II 

118TH CONGRESS 

2D SESSION S. 4231 

To provide for the establishment of Medicare part E public health plans, 

and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

MAY 1, 2024 

Mr. MERKLEY (for himself, Mr. MURPHY, Ms. BALDWIN, Mr. BLUMENTHAL, 

Mr. BOOKER, Ms. DUCKWORTH, Mr. DURBIN, Mrs. GILLIBRAND, Mr. 

REED, Mr. SCHATZ, Ms. SMITH, and Mr. VAN HOLLEN) introduced the 

following bill; which was read twice and referred to the Committee on Finance 

A BILL 

To provide for the establishment of Medicare part E public 

health plans, and for other purposes. 

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 ‘‘Choose Medicare Act’’. 

5 SEC. 2. PUBLIC HEALTH PLAN. 

6 (a) IN GENERAL.—The Social Security Act is amend7 ed by adding at the end the following: 

8 ‘‘TITLE XXII—MEDICARE PART E PUBLIC HEALTH PLANS

9 ‘‘SEC. 2201. PUBLIC HEALTH PLANS.— 


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1 ‘‘(a) ESTABLISHMENT.—The Secretary shall estab2 lish public health plans (to be known as ‘Medicare part 

3 E plans’) that are available in the individual market, small 

4 group market, and large group market. 

5 ‘‘(b) BENEFITS.— 

6 ‘‘(1) IN GENERAL.—Each Medicare part E 

7 plan, regardless of whether the plan is offered in the 

8 individual market, small group market, or large 

9 group market, shall be a qualified health plan within 

10 the meaning of section 1301(a) of the Patient Pro11 tection and Affordable Care Act (42 U.S.C. 

12 18021(a)) that— 

13 ‘‘(A) meets all requirements applicable to 

14 qualified health plans under subtitle D of title 

15 I of the Patient Protection and Affordable Care 

16 Act (42 U.S.C. 18021 et seq.) (other than the 

17 requirement under section 1301(a)(1)(C)(ii) of 

18 such Act) and title XXVII of the Public Health 

19 Service Act (42 U.S.C. 300gg et seq.); 

20 ‘‘(B) provides coverage of— 

21 ‘‘(i) the essential health benefits de22 scribed in section 1302(b) of the Patient 

23 Protection and Affordable Care Act (42 

24 U.S.C. 18022(b)); and 


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1 ‘‘(ii) all items and services for which 

2 benefits are available under title XVIII; 

3 ‘‘(C) provides gold-level coverage described 

4 in section 1302(d)(1)(C) of the Patient Protec5 tion and Affordable Care Act (42 U.S.C. 

6 18022(d)(1)(C)); and 

7 ‘‘(D) provides coverage of abortions and all 

8 other reproductive services. 

9 ‘‘(2) PREEMPTION.—Notwithstanding section 

10 1303(a)(1) of the Patient Protection and Affordable 

11 Care Act (42 U.S.C. 18023(a)(1))— 

12 ‘‘(A) a State may not prohibit a Medicare 

13 part E plan from offering the coverage de14 scribed in paragraph (1)(D); and 

15 ‘‘(B) no provision of State law that would 

16 prohibit such a plan from offering such cov17 erage shall apply to such plan. 

18 ‘‘(c) ELIGIBILITY; ENROLLMENT.— 

19 ‘‘(1) AVAILABILITY ON THE EXCHANGES.—The 

20 Medicare part E plans offered in the individual and 

21 small group markets shall be offered through the 

22 Federal and State Exchanges, including the Small 

23 Business Health Options Program Exchanges (com24 monly referred to as the ‘SHOP Exchanges’). 

25 ‘‘(2) ELIGIBILITY.— 


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1 ‘‘(A) IN GENERAL.—Any individual who is 

2 a resident of the United States, as determined 

3 by the Secretary under subparagraph (C), and 

4 who is not an individual described in subpara5 graph (B), is eligible to enroll in a Medicare 

6 part E plan. 

7 ‘‘(B) EXCLUSIONS.—An individual de8 scribed in this subparagraph is any individual 

9 who is— 

10 ‘‘(i) entitled to, or enrolled for, bene11 fits under title XVIII; 

12 ‘‘(ii) eligible for medical assistance 

13 under a State plan under title XIX; or 

14 ‘‘(iii) enrolled for child health assist15 ance or pregnancy-related assistance under 

16 a State plan under title XXI. 

