II 

116TH CONGRESS 

2D SESSION S. 4521 

To amend the Patient Protection and Affordable Care Act to reduce health 

care costs and expand health care coverage to more Americans. 

IN THE SENATE OF THE UNITED STATES 

AUGUST 11, 2020 

Mr. WARNER introduced the following bill; which was read twice and referred 

to the Committee on Finance 

A BILL 

To amend the Patient Protection and Affordable Care Act 

to reduce health care costs and expand health care coverage to more Americans. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Health Care Improve5 ment Act of 2020’’. 

6 SEC. 2. TABLE OF CONTENTS. 

7 The table of contents for this Act is as follows: 

Sec. 1. Short title. 

Sec. 2. Table of contents. 

TITLE I—REDUCING HEALTH CARE COSTS AND PROTECTING 

PEOPLE WITH PREEXISTING CONDITIONS 


pamtmann on DSKBC07HB2PROD with BILLS
2 

•S 4521 IS

Sec. 101. Improving affordability by expanding premium assistance for consumers. 

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

Sec. 103. Establishing a State Health Insurance Affordability and Innovation 

fund. 

Sec. 104. Rescinding the short-term limited duration insurance regulation. 

Sec. 105. Revoking section 1332 guidance. 

Sec. 106. Promoting consumer outreach and education. 

TITLE II—ENCOURAGING MEDICAID EXPANSION AND 

STRENGTHENING THE MEDICAID PROGRAM 

Sec. 201. Incentivizing Medicaid expansion. 

Sec. 202. Reducing the administrative FMAP for nonexpansion States. 

Sec. 203. State option to provide 12 months of postpartum Medicaid eligibility. 

Sec. 204. Supporting State Medicaid programs through economic downturns. 

Sec. 205. State flexibility to use administrative simplification policies for enrollment. 

TITLE III—ESTABLISHMENT OF A PUBLIC HEALTH CARE OPTION 

Sec. 301. Establishment of health plan. 

Sec. 302. Availability of plan. 

Sec. 303. Affordability. 

Sec. 304. Participating providers. 

Sec. 305. Provider payment rates. 

Sec. 306. No effect on Medicare benefits or Medicare trust funds. 

TITLE IV—FAIR MEDICARE PAYMENTS TO RURAL PROVIDERS 

Sec. 401. Ensuring fairness in Medicare hospital payments. 

TITLE V—COMMONSENSE COMPETITION AND ACCESS TO 

HEALTH INSURANCE 

Sec. 501. Providing small business health insurance across State lines. 

Sec. 502. Report and models. 

TITLE VI—EMPOWERING MEDICARE SENIORS TO NEGOTIATE 

PRESCRIPTION DRUG PRICES 

Sec. 601. Authority to negotiate fair prices for Medicare prescription drugs. 

TITLE VII—COMMONSENSE REPORTING FOR EMPLOYERS 

Sec. 701. Voluntary prospective reporting system. 

Sec. 702. Protection of dependent privacy. 

Sec. 703. Electronic statements. 

Sec. 704. GAO studies. 

Sec. 705. Tax Compliance. 

TITLE VIII—FEDERAL BAN ON SURPRISE MEDICAL BILLING 

Sec. 801. Protection against surprise bills. 


pamtmann on DSKBC07HB2PROD with BILLS
3 

•S 4521 IS

1 TITLE I—REDUCING HEALTH 

2 CARE COSTS AND PRO3 TECTING PEOPLE WITH PRE4 EXISTING CONDITIONS 

5 SEC. 101. IMPROVING AFFORDABILITY BY EXPANDING PRE6 MIUM ASSISTANCE FOR CONSUMERS. 

7 (a) IN GENERAL.—Section 36B(b)(3)(A) of the In8 ternal Revenue Code of 1986 is amended to read as fol9 lows: 

10 ‘‘(A) APPLICABLE PERCENTAGE.—The ap11 plicable percentage for any taxable year shall be 

12 the percentage such that the applicable percent13 age for any taxpayer whose household income is 

14 within an income tier specified in the following 

15 table shall increase, on a sliding scale in a lin16 ear manner, from the initial premium percent17 age to the final premium percentage specified in 

18 such table for such income tier: 

‘‘In the case of household 

income (expressed as 

a percent of poverty line) 

within the following income tier: 

The initial 

premium 

percentage is— 

The final 

premium 

percentage is— 

Up to 150.0 percent ................................... 0.0 0.0

150.0 percent up to 200.0 percent ............. 0.0 3.0

200.0 percent up to 250.0 percent ............. 3.0 4.0

250.0 percent up to 300.0 percent ............. 4.0 6.0

300.0 percent up to 400.0 percent ............. 6.0 8.5

400.0 percent and higher ........................... 8.5 8.5’’. 


pamtmann on DSKBC07HB2PROD with BILLS
4 

•S 4521 IS

1 (b) CONFORMING AMENDMENT.—Section 

2 36B(c)(1)(A) of the Internal Revenue Code of 1986 is 

3 amended by striking ‘‘but does not exceed 400 percent’’. 

4 (c) EFFECTIVE DATE.—The amendments made by 

5 this section shall apply to taxable years beginning after 

6 December 31, 2019. 

7 SEC. 102. EXPANDING AFFORDABILITY FOR WORKING FAM8 ILIES TO FIX THE FAMILY GLITCH. 

9 (a) IN GENERAL.—Clause (i) of section 36B(c)(2)(C) 

10 of the Internal Revenue Code of 1986 is amended to read 

11 as follows: 

12 ‘‘(i) COVERAGE MUST BE AFFORD13 ABLE.— 

14 ‘‘(I) EMPLOYEES.—An employee 

15 shall not be treated as eligible for 

16 minimum essential coverage if such 

17 coverage consists of an eligible em18 ployer-sponsored plan (as defined in 

19 section 5000A(f)(2)) and the employ20 ee’s required contribution (within the 

21 meaning of section 5000A(e)(1)(B)) 

22 with respect to the plan exceeds 9.5 

23 percent of the employee’s household 

24 income. 


pamtmann on DSKBC07HB2PROD with BILLS
5 

•S 4521 IS

1 ‘‘(II) FAMILY MEMBERS.—An in2 dividual who is eligible to enroll in an 

3 eligible employer-sponsored plan (as 

4 defined in section 5000A(f)(2)) by 

5 reason of a relationship the individual 

6 bears to the employee shall not be 

7 treated as eligible for minimum essen8 tial coverage by reason of such eligi9 bility to enroll if the employee’s re10 quired contribution (within the mean11 ing of section 5000A(e)(1)(B), deter12 mined by substituting ‘family’ for 

13 ‘self-only’) with respect to the plan ex14 ceeds 9.5 percent of the employee’s 

15 household income.’’. 

16 (b) CONFORMING AMENDMENTS.— 

17 (1) Clause (ii) of section 36B(c)(2)(C) of the 

18 Internal Revenue Code of 1986 is amended by strik19 ing ‘‘Except as provided in clause (iii), an employee’’ 

20 and inserting ‘‘An individual’’. 

21 (2) Clause (iii) of section 36B(c)(2)(C) of such 

22 Code is amended by striking ‘‘the last sentence of 

23 clause (i)’’ and inserting ‘‘clause (i)(II)’’. 

24 (3) Clause (iv) of section 36B(c)(2)(C) of such 

25 Code is amended by striking ‘‘the 9.5 percent under 


pamtmann on DSKBC07HB2PROD with BILLS
6 

•S 4521 IS

1 clause (i)(II)’’ and inserting ‘‘the 9.5 percent under 

2 clauses (i)(I) and (i)(II)’’. 

3 (c) EFFECTIVE DATE.—The amendments made by 

4 this section shall apply to taxable years beginning after 

5 December 31, 2021. 

6 SEC. 103. ESTABLISHING A STATE HEALTH INSURANCE AF7 FORDABILITY AND INNOVATION FUND. 

8 Subtitle D of title I of the Patient Protection and 

9 Affordable Care Act (42 U.S.C. 18021 et seq.) is amended 

10 by adding at the end the following: 

11 ‘‘PART 6—STATE HEALTH INSURANCE 

12 AFFORDABILITY AND INNOVATION FUND 

13 ‘‘SEC. 1351. ESTABLISHMENT OF PROGRAM. 

14 ‘‘There is hereby established the ‘State Health Insur15 ance Affordability and Innovation Fund’ to be adminis16 tered by the Secretary of Health and Human Services, act17 ing through the Administrator of the Centers for Medicare 

18 & Medicaid Services (referred to in this section as the ‘Ad19 ministrator’), to provide funding, in accordance with this 

20 part, to each of the 50 States and the District of Columbia 

21 (each referred to in this section as a ‘State’) beginning 

22 on January 1, 2022, for the purposes described in section 

23 1352. 


pamtmann on DSKBC07HB2PROD with BILLS
7 

•S 4521 IS

1 ‘‘SEC. 1352. USE OF FUNDS. 

2 ‘‘(a) IN GENERAL.—A State shall use the funds allo3 cated to the State under this part for one of the following 

4 purposes: 

5 ‘‘(1) To provide reinsurance payments to health 

6 insurance issuers with respect to individuals enrolled 

7 under individual health insurance coverage (other 

8 than through a plan described in subsection (b)) of9 fered by such issuers. 

10 ‘‘(2) To provide assistance (other than through 

11 payments described in paragraph (1)) to reduce out12 of-pocket costs, such as copayments, coinsurance, 

13 premiums, and deductibles, of individuals enrolled 

14 under qualified health plans offered on the indi15 vidual market through an Exchange. 

16 ‘‘(3) State efforts to streamline health insur17 ance enrollment procedures in order to reduce bur18 dens on consumers and facilitate greater enrollment 

19 in health insurance coverage in the individual and 

20 small group markets, including automatic enrollment 

21 and reenrollment of, or pre-populated applications 

22 for, individuals without health insurance who are eli23 gible for tax credits under section 36B of the Inter24 nal Revenue Code of 1986, with the ability to opt 

25 out of such enrollment. 


pamtmann on DSKBC07HB2PROD with BILLS
8 

•S 4521 IS

1 ‘‘(4) State investment in technology to improve 

2 data sharing and collection for the purposes of facili3 tating greater enrollment in health insurance cov4 erage in such markets. 

5 ‘‘(5) Feasibility studies to develop comprehen6 sive and coherent State plan for increasing enroll7 ment in the individual and small group market. 

8 ‘‘(b) EXCLUSION OF CERTAIN GRANDFATHERED AND

9 TRANSITIONAL PLANS.—For purposes of subsection (a), 

10 a plan described in this subsection is the following: 

11 ‘‘(1) A grandfathered health plan (as defined in 

12 section 1251). 

13 ‘‘(2) A plan (commonly referred to as a ‘transi14 tional plan’) continued under the letter issued by the 

15 Centers for Medicare & Medicaid Services on No16 vember 14, 2013, to the State Insurance Commis17 sioners outlining a transitional policy for coverage in 

18 the individual and small group markets to which sec19 tion 1251 does not apply, and under the extension 

20 of the transitional policy for such coverage set forth 

21 in the Insurance Standards Bulletin Series guidance 

22 issued by the Centers for Medicare & Medicaid Serv23 ices on March 5, 2014, February 29, 2016, Feb24 ruary 13, 2017, April 9, 2018, March 25, 2019, and 


pamtmann on DSKBC07HB2PROD with BILLS
9 

•S 4521 IS

1 January 31, 2020, or under any subsequent exten2 sions thereof. 

3 ‘‘(3) Student health insurance coverage (as de4 fined in section 147.145 of title 45, Code of Federal 

5 Regulations). 

6 ‘‘SEC. 1353. STATE ELIGIBILITY AND APPROVAL; DEFAULT 

7 SAFEGUARD. 

8 ‘‘(a) ENCOURAGING STATE OPTIONS FOR ALLOCA9 TIONS.— 

10 ‘‘(1) IN GENERAL.—To be eligible for an alloca11 tion of funds under this part for a year (beginning 

12 with 2022), a State shall submit to the Adminis13 trator an application at such time (but, in the case 

14 of allocations for 2022, not later than 90 days after 

15 the date of the enactment of this part and, in the 

16 case of allocations for a subsequent year, not later 

17 than March 1 of the previous year) and in such form 

18 and manner as specified by the Administrator con19 taining— 

20 ‘‘(A) a description of how the funds will be 

21 used; and 

22 ‘‘(B) such other information as the Admin23 istrator may require. 

24 ‘‘(2) AUTOMATIC APPROVAL.—An application so 

25 submitted is approved unless the Administrator notiVerDate Sep 11 2014 23:16 Aug 27, 2020 Jkt 099200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S4521.IS S4521

pamtmann on DSKBC07HB2PROD with BILLS
10 

•S 4521 IS

1 fies the State submitting the application, not later 

2 than 60 days after the date of the submission of 

3 such application, that the application has been de4 nied for not being in compliance with any require5 ment of this part and of the reason for such denial. 

6 ‘‘(3) 5-YEAR APPLICATION APPROVAL.—If an 

7 application of a State is approved for a purpose de8 scribed in section 1352 for a year, such application 

9 shall be treated as approved for such purpose for 

10 each of the subsequent 4 years. 

11 ‘‘(4) REVOCATION OF APPROVAL.—The ap12 proval of an application of a State, with respect to 

13 a purpose described in section 1352, may be revoked 

14 if the State fails to use funds provided to the State 

15 under this section for such purpose or otherwise fails 

16 to comply with the requirements of this section. 

17 ‘‘(b) DEFAULT FEDERAL SAFEGUARD.— 

18 ‘‘(1) 2022.—For 2022, in the case of a State 

19 that does not submit an application under subsection 

20 (a) by the 90-day submission date applicable to such 

21 year under subsection (a)(1) and in the case of a 

22 State that does submit such an application by such 

23 date that is not approved, the Administrator, in con24 sultation with the State insurance commissioner, 

25 shall, from the amount calculated under paragraph 


pamtmann on DSKBC07HB2PROD with BILLS
11 

•S 4521 IS

1 (4) for such year, carry out the purpose described in 

2 paragraph (3) in such State for such year. 

