[Senate Report 116-86]
[From the U.S. Government Publishing Office]
Calendar No. 190
116th Congress } { Report
SENATE
1st Session } { 116-86
_______________________________________________________________________
REPEAL INSURANCE PLANS OF THE
MULTI-STATE PROGRAM ACT
__________
R E P O R T
OF THE
COMMITTEE ON HOMELAND SECURITY AND
GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
TO ACCOMPANY
S. 1378
TO REPEAL THE MULTI-STATE PLAN PROGRAM
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
September 10, 2019.--Ordered to be printed
________
U.S. GOVERNMENT PUBLISHING OFFICE
89-010 WASHINGTON: 2019
_____________________________________________________________________________
COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
RON JOHNSON, Wisconsin, Chairman
ROB PORTMAN, Ohio GARY C. PETERS, Michigan
RAND PAUL, Kentucky THOMAS R. CARPER, Delaware
JAMES LANKFORD, Oklahoma MAGGIE HASSAN, New Hampshire
MITT ROMNEY, Utah KAMALA D. HARRIS, California
RICK SCOTT, Florida KYRSTEN SINEMA, Arizona
MICHAEL B. ENZI, Wyoming JACKY ROSEN, Nevada
JOSH HAWLEY, Missouri
Gabrielle D'Adamo Singer, Staff Director
Joseph C. Folio III, Chief Counsel
Patrick J. Bailey, Chief Counsel for Governmental Affairs
Joshua P. McLeod, Professional Staff Member
David M. Weinberg, Minority Staff Director
Zachary I. Schram, Minority Chief Counsel
Yelena L. Tsilker, Minority Professional Staff Member
Laura W. Kilbride, Chief Clerk
Calendar No. 190
116th Congress } { Report
SENATE
1st Session } { 116-86
======================================================================
REPEAL INSURANCE PLANS OF THE MULTI-STATE PROGRAM ACT
_______
September 10, 2019.--Ordered to be printed
_______
Mr. Johnson, from the Committee on Homeland Security and Governmental
Affairs, submitted the following
R E P O R T
[To accompany S. 1378]
[Including cost estimate of the Congressional Budget Office]
The Committee on Homeland Security and Governmental
Affairs, to which was referred the bill (S. 1378) to repeal the
multi-State plan program, having considered the same, reports
favorably thereon with an amendment (in the nature of a
substitute) and recommends that the bill, as amended, do pass.
CONTENTS
Page
I. Purpose and Summary..............................................1
II. Background and Need for the Legislation..........................2
III. Legislative History..............................................6
IV. Section-by-Section Analysis......................................6
V. Evaluation of Regulatory Impact..................................7
VI. Congressional Budget Office Cost Estimate........................7
VII. Changes in Existing Law Made by the Bill, as Reported............8
I. Purpose and Summary
S. 1378, the Repeal Insurance Plans of the Multi-State
Program Act, or the RIP MSP Act, repeals the Multi-State Plan
(MSP) Program authorized under Section 1334 of the Patient
Protection and Affordable Care Act (ACA). Section 1334 directs
the U.S. Office of Personnel Management (OPM) to ``contract
with private health insurers in each State to offer high-
quality, affordable health insurance options called Multi-State
Plans.''\1\ The MSP Program is not meeting statutory
requirements under the ACA and eliminating this program will
allow OPM to focus on mission-critical programs.\2\
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\1\Patient Protection and Affordable Care Act Sec. 1334 (codified
in 42 U.S.C. Sec. 18054).
\2\On June 18, 2018, the Committee approved S. 2221, the Repeal
Insurance Plans of the Multi-State Program Act. That bill is
substantially similar to S. 1378. Accordingly, this committee report is
in large part a reproduction of Chairman Johnson's committee report for
S. 2221, S. Rep. No. 115-277 (2018).
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II. Background and the Need for Legislation
On March 23, 2010, President Barack Obama signed the ACA
into law.\3\ Section 1334 of the ACA mandated a MSP Program to
increase competition and provide greater insurance choices for
consumers.\4\ To accomplish this task, the MSP authorized the
Director of OPM to contract with health care plans to offer at
least two multi-state plans on each state exchange for
individual or group coverage by 2017, thereby competing against
private plans offered through state exchanges.\5\
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\3\Patient Protection and Affordable Care Act, Pub. L. No. 111-148,
124 Stat. 119 (2010); see also H.R. 3590--Patient Protection and
Affordable Care Act, Congress.gov, https://www.congress.gov/bill/111th-
congress/house-bill/3590/all-actions (last updated Mar. 23, 2010).
