I 

116TH CONGRESS 

1ST SESSION H. R. 1346 

To amend title XVIII of the Social Security Act to provide for an option 

for individuals who are ages 50 to 64 to buy into Medicare, to provide 

for health insurance market stabilization, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

FEBRUARY 25, 2019 

Mr. HIGGINS of New York (for himself, Mr. LARSON of Connecticut, Mr. 

COURTNEY, Mr. WELCH, Mr. AGUILAR, Ms. BONAMICI, Mr. BRENDAN F. 

BOYLE of Pennsylvania, Mr. CLAY, Mr. DEUTCH, Mr. MICHAEL F. 

DOYLE of Pennsylvania, Mr. HECK, Mr. KRISHNAMOORTHI, Ms. KUSTER

of New Hampshire, Mr. LANGEVIN, Mr. LARSEN of Washington, Mr. 

LOWENTHAL, Mr. SEAN PATRICK MALONEY of New York, Mr. MEEKS, 

Ms. NORTON, Mr. PERLMUTTER, Mr. PETERSON, Mr. SCHIFF, Ms. 

TITUS, Mr. TONKO, Ms. WASSERMAN SCHULTZ, Ms. WILD, and Mr. 

MCGOVERN) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on 

Ways and Means, for a period to be subsequently determined by the 

Speaker, in each case for consideration of such provisions as fall within 

the jurisdiction of the committee concerned 

A BILL 

To amend title XVIII of the Social Security Act to provide 

for an option for individuals who are ages 50 to 64 

to buy into Medicare, to provide for health insurance 

market stabilization, 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, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Medicare Buy-In and 

3 Health Care Stabilization Act of 2019’’. 

4 SEC. 2. FINDINGS. 

5 Congress finds as follows: 

6 (1) Medicare has coverage gaps and should pro7 vide more comprehensive coverage, including increas8 ing coverage for the medical needs of beneficiaries 

9 relating to hearing, dental, and vision care. 

10 (2) Special needs populations face financial 

11 challenges to secure coverage for Medicare’s out of 

12 pocket costs and other hurdles. 

13 (3) Medicare Buy-In is a step in the right di14 rection as Congress considers additional needed leg15 islation to address these and other coverage issues 

16 and beneficiary financial challenges in Medicare and 

17 Medicare Buy-In. 

18 SEC. 3. MEDICARE BUY-IN OPTION. 

19 (a) IN GENERAL.—Title XVIII of the Social Security 

20 Act (42 U.S.C. 1395c et seq.) is amended by adding at 

21 the end the following new section: 

22 ‘‘MEDICARE BUY-IN OPTION

23 ‘‘SEC. 1899C. (a) OPTION.— 

24 ‘‘(1) IN GENERAL.—Every individual who meets 

25 the requirements described in paragraph (2) shall be 

26 eligible to enroll under this section. 


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1 ‘‘(2) ELIGIBILITY.—An individual who meets 

2 the following requirements is eligible to enroll under 

3 this section: 

4 ‘‘(A) AGE.—The individual has attained 50 

5 years of age, but has not attained 65 years of 

6 age. 

7 ‘‘(B) MEDICARE ELIGIBILITY (BUT FOR

8 AGE).—The individual is not otherwise entitled 

9 to benefits under part A or eligible to enroll 

10 under part A or part B but would be eligible for 

11 benefits under part A or part B if the indi12 vidual were 65 years of age. 

13 ‘‘(3) PART A, B, AND D BENEFITS AND PROTEC14 TIONS.—An individual enrolled under this section is 

15 entitled to the same benefits (and shall receive the 

16 same protections) under this title as an individual 

17 who is entitled to benefits under part A and enrolled 

18 under parts B and D, including the ability to enroll 

19 in a Medicare Advantage plan that provides qualified 

20 prescription drug coverage (an MA–PD plan) and 

21 including access to the Medicare Beneficiary Om22 budsman under section 1808(c). 

23 ‘‘(b) ENROLLMENT AND COVERAGE PERIODS.—The 

24 Secretary shall establish enrollment and coverage periods 

25 for individuals who enroll under this section. Such periods 


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1 shall be established in coordination with the enrollment 

2 and coverage periods for plans offered under an Exchange 

3 established under title I of the Patient Protection and Af4 fordable Care Act. The Secretary shall establish such peri5 ods so that coverage under this section shall first begin 

6 on January 1 of the first year beginning at least one year 

7 after the date of the enactment of this section and shall 

8 include special enrollment periods, in accordance with sec9 tion 155.420 of title 45 of the Code of Federal Regula10 tions, that are applicable to qualified health plans offered 

11 through an Exchange. 

12 ‘‘(c) BUY-IN PREMIUM.— 

13 ‘‘(1) AMOUNT OF MONTHLY PREMIUMS.—The 

14 Secretary shall (beginning for the first year that be15 gins more than 1 year after the date of the enact16 ment of this section), during September of the pre17 ceding year, determine a monthly premium for indi18 viduals enrolled under this section. Such monthly 

premium shall be equal to 1 19 ⁄12 of the annual pre20 mium computed under paragraph (2)(B), which 

21 shall apply with respect to coverage provided under 

22 this section for any month in such year. 