3 ‘‘(2) 2023 AND SUBSEQUENT YEARS.—For 

4 2023 or a subsequent year, in the case of a State 

5 that does not have in effect an approved application 

6 under this section for such year, the Administrator, 

7 in consultation with the State insurance commis8 sioner, shall, from the amount calculated under 

9 paragraph (4) for such year, carry out the purpose 

10 described in paragraph (3) in such State for such 

11 year. 

12 ‘‘(3) SPECIFIED USE.—The amount described 

13 in paragraph (4), with respect to 2022 or a subse14 quent year, shall be used to carry out the purpose 

15 described in section 1352(a)(1) in each State de16 scribed in paragraph (1) or (2) for such year, as ap17 plicable, by providing reinsurance payments to 

18 health insurance issuers with respect to attachment 

19 range claims (as defined in section 1354(b)(2)), 

20 using the dollar amounts specified in subparagraph 

21 (B) of such section for such year in an amount equal 

22 to, subject to paragraph (5), the percentage (speci23 fied for such year by the Secretary under such sub24 paragraph) of the amount of such claims. 


pamtmann on DSKBC07HB2PROD with BILLS
12 

•S 4521 IS

1 ‘‘(4) AMOUNT DESCRIBED.—The amount de2 scribed in this paragraph, with respect to 2022 or 

3 a subsequent year, is the amount equal to the total 

4 sum of amounts that the Secretary would otherwise 

5 estimate under section 1354(b)(2)(A)(i) for such 

6 year for each State described in paragraph (1) or 

7 (2) for such year, as applicable, if each such State 

8 were not so described for such year. 

9 ‘‘(5) ADJUSTMENT.—For purposes of this sub10 section, the Secretary may apply a percentage under 

11 paragraph (3) with respect to a year that is less 

12 than the percentage otherwise specified in section 

13 1354(b)(2)(B) for such year, if the cost of paying 

14 the total eligible attachment range claims for States 

15 described in this subsection for such year at such 

16 percentage otherwise specified would exceed the 

17 amount calculated under paragraph (4) for such 

18 year. 

19 ‘‘SEC. 1354. ALLOCATIONS. 

20 ‘‘(a) APPROPRIATION.—For the purpose of providing 

21 allocations for States under subsection (b) and payments 

22 under section 1353(b) there is appropriated, out of any 

23 money in the Treasury not otherwise appropriated, 

24 $10,000,000,000 for 2022 and each subsequent year. 

25 ‘‘(b) ALLOCATIONS.— 


pamtmann on DSKBC07HB2PROD with BILLS
13 

•S 4521 IS

1 ‘‘(1) PAYMENT.— 

2 ‘‘(A) IN GENERAL.—From amounts appro3 priated under subsection (a) for a year, the 

4 Secretary shall, with respect to a State not de5 scribed in section 1353(b) for such year and 

6 not later than the date specified under subpara7 graph (B) for such year, allocate for such State 

8 the amount determined for such State and year 

9 under paragraph (2). 

10 ‘‘(B) SPECIFIED DATE.—For purposes of 

11 subparagraph (A), the date specified in this 

12 subparagraph is— 

13 ‘‘(i) for 2022, the date that is 45 days 

14 after the date of the enactment of this 

15 part; and 

16 ‘‘(ii) for 2023 or a subsequent year, 

17 January 1 of the respective year. 

18 ‘‘(C) NOTIFICATIONS OF ALLOCATION

19 AMOUNTS.—For 2023 and each subsequent 

20 year, the Secretary shall notify each State of 

21 the amount determined for such State under 

22 paragraph (2) for such year by not later than 

23 January 1 of the previous year. 

24 ‘‘(2) ALLOCATION AMOUNT DETERMINA25 TIONS.— 


pamtmann on DSKBC07HB2PROD with BILLS
14 

•S 4521 IS

1 ‘‘(A) IN GENERAL.—For purposes of para2 graph (1), the amount determined under this 

3 paragraph for a year for a State described in 

4 paragraph (1)(A) for such year is the amount 

5 equal to— 

6 ‘‘(i) the amount that the Secretary es7 timates would be expended under this part 

8 for such year on attachment range claims 

9 of individuals residing in such State if such 

10 State used such funds only for the purpose 

11 described in paragraph (1) of section 

12 1352(a) at the dollar amounts and per13 centage specified under subparagraph (B) 

14 for such year; minus 

15 ‘‘(ii) the amount, if any, by which the 

16 Secretary determines— 

17 ‘‘(I) the estimated amount of 

18 premium tax credits under section 

19 36B of the Internal Revenue Code of 

20 1986 that would be attributable to in21 dividuals residing in such State for 

22 such year without application of this 

23 part; exceeds 

24 ‘‘(II) the estimated amount of 

25 premium tax credits under section 


pamtmann on DSKBC07HB2PROD with BILLS
15 

•S 4521 IS

1 36B of the Internal Revenue Code of 

2 1986 that would be attributable to in3 dividuals residing in such State for 

4 such year if such State were a State 

5 described in section 1353(b) for such 

6 year. 

7 For purposes of the previous sentence and sec8 tion 1353(b)(3), the term ‘attachment range 

9 claims’ means, with respect to an individual, the 

10 claims for such individual that exceed a dollar 

11 amount specified by the Secretary for a year, 

12 but do not exceed a ceiling dollar amount speci13 fied by the Secretary for such year, under sub14 paragraph (B). 

15 ‘‘(B) SPECIFICATIONS.—For purposes of 

16 subparagraph (A) and section 1353(b)(3), the 

17 Secretary shall determine the dollar amounts 

18 and the percentage to be specified under this 

19 subparagraph for a year in a manner to ensure 

20 that the total amount of expenditures under 

21 this part for such year is estimated to equal the 

22 total amount appropriated for such year under 

23 subsection (a) if such expenditures were used 

24 solely for the purpose described in paragraph 

25 (1) of section 1352(a) for attachment range 


pamtmann on DSKBC07HB2PROD with BILLS
16 

•S 4521 IS

1 claims at the dollar amounts and percentage so 

2 specified for such year. 

3 ‘‘(3) AVAILABILITY.—Funds allocated to a 

4 State under this subsection for a year shall remain 

5 available through the end of the subsequent year.’’. 

6 SEC. 104. RESCINDING THE SHORT-TERM LIMITED DURA7 TION INSURANCE REGULATION. 

8 (a) PROHIBITION.—The Secretary of Health and 

9 Human Services, the Secretary of the Treasury, and the 

10 Secretary of Labor— 

11 (1) may not take any action to implement, en12 force, or otherwise give effect to the rule entitled 

13 ‘‘Short-Term, Limited Duration Insurance’’ (83 

14 Fed. Reg. 38212 (August 3, 2018)); 

15 (2) shall apply any regulation revised by such 

16 rule as if such rule had not been issued; and 

17 (3) may not promulgate any substantially simi18 lar rule. 

19 SEC. 105. REVOKING SECTION 1332 GUIDANCE. 

20 (a) PROVIDING THAT CERTAIN GUIDANCE RELATED

21 TO WAIVERS FOR STATE INNOVATION UNDER THE PA22 TIENT PROTECTION AND AFFORDABLE CARE ACT SHALL

23 HAVE NO FORCE OR EFFECT.—Beginning July 1, 2020, 

24 the Secretary of Health and Human Services and the Sec25 retary of the Treasury may not take any action to impleVerDate Sep 11 2014 23:16 Aug 27, 2020 Jkt 099200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\S4521.IS S4521

pamtmann on DSKBC07HB2PROD with BILLS
17 

•S 4521 IS

1 ment, enforce, or otherwise give effect to the guidance en2 titled ‘‘State Relief and Empowerment Waivers’’ (83 Fed. 

3 Reg. 53575 (October 24, 2018)), including any such ac4 tion that would— 

5 (1) result in individuals losing health insurance 

6 coverage that includes the essential health benefits 

7 package (as defined in subsection (a) of section 

8 1302 of the Patient Protection and Affordable Care 

9 Act (42 U.S.C. 18022(a)) without regard to any 

10 waiver of any provision of such package under a 

11 waiver under such section 1332), including the ma12 ternity and newborn care essential health benefit de13 scribed in subsection (b)(1)(D) of such section; 

14 (2) result in a decrease in the number of such 

15 individuals enrolled in coverage that is at least as 

16 comprehensive as the coverage defined in section 

17 1302(a) of the Patient Protection and Affordable 

18 Care Act (42 U.S.C. 18022(a)) compared to the 

19 number of such individuals who would have been so 

20 enrolled in such coverage had such action not been 

21 taken; 

22 (3) with respect to individuals with substance 

23 use disorders, including opioid use disorders, reduce 

24 the availability or affordability of coverage that is at 

25 least as comprehensive as the coverage defined in 


pamtmann on DSKBC07HB2PROD with BILLS
18 

•S 4521 IS

1 section 1302(a) of the Patient Protection and Af2 fordable Care Act (42 U.S.C. 18022(a)) compared to 

3 the availability or affordability, respectively, of such 

4 coverage had such action not been taken; 

5 (4) result, with respect to vulnerable popu6 lations (including low-income individuals, elderly in7 dividuals, and individuals with serious health issues 

8 or who have a greater risk of developing serious 

9 health issues), in a decrease in the availability of 

10 coverage that is at least as comprehensive as the 

11 coverage defined in section 1302(a) of the Patient 

12 Protection and Affordable Care Act (42 U.S.C. 

13 18022(a)) with coverage and cost-sharing protec14 tions required under section 1332(b)(1)(B) of such 

15 Act (42 U.S.C. 18052(b)(1)(B)); 

16 (5) with respect to individuals with preexisting 

17 conditions, reduce the affordability of coverage that 

18 is at least as comprehensive as the coverage defined 

19 in section 1302(a) of the Patient Protection and Af20 fordable Care Act (42 U.S.C. 18022(a)) compared to 

21 the affordability of such coverage had such action 

22 not been taken; or 

23 (6) result in higher health insurance premiums 

24 for individuals enrolled in health insurance coverage 

25 that is at least as comprehensive as the coverage deVerDate Sep 11 2014 23:16 Aug 27, 2020 Jkt 099200 PO 00000 Frm 00018 Fmt 6652 Sfmt 6201 E:\BILLS\S4521.IS S4521

pamtmann on DSKBC07HB2PROD with BILLS
19 

•S 4521 IS

1 fined in section 1302(b) of such Act (42 U.S.C. 

2 18022(b)), and the Secretaries may not promulgate 

3 any substantially similar guidance or rule. 

4 (b) RULE OF CONSTRUCTION.—Nothing in sub5 section (a) shall be construed to affect the approval of 

6 waivers under section 1332 of the Patient Protection and 

7 Affordable Care Act (42 U.S.C. 18052) that establish re8 insurance programs that are consistent with the require9 ments under subsection (b)(1) of such section (42 U.S.C. 

10 18052(b)(1)), lower health insurance premiums, and pro11 tect health insurance coverage for people with preexisting 

12 conditions. 

13 SEC. 106. PROMOTING CONSUMER OUTREACH AND EDU14 CATION. 

15 (a) IN GENERAL.—Section 1311(i) of the Patient 

16 Protection and Affordable Care Act (42 U.S.C. 18031(i)) 

17 is amended— 

18 (1) in paragraph (2), by adding at the end the 

19 following new subparagraph: 

20 ‘‘(C) SELECTION OF RECIPIENTS.—In the 

21 case of an Exchange established and operated 

22 by the Secretary within a State pursuant to sec23 tion 1321(c), in awarding grants under para24 graph (1), the Exchange shall— 


pamtmann on DSKBC07HB2PROD with BILLS
20 

•S 4521 IS

1 ‘‘(i) select entities to receive such 

2 grants based on an entity’s demonstrated 

3 capacity to carry out each of the duties 

4 specified in paragraph (3); 

5 ‘‘(ii) not take into account whether or 

6 not the entity has demonstrated how the 

7 entity will provide information to individ8 uals relating to group health plans offered 

9 by a group or association of employers de10 scribed in section 2510.3–5(b) of title 29, 

11 Code of Federal Regulations (or any suc12 cessor regulation), or short-term limited 

13 duration insurance (as defined by the Sec14 retary for purposes of section 2791(b)(5) 

15 of the Public Health Service Act); and 

16 ‘‘(iii) ensure that, each year, the Ex17 change awards such a grant to— 

18 ‘‘(I) at least one entity described 

19 in this paragraph that is a community 

20 and consumer-focused nonprofit 

21 group; and 

22 ‘‘(II) at least one entity described 

23 in subparagraph (B), which may in24 clude another community and con25 sumer-focused nonprofit group in adVerDate Sep 11 2014 23:16 Aug 27, 2020 Jkt 099200 PO 00000 Frm 00020 Fmt 6652 Sfmt 6201 E:\BILLS\S4521.IS S4521

pamtmann on DSKBC07HB2PROD with BILLS
21 

•S 4521 IS

1 dition to any such group awarded a 

2 grant pursuant to subclause (I). 

