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SEC. 2. TABLE OF CONTENTS. 
The table of contents for this Act is as follows: 
Sec. 1. Short title. 
Sec. 2. Table of contents. 
TITLE I—LOWERING HEALTH CARE COSTS AND PROTECTING 
PEOPLE WITH PREEXISTING CONDITIONS 
Sec. 101. Improving affordability by expanding premium assistance for con-
sumers. 
Sec. 102. Improving affordability by reducing out-of-pocket and premium costs 
for consumers. 
Sec. 103. Expanding affordability for working families to fix the family glitch. 
Sec. 104. Tax credit reconciliation protections for individuals receiving social 
security lump-sum payments. 
Sec. 105. Preserving State option to implement health care Marketplaces. 
Sec. 106. Establishing a Health Insurance Affordability Fund. 
Sec. 107. Rescinding the short-term limited duration insurance regulation. 
Sec. 108. Revoking section 1332 guidance. 
Sec. 109. Requiring Marketplace outreach, educational activities, and annual 
enrollment targets. 
Sec. 110. Report on effects of website maintenance during open enrollment. 
Sec. 111. Promoting consumer outreach and education. 
Sec. 112. Improving transparency and accountability in the Marketplace. 
Sec. 113. Improving awareness of health coverage options. 
Sec. 114. Promoting State innovations to expand coverage. 
Sec. 115. Strengthening network adequacy. 
Sec. 116. Protecting consumers from unreasonable rate hikes. 
Sec. 117. Eligibility of DACA recipients for qualified health plans offered 
through Exchanges. 
TITLE II—ENCOURAGING MEDICAID EXPANSION AND 
STRENGTHENING THE MEDICAID PROGRAM 
Sec. 201. Incentivizing Medicaid expansion. 
Sec. 202. Providing 12-months of continuous eligibility for Medicaid and CHIP. 
Sec. 203. Mandatory 12-months of postpartum Medicaid eligibility. 
Sec. 204. Reducing the administrative FMAP for nonexpansion States. 
Sec. 205. Enhanced reporting requirements for nonexpansion states. 
Sec. 206. Primary care pay increase. 
Sec. 207. Permanent funding for CHIP. 
Sec. 208. Permanent extension of CHIP enrollment and quality measures. 
Sec. 209. State option to increase children’s eligibility for Medicaid and CHIP. 
Sec. 210. Medicaid coverage for citizens of Freely Associated States. 
Sec. 211. Extension of full Federal medical assistance percentage to Indian 
health care providers. 
TITLE III—LOWERING PRICES THROUGH FAIR DRUG PRICE 
NEGOTIATION 
Sec. 301. Establishing a Fair Drug Pricing Program. 
Sec. 302. Drug manufacturer excise tax for noncompliance. 
Sec. 303. Fair Price Negotiation Implementation Fund. 
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TITLE IV—PUBLIC HEALTH INVESTMENTS 
Sec. 401. Supporting increased innovation. 
TITLE 
I—LOWERING 
HEALTH 
CARE 
COSTS 
AND 
PRO-
TECTING PEOPLE WITH PRE-
EXISTING CONDITIONS 
SEC. 101. IMPROVING AFFORDABILITY BY EXPANDING PRE-
MIUM ASSISTANCE FOR CONSUMERS. 
(a) IN GENERAL.—Section 36B(b)(3)(A) of the In-
ternal Revenue Code of 1986 is amended to read as fol-
lows: 
‘‘(A) APPLICABLE PERCENTAGE.—The ap-
plicable percentage for any taxable year shall be 
the percentage such that the applicable percent-
age for any taxpayer whose household income is 
within an income tier specified in the following 
table shall increase, on a sliding scale in a lin-
ear manner, from the initial premium percent-
age to the final premium percentage specified in 
such table for such income tier: 
‘‘In the case of household 
income (expressed as 
a percent of poverty line) 
within the following income tier: 
The initial 
premium 
percentage is— 
The final 
premium 
percentage is— 
Up to 150.0 percent ...................................
0.0 
0.0
150.0 percent up to 200.0 percent .............
0.0 
3.0
200.0 percent up to 250.0 percent .............
3.0 
4.0
250.0 percent up to 300.0 percent .............
4.0 
6.0
300.0 percent up to 400.0 percent .............
6.0 
8.5
400.0 percent and higher ...........................
8.5 
8.5’’. 
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(b) 
CONFORMING
AMENDMENT.—Section 
36B(c)(1)(A) of the Internal Revenue Code of 1986 is 
amended by striking ‘‘but does not exceed 400 percent’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
December 31, 2019. 
SEC. 102. IMPROVING AFFORDABILITY BY REDUCING OUT- 
OF-POCKET AND PREMIUM COSTS FOR CON-
SUMERS. 
Section 1302(c)(4) of the Patient Protection and Af-
fordable Care Act (42 U.S.C. 18022(c)(4)) is amended by 
striking ‘‘calendar year)’’ and inserting ‘‘calendar year, 
based on estimates and projections for the applicable cal-
endar year of the percentage (if any) by which the average 
per enrollee premium for eligible employer-sponsored 
health plans (as defined in section 5000A(f)(2) of the In-
ternal Revenue Code of 1986) exceeds such average per 
enrollee premium for the preceding calendar year, as pub-
lished in the National Health Expenditure Accounts)’’. 
SEC. 103. EXPANDING AFFORDABILITY FOR WORKING FAM-
ILIES TO FIX THE FAMILY GLITCH. 
(a) IN GENERAL.—Clause (i) of section 36B(c)(2)(C) 
of the Internal Revenue Code of 1986 is amended to read 
as follows: 
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‘‘(i) COVERAGE
MUST
BE
AFFORD-
ABLE.— 
‘‘(I) EMPLOYEES.—An employee 
shall not be treated as eligible for 
minimum essential coverage if such 
coverage consists of an eligible em-
ployer-sponsored plan (as defined in 
section 5000A(f)(2)) and the employ-
ee’s required contribution (within the 
meaning of section 5000A(e)(1)(B)) 
with respect to the plan exceeds 9.5 
percent of the employee’s household 
income. 
‘‘(II) FAMILY MEMBERS.—An in-
dividual who is eligible to enroll in an 
eligible employer-sponsored plan (as 
defined in section 5000A(f)(2)) by 
reason of a relationship the individual 
bears to the employee shall not be 
treated as eligible for minimum essen-
tial coverage by reason of such eligi-
bility to enroll if the employee’s re-
quired contribution (within the mean-
ing of section 5000A(e)(1)(B), deter-
mined by substituting ‘family’ for 
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‘self-only’) with respect to the plan ex-
ceeds 9.5 percent of the employee’s 
household income.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) Clause (ii) of section 36B(c)(2)(C) of the 
Internal Revenue Code of 1986 is amended by strik-
ing ‘‘Except as provided in clause (iii), an employee’’ 
and inserting ‘‘An individual’’. 
(2) Clause (iii) of section 36B(c)(2)(C) of such 
Code is amended by striking ‘‘the last sentence of 
clause (i)’’ and inserting ‘‘clause (i)(II)’’. 
(3) Clause (iv) of section 36B(c)(2)(C) of such 
Code is amended by striking ‘‘the 9.5 percent under 
clause (i)(II)’’ and inserting ‘‘the 9.5 percent under 
clauses (i)(I) and (i)(II)’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
December 31, 2021. 
SEC. 104. TAX CREDIT RECONCILIATION PROTECTIONS FOR 
INDIVIDUALS RECEIVING SOCIAL SECURITY 
LUMP-SUM PAYMENTS. 
(a) IN GENERAL.—Section 36B(d)(2) of the Internal 
Revenue Code of 1986 is amended by adding at the end 
the following new subparagraph: 
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‘‘(C) EXCLUSION OF PORTION OF LUMP- 
SUM SOCIAL SECURITY BENEFITS.— 
‘‘(i) IN GENERAL.—The term ‘modi-
fied adjusted gross income’ shall not in-
clude so much of any lump-sum social se-
curity benefit payment as is attributable to 
months ending before the beginning of the 
taxable year. 
‘‘(ii) LUMP-SUM
SOCIAL
SECURITY 
BENEFIT PAYMENT.—For purposes of this 
subparagraph, the term ‘lump-sum social 
security benefit payment’ means any pay-
ment of social security benefits (as defined 
in section 86(d)(1)) which constitutes more 
than 1 month of such benefits. 
‘‘(iii) ELECTION
TO
INCLUDE
EX-
CLUDABLE
AMOUNT.—A taxpayer may 
elect (at such time and in such manner as 
the Secretary may provide) to have this 
subparagraph not apply for any taxable 
year.’’. 
(b) EFFECTIVE DATE.—The amendment made by 
this section shall apply to taxable years beginning after 
December 31, 2019. 
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SEC. 105. PRESERVING STATE OPTION TO IMPLEMENT 
HEALTH CARE MARKETPLACES. 
(a) IN GENERAL.—Section 1311 of the Patient Pro-
tection and Affordable Care Act (42 U.S.C. 18031) is 
amended— 
(1) in subsection (a)— 
(A) in paragraph (4)(B), by striking 
‘‘under this subsection’’ and inserting ‘‘under 
this paragraph or paragraph (1)’’; and 
(B) by adding at the end the following new 
paragraph: 
‘‘(6) ADDITIONAL PLANNING AND ESTABLISH-
MENT GRANTS.— 
‘‘(A) IN GENERAL.—There shall be appro-
priated to the Secretary, out of any moneys in 
the Treasury not otherwise appropriated, $200 
million to award grants to eligible States for 
the uses described in paragraph (3). 
‘‘(B) DURATION AND RENEWABILITY.—A 
grant awarded under subparagraph (A) shall be 
for a period of 2 years and may not be renewed. 
‘‘(C) LIMITATION.—A grant may not be 
awarded under subparagraph (A) after Decem-
ber 31, 2023. 
‘‘(D) ELIGIBLE
STATE
DEFINED.—For 
purposes of this paragraph, the term ‘eligible 
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State’ means a State that, as of the date of the 
enactment of this paragraph, is not operating 
an Exchange (other than an Exchange de-
scribed in section 155.200(f) of title 45, Code 
of Federal Regulations).’’; and 
(2) in subsection (d)(5)(A)— 
(A) by striking ‘‘OPERATIONS.—In estab-
lishing an Exchange under this section’’ and in-
serting ‘‘OPERATIONS.— 
‘‘(i) IN GENERAL.—In establishing an 
Exchange under this section (other than in 
establishing an Exchange pursuant to a 
grant awarded under subsection (a)(6))’’; 
and 
(B) by adding at the end the following: 
‘‘(ii) ADDITIONAL PLANNING AND ES-
TABLISHMENT
GRANTS.—In establishing 
an Exchange pursuant to a grant awarded 
under subsection (a)(6), the State shall en-
sure that such Exchange is self-sustaining 
beginning on January 1, 2025, including 
allowing the Exchange to charge assess-
ments or user fees to participating health 
insurance issuers, or to otherwise generate 
funding, to support its operations.’’. 
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(b) CLARIFICATION REGARDING FAILURE TO ESTAB-
LISH EXCHANGE OR IMPLEMENT REQUIREMENTS.—Sec-
tion 1321(c) of the Patient Protection and Affordable 
Care Act (42 U.S.C. 18041(c)) is amended— 
(1) in paragraph (1), by striking ‘‘If’’ and in-
serting ‘‘Subject to paragraph (3), if’’; and 
(2) by adding at the end the following new 
paragraph: 
‘‘(3) CLARIFICATION.—This subsection shall 
not apply in the case of a State that elects to apply 
the requirements described in subsection (a) and 
satisfies the requirement described in subsection (b) 
on or after January 1, 2014.’’. 
SEC. 106. ESTABLISHING A HEALTH INSURANCE AFFORD-
ABILITY FUND. 
Subtitle D of title I of the Patient Protection and 
Affordable Care Act is amended by inserting after part 
5 (42 U.S.C. 18061 et seq.) the following new part: 
‘‘PART 6—IMPROVE HEALTH INSURANCE 
AFFORDABILITY FUND 
‘‘SEC. 1351. ESTABLISHMENT OF PROGRAM. 
‘‘There is hereby established the ‘Improve Health In-
surance Affordability Fund’ to be administered by the Sec-
retary of Health and Human Services, acting through the 
Administrator of the Centers for Medicare & Medicaid 
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Services (in this section referred to as the ‘Adminis-
trator’), to provide funding, in accordance with this part, 
to the 50 States and the District of Columbia (each re-
ferred to in this section as a ‘State’) beginning on January 
1, 2022, for the purposes described in section 1352. 
‘‘SEC. 1352. USE OF FUNDS. 
‘‘(a) IN GENERAL.—A State shall use the funds allo-
cated to the State under this part for one of the following 
purposes: 
‘‘(1) To provide reinsurance payments to health 
insurance issuers with respect to individuals enrolled 
under individual health insurance coverage (other 
than through a plan described in subsection (b)) of-
fered by such issuers. 
‘‘(2) To 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 on the indi-
vidual market through an Exchange. 
‘‘(b) EXCLUSION OF CERTAIN GRANDFATHERED AND 
TRANSITIONAL PLANS.—For purposes of subsection (a), 
a plan described in this subsection is the following: 
‘‘(1) A grandfathered health plan (as defined in 
section 1251). 
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‘‘(2) A plan (commonly referred to as a ‘transi-
tional plan’) continued under the letter issued by the 
Centers for Medicare & Medicaid Services on No-
vember 14, 2013, to the State Insurance Commis-
sioners outlining a transitional policy for coverage in 
the individual and small group markets to which sec-
tion 1251 does not apply, and under the extension 
of the transitional policy for such coverage set forth 
in the Insurance Standards Bulletin Series guidance 
issued by the Centers for Medicare & Medicaid Serv-
ices on March 5, 2014, February 29, 2016, Feb-
ruary 13, 2017, April 9, 2018, March 25, 2019, and 
January 31, 2020, or under any subsequent exten-
sions thereof. 
‘‘(3) Student health insurance coverage (as de-
fined in section 147.145 of title 45, Code of Federal 
Regulations). 
‘‘SEC. 1353. STATE ELIGIBILITY AND APPROVAL; DEFAULT 
SAFEGUARD. 
‘‘(a) ENCOURAGING STATE OPTIONS FOR ALLOCA-
TIONS.— 
‘‘(1) IN GENERAL.—To be eligible for an alloca-
tion of funds under this part for a year (beginning 
with 2022), a State shall submit to the Adminis-
trator an application at such time (but, in the case 
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of allocations for 2022, not later than 90 days after 
the date of the enactment of this part and, in the 
case of allocations for a subsequent year, not later 
than March 1 of the previous year) and in such form 
and manner as specified by the Administrator con-
taining— 
‘‘(A) a description of how the funds will be 
used; and 
‘‘(B) such other information as the Admin-
istrator may require. 
‘‘(2) AUTOMATIC APPROVAL.—An application so 
submitted is approved unless the Administrator noti-
fies the State submitting the application, not later 
than 60 days after the date of the submission of 
such application, that the application has been de-
nied for not being in compliance with any require-
ment of this part and of the reason for such denial. 
‘‘(3) 5-YEAR
APPLICATION
APPROVAL.—If an 
application of a State is approved for a purpose de-
scribed in section 1352 for a year, such application 
shall be treated as approved for such purpose for 
each of the subsequent 4 years. 
‘‘(4) REVOCATION
OF
APPROVAL.—The ap-
proval of an application of a State, with respect to 
a purpose described in section 1352, may be revoked 
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fied by the Secretary for such year, under sub-
paragraph (B). 
‘‘(B) SPECIFICATIONS.—For purposes of 
subparagraph (A) and section 1353(b)(3), the 
Secretary shall determine the dollar amounts 
and the percentage to be specified under this 
subparagraph for a year in a manner to ensure 
that the total amount of expenditures under 
this part for such year is estimated to equal the 
total amount appropriated for such year under 
subsection (a) if such expenditures were used 
solely for the purpose described in paragraph 
(1) of section 1352(a) for attachment range 
claims at the dollar amounts and percentage so 
specified for such year. 
‘‘(3) AVAILABILITY.—Funds allocated to a 
State under this subsection for a year shall remain 
available through the end of the subsequent year.’’. 
SEC. 107. RESCINDING THE SHORT-TERM LIMITED DURA-
TION INSURANCE REGULATION. 
(a) FINDINGS.—Congress finds the following: 
(1) On August 3, 2018, the Administration 
issued a final rule entitled ‘‘Short-Term, Limited- 
Duration Insurance’’ (83 Fed. Reg. 38212). 
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(2) The final rule dramatically expands the sale 
and marketing of insurance that— 
(A) may discriminate against individuals 
living with preexisting health conditions, includ-
ing children with complex medical needs and 
disabilities and their families; 
(B) lacks important financial protections 
provided by the Patient Protection and Afford-
able Care Act (Public Law 111–148), including 
the prohibition of annual and lifetime coverage 
limits and annual out-of-pocket limits, that may 
increase the cost of treatment and cause finan-
cial hardship to those requiring medical care, 
including children with complex medical needs 
and disabilities and their families; and 
(C) excludes coverage of essential health 
benefits including hospitalization, prescription 
drugs, and other lifesaving care. 
(3) The implementation and enforcement of the 
final rule weakens critical protections for up to 130 
million Americans living with preexisting health con-
ditions and may place a large financial burden on 
those who enroll in short-term limited-duration in-
surance, which jeopardizes Americans’ access to 
quality, affordable health insurance. 
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(b) PROHIBITION.—The Secretary of Health and 
Human Services, the Secretary of the Treasury, and the 
Secretary of Labor— 
(1) may not take any action to implement, en-
force, or otherwise give effect to the rule entitled 
‘‘Short-Term, Limited Duration Insurance’’ (83 
Fed. Reg. 38212 (August 3, 2018)); 
(2) shall apply any regulation revised by such 
rule as if such rule had not been issued; and 
(3) may not promulgate any substantially simi-
lar rule. 
SEC. 108. REVOKING SECTION 1332 GUIDANCE. 
(a) FINDINGS.—Congress finds the following: 
(1) On October 24, 2018, the administration 
published new guidance to carry out section 1332 of 
the Patient Protection and Affordable Care Act (42 
U.S.C. 18052) entitled ‘‘State Relief and Empower-
ment Waivers’’ (83 Fed. Reg. 53575). 
(2) The new guidance encourages States to pro-
vide health insurance coverage through insurance 
plans that may discriminate against individuals with 
preexisting health conditions, including the one in 
four Americans living with a disability. 
(3) The implementation and enforcement of the 
new guidance weakens protections for the millions of 
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Americans living with preexisting health conditions 
and jeopardizes Americans’ access to quality, afford-
able health insurance coverage. 
(b) PROVIDING THAT CERTAIN GUIDANCE RELATED 
TO WAIVERS FOR STATE INNOVATION UNDER THE PA-
TIENT PROTECTION AND AFFORDABLE CARE ACT SHALL 
HAVE NO FORCE OR EFFECT.—Beginning July 1, 2020, 
the Secretary of Health and Human Services and the Sec-
retary of the Treasury may not take any action to imple-
ment, enforce, or otherwise give effect to the guidance en-
titled ‘‘State Relief and Empowerment Waivers’’ (83 Fed. 
Reg. 53575 (October 24, 2018)), including any such ac-
tion that would result in individuals losing health insur-
ance coverage that includes the essential health benefits 
package (as defined in subsection (a) of section 1302 of 
the Patient Protection and Affordable Care Act (42 
U.S.C. 18022(a)) without regard to any waiver of any pro-
vision of such package under a waiver under such section 
1332), including the maternity and newborn care essential 
health benefit described in subsection (b)(1)(D) of such 
section, including any such action that would result in a 
decrease in the number of such individuals enrolled in cov-
erage that is at least as comprehensive as the coverage 
defined in section 1302(a) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18022(a)) compared to 
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the number of such individuals who would have been so 
enrolled in such coverage had such action not been taken, 
including any such action that would, with respect to indi-
viduals with substance use disorders, including opioid use 
disorders, reduce the availability or affordability of cov-
erage that is at least as comprehensive as the coverage 
defined in section 1302(a) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18022(a)) compared to 
the availability or affordability, respectively, of such cov-
erage had such action not been taken, including any such 
action that would result, with respect to vulnerable popu-
lations (including low-income individuals, elderly individ-
uals, and individuals with serious health issues or who 
have a greater risk of developing serious health issues), 
in a decrease in the availability of coverage that is at least 
as comprehensive as the coverage defined in section 
1302(a) of the Patient Protection and Affordable Care Act 
(42 U.S.C. 18022(a)) with coverage and cost sharing pro-
tections required under section 1332(b)(1)(B) of such Act 
(42 U.S.C. 18052(b)(1)(B)), including any such action 
that would, with respect to individuals with preexisting 
conditions, reduce the affordability of coverage that is at 
least as comprehensive as the coverage defined in section 
1302(a) of the Patient Protection and Affordable Care Act 
(42 U.S.C. 18022(a)) compared to the affordability of 
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such coverage had such action not been taken, including 
any such action that would result in higher health insur-
ance premiums for individuals enrolled in health insurance 
coverage that is at least as comprehensive as the coverage 
defined in section 1302(b) of such Act (42 U.S.C. 
