I 
118TH CONGRESS 
2D SESSION 
H. R. 9020 
To amend the Patient Protection and Affordable Care Act to establish a 
public health insurance option, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 11, 2024 
Ms. SCHAKOWSKY (for herself, Mr. GRIJALVA, Ms. NORTON, Mr. SCHIFF, Mr. 
GARAMENDI, Ms. MOORE of Wisconsin, and Mr. COHEN) introduced the 
following bill; which was referred to the Committee on Energy and Com-
merce 
A BILL 
To amend the Patient Protection and Affordable Care Act 
to establish a public health insurance option, and for 
other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Consumer Health Op-
tions and Insurance Competition Enhancement Act’’ or 
the ‘‘CHOICE Act’’. 
SEC. 2. PUBLIC HEALTH INSURANCE OPTION. 
(a) IN GENERAL.—Part 2 of subtitle D of title I of 
the Patient Protection and Affordable Care Act (42 
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U.S.C. 18031 et seq.) is amended by adding at the end 
the following: 
‘‘SEC. 1314. PUBLIC HEALTH INSURANCE OPTION. 
‘‘(a) ESTABLISHMENT.— 
‘‘(1) IN GENERAL.—For plans years beginning 
on or after January 1, 2026, the Secretary shall es-
tablish, and provide for the offering through the Ex-
changes of, a qualified health plan (in this section 
referred to as the ‘public health insurance option’) 
that provides value, choice, competition, and stability 
of affordable, high-quality coverage throughout the 
United States in accordance with this section. 
‘‘(2) PRIMARY RESPONSIBILITY.—In designing 
the public health insurance option, the primary re-
sponsibility of the Secretary shall be to create an af-
fordable health plan without compromising quality 
or access to care. 
‘‘(b) ADMINISTRATING THE PUBLIC HEALTH INSUR-
ANCE OPTION.— 
‘‘(1) OFFERED THROUGH EXCHANGES.— 
‘‘(A) EXCLUSIVE
TO
EXCHANGES.—The 
public health insurance option shall be offered 
exclusively by the Secretary through the Ex-
changes and not by a health insurance issuer. 
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‘‘(B) 
ENSURING
A
LEVEL
PLAYING 
FIELD.—Except as otherwise provided under 
this section, the public health insurance option 
shall comply with requirements under this title, 
and title XXVII of the Public Health Service 
Act, that are applicable to health plans offered 
through the Exchanges, including requirements 
related to benefits, benefit levels, provider net-
works, notices, consumer protections, and cost- 
sharing. 
‘‘(C) PROVISION OF BENEFIT LEVELS.— 
The public health insurance option shall offer 
bronze, silver, and gold plans. 
‘‘(2) ADMINISTRATIVE CONTRACTING.— 
‘‘(A) AUTHORITIES.—The Secretary may 
enter into contracts for the purpose of per-
forming administrative functions (including 
functions described in subsection (a)(4) of sec-
tion 1874A of the Social Security Act) with re-
spect to the public health insurance option in 
the same manner as the Secretary may enter 
into contracts under subsection (a)(1) of such 
section. The Secretary shall have the same au-
thority with respect to the public health insur-
ance option as the Secretary has under such 
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subsection (a)(1) and subsection (b) of section 
1874A of the Social Security Act with respect 
to title XVIII of such Act. 
‘‘(B) TRANSFER
OF
INSURANCE
RISK.— 
Any contract under this paragraph shall not in-
volve the transfer of insurance risk from the 
Secretary to the entity entering into such con-
tract with the Secretary. 
‘‘(3) STATE ADVISORY COUNCIL.— 
‘‘(A) ESTABLISHMENT.—A State may es-
tablish a public or nonprofit entity to serve as 
the State Advisory Council to provide rec-
ommendations to the Secretary on the oper-
ations and policies of the public health insur-
ance option offered through the Exchange oper-
ating in the State. 