17 ‘‘(C) REGULATIONS.—The Secretary shall 

18 promulgate a rule for determining residency for 

19 purposes of subparagraph (A). 

20 ‘‘(3) EMPLOYER-SPONSORED PLANS.— 

21 ‘‘(A) EMPLOYER ENROLLMENT.—Effective 

22 with respect to the first plan year that begins 

23 1 year after the date of enactment of the 

24 Choose Medicare Act and each plan year there25 after, the Secretary shall provide options for 


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1 Medicare part E plans in the small group mar2 ket and large group market that are voluntary, 

3 and available to all employers. 

4 ‘‘(B) GROUP HEALTH PLANS.—The Sec5 retary, acting through the Administrator for the 

6 Centers for Medicare & Medicaid Services, at 

7 the request of a plan sponsor, shall serve as a 

8 third party administrator of a group health 

9 plan that is a Medicare part E plan offered by 

10 such sponsor. 

11 ‘‘(C) PORTABILITY FOR EMPLOYER-SPON12 SORED PLANS.—The Secretary shall develop a 

13 process for allowing individuals enrolled in a 

14 Medicare part E plan offered in the small group 

15 market or large group market to maintain 

16 health insurance coverage through a Medicare 

17 part E plan if the individual subsequently loses 

18 eligibility for enrollment in such a plan based 

19 on termination of the employment relationship. 

20 The ability to maintain such coverage shall 

21 exist regardless of whether the individual has 

22 the option to enroll in other health insurance 

23 coverage, including coverage offered in the indi24 vidual market or through a subsequent em25 ployer. 


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1 ‘‘(d) PREMIUMS.—The Secretary shall establish pre2 mium rates for the Medicare part E plans that— 

3 ‘‘(1) are adjusted based on— 

4 ‘‘(A) whether the plan is offered in the in5 dividual market, small group market, or large 

6 group market; and 

7 ‘‘(B) the applicable rating area; 

8 ‘‘(2) are at a level sufficient to fully finance— 

9 ‘‘(A) the costs of health benefits provided 

10 by such plans; and 

11 ‘‘(B) administrative costs related to oper12 ating the plans; and 

13 ‘‘(3) comply with the requirements under sec14 tion 2701 of the Public Health Service Act (42 

15 U.S.C. 300gg), including for such plans that are of16 fered in the large group market. 

17 ‘‘(e) PROVIDERS AND REIMBURSEMENT RATES.— 

18 ‘‘(1) IN GENERAL.—The Secretary shall estab19 lish a rate schedule for reimbursing types of health 

20 care providers furnishing items and services under 

21 the Medicare part E plans at rates that are con22 sistent with the negotiations described in paragraph 

23 (2) and are necessary to maintain network adequacy. 

24 ‘‘(2) MANNER OF NEGOTIATION.—The Sec25 retary shall negotiate the rates described in paraVerDate Sep 11 2014 01:59 May 30, 2024 Jkt 049200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S4231.IS S4231

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1 graph (1) in a manner that results in payment rates 

2 that are not lower, in the aggregate, than rates 

3 under title XVIII, and not higher, in the aggregate, 

4 than the average rates paid by other health insur5 ance issuers offering health insurance coverage 

6 through an Exchange. 

7 ‘‘(3) PARTICIPATING PROVIDERS.— 

8 ‘‘(A) IN GENERAL.—A health care provider 

9 that is a participating provider of services or 

10 supplier under the Medicare program under 

11 title XVIII on the date of enactment of the 

12 Choose Medicare Act shall be a participating 

13 provider for Medicare part E plans. 

14 ‘‘(B) ADDITIONAL PROVIDERS.—The Sec15 retary shall establish a process to allow health 

16 care providers not described in subparagraph 

17 (A) to become participating providers for Medi18 care part E plans. 

19 ‘‘(4) LIMITATIONS ON BALANCE BILLING.—The 

20 limitations on balance billing pursuant to the provi21 sions of section 1866(a)(1)(A) shall apply to partici22 pating providers for Medicare part E plans in the 

23 same manner as such provisions apply to partici24 pating providers under the Medicare program. 


