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[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 1261 Introduced in Senate (IS)]

<DOC>

116th CONGRESS
  1st Session
                                S. 1261

   To provide for the establishment of Medicare part E public health 
                     plans, and for other purposes.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

                              May 1, 2019

 Mr. Merkley (for himself, Mr. Murphy, Mrs. Feinstein, Ms. Harris, Mr. 
 Blumenthal, Mr. Schatz, Ms. Baldwin, Mr. Durbin, Mr. Reed, Ms. Smith, 
   Mrs. Shaheen, Ms. Duckworth, Mr. Booker, Mrs. Gillibrand, and Mr. 
   Heinrich) introduced the following bill; which was read twice and 
                  referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL

 
   To provide for the establishment of Medicare part E public health 
                     plans, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Choose Medicare Act''.

SEC. 2. PUBLIC HEALTH PLAN.

    The Social Security Act is amended by adding at the end the 
following:

           ``title xxii--medicare part e public health plans

    ``Sec. 2201. Public Health Plans.--
    ``(a) Establishment.--The Secretary shall establish public health 
plans (to be known as `Medicare part E plans') that are available in 
the individual market, small group market, and large group market.
    ``(b) Benefits.--
            ``(1) In general.--Each Medicare part E plan, regardless of 
        whether the plan is offered in the individual market, small 
        group market, or large group market, shall be a qualified 
        health plan within the meaning of section 1301(a) of the 
        Patient Protection and Affordable Care Act (42 U.S.C. 18021(a)) 
        that--
                    ``(A) meets all requirements applicable to 
                qualified health plans under subtitle D of title I of 
                the Patient Protection and Affordable Care Act (42 
                U.S.C. 18021 et seq.) (other than the requirement under 
                section 1301(a)(1)(C)(ii) of such Act) and title XXVII 
                of the Public Health Service Act (42 U.S.C. 300gg et 
                seq.);
                    ``(B) provides coverage of--
                            ``(i) the essential health benefits 
                        described in section 1302(b) of the Patient 
                        Protection and Affordable Care Act (42 U.S.C. 
                        18022(b)); and
                            ``(ii) all items and services for which 
                        benefits are available under title XVIII;
                    ``(C) provides gold-level coverage described in 
                section 1302(d)(1)(C) of the Patient Protection and 
                Affordable Care Act (42 U.S.C. 18022(d)(1)(C)); and
                    ``(D) provides coverage of abortions and all other 
                reproductive services.
            ``(2) Preemption.--Notwithstanding section 1303(a)(1) of 
        the Patient Protection and Affordable Care Act (42 U.S.C. 
        18023(a)(1))--
                    ``(A) a State may not prohibit a Medicare part E 
                plan from offering the coverage described in paragraph 
                (1)(D); and
                    ``(B) no State law that would prohibit such a plan 
                from offering such coverage shall apply to such plan.
    ``(c) Eligibility; Enrollment.--
            ``(1) Availability on the exchanges.--The Medicare part E 
        plans offered in the individual and small group markets shall 
        be offered through the Federal and State Exchanges, including 
        the Small Business Health Options Program Exchanges (commonly 
        referred to as the `SHOP Exchanges').
            ``(2) Eligibility.--
                    ``(A) In general.--Any individual who is a resident 
                of the United States, as determined by the Secretary 
                under subparagraph (C), and who is not an individual 
                described in subparagraph (B), is eligible to enroll in 
                a Medicare part E plan.
                    ``(B) Exclusions.--An individual described in this 
                subparagraph is any individual who is--
                            ``(i) entitled to, or enrolled for, 
                        benefits under title XVIII;
                            ``(ii) eligible for medical assistance 
                        under a State plan under title XIX; or
                            ``(iii) enrolled for child health 
                        assistance or pregnancy-related assistance 
                        under a State plan under title XXI.
                    ``(C) Regulations.--The Secretary shall promulgate 
                a rule for determining residency for purposes of 
                subparagraph (A).
            ``(3) Employer-sponsored plans.--
                    ``(A) Employer enrollment.--Effective with respect 
                to the first plan year that begins 1 year after the 
                date of enactment of the Choose Medicare Act and each 
                plan year thereafter, the Secretary shall provide 
                options for Medicare part E plans in the small group 
                market and large group market that are voluntary, and 
                available to all employers.
                    ``(B) Group health plans.--The Secretary, acting 
                through the Administrator for the Centers for Medicare 
                & Medicaid Services, at the request of a plan sponsor, 
