Medisave Accounts

(a)

In general

Part VIII of subchapter F of chapter 1 of the Internal Revenue Code of 1986 is amended by adding at the end the following new section:

530A.

Medisave Accounts

(a)

Medisave account

For purposes of this section—(1)

In general

The term Medisave account means a trust created or organized in the United States as a Medisave account exclusively for the purpose of paying the qualified medical expenses of the account beneficiary, but only if the written governing instrument creating the trust meets the following requirements:(A)Except in the case of a rollover contribution described in subparagraph (A) or (B) of subsection (e)(5), no contribution will be accepted—(i)unless it is in cash,(ii)to the extent such contribution, when added to previous contributions to the trust for the calendar year, exceeds the limitation amount specified in subsection (b)(1), or(iii)to the extent such contribution, when added to the balance of the account, exceeds the limitation amount specified in subsection (b)(2).(B)The trustee is a bank (as defined in section 408(n)), an insurance company (as defined in section 816), or another person who demonstrates to the satisfaction of the Secretary that the manner in which such person will administer the trust will be consistent with the requirements of this section.(C)No part of the trust assets will be invested in life insurance contracts.(D)The assets of the trust will not be commingled with other property except in a common trust fund or common investment fund.(E)The interest of an individual in the balance in his account is nonforfeitable.(2)

Qualified medical expenses

(A)

In general

The term qualified medical expenses means, with respect to an account beneficiary, amounts paid by such beneficiary for medical care, but only to the extent such amounts are not compensated for by insurance or otherwise—(i)for—(I)such individual,(II)the spouse of such individual,(III)any dependent (as defined in section 152, determined without regard to subsections (b)(1), (b)(2), and (d)(1)(B) thereof) of such individual, and(IV)any individual who bears a relationship to the account beneficiary that is described in subparagraph (C) or (D) of section 152(d) if the account beneficiary is or was a dependent of such individual for any taxable year ending before or with the taxable year in which the individual attained 18 years of age, and(ii)if, on the date such medical care was provided, such individual, spouse or dependent to whom such care was provided was covered under the qualified health insurance of the account beneficiary.(B)

Modified definition of medical care

For purposes of subparagraph (A), the term medical care has the meaning given such term by section 213(d), except that such term includes—(i)direct pay arrangements with primary physicians, and(ii)predetermined level of access to care from an integrated health plan.(3)

Account beneficiary

The term account beneficiary means the individual on whose behalf the Medisave account was established.(4)

Certain rules to apply

Rules similar to the following rules shall apply for purposes of this section:(A)Section 219(d)(2) (relating to no deduction for rollovers).(B)Section 219(f)(3) (relating to time when contributions deemed made).(C)Except as provided in section 106(d), section 219(f)(5) (relating to employer payments).(D)Section 408(g) (relating to community property laws).(E)Section 408(h) (relating to custodial accounts).(b)

Limitations

(1)

Annual limitation

(A)

In general

The limitation amount specified in this paragraph is—(i)$10,000 in the case of a qualified health plan with an actuarial value of less than 55 percent,(ii)$8,600 in the case of a qualified health plan with an actuarial value that is 55 percent or more and less than 65 percent, and(iii)$7,200 in the case of a qualified health plan with an actuarial value that is 65 percent or more.(B)

Actuarial value of qualified health plan

For purposes of subparagraph (A), the actuarial value of a qualified health plan is the percentage of the total average costs of covered benefits under the health plan.(2)

Account accumulation limitation

The limitation amount specified in this paragraph is $50,000.(3)

Indexing

(A)

In general

In the case of any taxable year beginning in a calendar year after 2020, each dollar amount contained in paragraph (1)(A) shall be increased by the medical care cost adjustment of such amount for such calendar year.(B)

Medical care cost adjustment

For purposes of subparagraph (A), the medical care cost adjustment for any calendar year is the percentage (if any) by which—(i)the medical care component of the C–CPI–U (as defined in section 1(f)(6)) for August of the preceding calendar year, exceeds(ii)such component of the C–CPI–U (as so defined) for August of 2019.(C)