18022(b)), and the Secretaries may not promulgate any 
substantially similar guidance or rule. Nothing in the pre-
vious sentence shall be construed to affect the approval 
of waivers under section 1332 of the Patient Protection 
and Affordable Care Act (42 U.S.C. 18052) that establish 
reinsurance programs that are consistent with the require-
ments under subsection (b)(1) of such section (42 U.S.C. 
18052(b)(1)), lower health insurance premiums, and pro-
tect health insurance coverage for people with preexisting 
conditions. 
(c) GAO REPORT ON AFFECT OF STATE INNOVATION 
WAIVERS ON COVERAGE OF INDIVIDUALS AND ON MEN-
TAL HEALTH HEALTH CARE TREATMENT.—Not later 
than 1 year after the date of the enactment of this Act, 
the Comptroller General of the United States shall submit 
to Congress a report on the number of individuals ex-
pected to lose access to health insurance coverage (as de-
fined in section 2791 of the Public Health Service Act (42 
U.S.C. 300gg–91)) if subsection (b) were not enacted and 
waivers under section 1332 of the Patient Protection and 
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Affordable Care Act (42 U.S.C. 18052) were approved 
under the guidance described in such subsection (b). Such 
report shall include an analysis of the expected effect such 
waivers approved under such guidance would have on men-
tal health care treatment. 
SEC. 109. REQUIRING MARKETPLACE OUTREACH, EDU-
CATIONAL ACTIVITIES, AND ANNUAL EN-
ROLLMENT TARGETS. 
(a) IN GENERAL.—Section 1321(c) of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18041(c)), 
as amended by section 105(b), is further amended by add-
ing at the end the following new paragraphs: 
‘‘(4) OUTREACH
AND
EDUCATIONAL
ACTIVI-
TIES.— 
‘‘(A) IN GENERAL.—In the case of an Ex-
change established or operated by the Secretary 
within a State pursuant to this subsection, the 
Secretary shall carry out outreach and edu-
cational activities for purposes of informing in-
dividuals about qualified health plans offered 
through the Exchange, including by informing 
such individuals of the availability of coverage 
under such plans and financial assistance for 
coverage under such plans. Such outreach and 
educational activities shall be provided in a 
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manner that is culturally and linguistically ap-
propriate to the needs of the populations being 
served by the Exchange (including hard-to- 
reach populations, such as racial and sexual mi-
norities, limited English proficient populations, 
individuals in rural areas, veterans, and young 
adults) and shall be provided to populations re-
siding in high health disparity areas (as defined 
in subparagraph (E)) served by the Exchange, 
in addition to other populations served by the 
Exchange. 
‘‘(B) LIMITATION ON USE OF FUNDS.—No 
funds appropriated under this paragraph shall 
be used for expenditures for promoting non- 
ACA compliant health insurance coverage. 
‘‘(C) NON-ACA COMPLIANT HEALTH INSUR-
ANCE
COVERAGE.—For purposes of subpara-
graph (B): 
‘‘(i) The term ‘non-ACA compliant 
health insurance coverage’ means health 
insurance coverage, or a group health plan, 
that is not a qualified health plan. 
‘‘(ii) Such term includes the following: 
‘‘(I) An association health plan. 
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‘‘(II) Short-term limited duration 
insurance. 
‘‘(D) FUNDING.—Out of any funds in the 
Treasury not otherwise appropriated, there are 
hereby appropriated for fiscal year 2022 and 
each subsequent fiscal year, $100,000,000 to 
carry out this paragraph. Funds appropriated 
under this subparagraph shall remain available 
until expended. 
‘‘(E) HIGH HEALTH DISPARITY AREA DE-
FINED.—For purposes of subparagraph (A), the 
term ‘high health disparity area’ means a con-
tiguous geographic area that— 
‘‘(i) is located in one census tract or 
ZIP code; 
‘‘(ii) has measurable and documented 
racial, ethnic, or geographic health dispari-
ties; 
‘‘(iii) has a low-income population, as 
demonstrated by— 
‘‘(I) average income below 138 
percent of the Federal poverty line; or 
‘‘(II) a rate of participation in 
the special supplemental nutrition 
program under section 17 of the Child 
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Nutrition Act of 1966 (42 U.S.C. 
1786) that is higher than the national 
average rate of participation in such 
program; 
‘‘(iv) has poor health outcomes, as 
demonstrated by— 
‘‘(I) lower life expectancy than 
the national average; or 
‘‘(II) a higher percentage of in-
stances of low birth weight than the 
national average; and 
‘‘(v) is part of a Metropolitan Statis-
tical Area identified by the Office of Man-
agement and Budget. 
‘‘(5) ANNUAL
ENROLLMENT
TARGETS.—For 
plan year 2021 and each subsequent plan year, in 
the case of an Exchange established or operated by 
the Secretary within a State pursuant to this sub-
section, the Secretary shall establish annual enroll-
ment targets for such Exchange for such year.’’. 
(b) STUDY AND REPORT.—Not later than 30 days 
after the date of the enactment of this Act, the Secretary 
of Health and Human Services shall release to Congress 
all aggregated documents relating to studies and data sets 
that were created on or after January 1, 2014, and related 
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to marketing and outreach with respect to qualified health 
plans offered through Exchanges under title I of the Pa-
tient Protection and Affordable Care Act (42 U.S.C. 
18001 et seq.). 
SEC. 110. REPORT ON EFFECTS OF WEBSITE MAINTENANCE 
DURING OPEN ENROLLMENT. 
Not later than 1 year after the date of the enactment 
of this Act, the Comptroller General of the United States 
shall submit to Congress a report examining whether the 
Department of Health and Human Services has been con-
ducting maintenance on the website commonly referred to 
as ‘‘Healthcare.gov’’ during annual open enrollment peri-
ods (as described in section 1311(c)(6)(B) of the Patient 
Protection 
and 
Affordable 
Care 
Act 
(42 
U.S.C. 
18031(c)(6)(B)) in such a manner so as to minimize any 
disruption to the use of such website resulting from such 
maintenance. 
SEC. 111. PROMOTING CONSUMER OUTREACH AND EDU-
CATION. 
(a) IN GENERAL.—Section 1311(i) of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18031(i)) 
is amended— 
(1) in paragraph (2), by adding at the end the 
following new subparagraph: 
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‘‘(C) SELECTION OF RECIPIENTS.—In the 
case of an Exchange established and operated 
by the Secretary within a State pursuant to sec-
tion 1321(c), in awarding grants under para-
graph (1), the Exchange shall— 
‘‘(i) select entities to receive such 
grants based on an entity’s demonstrated 
capacity to carry out each of the duties 
specified in paragraph (3); 
‘‘(ii) not take into account whether or 
not the entity has demonstrated how the 
entity will provide information to individ-
uals relating to group health plans offered 
by a group or association of employers de-
scribed in section 2510.3–5(b) of title 29, 
Code of Federal Regulations (or any suc-
cessor regulation), or short-term limited 
duration insurance (as defined by the Sec-
retary for purposes of section 2791(b)(5) 
of the Public Health Service Act); and 
‘‘(iii) ensure that, each year, the Ex-
change awards such a grant to— 
‘‘(I) at least one entity described 
in this paragraph that is a community 
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and 
consumer-focused 
nonprofit 
group; and 
‘‘(II) at least one entity described 
in subparagraph (B), which may in-
clude another community and con-
sumer-focused nonprofit group in ad-
dition to any such group awarded a 
grant pursuant to subclause (I). 
In awarding such grants, an Exchange may 
consider an entity’s record with respect to 
waste, fraud, and abuse for purposes of main-
taining the integrity of such Exchange.’’; 
(2) in paragraph (3)— 
(A) by amending subparagraph (C) to read 
as follows: 
‘‘(C) facilitate enrollment, including with 
respect to individuals with limited English pro-
ficiency and individuals with chronic illnesses, 
in qualified health plans, State medicaid plans 
under title XIX of the Social Security Act, and 
State child health plans under title XXI of such 
Act;’’; 
(B) in subparagraph (D), by striking 
‘‘and’’ at the end; 
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(C) in subparagraph (E), by striking the 
period at the end and inserting ‘‘; and’’; 
(D) by inserting after subparagraph (E) 
the following new subparagraph: 
‘‘(F) provide referrals to community-based 
organizations that address social needs related 
to health outcomes.’’; and 
(E) by adding at the end the following 
flush left sentence: 
‘‘The duties specified in the preceding sentence may 
be carried out by such a navigator at any time dur-
ing a year.’’; 
(3) in paragraph (4)(A)— 
(A) in the matter preceding clause (i), by 
striking ‘‘not’’; 
(B) in clause (i)— 
(i) by inserting ‘‘not’’ before ‘‘be’’; 
and 
(ii) by striking ‘‘; or’’ and inserting a 
semicolon; 
(C) in clause (ii)— 
(i) by inserting ‘‘not’’ before ‘‘re-
ceive’’; and 
(ii) by striking the period and insert-
ing a semicolon; and 
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(D) by adding at the end the following new 
clauses: 
‘‘(iii) maintain physical presence in 
the State of the Exchange so as to allow 
in-person assistance to consumers; and 
‘‘(iv) receive opioid specific education 
and training that ensures the navigator 
can best educate individuals on qualified 
health plans offered through an Exchange, 
specifically coverage under such plans for 
opioid health care treatment.’’; and 
(4) in paragraph (6)— 
(A) 
by 
striking 
‘‘FUNDING.—Grants 
under’’ and inserting ‘‘FUNDING.— 
‘‘(A) STATE EXCHANGES.—Grants under’’; 
and 
(B) by adding at the end the following new 
subparagraph: 
‘‘(B) FEDERAL
EXCHANGES.—For pur-
poses of carrying out this subsection, with re-
spect to an Exchange established and operated 
by the Secretary within a State pursuant to sec-
tion 1321(c), the Secretary shall obligate 
$100,000,000 out of amounts collected through 
the user fees on participating health insurance 
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issuers pursuant to section 156.50 of title 45, 
Code of Federal Regulations (or any successor 
regulations), for fiscal year 2022 and each sub-
sequent fiscal year. Such amount for a fiscal 
year shall remain available until expended.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to plan years begin-
ning on or after January 1, 2021. 
SEC. 112. IMPROVING TRANSPARENCY AND ACCOUNT-
ABILITY IN THE MARKETPLACE. 
(a) OPEN ENROLLMENT REPORTS.—For plan year 
2021 and each subsequent year, the Secretary of Health 
and Human Services (referred to in this section as the 
‘‘Secretary’’), in coordination with the Secretary of the 
Treasury and the Secretary of Labor, shall issue biweekly 
public reports during the annual open enrollment period 
on the performance of the federally facilitated Exchange 
operated pursuant to section 1321(c) of the Patient Pro-
tection and Affordable Care Act (42 U.S.C. 18041(c)). 
Each such report shall include a summary, including in-
formation on a State-by-State basis where available, of— 
(1) the number of unique website visits; 
(2) the number of individuals who create an ac-
count; 
(3) the number of calls to the call center; 
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(4) the average wait time for callers contacting 
the call center; 
(5) the number of individuals who enroll in a 
qualified health plan; and 
(6) the percentage of individuals who enroll in 
a qualified health plan through each of— 
(A) the website; 
(B) the call center; 
(C) navigators; 
(D) agents and brokers; 
(E) the enrollment assistant program; 
(F) directly from issuers or web brokers; 
and 
(G) other means. 
(b) OPEN ENROLLMENT AFTER ACTION REPORT.— 
For plan year 2021 and each subsequent year, the Sec-
retary, in coordination with the Secretary of the Treasury 
and the Secretary of Labor, shall publish an after action 
report not later than 3 months after the completion of the 
annual open enrollment period regarding the performance 
of the Exchange described in subsection (a) for the appli-
cable plan year. Each such report shall include a sum-
mary, including information on a State-by-State basis 
where available, of— 
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(1) the open enrollment data reported under 
subsection (a) for the entirety of the enrollment pe-
riod; and 
(2) activities related to patient navigators de-
scribed in section 1311(i) of the Patient Protection 
and Affordable Care Act (42 U.S.C. 18031(i)), in-
cluding— 
(A) the performance objectives established 
by the Secretary for such patient navigators; 
(B) the number of consumers enrolled by 
such a patient navigator; 
(C) an assessment of how such patient 
navigators have met established performance 
metrics, including a detailed list of all patient 
navigators, funding received by patient naviga-
tors, and whether established performance ob-
jectives of patient navigators were met; and 
(D) with respect to the performance objec-
tives described in subparagraph (A)— 
(i) whether such objectives assess the 
full scope of patient navigator responsibil-
ities, including general education, plan se-
lection, and determination of eligibility for 
tax credits, cost-sharing reductions, or 
other coverage; 
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(ii) how the Secretary worked with pa-
tient navigators to establish such objec-
tives; and 
(iii) how the Secretary adjusted such 
objectives for case complexity and other 
contextual factors. 
(c) REPORT ON ADVERTISING AND CONSUMER OUT-
REACH.—Not later than 3 months after the completion of 
the annual open enrollment period for plan year 2021, the 
Secretary shall issue a report on advertising and outreach 
to consumers for the open enrollment period for plan year 
2021. Such report shall include a description of— 
(1) the division of spending on individual adver-
tising platforms, including television and radio ad-
vertisements and digital media, to raise consumer 
awareness of open enrollment; 
(2) the division of spending on individual out-
reach platforms, including email and text messages, 
to raise consumer awareness of open enrollment; and 
(3) whether the Secretary conducted targeted 
outreach to specific demographic groups and geo-
graphic areas. 
(b) PROMOTING
TRANSPARENCY
AND
ACCOUNT-
ABILITY IN THE ADMINISTRATION’S EXPENDITURES OF 
EXCHANGE USER FEES.—For plan year 2021 and each 
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subsequent plan year, not later than the date that is 3 
months after the end of such plan year, the Secretary of 
Health and Human Services shall submit to the appro-
priate committees of Congress and make available to the 
public an annual report on the expenditures by the De-
partment of Health and Human Services of user fees col-
lected pursuant to section 156.50 of title 45, Code of Fed-
eral Regulations (or any successor regulations). Each such 
report for a plan year shall include a detailed accounting 
of the amount of such user fees collected during such plan 
year and of the amount of such expenditures used during 
such plan year for the federally facilitated Exchange oper-
ated pursuant to section 1321(c) of the Patient Protection 
and Affordable Care Act (42 U.S.C. 18041(c)) on out-
reach and enrollment activities, navigators, maintenance 
of Healthcare.gov, and operation of call centers. 
SEC. 113. IMPROVING AWARENESS OF HEALTH COVERAGE 
OPTIONS. 
(a) IN GENERAL.—Not later than 90 days after the 
date of the enactment of this Act, the Secretary of Labor, 
in consultation with the Secretary of Health and Human 
Services, shall update, and make publicly available in a 
prominent location on the website of the Department of 
Labor, the model Consolidated Omnibus Budget Reconcili-
ation Act of 1985 (referred to in this section as 
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‘‘COBRA’’) continuation coverage general notice and the 
model COBRA continuation coverage election notice devel-
oped by the Secretary of Labor for purposes of facilitating 
compliance of group health plans with the notification re-
quirements under section 606 of the Employee Retirement 
Income Security Act of 1974 (29 U.S.C. 1166). In updat-
ing each such notice, the Secretary of Labor shall include 
information regarding any Exchange established under 
title I of the Patient Protection and Affordable Care Act 
(42 U.S.C. 18001 et seq.) through which a qualified bene-
ficiary may be eligible to enroll in a qualified health plan, 
including— 
(1) the publicly accessible Internet website ad-
dress for such Exchange; 
(2) the publicly accessible Internet website ad-
dress for the Find Local Help directory maintained 
by the Department of Health and Human Services 
on the healthcare.gov Internet website (or a suc-
cessor website); 
(3) a clear explanation that— 
(A) an individual who is eligible for con-
tinuation coverage may also be eligible to enroll, 
with financial assistance, in a qualified health 
plan offered through such Exchange, but, in the 
case that such individual elects to enroll in such 
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continuation coverage and subsequently elects 
to terminate such continuation coverage before 
the period of such continuation coverage ex-
pires, such individual will not be eligible to en-
roll in a qualified health plan offered through 
such Exchange during a special enrollment pe-
riod; and 
(B) an individual who elects to enroll in 
continuation coverage will remain eligible to en-
roll in a qualified health plan offered through 
such Exchange during an open enrollment pe-
riod and may be eligible for financial assistance 
with respect to enrolling in such a qualified 
health plan; 
(4) information on consumer protections with 
respect to enrolling in a qualified health plan offered 
through such Exchange, including the requirement 
for such a qualified health plan to provide coverage 
for essential health benefits (as defined in section 
1302(b) of such Act (42 U.S.C. 18022(b)) and the 
requirements applicable to such a qualified health 
plan under part A of title XXVII of the Public 
Health Service Act (42 U.S.C. 300gg et seq.); and 
(5) information on the availability of financial 
assistance with respect to enrolling in a qualified 
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health plan, including the maximum income limit for 
eligibility for a premium tax credit under section 
36B of the Internal Revenue Code of 1986. 
(b) NAME OF NOTICES.—In addition to updating the 
model COBRA continuation coverage general notice and 
the model COBRA continuation coverage election notice 
under paragraph (1), the Secretary of Labor shall rename 
each such notice as the ‘‘model COBRA continuation cov-
erage and Affordable Care Act coverage general notice’’ 
and the ‘‘model COBRA continuation coverage and Af-
fordable Care Act coverage election notice’’, respectively. 
(c) CONSUMER TESTING.—Prior to making publicly 
available the model COBRA continuation coverage general 
notice and the model COBRA continuation coverage elec-
tion notice updated under paragraph (1), the Secretary 
of Labor shall provide an opportunity for consumer testing 
of each such notice, as so updated, to ensure that each 
such notice is clear and understandable to the average 
participant or beneficiary of a group health plan. 
(d) DEFINITIONS.—In this subsection: 
(1) 
CONTINUATION
COVERAGE.—The 
term 
‘‘continuation coverage’’, with respect to a group 
health plan, has the meaning given such term in sec-
tion 602 of the Employee Retirement Income Secu-
rity Act of 1974 (29 U.S.C. 1162). 
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(2) GROUP HEALTH PLAN.—The term ‘‘group 
health plan’’ has the meaning given such term in 
section 607 of such Act (29 U.S.C. 1167). 
(3) 
QUALIFIED
BENEFICIARY.—The 
term 
‘‘qualified beneficiary’’ has the meaning given such 
term in such section 607. 
(4) QUALIFIED
HEALTH
PLAN.—The term 
‘‘qualified health plan’’ has the meaning given such 
term in section 1301 of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18021). 
SEC. 114. PROMOTING STATE INNOVATIONS TO EXPAND 
COVERAGE. 
(a) IN GENERAL.—Subject to subsection (d), the Sec-
retary of Health and Human Services shall award grants 
to eligible State agencies to enable such States to explore 
innovative solutions to promote greater enrollment in 
health insurance coverage in the individual and small 
group markets, including activities described in subsection 
(c). 
(b) ELIGIBILITY.—For purposes of subsection (a), el-
igible State agencies are Exchanges established by a State 
under title I of the Patient Protection and Affordable Care 
Act (42 U.S.C. 18001 et seq.) and State agencies with 
primary responsibility over health and human services for 
the State involved. 
