II 

117TH CONGRESS 

1ST SESSION S. 411 

To improve Federal efforts with respect to the prevention of maternal 

mortality, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

FEBRUARY 24, 2021 

Mr. DURBIN (for himself, Ms. DUCKWORTH, Mrs. SHAHEEN, Mr. BROWN, Ms. 

STABENOW, Mr. BLUMENTHAL, Ms. KLOBUCHAR, Ms. SMITH, Mr. VAN

HOLLEN, and Mr. SANDERS) introduced the following bill; which was 

read twice and referred to the Committee on Finance 

A BILL 

To improve Federal efforts with respect to the prevention 

of maternal mortality, 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 ‘‘Mothers and Offspring 

5 Mortality and Morbidity Awareness Act’’ or the ‘‘MOM6 MA’s Act’’. 

7 SEC. 2. FINDINGS. 

8 Congress finds the following: 


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1 (1) Every year, across the United States, nearly 

2 4,000,000 women give birth, about 700 women suf3 fer fatal complications during pregnancy, while giv4 ing birth or during the postpartum period, and 

5 about 70,000 women suffer near-fatal, partum-re6 lated complications. 

7 (2) The maternal mortality rate is often used as 

8 a proxy to measure the overall health of a popu9 lation. While the infant mortality rate in the United 

10 States has reached its lowest point, the risk of death 

11 for women in the United States during pregnancy, 

12 childbirth, or the postpartum period is higher than 

13 such risk in many other high-income countries. The 

14 estimated maternal mortality rate (deaths per 

15 100,000 live births) for the 48 contiguous States 

16 and Washington, DC, increased from 14.5 percent in 

17 2000 to 17.3 in 2017. The United States is the only 

18 industrialized nation with a rising maternal mor19 tality rate. 

20 (3) The National Vital Statistics System of the 

21 Centers for Disease Control and Prevention has 

22 found that in 2018, there were 17.4 maternal deaths 

23 for every 100,000 live births in the United States. 

24 This ratio is more than double that of most other 

25 high-income countries. 


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1 (4) It is estimated that more than 60 percent 

2 of maternal deaths in the United States are prevent3 able. 

4 (5) According to the Centers for Disease Con5 trol and Prevention, the maternal mortality rate var6 ies drastically for women by race and ethnicity. 

7 There are about 13 deaths per 100,000 live births 

8 for White women, 40.8 deaths per 100,000 live 

9 births for non-Hispanic Black women, and 29.7 

10 deaths per 100,000 live births for American Indian/ 

11 Alaskan Native women. While maternal mortality 

12 disparately impacts Black women, this urgent public 

13 health crisis traverses race, ethnicity, socioeconomic 

14 status, educational background, and geography. 

15 (6) In the United States, non-Hispanic Black 

16 women are about 3 times more likely to die from 

17 causes related to pregnancy and childbirth compared 

18 to non-Hispanic White women, which is one of the 

19 most disconcerting racial disparities in public health. 

20 This disparity widens in certain cities and States 

21 across the country. 

22 (7) According to the National Center for Health 

23 Statistics of the Centers for Disease Control and 

24 Prevention, the maternal mortality rate heightens 

25 with age, as women 40 and older die at a rate of 


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1 81.9 per 100,000 births compared to 10.6 per 

2 100,000 for women under 25. This translates to 

3 women over 40 being 7.7 times more likely to die 

4 compared to their counterparts under 25 years of 

5 age. 

6 (8) The COVID–19 pandemic risks exacer7 bating the maternal health crisis. A recent study of 

8 the Centers for Disease Control and Prevention sug9 gests that pregnant women are at a significantly 

10 higher risk for severe outcomes, including death, 

11 from COVID–19 as compared to non-pregnant 

12 women. The COVID–19 pandemic has also de13 creased access to prenatal and postpartum care. 

14 (9) The findings described in paragraphs (1) 

15 through (8) are of major concern to researchers, 

16 academics, members of the business community, and 

17 providers across the obstetric continuum represented 

18 by organizations such as— 

19 (A) the American College of Nurse-Mid20 wives; 

21 (B) the American College of Obstetricians 

22 and Gynecologists; 

23 (C) the American Medical Association; 

24 (D) the Association of Women’s Health, 

25 Obstetric and Neonatal Nurses; 


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1 (E) the Black Mamas Matter Alliance; 

2 (F) the Black Women’s Health Imperative; 

3 (G) the California Maternal Quality Care 

4 Collaborative; 

5 (H) EverThrive Illinois; 

6 (I) the Illinois Perinatal Quality Collabo7 rative; 

8 (J) the March of Dimes; 

9 (K) the National Association of Certified 

10 Professional Midwives; 

11 (L) the National Birth Equity Collabo12 rative; 

13 (M) the National Partnership for Women 

14 & Families; 

15 (N) the National Polycystic Ovary Syn16 drome Association; 

17 (O) the Preeclampsia Foundation; 

18 (P) the Society for Maternal-Fetal Medi19 cine; and 

20 (Q) the What To Expect Project. 

21 (10) Hemorrhage, cardiovascular and coronary 

22 conditions, cardiomyopathy, infection or sepsis, em23 bolism, mental health conditions (including sub24 stance use disorder), hypertensive disorders, stroke 

25 and cerebrovascular accidents, and anesthesia comVerDate Sep 11 2014 00:50 Mar 17, 2021 Jkt 019200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S411.IS S411

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1 plications are the predominant medical causes of 

2 maternal-related deaths and complications. Most of 

3 these conditions are largely preventable or manage4 able. Even when these conditions are not prevent5 able, mortality and morbidity may be prevented 

6 when conditions are diagnosed and treated in a 

7 timely manner. 

8 (11) According to a study published by the 

9 Journal of Perinatal Education, doula-assisted 

10 mothers are 4 times less likely to have a low-birth11 weight baby, 2 times less likely to experience a birth 

12 complication involving themselves or their baby, and 

13 significantly more likely to initiate breastfeeding. 

14 Doula care has also been shown to produce cost sav15 ings resulting in part from reduced rates of cesarean 

16 and pre-term births. 

17 (12) Intimate partner violence is one of the 

18 leading causes of maternal death, and women are 

19 more likely to experience intimate partner violence 

20 during pregnancy than at any other time in their 

21 lives. It is also more dangerous than pregnancy. In22 timate partner violence during pregnancy and 

23 postpartum crosses every demographic and has been 

24 exacerbated by the COVID–19 pandemic. 


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1 (13) Oral health is an important part of 

2 perinatal health. Reducing bacteria in a woman’s 

3 mouth during pregnancy can significantly reduce her 

4 risk of developing oral diseases and spreading decay5 causing bacteria to her baby. Moreover, some evi6 dence suggests that women with periodontal disease 

7 during pregnancy could be at greater risk for poor 

8 birth outcomes, such as preeclampsia, pre-term 

9 birth, and low-birth weight. Furthermore, a woman’s 

10 oral health during pregnancy is a good predictor of 

11 her newborn’s oral health, and since mothers can 

12 unintentionally spread oral bacteria to their babies, 

13 putting their children at higher risk for tooth decay, 

14 prevention efforts should happen even before chil15 dren are born, as a matter of pre-pregnancy health 

16 and prenatal care during pregnancy. 