3 In awarding such grants, an Exchange may 

4 consider an entity’s record with respect to 

5 waste, fraud, and abuse for purposes of main6 taining the integrity of such Exchange.’’; 

7 (2) in paragraph (3)— 

8 (A) by amending subparagraph (C) to read 

9 as follows: 

10 ‘‘(C) facilitate enrollment, including with 

11 respect to individuals with limited English pro12 ficiency and individuals with chronic illnesses, 

13 in qualified health plans, State Medicaid plans 

14 under title XIX of the Social Security Act, and 

15 State child health plans under title XXI of such 

16 Act;’’; 

17 (B) in subparagraph (D), by striking 

18 ‘‘and’’ at the end; 

19 (C) in subparagraph (E), by striking the 

20 period at the end and inserting ‘‘; and’’; 

21 (D) by inserting after subparagraph (E) 

22 the following new subparagraph: 

23 ‘‘(F) provide referrals to community-based 

24 organizations that address social needs related 

25 to health outcomes.’’; and 


pamtmann on DSKBC07HB2PROD with BILLS
22 

•S 4521 IS

1 (E) by adding at the end the following 

2 flush text: 

3 ‘‘The duties specified in the preceding sentence may 

4 be carried out by such a navigator at any time dur5 ing a year.’’; 

6 (3) in paragraph (4)(A)— 

7 (A) in the matter preceding clause (i), by 

8 striking ‘‘not’’; 

9 (B) in clause (i)— 

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

11 and 

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

13 semicolon; 

14 (C) in clause (ii)— 

15 (i) by inserting ‘‘not’’ before ‘‘re16 ceive’’; and 

17 (ii) by striking the period and insert18 ing a semicolon; and 

19 (D) by adding at the end the following new 

20 clauses: 

21 ‘‘(iii) maintain physical presence in 

22 the State of the Exchange so as to allow 

23 in-person assistance to consumers; and 

24 ‘‘(iv) receive opioid specific education 

25 and training that ensures the navigator 


pamtmann on DSKBC07HB2PROD with BILLS
23 

•S 4521 IS

1 can best educate individuals on qualified 

2 health plans offered through an Exchange, 

3 specifically coverage under such plans for 

4 opioid health care treatment.’’; and 

5 (4) in paragraph (6)— 

6 (A) by striking ‘‘Grants under’’ and insert7 ing the following: 

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

9 and 

10 (B) by adding at the end the following new 

11 subparagraph: 

12 ‘‘(B) FEDERAL EXCHANGES.—For pur13 poses of carrying out this subsection, with re14 spect to an Exchange established and operated 

15 by the Secretary within a State pursuant to sec16 tion 1321(c), the Secretary shall obligate 

17 $100,000,000 out of amounts collected through 

18 the user fees on participating health insurance 

19 issuers pursuant to section 156.50 of title 45, 

20 Code of Federal Regulations (or any successor 

21 regulations), for fiscal year 2022 and each sub22 sequent fiscal year. Such amount for a fiscal 

23 year shall remain available until expended.’’. 


pamtmann on DSKBC07HB2PROD with BILLS
24 

•S 4521 IS

1 (b) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply with respect to plan years begin3 ning on or after January 1, 2021. 

4 TITLE II—ENCOURAGING MED5 ICAID EXPANSION AND 

6 STRENGTHENING THE MED7 ICAID PROGRAM 

8 SEC. 201. INCENTIVIZING MEDICAID EXPANSION. 

9 (a) IN GENERAL.—Section 1905 of the Social Secu10 rity Act (42 U.S.C. 1396d(y)(1)) is amended— 

11 (1) in subsection (y)(1)— 

12 (A) in subparagraph (A), by striking 

13 ‘‘2014, 2015, and 2016’’ and inserting ‘‘each of 

14 the first 3 consecutive 12-month periods in 

15 which the State provides medical assistance to 

16 newly eligible individuals’’; 

17 (B) in subparagraph (B), by striking 

18 ‘‘2017’’ and inserting ‘‘the fourth consecutive 

19 12-month period in which the State provides 

20 medical assistance to newly eligible individuals’’; 

21 (C) in subparagraph (C), by striking 

22 ‘‘2018’’ and inserting ‘‘the fifth consecutive 12- 

23 month period in which the State provides med24 ical assistance to newly eligible individuals’’; 


pamtmann on DSKBC07HB2PROD with BILLS
25 

•S 4521 IS

1 (D) in subparagraph (D), by striking 

2 ‘‘2019’’ and inserting ‘‘the sixth consecutive 12- 

3 month period in which the State provides med4 ical assistance to newly eligible individuals’’; 

5 and 

6 (E) in subparagraph (E), by striking 

7 ‘‘2020 and each year thereafter’’ and inserting 

8 ‘‘the seventh consecutive 12-month period in 

9 which the State provides medical assistance to 

10 newly eligible individuals and each such period 

11 thereafter’’; and 

12 (2) in subsection (z)(2)(B)(i)(II), by inserting 

13 ‘‘(as in effect on the day before the date of enact14 ment of the Health Care Improvement Act of 

15 2020)’’ after ‘‘subsection (y)(1)’’. 

16 (b) EFFECTIVE DATE.—Beginning on January 1, 

17 2022, the amendments made by subsection (a) shall take 

18 effect as if included in the enactment of the Patient Pro19 tection and Affordable Care Act (Public Law 111–148). 

20 SEC. 202. REDUCING THE ADMINISTRATIVE FMAP FOR 

21 NONEXPANSION STATES. 

22 Section 1903 of the Social Security Act (42 U.S.C. 

23 1396b) is amended— 


pamtmann on DSKBC07HB2PROD with BILLS
26 

•S 4521 IS

1 (1) in subsection (a)(7), by inserting ‘‘sub2 section (bb) and’’ before ‘‘section 1919(g)(3)(B)’’; 

3 and 

4 (2) by adding at the end the following new sub5 section: 

6 ‘‘(bb) REDUCTION OF FEDERAL PAYMENTS FOR

7 CERTAIN ADMINISTRATIVE COSTS OF NONEXPANSION

8 STATES.— 

9 ‘‘(1) IN GENERAL.—In the case of a State that 

10 does not provide under the State plan of such State 

11 (or waiver of such plan) for making medical assist12 ance available in accordance with section 1902(k)(1) 

13 to all individuals described in section 

14 1902(a)(10)(i)(VIII) for a calendar quarter begin15 ning on or after October 1, 2022, the Secretary may 

16 reduce the percentage specified in subsection (a)(7) 

17 for amounts described in such subsection expended 

18 during such quarter by such State by the number of 

19 percentage points specified in paragraph (2) for such 

20 quarter. 

21 ‘‘(2) AMOUNT OF REDUCTION.—For purposes 

22 of paragraph (1), the number of percentage points 

23 specified in this paragraph for a calendar quarter is 

24 the following: 


pamtmann on DSKBC07HB2PROD with BILLS
27 

•S 4521 IS

1 ‘‘(A) For the calendar quarter beginning 

2 on October 1, 2022, 0.5. 

3 ‘‘(B) For a calendar quarter beginning on 

4 or after January 1, 2023, and ending before 

5 July 1, 2027, the number of percentage points 

6 specified under this paragraph for the previous 

7 quarter, plus 0.5. 

8 ‘‘(C) For a calendar quarter beginning on 

9 or after July 1, 2027, 10. 

10 ‘‘(3) DEFINITION.—For purposes of this sub11 section, the term ‘State’ means a State that is one 

12 of the 50 States or the District of Columbia.’’. 

13 SEC. 203. STATE OPTION TO PROVIDE 12 MONTHS OF 

14 POSTPARTUM MEDICAID ELIGIBILITY. 

15 (a) OPTION TO PROVIDE CONTINUOUS MEDICAID

16 AND CHIP COVERAGE FOR PREGNANT AND POSTPARTUM

17 WOMEN.— 

18 (1) MEDICAID.—Title XIX of the Social Secu19 rity Act (42 U.S.C. 1396 et seq.) is amended— 

20 (A) in section 1902(l)(1)(A), by inserting 

21 ‘‘(or, at the option of the State, 365-day pe22 riod)’’ after ‘‘60-day period’’; 

23 (B) in section 1902(e)(6), by inserting 

24 ‘‘(or, at the option of the State, 365-day pe25 riod)’’ after ‘‘60-day period’’; 


pamtmann on DSKBC07HB2PROD with BILLS
28 

•S 4521 IS

1 (C) in section 1903(v)(4)(A)(i), by insert2 ing ‘‘(or, at the option of the State, 365-day pe3 riod)’’ after ‘‘60-day period’’; and 

4 (D) in section 1905(a), in the 4th sentence 

5 in the matter following paragraph (30), by in6 serting ‘‘(or, at the option of the State, 365-day 

7 period)’’ after ‘‘60-day period’’. 

8 (2) CHIP.—Section 2112 of the Social Security 

9 Act (42 U.S.C. 1397ll) is amended by inserting ‘‘(or, 

10 at the option of the State, 365-day period)’’ after 

11 ‘‘60-day period’’ each place it appears. 

12 (b) REQUIRING FULL BENEFITS FOR PREGNANT

13 AND POSTPARTUM WOMEN.— 

14 (1) MEDICAID.— 

15 (A) IN GENERAL.—Paragraph (5) of sec16 tion 1902(e) of the Social Security Act (24 

17 U.S.C. 1396a(e)) is amended to read as follows: 

18 ‘‘(5) Any woman who is eligible for medical as19 sistance under the State plan or a waiver of such 

20 plan and who is, or who while so eligible becomes, 

21 pregnant, shall continue to be eligible under the plan 

22 or waiver for medical assistance through the end of 

23 the month in which the 60-day period (or, at the op24 tion of the State, 365-day period) (beginning on the 

25 last day of her pregnancy) ends, regardless of the 


pamtmann on DSKBC07HB2PROD with BILLS
29 

•S 4521 IS

1 basis for the woman’s eligibility for medical assist2 ance, including if the woman’s eligibility for medical 

3 assistance is on the basis of being pregnant.’’. 

4 (B) CONFORMING AMENDMENT.—Section 

5 1902(a)(10) of the Social Security Act (42 

6 U.S.C. 1396a(a)(10)) is amended in the matter 

7 following subparagraph (G) by striking ‘‘(VII) 

8 the medical assistance’’ and all that follows 

9 through ‘‘complicate pregnancy,’’. 

10 (2) CHIP.—Section 2107(e)(1) of the Social 

11 Security Act (42 U.S.C. 1397gg(e)(1)) is amended— 

12 (A) by redesignating subparagraphs (H) 

13 through (S) as subparagraphs (I) through (T), 

14 respectively; and 

15 (B) by inserting after subparagraph (G), 

16 the following: 

17 ‘‘(H) Section 1902(e)(5) (requiring 60-day 

18 (or, at the option of the State, 365-day) contin19 uous coverage for pregnant and postpartum 

20 women).’’. 

21 (c) MAINTENANCE OF EFFORT.— 

22 (1) MEDICAID.—Section 1902 of the Social Se23 curity Act (42 U.S.C. 1396a) is amended— 


pamtmann on DSKBC07HB2PROD with BILLS
30 

•S 4521 IS

1 (A) in paragraph (74), by striking ‘‘sub2 section (gg); and’’ and inserting ‘‘subsections 

3 (gg) and (qq);’’; and 

4 (B) by adding at the end the following new 

5 subsection: 

6 ‘‘(qq) MAINTENANCE OF EFFORT RELATED TO LOW7 INCOME PREGNANT WOMEN.—For calendar quarters be8 ginning on or after the effective date described in section 

9 204(d) of the Health Care Improvement Act of 2020, and 

10 before January 1, 2023, no Federal payment shall be 

11 made to a State under section 1903(a) for amounts ex12 pended under a State plan under this title or a waiver 

13 of such plan if the State— 

14 ‘‘(1) has in effect under such plan eligibility 

15 standards, methodologies, or procedures for individ16 uals described in subsection (l)(1) who are eligible 

17 for medical assistance under the State plan or waiv18 er under subsection (a)(10)(A)(ii)(IX) that are more 

19 restrictive than the eligibility standards, methodolo20 gies, or procedures, respectively, for such individuals 

21 under such plan or waiver that are in effect on the 

22 date of the enactment of this subsection; or 

23 ‘‘(2) provides medical assistance to individuals 

24 described in subsection (l)(1) who are eligible for 

25 medical assistance under such plan or waiver under 


pamtmann on DSKBC07HB2PROD with BILLS
31 

•S 4521 IS

1 subsection (a)(10)(A)(ii)(IX) at a level that is less 

2 than the level at which the State provides such as3 sistance to such individuals under such plan or waiv4 er on the date of the enactment of this subsection.’’. 

5 (2) CHIP.—Section 2112 of the Social Security 

6 Act (42 U.S.C. 1397ll), as amended by subsection 

7 (b), is further amended by adding at the end the fol8 lowing subsection: 

9 ‘‘(g) MAINTENANCE OF EFFORT.—For calendar 

10 quarters beginning on or after the effective date described 

11 in section 204(d) of the Health Care Improvement Act of 

12 2020, and before January 1, 2023, no payment may be 

13 made under section 2105(a) with respect to a State child 

14 health plan if the State— 

15 ‘‘(1) has in effect under such plan eligibility 

16 standards, methodologies, or procedures for targeted 

17 low-income pregnant women that are more restric18 tive than the eligibility standards, methodologies, or 

19 procedures, respectively, under such plan that are in 

20 effect on the date of the enactment of this sub21 section; or 

22 ‘‘(2) provides pregnancy-related assistance to 

23 targeted low-income pregnant women under such 

24 plan at a level that is less than the level at which 

25 the State provides such assistance to such women 


pamtmann on DSKBC07HB2PROD with BILLS
32 

•S 4521 IS

1 under such plan on the date of the enactment of this 

2 subsection.’’. 

3 (d) EFFECTIVE DATE.— 

4 (1) IN GENERAL.—Except as provided under 

5 paragraph (2), the amendments made by subsections 

6 (a) and (b) shall take effect on (and the effective 

7 date described in this subsection shall be) the first 

8 day of the calendar quarter during which the last 

9 day of the emergency period described in section 

10 1135(g)(1)(B) of the Social Security Act (42 U.S.C. 

11 1320b–5(g)(1)(B)) occurs. 

12 (2) EXTENSION OF EFFECTIVE DATE FOR

13 STATE LAW AMENDMENT.—In the case of a State 

14 plan under title XIX or State child health plan 

15 under title XXI of the Social Security Act (42 

16 U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.) 

17 which the Secretary of Health and Human Services 

18 determines requires State legislation (other than leg19 islation appropriating funds) in order for the respec20 tive plan to meet the additional requirement imposed 

21 by the amendments made by subsection (a) or (b), 

22 respectively, the respective plan shall not be re23 garded as failing to comply with the requirements of 

24 such title solely on the basis of its failure to meet 

25 such applicable additional requirement before the 


pamtmann on DSKBC07HB2PROD with BILLS
33 

•S 4521 IS

1 first day of the first calendar quarter beginning 

2 after the close of the first regular session of the 

3 State legislature that begins after the date of enact4 ment of this Act. For purposes of the previous sen5 tence, in the case of a State that has a 2-year legis6 lative session, each year of the session is considered 

7 to be a separate regular session of the State legisla8 ture. 