\4\U.S. Off. of Pers. Mgmt., a new Day for Federal Service: An
Overview of the Multi-State Plan Program (2014), https://
marketplace.cms.gov/technical-assistance-resources/multistate-plan-
program.pdf; see also Robert Moffit, Will This Little-Known Obamacare
Provision Lead to a Public Option?, Daily Signal (Jan. 15, 2015),
http://dailysignal.com/2015/01/15/will-little-known-obamacare-
provision-lead-public-option.
\5\Patient Protection and Affordable Care Act Sec. 1334, supra note
1.
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Section 1334 was inserted into the ACA by former Senate
Majority Leader Harry Reid during floor consideration, after
the legislation passed the Senate Finance Committee, as part of
a Manager's Amendment.\6\ Due to its late addition, Congress
held no hearings to evaluate the merits of creating the MSP
program.\7\ Staff to former Senator Edward (``Ted'') Kennedy
explained the rushed origins of the program, stating, ``It's
happened so fast, in a brief window, that there was not a lot
of time for robust conversation . . . . The conversation was
like, `this is a good idea, let's cook something up.' It was
definitely not a thoughtful, nuanced conversation.''\8\
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\6\Moffit, supra note 4; S. Amdt. 3276 to H.R. 3590 (Dec. 19,
2009).
\7\See Robert Moffit, Dan Blair & Linda Springer, The Office of
Personnel Management: A Power Player in America's Health Insurance
Markets?, Heritage Found. (Feb. 19, 2010), https://www.heritage.org/
health-care-reform/report/the-office-personnel-management-power-player-
americas-health-insurance.
\8\Sarah Kliff, No, The Public Option is Not Back From the Dead,
Wash. Post: Wonkblog (Oct. 30, 2012), https://www.washingtonpost.com/
news/wonk/wp/2012/10/30/no-the-public-option-has-not-returned-from-the-
dead/?utm_term=.f7fddd750b03.
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News that some members of Congress were nearing an
agreement to create the MSP Program became public in December
2009 when Majority Leader Reid announced that a health reform
working group of ten senators had arrived at a ``tentative
consensus `that includes a public option.'''\9\ The working
group Majority Leader Reid referenced explored several reform
options before settling on the MSP Program. One proposal under
discussion by the working group was a public option; however a
public option in which the government acted directly as the
issuer did not have enough support to pass through
Congress.\10\ As a result, Senator Chuck Schumer (D-N.Y.)
worked with nine of his colleagues to come up with a backup
plan to the public option.\11\ One alternative under
consideration by the working group was the MSP Program through
which OPM would work with private insurers to offer health
insurance plans to compete with other plans available on state
exchanges.\12\ Another alternative was allowing individuals
over the age of 55 to enroll in Medicare.\13\ It was reported
that key Senators withheld support for the second idea, leaving
the MSP Program all that remained.\14\ With a public option in
which the government played the role of insurer off the table,
the MSP Program was added to the ACA as the public option
backup plan, described by some as ``sort of a catch-all for a
lot of different ideas.''\15\
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\9\Timothy Noah, Medicare Buy-in, RIP, Slate: Public Option Wiki
(Dec. 14, 2009), http://www.slate.com/articles/news_and_politics/
prescriptions/2009/12/public_option_wiki.html.
\10\Kliff, supra note 8.
\11\Id.
\12\Id.; Senators seek to put OPM in charge of health care public
option, Government Executive (Dec. 5, 2009) www.govexec.com/federal-
news/2009/12/senators-seek-to-put-opm-in-charge-of-healthcare-public-
option/30472/; see also, OPM could get role running national health
plan, Government Executive (Dec. 6, 2009), www.govexec.com/pay-
benefits/2009/12/opm-could-get-role-running-national-health-plan/
30473/.
\13\Id.
\14\Id.
\15\Rachana Pradhan & Paul Demko, Another Piece of Obamacare Falls
Short, Politico (Sept. 7, 2016), http://www.politico.com/story/2016/09/
obamacare-falls-short-227854.
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Additionally, the law requires OPM to contract with at
least one non-profit provider, and to ensure that at least one
MSP option does not provide abortion coverage.\16\
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\16\Patient Protection and Affordable Care Act Sec. 1334, supra
note 1.