Rounding

(i)

Annual limitation

If any increase in a dollar amount contained in paragraph (1)(A) determined under subparagraph (A) is not a multiple of $100, such increase shall be rounded to the nearest multiple of $100.(ii)

Account limitation

If any increase in the dollar amount contained in paragraph (2) determined under subparagraph (A) is not a multiple of $1,000, such increase shall be rounded to the nearest multiple of $1,000.(4)

Coordination with other contributions

The limitation which would (but for this paragraph) apply under paragraphs (1) and (2) to an individual for any taxable year shall be reduced (but not below zero) by the sum of—(A)the aggregate amount contributed to Medisave accounts of such individual which is excludable from the taxpayer’s gross income for such taxable year under section 106(d), and(B)the aggregate amount contributed to Medisave accounts of such individual for such taxable year under section 408(d)(9).(5)

Deposit of advance premium tax credit

An account beneficiary who is eligible for an advance payment of the premium tax credit may elect to have the Secretary deposit the advance payment into the Medisave account of the account beneficiary.(c)

Definitions and special rules

For purposes of this section—(1)

Eligible individual

(A)

In general

The term eligible individual means, with respect to any month, any individual if such individual is covered under a qualified health plan as of the 1st day of such month.(B)

Certain coverage disregarded

Subparagraph (A) shall be applied without regard to—(i)coverage for any benefit provided by permitted insurance, and(ii)coverage (whether through insurance or otherwise) for accidents, disability, dental care, vision care, or long-term care.(C)

Special rule for individuals eligible for certain veterans benefits

An individual shall not fail to be treated as an eligible individual for any period merely because the individual receives hospital care or medical services under any law administered by the Secretary of Veterans Affairs for a service-connected disability (within the meaning of section 101(16) of title 38, United States Code).(2)

Qualified health plan

(A)

In general

The term qualified health plan means a health plan that offers health insurance coverage. Such term includes entitlement to benefits under title XVIII or title XIX of the Social Security Act.(B)

Exclusion of certain plans

Such term does not include a health plan if substantially all of its coverage is disregarded under paragraph (1)(B).(C)

Health insurance coverage

The term health insurance coverage means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization contract offered by a health insurance issuer.(D)

Health insurance issuer

The term health insurance issuer means an insurance company, insurance service, or insurance organization (including a health maintenance organization) which is licensed to engage in the business of insurance in a State and which is subject to State law which regulates insurance (within the meaning of section 514(b)(2) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1144(b)(2)).(E)

Health maintenance organization

The term health maintenance organization means—(i)a Federally qualified health maintenance organization (as defined in section 1301(a) of the Public Health Service Act (42 U.S.C. 300e(a)),(ii)an organization recognized under State law as a health maintenance organization, or(iii)a similar organization regulated under State law for solvency in the same manner and to the same extent as such a health maintenance organization.(3)

Permitted insurance

The term permitted insurance means—(A)insurance if substantially all of the coverage provided under such insurance relates to—(i)liabilities incurred under workers’ compensation laws,(ii)tort liabilities,(iii)liabilities relating to ownership or use of property, or(iv)such other similar liabilities as the Secretary may specify by regulations,(B)insurance for a specified disease or illness, and(C)insurance paying a fixed amount per day (or other period) of hospitalization.(4)

Family coverage

The term family coverage means any coverage other than self-only coverage.(d)

Tax treatment of accounts

(1)

In general

A Medisave account is exempt from taxation under this subtitle unless such account has ceased to be a Medisave account. Notwithstanding the preceding sentence, any Medisave account is subject to the taxes imposed by section 511 (relating to imposition of tax on unrelated business income of charitable, etc. organizations).(2)

Account terminations

Rules similar to the rules of paragraphs (2) and (4) of section 408(e) shall apply to Medisave accounts, and any amount treated as distributed under such rules shall be treated as not used to pay qualified medical expenses.(e)