9 SEC. 204. SUPPORTING STATE MEDICAID PROGRAMS 

10 THROUGH ECONOMIC DOWNTURNS. 

11 (a) IN GENERAL.—Section 1905 of the Social Secu12 rity Act (42 U.S.C. 1396d) is amended— 

13 (1) in subsection (b), by striking ‘‘and (ff)’’ and 

14 inserting ‘‘(ff), and (gg)’’; and 

15 (2) by adding at the end the following new sub16 section: 

17 ‘‘(gg) INCREASED FMAP DURING ECONOMIC

18 DOWNTURNS.— 

19 ‘‘(1) IN GENERAL.—If a fiscal quarter that be20 gins on or after January 1, 2020, is an economic 

21 downturn quarter (as defined in paragraph (2)) with 

22 respect to a State, then the Federal medical assist23 ance percentage determined for each State for such 

24 quarter under subsection (b) shall be equal to the 


pamtmann on DSKBC07HB2PROD with BILLS
34 

•S 4521 IS

1 percentage determined for the State and quarter 

2 under paragraph (3). 

3 ‘‘(2) ECONOMIC DOWNTURN QUARTER.— 

4 ‘‘(A) IN GENERAL.— 

5 ‘‘(i) IN GENERAL.—In this subsection, 

6 the term ‘economic downturn quarter’ 

7 means, with respect to a State, a fiscal 

8 quarter during which the State’s unem9 ployment rate for the quarter exceeds the 

10 percentage determined for the State and 

11 quarter under clause (ii). 

12 ‘‘(ii) THRESHOLD PERCENTAGE.—The 

13 percentage determined under this clause 

14 for a State and fiscal quarter is the per15 centage equal to the lower of— 

16 ‘‘(I) the State unemployment 

17 rate at the 20th percentile of the dis18 tribution of the State’s quarterly un19 employment rates for the 60-quarter 

20 period preceding the quarter involved, 

21 increased by 1 percentage point; and 

22 ‘‘(II) the State’s average quar23 terly unemployment rate for the 12- 

24 quarter period preceding the quarter 


pamtmann on DSKBC07HB2PROD with BILLS
35 

•S 4521 IS

1 involved, increased by 1 percentage 

2 point. 

3 ‘‘(B) UNEMPLOYMENT DATA.— 

4 ‘‘(i) IN GENERAL.—Except as pro5 vided in clause (ii), for purposes of deter6 mining unemployment rates for a State 

7 and a quarter under this paragraph, the 

8 Secretary shall use data from the Local 

9 Area Unemployment Statistics from the 

10 Bureau of Labor Statistics. 

11 ‘‘(ii) APPLICATION TO CERTAIN TER12 RITORIES.—In the case of the Virgin Is13 lands, Guam, the Northern Mariana Is14 lands, American Samoa, or any other juris15 diction for which suitable data from the 

16 Local Area Unemployment Statistics from 

17 the Bureau of Labor Statistics are unavail18 able, the Secretary shall use data from the 

19 U–3 unemployment measure of the Bureau 

20 of Labor Statistics to make any necessary 

21 determinations under subparagraph (A). 

22 ‘‘(3) INCREASED FMAP DURING ECONOMIC

23 DOWNTURN QUARTER.— 

24 ‘‘(A) IN GENERAL.—During a fiscal quar25 ter that is an economic downturn quarter with 


pamtmann on DSKBC07HB2PROD with BILLS
36 

•S 4521 IS

1 respect to a State, the Federal medical assist2 ance percentage for the State and quarter de3 termined under subsection (b) shall be equal 

4 to— 

5 ‘‘(i) the Federal medical assistance 

6 percentage determined for the State and 

7 quarter under subsection (b) without re8 gard to this subsection (but including any 

9 increase to such percentage for such quar10 ter made pursuant to section 6008(a) of 

11 the Families First Coronavirus Response 

12 Act); increased by 

13 ‘‘(ii) the number of percentage points 

14 (rounded to the nearest tenth of a percent15 age point) equal to the product of— 

16 ‘‘(I) the number of percentage 

17 points (rounded to the nearest tenth 

18 of a percentage point) by which the 

19 unemployment rate for the State and 

20 quarter exceeds the percentage deter21 mined for the State and quarter 

22 under paragraph (2)(A)(ii); and 

23 ‘‘(II) 4.8. 

24 ‘‘(B) RULES OF APPLICATION.—The fol25 lowing rules shall apply with respect to the FedVerDate Sep 11 2014 23:16 Aug 27, 2020 Jkt 099200 PO 00000 Frm 00036 Fmt 6652 Sfmt 6201 E:\BILLS\S4521.IS S4521

pamtmann on DSKBC07HB2PROD with BILLS
37 

•S 4521 IS

1 eral medical assistance percentage determined 

2 for a State and an economic downturn quarter 

3 under this subsection: 

4 ‘‘(i) SCOPE OF APPLICATION.—Such 

5 Federal medical assistance percentage shall 

6 not apply for purposes of— 

7 ‘‘(I) disproportionate share hos8 pital payments described in section 

9 1923; 

10 ‘‘(II) payments under part D of 

11 title IV; or 

12 ‘‘(III) any payments under this 

13 title that are based on a Federal med14 ical assistance percentage determined 

15 for a State under subsection (aa) (but 

16 only to the extent that such Federal 

17 medical assistance percentage is high18 er than the economic recovery 

19 FMAP). 

20 ‘‘(ii) LIMITATION.—In no case shall— 

21 ‘‘(I) the Federal medical assist22 ance percentage determined for a 

23 State and quarter pursuant to this 

24 subsection exceed 95 percent; or 


pamtmann on DSKBC07HB2PROD with BILLS
38 

•S 4521 IS

1 ‘‘(II) any increase to the Federal 

2 medical assistance percentage deter3 mined for a State and quarter pursu4 ant to this subsection result in the ap5 plication of a Federal medical assist6 ance percentage that exceeds 95 per7 cent. 

8 ‘‘(iii) APPLICATION TO CHIP.—Not9 withstanding the first sentence of section 

10 2105(b), the application of this subsection 

11 may result in the enhanced FMAP of a 

12 State for a fiscal year under such section 

13 exceeding 85 percent, but in no case may 

14 the application of this subsection before 

15 application of the second sentence of such 

16 section result in the enhanced FMAP of 

17 the State exceeding 95 percent. 

18 ‘‘(4) ADVANCE PAYMENT; RETROSPECTIVE AD19 JUSTMENT.— 

20 ‘‘(A) IN GENERAL.—Prior to the beginning 

21 of each fiscal quarter that begins on or after 

22 July 1, 2020, the Secretary shall, with respect 

23 to each State— 

24 ‘‘(i) make an initial determination, 

25 based on the projections made for the 


pamtmann on DSKBC07HB2PROD with BILLS
39 

•S 4521 IS

1 State and quarter under subparagraph 

2 (B), as to— 

3 ‘‘(I) whether the application of 

4 this subsection is expected to result in 

5 the application of a higher Federal 

6 medical assistance percentage for the 

7 State and quarter than the percentage 

8 that would otherwise apply without re9 gard to this subsection; and— 

10 ‘‘(II) if the application of this 

11 subsection is expected to result in 

12 such a higher Federal medical assist13 ance percentage for the State and 

14 quarter, what such higher percentage 

15 is expected to be; and 

16 ‘‘(ii) if the Secretary determines under 

17 clause (i) that the application of this sub18 section is expected to result in the applica19 tion of a higher Federal medical assistance 

20 percentage for the State and quarter than 

21 the percentage that would otherwise apply 

22 without regard to this subsection— 

23 ‘‘(I) apply such higher Federal 

24 medical assistance percentage of the 

25 State for purposes of making payVerDate Sep 11 2014 23:16 Aug 27, 2020 Jkt 099200 PO 00000 Frm 00039 Fmt 6652 Sfmt 6201 E:\BILLS\S4521.IS S4521

pamtmann on DSKBC07HB2PROD with BILLS
40 

•S 4521 IS

1 ments to the State for amounts ex2 pended during such quarter as med3 ical assistance under the State plan; 

4 and 

5 ‘‘(II) take into account such 

6 higher Federal medical assistance per7 centage of the State for purposes of 

8 calculating the enhanced FMAP for 

9 the State and quarter under section 

10 2105(b). 

11 ‘‘(B) PROJECTION OF STATE UNEMPLOY12 MENT RATES.—Prior to the beginning of each 

13 fiscal quarter that begins on or after July 1, 

14 2020, the Secretary, acting through the Chief 

15 Actuary of the Centers for Medicare & Medicaid 

16 Services, shall, using the most recently available 

17 data described in paragraph (2)(B), make pro18 jections with respect to— 

19 ‘‘(i) the unemployment rates for each 

20 State for such quarter; 

21 ‘‘(ii) the threshold percentages de22 scribed in paragraph (2)(A)(ii) for each 

23 State for such quarter; and 

24 ‘‘(iii) the national unemployment rate 

25 for such quarter. 


pamtmann on DSKBC07HB2PROD with BILLS
41 

•S 4521 IS

1 ‘‘(C) RETROSPECTIVE ADJUSTMENT.—As 

2 soon as practicable after final unemployment 

3 data becomes available for a fiscal quarter that 

4 begins on or after July 1, 2020, the Secretary 

5 shall, with respect to each State— 

6 ‘‘(i) make a final determination with 

7 respect to the application of this subsection 

8 for purposes of determining the Federal 

9 medical assistance percentage and en10 hanced FMAP of the State for the quarter; 

11 and 

12 ‘‘(ii) in accordance with section 

13 1903(d)(2) and section 2105(e), reduce or 

14 increase the amount payable to the State 

15 under section 1903(a) or section 2105 for 

16 a subsequent fiscal quarter to the extent of 

17 any overpayment or underpayment under 

18 either such section which the Secretary de19 termines was made as a result of an incor20 rect initial determination under subpara21 graph (A)(i) with respect to the application 

22 of this subsection for purposes of deter23 mining the Federal medical assistance per24 centage and enhanced FMAP of the State 

25 for such prior fiscal quarter. 


pamtmann on DSKBC07HB2PROD with BILLS
42 

•S 4521 IS

1 ‘‘(5) RETROSPECTIVE APPLICATION OF OVER2 THE-LIMIT FMAP INCREASES.— 

3 ‘‘(A) IN GENERAL.—If a State has excess 

4 percentage points with respect to an economic 

5 downturn quarter and an applicable FMAP (as 

6 determined under subparagraph (B)), the State 

7 may elect to apply such excess percentage 

8 points to increase such applicable FMAP for 

9 one or more quarters during the look-back pe10 riod for the State and economic downturn quar11 ter in accordance with this paragraph. 

12 ‘‘(B) EXCESS PERCENTAGE POINTS.—For 

13 purposes of this paragraph, the number of ex14 cess percentage points for a State, economic 

15 downturn quarter, and an applicable FMAP 

16 shall be equal to the number of percentage 

17 points by which— 

18 ‘‘(i) the applicable FMAP for the 

19 State and quarter (after application of 

20 paragraph (3) but without regard to sub21 paragraph (B)(ii) of such paragraph); ex22 ceeds 

23 ‘‘(ii) 95 percent. 

24 ‘‘(C) EFFECT OF APPLICATION OF EXCESS

25 PERCENTAGE POINTS.—If a State elects to 


pamtmann on DSKBC07HB2PROD with BILLS
43 

•S 4521 IS

1 apply excess percentage points to an applicable 

2 FMAP to a quarter during a look-back period 

3 under this paragraph, the Secretary shall deter4 mine the additional amount of payment under 

5 section 1903(a) to which the State would have 

6 been entitled for such quarter if the applicable 

7 FMAP (as so increased) had been in effect for 

8 such quarter, and shall treat such additional 

9 amount as an underpayment for such quarter. 

10 ‘‘(D) DISTRIBUTION OF EXCESS PERCENT11 AGE POINTS.—A State that has excess percent12 age points with respect to an economic down13 turn quarter and applicable FMAP may elect to 

14 divide such points among more than 1 quarter 

15 during the look-back period for such State and 

16 quarter provided that no excess percentage 

17 point (or fraction of an excess percentage point) 

18 is applied to the applicable FMAP of more than 

19 1 quarter. 

20 ‘‘(E) LIMITATIONS.— 

21 ‘‘(i) NO INCREASES OVER 100 PER22 CENT.—A State may not increase an appli23 cable FMAP for any quarter during a look24 back period under this paragraph if such 

25 increase would result in the applicable 


pamtmann on DSKBC07HB2PROD with BILLS
44 

•S 4521 IS

1 FMAP for such quarter exceeding 100 per2 cent. 

3 ‘‘(ii) SCOPE OF APPLICATION.—Any 

4 increase to an applicable FMAP of a State 

5 for a fiscal quarter under this paragraph— 

6 ‘‘(I) shall only apply with respect 

7 to payments for amounts expended by 

8 the State for medical assistance for 

9 services furnished during such quarter 

10 to which such applicable FMAP is ap11 plicable; and 

12 ‘‘(II) shall not apply with respect 

13 to payments described in paragraph 

14 (3)(B)(i). 

15 ‘‘(F) DEFINITIONS.—In this paragraph: 

16 ‘‘(i) APPLICABLE FMAP.—The term 

17 ‘applicable FMAP’ means, with respect to 

18 a State and fiscal quarter— 

19 ‘‘(I) the Federal medical assist20 ance percentage determined for the 

21 State and quarter under subsection 

22 (b); 

23 ‘‘(II) the Federal medical assist24 ance percentage applicable under sub25 section (y); 


pamtmann on DSKBC07HB2PROD with BILLS
45 

•S 4521 IS

1 ‘‘(III) the Federal medical assist2 ance percentage applicable under sub3 section (z)(2); 

4 ‘‘(IV) the Federal medical assist5 ance percentage determined for the 

6 State and quarter under subsection 

7 (ff); or 

8 ‘‘(V) the enhanced FMAP deter9 mined for the State and quarter 

10 under section 2105(b). 

11 ‘‘(ii) LOOK-BACK PERIOD.—The term 

12 ‘look-back period’ means, with respect to a 

13 State and a fiscal quarter that is an eco14 nomic downturn quarter for the State, the 

15 period of 4 fiscal quarters that ends with 

16 the fourth quarter which precedes the most 

17 recent fiscal quarters that was not an eco18 nomic downturn quarter for the State. 

