[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)).''.
                                 <all>