II 

117TH CONGRESS 

1ST SESSION S. 352 

To amend the Patient Protection and Affordable Care Act to reduce health 

care costs and expand health care coverage to more Americans. 

IN THE SENATE OF THE UNITED STATES 

FEBRUARY 22, 2021 

Mr. WARNER introduced the following bill; which was read twice and referred 

to the Committee on Finance 

A BILL 

To amend the Patient Protection and Affordable Care Act 

to reduce health care costs and expand health care coverage to more Americans. 

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 ‘‘Health Care Improve5 ment Act of 2021’’. 

6 SEC. 2. TABLE OF CONTENTS. 

7 The table of contents for this Act is as follows: 

Sec. 1. Short title. 

Sec. 2. Table of contents. 

TITLE I—REDUCING HEALTH CARE COSTS AND PROTECTING 

PEOPLE WITH PREEXISTING CONDITIONS 


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Sec. 101. Improving affordability by expanding premium assistance for consumers. 

Sec. 102. Expanding affordability for working families to fix the family glitch. 

Sec. 103. Establishing a State Health Insurance Affordability and Innovation 

Fund. 

Sec. 104. Rescinding the short-term limited duration insurance regulation. 

Sec. 105. Revoking section 1332 guidance and rules. 

Sec. 106. Promoting consumer outreach and education. 

TITLE II—ENCOURAGING MEDICAID EXPANSION AND 

STRENGTHENING THE MEDICAID PROGRAM 

Sec. 201. Incentivizing Medicaid expansion. 

Sec. 202. Reducing the administrative FMAP for nonexpansion States. 

Sec. 203. State option to provide 12 months of postpartum Medicaid eligibility. 

Sec. 204. Supporting State Medicaid programs through economic downturns. 

Sec. 205. State flexibility to use administrative simplification policies for enrollment. 

TITLE III—ESTABLISHMENT OF A PUBLIC HEALTH CARE OPTION 

Sec. 301. Establishment of health plan. 

Sec. 302. Availability of plan. 

Sec. 303. Affordability. 

Sec. 304. Participating providers. 

Sec. 305. Provider payment rates. 

Sec. 306. No effect on Medicare benefits or Medicare trust funds. 

TITLE IV—FAIR MEDICARE PAYMENTS TO RURAL PROVIDERS 

Sec. 401. Ensuring fairness in Medicare hospital payments. 

TITLE V—COMMONSENSE COMPETITION AND ACCESS TO 

HEALTH INSURANCE 

Sec. 501. Providing small business health insurance across State lines. 

Sec. 502. Report and models. 

TITLE VI—EMPOWERING MEDICARE SENIORS TO NEGOTIATE 

PRESCRIPTION DRUG PRICES 

Sec. 601. Authority to negotiate fair prices for Medicare prescription drugs. 

TITLE VII—COMMONSENSE REPORTING FOR EMPLOYERS 

Sec. 701. Voluntary prospective reporting system. 

Sec. 702. Protection of dependent privacy. 

Sec. 703. Electronic statements. 

Sec. 704. GAO studies. 

Sec. 705. Tax compliance. 


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1 TITLE I—REDUCING HEALTH 

2 CARE COSTS AND PRO3 TECTING PEOPLE WITH PRE4 EXISTING CONDITIONS 

5 SEC. 101. IMPROVING AFFORDABILITY BY EXPANDING PRE6 MIUM ASSISTANCE FOR CONSUMERS. 

7 (a) IN GENERAL.—Section 36B(b)(3)(A) of the In8 ternal Revenue Code of 1986 is amended to read as fol9 lows: 

10 ‘‘(A) APPLICABLE PERCENTAGE.—The ap11 plicable percentage for any taxable year shall be 

12 the percentage such that the applicable percent13 age for any taxpayer whose household income is 

14 within an income tier specified in the following 

15 table shall increase, on a sliding scale in a lin16 ear manner, from the initial premium percent17 age to the final premium percentage specified in 

18 such table for such income tier: 

‘‘In the case of household 

income (expressed as 

a percent of poverty line) 

within the following income tier: 

The initial 

premium 

percentage is— 

The final 

premium 

percentage is— 

Up to 150.0 percent ................................... 0.0 0.0

150.0 percent up to 200.0 percent ............. 0.0 3.0

200.0 percent up to 250.0 percent ............. 3.0 4.0

250.0 percent up to 300.0 percent ............. 4.0 6.0

300.0 percent up to 400.0 percent ............. 6.0 8.5

400.0 percent and higher ........................... 8.5 8.5’’. 


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1 (b) CONFORMING AMENDMENT.—Section 

2 36B(c)(1)(A) of the Internal Revenue Code of 1986 is 

3 amended by striking ‘‘but does not exceed 400 percent’’. 

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

5 this section shall apply to taxable years beginning after 

6 December 31, 2021. 

7 SEC. 102. EXPANDING AFFORDABILITY FOR WORKING FAM8 ILIES TO FIX THE FAMILY GLITCH. 

9 (a) IN GENERAL.—Clause (i) of section 36B(c)(2)(C) 

10 of the Internal Revenue Code of 1986 is amended to read 

11 as follows: 

12 ‘‘(i) COVERAGE MUST BE AFFORD13 ABLE.— 

14 ‘‘(I) EMPLOYEES.—An employee 

15 shall not be treated as eligible for 

16 minimum essential coverage if such 

17 coverage consists of an eligible em18 ployer-sponsored plan (as defined in 

19 section 5000A(f)(2)) and the employ20 ee’s required contribution (within the 

21 meaning of section 5000A(e)(1)(B)) 

22 with respect to the plan exceeds 9.5 

23 percent of the employee’s household 

24 income. 


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1 ‘‘(II) FAMILY MEMBERS.—An in2 dividual who is eligible to enroll in an 

3 eligible employer-sponsored plan (as 

4 defined in section 5000A(f)(2)) by 

5 reason of a relationship the individual 

6 bears to the employee shall not be 

7 treated as eligible for minimum essen8 tial coverage by reason of such eligi9 bility to enroll if the employee’s re10 quired contribution (within the mean11 ing of section 5000A(e)(1)(B), deter12 mined by substituting ‘family’ for 

13 ‘self-only’) with respect to the plan ex14 ceeds 9.5 percent of the employee’s 

15 household income.’’. 

16 (b) CONFORMING AMENDMENTS.— 

17 (1) Clause (ii) of section 36B(c)(2)(C) of the 

18 Internal Revenue Code of 1986 is amended by strik19 ing ‘‘Except as provided in clause (iii), an employee’’ 

20 and inserting ‘‘An individual’’. 

21 (2) Clause (iii) of section 36B(c)(2)(C) of such 

22 Code is amended by striking ‘‘the last sentence of 

23 clause (i)’’ and inserting ‘‘clause (i)(II)’’. 

24 (3) Clause (iv) of section 36B(c)(2)(C) of such 

25 Code is amended by striking ‘‘the 9.5 percent under 


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1 clause (i)(II)’’ and inserting ‘‘the 9.5 percent under 

2 clauses (i)(I) and (i)(II)’’. 

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

4 this section shall apply to taxable years beginning after 

5 December 31, 2021. 

6 SEC. 103. ESTABLISHING A STATE HEALTH INSURANCE AF7 FORDABILITY AND INNOVATION FUND. 

8 Subtitle D of title I of the Patient Protection and 

9 Affordable Care Act (42 U.S.C. 18021 et seq.) is amended 

10 by adding at the end the following: 

11 ‘‘PART 6—STATE HEALTH INSURANCE 

12 AFFORDABILITY AND INNOVATION FUND 

13 ‘‘SEC. 1351. ESTABLISHMENT OF PROGRAM. 

14 ‘‘There is hereby established the ‘State Health Insur15 ance Affordability and Innovation Fund’ to be adminis16 tered by the Secretary of Health and Human Services, act17 ing through the Administrator of the Centers for Medicare 

18 & Medicaid Services (referred to in this section as the ‘Ad19 ministrator’), to provide funding, in accordance with this 

20 part, to each of the 50 States and the District of Columbia 

21 (each referred to in this section as a ‘State’) beginning 

22 on January 1, 2022, for the purposes described in section 

23 1352. 


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1 ‘‘SEC. 1352. USE OF FUNDS. 

2 ‘‘(a) IN GENERAL.—A State shall use the funds allo3 cated to the State under this part for one of the following 

4 purposes: 

5 ‘‘(1) To provide reinsurance payments to health 

6 insurance issuers with respect to individuals enrolled 

7 under individual health insurance coverage (other 

8 than through a plan described in subsection (b)) of9 fered by such issuers. 

10 ‘‘(2) To provide assistance (other than through 

11 payments described in paragraph (1)) to reduce out12 of-pocket costs, such as copayments, coinsurance, 

13 premiums, and deductibles, of individuals enrolled 

14 under qualified health plans offered on the indi15 vidual market through an Exchange. 

16 ‘‘(3) State efforts to streamline health insur17 ance enrollment procedures in order to reduce bur18 dens on consumers and facilitate greater enrollment 

19 in health insurance coverage in the individual and 

20 small group markets, including automatic enrollment 

21 and reenrollment of, or pre-populated applications 

22 for, individuals without health insurance who are eli23 gible for tax credits under section 36B of the Inter24 nal Revenue Code of 1986, with the ability to opt 

25 out of such enrollment. 


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1 ‘‘(4) State investment in technology to improve 

2 data sharing and collection for the purposes of facili3 tating greater enrollment in health insurance cov4 erage in such markets. 

5 ‘‘(5) Feasibility studies to develop a comprehen6 sive and coherent State plan for increasing enroll7 ment in the individual and small group market. 

8 ‘‘(b) EXCLUSION OF CERTAIN GRANDFATHERED AND

9 TRANSITIONAL PLANS.—For purposes of subsection (a), 

10 a plan described in this subsection is the following: 

11 ‘‘(1) A grandfathered health plan (as defined in 

12 section 1251). 

13 ‘‘(2) A plan (commonly referred to as a ‘transi14 tional plan’) continued under the letter issued by the 

15 Centers for Medicare & Medicaid Services on No16 vember 14, 2013, to the State Insurance Commis17 sioners outlining a transitional policy for coverage in 

18 the individual and small group markets to which sec19 tion 1251 does not apply, and under the extension 

20 of the transitional policy for such coverage set forth 

21 in the Insurance Standards Bulletin Series guidance 

22 issued by the Centers for Medicare & Medicaid Serv23 ices on March 5, 2014, February 29, 2016, Feb24 ruary 13, 2017, April 9, 2018, March 25, 2019, and 


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1 January 31, 2020, or under any subsequent exten2 sions thereof. 

