[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1425 Engrossed in House (EH)]

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116th CONGRESS
  2d Session
                                H. R. 1425

_______________________________________________________________________

                                 AN ACT


 
To amend the Patient Protection and Affordable Care Act to provide for 
 a Improve Health Insurance Affordability Fund to provide for certain 
    reinsurance payments to lower premiums in the individual health 
                           insurance market.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Patient Protection and Affordable 
Care Enhancement Act''.

SEC. 2. TABLE OF CONTENTS.

    The table of contents for this Act is as follows:

Sec. 1. Short title.
Sec. 2. Table of contents.
    TITLE I--LOWERING HEALTH CARE COSTS AND PROTECTING PEOPLE WITH 
                         PREEXISTING CONDITIONS

Sec. 101. Improving affordability by expanding premium assistance for 
                            consumers.
Sec. 102. Improving affordability by reducing out-of-pocket and premium 
                            costs for consumers.
Sec. 103. Expanding affordability for working families to fix the 
                            family glitch.
Sec. 104. Tax credit reconciliation protections for individuals 
                            receiving social security lump-sum 
                            payments.
Sec. 105. Preserving State option to implement health care 
                            Marketplaces.
Sec. 106. Establishing a Health Insurance Affordability Fund.
Sec. 107. Rescinding the short-term limited duration insurance 
                            regulation.
Sec. 108. Revoking section 1332 guidance.
Sec. 109. Requiring Marketplace outreach, educational activities, and 
                            annual enrollment targets.
Sec. 110. Report on effects of website maintenance during open 
                            enrollment.
Sec. 111. Promoting consumer outreach and education.
Sec. 112. Improving transparency and accountability in the Marketplace.
Sec. 113. Improving awareness of health coverage options.
Sec. 114. Promoting State innovations to expand coverage.
Sec. 115. Strengthening network adequacy.
Sec. 116. Protecting consumers from unreasonable rate hikes.
Sec. 117. Eligibility of DACA recipients for qualified health plans 
                            offered through Exchanges.
TITLE II--ENCOURAGING MEDICAID EXPANSION AND STRENGTHENING THE MEDICAID 
                                PROGRAM

Sec. 201. Incentivizing Medicaid expansion.
Sec. 202. Providing 12-months of continuous eligibility for Medicaid 
                            and CHIP.
Sec. 203. Mandatory 12-months of postpartum Medicaid eligibility.
Sec. 204. Reducing the administrative FMAP for nonexpansion States.
Sec. 205. Enhanced reporting requirements for nonexpansion states.
Sec. 206. Primary care pay increase.
Sec. 207. Permanent funding for CHIP.
Sec. 208. Permanent extension of CHIP enrollment and quality measures.
Sec. 209. State option to increase children's eligibility for Medicaid 
                            and CHIP.
Sec. 210. Medicaid coverage for citizens of Freely Associated States.
Sec. 211. Extension of full Federal medical assistance percentage to 
                            Indian health care providers.
     TITLE III--LOWERING PRICES THROUGH FAIR DRUG PRICE NEGOTIATION

Sec. 301. Establishing a Fair Drug Pricing Program.
Sec. 302. Drug manufacturer excise tax for noncompliance.
Sec. 303. Fair Price Negotiation Implementation Fund.
                  TITLE IV--PUBLIC HEALTH INVESTMENTS

Sec. 401. Supporting increased innovation.

    TITLE I--LOWERING HEALTH CARE COSTS AND PROTECTING PEOPLE WITH 
                         PREEXISTING CONDITIONS

SEC. 101. IMPROVING AFFORDABILITY BY EXPANDING PREMIUM ASSISTANCE FOR 
              CONSUMERS.

    (a) In General.--Section 36B(b)(3)(A) of the Internal Revenue Code 
of 1986 is amended to read as follows:
                    ``(A) Applicable percentage.--The applicable 
                percentage for any taxable year shall be the percentage 
                such that the applicable percentage for any taxpayer 
                whose household income is within an income tier 
                specified in the following table shall increase, on a 
                sliding scale in a linear manner, from the initial 
                premium percentage to the final premium percentage 
                specified in such table for such income tier:


------------------------------------------------------------------------
  ``In the case of household  income
 (expressed as  a percent of poverty     The initial        The final
  line)  within the following income       premium           premium
                tier:                  percentage is--   percentage is--
------------------------------------------------------------------------
Up to 150.0 percent..................              0.0              0.0
150.0 percent up to 200.0 percent....              0.0              3.0
200.0 percent up to 250.0 percent....              3.0              4.0
250.0 percent up to 300.0 percent....              4.0              6.0
300.0 percent up to 400.0 percent....              6.0              8.5
400.0 percent and higher.............              8.5           8.5''.
------------------------------------------------------------------------

    (b) Conforming Amendment.--Section 36B(c)(1)(A) of the Internal 
Revenue Code of 1986 is amended by striking ``but does not exceed 400 
percent''.
    (c) Effective Date.--The amendments made by this section shall 
apply to taxable years beginning after December 31, 2019.

SEC. 102. IMPROVING AFFORDABILITY BY REDUCING OUT-OF-POCKET AND PREMIUM 
              COSTS FOR CONSUMERS.

    Section 1302(c)(4) of the Patient Protection and Affordable Care 
Act (42 U.S.C. 18022(c)(4)) is amended by striking ``calendar year)'' 
and inserting ``calendar year, based on estimates and projections for 
the applicable calendar year of the percentage (if any) by which the 
average per enrollee premium for eligible employer-sponsored health 
plans (as defined in section 5000A(f)(2) of the Internal Revenue Code 
of 1986) exceeds such average per enrollee premium for the preceding 
calendar year, as published in the National Health Expenditure 
Accounts)''.

SEC. 103. EXPANDING AFFORDABILITY FOR WORKING FAMILIES TO FIX THE 
              FAMILY GLITCH.

    (a) In General.--Clause (i) of section 36B(c)(2)(C) of the Internal 
Revenue Code of 1986 is amended to read as follows:
                            ``(i) Coverage must be affordable.--
                                    ``(I) Employees.--An employee shall 
                                not be treated as eligible for minimum 
                                essential coverage if such coverage 
                                consists of an eligible employer-
                                sponsored plan (as defined in section 
                                5000A(f)(2)) and the employee's 
                                required contribution (within the 
                                meaning of section 5000A(e)(1)(B)) with 
                                respect to the plan exceeds 9.5 percent 
                                of the employee's household income.
                                    ``(II) Family members.--An 
                                individual who is eligible to enroll in 
                                an eligible employer-sponsored plan (as 
                                defined in section 5000A(f)(2)) by 
                                reason of a relationship the individual 
                                bears to the employee shall not be 
                                treated as eligible for minimum 
                                essential coverage by reason of such 
                                eligibility to enroll if the employee's 
                                required contribution (within the 
                                meaning of section 5000A(e)(1)(B), 
                                determined by substituting `family' for 
                                `self-only') with respect to the plan 
                                exceeds 9.5 percent of the employee's 
                                household income.''.
    (b) Conforming Amendments.--
            (1) Clause (ii) of section 36B(c)(2)(C) of the Internal 
        Revenue Code of 1986 is amended by striking ``Except as 
        provided in clause (iii), an employee'' and inserting ``An 
        individual''.
            (2) Clause (iii) of section 36B(c)(2)(C) of such Code is 
        amended by striking ``the last sentence of clause (i)'' and 
        inserting ``clause (i)(II)''.
            (3) Clause (iv) of section 36B(c)(2)(C) of such Code is 
        amended by striking ``the 9.5 percent under clause (i)(II)'' 
        and inserting ``the 9.5 percent under clauses (i)(I) and 
        (i)(II)''.
    (c) Effective Date.--The amendments made by this section shall 
apply to taxable years beginning after December 31, 2021.

SEC. 104. TAX CREDIT RECONCILIATION PROTECTIONS FOR INDIVIDUALS 
              RECEIVING SOCIAL SECURITY LUMP-SUM PAYMENTS.

    (a) In General.--Section 36B(d)(2) of the Internal Revenue Code of 
1986 is amended by adding at the end the following new subparagraph:
                    ``(C) Exclusion of portion of lump-sum social 
                security benefits.--
                            ``(i) In general.--The term `modified 
                        adjusted gross income' shall not include so 
                        much of any lump-sum social security benefit 
                        payment as is attributable to months ending 
                        before the beginning of the taxable year.
                            ``(ii) Lump-sum social security benefit 
                        payment.--For purposes of this subparagraph, 
                        the term `lump-sum social security benefit 
                        payment' means any payment of social security 
                        benefits (as defined in section 86(d)(1)) which 
                        constitutes more than 1 month of such benefits.
                            ``(iii) Election to include excludable 
                        amount.--A taxpayer may elect (at such time and 
                        in such manner as the Secretary may provide) to 
                        have this subparagraph not apply for any 
                        taxable year.''.
    (b) Effective Date.--The amendment made by this section shall apply 
to taxable years beginning after December 31, 2019.

SEC. 105. PRESERVING STATE OPTION TO IMPLEMENT HEALTH CARE 
              MARKETPLACES.

    (a) In General.--Section 1311 of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18031) is amended--
            (1) in subsection (a)--
                    (A) in paragraph (4)(B), by striking ``under this 
                subsection'' and inserting ``under this paragraph or 
                paragraph (1)''; and
                    (B) by adding at the end the following new 
                paragraph:
            ``(6) Additional planning and establishment grants.--
                    ``(A) In general.--There shall be appropriated to 
                the Secretary, out of any moneys in the Treasury not 
                otherwise appropriated, $200 million to award grants to 
                eligible States for the uses described in paragraph 
                (3).
                    ``(B) Duration and renewability.--A grant awarded 
                under subparagraph (A) shall be for a period of 2 years 
                and may not be renewed.
                    ``(C) Limitation.--A grant may not be awarded under 
                subparagraph (A) after December 31, 2023.
                    ``(D) Eligible state defined.--For purposes of this 
                paragraph, the term `eligible State' means a State 
                that, as of the date of the enactment of this 
                paragraph, is not operating an Exchange (other than an 
                Exchange described in section 155.200(f) of title 45, 
                Code of Federal Regulations).''; and
            (2) in subsection (d)(5)(A)--
                    (A) by striking ``operations.--In establishing an 
                Exchange under this section'' and inserting 
                ``operations.--
                            ``(i) In general.--In establishing an 
                        Exchange under this section (other than in 
                        establishing an Exchange pursuant to a grant 
                        awarded under subsection (a)(6))''; and
                    (B) by adding at the end the following:
                            ``(ii) Additional planning and 
                        establishment grants.--In establishing an 
                        Exchange pursuant to a grant awarded under 
                        subsection (a)(6), the State shall ensure that 
                        such Exchange is self-sustaining beginning on 
                        January 1, 2025, including allowing the 
                        Exchange to charge assessments or user fees to 
                        participating health insurance issuers, or to 
                        otherwise generate funding, to support its 
                        operations.''.
    (b) Clarification Regarding Failure to Establish Exchange or 
Implement Requirements.--Section 1321(c) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18041(c)) is amended--
            (1) in paragraph (1), by striking ``If'' and inserting 
        ``Subject to paragraph (3), if''; and
            (2) by adding at the end the following new paragraph:
            ``(3) Clarification.--This subsection shall not apply in 
        the case of a State that elects to apply the requirements 
        described in subsection (a) and satisfies the requirement 
        described in subsection (b) on or after January 1, 2014.''.

SEC. 106. ESTABLISHING A HEALTH INSURANCE AFFORDABILITY FUND.

    Subtitle D of title I of the Patient Protection and Affordable Care 
Act is amended by inserting after part 5 (42 U.S.C. 18061 et seq.) the 
following new part:

         ``PART 6--IMPROVE HEALTH INSURANCE AFFORDABILITY FUND

``SEC. 1351. ESTABLISHMENT OF PROGRAM.

    ``There is hereby established the `Improve Health Insurance 
Affordability Fund' to be administered by the Secretary of Health and 
Human Services, acting through the Administrator of the Centers for 
Medicare & Medicaid Services (in this section referred to as the 
`Administrator'), to provide funding, in accordance with this part, to 
the 50 States and the District of Columbia (each referred to in this 
section as a `State') beginning on January 1, 2022, for the purposes 
described in section 1352.

``SEC. 1352. USE OF FUNDS.

    ``(a) In General.--A State shall use the funds allocated to the 
State under this part for one of the following purposes:
            ``(1) To provide reinsurance payments to health insurance 
        issuers with respect to individuals enrolled under individual 
        health insurance coverage (other than through a plan described 
        in subsection (b)) offered by such issuers.
            ``(2) To provide assistance (other than through payments 
        described in paragraph (1)) to reduce out-of-pocket costs, such 
        as copayments, coinsurance, premiums, and deductibles, of 
        individuals enrolled under qualified health plans offered on 
        the individual market through an Exchange.
    ``(b) Exclusion of Certain Grandfathered and Transitional Plans.--
For purposes of subsection (a), a plan described in this subsection is 
the following:
            ``(1) A grandfathered health plan (as defined in section 
        1251).
            ``(2) A plan (commonly referred to as a `transitional 
        plan') continued under the letter issued by the Centers for 
        Medicare & Medicaid Services on November 14, 2013, to the State 
        Insurance Commissioners outlining a transitional policy for 
        coverage in the individual and small group markets to which 
        section 1251 does not apply, and under the extension of the 
        transitional policy for such coverage set forth in the 
        Insurance Standards Bulletin Series guidance issued by the 
        Centers for Medicare & Medicaid Services on March 5, 2014, 
        February 29, 2016, February 13, 2017, April 9, 2018, March 25, 
        2019, and January 31, 2020, or under any subsequent extensions 
        thereof.
            ``(3) Student health insurance coverage (as defined in 
        section 147.145 of title 45, Code of Federal Regulations).

``SEC. 1353. STATE ELIGIBILITY AND APPROVAL; DEFAULT SAFEGUARD.

    ``(a) Encouraging State Options for Allocations.--
            ``(1) In general.--To be eligible for an allocation of 
        funds under this part for a year (beginning with 2022), a State 
        shall submit to the Administrator an application at such time 
        (but, in the case of allocations for 2022, not later than 90 
        days after the date of the enactment of this part and, in the 
        case of allocations for a subsequent year, not later than March 
        1 of the previous year) and in such form and manner as 
        specified by the Administrator containing--
                    ``(A) a description of how the funds will be used; 
                and
                    ``(B) such other information as the Administrator 
                may require.
            ``(2) Automatic approval.--An application so submitted is 
        approved unless the Administrator notifies the State submitting 
        the application, not later than 60 days after the date of the 
        submission of such application, that the application has been 
        denied for not being in compliance with any requirement of this 
        part and of the reason for such denial.
            ``(3) 5-year application approval.--If an application of a 
        State is approved for a purpose described in section 1352 for a 
        year, such application shall be treated as approved for such 
        purpose for each of the subsequent 4 years.
            ``(4) Revocation of approval.--The approval of an 
        application of a State, with respect to a purpose described in 
        section 1352, may be revoked if the State fails to use funds 
        provided to the State under this section for such purpose or 
        otherwise fails to comply with the requirements of this 
        section.
    ``(b) Default Federal Safeguard.--
            ``(1) 2022.--For 2022, in the case of a State that does not 
        submit an application under subsection (a) by the 90-day 
        submission date applicable to such year under subsection (a)(1) 
        and in the case of a State that does submit such an application 
        by such date that is not approved, the Administrator, in 
        consultation with the State insurance commissioner, shall, from 
        the amount calculated under paragraph (4) for such year, carry 
        out the purpose described in paragraph (3) in such State for 
        such year.
            ``(2) 2023 and subsequent years.--For 2023 or a subsequent 
        year, in the case of a State that does not have in effect an 
        approved application under this section for such year, the 
        Administrator, in consultation with the State insurance 
        commissioner, shall, from the amount calculated under paragraph 
        (4) for such year, carry out the purpose described in paragraph 
        (3) in such State for such year.
            ``(3) Specified use.--The amount described in paragraph 
        (4), with respect to 2022 or a subsequent year, shall be used 
        to carry out the purpose described in section 1352(a)(1) in 
        each State described in paragraph (1) or (2) for such year, as 
        applicable, by providing reinsurance payments to health 
        insurance issuers with respect to attachment range claims (as 
        defined in section 1354(b)(2)), using the dollar amounts 
        specified in subparagraph (B) of such section for such year) in 
        an amount equal to, subject to paragraph (5), the percentage 
        (specified for such year by the Secretary under such 
        subparagraph) of the amount of such claims.
            ``(4) Amount described.--The amount described in this 
        paragraph, with respect to 2022 or a subsequent year, is the 
        amount equal to the total sum of amounts that the Secretary 
        would otherwise estimate under section 1354(b)(2)(A)(i) for 
        such year for each State described in paragraph (1) or (2) for 
        such year, as applicable, if each such State were not so 
        described for such year.
            ``(5) Adjustment.--For purposes of this subsection, the 
        Secretary may apply a percentage under paragraph (3) with 
        respect to a year that is less than the percentage otherwise 
        specified in section 1354(b)(2)(B) for such year, if the cost 
        of paying the total eligible attachment range claims for States 
        described in this subsection for such year at such percentage 
        otherwise specified would exceed the amount calculated under 
        paragraph (4) for such year.

``SEC. 1354. ALLOCATIONS.

    ``(a) Appropriation.--For the purpose of providing allocations for 
States under subsection (b) and payments under section 1353(b) there is 
appropriated, out of any money in the Treasury not otherwise 
appropriated, $10,000,000,000 for 2022 and each subsequent year.
    ``(b) Allocations.--
            ``(1) Payment.--
                    ``(A) In general.--From amounts appropriated under 
                subsection (a) for a year, the Secretary shall, with 
                respect to a State not described in section 1353(b) for 
                such year and not later than the date specified under 
                subparagraph (B) for such year, allocate for such State 
                the amount determined for such State and year under 
                paragraph (2).
                    ``(B) Specified date.--For purposes of subparagraph 
                (A), the date specified in this subparagraph is--
                            ``(i) for 2022, the date that is 45 days 
                        after the date of the enactment of this part; 
                        and
                            ``(ii) for 2023 or a subsequent year, 
                        January 1 of the respective year.
                    ``(C) Notifications of allocation amounts.--For 
                2023 and each subsequent year, the Secretary shall 
                notify each State of the amount determined for such 
                State under paragraph (2) for such year by not later 
                than January 1 of the previous year.
            ``(2) Allocation amount determinations.--
                    ``(A) In general.--For purposes of paragraph (1), 
                the amount determined under this paragraph for a year 
                for a State described in paragraph (1)(A) for such year 
                is the amount equal to--
                            ``(i) the amount that the Secretary 
                        estimates would be expended under this part for 
                        such year on attachment range claims of 
                        individuals residing in such State if such 
                        State used such funds only for the purpose 
                        described in paragraph (1) of section 1352(a) 
                        at the dollar amounts and percentage specified 
                        under subparagraph (B) for such year; minus
                            ``(ii) the amount, if any, by which the 
                        Secretary determines--
                                    ``(I) the estimated amount of 
                                premium tax credits under section 36B 
                                of the Internal Revenue Code of 1986 
                                that would be attributable to 
                                individuals residing in such State for 
                                such year without application of this 
                                part; exceeds
                                    ``(II) the estimated amount of 
                                premium tax credits under section 36B 
                                of the Internal Revenue Code of 1986 
                                that would be attributable to 
                                individuals residing in such State for 
                                such year if such State were a State 
                                described in section 1353(b) for such 
                                year.
                For purposes of the previous sentence and section 
                1353(b)(3), the term `attachment range claims' means, 
                with respect to an individual, the claims for such 
                individual that exceed a dollar amount specified by the 
                Secretary for a year, but do not exceed a ceiling 
                dollar amount specified by the Secretary for such year, 
                under subparagraph (B).
                    ``(B) Specifications.--For purposes of subparagraph 
                (A) and section 1353(b)(3), the Secretary shall 
                determine the dollar amounts and the percentage to be 
                specified under this subparagraph for a year in a 
                manner to ensure that the total amount of expenditures 
                under this part for such year is estimated to equal the 
                total amount appropriated for such year under 
                subsection (a) if such expenditures were used solely 
                for the purpose described in paragraph (1) of section 
                1352(a) for attachment range claims at the dollar 
                amounts and percentage so specified for such year.
            ``(3) Availability.--Funds allocated to a State under this 
        subsection for a year shall remain available through the end of 
        the subsequent year.''.