Tax treatment of distributions

(1)

Amounts used for qualified medical expenses

Any amount paid or distributed out of a Medisave account which is used exclusively to pay qualified medical expenses of any account beneficiary shall not be includible in gross income.(2)

Inclusion of amounts not used for qualified medical expenses

Any amount paid or distributed out of a Medisave account which is not used exclusively to pay the qualified medical expenses of the account beneficiary shall be included in the gross income of such beneficiary.(3)

Excess contributions returned before due date of return

(A)

In general

If any excess contribution is contributed for a taxable year to any Medisave account of an individual, paragraph (2) shall not apply to distributions from the Medisave accounts of such individual (to the extent such distributions do not exceed the aggregate excess contributions to all such accounts of such individual for such year) if—(i)such distribution is received by the individual on or before the last day prescribed by law (including extensions of time) for filing such individual’s return for such taxable year, and(ii)such distribution is accompanied by the amount of net income attributable to such excess contribution.

Any net income described in clause (ii) shall be included in the gross income of the individual for the taxable year in which it is received.

(B)

Excess contribution

For purposes of subparagraph (A), the term excess contribution means any contribution (other than a rollover contribution described in paragraph (5)) which exceeds the limitations specified in subsection (b).(4)

Additional tax on distributions not used for qualified medical expenses

(A)

In general

The tax imposed by this chapter on the account beneficiary for any taxable year in which there is a payment or distribution from a Medisave account of such beneficiary which is includible in gross income under paragraph (2) shall be increased by 20 percent of the amount which is so includible.(B)

Exception for disability or death

Subparagraph (A) shall not apply if the payment or distribution is made after the account beneficiary becomes disabled within the meaning of section 72(m)(7) or dies.(5)

Rollover contribution

(A)

In general

An amount is described in this subparagraph as a rollover contribution if it meets the requirements of clauses (i) and (ii).(i)

In general

Paragraph (2) shall not apply to any amount paid or distributed from a Medisave account to the account beneficiary to the extent the amount received is paid into a Medisave account for the benefit of such beneficiary not later than the 60th day after the day on which the beneficiary receives the payment or distribution.(ii)

Limitation

This paragraph shall not apply to any amount described in clause (i) received by an individual from a Medisave account if, at any time during the 1-year period ending on the day of such receipt, such individual received any other amount described in clause (i) from a Medisave account which was not includible in the individual’s gross income because of the application of this paragraph.(B)

Rollover from FSA, Archer MSA, and HSA

An amount is described in this subparagraph for a calendar year as a rollover contribution if the amount is the remaining balance in a flexible spending account, Archer MSA, or health savings account that is contributed to the Medisave account for a taxable year ending on or before one year after the date of the enactment of the Family First Medisave Empowerment Act.(6)

Coordination with medical expense deduction

For purposes of determining the amount of the deduction under section 213, any payment or distribution out of a Medisave account for qualified medical expenses shall not be treated as an expense paid for medical care.(7)

Transfer of account incident to divorce

The transfer of an individual’s interest in a Medisave account to an individual’s spouse or former spouse under a divorce or separation instrument described in clause (i) of section 121(d)(3)(C) shall not be considered a taxable transfer made by such individual notwithstanding any other provision of this subtitle, and such interest shall, after such transfer, be treated as a Medisave account with respect to which such spouse is the account beneficiary.(8)

Treatment after death of account beneficiary

(A)

Treatment if designated beneficiary is spouse

If the account beneficiary’s surviving spouse acquires such beneficiary’s interest in a Medisave account by reason of being the designated beneficiary of such account at the death of the account beneficiary, such Medisave account shall be treated as if the spouse were the account beneficiary.(B)

Other cases

(i)

