89–006 

116TH CONGRESS REPORT " ! HOUSE OF REPRESENTATIVES 1st Session 116–50 

EXPAND NAVIGATORS’ RESOURCES FOR OUTREACH, 

LEARNING, AND LONGEVITY ACT OF 2019 

MAY 3, 2019.—Committed to the Committee of the Whole House on the State of the 

Union and ordered to be printed 

Mr. PALLONE, from the Committee on Energy and Commerce, 

submitted the following 

R E P O R T 

together with 

DISSENTING VIEWS 

[To accompany H.R. 1386] 

The Committee on Energy and Commerce, to whom was referred 

the bill (H.R. 1386) to amend the Patient Protection and Affordable 

Care Act to provide for additional requirements with respect to the 

navigator program, and for other purposes, having considered the 

same, report favorably thereon with an amendment and recommend that the bill as amended do pass. 

CONTENTS 

Page 

Purpose and Summary ............................................................................................ 3 

Background and Need for the Legislation ............................................................. 3 

Committee Hearings ................................................................................................ 4 

Committee Consideration ........................................................................................ 4 

Committee Votes ...................................................................................................... 4 

Oversight Findings ..................................................................................................

New Budget Authority, Entitlement Authority, and Tax Expenditures .............

Congressional Budget Office Estimate ...................................................................

Federal Mandates Statement .................................................................................

Statement of General Performance Goals and Objectives ....................................

Duplication of Federal Programs ............................................................................ 8 

Committee Cost Estimate ....................................................................................... 8 

Earmarks, Limited Tax Benefits, and Limited Tariff Benefits ........................... 8 

Advisory Committee Statement .............................................................................. 8 

Applicability to Legislative Branch ........................................................................ 8 

Section-by-Section Analysis of the Legislation ...................................................... 8 

Changes in Existing Law Made by the Bill, as Reported ..................................... 9 

Dissenting Views ..................................................................................................... 21 


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The amendment is as follows: 

Strike all after the enacting clause and insert the following: 

SECTION 1. SHORT TITLE. 

This Act may be cited as the ‘‘Expand Navigators’ Resources for Outreach, Learning, and Longevity Act of 2019’’ or the ‘‘ENROLL Act of 2019’’. 

SEC. 2. PROVIDING FOR ADDITIONAL REQUIREMENTS WITH RESPECT TO THE NAVIGATOR 

PROGRAM. 

(a) IN GENERAL.—Section 1311(i) of the Patient Protection and Affordable Care 

Act (42 U.S.C. 18031(i)) is amended— 

(1) in paragraph (2), by adding at the end the following new subparagraph: 

‘‘(C) SELECTION OF RECIPIENTS.—In the case of an Exchange established 

and operated by the Secretary within a State pursuant to section 1321(c), 

in awarding grants under paragraph (1), the Exchange shall— 

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

‘‘(ii) not take into account whether or not the entity has demonstrated how the entity will provide information to individuals relating to group health plans offered by a group or association of employers 

described in section 2510.3–5(b) of title 29, Code of Federal Regulations 

(or any successor regulation), or short-term limited duration insurance 

(as defined by the Secretary for purposes of section 2791(b)(5) of the 

Public Health Service Act); and 

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

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

‘‘(II) at least one entity described in subparagraph (B), which 

may include another community and consumer-focused nonprofit 

group in addition to any such group awarded a grant pursuant to 

subclause (I). 

In awarding such grants, an Exchange may consider an entity’s record 

with respect to waste, fraud, and abuse for purposes of maintaining the 

integrity of such Exchange.’’; 

(2) in paragraph (3)— 

(A) in subparagraph (C), by inserting after ‘‘qualified health plans’’ the 

following: ‘‘, State medicaid plans under title XIX of the Social Security Act, 

and State children’s health insurance programs under title XXI of such 

Act’’; and 

(B) by adding at the end the following flush left sentence: 

‘‘The duties specified in the preceding sentence may be carried out by such a 

navigator at any time during a year.’’; 

(3) in paragraph (4)(A)— 

(A) in the matter preceding clause (i), by striking ‘‘not’’; 

(B) in clause (i)— 

(i) by inserting ‘‘not’’ before ‘‘be’’; and 

(ii) by striking ‘‘; or’’ and inserting ‘‘;’’; 

(C) in clause (ii)— 

(i) by inserting ‘‘not’’ before ‘‘receive’’; and 

(ii) by striking the period and inserting ‘‘;’’; and 

(D) by adding at the end the following new clause: 

‘‘(iii) maintain physical presence in the State of the Exchange so as 

to allow in-person assistance to consumers.’’; and 

(4) in paragraph (6)— 

(A) by striking ‘‘FUNDING.—Grants under’’ and inserting ‘‘FUNDING.— 

‘‘(A) STATE EXCHANGES.—Grants under’’; and 

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

‘‘(B) FEDERAL EXCHANGES.—For purposes of carrying out this subsection, 

with respect to an Exchange established and operated by the Secretary 

within a State pursuant to section 1321(c), the Secretary shall obligate 

$100,000,000 out of amounts collected through the user fees on participating health insurance issuers pursuant to section 156.50 of title 45, Code 

of Federal Regulations (or any successor regulations) for fiscal year 2020 

and each subsequent fiscal year. Such amount for a fiscal year shall remain 

available until expended.’’. 