SEC. 107. RESCINDING THE SHORT-TERM LIMITED DURATION INSURANCE 
              REGULATION.

    (a) Findings.--Congress finds the following:
            (1) On August 3, 2018, the Administration issued a final 
        rule entitled ``Short-Term, Limited-Duration Insurance'' (83 
        Fed. Reg. 38212).
            (2) The final rule dramatically expands the sale and 
        marketing of insurance that--
                    (A) may discriminate against individuals living 
                with preexisting health conditions, including children 
                with complex medical needs and disabilities and their 
                families;
                    (B) lacks important financial protections provided 
                by the Patient Protection and Affordable Care Act 
                (Public Law 111-148), including the prohibition of 
                annual and lifetime coverage limits and annual out-of-
                pocket limits, that may increase the cost of treatment 
                and cause financial hardship to those requiring medical 
                care, including children with complex medical needs and 
                disabilities and their families; and
                    (C) excludes coverage of essential health benefits 
                including hospitalization, prescription drugs, and 
                other lifesaving care.
            (3) The implementation and enforcement of the final rule 
        weakens critical protections for up to 130 million Americans 
        living with preexisting health conditions and may place a large 
        financial burden on those who enroll in short-term limited-
        duration insurance, which jeopardizes Americans' access to 
        quality, affordable health insurance.
    (b) Prohibition.--The Secretary of Health and Human Services, the 
Secretary of the Treasury, and the Secretary of Labor--
            (1) may not take any action to implement, enforce, or 
        otherwise give effect to the rule entitled ``Short-Term, 
        Limited Duration Insurance'' (83 Fed. Reg. 38212 (August 3, 
        2018));
            (2) shall apply any regulation revised by such rule as if 
        such rule had not been issued; and
            (3) may not promulgate any substantially similar rule.

SEC. 108. REVOKING SECTION 1332 GUIDANCE.

    (a) Findings.--Congress finds the following:
            (1) On October 24, 2018, the administration published new 
        guidance to carry out section 1332 of the Patient Protection 
        and Affordable Care Act (42 U.S.C. 18052) entitled ``State 
        Relief and Empowerment Waivers'' (83 Fed. Reg. 53575).
            (2) The new guidance encourages States to provide health 
        insurance coverage through insurance plans that may 
        discriminate against individuals with preexisting health 
        conditions, including the one in four Americans living with a 
        disability.
            (3) The implementation and enforcement of the new guidance 
        weakens protections for the millions of Americans living with 
        preexisting health conditions and jeopardizes Americans' access 
        to quality, affordable health insurance coverage.
    (b) Providing That Certain Guidance Related to Waivers for State 
Innovation Under the Patient Protection and Affordable Care Act Shall 
Have No Force or Effect.--Beginning July 1, 2020, the Secretary of 
Health and Human Services and the Secretary of the Treasury may not 
take any action to implement, enforce, or otherwise give effect to the 
guidance entitled ``State Relief and Empowerment Waivers'' (83 Fed. 
Reg. 53575 (October 24, 2018)), including any such action that would 
result in individuals losing health insurance coverage that includes 
the essential health benefits package (as defined in subsection (a) of 
section 1302 of the Patient Protection and Affordable Care Act (42 
U.S.C. 18022(a)) without regard to any waiver of any provision of such 
package under a waiver under such section 1332), including the 
maternity and newborn care essential health benefit described in 
subsection (b)(1)(D) of such section, including any such action that 
would result in a decrease in the number of such individuals enrolled 
in coverage that is at least as comprehensive as the coverage defined 
in section 1302(a) of the Patient Protection and Affordable Care Act 
(42 U.S.C. 18022(a)) compared to the number of such individuals who 
would have been so enrolled in such coverage had such action not been 
taken, including any such action that would, with respect to 
individuals with substance use disorders, including opioid use 
disorders, reduce the availability or affordability of coverage that is 
at least as comprehensive as the coverage defined in section 1302(a) of 
the Patient Protection and Affordable Care Act (42 U.S.C. 18022(a)) 
compared to the availability or affordability, respectively, of such 
coverage had such action not been taken, including any such action that 
would result, with respect to vulnerable populations (including low-
income individuals, elderly individuals, and individuals with serious 
health issues or who have a greater risk of developing serious health 
issues), in a decrease in the availability of coverage that is at least 
as comprehensive as the coverage defined in section 1302(a) of the 
Patient Protection and Affordable Care Act (42 U.S.C. 18022(a)) with 
coverage and cost sharing protections required under section 
1332(b)(1)(B) of such Act (42 U.S.C. 18052(b)(1)(B)), including any 
such action that would, with respect to individuals with preexisting 
conditions, reduce the affordability of coverage that is at least as 
comprehensive as the coverage defined in section 1302(a) of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18022(a)) compared to the 
affordability of such coverage had such action not been taken, 
including any such action that would result in higher health insurance 
premiums for individuals enrolled in health insurance coverage that is 
at least as comprehensive as the coverage defined in section 1302(b) of 
such Act (42 U.S.C. 18022(b)), and the Secretaries may not promulgate 
any substantially similar guidance or rule. Nothing in the previous 
sentence shall be construed to affect the approval of waivers under 
section 1332 of the Patient Protection and Affordable Care Act (42 
U.S.C. 18052) that establish reinsurance programs that are consistent 
with the requirements under subsection (b)(1) of such section (42 
U.S.C. 18052(b)(1)), lower health insurance premiums, and protect 
health insurance coverage for people with preexisting conditions.
    (c) GAO Report on Affect of State Innovation Waivers on Coverage of 
Individuals and on Mental Health Health Care Treatment.--Not later than 
1 year after the date of the enactment of this Act, the Comptroller 
General of the United States shall submit to Congress a report on the 
number of individuals expected to lose access to health insurance 
coverage (as defined in section 2791 of the Public Health Service Act 
(42 U.S.C. 300gg-91)) if subsection (b) were not enacted and waivers 
under section 1332 of the Patient Protection and Affordable Care Act 
(42 U.S.C. 18052) were approved under the guidance described in such 
subsection (b). Such report shall include an analysis of the expected 
effect such waivers approved under such guidance would have on mental 
health care treatment.

SEC. 109. REQUIRING MARKETPLACE OUTREACH, EDUCATIONAL ACTIVITIES, AND 
              ANNUAL ENROLLMENT TARGETS.

    (a) In General.--Section 1321(c) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18041(c)), as amended by section 105(b), 
is further amended by adding at the end the following new paragraphs:
            ``(4) Outreach and educational activities.--
                    ``(A) In general.--In the case of an Exchange 
                established or operated by the Secretary within a State 
                pursuant to this subsection, the Secretary shall carry 
                out outreach and educational activities for purposes of 
                informing individuals about qualified health plans 
                offered through the Exchange, including by informing 
                such individuals of the availability of coverage under 
                such plans and financial assistance for coverage under 
                such plans. Such outreach and educational activities 
                shall be provided in a manner that is culturally and 
                linguistically appropriate to the needs of the 
                populations being served by the Exchange (including 
                hard-to-reach populations, such as racial and sexual 
                minorities, limited English proficient populations, 
                individuals in rural areas, veterans, and young adults) 
                and shall be provided to populations residing in high 
                health disparity areas (as defined in subparagraph (E)) 
                served by the Exchange, in addition to other 
                populations served by the Exchange.
                    ``(B) Limitation on use of funds.--No funds 
                appropriated under this paragraph shall be used for 
                expenditures for promoting non-ACA compliant health 
                insurance coverage.
                    ``(C) Non-aca compliant health insurance 
                coverage.--For purposes of subparagraph (B):
                            ``(i) The term `non-ACA compliant health 
                        insurance coverage' means health insurance 
                        coverage, or a group health plan, that is not a 
                        qualified health plan.
                            ``(ii) Such term includes the following:
                                    ``(I) An association health plan.
                                    ``(II) Short-term limited duration 
                                insurance.
                    ``(D) Funding.--Out of any funds in the Treasury 
                not otherwise appropriated, there are hereby 
                appropriated for fiscal year 2022 and each subsequent 
                fiscal year, $100,000,000 to carry out this paragraph. 
                Funds appropriated under this subparagraph shall remain 
                available until expended.
                    ``(E) High health disparity area defined.--For 
                purposes of subparagraph (A), the term `high health 
                disparity area' means a contiguous geographic area 
                that--
                            ``(i) is located in one census tract or ZIP 
                        code;
                            ``(ii) has measurable and documented 
                        racial, ethnic, or geographic health 
                        disparities;
                            ``(iii) has a low-income population, as 
                        demonstrated by--
                                    ``(I) average income below 138 
                                percent of the Federal poverty line; or
                                    ``(II) a rate of participation in 
                                the special supplemental nutrition 
                                program under section 17 of the Child 
                                Nutrition Act of 1966 (42 U.S.C. 1786) 
                                that is higher than the national 
                                average rate of participation in such 
                                program;
                            ``(iv) has poor health outcomes, as 
                        demonstrated by--
                                    ``(I) lower life expectancy than 
                                the national average; or
                                    ``(II) a higher percentage of 
                                instances of low birth weight than the 
                                national average; and
                            ``(v) is part of a Metropolitan Statistical 
                        Area identified by the Office of Management and 
                        Budget.
            ``(5) Annual enrollment targets.--For plan year 2021 and 
        each subsequent plan year, in the case of an Exchange 
        established or operated by the Secretary within a State 
        pursuant to this subsection, the Secretary shall establish 
        annual enrollment targets for such Exchange for such year.''.
    (b) Study and Report.--Not later than 30 days after the date of the 
enactment of this Act, the Secretary of Health and Human Services shall 
release to Congress all aggregated documents relating to studies and 
data sets that were created on or after January 1, 2014, and related to 
marketing and outreach with respect to qualified health plans offered 
through Exchanges under title I of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18001 et seq.).

SEC. 110. REPORT ON EFFECTS OF WEBSITE MAINTENANCE DURING OPEN 
              ENROLLMENT.

    Not later than 1 year after the date of the enactment of this Act, 
the Comptroller General of the United States shall submit to Congress a 
report examining whether the Department of Health and Human Services 
has been conducting maintenance on the website commonly referred to as 
``Healthcare.gov'' during annual open enrollment periods (as described 
in section 1311(c)(6)(B) of the Patient Protection and Affordable Care 
Act (42 U.S.C. 18031(c)(6)(B)) in such a manner so as to minimize any 
disruption to the use of such website resulting from such maintenance.

SEC. 111. PROMOTING CONSUMER OUTREACH AND EDUCATION.

    (a) In General.--Section 1311(i) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18031(i)) is amended--
            (1) in paragraph (2), by adding at the end the following 
        new subparagraph:
                    ``(C) Selection of recipients.--In the case of an 
                Exchange established and operated by the Secretary 
                within a State pursuant to section 1321(c), in awarding 
                grants under paragraph (1), the Exchange shall--
                            ``(i) select entities to receive such 
                        grants based on an entity's demonstrated 
                        capacity to carry out each of the duties 
                        specified in paragraph (3);
                            ``(ii) not take into account whether or not 
                        the entity has demonstrated how the entity will 
                        provide information to individuals relating to 
                        group health plans offered by a group or 
                        association of employers described in section 
                        2510.3-5(b) of title 29, Code of Federal 
                        Regulations (or any successor regulation), or 
                        short-term limited duration insurance (as 
                        defined by the Secretary for purposes of 
                        section 2791(b)(5) of the Public Health Service 
                        Act); and
                            ``(iii) ensure that, each year, the 
                        Exchange awards such a grant to--
                                    ``(I) at least one entity described 
                                in this paragraph that is a community 
                                and consumer-focused nonprofit group; 
                                and
                                    ``(II) at least one entity 
                                described in subparagraph (B), which 
                                may include another community and 
                                consumer-focused nonprofit group in 
                                addition to any such group awarded a 
                                grant pursuant to subclause (I).
                In awarding such grants, an Exchange may consider an 
                entity's record with respect to waste, fraud, and abuse 
                for purposes of maintaining the integrity of such 
                Exchange.'';
            (2) in paragraph (3)--
                    (A) by amending subparagraph (C) to read as 
                follows:
                    ``(C) facilitate enrollment, including with respect 
                to individuals with limited English proficiency and 
                individuals with chronic illnesses, in qualified health 
                plans, State medicaid plans under title XIX of the 
                Social Security Act, and State child health plans under 
                title XXI of such Act;'';
                    (B) in subparagraph (D), by striking ``and'' at the 
                end;
                    (C) in subparagraph (E), by striking the period at 
                the end and inserting ``; and'';
                    (D) by inserting after subparagraph (E) the 
                following new subparagraph:
                    ``(F) provide referrals to community-based 
                organizations that address social needs related to 
                health outcomes.''; and
                    (E) by adding at the end the following flush left 
                sentence:
        ``The duties specified in the preceding sentence may be carried 
        out by such a navigator at any time during a year.'';
            (3) in paragraph (4)(A)--
                    (A) in the matter preceding clause (i), by striking 
                ``not'';
                    (B) in clause (i)--
                            (i) by inserting ``not'' before ``be''; and
                            (ii) by striking ``; or'' and inserting a 
                        semicolon;
                    (C) in clause (ii)--
                            (i) by inserting ``not'' before 
                        ``receive''; and
                            (ii) by striking the period and inserting a 
                        semicolon; and
                    (D) by adding at the end the following new clauses:
                            ``(iii) maintain physical presence in the 
                        State of the Exchange so as to allow in-person 
                        assistance to consumers; and
                            ``(iv) receive opioid specific education 
                        and training that ensures the navigator can 
                        best educate individuals on qualified health 
                        plans offered through an Exchange, specifically 
                        coverage under such plans for opioid health 
                        care treatment.''; and
            (4) in paragraph (6)--
                    (A) by striking ``Funding.--Grants under'' and 
                inserting ``Funding.--
                    ``(A) State exchanges.--Grants under''; and
                    (B) by adding at the end the following new 
                subparagraph:
                    ``(B) Federal exchanges.--For purposes of carrying 
                out this subsection, with respect to an Exchange 
                established and operated by the Secretary within a 
                State pursuant to section 1321(c), the Secretary shall 
                obligate $100,000,000 out of amounts collected through 
                the user fees on participating health insurance issuers 
                pursuant to section 156.50 of title 45, Code of Federal 
                Regulations (or any successor regulations), for fiscal 
                year 2022 and each subsequent fiscal year. Such amount 
                for a fiscal year shall remain available until 
                expended.''.
    (b) Effective Date.--The amendments made by this section shall 
apply with respect to plan years beginning on or after January 1, 2021.

SEC. 112. IMPROVING TRANSPARENCY AND ACCOUNTABILITY IN THE MARKETPLACE.

    (a) Open Enrollment Reports.--For plan year 2021 and each 
subsequent year, the Secretary of Health and Human Services (referred 
to in this section as the ``Secretary''), in coordination with the 
Secretary of the Treasury and the Secretary of Labor, shall issue 
biweekly public reports during the annual open enrollment period on the 
performance of the federally facilitated Exchange operated pursuant to 
section 1321(c) of the Patient Protection and Affordable Care Act (42 
U.S.C. 18041(c)). Each such report shall include a summary, including 
information on a State-by-State basis where available, of--
            (1) the number of unique website visits;
            (2) the number of individuals who create an account;
            (3) the number of calls to the call center;
            (4) the average wait time for callers contacting the call 
        center;
            (5) the number of individuals who enroll in a qualified 
        health plan; and
            (6) the percentage of individuals who enroll in a qualified 
        health plan through each of--
                    (A) the website;
                    (B) the call center;
                    (C) navigators;
                    (D) agents and brokers;
                    (E) the enrollment assistant program;
                    (F) directly from issuers or web brokers; and
                    (G) other means.
    (b) Open Enrollment After Action Report.--For plan year 2021 and 
each subsequent year, the Secretary, in coordination with the Secretary 
of the Treasury and the Secretary of Labor, shall publish an after 
action report not later than 3 months after the completion of the 
annual open enrollment period regarding the performance of the Exchange 
described in subsection (a) for the applicable plan year. Each such 
report shall include a summary, including information on a State-by-
State basis where available, of--
            (1) the open enrollment data reported under subsection (a) 
        for the entirety of the enrollment period; and
            (2) activities related to patient navigators described in 
        section 1311(i) of the Patient Protection and Affordable Care 
        Act (42 U.S.C. 18031(i)), including--
                    (A) the performance objectives established by the 
                Secretary for such patient navigators;
                    (B) the number of consumers enrolled by such a 
                patient navigator;
                    (C) an assessment of how such patient navigators 
                have met established performance metrics, including a 
                detailed list of all patient navigators, funding 
                received by patient navigators, and whether established 
                performance objectives of patient navigators were met; 
                and
                    (D) with respect to the performance objectives 
                described in subparagraph (A)--
                            (i) whether such objectives assess the full 
                        scope of patient navigator responsibilities, 
                        including general education, plan selection, 
                        and determination of eligibility for tax 
                        credits, cost-sharing reductions, or other 
                        coverage;
                            (ii) how the Secretary worked with patient 
                        navigators to establish such objectives; and
                            (iii) how the Secretary adjusted such 
                        objectives for case complexity and other 
                        contextual factors.
    (c) Report on Advertising and Consumer Outreach.--Not later than 3 
months after the completion of the annual open enrollment period for 
plan year 2021, the Secretary shall issue a report on advertising and 
outreach to consumers for the open enrollment period for plan year 
2021. Such report shall include a description of--
            (1) the division of spending on individual advertising 
        platforms, including television and radio advertisements and 
        digital media, to raise consumer awareness of open enrollment;
            (2) the division of spending on individual outreach 
        platforms, including email and text messages, to raise consumer 
        awareness of open enrollment; and
            (3) whether the Secretary conducted targeted outreach to 
        specific demographic groups and geographic areas.
    (b) Promoting Transparency and Accountability in the 
Administration's Expenditures of Exchange User Fees.--For plan year 
2021 and each subsequent plan year, not later than the date that is 3 
months after the end of such plan year, the Secretary of Health and 
Human Services shall submit to the appropriate committees of Congress 
and make available to the public an annual report on the expenditures 
by the Department of Health and Human Services of user fees collected 
pursuant to section 156.50 of title 45, Code of Federal Regulations (or 
any successor regulations). Each such report for a plan year shall 
include a detailed accounting of the amount of such user fees collected 
during such plan year and of the amount of such expenditures used 
during such plan year for the federally facilitated Exchange operated 
pursuant to section 1321(c) of the Patient Protection and Affordable 
Care Act (42 U.S.C. 18041(c)) on outreach and enrollment activities, 
navigators, maintenance of Healthcare.gov, and operation of call 
centers.

SEC. 113. IMPROVING AWARENESS OF HEALTH COVERAGE OPTIONS.