                shall serve as a third-party administrator of a group 
                health plan that is a Medicare part E plan offered by 
                such sponsor.
                    ``(C) Portability for employer-sponsored plans.--
                The Secretary shall develop a process for allowing 
                individuals enrolled in a Medicare part E plan offered 
                in the small group market or large group market to 
                maintain health insurance coverage through a Medicare 
                part E plan if the individual subsequently loses 
                eligibility for enrollment in such a plan based on 
                termination of the employment relationship. The ability 
                to maintain such coverage shall exist regardless of 
                whether the individual has the option to enroll in 
                other health insurance coverage, including coverage 
                offered in the individual market or through a 
                subsequent employer.
    ``(d) Premiums.--The Secretary shall establish premium rates for 
the Medicare part E plans that--
            ``(1) are adjusted based on--
                    ``(A) whether the plan is offered in the individual 
                market, small group market, or large group market; and
                    ``(B) the applicable rating area;
            ``(2) are at a level sufficient to fully finance--
                    ``(A) the costs of health benefits provided by such 
                plans; and
                    ``(B) administrative costs related to operating the 
                plans; and
            ``(3) comply with the requirements under section 2701 of 
        the Public Health Service Act, including for such plans that 
        are offered in the large group market.
    ``(e) Providers and Reimbursement Rates.--
            ``(1) In general.--The Secretary shall establish a rate 
        schedule for reimbursing types of health care providers 
        furnishing items and services under the Medicare part E plans 
        at rates that are consistent with the negotiations described in 
        paragraph (2) and are necessary to maintain network adequacy.
            ``(2) Manner of negotiation.--The Secretary shall negotiate 
        the rates described in paragraph (1) in a manner that results 
        in payment rates that are not lower, in the aggregate, than 
        rates under title XVIII, and not higher, in the aggregate, than 
        the average rates paid by other health insurance issuers 
        offering health insurance coverage through an Exchange.
            ``(3) Participating providers.--
                    ``(A) In general.--A health care provider that is a 
                participating provider of services or supplier under 
                the Medicare program under title XVIII on the date of 
                enactment of Choose Medicare Act shall be a 
                participating provider for Medicare part E plans.
                    ``(B) Additional providers.--The Secretary shall 
                establish a process to allow health care providers not 
                described in subparagraph (A) to become participating 
                providers for Medicare part E plans.
            ``(4) Limitations on balance billing.--The limitations on 
        balance billing pursuant to the provisions of section 
        1866(a)(1)(A) of the Social Security Act (42 U.S.C. 
        1395cc(a)(1)(A)) shall apply to participating providers for 
        Medicare part E plans in the same manner as such provisions 
        apply to participating providers under the Medicare program.
    ``(f) Encouraging Use of Alternative Payment Models.--The Secretary 
shall, as applicable, utilize alternative payment models, including 
those described in section 1833(z)(3)(C), as added by section 101(e)(2) 
of the Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 
114-10), in making payments for items and services (including 
prescription drugs) furnished under Medicare part E plans. The payment 
rates under such alternative payment models shall comply with the 
requirement for negotiated rates under subsection (e)(2).
    ``(g) Prescription Drugs.--The Secretary shall apply the provisions 
of section 1860D-11(i) to prescription drugs under Medicare part E 
plans in the same manner as such provisions apply with respect to 
applicable covered part D drugs under such section.
    ``(h) Appropriations.--
            ``(1) Start up funding.--For purposes of establishing the 
        Medicare part E plans, there is appropriated to the Secretary, 
        out of any funds in the Treasury not otherwise obligated, 
        $2,000,000,000, for fiscal year 2020.
            ``(2) Initial reserves.--There is appropriated to the 
        Secretary, out of any funds in the Treasury not otherwise 
        obligated, such sums as may be necessary, based on projected 
        enrollment in the Medicare part E plans in the first plan year 
        in which such plans are offered, to provide reserves for the 
        purpose of paying claims filed during the initial 90-day period 
        of such plan year.
            ``(3) Clarification.--Any provision of law restricting the 
        use of Federal funds with respect to any reproductive health 
        service shall not apply to funds appropriated under paragraph 
        (1) or (2).
    ``(i) Health Insurance Issuer.--With respect to any Medicare part E 
plan, the Secretary shall be considered a health insurance issuer, 
within the meaning of section 2791(b) of the Public Health Service 
Act.''.