‘‘(B) RECOMMENDATIONS.—A State Advi-
sory Council established under subparagraph 
(A) shall provide recommendations on at least 
the following: 
‘‘(i) Policies and procedures to inte-
grate quality improvement and cost con-
tainment mechanisms into the health care 
delivery system. 
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‘‘(ii) Mechanisms to facilitate public 
awareness of the availability of the public 
health insurance option. 
‘‘(iii) Alternative payment models and 
value-based insurance design under the 
public health insurance option that encour-
age quality improvement and cost control. 
‘‘(C) MEMBERS.—The members of any 
State Advisory Council shall be representatives 
of the public and include health care consumers 
and health care providers. 
‘‘(D) APPLICABILITY
OF
RECOMMENDA-
TIONS.—The Secretary may apply the rec-
ommendations of a State Advisory Council to 
the public health insurance option in that State, 
in any other State, or in all States. 
‘‘(4) DATA COLLECTION.—The Secretary shall 
collect such data as may be required— 
‘‘(A) to establish rates for premiums and 
health care provider reimbursement under sub-
section (c); and 
‘‘(B) for other purposes under this section, 
including to improve quality, and reduce racial, 
ethnic, and other disparities, in health and 
health care. 
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‘‘(c) FINANCING THE PUBLIC HEALTH INSURANCE 
OPTION.— 
‘‘(1) PREMIUMS.— 
‘‘(A) 
ESTABLISHMENT.—The 
Secretary 
shall establish geographically adjusted premium 
rates for the public health insurance option— 
‘‘(i) in a manner that complies with 
the requirement for premium rates under 
subparagraph (C) and considers the data 
collected under subsection (b)(4); and 
‘‘(ii) at a level sufficient to fully fi-
nance— 
‘‘(I) the costs of health benefits 
provided by the public health insur-
ance option; and 
‘‘(II) administrative costs related 
to operating the public health insur-
ance option. 
‘‘(B) CONTINGENCY
MARGIN.—In estab-
lishing premium rates under subparagraph (A), 
the Secretary shall include an appropriate 
amount for a contingency margin. 
‘‘(C) VARIATIONS IN PREMIUM RATES.— 
The premium rate charged for the public health 
insurance option may not vary except as pro-
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vided under section 2701 of the Public Health 
Service Act. 
‘‘(2) HEALTH CARE PROVIDER PAYMENT RATES 
FOR ITEMS AND SERVICES.— 
‘‘(A) IN GENERAL.— 
‘‘(i) RATES NEGOTIATED BY THE SEC-
RETARY.—Not later than January 1, 2025, 
and except as provided in clause (ii), the 
Secretary shall, through a negotiated 
agreement with health care providers, es-
tablish rates for reimbursing health care 
providers for providing the benefits covered 
by the public health insurance option. 
‘‘(ii) 
MEDICARE
REIMBURSEMENT 
RATES.—If the Secretary and health care 
providers are unable to reach a negotiated 
agreement on a reimbursement rate, the 
Secretary shall reimburse providers at 
rates determined for equivalent items and 
services under the original medicare fee- 
for-service program under parts A and B 
of title XVIII of the Social Security Act. 
‘‘(iii) FOR NEW SERVICES.—The Sec-
retary shall modify reimbursement rates 
described in clause (ii) in order to accom-
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modate payments for services, such as 
well-child visits, that are not otherwise cov-
ered under the original medicare fee-for- 
service program. 
‘‘(B) PRESCRIPTION
DRUGS.—Any pay-
ment rate under this subsection for a prescrip-
tion drug shall be at a rate negotiated by the 
Secretary. If the Secretary is unable to reach a 
negotiated agreement on such a reimbursement 
rate, the Secretary shall use rates determined 
for equivalent drugs paid for under the original 
medicare fee-for-service program. The Secretary 
shall modify such rates in order to accommo-
date payments for drugs that are not otherwise 
covered under the original medicare fee-for- 
service program. 
