Congressional Record, Volume 171 Issue 213 (Wednesday, December 17, 2025)

[Congressional Record Volume 171, Number 213 (Wednesday, December 17, 2025)]
[House]
[Pages H5956-H5978]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

{time} 1110
LOWER HEALTH CARE PREMIUMS FOR ALL AMERICANS ACT

Mr. GUTHRIE. Mr. Speaker, pursuant to House Resolution 953, I call up
the bill (H.R. 6703) to ensure access to affordable health insurance,
and ask for its immediate consideration in the House.
The Clerk read the title of the bill.
The SPEAKER pro tempore (Mr. Guest). Pursuant to House Resolution
953, the bill is considered read.
The text of the bill is as follows:

H.R. 6703

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 ``Lower Health Care Premiums
for All Americans Act''.

TITLE I--IMPROVING HEALTH CARE OPTIONS FOR WORKERS

SEC. 101. ASSOCIATION HEALTH PLANS.

(a) Treatment of Group or Association of Employers.--
Section 3(5) of the Employee Retirement Income Security Act
of 1974 (29 U.S.C. 1002(5)) is amended by inserting after
``capacity'' the following: ``(including, for the purpose of
establishing or maintaining a group health plan, a group or
association of employers that satisfies the requirements of
section 736(a))''.
(b) Rules Applicable to Group Health Plans Established and
Maintained by a Group or Association of Employers.--
(1) In general.--Part 7 of subtitle B of title I of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
1181, et seq.) is amended by adding at the end the following:

``SEC. 736. RULES APPLICABLE TO GROUP HEALTH PLANS
ESTABLISHED AND MAINTAINED BY A GROUP OR
ASSOCIATION OF EMPLOYERS.

``(a) Association Health Plans.--A group or association of
employers may maintain a group health plan, regardless of
whether the employers composing such group or association are
in the same industry, trade, or profession, if such group or
association satisfies the following requirements:
``(1) Group or association requirements.--The group or
association of employers--
``(A) shall--
``(i) have been formed and maintained in good faith for
purposes other than providing health insurance coverage
through a group health plan;
``(ii) establish a governing board or another indicator of
formality as described in paragraph (2); and
``(iii) have existed for at least 2 years prior to offering
a group health plan to the employees of such group or
association; and

[[Page H5957]]

``(iv) make health insurance coverage under the group
health plan offered by such group or association available--

``(I) to at least 51 employees; and
``(II) to all employees of the employer members, and any
dependents of such employees;

``(B) may only provide health insurance coverage through
the group health plan of the group or association--
``(i) to an employee of an employer member of the group or
association or a dependent of such an employee; or
``(ii) as necessary to comply with part 6;
``(C) may include a health insurance issuer as an employer
member, except that the group or association may not--
``(i) be a health insurance issuer; or
``(ii) be controlled or owned by a health insurance issuer
(or a subsidiary or affiliate of a health insurance issuer).
``(D) may not condition the membership of an employer in
the group or association on any health status-related factor
(as described in section 702(a)(1)) relating to any employee
or dependent of any employee of any employer member.
``(2) Organizational requirements.--
``(A) Governing board or formal organization of the group
or association.--
``(i) In general.--The group or association shall have--

``(I) a formal organizational structure with a governing
board and by-laws; or
``(II) another structure or indicator of formality.

``(ii) Requirement.--Both structures described in
subclauses (I) and (II) of clause (i) shall comply with the
requirements described in subparagraph (B).
``(B) Formal organization structure of group or
association.--
``(i) In general.--The functions and activities of the
group or association shall be controlled by the employer
members in substance and in fact.
``(ii) Control.--The control described in clause (i) shall
be satisfied so long as at least 75 percent of the positions
on the board or other formal organizational structure are
held by employer members.
``(iii) Elections.--Each position of the governing board or
other formal organizational structure shall be subject to
scheduled elections, as determined by the group or
association, and each employer-member shall be able to cast
only one vote in each such election.
``(C) Group health plan requirements.--
``(i) Control.--The group health plan shall be controlled
in substance and in fact by employer members participating in
the group health plan.
``(ii) Eligibility verification.--A plan fiduciary shall
verify, on a regular basis and pursuant to reasonable
monitoring procedures as established by the plan fiduciary,
whether an individual is a self-employed individual if such
individual (or a beneficiary thereof) participates in the
group health plan on the basis that such individual is a
self-employed individual.
``(iii) Ineligible self-employed individuals.--

``(I) In general.--Subject to subclause (II) and except as
required under part 6, in the case that the plan fiduciary
determines that an individual who participates in the group
health plan no longer meets the requirements under a self-
employed individual during a plan year, the group health plan
shall not make health insurance coverage available to such
individual for any plan year following the plan year in which
such determination was made.
``(II) Remedial action.--If, after the plan fiduciary
determines that an individual described in clause (i) is not
a self-employed individual, the individual furnishes to the
plan fiduciary evidence proving that such individual is a
self-employed individual, such individual shall be eligible
to participate in the group health plan.

``(3) Discrimination and pre-existing condition
protections.--A group health plan established and maintained
by the group or association of employers under this section
may not--
``(A) establish any rule for eligibility (including
continued eligibility) of any individual (including an
employee of an employer member or a self-employed individual,
or a dependent of such employee or self-employed individual)
to enroll for benefits under the terms of the plan that
discriminates based on any health status-related factor that
relates to such individual (consistent with the rules under
section 702(a)(1));
``(B) require an individual (including an employee of an
employer member or a self-employed individual, or a dependent
of such employee or self-employed individual), as a condition
of enrollment or continued enrollment under the plan, to pay
a premium or contribution that is greater than the premium or
contribution for a similarly situated individual enrolled in
the plan based on any health status-related factor that
relates to such individual (consistent with the rules under
section 702(b)(1)); and
``(C) deny coverage under such plan on the basis of a pre-
existing condition (consistent with the rules under section
2704 of the Public Health Service Act).
``(b) Premium Rates for a Group or Association of
Employers.--
``(1) In general.--A group health plan established and
maintained by a group or association of employers that meets
that requirements of this section may, to the extent not
prohibited under State law--
``(A) establish base premium rates formed on an actuarially
sound, modified community rating methodology that considers
the pooling of all plan participant claims; and
``(B) utilize the specific risk profile of each employer
member of such group or association to determine contribution
rates for each such employer member's share of a premium by
actuarially adjusting the established base premium rates.
``(2) Only self employed individuals.--In the case that a
group or association is composed only of self-employed
individuals, the group health plan established by such group
or association shall--
``(A) treat all such self-employed individuals as a single
risk pool;
``(B) pool all plan participant claims; and
``(C) charge each plan participant the same premium rate.
``(c) Treatment of Self-Employed Individuals.--For purposes
of this section, an individual who is a self-employed
individual shall be treated as--
``(1) an employer who may be a member of a group or
association of employers;
``(2) an employee who may participate in a group health
plan established and maintained by such group or association;
and
``(3) a participant of the group health plan in which the
individual participates, subject to the eligibility
determination and monitoring requirements set forth in
subsection (a)(2)(C)(i).
``(d) Determination of Employer or Joint Employer Status.--
The provision of health insurance coverage by a group or
association of employers may not be construed as evidence for
establishing an employer or joint employer relationship under
any Federal or State law.
``(e) Rules of Construction.--
``(1) No exemption from phsa.--Nothing in this section
shall be construed to exempt a group health plan (as defined
in section 733(a)(1)) offered through a group or association
of employers from the requirements of this part or from the
provisions of part A of title XXVII of the Public Health
Service Act as incorporated by reference into this Act
through section 715.
``(2) Prior or future guidance.--Nothing in this section
may be construed to limit or otherwise affect the ability of
a group or association of employers from establishing a
single plan multiple employer welfare arrangement as
specified in any prior or future guidance issued by the
Secretary of Labor that provides alternative pathways to
qualifying as a group or association of employer for purposes
of section 3(5).
``(f) Definitions.--In this section--
``(1) Employer member.--The term `employer member' means--
``(A) an employer who is a member of such group or
association of employers and employs at least 1 common law
employee; or
``(B) a group made up solely of self-employed individuals,
within which all of the self-employed individual members of
such group or association are aggregated together as a single
employer member group, provided that such group includes at
least 20 self-employed individual members.
``(2) Self-employed individual.--The term `self-employed
individual' means an individual who--
``(A) does not have any common law employees;
``(B) has a bona fide ownership right in a trade or
business, regardless of whether such trade or business is
incorporated or unincorporated;
``(C) earns a wage (as defined in section 3121(a) of the
Internal Revenue Code of 1986) or self-employment income (as
defined in section 1402(b) of such Code) from such trade or
business; and
``(D) works at least 10 hours a week, or 40 hours per
month, providing personal services to such trade or
business.''.
(2) Clerical amendment.--The table of contents is amended
by inserting after the item relating to section 734 the
following:

``735. Standardized reporting format.
``736. Rules applicable to group health plans established and
maintained by a group or association of employers.''.

SEC. 102. CERTAIN MEDICAL STOP-LOSS INSURANCE OBTAINED BY
CERTAIN PLAN SPONSORS OF GROUP HEALTH PLANS NOT
INCLUDED UNDER THE DEFINITION OF HEALTH
INSURANCE COVERAGE.

(a) In General.--Section 733(b)(1) of the Employee
Retirement Income Security Act of 1974 (29 U.S.C.
1191b(b)(1)) is amended by adding at the end the following
sentence: ``Such term shall not include a stop-loss policy
obtained by a self-insured group health plan or a plan
sponsor of a group health plan that self-insures the health
risks of its plan participants to reimburse the plan or
sponsor for losses that the plan or sponsor incurs in
providing health or medical benefits to such plan
participants in excess of a predetermined level set forth in
the stop-loss policy obtained by such plan or sponsor.''.
(b) Effect on Other Laws.--Section 514(b) of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1144(b)) is
amended by adding at the end the following:
``(10) The provisions of this title (including part 7
relating to group health plans) shall preempt State laws
insofar as they may now or hereafter prevent an employee
benefit plan that is a group health plan from insuring
against the risk of excess or unexpected health plan claims
losses.''.

[[Page H5958]]

SEC. 103. TREATMENT OF HEALTH REIMBURSEMENT ARRANGEMENTS
INTEGRATED WITH INDIVIDUAL MARKET COVERAGE.

(a) In General.--
(1) Treatment.--Section 9815(b) of the Internal Revenue
Code of 1986 is amended--
(A) by striking ``Exception.--Notwithstanding subsection
(a)'' and inserting the following: ``Exceptions.--
``(1) Self-insured group health plans.--Notwithstanding
subsection (a)'', and
(B) by adding at the end the following new paragraph:
``(2) Custom health option and individual care expense
arrangements.--
``(A) In general.--For purposes of this subchapter, a
custom health option and individual care expense arrangement
shall be treated as meeting the requirements of section 9802
and sections 2705, 2711, 2713, and 2715 of title XXVII of the
Public Health Service Act.
``(B) Custom health option and individual care expense
arrangements defined.--For purposes of this section, the term
`custom health option and individual care expense
arrangement' means a health reimbursement arrangement--
``(i) which is an employer-provided group health plan
funded solely by employer contributions to provide payments
or reimbursements for medical care subject to a maximum fixed
dollar amount for a period,
``(ii) under which such payments or reimbursements may only
be made for medical care provided during periods during which
the individual is covered--

``(I) under individual health insurance coverage (other
than coverage that consists solely of excepted benefits), or
``(II) under part A and B of title XVIII of the Social
Security Act or part C of such title,

``(iii) which meets the nondiscrimination requirements of
subparagraph (C),
``(iv) which meets the substantiation requirements of
subparagraph (D), and
``(v) which meets the notice requirements of subparagraph
(E).
``(C) Nondiscrimination.--
``(i) In general.--An arrangement meets the requirements of
this subparagraph if an employer offering such arrangement to
an employee within a specified class of employee--

``(I) offers such arrangement to all employees within such
specified class on the same terms, and
``(II) does not offer any other group health plan (other
than an account-based group health plan or a group health
plan that consists solely of excepted benefits) to any
employees within such specified class.

In the case of an employer who offers a group health plan
provided through health insurance coverage in the small group
market (that is subject to section 2701 of the Public Health
Service Act) to all employees within such specified class,
subclause (II) shall not apply to such group health plan.
``(ii) Specified class of employee.--For purposes of this
subparagraph, any of the following may be designated as a
specified class of employee:

``(I) Full-time employees.
``(II) Part-time employees.
``(III) Salaried employees.
``(IV) Non-salaried employees.
``(V) Employees whose primary site of employment is in the
same rating area.
``(VI) Employees who are included in a unit of employees
covered under a collective bargaining agreement to which the
employer is subject (determined under rules similar to the
rules of section 105(h)).
``(VII) Employees who have not met a group health plan, or
health insurance issuer offering group health insurance
coverage, waiting period requirement that satisfies section
2708 of the Public Health Service Act.
``(VIII) Seasonal employees.
``(IX) Employees who are nonresident aliens and who receive
no earned income (within the meaning of section 911(d)(2))
from the employer which constitutes income from sources
within the United States (within the meaning of section
861(a)(3)).
``(X) Under such rules as the Secretary may prescribe,
employees who are hired for temporary placement with an
unrelated person that is not the common law employer.
``(XI) Such other classes of employees as the Secretary may
designate.

An employer may designate (in such manner as is prescribed by
the Secretary) two or more of the classes described in the
preceding subclauses as the specified class of employees to
which the arrangement is offered for purposes of applying
this subparagraph.
``(iii) Special rule for new hires.--An employer may
designate prospectively so much of a specified class of
employees as are hired after a date set by the employer. Such
subclass of employees shall be treated as the specified class
for purposes of applying clause (i).
``(iv) Rules for determining type of employee.--For
purposes for clause (ii), any determination of full-time,
part-time, or seasonal employment status shall be made under
rules similar to the rules of section 105(h) or 4980H,
whichever the employer elects for the plan year. Such
election shall apply with respect to all employees of the
employer for the plan year.
``(v) Permitted variation.--For purposes of clause (i)(I),
an arrangement shall not fail to be treated as provided on
the same terms within a specified class merely because the
maximum dollar amount of payments and reimbursements which
may be made under the terms of the arrangement for the year
with respect to each employee within such class--

``(I) increases as additional dependents of the employee
are covered under the arrangement, and
``(II) increases with respect to a participant as the age
of the participant increases, but not in excess of an amount
equal to 300 percent of the lowest maximum dollar amount with
respect to such a participant determined without regard to
age.

``(D) Substantiation requirements.--An arrangement meets
the requirements of this subparagraph if the arrangement has
reasonable procedures to substantiate--
``(i) that the participant and any dependents are, or will
be, enrolled in coverage described in subparagraph (B)(ii) as
of the beginning of the plan year of the arrangement (or as
of the beginning of coverage under the arrangement in the
case of an employee who first becomes eligible to participate
in the arrangement after the date notice is given with
respect to the plan under subparagraph (E) (determined
without regard to clause (iii) thereof), and
``(ii) any requests made for payment or reimbursement of
medical care under the arrangement and that the participant
and any dependents remain so enrolled.
``(E) Notice.--
``(i) In general.--Except as provided in clause (iii), an
arrangement meets the requirements of this subparagraph if,
under the arrangement, each employee eligible to participate
is, not later than 60 days before the beginning of the plan
year, given written notice of the employee's rights and
obligations under the arrangement which--

``(I) is sufficiently accurate and comprehensive to apprise
the employee of such rights and obligations, and
``(II) is written in a manner calculated to be understood
by the average employee eligible to participate.

``(ii) Notice requirements.--Such notice shall include such
information as the Secretary may by regulation prescribe.
``(iii) Notice deadline for certain employees.--In the case
of an employee--

``(I) who first becomes eligible to participate in the
arrangement after the date notice is given with respect to
the plan under clause (i) (determined without regard to this
clause), or
``(II) whose employer is first established fewer than 120
days before the beginning of the first plan year of the
arrangement,

the requirements of this subparagraph shall be treated as met
if the notice required under clause (i) is provided not later
than the date the arrangement may take effect with respect to
such employee.''.
(2) Treatment of current rules relating to certain
arrangements.--
(A) No inference.--To the extent not inconsistent with the
amendments made by this subsection--
(i) no inference shall be made from such amendments with
respect to the rules prescribed in the Federal Register on
June 20, 2019, (84 Fed. Reg. 28888) relating to health
reimbursement arrangements and other account-based group
health plans, and
(ii) any reference to custom health option and individual
care expense arrangements shall for purposes of such rules be
treated as including a reference to individual coverage
health reimbursement arrangements.
(B) Other conforming of rules.--The Secretary of the
Treasury, the Secretary of Health and Human Services, and the
Secretary of Labor shall modify such rules as may be
necessary to conform to the amendments made by this
subsection.
(3) Participants in choice arrangement eligible for
purchase of exchange insurance under cafeteria plan.--Section
125(f)(3) of such Code is amended by adding at the end the
following new subparagraph:
``(C) Exception for participants in choice arrangement.--
Subparagraph (A) shall not apply in the case of an employee
participating in a custom health option and individual care
expense arrangement (within the meaning of section
9815(b)(2)) offered by the employee's employer.''.
(4) Effective date.--The amendments made by this subsection
shall apply to plan years beginning after December 31, 2025.
(b) Inclusion of CHOICE Arrangement Permitted Benefits on
W-2.--
(1) In general.--Section 6051(a) of such Code is amended by
striking ``and'' at the end of paragraph (18), by striking
the period at the end of paragraph (19) and inserting ``,
and'', and by inserting after paragraph (19) the following
new paragraph:
``(20) the total amount of permitted benefits for enrolled
individuals under a custom health option and individual care
expense arrangement (as defined in section 9815(b)(2)) with
respect to such employee.''.
(2) Effective date.--The amendment made by this subsection
shall apply to taxable years beginning after December 31,
2025.

TITLE II--LOWERING HEALTH CARE PREMIUMS FOR EVERYONE

SEC. 201. OVERSIGHT OF PHARMACY BENEFIT MANAGEMENT SERVICES.

(a) Public Health Service Act.--Title XXVII of the Public
Health Service Act (42 U.S.C. 300gg et seq.) is amended--
(1) in part D (42 U.S.C. 300gg-111 et seq.), by adding at
the end the following new section:

``SEC. 2799A-11. OVERSIGHT OF ENTITIES THAT PROVIDE PHARMACY
BENEFIT MANAGEMENT SERVICES.

