I 

116TH CONGRESS 

1ST SESSION H. R. 2463 

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

and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 1, 2019 

Mr. RICHMOND (for himself, Mr. HUFFMAN, and Ms. NORTON) introduced the 

following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Labor, 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 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: 


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

2 ‘‘SEC. 2201. PUBLIC HEALTH PLANS.— 

3 ‘‘(a) ESTABLISHMENT.—The Secretary shall estab4 lish public health plans (to be known as ‘Medicare part 

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

6 group market, and large group market. 

7 ‘‘(b) BENEFITS.— 

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

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

10 individual market, small group market, or large 

11 group market, shall be a qualified health plan within 

12 the meaning of section 1301(a) of the Patient Pro13 tection and Affordable Care Act (42 U.S.C. 

14 18021(a)) that— 

15 ‘‘(A) meets all requirements applicable to 

16 qualified health plans under subtitle D of title 

17 I of the Patient Protection and Affordable Care 

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

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

20 such Act) and title XXVII of the Public Health 

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

22 ‘‘(B) provides coverage of— 

23 ‘‘(i) the essential health benefits de24 scribed in section 1302(b) of the Patient 


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1 Protection and Affordable Care Act (42 

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

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

4 benefits are available under title XVIII; 

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

6 in section 1302(d)(1)(C) of the Patient Protec7 tion and Affordable Care Act (42 U.S.C. 

8 18022(d)(1)(C)); and 

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

10 other reproductive services. 

11 ‘‘(2) PREEMPTION.—Notwithstanding section 

12 1303(a)(1) of the Patient Protection and Affordable 

13 Care Act (42 U.S.C. 18023(a)(1))— 

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

15 part E plan from offering the coverage de16 scribed in paragraph (1)(D); and 

17 ‘‘(B) no State law that would prohibit such 

18 a plan from offering such coverage shall apply 

19 to such plan. 

20 ‘‘(c) ELIGIBILITY; ENROLLMENT.— 

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

22 Medicare part E plans offered in the individual and 

23 small group markets shall be offered through the 

24 Federal and State Exchanges, including the Small 


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1 Business Health Options Program Exchanges (com2 monly referred to as the ‘SHOP Exchanges’). 

3 ‘‘(2) ELIGIBILITY.— 

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

5 a resident of the United States, as determined 

6 by the Secretary under subparagraph (C), and 

7 who is not an individual described in subpara8 graph (B), is eligible to enroll in a Medicare 

9 part E plan. 

10 ‘‘(B) EXCLUSIONS.—An individual de11 scribed in this subparagraph is any individual 

12 who is— 

13 ‘‘(i) entitled to, or enrolled for, bene14 fits under title XVIII; 

15 ‘‘(ii) eligible for medical assistance 

16 under a State plan under title XIX; or 

17 ‘‘(iii) enrolled for child health assist18 ance or pregnancy-related assistance under 

19 a State plan under title XXI. 

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

21 promulgate a rule for determining residency for 

22 purposes of subparagraph (A). 

23 ‘‘(3) EMPLOYER-SPONSORED PLANS.— 

24 ‘‘(A) EMPLOYER ENROLLMENT.—Effective 

25 with respect to the first plan year that begins 


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1 1 year after the date of enactment of the 

2 Choose Medicare Act and each plan year there3 after, the Secretary shall provide options for 

4 Medicare part E plans in the small group mar5 ket and large group market that are voluntary, 

6 and available to all employers. 

7 ‘‘(B) GROUP HEALTH PLANS.—The Sec8 retary, acting through the Administrator for the 

9 Centers for Medicare & Medicaid Services, at 

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

11 third party administrator of a group health 

12 plan that is a Medicare part E plan offered by 

13 such sponsor. 

14 ‘‘(C) PORTABILITY FOR EMPLOYER-SPON15 SORED PLANS.—The Secretary shall develop a 

16 process for allowing individuals enrolled in a 

17 Medicare part E plan offered in the small group 

18 market or large group market to maintain 

19 health insurance coverage through a Medicare 

20 part E plan if the individual subsequently loses 

21 eligibility for enrollment in such a plan based 

22 on termination of the employment relationship. 

