SEC. 202. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS.

[a] Access to Coverage- In accordance with this section, all individuals are eligible to obtain coverage through enrollment in an Exchange-participating health benefits plan offered through the Health Insurance Exchange unless such individuals are enrolled in another qualified health benefits plan or other acceptable coverage.

[b] Definitions- In this division:

[1] EXCHANGE-ELIGIBLE INDIVIDUAL- The term "Exchange-eligible individual" means an individual who is eligible under this section to be enrolled through the Health Insurance Exchange in an Exchange-participating health benefits plan and, with respect to family coverage, includes dependents of such individual.

[2] EXCHANGE-ELIGIBLE EMPLOYER- The term "Exchange-eligible employer" means an employer that is eligible under this section to enroll through the Health Insurance Exchange employees of the employer [and their dependents] in Exchange-eligible health benefits plans.

[3] EMPLOYMENT-RELATED DEFINITIONS- The terms "employer", "employee", "full-time employee", and "part-time employee" have the meanings given such terms by the Commissioner for purposes of this division.

[c] Transition- Individuals and employers shall only be eligible to enroll or participate in the Health Insurance Exchange in accordance with the following transition schedule:

[1] FIRST YEAR- In Y1 [as defined in section 100[c]]--

[A] individuals described in subsection [d][1], including individuals described in paragraphs [3] and [4] of subsection [d]; and

[B] smallest employers described in subsection [e][1].

[2] SECOND YEAR- In Y2-- [A] individuals and employers described in paragraph [1]; and [B] smaller employers described in subsection [e][2].

[3] THIRD AND SUBSEQUENT YEARS- In Y3 and subsequent years--

[A] individuals and employers described in paragraph [2]; and

[B] larger employers as permitted by the Commissioner under subsection [e][3].

[d] Individuals-

[1] INDIVIDUAL DESCRIBED- Subject to the succeeding provisions of this subsection, an individual described in this paragraph is an individual who--

[A] is not enrolled in coverage described in subparagraphs [C] through [F] of paragraph [2]; and

[B] is not enrolled in coverage as a full-time employee [or as a dependent of such an employee] under a group health plan if the coverage and an employer contribution under the plan meet the requirements of section 312. For purposes of subparagraph [B], in the case of an individual who is self-employed, who has at least 1 employee, and who meets the requirements of section 312, such individual shall be deemed a full-time employee described in such subparagraph.

[2] ACCEPTABLE COVERAGE- For purposes of this division, the term "acceptable coverage" means any of the following:

[A] QUALIFIED HEALTH BENEFITS PLAN COVERAGE- Coverage under a qualified health benefits plan.

[B] GRANDFATHERED HEALTH INSURANCE COVERAGE; COVERAGE UNDER CURRENT GROUP HEALTH PLAN- Coverage under a grandfathered health insurance coverage [as defined in subsection [a] of section 102] or under a current group health plan [described in subsection [b] of such section].

[C] MEDICARE- Coverage under part A of title XVIII of the Social Security Act.

[D] MEDICAID- Coverage for medical assistance under title XIX of the Social Security Act, excluding such coverage that is only available because of the application of subsection [u], [z], or [aa] of section 1902 of such Act.

[E] MEMBERS OF THE ARMED FORCES AND DEPENDENTS [INCLUDING TRICARE]- Coverage under chapter 55 of title 10, United States Code, including similar coverage furnished under section 1781 of title 38 of such Code.

[F] VA- Coverage under the veteran's health care program under chapter 17 of title 38, United States Code, but only if the coverage for the individual involved is determined by the Commissioner in coordination with the Secretary of Treasury to be not less than a level specified by the Commissioner and Secretary of Veteran's Affairs, in coordination with the Secretary of Treasury, based on the individual's priority for services as provided under section 1705[a] of such title.

[G] OTHER COVERAGE- Such other health benefits coverage, such as a State health benefits risk pool, as the Commissioner, in coordination with the Secretary of the Treasury, recognizes for purposes of this paragraph.

The Commissioner shall make determinations under this paragraph in coordination with the Secretary of the Treasury.

[3] TREATMENT OF CERTAIN NON-TRADITIONAL MEDICAID ELIGIBLE INDIVIDUALS- An individual who is a non-traditional Medicaid eligible individual [as defined in section 205[e][4][C]] in a State may be an Exchange-eligible individual if the individual was enrolled in a qualified health benefits plan, grandfathered health insurance coverage, or current group health plan during the 6 months before the individual became a non-traditional Medicaid eligible individual. During the period in which such an individual has chosen to enroll in an Exchange-participating health benefits plan, the individual is not also eligible for medical assistance under Medicaid.

