or cost-sharing) must not be used for the purchase of the abortion coverage and must be segregated from private premium payments or state funds. (Section 1401, 1402 et esq).	Affordability Credits Provide affordability premium credits to eligible individuals and families with incomes up to 400% FPL to purchase insurance through the Health Insurance Exchange. The premium credits will be based on the average cost of the three lowest cost basic health plans in the area and will be set on a sliding scale such that the premium contributions are limited to the following percentages of income for specified income tiers: § 133-150% FPL: 1.5 - 3% of income § 150-200% FPL: 3 – 5.5% of income § 200-250% FPL: 5.5 - 8% of income § 250-300% FPL: 8 - 10% of income § 300-350% FPL: 10 - 11% of income § 350-400% FPL: 11 - 12% of income Index the affordability premium credits after 2013 to maintain the ratio of government to enrollee shares of the premiums over time. Provide affordability cost-sharing credits to eligible individuals and families with incomes up to 400% FPL. The cost-sharing credits reduce the cost-sharing amounts and annual cost-sharing limits and have the effect of increasing the actuarial value of the basic benefit plan to the following percentages of the full value of the plan for the specified income tier. Limit availability of premium and cost-sharing credits to US citizens and lawfully residing immigrants who meet the income limits and are not enrolled in qualified or grandfathered employer or individual coverage, Medicare, Medicaid (except those eligible to enroll in the Exchange), TRICARE, or VA coverage (with some exceptions). Individuals with access to employer-based coverage are eligible for the premium and cost-sharing credits if the cost of the employee premium exceeds 12% of the individuals’ income. Require verification of both income and citizenship status in determining eligibility for the federal premium and cost-sharing credits. Prohibit federal premium subsidies from being used to purchase a health plan in the Exchange that includes coverage for abortions except to save the life of the woman or in cases of rape or incest. Individuals receiving federal subsidies may purchase supplemental coverage for abortions but that coverage must be paid for entirely with private funds. Sec 341, 342, et seq Note that a sole proprietor who has employees, would not be eligible for affordability credits because the sole proprietor would be considered as employee under section 521. Therefore, unless the coverage is unaffordable, the sole proprietor could not get the credit but would be eligible for the small business credit for havinga small business.
Free Choice Voucher	2014		Free choice vouchers to employees who don’t qualify for tax credits but whose coverage is unaffordable. Requires employers that offer coverage and make a contribution to provide free choice vouchers to qualified employees for the purchase of qualified health plans through Exchanges. The free choice voucher must be equal to the contribution that the employer would have made to its own plan. Employees qualify if their required contribution under the employer’s plan would be between 8 and 9.8 percent of their income. Excludes free choice vouchers from taxation and voucher recipients are not eligible for tax credits. Sec. 10108.
Employer Requirements	2014	2013	Shared Employer Responsibility –"Free Rider" Businesses with 50 or fewer employees from any of the penalties. Assess employers with more than 50 employees that do not offer coverage and have at least one full-time employee who receives a premium tax credit will pay a fee of $750 per full-time employee. Employers with more than 50 employees that offer coverage but have at least one full-time employee receiving a premium tax credit, will pay the lesser of $3,000 for each employee receiving a premium credit or $750 for each full-time employee. Meaning a firm that offers coverage but has any one employee reciving an affordability credit will owe either $3,000 * number of employees receiving a credit or $750 * the number of employees employed. For employers that impose a waiting period before employees can enroll in coverage, require payment of $400 for any full-time employee in a 30-60 day waiting period and $600 for any employee in a 60-90 day waiting period. (Sec 1513) Require employers with more than 200 employees to automatically enroll employees into health insurance plans offered by the employer. Employees may opt out of coverage. (Sec 1511)	Shared Responsibility Businesses with less than 500,000 in payroll are exempt from the shared responsibility (Sec 512) Require employers to offer coverage to their employees and contribute at least 72.5% of the premium cost for single coverage and 65% of the premium cost for family coverage of the lowest cost plan that meets the essential benefits package requirements or pay 8% of payroll into the Health Insurance Exchange Trust Fund. (Sec 512) Eliminate or reduce the pay or play assessment for small employers with annual payroll of less than $750,000: · Annual payroll less than $500,000: exempt · Annual payroll between $500,000 and $585,000: 2% of payroll; · Annual payroll between $585,000 and $670,000: 4% of payroll; · Annual payroll between $670,000 and $750,000: 6% of payroll. (Effective January 1, 2013) Require employers that offer coverage to automatically enroll into the employer’s lowest cost premium plan any individual who does not elect coverage under the employer plan or does not opt out of such coverage. Employer contributions in lieu of coverage. Requires an offering employer to contribute to the Exchange for each employee who declines the employer’s coverage offer and enters the Exchange via the affordability test outlined in the act. The contribution is generally 8% of the average salary for the employer. Small employers with annual payrolls at or below $500,000, are exempt from this requirement. The contribution phases up from 0‐8% between an annual payroll of $500,000 and $750,00, at which point employers are subject to the full 8% contribution requirement. (Sec 413)
