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Title I — Reducing health care costs and protecting people with preexisting conditions

S. 4521 · 116th Congress · Aug 11, 2020 · Lineage

I Reducing health care costs and protecting people with preexisting conditions

101. Improving affordability by expanding premium assistance for consumers

(a)
In general— Section 36B(b)(3)(A) of the Internal Revenue Code of 1986 is amended to read as follows:

“(A) Applicable percentage—The applicable percentage for any taxable year shall be the percentage such that the applicable percentage for any taxpayer whose household income is within an income tier specified in the following table shall increase, on a sliding scale in a linear manner, from the initial premium percentage to the final premium percentage specified in such table for such income tier:”

(b)
Conforming amendment— Section 36B(c)(1)(A) of the Internal Revenue Code of 1986 is amended by striking “but does not exceed 400 percent”.
(c)
Effective date— The amendments made by this section shall apply to taxable years beginning after December 31, 2019.

102. Expanding affordability for working families to fix the family glitch

(a)
In general— Clause (i) of section 36B(c)(2)(C) of the Internal Revenue Code of 1986 is amended to read as follows:

“(i) Coverage must be affordable

“(I) Employees—An employee shall not be treated as eligible for minimum essential coverage if such coverage consists of an eligible employer-sponsored plan (as defined in section 5000A(f)(2)) and the employee’s required contribution (within the meaning of section 5000A(e)(1)(B)) with respect to the plan exceeds 9.5 percent of the employee’s household income.

“(II) Family members—An individual who is eligible to enroll in an eligible employer-sponsored plan (as defined in section 5000A(f)(2)) by reason of a relationship the individual bears to the employee shall not be treated as eligible for minimum essential coverage by reason of such eligibility to enroll if the employee’s required contribution (within the meaning of section 5000A(e)(1)(B), determined by substituting “family” for “self-only”) with respect to the plan exceeds 9.5 percent of the employee’s household income.”

(b)
Conforming amendments—
(1)
Clause (ii) of section 36B(c)(2)(C) of the Internal Revenue Code of 1986 is amended by striking “Except as provided in clause (iii), an employee” and inserting “An individual”.
(2)
Clause (iii) of section 36B(c)(2)(C) of such Code is amended by striking “the last sentence of clause (i)” and inserting “clause (i)(II)”.
(3)
Clause (iv) of section 36B(c)(2)(C) of such Code is amended by striking “the 9.5 percent under clause (i)(II)” and inserting “the 9.5 percent under clauses (i)(I) and (i)(II)”.
(c)
Effective date— The amendments made by this section shall apply to taxable years beginning after December 31, 2021.

103. Establishing a State Health Insurance Affordability and Innovation fund

Subtitle D of title I of the Patient Protection and Affordable Care Act (42 U.S.C. 18021 et seq.) is amended by adding at the end the following:

“6 State Health Insurance Affordability and Innovation Fund

“1351. Establishment of program

“There is hereby established the “State Health Insurance Affordability and Innovation Fund” to be administered by the Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services (referred to in this section as the “Administrator”), to provide funding, in accordance with this part, to each of the 50 States and the District of Columbia (each referred to in this section as a “State”) beginning on January 1, 2022, for the purposes described in section 1352.

“1352. Use of funds

“(a) In general—A State shall use the funds allocated to the State under this part for one of the following purposes:

“(1) To provide reinsurance payments to health insurance issuers with respect to individuals enrolled under individual health insurance coverage (other than through a plan described in subsection (b)) offered by such issuers.

“(2) To provide assistance (other than through payments described in paragraph (1)) to reduce out-of-pocket costs, such as copayments, coinsurance, premiums, and deductibles, of individuals enrolled under qualified health plans offered on the individual market through an Exchange.

“(3) State efforts to streamline health insurance enrollment procedures in order to reduce burdens on consumers and facilitate greater enrollment in health insurance coverage in the individual and small group markets, including automatic enrollment and reenrollment of, or pre-populated applications for, individuals without health insurance who are eligible for tax credits under section 36B of the Internal Revenue Code of 1986, with the ability to opt out of such enrollment.

“(4) State investment in technology to improve data sharing and collection for the purposes of facilitating greater enrollment in health insurance coverage in such markets.