23 ‘‘(2) ANNUAL PREMIUM.— 

24 ‘‘(A) COMBINED NATIONAL, PER CAPITA

25 AVERAGE FOR PARTS A, B, AND D BENEFITS.— 


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1 The Secretary shall estimate the average, an2 nual per capita amount for benefits and admin3 istrative expenses that will be payable under 

4 parts A, B, and D in the year for all individuals 

5 enrolled under this section. 

6 ‘‘(B) ANNUAL PREMIUM.—Subject to sub7 paragraphs (C) and (D), the annual premium 

8 under this subsection for months in a year is 

9 equal to the average, annual per capita amount 

10 estimated under subparagraph (A) for the year. 

11 ‘‘(C) ADJUSTMENTS.—The Secretary shall 

12 adjust the annual premium under this sub13 section as necessary— 

14 ‘‘(i) to ensure that expenditures under 

15 this title for any year are not increased by 

16 reason of this section; and 

17 ‘‘(ii) by a geographic adjustment fac18 tor to address regional affordability con19 cerns. 

20 ‘‘(D) AUTHORITY TO CALCULATE

21 AMOUNTS OF MONTHLY PREMIUMS SEPARATELY

22 FOR DIFFERENT AGES.—In determining the an23 nual premium amount under this paragraph for 

24 months in a year, the Secretary may make sep25 arate determinations of such amount for indiVerDate Sep 11 2014 20:29 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H1346.IH H1346

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1 viduals by age, if the Secretary determines that 

2 making such separate determinations would in3 crease enrollment under this section and reduce 

4 the risk of adverse selection. 

5 ‘‘(3) ADDITIONAL PREMIUM FOR CERTAIN PART

6 D PLANS.—Nothing in this section shall preclude an 

7 individual from choosing a prescription drug plan 

8 which requires the individual to pay an additional 

9 amount (because of the inclusion of supplemental 

10 prescription drug benefits or because the plan is a 

11 more expensive plan, pursuant to section 1860D– 

12 13(a)(1)). In such case, the monthly premium under 

13 paragraph (1) shall be increased with respect to 

14 such individual. 

15 ‘‘(d) PAYMENT OF PREMIUMS.— 

16 ‘‘(1) PAYMENT.—Premiums for enrollment 

17 under this section shall be paid to the Secretary at 

18 such times, and in such manner, as the Secretary 

19 determines appropriate. 

20 ‘‘(2) DEPOSIT.—Amounts collected by the Sec21 retary under this section shall be deposited in the 

22 Medicare Buy-In Trust Fund established under sub23 section (e). 

24 ‘‘(e) MEDICARE BUY-IN TRUST FUND.— 


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1 ‘‘(1) IN GENERAL.—There is hereby created on 

2 the books of the Treasury of the United States a 

3 trust fund to be known as the ‘Medicare Buy-In 

4 Trust Fund’ (in this subsection referred to as the 

5 ‘Trust Fund’). The Trust Fund shall consist of such 

6 gifts and bequests as may be made as provided in 

7 section 201(i)(1) and such amounts as may be de8 posited in, or appropriated to, such fund as provided 

9 in this title. 

10 ‘‘(2) PREMIUMS.—Premiums collected under 

11 subsection (d) shall be transferred to the Trust 

12 Fund. 

13 ‘‘(3) INCORPORATION OF PROVISIONS.—Sub14 sections (b) through (i) of section 1841 shall apply 

15 with respect to the Trust Fund and this title in the 

16 same manner as they apply with respect to the Fed17 eral Supplementary Medical Insurance Trust Fund 

18 and part B, respectively, except that in applying 

19 such section 1841, any reference in such section to 

20 ‘this part’ shall be construed to be a reference to 

21 this section and any reference in section 1841(h) to 

22 section 1840(d) and in section 1841(i) to sections 

23 1840(b)(1) and 1842(g) are deemed to be references 

24 to comparable authority exercised under this section. 


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1 ‘‘(f) CLARIFICATION.—Nothing in this section shall 

2 affect the benefits or eligibility under this title of individ3 uals who would otherwise be entitled to or eligible for ben4 efits under this title or title XIX, or both. 

5 ‘‘(g) ELIGIBILITY FOR FINANCIAL ASSISTANCE.— 

6 ‘‘(1) IN GENERAL.—Individuals enrolled in cov7 erage under this section shall, from amounts trans8 ferred under paragraph (2), receive financial assist9 ance for such coverage that is substantially similar 

10 to the assistance the individual would have received 

11 if the individual were enrolled in a qualified health 

12 plan through an Exchange. 

13 ‘‘(2) TRANSFER OF FUNDS TO MEDICARE BUY14 IN TRUST FUND.— 

15 ‘‘(A) IN GENERAL.—The Secretary shall 

16 transfer to the Medicare Buy-In Trust Fund 

17 under subsection (d) for each plan year the 

18 amount determined under paragraph (C) for 

19 such year. 

20 ‘‘(B) USE OF FUNDS.—The amounts 

21 transferred to the Medicare Buy-In Trust Fund 

22 under subparagraph (A) shall only be used to 

23 reduce the premiums and cost-sharing for cov24 erage under this section of individuals enrolled 

25 under such coverage who would be eligible for 


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1 cost-sharing reductions under section 1402 of 

2 the Patient Protection and Affordable Care Act 

3 and premium assistance under section 36B of 

4 the Internal Revenue Code of 1986 if such indi5 vidual were enrolled in a qualified health plan. 