23 The ability to maintain such coverage shall 

24 exist regardless of whether the individual has 

25 the option to enroll in other health insurance 


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1 coverage, including coverage offered in the indi2 vidual market or through a subsequent em3 ployer. 

4 ‘‘(d) PREMIUMS.—The Secretary shall establish pre5 mium rates for the Medicare part E plans that— 

6 ‘‘(1) are adjusted based on— 

7 ‘‘(A) whether the plan is offered in the in8 dividual market, small group market, or large 

9 group market; and 

10 ‘‘(B) the applicable rating area; 

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

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

13 by such plans; and 

14 ‘‘(B) administrative costs related to oper15 ating the plans; and 

16 ‘‘(3) comply with the requirements under sec17 tion 2701 of the Public Health Service Act, includ18 ing for such plans that are offered in the large 

19 group market. 

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

21 ‘‘(1) IN GENERAL.—The Secretary shall estab22 lish a rate schedule for reimbursing types of health 

23 care providers furnishing items and services under 

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1 sistent with the negotiations described in paragraph 

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

3 ‘‘(2) MANNER OF NEGOTIATION.—The Sec4 retary shall negotiate the rates described in para5 graph (1) in a manner that results in payment rates 

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

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

8 than the average rates paid by other health insur9 ance issuers offering health insurance coverage 

10 through an Exchange. 

11 ‘‘(3) PARTICIPATING PROVIDERS.— 

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

13 that is a participating provider of services or 

14 supplier under the Medicare program under 

15 title XVIII on the date of enactment of Choose 

16 Medicare Act shall be a participating provider 

17 for Medicare part E plans. 

18 ‘‘(B) ADDITIONAL PROVIDERS.—The Sec19 retary shall establish a process to allow health 

20 care providers not described in subparagraph 

21 (A) to become participating providers for Medi22 care part E plans. 

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

24 limitations on balance billing pursuant to the provi25 sions of section 1866(a)(1)(A) of the Social Security 


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1 Act (42 U.S.C. 1395cc(a)(1)(A)) shall apply to par2 ticipating providers for Medicare part E plans in the 

3 same manner as such provisions apply to partici4 pating providers under the Medicare program. 

5 ‘‘(f) ENCOURAGING USE OF ALTERNATIVE PAYMENT

6 MODELS.—The Secretary shall, as applicable, utilize alter7 native payment models, including those described in sec8 tion 1833(z)(3)(C), as added by section 101(e)(2) of the 

9 Medicare Access and CHIP Reauthorization Act of 2015 

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

11 services (including prescription drugs) furnished under 

12 Medicare part E plans. The payment rates under such al13 ternative payment models shall comply with the require14 ment for negotiated rates under subsection (e)(2). 

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

16 apply the provisions of section 1860D–11(i) to prescrip17 tion drugs under Medicare part E plans in the same man18 ner as such provisions apply with respect to applicable cov19 ered part D drugs under such section. 

20 ‘‘(h) APPROPRIATIONS.— 

21 ‘‘(1) START UP FUNDING.—For purposes of es22 tablishing the Medicare part E plans, there is appro23 priated to the Secretary, out of any funds in the 

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

25 for fiscal year 2020. 


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1 ‘‘(2) INITIAL RESERVES.—There is appro2 priated to the Secretary, out of any funds in the 

3 Treasury not otherwise obligated, such sums as may 

4 be necessary, based on projected enrollment in the 

5 Medicare part E plans in the first plan year in 

6 which such plans are offered, to provide reserves for 

7 the purpose of paying claims filed during the initial 

8 90-day period of such plan year. 

9 ‘‘(3) CLARIFICATION.—Any provision of law re10 stricting the use of Federal funds with respect to 

11 any reproductive health service shall not apply to 

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

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

14 any Medicare part E plan, the Secretary shall be consid15 ered a health insurance issuer, within the meaning of sec16 tion 2791(b) of the Public Health Service Act.’’. 