17 (14) In the United States, death reporting and 

18 analysis is a State function rather than a Federal 

19 process. States report all deaths—including mater20 nal deaths—on a semi-voluntary basis, without 

21 standardization across States. While the Centers for 

22 Disease Control and Prevention has the capacity and 

23 system for collecting death-related data based on 

24 death certificates, these data are not sufficiently re25 ported by States in an organized and standard forVerDate Sep 11 2014 00:50 Mar 17, 2021 Jkt 019200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S411.IS S411

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1 mat across States such that the Centers for Disease 

2 Control and Prevention is able to identify causes of 

3 maternal death and best practices for the prevention 

4 of such death. 

5 (15) Vital statistics systems often underesti6 mate maternal mortality and are insufficient data 

7 sources from which to derive a full scope of medical 

8 and social determinant factors contributing to ma9 ternal deaths, such as intimate partner violence. 

10 While the addition of pregnancy checkboxes on death 

11 certificates since 2003 have likely improved States’ 

12 abilities to identify pregnancy-related deaths, they 

13 are not generally completed by obstetric providers or 

14 persons trained to recognize pregnancy-related mor15 tality. Thus, these vital forms may be missing infor16 mation or may capture inconsistent data. Due to 

17 varying maternal mortality-related analyses, lack of 

18 reliability, and granularity in data, current maternal 

19 mortality informatics do not fully encapsulate the 

20 myriad medical and socially determinant factors that 

21 contribute to such high maternal mortality rates 

22 within the United States compared to other devel23 oped nations. Lack of standardization of data and 

24 data sharing across States and between Federal en25 tities, health networks, and research institutions 


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1 keep the Nation in the dark about ways to prevent 

2 maternal deaths. 

3 (16) Having reliable and valid State data ag4 gregated at the Federal level are critical to the Na5 tion’s ability to quell surges in maternal death and 

6 imperative for researchers to identify long-lasting 

7 interventions. 

8 (17) Leaders in maternal wellness highly rec9 ommend that maternal deaths and cases of maternal 

10 morbidity, including complications that result in 

11 chronic illness and future increased risk of death, be 

12 investigated at the State level first, and that stand13 ardized, streamlined, de-identified data regarding 

14 maternal deaths be sent annually to the Centers for 

15 Disease Control and Prevention. Such data stand16 ardization and collection would be similar in oper17 ation and effect to the National Program of Cancer 

18 Registries of the Centers for Disease Control and 

19 Prevention and akin to the Confidential Enquiry in 

20 Maternal Deaths Programme in the United King21 dom. Such a maternal mortalities and morbidities 

22 registry and surveillance system would help pro23 viders, academicians, lawmakers, and the public to 

24 address questions concerning the types of, causes of, 


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1 and best practices to thwart, maternal mortality and 

2 morbidity. 

3 (18) The United Nations’ Millennium Develop4 ment Goal 5a aimed to reduce by 75 percent, be5 tween 1990 and 2015, the maternal mortality rate, 

6 yet this metric has not been achieved. In fact, the 

7 maternal mortality rate in the United States has 

8 been estimated to have more than doubled between 

9 2000 and 2014. 

10 (19) Many States have struggled to establish or 

11 maintain Maternal Mortality Review Committees 

12 (referred to in this section as ‘‘MMRC’’). On the 

13 State level, MMRCs have lagged because States have 

14 not had the resources to mount local reviews. State15 level reviews are necessary as only the State depart16 ments of health have the authority to request med17 ical records, autopsy reports, and police reports crit18 ical to the function of the MMRC. 

19 (20) The United States has no comparable, co20 ordinated Federal process by which to review cases 

21 of maternal mortality, systems failures, or best prac22 tices. Many States have active MMRCs and leverage 

23 their work to impact maternal wellness. For exam24 ple, the State of California has worked extensively 

25 with their State health departments, health and hosVerDate Sep 11 2014 00:50 Mar 17, 2021 Jkt 019200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S411.IS S411

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1 pital systems, and research collaborative organiza2 tions, including the California Maternal Quality Care 

3 Collaborative and the Alliance for Innovation on Ma4 ternal Health, to establish MMRCs, wherein such 

5 State has determined the most prevalent causes of 

6 maternal mortality and recorded and shared data 

7 with providers and researchers, who have developed 

8 and implemented safety bundles and care protocols 

9 related to preeclampsia, maternal hemorrhage, 

10 peripartum cardiomyopathy, and the like. In this 

11 way, the State of California has been able to lever12 age its maternal mortality review board system, gen13 erate data, and apply those data to effect changes 

14 in maternal care-related protocol. To date, the State 

15 of California has reduced its maternal mortality 

16 rate, which is now comparable to the low rates of the 

17 United Kingdom. 

18 (21) Hospitals and health systems across the 

19 United States lack standardization of emergency ob20 stetric protocols before, during, and after delivery. 

21 Consequently, many providers are delayed in recog22 nizing critical signs indicating maternal distress that 

23 quickly escalate into fatal or near-fatal incidences. 

24 Moreover, any attempt to address an obstetric emer25 gency that does not consider both clinical and public 


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1 health approaches falls woefully under the mark of 

2 excellent care delivery. State-based perinatal quality 

3 collaboratives, or entities participating in the Alli4 ance for Innovation on Maternal Health (AIM), have 

5 formed obstetric protocols, tool kits, and other re6 sources to improve system care and response as they 

7 relate to maternal complications and warning signs 

8 for such conditions as maternal hemorrhage, hyper9 tension, and preeclampsia. These perinatal quality 

10 collaboratives serve an important role in providing 

11 infrastructure that supports quality improvement ef12 forts addressing obstetric care and outcomes. State13 based perinatal quality collaboratives partner with 

14 hospitals, physicians, nurses, patients, public health, 

15 and other stakeholders to provide opportunities for 

16 collaborative learning, rapid response data, and qual17 ity improvement science support to achieve systems18 level change. 

19 (22) The Centers for Disease Control and Pre20 vention reports that nearly half of all maternal 

21 deaths occur in the immediate postpartum period— 

22 the 42 days following a pregnancy—whereas more 

23 than one-third of maternal deaths occur while a per24 son is still pregnant. Further, 21 percent of mater25 nal deaths occur between 1 and 6 weeks postpartum, 


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1 and 12 percent of maternal deaths occur during the 

2 remaining portion of the postpartum year. Yet, for 

3 women eligible for the Medicaid program on the 

4 basis of pregnancy, such Medicaid coverage lapses at 

5 the end of the month on which the 60th postpartum 

6 day lands. 