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1 ‘‘(f) ENCOURAGING USE OF ALTERNATIVE PAYMENT

2 MODELS.—The Secretary shall, as applicable, utilize alter3 native payment models, including those described in sec4 tion 1833(z)(3)(C), as added by section 101(e)(2) of the 

5 Medicare Access and CHIP Reauthorization Act of 2015 

6 (Public Law 114–10), in making payments for items and 

7 services (including prescription drugs) furnished under 

8 Medicare part E plans. The payment rates under such al9 ternative payment models shall comply with the require10 ment for negotiated rates under subsection (e)(2). 

11 ‘‘(g) PRESCRIPTION DRUGS.—The Secretary shall 

12 apply the provisions of part E of title XI to prescription 

13 drugs under Medicare part E plans in the same manner 

14 as such provisions apply with respect to selected drugs 

15 under part E of title XI. 

16 ‘‘(h) APPROPRIATIONS.— 

17 ‘‘(1) START UP FUNDING.—For purposes of es18 tablishing the Medicare part E plans, there is appro19 priated to the Secretary, out of any funds in the 

20 Treasury not otherwise obligated, $2,000,000,000, 

21 for fiscal year 2025. 

22 ‘‘(2) INITIAL RESERVES.—There is appro23 priated to the Secretary, out of any funds in the 

24 Treasury not otherwise obligated, such sums as may 

25 be necessary, based on projected enrollment in the 


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1 Medicare part E plans in the first plan year in 

2 which such plans are offered, to provide reserves for 

3 the purpose of paying claims filed during the initial 

4 90-day period of such plan year. 

5 ‘‘(3) CLARIFICATION.—Any provision of law re6 stricting the use of Federal funds with respect to 

7 any reproductive health service shall not apply to 

8 funds appropriated under paragraph (1) or (2). 

9 ‘‘(i) HEALTH INSURANCE ISSUER.—With respect to 

10 any Medicare part E plan, the Secretary shall be consid11 ered a health insurance issuer, within the meaning of sec12 tion 2791(b) of the Public Health Service Act (42 U.S.C. 

13 300gg–91(b)).’’. 

14 (b) APPLICATION OF EXCISE TAX FOR NONCOMPLI15 ANCE WITH NEGOTIATION REQUIREMENTS.—Section 

16 5000D(e)(1) of the Internal Revenue Code of 1986 is 

17 amended by adding at the end the following new sentence: 

18 ‘‘Such term shall apply to any drug treated in the same 

19 manner as a drug described in the preceding sentence by 

20 reason of section 2201(g) of the Social Security Act.’’. 

21 SEC. 3. NOTICE AND NAVIGATOR REFERRAL FOR EMPLOY22 EES UNDER THE FAIR LABOR STANDARDS 

23 ACT OF 1938. 

24 (a) IN GENERAL.—Section 18B of the Fair Labor 

25 Standards Act of 1938 (29 U.S.C. 218b) is amended— 


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1 (1) in the heading, by striking ‘‘TO’’ and insert2 ing ‘‘AND NAVIGATOR REFERRAL FOR’’; 

3 (2) by redesignating subsection (b) as sub4 section (c); 

5 (3) by inserting after subsection (a) the fol6 lowing: 

7 ‘‘(b) NAVIGATOR REFERRAL.— 

8 ‘‘(1) IN GENERAL.—An employer described in 

9 paragraph (3) shall refer each full-time employee (as 

10 defined in section 4980H(c) of the Internal Revenue 

11 Code of 1986) to— 

12 ‘‘(A) an entity that serves as a navigator 

13 under section 1311(i) of the Patient Protection 

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

15 for the Exchange operating in the State of the 

16 employer; or 

17 ‘‘(B) if the Exchange operating in the 

18 State of the employer does not have an entity 

19 serving as such a navigator, another entity that 

20 shall carry out equivalent activities as such a 

21 navigator. 

22 ‘‘(2) REFERRAL.—The referral described in 

23 paragraph (1) shall occur— 

24 ‘‘(A) at the time the employer hires the 

25 employee; or 


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1 ‘‘(B) on the effective date described in sub2 section (c)(2) with respect to an employee who 

3 is currently employed by the employer on such 

4 date. 