SEC. 3. NOTICE AND NAVIGATOR REFERRAL FOR EMPLOYEES UNDER THE FAIR 
              LABOR STANDARDS ACT OF 1938.

    (a) In General.--Section 18B of the Fair Labor Standards Act of 
1938 (29 U.S.C. 218b) is amended--
            (1) in the heading, by striking ``to'' and inserting ``and 
        navigator referral for'';
            (2) by redesignating subsection (b) as subsection (c);
            (3) by inserting after subsection (a) the following:
    ``(b) Navigator Referral.--
            ``(1) In general.--An employer described in paragraph (3) 
        shall refer each full-time employee (as defined in section 
        4980H of the Internal Revenue Code of 1986) to--
                    ``(A) an entity that serves as a navigator under 
                section 1311(i) of the Patient Protection and 
                Affordable Care Act (42 U.S.C. 18031(i)) for the 
                Exchange operating in the State of the employer; or
                    ``(B) if the Exchange operating in the State of the 
                employer does not have an entity serving as such a 
                navigator, another entity that shall carry out 
                equivalent activities as such a navigator.
            ``(2) Referral.--The referral described in paragraph (1) 
        shall occur--
                    ``(A) at the time the employer hires the employee; 
                or
                    ``(B) on the effective date described in subsection 
                (c)(2) with respect to an employee who is currently 
                employed by the employer on such date.
            ``(3) Employer.--An employer described in this paragraph is 
        any employer that--
                    ``(A) does not provide an eligible employer-
                sponsored plan as defined in section 5000A(f)(2) of the 
                Internal Revenue Code of 1986; or
                    ``(B) provides such an eligible employer-sponsored 
                plan, but the plan is determined under section 
                36B(c)(2)(C) of such Code--
                            ``(i) to be unaffordable to the employee; 
                        or
                            ``(ii) to not provide the required minimum 
                        actuarial value.''; and
            (4) in subsection (c), as so redesignated--
                    (A) in the heading, by striking ``Effective Date'' 
                and inserting ``Effective Dates'';
                    (B) by striking ``Subsection (a)'' and inserting 
                the following:
            ``(1) Notice.--Subsection (a);''; and
                    (C) by adding at the end the following:
            ``(2) Navigator referral.--Subsection (b) shall take effect 
        with respect to employers in a State beginning on the date that 
        is 2 years after the date of enactment of the Choose Medicare 
        Act.''.
    (b) Study.--Not later than January 1, 2024, the Comptroller General 
of the United States shall conduct a study on the impact of the 
requirements under section 18B of the Fair Labor Standards Act of 1938 
(29 U.S.C. 218b), including the amendments made by subsection (a), on 
the rate of individuals without minimum essential coverage as defined 
in section 5000A of the Internal Revenue Code of 1986 in the United 
States and in each State.
    (c) Funding for Navigator Program.--Section 1311(i)(6) of the 
Patient Protection and Affordable Care Act (42 U.S.C. 18031(i)(6)) is 
amended--
            (1) by striking ``Grants'' and inserting the following:
                    ``(A) In general.--Grants''; and
            (2) by adding at the end the following:
                    ``(B) Authorization of appropriations.--There is 
                authorized to be appropriated such sums as may be 
                necessary to address capacity limitations of entities 
                serving as navigators through a grant under this 
                subsection.''.

SEC. 4. PROTECTING AGAINST HIGH OUT-OF-POCKET EXPENDITURES FOR MEDICARE 
              FEE-FOR-SERVICE BENEFITS.

    Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is 
amended by adding at the end the following new section:

          ``protection against high out-of-pocket expenditures

    ``Sec. 1899C.  (a) In General.--Notwithstanding any other provision 
of this title, in the case of an individual entitled to, or enrolled 
for, benefits under part A or enrolled in part B, if the amount of the 
out-of-pocket cost-sharing of such individual for a year (beginning 
with 2021) equals or exceeds the annual out-of-pocket limit under 
subsection (b) for that year, the individual shall not be responsible 
for additional out-of-pocket cost-sharing incurred during that year.
    ``(b) Annual Out-of-Pocket Limit.--
            ``(1) In general.--The amount of the annual out-of-pocket 
        limit under this subsection shall be--
                    ``(A) for 2021, $6,700; or
                    ``(B) for a subsequent year, the amount specified 
                in this subsection for the preceding year increased or 
                decreased by the percentage change in the medical care 
                component of the Consumer Price Index for All Urban 
                Consumers for the 12-month period ending with June of 
                such preceding year.
            ``(2) Rounding.--If any amount determined under paragraph 
        (1)(B) is not a multiple of $5, such amount shall be rounded to 
        the nearest multiple of $5.
    ``(c) Out-of-Pocket Cost-Sharing Defined.--
            ``(1) In general.--Subject to paragraphs (2) and (3), in 
        this section, the term `out-of-pocket cost-sharing' means, with 
        respect to an individual, the amount of the expenses incurred 
        by the individual that are attributable to--
                    ``(A) deductibles, coinsurance, and copayments 
                applicable under part A or B; or
                    ``(B) for items and services that would have 
                otherwise been covered under part A or B but for the 
                exhaustion of those benefits.
            ``(2) Certain costs not included.--
                    ``(A) Non-covered items and services.--Expenses 
                incurred for items and services which are not covered 
                under part A or B shall not be considered incurred 
                expenses for purposes of determining out-of-pocket 
                cost-sharing under paragraph (1).
                    ``(B) Items and services not furnished on an 
                assignment-related basis.--If an item or service is 
                furnished to an individual under this title and is not 
                furnished on an assignment-related basis, any 
                additional expenses the individual incurs above the 
                amount the individual would have incurred if the item 
                or service was furnished on an assignment-related basis 
                shall not be considered incurred expenses for purposes 
                of determining out-of-pocket cost-sharing under 
                paragraph (1).
            ``(3) Source of payment.--For purposes of paragraph (1), 
        the Secretary shall consider expenses to be incurred by the 
        individual without regard to whether the individual or another 
        person, including a State program, an employer, a Medicare 
        supplemental policy, or other third-party coverage, has paid 
        for such expenses.
    ``(d) Announcement of the Annual Out-of-Pocket Limit.--The 
Secretary shall (beginning in 2020) announce (in a manner intended to 
provide notice to all interested parties) the annual out-of-pocket 
limit under this section that will be applicable for the succeeding 
year.''.

SEC. 5. NEGOTIATING FAIR PRICES FOR MEDICARE PRESCRIPTION DRUGS.