7 (23) The experience of serious traumatic 

8 events, such as being exposed to domestic violence, 

9 substance use disorder, or pervasive and systematic 

10 racism, can over-activate the body’s stress-response 

11 system. Known as toxic stress, the repetition of 

12 high-doses of cortisol to the brain, can harm healthy 

13 neurological development and other body systems, 

14 which can have cascading physical and mental health 

15 consequences, as documented in the Adverse Child16 hood Experiences study of the Centers for Disease 

17 Control and Prevention. 

18 (24) A growing body of evidence-based research 

19 has shown the correlation between the stress associ20 ated with systematic racism and one’s birthing out21 comes. The undue stress of sex and race discrimina22 tion paired with institutional racism has been dem23 onstrated to contribute to a higher risk of maternal 

24 mortality, irrespective of one’s gestational age, ma25 ternal age, socioeconomic status, educational level, 


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1 or individual-level health risk factors, including pov2 erty, limited access to prenatal care, and poor phys3 ical and mental health (although these are not nomi4 nal factors). Black women remain the most at risk 

5 for pregnancy-associated or pregnancy-related causes 

6 of death. When it comes to preeclampsia, for exam7 ple, for which obesity is a risk factor, Black women 

8 of normal weight remain at a higher at risk of dying 

9 during the perinatal period compared to non-Black 

10 obese women. 

11 (25) The rising maternal mortality rate in the 

12 United States is driven predominantly by the dis13 proportionately high rates of Black maternal mor14 tality. 

15 (26) Compared to women from other racial and 

16 ethnic demographics, Black women across the socio17 economic spectrum experience prolonged, unrelenting 

18 stress related to systematic racial and gender dis19 crimination, contributing to higher rates of maternal 

20 mortality, giving birth to low-weight babies, and ex21 periencing pre-term birth. Racism is a risk-factor for 

22 these aforementioned experiences. This cumulative 

23 stress, called weathering, often extends across the 

24 life course and is situated in everyday spaces where 

25 Black women establish livelihood. Systematic racism, 


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1 structural barriers, lack of access to care, lack of ac2 cess to nutritious food, and social determinants of 

3 health exacerbate Black women’s likelihood to expe4 rience poor or fatal birthing outcomes, but do not 

5 fully account for the great disparity. 

6 (27) Black women are twice as likely to experi7 ence postpartum depression, and disproportionately 

8 higher rates of preeclampsia compared to White 

9 women. 

10 (28) Racism is deeply ingrained in United 

11 States systems, including in health care delivery sys12 tems between patients and providers, often resulting 

13 in disparate treatment for pain, irreverence for cul14 tural norms with respect to health, and dismissive15 ness. However, the provider pool is not primed with 

16 many people of color, nor are providers (whether 

17 maternity care clinicians or maternity care support 

18 personnel) consistently required to undergo implicit 

19 bias, cultural competency, respectful care practices, 

20 or empathy training on a consistent, on-going basis. 

21 (29) Not all people who have been pregnant or 

22 given birth identify as being a ‘‘woman’’. The terms 

23 ‘‘birthing people’’ or ‘‘birthing persons’’ are also 

24 used to describe pregnant and postpartum people. 


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1 SEC. 3. IMPROVING FEDERAL EFFORTS WITH RESPECT TO 

2 PREVENTION OF MATERNAL MORTALITY. 

3 (a) TECHNICAL ASSISTANCE FOR STATES WITH RE4 SPECT TO REPORTING MATERNAL MORTALITY.—Not 

5 later than one year after the date of enactment of this 

6 Act, the Director of the Centers for Disease Control and 

7 Prevention (referred to in this section as the ‘‘Director’’), 

8 in consultation with the Administrator of the Health Re9 sources and Services Administration, shall provide tech10 nical assistance to States that elect to report comprehen11 sive data on maternal mortality and factors relating to 

12 such mortality (including oral and mental health), inti13 mate partner violence, and breastfeeding health informa14 tion, for the purpose of encouraging uniformity in the re15 porting of such data and to encourage the sharing of such 

16 data among the respective States. 

17 (b) BEST PRACTICES RELATING TO PREVENTION OF

18 MATERNAL MORTALITY.— 

19 (1) IN GENERAL.—Not later than one year 

20 after the date of enactment of this Act— 

21 (A) the Director, in consultation with rel22 evant patient and provider groups, shall issue 

23 best practices to State maternal mortality re24 view committees on how best to identify and re25 view maternal mortality cases, taking into ac26 count any data made available by States relatVerDate Sep 11 2014 00:50 Mar 17, 2021 Jkt 019200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\S411.IS S411

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1 ing to maternal mortality, including data on 

2 oral, mental, and breastfeeding health, and uti3 lization of any emergency services; and 

4 (B) the Director, working in collaboration 

5 with the Health Resources and Services Admin6 istration, shall issue best practices to hospitals, 

7 State professional society groups, and perinatal 

8 quality collaboratives on how best to prevent 

9 maternal mortality. 

10 (2) AUTHORIZATION OF APPROPRIATIONS.—For 

11 purposes of carrying out this subsection, there is au12 thorized to be appropriated $5,000,000 for each of 

13 fiscal years 2021 through 2025. 

14 (c) ALLIANCE FOR INNOVATION ON MATERNAL

15 HEALTH GRANT PROGRAM.— 

16 (1) IN GENERAL.—Not later than one year 

17 after the date of enactment of this Act, the Sec18 retary of Health and Human Services (referred to in 

19 this subsection as the ‘‘Secretary’’), acting through 

20 the Associate Administrator of the Maternal and 

21 Child Health Bureau of the Health Resources and 

22 Services Administration, shall establish a grant pro23 gram to be known as the Alliance for Innovation on 

24 Maternal Health Grant Program (referred to in this 

25 subsection as ‘‘AIM’’) under which the Secretary 


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1 shall award grants to eligible entities for the purpose 

2 of— 

3 (A) directing widespread adoption and im4 plementation of maternal safety bundles 

5 through collaborative State-based teams; and 

6 (B) collecting and analyzing process, struc7 ture, and outcome data to drive continuous im8 provement in the implementation of such safety 

9 bundles by such State-based teams with the ul10 timate goal of eliminating preventable maternal 

11 mortality and severe maternal morbidity in the 

12 United States. 

13 (2) ELIGIBLE ENTITIES.—In order to be eligi14 ble for a grant under paragraph (1), an entity 

15 shall— 

16 (A) submit to the Secretary an application 

17 at such time, in such manner, and containing 

18 such information as the Secretary may require; 

19 and 

20 (B) demonstrate in such application that 

21 the entity is an interdisciplinary, multi-stake22 holder, national organization with a national 

23 data-driven maternal safety and quality im24 provement initiative based on implementation 

25 approaches that have been proven to improve 


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1 maternal safety and outcomes in the United 

2 States. 

3 (3) USE OF FUNDS.—An eligible entity that re4 ceives a grant under paragraph (1) shall use such 