19 ‘‘(6) REQUIREMENT FOR ALL STATES.—This 

20 subsection shall not apply to a State with respect to 

21 a fiscal quarter, if— 

22 ‘‘(A) eligibility standards, methodologies, 

23 or procedures under the State plan or a waiver 

24 of such plan are more restrictive during such 

25 quarter than the eligibility standards, methVerDate Sep 11 2014 23:16 Aug 27, 2020 Jkt 099200 PO 00000 Frm 00045 Fmt 6652 Sfmt 6201 E:\BILLS\S4521.IS S4521

pamtmann on DSKBC07HB2PROD with BILLS
46 

•S 4521 IS

1 odologies, or procedures, respectively, under 

2 such plan (or waiver) as in effect on the last 

3 day of the most recent fiscal quarter that was 

4 not an economic downturn quarter for the 

5 State; 

6 ‘‘(B) the amount of any premium imposed 

7 by the State pursuant to section 1916 or 1916A 

8 during such quarter, with respect to an indi9 vidual enrolled under such plan (or waiver), ex10 ceeds the amount of such premium as of the 

11 date described in subparagraph (A); or 

12 ‘‘(C) the State fails to provide that an in13 dividual who is enrolled for benefits under such 

14 plan (or waiver) as of the date described in sub15 paragraph (A) or enrolls for benefits under 

16 such plan (or waiver) during the period begin17 ning with such date and ending with the day 

18 before the first day of the next quarter that is 

19 not an economic downturn quarter for the State 

20 shall be treated as eligible for such benefits for 

21 not less than 12 months after such date or (if 

22 later) the date that such individual so enrolls 

23 unless the individual requests a voluntary ter24 mination of eligibility or the individual ceases to 

25 be a resident of the State.’’. 


pamtmann on DSKBC07HB2PROD with BILLS
47 

•S 4521 IS

1 (b) EXCLUSION OF ECONOMIC DOWNTURN FMAP 

2 INCREASES FROM TERRITORIAL CAPS; SPECIAL RULE

3 FOR CHIP ALLOTMENTS.— 

4 (1) EXCLUSION FROM TERRITORIAL CAPS.— 

5 Section 1108 of the Social Security Act (42 U.S.C. 

6 1308) is amended— 

7 (A) in subsection (f), in the matter pre8 ceding paragraph (1), by striking ‘‘subsection 

9 (g) and section 1935(e)(1)(B)’’ and inserting 

10 ‘‘subsections (g) and (h) and section 

11 1935(e)(1)(B)’’; and 

12 (B) by adding at the end the following: 

13 ‘‘(h) EXCLUSION FROM CAPS OF AMOUNTS ATTRIB14 UTABLE TO ECONOMIC DOWNTURN FMAP.—Any pay15 ment made to a territory for a fiscal year in which the 

16 Federal medical assistance percentage for the territory is 

17 determined under section 1905(gg) shall not be taken into 

18 account for purposes of applying payment limits under 

19 subsections (f) and (g) to the extent that such payment 

20 exceeds the amount of the payment that would have been 

21 made to the territory for the year if the Federal medical 

22 assistance percentage for the territory had been deter23 mined without regard to such section.’’. 


pamtmann on DSKBC07HB2PROD with BILLS
48 

•S 4521 IS

1 (2) CHIP ALLOTMENTS.—Section 2104(m) of 

2 the Social Security Act (42 U.S.C. 1397dd(m)) is 

3 amended— 

4 (A) in paragraph (2)(B), in the matter 

5 preceding clause (i), by striking ‘‘paragraphs 

6 (5) and (7)’’ and inserting ‘‘paragraphs (5), 

7 (7), and (12)’’; and 

8 (B) by adding at the end the following new 

9 paragraph: 

10 ‘‘(12) SPECIAL RULE FOR ADJUSTING ALLOT11 MENTS DURING FISCAL YEARS WITH ECONOMIC

12 DOWNTURN QUARTERS.— 

13 ‘‘(A) IN GENERAL.—If a fiscal quarter oc14 curring during fiscal year 2020 or any suc15 ceeding fiscal year is determined to be an eco16 nomic downturn quarter with respect to a State 

17 (as determined under section 1905(gg)) then, 

18 as soon as practicable after such determination, 

19 the Secretary shall increase the allotment for 

20 the State and fiscal year in accordance with 

21 subparagraph (B). 

22 ‘‘(B) AMOUNT OF INCREASE.— 

23 ‘‘(i) IN GENERAL.—The amount of an 

24 increase to the allotment of a State de25 scribed in subparagraph (A) for a fiscal 


pamtmann on DSKBC07HB2PROD with BILLS
49 

•S 4521 IS

1 year shall be equal to the amount by which 

2 Federal payments made to the State for 

3 the preceding fiscal year under this title 

4 would have been increased (without regard 

5 to whether such payments would exceed 

6 the amount of the State’s allotment for 

7 such preceding fiscal year) if the enhanced 

8 FMAP determined for the State for such 

9 preceding fiscal year had been increased to 

10 the same extent that the State’s enhanced 

11 FMAP for the fiscal year involved is ex12 pected to be increased as a result of the 

13 application of section 1905(gg) relative to 

14 the enhanced FMAP that would apply to 

15 the State for the fiscal year involved with16 out the application of such section. 

17 ‘‘(ii) INCLUSION OF PROJECTED IN18 CREASES.—In increasing the allotment of a 

19 State for a fiscal year under this para20 graph, the Secretary may base the calcula21 tion of such increase on projections made 

22 by the Secretary with respect to— 

23 ‘‘(I) the number of fiscal quar24 ters during such fiscal year that will 

25 be economic downturn quarters; and 


pamtmann on DSKBC07HB2PROD with BILLS
50 

•S 4521 IS

1 ‘‘(II) the effect that the applica2 tion of section 1905(gg) is expected to 

3 have on the enhanced FMAP of the 

4 State for such fiscal year. 

5 ‘‘(C) DISREGARD OF INCREASED PAY6 MENTS FOR PURPOSES OF FUTURE ALLOT7 MENTS.—Any Federal payment made to a State 

8 under this title for a fiscal year in which the 

9 Federal medical assistance percentage for the 

10 State is determined under section 1905(gg) 

11 shall be disregarded when determining the allot12 ment of the State for any subsequent year, in13 cluding for purposes of applying this paragraph, 

14 to the extent that such payment exceeds the 

15 amount of the payment that would have been 

16 made to the State for the year if the Federal 

17 medical assistance percentage for the State and 

18 year had been determined without regard to 

19 such section.’’. 

20 SEC. 205. STATE FLEXIBILITY TO USE ADMINISTRATIVE 

21 SIMPLIFICATION POLICIES FOR ENROLL22 MENT. 

23 (a) PERMANENT EXTENSION OF MEDICAID AND

24 CHIP EXPRESS LANE OPTION.—Section 1902(e)(13) of 


pamtmann on DSKBC07HB2PROD with BILLS
51 

•S 4521 IS

1 the Social Security Act (42 U.S.C. 1396a(e)(13)) is 

2 amended by striking subparagraph (I). 

3 (b) EXTENDING EXPRESS LANE ELIGIBILITY TO

4 ADULTS.—Section 1902(e)(13)(A) of the Social Security 

5 Act (42 U.S.C. 1396a(e)(13)(A)) is amended by adding 

6 at the end the following new clause: 

7 ‘‘(iii) STATE OPTION TO EXTEND EX8 PRESS LANE ELIGIBILITY TO ADULTS.— 

9 ‘‘(I) IN GENERAL.—At the option 

10 of the State, the State may apply the 

11 provisions of this paragraph with re12 spect to determining eligibility under 

13 this title for an eligible individual (as 

14 defined in subclause (II)). In applying 

15 this paragraph in the case of a State 

16 making such an option, any reference 

17 in this paragraph to a child with re18 spect to this title (other than a ref19 erence to child health assistance) shall 

20 be deemed to be a reference to an eli21 gible individual. 

22 ‘‘(II) ELIGIBLE INDIVIDUAL DE23 FINED.—In this clause, the term ‘eli24 gible individual’ means— 


pamtmann on DSKBC07HB2PROD with BILLS
52 

•S 4521 IS

1 ‘‘(aa) any individual (other 

2 than a child) whose income eligi3 bility under the State plan or 

4 under a waiver of the plan for 

5 medical assistance is determined 

6 under paragraph (14); and 

7 ‘‘(bb) an individual included 

8 in any other group of individuals 

9 the Secretary determines appro10 priate.’’. 

11 (c) CONSENT BY BENEFIT UTILIZATION.—Section 

12 1902(e)(13)(D)(i) of the Social Security Act (42 U.S.C. 

13 1396a(e)(13)(D)(i)) is amended by inserting ‘‘by using 

14 medical assistance to access care,’’ after ‘‘through elec15 tronic signature,’’. 

16 (d) STUDY AND REPORT ON OPTIONS FOR AUTO17 MATIC ENROLLMENT IN MEDICAID AND CHIP.— 

18 (1) STUDY.—The Secretary of Health and 

19 Human Services, by grant, contract, or interagency 

20 agency, shall conduct a study to identify options for, 

21 and barriers to, States automatically enrolling indi22 viduals who, on the basis of data and information 

23 from income tax returns and other sources, are like24 ly to be eligible for medical assistance under the 

25 State Medicaid plan established under title XIX of 


pamtmann on DSKBC07HB2PROD with BILLS
53 

•S 4521 IS

1 the Social Security Act (42 U.S.C. 1396 et seq.) (or 

2 a waiver of such plan) or for child health assistance 

3 (or, if applicable, pregnancy-related assistance) 

4 under the State child health plan established under 

5 title XXI of the Social Security Act (42 U.S.C. 

6 1397aa et seq.) (or a waiver of such plan), and 

7 would not be required to pay a premium for enroll8 ment in such a plan or waiver. 

9 (2) REPORT.—Not later than 1 year after the 

10 date of enactment of this Act, the Secretary of 

11 Health and Human Services shall submit a report to 

12 Congress on the results of the study conducted 

13 under subsection (a). The report shall include the 

14 following: 

15 (A) An analysis of the financial, regu16 latory, and legislative barriers that limit the 

17 ability of States to implement automatic enroll18 ment for individuals described in subsection (a). 

19 (B) An analysis of the extent to which 

20 State implementation of automatic enrollment 

21 for such individuals would reduce the number of 

22 uninsured individuals in each State. 

23 (C) Recommendations for administrative 

24 and legislative actions that, if taken, would 

25 eliminate the barriers identified under subparaVerDate Sep 11 2014 23:16 Aug 27, 2020 Jkt 099200 PO 00000 Frm 00053 Fmt 6652 Sfmt 6201 E:\BILLS\S4521.IS S4521

pamtmann on DSKBC07HB2PROD with BILLS
54 

•S 4521 IS

1 graph (A) and allow States to elect to automati2 cally enroll individuals described in subsection 

3 (a) in the State Medicaid plan established 

4 under title XIX of the Social Security Act (42 

5 U.S.C. 1396 et seq.) (or a waiver of such plan) 

6 or for child health assistance (or, if applicable, 

7 pregnancy-related assistance) under the State 

8 child health plan established under title XXI of 

9 the Social Security Act (42 U.S.C. 1397aa et 

10 seq.) (or a waiver of such plan). 

11 TITLE III—ESTABLISHMENT OF 

12 A PUBLIC HEALTH CARE OPTION 

13 SEC. 301. ESTABLISHMENT OF HEALTH PLAN. 

14 (a) IN GENERAL.—The Secretary shall establish a co15 ordinated and low-cost health plan (referred to in this sec16 tion as the ‘‘health plan’’) to provide access to quality 

17 health care for enrollees. 

18 (b) INDIVIDUAL MARKET AVAILABILITY.—The Sec19 retary shall make the health plan available in the indi20 vidual market for plan year 2022 and each subsequent 

21 plan year. 

22 (c) RULEMAKING.—The Secretary may promulgate 

23 such regulations as may be necessary to carry out this 

24 title. 


pamtmann on DSKBC07HB2PROD with BILLS
55 

•S 4521 IS

1 (d) AUTHORIZATION OF APPROPRIATIONS.—There 

2 are authorized to be appropriated such sums as may be 

3 necessary to carry out this title. 

4 SEC. 302. AVAILABILITY OF PLAN. 

5 (a) ELIGIBILITY.—An individual shall be eligible to 

6 enroll in the health plan if such individual, for the entire 

7 period for which enrollment is sought— 

8 (1) is a qualified individual within the meaning 

9 of section 1312 of the Patient Protection and Af10 fordable Care Act (42 U.S.C. 18032); 

11 (2) is not eligible for benefits under the Medi12 care program under title XVIII of the Social Secu13 rity Act (42 U.S.C. 1395 et seq.); and 

14 (3) is not otherwise eligible for, or has been 

15 otherwise offered, employer-sponsored health care 

16 coverage. 

17 (b) EXCHANGES.—The health plan shall be made 

18 available through the Exchanges, including the Small 

19 Business Health Options Program Exchange. 

20 SEC. 303. AFFORDABILITY. 

21 The Secretary shall ensure that coverage options for 

22 the health plan are not more costly than comparable op23 tions offered on the Exchange in the applicable market. 


pamtmann on DSKBC07HB2PROD with BILLS
56 

•S 4521 IS

1 SEC. 304. PARTICIPATING PROVIDERS. 

2 (a) REQUIREMENT TO PARTICIPATE IN ORDER TO

3 BE ENROLLED UNDER MEDICARE.—Beginning January 

4 1, 2021, the Secretary may require a health care provider 

5 enrolled under the Medicare program under section 

6 1866(j) of the Social Security Act (42 U.S.C. 1395cc(j)) 

7 to be a participating provider under the health plan. 

8 (b) REQUIREMENT TO PARTICIPATE IN ORDER TO

9 PARTICIPATE IN MEDICAID.—Beginning January 1, 2021, 

10 the Secretary may require a health care provider under 

11 a State Medicaid plan under title XIX of the Social Secu12 rity Act (42 U.S.C. 1396 et seq.) to also be a participating 

13 provider under the health plan. 