In general

If, by reason of the death of the account beneficiary, any person acquires the account beneficiary’s interest in a Medisave account in a case to which subparagraph (A) does not apply—(I)such account shall cease to be a Medisave account as of the date of death, and(II)an amount equal to the fair market value of the assets in such account on such date shall be includible if such person is not the estate of such beneficiary, in such person’s gross income for the taxable year which includes such date, or if such person is the estate of such beneficiary, in such beneficiary’s gross income for the last taxable year of such beneficiary.(ii)

Special rules

(I)

Reduction of inclusion for predeath expenses

The amount includible in gross income under clause (i) by any person (other than the estate) shall be reduced by the amount of qualified medical expenses which were incurred by the decedent before the date of the decedent’s death and paid by such person within 1 year after such date.(II)

Deduction for estate taxes

An appropriate deduction shall be allowed under section 691(c) to any person (other than the decedent or the decedent’s spouse) with respect to amounts included in gross income under clause (i) by such person.(f)

Reports

The Secretary may require—(1)the trustee of a Medisave account to make such reports regarding such account to the Secretary and to the account beneficiary with respect to contributions, distributions, the return of excess contributions, and such other matters as the Secretary determines appropriate, and(2)any person who provides an individual with a qualified health plan to make such reports to the Secretary and to the account beneficiary with respect to such plan as the Secretary determines appropriate.

The reports required by this subsection shall be filed at such time and in such manner and furnished to such individuals at such time and in such manner as may be required by the Secretary.

(g)

Regulations and guidance

For purposes of this section, the Secretary shall prescribe such regulations or other guidance as the Secretary determines necessary or appropriate to carry out this section, including regulations or guidance on the methods acceptable to the Secretary for determining qualified health plan actuarial value.

(b)

Treatment of employer payments

(1)

Exclusion limited to self-funded major medical plan of employers

Section 105(b) of such Code is amended by striking paid, and inserting paid under a self-funded major medical plan of the employer.(2)

Exclusion not applicable to health reimbursement arrangements

Subsection (h) of such Code is amended to read as follows:

(h)

Exclusion not applicable to health reimbursement arrangements

Subsection (b) shall not apply to health reimbursement arrangements.

(3)

Repeal of exclusions from income for Archer MSAs, FSAs, and HSAs

(A)

In general

Section 106 of such Code is amended—(i)by striking subsections (b), (d), and (e), and(ii)by redesignating subsections (f) and (g) as subsections (d) and (e), respectively.(B)

Exclusion from income for Medisave accounts

Section 106 of such Code, as amended by subparagraph (A), is amended by inserting after subsection (a) the following:

(b)

Contributions to Medisave accounts

(1)

In general

In the case of an employee who is an eligible individual (as defined in section 530A(c)(1)), amounts contributed by such employee’s employer to any Medisave account (as defined in section 530A(a)) of such employee shall be treated as employer-provided coverage for medical expenses under an accident or health plan to the extent such amounts do not exceed the limitations specified in clauses (ii) and (iii) of section 530A(a)(1)(A) (determined without regard to this subsection) which is applicable to such employee for such taxable year.(2)

No constructive receipt

No amount shall be included in the gross income of any employee solely because the employee may choose between the contributions referred to in paragraph (1) and employer contributions to another health plan of the employer.(3)

Special rule for deduction of employer contributions

Any employer contribution to a Medisave account, if otherwise allowable as a deduction under this chapter, shall be allowed only for the taxable year in which paid.(4)

Employer Medisave account contributions required to be shown on return

Every individual required to file a return under section 6012 for the taxable year shall include on such return the aggregate amount contributed by employers to the Medisave accounts of such individual or such individual’s spouse for such taxable year.(5)

Medisave account contributions not part of COBRA coverage

Paragraph (1) shall not apply for purposes of section 4980B.(6)

Cross reference

For penalty on failure by employer to make comparable contributions to the Medisave accounts of comparable employees, see section 4980G.