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(c) USE OF FUNDS.—For purposes of subsection (a), 
the activities described in this subsection are the following: 
(1) State efforts to streamline health insurance 
enrollment procedures in order to reduce burdens on 
consumers and facilitate greater enrollment in health 
insurance coverage in the individual and small group 
markets, including automatic enrollment and re-
enrollment of, or pre-populated applications for, in-
dividuals without health insurance who are eligible 
for tax credits under section 36B of the Internal 
Revenue Code of 1986, with the ability to opt out 
of such enrollment. 
(2) State investment in technology to improve 
data sharing and collection for the purposes of facili-
tating greater enrollment in health insurance cov-
erage in such markets. 
(3) Implementation of a State version of an in-
dividual mandate to be enrolled in health insurance 
coverage. 
(4) Feasibility studies to develop comprehensive 
and coherent State plan for increasing enrollment in 
the individual and small group market. 
(d) FUNDING.—For purposes of carrying out this 
section, there is hereby appropriated, out of any funds in 
the Treasury not otherwise appropriated, $200,000,000 
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for each of the fiscal years 2022 through 2024. Such 
amount shall remain available until expended. 
SEC. 115. STRENGTHENING NETWORK ADEQUACY. 
(a) IN GENERAL.—Section 1311(d) of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18031(d)) 
is amended by adding at the end the following new para-
graph: 
‘‘(8) NETWORK ADEQUACY STANDARDS.— 
‘‘(A) CERTAIN EXCHANGES.—In the case 
of an Exchange operated by the Secretary pur-
suant section 1321(c)(1) or an Exchange de-
scribed in section 155.200(f) of title 42, Code 
of Federal Regulations (or a successor regula-
tion), the Exchange shall require each qualified 
health plan offered through such Exchange to 
meet such quantitative network adequacy stand-
ards as the Secretary may prescribe for pur-
poses of this subparagraph. 
‘‘(B) STATE EXCHANGES.—In the case of 
an Exchange not described in subparagraph 
(A), the Exchange shall establish quantitative 
network adequacy standards with respect to 
qualified health plans offered through such Ex-
change and require such plans to meet such 
standards.’’. 
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(b) EFFECTIVE DATE.—The amendment made by 
this section shall apply with respect to plan years begin-
ning on or after January 1, 2022. 
SEC. 116. PROTECTING CONSUMERS FROM UNREASONABLE 
RATE HIKES. 
(a) PROTECTION FROM EXCESSIVE, UNJUSTIFIED, 
OR UNFAIRLY DISCRIMINATORY RATES.—The first sec-
tion 2794 of the Public Health Service Act (42 U.S.C. 
300gg–94), as added by section 1003 of the Patient Pro-
tection and Affordable Care Act (Public Law 111–148), 
is amended by adding at the end the following new sub-
section: 
‘‘(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 re-
lating to rate review standards and procedures and 
information reporting) on health insurance issuers 
with respect to rates that are in addition to the re-
quirements of this section and are more protective of 
consumers than such requirements. 
‘‘(2) CONSULTATION
IN
RATE
REVIEW
PROC-
ESS.—In carrying out this section, the Secretary 
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shall consult with the National Association of Insur-
ance Commissioners and consumer groups. 
‘‘(3) DETERMINATION OF WHO CONDUCTS RE-
VIEWS FOR EACH STATE.—The Secretary shall de-
termine, after the date of enactment of this section 
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), based on the Secretary’s 
determination that the State regulator is ade-
quately 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 determina-
tion that the State is not adequately under-
taking and utilizing such actions in that mar-
ket. 
‘‘(4) CORRECTIVE ACTION FOR EXCESSIVE, UN-
JUSTIFIED, 
OR
UNFAIRLY
DISCRIMINATORY 
RATES.—In accordance with the process established 
under this section, the Secretary or the relevant 
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State insurance commissioner or State regulator 
shall take corrective actions to ensure that any ex-
cessive, 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 under section 2723 and, if the 
Secretary determines appropriate, make the plan in-
volved 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 heading, by striking ‘‘PRE-
MIUM’’ and inserting ‘‘RATE’’; 
(B) in paragraph (1), by striking ‘‘unrea-
sonable increases in premiums’’ and inserting 
‘‘potentially excessive, unjustified, or unfairly 
discriminatory rates, including premiums,’’; and 
(C) in paragraph (2)— 
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(i) by striking ‘‘an unreasonable pre-
mium increase’’ and inserting ‘‘a poten-
tially excessive, unjustified, or unfairly dis-
criminatory rate’’; 
(ii) by striking ‘‘the increase’’ and in-
serting ‘‘the rate’’; and 
(iii) by striking ‘‘such increases’’ and 
inserting ‘‘such rates’’; and 
(2) in subsection (b)— 
(A) by striking ‘‘premium increases’’ each 
place it appears and inserting ‘‘rates’’; and 
(B) in paragraph (2)(B), by striking ‘‘pre-
mium’’ and inserting ‘‘rate’’. 
(c) CONFORMING AMENDMENTS.—Title XXVII of 
the Public Health Service Act (42 U.S.C. 300gg et seq.) 
is amended— 
(1) in section 2723 (42 U.S.C. 300gg–22), as 
redesignated by the Patient Protection and Afford-
able Care Act— 
(A) in subsection (a)— 
(i) in paragraph (1), by inserting 
‘‘and section 2794’’ after ‘‘this part’’; and 
(ii) in paragraph (2), by inserting ‘‘or 
section 2794’’ after ‘‘this part’’; and 
(B) in subsection (b)— 
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(i) in paragraph (1), by inserting 
‘‘and section 2794’’ after ‘‘this part’’; and 
(ii) in paragraph (2)— 
(I) in subparagraph (A), by in-
serting ‘‘or section 2794 that is’’ after 
‘‘this part’’; and 
(II) in subparagraph (C)(ii), by 
inserting ‘‘or section 2794’’ after 
‘‘this part’’; and 
(2) in section 2761 (42 U.S.C. 300gg–61)— 
(A) in subsection (a)— 
(i) in paragraph (1), by inserting 
‘‘and section 2794’’ after ‘‘this part’’; and 
(ii) in paragraph (2)— 
(I) by inserting ‘‘or section 
2794’’ after ‘‘set forth in this part’’; 
and 
(II) by inserting ‘‘and section 
2794’’ after ‘‘the requirements of this 
part’’; and 
(B) in subsection (b)— 
(i) by inserting ‘‘and section 2794’’ 
after ‘‘this part’’; and 
(ii) by inserting ‘‘and section 2794’’ 
after ‘‘part A’’. 
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(d) APPLICABILITY TO GRANDFATHERED PLANS.— 
Section 1251(a)(4)(A) of the Patient Protection and Af-
fordable Care Act (Public Law 111–148), as added by sec-
tion 2301 of the Health Care and Education Reconcili-
ation Act of 2010 (Public Law 111–152), is amended by 
adding at the end the following: 
‘‘(v) Section 2794 (relating to reason-
ableness of rates with respect to health in-
surance coverage).’’. 
(e) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated to carry out this Act 
such sums as may be necessary. 
(f) 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, 2022. 
SEC. 117. ELIGIBILITY OF DACA RECIPIENTS FOR QUALI-
FIED HEALTH PLANS OFFERED THROUGH EX-
CHANGES. 
(a) IN GENERAL.—Section 1312(f)(3) of the Patient 
Protection 
and 
Affordable 
Care 
Act 
(42 
U.S.C. 
18032(f)(3)) is amended— 
(1) by striking ‘‘or an alien lawfully present in 
the United States’’ and inserting ‘‘, an alien lawfully 
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present in the United States, or a DACA recipient’’; 
and 
(2) by adding at the end the following: ‘‘For 
purposes of the previous sentence, the term ‘DACA 
recipient’ means an individual who was granted de-
ferred action pursuant to the Deferred Action for 
Childhood Arrivals Program announced in the 
memorandum of the Secretary of Homeland Security 
dated June 15, 2012, and for whom such grant re-
mains valid.’’. 
(b) APPLICATION
OF REDUCED COST-SHARING.— 
Section 1402(e)(2) of the Patient Protection and Afford-
able Care Act (42 U.S.C. 18071(e)(2)) is amended by add-
ing at the end the following: ‘‘A DACA recipient (as de-
fined in section 1312(f)(3)) shall be treated as lawfully 
present for purposes of this section.’’. 
(c) ELIGIBILITY FOR ADVANCE PAYMENTS.—Section 
1412(d) of the Patient Protection and Affordable Care Act 
(42 U.S.C. 18082(d)) is amended by adding at the end 
the following: ‘‘For purposes of the previous sentence, a 
DACA recipient (as defined in section 1312(f)(3)) shall 
be treated as lawfully present in the United States.’’. 
(d) 
VERIFICATION
OF
ELIGIBILITY.—Section 
1411(c)(2)(B) of the Patient Protection and Affordable 
Care Act (42 U.S.C. 18081(c)(2)(B)) is amended— 
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(1) in clause (i)(I), by inserting ‘‘or a DACA 
recipient (as defined in section 1312(f)(3))’’ after 
‘‘an alien lawfully present in the United States’’; 
and 
(2) in clause (ii), by inserting ‘‘or a DACA re-
cipient (as defined in section 1312(f)(3))’’ after ‘‘an 
alien lawfully present in the United States’’. 
(e) APPLICATION OF TAX CREDIT FOR COVERAGE 
UNDER A QUALIFIED HEALTH PLAN.—Section 36B(e)(2) 
of the Internal Revenue Code of 1986 is amended by add-
ing at the end the following: ‘‘A DACA recipient (as de-
fined in section 1312(f)(3) of the Patient Protection and 
Affordable Care Act) shall be treated as lawfully present 
for purposes of this section.’’. 
(f) EFFECTIVE DATE.—The amendments made by 
this section shall take effect on January 1, 2021. 
TITLE II—ENCOURAGING MED-
ICAID 
EXPANSION 
AND 
STRENGTHENING THE MED-
ICAID PROGRAM 
SEC. 201. INCENTIVIZING MEDICAID EXPANSION. 
(a) IN GENERAL.—Section 1905(y)(1) of the Social 
Security Act (42 U.S.C. 1396d(y)(1)) is amended— 
(1) in subparagraph (A), by striking ‘‘2014, 
2015, and 2016’’ and inserting ‘‘each of the first 3 
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SEC. 202. PROVIDING 12-MONTHS OF CONTINUOUS ELIGI-
BILITY FOR MEDICAID AND CHIP. 
(a) REQUIREMENT OF 12-MONTH CONTINUOUS EN-
ROLLMENT UNDER MEDICAID.—Section 1902(e)(12) of 
the Social Security Act (42 U.S.C. 1396a(e)(12)) is 
amended to read as follows: 
‘‘(12) 12-MONTH CONTINUOUS ENROLLMENT.— 
Notwithstanding any other provision of this title, a 
State plan approved under this title (or under any 
waiver of such plan approved pursuant to section 
1115 or section 1915), shall provide that an indi-
vidual who is determined to be eligible for benefits 
under such plan (or waiver) shall remain eligible and 
enrolled for such benefits through the end of the 
month in which the 12-month period (beginning on 
the date of determination of eligibility) ends.’’. 
(b) REQUIREMENT OF 12-MONTH CONTINUOUS EN-
ROLLMENT UNDER CHIP.— 
(1) IN GENERAL.—Section 2102(b) of the So-
cial Security Act (42 U.S.C. 1397bb(b)) is amended 
by adding at the end the following new paragraph: 
‘‘(6) REQUIREMENT
FOR
12-MONTH
CONTIN-
UOUS
ENROLLMENT.—Notwithstanding any other 
provision of this title, a State child health plan that 
provides child health assistance under this title 
through a means other than described in section 
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2101(a)(2), shall provide that an individual who is 
determined to be eligible for benefits under such 
plan shall remain eligible and enrolled for such bene-
fits through the end of the month in which the 12- 
month period (beginning on the date of determina-
tion of eligibility) ends.’’. 
(2) 
CONFORMING
AMENDMENT.—Section 
2105(a)(4)(A) of the Social Security Act (42 U.S.C. 
1397ee(a)(4)(A)) is amended— 
(A) by striking ‘‘has elected the option of’’ 
and inserting ‘‘is in compliance with the re-
quirement for’’; and 
(B) by striking ‘‘applying such policy 
under its State child health plan under this 
title’’ and inserting ‘‘in compliance with section 
2102(b)’’. 
(c) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as provided in para-
graph (2) or (3), the amendments made by sub-
sections (a) and (b) shall apply to determinations 
(and redeterminations) of eligibility made on or after 
the date that is 12 months after the last day of the 
emergency period described in section 1135(g)(1)(B) 
of the Social Security Act (42 U.S.C. 1320b– 
5(g)(1)(B)). 
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(2) EXTENSION
OF
EFFECTIVE
DATE
FOR 
STATE LAW AMENDMENT.—In the case of a State 
plan under title XIX or State child health plan 
under title XXI of the Social Security Act (42 
U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.) 
which the Secretary of Health and Human Services 
determines requires State legislation (other than leg-
islation appropriating funds) in order for the respec-
tive plan to meet the additional requirement imposed 
by the amendment made by subsection (a) or (b), re-
spectively, the respective plan shall not be regarded 
as failing to comply with the requirements of such 
title solely on the basis of its failure to meet such 
applicable additional requirement before the first 
day of the first calendar quarter beginning after the 
close of the first regular session of the State legisla-
ture that begins after the date of enactment of this 
Act. For purposes of the previous sentence, in the 
case of a State that has a 2-year legislative session, 
each year of the session is considered to be a sepa-
rate regular session of the State legislature. 
(3) OPTION TO IMPLEMENT 12-MONTH CONTIN-
UOUS ELIGIBILITY PRIOR TO EFFECTIVE DATE.—A 
State may elect through a State plan amendment 
under title XIX or XXI of the Social Security Act 
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(42 U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.) 
to apply the amendment made by subsection (a) or 
(b), respectively, on any date prior to the date speci-
fied in paragraph (1), but not sooner than the date 
of the enactment of this Act. 
SEC. 203. MANDATORY 12-MONTHS OF POSTPARTUM MED-
ICAID ELIGIBILITY. 
(a) EXTENDING CONTINUOUS MEDICAID AND CHIP 
COVERAGE FOR PREGNANT AND POSTPARTUM WOMEN.— 
(1) MEDICAID.—Title XIX of the Social Secu-
rity Act (42 U.S.C. 1396 et seq.) is amended— 
(A) in section 1902(l)(1)(A), by striking 
‘‘60-day period’’ and inserting ‘‘365-day pe-
riod’’; 
(B) in section 1902(e)(6), by striking ‘‘60- 
day period’’ and inserting ‘‘365-day period’’; 
(C) in section 1903(v)(4)(A)(i), by striking 
‘‘60-day period’’ and inserting ‘‘365-day pe-
riod’’; and 
(D) in section 1905(a), in the 4th sentence 
in the matter following paragraph (30), by 
striking ‘‘60-day period’’ and inserting ‘‘365- 
day period’’. 
(2) CHIP.—Section 2112 of the Social Security 
Act (42 U.S.C. 1397ll) is amended by striking ‘‘60- 
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day period’’ each place it appears and inserting 
‘‘365-day period’’. 
(b) REQUIRING FULL BENEFITS
FOR PREGNANT 
AND POSTPARTUM WOMEN.— 
(1) MEDICAID.— 
(A) IN GENERAL.—Paragraph (5) of sec-
tion 1902(e) of the Social Security Act (24 
U.S.C. 1396a(e)) is amended to read as follows: 
‘‘(5) Any woman who is eligible for medical as-
sistance under the State plan or a waiver of such 
plan and who is, or who while so eligible becomes, 
pregnant, shall continue to be eligible under the plan 
or waiver for medical assistance through the end of 
the month in which the 365-day period (beginning 
on the last day of her pregnancy) ends, regardless 
of the basis for the woman’s eligibility for medical 
assistance, including if the woman’s eligibility for 
medical assistance is on the basis of being preg-
nant.’’. 
(B) CONFORMING
AMENDMENT.—Section 
1902(a)(10) of the Social Security Act (42 
U.S.C. 1396a(a)(10)) is amended in the matter 
following subparagraph (G) by striking ‘‘(VII) 
the medical assistance’’ and all that follows 
through ‘‘complicate pregnancy,’’. 
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(2) CHIP.—Section 2107(e)(1) of the Social 
Security Act (42 U.S.C. 1397gg(e)(1)) is amended— 
(A) by redesignating subparagraphs (H) 
through (S) as subparagraphs (I) through (T), 
respectively; and 
(B) by inserting after subparagraph (G), 
the following: 
‘‘(H) Section 1902(e)(5) (requiring 365- 
day continuous coverage for pregnant and 
postpartum women).’’. 
(c) MAINTENANCE OF EFFORT.— 
(1) MEDICAID.—Section 1902 of the Social Se-
curity Act (42 U.S.C. 1396a) is amended— 
(A) in paragraph (74), by striking ‘‘sub-
section (gg); and’’ and inserting ‘‘subsections 
(gg) and (qq);’’; and 
(B) by adding at the end the following new 
subsection: 
‘‘(qq) MAINTENANCE OF EFFORT RELATED TO LOW- 
INCOME PREGNANT WOMEN.—For calendar quarters be-
ginning on or after the effective date described in section 
203(d) of the Patient Protection and Affordable Care En-
hancement Act, and before January 1, 2023, no Federal 
payment shall be made to a State under section 1903(a) 
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for amounts expended under a State plan under this title 
or a waiver of such plan if the State— 
‘‘(1) has in effect under such plan eligibility 
standards, methodologies, or procedures for individ-
uals described in subsection (l)(1) who are eligible 
for medical assistance under the State plan or waiv-
er under subsection (a)(10)(A)(ii)(IX) that are more 
restrictive than the eligibility standards, methodolo-
gies, or procedures, respectively, for such individuals 
under such plan or waiver that are in effect on the 
date of the enactment of this subsection; or 
‘‘(2) provides medical assistance to individuals 
described in subsection (l)(1) who are eligible for 
medical assistance under such plan or waiver under 
subsection (a)(10)(A)(ii)(IX) at a level that is less 
than the level at which the State provides such as-
sistance to such individuals under such plan or waiv-
er on the date of the enactment of this subsection.’’. 
(2) CHIP.—Section 2112 of the Social Security 
Act (42 U.S.C. 1397ll), as amended by subsection 
(b), is further amended by adding at the end the fol-
lowing subsection: 
‘‘(g) MAINTENANCE
OF
EFFORT.—For calendar 
quarters beginning on or after the effective date described 
in section 203(d) of the Patient Protection and Affordable 
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Care Enhancement Act, and before January 1, 2023, no 
payment may be made under section 2105(a) with respect 
to a State child health plan if the State— 
‘‘(1) has in effect under such plan eligibility 
standards, methodologies, or procedures for targeted 
low-income pregnant women that are more restric-
tive than the eligibility standards, methodologies, or 
procedures, respectively, under such plan that are in 
effect on the date of the enactment of this sub-
section; or 
‘‘(2) provides pregnancy-related assistance to 
targeted low-income pregnant women under such 
plan at a level that is less than the level at which 
the State provides such assistance to such women 
under such plan on the date of the enactment of this 
subsection.’’. 
(d) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as provided under 
paragraph (2), the amendments made by subsections 
(a) and (b) shall take effect on (and the effective 
date described in this subsection shall be) the first 
day of the calendar quarter during which the last 
day of the emergency period described in section 
1135(g)(1)(B) of the Social Security Act (42 U.S.C. 
1320b–5(g)(1)(B)) occurs. 
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(2) EXTENSION
OF
EFFECTIVE
DATE
FOR 
STATE LAW AMENDMENT.—In the case of a State 
plan under title XIX or State child health plan 
under title XXI of the Social Security Act (42 
U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.) 
which the Secretary of Health and Human Services 
determines requires State legislation (other than leg-
islation appropriating funds) in order for the respec-
tive plan to meet the additional requirement imposed 
by the amendments made by subsection (a) or (b), 
respectively, the respective plan shall not be re-
garded as failing to comply with the requirements of 
such title solely on the basis of its failure to meet 
such applicable additional requirement before the 
first day of the first calendar quarter beginning 
after the close of the first regular session of the 
State legislature that begins after the date of enact-
ment of this Act. For purposes of the previous sen-
tence, in the case of a State that has a 2-year legis-
lative session, each year of the session is considered 
to be a separate regular session of the State legisla-
ture. 
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SEC. 204. REDUCING THE ADMINISTRATIVE FMAP FOR 
NONEXPANSION STATES. 