5 ‘‘(3) EMPLOYER.—An employer described in 

6 this paragraph is any employer that— 

7 ‘‘(A) does not provide an eligible employer8 sponsored plan as defined in section 

9 5000A(f)(2) of the Internal Revenue Code of 

10 1986; or 

11 ‘‘(B) provides such an eligible employer12 sponsored plan, but the plan is determined— 

13 ‘‘(i) to be unaffordable to the em14 ployee under clause (i) of section 

15 36B(c)(2)(C) of such Code; or 

16 ‘‘(ii) to not provide the required min17 imum value under clause (ii) of such sec18 tion.’’; and 

19 (4) in subsection (c), as so redesignated— 

20 (A) in the heading, by striking ‘‘EFFEC21 TIVE DATE’’ and inserting ‘‘EFFECTIVE

22 DATES’’; 

23 (B) by striking ‘‘Subsection (a)’’ and in24 serting the following: 

25 ‘‘(1) NOTICE.—Subsection (a);’’; and 


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1 (C) by adding at the end the following: 

2 ‘‘(2) NAVIGATOR REFERRAL.—Subsection (b) 

3 shall take effect with respect to employers in a State 

4 beginning on the date that is 2 years after the date 

5 of enactment of the Choose Medicare Act.’’. 

6 (b) STUDY.—Not later than January 1, 2029, the 

7 Comptroller General of the United States shall conduct 

8 a study on the impact of the requirements under section 

9 18B of the Fair Labor Standards Act of 1938 (29 U.S.C. 

10 218b), including the amendments made by subsection (a), 

11 on the rate of individuals without minimum essential cov12 erage as defined in section 5000A(f) of the Internal Rev13 enue Code of 1986 in the United States and in each State. 

14 (c) FUNDING FOR NAVIGATOR PROGRAM.—Section 

15 1311(i)(6) of the Patient Protection and Affordable Care 

16 Act (42 U.S.C. 18031(i)(6)) is amended— 

17 (1) by striking ‘‘Grants’’ and inserting the fol18 lowing: 

19 ‘‘(A) IN GENERAL.—Grants’’; and 

20 (2) by adding at the end the following: 

21 ‘‘(B) AUTHORIZATION OF APPROPRIA22 TIONS.—There is authorized to be appropriated 

23 such sums as may be necessary to address ca24 pacity limitations of entities serving as naviga25 tors through a grant under this subsection.’’. 


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1 SEC. 4. PROTECTING AGAINST HIGH OUT-OF-POCKET EX2 PENDITURES FOR MEDICARE FEE-FOR-SERV3 ICE BENEFITS. 

4 Title XVIII of the Social Security Act (42 U.S.C. 

5 1395 et seq.) is amended by adding at the end the fol6 lowing new section: 

7 ‘‘PROTECTION AGAINST HIGH OUT-OF-POCKET

8 EXPENDITURES

9 ‘‘SEC. 1899C. (a) IN GENERAL.—Notwithstanding 

10 any other provision of this title, in the case of an indi11 vidual entitled to, or enrolled for, benefits under part A 

12 or enrolled in part B, if the amount of the out-of-pocket 

13 cost-sharing of such individual for a year (beginning with 

14 2026) equals or exceeds the annual out-of-pocket limit 

15 under subsection (b) for that year, the individual shall not 

16 be responsible for additional out-of-pocket cost-sharing in17 curred during that year. 

18 ‘‘(b) ANNUAL OUT-OF-POCKET LIMIT.— 

19 ‘‘(1) IN GENERAL.—The amount of the annual 

20 out-of-pocket limit under this subsection shall be— 

21 ‘‘(A) for 2026, $6,700; or 

22 ‘‘(B) for a subsequent year, the amount 

23 specified in this subsection for the preceding 

24 year increased or decreased by the percentage 

25 change in the medical care component of the 

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1 sumers for the 12-month period ending with 

2 June of such preceding year. 

3 ‘‘(2) ROUNDING.—If any amount determined 

4 under paragraph (1)(B) is not a multiple of $5, such 

5 amount shall be rounded to the nearest multiple of 

6 $5. 

7 ‘‘(c) OUT-OF-POCKET COST-SHARING DEFINED.— 

8 ‘‘(1) IN GENERAL.—Subject to paragraphs (2) 

9 and (3), in this section, the term ‘out-of-pocket cost10 sharing’ means, with respect to an individual, the 

11 amount of the expenses incurred by the individual 

12 that are attributable to— 

13 ‘‘(A) deductibles, coinsurance, and copay14 ments applicable under part A or B; or 

15 ‘‘(B) for items and services that would 

16 have otherwise been covered under part A or B 

17 but for the exhaustion of those benefits. 