14 SEC. 305. PROVIDER PAYMENT RATES. 

15 The Secretary shall set competitive provider payment 

16 rates under the health plan using the best information 

17 publically available and data otherwise accessible to the 

18 Secretary. The Secretary shall give consideration to exist19 ing provider payment rates for commercial health plans 

20 and provider costs to deliver care, giving special consider21 ation to increased costs for providers to deliver care in 

22 rural and medically underserved areas. 

23 SEC. 306. NO EFFECT ON MEDICARE BENEFITS OR MEDI24 CARE TRUST FUNDS. 

25 Nothing in this title shall— 


pamtmann on DSKBC07HB2PROD with BILLS
57 

•S 4521 IS

1 (1) affect the benefits available under title 

2 XVIII of the Social Security Act (42 U.S.C. 1395 et 

3 seq.); or 

4 (2) impact the Federal Hospital Insurance 

5 Trust Fund under section 1817 of the Social Secu6 rity Act (42 U.S.C. 1395i) or the Federal Supple7 mentary Medical Insurance Trust Fund under sec8 tion 1841 of the Social Security Act (42 U.S.C. 

9 1395t) (including the Medicare Prescription Drug 

10 Account within such Trust Fund). 

11 TITLE IV—FAIR MEDICARE PAY12 MENTS TO RURAL PRO13 VIDERS 

14 SEC. 401. ENSURING FAIRNESS IN MEDICARE HOSPITAL 

15 PAYMENTS. 

16 (a) HOSPITAL INPATIENT SERVICES.— 

17 (1) IN GENERAL.—Section 1886(d)(3)(E)(i) of 

18 the Social Security Act (42 U.S.C. 

19 1395www(d)(3)(E)) is amended— 

20 (A) in clause (i), in the first sentence, by 

21 striking ‘‘or (iii)’’ and inserting ‘‘, (iii), or (iv)’’; 

22 and 

23 (B) by adding at the end the following new 

24 clause: 

25 ‘‘(iv) AREA WAGE INDEX FLOOR.— 


pamtmann on DSKBC07HB2PROD with BILLS
58 

•S 4521 IS

1 ‘‘(I) IN GENERAL.—For dis2 charges occurring on or after October 

3 1, 2020, the area wage index applica4 ble under this subparagraph to any 

5 hospital which is not located in a fron6 tier State (as defined in clause 

7 (iii)(II)) may not be less than 0.85. 

8 ‘‘(II) WAIVING BUDGET NEU9 TRALITY.—Pursuant to the fifth sen10 tence of clause (i), this clause shall 

11 not be applied in a budget neutral 

12 manner.’’. 

13 (2) WAIVING BUDGET NEUTRALITY.— 

14 (A) TECHNICAL AMENDATORY CORREC15 TION.—Section 10324(a)(2) of Public Law 

16 111–148 is amended by striking ‘‘third sen17 tence’’ and inserting ‘‘fifth sentence’’. 

18 (B) WAIVER.—Section 1886(d)(3)(E)(i) of 

19 the Social Security Act (42 U.S.C. 

20 1395ww(d)(3)(E)(i)) is amended, in the fifth 

21 sentence— 

22 (i) by striking ‘‘and the amendments’’ 

23 and inserting ‘‘, the amendments’’; and 

24 (ii) by inserting ‘‘, and the amend25 ments made by section 401(a)(1) of the 


pamtmann on DSKBC07HB2PROD with BILLS
59 

•S 4521 IS

1 Health Care Improvement Act of 2020’’ 

2 after ‘‘Care Act’’. 

3 (b) HOSPITAL OUTPATIENT DEPARTMENT SERV4 ICES.—Section 1833(t) of the Social Security Act (42 

5 U.S.C. 1395l(t)), is amended— 

6 (1) in paragraph (2)(D), by striking ‘‘(19), the 

7 Secretary’’and inserting ‘‘(19) and paragraph (23), 

8 the Secretary’’; and 

9 (2) by adding at the end the following new 

10 paragraph: 

11 ‘‘(23) FLOOR ON AREA WAGE ADJUSTMENT

12 FACTOR FOR HOSPITAL OUTPATIENT DEPARTMENT

13 SERVICES.—With respect to covered OPD services 

14 furnished on or after January 1, 2021, the area 

15 wage adjustment factor applicable under the pay16 ment system established under this subsection to 

17 any hospital outpatient department which is not lo18 cated in a frontier State (as defined in section 

19 1886(d)(3)(E)(iii)(II)) may not be less than 0.85. 

20 The preceding sentence shall not be implemented in 

21 a budget neutral manner.’’. 


pamtmann on DSKBC07HB2PROD with BILLS
60 

•S 4521 IS

1 TITLE V—COMMONSENSE COM2 PETITION AND ACCESS TO 

3 HEALTH INSURANCE 

4 SEC. 501. PROVIDING SMALL BUSINESS HEALTH INSUR5 ANCE ACROSS STATE LINES. 

6 Section 1333(a)(1)(A) of the Patient Protection and 

7 Affordable Care Act (42 U.S.C. 18053(a)(1)(A)) is 

8 amended by inserting ‘‘and small group markets’’ after 

9 ‘‘individual markets’’. 

10 SEC. 502. REPORT AND MODELS. 

11 Section 1333 of the Patient Protection and Afford12 able Care Act (42 U.S.C. 18053) is amended by adding 

13 at the end the following: 

14 ‘‘(b) NAIC REPORT AND MODELS.— 

15 ‘‘(1) IN GENERAL.—Not later than December 

16 31, 2021, the Secretary shall request that the Na17 tional Association of Insurance Commissioners sub18 mit to the Secretary a report concerning health 

19 plans provided for under this section. Such report 

20 shall include— 

21 ‘‘(A) a description of the challenges that 

22 States would face by permitting issuers of 

23 qualified health plans to offer such plans in 

24 States other than those States where such plan 

25 was originally written or issued; 


pamtmann on DSKBC07HB2PROD with BILLS
61 

•S 4521 IS

1 ‘‘(B) an assessment of how an out-of-State 

2 insurer would go about building an adequate 

3 provider network; 

4 ‘‘(C) a description of how such challenges 

5 could be lessened without weakening the en6 forcement of laws and regulations described in 

7 subsection (a)(1)(B)(i) in any State that is in8 cluded in a compact under this section; 

9 ‘‘(D) a description of the commonalities 

10 that exist in State laws and opportunities to 

11 allow issuers of qualified health plans to offer 

12 such plans in States other than those States 

13 where such plan was originally written or 

14 issued; and 

15 ‘‘(E) models to be used by States to estab16 lish and enter into interstate health care choice 

17 compacts under this section, which— 

18 ‘‘(i) may include model legislation for 

19 use by States to enact laws to enter into 

20 such compacts; 

21 ‘‘(ii) shall identify how States would 

22 continue to enforce, and not weaken, the 

23 laws and regulations described in sub24 section (a)(1)(B)(i) in any State that is in25 cluded in such compact; and 


pamtmann on DSKBC07HB2PROD with BILLS
62 

•S 4521 IS

1 ‘‘(iii) shall identify how such models 

2 would ensure that there is no violation of 

3 the conditions for Secretarial approval 

4 under subsection (a)(3). 

5 ‘‘(2) OTHER ORGANIZATIONS AND ENTITIES.— 

6 In making the request under paragraph (1), the Sec7 retary may also request that the National Associa8 tion of Insurance Commissioners gather concepts for 

9 inclusion in the report under such paragraph from 

10 organizations and entities that have experience in of11 fering qualified health plans in States in which such 

12 plans were not originally issued.’’. 

13 TITLE VI—EMPOWERING MEDI14 CARE SENIORS TO NEGO15 TIATE PRESCRIPTION DRUG 

16 PRICES 

17 SEC. 601. AUTHORITY TO NEGOTIATE FAIR PRICES FOR 

18 MEDICARE PRESCRIPTION DRUGS. 

19 (a) IN GENERAL.—Section 1860D–11 of the Social 

20 Security Act (42 U.S.C. 1395w–111) is amended by strik21 ing subsection (i). 

22 (b) EFFECTIVE DATE.—The amendment made by 

23 this section shall take effect on the date of the enactment 

24 of this Act. 


pamtmann on DSKBC07HB2PROD with BILLS
63 

•S 4521 IS

1 TITLE VII—COMMONSENSE 

2 REPORTING FOR EMPLOYERS 

3 SEC. 701. VOLUNTARY PROSPECTIVE REPORTING SYSTEM. 

4 (a) IN GENERAL.—Not later than 1 year after the 

5 date of the enactment of this Act, the Secretary of the 

6 Treasury, in consultation with the Secretary of Health and 

7 Human Services, the Secretary of Labor, and the Admin8 istrator of the Small Business Administration, shall de9 velop and implement guidance providing for a prospective 

10 reporting system meeting the requirements of subsection 

11 (b). Such system shall be available for use by employers 

12 on a voluntary basis beginning not later than January 1, 

13 2021. 

14 (b) REQUIREMENTS.—The system created under sub15 section (a) shall include— 

16 (1) voluntary reporting by each participating 

17 employer that offers minimum essential coverage to 

18 its full-time employees and their dependents under 

19 an eligible employer-sponsored plan, not later than 

20 45 days before the first day of the annual open en21 rollment period under section 1311(c)(6)(B) of the 

22 Patient Protection and Affordable Care Act (42 

23 U.S.C. 18031(c)(6)(B)) for each calendar year, of— 


pamtmann on DSKBC07HB2PROD with BILLS
64 

•S 4521 IS

1 (A) the name and employer identification 

2 number for purposes of section 6056 of the In3 ternal Revenue Code of 1986 of the employer; 

4 (B) a certification of— 

5 (i) whether coverage meeting the defi6 nition of minimum essential coverage in 

7 section 5000A(f) of the Internal Revenue 

8 Code of 1986 is offered to the full-time 

9 employees (within the meaning of section 

10 4980H of such Code) of the employer; 

11 (ii) whether such coverage is offered 

12 to part-time employees of the employer; 

13 (iii) whether such coverage is offered 

14 to dependents of employees; 

15 (iv) whether such coverage is offered 

16 to spouses of employees; 

17 (v) whether such coverage meets the 

18 minimum value requirement of section 

19 36B(c)(2)(C)(ii) of such Code; 

20 (vi) whether such coverage satisfies 

21 the requirements to qualify for one of the 

22 affordability safe harbors promulgated by 

23 the Secretary of the Treasury for purposes 

24 of section 4980H of such Code; and 


pamtmann on DSKBC07HB2PROD with BILLS
65 

•S 4521 IS

1 (vii) whether the employer reasonably 

2 expects to be liable for any shared respon3 sibility payment under section 4980H of 

4 such Code for such year; 

5 (C) the months during the prospective re6 porting period that such coverage is available to 

7 individuals described in clauses (i) through (iv) 

8 of subparagraph (B); 

9 (D) what waiting periods, if any, apply 

10 with respect to such coverage; and 

11 (E) a list of all employer identification 

12 numbers of the employer for entities that em13 ploy employees within the employers control 

14 group under subsection (b), (c), (m), or (o) of 

15 section 414 of the Internal Revenue Code for 

16 1986; 

17 (2) processes necessary to ensure that Ex18 changes, the Federal Marketplace Data Services 

19 Hub, and the Internal Revenue Service can securely 

20 and confidentially access the information described 

21 in paragraph (1) as necessary to carry out their re22 spective missions, and to provide to the Secretary of 

23 Health and Human Services additional information 

24 relating to eligibility determinations for advance pay25 ment of the premium tax credits under section 36B 


pamtmann on DSKBC07HB2PROD with BILLS
66 

•S 4521 IS

1 of such Code and the cost-sharing subsidies under 

2 section 1402 of the Patient Protection and Afford3 able Care Act (42 U.S.C. 18071); 

4 (3) a process to allow Exchanges to follow up 

5 with employers in order to obtain additional reason6 ably necessary information relating to an employee’s 

7 eligibility for such advance payment or such cost8 sharing subsidies, and to allow an employee to re9 ceive notification of any problem in verifying such 

10 eligibility; and 

11 (4) a process to allow employers using the sys12 tem to provide timely updates to the Federal Mar13 ketplace Data Services Hub regarding any cancella14 tion of coverage or significant change in coverage for 

15 participating employees that would change the infor16 mation reported under paragraph (1). 

17 (c) EMPLOYER NOTIFICATION OF EMPLOYEE EN18 ROLLMENT IN EXCHANGE PLANS.—Subparagraph (J) of 

19 section 1311(d)(4) of the Patient Protection and Afford20 able Care Act (42 U.S.C. 18031(d)(4)(J)) is amended by 

21 striking ‘‘to each employer’’ and all that follows through 

22 ‘‘(and the effective date of such cessation); and’’ and in23 serting ‘‘to each employer— 

24 ‘‘(i) the name of each employee of the 

25 employer who enrolls in a qualified health 


pamtmann on DSKBC07HB2PROD with BILLS
67 

•S 4521 IS

1 plan for a plan year, or whose dependents 

2 enroll in such a plan, at the time of such 

3 enrollment; or 

4 ‘‘(ii) the name of each employee of the 

5 employer described in subparagraph (I)(ii) 

6 who ceases coverage under a qualified 

7 health plan during a plan year (and the ef8 fective date of such cessation); and’’. 

9 (d) EXEMPTION FROM REPORTING REQUIREMENT

10 UNDER INTERNAL REVENUE CODE OF 1986.—Section 

11 6056 of the Internal Revenue Code of 1986 is amended 

12 by redesignating subsection (f) as subsection (g) and by 

13 inserting after subsection (e) the following new subsection: 

14 ‘‘(f) EXEMPTION.—If, through the system created 

15 pursuant to section 701(a) of the Health Care Improve16 ment Act of 2020, an employer provides prospective re17 porting for any calendar year that meets the requirements 

18 of section 701(b)(1) of such Act— 

19 ‘‘(1) such employer shall be treated as satis20 fying the return requirements of subsections (a) and 

21 (b) for such year; and 

22 ‘‘(2) such employer shall be treated as satis23 fying the requirements of subsection (c) for such 

24 year if the employer— 


pamtmann on DSKBC07HB2PROD with BILLS
68 

•S 4521 IS

1 ‘‘(A) furnishes the statement described in 

2 such section to those employees of the employer 

3 whose names have been provided to the em4 ployer by an Exchange under section 

5 1311(d)(4)(J)(i) of the Patient Protection and 

6 Affordable Care Act regarding enrollment of the 

7 employee or a dependent in a qualified health 

8 plan (as defined in section 1301 of such Act) 

9 through the Exchange; and 

10 ‘‘(B) furnishes a copy of such statement 

11 with respect to such employees to the Sec12 retary.’’. 

