II 

115TH CONGRESS 

2D SESSION S. 2708 

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

and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

APRIL 18, 2018 

Mr. MERKLEY (for himself, Mr. MURPHY, Ms. HARRIS, Mr. BOOKER, Ms. 

BALDWIN, Mrs. GILLIBRAND, Mr. SCHATZ, Mrs. SHAHEEN, Mr. HEINRICH, Mr. BLUMENTHAL, and Mr. UDALL) 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 The Social Security Act is amended by adding at the 

7 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 State law that would prohibit such 

16 a plan from offering such coverage shall apply 

17 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, includ15 ing for such plans that are offered in the large 

16 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 02:28 Apr 27, 2018 Jkt 079200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S2708.IS S2708

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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 Choose 

12 Medicare Act shall be a participating provider 

13 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 ‘‘(f) ENCOURAGING USE OF ALTERNATIVE PAYMENT

20 MODELS.—The Secretary shall, as applicable, utilize alter21 native payment models, including those described in sec22 tion 1833(z)(3)(C), as added by section 101(e)(2) of the 

23 Medicare Access and CHIP Reauthorization Act of 2015 

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

25 services (including prescription drugs) furnished under 


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1 Medicare part E plans. The payment rates under such al2 ternative payment models shall comply with the require3 ment for negotiated rates under subsection (e)(2). 

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

5 apply the provisions of section 1860D–11(i) to prescrip6 tion drugs under Medicare part E plans in the same man7 ner as such provisions apply with respect to applicable cov8 ered part D drugs under such section. 

9 ‘‘(h) APPROPRIATIONS.— 

10 ‘‘(1) START UP FUNDING.—For purposes of es11 tablishing the Medicare part E plans, there is appro12 priated to the Secretary, out of any funds in the 

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

14 for fiscal year 2019. 

15 ‘‘(2) INITIAL RESERVES.—There is appro16 priated to the Secretary, out of any funds in the 

17 Treasury not otherwise obligated, such sums as may 

18 be necessary, based on projected enrollment in the 

19 Medicare part E plans in the first plan year in 

20 which such plans are offered, to provide reserves for 

21 the purpose of paying claims filed during the initial 

22 90-day period of such plan year. 

23 ‘‘(3) CLARIFICATION.—Any provision of law re24 stricting the use of Federal funds with respect to 


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1 any reproductive health service shall not apply to 

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

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

4 any Medicare part E plan, the Secretary shall be consid5 ered a health insurance issuer, within the meaning of sec6 tion 2791(b) of the Public Health Service Act.’’. 

7 SEC. 3. NOTICE AND NAVIGATOR REFERRAL FOR EMPLOY8 EES UNDER THE FAIR LABOR STANDARDS 

9 ACT OF 1938. 

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

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

12 (1) in the heading, by striking ‘‘TO’’ and insert13 ing ‘‘AND NAVIGATOR REFERRAL FOR’’; 

14 (2) by redesignating subsection (b) as sub15 section (c); 

16 (3) by inserting after subsection (a) the fol17 lowing: 

18 ‘‘(b) NAVIGATOR REFERRAL.— 

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

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

21 defined in section 4980H of the Internal Revenue 

22 Code of 1986) to— 

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

24 under section 1311(i) of the Patient Protection 

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


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1 for the Exchange operating in the State of the 

2 employer; or 

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

4 State of the employer does not have an entity 

5 serving as such a navigator, another entity that 

6 shall carry out equivalent activities as such a 

7 navigator. 

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

9 paragraph (1) shall occur— 

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

11 employee; or 

12 ‘‘(B) on the effective date described in sub13 section (c)(2) with respect to an employee who 

14 is currently employed by the employer on such 

15 date. 

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

17 this paragraph is any employer that— 

18 ‘‘(A) does not provide an eligible employer19 sponsored plan as defined in section 

20 5000A(f)(2) of the Internal Revenue Code of 

21 1986; or 

22 ‘‘(B) provides such an eligible employer23 sponsored plan, but the plan is determined 

24 under section 36B(c)(2)(C) of such Code— 


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1 ‘‘(i) to be unaffordable to the em2 ployee; or 

3 ‘‘(ii) to not provide the required min4 imum actuarial value.’’; and 

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

6 (A) in the heading, by striking ‘‘EFFEC7 TIVE DATE’’ and inserting ‘‘EFFECTIVE

8 DATES’’; 

9 (B) by striking ‘‘Subsection (a)’’ and in10 serting the following: 

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

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

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

14 shall take effect with respect to employers in a State 

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

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

17 (b) STUDY.—Not later than January 1, 2023, the 

18 Comptroller General of the United States shall conduct 

19 a study on the impact of the requirements under section 

20 18B of the Fair Labor Standards Act of 1938 (29 U.S.C. 