``(a) In General.--For plan years beginning on or after the
date that is 30 months

[[Page H5959]]

after the date of enactment of this section (referred to in
this subsection and subsection (b) as the `effective date'),
a group health plan or a health insurance issuer offering
group health insurance coverage, or an entity providing
pharmacy benefit management services on behalf of such a plan
or issuer, shall not enter into a contract, including an
extension or renewal of a contract, entered into on or after
the effective date, with an applicable entity unless such
applicable entity agrees to--
``(1) not limit or delay the disclosure of information to
the group health plan (including such a plan offered through
a health insurance issuer) in such a manner that prevents an
entity providing pharmacy benefit management services on
behalf of a group health plan or health insurance issuer
offering group health insurance coverage from making the
reports described in subsection (b); and
``(2) provide the entity providing pharmacy benefit
management services on behalf of a group health plan or
health insurance issuer relevant information necessary to
make the reports described in subsection (b).
``(b) Reports.--
``(1) In general.--For plan years beginning on or after the
effective date, in the case of any contract between a group
health plan or a health insurance issuer offering group
health insurance coverage offered in connection with such a
plan and an entity providing pharmacy benefit management
services on behalf of such plan or issuer, including an
extension or renewal of such a contract, entered into on or
after the effective date, the entity providing pharmacy
benefit management services on behalf of such a group health
plan or health insurance issuer, not less frequently than
every 6 months (or, at the request of a group health plan,
not less frequently than quarterly, and under the same
conditions, terms, and cost of the semiannual report under
this subsection), shall submit to the group health plan a
report in accordance with this section. Each such report
shall be made available to such group health plan in plain
language, in a machine-readable format, and as the Secretary
may determine, other formats. Each such report shall include
the information described in paragraph (2).
``(2) Information described.--For purposes of paragraph
(1), the information described in this paragraph is, with
respect to drugs covered by a group health plan or group
health insurance coverage offered by a health insurance
issuer in connection with a group health plan during each
reporting period--
``(A) in the case of a group health plan that is offered by
a specified large employer or that is a specified large plan,
and is not offered as health insurance coverage, or in the
case of health insurance coverage for which the election
under paragraph (3) is made for the applicable reporting
period--
``(i) a list of drugs for which a claim was filed and, with
respect to each such drug on such list--

``(I) the contracted compensation paid by the group health
plan or health insurance issuer for each covered drug
(identified by the National Drug Code) to the entity
providing pharmacy benefit management services or other
applicable entity on behalf of the group health plan or
health insurance issuer;
``(II) the contracted compensation paid to the pharmacy, by
any entity providing pharmacy benefit management services or
other applicable entity on behalf of the group health plan or
health insurance issuer, for each covered drug (identified by
the National Drug Code);
``(III) for each such claim, the difference between the
amount paid under subclause (I) and the amount paid under
subclause (II);
``(IV) the proprietary name, established name or proper
name, and National Drug Code;
``(V) for each claim for the drug (including original
prescriptions and refills) and for each dosage unit of the
drug for which a claim was filed, the type of dispensing
channel used to furnish the drug, including retail, mail
order, or specialty pharmacy;
``(VI) with respect to each drug dispensed, for each type
of dispensing channel (including retail, mail order, or
specialty pharmacy)--

``(aa) whether such drug is a brand name drug or a generic
drug, and--
``(AA) in the case of a brand name drug, the wholesale
acquisition cost, listed as cost per days supply and cost per
dosage unit, on the date such drug was dispensed; and
``(BB) in the case of a generic drug, the average wholesale
price, listed as cost per days supply and cost per dosage
unit, on the date such drug was dispensed; and
``(bb) the total number of--
``(AA) prescription claims (including original
prescriptions and refills);
``(BB) participants and beneficiaries for whom a claim for
such drug was filed through the applicable dispensing
channel;
``(CC) dosage units and dosage units per fill of such drug;
and
``(DD) days supply of such drug per fill;

``(VII) the net price per course of treatment or single
fill, such as a 30-day supply or 90-day supply to the plan or
coverage after rebates, fees, alternative discounts, or other
remuneration received from applicable entities;
``(VIII) the total amount of out-of-pocket spending by
participants and beneficiaries on such drug, including
spending through copayments, coinsurance, and deductibles,
but not including any amounts spent by participants and
beneficiaries on drugs not covered under the plan or
coverage, or for which no claim is submitted under the plan
or coverage;
``(IX) the total net spending on the drug;
``(X) the total amount received, or expected to be
received, by the plan or issuer from any applicable entity in
rebates, fees, alternative discounts, or other remuneration;
``(XI) the total amount received, or expected to be
received, by the entity providing pharmacy benefit management
services, from applicable entities, in rebates, fees,
alternative discounts, or other remuneration from such
entities--

``(aa) for claims incurred during the reporting period; and
``(bb) that is related to utilization of such drug or
spending on such drug; and

``(XII) to the extent feasible, information on the total
amount of remuneration for such drug, including copayment
assistance dollars paid, copayment cards applied, or other
discounts provided by each drug manufacturer (or entity
administering copayment assistance on behalf of such drug
manufacturer), to the participants and beneficiaries enrolled
in such plan or coverage;

``(ii) a list of each therapeutic class (as defined by the
Secretary) for which a claim was filed under the group health
plan or health insurance coverage during the reporting
period, and, with respect to each such therapeutic class--

``(I) the total gross spending on drugs in such class
before rebates, price concessions, alternative discounts, or
other remuneration from applicable entities;
``(II) the net spending in such class after such rebates,
price concessions, alternative discounts, or other
remuneration from applicable entities;
``(III) the total amount received, or expected to be
received, by the entity providing pharmacy benefit management
services, from applicable entities, in rebates, fees,
alternative discounts, or other remuneration from such
entities--

``(aa) for claims incurred during the reporting period; and
``(bb) that is related to utilization of drugs or drug
spending;

``(IV) the average net spending per 30-day supply and per
90-day supply by the plan or by the issuer with respect to
such coverage and its participants and beneficiaries, among
all drugs within the therapeutic class for which a claim was
filed during the reporting period;
``(V) the number of participants and beneficiaries who
filled a prescription for a drug in such class, including the
National Drug Code for each such drug;
``(VI) if applicable, a description of the formulary tiers
and utilization mechanisms (such as prior authorization or
step therapy) employed for drugs in that class; and
``(VII) the total out-of-pocket spending under the plan or
coverage by participants and beneficiaries, including
spending through copayments, coinsurance, and deductibles,
but not including any amounts spent by participants and
beneficiaries on drugs not covered under the plan or coverage
or for which no claim is submitted under the plan or
coverage;

``(iii) with respect to any drug for which gross spending
under the group health plan or health insurance coverage
exceeded $10,000 during the reporting period or, in the case
that gross spending under the group health plan or coverage
exceeded $10,000 during the reporting period with respect to
fewer than 50 drugs, with respect to the 50 prescription
drugs with the highest spending during the reporting period--

``(I) a list of all other drugs in the same therapeutic
class as such drug;
``(II) if applicable, the rationale for the formulary
placement of such drug in that therapeutic category or class,
selected from a list of standard rationales established by
the Secretary, in consultation with stakeholders; and
``(III) any change in formulary placement compared to the
prior plan year; and

``(iv) in the case that such plan or issuer (or an entity
providing pharmacy benefit management services on behalf of
such plan or issuer) has an affiliated pharmacy or pharmacy
under common ownership, including mandatory mail and
specialty home delivery programs, retail and mail auto-refill
programs, and cost-sharing assistance incentives funded by an
entity providing pharmacy benefit services--

``(I) an explanation of any benefit design parameters that
encourage or require participants and beneficiaries in the
plan or coverage to fill prescriptions at mail order,
specialty, or retail pharmacies;
``(II) the percentage of total prescriptions dispensed by
such pharmacies to participants or beneficiaries in such plan
or coverage; and
``(III) a list of all drugs dispensed by such pharmacies to
participants or beneficiaries enrolled in such plan or
coverage, and, with respect to each drug dispensed--

[[Page H5960]]

pharmacies that are not affiliated with or under common
ownership with the entity and that are included in the
pharmacy network of such plan or coverage;
``(cc) the lowest cost per dosage unit, per 30-day supply
and per 90-day supply, for each such drug, including amounts
charged to the plan or coverage and to participants and
beneficiaries, that is available from any pharmacy included
in the network of such plan or coverage; and
``(dd) the net acquisition cost per dosage unit, per 30-day
supply, and per 90-day supply, if such drug is subject to a
maximum price discount; and
``(B) with respect to any group health plan, including
group health insurance coverage offered in connection with
such a plan, regardless of whether the plan or coverage is
offered by a specified large employer or whether it is a
specified large plan--
``(i) a summary document for the group health plan that
includes such information described in clauses (i) through
(iv) of subparagraph (A), as specified by the Secretary
through guidance, program instruction, or otherwise (with no
requirement of notice and comment rulemaking), that the
Secretary determines useful to group health plans for
purposes of selecting pharmacy benefit management services,
such as an estimated net price to group health plan and
participant or beneficiary, a cost per claim, the fee
structure or reimbursement model, and estimated cost per
participant or beneficiary;
``(ii) a summary document for plans and issuers to provide
to participants and beneficiaries, which shall be made
available to participants or beneficiaries upon request to
their group health plan (including in the case of group
health insurance coverage offered in connection with such a
plan), that--

``(I) contains such information described in clauses (iii),
(iv), (v), and (vi), as applicable, as specified by the
Secretary through guidance, program instruction, or otherwise
(with no requirement of notice and comment rulemaking) that
the Secretary determines useful to participants or
beneficiaries in better understanding the plan or coverage or
benefits under such plan or coverage;
``(II) contains only aggregate information; and
``(III) states that participants and beneficiaries may
request specific, claims-level information required to be
furnished under subsection (c) from the group health plan or
health insurance issuer;

``(iii) with respect to drugs covered by such plan or
coverage during such reporting period--

``(I) the total net spending by the plan or coverage for
all such drugs;
``(II) the total amount received, or expected to be
received, by the plan or issuer from any applicable entity in
rebates, fees, alternative discounts, or other remuneration;
and
``(III) to the extent feasible, information on the total
amount of remuneration for such drugs, including copayment
assistance dollars paid, copayment cards applied, or other
discounts provided by each drug manufacturer (or entity
administering copayment assistance on behalf of such drug
manufacturer) to participants and beneficiaries;

``(iv) amounts paid directly or indirectly in rebates,
fees, or any other type of compensation (as defined in
section 408(b)(2)(B)(ii)(dd)(AA) of the Employee Retirement
Income Security Act) to brokerage firms, brokers,
consultants, advisors, or any other individual or firm, for--

``(I) the referral of the group health plan's or health
insurance issuer's business to an entity providing pharmacy
benefit management services, including the identity of the
recipient of such amounts;
``(II) consideration of the entity providing pharmacy
benefit management services by the group health plan or
health insurance issuer; or
``(III) the retention of the entity by the group health
plan or health insurance issuer;

``(v) an explanation of any benefit design parameters that
encourage or require participants and beneficiaries in such
plan or coverage to fill prescriptions at mail order,
specialty, or retail pharmacies that are affiliated with or
under common ownership with the entity providing pharmacy
benefit management services under such plan or coverage,
including mandatory mail and specialty home delivery
programs, retail and mail auto-refill programs, and cost-
sharing assistance incentives directly or indirectly funded
by such entity; and
``(vi) total gross spending on all drugs under the plan or
coverage during the reporting period.
``(3) Opt-in for group health insurance coverage offered by
a specified large employer or that is a specified large
plan.--In the case of group health insurance coverage offered
in connection with a group health plan that is offered by a
specified large employer or is a specified large plan, such
group health plan may, on an annual basis, for plan years
beginning on or after the date that is 30 months after the
date of enactment of this section, elect to require an entity
providing pharmacy benefit management services on behalf of
the health insurance issuer to submit to such group health
plan a report that includes all of the information described
in paragraph (2)(A), in addition to the information described
in paragraph (2)(B).
``(4) Privacy requirements.--
``(A) In general.--An entity providing pharmacy benefit
management services on behalf of a group health plan or a
health insurance issuer offering group health insurance
coverage shall report information under paragraph (1) in a
manner consistent with the privacy regulations promulgated
under section 13402(a) of the Health Information Technology
for Economic and Clinical Health Act and consistent with the
privacy regulations promulgated under the Health Insurance
Portability and Accountability Act of 1996 in part 160 and
subparts A and E of part 164 of title 45, Code of Federal
Regulations (or successor regulations) (referred to in this
paragraph as the `HIPAA privacy regulations') and shall
restrict the use and disclosure of such information according
to such privacy regulations and such HIPAA privacy
regulations.
``(B) Additional requirements.--
``(i) In general.--An entity providing pharmacy benefit
management services on behalf of a group health plan or
health insurance issuer offering group health insurance
coverage that submits a report under paragraph (1) shall
ensure that such report contains only summary health
information, as defined in section 164.504(a) of title 45,
Code of Federal Regulations (or successor regulations).
``(ii) Restrictions.--In carrying out this subsection, a
group health plan shall comply with section 164.504(f) of
title 45, Code of Federal Regulations (or a successor
regulation), and a plan sponsor shall act in accordance with
the terms of the agreement described in such section.
``(C) Rule of construction.--
``(i) Nothing in this section shall be construed to modify
the requirements for the creation, receipt, maintenance, or
transmission of protected health information under the HIPAA
privacy regulations.
``(ii) Nothing in this section shall be construed to affect
the application of any Federal or State privacy or civil
rights law, including the HIPAA privacy regulations, the
Genetic Information Nondiscrimination Act of 2008 (Public Law
110-233) (including the amendments made by such Act), the
Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et
seq.), section 504 of the Rehabilitation Act of 1973 (29
U.S.C. 794), section 1557 of the Patient Protection and
Affordable Care Act (42 U.S.C. 18116), title VI of the Civil
Rights Act of 1964 (42 U.S.C. 2000d), and title VII of the
Civil Rights Act of 1964 (42 U.S.C. 2000e).
``(D) Written notice.--Each plan year, group health plans,
including with respect to group health insurance coverage
offered in connection with a group health plan, shall provide
to each participant or beneficiary written notice informing
the participant or beneficiary of the requirement for
entities providing pharmacy benefit management services on
behalf of the group health plan or health insurance issuer
offering group health insurance coverage to submit reports to
group health plans under paragraph (1), as applicable, which
may include incorporating such notification in plan documents
provided to the participant or beneficiary, or providing
individual notification.
``(E) Limitation to business associates.--A group health
plan receiving a report under paragraph (1) may disclose such
information only to the entity from which the report was
received or to that entity's business associates as defined
in section 160.103 of title 45, Code of Federal Regulations
(or successor regulations) or as permitted by the HIPAA
privacy regulations.
``(F) Clarification regarding public disclosure of
information.--Nothing in this section shall prevent an entity
providing pharmacy benefit management services on behalf of a
group health plan or health insurance issuer offering group
health insurance coverage, from placing reasonable
restrictions on the public disclosure of the information
contained in a report described in paragraph (1), except that
such plan, issuer, or entity may not--
``(i) restrict disclosure of such report to the Department
of Health and Human Services, the Department of Labor, or the
Department of the Treasury; or
``(ii) prevent disclosure for the purposes of subsection
(c), or any other public disclosure requirement under this
section.
``(G) Limited form of report.--The Secretary shall define
through rulemaking a limited form of the report under
paragraph (1) required with respect to any group health plan
established by a plan sponsor that is, or is affiliated with,
a drug manufacturer, drug wholesaler, or other direct
participant in the drug supply chain, in order to prevent
anti-competitive behavior.
``(5) Standard format and regulations.--
``(A) In general.--Not later than 18 months after the date
of enactment of this section, the Secretary shall specify
through rulemaking a standard format for entities providing
pharmacy benefit management services on behalf of group
health plans and health insurance issuers offering group
health insurance coverage, to submit reports required under
paragraph (1).
``(B) Additional regulations.--Not later than 18 months
after the date of enactment of this section, the Secretary
shall, through rulemaking, promulgate any other final
regulations necessary to implement the requirements of this
section. In promulgating such regulations, the Secretary
shall, to the extent practicable, align the reporting
requirements under this section with the reporting
requirements under section 2799A-10.
``(c) Requirement To Provide Information to Participants or
Beneficiaries.--A group health plan, including with respect
to group health insurance coverage offered in

[[Page H5961]]

connection with a group health plan, upon request of a
participant or beneficiary, shall provide to such participant
or beneficiary--
``(1) the summary document described in subsection
(b)(2)(B)(ii); and
``(2) the information described in subsection
(b)(2)(A)(i)(III) with respect to a claim made by or on
behalf of such participant or beneficiary.
``(d) Enforcement.--
``(1) In general.--The Secretary shall enforce this
section. The enforcement authority under this subsection
shall apply only with respect to group health plans
(including group health insurance coverage offered in
connection with such a plan) to which the requirements of
subparts I and II of part A and part D apply in accordance
with section 2722, and with respect to entities providing
pharmacy benefit management services on behalf of such plans
and applicable entities providing services on behalf of such
plans.
``(2) Failure to provide information.--A group health plan,
a health insurance issuer offering group health insurance
coverage, an entity providing pharmacy benefit management
services on behalf of such a plan or issuer, or an applicable
entity providing services on behalf of such a plan or issuer
that violates subsection (a); an entity providing pharmacy
benefit management services on behalf of such a plan or
issuer that fails to provide the information required under
subsection (b); or a group health plan that fails to provide
the information required under subsection (c), shall be
subject to a civil monetary penalty in the amount of $10,000
for each day during which such violation continues or such
information is not disclosed or reported.
``(3) False information.--A health insurance issuer, an
entity providing pharmacy benefit management services, or a
third party administrator providing services on behalf of
such issuer offered by a health insurance issuer that
knowingly provides false information under this section shall
be subject to a civil monetary penalty in an amount not to
exceed $100,000 for each item of false information. Such
civil monetary penalty shall be in addition to other
penalties as may be prescribed by law.
``(4) 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 monetary penalties under this subsection in
the same manner as such provisions apply to a penalty or
proceeding under such section.
``(5) Waivers.--The Secretary may waive penalties under
paragraph (2), or extend the period of time for compliance
with a requirement of this section, for an entity in
violation of this section that has made a good-faith effort
to comply with the requirements in this section.
``(e) Rule of Construction.--Nothing in this section shall
be construed to permit a health insurance issuer, group
health plan, entity providing pharmacy benefit management
services on behalf of a group health plan or health insurance
issuer, or other entity to restrict disclosure to, or
otherwise limit the access of, the Secretary to a report
described in subsection (b)(1) or information related to
compliance with subsections (a), (b), (c), or (d) by such
issuer, plan, or entity.
``(f) Definitions.--In this section:
``(1) Applicable entity.--The term `applicable entity'
means--
``(A) an applicable group purchasing organization, drug
manufacturer, distributor, wholesaler, rebate aggregator (or
other purchasing entity designed to aggregate rebates), or
associated third party;
``(B) any subsidiary, parent, affiliate, or subcontractor
of a group health plan, health insurance issuer, entity that
provides pharmacy benefit management services on behalf of
such a plan or issuer, or any entity described in
subparagraph (A); or
``(C) such other entity as the Secretary may specify
through rulemaking.
``(2) Applicable group purchasing organization.--The term
`applicable group purchasing organization' means a group
purchasing organization that is affiliated with or under
common ownership with an entity providing pharmacy benefit
management services.
``(3) Contracted compensation.--The term `contracted
compensation' means the sum of any ingredient cost and
dispensing fee for a drug (inclusive of the out-of-pocket
costs to the participant or beneficiary), or another
analogous compensation structure that the Secretary may
specify through regulations.
``(4) Gross spending.--The term `gross spending', with
respect to prescription drug benefits under a group health
plan or health insurance coverage, means the amount spent by
a group health plan or health insurance issuer on
prescription drug benefits, calculated before the application
of rebates, fees, alternative discounts, or other
remuneration.
``(5) Net spending.--The term `net spending', with respect
to prescription drug benefits under a group health plan or
health insurance coverage, means the amount spent by a group
health plan or health insurance issuer on prescription drug
benefits, calculated after the application of rebates, fees,
alternative discounts, or other remuneration.
``(6) Plan sponsor.--The term `plan sponsor' has the
meaning given such term in section 3(16)(B) of the Employee
Retirement Income Security Act of 1974.
``(7) Remuneration.--The term `remuneration' has the
meaning given such term by the Secretary through rulemaking,
which shall be reevaluated by the Secretary every 5 years.
``(8) Specified large employer.--The term `specified large
employer' means, in connection with a group health plan
(including group health insurance coverage offered in
connection with such a plan) established or maintained by a
single employer, with respect to a calendar year or a plan
year, as applicable, an employer who employed an average of
at least 100 employees on business days during the preceding
calendar year or plan year and who employs at least 1
employee on the first day of the calendar year or plan year.
``(9) Specified large plan.--The term `specified large
plan' means a group health plan (including group health
insurance coverage offered in connection with such a plan)
established or maintained by a plan sponsor described in
clause (ii) or (iii) of section 3(16)(B) of the Employee
Retirement Income Security Act of 1974 that had an average of
at least 100 participants on business days during the
preceding calendar year or plan year, as applicable.
``(10) Wholesale acquisition cost.--The term `wholesale
acquisition cost' has the meaning given such term in section
1847A(c)(6)(B) of the Social Security Act.''; and
(2) in section 2723 (42 U.S.C. 300gg-22)--
(A) in subsection (a)--
(i) in paragraph (1), by inserting ``(other than section
2799A-11)'' after ``part D''; and
(ii) in paragraph (2), by inserting ``(other than section
2799A-11)'' after ``part D''; and
(B) in subsection (b)--
(i) in paragraph (1), by inserting ``(other than section
2799A-11)'' after ``part D'';
(ii) in paragraph (2)(A), by inserting ``(other than
section 2799A-11)'' after ``part D''; and
(iii) in paragraph (2)(C)(ii), by inserting ``(other than
section 2799A-11)'' after ``part D''.
(b) Employee Retirement Income Security Act of 1974.--
(1) In general.--Subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1021 et
seq.) is amended--
(A) in subpart B of part 7 (29 U.S.C. 1185 et seq.), by
adding at the end the following:

``SEC. 726. OVERSIGHT OF ENTITIES THAT PROVIDE PHARMACY
BENEFIT MANAGEMENT SERVICES.