    (a) In General.--Not later than 90 days after the date of the 
enactment of this Act, the Secretary of Labor, in consultation with the 
Secretary of Health and Human Services, shall update, and make publicly 
available in a prominent location on the website of the Department of 
Labor, the model Consolidated Omnibus Budget Reconciliation Act of 1985 
(referred to in this section as ``COBRA'') continuation coverage 
general notice and the model COBRA continuation coverage election 
notice developed by the Secretary of Labor for purposes of facilitating 
compliance of group health plans with the notification requirements 
under section 606 of the Employee Retirement Income Security Act of 
1974 (29 U.S.C. 1166). In updating each such notice, the Secretary of 
Labor shall include information regarding any Exchange established 
under title I of the Patient Protection and Affordable Care Act (42 
U.S.C. 18001 et seq.) through which a qualified beneficiary may be 
eligible to enroll in a qualified health plan, including--
            (1) the publicly accessible Internet website address for 
        such Exchange;
            (2) the publicly accessible Internet website address for 
        the Find Local Help directory maintained by the Department of 
        Health and Human Services on the healthcare.gov Internet 
        website (or a successor website);
            (3) a clear explanation that--
                    (A) an individual who is eligible for continuation 
                coverage may also be eligible to enroll, with financial 
                assistance, in a qualified health plan offered through 
                such Exchange, but, in the case that such individual 
                elects to enroll in such continuation coverage and 
                subsequently elects to terminate such continuation 
                coverage before the period of such continuation 
                coverage expires, such individual will not be eligible 
                to enroll in a qualified health plan offered through 
                such Exchange during a special enrollment period; and
                    (B) an individual who elects to enroll in 
                continuation coverage will remain eligible to enroll in 
                a qualified health plan offered through such Exchange 
                during an open enrollment period and may be eligible 
                for financial assistance with respect to enrolling in 
                such a qualified health plan;
            (4) information on consumer protections with respect to 
        enrolling in a qualified health plan offered through such 
        Exchange, including the requirement for such a qualified health 
        plan to provide coverage for essential health benefits (as 
        defined in section 1302(b) of such Act (42 U.S.C. 18022(b)) and 
        the requirements applicable to such a qualified health plan 
        under part A of title XXVII of the Public Health Service Act 
        (42 U.S.C. 300gg et seq.); and
            (5) information on the availability of financial assistance 
        with respect to enrolling in a qualified health plan, including 
        the maximum income limit for eligibility for a premium tax 
        credit under section 36B of the Internal Revenue Code of 1986.
    (b) Name of Notices.--In addition to updating the model COBRA 
continuation coverage general notice and the model COBRA continuation 
coverage election notice under paragraph (1), the Secretary of Labor 
shall rename each such notice as the ``model COBRA continuation 
coverage and Affordable Care Act coverage general notice'' and the 
``model COBRA continuation coverage and Affordable Care Act coverage 
election notice'', respectively.
    (c) Consumer Testing.--Prior to making publicly available the model 
COBRA continuation coverage general notice and the model COBRA 
continuation coverage election notice updated under paragraph (1), the 
Secretary of Labor shall provide an opportunity for consumer testing of 
each such notice, as so updated, to ensure that each such notice is 
clear and understandable to the average participant or beneficiary of a 
group health plan.
    (d) Definitions.--In this subsection:
            (1) Continuation coverage.--The term ``continuation 
        coverage'', with respect to a group health plan, has the 
        meaning given such term in section 602 of the Employee 
        Retirement Income Security Act of 1974 (29 U.S.C. 1162).
            (2) Group health plan.--The term ``group health plan'' has 
        the meaning given such term in section 607 of such Act (29 
        U.S.C. 1167).
            (3) Qualified beneficiary.--The term ``qualified 
        beneficiary'' has the meaning given such term in such section 
        607.
            (4) Qualified health plan.--The term ``qualified health 
        plan'' has the meaning given such term in section 1301 of the 
        Patient Protection and Affordable Care Act (42 U.S.C. 18021).

SEC. 114. PROMOTING STATE INNOVATIONS TO EXPAND COVERAGE.

    (a) In General.--Subject to subsection (d), the Secretary of Health 
and Human Services shall award grants to eligible State agencies to 
enable such States to explore innovative solutions to promote greater 
enrollment in health insurance coverage in the individual and small 
group markets, including activities described in subsection (c).
    (b) Eligibility.--For purposes of subsection (a), eligible State 
agencies are Exchanges established by a State under title I of the 
Patient Protection and Affordable Care Act (42 U.S.C. 18001 et seq.) 
and State agencies with primary responsibility over health and human 
services for the State involved.
    (c) Use of Funds.--For purposes of subsection (a), the activities 
described in this subsection are the following:
            (1) State efforts to streamline health insurance enrollment 
        procedures in order to reduce burdens on consumers and 
        facilitate greater enrollment in health insurance coverage in 
        the individual and small group markets, including automatic 
        enrollment and reenrollment of, or pre-populated applications 
        for, individuals without health insurance who are eligible for 
        tax credits under section 36B of the Internal Revenue Code of 
        1986, with the ability to opt out of such enrollment.
            (2) State investment in technology to improve data sharing 
        and collection for the purposes of facilitating greater 
        enrollment in health insurance coverage in such markets.
            (3) Implementation of a State version of an individual 
        mandate to be enrolled in health insurance coverage.
            (4) Feasibility studies to develop comprehensive and 
        coherent State plan for increasing enrollment in the individual 
        and small group market.
    (d) Funding.--For purposes of carrying out this section, there is 
hereby appropriated, out of any funds in the Treasury not otherwise 
appropriated, $200,000,000 for each of the fiscal years 2022 through 
2024. Such amount shall remain available until expended.

SEC. 115. STRENGTHENING NETWORK ADEQUACY.

    (a) In General.--Section 1311(d) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18031(d)) is amended by adding at the 
end the following new paragraph:
            ``(8) Network adequacy standards.--
                    ``(A) Certain exchanges.--In the case of an 
                Exchange operated by the Secretary pursuant section 
                1321(c)(1) or an Exchange described in section 
                155.200(f) of title 42, Code of Federal Regulations (or 
                a successor regulation), the Exchange shall require 
                each qualified health plan offered through such 
                Exchange to meet such quantitative network adequacy 
                standards as the Secretary may prescribe for purposes 
                of this subparagraph.
                    ``(B) State exchanges.--In the case of an Exchange 
                not described in subparagraph (A), the Exchange shall 
                establish quantitative network adequacy standards with 
                respect to qualified health plans offered through such 
                Exchange and require such plans to meet such 
                standards.''.
    (b) Effective Date.--The amendment made by this section shall apply 
with respect to plan years beginning on or after January 1, 2022.

SEC. 116. PROTECTING CONSUMERS FROM UNREASONABLE RATE HIKES.

    (a) Protection From Excessive, Unjustified, or Unfairly 
Discriminatory Rates.--The first section 2794 of the Public Health 
Service Act (42 U.S.C. 300gg-94), as added by section 1003 of the 
Patient Protection and Affordable Care Act (Public Law 111-148), is 
amended by adding at the end the following new subsection:
    ``(e) Protection From Excessive, Unjustified, or Unfairly 
Discriminatory Rates.--
            ``(1) Authority of states.--Nothing in this section shall 
        be construed to prohibit a State from imposing requirements 
        (including requirements relating to rate review standards and 
        procedures and information reporting) on health insurance 
        issuers with respect to rates that are in addition to the 
        requirements of this section and are more protective of 
        consumers than such requirements.
            ``(2) Consultation in rate review process.--In carrying out 
        this section, the Secretary shall consult with the National 
        Association of Insurance Commissioners and consumer groups.
            ``(3) Determination of who conducts reviews for each 
        state.--The Secretary shall determine, after the date of 
        enactment of this section and periodically thereafter, the 
        following:
                    ``(A) In which markets in each State the State 
                insurance commissioner or relevant State regulator 
                shall undertake the corrective actions under paragraph 
                (4), based on the Secretary's determination that the 
                State regulator is adequately undertaking and utilizing 
                such actions in that market.
                    ``(B) In which markets in each State the Secretary 
                shall undertake the corrective actions under paragraph 
                (4), in cooperation with the relevant State insurance 
                commissioner or State regulator, based on the 
                Secretary's determination that the State is not 
                adequately undertaking and utilizing such actions in 
                that market.
            ``(4) Corrective action for excessive, unjustified, or 
        unfairly discriminatory rates.--In accordance with the process 
        established under this section, the Secretary or the relevant 
        State insurance commissioner or State regulator shall take 
        corrective actions to ensure that any excessive, unjustified, 
        or unfairly discriminatory rates are corrected prior to 
        implementation, or as soon as possible thereafter, through 
        mechanisms such as--
                    ``(A) denying rates;
                    ``(B) modifying rates; or
                    ``(C) requiring rebates to consumers.
            ``(5) Noncompliance.--Failure to comply with any corrective 
        action taken by the Secretary under this subsection may result 
        in the application of civil monetary penalties under section 
        2723 and, if the Secretary determines appropriate, make the 
        plan involved ineligible for classification as a qualified 
        health plan.''.
    (b) Clarification of Regulatory Authority.--Such section is further 
amended--
            (1) in subsection (a)--
                    (A) in the heading, by striking ``Premium'' and 
                inserting ``Rate'';
                    (B) in paragraph (1), by striking ``unreasonable 
                increases in premiums'' and inserting ``potentially 
                excessive, unjustified, or unfairly discriminatory 
                rates, including premiums,''; and
                    (C) in paragraph (2)--
                            (i) by striking ``an unreasonable premium 
                        increase'' and inserting ``a potentially 
                        excessive, unjustified, or unfairly 
                        discriminatory rate'';
                            (ii) by striking ``the increase'' and 
                        inserting ``the rate''; and
                            (iii) by striking ``such increases'' and 
                        inserting ``such rates''; and
            (2) in subsection (b)--
                    (A) by striking ``premium increases'' each place it 
                appears and inserting ``rates''; and
                    (B) in paragraph (2)(B), by striking ``premium'' 
                and inserting ``rate''.
    (c) Conforming Amendments.--Title XXVII of the Public Health 
Service Act (42 U.S.C. 300gg et seq.) is amended--
            (1) in section 2723 (42 U.S.C. 300gg-22), as redesignated 
        by the Patient Protection and Affordable Care Act--
                    (A) in subsection (a)--
                            (i) in paragraph (1), by inserting ``and 
                        section 2794'' after ``this part''; and
                            (ii) in paragraph (2), by inserting ``or 
                        section 2794'' after ``this part''; and
                    (B) in subsection (b)--
                            (i) in paragraph (1), by inserting ``and 
                        section 2794'' after ``this part''; and
                            (ii) in paragraph (2)--
                                    (I) in subparagraph (A), by 
                                inserting ``or section 2794 that is'' 
                                after ``this part''; and
                                    (II) in subparagraph (C)(ii), by 
                                inserting ``or section 2794'' after 
                                ``this part''; and
            (2) in section 2761 (42 U.S.C. 300gg-61)--
                    (A) in subsection (a)--
                            (i) in paragraph (1), by inserting ``and 
                        section 2794'' after ``this part''; and
                            (ii) in paragraph (2)--
                                    (I) by inserting ``or section 
                                2794'' after ``set forth in this 
                                part''; and
                                    (II) by inserting ``and section 
                                2794'' after ``the requirements of this 
                                part''; and
                    (B) in subsection (b)--
                            (i) by inserting ``and section 2794'' after 
                        ``this part''; and
                            (ii) by inserting ``and section 2794'' 
                        after ``part A''.
    (d) Applicability to Grandfathered Plans.--Section 1251(a)(4)(A) of 
the Patient Protection and Affordable Care Act (Public Law 111-148), as 
added by section 2301 of the Health Care and Education Reconciliation 
Act of 2010 (Public Law 111-152), is amended by adding at the end the 
following:
                            ``(v) Section 2794 (relating to 
                        reasonableness of rates with respect to health 
                        insurance coverage).''.
    (e) Authorization of Appropriations.--There are authorized to be 
appropriated to carry out this Act such sums as may be necessary.
    (f) Effective Date.--The amendments made by this section shall take 
effect on the date of enactment of this Act and shall be implemented 
with respect to health plans beginning not later than January 1, 2022.

SEC. 117. ELIGIBILITY OF DACA RECIPIENTS FOR QUALIFIED HEALTH PLANS 
              OFFERED THROUGH EXCHANGES.

    (a) In General.--Section 1312(f)(3) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18032(f)(3)) is amended--
            (1) by striking ``or an alien lawfully present in the 
        United States'' and inserting ``, an alien lawfully present in 
        the United States, or a DACA recipient''; and
            (2) by adding at the end the following: ``For purposes of 
        the previous sentence, the term `DACA recipient' means an 
        individual who was granted deferred action pursuant to the 
        Deferred Action for Childhood Arrivals Program announced in the 
        memorandum of the Secretary of Homeland Security dated June 15, 
        2012, and for whom such grant remains valid.''.
    (b) Application of Reduced Cost-Sharing.--Section 1402(e)(2) of the 
Patient Protection and Affordable Care Act (42 U.S.C. 18071(e)(2)) is 
amended by adding at the end the following: ``A DACA recipient (as 
defined in section 1312(f)(3)) shall be treated as lawfully present for 
purposes of this section.''.
    (c) Eligibility for Advance Payments.--Section 1412(d) of the 
Patient Protection and Affordable Care Act (42 U.S.C. 18082(d)) is 
amended by adding at the end the following: ``For purposes of the 
previous sentence, a DACA recipient (as defined in section 1312(f)(3)) 
shall be treated as lawfully present in the United States.''.
    (d) Verification of Eligibility.--Section 1411(c)(2)(B) of the 
Patient Protection and Affordable Care Act (42 U.S.C. 18081(c)(2)(B)) 
is amended--
            (1) in clause (i)(I), by inserting ``or a DACA recipient 
        (as defined in section 1312(f)(3))'' after ``an alien lawfully 
        present in the United States''; and
            (2) in clause (ii), by inserting ``or a DACA recipient (as 
        defined in section 1312(f)(3))'' after ``an alien lawfully 
        present in the United States''.
    (e) Application of Tax Credit for Coverage Under a Qualified Health 
Plan.--Section 36B(e)(2) of the Internal Revenue Code of 1986 is 
amended by adding at the end the following: ``A DACA recipient (as 
defined in section 1312(f)(3) of the Patient Protection and Affordable 
Care Act) shall be treated as lawfully present for purposes of this 
section.''.
    (f) Effective Date.--The amendments made by this section shall take 
effect on January 1, 2021.

TITLE II--ENCOURAGING MEDICAID EXPANSION AND STRENGTHENING THE MEDICAID 
                                PROGRAM

SEC. 201. INCENTIVIZING MEDICAID EXPANSION.

    (a) In General.--Section 1905(y)(1) of the Social Security Act (42 
U.S.C. 1396d(y)(1)) is amended--
            (1) in subparagraph (A), by striking ``2014, 2015, and 
        2016'' and inserting ``each of the first 3 consecutive 12-month 
        periods in which the State provides medical assistance to newly 
        eligible individuals'';
            (2) in subparagraph (B), by striking ``2017'' and inserting 
        ``the fourth consecutive 12-month period in which the State 
        provides medical assistance to newly eligible individuals'';
            (3) in subparagraph (C), by striking ``2018'' and inserting 
        ``the fifth consecutive 12-month period in which the State 
        provides medical assistance to newly eligible individuals'';
            (4) in subparagraph (D), by striking ``2019'' and inserting 
        ``the sixth consecutive 12-month period in which the State 
        provides medical assistance to newly eligible individuals''; 
        and
            (5) in subparagraph (E), by striking ``2020 and each year 
        thereafter'' and inserting ``the seventh consecutive 12-month 
        period in which the State provides medical assistance to newly 
        eligible individuals and each such period thereafter''.
    (b) Effective Date.--Beginning on January 1, 2022, the amendments 
made by subsection (a) shall take effect as if included in the 
enactment of the Patient Protection and Affordable Care Act (Public Law 
111-148).

SEC. 202. PROVIDING 12-MONTHS OF CONTINUOUS ELIGIBILITY FOR MEDICAID 
              AND CHIP.

    (a) Requirement of 12-Month Continuous Enrollment Under Medicaid.--
Section 1902(e)(12) of the Social Security Act (42 U.S.C. 1396a(e)(12)) 
is amended to read as follows:
            ``(12) 12-month continuous enrollment.--Notwithstanding any 
        other provision of this title, a State plan approved under this 
        title (or under any waiver of such plan approved pursuant to 
        section 1115 or section 1915), shall provide that an individual 
        who is determined to be eligible for benefits under such plan 
        (or waiver) shall remain eligible and enrolled for such 
        benefits through the end of the month in which the 12-month 
        period (beginning on the date of determination of eligibility) 
        ends.''.
    (b) Requirement of 12-Month Continuous Enrollment Under CHIP.--
            (1) In general.--Section 2102(b) of the Social Security Act 
        (42 U.S.C. 1397bb(b)) is amended by adding at the end the 
        following new paragraph:
            ``(6) Requirement for 12-month continuous enrollment.--
        Notwithstanding any other provision of this title, a State 
        child health plan that provides child health assistance under 
        this title through a means other than described in section 
        2101(a)(2), shall provide that an individual who is determined 
        to be eligible for benefits under such plan shall remain 
        eligible and enrolled for such benefits through the end of the 
        month in which the 12-month period (beginning on the date of 
        determination of eligibility) ends.''.
            (2) Conforming amendment.--Section 2105(a)(4)(A) of the 
        Social Security Act (42 U.S.C. 1397ee(a)(4)(A)) is amended--
                    (A) by striking ``has elected the option of'' and 
                inserting ``is in compliance with the requirement 
                for''; and
                    (B) by striking ``applying such policy under its 
                State child health plan under this title'' and 
                inserting ``in compliance with section 2102(b)''.
    (c) Effective Date.--
            (1) In general.--Except as provided in paragraph (2) or 
        (3), the amendments made by subsections (a) and (b) shall apply 
        to determinations (and redeterminations) of eligibility made on 
        or after the date that is 12 months after the last day of the 
        emergency period described in section 1135(g)(1)(B) of the 
        Social Security Act (42 U.S.C. 1320b-5(g)(1)(B)).
            (2) Extension of effective date for state law amendment.--
        In the case of a State plan under title XIX or State child 
        health plan under title XXI of the Social Security Act (42 
        U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.) which the 
        Secretary of Health and Human Services determines requires 
        State legislation (other than legislation appropriating funds) 
        in order for the respective plan to meet the additional 
        requirement imposed by the amendment made by subsection (a) or 
        (b), respectively, the respective plan shall not be regarded as 
        failing to comply with the requirements of such title solely on 
        the basis of its failure to meet such applicable additional 
        requirement before the first day of the first calendar quarter 
        beginning after the close of the first regular session of the 
        State legislature that begins after the date of enactment of 
        this Act. For purposes of the previous sentence, in the case of 
        a State that has a 2-year legislative session, each year of the 
        session is considered to be a separate regular session of the 
        State legislature.
            (3) Option to implement 12-month continuous eligibility 
        prior to effective date.--A State may elect through a State 
        plan amendment under title XIX or XXI of the Social Security 
        Act (42 U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.) to apply 
        the amendment made by subsection (a) or (b), respectively, on 
        any date prior to the date specified in paragraph (1), but not 
        sooner than the date of the enactment of this Act.

SEC. 203. MANDATORY 12-MONTHS OF POSTPARTUM MEDICAID ELIGIBILITY.