21 218b), including the amendments made by subsection (a), 

22 on the rate of individuals without minimum essential cov23 erage as defined in section 5000A of the Internal Revenue 

24 Code of 1986 in the United States and in each State. 


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1 (c) FUNDING FOR NAVIGATOR PROGRAM.—Section 

2 1311(i)(6) of the Patient Protection and Affordable Care 

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

4 (1) by striking ‘‘Grants’’ and inserting the fol5 lowing: 

6 ‘‘(A) IN GENERAL.—Grants’’; and 

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

8 ‘‘(B) AUTHORIZATION OF APPROPRIA9 TIONS.—There is authorized to be appropriated 

10 such sums as may be necessary to address ca11 pacity limitations of entities serving as naviga12 tors through a grant under this subsection.’’. 

13 SEC. 4. PROTECTING AGAINST HIGH OUT-OF-POCKET EX14 PENDITURES FOR MEDICARE FEE-FOR-SERV15 ICE BENEFITS. 

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

17 1395 et seq.) is amended by adding at the end the fol18 lowing new section: 

19 ‘‘PROTECTION AGAINST HIGH OUT-OF-POCKET

20 EXPENDITURES

21 ‘‘SEC. 1899D. (a) IN GENERAL.—Notwithstanding 

22 any other provision of this title, in the case of an indi23 vidual entitled to, or enrolled for, benefits under part A 

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

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

26 2020) equals or exceeds the annual out-of-pocket limit 


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

2 be responsible for additional out-of-pocket cost-sharing in3 curred during that year. 

4 ‘‘(b) ANNUAL OUT-OF-POCKET LIMIT.— 

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

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

7 ‘‘(A) for 2020, $6,700; or 

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

9 specified in this subsection for the preceding 

10 year increased or decreased by the percentage 

11 change in the medical care component of the 

12 Consumer Price Index for All Urban Con13 sumers for the 12-month period ending with 

14 June of such preceding year. 

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

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

17 amount shall be rounded to the nearest multiple of 

18 $5. 

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

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

21 and (3), in this section, the term ‘out-of-pocket cost22 sharing’ means, with respect to an individual, the 

23 amount of the expenses incurred by the individual 

24 that are attributable to— 


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1 ‘‘(A) deductibles, coinsurance, and copay2 ments applicable under part A or B; or 

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

4 have otherwise been covered under part A or B 

5 but for the exhaustion of those benefits. 

6 ‘‘(2) CERTAIN COSTS NOT INCLUDED.— 

7 ‘‘(A) NON-COVERED ITEMS AND SERV8 ICES.—Expenses incurred for items and serv9 ices which are not covered under part A or B 

10 shall not be considered incurred expenses for 

11 purposes of determining out-of-pocket cost12 sharing under paragraph (1). 

13 ‘‘(B) ITEMS AND SERVICES NOT FUR14 NISHED ON AN ASSIGNMENT-RELATED BASIS.— 

15 If an item or service is furnished to an indi16 vidual under this title and is not furnished on 

17 an assignment-related basis, any additional ex18 penses the individual incurs above the amount 

19 the individual would have incurred if the item 

20 or service was furnished on an assignment-re21 lated basis shall not be considered incurred ex22 penses for purposes of determining out-of-pock23 et cost-sharing under paragraph (1). 

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

25 paragraph (1), the Secretary shall consider expenses 


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1 to be incurred by the individual without regard to 

2 whether the individual or another person, including 

3 a State program, an employer, a medicare supple4 mental policy, or other third-party coverage, has 

5 paid for such expenses. 

6 ‘‘(d) ANNOUNCEMENT OF THE ANNUAL OUT-OF7 POCKET LIMIT.—The Secretary shall (beginning in 2019) 

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

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

10 this section that will be applicable for the succeeding 

11 year.’’. 

