I 

116TH CONGRESS 

1ST SESSION H. R. 2183 

To amend the Patient Protection and Affordable Care Act to streamline 

the State innovation waiver process, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

APRIL 9, 2019 

Mr. MARSHALL 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 the Patient Protection and Affordable Care Act 

to streamline the State innovation waiver process, 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 ‘‘State Flexibility and 

5 Patient Choice Act of 2019’’. 


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1 SEC. 2. STREAMLINING THE STATE INNOVATION WAIVER 

2 PROCESS. 

3 Section 1332 of the Patient Protection and Afford4 able Care Act (42 U.S.C. 18052) is amended— 

5 (1) in subsection (a)— 

6 (A) in paragraph (1)— 

7 (i) in subparagraph (B)(ii), by insert8 ing ‘‘over both the term of the proposed 

9 waiver and the 10-year budget plan’’ after 

10 ‘‘Government’’; and 

11 (ii) in subparagraph (C), by striking 

12 ‘‘the law described in subsection (b)(2)’’ 

13 and inserting ‘‘a law or has in effect a cer14 tification described in subsection (b)(3)’’; 

15 and 

16 (B) in paragraph (3)— 

17 (i) in the first sentence— 

18 (I) by inserting ‘‘or would qualify 

19 for a lesser amount of’’ after ‘‘would 

20 not qualify for’’; 

21 (II) by inserting ‘‘, or the State 

22 would not qualify for or would qualify 

23 for a lesser payment under section 

24 1331,’’ after ‘‘subtitle E’’; 

25 (III) by inserting ‘‘, or on behalf 

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1 gram established under section 1331 

2 had such participants been enrolled in 

3 an Exchange,’’ after ‘‘this title’’; and 

4 (IV) by inserting ‘‘or for imple5 menting a basic health program estab6 lished under section 1331’’ before the 

7 period; and 

8 (ii) in the second sentence, by insert9 ing before the period the following: ‘‘, and 

10 with respect to participation in the basic 

11 health program and funds provided to such 

12 other States under section 1331’’; 

13 (2) in subsection (b)— 

14 (A) in paragraph (1)— 

15 (i) in subparagraph (B), by striking 

16 ‘‘at least as affordable’’ and inserting ‘‘of 

17 comparable affordability’’; and 

18 (ii) in subparagraph (D), by inserting 

19 ‘‘over the term of the waiver and over the 

20 10-year budget plan with respect to such 

21 waiver’’ before the period at the end; 

22 (B) by redesignating paragraph (2) as 

23 paragraph (3); 

24 (C) by inserting after paragraph (1) the 

25 following new paragraph: 


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1 ‘‘(2) BUDGETARY EFFECT.— 

2 ‘‘(A) IN GENERAL.—In determining wheth3 er a State plan submitted under subsection (a) 

4 meets the deficit neutrality requirements of 

5 paragraph (1)(D), the Secretary shall take into 

6 consideration the direct budgetary effect of the 

7 provisions of such plan on sources of Federal 

8 funding other than the funding described in 

9 subsection (a)(3).’’; and 

10 (D) in paragraph (3) (as so redesig11 nated)— 

12 (i) in the paragraph heading, by in13 serting ‘‘OR HAVE IN EFFECT A CER14 TIFICATION’’ after ‘‘LAW’’; 

15 (ii) in subparagraph (A)— 

16 (I) by striking ‘‘A law’’ and in17 serting the following: 

18 ‘‘(i) LAWS.—A law’’; and 

19 (II) by adding at the end the fol20 lowing: 

21 ‘‘(ii) CERTIFICATIONS.—A certifi22 cation described in this paragraph is a doc23 ument, signed by the Governor of the 

24 State, that certifies that such Governor 

25 has the authority under existing State law 


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1 to take action under this section, including 

2 implementation of the State plan under 

3 subsection (a)(1)(B).’’; and 

4 (iii) in subparagraph (B)— 

5 (I) in the subparagraph heading, 

6 by striking ‘‘OF OPT OUT’’; and 

7 (II) by striking ‘‘may repeal a 

8 law’’ and all that follows through the 

9 period at the end and inserting the 

10 following: ‘‘may terminate the author11 ity provided under the waiver with re12 spect to the State by—’’ 