17 SEC. 3. NOTICE AND NAVIGATOR REFERRAL FOR EMPLOY18 EES UNDER THE FAIR LABOR STANDARDS 

19 ACT OF 1938. 

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

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

22 (1) in the heading, by striking ‘‘TO’’ and insert23 ing ‘‘AND NAVIGATOR REFERRAL FOR’’; 

24 (2) by redesignating subsection (b) as sub25 section (c); 


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1 (3) by inserting after subsection (a) the fol2 lowing: 

3 ‘‘(b) NAVIGATOR REFERRAL.— 

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

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

6 defined in section 4980H of the Internal Revenue 

7 Code of 1986) to— 

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

9 under section 1311(i) of the Patient Protection 

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

11 for the Exchange operating in the State of the 

12 employer; or 

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

14 State of the employer does not have an entity 

15 serving as such a navigator, another entity that 

16 shall carry out equivalent activities as such a 

17 navigator. 

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

19 paragraph (1) shall occur— 

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

21 employee; or 

22 ‘‘(B) on the effective date described in sub23 section (c)(2) with respect to an employee who 

24 is currently employed by the employer on such 

25 date. 


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

2 this paragraph is any employer that— 

3 ‘‘(A) does not provide an eligible employer4 sponsored plan as defined in section 

5 5000A(f)(2) of the Internal Revenue Code of 

6 1986; or 

7 ‘‘(B) provides such an eligible employer8 sponsored plan, but the plan is determined 

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

10 ‘‘(i) to be unaffordable to the em11 ployee; or 

12 ‘‘(ii) to not provide the required min13 imum actuarial value.’’; and 

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

15 (A) in the heading, by striking ‘‘EFFEC16 TIVE DATE’’ and inserting ‘‘EFFECTIVE

17 DATES’’; 

18 (B) by striking ‘‘Subsection (a)’’ and in19 serting the following: 

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

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

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

23 shall take effect with respect to employers in a State 

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

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


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1 (b) STUDY.—Not later than January 1, 2024, the 

2 Comptroller General of the United States shall conduct 

3 a study on the impact of the requirements under section 

4 18B of the Fair Labor Standards Act of 1938 (29 U.S.C. 

5 218b), including the amendments made by subsection (a), 

6 on the rate of individuals without minimum essential cov7 erage as defined in section 5000A of the Internal Revenue 

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

9 (c) FUNDING FOR NAVIGATOR PROGRAM.—Section 

10 1311(i)(6) of the Patient Protection and Affordable Care 

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

12 (1) by striking ‘‘Grants’’ and inserting the fol13 lowing: 

14 ‘‘(A) IN GENERAL.—Grants’’; and 

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

16 ‘‘(B) AUTHORIZATION OF APPROPRIA17 TIONS.—There is authorized to be appropriated 

18 such sums as may be necessary to address ca19 pacity limitations of entities serving as naviga20 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 2021) 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 2021, $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 2020) 

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. NEGOTIATING FAIR PRICES FOR MEDICARE PRE2 SCRIPTION DRUGS. 

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

4 Security Act (42 U.S.C. 1395w–111) is amended by strik5 ing subsection (i) (relating to noninterference) and by in6 serting the following: 

7 ‘‘(i) NEGOTIATING FAIR PRICES WITH DRUG MANU8 FACTURERS.— 

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

10 provision of law, in furtherance of the goals of pro11 viding quality care and containing costs under this 

12 part, the Secretary shall, with respect to applicable 

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

14 other covered part D drugs, negotiate, using the ne15 gotiation technique or techniques that the Secretary 

16 determines will maximize savings and value to the 

17 government for prescription drug plans and MA–PD 

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

19 be similar to Federal entities and that may include, 

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

21 discounts, rebates, other price concessions, and cov22 erage determinations), with drug manufacturers the 