    (a) Extending Continuous Medicaid and CHIP Coverage for Pregnant 
and Postpartum Women.--
            (1) Medicaid.--Title XIX of the Social Security Act (42 
        U.S.C. 1396 et seq.) is amended--
                    (A) in section 1902(l)(1)(A), by striking ``60-day 
                period'' and inserting ``365-day period'';
                    (B) in section 1902(e)(6), by striking ``60-day 
                period'' and inserting ``365-day period'';
                    (C) in section 1903(v)(4)(A)(i), by striking ``60-
                day period'' and inserting ``365-day period''; and
                    (D) in section 1905(a), in the 4th sentence in the 
                matter following paragraph (30), by striking ``60-day 
                period'' and inserting ``365-day period''.
            (2) CHIP.--Section 2112 of the Social Security Act (42 
        U.S.C. 1397ll) is amended by striking ``60-day period'' each 
        place it appears and inserting ``365-day period''.
    (b) Requiring Full Benefits for Pregnant and Postpartum Women.--
            (1) Medicaid.--
                    (A) In general.--Paragraph (5) of section 1902(e) 
                of the Social Security Act (24 U.S.C. 1396a(e)) is 
                amended to read as follows:
            ``(5) Any woman who is eligible for medical assistance 
        under the State plan or a waiver of such plan and who is, or 
        who while so eligible becomes, pregnant, shall continue to be 
        eligible under the plan or waiver for medical assistance 
        through the end of the month in which the 365-day period 
        (beginning on the last day of her pregnancy) ends, regardless 
        of the basis for the woman's eligibility for medical 
        assistance, including if the woman's eligibility for medical 
        assistance is on the basis of being pregnant.''.
                    (B) Conforming amendment.--Section 1902(a)(10) of 
                the Social Security Act (42 U.S.C. 1396a(a)(10)) is 
                amended in the matter following subparagraph (G) by 
                striking ``(VII) the medical assistance'' and all that 
                follows through ``complicate pregnancy,''.
            (2) CHIP.--Section 2107(e)(1) of the Social Security Act 
        (42 U.S.C. 1397gg(e)(1)) is amended--
                    (A) by redesignating subparagraphs (H) through (S) 
                as subparagraphs (I) through (T), respectively; and
                    (B) by inserting after subparagraph (G), the 
                following:
                    ``(H) Section 1902(e)(5) (requiring 365-day 
                continuous coverage for pregnant and postpartum 
                women).''.
    (c) Maintenance of Effort.--
            (1) Medicaid.--Section 1902 of the Social Security Act (42 
        U.S.C. 1396a) is amended--
                    (A) in paragraph (74), by striking ``subsection 
                (gg); and'' and inserting ``subsections (gg) and 
                (qq);''; and
                    (B) by adding at the end the following new 
                subsection:
    ``(qq) Maintenance of Effort Related to Low-Income Pregnant 
Women.--For calendar quarters beginning on or after the effective date 
described in section 203(d) of the Patient Protection and Affordable 
Care Enhancement Act, and before January 1, 2023, no Federal payment 
shall be made to a State under section 1903(a) for amounts expended 
under a State plan under this title or a waiver of such plan if the 
State--
            ``(1) has in effect under such plan eligibility standards, 
        methodologies, or procedures for individuals described in 
        subsection (l)(1) who are eligible for medical assistance under 
        the State plan or waiver under subsection (a)(10)(A)(ii)(IX) 
        that are more restrictive than the eligibility standards, 
        methodologies, or procedures, respectively, for such 
        individuals under such plan or waiver that are in effect on the 
        date of the enactment of this subsection; or
            ``(2) provides medical assistance to individuals described 
        in subsection (l)(1) who are eligible for medical assistance 
        under such plan or waiver under subsection (a)(10)(A)(ii)(IX) 
        at a level that is less than the level at which the State 
        provides such assistance to such individuals under such plan or 
        waiver on the date of the enactment of this subsection.''.
            (2) CHIP.--Section 2112 of the Social Security Act (42 
        U.S.C. 1397ll), as amended by subsection (b), is further 
        amended by adding at the end the following subsection:
    ``(g) Maintenance of Effort.--For calendar quarters beginning on or 
after the effective date described in section 203(d) of the Patient 
Protection and Affordable Care Enhancement Act, and before January 1, 
2023, no payment may be made under section 2105(a) with respect to a 
State child health plan if the State--
            ``(1) has in effect under such plan eligibility standards, 
        methodologies, or procedures for targeted low-income pregnant 
        women that are more restrictive than the eligibility standards, 
        methodologies, or procedures, respectively, under such plan 
        that are in effect on the date of the enactment of this 
        subsection; or
            ``(2) provides pregnancy-related assistance to targeted 
        low-income pregnant women under such plan at a level that is 
        less than the level at which the State provides such assistance 
        to such women under such plan on the date of the enactment of 
        this subsection.''.
    (d) Effective Date.--
            (1) In general.--Except as provided under paragraph (2), 
        the amendments made by subsections (a) and (b) shall take 
        effect on (and the effective date described in this subsection 
        shall be) the first day of the calendar quarter during which 
        the last day of the emergency period described in section 
        1135(g)(1)(B) of the Social Security Act (42 U.S.C. 1320b-
        5(g)(1)(B)) occurs.
            (2) Extension of effective date for state law amendment.--
        In the case of a State plan under title XIX or State child 
        health plan under title XXI of the Social Security Act (42 
        U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.) which the 
        Secretary of Health and Human Services determines requires 
        State legislation (other than legislation appropriating funds) 
        in order for the respective plan to meet the additional 
        requirement imposed by the amendments made by subsection (a) or 
        (b), respectively, the respective plan shall not be regarded as 
        failing to comply with the requirements of such title solely on 
        the basis of its failure to meet such applicable additional 
        requirement before the first day of the first calendar quarter 
        beginning after the close of the first regular session of the 
        State legislature that begins after the date of enactment of 
        this Act. For purposes of the previous sentence, in the case of 
        a State that has a 2-year legislative session, each year of the 
        session is considered to be a separate regular session of the 
        State legislature.

SEC. 204. REDUCING THE ADMINISTRATIVE FMAP FOR NONEXPANSION STATES.

    Section 1903 of the Social Security Act (42 U.S.C. 1396b) is 
amended--
            (1) in subsection (a)(7), by inserting ``subsection (bb) 
        and'' before ``section 1919(g)(3)(B)''; and
            (2) by adding at the end the following new subsection:
    ``(bb) Reduction of Federal Payments for Certain Administrative 
Costs of Nonexpansion States.--
            ``(1) In general.--In the case of a State that does not 
        provide under the State plan of such State (or waiver of such 
        plan) for making medical assistance available in accordance 
        with section 1902(k)(1) to all individuals described in section 
        1902(a)(10)(i)(VIII) for a calendar quarter beginning on or 
        after October 1, 2022, the Secretary may reduce the percentage 
        specified in subsection (a)(7) for amounts described in such 
        subsection expended during such quarter by such State by the 
        number of percentage points specified in paragraph (2) for such 
        quarter.
            ``(2) Amount of reduction.--For purposes of paragraph (1), 
        the number of percentage points specified in this paragraph for 
        a calendar quarter is the following:
                    ``(A) For the calendar quarter beginning on October 
                1, 2022, 0.5.
                    ``(B) For a calendar quarter beginning on or after 
                January 1, 2023, and ending before July 1, 2027, the 
                number of percentage points specified under this 
                paragraph for the previous quarter, plus 0.5.
                    ``(C) For a calendar quarter beginning on or after 
                July 1, 2027, 10.
            ``(3) Definition.--For purposes of this subsection, the 
        term `State' means a State that is one of the 50 States or the 
        District of Columbia.''.

SEC. 205. ENHANCED REPORTING REQUIREMENTS FOR NONEXPANSION STATES.

    Section 1903 of the Social Security Act (42 U.S.C. 1396b), as 
amended by section 204, is further amended--
            (1) in subsection (a)(7), by striking ``subsection (bb)'' 
        and inserting ``subsections (bb) and (cc)''; and
            (2) by adding at the end the following new subsection:
    ``(cc) Reduction of Federal Payments for Certain Administrative 
Costs of Nonexpansion States That Do Not Satisfy Reporting 
Requirements.--
            ``(1) In general.--
                    ``(A) Reduction.--In the case of a nonexpansion 
                State, with respect to a fiscal year (beginning with 
                fiscal year 2023) that does not satisfy the reporting 
                requirement under paragraph (2) for such fiscal year, 
                the percentage specified in subsection (a)(7) for 
                amounts described in such subsection expended by such 
                State during a calendar quarter described in paragraph 
                (4) with respect to such fiscal year, subject to 
                subparagraph (B), shall be reduced by the number of 
                percentage points specified in paragraph (4) for the 
                respective calendar quarter.
                    ``(B) Exception.--In the case of a nonexpansion 
                State that is subject to a reduction under subparagraph 
                (A) for the calendar quarter described in paragraph 
                (4)(A) with respect to a fiscal year, if the State 
                satisfies the criteria described in subparagraphs (A), 
                (B), and (C) of paragraph (2) (without regard to the 
                dates specified in such subparagraph (A) and (C)) 
                before the beginning of a subsequent calendar quarter 
                described in paragraph (4) with respect to such fiscal 
                year, then such State shall not be subject to a 
                reduction under subparagraph (A) for such subsequent 
                calendar quarter.
            ``(2) Reporting requirement.--For purposes of paragraph 
        (1), a nonexpansion State satisfies the reporting requirement 
        under this paragraph for a fiscal year, if the nonexpansion 
        State--
                    ``(A) by not later than January 1 of such year, 
                posts on the public website of the State agency 
                administering the State plan, the information described 
                in paragraph (3) with respect to such State for the 
                previous year;
                    ``(B) provides for at least a 30-day period for 
                notice and comment on such information; and
                    ``(C) by not later than March 1 of such year, 
                submits to the Secretary a complete report including 
                such information, comments submitted pursuant to 
                subparagraph (B), and a response by the State to each 
                such comment.
            ``(3) Information described.--The information described in 
        this paragraph, with respect to a State and year, is the 
        following:
                    ``(A) The the estimated number of individuals who 
                were uninsured for at least 6 months, shown by age-
                groups of 0 to 18 years of age and of 19 years of age 
                to 64 years of age, as well as a detailed description 
                of the basis for the estimates.
                    ``(B) The estimated number of the individuals 
                estimated under subparagraph (A) in the State who would 
                be eligible for medical assistance under the State plan 
                if the State were to make medical assistance under the 
                State plan available in accordance with section 
                1902(k)(1) to all individuals described in section 
                1902(a)(10)(i)(VIII), and a detailed description of the 
                basis for the estimates.
                    ``(C) A comprehensive listing of State income 
                eligibility criteria for all mandatory and optional 
                Medicaid eligibility groups for which the State plan 
                provides medical assistance (other than with respect to 
                individuals described in clause (i)(II), (ii)(VI), or 
                (ii)(XXII) of section 1902(a)(10)(A)).
                    ``(D) The total amount of hospital uncompensated-
                care costs and a breakdown of the source of such costs, 
                as well as a breakdown for rural and non-rural 
                hospitals.
            ``(4) Percentage described.--For purposes of paragraph (1), 
        a calendar quarter described in this paragraph, with respect to 
        a fiscal year, and the percentage points described in this 
        paragraph for such quarter, with respect to a State, are--
                    ``(A) for the calendar quarter beginning on the 
                April 1 occurring during such fiscal year, 0.5 
                percentage points;
                    ``(B) for the calendar quarter beginning on the 
                July 1 occurring during such fiscal year, 1.0 
                percentage point; and
                    ``(C) for the calendar quarter beginning on the 
                October 1 occurring during the subsequent fiscal year, 
                1.5 percentage points.
            ``(5) Payment in case of reporting state.--The expenses 
        incurred by a non-expansion State, with respect to any calendar 
        quarter with respect to a fiscal year (beginning with 2021), 
        for carrying out subparagraphs (A) through (C) of paragraph (2) 
        shall, for purposes of section 1903(a)(7), be considered to be 
        expenses necessary for the proper and efficient administration 
        of the State plan under this title.
            ``(6) Nonexpanion state defined.--For purposes of this 
        subsection, the term `nonexpansion State' means, with respect 
        to a fiscal year, a State that as of the first quarter of such 
        fiscal year does not provide under the State plan of such State 
        (or waiver of such plan) for making medical assistance 
        available in accordance with section 1902(k)(1) to all 
        individuals described in section 1902(a)(10)(i)(VIII).''.

SEC. 206. PRIMARY CARE PAY INCREASE.

    (a) Renewal of Payment Floor; Additional Providers.--
            (1) In general.--Section 1902(a)(13) of the Social Security 
        Act (42 U.S.C. 1396a(a)(13)) is amended by striking 
        subparagraph (C) and inserting the following:
                    ``(C) payment for primary care services (as defined 
                in subsection (jj)) at a rate that is not less than 100 
                percent of the payment rate that applies to such 
                services and physician under part B of title XVIII (or, 
                if greater, the payment rate that would be applicable 
                under such part if the conversion factor under section 
                1848(d) for the year involved were the conversion 
                factor under such section for 2009), and that is not 
                less than the rate that would otherwise apply to such 
                services under this title if the rate were determined 
                without regard to this subparagraph, and that are--
                            ``(i) furnished during 2013 and 2014, by a 
                        physician with a primary specialty designation 
                        of family medicine, general internal medicine, 
                        or pediatric medicine; or
                            ``(ii) furnished during the period that 
                        begins on the first day of the first month that 
                        begins one year after the date of enactment of 
                        the Patient Protection and Affordable Care 
                        Enhancement Act and ends September 30, 2024--
                                    ``(I) by a physician with a primary 
                                specialty designation of family 
                                medicine, general internal medicine, or 
                                pediatric medicine, but only if the 
                                physician self-attests that the 
                                physician is Board certified in family 
                                medicine, general internal medicine, or 
                                pediatric medicine;
                                    ``(II) by a physician with a 
                                primary specialty designation of 
                                obstetrics and gynecology, but only if 
                                the physician self-attests that the 
                                physician is Board certified in 
                                obstetrics and gynecology;
                                    ``(III) by an advanced practice 
                                clinician, as defined by the Secretary, 
                                that works under the supervision of--
                                            ``(aa) a physician that 
                                        satisfies the criteria 
                                        specified in subclause (I) or 
                                        (II); or
                                            ``(bb) a nurse practitioner 
                                        or a physician assistant (as 
                                        such terms are defined in 
                                        section 1861(aa)(5)(A)) who is 
                                        working in accordance with 
                                        State law, or a certified 
                                        nurse-midwife (as defined in 
                                        section 1861(gg)) who is 
                                        working in accordance with 
                                        State law;
                                    ``(IV) by a rural health clinic, 
                                Federally-qualified health center, or 
                                other health clinic that receives 
                                reimbursement on a fee schedule 
                                applicable to a physician, a nurse 
                                practitioner or a physician assistant 
                                (as such terms are defined in section 
                                1861(aa)(5)(A)) who is working in 
                                accordance with State law, or a 
                                certified nurse-midwife (as defined in 
                                section 1861(gg)) who is working in 
                                accordance with State law, for services 
                                furnished by a physician, nurse 
                                practitioner, physician assistant, or 
                                certified nurse-midwife, or services 
                                furnished by an advanced practice 
                                clinician supervised by a physician 
                                described in subclause (I)(aa) or 
                                (II)(aa), another advanced practice 
                                clinician, or a certified nurse-
                                midwife; or
                                    ``(V) by a nurse practitioner or a 
                                physician assistant (as such terms are 
                                defined in section 1861(aa)(5)(A)) who 
                                is working in accordance with State 
                                law, or a certified nurse-midwife (as 
                                defined in section 1861(gg)) who is 
                                working in accordance with State law, 
                                in accordance with procedures that 
                                ensure that the portion of the payment 
                                for such services that the nurse 
                                practitioner, physician assistant, or 
                                certified nurse-midwife is paid is not 
                                less than the amount that the nurse 
                                practitioner, physician assistant, or 
                                certified nurse-midwife would be paid 
                                if the services were provided under 
                                part B of title XVIII;''.
            (2) Conforming amendments.--Section 1905(dd) of the Social 
        Security Act (42 U.S.C. 1396d(dd)) is amended--
                    (A) by striking ``Notwithstanding'' and inserting 
                the following:
            ``(1) In general.--Notwithstanding'';
                    (B) by inserting ``or furnished during the 
                additional period specified in paragraph (2),'' after 
                ``2015,''; and
                    (C) by adding at the end the following:
            ``(2) Additional period.--For purposes of paragraph (1), 
        the additional period specified in this paragraph is the period 
        that begins on the first day of the first month that begins one 
        year after the date of enactment of the Patient Protection and 
        Affordable Care Enhancement Act.''.
    (b) Improved Targeting of Primary Care.--Section 1902(jj) of the 
Social Security Act (42 U.S.C. 1396a(jj)) is amended--
            (1) by redesignating paragraphs (1) and (2) as 
        subparagraphs (A) and (B), respectively and realigning the left 
        margins accordingly;
            (2) by striking ``For purposes of'' and inserting the 
        following:
            ``(1) In general.--For purposes of''; and
            (3) by adding at the end the following:
            ``(2) Exclusions.--Such term does not include any services 
        described in subparagraph (A) or (B) of paragraph (1) if such 
        services are provided in an emergency department of a 
        hospital.''.
    (c) Ensuring Payment by Managed Care Entities.--
            (1) In general.--Section 1903(m)(2)(A) of the Social 
        Security Act (42 U.S.C. 1396b(m)(2)(A)) is amended--
                    (A) in clause (xii), by striking ``and'' after the 
                semicolon;
                    (B) by realigning the left margin of clause (xiii) 
                so as to align with the left margin of clause (xii) and 
                by striking the period at the end of clause (xiii) and 
                inserting ``; and''; and
                    (C) by inserting after clause (xiii) the following:
            ``(xiv) such contract provides that (I) payments to 
        providers specified in section 1902(a)(13)(C) for primary care 
        services defined in section 1902(jj) that are furnished during 
        a year or period specified in section 1902(a)(13)(C) and 
        section 1905(dd) are at least equal to the amounts set forth 
        and required by the Secretary by regulation, (II) the entity 
        shall, upon request, provide documentation to the State, 
        sufficient to enable the State and the Secretary to ensure 
        compliance with subclause (I), and (III) the Secretary shall 
        approve payments described in subclause (I) that are furnished 
        through an agreed upon capitation, partial capitation, or other 
        value-based payment arrangement if the capitation, partial 
        capitation, or other value-based payment arrangement is based 
        on a reasonable methodology and the entity provides 
        documentation to the State sufficient to enable the State and 
        the Secretary to ensure compliance with subclause (I).''.
            (2) Conforming amendment.--Section 1932(f) of the Social 
        Security Act (42 U.S.C. 1396u-2(f)) is amended by inserting 
        ``and clause (xiv) of section 1903(m)(2)(A)'' before the 
        period.

SEC. 207. PERMANENT FUNDING FOR CHIP.

    (a) In General.--Section 2104(a) of the Social Security Act (42 
U.S.C. 1397dd(a)) is amended--
            (1) in paragraph (26), by inserting at the end ``and'';
            (2) by amending paragraph (27) to read as follows:
            ``(27) for each fiscal year beginning with fiscal year 
        2024, such sums as are necessary to fund allotments to States 
        under subsections (c) and (m).''; and
            (3) by striking paragraph (28).
    (b) In General.--Section 2104(a)(28) of the Social Security Act (42 
U.S.C. 1397dd(a)(28)) is amended to read as follows:
            ``(28) for fiscal year 2027 and each subsequent year, such 
        sums as are necessary to fund allotments to States under 
        subsections (c) and (m).''.
    (c) Allotments.--
            (1) In general.--Section 2104(m) of the Social Security Act 
        (42 U.S.C. 1397dd(m)) is amended--
                    (A) in paragraph (2)(B)(i), by striking ``,, 2023, 
                and 2027'' and inserting ``and 2023'';
                    (B) in paragraph (7)--
                            (i) in subparagraph (A), by striking ``and 
                        ending with fiscal year 2027,''; and
                            (ii) in the flush left matter at the end, 
                        by striking ``or fiscal year 2026'' and 
                        inserting ``fiscal year 2026, or a subsequent 
                        even-numbered fiscal year'';
                    (C) in paragraph (9)--
                            (i) by striking ``(10), or (11)'' and 
                        inserting ``or (10)''; and
                            (ii) by striking ``2023, or 2027,'' and 
                        inserting ``or 2023''; and
                    (D) by striking paragraph (11).
            (2) Conforming amendment.--Section 50101(b)(2) of the 
        Bipartisan Budget Act of 2018 (Public Law 115-123) is repealed.

SEC. 208. PERMANENT EXTENSION OF CHIP ENROLLMENT AND QUALITY MEASURES.