(b) EFFECTIVE DATE.—The amendments made by subsection (a) shall apply with 

respect to plan years beginning on or after January 1, 2020. 


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1 Centers for Medicare & Medicaid Services, Policies Related to the Navigator Program and 

Enrollment Education for the Upcoming Enrollment Period (Aug. 31, 2017) (https:// 

www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/downloads/policiesrelated-navigator-program-enrollment-education-8-31-2017pdf.pdf). 2 Centers for Medicare & Medicaid Services, Cooperative Agreement to Support Navigators in 

Federally-Facilitated Exchanges (July 10, 2018) (https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/2018-Navigator-FOA-FAQs.pdf). 3Government Accountability Office, Health Insurance Exchanges: HHS Should Enhance Its 

Management of Open Enrollment Performance (Aug 23, 2018) (https://www.gao.gov/products/ 

GAO-18-565). 4 Id. 5See note 2. 

PURPOSE AND SUMMARY

H.R. 1386, the ‘‘Expand Navigators’ Resources for Outreach, 

Learning, and Longevity Act of 2019’’ or the ‘‘ENROLL Act of 

2019’’, was introduced on February 27, 2019, by Representatives 

Castor (D–FL), Blunt Rochester (D–DE), Crist (D–FL), and Wilson 

(D–FL), and referred to the Committee on Energy and Commerce. 

The goal of H.R. 1386 is to fund the Navigator program for the 

Federally-Facilitated Marketplace (FFM) at $100 million per year. 

H.R. 1386 would require the Department of Health and Human 

Services (HHS) to ensure that Navigator grants are awarded to organizations with a demonstrated capacity to carry out the duties 

specified in the Affordable Care Act (ACA) and would require that 

there be at least two Navigator entities in each state. H.R. 1386 

would further provide Navigators new duties pertaining to enrolling individuals in Medicaid and the Children’s Health Insurance 

Program and would clarify that Navigators may carry out their duties at any time during a year. Lastly, the legislation would prohibit HHS from taking into account an entity’s capacity to provide 

information relating to association health plans or short-term limited duration insurance (STLDI) in awarding grants. 

BACKGROUND AND NEED FOR LEGISLATION

The ACA required exchanges to establish a Navigator program 

and award grants to Navigator entities. The law tasked Navigators 

with several marketplace enrollment responsibilities, including conducting public education activities to raise awareness of coverage 

availability on the marketplaces, facilitating enrollment in qualified health plans, and providing fair and impartial information on 

enrollment and financial assistance. 

On August 31, 2017, HHS reduced funding for the Navigator program from $63 million to $36.8 million, a 40 percent cut from the 

previous year.1 The Department further reduced funding for 2019 

to $10 million.2 The Department set the funding allocation based 

on a narrower goal of marketplace enrollment. A report by the Government Accountability Office (GAO) found that HHS described the 

enrollment goals in an ‘‘unclear manner’’ and failed to provide Navigator entities guidance on the performance measure.3 The GAO report also concluded that HHS’s decision to cut Navigator funding 

was based on ‘‘incomplete and problematic data.’’ 4

HHS stipulated that funding applications are to be evaluated 

based on a Navigator’s ability to establish relationships with individuals who ‘‘may be unaware of the range of available options in 

addition to qualified health plans, such as association health plans 

[and] STLDI.’’ 5 Lastly, HHS eliminated the requirement that each 


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6Department of Health and Human Services, HHS Notice of Benefit and Payment Parameters 

for 2019, 83 Fed. Reg. 16930 (April 17, 2018). 

marketplace have two Navigator entities and that Navigator entities maintain a physical presence in the area they are serving.6

H.R. 1386 would reverse HHS’s actions to weaken the Navigator program and would reinstate navigator funding at $100 million per 

year. It would further strengthen the Navigator program by clarifying that Navigators can provide year-round assistance and enroll 

individuals in Medicaid and the Children’s Health Insurance Program. 

COMMITTEE HEARINGS

For the purposes of section 103(i) of H. Res. 6 of the 116th Congress, the following hearing was used to develop or consider H.R. 

1386: 

On March 6, 2019, the Subcommittee on Health held a legislative 

hearing entitled, ‘‘Strengthening Our Health Care System: Legislation to Lower Consumer Costs and Expand Access.’’ The hearing focused on H.R. 1386 and two other bills. The Subcommittee received 

testimony from the following witnesses: 

• Peter Lee, Executive Director, Covered California; 

• Audrey Morse Gasteier, Chief of Policy, Massachusetts 

Health Connector; and 

• J.P. Wieske, Vice President, State Affairs, Council for Affordable Health Coverage. 

COMMITTEE CONSIDERATION

H.R. 1386, the ‘‘Expand Navigators’ Resources for Outreach, 

Learning, and Longevity Act of 2019 ’’ or the ‘‘ENROLL Act of 

2019’’, was introduced on February 27, 2019, by Rep. Castor (D– 

FL), and referred to the Committee on Energy and Commerce. The 

bill was subsequently referred to the Subcommittee on Health on 

February 28, 2019. Following legislative hearings, on March 26, 

2019, the Subcommittee met in open markup session, pursuant to 

notice, on H.R. 1386 for consideration of the bill. During markup, 

an amendment offered by Mr. Walden (R–OR) was defeated by a 

voice vote. Subsequently, the Subcommittee on Health agreed to a 

motion by Ms. Eshoo, Chairwoman of the Subcommittee, to favorably forward H.R. 1386 to the full Committee on Energy and Commerce, without amendment, by a voice vote. 