3 ‘‘(3) Student health insurance coverage (as de4 fined in section 147.145 of title 45, Code of Federal 

5 Regulations). 

6 ‘‘SEC. 1353. STATE ELIGIBILITY AND APPROVAL; DEFAULT 

7 SAFEGUARD. 

8 ‘‘(a) ENCOURAGING STATE OPTIONS FOR ALLOCA9 TIONS.— 

10 ‘‘(1) IN GENERAL.—To be eligible for an alloca11 tion of funds under this part for a year (beginning 

12 with 2022), a State shall submit to the Adminis13 trator an application at such time (but, in the case 

14 of allocations for 2022, not later than 90 days after 

15 the date of the enactment of this part and, in the 

16 case of allocations for a subsequent year, not later 

17 than March 1 of the previous year) and in such form 

18 and manner as specified by the Administrator con19 taining— 

20 ‘‘(A) a description of how the funds will be 

21 used; and 

22 ‘‘(B) such other information as the Admin23 istrator may require. 

24 ‘‘(2) AUTOMATIC APPROVAL.—An application so 

25 submitted is approved unless the Administrator notiVerDate Sep 11 2014 05:15 Mar 07, 2021 Jkt 019200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S352.IS S352

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1 fies the State submitting the application, not later 

2 than 60 days after the date of the submission of 

3 such application, that the application has been de4 nied for not being in compliance with any require5 ment of this part and of the reason for such denial. 

6 ‘‘(3) 5-YEAR APPLICATION APPROVAL.—If an 

7 application of a State is approved for a purpose de8 scribed in section 1352 for a year, such application 

9 shall be treated as approved for such purpose for 

10 each of the subsequent 4 years. 

11 ‘‘(4) REVOCATION OF APPROVAL.—The ap12 proval of an application of a State, with respect to 

13 a purpose described in section 1352, may be revoked 

14 if the State fails to use funds provided to the State 

15 under this section for such purpose or otherwise fails 

16 to comply with the requirements of this section. 

17 ‘‘(b) DEFAULT FEDERAL SAFEGUARD.— 

18 ‘‘(1) 2022.—For 2022, in the case of a State 

19 that does not submit an application under subsection 

20 (a) by the 90-day submission date applicable to such 

21 year under subsection (a)(1) and in the case of a 

22 State that does submit such an application by such 

23 date that is not approved, the Administrator, in con24 sultation with the State insurance commissioner, 

25 shall, from the amount calculated under paragraph 


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1 (4) for such year, carry out the purpose described in 

2 paragraph (3) in such State for such year. 

3 ‘‘(2) 2023 AND SUBSEQUENT YEARS.—For 

4 2023 or a subsequent year, in the case of a State 

5 that does not have in effect an approved application 

6 under this section for such year, the Administrator, 

7 in consultation with the State insurance commis8 sioner, shall, from the amount calculated under 

9 paragraph (4) for such year, carry out the purpose 

10 described in paragraph (3) in such State for such 

11 year. 

12 ‘‘(3) SPECIFIED USE.—The amount described 

13 in paragraph (4), with respect to 2022 or a subse14 quent year, shall be used to carry out the purpose 

15 described in section 1352(a)(1) in each State de16 scribed in paragraph (1) or (2) for such year, as ap17 plicable, by providing reinsurance payments to 

18 health insurance issuers with respect to attachment 

19 range claims (as defined in section 1354(b)(2)), 

20 using the dollar amounts specified in subparagraph 

21 (B) of such section for such year in an amount equal 

22 to, subject to paragraph (5), the percentage (speci23 fied for such year by the Secretary under such sub24 paragraph) of the amount of such claims. 


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1 ‘‘(4) AMOUNT DESCRIBED.—The amount de2 scribed in this paragraph, with respect to 2022 or 

3 a subsequent year, is the amount equal to the total 

4 sum of amounts that the Secretary would otherwise 

5 estimate under section 1354(b)(2)(A)(i) for such 

6 year for each State described in paragraph (1) or 

7 (2) for such year, as applicable, if each such State 

8 were not so described for such year. 

9 ‘‘(5) ADJUSTMENT.—For purposes of this sub10 section, the Secretary may apply a percentage under 

11 paragraph (3) with respect to a year that is less 

12 than the percentage otherwise specified in section 

13 1354(b)(2)(B) for such year, if the cost of paying 

14 the total eligible attachment range claims for States 

15 described in this subsection for such year at such 

16 percentage otherwise specified would exceed the 

17 amount calculated under paragraph (4) for such 

18 year. 

19 ‘‘SEC. 1354. ALLOCATIONS. 

20 ‘‘(a) APPROPRIATION.—For the purpose of providing 

21 allocations for States under subsection (b) and payments 

22 under section 1353(b), there is appropriated, out of any 

23 money in the Treasury not otherwise appropriated, 

24 $10,000,000,000 for 2022 and each subsequent year. 

25 ‘‘(b) ALLOCATIONS.— 


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1 ‘‘(1) PAYMENT.— 

2 ‘‘(A) IN GENERAL.—From amounts appro3 priated under subsection (a) for a year, the 

4 Secretary shall, with respect to a State not de5 scribed in section 1353(b) for such year and 

6 not later than the date specified under subpara7 graph (B) for such year, allocate for such State 

8 the amount determined for such State and year 

9 under paragraph (2). 

10 ‘‘(B) SPECIFIED DATE.—For purposes of 

11 subparagraph (A), the date specified in this 

12 subparagraph is— 

13 ‘‘(i) for 2022, the date that is 45 days 

14 after the date of the enactment of this 

15 part; and 

16 ‘‘(ii) for 2023 or a subsequent year, 

17 January 1 of the respective year. 

18 ‘‘(C) NOTIFICATIONS OF ALLOCATION

19 AMOUNTS.—For 2023 and each subsequent 

20 year, the Secretary shall notify each State of 

21 the amount determined for such State under 

22 paragraph (2) for such year by not later than 

23 January 1 of the previous year. 

24 ‘‘(2) ALLOCATION AMOUNT DETERMINA25 TIONS.— 


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1 ‘‘(A) IN GENERAL.—For purposes of para2 graph (1), the amount determined under this 

3 paragraph for a year for a State described in 

4 paragraph (1)(A) for such year is the amount 

5 equal to— 

6 ‘‘(i) the amount that the Secretary es7 timates would be expended under this part 

8 for such year on attachment range claims 

9 of individuals residing in such State if such 

10 State used such funds only for the purpose 

11 described in paragraph (1) of section 

12 1352(a) at the dollar amounts and per13 centage specified under subparagraph (B) 

14 for such year; minus 

15 ‘‘(ii) the amount, if any, by which the 

16 Secretary determines— 

17 ‘‘(I) the estimated amount of 

18 premium tax credits under section 

19 36B of the Internal Revenue Code of 

20 1986 that would be attributable to in21 dividuals residing in such State for 

22 such year without application of this 

23 part; exceeds 

24 ‘‘(II) the estimated amount of 

25 premium tax credits under section 


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1 36B of the Internal Revenue Code of 

2 1986 that would be attributable to in3 dividuals residing in such State for 

4 such year if such State were a State 

5 described in section 1353(b) for such 

6 year. 

7 For purposes of the previous sentence and sec8 tion 1353(b)(3), the term ‘attachment range 

9 claims’ means, with respect to an individual, the 

10 claims for such individual that exceed a dollar 

11 amount specified by the Secretary for a year, 

12 but do not exceed a ceiling dollar amount speci13 fied by the Secretary for such year, under sub14 paragraph (B). 

15 ‘‘(B) SPECIFICATIONS.—For purposes of 

16 subparagraph (A) and section 1353(b)(3), the 

17 Secretary shall determine the dollar amounts 

18 and the percentage to be specified under this 

19 subparagraph for a year in a manner to ensure 

20 that the total amount of expenditures under 

21 this part for such year is estimated to equal the 

22 total amount appropriated for such year under 

23 subsection (a) if such expenditures were used 

24 solely for the purpose described in paragraph 

25 (1) of section 1352(a) for attachment range 


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1 claims at the dollar amounts and percentage so 

2 specified for such year. 

3 ‘‘(3) AVAILABILITY.—Funds allocated to a 

4 State under this subsection for a year shall remain 

5 available through the end of the subsequent year.’’. 

6 SEC. 104. RESCINDING THE SHORT-TERM LIMITED DURA7 TION INSURANCE REGULATION. 

8 The Secretary of Health and Human Services, the 

9 Secretary of the Treasury, and the Secretary of Labor— 

10 (1) may not take any action to implement, en11 force, or otherwise give effect to the rule entitled 

12 ‘‘Short-Term, Limited Duration Insurance’’ (83 

13 Fed. Reg. 38212 (August 3, 2018)); 

14 (2) shall apply any regulation revised by such 

15 rule as if such rule had not been issued; and 

16 (3) may not promulgate any substantially simi17 lar rule. 

18 SEC. 105. REVOKING SECTION 1332 GUIDANCE AND RULES. 

19 (a) PROVIDING THAT CERTAIN GUIDANCE AND

20 RULES RELATED TO WAIVERS FOR STATE INNOVATION

21 UNDER THE PATIENT PROTECTION AND AFFORDABLE

22 CARE ACT SHALL HAVE NO FORCE OR EFFECT.—The 

23 Secretary of Health and Human Services and the Sec24 retary of the Treasury may not— 


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1 (1) take any action to implement, enforce, or 

2 otherwise give effect to the guidance entitled ‘‘State 

3 Relief and Empowerment Waivers’’ (83 Fed. Reg. 

4 53575 (October 24, 2018)), or any rule promulgated 

5 to give effect to such guidance, including any such 

6 action that would— 

7 (A) result in individuals losing health in8 surance coverage that includes the essential 

9 health benefits package (as defined in sub10 section (a) of section 1302 of the Patient Pro11 tection and Affordable Care Act (42 U.S.C. 

12 18022) without regard to any waiver of any 

13 provision of such package under a waiver under 

14 section 1332 of such Act (42 U.S.C. 18052)), 

15 including the maternity and newborn care es16 sential health benefit described in subsection 

17 (b)(1)(D) of such section 1302; 

18 (B) result in a decrease in the number of 

19 such individuals enrolled in coverage that is at 

20 least as comprehensive as the coverage defined 

21 in section 1302(a) of the Patient Protection 

22 and Affordable Care Act (42 U.S.C. 18022(a)) 

23 compared to the number of such individuals 

24 who would have been so enrolled in such cov25 erage had such action not been taken; 


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1 (C) with respect to individuals with sub2 stance use disorders, including opioid use dis3 orders, reduce the availability or affordability of 

4 coverage that is at least as comprehensive as 

5 the coverage defined in section 1302(a) of the 

6 Patient Protection and Affordable Care Act (42 

7 U.S.C. 18022(a)) compared to the availability 

8 or affordability, respectively, of such coverage 

9 had such action not been taken; 

10 (D) result, with respect to vulnerable popu11 lations (including low-income individuals, elder12 ly individuals, and individuals with serious 

13 health issues or who have a greater risk of de14 veloping serious health issues), in a decrease in 

15 the availability of coverage that is at least as 

16 comprehensive as the coverage defined in sec17 tion 1302(a) of the Patient Protection and Af18 fordable Care Act (42 U.S.C. 18022(a)) with 

19 coverage and cost-sharing protections required 

20 under section 1332(b)(1)(B) of such Act (42 

21 U.S.C. 18052(b)(1)(B)); 

22 (E) with respect to individuals with pre23 existing conditions, reduce the affordability of 

24 coverage that is at least as comprehensive as 

25 the coverage defined in section 1302(a) of the 


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1 Patient Protection and Affordable Care Act (42 

2 U.S.C. 18022(a)) compared to the affordability 

3 of such coverage had such action not been 

4 taken; or 

5 (F) result in higher health insurance pre6 miums for individuals enrolled in health insur7 ance coverage that is at least as comprehensive 

8 as the coverage defined in section 1302(b) of 

9 such Act (42 U.S.C. 18022(b)); or 

10 (2) promulgate any substantially similar guid11 ance or rule. 