5 grant funds— 

6 (A) to develop and implement, through a 

7 robust, multi-stakeholder process, maternal 

8 safety bundles to assist States, perinatal quality 

9 collaboratives, and health care systems in align10 ing national, State, and hospital-level quality 

11 improvement efforts to improve maternal health 

12 outcomes, specifically the reduction of maternal 

13 mortality and severe maternal morbidity; 

14 (B) to ensure, in developing and imple15 menting maternal safety bundles under sub16 paragraph (A), that such maternal safety bun17 dles— 

18 (i) satisfy the quality improvement 

19 needs of a State, perinatal quality collabo20 rative, or health care system by factoring 

21 in the results and findings of relevant data 

22 reviews, such as reviews conducted by a 

23 State maternal mortality review committee; 

24 and 


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1 (ii) address topics which may in2 clude— 

3 (I) information on evidence-based 

4 practices to improve the quality and 

5 safety of maternal health care in hos6 pitals and other health care settings 

7 of a State or health care system, in8 cluding by addressing topics com9 monly associated with health com10 plications or risks related to prenatal 

11 care, labor care, birthing, and post12 partum care; 

13 (II) best practices for improving 

14 maternal health care based on data 

15 findings and reviews conducted by a 

16 State maternal mortality review com17 mittee that address topics of relevance 

18 to common complications or health 

19 risks related to prenatal care, labor 

20 care, birthing, and postpartum care; 

21 (III) information on addressing 

22 determinants of health that impact 

23 maternal health outcomes for women 

24 before, during, and after pregnancy; 

25 (IV) obstetric hemorrhage; 


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1 (V) obstetric and postpartum 

2 care for women with substance use 

3 disorders, including opioid use dis4 order; 

5 (VI) maternal cardiovascular sys6 tem; 

7 (VII) maternal mental health; 

8 (VIII) postpartum care basics for 

9 maternal safety; 

10 (IX) reduction of peripartum ra11 cial and ethnic disparities; 

12 (X) reduction of primary cae13 sarean birth; 

14 (XI) severe hypertension in preg15 nancy; 

16 (XII) severe maternal morbidity 

17 reviews; 

18 (XIII) support after a severe ma19 ternal morbidity event; 

20 (XIV) thromboembolism; 

21 (XV) optimization of support for 

22 breastfeeding; 

23 (XVI) maternal oral health; and 

24 (XVII) intimate partner violence; 

25 and 


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1 (C) to provide ongoing technical assistance 

2 at the national and State levels to support im3 plementation of maternal safety bundles under 

4 subparagraph (A). 

5 (4) MATERNAL SAFETY BUNDLE DEFINED.— 

6 For purposes of this subsection, the term ‘‘maternal 

7 safety bundle’’ means standardized, evidence-in8 formed processes for maternal health care. 

9 (5) AUTHORIZATION OF APPROPRIATIONS.—For 

10 purposes of carrying out this subsection, there is au11 thorized to be appropriated $10,000,000 for each of 

12 fiscal years 2021 through 2025. 

13 (d) FUNDING FOR STATE-BASED PERINATAL QUAL14 ITY COLLABORATIVES DEVELOPMENT AND SUSTAIN15 ABILITY.— 

16 (1) IN GENERAL.—Not later than one year 

17 after the date of enactment of this Act, the Sec18 retary of Health and Human Services (referred to in 

19 this subsection as the ‘‘Secretary’’), acting through 

20 the Division of Reproductive Health of the Centers 

21 for Disease Control and Prevention, shall establish a 

22 grant program to be known as the State-Based 

23 Perinatal Quality Collaborative grant program under 

24 which the Secretary awards grants to eligible entities 

25 for the purpose of development and sustainability of 


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1 perinatal quality collaboratives in every State, the 

2 District of Columbia, and eligible territories, in 

3 order to measurably improve perinatal care and 

4 perinatal health outcomes for pregnant and 

5 postpartum women and their infants. 

6 (2) GRANT AMOUNTS.—Grants awarded under 

7 this subsection shall be in amounts not to exceed 

8 $250,000 per year, for the duration of the grant pe9 riod. 

10 (3) STATE-BASED PERINATAL QUALITY COL11 LABORATIVE DEFINED.—For purposes of this sub12 section, the term ‘‘State-based perinatal quality col13 laborative’’ means a network of teams that— 

14 (A) is multidisciplinary in nature and in15 cludes the full range of perinatal and maternity 

16 care providers; 

17 (B) works to improve measurable outcomes 

18 for maternal and infant health by advancing 

19 evidence-informed clinical practices using qual20 ity improvement principles; 

21 (C) works with hospital-based or out22 patient facility-based clinical teams, experts, 

23 and stakeholders, including patients and fami24 lies, to spread best practices and optimize re25 sources to improve perinatal care and outcomes; 


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1 (D) employs strategies that include the use 

2 of the collaborative learning model to provide 

3 opportunities for hospitals and clinical teams to 

4 collaborate on improvement strategies, rapid-re5 sponse data to provide timely feedback to hos6 pital and other clinical teams to track progress, 

7 and quality improvement science to provide sup8 port and coaching to hospital and clinical 

9 teams; 

10 (E) has the goal of improving population11 level outcomes in maternal and infant health; 

12 and 

13 (F) has the goal of improving outcomes of 

14 all birthing people, through the coordination, 

15 integration, and collaboration across birth set16 tings. 

17 (4) AUTHORIZATION OF APPROPRIATIONS.—For 

18 purposes of carrying out this subsection, there is au19 thorized to be appropriated $14,000,000 per year 

20 for each of fiscal years 2021 through 2025. 

21 (e) EXPANSION OF MEDICAID AND CHIP COVERAGE

22 FOR PREGNANT AND POSTPARTUM WOMEN.— 

23 (1) REQUIRING COVERAGE OF ORAL HEALTH

24 SERVICES FOR PREGNANT AND POSTPARTUM

25 WOMEN.— 


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1 (A) MEDICAID.—Section 1905 of the So2 cial Security Act (42 U.S.C. 1396d) is amend3 ed— 

4 (i) in subsection (a)(4)— 

5 (I) by striking ‘‘; and (D)’’ and 

6 inserting ‘‘; (D)’’; and 

7 (II) by inserting ‘‘; and (E) oral 

8 health services for pregnant and 

9 postpartum women (as defined in sub10 section (hh))’’ after ‘‘subsection 

11 (bb))’’; and 

12 (ii) by adding at the end the following 

13 new subsection: 

14 ‘‘(hh) ORAL HEALTH SERVICES FOR PREGNANT AND

15 POSTPARTUM WOMEN.— 

16 ‘‘(1) IN GENERAL.—For purposes of this title, 

17 the term ‘oral health services for pregnant and 

18 postpartum women’ means dental services necessary 

19 to prevent disease and promote oral health, restore 

20 oral structures to health and function, and treat 

21 emergency conditions that are furnished to a woman 

22 during pregnancy (or during the 1-year period be23 ginning on the last day of the pregnancy). 

