[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 4521 Introduced in Senate (IS)]
<DOC>
116th CONGRESS
2d Session
S. 4521
To amend the Patient Protection and Affordable Care Act to reduce
health care costs and expand health care coverage to more Americans.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
August 11, 2020
Mr. Warner introduced the following bill; which was read twice and
referred to the Committee on Finance
_______________________________________________________________________
A BILL
To amend the Patient Protection and Affordable Care Act to reduce
health care costs and expand health care coverage to more Americans.
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 ``Health Care Improvement Act of
2020''.
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--REDUCING HEALTH CARE COSTS AND PROTECTING PEOPLE WITH
PREEXISTING CONDITIONS
Sec. 101. Improving affordability by expanding premium assistance for
consumers.
Sec. 102. Expanding affordability for working families to fix the
family glitch.
Sec. 103. Establishing a State Health Insurance Affordability and
Innovation fund.
Sec. 104. Rescinding the short-term limited duration insurance
regulation.
Sec. 105. Revoking section 1332 guidance.
Sec. 106. Promoting consumer outreach and education.
TITLE II--ENCOURAGING MEDICAID EXPANSION AND STRENGTHENING THE MEDICAID
PROGRAM
Sec. 201. Incentivizing Medicaid expansion.
Sec. 202. Reducing the administrative FMAP for nonexpansion States.
Sec. 203. State option to provide 12 months of postpartum Medicaid
eligibility.
Sec. 204. Supporting State Medicaid programs through economic
downturns.
Sec. 205. State flexibility to use administrative simplification
policies for enrollment.
TITLE III--ESTABLISHMENT OF A PUBLIC HEALTH CARE OPTION
Sec. 301. Establishment of health plan.
Sec. 302. Availability of plan.
Sec. 303. Affordability.
Sec. 304. Participating providers.
Sec. 305. Provider payment rates.
Sec. 306. No effect on Medicare benefits or Medicare trust funds.
TITLE IV--FAIR MEDICARE PAYMENTS TO RURAL PROVIDERS
Sec. 401. Ensuring fairness in Medicare hospital payments.
TITLE V--COMMONSENSE COMPETITION AND ACCESS TO HEALTH INSURANCE
Sec. 501. Providing small business health insurance across State lines.
Sec. 502. Report and models.
TITLE VI--EMPOWERING MEDICARE SENIORS TO NEGOTIATE PRESCRIPTION DRUG
PRICES
Sec. 601. Authority to negotiate fair prices for Medicare prescription
drugs.
TITLE VII--COMMONSENSE REPORTING FOR EMPLOYERS
Sec. 701. Voluntary prospective reporting system.
Sec. 702. Protection of dependent privacy.
Sec. 703. Electronic statements.
Sec. 704. GAO studies.
Sec. 705. Tax Compliance.
TITLE VIII--FEDERAL BAN ON SURPRISE MEDICAL BILLING
Sec. 801. Protection against surprise bills.
TITLE I--REDUCING 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. 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. 103. ESTABLISHING A STATE HEALTH INSURANCE AFFORDABILITY AND
INNOVATION FUND.
Subtitle D of title I of the Patient Protection and Affordable Care
Act (42 U.S.C. 18021 et seq.) is amended by adding at the end the
following:
``PART 6--STATE HEALTH INSURANCE AFFORDABILITY AND INNOVATION FUND
``SEC. 1351. ESTABLISHMENT OF PROGRAM.
``There is hereby established the `State Health Insurance
Affordability and Innovation Fund' to be administered by the Secretary
of Health and Human Services, acting through the Administrator of the
Centers for Medicare & Medicaid Services (referred to in this section
as the `Administrator'), to provide funding, in accordance with this
part, to each of 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.
``(3) 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.
``(4) State investment in technology to improve data
sharing and collection for the purposes of facilitating greater
enrollment in health insurance coverage in such markets.
``(5) Feasibility studies to develop comprehensive and
coherent State plan for increasing enrollment in the individual
and small group market.
``(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. 104. RESCINDING THE SHORT-TERM LIMITED DURATION INSURANCE
REGULATION.
(a) 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. 105. REVOKING SECTION 1332 GUIDANCE.
(a) 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--
(1) 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;
(2) 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;
(3) 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;
(4) 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));
(5) 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; or
(6) 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.
(b) Rule of Construction.--Nothing in subsection (a) 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.
SEC. 106. 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 text:
``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 ``Grants under'' and inserting the
following:
``(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.
TITLE II--ENCOURAGING MEDICAID EXPANSION AND STRENGTHENING THE MEDICAID
PROGRAM
SEC. 201. INCENTIVIZING MEDICAID EXPANSION.
(a) In General.--Section 1905 of the Social Security Act (42 U.S.C.
1396d(y)(1)) is amended--
(1) in subsection (y)(1)--
(A) 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'';
(B) 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'';
(C) 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'';
(D) 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
(E) 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''; and
(2) in subsection (z)(2)(B)(i)(II), by inserting ``(as in
effect on the day before the date of enactment of the Health
Care Improvement Act of 2020)'' after ``subsection (y)(1)''.
(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. 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. 203. STATE OPTION TO PROVIDE 12 MONTHS OF POSTPARTUM MEDICAID
ELIGIBILITY.
(a) Option To Provide 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 inserting ``(or,
at the option of the State, 365-day period)'' after
``60-day period'';
(B) in section 1902(e)(6), by inserting ``(or, at
the option of the State, 365-day period)'' after ``60-
day period'';
(C) in section 1903(v)(4)(A)(i), by inserting
``(or, at the option of the State, 365-day period)''
after ``60-day period''; and
(D) in section 1905(a), in the 4th sentence in the
matter following paragraph (30), by inserting ``(or, at
the option of the State, 365-day period)'' after ``60-
day period''.
(2) CHIP.--Section 2112 of the Social Security Act (42
U.S.C. 1397ll) is amended by inserting ``(or, at the option of
the State, 365-day period)'' after ``60-day period'' each place
it appears.
(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 60-day period (or, at
the option of the State, 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 60-day (or, at
the option of the State, 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 204(d) of the Health Care Improvement Act of 2020,
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 204(d) of the Health Care
Improvement Act of 2020, 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. SUPPORTING STATE MEDICAID PROGRAMS THROUGH ECONOMIC
DOWNTURNS.
(a) In General.--Section 1905 of the Social Security Act (42 U.S.C.
1396d) is amended--
(1) in subsection (b), by striking ``and (ff)'' and
inserting ``(ff), and (gg)''; and
(2) by adding at the end the following new subsection:
``(gg) Increased FMAP During Economic Downturns.--
``(1) In general.--If a fiscal quarter that begins on or
after January 1, 2020, is an economic downturn quarter (as
defined in paragraph (2)) with respect to a State, then the
Federal medical assistance percentage determined for each State
for such quarter under subsection (b) shall be equal to the
percentage determined for the State and quarter under paragraph
(3).