12 (b) RULE OF CONSTRUCTION.—Nothing in sub13 section (a) shall be construed to affect the approval of 

14 waivers under section 1332 of the Patient Protection and 

15 Affordable Care Act (42 U.S.C. 18052) that establish re16 insurance programs that are consistent with the require17 ments under subsection (b)(1) of such section (42 U.S.C. 

18 18052(b)(1)), lower health insurance premiums, and pro19 tect health insurance coverage for people with preexisting 

20 conditions. 

21 SEC. 106. PROMOTING CONSUMER OUTREACH AND EDU22 CATION. 

23 (a) IN GENERAL.—Section 1311(i) of the Patient 

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

25 is amended— 


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1 (1) in paragraph (2), by adding at the end the 

2 following new subparagraph: 

3 ‘‘(C) SELECTION OF RECIPIENTS.—In the 

4 case of an Exchange established and operated 

5 by the Secretary within a State pursuant to sec6 tion 1321(c), in awarding grants under para7 graph (1), the Exchange shall— 

8 ‘‘(i) select entities to receive such 

9 grants based on an entity’s demonstrated 

10 capacity to carry out each of the duties 

11 specified in paragraph (3); 

12 ‘‘(ii) not take into account whether or 

13 not the entity has demonstrated how the 

14 entity will provide information to individ15 uals relating to group health plans offered 

16 by a group or association of employers de17 scribed in section 2510.3–5(b) of title 29, 

18 Code of Federal Regulations (or any suc19 cessor regulation), or short-term limited 

20 duration insurance (as defined by the Sec21 retary for purposes of section 2791(b)(5) 

22 of the Public Health Service Act); and 

23 ‘‘(iii) ensure that, each year, the Ex24 change awards such a grant to— 


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1 ‘‘(I) at least one entity described 

2 in this paragraph that is a community 

3 and consumer-focused nonprofit 

4 group; and 

5 ‘‘(II) at least one entity described 

6 in subparagraph (B), which may in7 clude another community and con8 sumer-focused nonprofit group in ad9 dition to any such group awarded a 

10 grant pursuant to subclause (I). 

11 In awarding such grants, an Exchange may 

12 consider an entity’s record with respect to 

13 waste, fraud, and abuse for purposes of main14 taining the integrity of such Exchange.’’; 

15 (2) in paragraph (3)— 

16 (A) by amending subparagraph (C) to read 

17 as follows: 

18 ‘‘(C) facilitate enrollment, including with 

19 respect to individuals with limited English pro20 ficiency and individuals with chronic illnesses, 

21 in qualified health plans, State Medicaid plans 

22 under title XIX of the Social Security Act, and 

23 State child health plans under title XXI of such 

24 Act;’’; 


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1 (B) in subparagraph (D), by striking 

2 ‘‘and’’ at the end; 

3 (C) in subparagraph (E), by striking the 

4 period at the end and inserting ‘‘; and’’; 

5 (D) by inserting after subparagraph (E) 

6 the following new subparagraph: 

7 ‘‘(F) provide referrals to community-based 

8 organizations that address social needs related 

9 to health outcomes.’’; and 

10 (E) by adding at the end the following 

11 flush text: 

12 ‘‘The duties specified in the preceding sentence may 

13 be carried out by such a navigator at any time dur14 ing a year.’’; 

15 (3) in paragraph (4)(A)— 

16 (A) in the matter preceding clause (i), by 

17 striking ‘‘not’’; 

18 (B) in clause (i)— 

19 (i) by inserting ‘‘not’’ before ‘‘be’’; 

20 and 

21 (ii) by striking ‘‘; or’’ and inserting a 

22 semicolon; 

23 (C) in clause (ii)— 

24 (i) by inserting ‘‘not’’ before ‘‘re25 ceive’’; and 


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1 (ii) by striking the period and insert2 ing a semicolon; and 

3 (D) by adding at the end the following new 

4 clauses: 

5 ‘‘(iii) maintain physical presence in 

6 the State of the Exchange so as to allow 

7 in-person assistance to consumers; and 

8 ‘‘(iv) receive opioid specific education 

9 and training that ensures the navigator 

10 can best educate individuals on qualified 

11 health plans offered through an Exchange, 

12 specifically coverage under such plans for 

13 opioid health care treatment.’’; and 

14 (4) in paragraph (6)— 

15 (A) by striking ‘‘Grants under’’ and insert16 ing the following: 

17 ‘‘(A) STATE EXCHANGES.—Grants under’’; 

18 and 

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

20 subparagraph: 

21 ‘‘(B) FEDERAL EXCHANGES.—For pur22 poses of carrying out this subsection, with re23 spect to an Exchange established and operated 

24 by the Secretary within a State pursuant to sec25 tion 1321(c), the Secretary shall obligate 


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1 $100,000,000 out of amounts collected through 

2 the user fees on participating health insurance 

3 issuers pursuant to section 156.50 of title 45, 

4 Code of Federal Regulations (or any successor 

5 regulations), for fiscal year 2022 and each sub6 sequent fiscal year. Such amount for a fiscal 

7 year shall remain available until expended.’’. 

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

9 this section shall apply with respect to plan years begin10 ning on or after January 1, 2022. 

11 TITLE II—ENCOURAGING MED12 ICAID EXPANSION AND 

13 STRENGTHENING THE MED14 ICAID PROGRAM 

15 SEC. 201. INCENTIVIZING MEDICAID EXPANSION. 

16 (a) IN GENERAL.—Section 1905 of the Social Secu17 rity Act (42 U.S.C. 1396d(y)(1)) is amended— 

18 (1) in subsection (y)(1)— 

19 (A) in subparagraph (A), by striking 

20 ‘‘2014, 2015, and 2016’’ and inserting ‘‘each of 

21 the first 3 consecutive 12-month periods in 

22 which the State provides medical assistance to 

23 newly eligible individuals’’; 

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

25 ‘‘2017’’ and inserting ‘‘the fourth consecutive 


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1 12-month period in which the State provides 

2 medical assistance to newly eligible individuals’’; 

3 (C) in subparagraph (C), by striking 

4 ‘‘2018’’ and inserting ‘‘the fifth consecutive 12- 

5 month period in which the State provides med6 ical assistance to newly eligible individuals’’; 

7 (D) in subparagraph (D), by striking 

8 ‘‘2019’’ and inserting ‘‘the sixth consecutive 12- 

9 month period in which the State provides med10 ical assistance to newly eligible individuals’’; 

11 and 

12 (E) in subparagraph (E), by striking 

13 ‘‘2020 and each year thereafter’’ and inserting 

14 ‘‘the seventh consecutive 12-month period in 

15 which the State provides medical assistance to 

16 newly eligible individuals and each such period 

17 thereafter’’; and 

18 (2) in subsection (z)(2)(B)(i)(II), by inserting 

19 ‘‘(as in effect on the day before the date of enact20 ment of the Health Care Improvement Act of 

21 2021)’’ after ‘‘subsection (y)(1)’’. 

22 (b) RETROACTIVE APPLICATION.—The amendments 

23 made by subsection (a)(1) shall take effect as if included 

24 in the enactment of Public Law 111–148 and shall apply 

25 to amounts expended by any State for medical assistance 


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1 for newly eligible individuals described in subclause (VIII) 

2 of section 1902(a)(10)(A)(i) of the Social Security Act 

3 under a State Medicaid plan (or a waiver of such plan) 

4 during the period before the date of enactment of this Act. 

5 SEC. 202. REDUCING THE ADMINISTRATIVE FMAP FOR 

6 NONEXPANSION STATES. 

7 Section 1903 of the Social Security Act (42 U.S.C. 

8 1396b) is amended— 

9 (1) in subsection (a)(7), by inserting ‘‘sub10 section (cc) and’’ before ‘‘section 1919(g)(3)(B)’’; 

11 and 

12 (2) by adding at the end the following new sub13 section: 

14 ‘‘(cc) REDUCTION OF FEDERAL PAYMENTS FOR CER15 TAIN ADMINISTRATIVE COSTS OF NONEXPANSION

16 STATES.— 

17 ‘‘(1) IN GENERAL.—In the case of a State that 

18 does not provide under the State plan of such State 

19 (or waiver of such plan) for making medical assist20 ance available in accordance with section 1902(k)(1) 

21 to all individuals described in section 

22 1902(a)(10)(i)(VIII) for a calendar quarter begin23 ning on or after October 1, 2022, the Secretary may 

24 reduce the percentage specified in subsection (a)(7) 

25 for amounts described in such subsection expended 


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1 during such quarter by such State by the number of 

2 percentage points specified in paragraph (2) for such 

3 quarter. 

4 ‘‘(2) AMOUNT OF REDUCTION.—For purposes 

5 of paragraph (1), the number of percentage points 

6 specified in this paragraph for a calendar quarter is 

7 the following: 

8 ‘‘(A) For the calendar quarter beginning 

9 on October 1, 2022, 0.5. 

10 ‘‘(B) For a calendar quarter beginning on 

11 or after January 1, 2023, and ending before 

12 July 1, 2027, the number of percentage points 

13 specified under this paragraph for the previous 

14 quarter, plus 0.5. 

15 ‘‘(C) For a calendar quarter beginning on 

16 or after July 1, 2027, 10. 

17 ‘‘(3) DEFINITION.—For purposes of this sub18 section, the term ‘State’ means a State that is one 

19 of the 50 States or the District of Columbia.’’. 

20 SEC. 203. STATE OPTION TO PROVIDE 12 MONTHS OF 

21 POSTPARTUM MEDICAID ELIGIBILITY. 

22 (a) OPTION TO PROVIDE CONTINUOUS MEDICAID

23 AND CHIP COVERAGE FOR PREGNANT AND POSTPARTUM

24 WOMEN.— 


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1 (1) MEDICAID.—Title XIX of the Social Secu2 rity Act (42 U.S.C. 1396 et seq.) is amended— 

3 (A) in section 1902(l)(1)(A), by inserting 

4 ‘‘(or, at the option of the State, 365-day pe5 riod)’’ after ‘‘60-day period’’; 

6 (B) in section 1902(e)(6), by inserting 

7 ‘‘(or, at the option of the State, 365-day pe8 riod)’’ after ‘‘60-day period’’; 

9 (C) in section 1903(v)(4)(A)(i), by insert10 ing ‘‘(or, at the option of the State, 365-day pe11 riod)’’ after ‘‘60-day period’’; and 

12 (D) in section 1905(a), in the 4th sentence 

13 in the matter following paragraph (30), by in14 serting ‘‘(or, at the option of the State, 365-day 

15 period)’’ after ‘‘60-day period’’. 