24 ‘‘(2) COVERAGE REQUIREMENTS.—To satisfy 

25 the requirement to provide oral health services for 


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1 pregnant and postpartum women, a State shall, at 

2 a minimum, provide coverage for preventive, diag3 nostic, periodontal, and restorative care consistent 

4 with recommendations for perinatal oral health care 

5 and dental care during pregnancy from the Amer6 ican Academy of Pediatric Dentistry and the Amer7 ican College of Obstetricians and Gynecologists.’’. 

8 (B) CHIP.—Section 2103(c)(5)(A) of the 

9 Social Security Act (42 U.S.C. 

10 1397cc(c)(5)(A)) is amended by inserting ‘‘or a 

11 targeted low-income pregnant woman’’ after 

12 ‘‘targeted low-income child’’. 

13 (2) EXTENDING MEDICAID COVERAGE FOR

14 PREGNANT AND POSTPARTUM WOMEN.—Section 

15 1902 of the Social Security Act (42 U.S.C. 1396a) 

16 is amended— 

17 (A) in subsection (e)— 

18 (i) in paragraph (5)— 

19 (I) by inserting ‘‘(including oral 

20 health services for pregnant and 

21 postpartum women (as defined in sec22 tion 1905(hh)))’’ after ‘‘postpartum 

23 medical assistance under the plan’’; 

24 and 


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1 (II) by striking ‘‘60-day’’ and in2 serting ‘‘1-year’’; and 

3 (ii) in paragraph (6), by striking ‘‘60- 

4 day’’ and inserting ‘‘1-year’’; and 

5 (B) in subsection (l)(1)(A), by striking 

6 ‘‘60-day’’ and inserting ‘‘1-year’’. 

7 (3) EXTENDING MEDICAID COVERAGE FOR

8 LAWFUL RESIDENTS.—Section 1903(v)(4)(A)(i) of 

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

10 1396b(v)(4)(A)(i)) is amended by striking ‘‘60-day’’ 

11 and inserting ‘‘1-year’’. 

12 (4) EXTENDING CHIP COVERAGE FOR PREG13 NANT AND POSTPARTUM WOMEN.—Section 

14 2112(d)(2)(A) of the Social Security Act (42 U.S.C. 

15 1397ll(d)(2)(A)) is amended by striking ‘‘60-day’’ 

16 and inserting ‘‘1-year’’. 

17 (5) MAINTENANCE OF EFFORT.— 

18 (A) MEDICAID.—Section 1902(l) of the So19 cial Security Act (42 U.S.C. 1396a(l)) is 

20 amended by adding at the end the following 

21 new paragraph: 

22 ‘‘(5) During the period that begins on the date of 

23 enactment of this paragraph and ends on the date that 

24 is five years after such date of enactment, as a condition 

25 for receiving any Federal payments under section 1903(a) 


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1 for calendar quarters occurring during such period, a 

2 State shall not have in effect, with respect to women who 

3 are eligible for medical assistance under the State plan 

4 or under a waiver of such plan on the basis of being preg5 nant or having been pregnant, eligibility standards, meth6 odologies, or procedures under the State plan or waiver 

7 that are more restrictive than the eligibility standards, 

8 methodologies, or procedures, respectively, under such 

9 plan or waiver that are in effect on the date of enactment 

10 of this paragraph.’’. 

11 (B) CHIP.—Section 2105(d) of the Social 

12 Security Act (42 U.S.C. 1397ee(d)) is amended 

13 by adding at the end the following new para14 graph: 

15 ‘‘(4) IN ELIGIBILITY STANDARDS FOR TAR16 GETED LOW-INCOME PREGNANT WOMEN.—During 

17 the period that begins on the date of enactment of 

18 this paragraph and ends on the date that is five 

19 years after such date of enactment, as a condition 

20 of receiving payments under subsection (a) and sec21 tion 1903(a), a State that elects to provide assist22 ance to women on the basis of being pregnant (in23 cluding pregnancy-related assistance provided to tar24 geted low-income pregnant women (as defined in 

25 section 2112(d)), pregnancy-related assistance proVerDate Sep 11 2014 00:50 Mar 17, 2021 Jkt 019200 PO 00000 Frm 00028 Fmt 6652 Sfmt 6201 E:\BILLS\S411.IS S411

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1 vided to women who are eligible for such assistance 

2 through application of section 1902(v)(4)(A)(i) 

3 under section 2107(e)(1), or any other assistance 

4 under the State child health plan (or a waiver of 

5 such plan) which is provided to women on the basis 

6 of being pregnant) shall not have in effect, with re7 spect to such women, eligibility standards, meth8 odologies, or procedures under such plan (or waiver) 

9 that are more restrictive than the eligibility stand10 ards, methodologies, or procedures, respectively, 

11 under such plan (or waiver) that are in effect on the 

12 date of enactment of this paragraph.’’. 

13 (6) INFORMATION ON BENEFITS.—The Sec14 retary of Health and Human Services shall make 

15 publicly available on the internet website of the De16 partment of Health and Human Services, informa17 tion regarding benefits available to pregnant and 

18 postpartum women and under the Medicaid program 

19 and the Children’s Health Insurance Program, in20 cluding information on— 

21 (A) benefits that States are required to 

22 provide to pregnant and postpartum women 

23 under such programs; 


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1 (B) optional benefits that States may pro2 vide to pregnant and postpartum women under 

3 such programs; and 

4 (C) the availability of different kinds of 

5 benefits for pregnant and postpartum women, 

6 including oral health and mental health bene7 fits, under such programs. 

8 (7) FEDERAL FUNDING FOR COST OF EX9 TENDED MEDICAID AND CHIP COVERAGE FOR

10 POSTPARTUM WOMEN.— 

11 (A) MEDICAID.—Section 1905 of the So12 cial Security Act (42 U.S.C. 1396d), as amend13 ed by paragraph (1), is further amended— 

14 (i) in subsection (b), by striking ‘‘and 

15 (ff)’’ and inserting ‘‘(aa), and (ii)’’; and 

16 (ii) by adding at the end the fol17 lowing: 

18 ‘‘(b) INCREASED FMAP FOR EXTENDED MEDICAL

19 ASSISTANCE FOR POSTPARTUM WOMEN.—Notwith20 standing subsection (b), the Federal medical assistance 

21 percentage for a State, with respect to amounts expended 

22 by such State for medical assistance for a woman who is 

23 eligible for such assistance on the basis of being pregnant 

24 or having been pregnant that is provided during the 305- 

25 day period that begins on the 60th day after the last day 


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1 of her pregnancy (including any such assistance provided 

2 during the month in which such period ends), shall be 

3 equal to— 

4 ‘‘(1) 100 percent for the first 20 calendar quar5 ters during which this subsection is in effect; and 

6 ‘‘(2) 90 percent for calendar quarters there7 after.’’. 