23 prices that may be charged to PDP sponsors and 

24 MA organizations for such drugs for part D eligible 

25 individuals who are enrolled in a prescription drug 

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1 gotiations, the Secretary shall consider the drug’s 

2 current price, initial launch price, prevalence of dis3 ease and usage, and approved indications, the num4 ber of similarly effective alternative treatments for 

5 each approved use of the drug, the budgetary impact 

6 of providing coverage under this part for such drug 

7 for all individuals who would likely benefit from the 

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

9 compared to similar drugs, and the quality and 

10 quantity of clinical data and rigor of the applicable 

11 process of approval of a drug under section 505 of 

12 the Federal Food, Drug, and Cosmetic Act or a bio13 logical product under section 351 of the Public 

14 Health Service Act. 

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

16 IF NEGOTIATIONS FAIL.—If, after attempting to ne17 gotiate for a price with respect to a covered part D 

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

19 Secretary is not successful in obtaining an appro20 priate price for the drug (as determined by the Sec21 retary), the Secretary shall establish the price that 

22 may be charged to PDP sponsors and MA organiza23 tions for such drug for part D eligible individuals 

24 who are enrolled in a prescription drug plan or in 


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

2 of— 

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

4 Veterans Affairs to procure the drug under the 

5 laws administered by the Secretary of Veterans 

6 Affairs; or 

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

8 under section 8126 of title 38, United States 

9 Code. 

10 ‘‘(3) APPLICABLE COVERED PART D DRUG DE11 FINED.—For purposes of this subsection, the term 

12 ‘applicable covered part D drug’ means a covered 

13 part D drug that the Secretary determines to be ap14 propriate for negotiation under paragraph (1) based 

15 on one or more of the following factors as applied 

16 to such drug: 

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

18 ‘‘(B) The proportion of total spending 

19 under this title. 

20 ‘‘(C) Unit price increases over the pre21 ceding 5 years. 

22 ‘‘(D) Initial launch price. 

23 ‘‘(E) Availability of less expensive, simi24 larly effective alternative treatments. 


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

2 previously approved drugs. 

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

4 Secretary. 

5 ‘‘(4) PDP SPONSORS AND MA ORGANIZATION

6 MAY NEGOTIATE LOWER PRICES.—Nothing in this 

7 subsection shall be construed as preventing the spon8 sor of a prescription drug plan, or an organization 

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

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

11 below the price negotiated under paragraph (1) or 

12 the price established under paragraph (2). 

13 ‘‘(5) NO EFFECT ON EXISTING APPEALS PROC14 ESS.—Nothing in this subsection shall be construed 

15 to affect the appeals procedures under subsections 

16 (g) and (h) of section 1860D–4.’’. 

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

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

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

20 for plan years beginning on January 1, 2020. 

21 SEC. 6. ENHANCEMENT OF PREMIUM ASSISTANCE CREDIT. 

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

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

24 36B(b)(2)(B) of the Internal Revenue Code of 1986 

25 is amended by striking ‘‘applicable second lowest 


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

2 lowest cost gold plan’’. 

3 (2) CONFORMING AMENDMENT RELATED TO

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

5 such Code is amended by striking ‘‘second lowest 

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

7 gold plan’’. 

8 (3) OTHER CONFORMING AMENDMENTS.—Sub9 paragraphs (B) and (C) of section 36B(b)(3) of such 

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

11 each place it appears in the text and the heading 

12 and inserting ‘‘gold plan’’. 

13 (b) EXPANSION OF ELIGIBILITY FOR REFUNDABLE

14 CREDITS FOR COVERAGE UNDER QUALIFIED HEALTH

15 PLANS.— 

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

17 Internal Revenue Code of 1986 is amended by strik18 ing ‘‘400 percent’’ and inserting ‘‘600 percent’’. 

19 (2) CONFORMING AMENDMENT.—The last line 

20 of the table contained in section 36B(b)(3)(A)(i) of 

21 such Code is amended by striking ‘‘400%’’ and in22 serting ‘‘600%’’. 