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The MSP program is failing to increase competition and choice
In its sixth year since the program's implementation in
2014, the program is both failing to fulfill program intent and
to meet statutory requirements. The MSP Program was created to
increase both competition and choice in state health care
exchanges.\17\ However, only one issuer association--the Blue
Cross Blue Shield Association (BCBSA)--has ever participated in
the MSP Program, despite a statutory requirement for OPM to
contract with at least two MSP issuers in all 50 states and the
District of Columbia by 2017.\18\ Further, BCBSA already had a
significant market share in the states that participated in the
MSP Program,\19\ and has approximately 70 percent of the market
share in the one remaining state participating (Arkansas) in
the MSP Program.\20\
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\17\S. Rep. No. 111-89 (2009); see also Sabrina Corlette, The
Multi-State Plans Unveiled, Geo. U. Ctr. On Health Ins. Reforms Blog
(Sept. 30, 2013), http://chirblog.org/multi-state-plans-unveiled/.
\18\Patient Protection and Affordable Care Act Sec. 1334, supra
note 1; see also U.S. Off. of Pers. Mgmt., supra note 4; U.S. Off. of
Pers. Mgmt., Multi-State Plan Program and the Health Insurance
Marketplace: FAQs, https://www.opm.gov/healthcare-insurance/multi-
state-plan-program/consumer/?page=1#url=FAQs (last visited Apr. 4,
2018).
\19\Corlette, supra note 17.
\20\Christine Monahan, Oh Where, Oh Where Are The Multi-State
Plans?, Geo. U. Ctr. On Health Ins. Reforms Blog (June 6, 2013), http:/
/chirblog.org/oh-where-oh-where-are-the-multi-state-plans/; see also
Sarah Goodell, The Multi-State Plan Program (Updated), Health Affairs
(May 29, 2014), https://www.healthaffairs.org/do/10.1377/
hpb20140529.10243/full/.
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The Obama administration told issuers to ``assume that each
national plan would have 750,000 people enrolled in the first
year.''\21\ However, approximately 350,000 individuals enrolled
in a MSP option in 2014.\22\ For plan year 2015, MSP coverage
expanded to 36 states and 437,000 individuals.\23\ For plan
year 2016, MSP coverage dipped to approximately 375,000
individuals in 33 states, and in 2017 the MSP enrollment fell
to 290,000 individuals in 22 states.\24\ By 2018, only one
state--Arkansas--was participating in the MSP Program, and
fewer than 48,000 individuals in Arkansas are likely to enroll
in MSP plans in 2019.\25\ With only one state participating,
the program has a state participation success rate of 1.9
percent.
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\21\Robert Pear, U.S. Set to Sponsor Health Insurance, N.Y. Times
(Oct. 27, 2012), https://www.nytimes.com/2012/10/28/health/us-to-
sponsor-health-insurance-plans-nationwide.html.
\22\Document productions from U.S. Off. of Pers. Mgmt. provided to
S. Comm. on Homeland Sec. & Governmental Aff. (Oct. 6, 2017 and Feb.
13, 2018) (on file with S. Comm. on Homeland Sec. & Governmental Aff.).
\23\Id.
\24\Id.
\25\E-mail from U.S. Off. of Pers. Mgmt. staff to S. Comm. on
Homeland Sec. & Governmental Aff. staff (on file with S. Comm. on
Homeland Sec. & Governmental Aff.).
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Shortly prior to passage of the ACA, the Congressional
Budget Office (CBO) questioned the utility of the MSP Program
and whether issuers would participate.\26\ In a 2009 letter to
Majority Leader Reid, CBO wrote:
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\26\Letter from Douglas W. Elmendorf, Dir., Cong. Budget Off., to
Harry Reid, Majority Leader, U.S. Senate (Dec. 19, 2009), http://
www.cbo.gov/sites/default/files/cbofiles/ftpdocs/108xx/doc10868/12-19-
reid_letter_managers_correction_noted.pdf.
[w]hether insurers would be interested in offering
[MSP] plans is unclear, and establishing a nationwide
plan comprising only nonprofit insurers might be
particularly difficult. Even if such plans were
arranged, the insurers offering them would probably
have participated in the insurance exchanges anyway, so
the inclusion of this provision did not have a
significant effect on the estimates of federal costs or
enrollment in the exchanges.\27\
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\27\Id.
At the time, CBO also estimated that the creation of MSP
was ``unlikely to have much effect on average insurance
premiums because the existence of that public plan would not
substantially change the average premiums that would be paid in
the exchanges.''\28\ In evaluating the merits of S. 1378, CBO
found that MSPs are not the lowest-cost or second-lowest cost
silver plans in any rating areas where they are offered.\29\
Because of this, eliminating MSPs would not affect Federal
subsidies for health insurance purchased through the
marketplaces, nor would it affect the Federal budget.\30\
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\28\Id.