‘‘(3) ACCOUNT.— 
‘‘(A) ESTABLISHMENT.—There is estab-
lished in the Treasury of the United States an 
account for the receipts and disbursements at-
tributable to the operation of the public health 
insurance option, including the start-up funding 
under subparagraph (C) and appropriations au-
thorized under subparagraph (D). 
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‘‘(B) PROHIBITION OF STATE IMPOSITION 
OF TAXES.—Section 1854(g) of the Social Se-
curity Act shall apply to receipts and disburse-
ments described in subparagraph (A) in the 
same manner as such section applies to pay-
ments or premiums described in such section. 
‘‘(C) START-UP FUNDING.— 
‘‘(i) AUTHORIZATION OF FUNDING.— 
There are authorized to be appropriated 
such sums as may be necessary to estab-
lish the public health insurance option and 
cover 90 days of claims reserves based on 
projected enrollment. 
‘‘(ii) AMORTIZATION
OF
START-UP 
FUNDING.—The Secretary shall provide for 
the repayment of the startup funding pro-
vided under clause (i) to the Treasury in 
an amortized manner over the 10-year pe-
riod beginning on January 1, 2026. 
‘‘(D) ADDITIONAL AUTHORIZATION OF AP-
PROPRIATIONS.—To carry out paragraph (2) of 
subsection (b), there are authorized to be ap-
propriated such sums as may be necessary. 
‘‘(d) HEALTH CARE PROVIDER PARTICIPATION.— 
‘‘(1) PROVIDER PARTICIPATION.— 
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‘‘(A) IN
GENERAL.—The Secretary shall 
establish conditions of participation for health 
care providers under the public health insurance 
option. 
‘‘(B) LICENSURE
OR
CERTIFICATION.— 
The Secretary shall not allow a health care pro-
vider to participate in the public health insur-
ance option unless such provider is appro-
priately licensed or certified under State law. 
‘‘(2) ESTABLISHMENT
OF
A
PROVIDER
NET-
WORK.— 
‘‘(A) MEDICARE AND MEDICAID PARTICI-
PATING
PROVIDERS.—A health care provider 
that is a participating provider of services or 
supplier under the Medicare program under 
title XVIII of the Social Security Act or under 
a State Medicaid plan under title XIX of such 
Act is a participating provider in the public 
health insurance option unless the health care 
provider opts out of participating in the public 
health insurance option through a process es-
tablished by the Secretary. 
‘‘(B) ADDITIONAL PROVIDERS.—The Sec-
retary shall establish a process to allow health 
care providers not described in subparagraph 
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(A) to become participating providers in the 
public health insurance option.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) TREATMENT
AS
A
QUALIFIED
HEALTH 
PLAN.—Section 1301(a) of the Patient Protection 
and Affordable Care Act (42 U.S.C. 18021(a)) is 
amended— 
(A) in paragraph (1)(C), by inserting ‘‘ex-
cept in the case of the public health insurance 
option established under section 1314,’’ before 
‘‘is offered by’’; 
(B) in paragraph (2)— 
(i) in the paragraph heading, by in-
serting ‘‘, THE
PUBLIC
HEALTH
INSUR-
ANCE OPTION,’’ before ‘‘AND’’; and 
(ii) by inserting ‘‘the public health in-
surance option under section 1314,’’ before 
‘‘and a multi-State plan’’; and 
(C) by adding at the end the following: 
‘‘(5) PUBLIC
HEALTH
INSURANCE
OPTION.— 
The term ‘qualified health plan’ shall include the 
public health insurance option established under sec-
tion 1314.’’. 
(2) LEVEL PLAYING FIELD.—Section 1324(a) 
of the Patient Protection and Affordable Care Act 
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(42 U.S.C. 18044(a)) is amended by inserting ‘‘the 
public health insurance option under section 1314,’’ 
before ‘‘or a multi-State qualified health plan’’. 
Æ 
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