16 (2) CHIP.—Section 2112 of the Social Security 

17 Act (42 U.S.C. 1397ll) is amended by inserting ‘‘(or, 

18 at the option of the State, 365-day period)’’ after 

19 ‘‘60-day period’’ each place it appears. 

20 (b) REQUIRING FULL BENEFITS FOR PREGNANT

21 AND POSTPARTUM WOMEN.— 

22 (1) MEDICAID.— 

23 (A) IN GENERAL.—Paragraph (5) of sec24 tion 1902(e) of the Social Security Act (24 

25 U.S.C. 1396a(e)) is amended to read as follows: 


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1 ‘‘(5) Any woman who is eligible for medical as2 sistance under the State plan or a waiver of such 

3 plan and who is, or who while so eligible becomes, 

4 pregnant, shall continue to be eligible under the plan 

5 or waiver for medical assistance through the end of 

6 the month in which the 60-day period (or, at the op7 tion of the State, 365-day period) (beginning on the 

8 last day of her pregnancy) ends, regardless of the 

9 basis for the woman’s eligibility for medical assist10 ance, including if the woman’s eligibility for medical 

11 assistance is on the basis of being pregnant.’’. 

12 (B) CONFORMING AMENDMENT.—Section 

13 1902(a)(10) of the Social Security Act (42 

14 U.S.C. 1396a(a)(10)) is amended in the matter 

15 following subparagraph (G) by striking ‘‘(VII) 

16 the medical assistance’’ and all that follows 

17 through ‘‘complicate pregnancy,’’. 

18 (2) CHIP.—Section 2107(e)(1) of the Social 

19 Security Act (42 U.S.C. 1397gg(e)(1)) is amended— 

20 (A) by redesignating subparagraphs (H) 

21 through (S) as subparagraphs (I) through (T), 

22 respectively; and 

23 (B) by inserting after subparagraph (G), 

24 the following: 


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1 ‘‘(H) Section 1902(e)(5) (requiring 60-day 

2 (or, at the option of the State, 365-day) contin3 uous coverage for pregnant and postpartum 

4 women).’’. 

5 (c) MAINTENANCE OF EFFORT.— 

6 (1) MEDICAID.—Section 1902 of the Social Se7 curity Act (42 U.S.C. 1396a) is amended— 

8 (A) in paragraph (74), by striking ‘‘sub9 section (gg); and’’ and inserting ‘‘subsections 

10 (gg) and (tt);’’; and 

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

12 subsection: 

13 ‘‘(tt) MAINTENANCE OF EFFORT RELATED TO LOW14 INCOME PREGNANT WOMEN.—For calendar quarters be15 ginning on or after the effective date described in section 

16 204(d) of the Health Care Improvement Act of 2021, and 

17 before January 1, 2023, no Federal payment shall be 

18 made to a State under section 1903(a) for amounts ex19 pended under a State plan under this title or a waiver 

20 of such plan if the State— 

21 ‘‘(1) has in effect under such plan eligibility 

22 standards, methodologies, or procedures for individ23 uals described in subsection (l)(1) who are eligible 

24 for medical assistance under the State plan or waiv25 er under subsection (a)(10)(A)(ii)(IX) that are more 


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1 restrictive than the eligibility standards, methodolo2 gies, or procedures, respectively, for such individuals 

3 under such plan or waiver that are in effect on the 

4 date of the enactment of this subsection; or 

5 ‘‘(2) provides medical assistance to individuals 

6 described in subsection (l)(1) who are eligible for 

7 medical assistance under such plan or waiver under 

8 subsection (a)(10)(A)(ii)(IX) at a level that is less 

9 than the level at which the State provides such as10 sistance to such individuals under such plan or waiv11 er on the date of the enactment of this subsection.’’. 

12 (2) CHIP.—Section 2112 of the Social Security 

13 Act (42 U.S.C. 1397ll), as amended by subsection 

14 (b), is further amended by adding at the end the fol15 lowing subsection: 

16 ‘‘(g) MAINTENANCE OF EFFORT.—For calendar 

17 quarters beginning on or after the effective date described 

18 in section 204(d) of the Health Care Improvement Act of 

19 2021, and before January 1, 2023, no payment may be 

20 made under section 2105(a) with respect to a State child 

21 health plan if the State— 

22 ‘‘(1) has in effect under such plan eligibility 

23 standards, methodologies, or procedures for targeted 

24 low-income pregnant women that are more restric25 tive than the eligibility standards, methodologies, or 


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1 procedures, respectively, under such plan that are in 

2 effect on the date of the enactment of this sub3 section; or 

4 ‘‘(2) provides pregnancy-related assistance to 

5 targeted low-income pregnant women under such 

6 plan at a level that is less than the level at which 

7 the State provides such assistance to such women 

8 under such plan on the date of the enactment of this 

9 subsection.’’. 

10 (d) EFFECTIVE DATE.— 

11 (1) IN GENERAL.—Except as provided under 

12 paragraph (2), the amendments made by subsections 

13 (a) and (b) shall take effect on (and the effective 

14 date described in this subsection shall be) the first 

15 day of the first calendar year that begins after the 

16 last day of the emergency period described in section 

17 1135(g)(1)(B) of the Social Security Act (42 U.S.C. 

18 1320b–5(g)(1)(B)). 

19 (2) EXTENSION OF EFFECTIVE DATE FOR

20 STATE LAW AMENDMENT.—In the case of a State 

21 plan under title XIX or State child health plan 

22 under title XXI of the Social Security Act (42 

23 U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.) 

24 which the Secretary of Health and Human Services 

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1 islation appropriating funds) in order for the respec2 tive plan to meet the additional requirement imposed 

3 by the amendments made by subsection (b), the re4 spective plan shall not be regarded as failing to com5 ply with the requirements of such title solely on the 

6 basis of its failure to meet such applicable additional 

7 requirement before the first day of the first calendar 

8 quarter beginning after the close of the first regular 

9 session of the State legislature that begins after the 

10 date of enactment of this Act. For purposes of the 

11 previous sentence, in the case of a State that has a 

12 2-year legislative session, each year of the session is 

13 considered to be a separate regular session of the 

14 State legislature. 

15 SEC. 204. SUPPORTING STATE MEDICAID PROGRAMS 

16 THROUGH ECONOMIC DOWNTURNS. 

17 (a) IN GENERAL.—Section 1905 of the Social Secu18 rity Act (42 U.S.C. 1396d) is amended— 

19 (1) in subsection (b), by striking ‘‘and (ff)’’ and 

20 inserting ‘‘(ff), and (hh)’’; and 

21 (2) by adding at the end the following new sub22 section: 

23 ‘‘(hh) INCREASED FMAP DURING ECONOMIC

24 DOWNTURNS.— 


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1 ‘‘(1) IN GENERAL.—If a fiscal quarter that be2 gins on or after January 1, 2021, is an economic 

3 downturn quarter (as defined in paragraph (2)) with 

4 respect to a State, then the Federal medical assist5 ance percentage determined for each State for such 

6 quarter under subsection (b) shall be equal to the 

7 percentage determined for the State and quarter 

8 under paragraph (3). 

9 ‘‘(2) ECONOMIC DOWNTURN QUARTER.— 

10 ‘‘(A) IN GENERAL.— 

11 ‘‘(i) IN GENERAL.—In this subsection, 

12 the term ‘economic downturn quarter’ 

13 means, with respect to a State, a fiscal 

14 quarter during which the State’s unem15 ployment rate for the quarter exceeds the 

16 percentage determined for the State and 

17 quarter under clause (ii). 

18 ‘‘(ii) THRESHOLD PERCENTAGE.—The 

19 percentage determined under this clause 

20 for a State and fiscal quarter is the per21 centage equal to the lower of— 

22 ‘‘(I) the State unemployment 

23 rate at the 20th percentile of the dis24 tribution of the State’s quarterly un25 employment rates for the 60-quarter 


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1 period preceding the quarter involved, 

2 increased by 1 percentage point; and 

3 ‘‘(II) the State’s average quar4 terly unemployment rate for the 12- 

5 quarter period preceding the quarter 

6 involved, increased by 1 percentage 

7 point. 

8 ‘‘(B) UNEMPLOYMENT DATA.— 

9 ‘‘(i) IN GENERAL.—Except as pro10 vided in clause (ii), for purposes of deter11 mining unemployment rates for a State 

12 and a quarter under this paragraph, the 

13 Secretary shall use data from the Local 

14 Area Unemployment Statistics from the 

15 Bureau of Labor Statistics. 

16 ‘‘(ii) APPLICATION TO CERTAIN TER17 RITORIES.—In the case of the Virgin Is18 lands, Guam, the Northern Mariana Is19 lands, American Samoa, or any other juris20 diction for which suitable data from the 

21 Local Area Unemployment Statistics from 

22 the Bureau of Labor Statistics are unavail23 able, the Secretary shall use data from the 

24 U–3 unemployment measure of the Bureau 


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1 of Labor Statistics to make any necessary 

2 determinations under subparagraph (A). 

3 ‘‘(3) INCREASED FMAP DURING ECONOMIC

4 DOWNTURN QUARTER.— 

5 ‘‘(A) IN GENERAL.—During a fiscal quar6 ter that is an economic downturn quarter with 

7 respect to a State, the Federal medical assist8 ance percentage for the State and quarter de9 termined under subsection (b) shall be equal 

10 to— 

11 ‘‘(i) the Federal medical assistance 

12 percentage determined for the State and 

13 quarter under subsection (b) without re14 gard to this subsection (but including any 

15 increase to such percentage for such quar16 ter made pursuant to section 6008(a) of 

17 the Families First Coronavirus Response 

18 Act); increased by 

19 ‘‘(ii) the number of percentage points 

20 (rounded to the nearest tenth of a percent21 age point) equal to the product of— 

22 ‘‘(I) the number of percentage 

23 points (rounded to the nearest tenth 

24 of a percentage point) by which the 

25 unemployment rate for the State and 


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1 quarter exceeds the percentage deter2 mined for the State and quarter 

3 under paragraph (2)(A)(ii); and 

4 ‘‘(II) 4.8. 