``(2) Economic downturn quarter.--
``(A) In general.--
``(i) In general.--In this subsection, the
term `economic downturn quarter' means, with
respect to a State, a fiscal quarter during
which the State's unemployment rate for the
quarter exceeds the percentage determined for
the State and quarter under clause (ii).
``(ii) Threshold percentage.--The
percentage determined under this clause for a
State and fiscal quarter is the percentage
equal to the lower of--
``(I) the State unemployment rate
at the 20th percentile of the
distribution of the State's quarterly
unemployment rates for the 60-quarter
period preceding the quarter involved,
increased by 1 percentage point; and
``(II) the State's average
quarterly unemployment rate for the 12-
quarter period preceding the quarter
involved, increased by 1 percentage
point.
``(B) Unemployment data.--
``(i) In general.--Except as provided in
clause (ii), for purposes of determining
unemployment rates for a State and a quarter
under this paragraph, the Secretary shall use
data from the Local Area Unemployment
Statistics from the Bureau of Labor Statistics.
``(ii) Application to certain
territories.--In the case of the Virgin
Islands, Guam, the Northern Mariana Islands,
American Samoa, or any other jurisdiction for
which suitable data from the Local Area
Unemployment Statistics from the Bureau of
Labor Statistics are unavailable, the Secretary
shall use data from the U-3 unemployment
measure of the Bureau of Labor Statistics to
make any necessary determinations under
subparagraph (A).
``(3) Increased fmap during economic downturn quarter.--
``(A) In general.--During a fiscal quarter that is
an economic downturn quarter with respect to a State,
the Federal medical assistance percentage for the State
and quarter determined under subsection (b) shall be
equal to--
``(i) the Federal medical assistance
percentage determined for the State and quarter
under subsection (b) without regard to this
subsection (but including any increase to such
percentage for such quarter made pursuant to
section 6008(a) of the Families First
Coronavirus Response Act); increased by
``(ii) the number of percentage points
(rounded to the nearest tenth of a percentage
point) equal to the product of--
``(I) the number of percentage
points (rounded to the nearest tenth of
a percentage point) by which the
unemployment rate for the State and
quarter exceeds the percentage
determined for the State and quarter
under paragraph (2)(A)(ii); and
``(II) 4.8.
``(B) Rules of application.--The following rules
shall apply with respect to the Federal medical
assistance percentage determined for a State and an
economic downturn quarter under this subsection:
``(i) Scope of application.--Such Federal
medical assistance percentage shall not apply
for purposes of--
``(I) disproportionate share
hospital payments described in section
1923;
``(II) payments under part D of
title IV; or
``(III) any payments under this
title that are based on a Federal
medical assistance percentage
determined for a State under subsection
(aa) (but only to the extent that such
Federal medical assistance percentage
is higher than the economic recovery
FMAP).
``(ii) Limitation.--In no case shall--
``(I) the Federal medical
assistance percentage determined for a
State and quarter pursuant to this
subsection exceed 95 percent; or
``(II) any increase to the Federal
medical assistance percentage
determined for a State and quarter
pursuant to this subsection result in
the application of a Federal medical
assistance percentage that exceeds 95
percent.
``(iii) Application to chip.--
Notwithstanding the first sentence of section
2105(b), the application of this subsection may
result in the enhanced FMAP of a State for a
fiscal year under such section exceeding 85
percent, but in no case may the application of
this subsection before application of the
second sentence of such section result in the
enhanced FMAP of the State exceeding 95
percent.
``(4) Advance payment; retrospective adjustment.--
``(A) In general.--Prior to the beginning of each
fiscal quarter that begins on or after July 1, 2020,
the Secretary shall, with respect to each State--
``(i) make an initial determination, based
on the projections made for the State and
quarter under subparagraph (B), as to--
``(I) whether the application of
this subsection is expected to result
in the application of a higher Federal
medical assistance percentage for the
State and quarter than the percentage
that would otherwise apply without
regard to this subsection; and--
``(II) if the application of this
subsection is expected to result in
such a higher Federal medical
assistance percentage for the State and
quarter, what such higher percentage is
expected to be; and
``(ii) if the Secretary determines under
clause (i) that the application of this
subsection is expected to result in the
application of a higher Federal medical
assistance percentage for the State and quarter
than the percentage that would otherwise apply
without regard to this subsection--
``(I) apply such higher Federal
medical assistance percentage of the
State for purposes of making payments
to the State for amounts expended
during such quarter as medical
assistance under the State plan; and
``(II) take into account such
higher Federal medical assistance
percentage of the State for purposes of
calculating the enhanced FMAP for the
State and quarter under section
2105(b).
``(B) Projection of state unemployment rates.--
Prior to the beginning of each fiscal quarter that
begins on or after July 1, 2020, the Secretary, acting
through the Chief Actuary of the Centers for Medicare &
Medicaid Services, shall, using the most recently
available data described in paragraph (2)(B), make
projections with respect to--
``(i) the unemployment rates for each State
for such quarter;
``(ii) the threshold percentages described
in paragraph (2)(A)(ii) for each State for such
quarter; and
``(iii) the national unemployment rate for
such quarter.
``(C) Retrospective adjustment.--As soon as
practicable after final unemployment data becomes
available for a fiscal quarter that begins on or after
July 1, 2020, the Secretary shall, with respect to each
State--
``(i) make a final determination with
respect to the application of this subsection
for purposes of determining the Federal medical
assistance percentage and enhanced FMAP of the
State for the quarter; and
``(ii) in accordance with section
1903(d)(2) and section 2105(e), reduce or
increase the amount payable to the State under
section 1903(a) or section 2105 for a
subsequent fiscal quarter to the extent of any
overpayment or underpayment under either such
section which the Secretary determines was made
as a result of an incorrect initial
determination under subparagraph (A)(i) with
respect to the application of this subsection
for purposes of determining the Federal medical
assistance percentage and enhanced FMAP of the
State for such prior fiscal quarter.
``(5) Retrospective application of over-the-limit fmap
increases.--
``(A) In general.--If a State has excess percentage
points with respect to an economic downturn quarter and
an applicable FMAP (as determined under subparagraph
(B)), the State may elect to apply such excess
percentage points to increase such applicable FMAP for
one or more quarters during the look-back period for
the State and economic downturn quarter in accordance
with this paragraph.
``(B) Excess percentage points.--For purposes of
this paragraph, the number of excess percentage points
for a State, economic downturn quarter, and an
applicable FMAP shall be equal to the number of
percentage points by which--
``(i) the applicable FMAP for the State and
quarter (after application of paragraph (3) but
without regard to subparagraph (B)(ii) of such
paragraph); exceeds
``(ii) 95 percent.
``(C) Effect of application of excess percentage
points.--If a State elects to apply excess percentage
points to an applicable FMAP to a quarter during a
look-back period under this paragraph, the Secretary
shall determine the additional amount of payment under
section 1903(a) to which the State would have been
entitled for such quarter if the applicable FMAP (as so
increased) had been in effect for such quarter, and
shall treat such additional amount as an underpayment
for such quarter.