    (a) In General.--Section 1860D-11 of the Social Security Act (42 
U.S.C. 1395w-111) is amended by striking subsection (i) (relating to 
noninterference) and by inserting the following:
    ``(i) Negotiating Fair Prices With Drug Manufacturers.--
            ``(1) In general.--Notwithstanding any other provision of 
        law, in furtherance of the goals of providing quality care and 
        containing costs under this part, the Secretary shall, with 
        respect to applicable covered part D drugs, and may, with 
        respect to other covered part D drugs, negotiate, using the 
        negotiation technique or techniques that the Secretary 
        determines will maximize savings and value to the government 
        for prescription drug plans and MA-PD plans and for plan 
        enrollees (in a manner that may be similar to Federal entities 
        and that may include, but is not limited to, formularies, 
        reference pricing, discounts, rebates, other price concessions, 
        and coverage determinations), with drug manufacturers the 
        prices that may be charged to PDP sponsors and MA organizations 
        for such drugs for part D eligible individuals who are enrolled 
        in a prescription drug plan or in an MA-PD plan. In conducting 
        such negotiations, the Secretary shall consider the drug's 
        current price, initial launch price, prevalence of disease and 
        usage, and approved indications, the number of similarly 
        effective alternative treatments for each approved use of the 
        drug, the budgetary impact of providing coverage under this 
        part for such drug for all individuals who would likely benefit 
        from the drug, evidence on the drug's effectiveness and safety 
        compared to similar drugs, and the quality and quantity of 
        clinical data and rigor of the applicable process of approval 
        of a drug under section 505 of the Federal Food, Drug, and 
        Cosmetic Act or a biological product under section 351 of the 
        Public Health Service Act.
            ``(2) Use of lower of va or big four price if negotiations 
        fail.--If, after attempting to negotiate for a price with 
        respect to a covered part D drug under paragraph (1) for a 
        period of 1 year, the Secretary is not successful in obtaining 
        an appropriate price for the drug (as determined by the 
        Secretary), the Secretary shall establish the price that may be 
        charged to PDP sponsors and MA organizations for such drug for 
        part D eligible individuals who are enrolled in a prescription 
        drug plan or in an MA-PD plan at an amount equal to the lesser 
        of--
                    ``(A) the price paid by the Secretary of Veterans 
                Affairs to procure the drug under the laws administered 
                by the Secretary of Veterans Affairs; or
                    ``(B) the price paid to procure the drug under 
                section 8126 of title 38, United States Code.
            ``(3) Applicable covered part d drug defined.--For purposes 
        of this subsection, the term `applicable covered part D drug' 
        means a covered part D drug that the Secretary determines to be 
        appropriate for negotiation under paragraph (1) based on one or 
        more of the following factors as applied to such drug:
                    ``(A) Spending on a per beneficiary basis.
                    ``(B) The proportion of total spending under this 
                title.
                    ``(C) Unit price increases over the preceding 5 
                years.
                    ``(D) Initial launch price.
                    ``(E) Availability of less expensive, similarly 
                effective alternative treatments.
                    ``(F) Status of the drug as a follow-on to 
                previously approved drugs.
                    ``(G) Any other criteria determined by the 
                Secretary.
            ``(4) PDP sponsors and ma organization may negotiate lower 
        prices.--Nothing in this subsection shall be construed as 
        preventing the sponsor of a prescription drug plan, or an 
        organization offering an MA-PD plan, from obtaining a discount 
        or reduction of the price for a covered part D drug below the 
        price negotiated under paragraph (1) or the price established 
        under paragraph (2).
            ``(5) No effect on existing appeals process.--Nothing in 
        this subsection shall be construed to affect the appeals 
        procedures under subsections (g) and (h) of section 1860D-4.''.
    (b) Effective Date.--The amendments made by this section shall take 
effect on the date of the enactment of this Act and shall first apply 
to negotiations and prices for plan years beginning on January 1, 2020.

SEC. 6. ENHANCEMENT OF PREMIUM ASSISTANCE CREDIT.

    (a) Use of Gold Level Plan for Benchmark.--
            (1) In general.--Clause (i) of section 36B(b)(2)(B) of the 
        Internal Revenue Code of 1986 is amended by striking 
        ``applicable second lowest cost silver plan'' and inserting 
        ``applicable second lowest cost gold plan''.
            (2) Conforming amendment related to affordability.--Section 
        36B(c)(4)(C)(i)(I) of such Code is amended by striking ``second 
        lowest cost silver plan'' and inserting ``second lowest cost 
        gold plan''.
            (3) Other conforming amendments.--Subparagraphs (B) and (C) 
        of section 36B(b)(3) of such Code are each amended by striking 
        ``silver plan'' each place it appears in the text and the 
        heading and inserting ``gold plan''.
    (b) Expansion of Eligibility for Refundable Credits for Coverage 
Under Qualified Health Plans.--
            (1) In general.--Section 36B(c)(1)(A) of the Internal 
        Revenue Code of 1986 is amended by striking ``400 percent'' and 
        inserting ``600 percent''.
            (2) Conforming amendment.--The last line of the table 
        contained in section 36B(b)(3)(A)(i) of such Code is amended by 
        striking ``400%'' and inserting ``600%''.
            (3) Conforming amendments relating to recapture of excess 
        advanced payments.--Clause (i) of section 36B(f)(2)(B) of such 
        Code is amended--
                    (A) by striking ``400 percent'' and inserting ``600 
                percent''; and
                    (B) by striking ``400%'' in the table therein and 
                inserting ``600%''.
    (c) Elimination of Failsafe.--Section 36B(b)(3)(A)(ii) of the 
Internal Revenue Code of 1986 is amended by striking subclause (III).
    (d) Effective Date.--The amendments made by this section shall 
apply to taxable years beginning after December 31, 2018.