18 ‘‘(2) CERTAIN COSTS NOT INCLUDED.— 

19 ‘‘(A) NON-COVERED ITEMS AND SERV20 ICES.—Expenses incurred for items and serv21 ices which are not covered under part A or B 

22 shall not be considered incurred expenses for 

23 purposes of determining out-of-pocket cost24 sharing under paragraph (1). 


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1 ‘‘(B) ITEMS AND SERVICES NOT FUR2 NISHED ON AN ASSIGNMENT-RELATED BASIS.— 

3 If an item or service is furnished to an indi4 vidual under this title and is not furnished on 

5 an assignment-related basis, any additional ex6 penses the individual incurs above the amount 

7 the individual would have incurred if the item 

8 or service was furnished on an assignment-re9 lated basis shall not be considered incurred ex10 penses for purposes of determining out-of-pock11 et cost-sharing under paragraph (1). 

12 ‘‘(3) SOURCE OF PAYMENT.—For purposes of 

13 paragraph (1), the Secretary shall consider expenses 

14 to be incurred by the individual without regard to 

15 whether the individual or another person, including 

16 a State program, an employer, a medicare supple17 mental policy, or other third-party coverage, has 

18 paid for such expenses. 

19 ‘‘(d) ANNOUNCEMENT OF THE ANNUAL OUT-OF20 POCKET LIMIT.—The Secretary shall (beginning in 2025) 

21 announce (in a manner intended to provide notice to all 

22 interested parties) the annual out-of-pocket limit under 

23 this section that will be applicable for the succeeding 

24 year.’’. 


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1 SEC. 5. ENHANCEMENT OF PREMIUM ASSISTANCE CREDIT. 

2 (a) USE OF GOLD LEVEL PLAN FOR BENCHMARK.— 

3 (1) IN GENERAL.—Clause (i) of section 

4 36B(b)(2)(B) of the Internal Revenue Code of 1986 

5 is amended by striking ‘‘applicable second lowest 

6 cost silver plan’’ and inserting ‘‘applicable second 

7 lowest cost gold plan’’. 

8 (2) CONFORMING AMENDMENT RELATED TO

9 AFFORDABILITY.—Section 36B(c)(4)(C)(i)(I) of 

10 such Code is amended by striking ‘‘second lowest 

11 cost silver plan’’ and inserting ‘‘second lowest cost 

12 gold plan’’. 

13 (3) OTHER CONFORMING AMENDMENTS.—Sub14 paragraphs (B) and (C) of section 36B(b)(3) of such 

15 Code are each amended by striking ‘‘silver plan’’ 

16 each place it appears in the text and the heading 

17 and inserting ‘‘gold plan’’. 

18 (b) PERMANENT EXTENSION OF ELIGIBILITY

19 RULES.— 

20 (1) IN GENERAL.—Section 36B(c)(1) of the In21 ternal Revenue Code of 1986 is amended— 

22 (A) in subparagraph (A), by striking ‘‘but 

23 does not exceed 400 percent’’, and 

24 (B) by striking subparagraph (E). 

25 (2) DETERMINATION OF APPLICABLE PERCENT26 AGE.—Subparagraph (A) of section 36B(b)(3) of 


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1 such Code is amended by striking all that precedes 

2 the table in clause (iii)(II) and inserting the fol3 lowing: 

4 ‘‘(A) APPLICABLE PERCENTAGE.—For 

5 purposes of paragraph (2), except as provided 

6 in clause (ii), the applicable percentage for any 

7 taxable year shall be the percentage such that 

8 the applicable percentage for any taxpayer 

9 whose household income is within an income 

10 tier specified in the following table shall in11 crease, on a sliding scale in a linear manner, 

12 from the initial premium percentage to the final 

13 premium percentage specified in such table for 

14 such income tier:’’. 