``(D) Distribution of excess percentage points.--A
State that has excess percentage points with respect to
an economic downturn quarter and applicable FMAP may
elect to divide such points among more than 1 quarter
during the look-back period for such State and quarter
provided that no excess percentage point (or fraction
of an excess percentage point) is applied to the
applicable FMAP of more than 1 quarter.
``(E) Limitations.--
``(i) No increases over 100 percent.--A
State may not increase an applicable FMAP for
any quarter during a look-back period under
this paragraph if such increase would result in
the applicable FMAP for such quarter exceeding
100 percent.
``(ii) Scope of application.--Any increase
to an applicable FMAP of a State for a fiscal
quarter under this paragraph--
``(I) shall only apply with respect
to payments for amounts expended by the
State for medical assistance for
services furnished during such quarter
to which such applicable FMAP is
applicable; and
``(II) shall not apply with respect
to payments described in paragraph
(3)(B)(i).
``(F) Definitions.--In this paragraph:
``(i) Applicable fmap.--The term
`applicable FMAP' means, with respect to a
State and fiscal quarter--
``(I) the Federal medical
assistance percentage determined for
the State and quarter under subsection
(b);
``(II) the Federal medical
assistance percentage applicable under
subsection (y);
``(III) the Federal medical
assistance percentage applicable under
subsection (z)(2);
``(IV) the Federal medical
assistance percentage determined for
the State and quarter under subsection
(ff); or
``(V) the enhanced FMAP determined
for the State and quarter under section
2105(b).
``(ii) Look-back period.--The term `look-
back period' means, with respect to a State and
a fiscal quarter that is an economic downturn
quarter for the State, the period of 4 fiscal
quarters that ends with the fourth quarter
which precedes the most recent fiscal quarters
that was not an economic downturn quarter for
the State.
``(6) Requirement for all states.--This subsection shall
not apply to a State with respect to a fiscal quarter, if--
``(A) eligibility standards, methodologies, or
procedures under the State plan or a waiver of such
plan are more restrictive during such quarter than the
eligibility standards, methodologies, or procedures,
respectively, under such plan (or waiver) as in effect
on the last day of the most recent fiscal quarter that
was not an economic downturn quarter for the State;
``(B) the amount of any premium imposed by the
State pursuant to section 1916 or 1916A during such
quarter, with respect to an individual enrolled under
such plan (or waiver), exceeds the amount of such
premium as of the date described in subparagraph (A);
or
``(C) the State fails to provide that an individual
who is enrolled for benefits under such plan (or
waiver) as of the date described in subparagraph (A) or
enrolls for benefits under such plan (or waiver) during
the period beginning with such date and ending with the
day before the first day of the next quarter that is
not an economic downturn quarter for the State shall be
treated as eligible for such benefits for not less than
12 months after such date or (if later) the date that
such individual so enrolls unless the individual
requests a voluntary termination of eligibility or the
individual ceases to be a resident of the State.''.
(b) Exclusion of Economic Downturn FMAP Increases From Territorial
Caps; Special Rule for CHIP Allotments.--
(1) Exclusion from territorial caps.--Section 1108 of the
Social Security Act (42 U.S.C. 1308) is amended--
(A) in subsection (f), in the matter preceding
paragraph (1), by striking ``subsection (g) and section
1935(e)(1)(B)'' and inserting ``subsections (g) and (h)
and section 1935(e)(1)(B)''; and
(B) by adding at the end the following:
``(h) Exclusion From Caps of Amounts Attributable to Economic
Downturn FMAP.--Any payment made to a territory for a fiscal year in
which the Federal medical assistance percentage for the territory is
determined under section 1905(gg) shall not be taken into account for
purposes of applying payment limits under subsections (f) and (g) to
the extent that such payment exceeds the amount of the payment that
would have been made to the territory for the year if the Federal
medical assistance percentage for the territory had been determined
without regard to such section.''.
(2) CHIP allotments.--Section 2104(m) of the Social
Security Act (42 U.S.C. 1397dd(m)) is amended--
(A) in paragraph (2)(B), in the matter preceding
clause (i), by striking ``paragraphs (5) and (7)'' and
inserting ``paragraphs (5), (7), and (12)''; and
(B) by adding at the end the following new
paragraph:
``(12) Special rule for adjusting allotments during fiscal
years with economic downturn quarters.--
``(A) In general.--If a fiscal quarter occurring
during fiscal year 2020 or any succeeding fiscal year
is determined to be an economic downturn quarter with
respect to a State (as determined under section
1905(gg)) then, as soon as practicable after such
determination, the Secretary shall increase the
allotment for the State and fiscal year in accordance
with subparagraph (B).
``(B) Amount of increase.--
``(i) In general.--The amount of an
increase to the allotment of a State described
in subparagraph (A) for a fiscal year shall be
equal to the amount by which Federal payments
made to the State for the preceding fiscal year
under this title would have been increased
(without regard to whether such payments would
exceed the amount of the State's allotment for
such preceding fiscal year) if the enhanced
FMAP determined for the State for such
preceding fiscal year had been increased to the
same extent that the State's enhanced FMAP for
the fiscal year involved is expected to be
increased as a result of the application of
section 1905(gg) relative to the enhanced FMAP
that would apply to the State for the fiscal
year involved without the application of such
section.
``(ii) Inclusion of projected increases.--
In increasing the allotment of a State for a
fiscal year under this paragraph, the Secretary
may base the calculation of such increase on
projections made by the Secretary with respect
to--
``(I) the number of fiscal quarters
during such fiscal year that will be
economic downturn quarters; and
``(II) the effect that the
application of section 1905(gg) is
expected to have on the enhanced FMAP
of the State for such fiscal year.
``(C) Disregard of increased payments for purposes
of future allotments.--Any Federal payment made to a
State under this title for a fiscal year in which the
Federal medical assistance percentage for the State is
determined under section 1905(gg) shall be disregarded
when determining the allotment of the State for any
subsequent year, including for purposes of applying
this paragraph, to the extent that such payment exceeds
the amount of the payment that would have been made to
the State for the year if the Federal medical
assistance percentage for the State and year had been
determined without regard to such section.''.
SEC. 205. STATE FLEXIBILITY TO USE ADMINISTRATIVE SIMPLIFICATION
POLICIES FOR ENROLLMENT.
(a) Permanent Extension of Medicaid and CHIP Express Lane Option.--
Section 1902(e)(13) of the Social Security Act (42 U.S.C. 1396a(e)(13))
is amended by striking subparagraph (I).
(b) Extending Express Lane Eligibility to Adults.--Section
1902(e)(13)(A) of the Social Security Act (42 U.S.C. 1396a(e)(13)(A))
is amended by adding at the end the following new clause:
``(iii) State option to extend express lane
eligibility to adults.--
``(I) In general.--At the option of
the State, the State may apply the
provisions of this paragraph with
respect to determining eligibility
under this title for an eligible
individual (as defined in subclause
(II)). In applying this paragraph in
the case of a State making such an
option, any reference in this paragraph
to a child with respect to this title
(other than a reference to child health
assistance) shall be deemed to be a
reference to an eligible individual.