23 (3) CONFORMING AMENDMENTS RELATING TO

24 RECAPTURE OF EXCESS ADVANCED PAYMENTS.— 


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

2 amended— 

3 (A) by striking ‘‘400 percent’’ and insert4 ing ‘‘600 percent’’; and 

5 (B) by striking ‘‘400%’’ in the table there6 in and inserting ‘‘600%’’. 

7 (c) ELIMINATION OF FAILSAFE.—Section 

8 36B(b)(3)(A)(ii) of the Internal Revenue Code of 1986 is 

9 amended by striking subclause (III). 

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

11 this section shall apply to taxable years beginning after 

12 December 31, 2018. 

13 SEC. 7. ENHANCEMENTS FOR REDUCED COST SHARING. 

14 (a) DEFINITION OF ELIGIBLE INDIVIDUAL.—Section 

15 1402(b)(1) of the Patient Protection and Affordable Care 

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

17 level’’ and inserting ‘‘gold level’’. 

18 (b) MODIFICATION OF AMOUNT.— 

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

20 Patient Protection and Affordable Care Act is 

21 amended to read as follows: 

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

23 shall establish procedures under which the issuer of 

24 a qualified health plan to which this section applies 


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1 shall further reduce cost-sharing under the plan in 

2 a manner sufficient to— 

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

4 whose household income is not less than 100 

5 percent but not more than 133 percent of the 

6 poverty line for a family of the size involved, in7 crease the plan’s share of the total allowed 

8 costs of benefits provided under the plan to 94 

9 percent of such costs; 

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

11 whose household income is more than 133 per12 cent but not more than 150 percent of the pov13 erty 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 92 

16 percent of such costs; 

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

18 whose household income is more than 150 per19 cent but not more than 200 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 90 

23 percent of such costs; 

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

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1 cent but not more than 300 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; and 

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

7 whose household income is more than 300 per8 cent but not more than 400 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 80 

12 percent of such costs.’’. 

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

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

15 read as follows: 

16 ‘‘(i) IN GENERAL.—The Secretary 

17 shall ensure the reduction under this para18 graph shall not result in an increase in the 

19 plan’s share of the total allowed costs of 

20 benefits provided under the plan above— 

21 ‘‘(I) 94 percent in the case of an 

22 eligible insured described in para23 graph (2)(A); 


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

2 eligible insured described in para3 graph (2)(B); 

4 ‘‘(III) 90 percent in the case of 

5 an eligible insured described in para6 graph (2)(C); 

7 ‘‘(IV) 85 percent in the case of 

8 an eligible insured described in para9 graph (2)(D); and 

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

11 eligible insured described in para12 graph (2)(E).’’. 

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

14 this section shall apply to plan years beginning after De15 cember 31, 2019. 

16 SEC. 8. REINSURANCE AND AFFORDABILITY FUND. 

17 Part 5 of subtitle D of title I of the Patient Protec18 tion and Affordable Care Act is amended by inserting 

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

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

21 FOR THE INDIVIDUAL MARKET IN EACH 

22 STATE. 

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

24 with the National Association of Insurance Commis25 sioners, shall establish a program to enable each State, 


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

2 January 1, 2020, to— 

3 ‘‘(1) provide reinsurance payments to health in4 surance issuers with respect to individuals enrolled 

5 under individual health insurance coverage offered 

6 by such issuers; or 

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

8 payments described in paragraph (1)) to reduce out9 of-pocket costs, such as copayments, coinsurance, 

10 premiums, and deductibles, of individuals enrolled 

11 under qualified health plans offered in the individual 

12 market through an Exchange. 

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

14 of any money in the Treasury not otherwise appropriated, 

15 $30,000,000,000 for the period of fiscal years 2020 

16 through 2022 for purposes of establishing and admin17 istering the program established under this section. Such 

18 amount shall remain available until expended.’’. 

19 SEC. 9. EXPANDING RATING RULES TO LARGE GROUP MAR20 KET. 

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

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

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

24 (2) by striking paragraph (5). 


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

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

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

4 any plan year thereafter. 