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

16 this section shall apply to taxable years beginning after 

17 December 31, 2023. 

18 SEC. 6. ENHANCEMENTS FOR REDUCED COST SHARING. 

19 (a) DEFINITION OF ELIGIBLE INDIVIDUAL.—Section 

20 1402(b)(1) of the Patient Protection and Affordable Care 

21 Act (42 U.S.C. 18071(b)(1)) is amended by striking ‘‘sil22 ver level’’ and inserting ‘‘gold level’’. 

23 (b) MODIFICATION OF AMOUNT.— 


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1 (1) IN GENERAL.—Section 1402(c)(2) of the 

2 Patient Protection and Affordable Care Act is 

3 amended to read as follows: 

4 ‘‘(2) ADDITIONAL REDUCTION.—The Secretary 

5 shall establish procedures under which the issuer of 

6 a qualified health plan to which this section applies 

7 shall further reduce cost-sharing under the plan in 

8 a manner sufficient to— 

9 ‘‘(A) in the case of an eligible insured 

10 whose household income is not less than 100 

11 percent but not more than 133 percent of the 

12 poverty line for a family of the size involved, in13 crease the plan’s share of the total allowed 

14 costs of benefits provided under the plan to 94 

15 percent of such costs; 

16 ‘‘(B) in the case of an eligible insured 

17 whose household income is more than 133 per18 cent but not more than 150 percent of the pov19 erty line for a family of the size involved, in20 crease the plan’s share of the total allowed 

21 costs of benefits provided under the plan to 92 

22 percent of such costs; 

23 ‘‘(C) in the case of an eligible insured 

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1 erty line for a family of the size involved, in2 crease the plan’s share of the total allowed 

3 costs of benefits provided under the plan to 90 

4 percent of such costs; 

5 ‘‘(D) in the case of an eligible insured 

6 whose household income is more than 200 per7 cent but not more than 300 percent of the pov8 erty line for a family of the size involved, in9 crease the plan’s share of the total allowed 

10 costs of benefits provided under the plan to 85 

11 percent of such costs; and 

12 ‘‘(E) in the case of an eligible insured 

13 whose household income is more than 300 per14 cent but not more than 400 percent of the pov15 erty line for a family of the size involved, in16 crease the plan’s share of the total allowed 

17 costs of benefits provided under the plan to 80 

18 percent of such costs.’’. 

19 (2) CONFORMING AMENDMENT.—Clause (i) of 

20 section 1402(c)(1)(B) of such Act is amended to 

21 read as follows: 

22 ‘‘(i) IN GENERAL.—The Secretary 

23 shall ensure the reduction under this para24 graph shall not result in an increase in the 


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1 plan’s share of the total allowed costs of 

2 benefits provided under the plan above— 

3 ‘‘(I) 94 percent in the case of an 

4 eligible insured described in para5 graph (2)(A); 

6 ‘‘(II) 92 percent in the case of an 

7 eligible insured described in para8 graph (2)(B); 

9 ‘‘(III) 90 percent in the case of 

10 an eligible insured described in para11 graph (2)(C); 

12 ‘‘(IV) 85 percent in the case of 

13 an eligible insured described in para14 graph (2)(D); and 

15 ‘‘(V) 80 percent in the case of an 

16 eligible insured described in para17 graph (2)(E).’’. 

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

19 this section shall apply to plan years beginning after De20 cember 31, 2024. 

21 SEC. 7. REINSURANCE AND AFFORDABILITY FUND. 

22 Part 5 of subtitle D of title I of the Patient Protec23 tion and Affordable Care Act is amended by inserting 

24 after section 1341 (42 U.S.C. 18061) the following: 


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1 ‘‘SEC. 1341A. REINSURANCE AND AFFORDABILITY FUND 

2 FOR THE INDIVIDUAL MARKET IN EACH 

3 STATE. 

4 ‘‘(a) IN GENERAL.—The Secretary, in consultation 

5 with the National Association of Insurance Commis6 sioners, shall establish a program to enable each State, 

7 for any plan year beginning in the 3-year period beginning 

8 January 1, 2025, to— 

9 ‘‘(1) provide reinsurance payments to health in10 surance issuers with respect to individuals enrolled 

11 under individual health insurance coverage offered 

12 by such issuers; or 

13 ‘‘(2) provide assistance (other than through 

14 payments described in paragraph (1)) to reduce out15 of-pocket costs, such as copayments, coinsurance, 

16 premiums, and deductibles, of individuals enrolled 

17 under qualified health plans offered in the individual 

18 market through an Exchange. 