“(5) Feasibility studies to develop comprehensive and coherent State plan for increasing enrollment in the individual and small group market.

“(b) Exclusion of certain grandfathered and transitional plans—For purposes of subsection (a), a plan described in this subsection is the following:

“(1) A grandfathered health plan (as defined in section 1251).

“(2) A plan (commonly referred to as a “transitional plan”) continued under the letter issued by the Centers for Medicare & Medicaid Services on November 14, 2013, to the State Insurance Commissioners outlining a transitional policy for coverage in the individual and small group markets to which section 1251 does not apply, and under the extension of the transitional policy for such coverage set forth in the Insurance Standards Bulletin Series guidance issued by the Centers for Medicare & Medicaid Services on March 5, 2014, February 29, 2016, February 13, 2017, April 9, 2018, March 25, 2019, and January 31, 2020, or under any subsequent extensions thereof.

“(3) Student health insurance coverage (as defined in section 147.145 of title 45, Code of Federal Regulations).

“1353. State eligibility and approval; default safeguard

“(a) Encouraging State options for allocations

“(1) In general—To be eligible for an allocation of funds under this part for a year (beginning with 2022), a State shall submit to the Administrator an application at such time (but, in the case of allocations for 2022, not later than 90 days after the date of the enactment of this part and, in the case of allocations for a subsequent year, not later than March 1 of the previous year) and in such form and manner as specified by the Administrator containing—

“(A) a description of how the funds will be used; and

“(B) such other information as the Administrator may require.

“(2) Automatic approval—An application so submitted is approved unless the Administrator notifies the State submitting the application, not later than 60 days after the date of the submission of such application, that the application has been denied for not being in compliance with any requirement of this part and of the reason for such denial.

“(3) 5-year application approval—If an application of a State is approved for a purpose described in section 1352 for a year, such application shall be treated as approved for such purpose for each of the subsequent 4 years.

“(4) Revocation of approval—The approval of an application of a State, with respect to a purpose described in section 1352, may be revoked if the State fails to use funds provided to the State under this section for such purpose or otherwise fails to comply with the requirements of this section.

“(b) Default Federal safeguard

“(1) 2022—For 2022, in the case of a State that does not submit an application under subsection (a) by the 90-day submission date applicable to such year under subsection (a)(1) and in the case of a State that does submit such an application by such date that is not approved, the Administrator, in consultation with the State insurance commissioner, shall, from the amount calculated under paragraph (4) for such year, carry out the purpose described in paragraph (3) in such State for such year.

“(2) 2023 and subsequent years—For 2023 or a subsequent year, in the case of a State that does not have in effect an approved application under this section for such year, the Administrator, in consultation with the State insurance commissioner, shall, from the amount calculated under paragraph (4) for such year, carry out the purpose described in paragraph (3) in such State for such year.

“(3) Specified use—The amount described in paragraph (4), with respect to 2022 or a subsequent year, shall be used to carry out the purpose described in section 1352(a)(1) in each State described in paragraph (1) or (2) for such year, as applicable, by providing reinsurance payments to health insurance issuers with respect to attachment range claims (as defined in section 1354(b)(2)), using the dollar amounts specified in subparagraph (B) of such section for such year in an amount equal to, subject to paragraph (5), the percentage (specified for such year by the Secretary under such subparagraph) of the amount of such claims.

“(4) Amount described—The amount described in this paragraph, with respect to 2022 or a subsequent year, is the amount equal to the total sum of amounts that the Secretary would otherwise estimate under section 1354(b)(2)(A)(i) for such year for each State described in paragraph (1) or (2) for such year, as applicable, if each such State were not so described for such year.

“(5) Adjustment—For purposes of this subsection, the Secretary may apply a percentage under paragraph (3) with respect to a year that is less than the percentage otherwise specified in section 1354(b)(2)(B) for such year, if the cost of paying the total eligible attachment range claims for States described in this subsection for such year at such percentage otherwise specified would exceed the amount calculated under paragraph (4) for such year.

“1354. Allocations

“(a) Appropriation—For the purpose of providing allocations for States under subsection (b) and payments under section 1353(b) there is appropriated, out of any money in the Treasury not otherwise appropriated, $10,000,000,000 for 2022 and each subsequent year.