SEC. 7. ENHANCEMENTS FOR REDUCED COST SHARING.

    (a) Definition of Eligible Individual.--Section 1402(b)(1) of the 
Patient Protection and Affordable Care Act (42 U.S.C. 1807(b)(1)) is 
amended by striking ``silver level'' and inserting ``gold level''.
    (b) Modification of Amount.--
            (1) In general.--Section 1402(c)(2) of the Patient 
        Protection and Affordable Care Act is amended to read as 
        follows:
            ``(2) Additional reduction.--The Secretary shall establish 
        procedures under which the issuer of a qualified health plan to 
        which this section applies shall further reduce cost-sharing 
        under the plan in a manner sufficient to--
                    ``(A) in the case of an eligible insured whose 
                household income is not less than 100 percent but not 
                more than 133 percent of the poverty line for a family 
                of the size involved, increase the plan's share of the 
                total allowed costs of benefits provided under the plan 
                to 94 percent of such costs;
                    ``(B) in the case of an eligible insured whose 
                household income is more than 133 percent but not more 
                than 150 percent of the poverty line for a family of 
                the size involved, increase the plan's share of the 
                total allowed costs of benefits provided under the plan 
                to 92 percent of such costs;
                    ``(C) in the case of an eligible insured whose 
                household income is more than 150 percent but not more 
                than 200 percent of the poverty line for a family of 
                the size involved, increase the plan's share of the 
                total allowed costs of benefits provided under the plan 
                to 90 percent of such costs;
                    ``(D) in the case of an eligible insured whose 
                household income is more than 200 percent but not more 
                than 300 percent of the poverty line for a family of 
                the size involved, increase the plan's share of the 
                total allowed costs of benefits provided under the plan 
                to 85 percent of such costs; and
                    ``(E) in the case of an eligible insured whose 
                household income is more than 300 percent but not more 
                than 400 percent of the poverty line for a family of 
                the size involved, increase the plan's share of the 
                total allowed costs of benefits provided under the plan 
                to 80 percent of such costs.''.
            (2) Conforming amendment.--Clause (i) of section 
        1402(c)(1)(B) of such Act is amended to read as follows:
                            ``(i) In general.--The Secretary shall 
                        ensure the reduction under this paragraph shall 
                        not result in an increase in the plan's share 
                        of the total allowed costs of benefits provided 
                        under the plan above--
                                    ``(I) 94 percent in the case of an 
                                eligible insured described in paragraph 
                                (2)(A);
                                    ``(II) 92 percent in the case of an 
                                eligible insured described in paragraph 
                                (2)(B);
                                    ``(III) 90 percent in the case of 
                                an eligible insured described in 
                                paragraph (2)(C);
                                    ``(IV) 85 percent in the case of an 
                                eligible insured described in paragraph 
                                (2)(D); and
                                    ``(V) 80 percent in the case of an 
                                eligible insured described in paragraph 
                                (2)(E).''.
    (c) Effective Date.--The amendments made by this section shall 
apply to plan years beginning after December 31, 2019.

SEC. 8. REINSURANCE AND AFFORDABILITY FUND.

    Part 5 of subtitle D of title I of the Patient Protection and 
Affordable Care Act is amended by inserting after section 1341 (42 
U.S.C. 18061) the following:

``SEC. 1341A. REINSURANCE AND AFFORDABILITY FUND FOR THE INDIVIDUAL 
              MARKET IN EACH STATE.