8 (B) CHIP.—Section 2105(c) of the Social 

9 Security Act (42 U.S.C. 1397ee(c)) is amended 

10 by adding at the end the following new para11 graph: 

12 ‘‘(12) ENHANCED PAYMENT FOR EXTENDED

13 ASSISTANCE PROVIDED TO PREGNANT WOMEN.— 

14 Notwithstanding subsection (b), the enhanced 

15 FMAP, with respect to payments under subsection 

16 (a) for expenditures under the State child health 

17 plan (or a waiver of such plan) for assistance pro18 vided under the plan (or waiver) to a woman who is 

19 eligible for such assistance on the basis of being 

20 pregnant (including pregnancy-related assistance 

21 provided to a targeted low-income pregnant woman 

22 (as defined in section 2112(d)), pregnancy-related 

23 assistance provided to a woman who is eligible for 

24 such assistance through application of section 

25 1902(v)(4)(A)(i) under section 2107(e)(1), or any 


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1 other assistance under the plan (or waiver) provided 

2 to a woman who is eligible for such assistance on the 

3 basis of being pregnant) during the 305-day period 

4 that begins on the 60th day after the last day of her 

5 pregnancy (including any such assistance provided 

6 during the month in which such period ends), shall 

7 be equal to— 

8 ‘‘(A) 100 percent for the first 20 calendar 

9 quarters during which this paragraph is in ef10 fect; and 

11 ‘‘(B) 90 percent for calendar quarters 

12 thereafter.’’. 

13 (8) GUIDANCE ON STATE OPTIONS FOR MED14 ICAID COVERAGE OF DOULA SERVICES.—Not later 

15 than 1 year after the date of the enactment of this 

16 Act, the Secretary of Health and Human Services, 

17 acting through the Administrator of the Centers for 

18 Medicare & Medicaid Services, shall issue guidance 

19 for the States concerning options for Medicaid cov20 erage and payment for support services provided by 

21 doulas. 

22 (9) EFFECTIVE DATE.— 

23 (A) IN GENERAL.—Subject to subpara24 graph (B), the amendments made by this sub25 section shall take effect on the first day of the 


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1 first calendar quarter that begins on or after 

2 the date that is one year after the date of en3 actment of this Act. 

4 (B) EXCEPTION FOR STATE LEGISLA5 TION.—In the case of a State plan under title 

6 XIX of the Social Security Act or a State child 

7 health plan under title XXI of such Act that 

8 the Secretary of Health and Human Services 

9 determines requires State legislation in order 

10 for the respective plan to meet any requirement 

11 imposed by amendments made by this sub12 section, the respective plan shall not be re13 garded as failing to comply with the require14 ments of such title solely on the basis of its fail15 ure to meet such an additional requirement be16 fore the first day of the first calendar quarter 

17 beginning after the close of the first regular 

18 session of the State legislature that begins after 

19 the date of enactment of this Act. For purposes 

20 of the previous sentence, in the case of a State 

21 that has a 2-year legislative session, each year 

22 of the session shall be considered to be a sepa23 rate regular session of the State legislature. 

24 (f) REGIONAL CENTERS OF EXCELLENCE.—Part P 

25 of title III of the Public Health Service Act (42 U.S.C. 


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1 280g et seq.) is amended by adding at the end the fol2 lowing new section: 

3 ‘‘SEC. 399V–7. REGIONAL CENTERS OF EXCELLENCE AD4 DRESSING IMPLICIT BIAS AND CULTURAL 

5 COMPETENCY IN PATIENT-PROVIDER INTER6 ACTIONS EDUCATION. 

7 ‘‘(a) IN GENERAL.—Not later than one year after the 

8 date of enactment of this section, the Secretary, in con9 sultation with such other agency heads as the Secretary 

10 determines appropriate, shall award cooperative agree11 ments for the establishment or support of regional centers 

12 of excellence addressing implicit bias, cultural competency, 

13 and respectful care practices in patient-provider inter14 actions education for the purpose of enhancing and im15 proving how health care professionals are educated in im16 plicit bias and delivering culturally competent health care. 

17 ‘‘(b) ELIGIBILITY.—To be eligible to receive a cooper18 ative agreement under subsection (a), an entity shall— 

19 ‘‘(1) be a public or other nonprofit entity speci20 fied by the Secretary that provides educational and 

21 training opportunities for students and health care 

22 professionals, which may be a health system, teach23 ing hospital, community health center, medical 

24 school, school of public health, school of nursing, 

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1 sional psychology, or any other health professional 

2 school or program at an institution of higher edu3 cation (as defined in section 101 of the Higher Edu4 cation Act of 1965) focused on the prevention, treat5 ment, or recovery of health conditions that con6 tribute to maternal mortality and the prevention of 

7 maternal mortality and severe maternal morbidity; 

8 ‘‘(2) demonstrate community engagement and 

9 participation, such as through partnerships with 

10 home visiting and case management programs; 

11 ‘‘(3) demonstrate engagement with groups en12 gaged in the implementation of health care profes13 sional training in implicit bias and delivering cul14 turally competent care, such as departments of pub15 lic health, perinatal quality collaboratives, hospital 

16 systems, and health care professional groups, in 

17 order to obtain input on resources needed for effec18 tive implementation strategies; and 

19 ‘‘(4) provide to the Secretary such information, 

20 at such time and in such manner, as the Secretary 

21 may require. 

22 ‘‘(c) DIVERSITY.—In awarding a cooperative agree23 ment under subsection (a), the Secretary shall take into 

24 account any regional differences among eligible entities 


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1 and make an effort to ensure geographic diversity among 

2 award recipients. 

3 ‘‘(d) DISSEMINATION OF INFORMATION.— 

4 ‘‘(1) PUBLIC AVAILABILITY.—The Secretary 

5 shall make publicly available on the internet website 

6 of the Department of Health and Human Services 

7 information submitted to the Secretary under sub8 section (b)(3). 

9 ‘‘(2) EVALUATION.—The Secretary shall evalu10 ate each regional center of excellence established or 

11 supported pursuant to subsection (a) and dissemi12 nate the findings resulting from each such evalua13 tion to the appropriate public and private entities. 

14 ‘‘(3) DISTRIBUTION.—The Secretary shall share 

15 evaluations and overall findings with State depart16 ments of health and other relevant State level offices 

17 to inform State and local best practices. 

18 ‘‘(e) MATERNAL MORTALITY DEFINED.—In this sec19 tion, the term ‘maternal mortality’ means death of a 

20 woman that occurs during pregnancy or within the one21 year period following the end of such pregnancy. 

22 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—For 

23 purposes of carrying out this section, there is authorized 

24 to be appropriated $5,000,000 for each of fiscal years 

25 2021 through 2025.’’. 