Section 1903 of the Social Security Act (42 U.S.C. 
1396b) is amended— 
(1) in subsection (a)(7), by inserting ‘‘sub-
section (bb) and’’ before ‘‘section 1919(g)(3)(B)’’; 
and 
(2) by adding at the end the following new sub-
section: 
‘‘(bb) REDUCTION
OF FEDERAL PAYMENTS
FOR 
CERTAIN ADMINISTRATIVE COSTS
OF NONEXPANSION 
STATES.— 
‘‘(1) IN GENERAL.—In the case of a State that 
does not provide under the State plan of such State 
(or waiver of such plan) for making medical assist-
ance available in accordance with section 1902(k)(1) 
to 
all 
individuals 
described 
in 
section 
1902(a)(10)(i)(VIII) for a calendar quarter begin-
ning on or after October 1, 2022, the Secretary may 
reduce the percentage specified in subsection (a)(7) 
for amounts described in such subsection expended 
during such quarter by such State by the number of 
percentage points specified in paragraph (2) for such 
quarter. 
‘‘(2) AMOUNT OF REDUCTION.—For purposes 
of paragraph (1), the number of percentage points 
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specified in this paragraph for a calendar quarter is 
the following: 
‘‘(A) For the calendar quarter beginning 
on October 1, 2022, 0.5. 
‘‘(B) For a calendar quarter beginning on 
or after January 1, 2023, and ending before 
July 1, 2027, the number of percentage points 
specified under this paragraph for the previous 
quarter, plus 0.5. 
‘‘(C) For a calendar quarter beginning on 
or after July 1, 2027, 10. 
‘‘(3) DEFINITION.—For purposes of this sub-
section, the term ‘State’ means a State that is one 
of the 50 States or the District of Columbia.’’. 
SEC. 205. ENHANCED REPORTING REQUIREMENTS FOR 
NONEXPANSION STATES. 
Section 1903 of the Social Security Act (42 U.S.C. 
1396b), as amended by section 204, is further amended— 
(1) in subsection (a)(7), by striking ‘‘subsection 
(bb)’’ and inserting ‘‘subsections (bb) and (cc)’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(cc) REDUCTION OF FEDERAL PAYMENTS FOR CER-
TAIN ADMINISTRATIVE COSTS OF NONEXPANSION STATES 
THAT DO NOT SATISFY REPORTING REQUIREMENTS.— 
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‘‘(1) IN GENERAL.— 
‘‘(A) REDUCTION.—In the case of a non-
expansion State, with respect to a fiscal year 
(beginning with fiscal year 2023) that does not 
satisfy the reporting requirement under para-
graph (2) for such fiscal year, the percentage 
specified in subsection (a)(7) for amounts de-
scribed in such subsection expended by such 
State during a calendar quarter described in 
paragraph (4) with respect to such fiscal year, 
subject to subparagraph (B), shall be reduced 
by the number of percentage points specified in 
paragraph (4) for the respective calendar quar-
ter. 
‘‘(B) EXCEPTION.—In the case of a non-
expansion State that is subject to a reduction 
under subparagraph (A) for the calendar quar-
ter described in paragraph (4)(A) with respect 
to a fiscal year, if the State satisfies the criteria 
described in subparagraphs (A), (B), and (C) of 
paragraph (2) (without regard to the dates 
specified in such subparagraph (A) and (C)) be-
fore the beginning of a subsequent calendar 
quarter described in paragraph (4) with respect 
to such fiscal year, then such State shall not be 
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subject to a reduction under subparagraph (A) 
for such subsequent calendar quarter. 
‘‘(2) REPORTING
REQUIREMENT.—For pur-
poses of paragraph (1), a nonexpansion State satis-
fies the reporting requirement under this paragraph 
for a fiscal year, if the nonexpansion State— 
‘‘(A) by not later than January 1 of such 
year, posts on the public website of the State 
agency administering the State plan, the infor-
mation described in paragraph (3) with respect 
to such State for the previous year; 
‘‘(B) provides for at least a 30-day period 
for notice and comment on such information; 
and 
‘‘(C) by not later than March 1 of such 
year, submits to the Secretary a complete re-
port including such information, comments sub-
mitted pursuant to subparagraph (B), and a re-
sponse by the State to each such comment. 
‘‘(3) INFORMATION DESCRIBED.—The informa-
tion described in this paragraph, with respect to a 
State and year, is the following: 
‘‘(A) The the estimated number of individ-
uals who were uninsured for at least 6 months, 
shown by age-groups of 0 to 18 years of age 
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and of 19 years of age to 64 years of age, as 
well as a detailed description of the basis for 
the estimates. 
‘‘(B) The estimated number of the individ-
uals estimated under subparagraph (A) in the 
State who would be eligible for medical assist-
ance under the State plan if the State were to 
make medical assistance under the State plan 
available in accordance with section 1902(k)(1) 
to 
all 
individuals 
described 
in 
section 
1902(a)(10)(i)(VIII), and a detailed description 
of the basis for the estimates. 
‘‘(C) A comprehensive listing of State in-
come eligibility criteria for all mandatory and 
optional Medicaid eligibility groups for which 
the State plan provides medical assistance 
(other than with respect to individuals described 
in clause (i)(II), (ii)(VI), or (ii)(XXII) of sec-
tion 1902(a)(10)(A)). 
‘‘(D) The total amount of hospital uncom-
pensated-care costs and a breakdown of the 
source of such costs, as well as a breakdown for 
rural and non-rural hospitals. 
‘‘(4) PERCENTAGE DESCRIBED.—For purposes 
of paragraph (1), a calendar quarter described in 
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this paragraph, with respect to a fiscal year, and the 
percentage points described in this paragraph for 
such quarter, with respect to a State, are— 
‘‘(A) for the calendar quarter beginning on 
the April 1 occurring during such fiscal year, 
0.5 percentage points; 
‘‘(B) for the calendar quarter beginning on 
the July 1 occurring during such fiscal year, 
1.0 percentage point; and 
‘‘(C) for the calendar quarter beginning on 
the October 1 occurring during the subsequent 
fiscal year, 1.5 percentage points. 
‘‘(5) 
PAYMENT
IN
CASE
OF
REPORTING 
STATE.—The expenses incurred by a non-expansion 
State, with respect to any calendar quarter with re-
spect to a fiscal year (beginning with 2021), for car-
rying out subparagraphs (A) through (C) of para-
graph (2) shall, for purposes of section 1903(a)(7), 
be considered to be expenses necessary for the prop-
er and efficient administration of the State plan 
under this title. 
‘‘(6) NONEXPANION
STATE
DEFINED.—For 
purposes of this subsection, the term ‘nonexpansion 
State’ means, with respect to a fiscal year, a State 
that as of the first quarter of such fiscal year does 
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not provide under the State plan of such State (or 
waiver of such plan) for making medical assistance 
available in accordance with section 1902(k)(1) to 
all 
individuals 
described 
in 
section 
1902(a)(10)(i)(VIII).’’. 
SEC. 206. PRIMARY CARE PAY INCREASE. 
(a) RENEWAL
OF PAYMENT FLOOR; ADDITIONAL 
PROVIDERS.— 
(1) IN GENERAL.—Section 1902(a)(13) of the 
Social Security Act (42 U.S.C. 1396a(a)(13)) is 
amended by striking subparagraph (C) and inserting 
the following: 
‘‘(C) payment for primary care services (as 
defined in subsection (jj)) at a rate that is not 
less than 100 percent of the payment rate that 
applies to such services and physician under 
part B of title XVIII (or, if greater, the pay-
ment rate that would be applicable under such 
part if the conversion factor under section 
1848(d) for the year involved were the conver-
sion factor under such section for 2009), and 
that is not less than the rate that would other-
wise apply to such services under this title if 
the rate were determined without regard to this 
subparagraph, and that are— 
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‘‘(i) furnished during 2013 and 2014, 
by a physician with a primary specialty 
designation of family medicine, general in-
ternal medicine, or pediatric medicine; or 
‘‘(ii) furnished during the period that 
begins on the first day of the first month 
that begins one year after the date of en-
actment of the Patient Protection and Af-
fordable Care Enhancement Act and ends 
September 30, 2024— 
‘‘(I) by a physician with a pri-
mary specialty designation of family 
medicine, general internal medicine, 
or pediatric medicine, but only if the 
physician self-attests that the physi-
cian is Board certified in family medi-
cine, general internal medicine, or pe-
diatric medicine; 
‘‘(II) by a physician with a pri-
mary specialty designation of obstet-
rics and gynecology, but only if the 
physician self-attests that the physi-
cian is Board certified in obstetrics 
and gynecology; 
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‘‘(III) by an advanced practice 
clinician, as defined by the Secretary, 
that works under the supervision of— 
‘‘(aa) a physician that satis-
fies the criteria specified in sub-
clause (I) or (II); or 
‘‘(bb) a nurse practitioner or 
a physician assistant (as such 
terms are defined in section 
1861(aa)(5)(A)) who is working 
in accordance with State law, or 
a certified nurse-midwife (as de-
fined in section 1861(gg)) who is 
working in accordance with State 
law; 
‘‘(IV) by a rural health clinic, 
Federally-qualified health center, or 
other health clinic that receives reim-
bursement on a fee schedule applica-
ble to a physician, a nurse practi-
tioner or a physician assistant (as 
such terms are defined in section 
1861(aa)(5)(A)) who is working in ac-
cordance with State law, or a certified 
nurse-midwife (as defined in section 
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1861(gg)) who is working in accord-
ance with State law, for services fur-
nished by a physician, nurse practi-
tioner, physician assistant, or certified 
nurse-midwife, or services furnished 
by an advanced practice clinician su-
pervised by a physician described in 
subclause (I)(aa) or (II)(aa), another 
advanced practice clinician, or a cer-
tified nurse-midwife; or 
‘‘(V) by a nurse practitioner or a 
physician assistant (as such terms are 
defined in section 1861(aa)(5)(A)) 
who is working in accordance with 
State law, or a certified nurse-midwife 
(as defined in section 1861(gg)) who 
is working in accordance with State 
law, in accordance with procedures 
that ensure that the portion of the 
payment for such services that the 
nurse practitioner, physician assist-
ant, or certified nurse-midwife is paid 
is not less than the amount that the 
nurse practitioner, physician assist-
ant, or certified nurse-midwife would 
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be paid if the services were provided 
under part B of title XVIII;’’. 
(2) 
CONFORMING
AMENDMENTS.—Section 
1905(dd) of the Social Security Act (42 U.S.C. 
1396d(dd)) is amended— 
(A) by striking ‘‘Notwithstanding’’ and in-
serting the following: 
‘‘(1) IN GENERAL.—Notwithstanding’’; 
(B) by inserting ‘‘or furnished during the 
additional period specified in paragraph (2),’’ 
after ‘‘2015,’’; and 
(C) by adding at the end the following: 
‘‘(2) ADDITIONAL
PERIOD.—For purposes of 
paragraph (1), the additional period specified in this 
paragraph is the period that begins on the first day 
of the first month that begins one year after the 
date of enactment of the Patient Protection and Af-
fordable Care Enhancement Act.’’. 
(b) IMPROVED TARGETING OF PRIMARY CARE.—Sec-
tion 1902(jj) of the Social Security Act (42 U.S.C. 
1396a(jj)) is amended— 
(1) by redesignating paragraphs (1) and (2) as 
subparagraphs (A) and (B), respectively and realign-
ing the left margins accordingly; 
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(2) by striking ‘‘For purposes of’’ and inserting 
the following: 
‘‘(1) IN GENERAL.—For purposes of’’; and 
(3) by adding at the end the following: 
‘‘(2) EXCLUSIONS.—Such term does not include 
any services described in subparagraph (A) or (B) of 
paragraph (1) if such services are provided in an 
emergency department of a hospital.’’. 
(c) ENSURING PAYMENT BY MANAGED CARE ENTI-
TIES.— 
(1) IN
GENERAL.—Section 1903(m)(2)(A) of 
the Social Security Act (42 U.S.C. 1396b(m)(2)(A)) 
is amended— 
(A) in clause (xii), by striking ‘‘and’’ after 
the semicolon; 
(B) by realigning the left margin of clause 
(xiii) so as to align with the left margin of 
clause (xii) and by striking the period at the 
end of clause (xiii) and inserting ‘‘; and’’; and 
(C) by inserting after clause (xiii) the fol-
lowing: 
‘‘(xiv) such contract provides that (I) payments 
to providers specified in section 1902(a)(13)(C) for 
primary care services defined in section 1902(jj) 
that are furnished during a year or period specified 
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in section 1902(a)(13)(C) and section 1905(dd) are 
at least equal to the amounts set forth and required 
by the Secretary by regulation, (II) the entity shall, 
upon request, provide documentation to the State, 
sufficient to enable the State and the Secretary to 
ensure compliance with subclause (I), and (III) the 
Secretary shall approve payments described in sub-
clause (I) that are furnished through an agreed 
upon capitation, partial capitation, or other value- 
based payment arrangement if the capitation, partial 
capitation, or other value-based payment arrange-
ment is based on a reasonable methodology and the 
entity provides documentation to the State sufficient 
to enable the State and the Secretary to ensure com-
pliance with subclause (I).’’. 
(2) 
CONFORMING
AMENDMENT.—Section 
1932(f) of the Social Security Act (42 U.S.C. 
1396u–2(f)) is amended by inserting ‘‘and clause 
(xiv) of section 1903(m)(2)(A)’’ before the period. 
SEC. 207. PERMANENT FUNDING FOR CHIP. 
(a) IN GENERAL.—Section 2104(a) of the Social Se-
curity Act (42 U.S.C. 1397dd(a)) is amended— 
(1) in paragraph (26), by inserting at the end 
‘‘and’’; 
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(2) by amending paragraph (27) to read as fol-
lows: 
‘‘(27) for each fiscal year beginning with fiscal 
year 2024, such sums as are necessary to fund allot-
ments to States under subsections (c) and (m).’’; 
and 
(3) by striking paragraph (28). 
(b) IN GENERAL.—Section 2104(a)(28) of the Social 
Security Act (42 U.S.C. 1397dd(a)(28)) is amended to 
read as follows: 
‘‘(28) for fiscal year 2027 and each subsequent 
year, such sums as are necessary to fund allotments 
to States under subsections (c) and (m).’’. 
(c) ALLOTMENTS.— 
(1) IN GENERAL.—Section 2104(m) of the So-
cial Security Act (42 U.S.C. 1397dd(m)) is amend-
ed— 
(A) in paragraph (2)(B)(i), by striking ‘‘,, 
2023, and 2027’’ and inserting ‘‘and 2023’’; 
(B) in paragraph (7)— 
(i) in subparagraph (A), by striking 
‘‘and ending with fiscal year 2027,’’; and 
(ii) in the flush left matter at the end, 
by striking ‘‘or fiscal year 2026’’ and in-
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serting ‘‘fiscal year 2026, or a subsequent 
even-numbered fiscal year’’; 
(C) in paragraph (9)— 
(i) by striking ‘‘(10), or (11)’’ and in-
serting ‘‘or (10)’’; and 
(ii) by striking ‘‘2023, or 2027,’’ and 
inserting ‘‘or 2023’’; and 
(D) by striking paragraph (11). 
(2) 
CONFORMING
AMENDMENT.—Section 
50101(b)(2) of the Bipartisan Budget Act of 2018 
(Public Law 115–123) is repealed. 
SEC. 208. PERMANENT EXTENSION OF CHIP ENROLLMENT 
AND QUALITY MEASURES. 
(a) PEDIATRIC QUALITY MEASURES PROGRAM.— 
Section 1139A(i)(1) of the Social Security Act (42 U.S.C. 
1320b–9a(i)(1)) is amended— 
(1) in subparagraph (C), by striking at the end 
‘‘and’’; 
(2) in subparagraph (D), by striking the period 
at the end and insert a semicolon; and 
(3) by adding at the end the following new sub-
paragraphs: 
‘‘(E) for fiscal year 2028, $15,000,000 for 
the purpose of carrying out this section (other 
than subsections (e), (f), and (g)); and 
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‘‘(F) for a subsequent fiscal year, the 
amount appropriated under this paragraph for 
the previous fiscal year, increased by the per-
centage increase in the consumer price index for 
all urban consumers (all items; United States 
city average) over such previous fiscal year, for 
the purpose of carrying out this section (other 
than subsections (e), (f), and (g)).’’. 
(b) EXPRESS LANE ELIGIBILITY OPTION.—Section 
1902(e)(13) of the Social Security Act (42 U.S.C. 
1396a(e)(13)) is amended by striking subparagraph (I). 
(c) ASSURANCE OF AFFORDABILITY STANDARD FOR 
CHILDREN AND FAMILIES.— 
(1) IN GENERAL.—Section 2105(d)(3) of the 
Social Security Act (42 U.S.C. 1397ee(d)(3)) is 
amended— 
(A) in the paragraph heading, by striking 
‘‘THROUGH SEPTEMBER 30, 2027’’; and 
(B) in subparagraph (A), in the matter 
preceding clause (i)— 
(i) by striking ‘‘During the period 
that begins on the date of enactment of 
the Patient Protection and Affordable Care 
Act and ends on September 30, 2027’’ and 
inserting ‘‘Beginning on the date of the en-
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actment of the Patient Protection and Af-
fordable Care Act’’; 
(ii) by striking ‘‘During the period 
that begins on October 1, 2019, and ends 
on September 30, 2027’’ and inserting 
‘‘Beginning on October 1, 2019’’; and 
(iii) by striking ‘‘The preceding sen-
tences shall not be construed as preventing 
a State during any such periods from’’ and 
inserting ‘‘The preceding sentences shall 
not be construed as preventing a State 
from’’. 
(2) 
CONFORMING
AMENDMENTS.—Section 
1902(gg)(2) of the Social Security Act (42 U.S.C. 
1396a(gg)(2)) is amended— 
(A) in the paragraph heading, by striking 
‘‘THROUGH SEPTEMBER 30, 2027’’; and 
(B) by striking ‘‘through September 30’’ 
and all that follows through ‘‘ends on Sep-
tember 30, 2027’’ and inserting ‘‘(but begin-
ning on October 1, 2019,’’. 
(d) 
QUALIFYING
STATES
OPTION.—Section 
2105(g)(4) of the Social Security Act (42 U.S.C. 
1397ee(g)(4)) is amended— 
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(1) in the paragraph heading, by striking ‘‘FOR 
FISCAL YEARS 2009 THROUGH 2027’’ and inserting 
‘‘AFTER FISCAL YEAR 2008’’; and 
(2) in subparagraph (A), by striking ‘‘for any 
of fiscal years 2009 through 2027’’ and inserting 
‘‘for any fiscal year after fiscal year 2008’’. 
(e) OUTREACH AND ENROLLMENT PROGRAM.—Sec-
tion 2113 of the Social Security Act (42 U.S.C. 1397mm) 
is amended— 
(1) in subsection (a)— 
(A) in paragraph (1), by striking ‘‘during 
the period of fiscal years 2009 through 2027’’ 
and inserting ‘‘, beginning with fiscal year 
2009,’’; 
(B) in paragraph (2)— 
(i) by striking ‘‘10 percent of such 
amounts’’ and inserting ‘‘10 percent of 
such amounts for the period or the fiscal 
year for which such amounts are appro-
priated’’; and 
(ii) by striking ‘‘during such period’’ 
and inserting ‘‘, during such period or such 
fiscal year,’’; and 
(C) in paragraph (3), by striking ‘‘For the 
period of fiscal years 2024 through 2027, an 
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amount equal to 10 percent of such amounts’’ 
and inserting ‘‘Beginning with fiscal year 2024, 
an amount equal to 10 percent of such amounts 
for the period or the fiscal year for which such 
amounts are appropriated’’; and 
(2) in subsection (g)— 
(A) by striking ‘‘2017,,’’ and inserting 
‘‘2017,’’; 
(B) by striking ‘‘and $48,000,000’’ and in-
serting ‘‘$48,000,000’’; and 
(C) by inserting after ‘‘through 2027’’ the 
following: ‘‘, $12,000,000 for fiscal year 2028, 
and, for each fiscal year after fiscal year 2028, 
the amount appropriated under this subsection 
for the previous fiscal year, increased by the 
percentage increase in the consumer price index 
for all urban consumers (all items; United 
States city average) over such previous fiscal 
year’’. 