    (a) Pediatric Quality Measures Program.--Section 1139A(i)(1) of the 
Social Security Act (42 U.S.C. 1320b-9a(i)(1)) is amended--
            (1) in subparagraph (C), by striking at the end ``and'';
            (2) in subparagraph (D), by striking the period at the end 
        and insert a semicolon; and
            (3) by adding at the end the following new subparagraphs:
                    ``(E) for fiscal year 2028, $15,000,000 for the 
                purpose of carrying out this section (other than 
                subsections (e), (f), and (g)); and
                    ``(F) for a subsequent fiscal year, the amount 
                appropriated under this paragraph for the previous 
                fiscal year, increased by the percentage increase in 
                the consumer price index for all urban consumers (all 
                items; United States city average) over such previous 
                fiscal year, for the purpose of carrying out this 
                section (other than subsections (e), (f), and (g)).''.
    (b) Express Lane Eligibility Option.--Section 1902(e)(13) of the 
Social Security Act (42 U.S.C. 1396a(e)(13)) is amended by striking 
subparagraph (I).
    (c) Assurance of Affordability Standard for Children and 
Families.--
            (1) In general.--Section 2105(d)(3) of the Social Security 
        Act (42 U.S.C. 1397ee(d)(3)) is amended--
                    (A) in the paragraph heading, by striking ``through 
                september 30, 2027''; and
                    (B) in subparagraph (A), in the matter preceding 
                clause (i)--
                            (i) by striking ``During the period that 
                        begins on the date of enactment of the Patient 
                        Protection and Affordable Care Act and ends on 
                        September 30, 2027'' and inserting ``Beginning 
                        on the date of the enactment of the Patient 
                        Protection and Affordable Care Act'';
                            (ii) by striking ``During the period that 
                        begins on October 1, 2019, and ends on 
                        September 30, 2027'' and inserting ``Beginning 
                        on October 1, 2019''; and
                            (iii) by striking ``The preceding sentences 
                        shall not be construed as preventing a State 
                        during any such periods from'' and inserting 
                        ``The preceding sentences shall not be 
                        construed as preventing a State from''.
            (2) Conforming amendments.--Section 1902(gg)(2) of the 
        Social Security Act (42 U.S.C. 1396a(gg)(2)) is amended--
                    (A) in the paragraph heading, by striking ``through 
                september 30, 2027''; and
                    (B) by striking ``through September 30'' and all 
                that follows through ``ends on September 30, 2027'' and 
                inserting ``(but beginning on October 1, 2019,''.
    (d) Qualifying States Option.--Section 2105(g)(4) of the Social 
Security Act (42 U.S.C. 1397ee(g)(4)) is amended--
            (1) in the paragraph heading, by striking ``for fiscal 
        years 2009 through 2027'' and inserting ``after fiscal year 
        2008''; and
            (2) in subparagraph (A), by striking ``for any of fiscal 
        years 2009 through 2027'' and inserting ``for any fiscal year 
        after fiscal year 2008''.
    (e) Outreach and Enrollment Program.--Section 2113 of the Social 
Security Act (42 U.S.C. 1397mm) is amended--
            (1) in subsection (a)--
                    (A) in paragraph (1), by striking ``during the 
                period of fiscal years 2009 through 2027'' and 
                inserting ``, beginning with fiscal year 2009,'';
                    (B) in paragraph (2)--
                            (i) by striking ``10 percent of such 
                        amounts'' and inserting ``10 percent of such 
                        amounts for the period or the fiscal year for 
                        which such amounts are appropriated''; and
                            (ii) by striking ``during such period'' and 
                        inserting ``, during such period or such fiscal 
                        year,''; and
                    (C) in paragraph (3), by striking ``For the period 
                of fiscal years 2024 through 2027, an amount equal to 
                10 percent of such amounts'' and inserting ``Beginning 
                with fiscal year 2024, an amount equal to 10 percent of 
                such amounts for the period or the fiscal year for 
                which such amounts are appropriated''; and
            (2) in subsection (g)--
                    (A) by striking ``2017,,'' and inserting ``2017,'';
                    (B) by striking ``and $48,000,000'' and inserting 
                ``$48,000,000''; and
                    (C) by inserting after ``through 2027'' the 
                following: ``, $12,000,000 for fiscal year 2028, and, 
                for each fiscal year after fiscal year 2028, the amount 
                appropriated under this subsection for the previous 
                fiscal year, increased by the percentage increase in 
                the consumer price index for all urban consumers (all 
                items; United States city average) over such previous 
                fiscal year''.
    (f) Child Enrollment Contingency Fund.--Section 2104(n) of the 
Social Security Act (42 U.S.C. 1397dd(n)) is amended--
            (1) in paragraph (2)--
                    (A) in subparagraph (A)(ii)--
                            (i) by striking ``and 2024 through 2026'' 
                        and inserting ``beginning with fiscal year 
                        2024''; and
                            (ii) by striking ``2023, and 2027'' and 
                        inserting ``, and 2023''; and
                    (B) in subparagraph (B)--
                            (i) by striking ``2024 through 2026'' and 
                        inserting ``beginning with fiscal year 2024''; 
                        and
                            (ii) by striking ``2023, and 2027'' and 
                        inserting ``, and 2023''; and
            (2) in paragraph (3)(A)--
                    (A) by striking ``fiscal years 2024 through 2026'' 
                and inserting ``beginning with fiscal year 2024''; and
                    (B) by striking ``2023, or 2027'' and inserting ``, 
                or 2023''.

SEC. 209. STATE OPTION TO INCREASE CHILDREN'S ELIGIBILITY FOR MEDICAID 
              AND CHIP.

    Section 2110(b)(1)(B)(ii) of the Social Security Act (42 U.S.C. 
1397jj(b)(1)(B)(ii)) is amended--
            (1) in subclause (II), by striking ``or'' at the end;
            (2) in subclause (III), by striking ``and'' at the end and 
        inserting ``or''; and
            (3) by inserting after subclause (III) the following new 
        subclause:
                                    ``(IV) at the option of the State, 
                                whose family income exceeds the maximum 
                                income level otherwise established for 
                                children under the State child health 
                                plan as of the date of the enactment of 
                                this subclause; and''.

SEC. 210. MEDICAID COVERAGE FOR CITIZENS OF FREELY ASSOCIATED STATES.

    (a) In General.--Section 402(b)(2) of the Personal Responsibility 
and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1612(b)(2)) 
is amended by adding at the end the following new subparagraph:
                    ``(G) Medicaid exception for citizens of freely 
                associated states.--With respect to eligibility for 
                benefits for the designated Federal program defined in 
                paragraph (3)(C) (relating to the Medicaid program), 
                section 401(a) and paragraph (1) shall not apply to any 
                individual who lawfully resides in 1 of the 50 States 
                or the District of Columbia in accordance with the 
                Compacts of Free Association between the Government of 
                the United States and the Governments of the Federated 
                States of Micronesia, the Republic of the Marshall 
                Islands, and the Republic of Palau and shall not apply, 
                at the option of the Governor of Puerto Rico, the 
                Virgin Islands, Guam, the Northern Mariana Islands, or 
                American Samoa as communicated to the Secretary of 
                Health and Human Services in writing, to any individual 
                who lawfully resides in the respective territory in 
                accordance with such Compacts.''.
    (b) Exception to 5-Year Limited Eligibility.--Section 403(d) of 
such Act (8 U.S.C. 1613(d)) is amended--
            (1) in paragraph (1), by striking ``or'' at the end;
            (2) in paragraph (2), by striking the period at the end and 
        inserting ``; or''; and
            (3) by adding at the end the following new paragraph:
            ``(3) an individual described in section 402(b)(2)(G), but 
        only with respect to the designated Federal program defined in 
        section 402(b)(3)(C).''.
    (c) Definition of Qualified Alien.--Section 431(b) of such Act (8 
U.S.C. 1641(b)) is amended--
            (1) in paragraph (6), by striking ``; or'' at the end and 
        inserting a comma;
            (2) in paragraph (7), by striking the period at the end and 
        inserting ``, or''; and
            (3) by adding at the end the following new paragraph:
            ``(8) an individual who lawfully resides in the United 
        States in accordance with a Compact of Free Association 
        referred to in section 402(b)(2)(G), but only with respect to 
        the designated Federal program defined in section 402(b)(3)(C) 
        (relating to the Medicaid program).''.
    (d) Application to State Plans.--Section 1902(a)(10)(A)(i) of the 
Social Security Act (42 U.S.C. 1396a(a)(10)(A)(i)) is amended by 
inserting after subclause (IX) the following:
                                    ``(X) who are described in section 
                                402(b)(2)(G) of the Personal 
                                Responsibility and Work Opportunity 
                                Reconciliation Act of 1996 and eligible 
                                for benefits under this title by reason 
                                of application of such section;''.
    (e) Conforming Amendments.--Section 1108 of the Social Security Act 
(42 U.S.C. 1308) is amended--
            (1) in subsection (f), in the matter preceding paragraph 
        (1), by striking ``subsections (g) and (h) and section 
        1935(e)(1)(B)'' and inserting ``subsections (g), (h), and (i) 
        and section 1935(e)(1)(B)''; and
            (2) by adding at the end the following:
    ``(i) Exclusion of Medical Assistance Expenditures for Citizens of 
Freely Associated States.--Expenditures for medical assistance provided 
to an individual described in section 431(b)(8) of the Personal 
Responsibility and Work Opportunity Reconciliation Act of 1996 (8 
U.S.C. 1641(b)(8)) shall not be taken into account for purposes of 
applying payment limits under subsections (f) and (g).''.
    (f) Effective Date.--The amendments made by this section shall 
apply to benefits for items and services furnished on or after the date 
of the enactment of this Act.

SEC. 211. EXTENSION OF FULL FEDERAL MEDICAL ASSISTANCE PERCENTAGE TO 
              INDIAN HEALTH CARE PROVIDERS.

    (a) In General.--Section 1905 of the Social Security Act (42 U.S.C. 
1396d) is amended--
            (1) in subsection (a), by amending paragraph (9) to read as 
        follows:
            ``(9) clinic services furnished by or under the direction 
        of a physician, without regard to whether the clinic itself is 
        administered by a physician, including--
                    ``(A) such services furnished outside the clinic by 
                clinic personnel to an eligible individual who does not 
                reside in a permanent dwelling or does not have a fixed 
                home or mailing address; and
                    ``(B) such services provided outside the clinic on 
                the basis of a referral from a clinic administered by 
                an Indian Health Program (as defined in paragraph (12) 
                of section 4 of the Indian Health Care Improvement Act, 
                or an Urban Indian Organization as defined in paragraph 
                (29) of section 4 of such Act that has a grant or 
                contract with the Indian Health Service under title V 
                of such Act;''.
            (2) in subsection (b), by inserting after ``(as defined in 
        section 4 of the Indian Health Care Improvement Act)'' the 
        following: ``; the Federal medical assistance percentage shall 
        also be 100 per centum with respect to amounts expended as 
        medical assistance for services which are received through an 
        Urban Indian organization (as defined in section 4 of the 
        Indian Health Care Improvement Act) that has a grant or 
        contract with the Indian Health Service under title V of such 
        Act''.
    (b) Extension of Full Federal Medical Assistance Percentage to 
Services Furnished by Native Hawaiian Health Care Systems.--
            (1) In general.--Beginning on the date of enactment of this 
        Act--
                    (A) for purposes of section 1905(a)(9) of the 
                Social Security Act (42 U.S.C. 1396d(a)(9)), services 
                described in subsection (b) that are furnished in any 
                location shall be deemed to be clinic services; and
                    (B) notwithstanding section 1905(b) of the Social 
                Security Act (42 U.S.C. 1396d(b)), the Federal medical 
                assistance percentage with respect to amounts expended 
                as medical assistance for such services shall be 100 
                percent.
            (2) Services described.--The services described in this 
        subsection are services for which payment is available under 
        the State plan under title XIX of the Social Security Act (42 
        U.S.C. 1396 et seq.) of Hawaii (or any waiver of such plan) 
        that--
                    (A) are furnished on or after the date of enactment 
                of this Act;
                    (B) are furnished to an individual who--
                            (i) is a Native Hawaiian; and
                            (ii) is eligible for medical assistance 
                        under such plan; and
                    (C) are furnished by an Indian health care provider 
                (as such term is defined in section 1932(h)(4)(A) of 
                the Social Security Act (42 U.S.C. 1396u-2(h)(4)(A)) or 
                a Native Hawaiian health care system (without regard to 
                whether such services are furnished through an Indian 
                Health Service facility).

     TITLE III--LOWERING PRICES THROUGH FAIR DRUG PRICE NEGOTIATION

SEC. 301. ESTABLISHING A FAIR DRUG PRICING PROGRAM.

    (a) Program To Lower Prices for Certain High-Priced Single Source 
Drugs.--Title XI of the Social Security Act (42 U.S.C. 1301 et seq.) is 
amended by adding at the end the following new part:

 ``PART E--FAIR PRICE NEGOTIATION PROGRAM TO LOWER PRICES FOR CERTAIN 
                    HIGH-PRICED SINGLE SOURCE DRUGS

``SEC. 1191. ESTABLISHMENT OF PROGRAM.

    ``(a) In General.--The Secretary shall establish a Fair Price 
Negotiation Program (in this part referred to as the `program'). Under 
the program, with respect to each price applicability period, the 
Secretary shall--
            ``(1) publish a list of selected drugs in accordance with 
        section 1192;
            ``(2) enter into agreements with manufacturers of selected 
        drugs with respect to such period, in accordance with section 
        1193;
            ``(3) negotiate and, if applicable, renegotiate maximum 
        fair prices for such selected drugs, in accordance with section 
        1194; and
            ``(4) carry out the administrative duties described in 
        section 1196.
    ``(b) Definitions Relating to Timing.--For purposes of this part:
            ``(1) Initial price applicability year.--The term `initial 
        price applicability year' means a plan year (beginning with 
        plan year 2023) or, if agreed to in an agreement under section 
        1193 by the Secretary and manufacturer involved, a period of 
        more than one plan year (beginning on or after January 1, 
        2023).
            ``(2) Price applicability period.--The term `price 
        applicability period' means, with respect to a drug, the period 
        beginning with the initial price applicability year with 
        respect to which such drug is a selected drug and ending with 
        the last plan year during which the drug is a selected drug.
            ``(3) Selected drug publication date.--The term `selected 
        drug publication date' means, with respect to each initial 
        price applicability year, April 15 of the plan year that begins 
        2 years prior to such year.
            ``(4) Voluntary negotiation period.--The term `voluntary 
        negotiation period' means, with respect to an initial price 
        applicability year with respect to a selected drug, the 
        period--
                    ``(A) beginning on the sooner of--
                            ``(i) the date on which the manufacturer of 
                        the drug and the Secretary enter into an 
                        agreement under section 1193 with respect to 
                        such drug; or
                            ``(ii) June 15 following the selected drug 
                        publication date with respect to such selected 
                        drug; and
                    ``(B) ending on March 31 of the year that begins 
                one year prior to the initial price applicability year.
    ``(c) Other Definitions.--For purposes of this part:
            ``(1) Fair price eligible individual.--The term `fair price 
        eligible individual' means, with respect to a selected drug--
                    ``(A) in the case such drug is furnished or 
                dispensed to the individual at a pharmacy or by a mail 
                order service--
                            ``(i) an individual who is enrolled under a 
                        prescription drug plan under part D of title 
                        XVIII or an MA-PD plan under part C of such 
                        title if coverage is provided under such plan 
                        for such selected drug; and
                            ``(ii) an individual who is enrolled under 
                        a group health plan or health insurance 
                        coverage offered in the group or individual 
                        market (as such terms are defined in section 
                        2791 of the Public Health Service Act) with 
                        respect to which there is in effect an 
                        agreement with the Secretary under section 1197 
                        with respect to such selected drug as so 
                        furnished or dispensed; and
                    ``(B) in the case such drug is furnished or 
                administered to the individual by a hospital, 
                physician, or other provider of services or supplier--
                            ``(i) an individual who is entitled to 
                        benefits under part A of title XVIII or 
                        enrolled under part B of such title if such 
                        selected drug is covered under the respective 
                        part; and
                            ``(ii) an individual who is enrolled under 
                        a group health plan or health insurance 
                        coverage offered in the group or individual 
                        market (as such terms are defined in section 
                        2791 of the Public Health Service Act) with 
                        respect to which there is in effect an 
                        agreement with the Secretary under section 1197 
                        with respect to such selected drug as so 
                        furnished or administered.
            ``(2) Maximum fair price.--The term `maximum fair price' 
        means, with respect to a plan year during a price applicability 
        period and with respect to a selected drug (as defined in 
        section 1192(c)) with respect to such period, the price 
        published pursuant to section 1195 in the Federal Register for 
        such drug and year.
            ``(3) Average international market price defined.--
                    ``(A) In general.--The terms `average international 
                market price' and `AIM price' mean, with respect to a 
                drug, the average price (which shall be the net average 
                price, if practicable, and volume-weighted, if 
                practicable) for a unit (as defined in paragraph (4)) 
                of the drug for sales of such drug (calculated across 
                different dosage forms and strengths of the drug and 
                not based on the specific formulation or package size 
                or package type), as computed (as of the date of 
                publication of such drug as a selected drug under 
                section 1192(a)) in all countries described in clause 
                (ii) of subparagraph (B) that are applicable countries 
                (as described in clause (i) of such subparagraph) with 
                respect to such drug.
                    ``(B) Applicable countries.--
                            ``(i) In general.--For purposes of 
                        subparagraph (A), a country described in clause 
                        (ii) is an applicable country described in this 
                        clause with respect to a drug if there is 
                        available an average price for any unit for the 
                        drug for sales of such drug in such country.
                            ``(ii) Countries described.--For purposes 
                        of this paragraph, the following are countries 
                        described in this clause:
                                    ``(I) Australia.
                                    ``(II) Canada.
                                    ``(III) France.
                                    ``(IV) Germany.
                                    ``(V) Japan.
                                    ``(VI) The United Kingdom.
            ``(4) Unit.--The term `unit' means, with respect to a drug, 
        the lowest identifiable quantity (such as a capsule or tablet, 
        milligram of molecules, or grams) of the drug that is 
        dispensed.

``SEC. 1192. SELECTION OF NEGOTIATION-ELIGIBLE DRUGS AS SELECTED DRUGS.