    ``(a) In General.--The Secretary, in consultation with the National 
Association of Insurance Commissioners, shall establish a program to 
enable each State, for any plan year beginning in the 3-year period 
beginning January 1, 2020, to--
            ``(1) provide reinsurance payments to health insurance 
        issuers with respect to individuals enrolled under individual 
        health insurance coverage offered by such issuers; or
            ``(2) provide assistance (other than through payments 
        described in paragraph (1)) to reduce out-of-pocket costs, such 
        as copayments, coinsurance, premiums, and deductibles, of 
        individuals enrolled under qualified health plans offered in 
        the individual market through an Exchange.
    ``(b) Appropriations.--There is appropriated, out of any money in 
the Treasury not otherwise appropriated, $30,000,000,000 for the period 
of fiscal years 2020 through 2022 for purposes of establishing and 
administering the program established under this section. Such amount 
shall remain available until expended.''.

SEC. 9. EXPANDING RATING RULES TO LARGE GROUP MARKET.

    (a) In General.--Section 2701(a) of the Public Health Service Act 
(42 U.S.C. 300gg(a)) is amended--
            (1) in paragraph (1), by striking ``small''; and
            (2) by striking paragraph (5).
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to plans offered in the first plan year beginning after the date 
of enactment of this Act and any plan year thereafter.

SEC. 10. PROTECTION OF CONSUMERS FROM EXCESSIVE, UNJUSTIFIED, OR 
              UNFAIRLY DISCRIMINATORY RATES.