(f) CHILD ENROLLMENT CONTINGENCY FUND.— 
Section 2104(n) of the Social Security Act (42 U.S.C. 
1397dd(n)) is amended— 
(1) in paragraph (2)— 
(A) in subparagraph (A)(ii)— 
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(i) by striking ‘‘and 2024 through 
2026’’ and inserting ‘‘beginning with fiscal 
year 2024’’; and 
(ii) by striking ‘‘2023, and 2027’’ and 
inserting ‘‘, and 2023’’; and 
(B) in subparagraph (B)— 
(i) by striking ‘‘2024 through 2026’’ 
and inserting ‘‘beginning with fiscal year 
2024’’; and 
(ii) by striking ‘‘2023, and 2027’’ and 
inserting ‘‘, and 2023’’; and 
(2) in paragraph (3)(A)— 
(A) by striking ‘‘fiscal years 2024 through 
2026’’ and inserting ‘‘beginning with fiscal year 
2024’’; and 
(B) by striking ‘‘2023, or 2027’’ and in-
serting ‘‘, or 2023’’. 
SEC. 209. STATE OPTION TO INCREASE CHILDREN’S ELIGI-
BILITY FOR MEDICAID AND CHIP. 
Section 2110(b)(1)(B)(ii) of the Social Security Act 
(42 U.S.C. 1397jj(b)(1)(B)(ii)) is amended— 
(1) in subclause (II), by striking ‘‘or’’ at the 
end; 
(2) in subclause (III), by striking ‘‘and’’ at the 
end and inserting ‘‘or’’; and 
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(3) by inserting after subclause (III) the fol-
lowing new subclause: 
‘‘(IV) at the option of the State, 
whose family income exceeds the max-
imum income level otherwise estab-
lished for children under the State 
child health plan as of the date of the 
enactment of this subclause; and’’. 
SEC. 210. MEDICAID COVERAGE FOR CITIZENS OF FREELY 
ASSOCIATED STATES. 
(a) IN GENERAL.—Section 402(b)(2) of the Personal 
Responsibility and Work Opportunity Reconciliation Act 
of 1996 (8 U.S.C. 1612(b)(2)) is amended by adding at 
the end the following new subparagraph: 
‘‘(G) MEDICAID EXCEPTION FOR CITIZENS 
OF FREELY ASSOCIATED STATES.—With respect 
to eligibility for benefits for the designated Fed-
eral program defined in paragraph (3)(C) (re-
lating to the Medicaid program), section 401(a) 
and paragraph (1) shall not apply to any indi-
vidual who lawfully resides in 1 of the 50 States 
or the District of Columbia in accordance with 
the Compacts of Free Association between the 
Government of the United States and the Gov-
ernments of the Federated States of Micro-
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nesia, the Republic of the Marshall Islands, and 
the Republic of Palau and shall not apply, at 
the option of the Governor of Puerto Rico, the 
Virgin Islands, Guam, the Northern Mariana 
Islands, or American Samoa as communicated 
to the Secretary of Health and Human Services 
in writing, to any individual who lawfully re-
sides in the respective territory in accordance 
with such Compacts.’’. 
(b) EXCEPTION TO 5–YEAR LIMITED ELIGIBILITY.— 
Section 403(d) of such Act (8 U.S.C. 1613(d)) is amend-
ed— 
(1) in paragraph (1), by striking ‘‘or’’ at the 
end; 
(2) in paragraph (2), by striking the period at 
the end and inserting ‘‘; or’’; and 
(3) by adding at the end the following new 
paragraph: 
‘‘(3) 
an 
individual 
described 
in 
section 
402(b)(2)(G), but only with respect to the des-
ignated 
Federal 
program 
defined 
in 
section 
402(b)(3)(C).’’. 
(c) DEFINITION
OF QUALIFIED ALIEN.—Section 
431(b) of such Act (8 U.S.C. 1641(b)) is amended— 
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(1) in paragraph (6), by striking ‘‘; or’’ at the 
end and inserting a comma; 
(2) in paragraph (7), by striking the period at 
the end and inserting ‘‘, or’’; and 
(3) by adding at the end the following new 
paragraph: 
‘‘(8) an individual who lawfully resides in the 
United States in accordance with a Compact of Free 
Association referred to in section 402(b)(2)(G), but 
only with respect to the designated Federal program 
defined in section 402(b)(3)(C) (relating to the Med-
icaid program).’’. 
(d) 
APPLICATION
TO
STATE
PLANS.—Section 
1902(a)(10)(A)(i) of the Social Security Act (42 U.S.C. 
1396a(a)(10)(A)(i)) is amended by inserting after sub-
clause (IX) the following: 
‘‘(X) who are described in section 
402(b)(2)(G) of the Personal Respon-
sibility and Work Opportunity Rec-
onciliation Act of 1996 and eligible 
for benefits under this title by reason 
of application of such section;’’. 
(e) CONFORMING AMENDMENTS.—Section 1108 of 
the Social Security Act (42 U.S.C. 1308) is amended— 
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(1) in subsection (f), in the matter preceding 
paragraph (1), by striking ‘‘subsections (g) and (h) 
and section 1935(e)(1)(B)’’ and inserting ‘‘sub-
sections (g), (h), and (i) and section 1935(e)(1)(B)’’; 
and 
(2) by adding at the end the following: 
‘‘(i) EXCLUSION OF MEDICAL ASSISTANCE EXPENDI-
TURES FOR CITIZENS OF FREELY ASSOCIATED STATES.— 
Expenditures for medical assistance provided to an indi-
vidual described in section 431(b)(8) of the Personal Re-
sponsibility and Work Opportunity Reconciliation Act of 
1996 (8 U.S.C. 1641(b)(8)) shall not be taken into ac-
count for purposes of applying payment limits under sub-
sections (f) and (g).’’. 
(f) EFFECTIVE DATE.—The amendments made by 
this section shall apply to benefits for items and services 
furnished on or after the date of the enactment of this 
Act. 
SEC. 211. EXTENSION OF FULL FEDERAL MEDICAL ASSIST-
ANCE 
PERCENTAGE 
TO 
INDIAN 
HEALTH 
CARE PROVIDERS. 
(a) IN GENERAL.—Section 1905 of the Social Secu-
rity Act (42 U.S.C. 1396d) is amended— 
(1) in subsection (a), by amending paragraph 
(9) to read as follows: 
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‘‘(9) clinic services furnished by or under the 
direction of a physician, without regard to whether 
the clinic itself is administered by a physician, in-
cluding— 
‘‘(A) such services furnished outside the 
clinic by clinic personnel to an eligible indi-
vidual who does not reside in a permanent 
dwelling or does not have a fixed home or mail-
ing address; and 
‘‘(B) such services provided outside the 
clinic on the basis of a referral from a clinic ad-
ministered by an Indian Health Program (as 
defined in paragraph (12) of section 4 of the 
Indian Health Care Improvement Act, or an 
Urban Indian Organization as defined in para-
graph (29) of section 4 of such Act that has a 
grant or contract with the Indian Health Serv-
ice under title V of such Act;’’. 
(2) in subsection (b), by inserting after ‘‘(as de-
fined in section 4 of the Indian Health Care Im-
provement Act)’’ the following: ‘‘; the Federal med-
ical assistance percentage shall also be 100 per cen-
tum with respect to amounts expended as medical 
assistance for services which are received through an 
Urban Indian organization (as defined in section 4 
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of the Indian Health Care Improvement Act) that 
has a grant or contract with the Indian Health Serv-
ice under title V of such Act’’. 
(b) EXTENSION OF FULL FEDERAL MEDICAL AS-
SISTANCE PERCENTAGE TO SERVICES FURNISHED BY NA-
TIVE HAWAIIAN HEALTH CARE SYSTEMS.— 
(1) IN GENERAL.—Beginning on the date of en-
actment of this Act— 
(A) for purposes of section 1905(a)(9) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1396d(a)(9)), services described in subsection 
(b) that are furnished in any location shall be 
deemed to be clinic services; and 
(B) notwithstanding section 1905(b) of the 
Social Security Act (42 U.S.C. 1396d(b)), the 
Federal medical assistance percentage with re-
spect to amounts expended as medical assist-
ance for such services shall be 100 percent. 
(2) SERVICES
DESCRIBED.—The services de-
scribed in this subsection are services for which pay-
ment is available under the State plan under title 
XIX of the Social Security Act (42 U.S.C. 1396 et 
seq.) of Hawaii (or any waiver of such plan) that— 
(A) are furnished on or after the date of 
enactment of this Act; 
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(B) are furnished to an individual who— 
(i) is a Native Hawaiian; and 
(ii) is eligible for medical assistance 
under such plan; and 
(C) are furnished by an Indian health care 
provider (as such term is defined in section 
1932(h)(4)(A) of the Social Security Act (42 
U.S.C. 1396u–2(h)(4)(A)) or a Native Hawai-
ian health care system (without regard to 
whether such services are furnished through an 
Indian Health Service facility). 
TITLE 
III—LOWERING 
PRICES 
THROUGH FAIR DRUG PRICE 
NEGOTIATION 
SEC. 301. ESTABLISHING A FAIR DRUG PRICING PROGRAM. 
(a) PROGRAM TO LOWER PRICES
FOR CERTAIN 
HIGH-PRICED SINGLE SOURCE DRUGS.—Title XI of the 
Social Security Act (42 U.S.C. 1301 et seq.) is amended 
by adding at the end the following new part: 
‘‘PART E—FAIR PRICE NEGOTIATION PROGRAM 
TO LOWER PRICES FOR CERTAIN HIGH- 
PRICED SINGLE SOURCE DRUGS 
‘‘SEC. 1191. ESTABLISHMENT OF PROGRAM. 
‘‘(a) IN GENERAL.—The Secretary shall establish a 
Fair Price Negotiation Program (in this part referred to 
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as the ‘program’). Under the program, with respect to 
each price applicability period, the Secretary shall— 
‘‘(1) publish a list of selected drugs in accord-
ance with section 1192; 
‘‘(2) enter into agreements with manufacturers 
of selected drugs with respect to such period, in ac-
cordance with section 1193; 
‘‘(3) negotiate and, if applicable, renegotiate 
maximum fair prices for such selected drugs, in ac-
cordance with section 1194; and 
‘‘(4) carry out the administrative duties de-
scribed in section 1196. 
‘‘(b) DEFINITIONS RELATING TO TIMING.—For pur-
poses of this part: 
‘‘(1) INITIAL PRICE APPLICABILITY YEAR.—The 
term ‘initial price applicability year’ means a plan 
year (beginning with plan year 2023) or, if agreed 
to in an agreement under section 1193 by the Sec-
retary and manufacturer involved, a period of more 
than one plan year (beginning on or after January 
1, 2023). 
‘‘(2) PRICE APPLICABILITY PERIOD.—The term 
‘price applicability period’ means, with respect to a 
drug, the period beginning with the initial price ap-
plicability year with respect to which such drug is a 
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selected drug and ending with the last plan year 
during which the drug is a selected drug. 
‘‘(3) SELECTED
DRUG
PUBLICATION
DATE.— 
The term ‘selected drug publication date’ means, 
with respect to each initial price applicability year, 
April 15 of the plan year that begins 2 years prior 
to such year. 
‘‘(4) VOLUNTARY NEGOTIATION PERIOD.—The 
term ‘voluntary negotiation period’ means, with re-
spect to an initial price applicability year with re-
spect to a selected drug, the period— 
‘‘(A) beginning on the sooner of— 
‘‘(i) the date on which the manufac-
turer of the drug and the Secretary enter 
into an agreement under section 1193 with 
respect to such drug; or 
‘‘(ii) June 15 following the selected 
drug publication date with respect to such 
selected drug; and 
‘‘(B) ending on March 31 of the year that 
begins one year prior to the initial price appli-
cability year. 
‘‘(c) OTHER DEFINITIONS.—For purposes of this 
part: 
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‘‘(1) FAIR PRICE ELIGIBLE INDIVIDUAL.—The 
term ‘fair price eligible individual’ means, with re-
spect to a selected drug— 
‘‘(A) in the case such drug is furnished or 
dispensed to the individual at a pharmacy or by 
a mail order service— 
‘‘(i) an individual who is enrolled 
under a prescription drug plan under part 
D of title XVIII or an MA–PD plan under 
part C of such title if coverage is provided 
under such plan for such selected drug; 
and 
‘‘(ii) an individual who is enrolled 
under a group health plan or health insur-
ance coverage offered in the group or indi-
vidual market (as such terms are defined 
in section 2791 of the Public Health Serv-
ice Act) with respect to which there is in 
effect an agreement with the Secretary 
under section 1197 with respect to such se-
lected drug as so furnished or dispensed; 
and 
‘‘(B) in the case such drug is furnished or 
administered to the individual by a hospital, 
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physician, or other provider of services or sup-
plier— 
‘‘(i) an individual who is entitled to 
benefits under part A of title XVIII or en-
rolled under part B of such title if such se-
lected drug is covered under the respective 
part; and 
‘‘(ii) an individual who is enrolled 
under a group health plan or health insur-
ance coverage offered in the group or indi-
vidual market (as such terms are defined 
in section 2791 of the Public Health Serv-
ice Act) with respect to which there is in 
effect an agreement with the Secretary 
under section 1197 with respect to such se-
lected drug as so furnished or adminis-
tered. 
‘‘(2) MAXIMUM FAIR PRICE.—The term ‘max-
imum fair price’ means, with respect to a plan year 
during a price applicability period and with respect 
to a selected drug (as defined in section 1192(c)) 
with respect to such period, the price published pur-
suant to section 1195 in the Federal Register for 
such drug and year. 
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‘‘(3) AVERAGE INTERNATIONAL MARKET PRICE 
DEFINED.— 
‘‘(A) IN
GENERAL.—The terms ‘average 
international market price’ and ‘AIM price’ 
mean, with respect to a drug, the average price 
(which shall be the net average price, if prac-
ticable, and volume-weighted, if practicable) for 
a unit (as defined in paragraph (4)) of the drug 
for sales of such drug (calculated across dif-
ferent dosage forms and strengths of the drug 
and not based on the specific formulation or 
package size or package type), as computed (as 
of the date of publication of such drug as a se-
lected drug under section 1192(a)) in all coun-
tries described in clause (ii) of subparagraph 
(B) that are applicable countries (as described 
in clause (i) of such subparagraph) with respect 
to such drug. 
‘‘(B) APPLICABLE COUNTRIES.— 
‘‘(i) IN
GENERAL.—For purposes of 
subparagraph (A), a country described in 
clause (ii) is an applicable country de-
scribed in this clause with respect to a 
drug if there is available an average price 
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for any unit for the drug for sales of such 
drug in such country. 
‘‘(ii) COUNTRIES
DESCRIBED.—For 
purposes of this paragraph, the following 
are countries described in this clause: 
‘‘(I) Australia. 
‘‘(II) Canada. 
‘‘(III) France. 
‘‘(IV) Germany. 
‘‘(V) Japan. 
‘‘(VI) The United Kingdom. 
‘‘(4) UNIT.—The term ‘unit’ means, with re-
spect to a drug, the lowest identifiable quantity 
(such as a capsule or tablet, milligram of molecules, 
or grams) of the drug that is dispensed. 
‘‘SEC. 1192. SELECTION OF NEGOTIATION-ELIGIBLE DRUGS 
AS SELECTED DRUGS. 
‘‘(a) IN GENERAL.—Not later than the selected drug 
publication date with respect to an initial price applica-
bility year, subject to subsection (h), the Secretary shall 
select and publish in the Federal Register a list of— 
‘‘(1)(A) with respect to an initial price applica-
bility year during 2023, at least 25 negotiation-eligi-
ble drugs described in subparagraphs (A) and (B), 
but not subparagraph (C), of subsection (d)(1) (or, 
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with respect to an initial price applicability year dur-
ing such period beginning after 2023, the maximum 
number (if such number is less than 25) of such ne-
gotiation-eligible drugs for the year) with respect to 
such year; and 
‘‘(B) with respect to an initial price applica-
bility year during 2024 or a subsequent year, at 
least 50 negotiation-eligible drugs described in sub-
paragraphs (A) and (B), but not subparagraph (C), 
of subsection (d)(1) (or, with respect to an initial 
price applicability year during such period, the max-
imum number (if such number is less than 50) of 
such negotiation-eligible drugs for the year) with re-
spect to such year; 
‘‘(2) all negotiation-eligible drugs described in 
subparagraph (C) of such subsection with respect to 
such year; and 
‘‘(3) all new-entrant negotiation-eligible drugs 
(as defined in subsection (g)(1)) with respect to such 
year. 
Each drug published on the list pursuant to the previous 
sentence shall be subject to the negotiation process under 
section 1194 for the voluntary negotiation period with re-
spect to such initial price applicability year (and the re-
negotiation process under such section as applicable for 
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any subsequent year during the applicable price applica-
bility period). In applying this subsection, any negotiation- 
eligible drug that is selected under this subsection for an 
initial price applicability year shall not count toward the 
required minimum amount of drugs to be selected under 
paragraph (1) for any subsequent year, including such a 
drug so selected that is subject to renegotiation under sec-
tion 1194. 
‘‘(b) SELECTION OF DRUGS.—In carrying out sub-
section (a)(1) the Secretary shall select for inclusion on 
the published list described in subsection (a) with respect 
to a price applicability period, the negotiation-eligible 
drugs that the Secretary projects will result in the greatest 
savings to the Federal Government or fair price eligible 
individuals during the price applicability period. In making 
this projection of savings for drugs for which there is an 
AIM price for a price applicability period, the savings shall 
be projected across different dosage forms and strengths 
of the drugs and not based on the specific formulation or 
package size or package type of the drugs, taking into con-
sideration both the volume of drugs for which payment 
is made, to the extent such data is available, and the 
amount by which the net price for the drugs exceeds the 
AIM price for the drugs. 
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‘‘(c) SELECTED DRUG.—For purposes of this part, 
each drug included on the list published under subsection 
(a) with respect to an initial price applicability year shall 
be referred to as a ‘selected drug’ with respect to such 
year and each subsequent plan year beginning before the 
first plan year beginning after the date on which the Sec-
retary determines two or more drug products— 
‘‘(1) are approved or licensed (as applicable)— 
‘‘(A) under section 505(j) of the Federal 
Food, Drug, and Cosmetic Act using such drug 
as the listed drug; or 
‘‘(B) under section 351(k) of the Public 
Health Service Act using such drug as the ref-
erence product; and 
‘‘(2) continue to be marketed. 
‘‘(d) NEGOTIATION-ELIGIBLE DRUG.— 
‘‘(1) IN GENERAL.—For purposes of this part, 
the term ‘negotiation-eligible drug’ means, with re-
spect to the selected drug publication date with re-
spect to an initial price applicability year, a quali-
fying single source drug, as defined in subsection 
(e), that meets any of the following criteria: 
‘‘(A) COVERED PART D DRUGS.—The drug 
is among the 125 covered part D drugs (as de-
fined in section 1860D–2(e)) for which there 
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was an estimated greatest net spending under 
parts C and D of title XVIII, as determined by 
the Secretary, during the most recent plan year 
prior to such drug publication date for which 
data are available. 
‘‘(B) OTHER DRUGS.—The drug is among 
the 125 drugs for which there was an estimated 
greatest net spending in the United States (in-
cluding the 50 States, the District of Columbia, 
and the territories of the United States), as de-
termined by the Secretary, during the most re-
cent plan year prior to such drug publication 
date for which data are available. 
‘‘(C) INSULIN.—The drug is a qualifying 
single source drug described in subsection 
(e)(3). 
‘‘(2) CLARIFICATION.—In determining whether 
a qualifying single source drug satisfies any of the 
criteria described in paragraph (1), the Secretary 
shall, to the extent practicable, use data that is ag-
gregated across dosage forms and strengths of the 
drug and not based on the specific formulation or 
package size or package type of the drug. 
‘‘(3) PUBLICATION.—Not later than the se-
lected drug publication date with respect to an ini-
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tial price applicability year, the Secretary shall pub-
lish in the Federal Register a list of negotiation-eli-
gible drugs with respect to such selected drug publi-
cation date. 
‘‘(e) QUALIFYING SINGLE SOURCE DRUG.—For pur-
poses of this part, the term ‘qualifying single source drug’ 
means any of the following: 
‘‘(1) DRUG PRODUCTS.—A drug that— 
‘‘(A) is approved under section 505(c) of 
the Federal Food, Drug, and Cosmetic Act and 
continues to be marketed pursuant to such ap-
proval; and 
‘‘(B) is not the listed drug for any drug 
that is approved and continues to be marketed 
under section 505(j) of such Act. 