``(a) In General.--For plan years beginning on or after the
date that is 30 months after the date of enactment of this
section (referred to in this subsection and subsection (b) as
the `effective date'), a group health plan or a health
insurance issuer offering group health insurance coverage, or
an entity providing pharmacy benefit management services on
behalf of such a plan or issuer, shall not enter into a
contract, including an extension or renewal of a contract,
entered into on or after the effective date, with an
applicable entity unless such applicable entity agrees to--
``(1) not limit or delay the disclosure of information to
the group health plan (including such a plan offered through
a health insurance issuer) in such a manner that prevents an
entity providing pharmacy benefit management services on
behalf of a group health plan or health insurance issuer
offering group health insurance coverage from making the
reports described in subsection (b); and
``(2) provide the entity providing pharmacy benefit
management services on behalf of a group health plan or
health insurance issuer relevant information necessary to
make the reports described in subsection (b).
``(b) Reports.--
``(1) In general.--For plan years beginning on or after the
effective date, in the case of any contract between a group
health plan or a health insurance issuer offering group
health insurance coverage offered in connection with such a
plan and an entity providing pharmacy benefit management
services on behalf of such plan or issuer, including an
extension or renewal of such a contract, entered into on or
after the effective date, the entity providing pharmacy
benefit management services on behalf of such a group health
plan or health insurance issuer, not less frequently than
every 6 months (or, at the request of a group health plan,
not less frequently than quarterly, and under the same
conditions, terms, and cost of the semiannual report under
this subsection), shall submit to the group health plan a
report in accordance with this section. Each such report
shall be made available to such group health plan in plain
language, in a machine-readable format, and as the Secretary
may determine, other formats. Each such report shall include
the information described in paragraph (2).
``(2) Information described.--For purposes of paragraph
(1), the information described in this paragraph is, with
respect to drugs covered by a group health plan or group
health insurance coverage offered by a health insurance
issuer in connection with a group health plan during each
reporting period--
``(A) in the case of a group health plan that is offered by
a specified large employer or that is a specified large plan,
and is not offered as health insurance coverage, or in the
case of health insurance coverage for which the election
under paragraph (3) is made for the applicable reporting
period--
``(i) a list of drugs for which a claim was filed and, with
respect to each such drug on such list--

[[Page H5962]]

``(aa) for claims incurred during the reporting period; and
``(bb) that is related to utilization of such drug or
spending on such drug; and

``(aa) for claims incurred during the reporting period; and
``(bb) that is related to utilization of drugs or drug
spending;

``(iv) in the case that such plan or issuer (or an entity
providing pharmacy benefit management services on behalf of
such plan or issuer) has an affiliated pharmacy or pharmacy
under common ownership, including mandatory mail and
specialty home delivery programs, retail and mail auto-refill
programs, and cost sharing assistance incentives funded by an
entity providing pharmacy benefit services--

``(aa) the amount charged, per dosage unit, per 30-day
supply, or per 90-day supply (as applicable) to the plan or
issuer, and to participants and beneficiaries;
``(bb) the median amount charged to such plan or issuer,
and the interquartile range of the costs, per dosage unit,
per 30-day supply, and per 90-day supply, including amounts
paid by the participants and beneficiaries, when the same
drug is dispensed by other pharmacies that are not affiliated
with or under common ownership with the entity and that are
included in the pharmacy network of such plan or coverage;
``(cc) the lowest cost per dosage unit, per 30-day supply
and per 90-day supply, for each such drug, including amounts
charged to the plan or coverage and to participants and
beneficiaries, that is available from any pharmacy included
in the network of such plan or coverage; and
``(dd) the net acquisition cost per dosage unit, per 30-day
supply, and per 90-day supply, if such drug is subject to a
maximum price discount; and
``(B) with respect to any group health plan, including
group health insurance coverage offered in connection with
such a plan, regardless of whether the plan or coverage is
offered by a specified large employer or whether it is a
specified large plan--
``(i) a summary document for the group health plan that
includes such information described in clauses (i) through
(iv) of subparagraph (A), as specified by the Secretary
through guidance, program instruction, or otherwise (with no
requirement of notice and comment rulemaking), that the
Secretary determines useful to group health plans for
purposes of selecting pharmacy benefit management services,
such as an estimated net price to group health plan and
participant or beneficiary, a cost per claim, the fee
structure or reimbursement model, and estimated cost per
participant or beneficiary;
``(ii) a summary document for plans and issuers to provide
to participants and beneficiaries, which shall be made
available to participants or beneficiaries upon request to
their group health plan (including in the case of group
health insurance coverage offered in connection with such a
plan), that--

``(iii) with respect to drugs covered by such plan or
coverage during such reporting period--

[[Page H5963]]

assistance on behalf of such drug manufacturer) to
participants and beneficiaries;

``(iv) amounts paid directly or indirectly in rebates,
fees, or any other type of compensation (as defined in
section 408(b)(2)(B)(ii)(dd)(AA)) to brokerage firms,
brokers, consultants, advisors, or any other individual or
firm, for--

``(v) an explanation of any benefit design parameters that
encourage or require participants and beneficiaries in such
plan or coverage to fill prescriptions at mail order,
specialty, or retail pharmacies that are affiliated with or
under common ownership with the entity providing pharmacy
benefit management services under such plan or coverage,
including mandatory mail and specialty home delivery
programs, retail and mail auto-refill programs, and cost-
sharing assistance incentives directly or indirectly funded
by such entity; and
``(vi) total gross spending on all drugs under the plan or
coverage during the reporting period.
``(3) Opt-in for group health insurance coverage offered by
a specified large employer or that is a specified large
plan.--In the case of group health insurance coverage offered
in connection with a group health plan that is offered by a
specified large employer or is a specified large plan, such
group health plan may, on an annual basis, for plan years
beginning on or after the date that is 30 months after the
date of enactment of this section, elect to require an entity
providing pharmacy benefit management services on behalf of
the health insurance issuer to submit to such group health
plan a report that includes all of the information described
in paragraph (2)(A), in addition to the information described
in paragraph (2)(B).
``(4) Privacy requirements.--
``(A) In general.--An entity providing pharmacy benefit
management services on behalf of a group health plan or a
health insurance issuer offering group health insurance
coverage shall report information under paragraph (1) in a
manner consistent with the privacy regulations promulgated
under section 13402(a) of the Health Information Technology
for Economic and Clinical Health Act (42 U.S.C. 17932(a)) and
consistent with the privacy regulations promulgated under the
Health Insurance Portability and Accountability Act of 1996
in part 160 and subparts A and E of part 164 of title 45,
Code of Federal Regulations (or successor regulations)
(referred to in this paragraph as the `HIPAA privacy
regulations') and shall restrict the use and disclosure of
such information according to such privacy regulations and
such HIPAA privacy regulations.
``(B) Additional requirements.--
``(i) In general.--An entity providing pharmacy benefit
management services on behalf of a group health plan or
health insurance issuer offering group health insurance
coverage that submits a report under paragraph (1) shall
ensure that such report contains only summary health
information, as defined in section 164.504(a) of title 45,
Code of Federal Regulations (or successor regulations).
``(ii) Restrictions.--In carrying out this subsection, a
group health plan shall comply with section 164.504(f) of
title 45, Code of Federal Regulations (or a successor
regulation), and a plan sponsor shall act in accordance with
the terms of the agreement described in such section.
``(C) Rule of construction.--
``(i) Nothing in this section shall be construed to modify
the requirements for the creation, receipt, maintenance, or
transmission of protected health information under the HIPAA
privacy regulations.
``(ii) Nothing in this section shall be construed to affect
the application of any Federal or State privacy or civil
rights law, including the HIPAA privacy regulations, the
Genetic Information Nondiscrimination Act of 2008 (Public Law
110-233) (including the amendments made by such Act), the
Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et
seq.), section 504 of the Rehabilitation Act of 1973 (29
U.S.C. 794), section 1557 of the Patient Protection and
Affordable Care Act (42 U.S.C. 18116), title VI of the Civil
Rights Act of 1964 (42 U.S.C. 2000d), and title VII of the
Civil Rights Act of 1964 (42 U.S.C. 2000e).
``(D) Written notice.--Each plan year, group health plans,
including with respect to group health insurance coverage
offered in connection with a group health plan, shall provide
to each participant or beneficiary written notice informing
the participant or beneficiary of the requirement for
entities providing pharmacy benefit management services on
behalf of the group health plan or health insurance issuer
offering group health insurance coverage to submit reports to
group health plans under paragraph (1), as applicable, which
may include incorporating such notification in plan documents
provided to the participant or beneficiary, or providing
individual notification.
``(E) Limitation to business associates.--A group health
plan receiving a report under paragraph (1) may disclose such
information only to the entity from which the report was
received or to that entity's business associates as defined
in section 160.103 of title 45, Code of Federal Regulations
(or successor regulations) or as permitted by the HIPAA
privacy regulations.
``(F) Clarification regarding public disclosure of
information.--Nothing in this section shall prevent an entity
providing pharmacy benefit management services on behalf of a
group health plan or health insurance issuer offering group
health insurance coverage, from placing reasonable
restrictions on the public disclosure of the information
contained in a report described in paragraph (1), except that
such plan, issuer, or entity may not--
``(i) restrict disclosure of such report to the Department
of Health and Human Services, the Department of Labor, or the
Department of the Treasury; or
``(ii) prevent disclosure for the purposes of subsection
(c), or any other public disclosure requirement under this
section.
``(G) Limited form of report.--The Secretary shall define
through rulemaking a limited form of the report under
paragraph (1) required with respect to any group health plan
established by a plan sponsor that is, or is affiliated with,
a drug manufacturer, drug wholesaler, or other direct
participant in the drug supply chain, in order to prevent
anti-competitive behavior.
``(5) Standard format and regulations.--
``(A) In general.--Not later than 18 months after the date
of enactment of this section, the Secretary shall specify
through rulemaking a standard format for entities providing
pharmacy benefit management services on behalf of group
health plans and health insurance issuers offering group
health insurance coverage, to submit reports required under
paragraph (1).
``(B) Additional regulations.--Not later than 18 months
after the date of enactment of this section, the Secretary
shall, through rulemaking, promulgate any other final
regulations necessary to implement the requirements of this
section. In promulgating such regulations, the Secretary
shall, to the extent practicable, align the reporting
requirements under this section with the reporting
requirements under section 725.
``(c) Requirement To Provide Information to Participants or
Beneficiaries.--A group health plan, including with respect
to group health insurance coverage offered in connection with
a group health plan, upon request of a participant or
beneficiary, shall provide to such participant or
beneficiary--
``(1) the summary document described in subsection
(b)(2)(B)(ii); and
``(2) the information described in subsection
(b)(2)(A)(i)(III) with respect to a claim made by or on
behalf of such participant or beneficiary.
``(d) Rule of Construction.--Nothing in this section shall
be construed to permit a health insurance issuer, group
health plan, entity providing pharmacy benefit management
services on behalf of a group health plan or health insurance
issuer, or other entity to restrict disclosure to, or
otherwise limit the access of, the Secretary to a report
described in subsection (b)(1) or information related to
compliance with subsections (a), (b), or (c) of this section
or section 502(c)(13) by such issuer, plan, or entity.
``(e) Definitions.--In this section:
``(1) Applicable entity.--The term `applicable entity'
means--
``(A) an applicable group purchasing organization, drug
manufacturer, distributor, wholesaler, rebate aggregator (or
other purchasing entity designed to aggregate rebates), or
associated third party;
``(B) any subsidiary, parent, affiliate, or subcontractor
of a group health plan, health insurance issuer, entity that
provides pharmacy benefit management services on behalf of
such a plan or issuer, or any entity described in
subparagraph (A); or
``(C) such other entity as the Secretary may specify
through rulemaking.
``(2) Applicable group purchasing organization.--The term
`applicable group purchasing organization' means a group
purchasing organization that is affiliated with or under
common ownership with an entity providing pharmacy benefit
management services.
``(3) Contracted compensation.--The term `contracted
compensation' means the sum of any ingredient cost and
dispensing fee for a drug (inclusive of the out-of-pocket
costs to the participant or beneficiary), or another
analogous compensation structure that the Secretary may
specify through regulations.
``(4) Gross spending.--The term `gross spending', with
respect to prescription drug benefits under a group health
plan or health insurance coverage, means the amount spent by
a group health plan or health insurance issuer on
prescription drug benefits, calculated before the application
of rebates, fees, alternative discounts, or other
remuneration.
``(5) Net spending.--The term `net spending', with respect
to prescription drug benefits under a group health plan or
health insurance coverage, means the amount spent by a group
health plan or health insurance issuer on prescription drug
benefits, calculated after the application of rebates, fees,
alternative discounts, or other remuneration.
``(6) Plan sponsor.--The term `plan sponsor' has the
meaning given such term in section 3(16)(B).
``(7) Remuneration.--The term `remuneration' has the
meaning given such term by

[[Page H5964]]

the Secretary through rulemaking, which shall be reevaluated
by the Secretary every 5 years.
``(8) Specified large employer.--The term `specified large
employer' means, in connection with a group health plan
(including group health insurance coverage offered in
connection with such a plan) established or maintained by a
single employer, with respect to a calendar year or a plan
year, as applicable, an employer who employed an average of
at least 100 employees on business days during the preceding
calendar year or plan year and who employs at least 1
employee on the first day of the calendar year or plan year.
``(9) Specified large plan.--The term `specified large
plan' means a group health plan (including group health
insurance coverage offered in connection with such a plan)
established or maintained by a plan sponsor described in
clause (ii) or (iii) of section 3(16)(B) that had an average
of at least 100 participants on business days during the
preceding calendar year or plan year, as applicable.
``(10) Wholesale acquisition cost.--The term `wholesale
acquisition cost' has the meaning given such term in section
1847A(c)(6)(B) of the Social Security Act (42 U.S.C. 1395w-
3a(c)(6)(B)).'';
(B) in section 502 (29 U.S.C. 1132)--
(i) in subsection (a)(6), by striking ``or (9)'' and
inserting ``(9), or (13)'';
(ii) in subsection (b)(3), by striking ``under subsection
(c)(9)'' and inserting ``under paragraphs (9) and (13) of
subsection (c)''; and
(iii) in subsection (c), by adding at the end the
following:
``(13) Secretarial enforcement authority relating to
oversight of pharmacy benefit management services.--
``(A) Failure to provide information.--The Secretary may
impose a penalty against a plan administrator of a group
health plan, a health insurance issuer offering group health
insurance coverage, or an entity providing pharmacy benefit
management services on behalf of such a plan or issuer, or an
applicable entity (as defined in section 726(f)) that
violates section 726(a); an entity providing pharmacy benefit
management services on behalf of such a plan or issuer that
fails to provide the information required under section
726(b); or any person who causes a group health plan to fail
to provide the information required under section 726(c), in
the amount of $10,000 for each day during which such
violation continues or such information is not disclosed or
reported.
``(B) False information.--The Secretary may impose a
penalty against a plan administrator of a group health plan,
a health insurance issuer offering group health insurance
coverage, an entity providing pharmacy benefit management
services, or an applicable entity (as defined in section
726(f)) that knowingly provides false information under
section 726, in an amount not to exceed $100,000 for each
item of false information. Such penalty shall be in addition
to other penalties as may be prescribed by law.
``(C) Waivers.--The Secretary may waive penalties under
subparagraph (A), or extend the period of time for compliance
with a requirement of this section, for an entity in
violation of section 726 that has made a good-faith effort to
comply with the requirements of section 726.''; and
(C) in section 732(a) (29 U.S.C. 1191a(a)), by striking
``section 711'' and inserting ``sections 711 and 726''.
(2) Clerical amendment.--The table of contents in section 1
of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1001 et seq.) is amended by inserting after the item
relating to section 725 the following new item:

``Sec. 726. Oversight of entities that provide pharmacy benefit
management services.''.
(c) Internal Revenue Code of 1986.--
(1) In general.--Chapter 100 of the Internal Revenue Code
of 1986 is amended by adding at the end of subchapter B the
following:

``SEC. 9826. OVERSIGHT OF ENTITIES THAT PROVIDE PHARMACY
BENEFIT MANAGEMENT SERVICES.