5 ‘‘(B) RULES OF APPLICATION.—The fol6 lowing rules shall apply with respect to the Fed7 eral medical assistance percentage determined 

8 for a State and an economic downturn quarter 

9 under this subsection: 

10 ‘‘(i) SCOPE OF APPLICATION.—Such 

11 Federal medical assistance percentage shall 

12 not apply for purposes of— 

13 ‘‘(I) disproportionate share hos14 pital payments described in section 

15 1923; 

16 ‘‘(II) payments under part D of 

17 title IV; or 

18 ‘‘(III) any payments under this 

19 title that are based on a Federal med20 ical assistance percentage determined 

21 for a State under subsection (aa) (but 

22 only to the extent that such Federal 

23 medical assistance percentage is high24 er than the economic recovery 

25 FMAP). 


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1 ‘‘(ii) LIMITATION.—In no case shall— 

2 ‘‘(I) the Federal medical assist3 ance percentage determined for a 

4 State and quarter pursuant to this 

5 subsection exceed 95 percent; or 

6 ‘‘(II) any increase to the Federal 

7 medical assistance percentage deter8 mined for a State and quarter pursu9 ant to this subsection result in the ap10 plication of a Federal medical assist11 ance percentage that exceeds 95 per12 cent. 

13 ‘‘(iii) APPLICATION TO CHIP.—Not14 withstanding the first sentence of section 

15 2105(b), the application of this subsection 

16 may result in the enhanced FMAP of a 

17 State for a fiscal year under such section 

18 exceeding 85 percent, but in no case may 

19 the application of this subsection before 

20 application of the second sentence of such 

21 section result in the enhanced FMAP of 

22 the State exceeding 95 percent. 

23 ‘‘(4) ADVANCE PAYMENT; RETROSPECTIVE AD24 JUSTMENT.— 


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1 ‘‘(A) IN GENERAL.—Prior to the beginning 

2 of the second fiscal quarter that begins after 

3 the date of enactment of this subsection, and 

4 each subsequent fiscal quarter, the Secretary 

5 shall, with respect to each State— 

6 ‘‘(i) make an initial determination, 

7 based on the projections made for the 

8 State and quarter under subparagraph 

9 (B), as to— 

10 ‘‘(I) whether the application of 

11 this subsection is expected to result in 

12 the application of a higher Federal 

13 medical assistance percentage for the 

14 State and quarter than the percentage 

15 that would otherwise apply without re16 gard to this subsection; and 

17 ‘‘(II) if the application of this 

18 subsection is expected to result in 

19 such a higher Federal medical assist20 ance percentage for the State and 

21 quarter, what such higher percentage 

22 is expected to be; and 

23 ‘‘(ii) if the Secretary determines under 

24 clause (i) that the application of this sub25 section is expected to result in the applicaVerDate Sep 11 2014 05:15 Mar 07, 2021 Jkt 019200 PO 00000 Frm 00039 Fmt 6652 Sfmt 6201 E:\BILLS\S352.IS S352

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1 tion of a higher Federal medical assistance 

2 percentage for the State and quarter than 

3 the percentage that would otherwise apply 

4 without regard to this subsection— 

5 ‘‘(I) apply such higher Federal 

6 medical assistance percentage of the 

7 State for purposes of making pay8 ments to the State for amounts ex9 pended during such quarter as med10 ical assistance under the State plan; 

11 and 

12 ‘‘(II) take into account such 

13 higher Federal medical assistance per14 centage of the State for purposes of 

15 calculating the enhanced FMAP for 

16 the State and quarter under section 

17 2105(b). 

18 ‘‘(B) PROJECTION OF STATE UNEMPLOY19 MENT RATES.—Prior to the beginning of the 

20 second fiscal quarter that begins after the date 

21 of enactment of this subsection, and each subse22 quent fiscal quarter, the Secretary, acting 

23 through the Chief Actuary of the Centers for 

24 Medicare & Medicaid Services, shall, using the 

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1 graph (2)(B), make projections with respect 

2 to— 

3 ‘‘(i) the unemployment rates for each 

4 State for such quarter; 

5 ‘‘(ii) the threshold percentages de6 scribed in paragraph (2)(A)(ii) for each 

7 State for such quarter; and 

8 ‘‘(iii) the national unemployment rate 

9 for such quarter. 

10 ‘‘(C) RETROSPECTIVE ADJUSTMENT.—As 

11 soon as practicable after final unemployment 

12 data becomes available for a fiscal quarter for 

13 which the Secretary made an initial determina14 tion under this paragraph, the Secretary shall, 

15 with respect to each State— 

16 ‘‘(i) make a final determination with 

17 respect to the application of this subsection 

18 for purposes of determining the Federal 

19 medical assistance percentage and en20 hanced FMAP of the State for the quarter; 

21 and 

22 ‘‘(ii) in accordance with section 

23 1903(d)(2) and section 2105(e), reduce or 

24 increase the amount payable to the State 

25 under section 1903(a) or section 2105 for 


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1 a subsequent fiscal quarter to the extent of 

2 any overpayment or underpayment under 

3 either such section which the Secretary de4 termines was made as a result of an incor5 rect initial determination under subpara6 graph (A)(i) with respect to the application 

7 of this subsection for purposes of deter8 mining the Federal medical assistance per9 centage and enhanced FMAP of the State 

10 for such prior fiscal quarter. 

11 ‘‘(5) RETROSPECTIVE APPLICATION OF OVER12 THE-LIMIT FMAP INCREASES.— 

13 ‘‘(A) IN GENERAL.—If a State has excess 

14 percentage points with respect to an economic 

15 downturn quarter and an applicable FMAP (as 

16 determined under subparagraph (B)), the State 

17 may elect to apply such excess percentage 

18 points to increase such applicable FMAP for 

19 one or more quarters during the look-back pe20 riod for the State and economic downturn quar21 ter in accordance with this paragraph. 

22 ‘‘(B) EXCESS PERCENTAGE POINTS.—For 

23 purposes of this paragraph, the number of ex24 cess percentage points for a State, economic 

25 downturn quarter, and an applicable FMAP 


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1 shall be equal to the number of percentage 

2 points by which— 

3 ‘‘(i) the applicable FMAP for the 

4 State and quarter (after application of 

5 paragraph (3) but without regard to sub6 paragraph (B)(ii) of such paragraph); ex7 ceeds 

8 ‘‘(ii) 95 percent. 

9 ‘‘(C) EFFECT OF APPLICATION OF EXCESS

10 PERCENTAGE POINTS.—If a State elects to 

11 apply excess percentage points to an applicable 

12 FMAP to a quarter during a look-back period 

13 under this paragraph, the Secretary shall deter14 mine the additional amount of payment under 

15 section 1903(a) to which the State would have 

16 been entitled for such quarter if the applicable 

17 FMAP (as so increased) had been in effect for 

18 such quarter, and shall treat such additional 

19 amount as an underpayment for such quarter. 

20 ‘‘(D) DISTRIBUTION OF EXCESS PERCENT21 AGE POINTS.—A State that has excess percent22 age points with respect to an economic down23 turn quarter and applicable FMAP may elect to 

24 divide such points among more than 1 quarter 

25 during the look-back period for such State and 


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1 quarter provided that no excess percentage 

2 point (or fraction of an excess percentage point) 

3 is applied to the applicable FMAP of more than 

4 1 quarter. 

5 ‘‘(E) LIMITATIONS.— 

6 ‘‘(i) NO INCREASES OVER 100 PER7 CENT.—A State may not increase an appli8 cable FMAP for any quarter during a look9 back period under this paragraph if such 

10 increase would result in the applicable 

11 FMAP for such quarter exceeding 100 per12 cent. 

13 ‘‘(ii) SCOPE OF APPLICATION.—Any 

14 increase to an applicable FMAP of a State 

15 for a fiscal quarter under this paragraph— 

16 ‘‘(I) shall only apply with respect 

17 to payments for amounts expended by 

18 the State for medical assistance for 

19 services furnished during such quarter 

20 to which such applicable FMAP is ap21 plicable; and 

22 ‘‘(II) shall not apply with respect 

23 to payments described in paragraph 

24 (3)(B)(i). 

25 ‘‘(F) DEFINITIONS.—In this paragraph: 


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1 ‘‘(i) APPLICABLE FMAP.—The term 

2 ‘applicable FMAP’ means, with respect to 

3 a State and fiscal quarter— 

4 ‘‘(I) the Federal medical assist5 ance percentage determined for the 

6 State and quarter under subsection 

7 (b); 

8 ‘‘(II) the Federal medical assist9 ance percentage applicable under sub10 section (y); 

11 ‘‘(III) the Federal medical assist12 ance percentage applicable under sub13 section (z)(2); 

14 ‘‘(IV) the Federal medical assist15 ance percentage determined for the 

16 State and quarter under subsection 

17 (ff); or 

18 ‘‘(V) the enhanced FMAP deter19 mined for the State and quarter 

20 under section 2105(b). 

21 ‘‘(ii) LOOK-BACK PERIOD.—The term 

22 ‘look-back period’ means, with respect to a 

23 State and a fiscal quarter that is an eco24 nomic downturn quarter for the State, the 

25 period of 4 fiscal quarters that ends with 


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1 the fourth quarter which precedes the most 

2 recent fiscal quarters that was not an eco3 nomic downturn quarter for the State. 

4 ‘‘(6) REQUIREMENT FOR ALL STATES.—This 

5 subsection shall not apply to a State with respect to 

6 a fiscal quarter, if— 

7 ‘‘(A) eligibility standards, methodologies, 

8 or procedures under the State plan or a waiver 

9 of such plan are more restrictive during such 

10 quarter than the eligibility standards, meth11 odologies, or procedures, respectively, under 

12 such plan (or waiver) as in effect on the last 

13 day of the most recent fiscal quarter that was 

14 not an economic downturn quarter for the 

15 State; 

16 ‘‘(B) the amount of any premium imposed 

17 by the State pursuant to section 1916 or 1916A 

18 during such quarter, with respect to an indi19 vidual enrolled under such plan (or waiver), ex20 ceeds the amount of such premium as of the 

21 date described in subparagraph (A); or 

22 ‘‘(C) the State fails to provide that an in23 dividual who is enrolled for benefits under such 

24 plan (or waiver) as of the date described in sub25 paragraph (A) or enrolls for benefits under 


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•S 352 IS

1 such plan (or waiver) during the period begin2 ning with such date and ending with the day 

3 before the first day of the next quarter that is 

4 not an economic downturn quarter for the State 

5 shall be treated as eligible for such benefits for 

6 not less than 12 months after such date or (if 

7 later) the date that such individual so enrolls 

8 unless the individual requests a voluntary ter9 mination of eligibility or the individual ceases to 

10 be a resident of the State.’’. 

11 (b) EXCLUSION OF ECONOMIC DOWNTURN FMAP 

12 INCREASES FROM TERRITORIAL CAPS; SPECIAL RULE

13 FOR CHIP ALLOTMENTS.— 

14 (1) EXCLUSION FROM TERRITORIAL CAPS.— 

15 Section 1108 of the Social Security Act (42 U.S.C. 

16 1308) is amended— 

17 (A) in subsection (f), in the matter pre18 ceding paragraph (1), by striking ‘‘subsections 

19 (g) and (h)’’ and inserting ‘‘subsections (g), 

20 (h), and (i)’’; and 

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

22 ‘‘(i) EXCLUSION FROM CAPS OF AMOUNTS ATTRIB23 UTABLE TO ECONOMIC DOWNTURN FMAP.—Any pay24 ment made to a territory for a fiscal year in which the 

25 Federal medical assistance percentage for the territory is 


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1 determined under section 1905(hh) shall not be taken into 

2 account for purposes of applying payment limits under 

3 subsections (f) and (g) to the extent that such payment 

4 exceeds the amount of the payment that would have been 

5 made to the territory for the year if the Federal medical 

6 assistance percentage for the territory had been deter7 mined without regard to such section.’’. 