6 ‘‘(C) AMOUNT OF TRANSFER.— 

7 ‘‘(i) IN GENERAL.—The amount de8 termined under this subparagraph for any 

9 plan year is the aggregate amount the Sec10 retary determines is equal to 100 percent 

11 of the premium tax credits under section 

12 36B of the Internal Revenue Code of 

13 1986, and 100 percent of the cost-sharing 

14 reductions under section 1402 of the Pa15 tient Protection and Affordable Care Act, 

16 that would have been provided for the plan 

17 year to eligible individuals who meet speci18 fied income criteria and are enrolled for 

19 such plan year in coverage provided 

20 through enrollment under this section if 

21 such individuals were enrolled for such 

22 year in a qualified health plan through an 

23 Exchange. 

24 ‘‘(ii) SPECIFIC REQUIREMENTS.—The 

25 Secretary shall make the determination 


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1 under clause (i) on a per enrollee basis and 

2 shall take into account all relevant factors 

3 necessary to determine the value of the 

4 premium tax credits and cost-sharing re5 ductions that would have been provided to 

6 eligible individuals described in section 

7 1331 of the Patient Protection and Afford8 able Care Act, including the age and in9 come of the enrollee, geographic differences 

10 in average spending for health care across 

11 rating areas, the health status of the en12 rollee for purposes of determining risk ad13 justment payments and reinsurance pay14 ments that would have been made if the 

15 enrollee had enrolled in a qualified health 

16 plan through an Exchange, and whether 

17 any reconciliation of the credit or cost18 sharing reductions would have occurred if 

19 the enrollee had been so enrolled. This de20 termination shall take into consideration 

21 the experience of other States with respect 

22 to participation in an Exchange and such 

23 credits and reductions provided to resi24 dents of the other States, with a special 


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1 focus on enrollees with income below 200 

2 percent of poverty. 

3 ‘‘(D) CERTIFICATION.— 

4 ‘‘(i) IN GENERAL.—The Chief Actuary 

5 of the Centers for Medicare & Medicaid 

6 Services, in consultation with the Office of 

7 Tax Analysis of the Department of the 

8 Treasury, shall certify whether the method9 ology used to make determinations under 

10 subparagraph (C), and such determina11 tions, meet the requirements of this para12 graph. Such certifications shall be based 

13 on sufficient data from the federal ex14 change and from comparable States about 

15 their experience with programs created by 

16 the Basic Health Plan. 

17 ‘‘(ii) CORRECTIONS.—The Secretary 

18 shall adjust the payment to the Trust 

19 Fund for any plan year to reflect any error 

20 in the determinations under subparagraph 

21 (C) for any preceding plan year. 

22 ‘‘(iii) APPLICATION.—Coverage pro23 vided through enrollment under this part 

24 and parts B and D pursuant to this sec25 tion shall be treated as coverage under a 


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1 qualified health plan in the silver level of 

2 coverage in the individual market offered 

3 through an Exchange and the Secretary 

4 shall be treated as the issuer of such plan. 

5 ‘‘(h) TREATMENT IN RELATION TO THE AFFORD6 ABLE CARE ACT.— 

7 ‘‘(1) TREATMENT AS MINIMUM ESSENTIAL COV8 ERAGE.—For purposes of applying section 5000A of 

9 the Internal Revenue Code of 1986, the coverage 

10 provided through enrollment under this section con11 stitutes minimum essential coverage under sub12 section (f)(1)(A)(i) of such section. 

13 ‘‘(2) USE OF EXCHANGES.—Coverage provided 

14 through enrollment under this section shall be 

15 deemed to be coverage under a qualified health plan 

16 for purposes of section 1311(d)(4)(C) of the Patient 

17 Protection and Affordable Care Act and shall be 

18 made available for enrollment, information compari19 son, and otherwise as such a plan through any inter20 net website maintained by an Exchange established 

21 under title I of such Act (as described in such sec22 tion). 

23 ‘‘(3) MEDICAID MANAGED CARE.—States are 

24 prohibited from buying their Medicaid beneficiaries 

25 ages 50 to 64 into Medicare under this section, and 


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1 individuals otherwise eligible for enrollment under a 

2 State plan under title XIX are prohibited from cov3 erage under this title pursuant to enrollment under 

4 this section. The preceding sentence shall not apply 

5 to Medicaid beneficiaries whose Medicaid coverage or 

6 eligibility does not meet the definition of minimum 

7 essential coverage under a government-sponsored 

8 program under section 1.5000A–2 of title 26, Code 

9 of Federal Regulations (or any successor regulation). 

10 ‘‘(4) ACCESS TO MEDIGAP.—Coverage provided 

11 through medicare supplemental policies certified 

12 under section 1882 shall be made available to indi13 viduals eligible for enrollment pursuant to this sec14 tion for enrollment, information, comparison, and 

15 otherwise as such a policy through any internet 

16 website described in paragraph (2). 