12 SEC. 5. NEGOTIATING FAIR PRICES FOR MEDICARE PRE13 SCRIPTION DRUGS. 

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

15 Security Act (42 U.S.C. 1395w–111) is amended by strik16 ing subsection (i) (relating to noninterference) and by in17 serting the following: 

18 ‘‘(i) NEGOTIATING FAIR PRICES WITH DRUG MANU19 FACTURERS.— 

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

21 provision of law, in furtherance of the goals of pro22 viding quality care and containing costs under this 

23 part, the Secretary shall, with respect to applicable 

24 covered part D drugs, and may, with respect to 

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1 gotiation technique or techniques that the Secretary 

2 determines will maximize savings and value to the 

3 government for prescription drug plans and MA–PD 

4 plans and for plan enrollees (in a manner that may 

5 be similar to Federal entities and that may include, 

6 but is not limited to, formularies, reference pricing, 

7 discounts, rebates, other price concessions, and cov8 erage determinations), with drug manufacturers the 

9 prices that may be charged to PDP sponsors and 

10 MA organizations for such drugs for part D eligible 

11 individuals who are enrolled in a prescription drug 

12 plan or in an MA–PD plan. In conducting such ne13 gotiations, the Secretary shall consider the drug’s 

14 current price, initial launch price, prevalence of dis15 ease and usage, and approved indications, the num16 ber of similarly effective alternative treatments for 

17 each approved use of the drug, the budgetary impact 

18 of providing coverage under this part for such drug 

19 for all individuals who would likely benefit from the 

20 drug, evidence on the drug’s effectiveness and safety 

21 compared to similar drugs, and the quality and 

22 quantity of clinical data and rigor of the applicable 

23 process of approval of a drug under section 505 of 

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1 logical product under section 351 of the Public 

2 Health Service Act. 

3 ‘‘(2) USE OF LOWER OF VA OR BIG FOUR PRICE

4 IF NEGOTIATIONS FAIL.—If, after attempting to ne5 gotiate for a price with respect to a covered part D 

6 drug under paragraph (1) for a period of 1 year, the 

7 Secretary is not successful in obtaining an appro8 priate price for the drug (as determined by the Sec9 retary), the Secretary shall establish the price that 

10 may be charged to PDP sponsors and MA organiza11 tions for such drug for part D eligible individuals 

12 who are enrolled in a prescription drug plan or in 

13 an MA–PD plan at an amount equal to the lesser 

14 of— 

15 ‘‘(A) the price paid by the Secretary of 

16 Veterans Affairs to procure the drug under the 

17 laws administered by the Secretary of Veterans 

18 Affairs; or 

19 ‘‘(B) the price paid to procure the drug 

20 under section 8126 of title 38, United States 

21 Code. 

22 ‘‘(3) APPLICABLE COVERED PART D DRUG DE23 FINED.—For purposes of this subsection, the term 

24 ‘applicable covered part D drug’ means a covered 

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1 propriate for negotiation under paragraph (1) based 

2 on one or more of the following factors as applied 

3 to such drug: 

4 ‘‘(A) Spending on a per beneficiary basis. 

5 ‘‘(B) The proportion of total spending 

6 under this title. 

7 ‘‘(C) Unit price increases over the pre8 ceding 5 years. 

9 ‘‘(D) Initial launch price. 

10 ‘‘(E) Availability of less expensive, simi11 larly effective alternative treatments. 

12 ‘‘(F) Status of the drug as a follow-on to 

13 previously approved drugs. 

14 ‘‘(G) Any other criteria determined by the 

15 Secretary. 

16 ‘‘(4) PDP SPONSORS AND MA ORGANIZATION

17 MAY NEGOTIATE LOWER PRICES.—Nothing in this 

18 subsection shall be construed as preventing the spon19 sor of a prescription drug plan, or an organization 

20 offering an MA–PD plan, from obtaining a discount 

21 or reduction of the price for a covered part D drug 

22 below the price negotiated under paragraph (1) or 

23 the price established under paragraph (2). 

24 ‘‘(5) NO EFFECT ON EXISTING APPEALS PROC25 ESS.—Nothing in this subsection shall be construed 


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1 to affect the appeals procedures under subsections 

2 (g) and (h) of section 1860D–4.’’. 

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

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

5 of this Act and shall first apply to negotiations and prices 

6 for plan years beginning on January 1, 2019. 

7 SEC. 6. ENHANCEMENT OF PREMIUM ASSISTANCE CREDIT. 

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

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

10 36B(b)(2)(B) of the Internal Revenue Code of 1986 

11 is amended by striking ‘‘applicable second lowest 

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

13 lowest cost gold plan’’. 

14 (2) CONFORMING AMENDMENT RELATED TO

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

16 such Code is amended by striking ‘‘second lowest 

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

18 gold plan’’. 

19 (3) OTHER CONFORMING AMENDMENTS.—Sub20 paragraphs (B) and (C) of section 36B(b)(3) of such 

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

22 each place it appears in the text and the heading 

23 and inserting ‘‘gold plan’’. 