‘‘(2) BIOLOGICAL
PRODUCTS.—A biological 
product that— 
‘‘(A) is licensed under section 351(a) of 
the Public Health Service Act, including any 
product that has been deemed to be licensed 
under section 351 of such Act pursuant to sec-
tion 7002(e)(4) of the Biologics Price Competi-
tion and Innovation Act of 2009, and continues 
to be marketed under section 351 of such Act; 
and 
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‘‘(B) is not the reference product for any 
biological product that is licensed and continues 
to be marketed under section 351(k) of such 
Act. 
‘‘(3) 
INSULIN
PRODUCT.—Notwithstanding 
paragraphs (1) and (2), any insulin product that is 
approved under subsection (c) or (j) of section 505 
of the Federal Food, Drug, and Cosmetic Act or li-
censed under subsection (a) or (k) of section 351 of 
the Public Health Service Act and continues to be 
marketed under such section 505 or 351, including 
any insulin product that has been deemed to be li-
censed under section 351(a) of the Public Health 
Service Act pursuant to section 7002(e)(4) of the 
Biologics Price Competition and Innovation Act of 
2009 and continues to be marketed pursuant to such 
licensure. 
For purposes of applying paragraphs (1) and (2), a drug 
or biological product that is marketed by the same sponsor 
or manufacturer (or an affiliate thereof or a cross-licensed 
producer or distributor) as the listed drug or reference 
product described in such respective paragraph shall not 
be taken into consideration. 
‘‘(f) INFORMATION
ON
INTERNATIONAL
DRUG 
PRICES.—For purposes of determining which negotiation- 
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eligible drugs to select under subsection (a) and, in the 
case of such drugs that are selected drugs, to determine 
the maximum fair price for such a drug and whether such 
maximum fair price should be renegotiated under section 
1194, the Secretary shall use data relating to the AIM 
price with respect to such drug as available or provided 
to the Secretary and shall on an ongoing basis request 
from manufacturers of selected drugs information on the 
AIM price of such a drug. 
‘‘(g) 
NEW-ENTRANT
NEGOTIATION-ELIGIBLE 
DRUGS.— 
‘‘(1) IN GENERAL.—For purposes of this part, 
the term ‘new-entrant negotiation-eligible drug’ 
means, with respect to the selected drug publication 
date with respect to an initial price applicability 
year, a qualifying single source drug— 
‘‘(A) that is first approved or licensed, as 
described in paragraph (1), (2), or (3) of sub-
section (e), as applicable, during the year pre-
ceding such selected drug publication date; and 
‘‘(B) that the Secretary determines under 
paragraph (2) is likely to be included as a nego-
tiation-eligible drug with respect to the subse-
quent selected drug publication date. 
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‘‘(2) DETERMINATION.—In the case of a quali-
fying single source drug that meets the criteria de-
scribed in subparagraph (A) of paragraph (1), with 
respect to an initial price applicability year, if the 
wholesale acquisition cost at which such drug is first 
marketed in the United States is equal to or greater 
than the median household income (as determined 
according to the most recent data collected by the 
United States Census Bureau), the Secretary shall 
determine before the selected drug publication date 
with respect to the initial price applicability year, if 
the drug is likely to be included as a negotiation-eli-
gible drug with respect to the subsequent selected 
drug publication date, based on the projected spend-
ing under title XVIII or in the United States on 
such drug. For purposes of this paragraph the term 
‘United States’ includes the 50 States, the District 
of Columbia, and the territories of the United 
States. 
‘‘(h) CONFLICT OF INTEREST.— 
‘‘(1) IN GENERAL.—In the case the Inspector 
General of the Department of Health and Human 
Services determines the Secretary has a conflict, 
with respect to a matter described in paragraph (2), 
the individual described in paragraph (3) shall carry 
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out the duties of the Secretary under this part, with 
respect to a negotiation-eligible drug, that would 
otherwise be such a conflict. 
‘‘(2) MATTER DESCRIBED.—A matter described 
in this paragraph is— 
‘‘(A) a financial interest (as described in 
section 2635.402 of title 5, Code of Federal 
Regulations (except for an interest described in 
subsection (b)(2)(iv) of such section)) on the 
date of the selected drug publication date, with 
respect the price applicability year (as applica-
ble); 
‘‘(B) a personal or business relationship 
(as described in section 2635.502 of such title) 
on the date of the selected drug publication 
date, with respect the price applicability year; 
‘‘(C) employment by a manufacturer of a 
negotiation-eligible drug during the preceding 
10-year period beginning on the date of the se-
lected drug publication date, with respect to 
each price applicability year; and 
‘‘(D) any other matter the General Counsel 
determines appropriate. 
‘‘(3) INDIVIDUAL
DESCRIBED.—An individual 
described in this paragraph is— 
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‘‘(A) the highest-ranking officer or em-
ployee of the Department of Health and 
Human Services (as determined by the organi-
zational chart of the Department) that does not 
have a conflict under this subsection; and 
‘‘(B) is nominated by the President and 
confirmed by the Senate with respect to the po-
sition. 
‘‘SEC. 1193. MANUFACTURER AGREEMENTS. 
‘‘(a) 
IN
GENERAL.—For 
purposes 
of 
section 
1191(a)(2), the Secretary shall enter into agreements with 
manufacturers of selected drugs with respect to a price 
applicability period, by not later than June 15 following 
the selected drug publication date with respect to such se-
lected drug, under which— 
‘‘(1) during the voluntary negotiation period for 
the initial price applicability year for the selected 
drug, the Secretary and manufacturer, in accordance 
with section 1194, negotiate to determine (and, by 
not later than the last date of such period and in ac-
cordance with subsection (c), agree to) a maximum 
fair price for such selected drug of the manufacturer 
in order to provide access to such price— 
‘‘(A) to fair price eligible individuals who 
with respect to such drug are described in sub-
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paragraph (A) of section 1191(c)(1) and are 
furnished or dispensed such drug during, sub-
ject to subparagraph (2), the price applicability 
period; and 
‘‘(B) to hospitals, physicians, and other 
providers of services and suppliers with respect 
to fair price eligible individuals who with re-
spect to such drug are described in subpara-
graph (B) of such section and are furnished or 
administered such drug during, subject to sub-
paragraph (2), the price applicability period; 
‘‘(2) the Secretary and the manufacturer shall, 
in accordance with a process and during a period 
specified by the Secretary pursuant to rulemaking, 
renegotiate (and, by not later than the last date of 
such period and in accordance with subsection (c), 
agree to) the maximum fair price for such drug if 
the Secretary determines that there is a material 
change in any of the factors described in section 
1194(d) relating to the drug, including changes in 
the AIM price for such drug, in order to provide ac-
cess to such maximum fair price (as so renegoti-
ated)— 
‘‘(A) to fair price eligible individuals who 
with respect to such drug are described in sub-
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paragraph (A) of section 1191(c)(1) and are 
furnished or dispensed such drug during any 
year during the price applicability period (be-
ginning after such renegotiation) with respect 
to such selected drug; and 
‘‘(B) to hospitals, physicians, and other 
providers of services and suppliers with respect 
to fair price eligible individuals who with re-
spect to such drug are described in subpara-
graph (B) of such section and are furnished or 
administered such drug during any year de-
scribed in subparagraph (A); 
‘‘(3) the maximum fair price (including as re-
negotiated pursuant to paragraph (2)), with respect 
to such a selected drug, shall be provided to fair 
price eligible individuals, who with respect to such 
drug are described in subparagraph (A) of section 
1191(c)(1), at the pharmacy or by a mail order serv-
ice at the point-of-sale of such drug; 
‘‘(4) the manufacturer, subject to subsection 
(d), submits to the Secretary, in a form and manner 
specified by the Secretary— 
‘‘(A) for the voluntary negotiation period 
for the price applicability period (and, if appli-
cable, before any period of renegotiation speci-
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fied pursuant to paragraph (2)) with respect to 
such drug all information that the Secretary re-
quires to carry out the negotiation (or renegoti-
ation process) under this part, including infor-
mation described in section 1192(f) and section 
1194(d)(1); and 
‘‘(B) on an ongoing basis, information on 
changes in prices for such drug that would af-
fect the AIM price for such drug or otherwise 
provide a basis for renegotiation of the max-
imum fair price for such drug pursuant to 
paragraph (2); 
‘‘(5) the manufacturer agrees that in the case 
the selected drug of a manufacturer is a drug de-
scribed in subsection (c), the manufacturer will, in 
accordance with such subsection, make any payment 
required under such subsection with respect to such 
drug; and 
‘‘(6) the manufacturer complies with require-
ments imposed by the Secretary for purposes of ad-
ministering the program, including with respect to 
the duties described in section 1196. 
‘‘(b) AGREEMENT IN EFFECT UNTIL DRUG IS NO 
LONGER A SELECTED DRUG.—An agreement entered into 
under this section shall be effective, with respect to a drug, 
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until such drug is no longer considered a selected drug 
under section 1192(c). 
‘‘(c) SPECIAL RULE FOR CERTAIN SELECTED DRUGS 
WITHOUT AIM PRICE.— 
‘‘(1) IN GENERAL.—In the case of a selected 
drug for which there is no AIM price available with 
respect to the initial price applicability year for such 
drug and for which an AIM price becomes available 
beginning with respect to a subsequent plan year 
during the price applicability period for such drug, 
if the Secretary determines that the amount de-
scribed in paragraph (2)(A) for a unit of such drug 
is greater than the amount described in paragraph 
(2)(B) for a unit of such drug, then by not later 
than one year after the date of such determination, 
the manufacturer of such selected drug shall pay to 
the Treasury an amount equal to the product of— 
‘‘(A) the difference between such amount 
described in paragraph (2)(A) for a unit of 
such drug and such amount described in para-
graph (2)(B) for a unit of such drug; and 
‘‘(B) the number of units of such drug sold 
in the United States, including the 50 States, 
the District of Columbia, and the territories of 
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the United States, during the period described 
in paragraph (2)(B). 
‘‘(2) AMOUNTS DESCRIBED.— 
‘‘(A) WEIGHTED AVERAGE PRICE BEFORE 
AIM PRICE AVAILABLE.—For purposes of para-
graph (1), the amount described in this sub-
paragraph for a selected drug described in such 
paragraph, is the amount equal to the weighted 
average manufacturer price (as defined in sec-
tion 1927(k)(1)) for such dosage strength and 
form for the drug during the period beginning 
with the first plan year for which the drug is 
included on the list of negotiation-eligible drugs 
published under section 1192(d) and ending 
with the last plan year during the price applica-
bility period for such drug with respect to which 
there is no AIM price available for such drug. 
‘‘(B) AMOUNT
MULTIPLIER
AFTER
AIM 
PRICE AVAILABLE.—For purposes of paragraph 
(1), the amount described in this subparagraph 
for a selected drug described in such paragraph, 
is the amount equal to 200 percent of the AIM 
price for such drug with respect to the first 
plan year during the price applicability period 
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for such drug with respect to which there is an 
AIM price available for such drug. 
‘‘(d) CONFIDENTIALITY
OF INFORMATION.—Infor-
mation submitted to the Secretary under this part by a 
manufacturer of a selected drug that is proprietary infor-
mation of such manufacturer (as determined by the Sec-
retary) may be used only by the Secretary or disclosed 
to and used by the Comptroller General of the United 
States or the Medicare Payment Advisory Commission for 
purposes of carrying out this part. 
‘‘(e) REGULATIONS.— 
‘‘(1) IN GENERAL.—The Secretary shall, pursu-
ant to rulemaking, specify, in accordance with para-
graph (2), the information that must be submitted 
under subsection (a)(4). 
‘‘(2) INFORMATION
SPECIFIED.—Information 
described in paragraph (1), with respect to a se-
lected drug, shall include information on sales of the 
drug (by the manufacturer of the drug or by another 
entity under license or other agreement with the 
manufacturer, with respect to the sales of such drug, 
regardless of the name under which the drug is sold) 
in any foreign country that is part of the AIM price. 
The Secretary shall verify, to the extent practicable, 
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such sales from appropriate officials of the govern-
ment of the foreign country involved. 
‘‘(f) COMPLIANCE WITH REQUIREMENTS FOR AD-
MINISTRATION OF PROGRAM.—Each manufacturer with 
an agreement in effect under this section shall comply with 
requirements imposed by the Secretary or a third party 
with a contract under section 1196(c)(1), as applicable, 
for purposes of administering the program. 
‘‘SEC. 1194. NEGOTIATION AND RENEGOTIATION PROCESS. 
‘‘(a) IN GENERAL.—For purposes of this part, under 
an agreement under section 1193 between the Secretary 
and a manufacturer of a selected drug, with respect to 
the period for which such agreement is in effect and in 
accordance with subsections (b) and (c), the Secretary and 
the manufacturer— 
‘‘(1) shall during the voluntary negotiation pe-
riod with respect to the initial price applicability 
year for such drug, in accordance with this section, 
negotiate a maximum fair price for such drug for 
the purpose described in section 1193(a)(1); and 
‘‘(2) 
as 
applicable 
pursuant 
to 
section 
1193(a)(2) and in accordance with the process speci-
fied pursuant to such section, renegotiate such max-
imum fair price for such drug for the purpose de-
scribed in such section. 
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‘‘(b) NEGOTIATING
METHODOLOGY
AND
OBJEC-
TIVE.— 
‘‘(1) IN GENERAL.—The Secretary shall develop 
and use a consistent methodology for negotiations 
under subsection (a) that, in accordance with para-
graph (2) and subject to paragraph (3), achieves the 
lowest maximum fair price for each selected drug 
while appropriately rewarding innovation. 
‘‘(2) PRIORITIZING
FACTORS.—In considering 
the factors described in subsection (d) in negotiating 
(and, as applicable, renegotiating) the maximum fair 
price for a selected drug, the Secretary shall, to the 
extent practicable, consider all of the available fac-
tors listed but shall prioritize the following factors: 
‘‘(A) 
RESEARCH
AND
DEVELOPMENT 
COSTS.—The factor described in paragraph 
(1)(A) of subsection (d). 
‘‘(B) MARKET
DATA.—The factor de-
scribed in paragraph (1)(B) of such subsection. 
‘‘(C) UNIT
COSTS
OF
PRODUCTION
AND 
DISTRIBUTION.—The factor described in para-
graph (1)(C) of such subsection. 
‘‘(D) COMPARISON
TO
EXISTING
THERA-
PEUTIC ALTERNATIVES.—The factor described 
in paragraph (2)(A) of such subsection. 
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‘‘(3) REQUIREMENT.— 
‘‘(A) IN
GENERAL.—In negotiating the 
maximum fair price of a selected drug, with re-
spect to an initial price applicability year for 
the selected drug, and, as applicable, in renego-
tiating the maximum fair price for such drug, 
with respect to a subsequent year during the 
price applicability period for such drug, in the 
case that the manufacturer of the selected drug 
offers under the negotiation or renegotiation, as 
applicable, a price for such drug that is not 
more than the target price described in sub-
paragraph (B) for such drug for the respective 
year, the Secretary shall agree under such ne-
gotiation or renegotiation, respectively, to such 
offered price as the maximum fair price. 
‘‘(B) TARGET PRICE.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), the target price described in this sub-
paragraph for a selected drug with respect 
to a year, is the average price (which shall 
be the net average price, if practicable, and 
volume-weighted, if practicable) for a unit 
of such drug for sales of such drug, as 
computed (across different dosage forms 
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and strengths of the drug and not based 
on the specific formulation or package size 
or package type of the drug) in the appli-
cable 
country 
described 
in 
section 
1191(c)(3)(B) with respect to such drug 
that, with respect to such year, has the 
lowest average price for such drug as com-
pared to the average prices (as so com-
puted) of such drug with respect to such 
year in the other applicable countries de-
scribed in such section with respect to such 
drug. 
‘‘(ii) SELECTED DRUGS WITHOUT AIM 
PRICE.—In applying this paragraph in the 
case of negotiating the maximum fair price 
of a selected drug for which there is no 
AIM price available with respect to the ini-
tial price applicability year for such drug, 
or, as applicable, renegotiating the max-
imum fair price for such drug with respect 
to a subsequent year during the price ap-
plicability period for such drug before the 
first plan year for which there is an AIM 
price available for such drug, the target 
price described in this subparagraph for 
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such drug and respective year is the 
amount that is 80 percent of the average 
manufacturer price (as defined in section 
1927(k)(1)) for such drug and year. 
‘‘(4) ANNUAL REPORT.—After the completion 
of each voluntary negotiation period, the Secretary 
shall submit to Congress a report on the maximum 
fair prices negotiated (or, as applicable, renegoti-
ated) for such period. Such report shall include in-
formation on how such prices so negotiated (or re-
negotiated) meet the requirements of this part, in-
cluding the requirements of this subsection. 
‘‘(c) LIMITATION.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
the maximum fair price negotiated (including as re-
negotiated) under this section for a selected drug, 
with respect to each plan year during a price appli-
cability period for such drug, shall not exceed 120 
percent of the AIM price applicable to such drug 
with respect to such year. 
‘‘(2) SELECTED DRUGS WITHOUT AIM PRICE.— 
In the case of a selected drug for which there is no 
AIM price available with respect to the initial price 
applicability year for such drug, for each plan year 
during the price applicability period before the first 
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plan year for which there is an AIM price available 
for such drug, the maximum fair price negotiated 
(including as renegotiated) under this section for the 
selected drug shall not exceed the amount equal to 
85 percent of the average manufacturer price for the 
drug with respect to such year. 
‘‘(d) CONSIDERATIONS.—For purposes of negotiating 
and, as applicable, renegotiating (including for purposes 
of determining whether to renegotiate) the maximum fair 
price of a selected drug under this part with the manufac-
turer of the drug, the Secretary, consistent with sub-
section (b)(2), shall take into consideration the factors de-
scribed in paragraphs (1), (2), (3), and (5), and may take 
into consideration the factor described in paragraph (4): 
‘‘(1) 
MANUFACTURER-SPECIFIC
INFORMA-
TION.—The following information, including as sub-
mitted by the manufacturer: 
‘‘(A) Research and development costs of 
the manufacturer for the drug and the extent to 
which the manufacturer has recouped research 
and development costs. 
‘‘(B) Market data for the drug, including 
the distribution of sales across different pro-
grams and purchasers and projected future rev-
enues for the drug. 
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‘‘(C) Unit costs of production and distribu-
tion of the drug. 
‘‘(D) Prior Federal financial support for 
novel therapeutic discovery and development 
with respect to the drug. 
‘‘(E) Data on patents and on existing and 
pending exclusivity for the drug. 
‘‘(F) National sales data for the drug. 
‘‘(G) Information on clinical trials for the 
drug in the United States or in applicable coun-
tries described in section 1191(c)(3)(B). 
‘‘(2) INFORMATION
ON
ALTERNATIVE
PROD-
UCTS.—The following information: 
‘‘(A) The extent to which the drug rep-
resents a therapeutic advance as compared to 
existing therapeutic alternatives and, to the ex-
tent such information is available, the costs of 
such existing therapeutic alternatives. 
‘‘(B) Information on approval by the Food 
and Drug Administration of alternative drug 
products. 
‘‘(C) Information on comparative effective-
ness analysis for such products, taking into 
consideration the effects of such products on 
specific populations, such as individuals with 
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disabilities, the elderly, terminally ill, children, 
and other patient populations. 
In considering information described in subpara-
graph (C), the Secretary shall not use evidence or 
findings from comparative clinical effectiveness re-
search in a manner that treats extending the life of 
an elderly, disabled, or terminally ill individual as of 
lower value than extending the life of an individual 
who is younger, nondisabled, or not terminally ill. 
Nothing in the previous sentence shall affect the ap-
plication or consideration of an AIM price for a se-
lected drug. 
‘‘(3) FOREIGN
SALES
INFORMATION.—To the 
extent available on a timely basis, including as pro-
vided by a manufacturer of the selected drug or oth-
erwise, information on sales of the selected drug in 
each 
of 
the 
countries 
described 
in 
section 
1191(c)(3)(B). 
‘‘(4) VA DRUG PRICING INFORMATION.—Infor-
mation disclosed to the Secretary pursuant to sub-
section (f). 