17 ‘‘(i) OVERSIGHT.—There is established an advisory 

18 committee to be known as the ‘Medicare Buy In Oversight 

19 Board’ to monitor and oversee the implementation of this 

20 section, including the experience of the individuals enroll21 ing under this section. The Medicare Buy In Oversight 

22 Board shall make periodic recommendations for the con23 tinual improvement of the implementation of this section 

24 as well as the relationship of enrollment under this section 

25 to other health care programs. 


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1 ‘‘(j) OUTREACH AND ENROLLMENT.— 

2 ‘‘(1) IN GENERAL.—During the period that be3 gins on January 1, 2019, and ends on December 31, 

4 2021, the Secretary shall award grants to eligible 

5 entities for the following purposes: 

6 ‘‘(A) OUTREACH AND ENROLLMENT.—To 

7 carry out outreach, public education activities, 

8 and enrollment activities to raise awareness of 

9 the availability of, and encourage, enrollment 

10 under this section. 

11 ‘‘(B) ASSISTING INDIVIDUALS TRANSITION

12 UNDER THIS SECTION.—To provide assistance 

13 to individuals to enroll under this section. 

14 ‘‘(C) RAISING AWARENESS OF PREMIUM

15 ASSISTANCE AND COST-SHARING REDUC16 TIONS.—To distribute fair and impartial infor17 mation concerning enrollment under this section 

18 and the availability of premium assistance tax 

19 credits under section 36B of the Internal Rev20 enue Code of 1986 and cost-sharing reductions 

21 under section 1402 of the Patient Protection 

22 and Affordable Care Act, and to assist eligible 

23 individuals in applying for such tax credits and 

24 cost-sharing reductions. 

25 ‘‘(2) ELIGIBLE ENTITIES.— 


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1 ‘‘(A) IN GENERAL.—In this subsection, the 

2 term ‘eligible entity’ means— 

3 ‘‘(i) a State; or 

4 ‘‘(ii) a nonprofit community-based or5 ganization. 

6 ‘‘(B) ENROLLMENT AGENTS.—Such term 

7 includes a licensed independent insurance agent 

8 or broker that has an arrangement with a State 

9 or nonprofit community-based organization to 

10 enroll eligible individuals under this section. 

11 ‘‘(C) EXCLUSIONS.—Such term does not 

12 include an entity that— 

13 ‘‘(i) is a health insurance issuer; or 

14 ‘‘(ii) receives any consideration, either 

15 directly or indirectly, from any health in16 surance issuer in connection with the en17 rollment of any individuals under this sec18 tion. 

19 ‘‘(3) PRIORITY.—In awarding grants under this 

20 subsection, the Secretary shall give priority to 

21 awarding grants to States or eligible entities in 

22 States that have geographic rating areas at risk of 

23 having no qualified health plans in the individual 

24 market. 


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1 ‘‘(4) FUNDING.—Out of any moneys in the 

2 Treasury not otherwise appropriated, $500,000,000 

3 is appropriated to the Secretary for each of calendar 

4 years 2019 through 2021, to carry out this sub5 section. 

6 ‘‘(k) IMPLEMENTATION.— 

7 ‘‘(1) CONSULTATION.—In carrying out this sec8 tion, the Secretary shall— 

9 ‘‘(A) consult with other Federal agencies, 

10 including the Department of the Treasury, the 

11 Department of Labor, the Department of Vet12 erans Affairs, the Department of Defense, and 

13 the Office of Personnel Management; and 

14 ‘‘(B) incorporate significant public con15 sultation and feedback, through public forums, 

16 notice and comment rulemaking, and any other 

17 appropriate mediums. 

18 ‘‘(2) REPORT.—No later than one year after 

19 the date of the enactment of this section, the Sec20 retary shall submit to Congress a report establishing 

21 the administrative parameters for the implementa22 tion of this section. 

23 ‘‘(l) FEASIBILITY STUDY.—The Secretary shall con24 duct a study on the feasibility of applying this section with 


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1 respect to individuals residing in States that are not with2 in the 50 States or the District of Columbia.’’. 

3 (b) MEDIGAP.—Section 1882 of the Social Security 

4 Act is amended by adding at the end the following new 

5 subsection: 

6 ‘‘(aa) DEVELOPMENT OF NEW STANDARDS FOR CER7 TAIN MEDICARE SUPPLEMENTAL POLICIES RELATING TO

8 BUY-IN OPTION.—The Secretary shall request the Na9 tional Association of Insurance Commissioners to review 

10 and revise the standards for benefit packages described 

11 in subsection (p)(1), to otherwise update standards to in12 clude requirements for each medicare supplemental policy 

13 that offers such a policy in a State, with respect to each 

14 year, to accept every individual in the State who is eligible 

15 for enrollment pursuant to section 1899C and who applies 

16 for such coverage for such year if the individual applies 

17 for enrollment in such policy during the 30-day period fol18 lowing the date of enrollment pursuant to section 1899C 

19 and to accept every such individual during a period of 

20 transition from enrollment pursuant to such section to en21 rollment under this title pursuant to eligibility other than 

22 under such section. Such revisions shall be made con23 sistent with the rules applicable under subsection 

24 (p)(1)(E) with the reference to the ‘1991 NAIC Model 

25 Regulation’ deemed a reference to the NAIC Model ReguVerDate Sep 11 2014 20:29 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00017 Fmt 6652 Sfmt 6201 E:\BILLS\H1346.IH H1346

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1 lation as published in the Federal Register on December 

2 4, 1998, and as subsequently updated by the National As3 sociation of Insurance Commissioners to reflect previous 

4 changes in law and the reference to ‘date of enactment 

5 of this subsection’ deemed a reference to the date of enact6 ment of this subsection (aa).’’. 