8 (2) CHIP ALLOTMENTS.—Section 2104(m) of 

9 the Social Security Act (42 U.S.C. 1397dd(m)) is 

10 amended— 

11 (A) in paragraph (2)(B), in the matter 

12 preceding clause (i), by striking ‘‘paragraphs 

13 (5) and (7)’’ and inserting ‘‘paragraphs (5), 

14 (7), and (12)’’; and 

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

16 paragraph: 

17 ‘‘(12) SPECIAL RULE FOR ADJUSTING ALLOT18 MENTS DURING FISCAL YEARS WITH ECONOMIC

19 DOWNTURN QUARTERS.— 

20 ‘‘(A) IN GENERAL.—If a fiscal quarter is 

21 determined under section 1905(hh) to be an 

22 economic downturn quarter with respect to a 

23 State then, as soon as practicable after such de24 termination, the Secretary shall increase the al25 lotment for the State and the fiscal year in 


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1 which such fiscal quarter occurs in accordance 

2 with subparagraph (B). 

3 ‘‘(B) AMOUNT OF INCREASE.— 

4 ‘‘(i) IN GENERAL.—The amount of an 

5 increase to the allotment of a State de6 scribed in subparagraph (A) for a fiscal 

7 year shall be equal to the amount by which 

8 Federal payments made to the State for 

9 the preceding fiscal year under this title 

10 would have been increased (without regard 

11 to whether such payments would exceed 

12 the amount of the State’s allotment for 

13 such preceding fiscal year) if the enhanced 

14 FMAP determined for the State for such 

15 preceding fiscal year had been increased to 

16 the same extent that the State’s enhanced 

17 FMAP for the fiscal year involved is ex18 pected to be increased as a result of the 

19 application of section 1905(hh) relative to 

20 the enhanced FMAP that would apply to 

21 the State for the fiscal year involved with22 out the application of such section. 

23 ‘‘(ii) INCLUSION OF PROJECTED IN24 CREASES.—In increasing the allotment of a 

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1 graph, the Secretary may base the calcula2 tion of such increase on projections made 

3 by the Secretary with respect to— 

4 ‘‘(I) the number of fiscal quar5 ters during such fiscal year that will 

6 be economic downturn quarters; and 

7 ‘‘(II) the effect that the applica8 tion of section 1905(hh) is expected to 

9 have on the enhanced FMAP of the 

10 State for such fiscal year. 

11 ‘‘(C) DISREGARD OF INCREASED PAY12 MENTS FOR PURPOSES OF FUTURE ALLOT13 MENTS.—Any Federal payment made to a State 

14 under this title for a fiscal year in which the 

15 Federal medical assistance percentage for the 

16 State is determined under section 1905(hh) 

17 shall be disregarded when determining the allot18 ment of the State for any subsequent year, in19 cluding for purposes of applying this paragraph, 

20 to the extent that such payment exceeds the 

21 amount of the payment that would have been 

22 made to the State for the year if the Federal 

23 medical assistance percentage for the State and 

24 year had been determined without regard to 

25 such section.’’. 


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1 SEC. 205. STATE FLEXIBILITY TO USE ADMINISTRATIVE 

2 SIMPLIFICATION POLICIES FOR ENROLL3 MENT. 

4 (a) PERMANENT EXTENSION OF MEDICAID AND

5 CHIP EXPRESS LANE OPTION.—Section 1902(e)(13) of 

6 the Social Security Act (42 U.S.C. 1396a(e)(13)) is 

7 amended by striking subparagraph (I). 

8 (b) EXTENDING EXPRESS LANE ELIGIBILITY TO

9 ADULTS.—Section 1902(e)(13)(A) of the Social Security 

10 Act (42 U.S.C. 1396a(e)(13)(A)) is amended by adding 

11 at the end the following new clause: 

12 ‘‘(iii) STATE OPTION TO EXTEND EX13 PRESS LANE ELIGIBILITY TO ADULTS.— 

14 ‘‘(I) IN GENERAL.—At the option 

15 of the State, the State may apply the 

16 provisions of this paragraph with re17 spect to determining eligibility under 

18 this title for an eligible individual (as 

19 defined in subclause (II)). In applying 

20 this paragraph in the case of a State 

21 making such an option, any reference 

22 in this paragraph to a child with re23 spect to this title (other than a ref24 erence to child health assistance) shall 

25 be deemed to be a reference to an eli26 gible individual. 


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1 ‘‘(II) ELIGIBLE INDIVIDUAL DE2 FINED.—In this clause, the term ‘eli3 gible individual’ means— 

4 ‘‘(aa) any individual (other 

5 than a child) whose income eligi6 bility under the State plan or 

7 under a waiver of the plan for 

8 medical assistance is determined 

9 under paragraph (14); and 

10 ‘‘(bb) an individual included 

11 in any other group of individuals 

12 the Secretary determines appro13 priate.’’. 

14 (c) CONSENT BY BENEFIT UTILIZATION.—Section 

15 1902(e)(13)(D)(i) of the Social Security Act (42 U.S.C. 

16 1396a(e)(13)(D)(i)) is amended by inserting ‘‘by using 

17 medical assistance to access care,’’ after ‘‘through elec18 tronic signature,’’. 

19 (d) STUDY AND REPORT ON OPTIONS FOR AUTO20 MATIC ENROLLMENT IN MEDICAID AND CHIP.— 

21 (1) STUDY.—The Secretary of Health and 

22 Human Services, by grant, contract, or interagency 

23 agency, shall conduct a study to identify options for, 

24 and barriers to, States automatically enrolling indi25 viduals who, on the basis of data and information 


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1 from income tax returns and other sources, are like2 ly to be eligible for medical assistance under the 

3 State Medicaid plan established under title XIX of 

4 the Social Security Act (42 U.S.C. 1396 et seq.) (or 

5 a waiver of such plan) or for child health assistance 

6 (or, if applicable, pregnancy-related assistance) 

7 under the State child health plan established under 

8 title XXI of the Social Security Act (42 U.S.C. 

9 1397aa et seq.) (or a waiver of such plan), and 

10 would not be required to pay a premium for enroll11 ment in such a plan or waiver. 

12 (2) REPORT.—Not later than 1 year after the 

13 date of enactment of this Act, the Secretary of 

14 Health and Human Services shall submit a report to 

15 Congress on the results of the study conducted 

16 under subsection (a). The report shall include the 

17 following: 

18 (A) An analysis of the financial, regu19 latory, and legislative barriers that limit the 

20 ability of States to implement automatic enroll21 ment for individuals described in subsection (a). 

22 (B) An analysis of the extent to which 

23 State implementation of automatic enrollment 

24 for such individuals would reduce the number of 

25 uninsured individuals in each State. 


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1 (C) Recommendations for administrative 

2 and legislative actions that, if taken, would 

3 eliminate the barriers identified under subpara4 graph (A) and allow States to elect to automati5 cally enroll individuals described in subsection 

6 (a) in the State Medicaid plan established 

7 under title XIX of the Social Security Act (42 

8 U.S.C. 1396 et seq.) (or a waiver of such plan) 

9 or for child health assistance (or, if applicable, 

10 pregnancy-related assistance) under the State 

11 child health plan established under title XXI of 

12 the Social Security Act (42 U.S.C. 1397aa et 

13 seq.) (or a waiver of such plan). 

14 TITLE III—ESTABLISHMENT OF 

15 A PUBLIC HEALTH CARE OPTION 

16 SEC. 301. ESTABLISHMENT OF HEALTH PLAN. 

17 (a) IN GENERAL.—The Secretary of Health and 

18 Human Services (referred to in this title as the ‘‘Sec19 retary’’) shall establish a coordinated and low-cost health 

20 plan (referred to in this section as the ‘‘health plan’’) to 

21 provide access to quality health care for enrollees. 

22 (b) INDIVIDUAL MARKET AVAILABILITY.—The Sec23 retary shall make the health plan available in the indi24 vidual market for plan year 2022 and each subsequent 

25 plan year. 


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1 (c) RULEMAKING.—The Secretary may promulgate 

2 such regulations as may be necessary to carry out this 

3 title. 

4 (d) AUTHORIZATION OF APPROPRIATIONS.—There 

5 are authorized to be appropriated such sums as may be 

6 necessary to carry out this title. 

7 SEC. 302. AVAILABILITY OF PLAN. 

8 (a) ELIGIBILITY.—An individual shall be eligible to 

9 enroll in the health plan if such individual, for the entire 

10 period for which enrollment is sought— 

11 (1) is a qualified individual within the meaning 

12 of section 1312 of the Patient Protection and Af13 fordable Care Act (42 U.S.C. 18032); 

14 (2) is not eligible for benefits under the Medi15 care program under title XVIII of the Social Secu16 rity Act (42 U.S.C. 1395 et seq.); and 

17 (3) is not otherwise eligible for, or has been 

18 otherwise offered, employer-sponsored health care 

19 coverage. 

20 (b) EXCHANGES.—The health plan shall be made 

21 available through the Exchanges, including the Small 

22 Business Health Options Program Exchange. 


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1 SEC. 303. AFFORDABILITY. 

2 The Secretary shall ensure that coverage options for 

3 the health plan are not more costly than comparable op4 tions offered on the Exchange in the applicable market. 

5 SEC. 304. PARTICIPATING PROVIDERS. 

6 (a) REQUIREMENT TO PARTICIPATE IN ORDER TO

7 BE ENROLLED UNDER MEDICARE.—Beginning January 

8 1, 2022, the Secretary may require a health care provider 

9 enrolled under the Medicare program under section 

10 1866(j) of the Social Security Act (42 U.S.C. 1395cc(j)) 

11 to be a participating provider under the health plan. 

12 (b) REQUIREMENT TO PARTICIPATE IN ORDER TO

13 PARTICIPATE IN MEDICAID.—Beginning January 1, 2022, 

14 the Secretary may require a health care provider under 

15 a State Medicaid plan under title XIX of the Social Secu16 rity Act (42 U.S.C. 1396 et seq.) to also be a participating 

17 provider under the health plan. 

18 SEC. 305. PROVIDER PAYMENT RATES. 

19 The Secretary shall set competitive provider payment 

20 rates under the health plan using the best information 

21 publicly available and data otherwise accessible to the Sec22 retary. The Secretary shall give consideration to existing 

23 provider payment rates for commercial health plans and 

24 provider costs to deliver care, giving special consideration 

25 to increased costs for providers to deliver care in rural 

26 and medically underserved areas. 


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1 SEC. 306. NO EFFECT ON MEDICARE BENEFITS OR MEDI2 CARE TRUST FUNDS. 