13 ‘‘(i) repealing the law described in 

14 subparagraph (A)(i); or 

15 ‘‘(ii) terminating the certification de16 scribed in subparagraph (A)(ii), through a 

17 certification for such termination signed by 

18 the Governor of the State.’’; 

19 (3) in subsection (d)— 

20 (A) in paragraph (1), by striking ‘‘180’’ 

21 and inserting ‘‘90’’; and 

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

23 paragraph: 

24 ‘‘(3) EXPEDITED DETERMINATION.— 


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1 ‘‘(A) IN GENERAL.—With respect to any 

2 application under subsection (a)(1) submitted 

3 on or after the date of the enactment of this 

4 paragraph, the Secretary shall make a deter5 mination on such application, using the criteria 

6 for approval otherwise applicable under this sec7 tion, not later than 60 days after the receipt of 

8 such application and shall allow the public no9 tice and comment at the State and Federal lev10 els described under subsection (a)(4) to occur 

11 concurrently if such State application— 

12 ‘‘(i) is submitted in response to an ur13 gent situation, with respect to areas in the 

14 State that the Secretary determines are at 

15 risk for substantial increases in premium 

16 rates or having no health plans offered in 

17 the applicable health insurance market for 

18 the current or following plan year; or 

19 ‘‘(ii) is for a waiver that is the same 

20 or substantially similar to a waiver that 

21 the Secretary already has approved for an22 other State. 

23 ‘‘(B) APPROVAL LIMITATIONS FOR URGENT

24 SITUATIONS.— 


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1 ‘‘(i) PROVISIONAL APPROVAL.—A 

2 waiver approved under the expedited deter3 mination process under subparagraph 

4 (A)(i) may extend over a period of not 

5 longer than 3 years. 

6 ‘‘(ii) FULL APPROVAL.—Subject to 

7 the requirements for approval otherwise 

8 applicable under this section, not later 

9 than 1 year before the expiration of a pro10 visional waiver period described in clause 

11 (i) with respect to an application described 

12 in subparagraph (A)(i), the Secretary shall 

13 make a determination on whether to ex14 tend the term of such waiver for longer 

15 than the period described in clause (i), for 

16 a total waiver term not to exceed 6 years. 

17 The Secretary may request additional in18 formation as the Secretary determines ap19 propriate to make such determination. 

20 ‘‘(C) GAO STUDY.—Not later than 5 years 

21 after the date of enactment of the State Flexi22 bility and Patient Choice Act of 2019, the 

23 Comptroller General of the United States shall 

24 conduct a review of all waivers approved pursu25 ant to an application under subparagraph 


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1 (A)(ii) to evaluate whether such waivers met 

2 the requirements of subsection (b)(1) and 

3 whether the applications should have qualified 

4 for such an expedited determination.’’; 

5 (4) in subsection (e), by inserting ‘‘(or, in the 

6 case of an application under subsection (a)(1) sub7 mitted on or after the date of the enactment of the 

8 State Flexibility and Patient Choice Act of 2019, 6 

9 years)’’ after ‘‘5 years’’; and 

10 (5) by adding at the end the following new sub11 section: 

12 ‘‘(f) ADDITIONAL PROVISIONS.—In carrying out this 

13 section, the Secretary shall— 

14 ‘‘(1) issue guidance, not later than 30 days 

15 after the date of the enactment of this subsection, 

16 that includes initial examples of model State plans 

17 that may meet the requirements for approval under 

18 this section; and 

19 ‘‘(2) periodically review the guidance issued 

20 under paragraph (1) and, when appropriate, issue 

21 additional examples of model State plans that may 

22 meet the requirements for approval under this sec23 tion, which may include— 

24 ‘‘(A) model plans establishing reinsurance 

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1 poses of covering the cost of high-risk individ2 uals; 

3 ‘‘(B) model plans expanding insurer par4 ticipation, access to affordable health plans, 

5 network adequacy, and health plan options over 

6 the entire applicable health insurance market in 

7 the State; 

8 ‘‘(C) model plans that encourage or require 

9 health plans in a State to deploy value-based in10 surance designs which structure enrollee cost11 sharing and other health plan design elements 

12 to encourage enrollees to consume high-value 

13 clinical services; 

14 ‘‘(D) model plans allowing for significant 

15 variation in health plan benefit design; or 

16 ‘‘(E) any other model plan determined ap17 propriate by the Secretary.’’. 

Æ 


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