7 SEC. 4. MEDICARE DIRECT SUPPLEMENTAL INSURANCE 

8 OPTION. 

9 (a) IN GENERAL.—Title XVIII of the Social Security 

10 Act is amended by inserting after section 1882 (42 U.S.C. 

11 1395ss) the following new section: 

12 ‘‘SEC. 1882A. MEDICARE DIRECT SUPPLEMENTAL INSUR13 ANCE OPTION. 

14 ‘‘(a) IN GENERAL.—The Secretary shall provide for 

15 the offering under this section of a voluntary program to 

16 supplement the benefits provided to individuals under 

17 parts A and B of this title. 

18 ‘‘(b) ELIGIBILITY; ENROLLMENT.—The Secretary 

19 shall provide procedures for the enrollment under the pro20 gram under this section of individuals who are entitled to 

21 benefits under part A and enrolled under part B, but who 

22 are not enrolled in a Medicare Advantage plan (or in a 

23 plan under section 1876). Such procedures shall be con24 sistent with the following: 


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1 ‘‘(1) There shall be an initial enrollment period 

2 during the last calendar quarter of 2020 that per3 mits all individuals who are eligible to enroll at that 

4 time under this subsection to enroll and obtain bene5 fits effective on January 1, 2021. 

6 ‘‘(2) For individuals who are not eligible to en7 roll at such time but who subsequently become eligi8 ble, there shall be an individual enrollment period 

9 which is the 6-month period described in section 

10 1882(s)(2)(A). 

11 ‘‘(3) The Secretary shall permit eligible individ12 uals to enroll at other times (and not less frequently 

13 than annually) in a uniform manner, but such en14 rollment shall be subject to a late enrollment penalty 

15 under subsection (d)(2)(B). 

16 ‘‘(c) BENEFITS.— 

17 ‘‘(1) IN GENERAL.—The benefits provided 

18 under the program under this section shall consist of 

19 payment of the cost of deductibles, copayments, and 

20 other cost-sharing amounts (including amounts at21 tributable to and permitted as balance billing) other22 wise imposed or permitted under this title, subject to 

23 an annual deductible of $100. 

24 ‘‘(2) ADMINISTRATION.—The Secretary shall 

25 coordinate payment of benefits under this part with 


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1 those under parts A and B and may, for such pur2 pose, enter into appropriate arrangements with 

3 qualified entities (which may include fiscal inter4 mediaries and carriers). 

5 ‘‘(3) NO PRE-EXISTING CONDITION LIMITA6 TIONS.—The benefits under this section shall not be 

7 subject to any pre-existing condition or similar un8 derwriting limitation. 

9 ‘‘(d) PREMIUMS.— 

10 ‘‘(1) ACTUARIAL COST.—The Secretary shall, 

11 during September of each year beginning with 2020, 

12 determine a monthly actuarial rate for all enrollees 

13 under this section, which rate shall be applicable for 

14 months in the succeeding calendar year. Such actu15 arial rate shall be the amount the Secretary esti16 mates to be necessary so that the aggregate amount 

17 for such calendar year with respect to those enrollees 

18 will equal the total amount which the Secretary esti19 mates will be payable under this section for benefits 

20 accrued (including services performed and related 

21 administrative costs incurred) in such calendar year 

22 under the program under this section. In calculating 

23 the monthly actuarial rate, the Secretary shall make 

24 adjustments to take into account errors in esti25 mations under this paragraph for previous years and 


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1 shall include an appropriate amount for a contin2 gency margin. 

3 ‘‘(2) PREMIUM.— 

4 ‘‘(A) IN GENERAL.—The monthly premium 

5 of each individual enrolled under this section 

6 for a month in a year shall be the monthly ac7 tuarial rate determined under paragraph (1) for 

8 months in such year. Such premium shall be 

9 community-rated and shall not vary among en10 rollees based upon the age, place of residence, 

11 or any other factors, except as provided under 

12 subparagraph (B). 

13 ‘‘(B) PENALTY FOR LATE ENROLLMENT.— 

14 In the case of an individual who does not enroll 

15 under this section in a period provided under 

16 paragraph (1) or (2) of subsection (b), the Sec17 retary shall increase the monthly premium (in 

18 a manner similar to that applied under part B 

19 pursuant to section 1839(b)) of 10 percent for 

20 each full 12 months in which the individual 

21 could have been but was not so enrolled. In ap22 plying such an increase— 

23 ‘‘(i) the aggregate percentage increase 

24 may not exceed 100 percent; and 


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1 ‘‘(ii) periods of time in which an indi2 vidual is enrolled under an employee wel3 fare benefit plan described in section 

4 1882(s)(3)(B)(i), under a Medicare Advan5 tage plan, with an organization described 

6 in section 1882(s)(3)(B)(iii), or under a 

7 PACE program under section 1894 shall 

8 not be taken into account. 