5 SEC. 10. PROTECTION OF CONSUMERS FROM EXCESSIVE, 

6 UNJUSTIFIED, OR UNFAIRLY DISCRIMINA7 TORY RATES. 

8 (a) PROTECTION FROM EXCESSIVE, UNJUSTIFIED, 

9 OR UNFAIRLY DISCRIMINATORY RATES.—The first sec10 tion 2794 of the Public Health Service Act (42 U.S.C. 

11 300gg–94), as added by section 1003 of the Patient Pro12 tection and Affordable Care Act (Public Law 111–148), 

13 is amended by adding at the end the following new sub14 section: 

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

16 OR UNFAIRLY DISCRIMINATORY RATES.— 

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

18 section shall be construed to prohibit a State from 

19 imposing requirements (including requirements re20 lating to rate review standards and procedures and 

21 information reporting) on health insurance issuers 

22 with respect to rates that are in addition to the re23 quirements of this section and are more protective of 

24 consumers than such requirements. 


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1 ‘‘(2) CONSULTATION IN RATE REVIEW PROC2 ESS.—In carrying out this section, the Secretary 

3 shall consult with the National Association of Insur4 ance Commissioners and consumer groups. 

5 ‘‘(3) DETERMINATION OF WHO CONDUCTS RE6 VIEWS FOR EACH STATE.—The Secretary shall de7 termine, after the date of enactment of this sub8 section and periodically thereafter, the following: 

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

10 State insurance commissioner or relevant State 

11 regulator shall undertake the corrective actions 

12 under paragraph (4), as a condition of the 

13 State receiving the grant in subsection (c), 

14 based on the Secretary’s determination that the 

15 State insurance commissioner or relevant State 

16 regulator is adequately undertaking and uti17 lizing such actions in that market. 

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

19 Secretary shall undertake the corrective actions 

20 under paragraph (4), in cooperation with the 

21 relevant State insurance commissioner or State 

22 regulator, based on the Secretary’s determina23 tion that the State is not adequately under24 taking and utilizing such actions in that mar25 ket. 


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1 ‘‘(4) CORRECTIVE ACTION FOR EXCESSIVE, UN2 JUSTIFIED, OR UNFAIRLY DISCRIMINATORY

3 RATES.—In accordance with the process established 

4 under this section, the Secretary or the relevant 

5 State insurance commissioner or State regulator 

6 shall take corrective actions to ensure that any ex7 cessive, unjustified, or unfairly discriminatory rates 

8 are corrected prior to implementation, or as soon as 

9 possible thereafter, through mechanisms such as— 

10 ‘‘(A) denying rates; 

11 ‘‘(B) modifying rates; or 

12 ‘‘(C) requiring rebates to consumers. 

13 ‘‘(5) NONCOMPLIANCE.—Failure to comply with 

14 any corrective action taken by the Secretary under 

15 this subsection may result in the application of civil 

16 monetary penalties and, if the Secretary determines 

17 appropriate, make the plan involved ineligible for 

18 classification as a qualified health plan.’’. 

19 (b) CLARIFICATION OF REGULATORY AUTHORITY.— 

20 Such section is further amended— 

21 (1) in subsection (a)— 

22 (A) in the subsection heading, by striking 

23 ‘‘PREMIUM’’ and inserting ‘‘RATE’’; 

24 (B) in paragraph (1), by striking ‘‘unrea25 sonable increases in premiums’’ and inserting 


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1 ‘‘potentially excessive, unjustified, or unfairly 

2 discriminatory rates, including premiums,’’; and 

3 (C) in paragraph (2)— 

4 (i) by striking ‘‘an unreasonable pre5 mium increase’’ and inserting ‘‘a poten6 tially excessive, unjustified, or unfairly dis7 criminatory rate’’; 

8 (ii) by striking ‘‘the increase’’ and in9 serting ‘‘the rate’’; and 

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

11 inserting ‘‘such rates’’; 