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1 (g) SPECIAL SUPPLEMENTAL NUTRITION PROGRAM

2 FOR WOMEN, INFANTS, AND CHILDREN.—Section 

3 17(d)(3)(A)(ii) of the Child Nutrition Act of 1966 (42 

4 U.S.C. 1786(d)(3)(A)(ii)) is amended— 

5 (1) by striking the clause designation and head6 ing and all that follows through ‘‘A State’’ and in7 serting the following: 

8 ‘‘(ii) WOMEN.— 

9 ‘‘(I) BREASTFEEDING WOMEN.— 

10 A State’’; 

11 (2) in subclause (I) (as so designated), by strik12 ing ‘‘1 year’’ and all that follows through ‘‘earlier’’ 

13 and inserting ‘‘2 years postpartum’’; and 

14 (3) by adding at the end the following: 

15 ‘‘(II) POSTPARTUM WOMEN.—A 

16 State may elect to certify a postpar17 tum woman for a period of 2 years.’’. 

18 (h) DEFINITIONS.—In this section: 

19 (1) MATERNAL MORTALITY.—The term ‘‘mater20 nal mortality’’ means death of a woman that occurs 

21 during pregnancy or within the one-year period fol22 lowing the end of such pregnancy. 

23 (2) PREGNANCY RELATED DEATH.—The term 

24 ‘‘pregnancy related death’’ includes the death of a 

25 woman during pregnancy or within one year of the 


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1 end of pregnancy from a pregnancy complication, a 

2 chain of events initiated by pregnancy, or the aggra3 vation of an unrelated condition by the physiologic 

4 effects of pregnancy. 

5 (3) SEVERE MATERNAL MORBIDITY.—The term 

6 ‘‘severe maternal morbidity’’ includes unexpected 

7 outcomes of labor and delivery that result in signifi8 cant short-term or long-term consequences to a 

9 woman’s health. 

10 SEC. 4. INCREASING EXCISE TAXES ON CIGARETTES AND 

11 ESTABLISHING EXCISE TAX EQUITY AMONG 

12 ALL TOBACCO PRODUCT TAX RATES. 

13 (a) TAX PARITY FOR ROLL-YOUR-OWN TOBACCO.— 

14 Section 5701(g) of the Internal Revenue Code of 1986 is 

15 amended by striking ‘‘$24.78’’ and inserting ‘‘$49.56’’. 

16 (b) TAX PARITY FOR PIPE TOBACCO.—Section 

17 5701(f) of the Internal Revenue Code of 1986 is amended 

18 by striking ‘‘$2.8311 cents’’ and inserting ‘‘$49.56’’. 

19 (c) TAX PARITY FOR SMOKELESS TOBACCO.— 

20 (1) Section 5701(e) of the Internal Revenue 

21 Code of 1986 is amended— 

22 (A) in paragraph (1), by striking ‘‘$1.51’’ 

23 and inserting ‘‘$26.84’’; 

24 (B) in paragraph (2), by striking ‘‘50.33 

25 cents’’ and inserting ‘‘$10.74’’; and 


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

2 ‘‘(3) SMOKELESS TOBACCO SOLD IN DISCRETE

3 SINGLE-USE UNITS.—On discrete single-use units, 

4 $100.66 per thousand.’’. 

5 (2) Section 5702(m) of such Code is amend6 ed— 

7 (A) in paragraph (1), by striking ‘‘or chew8 ing tobacco’’ and inserting ‘‘, chewing tobacco, 

9 or discrete single-use unit’’; 

10 (B) in paragraphs (2) and (3), by inserting 

11 ‘‘that is not a discrete single-use unit’’ before 

12 the period in each such paragraph; and 

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

14 ‘‘(4) DISCRETE SINGLE-USE UNIT.—The term 

15 ‘discrete single-use unit’ means any product con16 taining, made from, or derived from tobacco or nico17 tine that— 

18 ‘‘(A) is not intended to be smoked; and 

19 ‘‘(B) is in the form of a lozenge, tablet, 

20 pill, pouch, dissolvable strip, or other discrete 

21 single-use or single-dose unit.’’. 

22 (d) TAX PARITY FOR SMALL CIGARS.—Paragraph 

23 (1) of section 5701(a) of the Internal Revenue Code of 

24 1986 is amended by striking ‘‘$50.33’’ and inserting 

25 ‘‘$100.66’’. 


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1 (e) TAX PARITY FOR LARGE CIGARS.— 

2 (1) IN GENERAL.—Paragraph (2) of section 

3 5701(a) of the Internal Revenue Code of 1986 is 

4 amended by striking ‘‘52.75 percent’’ and all that 

5 follows through the period and inserting the fol6 lowing: ‘‘$49.56 per pound and a proportionate tax 

7 at the like rate on all fractional parts of a pound but 

8 not less than 10.066 cents per cigar.’’. 

9 (2) GUIDANCE.—The Secretary of the Treas10 ury, or the Secretary’s delegate, may issue guidance 

11 regarding the appropriate method for determining 

12 the weight of large cigars for purposes of calculating 

13 the applicable tax under section 5701(a)(2) of the 

14 Internal Revenue Code of 1986. 

15 (f) TAX PARITY FOR ROLL-YOUR-OWN TOBACCO

16 AND CERTAIN PROCESSED TOBACCO.—Subsection (o) of 

17 section 5702 of the Internal Revenue Code of 1986 is 

18 amended by inserting ‘‘, and includes processed tobacco 

19 that is removed for delivery or delivered to a person other 

20 than a person with a permit provided under section 5713, 

21 but does not include removals of processed tobacco for ex22 portation’’ after ‘‘wrappers thereof’’. 

23 (g) CLARIFYING TAX RATE FOR OTHER TOBACCO

24 PRODUCTS.— 


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1 (1) IN GENERAL.—Section 5701 of the Internal 

2 Revenue Code of 1986 is amended by adding at the 

3 end the following new subsection: 

4 ‘‘(i) OTHER TOBACCO PRODUCTS.—Any product not 

5 otherwise described under this section that has been deter6 mined to be a tobacco product by the Food and Drug Ad7 ministration through its authorities under the Family 

8 Smoking Prevention and Tobacco Control Act shall be 

9 taxed at a level of tax equivalent to the tax rate for ciga10 rettes on an estimated per use basis as determined by the 

11 Secretary.’’. 

12 (2) ESTABLISHING PER USE BASIS.—For pur13 poses of section 5701(i) of the Internal Revenue 

14 Code of 1986, not later than 12 months after the 

15 later of the date of the enactment of this Act or the 

16 date that a product has been determined to be a to17 bacco product by the Food and Drug Administra18 tion, the Secretary of the Treasury (or the Secretary 

19 of the Treasury’s delegate) shall issue final regula20 tions establishing the level of tax for such product 

21 that is equivalent to the tax rate for cigarettes on 

22 an estimated per use basis. 

23 (h) CLARIFYING DEFINITION OF TOBACCO PROD24 UCTS.— 


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1 (1) IN GENERAL.—Subsection (c) of section 

2 5702 of the Internal Revenue Code of 1986 is 

3 amended to read as follows: 

4 ‘‘(c) TOBACCO PRODUCTS.—The term ‘tobacco prod5 ucts’ means— 

6 ‘‘(1) cigars, cigarettes, smokeless tobacco, pipe 

7 tobacco, and roll-your-own tobacco, and 

8 ‘‘(2) any other product subject to tax pursuant 

9 to section 5701(i).’’. 