``(II) Eligible individual
defined.--In this clause, the term
`eligible individual' means--
``(aa) any individual
(other than a child) whose
income eligibility under the
State plan or under a waiver of
the plan for medical assistance
is determined under paragraph
(14); and
``(bb) an individual
included in any other group of
individuals the Secretary
determines appropriate.''.
(c) Consent by Benefit Utilization.--Section 1902(e)(13)(D)(i) of
the Social Security Act (42 U.S.C. 1396a(e)(13)(D)(i)) is amended by
inserting ``by using medical assistance to access care,'' after
``through electronic signature,''.
(d) Study and Report on Options for Automatic Enrollment in
Medicaid and CHIP.--
(1) Study.--The Secretary of Health and Human Services, by
grant, contract, or interagency agency, shall conduct a study
to identify options for, and barriers to, States automatically
enrolling individuals who, on the basis of data and information
from income tax returns and other sources, are likely to be
eligible for medical assistance under the State Medicaid plan
established under title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) (or a waiver of such plan) or for child
health assistance (or, if applicable, pregnancy-related
assistance) under the State child health plan established under
title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.)
(or a waiver of such plan), and would not be required to pay a
premium for enrollment in such a plan or waiver.
(2) Report.--Not later than 1 year after the date of
enactment of this Act, the Secretary of Health and Human
Services shall submit a report to Congress on the results of
the study conducted under subsection (a). The report shall
include the following:
(A) An analysis of the financial, regulatory, and
legislative barriers that limit the ability of States
to implement automatic enrollment for individuals
described in subsection (a).
(B) An analysis of the extent to which State
implementation of automatic enrollment for such
individuals would reduce the number of uninsured
individuals in each State.
(C) Recommendations for administrative and
legislative actions that, if taken, would eliminate the
barriers identified under subparagraph (A) and allow
States to elect to automatically enroll individuals
described in subsection (a) in the State Medicaid plan
established under title XIX of the Social Security Act
(42 U.S.C. 1396 et seq.) (or a waiver of such plan) or
for child health assistance (or, if applicable,
pregnancy-related assistance) under the State child
health plan established under title XXI of the Social
Security Act (42 U.S.C. 1397aa et seq.) (or a waiver of
such plan).
TITLE III--ESTABLISHMENT OF A PUBLIC HEALTH CARE OPTION
SEC. 301. ESTABLISHMENT OF HEALTH PLAN.
(a) In General.--The Secretary shall establish a coordinated and
low-cost health plan (referred to in this section as the ``health
plan'') to provide access to quality health care for enrollees.
(b) Individual Market Availability.--The Secretary shall make the
health plan available in the individual market for plan year 2022 and
each subsequent plan year.
(c) Rulemaking.--The Secretary may promulgate such regulations as
may be necessary to carry out this title.
(d) Authorization of Appropriations.--There are authorized to be
appropriated such sums as may be necessary to carry out this title.
SEC. 302. AVAILABILITY OF PLAN.
(a) Eligibility.--An individual shall be eligible to enroll in the
health plan if such individual, for the entire period for which
enrollment is sought--
(1) is a qualified individual within the meaning of section
1312 of the Patient Protection and Affordable Care Act (42
U.S.C. 18032);
(2) is not eligible for benefits under the Medicare program
under title XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.); and
(3) is not otherwise eligible for, or has been otherwise
offered, employer-sponsored health care coverage.
(b) Exchanges.--The health plan shall be made available through the
Exchanges, including the Small Business Health Options Program
Exchange.
SEC. 303. AFFORDABILITY.
The Secretary shall ensure that coverage options for the health
plan are not more costly than comparable options offered on the
Exchange in the applicable market.
SEC. 304. PARTICIPATING PROVIDERS.
(a) Requirement To Participate in Order To Be Enrolled Under
Medicare.--Beginning January 1, 2021, the Secretary may require a
health care provider enrolled under the Medicare program under section
1866(j) of the Social Security Act (42 U.S.C. 1395cc(j)) to be a
participating provider under the health plan.
(b) Requirement To Participate in Order To Participate in
Medicaid.--Beginning January 1, 2021, the Secretary may require a
health care provider under a State Medicaid plan under title XIX of the
Social Security Act (42 U.S.C. 1396 et seq.) to also be a participating
provider under the health plan.
SEC. 305. PROVIDER PAYMENT RATES.
The Secretary shall set competitive provider payment rates under
the health plan using the best information publically available and
data otherwise accessible to the Secretary. The Secretary shall give
consideration to existing provider payment rates for commercial health
plans and provider costs to deliver care, giving special consideration
to increased costs for providers to deliver care in rural and medically
underserved areas.
SEC. 306. NO EFFECT ON MEDICARE BENEFITS OR MEDICARE TRUST FUNDS.
Nothing in this title shall--
(1) affect the benefits available under title XVIII of the
Social Security Act (42 U.S.C. 1395 et seq.); or
(2) impact the Federal Hospital Insurance Trust Fund under
section 1817 of the Social Security Act (42 U.S.C. 1395i) or
the Federal Supplementary Medical Insurance Trust Fund under
section 1841 of the Social Security Act (42 U.S.C. 1395t)
(including the Medicare Prescription Drug Account within such
Trust Fund).
TITLE IV--FAIR MEDICARE PAYMENTS TO RURAL PROVIDERS
SEC. 401. ENSURING FAIRNESS IN MEDICARE HOSPITAL PAYMENTS.
(a) Hospital Inpatient Services.--
(1) In general.--Section 1886(d)(3)(E)(i) of the Social
Security Act (42 U.S.C. 1395www(d)(3)(E)) is amended--
(A) in clause (i), in the first sentence, by
striking ``or (iii)'' and inserting ``, (iii), or
(iv)''; and
(B) by adding at the end the following new clause:
``(iv) Area wage index floor.--
``(I) In general.--For discharges
occurring on or after October 1, 2020,
the area wage index applicable under
this subparagraph to any hospital which
is not located in a frontier State (as
defined in clause (iii)(II)) may not be
less than 0.85.
``(II) Waiving budget neutrality.--
Pursuant to the fifth sentence of
clause (i), this clause shall not be
applied in a budget neutral manner.''.
(2) Waiving budget neutrality.--
(A) Technical amendatory correction.--Section
10324(a)(2) of Public Law 111-148 is amended by
striking ``third sentence'' and inserting ``fifth
sentence''.
(B) Waiver.--Section 1886(d)(3)(E)(i) of the Social
Security Act (42 U.S.C. 1395ww(d)(3)(E)(i)) is amended,
in the fifth sentence--
(i) by striking ``and the amendments'' and
inserting ``, the amendments''; and
(ii) by inserting ``, and the amendments
made by section 401(a)(1) of the Health Care
Improvement Act of 2020'' after ``Care Act''.