12 (2) in subsection (b)— 

13 (A) in the subsection heading, by striking 

14 ‘‘PREMIUM’’ and inserting ‘‘RATE’’; 

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

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

17 (C) in paragraph (1), in the paragraph 

18 heading, by striking ‘‘PREMIUM INCREASE’’ and 

19 inserting ‘‘RATE’’; and 

20 (D) in paragraph (2)— 

21 (i) in the paragraph heading, by strik22 ing ‘‘PREMIUM INCREASES’’ and inserting 

23 ‘‘RATES’’; and 

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

25 ‘‘premium’’ and inserting ‘‘rate’’; and 


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1 (3) in subsection (c)(1)— 

2 (A) in the heading, by striking ‘‘PRE3 MIUM’’ and inserting ‘‘RATE’’; 

4 (B) by inserting ‘‘that satisfy the condition 

5 under subsection (e)(3)(A)’’ after ‘‘award 

6 grants to States’’; and 

7 (C) in subparagraph (A), by striking ‘‘pre8 mium increases’’ and inserting ‘‘rates’’. 

9 (c) CONFORMING AMENDMENTS.— 

10 (1) PUBLIC HEALTH SERVICE ACT.—Title 

11 XXVII of the Public Health Service Act (42 U.S.C. 

12 300gg et seq.) is amended— 

13 (A) in section 2723 (42 U.S.C. 300gg– 

14 22)— 

15 (i) in subsection (a)— 

16 (I) in paragraph (1), by inserting 

17 ‘‘and section 2794 (relating to the 

18 reasonableness of rates with respect to 

19 health insurance coverage)’’ after 

20 ‘‘this part’’; and 

21 (II) in paragraph (2), by insert22 ing ‘‘or such section 2794’’ after ‘‘this 

23 part’’; and 

24 (ii) in subsection (b)— 


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1 (I) in paragraph (1), by inserting 

2 ‘‘and section 2794 (relating to the 

3 reasonableness of rates with respect to 

4 health insurance coverage)’’ after 

5 ‘‘this part’’; and 

6 (II) in paragraph (2)— 

7 (aa) in subparagraph (A), 

8 by inserting ‘‘or such section 

9 2794 that is’’ after ‘‘this part’’; 

10 and 

11 (bb) in subparagraph (C)(ii), 

12 by inserting ‘‘or such section 

13 2794’’ after ‘‘this part’’; and 

14 (B) in section 2761 (42 U.S.C. 300gg– 

15 61)— 

16 (i) in subsection (a)— 

17 (I) in paragraph (1), by inserting 

18 ‘‘and section 2794 (relating to the 

19 reasonableness of rates with respect to 

20 health insurance coverage)’’ after 

21 ‘‘this part’’; and 

22 (II) in paragraph (2)— 

23 (aa) by inserting ‘‘or such 

24 section 2794’’ after ‘‘set forth in 

25 this part’’; and 


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1 (bb) by inserting ‘‘and such 

2 section 2794’’ after ‘‘the require3 ments of this part’’; and 

4 (ii) in subsection (b), by inserting 

5 ‘‘and such section 2794’’ after ‘‘this part’’. 

6 (2) PATIENT PROTECTION AND AFFORDABLE

7 CARE ACT.—Section 1311(e)(2) of the Patient Pro8 tection and Affordable Care Act (42 U.S.C. 

9 18031(e)(2)) is amended by striking ‘‘unjustified 

10 premium increases’’ and inserting ‘‘unjustified 

11 rates’’. 

12 (d) APPLICABILITY TO GRANDFATHERED PLANS.— 

13 Section 1251(a)(4)(A) of the Patient Protection and Af14 fordable Care Act (42 U.S.C. 18011(a)(4)(A)) is amended 

15 by adding at the end the following: 

16 ‘‘(v) Section 2794 (relating to reason17 ableness of rates with respect to health in18 surance coverage).’’. 

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

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

21 this Act and shall be implemented with respect to health 

22 plans beginning not later than January 1, 2020. 

23 SEC. 11. SENSE OF CONGRESS. 

24 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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