“(b) Allocations

“(1) Payment

“(A) In general—From amounts appropriated under subsection (a) for a year, the Secretary shall, with respect to a State not described in section 1353(b) for such year and not later than the date specified under subparagraph (B) for such year, allocate for such State the amount determined for such State and year under paragraph (2).

“(B) Specified date—For purposes of subparagraph (A), the date specified in this subparagraph is—

“(i) for 2022, the date that is 45 days after the date of the enactment of this part; and

“(ii) for 2023 or a subsequent year, January 1 of the respective year.

“(C) Notifications of allocation amounts—For 2023 and each subsequent year, the Secretary shall notify each State of the amount determined for such State under paragraph (2) for such year by not later than January 1 of the previous year.

“(2) Allocation amount determinations

“(A) In general—For purposes of paragraph (1), the amount determined under this paragraph for a year for a State described in paragraph (1)(A) for such year is the amount equal to—

“(i) the amount that the Secretary estimates would be expended under this part for such year on attachment range claims of individuals residing in such State if such State used such funds only for the purpose described in paragraph (1) of section 1352(a) at the dollar amounts and percentage specified under subparagraph (B) for such year; minus

“(ii) the amount, if any, by which the Secretary determines—

“(I) the estimated amount of premium tax credits under section 36B of the Internal Revenue Code of 1986 that would be attributable to individuals residing in such State for such year without application of this part; exceeds

“(II) the estimated amount of premium tax credits under section 36B of the Internal Revenue Code of 1986 that would be attributable to individuals residing in such State for such year if such State were a State described in section 1353(b) for such year.

“(B) Specifications—For purposes of subparagraph (A) and section 1353(b)(3), the Secretary shall determine the dollar amounts and the percentage to be specified under this subparagraph for a year in a manner to ensure that the total amount of expenditures under this part for such year is estimated to equal the total amount appropriated for such year under subsection (a) if such expenditures were used solely for the purpose described in paragraph (1) of section 1352(a) for attachment range claims at the dollar amounts and percentage so specified for such year.

“(3) Availability—Funds allocated to a State under this subsection for a year shall remain available through the end of the subsequent year.”

104. Rescinding the short-term limited duration insurance regulation

(a)
Prohibition— The Secretary of Health and Human Services, the Secretary of the Treasury, and the Secretary of Labor—
(1)
may not take any action to implement, enforce, or otherwise give effect to the rule entitled “Short-Term, Limited Duration Insurance” (83 Fed. Reg. 38212 (August 3, 2018));
(2)
shall apply any regulation revised by such rule as if such rule had not been issued; and
(3)
may not promulgate any substantially similar rule.

105. Revoking section 1332 guidance

(a)
Providing that certain guidance related to waivers for State innovation under the Patient Protection and Affordable Care Act shall have no force or effect— Beginning July 1, 2020, the Secretary of Health and Human Services and the Secretary of the Treasury may not take any action to implement, enforce, or otherwise give effect to the guidance entitled “State Relief and Empowerment Waivers” (83 Fed. Reg. 53575 (October 24, 2018)), including any such action that would—
(1)
result in individuals losing health insurance coverage that includes the essential health benefits package (as defined in subsection (a) of section 1302 of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(a)) without regard to any waiver of any provision of such package under a waiver under such section 1332), including the maternity and newborn care essential health benefit described in subsection (b)(1)(D) of such section;
(2)
result in a decrease in the number of such individuals enrolled in coverage that is at least as comprehensive as the coverage defined in section 1302(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(a)) compared to the number of such individuals who would have been so enrolled in such coverage had such action not been taken;
(3)
with respect to individuals with substance use disorders, including opioid use disorders, reduce the availability or affordability of coverage that is at least as comprehensive as the coverage defined in section 1302(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(a)) compared to the availability or affordability, respectively, of such coverage had such action not been taken;
(4)
result, with respect to vulnerable populations (including low-income individuals, elderly individuals, and individuals with serious health issues or who have a greater risk of developing serious health issues), in a decrease in the availability of coverage that is at least as comprehensive as the coverage defined in section 1302(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(a)) with coverage and cost-sharing protections required under section 1332(b)(1)(B) of such Act (42 U.S.C. 18052(b)(1)(B));
(5)
with respect to individuals with preexisting conditions, reduce the affordability of coverage that is at least as comprehensive as the coverage defined in section 1302(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(a)) compared to the affordability of such coverage had such action not been taken; or
(6)
result in higher health insurance premiums for individuals enrolled in health insurance coverage that is at least as comprehensive as the coverage defined in section 1302(b) of such Act (42 U.S.C. 18022(b)), and the Secretaries may not promulgate any substantially similar guidance or rule.
(b)
Rule of construction— Nothing in subsection (a) shall be construed to affect the approval of waivers under section 1332 of the Patient Protection and Affordable Care Act (42 U.S.C. 18052) that establish reinsurance programs that are consistent with the requirements under subsection (b)(1) of such section (42 U.S.C. 18052(b)(1)), lower health insurance premiums, and protect health insurance coverage for people with preexisting conditions.