(4)

Distribution from certain retirement accounts for Medisave account funding

Section 408(d)(9) of such Code is amended to read as follows:

(9)

Distribution for Medisave account funding

(A)

In general

In the case of an individual who is an eligible individual (as defined in section 530A(c)(1)) and who elects the application of this paragraph for a taxable year, gross income of the individual for the taxable year does not include a qualified Medisave account funding distribution to the extent such distribution is otherwise includible in gross income.(B)

Qualified Medisave account funding distribution

For purposes of this paragraph, the term qualified Medisave account funding distribution means a distribution from an individual retirement plan (other than a plan described in subsection (k) or (p)) of the employee to the extent that—(i)such distribution is contributed to the Medisave account of the individual in a direct trustee-to-trustee transfer, and(ii)such distribution—(I)when added to previous contributions to the Medisave account for the calendar year does not exceed the limitation amount specified in section 530A(b)(1), and(II)when added to the balance of the Medisave account, exceeds the limitation amount specified in section 530A(b)(2).(C)

One-time transfer

An individual may make an election under subparagraph (A) only for one qualified Medisave account funding distribution during the lifetime of the individual. Such an election, once made, shall be irrevocable.(D)

Application of section 72

Notwithstanding section 72, in determining the extent to which an amount is treated as otherwise includible in gross income for purposes of subparagraph (A), the aggregate amount distributed from an individual retirement plan shall be treated as includible in gross income to the extent that such amount does not exceed the aggregate amount which would have been so includible if all amounts from all individual retirement plans were distributed. Proper adjustments shall be made in applying section 72 to other distributions in such taxable year and subsequent taxable years.

(5)

Failure of employer to make comparable contributions

(A)Section 4980G(a) of such Code is amended by striking health savings account and inserting Medisave account.(B)Section 4980G(c) of such Code is amended by striking Archer MSAs and health savings accounts and inserting Medisave accounts.(6)

W–2 statements

Section 6051(a) of such Code is amended—(A)by striking paragraph (11) and redesignating paragraphs (12) through (17) as paragraphs (11) through (16), respectively, and(B)by amending paragraph (11), as so redesignated, to read as follows:

(11)the amount contributed to any Medisave account (as defined in section 530A) of such employee or such employee’s spouse,

(c)

Other conforming amendments

(1)

Archer MSAs

Section 220(a) of such Code is amended by adding at the end the following: No amount is allowed as a deduction under the preceding sentence for any taxable year beginning after one year after the date of the enactment of Family First Medisave Empowerment Act..(2)

Health savings accounts

Section 223(a) of such Code is amended by adding at the end the following: No amount is allowed as a deduction under the preceding sentence for any taxable year beginning after one year after the date of the enactment of the Family First Medisave Empowerment Act..(d)

Rollover of FSA, Archer MSA, HSA to Medisave account

Notwithstanding any other provision of law, if the remaining balance in a health flexible spending arrangement, Archer MSA, or Health Savings Account is transferred to a Medisave account before the end of any taxable year ending on or before one year after the date of the enactment of the Family First Medisave Empowerment Act, such transfer shall be treated as a rollover to the Medisave account under section 530A(e)(5)(B) of the Internal Revenue Code of 1986 and the distribution from the health flexible spending arrangement, Archer MSA, or Health Savings Account shall not be includible in gross income.(e)

Clerical amendments

The table of sections for part VIII of subchapter F of chapter 1 of such Code is amended by adding at the end the following new item:

Sec. 530A. Medisave Accounts.

(f)

Effective date

The amendments made by this section shall apply to taxable years beginning after one year after the date of the enactment of this Act.

Alternative waiver for State innovation; cost-sharing reduction payments

(a)

Alternative waiver for State innovation

Section 1332 of the Patient Protection and Affordable Care Act (42 U.S.C. 18052) is amended by adding at the end the following new subsection:

(f)

Alternative waiver for State innovation

(1)

In general

Notwithstanding any preceding provision of this section, a State may apply to the Secretary for the waiver of any requirement of subsection (a)(2) with respect to health insurance coverage within that State for plan years beginning on or after January 1, 2022, if instead of complying with section 1402 the State provides for the distribution of funding received under paragraph (2) to Medisave accounts of qualifying individuals with respect to such State. Such application shall be filed at such time and in such manner as the Secretary may require, and shall include such information as the Secretary may require (including a 10-year budget plan for such plan that is budget neutral for the Federal Government).(2)