9 ‘‘(3) COLLECTION.—The Secretary shall pro10 vide for the collection of premiums for enrollees 

11 under this part in the same manner as premiums 

12 under part B are collected under section 1840, ex13 cept that any reference in such section to the Fed14 eral Supplementary Medical Insurance Trust Fund 

15 shall be deemed a reference to an account (to be 

16 known as the ‘Direct Medicare Supplemental Insur17 ance Account’) to be established in the Treasury by 

18 the Secretary to carry out the program under this 

19 section. Amounts in such account may be invested 

20 and draw interest in the same manner as such Trust 

21 Fund under section 1840(c). 

22 ‘‘(4) USE OF FUNDS.—Premium amounts de23 posited into the account established under paragraph 

24 (3) shall be available without regard to appropria25 tions to the Secretary to make payment for benefits 


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1 and administrative costs incurred in carrying out 

2 this section. 

3 ‘‘(e) NONDUPLICATION OF COVERAGE.—For pur4 poses of applying section 1882(d)(3)(A), coverage under 

5 this section shall be treated as coverage under a Medicare 

6 supplemental policy.’’. 

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

8 subsection (a) shall take effect on the date of the enact9 ment of this Act and shall apply to benefits for months 

10 beginning with January 2020. 

11 SEC. 5. NEGOTIATION OF LOWER COVERED PART D DRUG 

12 PRICES ON BEHALF OF MEDICARE BENE13 FICIARIES. 

14 (a) NEGOTIATION BY SECRETARY.—Section 1860D– 

15 11 of the Social Security Act (42 U.S.C. 1395w–111) is 

16 amended by striking subsection (i) (relating to noninter17 ference) and inserting the following: 

18 ‘‘(i) NEGOTIATION OF LOWER DRUG PRICES.— 

19 ‘‘(1) IN GENERAL.—Notwithstanding any other 

20 provision of law, the Secretary shall negotiate with 

21 pharmaceutical manufacturers the prices (including 

22 discounts, rebates, and other price concessions) that 

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1 dividuals who are enrolled under a prescription drug 

2 plan or under an MA–PD plan. 

3 ‘‘(2) NO CHANGE IN RULES FOR

4 FORMULARIES.— 

5 ‘‘(A) IN GENERAL.—Nothing in paragraph 

6 (1) shall be construed to authorize the Sec7 retary to establish or require a particular for8 mulary. 

9 ‘‘(B) CONSTRUCTION.—Subparagraph (A) 

10 shall not be construed as affecting the Sec11 retary’s authority to ensure appropriate and 

12 adequate access to covered part D drugs under 

13 prescription drug plans and under MA–PD 

14 plans, including compliance of such plans with 

15 formulary requirements under section 1860D– 

16 4(b)(3). 

17 ‘‘(3) CONSTRUCTION.—Nothing in this sub18 section shall be construed as preventing the sponsor 

19 of a prescription drug plan, or an organization offer20 ing an MA–PD plan, from obtaining a discount or 

21 reduction of the price for a covered part D drug 

22 below the price negotiated under paragraph (1). 

23 ‘‘(4) SEMI-ANNUAL REPORTS TO CONGRESS.— 

24 Not later than June 1, 2022, and every 6 months 

25 thereafter, the Secretary shall submit to the ComVerDate Sep 11 2014 20:29 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00024 Fmt 6652 Sfmt 6201 E:\BILLS\H1346.IH H1346

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1 mittees on Ways and Means, Energy and Commerce, 

2 and Oversight and Reform of the House of Rep3 resentatives and the Committee on Finance of the 

4 Senate a report on negotiations conducted by the 

5 Secretary to achieve lower prices for Medicare bene6 ficiaries, and the prices and price discounts achieved 

7 by the Secretary as a result of such negotiations.’’. 

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

9 subsection (a) shall take effect on the date of the enact10 ment of this Act and shall first apply to negotiations and 

11 prices for plan years beginning on January 1, 2022. 

12 SEC. 6. INDIVIDUAL MARKET REINSURANCE FUND. 

13 (a) ESTABLISHMENT OF FUND.— 

14 (1) IN GENERAL.—There is established the ‘‘In15 dividual Market Reinsurance Fund’’ (in this section 

16 referred to as the ‘‘Fund’’) to be administered by 

17 the Secretary to provide funding for an individual 

18 market stabilization reinsurance program in each 

19 State that complies with the requirements of this 

20 section. 

21 (2) FUNDING.—Amounts made available to the 

22 Fund shall consist of the funds deposited into the 

23 Fund under paragraph (3) and shall be used to 

24 carry out this section (other than subsection (c)) for 

25 each calendar year beginning with 2021. Amounts 


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1 made available to the Fund shall remain available 

2 without fiscal or calendar year limitation to carry 

3 out this section. 

4 (3) COST-SHARING IN COSTS OF PROGRAM.— 

5 (A) IN GENERAL.—A qualified health plan 

6 that participates in the reinsurance program es7 tablished under subsection (b) shall pay the fee 

8 established under subparagraph (B). 