``(a) In General.--For plan years beginning on or after the
date that is 30 months after the date of enactment of this
section (referred to in this subsection and subsection (b) as
the `effective date'), a group health plan, or an entity
providing pharmacy benefit management services on behalf of
such a plan, shall not enter into a contract, including an
extension or renewal of a contract, entered into on or after
the effective date, with an applicable entity unless such
applicable entity agrees to--
``(1) not limit or delay the disclosure of information to
the group health plan in such a manner that prevents an
entity providing pharmacy benefit management services on
behalf of a group health plan from making the reports
described in subsection (b); and
``(2) provide the entity providing pharmacy benefit
management services on behalf of a group health plan relevant
information necessary to make the reports described in
subsection (b).
``(b) Reports.--
``(1) In general.--For plan years beginning on or after the
effective date, in the case of any contract between a group
health plan and an entity providing pharmacy benefit
management services on behalf of such plan, including an
extension or renewal of such a contract, entered into on or
after the effective date, the entity providing pharmacy
benefit management services on behalf of such a group health
plan, not less frequently than every 6 months (or, at the
request of a group health plan, not less frequently than
quarterly, and under the same conditions, terms, and cost of
the semiannual report under this subsection), shall submit to
the group health plan a report in accordance with this
section. Each such report shall be made available to such
group health plan in plain language, in a machine-readable
format, and as the Secretary may determine, other formats.
Each such report shall include the information described in
paragraph (2).
``(2) Information described.--For purposes of paragraph
(1), the information described in this paragraph is, with
respect to drugs covered by a group health plan during each
reporting period--
``(A) in the case of a group health plan that is offered by
a specified large employer or that is a specified large plan,
and is not offered as health insurance coverage, or in the
case of health insurance coverage for which the election
under paragraph (3) is made for the applicable reporting
period--
``(i) a list of drugs for which a claim was filed and, with
respect to each such drug on such list--

``(I) the contracted compensation paid by the group health
plan for each covered drug (identified by the National Drug
Code) to the entity providing pharmacy benefit management
services or other applicable entity on behalf of the group
health plan;
``(II) the contracted compensation paid to the pharmacy, by
any entity providing pharmacy benefit management services or
other applicable entity on behalf of the group health plan,
for each covered drug (identified by the National Drug Code);
``(III) for each such claim, the difference between the
amount paid under subclause (I) and the amount paid under
subclause (II);
``(IV) the proprietary name, established name or proper
name, and National Drug Code;
``(V) for each claim for the drug (including original
prescriptions and refills) and for each dosage unit of the
drug for which a claim was filed, the type of dispensing
channel used to furnish the drug, including retail, mail
order, or specialty pharmacy;
``(VI) with respect to each drug dispensed, for each type
of dispensing channel (including retail, mail order, or
specialty pharmacy)--

``(VII) the net price per course of treatment or single
fill, such as a 30-day supply or 90-day supply to the plan
after rebates, fees, alternative discounts, or other
remuneration received from applicable entities;
``(VIII) the total amount of out-of-pocket spending by
participants and beneficiaries on such drug, including
spending through copayments, coinsurance, and deductibles,
but not including any amounts spent by participants and
beneficiaries on drugs not covered under the plan, or for
which no claim is submitted under the plan;
``(IX) the total net spending on the drug;
``(X) the total amount received, or expected to be
received, by the plan from any applicable entity in rebates,
fees, alternative discounts, or other remuneration;
``(XI) the total amount received, or expected to be
received, by the entity providing pharmacy benefit management
services, from applicable entities, in rebates, fees,
alternative discounts, or other remuneration from such
entities--

``(aa) for claims incurred during the reporting period; and
``(bb) that is related to utilization of such drug or
spending on such drug; and

``(ii) a list of each therapeutic class (as defined by the
Secretary) for which a claim was filed under the group health
plan during the reporting period, and, with respect to each
such therapeutic class--

[[Page H5965]]

``(III) the total amount received, or expected to be
received, by the entity providing pharmacy benefit management
services, from applicable entities, in rebates, fees,
alternative discounts, or other remuneration from such
entities--

``(aa) for claims incurred during the reporting period; and
``(bb) that is related to utilization of drugs or drug
spending;

``(IV) the average net spending per 30-day supply and per
90-day supply by the plan and its participants and
beneficiaries, among all drugs within the therapeutic class
for which a claim was filed during the reporting period;
``(V) the number of participants and beneficiaries who
filled a prescription for a drug in such class, including the
National Drug Code for each such drug;
``(VI) if applicable, a description of the formulary tiers
and utilization mechanisms (such as prior authorization or
step therapy) employed for drugs in that class; and
``(VII) the total out-of-pocket spending under the plan by
participants and beneficiaries, including spending through
copayments, coinsurance, and deductibles, but not including
any amounts spent by participants and beneficiaries on drugs
not covered under the plan or for which no claim is submitted
under the plan;

``(iii) with respect to any drug for which gross spending
under the group health plan exceeded $10,000 during the
reporting period or, in the case that gross spending under
the group health plan exceeded $10,000 during the reporting
period with respect to fewer than 50 drugs, with respect to
the 50 prescription drugs with the highest spending during
the reporting period--

``(iv) in the case that such plan (or an entity providing
pharmacy benefit management services on behalf of such plan)
has an affiliated pharmacy or pharmacy under common
ownership, including mandatory mail and specialty home
delivery programs, retail and mail auto-refill programs, and
cost sharing assistance incentives funded by an entity
providing pharmacy benefit services--

``(I) an explanation of any benefit design parameters that
encourage or require participants and beneficiaries in the
plan to fill prescriptions at mail order, specialty, or
retail pharmacies;
``(II) the percentage of total prescriptions dispensed by
such pharmacies to participants or beneficiaries in such
plan; and
``(III) a list of all drugs dispensed by such pharmacies to
participants or beneficiaries enrolled in such plan, and,
with respect to each drug dispensed--

``(aa) the amount charged, per dosage unit, per 30-day
supply, or per 90-day supply (as applicable) to the plan, and
to participants and beneficiaries;
``(bb) the median amount charged to such plan, and the
interquartile range of the costs, per dosage unit, per 30-day
supply, and per 90-day supply, including amounts paid by the
participants and beneficiaries, when the same drug is
dispensed by other pharmacies that are not affiliated with or
under common ownership with the entity and that are included
in the pharmacy network of such plan;
``(cc) the lowest cost per dosage unit, per 30-day supply
and per 90-day supply, for each such drug, including amounts
charged to the plan and to participants and beneficiaries,
that is available from any pharmacy included in the network
of such plan; and
``(dd) the net acquisition cost per dosage unit, per 30-day
supply, and per 90-day supply, if such drug is subject to a
maximum price discount; and
``(B) with respect to any group health plan, regardless of
whether the plan is offered by a specified large employer or
whether it is a specified large plan--
``(i) a summary document for the group health plan that
includes such information described in clauses (i) through
(iv) of subparagraph (A), as specified by the Secretary
through guidance, program instruction, or otherwise (with no
requirement of notice and comment rulemaking), that the
Secretary determines useful to group health plans for
purposes of selecting pharmacy benefit management services,
such as an estimated net price to group health plan and
participant or beneficiary, a cost per claim, the fee
structure or reimbursement model, and estimated cost per
participant or beneficiary;
``(ii) a summary document for plans to provide to
participants and beneficiaries, which shall be made available
to participants or beneficiaries upon request to their group
health plan, that--

``(I) contains such information described in clauses (iii),
(iv), (v), and (vi), as applicable, as specified by the
Secretary through guidance, program instruction, or otherwise
(with no requirement of notice and comment rulemaking) that
the Secretary determines useful to participants or
beneficiaries in better understanding the plan or benefits
under such plan;
``(II) contains only aggregate information; and
``(III) states that participants and beneficiaries may
request specific, claims-level information required to be
furnished under subsection (c) from the group health plan;

``(iii) with respect to drugs covered by such plan during
such reporting period--

``(I) the total net spending by the plan for all such
drugs;
``(II) the total amount received, or expected to be
received, by the plan from any applicable entity in rebates,
fees, alternative discounts, or other remuneration; and
``(III) to the extent feasible, information on the total
amount of remuneration for such drugs, including copayment
assistance dollars paid, copayment cards applied, or other
discounts provided by each drug manufacturer (or entity
administering copayment assistance on behalf of such drug
manufacturer) to participants and beneficiaries;

``(iv) amounts paid directly or indirectly in rebates,
fees, or any other type of compensation (as defined in
section 408(b)(2)(B)(ii)(dd)(AA) of the Employee Retirement
Income Security Act (29 U.S.C. 1108(b)(2)(B)(ii)(dd)(AA))) to
brokerage firms, brokers, consultants, advisors, or any other
individual or firm, for--

``(I) the referral of the group health plan's business to
an entity providing pharmacy benefit management services,
including the identity of the recipient of such amounts;
``(II) consideration of the entity providing pharmacy
benefit management services by the group health plan; or
``(III) the retention of the entity by the group health
plan;

``(v) an explanation of any benefit design parameters that
encourage or require participants and beneficiaries in such
plan to fill prescriptions at mail order, specialty, or
retail pharmacies that are affiliated with or under common
ownership with the entity providing pharmacy benefit
management services under such plan, including mandatory mail
and specialty home delivery programs, retail and mail auto-
refill programs, and cost-sharing assistance incentives
directly or indirectly funded by such entity; and
``(vi) total gross spending on all drugs under the plan
during the reporting period.
``(3) Opt-in for group health insurance coverage offered by
a specified large employer or that is a specified large
plan.--In the case of group health insurance coverage offered
in connection with a group health plan that is offered by a
specified large employer or is a specified large plan, such
group health plan may, on an annual basis, for plan years
beginning on or after the date that is 30 months after the
date of enactment of this section, elect to require an entity
providing pharmacy benefit management services on behalf of
the health insurance issuer to submit to such group health
plan a report that includes all of the information described
in paragraph (2)(A), in addition to the information described
in paragraph (2)(B).
``(4) Privacy requirements.--
``(A) In general.--An entity providing pharmacy benefit
management services on behalf of a group health plan shall
report information under paragraph (1) in a manner consistent
with the privacy regulations promulgated under section
13402(a) of the Health Information Technology for Economic
and Clinical Health Act (42 U.S.C. 17932(a)) and consistent
with the privacy regulations promulgated under the Health
Insurance Portability and Accountability Act of 1996 in part
160 and subparts A and E of part 164 of title 45, Code of
Federal Regulations (or successor regulations) (referred to
in this paragraph as the `HIPAA privacy regulations') and
shall restrict the use and disclosure of such information
according to such privacy regulations and such HIPAA privacy
regulations.
``(B) Additional requirements.--
``(i) In general.--An entity providing pharmacy benefit
management services on behalf of a group health plan that
submits a report under paragraph (1) shall ensure that such
report contains only summary health information, as defined
in section 164.504(a) of title 45, Code of Federal
Regulations (or successor regulations).
``(ii) Restrictions.--In carrying out this subsection, a
group health plan shall comply with section 164.504(f) of
title 45, Code of Federal Regulations (or a successor
regulation), and a plan sponsor shall act in accordance with
the terms of the agreement described in such section.
``(C) Rule of construction.--
``(i) Nothing in this section shall be construed to modify
the requirements for the creation, receipt, maintenance, or
transmission of protected health information under the HIPAA
privacy regulations.
``(ii) Nothing in this section shall be construed to affect
the application of any Federal or State privacy or civil
rights law, including the HIPAA privacy regulations, the
Genetic Information Nondiscrimination Act of 2008 (Public Law
110-233) (including the amendments made by such Act), the
Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et
seq.), section 504 of the Rehabilitation Act of 1973 (29
U.S.C. 794), section 1557 of the Patient Protection and
Affordable Care Act (42 U.S.C. 18116), title VI of the Civil
Rights Act of 1964 (42 U.S.C. 2000d), and title VII of the
Civil Rights Act of 1964 (42 U.S.C. 2000e).
``(D) Written notice.--Each plan year, group health plans
shall provide to each participant or beneficiary written
notice informing the participant or beneficiary of the
requirement for entities providing pharmacy benefit
management services on behalf of the group health plan to
submit reports to group health plans under paragraph (1), as
applicable, which may include incorporating such

[[Page H5966]]

notification in plan documents provided to the participant or
beneficiary, or providing individual notification.
``(E) Limitation to business associates.--A group health
plan receiving a report under paragraph (1) may disclose such
information only to the entity from which the report was
received or to that entity's business associates as defined
in section 160.103 of title 45, Code of Federal Regulations
(or successor regulations) or as permitted by the HIPAA
privacy regulations.
``(F) Clarification regarding public disclosure of
information.--Nothing in this section shall prevent an entity
providing pharmacy benefit management services on behalf of a
group health plan, from placing reasonable restrictions on
the public disclosure of the information contained in a
report described in paragraph (1), except that such plan or
entity may not--
``(i) restrict disclosure of such report to the Department
of Health and Human Services, the Department of Labor, or the
Department of the Treasury; or
``(ii) prevent disclosure for the purposes of subsection
(c), or any other public disclosure requirement under this
section.
``(G) Limited form of report.--The Secretary shall define
through rulemaking a limited form of the report under
paragraph (1) required with respect to any group health plan
established by a plan sponsor that is, or is affiliated with,
a drug manufacturer, drug wholesaler, or other direct
participant in the drug supply chain, in order to prevent
anti-competitive behavior.
``(5) Standard format and regulations.--
``(A) In general.--Not later than 18 months after the date
of enactment of this section, the Secretary shall specify
through rulemaking a standard format for entities providing
pharmacy benefit management services on behalf of group
health plans, to submit reports required under paragraph (1).
``(B) Additional regulations.--Not later than 18 months
after the date of enactment of this section, the Secretary
shall, through rulemaking, promulgate any other final
regulations necessary to implement the requirements of this
section. In promulgating such regulations, the Secretary
shall, to the extent practicable, align the reporting
requirements under this section with the reporting
requirements under section 9825.
``(c) Requirement To Provide Information to Participants or
Beneficiaries.--A group health plan, upon request of a
participant or beneficiary, shall provide to such participant
or beneficiary--
``(1) the summary document described in subsection
(b)(2)(B)(ii); and
``(2) the information described in subsection
(b)(2)(A)(i)(III) with respect to a claim made by or on
behalf of such participant or beneficiary.
``(d) Rule of Construction.--Nothing in this section shall
be construed to permit a health insurance issuer, group
health plan, entity providing pharmacy benefit management
services on behalf of a group health plan or health insurance
issuer, or other entity to restrict disclosure to, or
otherwise limit the access of, the Secretary to a report
described in subsection (b)(1) or information related to
compliance with subsections (a), (b), or (c) of this section
or section 4980D(g) by such issuer, plan, or entity.
``(e) Definitions.--In this section:
``(1) Applicable entity.--The term `applicable entity'
means--
``(A) an applicable group purchasing organization, drug
manufacturer, distributor, wholesaler, rebate aggregator (or
other purchasing entity designed to aggregate rebates), or
associated third party;
``(B) any subsidiary, parent, affiliate, or subcontractor
of a group health plan, health insurance issuer, entity that
provides pharmacy benefit management services on behalf of
such a plan or issuer, or any entity described in
subparagraph (A); or
``(C) such other entity as the Secretary may specify
through rulemaking.
``(2) Applicable group purchasing organization.--The term
`applicable group purchasing organization' means a group
purchasing organization that is affiliated with or under
common ownership with an entity providing pharmacy benefit
management services.
``(3) Contracted compensation.--The term `contracted
compensation' means the sum of any ingredient cost and
dispensing fee for a drug (inclusive of the out-of-pocket
costs to the participant or beneficiary), or another
analogous compensation structure that the Secretary may
specify through regulations.
``(4) Gross spending.--The term `gross spending', with
respect to prescription drug benefits under a group health
plan, means the amount spent by a group health plan on
prescription drug benefits, calculated before the application
of rebates, fees, alternative discounts, or other
remuneration.
``(5) Net spending.--The term `net spending', with respect
to prescription drug benefits under a group health plan,
means the amount spent by a group health plan on prescription
drug benefits, calculated after the application of rebates,
fees, alternative discounts, or other remuneration.
``(6) Plan sponsor.--The term `plan sponsor' has the
meaning given such term in section 3(16)(B) of the Employee
Retirement Income Security Act of 1974 (29 U.S.C.
1002(16)(B)).
``(7) Remuneration.--The term `remuneration' has the
meaning given such term by the Secretary, through rulemaking,
which shall be reevaluated by the Secretary every 5 years.
``(8) Specified large employer.--The term `specified large
employer' means, in connection with a group health plan
established or maintained by a single employer, with respect
to a calendar year or a plan year, as applicable, an employer
who employed an average of at least 100 employees on business
days during the preceding calendar year or plan year and who
employs at least 1 employee on the first day of the calendar
year or plan year.
``(9) Specified large plan.--The term `specified large
plan' means a group health plan established or maintained by
a plan sponsor described in clause (ii) or (iii) of section
3(16)(B) of the Employee Retirement Income Security Act of
1974 (29 U.S.C. 1002(16)(B)) that had an average of at least
100 participants on business days during the preceding
calendar year or plan year, as applicable.
``(10) Wholesale acquisition cost.--The term `wholesale
acquisition cost' has the meaning given such term in section
1847A(c)(6)(B) of the Social Security Act (42 U.S.C. 1395w-
3a(c)(6)(B)).''.
(2) Exception for certain group health plans.--Section
9831(a)(2) of the Internal Revenue Code of 1986 is amended by
inserting ``other than with respect to section 9826,'' before
``any group health plan''.
(3) Enforcement.--Section 4980D of the Internal Revenue
Code of 1986 is amended by adding at the end the following
new subsection:
``(g) Application to Requirements Imposed on Certain
Entities Providing Pharmacy Benefit Management Services.--In
the case of any requirement under section 9826 that applies
with respect to an entity providing pharmacy benefit
management services on behalf of a group health plan, any
reference in this section to such group health plan (and the
reference in subsection (e)(1) to the employer) shall be
treated as including a reference to such entity.''.
(4) Clerical amendment.--The table of sections for
subchapter B of chapter 100 of the Internal Revenue Code of
1986 is amended by adding at the end the following new item:

``Sec. 9826. Oversight of entities that provide pharmacy benefit
management services.''.

SEC. 202. FUNDING COST SHARING REDUCTION PAYMENTS.

Section 1402 of the Patient Protection and Affordable Care
Act (42 U.S.C. 18071) is amended by adding at the end the
following new subsection:
``(h) Funding.--
``(1) In general.--There are appropriated out of any monies
in the Treasury not otherwise appropriated such sums as may
be necessary for purposes of making payments under this
section for plan years beginning on or after January 1, 2027.
``(2) Limitation.--
``(A) In general.--The amounts appropriated under paragraph
(1) may not be used for purposes of making payments under
this section for a qualified health plan that provides health
benefit coverage that includes coverage of abortion.
``(B) Exception.--Subparagraph (A) shall not apply to
payments for a qualified health plan that provides coverage
of abortion only if necessary to save the life of the mother
or if the pregnancy is a result of an act of rape or
incest.''.

The SPEAKER pro tempore. The bill shall be debatable for 1 hour,
equally divided and controlled by the chair and ranking minority member
of the Committee on Education and Workforce or their respective
designees, the chair and ranking member of the Committee on Energy and
Commerce or their respective designees, and the chair and ranking
member of the Committee on Ways and Means or their respective
designees.
The gentleman from Michigan (Mr. Walberg), the gentleman from
Virginia (Mr. Scott), the gentleman from Kentucky (Mr. Guthrie), the
gentleman from New Jersey (Mr. Pallone), the gentleman from Missouri
(Mr. Smith), and the gentleman from Massachusetts (Mr. Neal) shall each
control 10 minutes.
The Chair recognizes the gentleman from Kentucky.

General Leave

Mr. GUTHRIE. Mr. Speaker, I ask unanimous consent that all Members
may have 5 legislative days in which to revise and extend their remarks
and insert extraneous material on the legislation, H.R. 6703.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Kentucky?
There was no objection.
Mr. GUTHRIE. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, I rise today in strong support of H.R. 6703, the Lower
Health Care Premiums for All Americans Act.
When the Democrats passed ObamaCare over a decade ago, they sold the
bill on the promise that it would lower healthcare costs and preserve
plan options. If you like your plan, you can keep it and if you like
your doctor, you can keep them, we remember being quoted. These famous
last words still haunt us.