Pass-through funding

With respect to a State waiver under paragraph (1), under which, due to the structure of such waiver, individuals in the State would not qualify for cost-sharing reductions under section 1402 for which they would otherwise be eligible, the Secretary shall provide for an alternative means by which an amount is transferred to the State equal to the aggregate amount of such reductions that would have been paid on behalf of the participants in the Exchanges established under this title—(A)had the State not received such waiver;(B)had references to eligible insureds under section 1402 referred to qualifying insureds (as defined in section 1332(f)); and(C)had, after application of clause (ii), in the case of a qualifying insured enrolled in the bronze level of coverage—(i)the percentages specified in subclauses (I), (II), and (III) of section 1402(c)(1)(B) were references to 84 percent, 77 percent, and 63 percent, respectively; and(ii)the references in subparagraphs (A), (B), and (C) of section 1402(c)(2) to 94 percent, 87 percent, and 73 percent, respectively, were references to 84 percent, 77 percent, and 63 percent, respectively.

The amount transferred pursuant to the previous sentence shall be determined annually by the Secretary, taking into consideration the experience of other States with respect to participation in an Exchange and reductions provided under such provisions to residents of the other States, and shall be paid to the State for purposes of implementing such waiver.

(3)

Waiver consideration and transparency

The provisions of paragraph (4) of subsection (a) shall apply to an application for a waiver under paragraph (1) in the same manner as such provisions apply with respect to an application for a waiver under subsection (a)(1), except that, for purposes of this paragraph, the provisions of subsection (a)(4)(B)(ii) shall not apply.(4)

Determinations; term of waiver

The provisions of subsections (d) and (e) shall apply with respect to a determination with respect to an application under paragraph (1), and with respect to the term of a waiver under such paragraph, in the same manner as such provisions apply with respect to a determination with respect to an application under subsection (a)(1), and with respect to the term of a waiver under such subsection.(5)

Definitions

For purposes of this subsection:(A)

Medisave account

The term Medisave account has the meaning given such term in section 530A(a) of the Internal Revenue Code of 1986.(B)

Qualifying insured

The term qualifying insured means, with respect to a State and a year, an individual—(i)who is enrolled in a Medisave account;(ii)who is enrolled for such year in a silver level or bronze level coverage offered through an Exchange; and(iii)whose household income is not less than 100 percent but not more than 250 percent of the Federal poverty line for a family of the size involved.

(b)

Conforming amendments

Section 1332 of the Patient Protection and Affordable Care Act (42 U.S.C. 18052), as amended by subsection (a), is further amended in subsection (a)(4)—(1)in subparagraph (A) by striking the period and inserting , except in the case of a waiver described in subsection (f).; and(2)in subparagraph (B)(ii) by inserting after an application the following: (except in the case of a waiver described in subsection (f)).(c)

Appropriation for cost-Sharing payments

Section 1402 of the Patient Protection and Affordable Care Act (42 U.S.C. 18071) is amended by adding at the end the following new subsection:

(g)

Funding

(1)

Appropriations

Out of any funds in the Treasury not otherwise appropriated, there is appropriated such sums as may be necessary to, subject to paragraph (2), provide health benefits coverage through payment to issuers (under this section or through advance payment by the Secretary of the Treasury under section 1412(c)(3)) of the amounts computed under this section for each of plan years 2022 through 2026.(2)

Adjustments

Notwithstanding any other provision of law, payments and other actions for adjustments to obligations incurred prior to December 31, 2022, may be made through December 31, 2022.(3)

Limitation

Amounts appropriated under paragraph (1) for each of plan years 2022 through 2026 are subject to the requirements and limitations under sections 506 and 507 of division H of Public Law 115–31 in the same manner and to the same extent as if such amounts for each such year were appropriated under such division.