13 (e) THIRD-PARTY FILING.—An employer may con14 tract with a third party to make the report under sub15 section (b)(1) without affecting the employer’s treatment 

16 as having satisfied the return requirements of subsections 

17 (a) and (b) of section 6056 of the Internal Revenue Code 

18 of 1986. 

19 (f) ACCESS TO THE NATIONAL DIRECTORY OF NEW

20 HIRES.—Subsection (i)(3) of section 453 of the Social Se21 curity Act (42 U.S.C. 653) is amended by adding at the 

22 end the following new sentence: ‘‘The Secretary of the 

23 Treasury and the Secretary of Health and Human Serv24 ices shall have access to the information in the National 

25 Directory of New Hires for purposes of administering secVerDate Sep 11 2014 23:16 Aug 27, 2020 Jkt 099200 PO 00000 Frm 00068 Fmt 6652 Sfmt 6201 E:\BILLS\S4521.IS S4521

pamtmann on DSKBC07HB2PROD with BILLS
69 

•S 4521 IS

1 tion 36B and 4980H of the Internal Revenue Code of 

2 1986 and section 1402 of the Patient Protection and Af3 fordable Care Act (42 U.S.C. 18071). Subsection (k)(3) 

4 shall not apply to information received for purposes of the 

5 administration of such sections 36B and 4980H of such 

6 Code and section 1402 of such Act.’’. 

7 (g) IMPROVING EMPLOYEE ACCESS TO ACCURATE

8 EINS.—Not later than 1 year after the date of the enact9 ment of this Act, the Secretary of the Treasury shall de10 velop and implement guidance for allowing any employee 

11 of an employer to receive, on request, the employer’s em12 ployer identification number for purposes of section 6056 

13 of the Internal Revenue Code of 1986. Employers shall 

14 provide the employer’s employer identification number for 

15 purposes of section 6056 of the Internal Revenue Code 

16 of 1986 on one of the following documents of the employ17 er’s election: 

18 (1) Health Insurance Marketplace Coverage 

19 Options Notice required under section 18B of the 

20 Fair Labor Standards Act. 

21 (2) Summary of Benefits and Coverage de22 scribed in section 2715 of the Patient Protection 

23 and Affordable Care Act (42 U.S.C. 18071). 

24 (3) Marketplace Employer Coverage tool. 


pamtmann on DSKBC07HB2PROD with BILLS
70 

•S 4521 IS

1 (4) Annual benefits enrollment materials dis2 tributed to employees, including through an intranet 

3 or an online portal accessible by employees. 

4 (5) Employee pay statements or Form W–2. 

5 (h) FUNDING FOR VOLUNTARY PROSPECTIVE RE6 PORTING SYSTEM.—It is the sense of Congress that build7 ing and maintaining the voluntary prospective reporting 

8 system described in this section will require appropriations 

9 to the Secretary of the Treasury, the Secretary of Health 

10 and Human Services, the Secretary of Labor, and the Ad11 ministrator of the Small Business Administration, and 

12 that necessary sums to carry out the requirements of this 

13 section should be appropriated for such purpose. 

14 SEC. 702. PROTECTION OF DEPENDENT PRIVACY. 

15 (a) IN GENERAL.—Paragraph (1) of section 6055(b) 

16 of the Internal Revenue Code of 1986 is amended by add17 ing at the end the following flush sentence: 

18 ‘‘For purposes of subparagraph (B)(i), in the case of 

19 an individual other than the primary insured, if the health 

20 insurance issuer or the employer is unable to collect or 

21 maintain information on the TINs of such individuals 

22 (other than for purposes of this section), the Secretary 

23 may allow the individual’s full name and date of birth to 

24 be substituted for the name and TIN. In the event the 

25 Secretary allows the use of the individual’s full name and 


pamtmann on DSKBC07HB2PROD with BILLS
71 

•S 4521 IS

1 date of birth in lieu of the TIN, the Social Security Ad2 ministration shall assist the Internal Revenue Service in 

3 providing data matches to determine the TIN associated 

4 with the name and date of birth provided by the Internal 

5 Revenue Service with respect to such individual.’’. 

6 (b) EFFECTIVE DATE.—The amendment made by 

7 this section shall apply to returns the due date for which 

8 is after the date that is 60 days after the date of the enact9 ment of this Act. 

10 SEC. 703. ELECTRONIC STATEMENTS. 

11 (a) IN GENERAL.—Subsection (c) of section 6056 of 

12 the Internal Revenue Code of 1986 is amended by adding 

13 at the end the following new paragraph: 

14 ‘‘(3) ELECTRONIC DELIVERY.—An individual 

15 shall be deemed to have consented to receive the 

16 statement under this subsection in electronic form if 

17 such individual has affirmatively consented at any 

18 prior time, to the person who is the employer of the 

19 individual during the calendar year to which the 

20 statement relates, to receive such statement in elec21 tronic form. The preceding sentence shall not apply 

22 if the individual revokes consent in writing with re23 spect to the statement under this subsection.’’. 

24 (b) STATEMENTS RELATING TO HEALTH INSURANCE

25 COVERAGE.—Subsection (c) of section 6055 of the InterVerDate Sep 11 2014 23:16 Aug 27, 2020 Jkt 099200 PO 00000 Frm 00071 Fmt 6652 Sfmt 6201 E:\BILLS\S4521.IS S4521

pamtmann on DSKBC07HB2PROD with BILLS
72 

•S 4521 IS

1 nal Revenue Code of 1986 is amended by adding at the 

2 end the following new paragraph: 

3 ‘‘(3) ELECTRONIC DELIVERY.—An individual 

4 shall be deemed to have consented to receive the 

5 statement under this subsection in electronic form if 

6 such individual has affirmatively consented at any 

7 prior time, to the person required to make such 

8 statement (such as the provider of the individual’s 

9 health coverage), to receive in electronic form any 

10 private health information (such as electronic health 

11 records), unless the individual revokes such consent 

12 in writing.’’. 

13 (c) EFFECTIVE DATE.—The amendments made by 

14 this section shall apply to statements the due date for 

15 which is after December 31, 2019. 

16 SEC. 704. GAO STUDIES. 

17 (a) STUDY OF FIRST YEARS OF EMPLOYER REPORT18 ING.— 

19 (1) IN GENERAL.—The Comptroller General of 

20 the United States shall conduct a study that evalu21 ates, with respect to the period beginning on Janu22 ary 1, 2015, and ending on December 31, 2018— 

23 (A) the notification of employers by Ex24 changes established under title I of the Patient 

25 Protection and Affordable Care Act (Public 


pamtmann on DSKBC07HB2PROD with BILLS
73 

•S 4521 IS

1 Law 111–148) that a full-time employee of the 

2 employer has been determined eligible for ad3 vance payment of premium tax credits under 

4 section 36B of the Internal Revenue Code of 

5 1986 or cost-sharing subsidies under section 

6 1402 of such Act (42 U.S.C. 18071), including 

7 information regarding— 

8 (i) the data elements included in the 

9 employer notification; 

10 (ii) the process by which the notifica11 tion forms were developed and sent to em12 ployers, including whether the process pro13 vided for a formal notice and comment pe14 riod; 

15 (iii) whether employers report that 

16 such notifications provided sufficient and 

17 relevant information for them to make ap18 propriate decisions about whether to utilize 

19 the appeals process; 

20 (iv) the total number of notifications 

21 sent to employers and the timeline of when 

22 such notifications were sent; 

23 (v) differences in the notification proc24 ess between the marketplace facilitated by 


pamtmann on DSKBC07HB2PROD with BILLS
74 

•S 4521 IS

1 the Federal Government and the State2 Based Marketplaces; and 

3 (vi) challenges that have arisen in the 

4 notification process, and recommendations 

5 to address these challenges; and 

6 (B) the extent to which the Secretary of 

7 Health and Human Services has established a 

8 separate appeals process for employers who re9 ceived such a notification to challenge the eligi10 bility determination, as required by section 

11 1411(f)(2) of the Patient Protection and Af12 fordable Care Act (42 U.S.C. 18081(f)(2)). 

13 (2) REPORT.—Not later than 1 year after the 

14 date of the enactment of this Act, the Comptroller 

15 General shall submit to the Committees on Finance 

16 and Health, Education, Labor, and Pensions of the 

17 Senate and the Committees on Ways and Means, 

18 Energy and Commerce, and Education and Labor of 

19 the House of Representatives a report on the results 

20 of the study conducted under paragraph (1). 

21 (b) STUDY OF PROSPECTIVE REPORTING SYSTEM.— 

22 (1) IN GENERAL.—The Comptroller General of 

23 the United States shall conduct a study that evalu24 ates, with respect to the period beginning on Janu25 ary 1, 2020, and ending on December 31, 2020, the 


pamtmann on DSKBC07HB2PROD with BILLS
75 

•S 4521 IS

1 functionality of the prospective reporting system es2 tablished pursuant to section 701, including the ac3 curacy of information collected, the number of em4 ployers electing to report under such system, and 

5 any challenges that have arisen in implementing 

6 such system. 

7 (2) REPORT.—Not later than July 1, 2021, the 

8 Comptroller General shall submit to the Committees 

9 on Finance and Health, Education, Labor, and Pen10 sions of the Senate and the Committees on Ways 

11 and Means, Energy and Commerce, and Education 

12 and Labor of the House of Representatives a report 

13 on the results of the study conducted under para14 graph (1). 

15 SEC. 705. TAX COMPLIANCE. 

16 (a) IN GENERAL.—Section 6724(d)(1)(B)(xxv) of the 

17 Internal Revenue Code of 1986 is amended by inserting 

18 ‘‘or, in the case of an employer to which section 6056(f) 

19 applies, section 701(b)(1) of the Health Care Improve20 ment Act of 2020’’ before ‘‘, or’’. 

21 (b) EFFECTIVE DATE.—The amendment made by 

22 this section shall apply to returns required to be filed after 

23 the date of the enactment of this Act. 


pamtmann on DSKBC07HB2PROD with BILLS
76 

•S 4521 IS

1 TITLE VIII—FEDERAL BAN ON 

2 SURPRISE MEDICAL BILLING 

3 SEC. 801. PROTECTION AGAINST SURPRISE BILLS. 

4 (a) PHSA.—Section 2719A of the Public Health 

5 Service Act (42 U.S.C. 300gg–19a) is amended by adding 

6 at the end the following: 

7 ‘‘(e) OUT-OF-NETWORK ANCILLARY SERVICES.— 

8 ‘‘(1) COVERAGE OF SERVICES.—Subject to sub9 section (h), in the case of an enrollee in a group 

10 health plan or group or individual health insurance 

11 coverage who receives out-of-network ancillary serv12 ices at an in-network facility, including any referrals 

13 for diagnostic services, and such services would be 

14 covered under such plan or coverage if provided in15 network— 

16 ‘‘(A) the cost-sharing requirement (ex17 pressed as a copayment amount, coinsurance 

18 rate, or deductible) with respect to such services 

19 shall be the same requirement that would apply 

20 if such services were provided by an in-network 

21 practitioner, and any coinsurance or deductible 

22 shall be based on in-network rates; and 

23 ‘‘(B) amounts paid toward such cost-shar24 ing shall be counted towards the in-network de25 ductible and in-network out-of-pocket maximum 


pamtmann on DSKBC07HB2PROD with BILLS
77 

•S 4521 IS

1 amount, as applicable, under the plan or cov2 erage for the plan year. 

3 ‘‘(2) NOTICE BEFORE PROVIDING NON-EMER4 GENCY SERVICES.—Subject to subsection (h), in the 

5 case of an enrollee in a group health plan or group 

6 or individual health insurance coverage who receives 

7 out-of-network, non-emergency services that are not 

8 ancillary services, from an out-of-network provider 

9 at an in-network facility, and such services would be 

10 covered under such plan or coverage if provided in11 network, the cost-sharing requirement (expressed as 

12 a copayment amount, coinsurance rate, or deduct13 ible) with respect to such services shall be the same 

14 requirement that would apply if such services were 

15 provided by an in-network practitioner, and any co16 insurance or deductible shall be based on in-network 

17 rates, unless, as soon as practicable, and in no case 

18 later than 48 hours prior to providing non-emer19 gency services that are not ancillary services— 

20 ‘‘(A) the in-network facility provides to the 

21 enrollee who is scheduled to receive such serv22 ices notice that— 

23 ‘‘(i) is provided in paper or electronic 

24 form (and including electronic notification 

25 whenever practicable); 


pamtmann on DSKBC07HB2PROD with BILLS
78 

•S 4521 IS

1 ‘‘(ii) states that such service will be 

2 provided out-of-network; 

3 ‘‘(iii) includes the estimated amount 

4 that such practitioner or facility may 

5 charge the enrollee for such services; and 

6 ‘‘(iv) provides the option to affirma7 tively consent to receiving such services 

8 from such practitioner or facility; 

9 ‘‘(B) such enrollee signs such notice con10 senting to receive such services from an out-of11 network provider at an in-network facility, and 

12 acknowledging that the out-of-network services 

13 may be covered at an out-of-network cost-shar14 ing amount, requiring higher cost-sharing obli15 gations of the enrollee than if the service were 

16 provided by an in-network practitioner or facil17 ity; and 

18 ‘‘(C) such facility maintains documentation 

19 of the enrollee’s signature or confirmation of re20 ceipt of such information under subparagraph 

21 (B) in the enrollee’s patient record for 2 years 

22 after the date of services. 