Insurance Rating Rules	2014	2013	Fair health insurance premiums. Establishes that premiums in the individual and small group markets may vary only by family structure, geography, the actuarial value of the benefit, age (limited to a ratio of 3 to 1), and tobacco use (limited to a ratio of 1.5 to 1). Sec. 2701	Insurance rating rules. Limits age rating to a ratio of 2 to 1; allows variation based on geographic area and family size as permitted by state insurance commissioners and the Health Choices Commissioner. Requires a study and reports by the Health Choices Commissioner describing the differences between insured and self insured plans and providing recommendations as appropriate to ensure that the law does not create incentives for small and midsize employers to self insure or create adverse selection in the risk pools of insured plans. Sec. 213.
Guaranteed Issue and Renewability	2014	2013	Guaranteed availability of coverage. Each health insurance issuer must accept every employer and individual in the State that applies for coverage, permitting annual and special open enrollment periods for those with qualifying lifetime events. Sec. 2702. Guaranteed renewability of coverage. Requires guaranteed renewability of coverage regardless of health status, utilization of health services or any other related factor. Sec. 2703.	Guaranteed issue and renewal for insured plans and prohibiting rescissions. Requires guaranteed issue (no one can be denied health insurance) and renewal of insurance policies and prohibits the use of rescissions except in instances of fraud. Sec. 212.
Prohibiting pre‐existing condition exclusions.	2014	2013	Prohibition of preexisting condition exclusions or other discrimination based on health status. No group health plan or insurer offering group or individual coverage may impose any pre-existing condition exclusion or discriminate against those who have been sick in the past. Sec. 2704. Prohibiting discrimination against individual participants and beneficiaries based on health status. No group health plan or insurer offering group or individual coverage may set eligibility rules based on health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability – including acts of domestic violence or disability. Permits employers to vary insurance premiums by as much as 30 percent for employee participation in certain health promotion and disease prevention programs. Authorizes a 10-State demonstration to apply such a program in the individual market. Sec. 2705.	Prohibiting pre‐existing condition exclusions. Prohibits the application of pre‐existing condition exclusions. Sec. 211.
National Workforce Commission			Workforce Commission. The Patient Protection and Affordable Care Act establishes a national workforce commission to gather information on the health care workforce and better coordinate and implement workforce planning and analysis. The Manager’s Amendment ensures that small businesses will be represented on the commission Sec. 10501.
Revenue Generation	2013	2011	Excise Tax on High Cost Plans: Impose an excise tax on insurers of employer-sponsored health plans with aggregate values that exceed $8,500 for individual coverage and $23,000 for family coverage (these threshold values will be indexed to the consumer price index for urban consumers (CPI-U) plus one percentage point). The threshold amounts will be increased for retired individuals age 55 and older who are not eligible for Medicare and for employees engaged in high-risk professions by $1,350 for individual coverage and $3,000 for family coverage. In the 17 states with the highest health care costs, the threshold amount is increased by 20% initially; this increase is subsequently reduced by half each year until it is phased out in 2015. The tax is equal to 40% of the value of the plan that exceeds the threshold amounts and is imposed on the issuer of the health insurance policy, which in the case of a self-insured plan is the plan administrator or, in some cases, the employer. The aggregate value of the health insurance plan includes reimbursements under a flexible spending account for medical expenses (health FSA) or health reimbursement arrangement (HRA), employer contributions to a health savings account (HSA), and coverage for dental, vision, and other supplementary health insurance coverage. Sec 9001	Surcharge on high income individuals. Establishes a 5.4 percent tax on modified adjusted gross income in excess of $1 million in the case of a joint return ($500,000 in the case of other returns). The tax is estimated to affect only 0.3 percent of all households and only 1.2 percent of sole proprietors, partners, and s corporation shareholders operating a business. Sec 551