‘‘(3) APPLICABLE COVERED PART D DRUG DE-
FINED.—For purposes of this subsection, the term 
‘applicable covered part D drug’ means a covered 
part D drug that the Secretary determines to be ap-
propriate 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 pre-
ceding 5 years. 
‘‘(D) Initial launch price. 
‘‘(E) Availability of less expensive, simi-
larly 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 spon-
sor 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 
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below the price negotiated under paragraph (1) or 
the price established under paragraph (2). 
‘‘(5) NO EFFECT ON EXISTING APPEALS PROC-
ESS.—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, 2019. 
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.—Sub-
paragraphs (B) and (C) of section 36B(b)(3) of such 
Code are each amended by striking ‘‘silver plan’’ 
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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 strik-
ing ‘‘400 percent’’ and inserting ‘‘600 percent’’. 
(2) 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 insert-
ing ‘‘600 percent’’; and 
(B) by striking ‘‘400%’’ in the table there-
in 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 
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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, in-
crease 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 per-
cent but not more than 150 percent of the pov-
erty line for a family of the size involved, in-
crease the plan’s share of the total allowed 
costs of benefits provided under the plan to 92 
percent of such costs; 
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‘‘(C) in the case of an eligible insured 
whose household income is more than 150 per-
cent but not more than 200 percent of the pov-
erty line for a family of the size involved, in-
crease 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 per-
cent but not more than 300 percent of the pov-
erty line for a family of the size involved, in-
crease 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 per-
cent but not more than 400 percent of the pov-
erty line for a family of the size involved, in-
crease 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: 
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‘‘(i) IN
GENERAL.—The Secretary 
shall ensure the reduction under this para-
graph 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 para-
graph (2)(A); 
‘‘(II) 92 percent in the case of an 
eligible insured described in para-
graph (2)(B); 
‘‘(III) 90 percent in the case of 
an eligible insured described in para-
graph (2)(C); 
‘‘(IV) 85 percent in the case of 
an eligible insured described in para-
graph (2)(D); and 
‘‘(V) 80 percent in the case of an 
eligible insured described in para-
graph (2)(E).’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to plan years beginning after De-
cember 31, 2018. 
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SEC. 8. REINSURANCE PROGRAM. 
Part 5 of subtitle D of title I of the Patient Protec-
tion and Affordable Care Act is amended by inserting 
after section 1341 (42 U.S.C. 18061) the following: 
‘‘SEC. 1341A. REINSURANCE PROGRAM FOR INDIVIDUAL 
MARKET IN EACH STATE. 
‘‘(a) IN GENERAL.—The Secretary, in consultation 
with the National Association of Insurance Commis-
sioners, shall establish a program to enable each State to 
carry out a reinsurance program consistent with the provi-
sions described in section 1341 for any plan year begin-
ning in the 3-year period beginning January 1, 2019. 
‘‘(b) APPROPRIATIONS.—There is appropriated, out 
of any money in the Treasury not otherwise appropriated, 
$10,000,000,000 for the period of fiscal years 2019 
through 2021 for purposes of establishing and admin-
istering the program established under this section. Such 
amount shall remain available until expended.’’. 
SEC. 9. EXPANDING RATING RULES TO LARGE GROUP MAR-
KET. 
(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 
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year beginning after the date of enactment of this Act and 
any plan year thereafter. 
SEC. 10. SENSE OF CONGRESS. 
It is the sense of the Congress that— 
(1) the Federal Government, acting in its ca-
pacity as an insurer, employer, or health care pro-
vider, should serve as a model for the Nation to en-
sure coverage of all reproductive services; and 
(2) all restrictions on coverage of reproductive 
services in the private insurance market should end. 
Æ 
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