    ``(a) In General.--Not later than the selected drug publication 
date with respect to an initial price applicability year, subject to 
subsection (h), the Secretary shall select and publish in the Federal 
Register a list of--
            ``(1)(A) with respect to an initial price applicability 
        year during 2023, at least 25 negotiation-eligible drugs 
        described in subparagraphs (A) and (B), but not subparagraph 
        (C), of subsection (d)(1) (or, with respect to an initial price 
        applicability year during such period beginning after 2023, the 
        maximum number (if such number is less than 25) of such 
        negotiation-eligible drugs for the year) with respect to such 
        year; and
            ``(B) with respect to an initial price applicability year 
        during 2024 or a subsequent year, at least 50 negotiation-
        eligible drugs described in subparagraphs (A) and (B), but not 
        subparagraph (C), of subsection (d)(1) (or, with respect to an 
        initial price applicability year during such period, the 
        maximum number (if such number is less than 50) of such 
        negotiation-eligible drugs for the year) with respect to such 
        year;
            ``(2) all negotiation-eligible drugs described in 
        subparagraph (C) of such subsection with respect to such year; 
        and
            ``(3) all new-entrant negotiation-eligible drugs (as 
        defined in subsection (g)(1)) with respect to such year.
Each drug published on the list pursuant to the previous sentence shall 
be subject to the negotiation process under section 1194 for the 
voluntary negotiation period with respect to such initial price 
applicability year (and the renegotiation process under such section as 
applicable for any subsequent year during the applicable price 
applicability period). In applying this subsection, any negotiation-
eligible drug that is selected under this subsection for an initial 
price applicability year shall not count toward the required minimum 
amount of drugs to be selected under paragraph (1) for any subsequent 
year, including such a drug so selected that is subject to 
renegotiation under section 1194.
    ``(b) Selection of Drugs.--In carrying out subsection (a)(1) the 
Secretary shall select for inclusion on the published list described in 
subsection (a) with respect to a price applicability period, the 
negotiation-eligible drugs that the Secretary projects will result in 
the greatest savings to the Federal Government or fair price eligible 
individuals during the price applicability period. In making this 
projection of savings for drugs for which there is an AIM price for a 
price applicability period, the savings shall be projected across 
different dosage forms and strengths of the drugs and not based on the 
specific formulation or package size or package type of the drugs, 
taking into consideration both the volume of drugs for which payment is 
made, to the extent such data is available, and the amount by which the 
net price for the drugs exceeds the AIM price for the drugs.
    ``(c) Selected Drug.--For purposes of this part, each drug included 
on the list published under subsection (a) with respect to an initial 
price applicability year shall be referred to as a `selected drug' with 
respect to such year and each subsequent plan year beginning before the 
first plan year beginning after the date on which the Secretary 
determines two or more drug products--
            ``(1) are approved or licensed (as applicable)--
                    ``(A) under section 505(j) of the Federal Food, 
                Drug, and Cosmetic Act using such drug as the listed 
                drug; or
                    ``(B) under section 351(k) of the Public Health 
                Service Act using such drug as the reference product; 
                and
            ``(2) continue to be marketed.
    ``(d) Negotiation-Eligible Drug.--
            ``(1) In general.--For purposes of this part, the term 
        `negotiation-eligible drug' means, with respect to the selected 
        drug publication date with respect to an initial price 
        applicability year, a qualifying single source drug, as defined 
        in subsection (e), that meets any of the following criteria:
                    ``(A) Covered part d drugs.--The drug is among the 
                125 covered part D drugs (as defined in section 1860D-
                2(e)) for which there was an estimated greatest net 
                spending under parts C and D of title XVIII, as 
                determined by the Secretary, during the most recent 
                plan year prior to such drug publication date for which 
                data are available.
                    ``(B) Other drugs.--The drug is among the 125 drugs 
                for which there was an estimated greatest net spending 
                in the United States (including the 50 States, the 
                District of Columbia, and the territories of the United 
                States), as determined by the Secretary, during the 
                most recent plan year prior to such drug publication 
                date for which data are available.
                    ``(C) Insulin.--The drug is a qualifying single 
                source drug described in subsection (e)(3).
            ``(2) Clarification.--In determining whether a qualifying 
        single source drug satisfies any of the criteria described in 
        paragraph (1), the Secretary shall, to the extent practicable, 
        use data that is aggregated across dosage forms and strengths 
        of the drug and not based on the specific formulation or 
        package size or package type of the drug.
            ``(3) Publication.--Not later than the selected drug 
        publication date with respect to an initial price applicability 
        year, the Secretary shall publish in the Federal Register a 
        list of negotiation-eligible drugs with respect to such 
        selected drug publication date.
    ``(e) Qualifying Single Source Drug.--For purposes of this part, 
the term `qualifying single source drug' means any of the following:
            ``(1) Drug products.--A drug that--
                    ``(A) is approved under section 505(c) of the 
                Federal Food, Drug, and Cosmetic Act and continues to 
                be marketed pursuant to such approval; and
                    ``(B) is not the listed drug for any drug that is 
                approved and continues to be marketed under section 
                505(j) of such Act.
            ``(2) Biological products.--A biological product that--
                    ``(A) is licensed under section 351(a) of the 
                Public Health Service Act, including any product that 
                has been deemed to be licensed under section 351 of 
                such Act pursuant to section 7002(e)(4) of the 
                Biologics Price Competition and Innovation Act of 2009, 
                and continues to be marketed under section 351 of such 
                Act; and
                    ``(B) is not the reference product for any 
                biological product that is licensed and continues to be 
                marketed under section 351(k) of such Act.
            ``(3) Insulin product.--Notwithstanding paragraphs (1) and 
        (2), any insulin product that is approved under subsection (c) 
        or (j) of section 505 of the Federal Food, Drug, and Cosmetic 
        Act or licensed under subsection (a) or (k) of section 351 of 
        the Public Health Service Act and continues to be marketed 
        under such section 505 or 351, including any insulin product 
        that has been deemed to be licensed under section 351(a) of the 
        Public Health Service Act pursuant to section 7002(e)(4) of the 
        Biologics Price Competition and Innovation Act of 2009 and 
        continues to be marketed pursuant to such licensure.
For purposes of applying paragraphs (1) and (2), a drug or biological 
product that is marketed by the same sponsor or manufacturer (or an 
affiliate thereof or a cross-licensed producer or distributor) as the 
listed drug or reference product described in such respective paragraph 
shall not be taken into consideration.
    ``(f) Information on International Drug Prices.--For purposes of 
determining which negotiation-eligible drugs to select under subsection 
(a) and, in the case of such drugs that are selected drugs, to 
determine the maximum fair price for such a drug and whether such 
maximum fair price should be renegotiated under section 1194, the 
Secretary shall use data relating to the AIM price with respect to such 
drug as available or provided to the Secretary and shall on an ongoing 
basis request from manufacturers of selected drugs information on the 
AIM price of such a drug.
    ``(g) New-Entrant Negotiation-Eligible Drugs.--
            ``(1) In general.--For purposes of this part, the term 
        `new-entrant negotiation-eligible drug' means, with respect to 
        the selected drug publication date with respect to an initial 
        price applicability year, a qualifying single source drug--
                    ``(A) that is first approved or licensed, as 
                described in paragraph (1), (2), or (3) of subsection 
                (e), as applicable, during the year preceding such 
                selected drug publication date; and
                    ``(B) that the Secretary determines under paragraph 
                (2) is likely to be included as a negotiation-eligible 
                drug with respect to the subsequent selected drug 
                publication date.
            ``(2) Determination.--In the case of a qualifying single 
        source drug that meets the criteria described in subparagraph 
        (A) of paragraph (1), with respect to an initial price 
        applicability year, if the wholesale acquisition cost at which 
        such drug is first marketed in the United States is equal to or 
        greater than the median household income (as determined 
        according to the most recent data collected by the United 
        States Census Bureau), the Secretary shall determine before the 
        selected drug publication date with respect to the initial 
        price applicability year, if the drug is likely to be included 
        as a negotiation-eligible drug with respect to the subsequent 
        selected drug publication date, based on the projected spending 
        under title XVIII or in the United States on such drug. For 
        purposes of this paragraph the term `United States' includes 
        the 50 States, the District of Columbia, and the territories of 
        the United States.
    ``(h) Conflict of Interest.--
            ``(1) In general.--In the case the Inspector General of the 
        Department of Health and Human Services determines the 
        Secretary has a conflict, with respect to a matter described in 
        paragraph (2), the individual described in paragraph (3) shall 
        carry out the duties of the Secretary under this part, with 
        respect to a negotiation-eligible drug, that would otherwise be 
        such a conflict.
            ``(2) Matter described.--A matter described in this 
        paragraph is--
                    ``(A) a financial interest (as described in section 
                2635.402 of title 5, Code of Federal Regulations 
                (except for an interest described in subsection 
                (b)(2)(iv) of such section)) on the date of the 
                selected drug publication date, with respect the price 
                applicability year (as applicable);
                    ``(B) a personal or business relationship (as 
                described in section 2635.502 of such title) on the 
                date of the selected drug publication date, with 
                respect the price applicability year;
                    ``(C) employment by a manufacturer of a 
                negotiation-eligible drug during the preceding 10-year 
                period beginning on the date of the selected drug 
                publication date, with respect to each price 
                applicability year; and
                    ``(D) any other matter the General Counsel 
                determines appropriate.
            ``(3) Individual described.--An individual described in 
        this paragraph is--
                    ``(A) the highest-ranking officer or employee of 
                the Department of Health and Human Services (as 
                determined by the organizational chart of the 
                Department) that does not have a conflict under this 
                subsection; and
                    ``(B) is nominated by the President and confirmed 
                by the Senate with respect to the position.

``SEC. 1193. MANUFACTURER AGREEMENTS.

    ``(a) In General.--For purposes of section 1191(a)(2), the 
Secretary shall enter into agreements with manufacturers of selected 
drugs with respect to a price applicability period, by not later than 
June 15 following the selected drug publication date with respect to 
such selected drug, under which--
            ``(1) during the voluntary negotiation period for the 
        initial price applicability year for the selected drug, the 
        Secretary and manufacturer, in accordance with section 1194, 
        negotiate to determine (and, by not later than the last date of 
        such period and in accordance with subsection (c), agree to) a 
        maximum fair price for such selected drug of the manufacturer 
        in order to provide access to such price--
                    ``(A) to fair price eligible individuals who with 
                respect to such drug are described in subparagraph (A) 
                of section 1191(c)(1) and are furnished or dispensed 
                such drug during, subject to subparagraph (2), the 
                price applicability period; and
                    ``(B) to hospitals, physicians, and other providers 
                of services and suppliers with respect to fair price 
                eligible individuals who with respect to such drug are 
                described in subparagraph (B) of such section and are 
                furnished or administered such drug during, subject to 
                subparagraph (2), the price applicability period;
            ``(2) the Secretary and the manufacturer shall, in 
        accordance with a process and during a period specified by the 
        Secretary pursuant to rulemaking, renegotiate (and, by not 
        later than the last date of such period and in accordance with 
        subsection (c), agree to) the maximum fair price for such drug 
        if the Secretary determines that there is a material change in 
        any of the factors described in section 1194(d) relating to the 
        drug, including changes in the AIM price for such drug, in 
        order to provide access to such maximum fair price (as so 
        renegotiated)--
                    ``(A) to fair price eligible individuals who with 
                respect to such drug are described in subparagraph (A) 
                of section 1191(c)(1) and are furnished or dispensed 
                such drug during any year during the price 
                applicability period (beginning after such 
                renegotiation) with respect to such selected drug; and
                    ``(B) to hospitals, physicians, and other providers 
                of services and suppliers with respect to fair price 
                eligible individuals who with respect to such drug are 
                described in subparagraph (B) of such section and are 
                furnished or administered such drug during any year 
                described in subparagraph (A);
            ``(3) the maximum fair price (including as renegotiated 
        pursuant to paragraph (2)), with respect to such a selected 
        drug, shall be provided to fair price eligible individuals, who 
        with respect to such drug are described in subparagraph (A) of 
        section 1191(c)(1), at the pharmacy or by a mail order service 
        at the point-of-sale of such drug;
            ``(4) the manufacturer, subject to subsection (d), submits 
        to the Secretary, in a form and manner specified by the 
        Secretary--
                    ``(A) for the voluntary negotiation period for the 
                price applicability period (and, if applicable, before 
                any period of renegotiation specified pursuant to 
                paragraph (2)) with respect to such drug all 
                information that the Secretary requires to carry out 
                the negotiation (or renegotiation process) under this 
                part, including information described in section 
                1192(f) and section 1194(d)(1); and
                    ``(B) on an ongoing basis, information on changes 
                in prices for such drug that would affect the AIM price 
                for such drug or otherwise provide a basis for 
                renegotiation of the maximum fair price for such drug 
                pursuant to paragraph (2);
            ``(5) the manufacturer agrees that in the case the selected 
        drug of a manufacturer is a drug described in subsection (c), 
        the manufacturer will, in accordance with such subsection, make 
        any payment required under such subsection with respect to such 
        drug; and
            ``(6) the manufacturer complies with requirements imposed 
        by the Secretary for purposes of administering the program, 
        including with respect to the duties described in section 1196.
    ``(b) Agreement in Effect Until Drug Is No Longer a Selected 
Drug.--An agreement entered into under this section shall be effective, 
with respect to a drug, until such drug is no longer considered a 
selected drug under section 1192(c).
    ``(c) Special Rule for Certain Selected Drugs Without AIM Price.--
            ``(1) In general.--In the case of a selected drug for which 
        there is no AIM price available with respect to the initial 
        price applicability year for such drug and for which an AIM 
        price becomes available beginning with respect to a subsequent 
        plan year during the price applicability period for such drug, 
        if the Secretary determines that the amount described in 
        paragraph (2)(A) for a unit of such drug is greater than the 
        amount described in paragraph (2)(B) for a unit of such drug, 
        then by not later than one year after the date of such 
        determination, the manufacturer of such selected drug shall pay 
        to the Treasury an amount equal to the product of--
                    ``(A) the difference between such amount described 
                in paragraph (2)(A) for a unit of such drug and such 
                amount described in paragraph (2)(B) for a unit of such 
                drug; and
                    ``(B) the number of units of such drug sold in the 
                United States, including the 50 States, the District of 
                Columbia, and the territories of the United States, 
                during the period described in paragraph (2)(B).
            ``(2) Amounts described.--
                    ``(A) Weighted average price before aim price 
                available.--For purposes of paragraph (1), the amount 
                described in this subparagraph for a selected drug 
                described in such paragraph, is the amount equal to the 
                weighted average manufacturer price (as defined in 
                section 1927(k)(1)) for such dosage strength and form 
                for the drug during the period beginning with the first 
                plan year for which the drug is included on the list of 
                negotiation-eligible drugs published under section 
                1192(d) and ending with the last plan year during the 
                price applicability period for such drug with respect 
                to which there is no AIM price available for such drug.
                    ``(B) Amount multiplier after aim price 
                available.--For purposes of paragraph (1), the amount 
                described in this subparagraph for a selected drug 
                described in such paragraph, is the amount equal to 200 
                percent of the AIM price for such drug with respect to 
                the first plan year during the price applicability 
                period for such drug with respect to which there is an 
                AIM price available for such drug.
    ``(d) Confidentiality of Information.--Information submitted to the 
Secretary under this part by a manufacturer of a selected drug that is 
proprietary information of such manufacturer (as determined by the 
Secretary) may be used only by the Secretary or disclosed to and used 
by the Comptroller General of the United States or the Medicare Payment 
Advisory Commission for purposes of carrying out this part.
    ``(e) Regulations.--
            ``(1) In general.--The Secretary shall, pursuant to 
        rulemaking, specify, in accordance with paragraph (2), the 
        information that must be submitted under subsection (a)(4).
            ``(2) Information specified.--Information described in 
        paragraph (1), with respect to a selected drug, shall include 
        information on sales of the drug (by the manufacturer of the 
        drug or by another entity under license or other agreement with 
        the manufacturer, with respect to the sales of such drug, 
        regardless of the name under which the drug is sold) in any 
        foreign country that is part of the AIM price. The Secretary 
        shall verify, to the extent practicable, such sales from 
        appropriate officials of the government of the foreign country 
        involved.
    ``(f) Compliance With Requirements for Administration of Program.--
Each manufacturer with an agreement in effect under this section shall 
comply with requirements imposed by the Secretary or a third party with 
a contract under section 1196(c)(1), as applicable, for purposes of 
administering the program.

``SEC. 1194. NEGOTIATION AND RENEGOTIATION PROCESS.

    ``(a) In General.--For purposes of this part, under an agreement 
under section 1193 between the Secretary and a manufacturer of a 
selected drug, with respect to the period for which such agreement is 
in effect and in accordance with subsections (b) and (c), the Secretary 
and the manufacturer--
            ``(1) shall during the voluntary negotiation period with 
        respect to the initial price applicability year for such drug, 
        in accordance with this section, negotiate a maximum fair price 
        for such drug for the purpose described in section 1193(a)(1); 
        and
            ``(2) as applicable pursuant to section 1193(a)(2) and in 
        accordance with the process specified pursuant to such section, 
        renegotiate such maximum fair price for such drug for the 
        purpose described in such section.
    ``(b) Negotiating Methodology and Objective.--
            ``(1) In general.--The Secretary shall develop and use a 
        consistent methodology for negotiations under subsection (a) 
        that, in accordance with paragraph (2) and subject to paragraph 
        (3), achieves the lowest maximum fair price for each selected 
        drug while appropriately rewarding innovation.
            ``(2) Prioritizing factors.--In considering the factors 
        described in subsection (d) in negotiating (and, as applicable, 
        renegotiating) the maximum fair price for a selected drug, the 
        Secretary shall, to the extent practicable, consider all of the 
        available factors listed but shall prioritize the following 
        factors:
                    ``(A) Research and development costs.--The factor 
                described in paragraph (1)(A) of subsection (d).
                    ``(B) Market data.--The factor described in 
                paragraph (1)(B) of such subsection.
                    ``(C) Unit costs of production and distribution.--
                The factor described in paragraph (1)(C) of such 
                subsection.
                    ``(D) Comparison to existing therapeutic 
                alternatives.--The factor described in paragraph (2)(A) 
                of such subsection.
            ``(3) Requirement.--
                    ``(A) In general.--In negotiating the maximum fair 
                price of a selected drug, with respect to an initial 
                price applicability year for the selected drug, and, as 
                applicable, in renegotiating the maximum fair price for 
                such drug, with respect to a subsequent year during the 
                price applicability period for such drug, in the case 
                that the manufacturer of the selected drug offers under 
                the negotiation or renegotiation, as applicable, a 
                price for such drug that is not more than the target 
                price described in subparagraph (B) for such drug for 
                the respective year, the Secretary shall agree under 
                such negotiation or renegotiation, respectively, to 
                such offered price as the maximum fair price.
                    ``(B) Target price.--
                            ``(i) In general.--Subject to clause (ii), 
                        the target price described in this subparagraph 
                        for a selected drug with respect to a year, is 
                        the average price (which shall be the net 
                        average price, if practicable, and volume-
                        weighted, if practicable) for a unit of such 
                        drug for sales of such drug, as computed 
                        (across different dosage forms and strengths of 
                        the drug and not based on the specific 
                        formulation or package size or package type of 
                        the drug) in the applicable country described 
                        in section 1191(c)(3)(B) with respect to such 
                        drug that, with respect to such year, has the 
                        lowest average price for such drug as compared 
                        to the average prices (as so computed) of such 
                        drug with respect to such year in the other 
                        applicable countries described in such section 
                        with respect to such drug.
                            ``(ii) Selected drugs without aim price.--
                        In applying this paragraph in the case of 
                        negotiating the maximum fair price of a 
                        selected drug for which there is no AIM price 
                        available with respect to the initial price 
                        applicability year for such drug, or, as 
                        applicable, renegotiating the maximum fair 
                        price for such drug with respect to a 
                        subsequent year during the price applicability 
                        period for such drug before the first plan year 
                        for which there is an AIM price available for 
                        such drug, the target price described in this 
                        subparagraph for such drug and respective year 
                        is the amount that is 80 percent of the average 
                        manufacturer price (as defined in section 
                        1927(k)(1)) for such drug and year.
            ``(4) Annual report.--After the completion of each 
        voluntary negotiation period, the Secretary shall submit to 
        Congress a report on the maximum fair prices negotiated (or, as 
        applicable, renegotiated) for such period. Such report shall 
        include information on how such prices so negotiated (or 
        renegotiated) meet the requirements of this part, including the 
        requirements of this subsection.
    ``(c) Limitation.--
            ``(1) In general.--Subject to paragraph (2), the maximum 
        fair price negotiated (including as renegotiated) under this 
        section for a selected drug, with respect to each plan year 
        during a price applicability period for such drug, shall not 
        exceed 120 percent of the AIM price applicable to such drug 
        with respect to such year.
            ``(2) Selected drugs without aim price.--In the case of a 
        selected drug for which there is no AIM price available with 
        respect to the initial price applicability year for such drug, 
        for each plan year during the price applicability period before 
        the first plan year for which there is an AIM price available 
        for such drug, the maximum fair price negotiated (including as 
        renegotiated) under this section for the selected drug shall 
        not exceed the amount equal to 85 percent of the average 
        manufacturer price for the drug with respect to such year.
    ``(d) Considerations.--For purposes of negotiating and, as 
applicable, renegotiating (including for purposes of determining 
whether to renegotiate) the maximum fair price of a selected drug under 
this part with the manufacturer of the drug, the Secretary, consistent 
with subsection (b)(2), shall take into consideration the factors 
described in paragraphs (1), (2), (3), and (5), and may take into 
consideration the factor described in paragraph (4):
            ``(1) Manufacturer-specific information.--The following 
        information, including as submitted by the manufacturer:
                    ``(A) Research and development costs of the 
                manufacturer for the drug and the extent to which the 
                manufacturer has recouped research and development 
                costs.
                    ``(B) Market data for the drug, including the 
                distribution of sales across different programs and 
                purchasers and projected future revenues for the drug.
                    ``(C) Unit costs of production and distribution of 
                the drug.
                    ``(D) Prior Federal financial support for novel 
                therapeutic discovery and development with respect to 
                the drug.
                    ``(E) Data on patents and on existing and pending 
                exclusivity for the drug.
                    ``(F) National sales data for the drug.
                    ``(G) Information on clinical trials for the drug 
                in the United States or in applicable countries 
                described in section 1191(c)(3)(B).
            ``(2) Information on alternative products.--The following 
        information:
                    ``(A) The extent to which the drug represents a 
                therapeutic advance as compared to existing therapeutic 
                alternatives and, to the extent such information is 
                available, the costs of such existing therapeutic 
                alternatives.
                    ``(B) Information on approval by the Food and Drug 
                Administration of alternative drug products.
                    ``(C) Information on comparative effectiveness 
                analysis for such products, taking into consideration 
                the effects of such products on specific populations, 
                such as individuals with disabilities, the elderly, 
                terminally ill, children, and other patient 
                populations.
        In considering information described in subparagraph (C), the 
        Secretary shall not use evidence or findings from comparative 
        clinical effectiveness research in a manner that treats 
        extending the life of an elderly, disabled, or terminally ill 
        individual as of lower value than extending the life of an 
        individual who is younger, nondisabled, or not terminally ill. 
        Nothing in the previous sentence shall affect the application 
        or consideration of an AIM price for a selected drug.
            ``(3) Foreign sales information.--To the extent available 
        on a timely basis, including as provided by a manufacturer of 
        the selected drug or otherwise, information on sales of the 
        selected drug in each of the countries described in section 
        1191(c)(3)(B).
            ``(4) VA drug pricing information.--Information disclosed 
        to the Secretary pursuant to subsection (f).
            ``(5) Additional information.--Information submitted to the 
        Secretary, in accordance with a process specified by the 
        Secretary, by other parties that are affected by the 
        establishment of a maximum fair price for the selected drug.
    ``(e) Request for Information.--For purposes of negotiating and, as 
applicable, renegotiating (including for purposes of determining 
whether to renegotiate) the maximum fair price of a selected drug under 
this part with the manufacturer of the drug, with respect to a price 
applicability period, and other relevant data for purposes of this 
section--
            ``(1) the Secretary shall, not later than the selected drug 
        publication date with respect to the initial price 
        applicability year of such period, request drug pricing 
        information from the manufacturer of such selected drug, 
        including information described in subsection (d)(1); and
            ``(2) by not later than October 1 following the selected 
        drug publication date, the manufacturer of such selected drug 
        shall submit to the Secretary such requested information in 
        such form and manner as the Secretary may require.
The Secretary shall request, from the manufacturer or others, such 
additional information as may be needed to carry out the negotiation 
and renegotiation process under this section.
    ``(f) Disclosure of Information.--For purposes of this part, the 
Secretary of Veterans Affairs may disclose to the Secretary of Health 
and Human Services the price of any negotiation-eligible drug that is 
purchased pursuant to section 8126 of title 38, United States Code.