9 (B) AUTHORIZATION.—The Secretary is 

10 authorized to charge a fee to each qualified 

11 health plan that participates in the reinsurance 

12 program established under subsection (b). Any 

13 amounts collected pursuant to this paragraph 

14 shall be deposited into the Fund for purposes of 

15 payments under subsection (b). 

16 (C) REQUIREMENTS.—In establishing the 

17 fee under subparagraph (B)— 

18 (i) the Secretary shall consult with in19 terested parties; and 

20 (ii) shall ensure that the amount of 

21 such fee is not excessive so as to unduly 

22 discourage qualified health plans from par23 ticipating in the reinsurance program. 

24 (b) INDIVIDUAL MARKET REINSURANCE PRO25 GRAM.— 


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1 (1) USE OF FUNDS.—The Secretary shall use 

2 amounts in the Fund to establish a reinsurance pro3 gram under which the Secretary shall make reinsur4 ance payments, subject to subsection (a)(3), to 

5 health insurance issuers with respect to high-cost in6 dividuals enrolled in qualified health plans offered by 

7 such issuers that are not grandfathered health plans 

8 or transitional health plans for any plan year begin9 ning with the 2018 plan year. This subsection con10 stitutes budget authority in advance of appropria11 tions Acts and represents the obligation of the Sec12 retary to provide payments from the Fund in ac13 cordance with this subsection. 

14 (2) AMOUNT OF PAYMENT.—The payment 

15 made to a health insurance issuer under paragraph 

16 (1) with respect to each high-cost individual enrolled 

17 in a qualified health plan issued by the issuer that 

18 is not a grandfathered health plan or a transitional 

19 health plan shall equal 80 percent of the lesser of— 

20 (A) the amount (if any) by which the indi21 vidual’s claims incurred during the plan year 

22 exceeds— 

23 (i) in the case of the 2019, 2020, or 

24 2021 plan year, $50,000; and 


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1 (ii) in the case of any other plan year, 

2 $100,000; or 

3 (B) for plan years described in— 

4 (i) subparagraph (A)(i), $450,000; 

5 and 

6 (ii) subparagraph (A)(ii), $400,000. 

7 (3) INDEXING.—In the case of plan years be8 ginning after 2019, the dollar amounts that appear 

9 in subparagraphs (A) and (B) of paragraph (2) shall 

10 each be increased by an amount equal to— 

11 (A) such amount; multiplied by 

12 (B) the premium adjustment percentage 

13 specified under section 1302(c)(4) of the Af14 fordable Care Act, but determined by sub15 stituting ‘‘2019’’ for ‘‘2013’’. 

16 (4) PAYMENT METHODS.— 

17 (A) IN GENERAL.—Payments under this 

18 subsection shall be based on such a method as 

19 the Secretary determines. The Secretary may 

20 establish a payment method by which interim 

21 payments of amounts under this subsection are 

22 made during a plan year based on the Sec23 retary’s best estimate of amounts that will be 

24 payable after obtaining all of the information. 


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1 (B) REQUIREMENT FOR PROVISION OF IN2 FORMATION.— 

3 (i) REQUIREMENT.—Payments under 

4 this subsection to a health insurance issuer 

5 are conditioned upon the furnishing to the 

6 Secretary, in a form and manner specified 

7 by the Secretary, of such information as 

8 may be required to carry out this sub9 section. 

10 (ii) RESTRICTION ON USE OF INFOR11 MATION.—Information disclosed or ob12 tained pursuant to clause (i) is subject to 

13 the HIPAA privacy and security law, as 

14 defined in section 3009(a) of the Public 

15 Health Service Act (42 U.S.C. 300jj– 

16 19(a)). 

17 (5) SECRETARY FLEXIBILITY FOR BUDGET

18 NEUTRAL REVISIONS TO REINSURANCE PAYMENT

19 SPECIFICATIONS.—If the Secretary determines ap20 propriate, the Secretary may substitute higher dollar 

21 amounts for the dollar amounts specified under sub22 paragraphs (A) and (B) of paragraph (2) (and ad23 justed under paragraph (3), if applicable) if the Sec24 retary certifies that such substitutions, considered 


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1 together, neither increase nor decease the total pro2 jected payments under this subsection. 

3 (c) REPORTS TO CONGRESS.— 

4 (1) ANNUAL REPORT.—The Secretary shall 

5 submit a report to Congress, not later than January 

6 21, 2019, and each year thereafter, that contains 

7 the following information for the most recently 

8 ended year: 

9 (A) The number and types of plans in each 

10 State’s individual market, specifying the num11 ber that are qualified health plans, grand12 fathered health plans, or health insurance cov13 erage that is not a qualified health plan. 

14 (B) The impact of the reinsurance pay15 ments provided under this section on the avail16 ability of coverage, cost of coverage, and cov17 erage options in each State. 

18 (C) The amount of premiums paid by indi19 viduals in each State by age, family size, geo20 graphic area in the State’s individual market, 

21 and category of health plan (as described in 

22 subparagraph (A)). 

23 (D) The process used to award funds for 

24 outreach and enrollment activities awarded to 

25 eligible entities under subsection (c), the 


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1 amount of such funds awarded, and the activi2 ties carried out with such funds. 

3 (E) Such other information as the Sec4 retary deems relevant. 