(b) Hospital Outpatient Department Services.--Section 1833(t) of
the Social Security Act (42 U.S.C. 1395l(t)), is amended--
(1) in paragraph (2)(D), by striking ``(19), the
Secretary''and inserting ``(19) and paragraph (23), the
Secretary''; and
(2) by adding at the end the following new paragraph:
``(23) Floor on area wage adjustment factor for hospital
outpatient department services.--With respect to covered OPD
services furnished on or after January 1, 2021, the area wage
adjustment factor applicable under the payment system
established under this subsection to any hospital outpatient
department which is not located in a frontier State (as defined
in section 1886(d)(3)(E)(iii)(II)) may not be less than 0.85.
The preceding sentence shall not be implemented in a budget
neutral manner.''.
TITLE V--COMMONSENSE COMPETITION AND ACCESS TO HEALTH INSURANCE
SEC. 501. PROVIDING SMALL BUSINESS HEALTH INSURANCE ACROSS STATE LINES.
Section 1333(a)(1)(A) of the Patient Protection and Affordable Care
Act (42 U.S.C. 18053(a)(1)(A)) is amended by inserting ``and small
group markets'' after ``individual markets''.
SEC. 502. REPORT AND MODELS.
Section 1333 of the Patient Protection and Affordable Care Act (42
U.S.C. 18053) is amended by adding at the end the following:
``(b) NAIC Report and Models.--
``(1) In general.--Not later than December 31, 2021, the
Secretary shall request that the National Association of
Insurance Commissioners submit to the Secretary a report
concerning health plans provided for under this section. Such
report shall include--
``(A) a description of the challenges that States
would face by permitting issuers of qualified health
plans to offer such plans in States other than those
States where such plan was originally written or
issued;
``(B) an assessment of how an out-of-State insurer
would go about building an adequate provider network;
``(C) a description of how such challenges could be
lessened without weakening the enforcement of laws and
regulations described in subsection (a)(1)(B)(i) in any
State that is included in a compact under this section;
``(D) a description of the commonalities that exist
in State laws and opportunities to allow issuers of
qualified health plans to offer such plans in States
other than those States where such plan was originally
written or issued; and
``(E) models to be used by States to establish and
enter into interstate health care choice compacts under
this section, which--
``(i) may include model legislation for use
by States to enact laws to enter into such
compacts;
``(ii) shall identify how States would
continue to enforce, and not weaken, the laws
and regulations described in subsection
(a)(1)(B)(i) in any State that is included in
such compact; and
``(iii) shall identify how such models
would ensure that there is no violation of the
conditions for Secretarial approval under
subsection (a)(3).
``(2) Other organizations and entities.--In making the
request under paragraph (1), the Secretary may also request
that the National Association of Insurance Commissioners gather
concepts for inclusion in the report under such paragraph from
organizations and entities that have experience in offering
qualified health plans in States in which such plans were not
originally issued.''.
TITLE VI--EMPOWERING MEDICARE SENIORS TO NEGOTIATE PRESCRIPTION DRUG
PRICES
SEC. 601. AUTHORITY TO NEGOTIATE FAIR PRICES FOR MEDICARE PRESCRIPTION
DRUGS.
(a) In General.--Section 1860D-11 of the Social Security Act (42
U.S.C. 1395w-111) is amended by striking subsection (i).
(b) Effective Date.--The amendment made by this section shall take
effect on the date of the enactment of this Act.
TITLE VII--COMMONSENSE REPORTING FOR EMPLOYERS
SEC. 701. VOLUNTARY PROSPECTIVE REPORTING SYSTEM.
(a) In General.--Not later than 1 year after the date of the
enactment of this Act, the Secretary of the Treasury, in consultation
with the Secretary of Health and Human Services, the Secretary of
Labor, and the Administrator of the Small Business Administration,
shall develop and implement guidance providing for a prospective
reporting system meeting the requirements of subsection (b). Such
system shall be available for use by employers on a voluntary basis
beginning not later than January 1, 2021.
(b) Requirements.--The system created under subsection (a) shall
include--
(1) voluntary reporting by each participating employer that
offers minimum essential coverage to its full-time employees
and their dependents under an eligible employer-sponsored plan,
not later than 45 days before the first day of the annual open
enrollment period under section 1311(c)(6)(B) of the Patient
Protection and Affordable Care Act (42 U.S.C. 18031(c)(6)(B))
for each calendar year, of--
(A) the name and employer identification number for
purposes of section 6056 of the Internal Revenue Code
of 1986 of the employer;
(B) a certification of--
(i) whether coverage meeting the definition
of minimum essential coverage in section
5000A(f) of the Internal Revenue Code of 1986
is offered to the full-time employees (within
the meaning of section 4980H of such Code) of
the employer;
(ii) whether such coverage is offered to
part-time employees of the employer;
(iii) whether such coverage is offered to
dependents of employees;
(iv) whether such coverage is offered to
spouses of employees;
(v) whether such coverage meets the minimum
value requirement of section 36B(c)(2)(C)(ii)
of such Code;
(vi) whether such coverage satisfies the
requirements to qualify for one of the
affordability safe harbors promulgated by the
Secretary of the Treasury for purposes of
section 4980H of such Code; and
(vii) whether the employer reasonably
expects to be liable for any shared
responsibility payment under section 4980H of
such Code for such year;
(C) the months during the prospective reporting
period that such coverage is available to individuals
described in clauses (i) through (iv) of subparagraph
(B);
(D) what waiting periods, if any, apply with
respect to such coverage; and
(E) a list of all employer identification numbers
of the employer for entities that employ employees
within the employers control group under subsection
(b), (c), (m), or (o) of section 414 of the Internal
Revenue Code for 1986;
(2) processes necessary to ensure that Exchanges, the
Federal Marketplace Data Services Hub, and the Internal Revenue
Service can securely and confidentially access the information
described in paragraph (1) as necessary to carry out their
respective missions, and to provide to the Secretary of Health
and Human Services additional information relating to
eligibility determinations for advance payment of the premium
tax credits under section 36B of such Code and the cost-sharing
subsidies under section 1402 of the Patient Protection and
Affordable Care Act (42 U.S.C. 18071);
(3) a process to allow Exchanges to follow up with
employers in order to obtain additional reasonably necessary
information relating to an employee's eligibility for such
advance payment or such cost-sharing subsidies, and to allow an
employee to receive notification of any problem in verifying
such eligibility; and
(4) a process to allow employers using the system to
provide timely updates to the Federal Marketplace Data Services
Hub regarding any cancellation of coverage or significant
change in coverage for participating employees that would
change the information reported under paragraph (1).
(c) Employer Notification of Employee Enrollment in Exchange
Plans.--Subparagraph (J) of section 1311(d)(4) of the Patient
Protection and Affordable Care Act (42 U.S.C. 18031(d)(4)(J)) is
amended by striking ``to each employer'' and all that follows through
``(and the effective date of such cessation); and'' and inserting ``to
each employer--
``(i) the name of each employee of the
employer who enrolls in a qualified health plan
for a plan year, or whose dependents enroll in
such a plan, at the time of such enrollment; or
``(ii) the name of each employee of the
employer described in subparagraph (I)(ii) who
ceases coverage under a qualified health plan
during a plan year (and the effective date of
such cessation); and''.