106. Promoting consumer outreach and education

(a)
In general— Section 1311(i) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(i)) is amended—
(1)
in paragraph (2), by adding at the end the following new subparagraph:

“(C) Selection of recipients—In the case of an Exchange established and operated by the Secretary within a State pursuant to section 1321(c), in awarding grants under paragraph (1), the Exchange shall—

“(i) select entities to receive such grants based on an entity’s demonstrated capacity to carry out each of the duties specified in paragraph (3);

“(ii) not take into account whether or not the entity has demonstrated how the entity will provide information to individuals relating to group health plans offered by a group or association of employers described in section 2510.3–5(b) of title 29, Code of Federal Regulations (or any successor regulation), or short-term limited duration insurance (as defined by the Secretary for purposes of section 2791(b)(5) of the Public Health Service Act); and

“(iii) ensure that, each year, the Exchange awards such a grant to—

“(I) at least one entity described in this paragraph that is a community and consumer-focused nonprofit group; and

“(II) at least one entity described in subparagraph (B), which may include another community and consumer-focused nonprofit group in addition to any such group awarded a grant pursuant to subclause (I).”

(2)
in paragraph (3)—
(A)
by amending subparagraph (C) to read as follows:

“(C) facilitate enrollment, including with respect to individuals with limited English proficiency and individuals with chronic illnesses, in qualified health plans, State Medicaid plans under title XIX of the Social Security Act, and State child health plans under title XXI of such Act;”

(B)
in subparagraph (D), by striking “and” at the end;
(C)
in subparagraph (E), by striking the period at the end and inserting “; and”;
(D)
by inserting after subparagraph (E) the following new subparagraph:

“(F) provide referrals to community-based organizations that address social needs related to health outcomes.”

(E)
by adding at the end the following flush text:
(3)
in paragraph (4)(A)—
(A)
in the matter preceding clause (i), by striking “not”;
(B)
in clause (i)—
(i)
by inserting “not” before “be”; and
(ii)
by striking “; or” and inserting a semicolon;
(C)
in clause (ii)—
(i)
by inserting “not” before “receive”; and
(ii)
by striking the period and inserting a semicolon; and
(D)
by adding at the end the following new clauses:

“(iii) maintain physical presence in the State of the Exchange so as to allow in-person assistance to consumers; and

“(iv) receive opioid specific education and training that ensures the navigator can best educate individuals on qualified health plans offered through an Exchange, specifically coverage under such plans for opioid health care treatment.”

(4)
in paragraph (6)—
(A)
by striking “Grants under” and inserting the following:

“(A) State exchanges—Grants under”

(B)
by adding at the end the following new subparagraph:

“(B) Federal exchanges—For purposes of carrying out this subsection, with respect to an Exchange established and operated by the Secretary within a State pursuant to section 1321(c), the Secretary shall obligate $100,000,000 out of amounts collected through the user fees on participating health insurance issuers pursuant to section 156.50 of title 45, Code of Federal Regulations (or any successor regulations), for fiscal year 2022 and each subsequent fiscal year. Such amount for a fiscal year shall remain available until expended.”

(b)
Effective date— The amendments made by this section shall apply with respect to plan years beginning on or after January 1, 2021.