On April 3, 2019, the full Committee met in open markup session, pursuant to notice, to consider H.R. 1386. During the markup, 

Mr. Latta (R–OH)) offered an amendment to the bill that was defeated by a record vote of 22 years and 30 nays. An amendment 

was offered by Mr. Burgess that was adopted by a voice vote. At 

the conclusion of consideration of the bill, the Committee on Energy and Commerce agreed to a motion by Mr. Pallone, Chairman 

of the Committee, to order H.R. 1386 favorably reported to the 

House, amended, by a record vote of 30 yeas to 22 nays. 

COMMITTEE VOTES

Clause 3(b) of rule XIII of the Rules of the House of Representatives requires the Committee to list each record vote on the motion 


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to report legislation and amendments thereto. The Committee advises that two record votes were taken during consideration of H.R. 

1386. An amendment offered by Mr. Latta was defeated by a record 

vote of 22 years to 30 nays. A motion by Mr. Pallone to order H.R. 

1385 favorably reported to the House, amended, was agreed to by 

a record vote of 30 yeas to 22 nays. The following are the record 

votes taken during Committee consideration, including the names 

of those members voting for and against: 


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DUPLICATION OF FEDERAL PROGRAMS

Pursuant to clause 3(c)(5) of rule XIII, no provision of H.R. 1386 

is known to be duplicative of another Federal program, including 

any program that was included in a report to Congress pursuant 

to section 21 of Public Law 111–139 or the most recent Catalog of 

Federal Domestic Assistance. 

COMMITTEE COST ESTIMATE

Pursuant to clause 3(d)(1) of rule XIII, the Committee adopts as 

its own the cost estimate prepared by the Director of the Congressional Budget Office pursuant to section 402 of the Congressional 

Budget Act of 1974. 

EARMARKS, LIMITED TAX BENEFITS, AND LIMITED TARIFF BENEFITS

Pursuant to clause 9(e), 9(f), and 9(g) of rule XXI, the Committee 

finds that H.R. 1386 contains no earmarks, limited tax benefits, or 

limited tariff benefits. 

ADVISORY COMMITTEE STATEMENT

No advisory committees within the meaning of section 5(b) of the 

Federal Advisory Committee Act were created by this legislation. 

APPLICABILITY TO LEGISLATIVE BRANCH

The Committee finds that the legislation does not relate to the 

terms and conditions of employment or access to public services or 

accommodations within the meaning of section 102(b)(3) of the Congressional Accountability Act. 

SECTION-BY-SECTION ANALYSIS OF THE LEGISLATION

Section 1. Short title 

Section 1 designates that the Act may be cited as the ‘‘Expand 

Navigators’ Resources for Outreach, Learning, and Longevity Act of 

2019’’ or the ‘‘ENROLL Act of 2019’’. 

Section 2. Providing for additional requirements with respect to the 

Navigator Program 

Section 2 amends Section 1311 of the ACA and requires HHS to 

award grants to Navigator entities based on an entity’s demonstrated capacity to carry out the duties specific under Section 

1311 of the ACA. The section prohibits HHS from taking into account a Navigator entity’s capacity to provide information relating 

to association health plans or STLDI in awarding grants. The section requires that grants are awarded to at least two entities, one 

of which must be a community and consumer-focused nonprofit 

group. The section establishes new Navigator duties pertaining to 

enrolling individuals in Medicaid and the Children’s Health Insurance Program and clarifies that all Navigator duties may be carried out at any time during a year. The section funds Navigator 

grants at $100 million per year out of the user fees collected from 

participating health issuers on the FFM and establishes that the 

funds may remain available until expended. 


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CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

In compliance with clause 3(e) of rule XIII of the Rules of the 

House of Representatives, changes in existing law made by the bill, 

as reported, are shown as follows (existing law proposed to be omitted is enclosed in black 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 2—CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH 

BENEFIT EXCHANGES 

SEC. 1311. AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS. 

(a) ASSISTANCE TO STATES TO ESTABLISH AMERICAN HEALTH BEN- EFIT EXCHANGES.— (1) PLANNING AND ESTABLISHMENT GRANTS.—There shall be 

appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, an amount necessary to enable 

the Secretary to make awards, not later than 1 year after the 

date of enactment of this Act, to States in the amount specified 

in paragraph (2) for the uses described in paragraph (3). 

(2) AMOUNT SPECIFIED.—For each fiscal year, the Secretary 

shall determine the total amount that the Secretary will make 

available to each State for grants under this subsection. 

(3) USE OF FUNDS.—A State shall use amounts awarded 

under this subsection for activities (including planning activities) related to establishing an American Health Benefit Exchange, as described in subsection (b). 

(4) RENEWABILITY OF GRANT.— 

(A) IN GENERAL.—Subject to subsection (d)(4), the Secretary may renew a grant awarded under paragraph (1) if 

the State recipient of such grant— 

(i) is making progress, as determined by the Secretary, toward— 

(I) establishing an Exchange; and 

(II) implementing the reforms described in subtitles A and C (and the amendments made by 

such subtitles); and 


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(ii) is meeting such other benchmarks as the Secretary may establish. 