[4] CONTINUING ELIGIBILITY PERMITTED-

[A] IN GENERAL- Except as provided in subparagraph [B], once an individual qualifies as an Exchange-eligible individual under this subsection [including as an employee or dependent of an employee of an Exchange-eligible employer] and enrolls under an Exchange-participating health benefits plan through the Health Insurance Exchange, the individual shall continue to be treated as an Exchange-eligible individual until the individual is no longer enrolled with an Exchange-participating health benefits plan.

[B] EXCEPTIONS-

[i] IN GENERAL- Subparagraph [A] shall not apply to an individual once the individual becomes eligible for coverage--

[I] under part A of the Medicare program;

[II] under the Medicaid program as a Medicaid eligible individual, except as permitted under paragraph [3] or clause [ii]; or

[III] in such other circumstances as the Commissioner may provide.

[ii] TRANSITION PERIOD- In the case described in clause [i][II], the Commissioner shall permit the individual to continue treatment under subparagraph [A] until such limited time as the Commissioner determines it is administratively feasible, consistent with minimizing disruption in the individual's access to health care.

[e] Employers-

[1] SMALLEST EMPLOYER- Subject to paragraph [4], smallest employers described in this paragraph are employers with 10 or fewer employees.

[2] SMALLER EMPLOYERS- Subject to paragraph [4], smaller employers described in this paragraph are employers that are not smallest employers described in paragraph [1] and have 20 or fewer employees.

[3] LARGER EMPLOYERS-

[A] IN GENERAL- Beginning with Y3, the Commissioner may permit employers not described in paragraph [1] or [2] to be Exchange-eligible employers.

[B] PHASE-IN- In applying subparagraph [A], the Commissioner may phase-in the application of such subparagraph based on the number of full-time employees of an employer and such other considerations as the Commissioner deems appropriate.

[4] CONTINUING ELIGIBILITY- Once an employer is permitted to be an Exchange-eligible employer under this subsection and enrolls employees through the Health Insurance Exchange, the employer shall continue to be treated as an Exchange-eligible employer for each subsequent plan year regardless of the number of employees involved unless and until the employer meets the requirement of section 311[a] through paragraph [1] of such section by offering a group health plan and not through offering Exchange-participating health benefits plan.

[5] EMPLOYER PARTICIPATION AND CONTRIBUTIONS-

[A] SATISFACTION OF EMPLOYER RESPONSIBILITY- For any year in which an employer is an Exchange-eligible employer, such employer may meet the requirements of section 312 with respect to employees of such employer by offering such employees the option of enrolling with Exchange-participating health benefits plans through the Health Insurance Exchange consistent with the provisions of subtitle B of title III.

[B] EMPLOYEE CHOICE- Any employee offered Exchange-participating health benefits plans by the employer of such employee under subparagraph [A] may choose coverage under any such plan. That choice includes, with respect to family coverage, coverage of the dependents of such employee.

[6] AFFILIATED GROUPS- Any employer which is part of a group of employers who are treated as a single employer under subsection [b], [c], [m], or [o] of section 414 of the Internal Revenue Code of 1986 shall be treated, for purposes of this subtitle, as a single employer.

[7] OTHER COUNTING RULES- The Commissioner shall establish rules relating to how employees are counted for purposes of carrying out this subsection.

[f] Special Situation Authority- The Commissioner shall have the authority to establish such rules as may be necessary to deal with special situations with regard to uninsured individuals and employers participating as Exchange-eligible individuals and employers, such as transition periods for individuals and employers who gain, or lose, Exchange-eligible participation status, and to establish grace periods for premium payment.

[g] Surveys of Individuals and Employers- The Commissioner shall provide for periodic surveys of Exchange-eligible individuals and employers concerning satisfaction of such individuals and employers with the Health Insurance Exchange and Exchange-participating health benefits plans.

[h] Exchange Access Study-

[1] IN GENERAL- The Commissioner shall conduct a study of access to the Health Insurance Exchange for individuals and for employers, including individuals and employers who are not eligible and enrolled in Exchange-participating health benefits plans. The goal of the study is to determine if there are significant groups and types of individuals and employers who are not Exchange eligible individuals or employers, but who would have improved benefits and affordability if made eligible for coverage in the Exchange.

[2] ITEMS INCLUDED IN STUDY- Such study also shall examine--

[A] the terms, conditions, and affordability of group health coverage offered by employers and QHBP offering entities outside of the Exchange compared to Exchange-participating health benefits plans; and

[B] the affordability-test standard for access of certain employed individuals to coverage in the Health Insurance Exchange.

[3] REPORT- Not later than January 1 of Y3, in Y6, and thereafter, the Commissioner shall submit to Congress on the study conducted under this subsection and shall include in such report recommendations regarding changes in standards for Exchange eligibility for for individuals and employers.