3 Nothing in this title shall— 

4 (1) affect the benefits available under title 

5 XVIII of the Social Security Act (42 U.S.C. 1395 et 

6 seq.); or 

7 (2) impact the Federal Hospital Insurance 

8 Trust Fund under section 1817 of the Social Secu9 rity Act (42 U.S.C. 1395i) or the Federal Supple10 mentary Medical Insurance Trust Fund under sec11 tion 1841 of the Social Security Act (42 U.S.C. 

12 1395t) (including the Medicare Prescription Drug 

13 Account within such Trust Fund). 

14 TITLE IV—FAIR MEDICARE PAY15 MENTS TO RURAL PRO16 VIDERS 

17 SEC. 401. ENSURING FAIRNESS IN MEDICARE HOSPITAL 

18 PAYMENTS. 

19 (a) HOSPITAL INPATIENT SERVICES.— 

20 (1) IN GENERAL.—Section 1886(d)(3)(E) of 

21 the Social Security Act (42 U.S.C. 

22 1395www(d)(3)(E)) is amended— 

23 (A) in clause (i), in the first sentence, by 

24 striking ‘‘or (iii)’’ and inserting ‘‘, (iii), or (iv)’’; 

25 and 


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

2 clause: 

3 ‘‘(iv) AREA WAGE INDEX FLOOR.— 

4 ‘‘(I) IN GENERAL.—For discharges 

5 occurring on or after October 1, 2021, the 

6 area wage index applicable under this sub7 paragraph to any hospital which is not lo8 cated in a frontier State (as defined in 

9 clause (iii)(II)) may not be less than 0.85. 

10 ‘‘(II) WAIVING BUDGET NEU11 TRALITY.—Pursuant to the fifth sentence 

12 of clause (i), this clause shall not be ap13 plied in a budget neutral manner.’’. 

14 (2) WAIVING BUDGET NEUTRALITY.— 

15 (A) TECHNICAL AMENDATORY CORREC16 TION.—Section 10324(a)(2) of Public Law 

17 111–148 is amended by striking ‘‘third sen18 tence’’ and inserting ‘‘fifth sentence’’. 

19 (B) WAIVER.—Section 1886(d)(3)(E)(i) of 

20 the Social Security Act (42 U.S.C. 

21 1395ww(d)(3)(E)(i)) is amended, in the fifth 

22 sentence— 

23 (i) by striking ‘‘and the amendments’’ 

24 and inserting ‘‘, the amendments’’; and 


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1 (ii) by inserting ‘‘, and the amend2 ments made by section 401(a)(1) of the 

3 Health Care Improvement Act of 2021’’ 

4 after ‘‘Care Act’’. 

5 (b) HOSPITAL OUTPATIENT DEPARTMENT SERV6 ICES.—Section 1833(t) of the Social Security Act (42 

7 U.S.C. 1395l(t)), is amended— 

8 (1) in paragraph (2)(D), by striking ‘‘(19), the 

9 Secretary’’ and inserting ‘‘(19) and paragraph (23), 

10 the Secretary’’; and 

11 (2) by adding at the end the following new 

12 paragraph: 

13 ‘‘(23) FLOOR ON AREA WAGE ADJUSTMENT

14 FACTOR FOR HOSPITAL OUTPATIENT DEPARTMENT

15 SERVICES.—With respect to covered OPD services 

16 furnished on or after January 1, 2022, the area 

17 wage adjustment factor applicable under the pay18 ment system established under this subsection to 

19 any hospital outpatient department which is not lo20 cated in a frontier State (as defined in section 

21 1886(d)(3)(E)(iii)(II)) may not be less than 0.85. 

22 The preceding sentence shall not be implemented in 

23 a budget neutral manner.’’. 


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1 TITLE V—COMMONSENSE COM2 PETITION AND ACCESS TO 

3 HEALTH INSURANCE 

4 SEC. 501. PROVIDING SMALL BUSINESS HEALTH INSUR5 ANCE ACROSS STATE LINES. 

6 Section 1333(a)(1)(A) of the Patient Protection and 

7 Affordable Care Act (42 U.S.C. 18053(a)(1)(A)) is 

8 amended by inserting ‘‘and small group markets’’ after 

9 ‘‘individual markets’’. 

10 SEC. 502. REPORT AND MODELS. 

11 Section 1333 of the Patient Protection and Afford12 able Care Act (42 U.S.C. 18053) is amended by adding 

13 at the end the following: 

14 ‘‘(b) NAIC REPORT AND MODELS.— 

15 ‘‘(1) IN GENERAL.—The Secretary shall request 

16 that the National Association of Insurance Commis17 sioners submit, not later than December 31, 2021, 

18 to the Secretary a report concerning health plans 

19 provided for under this section. Such report shall in20 clude— 

21 ‘‘(A) a description of the challenges that 

22 States would face by permitting issuers of 

23 qualified health plans to offer such plans in 

24 States other than those States where such plan 

25 was originally written or issued; 


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1 ‘‘(B) an assessment of how an out-of-State 

2 insurer would go about building an adequate 

3 provider network; 

4 ‘‘(C) a description of how such challenges 

5 could be lessened without weakening the en6 forcement of laws and regulations described in 

7 subsection (a)(1)(B)(i) in any State that is in8 cluded in a compact under this section; 

9 ‘‘(D) a description of the commonalities 

10 that exist in State laws and opportunities to 

11 allow issuers of qualified health plans to offer 

12 such plans in States other than those States 

13 where such plan was originally written or 

14 issued; and 

15 ‘‘(E) models to be used by States to estab16 lish and enter into interstate health care choice 

17 compacts under this section, which— 

18 ‘‘(i) may include model legislation for 

19 use by States to enact laws to enter into 

20 such compacts; 

21 ‘‘(ii) shall identify how States would 

22 continue to enforce, and not weaken, the 

23 laws and regulations described in sub24 section (a)(1)(B)(i) in any State that is in25 cluded in such compact; and 


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1 ‘‘(iii) shall identify how such models 

2 would ensure that there is no violation of 

3 the conditions for Secretarial approval 

4 under subsection (a)(3). 

5 ‘‘(2) OTHER ORGANIZATIONS AND ENTITIES.— 

6 In making the request under paragraph (1), the Sec7 retary may also request that the National Associa8 tion of Insurance Commissioners gather concepts for 

9 inclusion in the report under such paragraph from 

10 organizations and entities that have experience in of11 fering qualified health plans in States in which such 

12 plans were not originally issued.’’. 

13 TITLE VI—EMPOWERING MEDI14 CARE SENIORS TO NEGO15 TIATE PRESCRIPTION DRUG 

16 PRICES 

17 SEC. 601. AUTHORITY TO NEGOTIATE FAIR PRICES FOR 

18 MEDICARE PRESCRIPTION DRUGS. 

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

20 Security Act (42 U.S.C. 1395w–111) is amended by strik21 ing subsection (i). 

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

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

24 of this Act. 


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1 TITLE VII—COMMONSENSE 

2 REPORTING FOR EMPLOYERS 

3 SEC. 701. VOLUNTARY PROSPECTIVE REPORTING SYSTEM. 

4 (a) IN GENERAL.—Not later than 1 year after the 

5 date of the enactment of this Act, the Secretary of the 

6 Treasury, in consultation with the Secretary of Health and 

7 Human Services, the Secretary of Labor, and the Admin8 istrator of the Small Business Administration, shall de9 velop and implement guidance providing for a prospective 

10 reporting system meeting the requirements of subsection 

11 (b). Such system shall be available for use by employers 

12 on a voluntary basis beginning not later than January 1, 

13 2023. 

14 (b) REQUIREMENTS.—The system created under sub15 section (a) shall include— 

16 (1) voluntary reporting by each participating 

17 employer that offers minimum essential coverage to 

18 its full-time employees and their dependents under 

19 an eligible employer-sponsored plan, not later than 

20 45 days before the first day of the annual open en21 rollment period under section 1311(c)(6)(B) of the 

22 Patient Protection and Affordable Care Act (42 

23 U.S.C. 18031(c)(6)(B)) for each calendar year, of— 


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1 (A) the name and employer identification 

2 number for purposes of section 6056 of the In3 ternal Revenue Code of 1986 of the employer; 

4 (B) a certification of— 

5 (i) whether coverage meeting the defi6 nition of minimum essential coverage in 

7 section 5000A(f) of the Internal Revenue 

8 Code of 1986 is offered to the full-time 

9 employees (within the meaning of section 

10 4980H of such Code) of the employer; 

11 (ii) whether such coverage is offered 

12 to part-time employees of the employer; 

13 (iii) whether such coverage is offered 

14 to dependents of employees; 

15 (iv) whether such coverage is offered 

16 to spouses of employees; 

17 (v) whether such coverage meets the 

18 minimum value requirement of section 

19 36B(c)(2)(C)(ii) of such Code; 

20 (vi) whether such coverage satisfies 

21 the requirements to qualify for one of the 

22 affordability safe harbors promulgated by 

23 the Secretary of the Treasury for purposes 

24 of section 4980H of such Code; and 


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1 (vii) whether the employer reasonably 

2 expects to be liable for any shared respon3 sibility payment under section 4980H of 

4 such Code for such year; 

5 (C) the months during the prospective re6 porting period that such coverage is available to 

7 individuals described in clauses (i) through (iv) 

8 of subparagraph (B); 

9 (D) what waiting periods, if any, apply 

10 with respect to such coverage; and 

11 (E) a list of all employer identification 

12 numbers of the employer for entities that em13 ploy employees within the employers control 

14 group under subsection (b), (c), (m), or (o) of 

15 section 414 of the Internal Revenue Code for 

16 1986; 

17 (2) processes necessary to ensure that Ex18 changes, the Federal Marketplace Data Services 

19 Hub, and the Internal Revenue Service can securely 

20 and confidentially access the information described 

21 in paragraph (1) as necessary to carry out their re22 spective missions, and to provide to the Secretary of 

23 Health and Human Services additional information 

24 relating to eligibility determinations for advance pay25 ment of the premium tax credits under section 36B 


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1 of such Code and the cost-sharing subsidies under 

2 section 1402 of the Patient Protection and Afford3 able Care Act (42 U.S.C. 18071); 

4 (3) a process to allow Exchanges to follow up 

5 with employers in order to obtain additional reason6 ably necessary information relating to an employee’s 

7 eligibility for such advance payment or such cost8 sharing subsidies, and to allow an employee to re9 ceive notification of any problem in verifying such 

10 eligibility; and 

11 (4) a process to allow employers using the sys12 tem to provide timely updates to the Federal Mar13 ketplace Data Services Hub regarding any cancella14 tion of coverage or significant change in coverage for 

15 participating employees that would change the infor16 mation reported under paragraph (1). 