(B) LIMITATION.—No grant shall be awarded under this 

subsection after January 1, 2015. 

(5) TECHNICAL ASSISTANCE TO FACILITATE PARTICIPATION IN

SHOP EXCHANGES.—The Secretary shall provide technical assistance to States to facilitate the participation of qualified 

small businesses in such States in SHOP Exchanges. 

(b) AMERICAN HEALTH BENEFIT EXCHANGES.— (1) IN GENERAL.—Each State shall, not later than January 1, 

2014, establish an American Health Benefit Exchange (referred 

to in this title as an ‘‘Exchange’’) for the State that— 

(A) facilitates the purchase of qualified health plans; 

(B) provides for the establishment of a Small Business 

Health Options Program (in this title referred to as a 

‘‘SHOP Exchange’’) that is designed to assist qualified employers in the State who are small employers in facilitating the enrollment of their employees in qualified 

health plans offered in the small group market in the 

State; and 

(C) meets the requirements of subsection (d). 

(2) MERGER OF INDIVIDUAL AND SHOP EXCHANGES.—A State 

may elect to provide only one Exchange in the State for providing both Exchange and SHOP Exchange services to both 

qualified individuals and qualified small employers, but only if 

the Exchange has adequate resources to assist such individuals 

and employers. 

(c) RESPONSIBILITIES OF THE SECRETARY.— (1) IN GENERAL.—The Secretary shall, by regulation, establish criteria for the certification of health plans as qualified 

health plans. Such criteria shall require that, to be certified, 

a plan shall, at a minimum— 

(A) meet marketing requirements, and not employ marketing practices or benefit designs that have the effect of 

discouraging the enrollment in such plan by individuals 

with significant health needs; 

(B) ensure a sufficient choice of providers (in a manner 

consistent with applicable network adequacy provisions 

under section 2702(c) of the Public Health Service Act), 

and provide information to enrollees and prospective enrollees on the availability of in-network and out-of-network 

providers; 

(C) include within health insurance plan networks those 

essential community providers, where available, that serve 

predominately low-income, medically-underserved individuals, such as health care providers defined in section 

340B(a)(4) of the Public Health Service Act and providers 

described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act as set forth by section 221 of Public Law 111–8, 

except that nothing in this subparagraph shall be construed to require any health plan to provide coverage for 

any specific medical procedure; 

(D)(i) be accredited with respect to local performance on 

clinical quality measures such as the Healthcare Effectiveness Data and Information Set, patient experience ratings 


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on a standardized Consumer Assessment of Healthcare 

Providers and Systems survey, as well as consumer access, 

utilization management, quality assurance, provider 

credentialing, complaints and appeals, network adequacy 

and access, and patient information programs by any entity recognized by the Secretary for the accreditation of 

health insurance issuers or plans (so long as any such entity has transparent and rigorous methodological and scoring criteria); or 

(ii) receive such accreditation within a period established 

by an Exchange for such accreditation that is applicable to 

all qualified health plans; 

(E) implement a quality improvement strategy described 

in subsection (g)(1); 

(F) utilize a uniform enrollment form that qualified individuals and qualified employers may use (either electronically or on paper) in enrolling in qualified health plans offered through such Exchange, and that takes into account 

criteria that the National Association of Insurance Commissioners develops and submits to the Secretary; 

(G) utilize the standard format established for presenting health benefits plan options; 

(H) provide information to enrollees and prospective enrollees, and to each Exchange in which the plan is offered, 

on any quality measures for health plan performance endorsed under section 399JJ of the Public Health Service 

Act, as applicable; and 

(I) report to the Secretary at least annually and in such 

manner as the Secretary shall require, pediatric quality reporting measures consistent with the pediatric quality reporting measures established under section 1139A of the 

Social Security Act. 

(2) RULE OF CONSTRUCTION.—Nothing in paragraph (1)(C) 

shall be construed to require a qualified health plan to contract 

with a provider described in such paragraph if such provider 

refuses to accept the generally applicable payment rates of 

such plan. 

(3) RATING SYSTEM.—The Secretary shall develop a rating 

system that would rate qualified health plans offered through 

an Exchange in each benefits level on the basis of the relative 

quality and price. The Exchange shall include the quality rating in the information provided to individuals and employers 

through the Internet portal established under paragraph (4). 

(4) ENROLLEE SATISFACTION SYSTEM.—The Secretary shall 

develop an enrollee satisfaction survey system that would 

evaluate the level of enrollee satisfaction with qualified health 

plans offered through an Exchange, for each such qualified 

health plan that had more than 500 enrollees in the previous 

year. The Exchange shall include enrollee satisfaction information in the information provided to individuals and employers 

through the Internet portal established under paragraph (5) in 

a manner that allows individuals to easily compare enrollee 

satisfaction levels between comparable plans. 

(5) INTERNET PORTALS.—The Secretary shall— 


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(A) continue to operate, maintain, and update the Internet portal developed under section 1103(a) and to assist 

States in developing and maintaining their own such portal; and 

(B) make available for use by Exchanges a model template for an Internet portal that may be used to direct 

qualified individuals and qualified employers to qualified 

health plans, to assist such individuals and employers in 

determining whether they are eligible to participate in an 

Exchange or eligible for a premium tax credit or cost-sharing reduction, and to present standardized information (including quality ratings) regarding qualified health plans 

offered through an Exchange to assist consumers in making easy health insurance choices. 