``SEC. 1195. PUBLICATION OF MAXIMUM FAIR PRICES.

    ``(a) In General.--With respect to an initial price applicability 
year and selected drug with respect to such year, not later than April 
1 of the plan year prior to such initial price applicability year, the 
Secretary shall publish in the Federal Register the maximum fair price 
for such drug negotiated under this part with the manufacturer of such 
drug.
    ``(b) Updates.--
            ``(1) Subsequent year maximum fair prices.--For a selected 
        drug, for each plan year subsequent to the initial price 
        applicability year for such drug with respect to which an 
        agreement for such drug is in effect under section 1193, the 
        Secretary shall publish in the Federal Register--
                    ``(A) subject to subparagraph (B), the amount equal 
                to the maximum fair price published for such drug for 
                the previous year, increased by the annual percentage 
                increase in the consumer price index for all urban 
                consumers (all items; U.S. city average) as of 
                September of such previous year; or
                    ``(B) in the case the maximum fair price for such 
                drug was renegotiated, for the first year for which 
                such price as so renegotiated applies, such 
                renegotiated maximum fair price.
            ``(2) Prices negotiated after deadline.--In the case of a 
        selected drug with respect to an initial price applicability 
        year for which the maximum fair price is determined under this 
        part after the date of publication under this section, the 
        Secretary shall publish such maximum fair price in the Federal 
        Register by not later than 30 days after the date such maximum 
        price is so determined.

``SEC. 1196. ADMINISTRATIVE DUTIES; COORDINATION PROVISIONS.

    ``(a) Administrative Duties.--
            ``(1) In general.--For purposes of section 1191, the 
        administrative duties described in this section are the 
        following:
                    ``(A) The establishment of procedures (including 
                through agreements with manufacturers under this part, 
                contracts with prescription drug plans under part D of 
                title XVIII and MA-PD plans under part C of such title, 
                and agreements under section 1197 with group health 
                plans and health insurance issuers of health insurance 
                coverage offered in the individual or group market) 
                under which the maximum fair price for a selected drug 
                is provided to fair price eligible individuals, who 
                with respect to such drug are described in subparagraph 
                (A) of section 1191(c)(1), at pharmacies or by mail 
                order service at the point-of-sale of the drug for the 
                applicable price period for such drug and providing 
                that such maximum fair price is used for determining 
                cost-sharing under such plans or coverage for the 
                selected drug.
                    ``(B) The establishment of procedures (including 
                through agreements with manufacturers under this part 
                and contracts with hospitals, physicians, and other 
                providers of services and suppliers and agreements 
                under section 1197 with group health plans and health 
                insurance issuers of health insurance coverage offered 
                in the individual or group market) under which, in the 
                case of a selected drug furnished or administered by 
                such a hospital, physician, or other provider of 
                services or supplier to fair price eligible individuals 
                (who with respect to such drug are described in 
                subparagraph (B) of section 1191(c)(1)), the maximum 
                fair price for the selected drug is provided to such 
                hospitals, physicians, and other providers of services 
                and suppliers (as applicable) with respect to such 
                individuals and providing that such maximum fair price 
                is used for determining cost-sharing under the 
                respective part, plan, or coverage for the selected 
                drug.
                    ``(C) The establishment of procedures (including 
                through agreements and contracts described in 
                subparagraphs (A) and (B)) to ensure that, not later 
                than 90 days after the dispensing of a selected drug to 
                a fair price eligible individual by a pharmacy or mail 
                order service, the pharmacy or mail order service is 
                reimbursed for an amount equal to the difference 
                between--
                            ``(i) the lesser of--
                                    ``(I) the wholesale acquisition 
                                cost of the drug;
                                    ``(II) the national average drug 
                                acquisition cost of the drug; and
                                    ``(III) any other similar 
                                determination of pharmacy acquisition 
                                costs of the drug, as determined by the 
                                Secretary; and
                            ``(ii) the maximum fair price for the drug.
                    ``(D) The establishment of procedures to ensure 
                that the maximum fair price for a selected drug is 
                applied before--
                            ``(i) any coverage or financial assistance 
                        under other health benefit plans or programs 
                        that provide coverage or financial assistance 
                        for the purchase or provision of prescription 
                        drug coverage on behalf of fair price eligible 
                        individuals as the Secretary may specify; and
                            ``(ii) any other discounts.
                    ``(E) The establishment of procedures to enter into 
                appropriate agreements and protocols for the ongoing 
                computation of AIM prices for selected drugs, 
                including, to the extent possible, to compute the AIM 
                price for selected drugs and including by providing 
                that the manufacturer of such a selected drug should 
                provide information for such computation not later than 
                3 months after the first date of the voluntary 
                negotiation period for such selected drug.
                    ``(F) The establishment of procedures to compute 
                and apply the maximum fair price across different 
                strengths and dosage forms of a selected drug and not 
                based on the specific formulation or package size or 
                package type of the drug.
                    ``(G) The establishment of procedures to negotiate 
                and apply the maximum fair price in a manner that does 
                not include any dispensing or similar fee.
                    ``(H) The establishment of procedures to carry out 
                the provisions of this part, as applicable, with 
                respect to--
                            ``(i) fair price eligible individuals who 
                        are enrolled under a prescription drug plan 
                        under part D of title XVIII or an MA-PD plan 
                        under part C of such title;
                            ``(ii) fair price eligible individuals who 
                        are enrolled under a group health plan or 
                        health insurance coverage offered by a health 
                        insurance issuer in the individual or group 
                        market with respect to which there is an 
                        agreement in effect under section 1197; and
                            ``(iii) fair price eligible individuals who 
                        are entitled to benefits under part A of title 
                        XVIII or enrolled under part B of such title.
                    ``(I) The establishment of a negotiation process 
                and renegotiation process in accordance with section 
                1194, including a process for acquiring information 
                described in subsection (d) of such section and 
                determining amounts described in subsection (b) of such 
                section.
                    ``(J) The provision of a reasonable dispute 
                resolution mechanism to resolve disagreements between 
                manufacturers, fair price eligible individuals, and the 
                third party with a contract under subsection (c)(1).
            ``(2) Monitoring compliance.--
                    ``(A) In general.--The Secretary shall monitor 
                compliance by a manufacturer with the terms of an 
                agreement under section 1193, including by establishing 
                a mechanism through which violations of such terms may 
                be reported.
                    ``(B) Notification.--If a third party with a 
                contract under subsection (c)(1) determines that the 
                manufacturer is not in compliance with such agreement, 
                the third party shall notify the Secretary of such 
                noncompliance for appropriate enforcement under section 
                4192 of the Internal Revenue Code of 1986 or section 
                1198, as applicable.
    ``(b) Collection of Data.--
            ``(1) From prescription drug plans and ma-pd plans.--The 
        Secretary may collect appropriate data from prescription drug 
        plans under part D of title XVIII and MA-PD plans under part C 
        of such title in a timeframe that allows for maximum fair 
        prices to be provided under this part for selected drugs.
            ``(2) From health plans.--The Secretary may collect 
        appropriate data from group health plans or health insurance 
        issuers offering group or individual health insurance coverage 
        in a timeframe that allows for maximum fair prices to be 
        provided under this part for selected drugs.
            ``(3) Coordination of data collection.--To the extent 
        feasible, as determined by the Secretary, the Secretary shall 
        ensure that data collected pursuant to this subsection is 
        coordinated with, and not duplicative of, other Federal data 
        collection efforts.
    ``(c) Contract With Third Parties.--
            ``(1) In general.--The Secretary may enter into a contract 
        with 1 or more third parties to administer the requirements 
        established by the Secretary in order to carry out this part. 
        At a minimum, the contract with a third party under the 
        preceding sentence shall require that the third party--
                    ``(A) receive and transmit information between the 
                Secretary, manufacturers, and other individuals or 
                entities the Secretary determines appropriate;
                    ``(B) receive, distribute, or facilitate the 
                distribution of funds of manufacturers to appropriate 
                individuals or entities in order to meet the 
                obligations of manufacturers under agreements under 
                this part;
                    ``(C) provide adequate and timely information to 
                manufacturers, consistent with the agreement with the 
                manufacturer under this part, as necessary for the 
                manufacturer to fulfill its obligations under this 
                part; and
                    ``(D) permit manufacturers to conduct periodic 
                audits, directly or through contracts, of the data and 
                information used by the third party to determine 
                discounts for applicable drugs of the manufacturer 
                under the program.
            ``(2) Performance requirements.--The Secretary shall 
        establish performance requirements for a third party with a 
        contract under paragraph (1) and safeguards to protect the 
        independence and integrity of the activities carried out by the 
        third party under the program under this part.

``SEC. 1197. VOLUNTARY PARTICIPATION BY OTHER HEALTH PLANS.

    ``(a) Agreement to Participate Under Program.--
            ``(1) In general.--Subject to paragraph (2), under the 
        program under this part the Secretary shall be treated as 
        having in effect an agreement with a group health plan or 
        health insurance issuer offering group or individual health 
        insurance coverage (as such terms are defined in section 2791 
        of the Public Health Service Act), with respect to a price 
        applicability period and a selected drug with respect to such 
        period--
                    ``(A) with respect to such selected drug furnished 
                or dispensed at a pharmacy or by mail order service if 
                coverage is provided under such plan or coverage during 
                such period for such selected drug as so furnished or 
                dispensed; and
                    ``(B) with respect to such selected drug furnished 
                or administered by a hospital, physician, or other 
                provider of services or supplier if coverage is 
                provided under such plan or coverage during such period 
                for such selected drug as so furnished or administered.
            ``(2) Opting out of agreement.--The Secretary shall not be 
        treated as having in effect an agreement under the program 
        under this part with a group health plan or health insurance 
        issuer offering group or individual health insurance coverage 
        with respect to a price applicability period and a selected 
        drug with respect to such period if such a plan or issuer 
        affirmatively elects, through a process specified by the 
        Secretary, not to participate under the program with respect to 
        such period and drug.
    ``(b) Publication of Election.--With respect to each price 
applicability period and each selected drug with respect to such 
period, the Secretary and the Secretary of Labor and the Secretary of 
the Treasury, as applicable, shall make public a list of each group 
health plan and each health insurance issuer offering group or 
individual health insurance coverage, with respect to which coverage is 
provided under such plan or coverage for such drug, that has elected 
under subsection (a) not to participate under the program with respect 
to such period and drug.

``SEC. 1198. CIVIL MONETARY PENALTY.

    ``(a) Violations Relating To Offering of Maximum Fair Price.--Any 
manufacturer of a selected drug that has entered into an agreement 
under section 1193, with respect to a plan year during the price 
applicability period for such drug, that does not provide access to a 
price that is not more than the maximum fair price (or a lesser price) 
for such drug for such year--
            ``(1) to a fair price eligible individual who with respect 
        to such drug is described in subparagraph (A) of section 
        1191(c)(1) and who is furnished or dispensed such drug during 
        such year; or
            ``(2) to a hospital, physician, or other provider of 
        services or supplier with respect to fair price eligible 
        individuals who with respect to such drug is described in 
        subparagraph (B) of such section and is furnished or 
        administered such drug by such hospital, physician, or provider 
        or supplier during such year;
shall be subject to a civil monetary penalty equal to ten times the 
amount equal to the difference between the price for such drug made 
available for such year by such manufacturer with respect to such 
individual or hospital, physician, provider, or supplier and the 
maximum fair price for such drug for such year.
    ``(b) Violations of Certain Terms of Agreement.--Any manufacturer 
of a selected drug that has entered into an agreement under section 
1193, with respect to a plan year during the price applicability period 
for such drug, that is in violation of a requirement imposed pursuant 
to section 1193(a)(6) shall be subject to a civil monetary penalty of 
not more than $1,000,000 for each such violation.
    ``(c) Application.--The provisions of section 1128A (other than 
subsections (a) and (b)) shall apply to a civil monetary penalty under 
this section in the same manner as such provisions apply to a penalty 
or proceeding under section 1128A(a).

``SEC. 1199. MISCELLANEOUS PROVISIONS.

    ``(a) Paperwork Reduction Act.--Chapter 35 of title 44, United 
States Code, shall not apply to data collected under this part.
    ``(b) National Academy of Medicine Study.--Not later than December 
31, 2025, the National Academy of Medicine shall conduct a study, and 
submit to Congress a report, on recommendations for improvements to the 
program under this part, including the determination of the limits 
applied under section 1194(c).
    ``(c) MedPAC Study.--Not later than December 31, 2025, the Medicare 
Payment Advisory Commission shall conduct a study, and submit to 
Congress a report, on the program under this part with respect to the 
Medicare program under title XVIII, including with respect to the 
effect of the program on individuals entitled to benefits or enrolled 
under such title.
    ``(d) Limitation on Judicial Review.--The following shall not be 
subject to judicial review:
            ``(1) The selection of drugs for publication under section 
        1192(a).
            ``(2) The determination of whether a drug is a negotiation-
        eligible drug under section 1192(d).
            ``(3) The determination of the maximum fair price of a 
        selected drug under section 1194.
            ``(4) The determination of units of a drug for purposes of 
        section 1191(c)(3).
    ``(e) Coordination.--In carrying out this part with respect to 
group health plans or health insurance coverage offered in the group 
market that are subject to oversight by the Secretary of Labor or the 
Secretary of the Treasury, the Secretary of Health and Human Services 
shall coordinate with such respective Secretary.
    ``(f) Data Sharing.--The Secretary shall share with the Secretary 
of the Treasury such information as is necessary to determine the tax 
imposed by section 4192 of the Internal Revenue Code of 1986.
    ``(g) GAO Study.--Not later than December 31, 2025, the Comptroller 
General of the United States shall conduct a study of, and submit to 
Congress a report on, the implementation of the Fair Price Negotiation 
Program under this part.''.
    (b) Application of Maximum Fair Prices and Conforming Amendments.--
            (1) Under medicare.--
                    (A) Application to payments under part b.--Section 
                1847A(b)(1)(B) of the Social Security Act (42 U.S.C. 
                1395w-3a(b)(1)(B)) is amended by inserting ``or in the 
                case of such a drug or biological that is a selected 
                drug (as defined in section 1192(c)), with respect to a 
                price applicability period (as defined in section 
                1191(b)(2)), 106 percent of the maximum fair price (as 
                defined in section 1191(c)(2) applicable for such drug 
                and a plan year during such period'' after ``paragraph 
                (4)''.
                    (B) Exception to part d non-interference.--Section 
                1860D-11(i) of the Social Security Act (42 U.S.C. 
                1395w-111(i)) is amended by inserting ``, except as 
                provided under part E of title XI'' after ``the 
                Secretary''.
                    (C) Application as negotiated price under part d.--
                Section 1860D-2(d)(1) of the Social Security Act (42 
                U.S.C. 1395w-102(d)(1)) is amended--
                            (i) in subparagraph (B), by inserting ``, 
                        subject to subparagraph (D),'' after 
                        ``negotiated prices''; and
                            (ii) by adding at the end the following new 
                        subparagraph:
                    ``(D) Application of maximum fair price for 
                selected drugs.--In applying this section, in the case 
                of a covered part D drug that is a selected drug (as 
                defined in section 1192(c)), with respect to a price 
                applicability period (as defined in section 
                1191(b)(2)), the negotiated prices used for payment (as 
                described in this subsection) shall be the maximum fair 
                price (as defined in section 1191(c)(2)) for such drug 
                and for each plan year during such period.''.
                    (D) Information from prescription drug plans and 
                ma-pd plans required.--
                            (i) Prescription drug plans.--Section 
                        1860D-12(b) of the Social Security Act (42 
                        U.S.C. 1395w-112(b)) is amended by adding at 
                        the end the following new paragraph:
            ``(8) Provision of information related to maximum fair 
        prices.--Each contract entered into with a PDP sponsor under 
        this part with respect to a prescription drug plan offered by 
        such sponsor shall require the sponsor to provide information 
        to the Secretary as requested by the Secretary in accordance 
        with section 1196(b).''.
                            (ii) MA-PD plans.--Section 1857(f)(3) of 
                        the Social Security Act (42 U.S.C. 1395w-
                        27(f)(3)) is amended by adding at the end the 
                        following new subparagraph:
                    ``(E) Provision of information related to maximum 
                fair prices.--Section 1860D-12(b)(8).''.
            (2) Under group health plans and health insurance 
        coverage.--
                    (A) PHSA.--Part A of title XXVII of the Public 
                Health Service Act is amended by inserting after 
                section 2729 the following new section:

``SEC. 2729A. FAIR PRICE NEGOTIATION PROGRAM AND APPLICATION OF MAXIMUM 
              FAIR PRICES.