10 (2) CONFORMING AMENDMENTS.—Subsection 

11 (d) of section 5702 of such Code is amended by 

12 striking ‘‘cigars, cigarettes, smokeless tobacco, pipe 

13 tobacco, or roll-your-own tobacco’’ each place it ap14 pears and inserting ‘‘tobacco products’’. 

15 (i) INCREASING TAX ON CIGARETTES.— 

16 (1) SMALL CIGARETTES.—Section 5701(b)(1) 

17 of such Code is amended by striking ‘‘$50.33’’ and 

18 inserting ‘‘$100.66’’. 

19 (2) LARGE CIGARETTES.—Section 5701(b)(2) 

20 of such Code is amended by striking ‘‘$105.69’’ and 

21 inserting ‘‘$211.38’’. 

22 (j) TAX RATES ADJUSTED FOR INFLATION.—Section 

23 5701 of such Code, as amended by subsection (g), is 

24 amended by adding at the end the following new sub25 section: 


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1 ‘‘(j) INFLATION ADJUSTMENT.— 

2 ‘‘(1) IN GENERAL.—In the case of any calendar 

3 year beginning after 2021, the dollar amounts pro4 vided under this chapter shall each be increased by 

5 an amount equal to— 

6 ‘‘(A) such dollar amount, multiplied by 

7 ‘‘(B) the cost-of-living adjustment deter8 mined under section 1(f)(3) for the calendar 

9 year, determined by substituting ‘calendar year 

10 2020’ for ‘calendar year 2016’ in subparagraph 

11 (A)(ii) thereof. 

12 ‘‘(2) ROUNDING.—If any amount as adjusted 

13 under paragraph (1) is not a multiple of $0.01, such 

14 amount shall be rounded to the next highest multiple 

15 of $0.01.’’. 

16 (k) FLOOR STOCKS TAXES.— 

17 (1) IMPOSITION OF TAX.—On tobacco products 

18 manufactured in or imported into the United States 

19 which are removed before any tax increase date and 

20 held on such date for sale by any person, there is 

21 hereby imposed a tax in an amount equal to the ex22 cess of— 

23 (A) the tax which would be imposed under 

24 section 5701 of the Internal Revenue Code of 


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1 1986 on the article if the article had been re2 moved on such date, over 

3 (B) the prior tax (if any) imposed under 

4 section 5701 of such Code on such article. 

5 (2) CREDIT AGAINST TAX.—Each person shall 

6 be allowed as a credit against the taxes imposed by 

7 paragraph (1) an amount equal to $500. Such credit 

8 shall not exceed the amount of taxes imposed by 

9 paragraph (1) on such date for which such person 

10 is liable. 

11 (3) LIABILITY FOR TAX AND METHOD OF PAY12 MENT.— 

13 (A) LIABILITY FOR TAX.—A person hold14 ing tobacco products on any tax increase date 

15 to which any tax imposed by paragraph (1) ap16 plies shall be liable for such tax. 

17 (B) METHOD OF PAYMENT.—The tax im18 posed by paragraph (1) shall be paid in such 

19 manner as the Secretary shall prescribe by reg20 ulations. 

21 (C) TIME FOR PAYMENT.—The tax im22 posed by paragraph (1) shall be paid on or be23 fore the date that is 120 days after the effective 

24 date of the tax rate increase. 


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1 (4) ARTICLES IN FOREIGN TRADE ZONES.— 

2 Notwithstanding the Act of June 18, 1934 (com3 monly known as the Foreign Trade Zone Act, 48 

4 Stat. 998, 19 U.S.C. 81a et seq.), or any other pro5 vision of law, any article which is located in a for6 eign trade zone on any tax increase date shall be 

7 subject to the tax imposed by paragraph (1) if— 

8 (A) internal revenue taxes have been deter9 mined, or customs duties liquidated, with re10 spect to such article before such date pursuant 

11 to a request made under the first proviso of 

12 section 3(a) of such Act, or 

13 (B) such article is held on such date under 

14 the supervision of an officer of the United 

15 States Customs and Border Protection of the 

16 Department of Homeland Security pursuant to 

17 the second proviso of such section 3(a). 

18 (5) DEFINITIONS.—For purposes of this sub19 section— 

20 (A) IN GENERAL.—Any term used in this 

21 subsection which is also used in section 5702 of 

22 such Code shall have the same meaning as such 

23 term has in such section. 

24 (B) TAX INCREASE DATE.—The term ‘‘tax 

25 increase date’’ means the effective date of any 


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1 increase in any tobacco product excise tax rate 

2 pursuant to the amendments made by this sec3 tion (other than subsection (j) thereof). 

4 (C) SECRETARY.—The term ‘‘Secretary’’ 

5 means the Secretary of the Treasury or the 

6 Secretary’s delegate. 

7 (6) CONTROLLED GROUPS.—Rules similar to 

8 the rules of section 5061(e)(3) of such Code shall 

9 apply for purposes of this subsection. 

10 (7) OTHER LAWS APPLICABLE.—All provisions 

11 of law, including penalties, applicable with respect to 

12 the taxes imposed by section 5701 of such Code 

13 shall, insofar as applicable and not inconsistent with 

14 the provisions of this subsection, apply to the floor 

15 stocks taxes imposed by paragraph (1), to the same 

16 extent as if such taxes were imposed by such section 

17 5701. The Secretary may treat any person who bore 

18 the ultimate burden of the tax imposed by para19 graph (1) as the person to whom a credit or refund 

20 under such provisions may be allowed or made. 

21 (l) EFFECTIVE DATES.— 

22 (1) IN GENERAL.—Except as provided in para23 graphs (2) through (4), the amendments made by 

24 this section shall apply to articles removed (as de25 fined in section 5702(j) of the Internal Revenue 


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1 Code of 1986) after the last day of the month which 

2 includes the date of the enactment of this Act. 

3 (2) DISCRETE SINGLE-USE UNITS AND PROC4 ESSED TOBACCO.—The amendments made by sub5 sections (c)(1)(C), (c)(2), and (f) shall apply to arti6 cles removed (as defined in section 5702(j) of the 

7 Internal Revenue Code of 1986) after the date that 

8 is 6 months after the date of the enactment of this 

9 Act. 

10 (3) LARGE CIGARS.—The amendments made by 

11 subsection (e) shall apply to articles removed after 

12 December 31, 2021. 

13 (4) OTHER TOBACCO PRODUCTS.—The amend14 ments made by subsection (g)(1) shall apply to prod15 ucts removed after the last day of the month which 

16 includes the date that the Secretary of the Treasury 

17 (or the Secretary of the Treasury’s delegate) issues 

18 final regulations establishing the level of tax for 

19 such product. 

Æ 


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