17 (c) EMPLOYER NOTIFICATION OF EMPLOYEE EN18 ROLLMENT IN EXCHANGE PLANS.—Subparagraph (J) of 

19 section 1311(d)(4) of the Patient Protection and Afford20 able Care Act (42 U.S.C. 18031(d)(4)(J)) is amended by 

21 striking ‘‘to each employer’’ and all that follows through 

22 ‘‘(and the effective date of such cessation); and’’ and in23 serting ‘‘to each employer— 

24 ‘‘(i) the name of each employee of the 

25 employer who enrolls in a qualified health 


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1 plan for a plan year, or whose dependents 

2 enroll in such a plan, at the time of such 

3 enrollment; or 

4 ‘‘(ii) the name of each employee of the 

5 employer described in subparagraph (I)(ii) 

6 who ceases coverage under a qualified 

7 health plan during a plan year (and the ef8 fective date of such cessation); and’’. 

9 (d) EXEMPTION FROM REPORTING REQUIREMENT

10 UNDER INTERNAL REVENUE CODE OF 1986.—Section 

11 6056 of the Internal Revenue Code of 1986 is amended 

12 by redesignating subsection (f) as subsection (g) and by 

13 inserting after subsection (e) the following new subsection: 

14 ‘‘(f) EXEMPTION.—If, through the system created 

15 pursuant to section 701(a) of the Health Care Improve16 ment Act of 2021, an employer provides prospective re17 porting for any calendar year that meets the requirements 

18 of section 701(b)(1) of such Act— 

19 ‘‘(1) such employer shall be treated as satis20 fying the return requirements of subsections (a) and 

21 (b) for such year; and 

22 ‘‘(2) such employer shall be treated as satis23 fying the requirements of subsection (c) for such 

24 year if the employer— 


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1 ‘‘(A) furnishes the statement described in 

2 such section to those employees of the employer 

3 whose names have been provided to the em4 ployer by an Exchange under section 

5 1311(d)(4)(J)(i) of the Patient Protection and 

6 Affordable Care Act regarding enrollment of the 

7 employee or a dependent in a qualified health 

8 plan (as defined in section 1301 of such Act) 

9 through the Exchange; and 

10 ‘‘(B) furnishes a copy of such statement 

11 with respect to such employees to the Sec12 retary.’’. 

13 (e) THIRD-PARTY FILING.—An employer may con14 tract with a third party to make the report under sub15 section (b)(1) without affecting the employer’s treatment 

16 as having satisfied the return requirements of subsections 

17 (a) and (b) of section 6056 of the Internal Revenue Code 

18 of 1986. 

19 (f) ACCESS TO THE NATIONAL DIRECTORY OF NEW

20 HIRES.—Subsection (i)(3) of section 453 of the Social Se21 curity Act (42 U.S.C. 653) is amended by adding at the 

22 end the following new sentence: ‘‘The Secretary of the 

23 Treasury and the Secretary of Health and Human Serv24 ices shall have access to the information in the National 

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1 tion 36B and 4980H of the Internal Revenue Code of 

2 1986 and section 1402 of the Patient Protection and Af3 fordable Care Act (42 U.S.C. 18071). Subsection (k)(3) 

4 shall not apply to information received for purposes of the 

5 administration of such sections 36B and 4980H of such 

6 Code and section 1402 of such Act.’’. 

7 (g) IMPROVING EMPLOYEE ACCESS TO ACCURATE

8 EINS.—Not later than 1 year after the date of the enact9 ment of this Act, the Secretary of the Treasury shall de10 velop and implement guidance for allowing any employee 

11 of an employer to receive, on request, the employer’s em12 ployer identification number for purposes of section 6056 

13 of the Internal Revenue Code of 1986. Employers shall 

14 provide the employer’s employer identification number for 

15 purposes of section 6056 of the Internal Revenue Code 

16 of 1986 on one of the following documents of the employ17 er’s election: 

18 (1) Health Insurance Marketplace Coverage 

19 Options Notice required under section 18B of the 

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

21 218b). 

22 (2) Summary of Benefits and Coverage de23 scribed in section 2715 of the Public Health Service 

24 Act (42 U.S.C. 300gg–15). 

25 (3) Marketplace Employer Coverage tool. 


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1 (4) Annual benefits enrollment materials dis2 tributed to employees, including through an intranet 

3 or an online portal accessible by employees. 

4 (5) Employee pay statements or Form W–2. 

5 (h) FUNDING FOR VOLUNTARY PROSPECTIVE RE6 PORTING SYSTEM.—It is the sense of Congress that build7 ing and maintaining the voluntary prospective reporting 

8 system described in this section will require appropriations 

9 to the Secretary of the Treasury, the Secretary of Health 

10 and Human Services, the Secretary of Labor, and the Ad11 ministrator of the Small Business Administration, and 

12 that necessary sums to carry out the requirements of this 

13 section should be appropriated for such purpose. 

14 SEC. 702. PROTECTION OF DEPENDENT PRIVACY. 

15 (a) IN GENERAL.—Paragraph (1) of section 6055(b) 

16 of the Internal Revenue Code of 1986 is amended by add17 ing at the end the following flush sentence: 

18 ‘‘For purposes of subparagraph (B)(i), in the case of 

19 an individual other than the primary insured, if the health 

20 insurance issuer or the employer is unable to collect or 

21 maintain information on the TINs of such individuals 

22 (other than for purposes of this section), the Secretary 

23 may allow the individual’s full name and date of birth to 

24 be substituted for the name and TIN. In the event the 

25 Secretary allows the use of the individual’s full name and 


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1 date of birth in lieu of the TIN, the Social Security Ad2 ministration shall assist the Internal Revenue Service in 

3 providing data matches to determine the TIN associated 

4 with the name and date of birth provided by the Internal 

5 Revenue Service with respect to such individual.’’. 

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

7 this section shall apply to returns the due date for which 

8 is after the date that is 60 days after the date of the enact9 ment of this Act. 

10 SEC. 703. ELECTRONIC STATEMENTS. 

11 (a) IN GENERAL.—Subsection (c) of section 6056 of 

12 the Internal Revenue Code of 1986 is amended by adding 

13 at the end the following new paragraph: 

14 ‘‘(3) ELECTRONIC DELIVERY.—An individual 

15 shall be deemed to have consented to receive the 

16 statement under this subsection in electronic form if 

17 such individual has affirmatively consented at any 

18 prior time, to the person who is the employer of the 

19 individual during the calendar year to which the 

20 statement relates, to receive such statement in elec21 tronic form. The preceding sentence shall not apply 

22 if the individual revokes consent in writing with re23 spect to the statement under this subsection.’’. 

24 (b) STATEMENTS RELATING TO HEALTH INSURANCE

25 COVERAGE.—Subsection (c) of section 6055 of the InterVerDate Sep 11 2014 05:15 Mar 07, 2021 Jkt 019200 PO 00000 Frm 00071 Fmt 6652 Sfmt 6201 E:\BILLS\S352.IS S352

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1 nal Revenue Code of 1986 is amended by adding at the 

2 end the following new paragraph: 

3 ‘‘(3) ELECTRONIC DELIVERY.—An individual 

4 shall be deemed to have consented to receive the 

5 statement under this subsection in electronic form if 

6 such individual has affirmatively consented at any 

7 prior time, to the person required to make such 

8 statement (such as the provider of the individual’s 

9 health coverage), to receive in electronic form any 

10 private health information (such as electronic health 

11 records), unless the individual revokes such consent 

12 in writing.’’. 

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

14 this section shall apply to statements the due date for 

15 which is after December 31, 2021. 

16 SEC. 704. GAO STUDIES. 

17 (a) STUDY OF PAST EMPLOYER REPORTING.— 

18 (1) IN GENERAL.—The Comptroller General of 

19 the United States shall conduct a study that evalu20 ates, with respect to the period beginning on Janu21 ary 1, 2017, and ending on December 31, 2020— 

22 (A) the notification of employers by Ex23 changes established under title I of the Patient 

24 Protection and Affordable Care Act (Public 

25 Law 111–148) that a full-time employee of the 


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1 employer has been determined eligible for ad2 vance payment of premium tax credits under 

3 section 36B of the Internal Revenue Code of 

4 1986 or cost-sharing subsidies under section 

5 1402 of such Act (42 U.S.C. 18071), including 

6 information regarding— 

7 (i) the data elements included in the 

8 employer notification; 

9 (ii) the process by which the notifica10 tion forms were developed and sent to em11 ployers, including whether the process pro12 vided for a formal notice and comment pe13 riod; 

14 (iii) whether employers report that 

15 such notifications provided sufficient and 

16 relevant information for them to make ap17 propriate decisions about whether to utilize 

18 the appeals process; 

19 (iv) the total number of notifications 

20 sent to employers and the timeline of when 

21 such notifications were sent; 

22 (v) differences in the notification proc23 ess between the marketplace facilitated by 

24 the Federal Government and the State25 Based Marketplaces; and 


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1 (vi) challenges that have arisen in the 

2 notification process, and recommendations 

3 to address these challenges; and 

4 (B) the extent to which the Secretary of 

5 Health and Human Services has established a 

6 separate appeals process for employers who re7 ceived such a notification to challenge the eligi8 bility determination, as required by section 

9 1411(f)(2) of the Patient Protection and Af10 fordable Care Act (42 U.S.C. 18081(f)(2)). 

11 (2) REPORT.—Not later than 1 year after the 

12 date of the enactment of this Act, the Comptroller 

13 General shall submit to the Committees on Finance 

14 and Health, Education, Labor, and Pensions of the 

15 Senate and the Committees on Ways and Means, 

16 Energy and Commerce, and Education and Labor of 

17 the House of Representatives a report on the results 

18 of the study conducted under paragraph (1). 

19 (b) STUDY OF PROSPECTIVE REPORTING SYSTEM.— 

20 (1) IN GENERAL.—The Comptroller General of 

21 the United States shall conduct a study that evalu22 ates, with respect to the period beginning on Janu23 ary 1, 2023, and ending on December 31, 2023, the 

24 functionality of the prospective reporting system es25 tablished pursuant to section 701, including the acVerDate Sep 11 2014 05:15 Mar 07, 2021 Jkt 019200 PO 00000 Frm 00074 Fmt 6652 Sfmt 6201 E:\BILLS\S352.IS S352

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1 curacy of information collected, the number of em2 ployers electing to report under such system, and 

3 any challenges that have arisen in implementing 

4 such system. 

5 (2) REPORT.—Not later than July 1, 2024, the 

6 Comptroller General shall submit to the Committees 

7 on Finance and Health, Education, Labor, and Pen8 sions of the Senate and the Committees on Ways 

9 and Means, Energy and Commerce, and Education 

10 and Labor of the House of Representatives a report 

11 on the results of the study conducted under para12 graph (1). 

13 SEC. 705. TAX COMPLIANCE. 

14 (a) IN GENERAL.—Section 6724(d)(1)(B)(xxv) of the 

15 Internal Revenue Code of 1986 is amended by inserting 

16 ‘‘or, in the case of an employer to which section 6056(f) 

17 applies, section 701(b)(1) of the Health Care Improve18 ment Act of 2021’’ before ‘‘, or’’. 

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

20 this section shall apply to returns required to be filed after 

21 the date of the enactment of this Act. 

Æ 


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