‘‘(5) ADDITIONAL INFORMATION.—Information 
submitted to the Secretary, in accordance with a 
process specified by the Secretary, by other parties 
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that are affected by the establishment of a maximum 
fair price for the selected drug. 
‘‘(e) REQUEST FOR INFORMATION.—For purposes of 
negotiating and, as applicable, renegotiating (including for 
purposes of determining whether to renegotiate) the max-
imum fair price of a selected drug under this part with 
the manufacturer of the drug, with respect to a price ap-
plicability period, and other relevant data for purposes of 
this section— 
‘‘(1) the Secretary shall, not later than the se-
lected drug publication date with respect to the ini-
tial price applicability year of such period, request 
drug pricing information from the manufacturer of 
such selected drug, including information described 
in subsection (d)(1); and 
‘‘(2) by not later than October 1 following the 
selected drug publication date, the manufacturer of 
such selected drug shall submit to the Secretary 
such requested information in such form and man-
ner as the Secretary may require. 
The Secretary shall request, from the manufacturer or 
others, such additional information as may be needed to 
carry out the negotiation and renegotiation process under 
this section. 
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‘‘(f) DISCLOSURE OF INFORMATION.—For purposes 
of this part, the Secretary of Veterans Affairs may disclose 
to the Secretary of Health and Human Services the price 
of any negotiation-eligible drug that is purchased pursuant 
to section 8126 of title 38, United States Code. 
‘‘SEC. 1195. PUBLICATION OF MAXIMUM FAIR PRICES. 
‘‘(a) IN GENERAL.—With respect to an initial price 
applicability year and selected drug with respect to such 
year, not later than April 1 of the plan year prior to such 
initial price applicability year, the Secretary shall publish 
in the Federal Register the maximum fair price for such 
drug negotiated under this part with the manufacturer of 
such drug. 
‘‘(b) UPDATES.— 
‘‘(1) 
SUBSEQUENT
YEAR
MAXIMUM
FAIR 
PRICES.—For a selected drug, for each plan year 
subsequent to the initial price applicability year for 
such drug with respect to which an agreement for 
such drug is in effect under section 1193, the Sec-
retary shall publish in the Federal Register— 
‘‘(A) subject to subparagraph (B), the 
amount equal to the maximum fair price pub-
lished for such drug for the previous year, in-
creased by the annual percentage increase in 
the consumer price index for all urban con-
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sumers (all items; U.S. city average) as of Sep-
tember of such previous year; or 
‘‘(B) in the case the maximum fair price 
for such drug was renegotiated, for the first 
year for which such price as so renegotiated ap-
plies, such renegotiated maximum fair price. 
‘‘(2) PRICES NEGOTIATED AFTER DEADLINE.— 
In the case of a selected drug with respect to an ini-
tial price applicability year for which the maximum 
fair price is determined under this part after the 
date of publication under this section, the Secretary 
shall publish such maximum fair price in the Fed-
eral Register by not later than 30 days after the 
date such maximum price is so determined. 
‘‘SEC. 1196. ADMINISTRATIVE DUTIES; COORDINATION PRO-
VISIONS. 
‘‘(a) ADMINISTRATIVE DUTIES.— 
‘‘(1) IN
GENERAL.—For purposes of section 
1191, the administrative duties described in this sec-
tion are the following: 
‘‘(A) The establishment of procedures (in-
cluding through agreements with manufacturers 
under this part, contracts with prescription 
drug plans under part D of title XVIII and 
MA–PD plans under part C of such title, and 
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agreements under section 1197 with group 
health plans and health insurance issuers of 
health insurance coverage offered in the indi-
vidual or group market) under which the max-
imum fair price for a selected drug is provided 
to fair price eligible individuals, who with re-
spect to such drug are described in subpara-
graph (A) of section 1191(c)(1), at pharmacies 
or by mail order service at the point-of-sale of 
the drug for the applicable price period for such 
drug and providing that such maximum fair 
price is used for determining cost-sharing under 
such plans or coverage for the selected drug. 
‘‘(B) The establishment of procedures (in-
cluding through agreements with manufacturers 
under this part and contracts with hospitals, 
physicians, and other providers of services and 
suppliers and agreements under section 1197 
with group health plans and health insurance 
issuers of health insurance coverage offered in 
the individual or group market) under which, in 
the case of a selected drug furnished or admin-
istered by such a hospital, physician, or other 
provider of services or supplier to fair price eli-
gible individuals (who with respect to such drug 
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are described in subparagraph (B) of section 
1191(c)(1)), the maximum fair price for the se-
lected drug is provided to such hospitals, physi-
cians, and other providers of services and sup-
pliers (as applicable) with respect to such indi-
viduals and providing that such maximum fair 
price is used for determining cost-sharing under 
the respective part, plan, or coverage for the se-
lected drug. 
‘‘(C) The establishment of procedures (in-
cluding through agreements and contracts de-
scribed in subparagraphs (A) and (B)) to en-
sure that, not later than 90 days after the dis-
pensing of a selected drug to a fair price eligi-
ble individual by a pharmacy or mail order serv-
ice, the pharmacy or mail order service is reim-
bursed for an amount equal to the difference 
between— 
‘‘(i) the lesser of— 
‘‘(I) the wholesale acquisition 
cost of the drug; 
‘‘(II) the national average drug 
acquisition cost of the drug; and 
‘‘(III) any other similar deter-
mination of pharmacy acquisition 
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costs of the drug, as determined by 
the Secretary; and 
‘‘(ii) the maximum fair price for the 
drug. 
‘‘(D) The establishment of procedures to 
ensure that the maximum fair price for a se-
lected drug is applied before— 
‘‘(i) any coverage or financial assist-
ance under other health benefit plans or 
programs that provide coverage or finan-
cial assistance for the purchase or provi-
sion of prescription drug coverage on be-
half of fair price eligible individuals as the 
Secretary may specify; and 
‘‘(ii) any other discounts. 
‘‘(E) The establishment of procedures to 
enter into appropriate agreements and protocols 
for the ongoing computation of AIM prices for 
selected drugs, including, to the extent possible, 
to compute the AIM price for selected drugs 
and including by providing that the manufac-
turer of such a selected drug should provide in-
formation for such computation not later than 
3 months after the first date of the voluntary 
negotiation period for such selected drug. 
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‘‘(F) The establishment of procedures to 
compute and apply the maximum fair price 
across different strengths and dosage forms of 
a selected drug and not based on the specific 
formulation or package size or package type of 
the drug. 
‘‘(G) The establishment of procedures to 
negotiate and apply the maximum fair price in 
a manner that does not include any dispensing 
or similar fee. 
‘‘(H) The establishment of procedures to 
carry out the provisions of this part, as applica-
ble, with respect to— 
‘‘(i) fair price eligible individuals who 
are enrolled under a prescription drug plan 
under part D of title XVIII or an MA–PD 
plan under part C of such title; 
‘‘(ii) fair price eligible individuals who 
are enrolled under a group health plan or 
health insurance coverage offered by a 
health insurance issuer in the individual or 
group market with respect to which there 
is an agreement in effect under section 
1197; and 
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‘‘(iii) fair price eligible individuals who 
are entitled to benefits under part A of 
title XVIII or enrolled under part B of 
such title. 
‘‘(I) The establishment of a negotiation 
process and renegotiation process in accordance 
with section 1194, including a process for ac-
quiring information described in subsection (d) 
of such section and determining amounts de-
scribed in subsection (b) of such section. 
‘‘(J) The provision of a reasonable dispute 
resolution mechanism to resolve disagreements 
between manufacturers, fair price eligible indi-
viduals, and the third party with a contract 
under subsection (c)(1). 
‘‘(2) MONITORING COMPLIANCE.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
monitor compliance by a manufacturer with the 
terms of an agreement under section 1193, in-
cluding by establishing a mechanism through 
which violations of such terms may be reported. 
‘‘(B) NOTIFICATION.—If a third party 
with a contract under subsection (c)(1) deter-
mines that the manufacturer is not in compli-
ance with such agreement, the third party shall 
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HR 1425 PCS
notify the Secretary of such noncompliance for 
appropriate enforcement under section 4192 of 
the Internal Revenue Code of 1986 or section 
1198, as applicable. 
‘‘(b) COLLECTION OF DATA.— 
‘‘(1) FROM
PRESCRIPTION
DRUG
PLANS
AND 
MA–PD PLANS.—The Secretary may collect appro-
priate data from prescription drug plans under part 
D of title XVIII and MA–PD plans under part C of 
such title in a timeframe that allows for maximum 
fair prices to be provided under this part for selected 
drugs. 
‘‘(2) FROM
HEALTH
PLANS.—The Secretary 
may collect appropriate data from group health 
plans or health insurance issuers offering group or 
individual health insurance coverage in a timeframe 
that allows for maximum fair prices to be provided 
under this part for selected drugs. 
‘‘(3) COORDINATION OF DATA COLLECTION.— 
To the extent feasible, as determined by the Sec-
retary, the Secretary shall ensure that data collected 
pursuant to this subsection is coordinated with, and 
not duplicative of, other Federal data collection ef-
forts. 
‘‘(c) CONTRACT WITH THIRD PARTIES.— 
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‘‘(1) IN GENERAL.—The Secretary may enter 
into a contract with 1 or more third parties to ad-
minister the requirements established by the Sec-
retary in order to carry out this part. At a min-
imum, the contract with a third party under the pre-
ceding sentence shall require that the third party— 
‘‘(A) receive and transmit information be-
tween the Secretary, manufacturers, and other 
individuals or entities the Secretary determines 
appropriate; 
‘‘(B) receive, distribute, or facilitate the 
distribution of funds of manufacturers to ap-
propriate individuals or entities in order to 
meet the obligations of manufacturers under 
agreements under this part; 
‘‘(C) provide adequate and timely informa-
tion to manufacturers, consistent with the 
agreement with the manufacturer under this 
part, as necessary for the manufacturer to ful-
fill its obligations under this part; and 
‘‘(D) permit manufacturers to conduct 
periodic audits, directly or through contracts, of 
the data and information used by the third 
party to determine discounts for applicable 
drugs of the manufacturer under the program. 
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‘‘(2) 
PERFORMANCE
REQUIREMENTS.—The 
Secretary shall establish performance requirements 
for a third party with a contract under paragraph 
(1) and safeguards to protect the independence and 
integrity of the activities carried out by the third 
party under the program under this part. 
‘‘SEC. 
1197. 
VOLUNTARY 
PARTICIPATION 
BY 
OTHER 
HEALTH PLANS. 
‘‘(a) AGREEMENT
TO PARTICIPATE UNDER PRO-
GRAM.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
under the program under this part the Secretary 
shall be treated as having in effect an agreement 
with a group health plan or health insurance issuer 
offering group or individual health insurance cov-
erage (as such terms are defined in section 2791 of 
the Public Health Service Act), with respect to a 
price applicability period and a selected drug with 
respect to such period— 
‘‘(A) with respect to such selected drug 
furnished or dispensed at a pharmacy or by 
mail order service if coverage is provided under 
such plan or coverage during such period for 
such selected drug as so furnished or dispensed; 
and 
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‘‘(B) with respect to such selected drug 
furnished or administered by a hospital, physi-
cian, or other provider of services or supplier if 
coverage is provided under such plan or cov-
erage during such period for such selected drug 
as so furnished or administered. 
‘‘(2) OPTING OUT OF AGREEMENT.—The Sec-
retary shall not be treated as having in effect an 
agreement under the program under this part with 
a group health plan or health insurance issuer offer-
ing group or individual health insurance coverage 
with respect to a price applicability period and a se-
lected drug with respect to such period if such a 
plan or issuer affirmatively elects, through a process 
specified by the Secretary, not to participate under 
the program with respect to such period and drug. 
‘‘(b) PUBLICATION OF ELECTION.—With respect to 
each price applicability period and each selected drug with 
respect to such period, the Secretary and the Secretary 
of Labor and the Secretary of the Treasury, as applicable, 
shall make public a list of each group health plan and each 
health insurance issuer offering group or individual health 
insurance coverage, with respect to which coverage is pro-
vided under such plan or coverage for such drug, that has 
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elected under subsection (a) not to participate under the 
program with respect to such period and drug. 
‘‘SEC. 1198. CIVIL MONETARY PENALTY. 
‘‘(a) VIOLATIONS RELATING TO OFFERING OF MAX-
IMUM FAIR PRICE.—Any manufacturer of a selected drug 
that has entered into an agreement under section 1193, 
with respect to a plan year during the price applicability 
period for such drug, that does not provide access to a 
price that is not more than the maximum fair price (or 
a lesser price) for such drug for such year— 
‘‘(1) to a fair price eligible individual who with 
respect to such drug is described in subparagraph 
(A) of section 1191(c)(1) and who is furnished or 
dispensed such drug during such year; or 
‘‘(2) to a hospital, physician, or other provider 
of services or supplier with respect to fair price eligi-
ble individuals who with respect to such drug is de-
scribed in subparagraph (B) of such section and is 
furnished or administered such drug by such hos-
pital, physician, or provider or supplier during such 
year; 
shall be subject to a civil monetary penalty equal to ten 
times the amount equal to the difference between the price 
for such drug made available for such year by such manu-
facturer with respect to such individual or hospital, physi-
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cian, provider, or supplier and the maximum fair price for 
such drug for such year. 
‘‘(b) VIOLATIONS OF CERTAIN TERMS OF AGREE-
MENT.—Any manufacturer of a selected drug that has en-
tered into an agreement under section 1193, with respect 
to a plan year during the price applicability period for 
such drug, that is in violation of a requirement imposed 
pursuant to section 1193(a)(6) shall be subject to a civil 
monetary penalty of not more than $1,000,000 for each 
such violation. 
‘‘(c) APPLICATION.—The provisions of section 1128A 
(other than subsections (a) and (b)) shall apply to a civil 
monetary penalty under this section in the same manner 
as such provisions apply to a penalty or proceeding under 
section 1128A(a). 
‘‘SEC. 1199. MISCELLANEOUS PROVISIONS. 
‘‘(a) PAPERWORK REDUCTION ACT.—Chapter 35 of 
title 44, United States Code, shall not apply to data col-
lected under this part. 
‘‘(b) NATIONAL ACADEMY OF MEDICINE STUDY.— 
Not later than December 31, 2025, the National Academy 
of Medicine shall conduct a study, and submit to Congress 
a report, on recommendations for improvements to the 
program under this part, including the determination of 
the limits applied under section 1194(c). 
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‘‘(c) MEDPAC STUDY.—Not later than December 31, 
2025, the Medicare Payment Advisory Commission shall 
conduct a study, and submit to Congress a report, on the 
program under this part with respect to the Medicare pro-
gram under title XVIII, including with respect to the ef-
fect of the program on individuals entitled to benefits or 
enrolled under such title. 
‘‘(d) LIMITATION ON JUDICIAL REVIEW.—The fol-
lowing shall not be subject to judicial review: 
‘‘(1) The selection of drugs for publication 
under section 1192(a). 
‘‘(2) The determination of whether a drug is a 
negotiation-eligible drug under section 1192(d). 
‘‘(3) The determination of the maximum fair 
price of a selected drug under section 1194. 
‘‘(4) The determination of units of a drug for 
purposes of section 1191(c)(3). 
‘‘(e) COORDINATION.—In carrying out this part with 
respect to group health plans or health insurance coverage 
offered in the group market that are subject to oversight 
by the Secretary of Labor or the Secretary of the Treas-
ury, the Secretary of Health and Human Services shall 
coordinate with such respective Secretary. 
‘‘(f) DATA SHARING.—The Secretary shall share with 
the Secretary of the Treasury such information as is nec-
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essary to determine the tax imposed by section 4192 of 
the Internal Revenue Code of 1986. 
‘‘(g) GAO STUDY.—Not later than December 31, 
2025, the Comptroller General of the United States shall 
conduct a study of, and submit to Congress a report on, 
the implementation of the Fair Price Negotiation Program 
under this part.’’. 
(b) APPLICATION OF MAXIMUM FAIR PRICES AND 
CONFORMING AMENDMENTS.— 
(1) UNDER MEDICARE.— 
(A) APPLICATION
TO
PAYMENTS
UNDER 
PART B.—Section 1847A(b)(1)(B) of the Social 
Security Act (42 U.S.C. 1395w–3a(b)(1)(B)) is 
amended by inserting ‘‘or in the case of such a 
drug or biological that is a selected drug (as de-
fined in section 1192(c)), with respect to a 
price applicability period (as defined in section 
1191(b)(2)), 106 percent of the maximum fair 
price (as defined in section 1191(c)(2) applica-
ble for such drug and a plan year during such 
period’’ after ‘‘paragraph (4)’’. 
(B) EXCEPTION TO PART D NON-INTER-
FERENCE.—Section 1860D–11(i) of the Social 
Security Act (42 U.S.C. 1395w–111(i)) is 
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HR 1425 PCS
amended by inserting ‘‘, except as provided 
under part E of title XI’’ after ‘‘the Secretary’’. 
(C) APPLICATION AS NEGOTIATED PRICE 
UNDER PART D.—Section 1860D–2(d)(1) of the 
Social 
Security 
Act 
(42 
U.S.C. 
1395w– 
102(d)(1)) is amended— 
(i) in subparagraph (B), by inserting 
‘‘, subject to subparagraph (D),’’ after 
‘‘negotiated prices’’; and 
(ii) by adding at the end the following 
new subparagraph: 
‘‘(D) APPLICATION
OF
MAXIMUM
FAIR 
PRICE FOR SELECTED DRUGS.—In applying this 
section, in the case of a covered part D drug 
that is a selected drug (as defined in section 
1192(c)), with respect to a price applicability 
period (as defined in section 1191(b)(2)), the 
negotiated prices used for payment (as de-
scribed in this subsection) shall be the max-
imum 
fair 
price 
(as 
defined 
in 
section 
1191(c)(2)) for such drug and for each plan 
year during such period.’’. 
(D) INFORMATION
FROM
PRESCRIPTION 
DRUG PLANS AND MA–PD PLANS REQUIRED.— 
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(i) PRESCRIPTION DRUG PLANS.—Sec-
tion 1860D–12(b) of the Social Security 
Act (42 U.S.C. 1395w–112(b)) is amended 
by adding at the end the following new 
paragraph: 
‘‘(8) PROVISION OF INFORMATION RELATED TO 
MAXIMUM FAIR PRICES.—Each contract entered into 
with a PDP sponsor under this part with respect to 
a prescription drug plan offered by such sponsor 
shall require the sponsor to provide information to 
the Secretary as requested by the Secretary in ac-
cordance with section 1196(b).’’. 
(ii) 
MA–PD 
PLANS.—Section 
1857(f)(3) of the Social Security Act (42 
U.S.C. 1395w–27(f)(3)) is amended by 
adding at the end the following new sub-
paragraph: 
‘‘(E) PROVISION
OF
INFORMATION
RE-
LATED
TO
MAXIMUM
FAIR
PRICES.—Section 
1860D–12(b)(8).’’. 
(2) UNDER
GROUP
HEALTH
PLANS
AND 
HEALTH INSURANCE COVERAGE.— 
(A) PHSA.—Part A of title XXVII of the 
Public Health Service Act is amended by insert-
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HR 1425 PCS
ing after section 2729 the following new sec-
tion: 
‘‘SEC. 2729A. FAIR PRICE NEGOTIATION PROGRAM AND AP-
PLICATION OF MAXIMUM FAIR PRICES. 