(d) Exemption From Reporting Requirement Under Internal Revenue
Code of 1986.--Section 6056 of the Internal Revenue Code of 1986 is
amended by redesignating subsection (f) as subsection (g) and by
inserting after subsection (e) the following new subsection:
``(f) Exemption.--If, through the system created pursuant to
section 701(a) of the Health Care Improvement Act of 2020, an employer
provides prospective reporting for any calendar year that meets the
requirements of section 701(b)(1) of such Act--
``(1) such employer shall be treated as satisfying the
return requirements of subsections (a) and (b) for such year;
and
``(2) such employer shall be treated as satisfying the
requirements of subsection (c) for such year if the employer--
``(A) furnishes the statement described in such
section to those employees of the employer whose names
have been provided to the employer by an Exchange under
section 1311(d)(4)(J)(i) of the Patient Protection and
Affordable Care Act regarding enrollment of the
employee or a dependent in a qualified health plan (as
defined in section 1301 of such Act) through the
Exchange; and
``(B) furnishes a copy of such statement with
respect to such employees to the Secretary.''.
(e) Third-Party Filing.--An employer may contract with a third
party to make the report under subsection (b)(1) without affecting the
employer's treatment as having satisfied the return requirements of
subsections (a) and (b) of section 6056 of the Internal Revenue Code of
1986.
(f) Access to the National Directory of New Hires.--Subsection
(i)(3) of section 453 of the Social Security Act (42 U.S.C. 653) is
amended by adding at the end the following new sentence: ``The
Secretary of the Treasury and the Secretary of Health and Human
Services shall have access to the information in the National Directory
of New Hires for purposes of administering section 36B and 4980H of the
Internal Revenue Code of 1986 and section 1402 of the Patient
Protection and Affordable Care Act (42 U.S.C. 18071). Subsection (k)(3)
shall not apply to information received for purposes of the
administration of such sections 36B and 4980H of such Code and section
1402 of such Act.''.
(g) Improving Employee Access to Accurate EINs.--Not later than 1
year after the date of the enactment of this Act, the Secretary of the
Treasury shall develop and implement guidance for allowing any employee
of an employer to receive, on request, the employer's employer
identification number for purposes of section 6056 of the Internal
Revenue Code of 1986. Employers shall provide the employer's employer
identification number for purposes of section 6056 of the Internal
Revenue Code of 1986 on one of the following documents of the
employer's election:
(1) Health Insurance Marketplace Coverage Options Notice
required under section 18B of the Fair Labor Standards Act.
(2) Summary of Benefits and Coverage described in section
2715 of the Patient Protection and Affordable Care Act (42
U.S.C. 18071).
(3) Marketplace Employer Coverage tool.
(4) Annual benefits enrollment materials distributed to
employees, including through an intranet or an online portal
accessible by employees.
(5) Employee pay statements or Form W-2.
(h) Funding for Voluntary Prospective Reporting System.--It is the
sense of Congress that building and maintaining the voluntary
prospective reporting system described in this section will require
appropriations to the Secretary of the Treasury, the Secretary of
Health and Human Services, the Secretary of Labor, and the
Administrator of the Small Business Administration, and that necessary
sums to carry out the requirements of this section should be
appropriated for such purpose.
SEC. 702. PROTECTION OF DEPENDENT PRIVACY.
(a) In General.--Paragraph (1) of section 6055(b) of the Internal
Revenue Code of 1986 is amended by adding at the end the following
flush sentence:
``For purposes of subparagraph (B)(i), in the case of an individual
other than the primary insured, if the health insurance issuer or the
employer is unable to collect or maintain information on the TINs of
such individuals (other than for purposes of this section), the
Secretary may allow the individual's full name and date of birth to be
substituted for the name and TIN. In the event the Secretary allows the
use of the individual's full name and date of birth in lieu of the TIN,
the Social Security Administration shall assist the Internal Revenue
Service in providing data matches to determine the TIN associated with
the name and date of birth provided by the Internal Revenue Service
with respect to such individual.''.
(b) Effective Date.--The amendment made by this section shall apply
to returns the due date for which is after the date that is 60 days
after the date of the enactment of this Act.
SEC. 703. ELECTRONIC STATEMENTS.
(a) In General.--Subsection (c) of section 6056 of the Internal
Revenue Code of 1986 is amended by adding at the end the following new
paragraph:
``(3) Electronic delivery.--An individual shall be deemed
to have consented to receive the statement under this
subsection in electronic form if such individual has
affirmatively consented at any prior time, to the person who is
the employer of the individual during the calendar year to
which the statement relates, to receive such statement in
electronic form. The preceding sentence shall not apply if the
individual revokes consent in writing with respect to the
statement under this subsection.''.
(b) Statements Relating to Health Insurance Coverage.--Subsection
(c) of section 6055 of the Internal Revenue Code of 1986 is amended by
adding at the end the following new paragraph:
``(3) Electronic delivery.--An individual shall be deemed
to have consented to receive the statement under this
subsection in electronic form if such individual has
affirmatively consented at any prior time, to the person
required to make such statement (such as the provider of the
individual's health coverage), to receive in electronic form
any private health information (such as electronic health
records), unless the individual revokes such consent in
writing.''.
(c) Effective Date.--The amendments made by this section shall
apply to statements the due date for which is after December 31, 2019.
SEC. 704. GAO STUDIES.
(a) Study of First Years of Employer Reporting.--
(1) In general.--The Comptroller General of the United
States shall conduct a study that evaluates, with respect to
the period beginning on January 1, 2015, and ending on December
31, 2018--
(A) the notification of employers by Exchanges
established under title I of the Patient Protection and
Affordable Care Act (Public Law 111-148) that a full-
time employee of the employer has been determined
eligible for advance payment of premium tax credits
under section 36B of the Internal Revenue Code of 1986
or cost-sharing subsidies under section 1402 of such
Act (42 U.S.C. 18071), including information
regarding--
(i) the data elements included in the
employer notification;
(ii) the process by which the notification
forms were developed and sent to employers,
including whether the process provided for a
formal notice and comment period;
(iii) whether employers report that such
notifications provided sufficient and relevant
information for them to make appropriate
decisions about whether to utilize the appeals
process;
(iv) the total number of notifications sent
to employers and the timeline of when such
notifications were sent;
(v) differences in the notification process
between the marketplace facilitated by the
Federal Government and the State-Based
Marketplaces; and
(vi) challenges that have arisen in the
notification process, and recommendations to
address these challenges; and
(B) the extent to which the Secretary of Health and
Human Services has established a separate appeals
process for employers who received such a notification
to challenge the eligibility determination, as required
by section 1411(f)(2) of the Patient Protection and
Affordable Care Act (42 U.S.C. 18081(f)(2)).