    (a) Protection From Excessive, Unjustified, or Unfairly 
Discriminatory Rates.--The first section 2794 of the Public Health 
Service Act (42 U.S.C. 300gg-94), as added by section 1003 of the 
Patient Protection and Affordable Care Act (Public Law 111-148), is 
amended by adding at the end the following new subsection:
    ``(e) Protection From Excessive, Unjustified, or Unfairly 
Discriminatory Rates.--
            ``(1) Authority of states.--Nothing in this section shall 
        be construed to prohibit a State from imposing requirements 
        (including requirements relating to rate review standards and 
        procedures and information reporting) on health insurance 
        issuers with respect to rates that are in addition to the 
        requirements of this section and are more protective of 
        consumers than such requirements.
            ``(2) Consultation in rate review process.--In carrying out 
        this section, the Secretary shall consult with the National 
        Association of Insurance Commissioners and consumer groups.
            ``(3) Determination of who conducts reviews for each 
        state.--The Secretary shall determine, after the date of 
        enactment of this subsection and periodically thereafter, the 
        following:
                    ``(A) In which markets in each State the State 
                insurance commissioner or relevant State regulator 
                shall undertake the corrective actions under paragraph 
                (4), as a condition of the State receiving the grant in 
                subsection (c), based on the Secretary's determination 
                that the State insurance commissioner or relevant State 
                regulator is adequately undertaking and utilizing such 
                actions in that market.
                    ``(B) In which markets in each State the Secretary 
                shall undertake the corrective actions under paragraph 
                (4), in cooperation with the relevant State insurance 
                commissioner or State regulator, based on the 
                Secretary's determination that the State is not 
                adequately undertaking and utilizing such actions in 
                that market.
            ``(4) Corrective action for excessive, unjustified, or 
        unfairly discriminatory rates.--In accordance with the process 
        established under this section, the Secretary or the relevant 
        State insurance commissioner or State regulator shall take 
        corrective actions to ensure that any excessive, unjustified, 
        or unfairly discriminatory rates are corrected prior to 
        implementation, or as soon as possible thereafter, through 
        mechanisms such as--
                    ``(A) denying rates;
                    ``(B) modifying rates; or
                    ``(C) requiring rebates to consumers.
            ``(5) Noncompliance.--Failure to comply with any corrective 
        action taken by the Secretary under this subsection may result 
        in the application of civil monetary penalties and, if the 
        Secretary determines appropriate, make the plan involved 
        ineligible for classification as a qualified health plan.''.
    (b) Clarification of Regulatory Authority.--Such section is further 
amended--
            (1) in subsection (a)--
                    (A) in the subsection heading, by striking 
                ``Premium'' and inserting ``Rate'';
                    (B) in paragraph (1), by striking ``unreasonable 
                increases in premiums'' and inserting ``potentially 
                excessive, unjustified, or unfairly discriminatory 
                rates, including premiums,''; and
                    (C) in paragraph (2)--
                            (i) by striking ``an unreasonable premium 
                        increase'' and inserting ``a potentially 
                        excessive, unjustified, or unfairly 
                        discriminatory rate'';
                            (ii) by striking ``the increase'' and 
                        inserting ``the rate''; and
                            (iii) by striking ``such increases'' and 
                        inserting ``such rates'';
            (2) in subsection (b)--
                    (A) in the subsection heading, by striking 
                ``Premium'' and inserting ``Rate'';
                    (B) by striking ``premium increases'' each place it 
                appears and inserting ``rates'';
                    (C) in paragraph (1), in the paragraph heading, by 
                striking ``Premium increase'' and inserting ``Rate''; 
                and
                    (D) in paragraph (2)--
                            (i) in the paragraph heading, by striking 
                        ``Premium increases'' and inserting ``Rates''; 
                        and
                            (ii) in subparagraph (B), by striking 
                        ``premium'' and inserting ``rate''; and
            (3) in subsection (c)(1)--
                    (A) in the heading, by striking ``Premium'' and 
                inserting ``Rate'';
                    (B) by inserting ``that satisfy the condition under 
                subsection (e)(3)(A)'' after ``award grants to 
                States''; and
                    (C) in subparagraph (A), by striking ``premium 
                increases'' and inserting ``rates''.
    (c) Conforming Amendments.--
            (1) Public health service act.--Title XXVII of the Public 
        Health Service Act (42 U.S.C. 300gg et seq.) is amended--
                    (A) in section 2723 (42 U.S.C. 300gg-22)--
                            (i) in subsection (a)--
                                    (I) in paragraph (1), by inserting 
                                ``and section 2794 (relating to the 
                                reasonableness of rates with respect to 
                                health insurance coverage)'' after 
                                ``this part''; and
                                    (II) in paragraph (2), by inserting 
                                ``or such section 2794'' after ``this 
                                part''; and
                            (ii) in subsection (b)--
                                    (I) in paragraph (1), by inserting 
                                ``and section 2794 (relating to the 
                                reasonableness of rates with respect to 
                                health insurance coverage)'' after 
                                ``this part''; and
                                    (II) in paragraph (2)--
                                            (aa) in subparagraph (A), 
                                        by inserting ``or such section 
                                        2794 that is'' after ``this 
                                        part''; and
                                            (bb) in subparagraph 
                                        (C)(ii), by inserting ``or such 
                                        section 2794'' after ``this 
                                        part''; and
                    (B) in section 2761 (42 U.S.C. 300gg-61)--
                            (i) in subsection (a)--
                                    (I) in paragraph (1), by inserting 
                                ``and section 2794 (relating to the 
                                reasonableness of rates with respect to 
                                health insurance coverage)'' after 
                                ``this part''; and
                                    (II) in paragraph (2)--
                                            (aa) by inserting ``or such 
                                        section 2794'' after ``set 
                                        forth in this part''; and
                                            (bb) by inserting ``and 
                                        such section 2794'' after ``the 
                                        requirements of this part''; 
                                        and
                            (ii) in subsection (b), by inserting ``and 
                        such section 2794'' after ``this part''.
            (2) Patient protection and affordable care act.--Section 
        1311(e)(2) of the Patient Protection and Affordable Care Act 
        (42 U.S.C. 18031(e)(2)) is amended by striking ``unjustified 
        premium increases'' and inserting ``unjustified rates''.
    (d) Applicability to Grandfathered Plans.--Section 1251(a)(4)(A) of 
the Patient Protection and Affordable Care Act (42 U.S.C. 
18011(a)(4)(A)) is amended by adding at the end the following:
                            ``(v) Section 2794 (relating to 
                        reasonableness of rates with respect to health 
                        insurance coverage).''.
    (e) Effective Date.--The amendments made by this section shall take 
effect on the date of enactment of this Act and shall be implemented 
with respect to health plans beginning not later than January 1, 2020.

SEC. 11. SENSE OF CONGRESS.

    It is the sense of the Congress that--
            (1) the Federal Government, acting in its capacity as an 
        insurer, employer, or health care provider, should serve as a 
        model for the Nation to ensure coverage of all reproductive 
        services; and
            (2) all restrictions on coverage of reproductive services 
        in the private insurance market should end.
                                 <all>
```