\29\Cong. Budget Off., Congressional Budget Office Cost Estimate:
S. 1378 Repeal Insurance Plans of the Multi-State Program Act (2019),
https://www.cbo.gov/publication/55294.
\30\Id.
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On April 29, 2019, OPM notified members of Congress that
the Department would suspend MSP Program operations, beginning
with the 2020 plan year.\31\ In letters to Committee Chairman
Ron Johnson and Ranking Member Gary Peters, Acting Director
Margaret Weichert noted that despite OPM's efforts to encourage
issuer participation in the MSP Program, beginning in 2016,
issuer interest declined considerably.\32\ Due to OPM's
inability to achieve the statutory goals and objectives of the
Program, OPM determined ``the prudent course of action is to
suspend MSP Program operations.''\33\
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\31\Letter from Margaret Weichert to Sen. Ron Johnson (Apr. 29,
2019).
\32\Id.
\33\Id.
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Obamacare's MSP Program detracts OPM from mission-critical programs
that serve the Federal workforce
OPM, the agency tasked under law with the administration of
the MSP Program, supports passage of S. 1378, noting that
``[r]epealing this statutory requirement would allow OPM to
further strengthen its capacity to meet the important needs of
our benefit programs serving the 2.7 million employees of the
Federal workforce and over 2 million Federal workforce
retirees.''\34\
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\34\Letter from OPM Director Pon to Chairman Ron Johnson and
Ranking Member McCaskill, S. Comm. on Homeland Sec. & Governmental Aff.
(June 15, 2018) (on file with S. Comm. on Homeland Sec. & Governmental
Aff.).
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Since 1978, OPM's core mission has been to serve the
Federal workforce.\35\ The creation of the MSP Program diverted
OPM's focus from this mission for the first time by requiring
OPM to begin providing non-Federal services to the American
public.\36\ From fiscal year (FY) 2011 to FY 2019, OPM spent
approximately $60 million in ``salaries and expenses'' to
administer the MSP Program.\37\ This funding supported 42 full-
time equivalents in FY2017 alone.\38\
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\35\Our Mission, Role & History, U.S. Off. of Pers. Mgmt., https://
www.opm.gov/about-us/our-mission-role-history/ (last visited Apr. 4,
2018).
\36\U.S. Off. of Pers. Mgmt., Congressional Budget Justification:
Fiscal Year 2018 2 (2017), https://www.opm.gov/about-us/budget-
performance/budgets/congressional-budget-justification-fy2018.pdf.
\37\Document production from U.S. Off. of Pers. Mgmt. provided to
S. Comm. on Homeland Sec. & Governmental Aff. (Oct. 6, 2017) (on file
with S. Comm. on Homeland Sec. & Governmental Aff.).
\38\Id.
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Prior to FY2019, additional resources were requested for
the MSP Program in the annual Congressional Budget
Justification instead of being requested for mission-critical
programs that serve the Federal workforce and its retirees.
Diverting OPM resources away from its core mission is
significant given the agency is currently struggling to provide
acceptable levels of service to Federal employees.\39\ For
instance, in fiscal year 2017, OPM requested $3.35 million less
money to support processing of its substantial backlog of
Federal retirement claims.\40\ At the same time, OPM expended
$10.3 million for MSP Program salaries and expenses alone.\41\
In its FY2019 Congressional Budget Justification, OPM
recognized the lack of interest and participation in the MSP
Program and proposed reallocating funding to the increasing
needs of other mission critical programs.\42\
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\39\For example, as of June 30, 2019, OPM had an inventory of
18,501 in unprocessed retirement claims. See Michael O' Connell, OPM
Cuts Retirement Backlog to its Lowest Level in More Than a Year, Fed.
News Radio (Jan. 5, 2018), https://federalnewsradio.com/retirement/
2018/01/opm-cuts-retirement-backlog-to-its-lowest-level-in-more-than-a-
year/; see also U.S. Off. of Pers. Mgmt. Statistical Abstracts: Fiscal
Year 2016 (2017).
\40\U.S. Off. of Pers. Mgmt., supra note 36.
\41\Document production from U.S. Off. of Pers. Mgmt. provided to
S. Comm. on Homeland Sec. & Governmental Aff., supra note 37.
\42\U.S. Office of Pers. Mgmt., Congressional Budget Justification
and Annual Performance Plan 85 (2019), https://www.opm.gov/about-us/
budget-performance/budgets/congressional-budget-justification-
fy2019.pdf.