(2) Report.--Not later than 1 year after the date of the
enactment of this Act, the Comptroller General shall submit to
the Committees on Finance and Health, Education, Labor, and
Pensions of the Senate and the Committees on Ways and Means,
Energy and Commerce, and Education and Labor of the House of
Representatives a report on the results of the study conducted
under paragraph (1).
(b) Study of Prospective Reporting System.--
(1) In general.--The Comptroller General of the United
States shall conduct a study that evaluates, with respect to
the period beginning on January 1, 2020, and ending on December
31, 2020, the functionality of the prospective reporting system
established pursuant to section 701, including the accuracy of
information collected, the number of employers electing to
report under such system, and any challenges that have arisen
in implementing such system.
(2) Report.--Not later than July 1, 2021, the Comptroller
General shall submit to the Committees on Finance and Health,
Education, Labor, and Pensions of the Senate and the Committees
on Ways and Means, Energy and Commerce, and Education and Labor
of the House of Representatives a report on the results of the
study conducted under paragraph (1).
SEC. 705. TAX COMPLIANCE.
(a) In General.--Section 6724(d)(1)(B)(xxv) of the Internal Revenue
Code of 1986 is amended by inserting ``or, in the case of an employer
to which section 6056(f) applies, section 701(b)(1) of the Health Care
Improvement Act of 2020'' before ``, or''.
(b) Effective Date.--The amendment made by this section shall apply
to returns required to be filed after the date of the enactment of this
Act.
TITLE VIII--FEDERAL BAN ON SURPRISE MEDICAL BILLING
SEC. 801. PROTECTION AGAINST SURPRISE BILLS.
(a) PHSA.--Section 2719A of the Public Health Service Act (42
U.S.C. 300gg-19a) is amended by adding at the end the following:
``(e) Out-of-Network Ancillary Services.--
``(1) Coverage of services.--Subject to subsection (h), in
the case of an enrollee in a group health plan or group or
individual health insurance coverage who receives out-of-
network ancillary services at an in-network facility, including
any referrals for diagnostic services, and such services would
be covered under such plan or coverage if provided in-network--
``(A) the cost-sharing requirement (expressed as a
copayment amount, coinsurance rate, or deductible) with
respect to such services shall be the same requirement
that would apply if such services were provided by an
in-network practitioner, and any coinsurance or
deductible shall be based on in-network rates; and
``(B) amounts paid toward such cost-sharing shall
be counted towards the in-network deductible and in-
network out-of-pocket maximum amount, as applicable,
under the plan or coverage for the plan year.
``(2) Notice before providing non-emergency services.--
Subject to subsection (h), in the case of an enrollee in a
group health plan or group or individual health insurance
coverage who receives out-of-network, non-emergency services
that are not ancillary services, from an out-of-network
provider at an in-network facility, and such services would be
covered under such plan or coverage if provided in-network, the
cost-sharing requirement (expressed as a copayment amount,
coinsurance rate, or deductible) with respect to such services
shall be the same requirement that would apply if such services
were provided by an in-network practitioner, and any
coinsurance or deductible shall be based on in-network rates,
unless, as soon as practicable, and in no case later than 48
hours prior to providing non-emergency services that are not
ancillary services--
``(A) the in-network facility provides to the
enrollee who is scheduled to receive such services
notice that--
``(i) is provided in paper or electronic
form (and including electronic notification
whenever practicable);
``(ii) states that such service will be
provided out-of-network;
``(iii) includes the estimated amount that
such practitioner or facility may charge the
enrollee for such services; and
``(iv) provides the option to affirmatively
consent to receiving such services from such
practitioner or facility;
``(B) such enrollee signs such notice consenting to
receive such services from an out-of-network provider
at an in-network facility, and acknowledging that the
out-of-network services may be covered at an out-of-
network cost-sharing amount, requiring higher cost-
sharing obligations of the enrollee than if the service
were provided by an in-network practitioner or
facility; and
``(C) such facility maintains documentation of the
enrollee's signature or confirmation of receipt of such
information under subparagraph (B) in the enrollee's
patient record for 2 years after the date of services.
``(f) Coverage of Out-of-Network Services for Enrollees Admitted
After Emergency Services.--
``(1) Protection for enrollees admitted to the hospital for
emergency services prior to stabilization.--In the case of an
enrollee in a group health plan or group or individual health
insurance coverage who receives emergency services, or maternal
care for a woman in labor, in the emergency department of an
out-of-network facility and has not been stabilized (within the
meaning of subsection (b)(2)(C)), if the patient is
subsequently admitted to the out-of-network facility for care,
the cost-sharing requirement (expressed as a copayment amount,
coinsurance rate, or deductible) with respect to any out-of-
network services provided to the enrollee prior to being stable
and in a condition to receive information under (2), is the
same requirement that would apply as under subsection
(b)(2)(C)(ii)(II).
``(2) Notice and consent.--
``(A) In general.--Subject to subsection (h), in
the case of an enrollee in a group health plan or group
or individual health insurance coverage who receives
emergency services, or maternal care for a woman in
labor, in the emergency department of an out-of-network
facility and has been stabilized (within the meaning of
subsection (b)(2)(C)), if the patient is subsequently
admitted to the out-of-network facility for care, the
cost-sharing requirement (expressed as a copayment
amount, coinsurance rate, or deductible) with respect
to any out-of-network services is the same requirement
that would apply if such services were provided by an
in-network provider, unless the enrollee, once stable
and in a condition to receive such information,
including having sufficient mental capacity--
``(i) has been provided by the facility,
prior to the provision of any post-
stabilization, out-of-network service at such
facility, with--
``(I) paper or electronic
notification that the practitioner or
facility is an out-of-network health
care provider and the out-of-network
rate of the provider, as applicable,
and the option to affirmatively consent
to receiving services from such
practitioner or facility; and
``(II) the estimated amount that
such provider may charge the
participant, beneficiary, or enrollee
for such services involved;
``(ii) has been provided by the plan or
coverage, prior to the provision of any post-
stabilization, out-of-network service at such
facility, with--
``(I) paper or electronic
notification (and including electronic
notification whenever practicable) that
the practitioner or facility is an out-
of-network health care provider, and
the option to affirmatively consent to
receiving services from such
practitioner or facility;
``(II) a list of in-network
practitioners or facilities in the
relevant geographic area that could
provide the same services, and an
option for a referral to such
providers; and
``(III) information about whether
prior authorization or other care
management limitations may be required
in advance of receiving in-network
services at the facility; and
``(iii) has acknowledged, in writing, that
the out-of-network services provided after the
individual has been stabilized may not be
covered or may be covered at an out-of-network
cost-sharing amount, requiring higher cost-
sharing obligations of the enrollee than if the
service were provided at an in-network
facility.