Such template shall include, with respect to each qualified 

health plan offered through the Exchange in each rating area, 

access to the uniform outline of coverage the plan is required 

to provide under section 2716 of the Public Health Service Act 

and to a copy of the plan’s written policy. 

(6) ENROLLMENT PERIODS.—The Secretary shall require an 

Exchange to provide for— 

(A) an initial open enrollment, as determined by the Secretary (such determination to be made not later than July 

1, 2012); 

(B) annual open enrollment periods, as determined by 

the Secretary for calendar years after the initial enrollment period; 

(C) special enrollment periods specified in section 9801 

of the Internal Revenue Code of 1986 and other special enrollment periods under circumstances similar to such periods under part D of title XVIII of the Social Security Act; 

and 

(D) special monthly enrollment periods for Indians (as 

defined in section 4 of the Indian Health Care Improvement Act). 

(d) REQUIREMENTS.— (1) IN GENERAL.—An Exchange shall be a governmental 

agency or nonprofit entity that is established by a State. 

(2) OFFERING OF COVERAGE.— (A) IN GENERAL.—An Exchange shall make available 

qualified health plans to qualified individuals and qualified employers. 

(B) LIMITATION.— 

(i) IN GENERAL.—An Exchange may not make available any health plan that is not a qualified health 

plan. 

(ii) OFFERING OF STAND-ALONE DENTAL BENEFITS.— 

Each Exchange within a State shall allow an issuer of 

a plan that only provides limited scope dental benefits 

meeting the requirements of section 9832(c)(2)(A) of 

the Internal Revenue Code of 1986 to offer the plan 

through the Exchange (either separately or in conjunction with a qualified health plan) if the plan provides 

pediatric dental benefits meeting the requirements of 

section 1302(b)(1)(J)). 


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(3) RULES RELATING TO ADDITIONAL REQUIRED BENEFITS.— (A) IN GENERAL.—Except as provided in subparagraph 

(B), an Exchange may make available a qualified health 

plan notwithstanding any provision of law that may require benefits other than the essential health benefits 

specified under section 1302(b). 

(B) STATES MAY REQUIRE ADDITIONAL BENEFITS.— (i) IN GENERAL.—Subject to the requirements of 

clause (ii), a State may require that a qualified health 

plan offered in such State offer benefits in addition to 

the essential health benefits specified under section 

1302(b). 

(ii) STATE MUST ASSUME COST.—A State shall make 

payments— 

(I) to an individual enrolled in a qualified health 

plan offered in such State; or 

(II) on behalf of an individual described in subclause (I) directly to the qualified health plan in 

which such individual is enrolled; 

to defray the cost of any additional benefits described 

in clause (i). 

(4) FUNCTIONS.—An Exchange shall, at a minimum— 

(A) implement procedures for the certification, recertification, and decertification, consistent with guidelines developed by the Secretary under subsection (c), of health 

plans as qualified health plans; 

(B) provide for the operation of a toll-free telephone hotline to respond to requests for assistance; 

(C) maintain an Internet website through which enrollees and prospective enrollees of qualified health plans may 

obtain standardized comparative information on such 

plans; 

(D) assign a rating to each qualified health plan offered 

through such Exchange in accordance with the criteria developed by the Secretary under subsection (c)(3); 

(E) utilize a standardized format for presenting health 

benefits plan options in the Exchange, including the use of 

the uniform outline of coverage established under section 

2715 of the Public Health Service Act; 

(F) in accordance with section 1413, inform individuals 

of eligibility requirements for the medicaid program under 

title XIX of the Social Security Act, the CHIP program 

under title XXI of such Act, or any applicable State or local 

public program and if through screening of the application 

by the Exchange, the Exchange determines that such individuals are eligible for any such program, enroll such individuals in such program; 

(G) establish and make available by electronic means a 

calculator to determine the actual cost of coverage after 

the application of any premium tax credit under section 

36B of the Internal Revenue Code of 1986 and any costsharing reduction under section 1402; 

(H) subject to section 1411, grant a certification attesting that, for purposes of the individual responsibility penalty under section 5000A of the Internal Revenue Code of 


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1986, an individual is exempt from the individual requirement or from the penalty imposed by such section because— 

(i) there is no affordable qualified health plan available through the Exchange, or the individual’s employer, covering the individual; or 

(ii) the individual meets the requirements for any 

other such exemption from the individual responsibility requirement or penalty; 

(I) transfer to the Secretary of the Treasury— 

(i) a list of the individuals who are issued a certification under subparagraph (H), including the name 

and taxpayer identification number of each individual; 

(ii) the name and taxpayer identification number of 

each individual who was an employee of an employer 

but who was determined to be eligible for the premium 

tax credit under section 36B of the Internal Revenue 

Code of 1986 because— 

(I) the employer did not provide minimum essential coverage; or 

(II) the employer provided such minimum essential coverage but it was determined under section 

36B(c)(2)(C) of such Code to either be unaffordable 

to the employee or not provide the required minimum actuarial value; and 

(iii) the name and taxpayer identification number of 

each individual who notifies the Exchange under section 1411(b)(4) that they have changed employers and 

of each individual who ceases coverage under a qualified health plan during a plan year (and the effective 

date of such cessation); 

(J) provide to each employer the name of each employee 

of the employer described in subparagraph (I)(ii) who 

ceases coverage under a qualified health plan during a 

plan year (and the effective date of such cessation); and 

(K) establish the Navigator program described in subsection (i). 