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S. 1378 will allow OPM the ability to focus on mission
critical programs that benefit members of the Federal
workforce, tribes and tribal organizations, and retirees.
Lastly, the volume of staffing devoted to the program has
been disproportionate to the volume of people served. In 2018,
42 employees served no more than 55,000 participants in
Arkansas.\43\ The Federal Employee Health Benefits Program
(FEHBP), by comparison, had 117 full-time employees but served
8.2 million people.\44\ Therefore, throughout most of the
program's existence, OPM has dedicated only 3.3 employees per
100,000 FEHBP enrollees while dedicating 14 employees per
100,000 MSP enrollees.
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\43\Goodell, supra note 20.
\44\See Kirstin B. Blom & Ada S. Cornell, Cong. Res. Serv., R43922,
Federal Employees Health Benefits (FEHB) Program: An Overview (2016),
https://fas.org/sgp/crs/misc/R43922.pdf.
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In addition to the MSP Program detracting from OPM's
mission-critical programs, the program continues to be a
concern for the OPM Office of Inspector General (OIG). In
December 2016, the OIG issued a Management Alert for the
program due to a lack of participation on the part of states
and providers, and confusion about the name incorrectly
signaling coverage would cross state boundaries when MSP
coverage does not.\45\ In FYs 2016 and 2017, the OIG also
included the program in its list of top management challenges
facing the agency.\46\ S. 1378 will repeal the MSP Program and
allow OPM to focus exclusively on mission-critical programs.
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\45\Memorandum from Norbert E. Vint, Deputy Inspector Gen., U.S.
Off. of Pers. Mgmt. Off. of Inspector Gen., to Beth F. Cobert, Acting
Dir., U.S. Off. of Pers. Mgmt. (Dec. 8, 2016), https://www.opm.gov/our-
inspector-general/reports/2016/management-alert-status-of-the-multi-
state-plan-program-4a-hi-00-17-013.pdf.
\46\U.S. Off. of Pers. Mgmt. Off. of Inspector Gen., Top Management
Challenges: Fiscal Year 2017 (2017), https://www.opm.gov/our-inspector-
general/special-reports-and-reviews/fy2017-top-management-
challenges.pdf; see also Memorandum from Norbert E. Vint, Deputy
Inspector Gen., U.S. Off. of Pers. Mgmt. Off. of Inspector Gen. to Beth
F. Cobert, Acting Dir., U.S. Off. of Pers. Mgmt. (Oct. 12, 2016),
https://www.opm.gov/our-inspector-general/special-reports-and-reviews/
fy2016-management-challenges.pdf.
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III. Legislative History
S. 1378, the RIP MSP Act, was introduced on May 8, 2019, by
Chairman Ron Johnson along with Senators John Barrasso, Mike
Braun, Roger Wicker, Mike Lee, Lamar Alexander, Michael Enzi,
Kevin Cramer, and Rand Paul. The bill was referred to the
Committee on Homeland Security and Governmental Affairs.
The Committee considered S. 1378 at a May 15, 2019 business
meeting. A substitute amendment offered by Chairman Johnson
removed a rescission of unused funds provision, and a related
Sense of Congress, to ensure Federal funds remain in OPM's
control for authorized functions. The substitute amendment was
adopted by unanimous consent.
The Committee ordered S. 1378, as amended, reported
favorably, by a roll call vote of 8 ``yeas'' to 4 ``nays.''
Senators voting in the affirmative were Johnson, Portman, Paul,
Lankford, Romney, Scott, Hawley, and Sinema. Senators voting in
the negative were Peters, Carper, Hassan, and Rosen. For the
record only, Senator Enzi voted ``yea'' by proxy and Senator
Harris voted ``nay'' by proxy.
IV. Section-by-Section Analysis of the Bill, as Reported
Section 1. Short title
This section establishes the short title of the bill as the
``Repeal Insurance Plans of the Multi-State Program Act'' or
the ``RIP MSP Act.''
Section 2. Repeal of Multi-State Plan Program
This section repeals section 1334, the MSP Program, of the
Patient Protection and Affordable Care Act (Public Law 111-
148), effective January 1, 2020. It requires the termination of
external review by the OPM Director, and no later than 60 days
after the date of enactment of the legislation, the OPM
Director to brief the Committee on Homeland Security and
Governmental Affairs and the Committee on Health, Education,
Labor, and Pensions of the Senate and the Committee on
Oversight and Reform and the Committee on Energy and Commerce
of the House of Representatives. The briefing must include
information concerning how OPM and MSP issuers are notifying
current enrollees that there will no longer be MSP options
available; a description of how the OPM Director will work with
the Secretary of Health and Human Services to ensure no MSP
plans are made available; and a timeline detailing how OPM will
close the information technology portal that MSP issuers
utilize.