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1 (b) EXPANSION OF ELIGIBILITY FOR REFUNDABLE

2 CREDITS FOR COVERAGE UNDER QUALIFIED HEALTH

3 PLANS.— 

4 (1) IN GENERAL.—Section 36B(c)(1)(A) of the 

5 Internal Revenue Code of 1986 is amended by strik6 ing ‘‘400 percent’’ and inserting ‘‘600 percent’’. 

7 (2) CONFORMING AMENDMENTS RELATING TO

8 RECAPTURE OF EXCESS ADVANCED PAYMENTS.— 

9 Clause (i) of section 36B(f)(2)(B) of such Code is 

10 amended— 

11 (A) by striking ‘‘400 percent’’ and insert12 ing ‘‘600 percent’’; and 

13 (B) by striking ‘‘400%’’ in the table there14 in and inserting ‘‘600%’’. 

15 (c) ELIMINATION OF FAILSAFE.—Section 

16 36B(b)(3)(A)(ii) of the Internal Revenue Code of 1986 is 

17 amended by striking subclause (III). 

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

19 this section shall apply to taxable years beginning after 

20 December 31, 2018. 

21 SEC. 7. ENHANCEMENTS FOR REDUCED COST SHARING. 

22 (a) DEFINITION OF ELIGIBLE INDIVIDUAL.—Section 

23 1402(b)(1) of the Patient Protection and Affordable Care 

24 Act (42 U.S.C. 1807(b)(1)) is amended by striking ‘‘silver 

25 level’’ and inserting ‘‘gold level’’. 


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1 (b) MODIFICATION OF AMOUNT.— 

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

3 Patient Protection and Affordable Care Act is 

4 amended to read as follows: 

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

6 shall establish procedures under which the issuer of 

7 a qualified health plan to which this section applies 

8 shall further reduce cost-sharing under the plan in 

9 a manner sufficient to— 

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

11 whose household income is not less than 100 

12 percent but not more than 133 percent of the 

13 poverty line for a family of the size involved, in14 crease the plan’s share of the total allowed 

15 costs of benefits provided under the plan to 94 

16 percent of such costs; 

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

18 whose household income is more than 133 per19 cent but not more than 150 percent of the pov20 erty line for a family of the size involved, in21 crease the plan’s share of the total allowed 

22 costs of benefits provided under the plan to 92 

23 percent of such costs; 

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

25 whose household income is more than 150 perVerDate Sep 11 2014 02:28 Apr 27, 2018 Jkt 079200 PO 00000 Frm 00021 Fmt 6652 Sfmt 6201 E:\BILLS\S2708.IS S2708

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1 cent but not more than 200 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 90 

5 percent of such costs; 

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

7 whose household income is more than 200 per8 cent but not more than 300 percent of the pov9 erty line for a family of the size involved, in10 crease the plan’s share of the total allowed 

11 costs of benefits provided under the plan to 85 

12 percent of such costs; and 

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

14 whose household income is more than 300 per15 cent but not more than 400 percent of the pov16 erty line for a family of the size involved, in17 crease the plan’s share of the total allowed 

18 costs of benefits provided under the plan to 80 

19 percent of such costs.’’. 

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

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

22 read as follows: 

23 ‘‘(i) IN GENERAL.—The Secretary 

24 shall ensure the reduction under this para25 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, 2018. 

21 SEC. 8. REINSURANCE PROGRAM. 

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 PROGRAM FOR INDIVIDUAL 

2 MARKET IN EACH STATE. 

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

4 with the National Association of Insurance Commis5 sioners, shall establish a program to enable each State to 

6 carry out a reinsurance program consistent with the provi7 sions described in section 1341 for any plan year begin8 ning in the 3-year period beginning January 1, 2019. 

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

10 of any money in the Treasury not otherwise appropriated, 

11 $10,000,000,000 for the period of fiscal years 2019 

12 through 2021 for purposes of establishing and admin13 istering the program established under this section. Such 

14 amount shall remain available until expended.’’. 

15 SEC. 9. EXPANDING RATING RULES TO LARGE GROUP MAR16 KET. 

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

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

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

20 (2) by striking paragraph (5). 

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

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

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

24 any plan year thereafter. 

25 SEC. 10. SENSE OF CONGRESS. 

26 It is the sense of the Congress that— 


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1 (1) the Federal Government, acting in its ca2 pacity as an insurer, employer, or health care pro3 vider, should serve as a model for the Nation to en4 sure coverage of all reproductive services; and 

5 (2) all restrictions on coverage of reproductive 

6 services in the private insurance market should end. 

Æ 


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