23 ‘‘(f) COVERAGE OF OUT-OF-NETWORK SERVICES FOR

24 ENROLLEES ADMITTED AFTER EMERGENCY SERVICES.— 


pamtmann on DSKBC07HB2PROD with BILLS
79 

•S 4521 IS

1 ‘‘(1) PROTECTION FOR ENROLLEES ADMITTED

2 TO THE HOSPITAL FOR EMERGENCY SERVICES PRIOR

3 TO STABILIZATION.—In the case of an enrollee in a 

4 group health plan or group or individual health in5 surance coverage who receives emergency services, or 

6 maternal care for a woman in labor, in the emer7 gency department of an out-of-network facility and 

8 has not been stabilized (within the meaning of sub9 section (b)(2)(C)), if the patient is subsequently ad10 mitted to the out-of-network facility for care, the 

11 cost-sharing requirement (expressed as a copayment 

12 amount, coinsurance rate, or deductible) with re13 spect to any out-of-network services provided to the 

14 enrollee prior to being stable and in a condition to 

15 receive information under (2), is the same require16 ment that would apply as under subsection 

17 (b)(2)(C)(ii)(II). 

18 ‘‘(2) NOTICE AND CONSENT.— 

19 ‘‘(A) IN GENERAL.—Subject to subsection 

20 (h), in the case of an enrollee in a group health 

21 plan or group or individual health insurance 

22 coverage who receives emergency services, or 

23 maternal care for a woman in labor, in the 

24 emergency department of an out-of-network fa25 cility and has been stabilized (within the meanVerDate Sep 11 2014 23:16 Aug 27, 2020 Jkt 099200 PO 00000 Frm 00079 Fmt 6652 Sfmt 6201 E:\BILLS\S4521.IS S4521

pamtmann on DSKBC07HB2PROD with BILLS
80 

•S 4521 IS

1 ing of subsection (b)(2)(C)), if the patient is 

2 subsequently admitted to the out-of-network fa3 cility for care, the cost-sharing requirement (ex4 pressed as a copayment amount, coinsurance 

5 rate, or deductible) with respect to any out-of6 network services is the same requirement that 

7 would apply if such services were provided by 

8 an in-network provider, unless the enrollee, once 

9 stable and in a condition to receive such infor10 mation, including having sufficient mental ca11 pacity— 

12 ‘‘(i) has been provided by the facility, 

13 prior to the provision of any post-stabiliza14 tion, out-of-network service at such facility, 

15 with— 

16 ‘‘(I) paper or electronic notifica17 tion that the practitioner or facility is 

18 an out-of-network health care provider 

19 and the out-of-network rate of the 

20 provider, as applicable, and the option 

21 to affirmatively consent to receiving 

22 services from such practitioner or fa23 cility; and 

24 ‘‘(II) the estimated amount that 

25 such provider may charge the particiVerDate Sep 11 2014 23:16 Aug 27, 2020 Jkt 099200 PO 00000 Frm 00080 Fmt 6652 Sfmt 6201 E:\BILLS\S4521.IS S4521

pamtmann on DSKBC07HB2PROD with BILLS
81 

•S 4521 IS

1 pant, beneficiary, or enrollee for such 

2 services involved; 

3 ‘‘(ii) has been provided by the plan or 

4 coverage, prior to the provision of any 

5 post-stabilization, out-of-network service at 

6 such facility, with— 

7 ‘‘(I) paper or electronic notifica8 tion (and including electronic notifica9 tion whenever practicable) that the 

10 practitioner or facility is an out-of11 network health care provider, and the 

12 option to affirmatively consent to re13 ceiving services from such practitioner 

14 or facility; 

15 ‘‘(II) a list of in-network practi16 tioners or facilities in the relevant ge17 ographic area that could provide the 

18 same services, and an option for a re19 ferral to such providers; and 

20 ‘‘(III) information about whether 

21 prior authorization or other care man22 agement limitations may be required 

23 in advance of receiving in-network 

24 services at the facility; and 


pamtmann on DSKBC07HB2PROD with BILLS
82 

•S 4521 IS

1 ‘‘(iii) has acknowledged, in writing, 

2 that the out-of-network services provided 

3 after the individual has been stabilized 

4 may not be covered or may be covered at 

5 an out-of-network cost-sharing amount, re6 quiring higher cost-sharing obligations of 

7 the enrollee than if the service were pro8 vided at an in-network facility. 

9 ‘‘(B) REQUIREMENTS OF NOTICE.—The 

10 notice under subparagraph (A) shall be in a for11 mat determined by the Secretary to give a rea12 sonable layperson clear comprehension of the 

13 terms of the agreement, including all possible 

14 financial responsibilities, including the require15 ments that the notice— 

16 ‘‘(i) does not exceed one page in 

17 length; 

18 ‘‘(ii) is readily identifiable for its pur19 pose and as a contract of consent; 

20 ‘‘(iii) clearly states that consent to po21 tential out-of-network charges is optional 

22 and that the enrollee has the choice to 

23 transfer to an in-network facility; 

24 ‘‘(iv) includes an estimate of the 

25 amount that such provider will charge the 


pamtmann on DSKBC07HB2PROD with BILLS
83 

•S 4521 IS

1 participant, beneficiary, or enrollee for 

2 such services involved; and 

3 ‘‘(v) be available in the 15 most com4 mon languages in the facility’s geographic 

5 area, with the facility making a good faith 

6 effort to provide oral notice in the enroll7 ee’s primary language if it is not one of 

8 such 15 languages. 

9 ‘‘(C) MAINTENANCE OF RECORDS.—A fa10 cility shall maintain documentation of notice 

11 given to an enrollee pursuant to this subsection 

12 and the enrollee’s confirmation of receipt of 

13 such information in the enrollee’s patient record 

14 for 2 years after the date of services. 

15 ‘‘(3) RULEMAKING.—Not later than 6 months 

16 after the date of enactment of this subsection, the 

17 Secretary shall issue regulations to carry out this 

18 subsection, which shall include clarification on how 

19 to determine whether an individual is stabilized and 

20 the timing of the notice required under this para21 graph. 

22 ‘‘(g) PROHIBITION ON BILLING MORE THAN AN IN23 NETWORK RATE UNDER CERTAIN CIRCUMSTANCES.— 

24 ‘‘(1) IN GENERAL.—A facility or practitioner 

25 furnishing— 


pamtmann on DSKBC07HB2PROD with BILLS
84 

•S 4521 IS

1 ‘‘(A) emergency services, as defined in sub2 section (b)(2), regardless of the State in which 

3 the patient resides; 

4 ‘‘(B) out-of-network services at an in-net5 work facility described in subsection (e)(1); 

6 ‘‘(C) out-of-network services at an in-net7 work facility described in subsection (e)(2), 

8 where the notice and consent for receiving such 

9 services out-of-network did not meet the re10 quirement of such subsection; 

11 ‘‘(D) services furnished by an out-of-net12 work provider after an enrollee has been admit13 ted to the hospital for emergency services but 

14 prior to stabilization, as described in subsection 

15 (f)(1); or 

16 ‘‘(E) out-of-network services furnished 

17 after the enrollee has been stabilized (within the 

18 meaning of subsection (b)(2)(C)), where the no19 tice and option for receiving care at an alter20 nate facility required under subsection (f)(2) 

21 have not been provided to the enrollee and the 

22 enrollee did not give consent under subsection 

23 (f)(3), 

24 may not bill an enrollee in a group health plan or 

25 group or individual health insurance coverage for 


pamtmann on DSKBC07HB2PROD with BILLS
85 

•S 4521 IS

1 amounts beyond the cost-sharing amount that would 

2 apply under subsection (b)(1)(C)(ii)(II), (e)(1), 

3 (e)(2), or (f), as applicable. 

4 ‘‘(2) NOTICE.—A facility furnishing services de5 scribed in paragraph (1) shall provide enrollees in a 

6 group health plan or group or individual health in7 surance coverage with a one-page notice, in 16-point 

8 font, upon intake at the emergency room or being 

9 admitted at the facility of the prohibition on balance 

10 billing under paragraph (1) and who to contact for 

11 recourse if they are sent a balance bill in violation 

12 of such paragraph. The facility shall be responsible 

13 for obtaining the signature from the enrollee on such 

14 notice. The Secretary shall issue regulations within 

15 6 months of the date of enactment of this subsection 

16 on the requirements for the notice under this para17 graph. 

18 ‘‘(h) MAINTAINING STATE SURPRISE BILLING PRO19 TECTIONS.— 

20 ‘‘(1) IN GENERAL.—Nothing in this section 

21 shall prevent a State from establishing or continuing 

22 in effect, with respect to health insurance issuers, 

23 facilities, or practitioners, an alternate method under 

24 State law for determining the appropriate compensaVerDate Sep 11 2014 23:16 Aug 27, 2020 Jkt 099200 PO 00000 Frm 00085 Fmt 6652 Sfmt 6201 E:\BILLS\S4521.IS S4521

pamtmann on DSKBC07HB2PROD with BILLS
86 

•S 4521 IS

1 tion for services described in subsection (b), (e), or 

2 (f). 

3 ‘‘(2) ADDITIONAL APPLICATION.—In the case of 

4 group health plans or group or individual health in5 surance coverage offered in a State that has not es6 tablished an alternate method described in para7 graph (1), such as arbitration or a benchmark, or 

8 for services described in subsection (b), (e), or (f) 

9 that are not covered by such State’s alternate meth10 od described in paragraph (1), the provisions of this 

11 section shall apply. 

12 ‘‘(3) SELF-INSURED PLANS.—Subsections (b), 

13 (e), and (f) shall apply to a self-insured group health 

14 plan that is not subject to State insurance regula15 tion. 

16 ‘‘(i) DEFINITIONS.—In this section: 

17 ‘‘(1) IN-NETWORK.—The term ‘in-network’, 

18 with respect to a group health plan or health insur19 ance coverage means a provider that has a contrac20 tual relationship with the plan. 

21 ‘‘(2) ENROLLEE.—The term ‘enrollee’, with re22 spect to health insurance coverage or a group health 

23 plan, includes a participant, dependent, or bene24 ficiary. 


pamtmann on DSKBC07HB2PROD with BILLS
87 

•S 4521 IS

1 ‘‘(3) ANCILLARY SERVICES.—The term ‘ancil2 lary services’ means non-emergency care that is— 

3 ‘‘(A) provided by anesthesiologists, pa4 thologists, emergency medicine providers, 

5 intensivists, radiologists, neonatologists, 

6 hospitalists, and assistant surgeons, whether 

7 the care is provided by a physician or non-phy8 sician practitioner; 

9 ‘‘(B) a diagnostic service (including radi10 ology and lab services); or 

11 ‘‘(C) provided by such other specialty prac12 titioner not typically selected by the patients re13 ceiving the care, which the Secretary may add 

14 periodically to such definition through rule15 making.’’. 

16 (b) ENFORCEMENT OF BALANCE BILLING PROHIBI17 TIONS.—Part C of title XXVII of the Public Health Serv18 ice Act (42 U.S.C. 300gg–91 et seq.) is amended by add19 ing at the end the following: 

20 ‘‘SEC. 2795. ENFORCEMENT OF BALANCE BILLING PROHIBI21 TIONS. 

22 ‘‘(a) IN GENERAL.—Subject to subsection (b), a facil23 ity or practitioner that violates a requirement under sec24 tion 2719A(g)(1) or fails to provide notice or obtain con25 sent as required under subsection (e)(2) or (f)(2) shall be 


pamtmann on DSKBC07HB2PROD with BILLS
88 

•S 4521 IS

1 subject to a civil monetary penalty of not more than 

2 $10,000 for each act constituting such violation. 

3 ‘‘(b) PROCEDURE.—The provisions of section 1128A 

4 of the Social Security Act, other than subsections (a) and 

5 (b) and the first sentence of subsection (c)(1) of such sec6 tion, shall apply to civil money penalties under this sub7 section in the same manner as such provisions apply to 

8 a penalty or proceeding under section 1128A of the Social 

9 Security Act. 

10 ‘‘(c) SAFE HARBOR.— 

11 ‘‘(1) IN GENERAL.—The Secretary shall waive 

12 the penalties described under subsection (a) with re13 spect to a facility or, practitioner who does not 

14 knowingly violate, and should not have reasonably 

15 known it violated, section 2719A(g)(1) with respect 

16 to an enrollee, if such facility or practitioner, within 

17 30 days of the violation, withdraws the bill that was 

18 in violation of section 2719A(g)(1), and, as applica19 ble, reimburses the group health plan, health insur20 ance issuer, or enrollee, in an amount equal to the 

21 difference between the amount billed and the 

22 amount allowed to be billed under section 

23 2719A(g)(1), plus interest, at an interest rate deter24 mined by the Secretary. 


pamtmann on DSKBC07HB2PROD with BILLS
89 

•S 4521 IS

1 ‘‘(2) HARDSHIP EXEMPTION.—The Secretary 

2 may establish a hardship exemption to the penalties 

3 under this section. 

4 ‘‘(3) STATE ENFORCEMENT.—The Secretary 

5 shall waive penalties under this section with respect 

6 to a facility or practitioner that has already been 

7 subject to enforcement action under State law for a 

8 violation described in subsection (a).’’. 

9 (c) APPLICATION TO GRANDFATHERED PLANS.— 

10 Section 1251(a) of the Patient Protection and Affordable 

11 Care Act (42 U.S.C. 18011(a)) is amended by adding at 

12 the end the following: 

13 ‘‘(5) APPLICATION OF ADDITIONAL PROVI14 SIONS.—Subsections (b) through (h) of section 

15 2719A of the Public Health Service Act (42 U.S.C. 

16 300gg–19a) shall apply to grandfathered health 

17 plans for plan years beginning with the second plan 

18 year that begins after the date of enactment of this 

19 paragraph.’’. 

20 (d) COVERAGE UNDER FEDERAL EMPLOYEES

21 HEALTH BENEFITS PROGRAM.—Section 8904 of title 5, 

22 United States Code, is amended by adding at the end the 

23 following: 

24 ‘‘(c) Any health benefits plan offered under this chap25 ter shall be treated as a group health plan or group or 


pamtmann on DSKBC07HB2PROD with BILLS
90 

•S 4521 IS

1 individual health insurance coverage for purposes of sub2 sections (e) through (g) of section 2719A of the Public 

3 Health Service Act (42 U.S.C. 300gg–19a) (except for 

4 paragraph (3) of such subsection (g)).’’. 

Æ 


pamtmann on DSKBC07HB2PROD with BILLS