(5) FUNDING LIMITATIONS.— (A) NO FEDERAL FUNDS FOR CONTINUED OPERATIONS.—In 

establishing an Exchange under this section, the State 

shall ensure that such Exchange is self-sustaining beginning on January 1, 2015, including allowing the Exchange 

to charge assessments or user fees to participating health 

insurance issuers, or to otherwise generate funding, to 

support its operations. 

(B) PROHIBITING WASTEFUL USE OF FUNDS.—In carrying 

out activities under this subsection, an Exchange shall not 

utilize any funds intended for the administrative and operational expenses of the Exchange for staff retreats, promotional giveaways, excessive executive compensation, or 

promotion of Federal or State legislative and regulatory 

modifications. 

(6) CONSULTATION.—An Exchange shall consult with stakeholders relevant to carrying out the activities under this section, including— 


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(A) educated health care consumers who are enrollees in 

qualified health plans; 

(B) individuals and entities with experience in facilitating enrollment in qualified health plans; 

(C) representatives of small businesses and self-employed individuals; 

(D) State Medicaid offices; and 

(E) advocates for enrolling hard to reach populations. 

(7) PUBLICATION OF COSTS.—An Exchange shall publish the 

average costs of licensing, regulatory fees, and any other payments required by the Exchange, and the administrative costs 

of such Exchange, on an Internet website to educate consumers 

on such costs. Such information shall also include monies lost 

to waste, fraud, and abuse. 

(e) CERTIFICATION.— (1) IN GENERAL.—An Exchange may certify a health plan as 

a qualified health plan if— 

(A) such health plan meets the requirements for certification as promulgated by the Secretary under subsection 

(c)(1); and 

(B) the Exchange determines that making available such 

health plan through such Exchange is in the interests of 

qualified individuals and qualified employers in the State 

or States in which such Exchange operates, except that the 

Exchange may not exclude a health plan— 

(i) on the basis that such plan is a fee-for-service 

plan; 

(ii) through the imposition of premium price controls; or 

(iii) on the basis that the plan provides treatments 

necessary to prevent patients’ deaths in circumstances 

the Exchange determines are inappropriate or too 

costly. 

(2) PREMIUM CONSIDERATIONS.—The Exchange shall require 

health plans seeking certification as qualified health plans to 

submit a justification for any premium increase prior to implementation of the increase. Such plans shall prominently post 

such information on their websites. The Exchange shall take 

this information, and the information and the recommendations provided to the Exchange by the State under section 

2794(b)(1) of the Public Health Service Act (relating to patterns or practices of excessive or unjustified premium increases), into consideration when determining whether to make 

such health plan available through the Exchange. The Exchange shall take into account any excess of premium growth 

outside the Exchange as compared to the rate of such growth 

inside the Exchange, including information reported by the 

States. 

(3) TRANSPARENCY IN COVERAGE.— (A) IN GENERAL.—The Exchange shall require health 

plans seeking certification as qualified health plans to submit to the Exchange, the Secretary, the State insurance 

commissioner, and make available to the public, accurate 

and timely disclosure of the following information: 

(i) Claims payment policies and practices. 


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16 

(ii) Periodic financial disclosures. 

(iii) Data on enrollment. 

(iv) Data on disenrollment. 

(v) Data on the number of claims that are denied. 

(vi) Data on rating practices. 

(vii) Information on cost-sharing and payments with 

respect to any out-of-network coverage. 

(viii) Information on enrollee and participant rights 

under this title. 

(ix) Other information as determined appropriate by 

the Secretary. 

(B) USE OF PLAIN LANGUAGE.—The information required 

to be submitted under subparagraph (A) shall be provided 

in plain language. The term ‘‘plain language’’ means language that the intended audience, including individuals 

with limited English proficiency, can readily understand 

and use because that language is concise, well-organized, 

and follows other best practices of plain language writing. 

The Secretary and the Secretary of Labor shall jointly develop and issue guidance on best practices of plain language writing. 

(C) COST SHARING TRANSPARENCY.—The Exchange shall 

require health plans seeking certification as qualified 

health plans to permit individuals to learn the amount of 

cost-sharing (including deductibles, copayments, and coinsurance) under the individual’s plan or coverage that the 

individual would be responsible for paying with respect to 

the furnishing of a specific item or service by a participating provider in a timely manner upon the request of the 

individual. At a minimum, such information shall be made 

available to such individual through an Internet website 

and such other means for individuals without access to the 

Internet. 

(D) GROUP HEALTH PLANS.—The Secretary of Labor shall 

update and harmonize the Secretary’s rules concerning the 

accurate and timely disclosure to participants by group 

health plans of plan disclosure, plan terms and conditions, 

and periodic financial disclosure with the standards established by the Secretary under subparagraph (A). 

(f) FLEXIBILITY.— 

(1) REGIONAL OR OTHER INTERSTATE EXCHANGES.—An Exchange may operate in more than one State if— 

(A) each State in which such Exchange operates permits 

such operation; and 

(B) the Secretary approves such regional or interstate 

Exchange. 

(2) SUBSIDIARY EXCHANGES.—A State may establish one or 

more subsidiary Exchanges if— 

(A) each such Exchange serves a geographically distinct 

area; and 

(B) the area served by each such Exchange is at least as 

large as a rating area described in section 2701(a) of the 

Public Health Service Act. 

