I 
116TH CONGRESS 
1ST SESSION H. R. 2183 
To amend the Patient Protection and Affordable Care Act to streamline 
the State innovation waiver process, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
APRIL 9, 2019 
Mr. MARSHALL introduced the following bill; which was referred to the Com-
mittee on Energy and Commerce, and in addition to the Committee on 
Ways and Means, for a period to be subsequently determined by the 
Speaker, in each case for consideration of such provisions as fall within 
the jurisdiction of the committee concerned 
A BILL 
To amend the Patient Protection and Affordable Care Act 
to streamline the State innovation waiver process, 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 ‘‘State Flexibility and 
Patient Choice Act of 2019’’. 
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SEC. 2. STREAMLINING THE STATE INNOVATION WAIVER 
PROCESS. 
Section 1332 of the Patient Protection and Afford-
able Care Act (42 U.S.C. 18052) is amended— 
(1) in subsection (a)— 
(A) in paragraph (1)— 
(i) in subparagraph (B)(ii), by insert-
ing ‘‘over both the term of the proposed 
waiver and the 10-year budget plan’’ after 
‘‘Government’’; and 
(ii) in subparagraph (C), by striking 
‘‘the law described in subsection (b)(2)’’ 
and inserting ‘‘a law or has in effect a cer-
tification described in subsection (b)(3)’’; 
and 
(B) in paragraph (3)— 
(i) in the first sentence— 
(I) by inserting ‘‘or would qualify 
for a lesser amount of’’ after ‘‘would 
not qualify for’’; 
(II) by inserting ‘‘, or the State 
would not qualify for or would qualify 
for a lesser payment under section 
1331,’’ after ‘‘subtitle E’’; 
(III) by inserting ‘‘, or on behalf 
of participants in a basic health pro-
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‘‘(2) BUDGETARY EFFECT.— 
‘‘(A) IN GENERAL.—In determining wheth-
er a State plan submitted under subsection (a) 
meets the deficit neutrality requirements of 
paragraph (1)(D), the Secretary shall take into 
consideration the direct budgetary effect of the 
provisions of such plan on sources of Federal 
funding other than the funding described in 
subsection (a)(3).’’; and 
(D) in paragraph (3) (as so redesig-
nated)— 
(i) in the paragraph heading, by in-
serting ‘‘OR HAVE IN EFFECT A CER-
TIFICATION’’ after ‘‘LAW’’; 
(ii) in subparagraph (A)— 
(I) by striking ‘‘A law’’ and in-
serting the following: 
‘‘(i) LAWS.—A law’’; and 
(II) by adding at the end the fol-
lowing: 
‘‘(ii) 
CERTIFICATIONS.—A 
certifi-
cation described in this paragraph is a doc-
ument, signed by the Governor of the 
State, that certifies that such Governor 
has the authority under existing State law 
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to take action under this section, including 
implementation of the State plan under 
subsection (a)(1)(B).’’; and 
(iii) in subparagraph (B)— 
(I) in the subparagraph heading, 
by striking ‘‘OF OPT OUT’’; and 
(II) by striking ‘‘may repeal a 
law’’ and all that follows through the 
period at the end and inserting the 
following: ‘‘may terminate the author-
ity provided under the waiver with re-
spect to the State by—’’ 
‘‘(i) repealing the law described in 
subparagraph (A)(i); or 
‘‘(ii) terminating the certification de-
scribed in subparagraph (A)(ii), through a 
certification for such termination signed by 
the Governor of the State.’’; 
(3) in subsection (d)— 
(A) in paragraph (1), by striking ‘‘180’’ 
and inserting ‘‘90’’; and 
(B) by adding at the end the following new 
paragraph: 
‘‘(3) EXPEDITED DETERMINATION.— 
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‘‘(A) IN GENERAL.—With respect to any 
application under subsection (a)(1) submitted 
on or after the date of the enactment of this 
paragraph, the Secretary shall make a deter-
mination on such application, using the criteria 
for approval otherwise applicable under this sec-
tion, not later than 60 days after the receipt of 
such application and shall allow the public no-
tice and comment at the State and Federal lev-
els described under subsection (a)(4) to occur 
concurrently if such State application— 
‘‘(i) is submitted in response to an ur-
gent situation, with respect to areas in the 
State that the Secretary determines are at 
risk for substantial increases in premium 
rates or having no health plans offered in 
the applicable health insurance market for 
the current or following plan year; or 
‘‘(ii) is for a waiver that is the same 
or substantially similar to a waiver that 
the Secretary already has approved for an-
other State. 
‘‘(B) APPROVAL LIMITATIONS FOR URGENT 
SITUATIONS.— 
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‘‘(i) 
PROVISIONAL
APPROVAL.—A 
waiver approved under the expedited deter-
mination 
process 
under 
subparagraph 
(A)(i) may extend over a period of not 
longer than 3 years. 
‘‘(ii) FULL
APPROVAL.—Subject to 
the requirements for approval otherwise 
applicable under this section, not later 
than 1 year before the expiration of a pro-
visional waiver period described in clause 
(i) with respect to an application described 
in subparagraph (A)(i), the Secretary shall 
make a determination on whether to ex-
tend the term of such waiver for longer 
than the period described in clause (i), for 
a total waiver term not to exceed 6 years. 
The Secretary may request additional in-
formation as the Secretary determines ap-
propriate to make such determination. 
‘‘(C) GAO STUDY.—Not later than 5 years 
after the date of enactment of the State Flexi-
bility and Patient Choice Act of 2019, the 
Comptroller General of the United States shall 
conduct a review of all waivers approved pursu-
ant to an application under subparagraph 
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(A)(ii) to evaluate whether such waivers met 
the requirements of subsection (b)(1) and 
whether the applications should have qualified 
for such an expedited determination.’’; 
(4) in subsection (e), by inserting ‘‘(or, in the 
case of an application under subsection (a)(1) sub-
mitted on or after the date of the enactment of the 
State Flexibility and Patient Choice Act of 2019, 6 
years)’’ after ‘‘5 years’’; and 
(5) by adding at the end the following new sub-
section: 
‘‘(f) ADDITIONAL PROVISIONS.—In carrying out this 
section, the Secretary shall— 
‘‘(1) issue guidance, not later than 30 days 
after the date of the enactment of this subsection, 
that includes initial examples of model State plans 
that may meet the requirements for approval under 
this section; and 
‘‘(2) periodically review the guidance issued 
under paragraph (1) and, when appropriate, issue 
additional examples of model State plans that may 
meet the requirements for approval under this sec-
tion, which may include— 
‘‘(A) model plans establishing reinsurance 
or invisible high-risk pool arrangements for pur-
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poses of covering the cost of high-risk individ-
uals; 
‘‘(B) model plans expanding insurer par-
ticipation, access to affordable health plans, 
network adequacy, and health plan options over 
the entire applicable health insurance market in 
the State; 
‘‘(C) model plans that encourage or require 
health plans in a State to deploy value-based in-
surance designs which structure enrollee cost- 
sharing and other health plan design elements 
to encourage enrollees to consume high-value 
clinical services; 
‘‘(D) model plans allowing for significant 
variation in health plan benefit design; or 
‘‘(E) any other model plan determined ap-
propriate by the Secretary.’’. 
Æ 
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