19 ‘‘(b) APPROPRIATIONS.—There is appropriated, out 

20 of any money in the Treasury not otherwise appropriated, 

21 $30,000,000,000 for the period of fiscal years 2025 to 

22 2027 for purposes of establishing and administering the 

23 program established under this section. Such amount shall 

24 remain available until expended.’’. 


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1 SEC. 8. EXPANDING RATING RULES TO LARGE GROUP MAR2 KET. 

3 (a) IN GENERAL.—Section 2701(a) of the Public 

4 Health Service Act (42 U.S.C. 300gg(a)) is amended— 

5 (1) in paragraph (1), by striking ‘‘small’’; and 

6 (2) by striking paragraph (5). 

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

8 subsection (a) shall apply to plans offered in the first plan 

9 year beginning after the date of enactment of this Act and 

10 any plan year thereafter. 

11 SEC. 9. PROTECTION OF CONSUMERS FROM EXCESSIVE, 

12 UNJUSTIFIED, OR UNFAIRLY DISCRIMINA13 TORY RATES. 

14 (a) PROTECTION FROM EXCESSIVE, UNJUSTIFIED, 

15 OR UNFAIRLY DISCRIMINATORY RATES.—Section 2794 of 

16 the Public Health Service Act (42 U.S.C. 300gg–94) is 

17 amended by adding at the end the following new sub18 section: 

19 ‘‘(e) PROTECTION FROM EXCESSIVE, UNJUSTIFIED, 

20 OR UNFAIRLY DISCRIMINATORY RATES.— 

21 ‘‘(1) AUTHORITY OF STATES.—Nothing in this 

22 section shall be construed to prohibit a State from 

23 imposing requirements (including requirements re24 lating to rate review standards and procedures and 

25 information reporting) on health insurance issuers 

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1 quirements of this section and are more protective of 

2 consumers than such requirements. 

3 ‘‘(2) CONSULTATION IN RATE REVIEW PROC4 ESS.—In carrying out this section, the Secretary 

5 shall consult with the National Association of Insur6 ance Commissioners and consumer groups. 

7 ‘‘(3) DETERMINATION OF WHO CONDUCTS RE8 VIEWS FOR EACH STATE.—The Secretary shall de9 termine, after the date of enactment of this sub10 section and periodically thereafter, the following: 

11 ‘‘(A) In which markets in each State the 

12 State insurance commissioner or relevant State 

13 regulator shall undertake the corrective actions 

14 under paragraph (4), based on the Secretary’s 

15 determination that the State insurance commis16 sioner or relevant State regulator is adequately 

17 undertaking and utilizing such actions in that 

18 market. 

19 ‘‘(B) In which markets in each State the 

20 Secretary shall undertake the corrective actions 

21 under paragraph (4), in cooperation with the 

22 relevant State insurance commissioner or State 

23 regulator, based on the Secretary’s determina24 tion that the State is not adequately underVerDate Sep 11 2014 01:59 May 30, 2024 Jkt 049200 PO 00000 Frm 00023 Fmt 6652 Sfmt 6201 E:\BILLS\S4231.IS S4231

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1 taking and utilizing such actions in that mar2 ket. 

3 ‘‘(4) CORRECTIVE ACTION FOR EXCESSIVE, UN4 JUSTIFIED, OR UNFAIRLY DISCRIMINATORY

5 RATES.—In accordance with the process established 

6 under this section, the Secretary or the relevant 

7 State insurance commissioner or State regulator 

8 shall take corrective actions to ensure that any ex9 cessive, unjustified, or unfairly discriminatory rates 

10 are corrected prior to implementation, or as soon as 

11 possible thereafter, through mechanisms such as— 

12 ‘‘(A) denying rates; 

13 ‘‘(B) modifying rates; or 

14 ‘‘(C) requiring rebates to consumers. 

15 ‘‘(5) NONCOMPLIANCE.— 

16 ‘‘(A) IN GENERAL.—Failure to comply 

17 with any corrective action taken by the Sec18 retary under this subsection may result in the 

19 application of civil monetary penalties described 

20 in subparagraph (B) and, if the Secretary de21 termines appropriate, make the plan involved 

22 ineligible for classification as a qualified health 

23 plan. 