5 (2) EVALUATION REPORT.—Not later than Jan6 uary 31, 2022, the Secretary shall submit to Con7 gress a report that— 

8 (A) analyzes the impact of the funds pro9 vided under this section on premiums and en10 rollment in the individual market in all States; 

11 and 

12 (B) contains a State-by-State comparison 

13 of the design of the programs carried out by 

14 States with funds provided under this section. 

15 (d) DEFINITIONS.—In this section: 

16 (1) SECRETARY.—The term ‘‘Secretary’’ means 

17 the Secretary of the Department of Health and 

18 Human Services. 

19 (2) FUND.—The term ‘‘Fund’’ means the Indi20 vidual Market Reinsurance Fund established under 

21 subsection (a). 

22 (3) GRANDFATHERED HEALTH PLAN.—The 

23 term ‘‘grandfathered health plan’’ has the meaning 

24 given that term in section 1251(e) of the Patient 

25 Protection and Affordable Care Act. 


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1 (4) HIGH-COST INDIVIDUAL.—The term ‘‘high2 cost individual’’ means an individual enrolled in a 

3 qualified health plan (other than a grandfathered 

4 health plan or a transitional health plan) who incurs 

5 claims in excess of $50,000 during a plan year. 

6 (5) STATE.—The term ‘‘State’’ means each of 

7 the 50 States and the District of Columbia. 

8 (6) TRANSITIONAL HEALTH PLAN.—The term 

9 ‘‘transitional health plan’’ means a plan continued 

10 under the letter issued by the Centers for Medicare 

11 & Medicaid Services on November 14, 2013, to the 

12 State Insurance Commissioners outlining a transi13 tional policy for coverage in the individual and small 

14 group markets to which section 1251 of the Patient 

15 Protection and Affordable Care Act does not apply, 

16 and under the extension of the transitional policy for 

17 such coverage set forth in the Insurance Standards 

18 Bulletin Series guidance issued by the Centers for 

19 Medicare & Medicaid Services on March 5, 2014, 

20 February 29, 2016, and February 13, 2017. 

21 SEC. 7. REAUTHORIZATION OF RISK CORRIDORS. 

22 Section 1342(a) of the Patient Protection and Af23 fordable Care Act (42 U.S.C. 18062(a)) is amended by 

24 inserting ‘‘and calendar years 2021 through 2024’’ after 

25 ‘‘2016’’. 


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1 SEC. 8. ENHANCEMENTS FOR REDUCED COST SHARING. 

2 (a) MODIFICATION OF AMOUNT.— 

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

4 Patient Protection and Affordable Care Act (42 

5 U.S.C. 18071(c)(2)) is amended to read as follows: 

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

7 shall establish procedures under which the issuer of 

8 a qualified health plan to which this section applies 

9 shall further reduce cost-sharing under the plan in 

10 a manner sufficient to— 

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

12 whose household income is not less than 100 

13 percent but not more than 200 percent of the 

14 poverty line for a family of the size involved, in15 crease the plan’s share of the total allowed 

16 costs of benefits provided under the plan to 95 

17 percent of such costs; 

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

19 whose household income is more than 200 per20 cent but not more than 300 percent of the pov21 erty line for a family of the size involved, in22 crease the plan’s share of the total allowed 

23 costs of benefits provided under the plan to 90 

24 percent of such costs; and 

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

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1 cent but not more than 400 percent of the pov2 erty line for a family of the size involved, in3 crease the plan’s share of the total allowed 

4 costs of benefits provided under the plan to 85 

5 percent of such costs.’’. 

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

7 section 1402(c)(1)(B) of such Act (42 U.S.C. 

8 18071(c)(1)(B)) is amended to read as follows: 

9 ‘‘(i) IN GENERAL.—The Secretary 

10 shall ensure the reduction under this para11 graph shall not result in an increase in the 

12 plan’s share of the total allowed costs of 

13 benefits provided under the plan above— 

14 ‘‘(I) 95 percent in the case of an 

15 eligible insured described in para16 graph (2)(A); 

17 ‘‘(II) 90 percent in the case of an 

18 eligible insured described in para19 graph (2)(B); and 

20 ‘‘(III) 85 percent in the case of 

21 an eligible insured described in para22 graph (2)(C).’’. 

23 (3) EFFECTIVE DATE.—The amendments made 

24 by this subsection shall apply to plan years begin25 ning after December 31, 2019. 


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1 (b) FUNDING.—Section 1402 of the Patient Protec2 tion and Affordable Care Act (42 U.S.C. 18071) is amend3 ed by adding at the end the following new subsection: 

4 ‘‘(g) FUNDING.—Out of any funds in the Treasury 

5 not otherwise appropriated, there are appropriated to the 

6 Secretary such sums as may be necessary for payments 

7 under this section.’’. 

8 SEC. 9. INTEGRATION OF INDIVIDUALS AGED 50 TO 64 INTO 

9 HEALTH DEMONSTRATIONS. 

10 The Center for Medicare and Medicaid Innovation 

11 under section 1115A of the Social Security Act (42 U.S.C. 

12 1315a) is authorized to include the individuals enrolled 

13 under title XVIII of the Social Security Act pursuant to 

14 section 1899C of such Act, as added by section 3, into 

15 existing and future demonstrations conducted by such 

16 Center. 

Æ 


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