V. Evaluation of Regulatory Impact
Pursuant to the requirements of paragraph 11(b) of rule
XXVI of the Standing Rules of the Senate, the Committee has
considered the regulatory impact of this bill and determined
that the bill will have no regulatory impact within the meaning
of the rules. The Committee agrees with the Congressional
Budget Office's statement that the bill contains no
intergovernmental or private-sector mandates as defined in the
Unfunded Mandates Reform Act and would impose no costs on
state, local, or tribal governments.
VI. Congressional Budget Office Cost Estimate
U.S. Congress,
Congressional Budget Office,
Washington, DC, May 23, 2019.
Hon. Ron Johnson,
Chairman, Committee on Homeland Security and Governmental Affairs, U.S.
Senate, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S. 1378, the Repeal
Insurance Plans of the Multi-State Program Act.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Kevin
McNellis.
Sincerely,
Keith Hall,
Director.
Enclosure.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
S. 1378 would repeal the multi-state plan program
established by Section 1334 of the Affordable Care Act (ACA).
Section 1334 requires the Office of Personnel Management (OPM)
to contract with health insurers to offer multi-state plan
(MSP) insurance options on each exchange in each state. Under
current law, the plans generally must meet the various
insurance requirements under the ACA and are available to
eligible individuals and small business. The repeal would be
effective January 1, 2020. Within 60 days of enactment, the
bill also would require OPM to brief the Senate Committee on
Homeland Security and Governmental Affairs; the Senate
Committee on Health, Education, Labor, and Pensions; the House
Committee on Oversight and Reform; and the House Committee on
Energy and Commerce on OPM's efforts to wind-down the program.
OPM reports that in 2019 Arkansas Blue Cross and Blue
Shield is the only insurer to offer MSPs, and such plans are
only available in Arkansas. Premium data from the Department of
Health and Human Services (HHS) show that MSPs are not the
lowest cost or second-lowest cost silver plans in any rating
areas where they are offered. Because premiums for silver plans
with the second-lowest-cost are the basis for calculating
federal subsidies for health insurance purchased through the
marketplaces, eliminating plans with premiums higher than those
second-lowest cost plans would not affect subsidies and thus
the bill's enactment would not affect the federal budget.
The CBO contact for this estimate is Kevin McNellis. The
estimate was approved by Leo Lex, Deputy Assistant Director for
Budget Analysis.
VII. Changes in Existing Law Made by the Bill, as Reported
In compliance with paragraph 12 of rule XXVI of the
Standing Rules of the Senate, changes in existing law made by
S. 1378 as reported are shown as follows (existing law proposed
to be omitted is enclosed in brackets, new matter is printed in
italic, and existing law in which no change is proposed is
shown in roman):
PATIENT PROTECTION AND AFFORDABLE CARE ACT
* * * * * * *
TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
* * * * * * *
Subtitle D--Available Coverage Choices for All Americans
* * * * * * *
PART 1--ESTABLISHMENT OF QUALIFIED HEALTH PLANS
* * * * * * *
SEC. 1301. QUALIFIED HEALTH PLAN DEFINED
(a) * * *
(1) * * *
(2) Inclusion of co-op plans [and multi-state
qualified health plans].--Any reference in this title
to a qualified health plan shall be deemed to include a
qualified health plan offered through the CO-OP program
under section 1322, [and a multi-State plan under
section 1334,] unless specifically provided for
otherwise.
(3) * * *
(4) Variation based on rating area.--A qualified
health plan[, including a multi-State qualified health
plan,] may as appropriate vary premiums by rating area
(as defined in section 2701(a)(2) of the Public Health
Service Act.)
* * * * * * *
PART III--STATE FLEXIBILITY RELATING TO EXCHANGES
* * * * * * *
SEC. 1324. LEVEL PLAYING FIELD
(a) In General.--Notwithstanding any other provision of
law, any health insurance coverage offered by a private health
insurance issuer shall not be subject to any Federal or State
law described in subsection (b) if a qualified health plan
offered under the Consumer Operated and Oriented Plan program
under section 1322 [, or a multi-State qualified health plan
under section 1334,] is not subject to such law.
* * * * * * *