[[Page H5967]]

Today, we know that ObamaCare has not lived up to the Democrats'
lofty promises. Instead, the consequences of that bill continue to
burden American patients as they have since its enactment. Healthcare
spending has nearly doubled since ObamaCare passed.
Healthcare plan options have been decimated by Democratic overreach,
and millions of Americans are saddled with medical debt across the
country.
ObamaCare premiums are up 80 percent since the program's inception,
with patients paying on average $5,000 out of their own pocket to hit
their deductible. The average out-of-pocket spending maximum for 1 year
is over $20,000. Without a doubt, ObamaCare has proven to be
unaffordable and unsustainable.
In an attempt to respond to the affordability crisis created by
ObamaCare, Democrats leveraged a public health emergency to shovel
hundreds of billions of dollars to big health insurance plans to mask
the risk of rising unaffordability of coverage. First, in the American
Rescue Plan of 2021 and then again in the Inflation Reduction Act of
2023, Democrats sent temporary taxpayer-funded enhanced premium tax
credits directly to the coffers of big insurance plans.
They did this without a single Republican vote of support. On both
occasions, Democrats chose to make these COVID credits temporary. They
could have made them permanent, but they chose instead to focus on
advancing priorities for wealthy Americans, which some of these they
did make permanent by subsidizing electric vehicles for politically
connected cronies to siphon off Federal dollars of the greenhouse gas
slush fund.
Now, Democrats are uniting behind that policy to send billions more
of taxpayer dollars to big health insurance plans. With the Democrats'
temporary COVID credits set to expire at the end of the year, they are
attempting to turn their policy failures into political gains using the
American people as collateral.
It is worth reiterating. Democrats funded temporary Band-Aids to
cover up unaffordable care. They set the expiration dates. They chose
to fund liberal priorities instead of making them permanent.
While Democrats continue to fearmonger, I want to shed light on what
Republicans are doing to fix the Democrats' affordability crisis, with
policies that deliver real, lasting relief to the American people.
These include eliminating health plan gimmicks like silver loading,
which will lower ACA premiums by 11 percent; increasing transparency
for pharmacy benefit managers, the middlemen that will lower costs of
drugs for all Americans; and increasing affordable plan choices and
putting patients back in the driver's seat for their own healthcare
plan choices by instituting association health plans, CHOICE
arrangements, and stop-loss insurance.
This proposal results in more than double the premium reduction that
Democrats' extension of the enhanced tax credit subsidies would. The
Congressional Budget Office estimates this plan will lower premiums by
11 percent compared to just 5 percent from the Democratic subsidies.
These policies will also lower healthcare costs for all Americans, not
just the roughly 7 percent enrolled in the ObamaCare marketplace. Many
of these policies are bipartisan: Ending silver loading, addressing
nefarious PBM practices, and strengthening the employer insurance
marketplace all have garnered broad bipartisan support.
I hope we can overlook politics that are clouding the issue and come
together to pass this bill and continue to work together in 2026 to
deliver more affordable healthcare to all Americans.
Mr. Speaker, I reserve the balance of my time.

{time} 1120

Mr. PALLONE. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, I rise to call on Speaker Johnson to immediately bring
the bipartisan 3-year extension of the Affordable Care Act tax credits
to the floor. This bill now has the support, pursuant to a discharge
petition, of a majority of House Members and should get a vote
immediately before the ACA tax credits expire.
Mr. Speaker, without this tax credit extension bill by Mr. Jeffries,
health insurance premiums are going to skyrocket for more than 20
million Americans across the country. They will see prices double,
triple, and even quadruple. It will leave millions with the difficult
decision of going without coverage because they simply cannot afford
rising costs.
Just days before prices skyrocket for American families, Republicans
are bringing a bill to the floor that does absolutely nothing to lower
prices. Instead, Republicans are using this affordability crisis to
prop up junk health insurance plans that discriminate against people
and leave them hanging when they get sick.
Mr. Speaker, the American people are desperate for our help, and this
Republican bill doesn't do a thing to provide it. This bill is a sham,
and a majority of the House knows it.
I urge my colleagues to vote ``no.'' We should take real action
immediately by passing the Jeffries bill.
Mr. Speaker, I reserve the balance of my time.
Mr. GUTHRIE. Mr. Speaker, I yield 2 minutes to the gentlewoman from
Iowa (Mrs. Miller-Meeks), the sponsor of this legislation.
Mrs. MILLER-MEEKS. Mr. Speaker, I rise today in strong support of my
bill, the Lower Health Care Premiums for All Americans Act, a bill
rightfully named because that is exactly what it does.
Republicans want to lower healthcare costs and premiums for all
Americans, all the Americans on commercial insurance, all the small
businesses, all the people on the ACA exchanges, and all the self-
insured, not just a select few, and not subsidizing profitable
insurance companies.
Insurance, especially bad insurance, is not care.
The Lower Health Care Premiums for All Americans Act offers
commonsense solutions to America's broken healthcare system.
It lowers premiums through choice and competition. By expanding
association health plans, we give small businesses and self-employed
workers the buying power of large employers, cutting premiums by as
much as 30 percent.
It gives families control over their dollars. We strengthen CHOICE
arrangements, allowing defined contributions and pretax options so
workers can choose the right plan for their needs, rather than being
stuck in plans that cost too much and deliver too little care.
It brings transparency transparent to drug pricing. We take on the
pharmacy benefit managers, which have long operated behind the scenes
as middlemen, collecting hidden fees while prescription prices climb.
Our reforms force transparency so families can finally see where their
healthcare dollars go and pay less at the pharmacy counter.
It protects access to employer-sponsored insurance. By clarifying
access to stop-loss insurance, we safeguard small businesses from being
financially ruined by catastrophic health claims.
It stabilizes premiums responsibly. We responsibly fund cost-sharing
reduction payments, lowering ACA premium costs for all in the
marketplace by 11 percent. This policy alone results in an average
premium savings of $900 nationally, while reducing Federal spending,
saving taxpayers $36 billion.
Contrary to what we hear from my colleagues on the other side of the
aisle, the premium tax credits continue and revert back to their 2021
levels.
This bill delivers what Americans have been asking for: lower
premiums, more choices, and a healthcare system that works for them,
not against them. It is time to put all Americans and their doctors in
the driver's seat and ahead of profitable insurance companies.
Mr. Speaker, I urge my colleagues to support this legislation.
Mr. PALLONE. Mr. Speaker, before I yield time, I will make sure that
the gentlewoman from Iowa knows that without the ACA tax credit
extension, a middle-class 60-year-old couple in her district is seeing
their premium go up by $1,422 per month.
Mr. Speaker, I yield 2 minutes to the gentlewoman from Massachusetts
(Ms. Clark), the Democratic whip.
Ms. CLARK of Massachusetts. Mr. Speaker, I thank the gentleman for
yielding.
Mr. Speaker, my question to the Republican Party is, what are you
doing?

[[Page H5968]]

What are you doing? Why won't you use your immense powers as the
majority to help the American people?
The bill before us does nothing for the 15 million Americans who are
about to lose their health insurance, the 1 million children who are
about to become uninsured, the hundreds of hospitals that are closing
or on the verge of closing, or the 24 million people who are staring
down premiums they simply cannot afford.
It does nothing to solve a crisis that the Republicans have inflicted
on the American people, but, but, but, in typical fashion, here is what
it does do. It does promote the GOP dream of a nationwide abortion ban.
You found time for that, but today is the day to stop these tax
credits from expiring. You called us back in July from recess to make
sure that we voted on tax cuts, to make them permanent for the very
richest Americans, but now that we have a bipartisan discharge petition
ready to vote on today, you can't find the time to do it.
We are ready to vote, Mr. Speaker. You have the power to bring that
to the floor today.
Let the will of the people be the will of the people's House. Let's
stop the premium hikes, extend the ACA tax credits, and get back to
building a healthcare system that is worthy of the American people.
Mr. GUTHRIE. Mr. Speaker, I will remind my friends that the premium
tax credits from the ACA are extended. They are permanent. These are
the enhanced premium tax credits. It is good, and sad, that my
colleagues are recognizing that the Affordable Care Act is failing.
Mr. Speaker, I yield 2 minutes to the gentleman from Texas (Mr.
Pfluger), my good friend and leader on the Energy and Commerce
Committee.
Mr. PFLUGER. Mr. Speaker, I will remind my colleagues across the
aisle that not a single Republican has ever voted for ObamaCare. This
is your plan. You put it into law. It was a disaster then. It is a
disaster now. It was more expensive now than it has ever been, and it
is your plan. It is our job to fix it, which is exactly what we are
doing.
Mr. Speaker, ObamaCare has failed to deliver on its promises. It has
left millions of Americans with higher premiums. Again, your votes did
that. It has fewer choices, less coverage, and is plagued by fraud,
waste, and abuse.
Mr. Speaker, I recently had a constituent write to me, outlining her
and her husband's experience, demonstrating systematic fraud within the
ACA marketplace. Her husband has been repeatedly enrolled in an ACA
plan without consent since November 2023 in a scheme where brokers and
agents are fraudulently enrolling individuals to collect commissions
and meet enrollment quotas. This broker gained unauthorized access to
his prescription records and replaced his legitimate employer-sponsored
insurance coverage at his pharmacy.
I wish I could say that these examples are one-time instances, but we
know they are not. The system was built for this kind of fraud. They
represent the broader failure that is ObamaCare.
We must take action to fix this broken system and make healthcare
actually affordable, not the Ponzi scheme that it currently is.
The Lower Health Care Premiums for All Americans Act is a great first
step toward this mission, and we will drive down health insurance
premiums immediately by 11 percent through cost-sharing reduction
payments, provide patients with greater transparency, and support small
businesses that offer employment-based healthcare.
Mr. Speaker, we should do more as a Republican Conference, including
creating Trump health freedom accounts and allowing Americans to shop
across State lines, encouraging competition.
Not a single Republican ever voted for your plan, but we are fixing
it now. This is a good first step.
Mr. PALLONE. Mr. Speaker, before I yield time, I will make sure that
the gentleman from Texas knows that without the ACA tax credit
extension, a middle-class 60-year-old couple in his district is seeing
their premium go up by $2,049 per month.
Mr. Speaker, I yield 1 minute to the gentlewoman from California (Ms.
Matsui).

{time} 1130

Ms. MATSUI. Mr. Speaker, I rise today in opposition to this bill.
This should be called the lower healthcare premiums for none act.
Next year, my constituent, Natalie's, insurance will go from $175 to
$400 a month, a fifth of her monthly wages. She is a college student
who relies on her insurance for mental health care. She wrote to me: I
don't want to pick between my dream, mental health, and food.
What does this bill do for her? Nothing. I know Republicans are
getting similar calls. Yet, instead of caring about the millions of
Americans who are being forced to make impossible choices, they are
putting up this sham of a bill. They should be ashamed.
Mr. Speaker, we came here to deliver for our constituents. Let's vote
on a clean extension and avert the cliff. Let's put an end to this
scam.
Mr. GUTHRIE. Mr. Speaker, I yield myself 1 minute.
Mr. Speaker, we have heard sad stories. Last night, in the Rules
Committee, the Rules chairman read through different stuff. The Rules'
ranking member was in townhalls and heard stories about people who had
to buy care on the Affordable Care Act marketplace that is failing.
There is one thing nobody has ever answered. They say they have to
face their constituents. Do my colleagues explain to their constituents
that in the bill that they voted for that gave billions of dollars of
the Green New Deal; in the same bill they set these tax cuts to expire?
I know it was during reconciliation they could have done them within
10 years instead of 5. They also could have done them permanently.
There is a way in reconciliation to do them permanently, as well.
No one on the other side has ever explained why they chose to make
these tax credits expire. I am still waiting to hear the answer for
that.
In the meantime, we have our bill that will lower premiums,
calculated by CBO, in the individual market by 11 percent, as opposed
to the 5 percent that would happen if we just passed the enhanced tax
credits. Not just the 7 percent in the ObamaCare marketplace will
benefit but all Americans will benefit from this bill.
Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I want to make sure the chairman from
Kentucky knows that a middle-class, 60-year-old couple in his district
is seeing their premium go up by $1,711 per month unless we extend the
ACA tax credits.
Mr. Speaker, I yield 1 minute to the gentlewoman from Florida (Ms.
Castor), the ranking member of the Subcommittee on Energy.
Ms. CASTOR of Florida. Mr. Speaker, I rise to oppose this Republican
charade and to stand up for my neighbors back home who deserve quality
and affordable health coverage. That includes over half a million of my
hardworking neighbors across the Tampa Bay area.
Mr. Speaker, 4.7 Floridians, or one in five who live in the Sunshine
State, are doing everything right. They are entrepreneurs. They are
caregivers.
They are part-time workers and small business owners like Linda
Misener and her husband. Their premiums will go from $288 per month to
over $3,200 per month next year. They cannot afford $39,000 for their
healthcare. They are terrified that they are going to lose everything.
David, who is being treated for pancreatic cancer, is unsure how he
will continue treatments and afford everything else.
It is unconscionable that Republicans are ripping away coverage to
fund their tax breaks for billionaires, the wealthy, and the well-
connected. Americans deserve so much better.
Mr. Speaker, defeat this Republican bill. Bring the 3-year bipartisan
extension to the floor now.
Mr. GUTHRIE. Mr. Speaker, I yield myself 30 seconds.
Mr. Speaker, I again ask the question: Why were these set to expire?
We hear the stories that people are reading about people in their
districts, and they say how it is unconscionable. It is unconscionable
that money was spent on the Green New Deal at the expense of the
enhanced tax credits they talk about.
We want to solve it. Mr. Speaker, $39,000 is what is brought up for

[[Page H5969]]

healthcare. That is the problem in America. Mr. Speaker, $39,000 for
health insurance is what we have to fix.
Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentleman from New
York (Mr. Tonko), the ranking member of our Subcommittee on
Environment.
Mr. TONKO. Mr. Speaker, as a result, 4 million people will lose their
insurance. Everyone else on an ACA plan will pay more for worse
coverage, while billionaires sit comfortably and enjoy their tax breaks
from the One Big Beautiful Bill Act.
Remember in the summer and fall, when Republicans told us that this
wasn't the right time to negotiate these subsidies over the shutdown,
they said: Don't worry. That doesn't expire until later in the year. We
are working on a plan.
Later is here. What does this Republican plan do to extend the ACA
subsidies? It does nothing. It does absolutely nothing. This is
unacceptable and downright cruel. While I am disappointed that
Republicans refuse to extend this lifeline, I am not surprised. They
had no intention of voting on extending ACA subsidies.
In fact, I heard that Republican leadership told my fellow New York
Republicans that they needed to find a way to pay for the ACA subsidy
extension if they wanted to even have a vote on it.
Playing under the Republicans' new rules, shouldn't this be free, or
does that math only apply for their billionaire buddies and their tax
breaks?
Mr. Speaker, I urge every Member who cares about their constituents
having affordable healthcare to oppose this plan and sign Leader
Jeffries' petition. Do it for the people.
Mr. GUTHRIE. Mr. Speaker, I reserve the balance of my time.

Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentlewoman from
California (Ms. Barragan), a member of our committee.
Ms. BARRAGAN. Mr. Speaker, Americans should run away as far and as
fast as they can from Republicans' last-minute mess of a healthcare
plan.
Under the Republicans' plan, millions of Americans will not be able
to afford health insurance because Republicans don't provide money for
Americans to pay for the healthcare under the Affordable Care Act.
Americans don't have an extra $1,000 or $2,000 in their pockets every
month to pay for health insurance. They shouldn't have to choose
between being able to afford a doctor's visit or feeding their family.
House Democrats' discharge petition will extend the tax credits that
lower costs and help Americans buy health insurance. Mr. Speaker, four
Republicans just joined our efforts. We welcome more.
Speaker Johnson should bring the bill to the floor immediately. Don't
send Congress on holiday without making sure that we protect healthcare
for over 20 million Americans.
Mr. GUTHRIE. Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentlewoman from
Massachusetts (Mrs. Trahan), also a member of our committee.
Mrs. TRAHAN. Mr. Speaker, this vote is a waste of time. Nothing in
this Republican healthcare plan will stop Americans' healthcare
premiums from skyrocketing.
When this bill fails to become law--and it will fail--20 million
Americans will see their premiums surge on January 1. Many will not
even be able to afford hundreds or even thousands more each month, they
will lose their healthcare coverage completely.
This is a partisan exercise that does nothing to address the crisis
before us. That is why, moments ago, four Republicans signed onto the
bipartisan legislation to end this crisis and protect Americans'
healthcare, giving it the signatures necessary to be considered on the
House floor. The American people expect us to act with urgency,
decisiveness, and transparency.
Mr. Speaker, cancel this vote. Call up the bipartisan bill to save
Americans' healthcare before you take another vacation.
Mr. GUTHRIE. Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, may I inquire as to how much time is
remaining.
The SPEAKER pro tempore. The gentleman from New Jersey has 1 minute
remaining. The gentleman from Kentucky has 15 seconds remaining.
Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentlewoman from
Texas (Mrs. Fletcher), the vice ranking member of the Energy and
Commerce Committee.
Mrs. FLETCHER. Mr. Speaker, I rise in opposition to the
disingenuously named Lower Healthcare Premiums for All Americans Act,
which does not, in fact, lower healthcare premiums for all Americans.
In response to political pressure from the very real healthcare
crisis before us, House Republicans have rushed this bill to the floor
without input from House Democrats and without going through the Energy
and Commerce Committee, as it should, or any actual legislative
process.
That might sound like it is in the weeds, but it is not. It is a
glaring failure to engage in real and meaningful policy that the
country is demanding. It is a response to the crisis that this
Republican Congress has created with the cuts it made earlier this year
and its failure to extend the premium tax credits, which we can fix
today. It is another example of this Congress failing to do its real
work.
We have to see the big picture here. Congress isn't working as it
should. Speaker Johnson and House Republicans are pushing this bill on
the floor to address a political crisis, not the healthcare crisis.
If House Republicans were serious, this bill would actually do
something to lower costs. Instead, the experts tell us this bill will
do nothing to decrease costs for Americans and nothing to curb junk
plans, but it does have a backdoor ban on abortion for people on ACA
plans.
The SPEAKER pro tempore. The time of the gentleman from New Jersey
(Mr. Pallone) has expired.
Mr. GUTHRIE. Mr. Speaker, I yield myself the balance of my time.
Mr. Speaker, we are here to solve the problem for all Americans. Mr.
Speaker, 20 million people are trapped in the Affordable Care Act
marketplace. Our proposal lowers those premiums by 11 percent.
There are over 160 million Americans who get it through their
employers. There are Americans on other types of health insurance. We
need to fix this problem.
My good friend from Florida, Mr. Speaker, said $39,000 is what they
pay for health insurance. That is the problem. That is what we need to
fix.
Mr. Speaker, I yield back the balance of my time.