(3) AUTHORITY TO CONTRACT.— 


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(A) IN GENERAL.—A State may elect to authorize an Exchange established by the State under this section to enter 

into an agreement with an eligible entity to carry out 1 or 

more responsibilities of the Exchange. 

(B) ELIGIBLE ENTITY.—In this paragraph, the term ‘‘eligible entity’’ means— 

(i) a person— 

(I) incorporated under, and subject to the laws 

of, 1 or more States; 

(II) that has demonstrated experience on a 

State or regional basis in the individual and small 

group health insurance markets and in benefits 

coverage; and 

(III) that is not a health insurance issuer or 

that is treated under subsection (a) or (b) of section 52 of the Internal Revenue Code of 1986 as 

a member of the same controlled group of corporations (or under common control with) as a health 

insurance issuer; or 

(ii) the State medicaid agency under title XIX of the 

Social Security Act. 

(g) REWARDING QUALITY THROUGH MARKET-BASED INCENTIVES.— 

(1) STRATEGY DESCRIBED.—A strategy described in this paragraph is a payment structure that provides increased reimbursement or other incentives for— 

(A) improving health outcomes through the implementation of activities that shall include quality reporting, effective case management, care coordination, chronic disease 

management, medication and care compliance initiatives, 

including through the use of the medical home model, for 

treatment or services under the plan or coverage; 

(B) the implementation of activities to prevent hospital 

readmissions through a comprehensive program for hospital discharge that includes patient-centered education 

and counseling, comprehensive discharge planning, and 

post discharge reinforcement by an appropriate health care 

professional; 

(C) the implementation of activities to improve patient 

safety and reduce medical errors through the appropriate 

use of best clinical practices, evidence based medicine, and 

health information technology under the plan or coverage; 

(D) the implementation of wellness and health promotion activities; and 

(E) the implementation of activities to reduce health and 

health care disparities, including through the use of language services, community outreach, and cultural competency trainings. 

(2) GUIDELINES.—The Secretary, in consultation with experts 

in health care quality and stakeholders, shall develop guidelines concerning the matters described in paragraph (1). 

(3) REQUIREMENTS.—The guidelines developed under paragraph (2) shall require the periodic reporting to the applicable 

Exchange of the activities that a qualified health plan has conducted to implement a strategy described in paragraph (1). 


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(h) QUALITY IMPROVEMENT.— 

(1) ENHANCING PATIENT SAFETY.—Beginning on January 1, 

2015, a qualified health plan may contract with— 

(A) a hospital with greater than 50 beds only if such hospital— 

(i) utilizes a patient safety evaluation system as described in part C of title IX of the Public Health Service Act; and 

(ii) implements a mechanism to ensure that each patient receives a comprehensive program for hospital 

discharge that includes patient-centered education and 

counseling, comprehensive discharge planning, and 

post discharge reinforcement by an appropriate health 

care professional; or 

(B) a health care provider only if such provider implements such mechanisms to improve health care quality as 

the Secretary may by regulation require. 

(2) EXCEPTIONS.—The Secretary may establish reasonable 

exceptions to the requirements described in paragraph (1). 

(3) ADJUSTMENT.—The Secretary may by regulation adjust 

the number of beds described in paragraph (1)(A). 

(i) NAVIGATORS.— 

(1) IN GENERAL.—An Exchange shall establish a program 

under which it awards grants to entities described in paragraph (2) to carry out the duties described in paragraph (3). 

(2) ELIGIBILITY.— 

(A) IN GENERAL.—To be eligible to receive a grant under 

paragraph (1), an entity shall demonstrate to the Exchange involved that the entity has existing relationships, 

or could readily establish relationships, with employers 

and employees, consumers (including uninsured and 

underinsured consumers), or self-employed individuals 

likely to be qualified to enroll in a qualified health plan. 

(B) TYPES.—Entities described in subparagraph (A) may 

include trade, industry, and professional associations, commercial fishing industry organizations, ranching and farming organizations, community and consumer-focused nonprofit groups, chambers of commerce, unions, resource 

partners of the Small Business Administration, other licensed insurance agents and brokers, and other entities 

that— 

(i) are capable of carrying out the duties described 

in paragraph (3); 

(ii) meet the standards described in paragraph (4); 

and 

(iii) provide information consistent with the standards developed under paragraph (5). 

(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); 


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19 

(ii) not take into account whether or not the entity 

has demonstrated how the entity will provide information to individuals relating to group health plans offered by a group or association of employers described 

in section 2510.3–5(b) of title 29, Code of Federal Regulations (or any successor regulation), or short-term limited duration insurance (as defined by the Secretary for 

purposes of section 2791(b)(5) of the Public Health 

Service Act); and 

(iii) ensure that, each year, the Exchange awards 

such a grant to— 

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

nonprofit group; and 

(II) at least one entity described in subparagraph 

(B), which may include another community and 

consumer-focused nonprofit group in addition to 

any such group awarded a grant pursuant to subclause (I). 

In awarding such grants, an Exchange may consider 

an entity’s record with respect to waste, fraud, and 

abuse for purposes of maintaining the integrity of such 

Exchange. 