24 ‘‘(B) CIVIL MONETARY PENALTIES.— 


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1 ‘‘(i) IN GENERAL.—The provisions of 

2 section 1128A of the Social Security Act, 

3 other than subsection (a) and (b) and the 

4 first sentence of subsection (c)(1) of such 

5 section, shall apply to civil monetary pen6 alties under this paragraph in the same 

7 manner as such provisions apply to a pen8 alty or proceeding under section 1128A of 

9 the Social Security Act. 

10 ‘‘(ii) AMOUNT.—The provisions of 

11 subparagraph (C) of section 2723(b)(2) 

12 shall apply to civil monetary penalties 

13 under this paragraph in the same manner 

14 as such provisions apply to a penalty under 

15 such section.’’. 

16 (b) CLARIFICATION OF REGULATORY AUTHORITY.— 

17 Section 2794 of the Public Health Service Act (42 U.S.C. 

18 300gg–94) is further amended— 

19 (1) in subsection (a)— 

20 (A) in the subsection heading, by striking 

21 ‘‘PREMIUM’’ and inserting ‘‘RATE’’; 

22 (B) in paragraph (1), by striking ‘‘unrea23 sonable increases in premiums’’ and inserting 

24 ‘‘potentially excessive, unjustified, or unfairly 

25 discriminatory rates, including premiums,’’; and 


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1 (C) in paragraph (2)— 

2 (i) by striking ‘‘an unreasonable pre3 mium increase’’ and inserting ‘‘a poten4 tially excessive, unjustified, or unfairly dis5 criminatory rate’’; 

6 (ii) by striking ‘‘the increase’’ and in7 serting ‘‘the rate’’; and 

8 (iii) by striking ‘‘such increases’’ and 

9 inserting ‘‘such rates’’; and 

10 (2) in subsection (b)— 

11 (A) in the subsection heading, by striking 

12 ‘‘PREMIUM’’ and inserting ‘‘RATE’’; 

13 (B) by striking ‘‘premium increases’’ each 

14 place it appears and inserting ‘‘rates’’; 

15 (C) in paragraph (1)— 

16 (i) in the paragraph heading, by strik17 ing ‘‘PREMIUM INCREASE’’ and inserting 

18 ‘‘RATE’’; and 

19 (ii) in subparagraph (B), by striking 

20 ‘‘excessive or unjustified’’ and inserting 

21 ‘‘excessive, unjustified, or unfairly discrimi22 natory’’; and 

23 (D) in paragraph (2)— 


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1 (i) in the paragraph heading, by strik2 ing ‘‘PREMIUM INCREASES’’ and inserting 

3 ‘‘RATES’’; and 

4 (ii) in subparagraph (B), by striking 

5 ‘‘premium’’ and inserting ‘‘rate’’. 

6 (c) CONFORMING AMENDMENT.—Section 1311(e)(2) 

7 of the Patient Protection and Affordable Care Act (42 

8 U.S.C. 18031(e)(2)) is amended by striking ‘‘excessive or 

9 unjustified premium increases’’ and inserting ‘‘excessive, 

10 unjustified, or unfairly discriminatory rates’’. 

11 (d) APPLICABILITY TO GRANDFATHERED HEALTH

12 PLANS.—Section 1251(a)(5) of the Patient Protection 

13 and Affordable Care Act (42 U.S.C. 18011(a)(5)) is 

14 amended— 

15 (1) by striking ‘‘Sections 2799A–1’’ and insert16 ing the following: 

17 ‘‘(A) IN GENERAL.—Sections 2799A–1’’; 

18 and 

19 (2) by adding at the end the following: 

20 ‘‘(B) ENSURING THAT CONSUMERS GET

21 VALUE FOR THEIR DOLLARS.—Section 2794 of 

22 the Public Health Service Act shall apply to 

23 grandfathered health plans for plan years be24 ginning on or after January 1, 2025.’’. 


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

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

3 this Act and shall be implemented with respect to health 

4 plans beginning not later than January 1, 2025. 

5 SEC. 10. SENSE OF CONGRESS. 

6 It is the sense of the Congress that— 

7 (1) the Federal Government, acting in its ca8 pacity as an insurer, employer, or health care pro9 vider, should serve as a model for the Nation to en10 sure coverage of all reproductive services; and 

11 (2) all restrictions on coverage of reproductive 

12 services in the private insurance market should end. 

Æ 


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