{time} 1140

The SPEAKER pro tempore. The gentleman from Missouri (Mr. Smith) and
the gentleman from Massachusetts (Mr. Neal) will each control 10
minutes.
The Chair recognizes the gentleman from Missouri.
Mr. SMITH of Missouri. Mr. Speaker, I yield myself such time as I may
consume.
Mr. Speaker, when it comes to healthcare, Republicans are focused on
lowering costs and expanding choice for all Americans. That is 347
million people, not just 7 percent of the population, which is all you
are going to hear from the other side of the aisle, and that is all you
have been hearing from the other side of the aisle.
Mr. Speaker, for more than a decade, Democrats have promised that
ObamaCare would lower costs. They actually named the bill the
``Affordable Care Act.'' Find one American--find one American who says
that their healthcare is now cheaper today than it was when they passed
this disastrous bill. You won't. You won't find one.
In fact, the sky is falling because of their enhanced premium tax
credits that they made temporary because they decided to make permanent
tax benefits for wealthy environmentalists who support them. That is
why we are where we are today.
Mr. Speaker, since ObamaCare has passed, we have seen 150-plus
hospitals close their doors. Since ObamaCare has passed, we have seen
premiums go up more than 80 percent. It doesn't sound like the
Affordable Care Act by any means.
Even worse, the Government Accountability Office has confirmed what
Republicans have been warning for years: ObamaCare is riddled with

[[Page H5970]]

waste, fraud, and abuse. The GAO led a covert investigation by creating
fictitious ObamaCare applicants with fake documentation where 100
percent of those applicants were accepted and enrolled.
Guess what? A year later, this year, of that 100 percent, 90 percent
were still receiving subsidies. That means that insurance companies
were still being subsidized for fake accounts where the people didn't
even exist.
Data analysis from GAO also finds that 58,000-plus enrollees matched
Social Security numbers with death records, with 7,000 of them dead
before enrollment even began. There were dead people on the rolls, but
what do they want to do? Their answer is to just continue the same old-
same old by extending the current program with no reforms.
Mr. Speaker, one Social Security number alone had more than 125
different policies attached to it--just one. This all came from the
GAO. This didn't come from the House Republicans.
We should not continue propping up a system that has completely
failed to lower costs for Americans. The Lower Healthcare Premiums for
All Americans Act takes a much different approach. It is one that
delivers real relief.
First, it provides more freedom and flexibility through CHOICE
Arrangements, empowering small businesses to offer tax-free benefits so
that their employees can find health coverage that works for them.
This levels the playing field for small businesses, putting them on
equal footing with large employers when competing for workers. These
arrangements are proven to be successful. In fact, 83 percent of
employers using CHOICE Arrangements are offering coverage for the very
first time.
The bill also brings transparency to pharmacy benefit managers,
requiring them to open up the books to finally give employers the data
that they need to increase competition and negotiate better drug prices
for workers. The result: Healthcare costs and premiums will be lowered
for all--for all Americans, not just the 7 percent that the Democrats
are fighting for in the enhanced COVID-era premium tax credits, but
also for the 300 million-plus Americans.
Mr. Speaker, ObamaCare has driven costs up and choice down. This bill
does the complete opposite.
Mr. Speaker, I urge my colleagues to support the Lower Healthcare
Premiums for All Americans Act and stand with families, workers, and
small businesses who deserve--they deserve a real affordable,
accountable healthcare plan.
Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, the Republican bill was put together with bubble gum and
Elmer's glue last Friday night. This isn't a plan. It sounds like their
argument that 300-year-olds are receiving Social Security benefits.
Families are staring at massive premium hikes, and now, thanks to
four Republicans, we can force a vote. When you listen to the argument
earlier from the gentleman from Texas (Mr. Pfluger), he said that
Republicans never had a chance to vote on the Affordable Care Act. This
morning, we want to give you a chance.
Speaker Johnson could end this crisis and bring the bill up. Instead,
they are wasting time on this dusty bill that will increase the number
of uninsured Americans, and that is a fact. People don't need
healthcare that costs more and covers less. To stave off this crisis,
this bipartisan discharge petition is a workable path forward, and over
the course of the next few minutes, we intend to tell you that you can
hear why.
Mr. Speaker, I reserve the balance of my time.
Mr. SMITH of Missouri. Mr. Speaker, I yield 2 minutes to the
gentleman from Texas (Mr. Arrington), the chairman of the Budget
Committee.
Mr. ARRINGTON. Mr. Speaker, let me simplify the debate today for the
American people.
Republicans are bringing forward reforms that will actually lower the
cost of care. According to CBO, which is the gold standard for my
Democratic colleagues, it will reduce premiums by 11 percent.
Mr. Speaker, the only other time premiums have gone down since
ObamaCare was enacted was when Republicans actually advanced reforms in
the One Big Beautiful Bill Act; namely, rooting out waste, fraud, and
abuse. That lowered the cost of care.

We continue to bail out the unaffordable care act and actually make
it more affordable, along with other policies that provide the Federal
assistance to the people, not insurance agencies, and give the private
market more competition and transparency so that people have more
choice. That is our plan, and it lowers costs for everybody.
The Democrats are trying to put forward an extension of a COVID-era,
fraud-ridden subsidy that has proven time and again--GAO, CBO, all the
watchdogs say it is fraught with tens of billions of dollars of fraud.
Tens of thousands of Social Security numbers from dead people have been
used to siphon money away from this program.
Millions of people, according to CBO, are ineligibly on the program,
and the answer from the Democrats is to perpetuate this fraud bag,
which is a completely egregious and reckless thing to do as stewards of
tax dollars. This is not to mention that it is propping up the
underlying program that, year after year, has raised premiums and
deductibles two times--it has doubled premiums and deductibles since
ObamaCare has been enacted.
We have fewer choices. Things are worse.
As Ronald Reagan said so beautifully, so aptly, in this moment, I
can't think of any better words: ``Government is not the solution . .
.'' here. Democrats all have proven that. ``Government is the
problem,'' and we have the solution that actually delivers the
affordability to the American people.
Mr. Speaker, I urge my colleagues to support it.
Mr. NEAL. Mr. Speaker, I yield 45 seconds to the gentleman from
California (Mr. Thompson).

{time} 1150

Mr. THOMPSON of California. Mr. Speaker, I thank the gentleman for
yielding.
Mr. Speaker, I rise to call for a vote immediately to save America's
healthcare.
Across our country, American families are being squeezed by high
grocery prices, high utility bills, and soaring costs for holiday
gifts. Families can't afford to pay double for their healthcare.
Republicans cut $1 trillion from healthcare to give a tax break to
their billionaire donors. Americans of every party stripe are being
hurt, and they have had enough.
This morning, four Republicans joined every Democrat to sign a
petition forcing you to hold a vote on our bill that will save
healthcare for 4 million people. Mr. Speaker, it is your turn to act.
Hold the vote to save healthcare now.
It is important to point out that the CBO analysis that my Republican
friends keep talking about says that it is going to cost 100,000 people
more every year for healthcare.
Hold the vote on the bill that will save healthcare.
The SPEAKER pro tempore. Members are reminded to direct their remarks
to the Chair.
Mr. SMITH of Missouri. Mr. Speaker, I yield 2 minutes to the
gentleman from Oklahoma (Mr. Hern).
Mr. HERN of Oklahoma. Mr. Speaker, I am pleased this bill is coming
to the floor today.
Every patient's health needs are unique, and every person's situation
is different. This is why it is so important to expand and protect the
different options available to individuals, and this bill does exactly
that. It gives the decisionmaking process back to the American people.
I am honored that this package includes my bill, the CHOICE
Arrangement Act, which makes it easier for small businesses--something
that I know something about after 35 years in business--to offer
healthcare coverage. It gives individuals more options to choose health
plans that work for them.
CHOICE accounts put individuals in the driver's seat when it comes to
picking their healthcare plan and lets their employer financially
support their decision. This empowers people in one of their most
personal decisions, their healthcare.

[[Page H5971]]

Over the last 15 years, healthcare has become unaffordable for
everyone, including 164 million Americans covered by employer-sponsored
plans. Yet, my colleagues on the other side of the aisle continue to
ignore these individuals in their healthcare conversations.
The gentleman from California just stated, ``This is for 4 million,''
what they are talking about. We want to lower the healthcare costs for
over 300 million people in America.
Premiums are rising for all Americans, whether you are on the
exchange or an employer-sponsored plan, whether you are a Democrat or a
Republican, whether you are healthy or you are unhealthy.
We should be focused on making healthcare affordable for all
Americans and include those on the exchange, employer-sponsored plans,
Medicare, and Medicaid.
The provisions of this bill are a start to doing so by giving
Americans what they need: lower costs, more choices, and increased
transparency.
Mr. Speaker, I strongly urge my colleagues to vote ``yes.''
Mr. NEAL. Mr. Speaker, I yield 45 seconds to the gentleman from
Connecticut (Mr. Larson).
Mr. LARSON of Connecticut. Mr. Speaker, I thank Mr. Neal for the
time.
Mr. Speaker, a constituent in my district in Middletown is going to
be paying more for health insurance than he does for his mortgage.
Let's cut right to the chase. This is about a vote for the American
people. This great democracy that we live in, this Chamber that could
once actually discuss and debate issues, Speaker Johnson should be
bringing this bill to the floor today.
Do Republicans have the courage to vote, or are they going to run and
hide? Four Republicans have stood up and said: You know what, in a
democracy, this deserves a vote.
Listen carefully, American people, how they decry this bill, yet they
won't even have a vote.
Mr. SMITH of Missouri. Mr. Speaker, may I inquire as to how much time
I have remaining.
The SPEAKER pro tempore. The gentleman from Missouri has 1 minute and
15 seconds remaining.
Mr. SMITH of Missouri. Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield 45 seconds to the gentleman from
Illinois (Mr. Davis).
Mr. DAVIS of Illinois. Mr. Speaker, I got this note this morning from
a constituent of mine who said: ``Dear Congressman Davis, I wish you
were voting to extend the tax credits for healthcare today. I am a
single mother with a daughter in college. Without these Federal tax
credits, we will be in an extremely vulnerable position. Accessing
healthcare would be virtually impossible, and the stability of our
lives would be at serious risk. These tax credits are not just helpful.
They are essential. I don't know what we would do without them.''
Mr. Speaker, I agree with Shameka.
Mr. SMITH of Missouri. Mr. Speaker, I yield 1 minute to the gentleman
from Ohio (Mr. Miller).
Mr. MILLER of Ohio. Mr. Speaker, Ohio families and small businesses
continue to face unprecedented healthcare costs, making it increasingly
difficult for my constituents to access affordable, high-quality care.
Since the enactment of the so-called Affordable Care Act in 2010,
healthcare costs have risen dramatically, with premiums increasing by
more than 25 percent over the last 5 years. This trend makes clear that
our Nation's healthcare system needs reform to lower costs for patients
and ensure stability for providers.
The Lower Health Care Premiums for All Americans Act is a critical
step forward in curbing rising premiums, expanding choice, and
improving transparency. The legislation includes provisions to improve
affordability, particularly for small businesses, along with cost-
sharing reduction funding and PBM reforms.

As we move toward these goals, I urge the adoption of the Lower
Health Care Premiums for All Americans Act and remain committed to
reforming a broken healthcare system, increasing choice and competition
to lower healthcare costs for our Nation.
Mr. NEAL. Mr. Speaker, I yield 45 seconds to the gentlewoman from
Alabama (Ms. Sewell).
Ms. SEWELL. Mr. Speaker, I rise today in strong opposition to this
bill.
In a matter of days, roughly 130,000 people in my home State of
Alabama will lose their healthcare coverage because Republicans in this
body refuse to extend the ACA tax credits. Millions of Americans will
find themselves one diagnosis away from bankruptcy.
Rather than addressing the crisis that they created, Republicans are
pushing legislation that will make matters worse. Not only does this
bill fail to extend the tax credits, but it promotes junk insurance
plans that will rip off consumers and make healthcare even more
unaffordable.
House Republicans are incapable of dealing with our Nation's
affordability crisis. They should stop their political games and put
the bipartisan Jeffries bills on the floor today.
Mr. Speaker, we deserve better. My constituents deserve better. Every
American deserves better.
Mr. SMITH of Missouri. Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield 45 seconds to the gentlewoman from
California (Ms. Chu).
Ms. CHU. Mr. Speaker, in 2 weeks, 22 million Americans will see their
health insurance premiums skyrocket, not by accident, but because
Republicans refuse to extend ACA tax credits that keep care affordable.
After 15 years, this is the Republican healthcare plan: higher costs,
weaker coverage, and recycled ACA sabotage. Millions will pay hundreds
or thousands of dollars more, and millions could lose coverage
altogether.
Democrats have a solution right now and have the 218 bipartisan
signatures for a clean bill to extend these tax credits. Speaker
Johnson must put this bill on the floor now. The consequences are real.
The American people are watching.
Mr. SMITH of Missouri. Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield 45 seconds to the gentlewoman from
Wisconsin (Ms. Moore).
Ms. MOORE of Wisconsin. Mr. Speaker, I thank Mr. Neal for the time.
Mr. Speaker, time is up. The ACA tax credits are expiring December
31.
The ACA premium tax credits have provided healthcare access for 15
years to over 20 million people who were previously uninsured. The ACA
has saved lives, but time is up. America can't wait another 15 years
for Republicans to offer a real healthcare proposal that provides full
coverage to all Americans.
``Lowering healthcare costs'' may be in the title, but it is nowhere
in this proposal today.
I know that my own Senator, Ron Johnson, a millionaire, has told me
he would be just fine reverting to the pre-ACA world of high-risk pools
and plans with limited benefits. This bill carries us back to a time
when millions have an insurance card in their wallets that covers
little to nothing.
The SPEAKER pro tempore. The time of the gentlewoman has expired.
Ms. MOORE of Wisconsin. The one big, beautiful bill transferred
healthcare dollars--
The SPEAKER pro tempore. The gentlewoman is out of order. Her time
has expired.
Mr. SMITH of Missouri. Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield 1 minute to the gentleman from New
York (Mr. Jeffries), the minority leader, who has done a terrific job
on managing this legislation.

{time} 1200

Mr. JEFFRIES. Mr. Speaker, let me first thank Richard Neal, the once
and future chairman of the powerful Ways and Means Committee, as well
as Frank Pallone, Bobby Scott, all my colleagues in government on the
Democratic side, and the Republicans who have joined us now to make
sure that we extend the Affordable Care Act tax credits which are
scheduled to expire at the end of this month.
For months now, Democrats have made clear that we have a broken
healthcare system that Republicans continue to destroy. They have
exacerbated our healthcare crisis month after month after month,
including with the one big, ugly bill, with the largest cut to Medicaid
in American history, ripping healthcare away from 14 million Americans.

[[Page H5972]]

Hospitals, nursing homes, and community-based health centers are
closing all across the country, including in rural America because of
the Republican healthcare crisis.
Republicans, Mr. Speaker, continue to attack the National Institutes
of Health, the Centers for Disease Control, the FDA, and vaccine
availability.
Republicans have launched an all-out assault on the healthcare of the
American people, and it continues today with this toxic piece of
legislation that will rip healthcare away from an additional 4 million
people and jam junk health insurance plans down the throats of the
American people.
Democrats are strongly opposed to this legislation, and the American
people know Republicans have zero credibility on fighting to protect
their healthcare.
In this great country of ours, the wealthiest country in the history
of the world, it should be the case, we believe, that access to high-
quality healthcare should not simply be a privilege available only to
the wealthy, the well-off, and the well-connected. Access to high-
quality healthcare should be a right available to every single
American. That is what House Democrats are continuing to fight hard to
achieve.
One of the ways we can make sure that we strive to achieve that
principle is to extend the Affordable Care Act tax credits, which are
scheduled to expire in 15 days. That means that tens of millions of
Americans, working-class Americans, middle-class Americans, people in
urban America, rural America, small-town America, suburban America, the
heartland of America, Black and Brown communities all throughout
America, tens of millions of people, Americans of every stripe, in
every region, are about to experience their health insurance premiums
increase in some instances by $1,000 or $2,000 per month. That is
unacceptable.
Now, we have a bipartisan coalition here in the House of
Representatives, at least 218 votes, to extend the Affordable Care Act
tax credits for 3 years, to provide everyday Americans with the
certainty they deserve in terms of being able to afford to go see a
doctor when they need one.
Mr. Speaker, Republicans need to bring the Affordable Care Act tax
credit extension bill to the floor today. Under no circumstances should
we leave this Capitol this week before voting on an extension of the
Affordable Care Act tax credit bill that we know will pass, that the
votes exist, in a bipartisan way, to protect the healthcare of everyday
Americans.
House Democrats have made clear we are in this fight until we win
this fight, to cancel the cuts, lower the costs, save healthcare, and
extend the Affordable Care Act tax credits.
Mr. SMITH of Missouri. Mr. Speaker, I include in the Record the
bombshell GAO report showing the waste, fraud, and abuse within the
ObamaCare exchanges.
GAO, U.S. Government

Accountability Office,

Washington, DC, December 3, 2025.
Hon. Brett Guthrie,
Chairman, Committee on Energy and Commerce,
House of Representatives.
Hon. Jim Jordan,
Chairman, Committee on the Judiciary,
House of Representatives.
Hon. Jason Smith,
Chairman, Committee on Ways and Means,
House of Representatives.