``(B) Requirements of notice.--The notice under
subparagraph (A) shall be in a format determined by the
Secretary to give a reasonable layperson clear
comprehension of the terms of the agreement, including
all possible financial responsibilities, including the
requirements that the notice--
``(i) does not exceed one page in length;
``(ii) is readily identifiable for its
purpose and as a contract of consent;
``(iii) clearly states that consent to
potential out-of-network charges is optional
and that the enrollee has the choice to
transfer to an in-network facility;
``(iv) includes an estimate of the amount
that such provider will charge the participant,
beneficiary, or enrollee for such services
involved; and
``(v) be available in the 15 most common
languages in the facility's geographic area,
with the facility making a good faith effort to
provide oral notice in the enrollee's primary
language if it is not one of such 15 languages.
``(C) Maintenance of records.--A facility shall
maintain documentation of notice given to an enrollee
pursuant to this subsection and the enrollee's
confirmation of receipt of such information in the
enrollee's patient record for 2 years after the date of
services.
``(3) Rulemaking.--Not later than 6 months after the date
of enactment of this subsection, the Secretary shall issue
regulations to carry out this subsection, which shall include
clarification on how to determine whether an individual is
stabilized and the timing of the notice required under this
paragraph.
``(g) Prohibition on Billing More Than an In-Network Rate Under
Certain Circumstances.--
``(1) In general.--A facility or practitioner furnishing--
``(A) emergency services, as defined in subsection
(b)(2), regardless of the State in which the patient
resides;
``(B) out-of-network services at an in-network
facility described in subsection (e)(1);
``(C) out-of-network services at an in-network
facility described in subsection (e)(2), where the
notice and consent for receiving such services out-of-
network did not meet the requirement of such
subsection;
``(D) services furnished by an out-of-network
provider after an enrollee has been admitted to the
hospital for emergency services but prior to
stabilization, as described in subsection (f)(1); or
``(E) out-of-network services furnished after the
enrollee has been stabilized (within the meaning of
subsection (b)(2)(C)), where the notice and option for
receiving care at an alternate facility required under
subsection (f)(2) have not been provided to the
enrollee and the enrollee did not give consent under
subsection (f)(3),
may not bill an enrollee in a group health plan or group or
individual health insurance coverage for amounts beyond the
cost-sharing amount that would apply under subsection
(b)(1)(C)(ii)(II), (e)(1), (e)(2), or (f), as applicable.
``(2) Notice.--A facility furnishing services described in
paragraph (1) shall provide enrollees in a group health plan or
group or individual health insurance coverage with a one-page
notice, in 16-point font, upon intake at the emergency room or
being admitted at the facility of the prohibition on balance
billing under paragraph (1) and who to contact for recourse if
they are sent a balance bill in violation of such paragraph.
The facility shall be responsible for obtaining the signature
from the enrollee on such notice. The Secretary shall issue
regulations within 6 months of the date of enactment of this
subsection on the requirements for the notice under this
paragraph.
``(h) Maintaining State Surprise Billing Protections.--
``(1) In general.--Nothing in this section shall prevent a
State from establishing or continuing in effect, with respect
to health insurance issuers, facilities, or practitioners, an
alternate method under State law for determining the
appropriate compensation for services described in subsection
(b), (e), or (f).
``(2) Additional application.--In the case of group health
plans or group or individual health insurance coverage offered
in a State that has not established an alternate method
described in paragraph (1), such as arbitration or a benchmark,
or for services described in subsection (b), (e), or (f) that
are not covered by such State's alternate method described in
paragraph (1), the provisions of this section shall apply.
``(3) Self-insured plans.--Subsections (b), (e), and (f)
shall apply to a self-insured group health plan that is not
subject to State insurance regulation.
``(i) Definitions.--In this section:
``(1) In-network.--The term `in-network', with respect to a
group health plan or health insurance coverage means a provider
that has a contractual relationship with the plan.
``(2) Enrollee.--The term `enrollee', with respect to
health insurance coverage or a group health plan, includes a
participant, dependent, or beneficiary.
``(3) Ancillary services.--The term `ancillary services'
means non-emergency care that is--
``(A) provided by anesthesiologists, pathologists,
emergency medicine providers, intensivists,
radiologists, neonatologists, hospitalists, and
assistant surgeons, whether the care is provided by a
physician or non-physician practitioner;
``(B) a diagnostic service (including radiology and
lab services); or
``(C) provided by such other specialty practitioner
not typically selected by the patients receiving the
care, which the Secretary may add periodically to such
definition through rulemaking.''.
(b) Enforcement of Balance Billing Prohibitions.--Part C of title
XXVII of the Public Health Service Act (42 U.S.C. 300gg-91 et seq.) is
amended by adding at the end the following:
``SEC. 2795. ENFORCEMENT OF BALANCE BILLING PROHIBITIONS.
``(a) In General.--Subject to subsection (b), a facility or
practitioner that violates a requirement under section 2719A(g)(1) or
fails to provide notice or obtain consent as required under subsection
(e)(2) or (f)(2) shall be subject to a civil monetary penalty of not
more than $10,000 for each act constituting such violation.
``(b) Procedure.--The provisions of section 1128A of the Social
Security Act, other than subsections (a) and (b) and the first sentence
of subsection (c)(1) of such section, shall apply to civil money
penalties under this subsection in the same manner as such provisions
apply to a penalty or proceeding under section 1128A of the Social
Security Act.
``(c) Safe Harbor.--
``(1) In general.--The Secretary shall waive the penalties
described under subsection (a) with respect to a facility or,
practitioner who does not knowingly violate, and should not
have reasonably known it violated, section 2719A(g)(1) with
respect to an enrollee, if such facility or practitioner,
within 30 days of the violation, withdraws the bill that was in
violation of section 2719A(g)(1), and, as applicable,
reimburses the group health plan, health insurance issuer, or
enrollee, in an amount equal to the difference between the
amount billed and the amount allowed to be billed under section
2719A(g)(1), plus interest, at an interest rate determined by
the Secretary.
``(2) Hardship exemption.--The Secretary may establish a
hardship exemption to the penalties under this section.
``(3) State enforcement.--The Secretary shall waive
penalties under this section with respect to a facility or
practitioner that has already been subject to enforcement
action under State law for a violation described in subsection
(a).''.
(c) Application to Grandfathered Plans.--Section 1251(a) of the
Patient Protection and Affordable Care Act (42 U.S.C. 18011(a)) is
amended by adding at the end the following:
``(5) Application of additional provisions.--Subsections
(b) through (h) of section 2719A of the Public Health Service
Act (42 U.S.C. 300gg-19a) shall apply to grandfathered health
plans for plan years beginning with the second plan year that
begins after the date of enactment of this paragraph.''.
(d) Coverage Under Federal Employees Health Benefits Program.--
Section 8904 of title 5, United States Code, is amended by adding at
the end the following:
``(c) Any health benefits plan offered under this chapter shall be
treated as a group health plan or group or individual health insurance
coverage for purposes of subsections (e) through (g) of section 2719A
of the Public Health Service Act (42 U.S.C. 300gg-19a) (except for
paragraph (3) of such subsection (g)).''.
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