    ``(a) In General.--In the case of a group health plan or health 
insurance issuer offering group or individual health insurance coverage 
that is treated under section 1197 of the Social Security Act as having 
in effect an agreement with the Secretary under the Fair Price 
Negotiation Program under part E of title XI of such Act, with respect 
to a price applicability period (as defined in section 1191(b) of such 
Act) and a selected drug (as defined in section 1192(c) of such Act) 
with respect to such period with respect to which coverage is provided 
under such plan or coverage--
            ``(1) the provisions of such part shall apply--
                    ``(A) if coverage of such selected drug is provided 
                under such plan or coverage if the drug is furnished or 
                dispensed at a pharmacy or by a mail order service, to 
                the plans or coverage offered by such plan or issuer, 
                and to the individuals enrolled under such plans or 
                coverage, during such period, with respect to such 
                selected drug, in the same manner as such provisions 
                apply to prescription drug plans and MA-PD plans, and 
                to individuals enrolled under such prescription drug 
                plans and MA-PD plans during such period; and
                    ``(B) if coverage of such selected drug is provided 
                under such plan or coverage if the drug is furnished or 
                administered by a hospital, physician, or other 
                provider of services or supplier, to the plans or 
                coverage offered by such plan or issuers, to the 
                individuals enrolled under such plans or coverage, and 
                to hospitals, physicians, and other providers of 
                services and suppliers during such period, with respect 
                to such drug in the same manner as such provisions 
                apply to the Secretary, to individuals entitled to 
                benefits under part A of title XVIII or enrolled under 
                part B of such title, and to hospitals, physicians, and 
                other providers and suppliers participating under title 
                XVIII during such period;
            ``(2) the plan or issuer shall apply any cost-sharing 
        responsibilities under such plan or coverage, with respect to 
        such selected drug, by substituting an amount not more than the 
        maximum fair price negotiated under such part E of title XI for 
        such drug in lieu of the drug price upon which the cost-sharing 
        would have otherwise applied, and such cost-sharing 
        responsibilities with respect to such selected drug may not 
        exceed such maximum fair price; and
            ``(3) the Secretary shall apply the provisions of such part 
        E to such plan, issuer, and coverage, such individuals so 
        enrolled in such plans and coverage, and such hospitals, 
        physicians, and other providers and suppliers participating in 
        such plans and coverage.
    ``(b) Notification Regarding Nonparticipation in Fair Price 
Negotiation Program.--A group health plan or a health insurance issuer 
offering group or individual health insurance coverage shall publicly 
disclose in a manner and in accordance with a process specified by the 
Secretary any election made under section 1197 of the Social Security 
Act by the plan or issuer to not participate in the Fair Price 
Negotiation Program under part E of title XI of such Act with respect 
to a selected drug (as defined in section 1192(c) of such Act) for 
which coverage is provided under such plan or coverage before the 
beginning of the plan year for which such election was made.''.
                    (B) ERISA.--
                            (i) In general.--Subpart B of part 7 of 
                        subtitle B of title I of the Employee 
                        Retirement Income Security Act of 1974 (29 
                        U.S.C. 1181 et seq.) is amended by adding at 
                        the end the following new section:

``SEC. 716. FAIR PRICE NEGOTIATION PROGRAM AND APPLICATION OF MAXIMUM 
              FAIR PRICES.

    ``(a) In General.--In the case of a group health plan or health 
insurance issuer offering group health insurance coverage that is 
treated under section 1197 of the Social Security Act as having in 
effect an agreement with the Secretary under the Fair Price Negotiation 
Program under part E of title XI of such Act, with respect to a price 
applicability period (as defined in section 1191(b) of such Act) and a 
selected drug (as defined in section 1192(c) of such Act) with respect 
to such period with respect to which coverage is provided under such 
plan or coverage--
            ``(1) the provisions of such part shall apply, as 
        applicable--
                    ``(A) if coverage of such selected drug is provided 
                under such plan or coverage if the drug is furnished or 
                dispensed at a pharmacy or by a mail order service, to 
                the plans or coverage offered by such plan or issuer, 
                and to the individuals enrolled under such plans or 
                coverage, during such period, with respect to such 
                selected drug, in the same manner as such provisions 
                apply to prescription drug plans and MA-PD plans, and 
                to individuals enrolled under such prescription drug 
                plans and MA-PD plans during such period; and
                    ``(B) if coverage of such selected drug is provided 
                under such plan or coverage if the drug is furnished or 
                administered by a hospital, physician, or other 
                provider of services or supplier, to the plans or 
                coverage offered by such plan or issuers, to the 
                individuals enrolled under such plans or coverage, and 
                to hospitals, physicians, and other providers of 
                services and suppliers during such period, with respect 
                to such drug in the same manner as such provisions 
                apply to the Secretary, to individuals entitled to 
                benefits under part A of title XVIII or enrolled under 
                part B of such title, and to hospitals, physicians, and 
                other providers and suppliers participating under title 
                XVIII during such period;
            ``(2) the plan or issuer shall apply any cost-sharing 
        responsibilities under such plan or coverage, with respect to 
        such selected drug, by substituting an amount not more than the 
        maximum fair price negotiated under such part E of title XI for 
        such drug in lieu of the drug price upon which the cost-sharing 
        would have otherwise applied, and such cost-sharing 
        responsibilities with respect to such selected drug may not 
        exceed such maximum fair price; and
            ``(3) the Secretary shall apply the provisions of such part 
        E to such plan, issuer, and coverage, and such individuals so 
        enrolled in such plans.
    ``(b) Notification Regarding Nonparticipation in Fair Price 
Negotiation Program.--A group health plan or a health insurance issuer 
offering group health insurance coverage shall publicly disclose in a 
manner and in accordance with a process specified by the Secretary any 
election made under section 1197 of the Social Security Act by the plan 
or issuer to not participate in the Fair Price Negotiation Program 
under part E of title XI of such Act with respect to a selected drug 
(as defined in section 1192(c) of such Act) for which coverage is 
provided under such plan or coverage before the beginning of the plan 
year for which such election was made.''.
                            (ii) Application to retiree and certain 
                        small group health plans.--Section 732(a) of 
                        the Employee Retirement Income Security Act of 
                        1974 (29 U.S.C. 1191a(a)) is amended by 
                        striking ``section 711'' and inserting 
                        ``sections 711 and 716''.
                            (iii) Clerical amendment.--The table of 
                        sections for subpart B of part 7 of subtitle B 
                        of title I of the Employee Retirement Income 
                        Security Act of 1974 is amended by adding at 
                        the end the following:

``Sec. 716. Fair Price Negotiation Program and application of maximum 
                            fair prices.''.
                    (C) IRC.--
                            (i) In general.--Subchapter B of chapter 
                        100 of the Internal Revenue Code of 1986 is 
                        amended by adding at the end the following new 
                        section:

``SEC. 9816. FAIR PRICE NEGOTIATION PROGRAM AND APPLICATION OF MAXIMUM 
              FAIR PRICES.

    ``(a) In General.--In the case of a group health plan that is 
treated under section 1197 of the Social Security Act as having in 
effect an agreement with the Secretary under the Fair Price Negotiation 
Program under part E of title XI of such Act, with respect to a price 
applicability period (as defined in section 1191(b) of such Act) and a 
selected drug (as defined in section 1192(c) of such Act) with respect 
to such period with respect to which coverage is provided under such 
plan--
            ``(1) the provisions of such part shall apply, as 
        applicable--
                    ``(A) if coverage of such selected drug is provided 
                under such plan if the drug is furnished or dispensed 
                at a pharmacy or by a mail order service, to the plan, 
                and to the individuals enrolled under such plan during 
                such period, with respect to such selected drug, in the 
                same manner as such provisions apply to prescription 
                drug plans and MA-PD plans, and to individuals enrolled 
                under such prescription drug plans and MA-PD plans 
                during such period; and
                    ``(B) if coverage of such selected drug is provided 
                under such plan if the drug is furnished or 
                administered by a hospital, physician, or other 
                provider of services or supplier, to the plan, to the 
                individuals enrolled under such plan, and to hospitals, 
                physicians, and other providers of services and 
                suppliers during such period, with respect to such drug 
                in the same manner as such provisions apply to the 
                Secretary, to individuals entitled to benefits under 
                part A of title XVIII or enrolled under part B of such 
                title, and to hospitals, physicians, and other 
                providers and suppliers participating under title XVIII 
                during such period;
            ``(2) the plan shall apply any cost-sharing 
        responsibilities under such plan, with respect to such selected 
        drug, by substituting an amount not more than the maximum fair 
        price negotiated under such part E of title XI for such drug in 
        lieu of the drug price upon which the cost-sharing would have 
        otherwise applied, and such cost-sharing responsibilities with 
        respect to such selected drug may not exceed such maximum fair 
        price; and
            ``(3) the Secretary shall apply the provisions of such part 
        E to such plan and such individuals so enrolled in such plan.
    ``(b) Notification Regarding Nonparticipation in Fair Price 
Negotiation Program.--A group health plan shall publicly disclose in a 
manner and in accordance with a process specified by the Secretary any 
election made under section 1197 of the Social Security Act by the plan 
to not participate in the Fair Price Negotiation Program under part E 
of title XI of such Act with respect to a selected drug (as defined in 
section 1192(c) of such Act) for which coverage is provided under such 
plan before the beginning of the plan year for which such election was 
made.''.
                            (ii) Application to retiree and certain 
                        small group health plans.--Section 9831(a)(2) 
                        of the Internal Revenue Code of 1986 is amended 
                        by inserting ``other than with respect to 
                        section 9816,'' before ``any group health 
                        plan''.
                            (iii) Clerical amendment.--The table of 
                        sections for subchapter B of chapter 100 of 
                        such Code is amended by adding at the end the 
                        following new item:

``Sec. 9816. Fair Price Negotiation Program and application of maximum 
                            fair prices.''.
            (3) Fair price negotiation program prices included in best 
        price and amp.--Section 1927 of the Social Security Act (42 
        U.S.C. 1396r-8) is amended--
                    (A) in subsection (c)(1)(C)(ii)--
                            (i) in subclause (III), by striking at the 
                        end ``; and'';
                            (ii) in subclause (IV), by striking at the 
                        end the period and inserting ``; and''; and
                            (iii) by adding at the end the following 
                        new subclause:
                                    ``(V) in the case of a rebate 
                                period and a covered outpatient drug 
                                that is a selected drug (as defined in 
                                section 1192(c)) during such rebate 
                                period, shall be inclusive of the price 
                                for such drug made available from the 
                                manufacturer during the rebate period 
                                by reason of application of part E of 
                                title XI to any wholesaler, retailer, 
                                provider, health maintenance 
                                organization, nonprofit entity, or 
                                governmental entity within the United 
                                States.''; and
                    (B) in subsection (k)(1)(B), by adding at the end 
                the following new clause:
                            ``(iii) Clarification.--Notwithstanding 
                        clause (i), in the case of a rebate period and 
                        a covered outpatient drug that is a selected 
                        drug (as defined in section 1192(c)) during 
                        such rebate period, any reduction in price paid 
                        during the rebate period to the manufacturer 
                        for the drug by a wholesaler or retail 
                        community pharmacy described in subparagraph 
                        (A) by reason of application of part E of title 
                        XI shall be included in the average 
                        manufacturer price for the covered outpatient 
                        drug.''.
            (4) FEHBP.--Section 8902 of title 5, United States Code, is 
        amended by adding at the end the following:
    ``(p) A contract may not be made or a plan approved under this 
chapter with any carrier that has affirmatively elected, pursuant to 
section 1197 of the Social Security Act, not to participate in the Fair 
Price Negotiation Program established under section 1191 of such Act 
for any selected drug (as that term is defined in section 1192(c) of 
such Act).''.
            (5) Option of secretary of veterans affairs to purchase 
        covered drugs at maximum fair prices.--Section 8126 of title 
        38, United States Code, is amended--
                    (A) in subsection (a)(2), by inserting ``, subject 
                to subsection (j),'' after ``may not exceed'';
                    (B) in subsection (d), in the matter preceding 
                paragraph (1), by inserting ``, subject to subsection 
                (j)'' after ``for the procurement of the drug''; and
                    (C) by adding at the end the following new 
                subsection:
    ``(j)(1) In the case of a covered drug that is a selected drug, for 
any year during the price applicability period for such drug, if the 
Secretary determines that the maximum fair price of such drug for such 
year is less than the price for such drug otherwise in effect pursuant 
to this section (including after application of any reduction under 
subsection (a)(2) and any discount under subsection (c)), at the option 
of the Secretary, in lieu of the maximum price (determined after 
application of the reduction under subsection (a)(2) and any discount 
under subsection (c), as applicable) that would be permitted to be 
charged during such year for such drug pursuant to this section without 
application of this subsection, the maximum price permitted to be 
charged during such year for such drug pursuant to this section shall 
be such maximum fair price for such drug and year.
    ``(2) For purposes of this subsection:
            ``(A) The term `maximum fair price' means, with respect to 
        a selected drug and year during the price applicability period 
        for such drug, the maximum fair price (as defined in section 
        1191(c)(2) of the Social Security Act) for such drug and year.
            ``(B) The term `negotiation eligible drug' has the meaning 
        given such term in section 1192(d)(1) of the Social Security 
        Act.
            ``(C) The term `price applicability period' has, with 
        respect to a selected drug, the meaning given such term in 
        section 1191(b)(2) of such Act.
            ``(D) The term `selected drug' means, with respect to a 
        year, a drug that is a selected drug under section 1192(c) of 
        such Act for such year.''.

SEC. 302. DRUG MANUFACTURER EXCISE TAX FOR NONCOMPLIANCE.

    (a) In General.--Subchapter E of chapter 32 of the Internal Revenue 
Code of 1986 is amended by adding at the end the following new section:

``SEC. 4192. SELECTED DRUGS DURING NONCOMPLIANCE PERIODS.

    ``(a) In General.--There is hereby imposed on the sale by the 
manufacturer, producer, or importer of any selected drug during a day 
described in subsection (b) a tax in an amount such that the applicable 
percentage is equal to the ratio of--
            ``(1) such tax, divided by
            ``(2) the sum of such tax and the price for which so sold.
    ``(b) Noncompliance Periods.--A day is described in this subsection 
with respect to a selected drug if it is a day during one of the 
following periods:
            ``(1) The period beginning on the June 16th immediately 
        following the selected drug publication date and ending on the 
        first date during which the manufacturer of the drug has in 
        place an agreement described in subsection (a) of section 1193 
        of the Social Security Act with respect to such drug.
            ``(2) The period beginning on the April 1st immediately 
        following the June 16th described in paragraph (1) and ending 
        on the first date during which the manufacturer of the drug has 
        agreed to a maximum fair price under such agreement.
            ``(3) In the case of a selected drug with respect to which 
        the Secretary of Health and Human Services has specified a 
        renegotiation period under such agreement, the period beginning 
        on the first date after the last date of such renegotiation 
        period and ending on the first date during which the 
        manufacturer of the drug has agreed to a renegotiated maximum 
        fair price under such agreement.
            ``(4) With respect to information that is required to be 
        submitted to the Secretary of Health and Human Services under 
        such agreement, the period beginning on the date on which such 
        Secretary certifies that such information is overdue and ending 
        on the date that such information is so submitted.
            ``(5) In the case of a selected drug with respect to which 
        a payment is due under subsection (c) of such section 1193, the 
        period beginning on the date on which the Secretary of Health 
        and Human Services certifies that such payment is overdue and 
        ending on the date that such payment is made in full.
    ``(c) Applicable Percentage.--For purposes of this section, the 
term `applicable percentage' means--
            ``(1) in the case of sales of a selected drug during the 
        first 90 days described in subsection (b) with respect to such 
        drug, 65 percent,
            ``(2) in the case of sales of such drug during the 91st day 
        through the 180th day described in subsection (b) with respect 
        to such drug, 75 percent,
            ``(3) in the case of sales of such drug during the 181st 
        day through the 270th day described in subsection (b) with 
        respect to such drug, 85 percent, and
            ``(4) in the case of sales of such drug during any 
        subsequent day, 95 percent.
    ``(d) Selected Drug.--For purposes of this section--
            ``(1) In general.--The term `selected drug' means any 
        selected drug (within the meaning of section 1192 of the Social 
        Security Act) which is manufactured or produced in the United 
        States or entered into the United States for consumption, use, 
        or warehousing.
            ``(2) United states.--The term `United States' has the 
        meaning given such term by section 4612(a)(4).
            ``(3) Coordination with rules for possessions of the united 
        states.--Rules similar to the rules of paragraphs (2) and (4) 
        of section 4132(c) shall apply for purposes of this section.
    ``(e) Other Definitions.--For purposes of this section, the terms 
`selected drug publication date' and `maximum fair price' have the 
meaning given such terms in section 1191 of the Social Security Act.
    ``(f) Anti-Abuse Rule.--In the case of a sale which was timed for 
the purpose of avoiding the tax imposed by this section, the Secretary 
may treat such sale as occurring during a day described in subsection 
(b).''.
    (b) No Deduction for Excise Tax Payments.--Section 275 of the 
Internal Revenue Code of 1986 is amended by adding ``or by section 
4192'' before the period at the end of subsection (a)(6).
    (c) Conforming Amendments.--
            (1) Section 4221(a) of the Internal Revenue Code of 1986 is 
        amended by inserting ``or 4192'' after ``section 4191''.
            (2) Section 6416(b)(2) of such Code is amended by inserting 
        ``or 4192'' after ``section 4191''.
    (d) Clerical Amendments.--
            (1) The heading of subchapter E of chapter 32 of the 
        Internal Revenue Code of 1986 is amended by striking ``Medical 
        Devices'' and inserting ``Other Medical Products''.
            (2) The table of subchapters for chapter 32 of such Code is 
        amended by striking the item relating to subchapter E and 
        inserting the following new item:

               ``subchapter e. other medical products''.

            (3) The table of sections for subchapter E of chapter 32 of 
        such Code is amended by adding at the end the following new 
        item:

``Sec. 4192. Selected drugs during noncompliance periods.''.
    (e) Effective Date.--The amendments made by this section shall 
apply to sales after the date of the enactment of this Act.

SEC. 303. FAIR PRICE NEGOTIATION IMPLEMENTATION FUND.

    (a) In General.--There is hereby established a Fair Price 
Negotiation Implementation Fund (referred to in this section as the 
``Fund''). The Secretary of Health and Human Services may obligate and 
expend amounts in the Fund to carry out this title (and the amendments 
made by such title).
    (b) Funding.--There is authorized to be appropriated, and there is 
hereby appropriated, out of any monies in the Treasury not otherwise 
appropriated, to the Fund $3,000,000,000, to remain available until 
expended, of which--
            (1) $600,000,000 shall become available on the date of the 
        enactment of this Act;
            (2) $600,000,000 shall become available on October 1, 2020;
            (3) $600,000,000 shall become available on October 1, 2021;
            (4) $600,000,000 shall become available on October 1, 2022; 
        and
            (5) $600,000,000 shall become available on October 1, 2023.
    (c) Supplement Not Supplant.--Any amounts appropriated pursuant to 
this section shall be in addition to any other amounts otherwise 
appropriated pursuant to any other provision of law.

                  TITLE IV--PUBLIC HEALTH INVESTMENTS

SEC. 401. SUPPORTING INCREASED INNOVATION.

    (a) In General.--The Secretary of Health and Human Services, acting 
through the Director of the National Institutes of Health, shall 
continue to support and to expand, as applicable, biomedical research 
carried out through the National Institutes of Health innovation 
projects described in section 1001(b)(4) of the 21st Century Cures Act 
(Public Law 114-255). The Secretary shall ensure that any such research 
(and related activities) is conducted in compliance with section 492B 
of the Public Health Service Act (42 U.S.C. 289a-2) (relating to the 
inclusion of women and members of minority groups in research).
    (b) Authorization of Appropriations.--To carry out this subsection, 
in addition to funds made available under paragraph (2) of section 
1001(b) of the 21st Century Cures Act (Public Law 114-255), there is 
authorized to be appropriated, and there is appropriated to the NIH 
Innovation Account established under such section 1001(b), out of any 
moneys in the Treasury not otherwise obligated, $2,000,000,000 for 
fiscal year 2021, to remain available until expended.

            Passed the House of Representatives June 29, 2020.

            Attest:

                                                                 Clerk.
116th CONGRESS

  2d Session

                               H. R. 1425

_______________________________________________________________________

                                 AN ACT

To amend the Patient Protection and Affordable Care Act to provide for 
 a Improve Health Insurance Affordability Fund to provide for certain 
    reinsurance payments to lower premiums in the individual health 
                           insurance market.