Patient Protection and Affordable Care Act: Preliminary Results from
Ongoing Review Suggest Fraud Risks in the Advance Premium Tax Credit
Persist

The Patient Protection and Affordable Care Act (PPACA)
provides premium tax credits to those who purchase private
health insurance plans and meet certain income and other
requirements. Individuals may have the federal government pay
this credit to their health insurance issuers in advance on
their behalf, known as the advance premium tax credit (APTC),
which lowers their monthly premium payments.
Millions of consumers have purchased health insurance plans
through the marketplaces established under PPACA. The Centers
for Medicare & Medicaid Services (CMS), within the Department
of Health and Human Services (HHS), is responsible for
maintaining the federal Marketplace and overseeing state-
based marketplaces. Under PPACA, states may elect to operate
their own state-based marketplace or to use the federal
Marketplace. These marketplaces determine eligibility for
APTC, based in part on income, and allow individuals to
compare and choose among insurance plans offered by
participating private health care coverage issuers. CMS
estimated it paid nearly $124 billion in APTC for about 19.5
million enrollees for plan year 2024.
Consumers can enroll in health insurance coverage through a
marketplace independently or with assistance, such as from an
insurance agent or broker. As discussed later in this report,
agents and brokers can help a consumer apply for coverage,
including for related financial assistance, and enroll in a
plan. Assistance from an agent or broker is of no cost to a
consumer. Rather, agents and brokers are allowed to receive
compensation directly from health insurance issuers in
accordance with agreements with those issuers and any
applicable state requirements.
Indictments from December 2024 and February 2025 highlight
concerns about agent and broker practices in the federal
Marketplace. Specifically, the indictments allege that bad
actors enrolled consumers in insurance through the federal
Marketplace by falsifying information on their applications.
Additionally, according to CMS, the agency received
approximately 275,000 complaints between January and August
2024 that consumers were enrolled in a plan or had their plan
changed without their consent. Such practices can result in
wasteful federal spending on APTC for enrollees who are not
eligible. Further, such practices can result in harm and
unexpected costs for consumers. These can include loss of
access to medical providers and medications, higher
copayments and deductibles, or repayment of APTC if income or
other eligibility was misrepresented.
We previously reported that APTC is at risk of fraud. For
example, in September 2016, we found that federal and state
marketplaces approved coverage for our fictitious applicants.
Nearly all of these fictitious applicants remained covered
after we sent fictitious documents or no documents to resolve
issues with our applications. Further, in July 2017, we found
that CMS did not design processes to verify eligibility for
APTC, including preventing duplicate coverage.
You asked us to review issues related to fraud risk
management in APTC. This report is based on preliminary
results and analyses from that ongoing work. Specifically.
this report addresses preliminary results from our
1. covert testing of federal Marketplace enrollment
controls'for plan years 2024 and 2025,
2. analyses of federal Marketplace enrollment data for plan
years 2023 and 2024, and
3. evaluation of CMS's fraud risk assessment and antifraud
strategy for APTC.
To perform covert testing of federal Marketplace enrollment
controls, we created 20 fictitious identities and submitted
applications for individual health care coverage in the
federal Marketplace. We submitted applications for four of
these fictitious identities in October 2024 for coverage
through December 2024, which was the remainder of that plan
year. We pursued coverage for plan year 2025 for all 20
fictitious identities, including the four identities for
which we already submitted applications. Our covert testing
for plan year 2025 is ongoing, since the plan year is not yet
complete. As a result, we will describe additional details of
the 2025 applications in a future report.
Our covert testing included applications submitted
independently through HealthCare.gov, which is the federal
Marketplace's website, and applications submitted with
assistance from an insurance agent or broker. For all our
applicant scenarios, we sought to act as an ordinary
consumer would in attempting to make a successful
application. For example, if, during online applications,
we were directed to make phone calls to complete the
process, we acted as instructed.
For applications for plan year 2024, our covert tests
included fictitious applicants who provided invalid (i.e.,
never issued) Social Security numbers (SSN). Additionally, we
stated income at a level eligible to obtain APTC. As
appropriate, we used publicly available information to
construct our applications for coverage and subsidies. We
also used publicly available hardware, software, and
materials to produce counterfeit documents that we submitted,
if appropriate for our testing, when instructed to do so. We
then observed the outcomes of the document submissions, such
as any approvals received or requests to provide additional
supporting documentation. The results of our covert testing,
while illustrative of potential enrollment control
weaknesses, cannot be generalized to the overall enrollment
population.
To examine federal Marketplace enrollment for plan years
2023 and 2024, we obtained and analyzed federal Marketplace
enrollment and payment data, including APTC information, from
CMS. We also matched enrollee SSNs in the data to two
additional data sources: (1) Social Security Administration's
(SSA) full death file, a database containing records of death
that have been reported to SSA, as of November 2024 and (2)
April 2025 data from the Internal Revenue Service (IRS) on
APTC reconciliation from tax forms filed for tax year 2023.
We assessed the reliability of all data sets by performing
electronic tests to determine the completeness and accuracy
of key fields. We also reviewed agency documentation and
interviewed knowledgeable agency officials about the
reliability of the data. Overall, we found that the data were
reliable for our purposes.
To examine CMS's fraud risk assessment and antifraud
strategy for APTC, we reviewed documentation of CMS's
policies and fraud risk management activities related to
APTC. This included CMS's 2018 fraud risk

[[Page H5973]]

assessment for APTC. Additionally, we interviewed agency
officials about CMS's fraud risk management activities in
this program. We reviewed relevant reports from GAO and HHS's
Office of the Inspector General. We evaluated information
from relevant documentation and interviews of agency
officials against relevant leading practices in GAO's A
Framework for Managing Fraud Risks in Federal Programs (Fraud
Risk Framework).
To support all three objectives, we interviewed CMS
officials and representatives from seven stakeholder
organizations that represent agents and brokers, state
insurance regulators, researchers, and one of the entities
that CMS approved to host a non-marketplace website where
consumers can apply for and enroll in a plan offered through
the federal Marketplace.
The ongoing work upon which this report is based is being
conducted in accordance with generally accepted government
auditing standards. Those standards require that we plan and
perform the audit to obtain sufficient, appropriate evidence
to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our
preliminary findings and conclusions based on our audit
objectives. Additionally, our related investigative work is
being conducted in accordance with standards prescribed by
the Council of the Inspectors General on Integrity and
Efficiency.

Background

APTC Eligibility and Enrollment Processes
APTC Eligibility
To qualify for a premium tax credit, individuals must be
enrolled in a qualified health plan offered through a
marketplace and meet certain criteria. These tax credits can
be paid in advance through APTC. See figure 1 for the APTC
eligibility requirements.
The amount of the premium tax credit varies based on
household income and the cost of a benchmark plan. The credit
limits what the consumer would pay for that plan to be no
more than a certain percentage of their household income. The
American Rescue Plan Act of 2021 made temporary changes to
premium tax credits by expanding eligibility to higher-income
individuals and increasing premium tax credits for lower-
income individuals for tax years 2021 and 2022. For example,
the law increased the premium tax credit amounts for eligible
individuals and families, resulting in access to plans with
no premium contributions for those earning 100 to 150 percent
of the federal poverty level. It also expanded eligibility
for premium tax credits to include certain individuals and
families with incomes at or above 400 percent of the
federal poverty level. Public Law 117-169--commonly known
as the Inflation Reduction Act of 2022--extended these
provisions through the end of tax year 2025. See table 1.
In 2013, CMS developed the Data Services Hub (Hub) to help
verify applicant eligibility in an automated manner. To do
so, the Hub matches applicant information, such as SSN and
estimated income, against trusted data sources. These sources
include records from SSA and IRS. In the federal Marketplace,
the system generates an inconsistency when data matching
processes are not able to verify applicant information
against the Hub's trusted sources. When an inconsistency is
generated, applicants are instructed to provide documentation
to support information on their applications that cannot be
verified by the Hub's data matching.
Marketplaces and Enrollment Pathways
States, along with the District of Columbia, may elect to
rely on the federal Marketplace or operate their own health
insurance marketplace. Table 2 describes the types of health
insurance marketplaces.
The federal Marketplace offers multiple pathways to enroll
in health insurance coverage and receive APTC. Consumers in
states that use the federal Marketplace may enroll in
coverage through the pathway known as HealthCare.gov or an
enhanced direct enrollment (EDE) pathway, among others. Table
3 describes examples of enrollment pathways in the federal
Marketplace.
Role of Agents and Brokers
Consumers seeking to obtain health insurance through the
federal Marketplace may receive assistance from agents and
brokers who help them apply for coverage, including related
financial assistance, and enroll in a health plan. In return,
agents and brokers receive payment (commissions or salaries)
from the issuers of the health plans. Agents and brokers must
be licensed in the state in which they sell plans and
registered with CMS to sell plans through the federal
Marketplace. According to CMS, most enrollments in the
federal Marketplace are assisted by an agent or broker
through the EDE and direct enrollment pathways.
CMS is responsible for oversight of agents and brokers in
the federal Marketplace and ensuring that they comply with
federal rules. Agents and brokers are required to, among
other things, obtain and document consumers' consent before
assisting them with applying for and enrolling in coverage
through the federal Marketplace. For example, consumer
consent is required before the agent or broker can:
collect or use any personally identifiable information,
such as name, date of birth, and SSN;
help a consumer apply for coverage or financial assistance
by completing an eligibility application on their behalf; and
actively enroll a consumer in a plan offered through the
federal Marketplace.
After a consumer has applied or is enrolled, the agent or
broker can also update a consumer's eligibility application
or plan selection on their behalf, if the initial consent
authorized the agent or broker to do so, or if they obtained
subsequent consent for any new actions. Agents and brokers
are required to make documentation of consumer consent
available to CMS upon request in response to monitoring,
audit, and enforcement actions.
Fraud Risk Management
The objective of fraud risk management is to ensure program
integrity by continuously and strategically mitigating both
the likelihood and effects of fraud, while also facilitating
a program's mission. The Fraud Risk Framework provides a
comprehensive set of leading practices that serve as a guide
for agency managers to use when developing efforts to combat
fraud in a strategic, risk-based manner. As depicted in
figure 2, the framework organizes the leading practices
within four components: (1) Commit, (2) Assess, (3) Design
and Implement, and (4) Evaluate and Adapt.
In June 2016, the Fraud Reduction and Data Analytics Act of
2015 (FRDAA) required the Office of Management and Budget
(OMB) to establish guidelines for federal agencies to create
controls to identify and assess fraud risks to design and
implement antifraud control activities. The act further
required OMB to incorporate the leading practices from the
Fraud Risk Framework in the guidelines. The Payment Integrity
Information Act of 2019 repealed FRDAA but maintained the
requirement for OMB to provide guidelines to agencies in
implementing the Fraud Risk Framework.
In its 2016 Circular No. A-123 guidelines, OMB directed
agencies to adhere to, the Fraud Risk Frameworks leading
practices. In October 2022, OMB issued a Controller Alert
reminding agencies that they must establish financial and
administrative controls to identify and assess fraud risks.
In addition, the alert reminded agencies that they should
adhere to the leading practices in the Fraud Risk Framework
as part of their efforts to effectively design, implement,
and operate an internal control system that addresses fraud
risks.

The Federal Marketplace Approved Subsidized Coverage for Nearly All of
Our Fictitious Applicants in Plan Years 2024 and 2025, Suggesting
Weaknesses Persist

Our convert testing of enrollment controls in the federal
Marketplace suggests weaknesses have persisted since our
tests in plan years 2015 through 2016. All four of our
fictitious applications received subsidized coverage through
the federal Marketplace in late 2024. Additionally, although
our work is ongoing, as of September 2025 18 of our 20
fictitious applications for plan year 2025 were receiving
subsidized coverage. We will continue to monitor the status
of these applications during plan year 2025.
All Four of Our Fictitious Applicants Received Subsidized
Coverage in Late 2024
To test enrollment controls, we developed and submitted
four fictitious applications to obtain insurance coverage
with APTC through the federal Marketplace. We applied for
coverage for these four applicants in October 2024. We
submitted the applications outside of the open enrollment
period, using a special enrollment period for low-income
applicants. in two cases, we applied for coverage directly
through HealthCare.gov. In the other two cases, we applied
via telephone with assistance from an insurance broker. The
brokers that assisted us used EDE systems to submit our
applications.
The federal Marketplace approved fully subsidized insurance
coverage for all four of our fictitious applicants for
November through December 2024. The combined total amount of
APTC paid to insurance companies for all four fictitious
enrollees was about $2,350 per month. While our fictitious
enrollees are not generalizable to the universe of enrollees,
they suggest weaknesses in enrollment controls--such as
identity proofing and income verification--in the federal
Marketplace through both HealthCare.gov and EDE systems.
Table 4 summarizes the results of our covert testing of
enrollment controls for plan year 2024.
The results of our covert testing for plan year 2024 are
generally consistent with results of similar testing we
conducted for plan years 2014 through 2016.

Mr. NEAL. Mr. Speaker, I yield 45 seconds to the gentleman from
Virginia (Mr. Beyer).
Mr. BEYER. Mr. Speaker, earlier this year, House Republicans passed a
bill that strips healthcare from millions of Americans and raises costs
for millions more.
That was a monstrous bill, but this is a cowardly bill. It does
nothing to stop the skyrocketing costs that we have been warning about
for months. Nothing in this bill will extend the tax credits that help
20 million Americans afford health insurance.
This bill won't stop the Republican cuts that will raise my
constituents' costs by $900 a month or restore coverage to millions
whose coverage was sacrificed to give billionaires tax cuts.
The developed countries around the world have figured out how to give
affordable healthcare to their citizens.

[[Page H5974]]

A vote for this bill is a vote for the Republican healthcare crisis.
Mr. SMITH of Missouri. Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield 45 seconds to the gentleman from
Illinois (Mr. Schneider).
Mr. SCHNEIDER. Mr. Speaker, my Republican colleagues are saying we
are seeing inflation. Inflation in healthcare has been going on for
generations. In fact, during the years of the George W. Bush
administration, premiums increased 118 percent.
The Republican-led legislation they are presenting to us today is
barely even a concept of a healthcare plan. After 15 years of efforts,
they should be embarrassed by this slapdash effort.
Not only does the bill not address the expiring tax credits, it hurts
patients, it hurts families, and it hurts women and seniors.
I want to be very clear. My Republican colleagues are taking zero
action to extend the tax subsidies that help American families provide
insurance to their families.
We need to do better. We can vote today on a clean 3-year extension
because we have Republicans who have joined Democrats to call for that.
Mr. Speaker, I urge my colleagues to support the 3-year extension.
Mr. SMITH of Missouri. Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield 45 seconds to the gentleman from
California (Mr. Panetta).
Mr. PANETTA. Mr. Speaker, if we don't extend the tax credits for the
Affordable Care Act, costs for healthcare will go up for 20 million
people and millions more will lose their health insurance.
Three-quarters of those who rely on those tax credits live in
Republican-won States. Yet Speaker Johnson and President Trump, who are
in charge and had all year to do anything, to do something, on
healthcare, did nothing.
Rather than fulfill the President's promise to reduce prices, they
gave tax breaks to billionaires, they gutted Medicaid, and they added
trillions to our debt.
I get that division and dysfunction define the Republican Party, but
we can't keep letting it define Congress. Put the Democratic discharge
petition on the floor, extend the tax credits, so that together we can
actually do something to fix healthcare. By doing that, we do our job,
not just in Congress but for all Americans.
Mr. SMITH of Missouri. Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield 45 seconds to the gentleman from
Nevada (Mr. Horsford).
Mr. HORSFORD. Mr. Speaker, after 15 years of talk, House Republicans
have finally brought their healthcare bill to the floor, yet it fails
working families. Despite its name, it does nothing to lower costs.
Republicans found time to lock in tax breaks for big corporations and
billionaires but not the urgency or respect to help Americans afford
their healthcare.
House Democrats are 100 percent united, and now four Republicans,
after months of delay, have finally chosen to join us to extend the
advanced premium tax credits.
That is why it is time for the Speaker to bring the House Democrats'
bipartisan discharge petition to the floor immediately.
Every Member must make a choice. Stand with the working men and women
of this country and small businesses or Donald Trump.
Vote ``no'' on this sham of a bill. Vote ``yes'' on the Jeffries
discharge petition.
Mr. SMITH of Missouri. Mr. Speaker, I have no additional speakers. I
am prepared to close, and I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, may I inquire as to the time remaining.
The SPEAKER pro tempore (Mr. Patronis). The gentleman from
Massachusetts has 30 seconds remaining.
Mr. NEAL. Mr. Speaker, I yield myself the balance of my time.
Mr. Speaker, my constituent company, Merriam-Webster, declared this
week that the word of the year is ``slop,'' and it is appropriate
today.
This bill won't lower costs. Without the ACA tax credits, costs are
going to skyrocket for the American people. That is a bombshell report.
They are undermining protections and forcing people into junk plans.
The only path forward is Leader Jeffries' discharge petition. It is a
3-year extension, clear and clean, bipartisan.
Mr. Speaker, I urge Speaker Johnson to bring this legislation up, and
I yield back the balance of my time.
Mr. SMITH of Missouri. Mr. Speaker, we have heard a lot of comments
from the Democrats on this side of the floor.
Back where I come from, the comments that I have heard, we call it
hogwash, because it has not been true and it has not been factual. This
bill before you will lower healthcare costs for all Americans, not just
the 7 percent that they are fighting for. It lowers costs for all 347
million.
The SPEAKER pro tempore. The time of the gentleman has expired.

{time} 1210

The SPEAKER pro tempore. The gentleman from Michigan (Mr. Walberg)
and the gentleman from Virginia (Mr. Scott) each will control 10
minutes.
The Chair recognizes the gentleman from Michigan.
Mr. WALBERG. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, I rise today in support of H.R. 6703.
Because of the unaffordable care act, healthcare costs are out-of-
control, and small businesses and the families that they employ are
paying the price. The unaffordable care act drove premiums up and added
red tape forcing many small employers to drop coverage or stop offering
it altogether.
Now my Democrat colleagues want to extend enhanced benefits that they
couldn't get their own party to support for more than 3 years when they
passed them.
They made this problem, and now they want us to fix it by doing the
same thing that has extended this problem. They want our family,
friends, and neighbors to suffer further pain as opposed to joining us
and fixing the problem as opposed to extending it.
My bill, the Association Health Plans Act, allows small businesses
and self-employed Americans to band together, like large companies, to
lower costs and deliver high-quality coverage. The CBO report today
estimates that this could cover more than 200,000 previously uninsured
Americans and attract 700,000 people annually to association health
plans.
Complementing this, the Self-Insurance Protection Act, authored by
Representative Bob Onder, shields small businesses from regulatory
overreach while expanding affordable healthcare options.
Together, these measures, included in the Lower Health Care Premiums
for All Americans Act, cut red tape, protect choice, and lower costs.
I plead with my Democrat colleagues to join us in bringing about a
remedy to our healthcare system which is broken because of the
unaffordable care act.
They broke it, but please join us to fix it.
Mr. Speaker, I reserve the balance of my time.
Mr. SCOTT of Virginia. Mr. Speaker, I yield myself such time as I may
consume.
Mr. Speaker, I rise in opposition to the so-called Lower Health Care
Premiums for All Americans Act.
This package includes two partisan proposals marked up in the
Education and Workforce Committee. First, it recklessly expands
association health plans which would allow small employer groups and
individuals to join associations to offer health insurance that are
subject to fewer regulations than traditional plans in the individual
and small group markets.
AHPs would make it easier for associations to cherry-pick small
employers with younger, mostly male workforces who are healthier and
can be charged lower rates. Smaller employers whose workers are older
and sicker would remain in the traditional market. Simple arithmetic
dictates that if you pull healthy groups out, then all of those left
behind will be paying more.
Furthermore, these plans, if history is any guide, will show that
they are more vulnerable to fraud and insolvency than those in the
marketplace.
The second proposal is the Self-Insurance Protection Plan which would
prohibit the Department of Labor and States from ever regulating stop-
loss

[[Page H5975]]

insurance, inviting nefarious practices that could hurt consumers and
employers by creating loopholes for plans that will escape any
regulatory oversight.
Further, Mr. Speaker, this plan does nothing to extend the ACA
enhanced tax credits which are set to expire. Millions of people will
see their premiums skyrocket, and millions more won't be able to afford
any insurance at all. If we bring up the bipartisan bill, then we could
avoid that result.
Mr. Speaker, I reserve the balance of my time.
Mr. WALBERG. Mr. Speaker, I yield 2 minutes to the gentleman from
Utah (Mr. Owens), who is the chairman of the Subcommittee on Higher
Education.
Mr. OWENS. Mr. Speaker, today I rise to speak in strong support of
the Lower Health Care Premiums for All Americans Act.
This legislation will make it easier for small businesses to offer
quality, affordable healthcare coverage to their employees by allowing
them to band together to have access to the same regulatory and
economic benefits as large group plans.
Right now, small businesses are on an unequal playing field with
larger companies and unions. Because they have fewer employees, small
business have limited bargaining power when it comes to negotiating
lower insurance costs for their workers. Since 2010, the share of small
businesses with fewer than 50 employees offering health coverage has
dropped from 39 to 30 percent.
Small businesses have ranked the cost of health insurance as their
number one problem for 32 straight years. For nearly four decades, it
has remained the top concern. In fact, 98 percent of small businesses
report that healthcare costs will become unsustainable in the next 5 to
10 years, threatening their ability to survive and remain competitive.
This is not because small businesses do not want to offer healthcare
benefits. Small business owners work very hard to provide for their
employees. The problem is that healthcare in this country has become
simply unaffordable for far too many businesses and working families.
Employers are looking for innovative solutions to lower costs and
increase coverage for their employees. When asked, 79 percent of
employers reported they were interested in joining an association
health plan. We know these plans work. Under the first Trump
administration's association health plan rule, healthcare costs for
those enrolled in an AHP decreased for some industries by more than 50
percent.
The Lower Health Care Premiums for All Americans Act would level the
playing field for small businesses and empower their employees to
access quality healthcare at a lower cost. It also represents an
essential step toward purchasing health insurance across State lines.
As we continue our efforts to lower costs for small business owners
and workers, this is just one step we can take to make sure that more
Americans can access high-quality, affordable healthcare.