(3) DUTIES.—An entity that serves as a navigator under a 

grant under this subsection shall— 

(A) conduct public education activities to raise awareness of the availability of qualified health plans; 

(B) distribute fair and impartial information concerning 

enrollment in qualified health plans, and the availability 

of premium tax credits under section 36B of the Internal 

Revenue Code of 1986 and cost-sharing reductions under 

section 1402; 

(C) facilitate enrollment in qualified health plans, State 

medicaid plans under title XIX of the Social Security Act, 

and State children’s health insurance programs under title 

XXI of such Act; 

(D) provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under section 2793 of the Public Health 

Service Act, or any other appropriate State agency or 

agencies, for any enrollee with a grievance, complaint, or 

question regarding their health plan, coverage, or a determination under such plan or coverage; and 

(E) provide information in a manner that is culturally 

and linguistically appropriate to the needs of the population being served by the Exchange or Exchanges. 

The duties specified in the preceding sentence may be carried 

out by such a navigator at any time during a year. 

(4) STANDARDS.— 

(A) IN GENERAL.—The Secretary shall establish standards for navigators under this subsection, including provisions to ensure that any private or public entity that is selected as a navigator is qualified, and licensed if appropriate, to engage in the navigator activities described in 


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this subsection and to avoid conflicts of interest. Under 

such standards, a navigator shall ønot¿— (i) not be a health insurance issuerø; or¿; 

(ii) not receive any consideration directly or indirectly from any health insurance issuer in connection 

with the enrollment of any qualified individuals or employees of a qualified employer in a qualified health 

planø.¿; 

(iii) maintain physical presence in the State of the 

Exchange so as to allow in-person assistance to consumers. 

(5) FAIR AND IMPARTIAL INFORMATION AND SERVICES.—The 

Secretary, in collaboration with States, shall develop standards 

to ensure that information made available by navigators is 

fair, accurate, and impartial. 

(6) øFUNDING.—¿ øGrants under¿ FUNDING.— (A) STATE EXCHANGES.—Grants under this subsection 

shall be made from the operational funds of the Exchange 

and not Federal funds received by the State to establish 

the Exchange. 

(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 2020 and each subsequent fiscal 

year. Such amount for a fiscal year shall remain available 

until expended. 

(j) APPLICABILITY OF MENTAL HEALTH PARITY.—Section 2726 of 

the Public Health Service Act shall apply to qualified health plans 

in the same manner and to the same extent as such section applies 

to health insurance issuers and group health plans. 

(k) CONFLICT.—An Exchange may not establish rules that conflict with or prevent the application of regulations promulgated by 

the Secretary under this subtitle. 

* * * * * * * 


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(21) 

1Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters 

for 2020, 84 Fed. Reg. 227 (2019), Centers for Medicare and Medicaid Services, Proposed rule: 

Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 

2020, (Jan. 17, 2019), available at https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-00077.pdf. 2Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters 

for 2020, 84 Fed. Reg. 17454 (2019); Centers for Medicare and Medicaid Services, Final rule: 

Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 

2020, (April 25, 2019), available at https://www.federalregister.gov/documents/2019/04/25/2019- 

08017/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parametersfor-2020. 3Patient Protection and Affordable Care Act, Pub. L. No. 111–148, 124 Stat. 119, (2010) (as 

amended by Health Care and Education Reconciliation Act of 2010, Pub L. No. 111–152, 124 

Stat. 1029 (2010)). 4 Centers for Medicare and Medicaid Services, CMS Announcement on ACA Navigator Program and Promotion for Upcoming Open Enrollment, (Aug. 31, 2017), available at https.// 

www.cms.gov/newsroom/press-releases/cms-announcement-aca-navigator-program-and-promotion-upcoming-open-enrollment. 5 Id. 

DISSENTING VIEWS 

This legislation redirects $100 million annually from the exchange user fee program to the Navigator program. The Centers for 

Medicare and Medicaid Services (CMS) recently proposed reducing 

the Federally-facilitated marketplace (FFM) exchange user fee from 

3.5 to 3.0 percent, prior to the introduction of H.R. 1386.1 This user 

fee reduction was maintained in the final rule published in the 

Federal Register April 25, 2019.2

The Patient Protection and Affordable Care Act (PPACA) established the Navigator program and enrollment education to provide 

guidance to enrollees, inform consumers of Open Enrollment Periods, and notify potential enrollees about ways to sign up for coverage.3 For plan year 2017, Navigators received a total of $62.5 

million in grants and enrolled 81,426 individuals,4 which accounted 

for less than one percent of total enrollees. Meanwhile, according 

to CMS, ‘‘[b]y contrast, agents and brokers assisted with 42 percent 

of [Federally Facilitated Exchange (FFE)] enrollment for plan year 

2018, which cost the FFE only $2.40 per enrollee to provide training and technical assistance.’’ 5 For this reason, Navigator grantees 

received funding for plan year 2018 based on their ability to reach 

enrollment goals for the previous year. Therefore, the Navigator 

program should not be provided additional funding, particularly because the program has failed to reach enrollment goals and have 


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been proven highly inefficient and susceptible to waste. The program should not be granted further taxpayer dollars that are likely 

to be inefficiently used. 

GREG WALDEN, Republican Leader, Committee on Energy and 

Commerce. 

MICHAEL C. BURGESS, M.D., 

Rublican Leader, Subcommittee on Health, 

Committee on Energy and 

Commerce. 

Æ 


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