Mr. Speaker, I urge my colleagues to vote ``yes'' on H.R. 6703.
Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the gentleman
from California (Mr. DeSaulnier), who is the ranking member of the
Health Employment Subcommittee.
Mr. DeSAULNIER. Mr. Speaker, I thank the ranking member for yielding.
Mr. Speaker, I rise as a former small business owner having over
three decades owning and managing restaurants in strong opposition to
this sad healthcare plan.
After kicking 10 million Americans off Medicaid in the big, ugly
bill, Republicans are following up with this proposal that the
Congressional Budget Office says will take healthcare away from an
additional 100,000 Americans a year.
We need to make healthcare more affordable for all Americans. Despite
spending 18\1/2\ percent of our GDP in the United States on healthcare,
we have the worst outcomes: the highest mortality rate, life
expectancy, and acuity.
We need to make it more affordable. I agree with the ranking member
and the chair that we should work together on the inefficiencies in the
system. However, this is not it.
After spending 15 years on their healthcare plan, Republicans have
just repackaged some of their old ideas, and they are hoping the
American people won't notice that it is not going to help. Instead, we
should extend the tax credits for 3 years and come together.
Mr. WALBERG. Mr. Speaker, I yield 2 minutes to the gentleman from
California (Mr. Kiley), who is the chairman of the Subcommittee on
Early Childhood, Elementary, and Secondary Education.

{time} 1220

Mr. KILEY of California. Mr. Speaker, I will be voting for this
measure today because the policy is good, but let's be realistic. It is
extremely modest, and it has no chance of becoming law because it was
hastily thrown together without, apparently, any bipartisan input, when
bipartisan support is necessary to pass any measure like this.
However, worst of all, the bill does not address the immediate urgent
problem in front of us, which is that 22 million people are about to
pay a lot more for health insurance. These are independent contractors,
freelancers, gig workers, and Uber drivers. It is small business owners
and their employees, and retirees who are not yet eligible for Medicare
who are going to pay thousands of dollars more in many cases. Some
people won't be able to afford health insurance at all.
What are we supposed to tell these folks? ``Oh, don't worry, it is
Obama's fault.'' Or, ``Oh, no, don't worry, we did a show vote on this
Lower Health Care Premiums for All Americans Act.'' Is that going to be
any consolation?
Now, I have been extremely critical of the House Speaker for refusing
to put any measure to extend these tax credits on the floor, and I
think that criticism right now is more well deserved than ever.
We have in the past seen measures come to the floor that divided the
Republican Conference but that were able to pass with bipartisan
support on continuing resolutions or on foreign aid bills. There is no
reason that cannot be done here, and let the House work its will. That,
after all, is the best expression of the will of the people.
What about the minority leader, Hakeem Jeffries? He has had every
opportunity to endorse a compromise measure that has a temporary
extension with reforms. There are three bills that have numerous
bipartisan coauthors, but instead of supporting any of those, he has
directed his Members to only support an uncompromising measure that has
zero bipartisan cosponsors. That has already been rejected by the
Senate and so has no chance of becoming law.
This whole issue encapsulates what is wrong with this institution,
where party leaders focus most of their time and energy on trying to
blame problems on the other side rather than trying to solve those
problems, but it is not too late for action now. I am calling on the
Speaker or the minority leader or both to get a bill to the floor. That
is what this institution needs. It is what America needs.
Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the
gentlewoman from North Carolina (Ms. Adams), the ranking member of the
Higher Education and Workforce Development Subcommittee.
Ms. ADAMS. Mr. Speaker, I rise to speak for the 186 Americans who
have lost their lives today, not because of disease or illness, but
because they did not have access to the health insurance they needed to
get treatment.
Every year, 68,000 Americans die because they do not have health
insurance, and Republicans have chosen to turn their backs on these
Americans and make this crisis worse.
Not only does their bill fail to extend the ACA tax credits,
something that helps 88,000 folks in my district afford health
insurance, it abandons financial assistance for middle-class families
when they are already struggling to make ends meet. It strips away
protections for patients, opening them up to discrimination and
predatory practices. It restricts access to abortion care which, by the
way, is healthcare, putting the government, not a woman and her doctor,
in charge of her body.
People are dying, Mr. Speaker, and it is time Republicans take this
crisis seriously. Republicans need to wake up. Have some compassion.
Our constituents cannot wait. Let's vote ``no'' on

[[Page H5976]]

this awful Republican bill, Mr. Speaker.
Mr. WALBERG. Mr. Speaker, I yield 2 minutes to the gentleman from
Missouri (Mr. Onder).
Mr. ONDER. Mr. Speaker, I rise in strong support of the Lower Health
Care Premiums for All Americans Act, which includes legislation which I
introduced earlier this year, the Self-Insurance Protection Act. This
bill ensures that employers who choose to self-insure retain access to
a critical financial tool: stop-loss insurance.
Many employers choose to self-insure so they can tailor coverage to
the specific needs of their workforce. This flexibility lowers
healthcare costs and increases take-home pay for employees. However,
self-insurance carries a greater financial risk, which is why employers
rely on stop-loss insurance to protect against catastrophic claims.
In recent years, some States have tried to regulate self-insurance
out of existence. States like New York have barred small employers from
purchasing stop-loss insurance. For years, Democrats, in their pursuit
of single-payer healthcare, have tried to regulate it as traditional
health insurance. The Self-Insurance Protection Act makes it clear that
stop-loss insurance is a financial safeguard, not health insurance.
The Lower Health Care Premiums for All Americans Act will expand
access to other options that increase competition and lower costs, like
association health plans. The first Trump administration expanded
access to associated health plans and lowered costs by 26 percent.
Through AHPs, employers can pool together to set up their own
insurance plan and negotiate better healthcare coverage. This approach
could eventually allow Costco or Sam's Club to offer their own
revolutionary low-cost health insurance.
As a physician, I have seen firsthand that increasing competition and
choice lowers costs, and the Lower Health Care Premiums for All
Americans Act will deliver lower costs for the 78 percent of Americans
who receive insurance through their employer. In addition, it will
lower ObamaCare premiums by 11 percent.
Mr. Speaker, I strongly support this bill and urge its passage.
Mr. SCOTT of Virginia. Mr. Speaker, I yield 45 seconds to the
gentleman from Ohio (Mr. Landsman).

Mr. LANDSMAN. Mr. Speaker, of the 22 million Americans who rely on
the Affordable Care Act subsidies, 32,000 live in my district. They are
about to experience healthcare costs that are skyrocketing. They want
one thing, that is it, Mr. Speaker. They want one thing. They want us
to extend the Affordable Care Act subsidies. Eighty percent of
Americans have said this is what they want. These are farmers, small
businesses, and families. If they were in this Chamber today, they
would point to the well and say: There are 218 signatures on this
discharge petition. Just put it on the floor, vote for it, and give us
the subsidies that help us pay for our healthcare.
Mr. WALBERG. Mr. Speaker, I yield 1 minute to the gentleman from
Georgia (Mr. Carter).
Mr. CARTER of Georgia. Mr. Speaker, I rise today in strong support of
the Lower Health Care Premiums for All Americans Act, which is the
right prescription to lower healthcare costs and provide American
citizens with more affordable coverage.
Nearly 15 years ago, the Democrats unaffordable care act broke our
healthcare system. They broke our healthcare system. Since its
inception, ObamaCare premiums have skyrocketed by over 220 percent. A
family of four now pays $10,000 more for coverage today than they did
before ObamaCare, and their deductibles have doubled, in part to offset
waste, fraud, and abuse that runs rampant throughout the program.
Rather than fix the problems of the unaffordable care act, Democrats
in Congress want to continue to send billions of taxpayer money
directly to giant insurance companies and leave families with thousands
of dollars in healthcare costs that they cannot afford.
The unaffordable care act is broken, and throwing more hard-earned
taxpayer money after bad policy is not going to fix it. That is why we
must give power to the patient, not to the big insurance companies.
While Republicans are working to make life more affordable,
Democrats' prescription is to raise taxes. Mr. Speaker, I encourage my
colleagues to support the Lower Health Care Premiums for All Americans
Act.
Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the gentleman
from California (Mr. Takano), the ranking member of the Veterans'
Affairs Committee.
Mr. TAKANO. Mr. Speaker, I rise in strong opposition to this bill.
My Republican colleagues have tried and failed to repeal or weaken
the Affordable Care Act more than 70 times over the past 15 years.
The bill before us does nothing to address the expiring tax credits,
and contrary to what my colleague Mr. Kiley has said, the bill that
would extend the tax credits is bipartisan. It would pass this House.
In the richest country in the world, the country that is the global
leader in medical innovation, Americans will die from treatable
conditions.
Republicans claim that their bill will give consumers more choices.
No choice, this is not about choice. People will have the choice to be
refused health insurance for preexisting conditions by unregulated junk
health insurance plans and be denied reproductive healthcare.
Instead of making the ACA tax credits permanent, Republicans have
once again proposed a piecemeal, nonsolution that makes health
insurance more expensive and strips Americans of their basic healthcare
rights.
Mr. Speaker, vote against this bill. Bring the bipartisan solution to
the floor.
Mr. WALBERG. Mr. Speaker, may I inquire how much time I have
remaining.
The SPEAKER pro tempore. The gentleman from Michigan has 30 seconds
remaining.
Mr. WALBERG. Mr. Speaker, I reserve the balance of my time.
Mr. SCOTT of Virginia. Mr. Speaker, I yield 45 seconds to the
gentlewoman from Virginia (Ms. McClellan).
Ms. McCLELLAN. Mr. Speaker, I rise in opposition to this bill. In
just 15 days, health insurance premiums will skyrocket for more than 20
million Americans.
At a time when people are already struggling with higher costs for
groceries, rent, childcare, and utilities, this bill does nothing to
stop the immediate harm heading their way on January 1.
Here is what that looks like for Virginians in Virginia: A 60-year-
old couple earning $85,600 a year will see their premiums rise by
$15,446, and a family of four earning $66,000 a year will see their
premiums jump $2,651.
Mr. Speaker, these are not abstract numbers. They are small business
owners, employees, farmers, gig workers, self-employed, and more who
will be forced to make impossible choices.
We still have time. We can pass a bill now to extend the tax credits.
We should do so.

{time} 1230

Mr. WALBERG. Mr. Speaker, I am prepared to close, and I reserve the
balance of my time.
Mr. SCOTT of Virginia. Mr. Speaker, may I inquire as to the time
remaining.
The SPEAKER pro tempore (Mr. Rogers of Alabama). The gentleman from
Virginia has 4 minutes remaining.
Mr. SCOTT of Virginia. Mr. Speaker, I yield 45 seconds to the
gentlewoman from Arizona (Mrs. Grijalva).
Mrs. GRIJALVA. Mr. Speaker, I thank the gentleman for yielding.
Mr. Speaker, first and foremost, I will state that nobody should ever
be denied basic healthcare, period. No one is better off when people
are forced to receive healthcare in emergency rooms or receive a later
stage diagnosis because of lack of preventive care and seeing a doctor
on a regular basis.
Over 22 million people, including 400,000 Arizonans, with marketplace
coverage are seeing their premiums skyrocket.
I cannot state this any clearer: People cannot afford to pay more for
their healthcare and shouldn't be forced to. Allowing premiums to
skyrocket, enacting a backdoor abortion ban, and allowing plans to not
cover things like maternity care and preexisting conditions is not a
solution. It is abandonment.

[[Page H5977]]

Mr. Speaker, I urge a ``no'' vote on this bill.
Mr. WALBERG. Mr. Speaker, I reserve the balance of my time.
Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the gentleman
from Louisiana (Mr. Carter).
Mr. CARTER of Louisiana. Mr. Speaker, for months, Democrats have
urged Republicans to come to the table to work together on a clean
extension of the Affordable Care Act tax credits. Now, we are just days
away from the deadline, and Republicans are scrambling to push through
an unserious proposal at the eleventh hour. People aren't stupid. They
can see this.
Their so-called Lower Health Care Premiums for All Americans Act
would have the exact opposite effect than what it claims to do.
Most importantly, it does nothing to extend the ACA tax credits. The
tax credits have been a lifeline for countless hardworking families,
small business owners, and seniors in Louisiana and across our country,
helping them afford coverage in a time when the cost of living
continues to climb. This is something that we, as Members of Congress,
should do. Without these extensions, their premiums will skyrocket.
Healthcare is not a luxury. It is a fundamental human right.
Mr. Speaker, I stand with Leader Jeffries and House Democrats as we
continue our fight for affordable, quality healthcare in this country.
Mr. WALBERG. Mr. Speaker, I reserve the balance of my time.
Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the
gentlewoman from Illinois (Ms. Underwood).
Ms. UNDERWOOD. Mr. Speaker, I rise today because, in just 2 weeks,
the Affordable Care Act tax credits that help millions of Americans
afford their premiums will expire, and this Republican healthcare bill
does absolutely nothing to keep costs from surging.
In fact, every House Democrat has signed a discharge petition for my
bill to extend these tax credits for 3 years, and now four Republicans
have signed on, as well.
For this reason, at the appropriate time, I will offer a motion to
recommit this bill back to committee. If the House rules permitted, I
would have offered the motion with an important amendment to this bill.
My amendment would extend the enhanced premium tax credits for 3
years to do what this Republican bill fails to do and help American
families afford their healthcare.
Mr. Speaker, I ask unanimous consent to include in the Record the
text of this amendment immediately prior to the motion to recommit.
The SPEAKER pro tempore. Is there objection to the request of the
gentlewoman from Illinois?
There was no objection.
Ms. UNDERWOOD. Mr. Speaker, I hope my colleagues will join me in
voting for the motion to recommit.
Mr. WALBERG. Mr. Speaker, I reserve the balance of my time.
Mr. SCOTT of Virginia. Mr. Speaker, may I inquire as to the time
remaining.
The SPEAKER pro tempore. The gentleman from Virginia has 1\1/4\
minutes remaining.
Mr. SCOTT of Virginia. Mr. Speaker, I yield 30 seconds to the
gentleman from California (Mr. Ruiz).
Mr. RUIZ. Mr. Speaker, Republicans just passed their big, ugly law
that rips Medicaid by nearly a trillion dollars, adds 15 million people
uninsured, and raises costs for everybody. Now, to add insult to
injury, they refuse to extend the Affordable Care Act.
This bill that they want to replace it with is a bamboozle. It is a
hoodwink. It is a scam for the American people. It promotes junk plans
that rip off the American people. It does not cover essential health
benefits. It allows them to discriminate against people with
preexisting conditions, increases out-of-pocket costs, and will lead to
millions more uninsured.
Mr. WALBERG. Mr. Speaker, I reserve the balance of my time.
Mr. SCOTT of Virginia. Mr. Speaker, I yield 30 seconds to the
gentlewoman from Oregon (Ms. Dexter).
Ms. DEXTER. Mr. Speaker, I rise today in strong opposition to the GOP
higher healthcare costs for worse coverage act.

I did not spend 20 years as an ICU doctor saving lives to come to
Congress and sit back while Republicans strip healthcare coverage from
millions. No. I came to Congress to fight for affordable, accessible
healthcare for all.
This bill does nothing to accomplish that goal. Worse than that, it
pushes people toward less coverage at a higher cost and opens a
backdoor abortion ban that marches us a step closer to a national one.
Mr. WALBERG. Mr. Speaker, I am prepared to close, and I reserve the
balance of my time.
Mr. SCOTT of Virginia. Mr. Speaker, I yield myself the balance of my
time.
Mr. Speaker, this bill does nothing to reduce costs for all
Americans. By weakening protections, undermining State oversight, and
siphoning healthy individuals out of the ACA, this bill will actually
increase premiums and reduce oversight and protection for families.
We need to extend the 3-year extension for the enhanced tax credits.
I oppose the bill and urge my colleagues to do the same.
Mr. Speaker, I yield back the balance of my time.
Mr. WALBERG. Mr. Speaker, I yield myself the balance of my time.
Mr. Speaker, most Americans rely on employer-provided healthcare, but
government-driven costs are making that coverage more expensive every
year. Families are paying more, and small businesses are struggling to
keep up with the mandates and the red tape.
Americans deserve affordable, high-quality coverage that puts
decisions back where they belong with workers, families, and employers,
not the Federal Government.
Bottom line, the Lower Health Care Premiums for All Americans Act
empowers workers and job creators and makes healthcare more affordable
for everyday Americans. By the way, perchance you want to keep the
unaffordable care act for yourself, you still can.
Mr. Speaker, I yield back the balance of my time.
The SPEAKER pro tempore. All time for debate has expired.
Pursuant to House Resolution 953, the previous question is ordered on
the bill.
The question is on the engrossment and third reading of the bill.
The bill was ordered to be engrossed and read a third time, and was
read the third time.

Motion to Recommit

Ms. UNDERWOOD. Mr. Speaker, I have a motion to recommit at the desk.
The SPEAKER pro tempore. The Clerk will report the motion to
recommit.
The Clerk read as follows:

Ms. Underwood of Illinois moves to recommit the bill H.R.
6703 to the Committee on Energy and Commerce.

The material previously referred to by Ms. Underwood is as follows:

Ms. Underwood moves to recommit the bill H.R. 6703 to the
Committee on Energy and Commerce with instructions to report
the same back to the House forthwith with the following
amendment:

Strike all after the enacting clause and insert the
following:

SECTION 1. EXTENSION OF ENHANCED HEALTH INSURANCE PREMIUM TAX
CREDIT.

(a) In General.--Section 36B(c)(1)(E) of the Internal
Revenue Code of 1986 is amended--
(1) by striking ``January 1, 2026'' and inserting ``January
1, 2029'', and
(2) by striking ``2025'' in the heading thereof and
inserting ``2028''.
(b) Applicable Percentages.--Section 36B(b)(3)(A)(iii) of
such Code is amended--
(1) by striking ``January 1, 2026'' and inserting ``January
1, 2029'', and
(2) by striking ``2025'' in the heading thereof and
inserting ``2028''.
(c) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2025.

The SPEAKER pro tempore. Pursuant to clause 2(b) of rule XIX, the
previous question is ordered on the motion to recommit.
The question is on the motion to recommit.
The question was taken; and the Speaker pro tempore announced that
the noes appeared to have it.
Ms. UNDERWOOD. Mr. Speaker, on that I demand the yeas and nays.
The yeas and nays were ordered.
The SPEAKER pro tempore. Pursuant to clause 8 of rule XX, further
proceedings on this question will be postponed.

[[Page H5978]]

____________________