‘‘(a) IN GENERAL.—In the case of a group health 
plan or health insurance issuer offering group or indi-
vidual health insurance coverage that is treated under sec-
tion 1197 of the Social Security Act as having in effect 
an agreement with the Secretary under the Fair Price Ne-
gotiation Program under part E of title XI of such Act, 
with respect to a price applicability period (as defined in 
section 1191(b) of such Act) and a selected drug (as de-
fined in section 1192(c) of such Act) with respect to such 
period with respect to which coverage is provided under 
such plan or coverage— 
‘‘(1) the provisions of such part shall apply— 
‘‘(A) if coverage of such selected drug is 
provided under such plan or coverage if the 
drug is furnished or dispensed at a pharmacy 
or by a mail order service, to the plans or cov-
erage offered by such plan or issuer, and to the 
individuals enrolled under such plans or cov-
erage, during such period, with respect to such 
selected drug, in the same manner as such pro-
visions apply to prescription drug plans and 
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MA–PD plans, and to individuals enrolled 
under such prescription drug plans and MA– 
PD plans during such period; and 
‘‘(B) if coverage of such selected drug is 
provided under such plan or coverage if the 
drug is furnished or administered by a hospital, 
physician, or other provider of services or sup-
plier, to the plans or coverage offered by such 
plan or issuers, to the individuals enrolled 
under such plans or coverage, and to hospitals, 
physicians, and other providers of services and 
suppliers during such period, with respect to 
such drug in the same manner as such provi-
sions apply to the Secretary, to individuals enti-
tled to benefits under part A of title XVIII or 
enrolled under part B of such title, and to hos-
pitals, physicians, and other providers and sup-
pliers participating under title XVIII during 
such period; 
‘‘(2) the plan or issuer shall apply any cost- 
sharing responsibilities under such plan or coverage, 
with respect to such selected drug, by substituting 
an amount not more than the maximum fair price 
negotiated under such part E of title XI for such 
drug in lieu of the drug price upon which the cost- 
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sharing would have otherwise applied, and such cost- 
sharing responsibilities with respect to such selected 
drug may not exceed such maximum fair price; and 
‘‘(3) the Secretary shall apply the provisions of 
such part E to such plan, issuer, and coverage, such 
individuals so enrolled in such plans and coverage, 
and such hospitals, physicians, and other providers 
and suppliers participating in such plans and cov-
erage. 
‘‘(b) NOTIFICATION REGARDING NONPARTICIPATION 
IN FAIR PRICE NEGOTIATION PROGRAM.—A group health 
plan or a health insurance issuer offering group or indi-
vidual health insurance coverage shall publicly disclose in 
a manner and in accordance with a process specified by 
the Secretary any election made under section 1197 of the 
Social Security Act by the plan or issuer to not participate 
in the Fair Price Negotiation Program under part E of 
title XI of such Act with respect to a selected drug (as 
defined in section 1192(c) of such Act) for which coverage 
is provided under such plan or coverage before the begin-
ning of the plan year for which such election was made.’’. 
(B) ERISA.— 
(i) IN GENERAL.—Subpart B of part 
7 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974 
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HR 1425 PCS
(29 U.S.C. 1181 et seq.) is amended by 
adding at the end the following new sec-
tion: 
‘‘SEC. 716. FAIR PRICE NEGOTIATION PROGRAM AND APPLI-
CATION OF MAXIMUM FAIR PRICES. 
‘‘(a) IN GENERAL.—In the case of a group health 
plan or health insurance issuer offering group health in-
surance coverage that is treated under section 1197 of the 
Social Security Act as having in effect an agreement with 
the Secretary under the Fair Price Negotiation Program 
under part E of title XI of such Act, with respect to a 
price applicability period (as defined in section 1191(b) 
of such Act) and a selected drug (as defined in section 
1192(c) of such Act) with respect to such period with re-
spect to which coverage is provided under such plan or 
coverage— 
‘‘(1) the provisions of such part shall apply, as 
applicable— 
‘‘(A) if coverage of such selected drug is 
provided under such plan or coverage if the 
drug is furnished or dispensed at a pharmacy 
or by a mail order service, to the plans or cov-
erage offered by such plan or issuer, and to the 
individuals enrolled under such plans or cov-
erage, during such period, with respect to such 
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selected drug, in the same manner as such pro-
visions apply to prescription drug plans and 
MA–PD plans, and to individuals enrolled 
under such prescription drug plans and MA– 
PD plans during such period; and 
‘‘(B) if coverage of such selected drug is 
provided under such plan or coverage if the 
drug is furnished or administered by a hospital, 
physician, or other provider of services or sup-
plier, to the plans or coverage offered by such 
plan or issuers, to the individuals enrolled 
under such plans or coverage, and to hospitals, 
physicians, and other providers of services and 
suppliers during such period, with respect to 
such drug in the same manner as such provi-
sions apply to the Secretary, to individuals enti-
tled to benefits under part A of title XVIII or 
enrolled under part B of such title, and to hos-
pitals, physicians, and other providers and sup-
pliers participating under title XVIII during 
such period; 
‘‘(2) the plan or issuer shall apply any cost- 
sharing responsibilities under such plan or coverage, 
with respect to such selected drug, by substituting 
an amount not more than the maximum fair price 
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negotiated under such part E of title XI for such 
drug in lieu of the drug price upon which the cost- 
sharing would have otherwise applied, and such cost- 
sharing responsibilities with respect to such selected 
drug may not exceed such maximum fair price; and 
‘‘(3) the Secretary shall apply the provisions of 
such part E to such plan, issuer, and coverage, and 
such individuals so enrolled in such plans. 
‘‘(b) NOTIFICATION REGARDING NONPARTICIPATION 
IN FAIR PRICE NEGOTIATION PROGRAM.—A group health 
plan or a health insurance issuer offering group health in-
surance coverage shall publicly disclose in a manner and 
in accordance with a process specified by the Secretary 
any election made under section 1197 of the Social Secu-
rity Act by the plan or issuer to not participate in the 
Fair Price Negotiation Program under part E of title XI 
of such Act with respect to a selected drug (as defined 
in section 1192(c) of such Act) for which coverage is pro-
vided under such plan or coverage before the beginning 
of the plan year for which such election was made.’’. 
(ii) APPLICATION
TO
RETIREE
AND 
CERTAIN SMALL GROUP HEALTH PLANS.— 
Section 732(a) of the Employee Retire-
ment Income Security Act of 1974 (29 
U.S.C. 1191a(a)) is amended by striking 
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‘‘section 711’’ and inserting ‘‘sections 711 
and 716’’. 
(iii) 
CLERICAL
AMENDMENT.—The 
table of sections for subpart B of part 7 of 
subtitle B of title I of the Employee Re-
tirement Income Security Act of 1974 is 
amended by adding at the end the fol-
lowing: 
‘‘Sec. 716. Fair Price Negotiation Program and application of maximum fair 
prices.’’. 
(C) IRC.— 
(i) IN
GENERAL.—Subchapter B of 
chapter 100 of the Internal Revenue Code 
of 1986 is amended by adding at the end 
the following new section: 
‘‘SEC. 9816. FAIR PRICE NEGOTIATION PROGRAM AND AP-
PLICATION OF MAXIMUM FAIR PRICES. 
‘‘(a) IN GENERAL.—In the case of a group health 
plan that is treated under section 1197 of the Social Secu-
rity Act as having in effect an agreement with the Sec-
retary under the Fair Price Negotiation Program under 
part E of title XI of such Act, with respect to a price 
applicability period (as defined in section 1191(b) of such 
Act) and a selected drug (as defined in section 1192(c) 
of such Act) with respect to such period with respect to 
which coverage is provided under such plan— 
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‘‘(1) the provisions of such part shall apply, as 
applicable— 
‘‘(A) if coverage of such selected drug is 
provided under such plan if the drug is fur-
nished or dispensed at a pharmacy or by a mail 
order service, to the plan, and to the individuals 
enrolled under such plan during such period, 
with respect to such selected drug, in the same 
manner as such provisions apply to prescription 
drug plans and MA–PD plans, and to individ-
uals enrolled under such prescription drug 
plans and MA–PD plans during such period; 
and 
‘‘(B) if coverage of such selected drug is 
provided under such plan if the drug is fur-
nished or administered by a hospital, physician, 
or other provider of services or supplier, to the 
plan, to the individuals enrolled under such 
plan, and to hospitals, physicians, and other 
providers of services and suppliers during such 
period, with respect to such drug in the same 
manner as such provisions apply to the Sec-
retary, to individuals entitled to benefits under 
part A of title XVIII or enrolled under part B 
of such title, and to hospitals, physicians, and 
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other providers and suppliers participating 
under title XVIII during such period; 
‘‘(2) the plan shall apply any cost-sharing re-
sponsibilities under such plan, with respect to such 
selected drug, by substituting an amount not more 
than the maximum fair price negotiated under such 
part E of title XI for such drug in lieu of the drug 
price upon which the cost-sharing would have other-
wise applied, and such cost-sharing responsibilities 
with respect to such selected drug may not exceed 
such maximum fair price; and 
‘‘(3) the Secretary shall apply the provisions of 
such part E to such plan and such individuals so en-
rolled in such plan. 
‘‘(b) NOTIFICATION REGARDING NONPARTICIPATION 
IN FAIR PRICE NEGOTIATION PROGRAM.—A group health 
plan shall publicly disclose in a manner and in accordance 
with a process specified by the Secretary any election 
made under section 1197 of the Social Security Act by 
the plan to not participate in the Fair Price Negotiation 
Program under part E of title XI of such Act with respect 
to a selected drug (as defined in section 1192(c) of such 
Act) for which coverage is provided under such plan before 
the beginning of the plan year for which such election was 
made.’’. 
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(ii) APPLICATION
TO
RETIREE
AND 
CERTAIN SMALL GROUP HEALTH PLANS.— 
Section 9831(a)(2) of the Internal Revenue 
Code of 1986 is amended by inserting 
‘‘other than with respect to section 9816,’’ 
before ‘‘any group health plan’’. 
(iii) 
CLERICAL
AMENDMENT.—The 
table of sections for subchapter B of chap-
ter 100 of such Code is amended by add-
ing at the end the following new item: 
‘‘Sec. 9816. Fair Price Negotiation Program and application of maximum fair 
prices.’’. 
(3) FAIR PRICE NEGOTIATION PROGRAM PRICES 
INCLUDED IN BEST PRICE AND AMP.—Section 1927 
of the Social Security Act (42 U.S.C. 1396r–8) is 
amended— 
(A) in subsection (c)(1)(C)(ii)— 
(i) in subclause (III), by striking at 
the end ‘‘; and’’; 
(ii) in subclause (IV), by striking at 
the end the period and inserting ‘‘; and’’; 
and 
(iii) by adding at the end the fol-
lowing new subclause: 
‘‘(V) in the case of a rebate pe-
riod and a covered outpatient drug 
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that is a selected drug (as defined in 
section 1192(c)) during such rebate 
period, shall be inclusive of the price 
for such drug made available from the 
manufacturer during the rebate period 
by reason of application of part E of 
title XI to any wholesaler, retailer, 
provider, health maintenance organi-
zation, nonprofit entity, or govern-
mental entity within the United 
States.’’; and 
(B) in subsection (k)(1)(B), by adding at 
the end the following new clause: 
‘‘(iii) 
CLARIFICATION.—Notwith-
standing clause (i), in the case of a rebate 
period and a covered outpatient drug that 
is a selected drug (as defined in section 
1192(c)) during such rebate period, any 
reduction in price paid during the rebate 
period to the manufacturer for the drug by 
a wholesaler or retail community pharmacy 
described in subparagraph (A) by reason of 
application of part E of title XI shall be 
included in the average manufacturer price 
for the covered outpatient drug.’’. 
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(4) FEHBP.—Section 8902 of title 5, United 
States Code, is amended by adding at the end the 
following: 
‘‘(p) A contract may not be made or a plan approved 
under this chapter with any carrier that has affirmatively 
elected, pursuant to section 1197 of the Social Security 
Act, not to participate in the Fair Price Negotiation Pro-
gram established under section 1191 of such Act for any 
selected drug (as that term is defined in section 1192(c) 
of such Act).’’. 
(5) OPTION OF SECRETARY OF VETERANS AF-
FAIRS TO PURCHASE COVERED DRUGS AT MAXIMUM 
FAIR
PRICES.—Section 8126 of title 38, United 
States Code, is amended— 
(A) in subsection (a)(2), by inserting ‘‘, 
subject to subsection (j),’’ after ‘‘may not ex-
ceed’’; 
(B) in subsection (d), in the matter pre-
ceding paragraph (1), by inserting ‘‘, subject to 
subsection (j)’’ after ‘‘for the procurement of 
the drug’’; and 
(C) by adding at the end the following new 
subsection: 
‘‘(j)(1) In the case of a covered drug that is a selected 
drug, for any year during the price applicability period for 
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such drug, if the Secretary determines that the maximum 
fair price of such drug for such year is less than the price 
for such drug otherwise in effect pursuant to this section 
(including after application of any reduction under sub-
section (a)(2) and any discount under subsection (c)), at 
the option of the Secretary, in lieu of the maximum price 
(determined after application of the reduction under sub-
section (a)(2) and any discount under subsection (c), as 
applicable) that would be permitted to be charged during 
such year for such drug pursuant to this section without 
application of this subsection, the maximum price per-
mitted to be charged during such year for such drug pur-
suant to this section shall be such maximum fair price for 
such drug and year. 
‘‘(2) For purposes of this subsection: 
‘‘(A) The term ‘maximum fair price’ means, 
with respect to a selected drug and year during the 
price applicability period for such drug, the max-
imum fair price (as defined in section 1191(c)(2) of 
the Social Security Act) for such drug and year. 
‘‘(B) The term ‘negotiation eligible drug’ has 
the meaning given such term in section 1192(d)(1) 
of the Social Security Act. 
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‘‘(C) The term ‘price applicability period’ has, 
with respect to a selected drug, the meaning given 
such term in section 1191(b)(2) of such Act. 
‘‘(D) The term ‘selected drug’ means, with re-
spect to a year, a drug that is a selected drug under 
section 1192(c) of such Act for such year.’’. 
SEC. 302. DRUG MANUFACTURER EXCISE TAX FOR NON-
COMPLIANCE. 
(a) IN GENERAL.—Subchapter E of chapter 32 of the 
Internal Revenue Code of 1986 is amended by adding at 
the end the following new section: 
‘‘SEC. 4192. SELECTED DRUGS DURING NONCOMPLIANCE 
PERIODS. 
‘‘(a) IN GENERAL.—There is hereby imposed on the 
sale by the manufacturer, producer, or importer of any 
selected drug during a day described in subsection (b) a 
tax in an amount such that the applicable percentage is 
equal to the ratio of— 
‘‘(1) such tax, divided by 
‘‘(2) the sum of such tax and the price for 
which so sold. 
‘‘(b) NONCOMPLIANCE PERIODS.—A day is described 
in this subsection with respect to a selected drug if it is 
a day during one of the following periods: 
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‘‘(1) The period beginning on the June 16th 
immediately following the selected drug publication 
date and ending on the first date during which the 
manufacturer of the drug has in place an agreement 
described in subsection (a) of section 1193 of the 
Social Security Act with respect to such drug. 
‘‘(2) The period beginning on the April 1st im-
mediately following the June 16th described in para-
graph (1) and ending on the first date during which 
the manufacturer of the drug has agreed to a max-
imum fair price under such agreement. 
‘‘(3) In the case of a selected drug with respect 
to which the Secretary of Health and Human Serv-
ices has specified a renegotiation period under such 
agreement, the period beginning on the first date 
after the last date of such renegotiation period and 
ending on the first date during which the manufac-
turer of the drug has agreed to a renegotiated max-
imum fair price under such agreement. 
‘‘(4) With respect to information that is re-
quired to be submitted to the Secretary of Health 
and Human Services under such agreement, the pe-
riod beginning on the date on which such Secretary 
certifies that such information is overdue and ending 
on the date that such information is so submitted. 
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‘‘(5) In the case of a selected drug with respect 
to which a payment is due under subsection (c) of 
such section 1193, the period beginning on the date 
on which the Secretary of Health and Human Serv-
ices certifies that such payment is overdue and end-
ing on the date that such payment is made in full. 
‘‘(c) APPLICABLE PERCENTAGE.—For purposes of 
this section, the term ‘applicable percentage’ means— 
‘‘(1) in the case of sales of a selected drug dur-
ing the first 90 days described in subsection (b) with 
respect to such drug, 65 percent, 
‘‘(2) in the case of sales of such drug during 
the 91st day through the 180th day described in 
subsection (b) with respect to such drug, 75 percent, 
‘‘(3) in the case of sales of such drug during 
the 181st day through the 270th day described in 
subsection (b) with respect to such drug, 85 percent, 
and 
‘‘(4) in the case of sales of such drug during 
any subsequent day, 95 percent. 
‘‘(d) SELECTED DRUG.—For purposes of this sec-
tion— 
‘‘(1) IN GENERAL.—The term ‘selected drug’ 
means any selected drug (within the meaning of sec-
tion 1192 of the Social Security Act) which is manu-
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factured or produced in the United States or entered 
into the United States for consumption, use, or 
warehousing. 
‘‘(2) UNITED
STATES.—The term ‘United 
States’ has the meaning given such term by section 
4612(a)(4). 
‘‘(3) COORDINATION WITH RULES FOR POSSES-
SIONS OF THE UNITED STATES.—Rules similar to 
the rules of paragraphs (2) and (4) of section 
4132(c) shall apply for purposes of this section. 
‘‘(e) OTHER DEFINITIONS.—For purposes of this 
section, the terms ‘selected drug publication date’ and 
‘maximum fair price’ have the meaning given such terms 
in section 1191 of the Social Security Act. 
‘‘(f) ANTI-ABUSE RULE.—In the case of a sale which 
was timed for the purpose of avoiding the tax imposed by 
this section, the Secretary may treat such sale as occur-
ring during a day described in subsection (b).’’. 
(b) NO DEDUCTION FOR EXCISE TAX PAYMENTS.— 
Section 275 of the Internal Revenue Code of 1986 is 
amended by adding ‘‘or by section 4192’’ before the period 
at the end of subsection (a)(6). 
(c) CONFORMING AMENDMENTS.— 
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(1) Section 4221(a) of the Internal Revenue 
Code of 1986 is amended by inserting ‘‘or 4192’’ 
after ‘‘section 4191’’. 
(2) Section 6416(b)(2) of such Code is amend-
ed by inserting ‘‘or 4192’’ after ‘‘section 4191’’. 
(d) CLERICAL AMENDMENTS.— 
(1) The heading of subchapter E of chapter 32 
of the Internal Revenue Code of 1986 is amended by 
striking 
‘‘Medical 
Devices’’ 
and 
inserting 
‘‘Other Medical Products’’. 
(2) The table of subchapters for chapter 32 of 
such Code is amended by striking the item relating 
to subchapter E and inserting the following new 
item: 
‘‘SUBCHAPTER E. OTHER MEDICAL PRODUCTS’’. 
(3) The table of sections for subchapter E of 
chapter 32 of such Code is amended by adding at 
the end the following new item: 
‘‘Sec. 4192. Selected drugs during noncompliance periods.’’. 
(e) EFFECTIVE DATE.—The amendments made by 
this section shall apply to sales after the date of the enact-
ment of this Act. 
SEC. 303. FAIR PRICE NEGOTIATION IMPLEMENTATION 
FUND. 
(a) IN GENERAL.—There is hereby established a Fair 
Price Negotiation Implementation Fund (referred to in 
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this section as the ‘‘Fund’’). The Secretary of Health and 
Human Services may obligate and expend amounts in the 
Fund to carry out this title (and the amendments made 
by such title). 
(b) FUNDING.—There is authorized to be appro-
priated, and there is hereby appropriated, out of any mon-
ies in the Treasury not otherwise appropriated, to the 
Fund $3,000,000,000, to remain available until expended, 
of which— 
(1) $600,000,000 shall become available on the 
date of the enactment of this Act; 
(2) $600,000,000 shall become available on Oc-
tober 1, 2020; 
(3) $600,000,000 shall become available on Oc-
tober 1, 2021; 
(4) $600,000,000 shall become available on Oc-
tober 1, 2022; and 
(5) $600,000,000 shall become available on Oc-
tober 1, 2023. 
(c) SUPPLEMENT NOT SUPPLANT.—Any amounts 
appropriated pursuant to this section shall be in addition 
to any other amounts otherwise appropriated pursuant to 
any other provision of law. 
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TITLE IV—PUBLIC HEALTH 
INVESTMENTS 
SEC. 401. SUPPORTING INCREASED INNOVATION. 
(a) IN GENERAL.—The Secretary of Health and 
Human Services, acting through the Director of the Na-
tional Institutes of Health, shall continue to support and 
to expand, as applicable, biomedical research carried out 
through the National Institutes of Health innovation 
projects described in section 1001(b)(4) of the 21st Cen-
tury Cures Act (Public Law 114–255). The Secretary 
shall ensure that any such research (and related activities) 
is conducted in compliance with section 492B of the Public 
Health Service Act (42 U.S.C. 289a–2) (relating to the 
inclusion of women and members of minority groups in 
research). 
(b) AUTHORIZATION OF APPROPRIATIONS.—To carry 
out this subsection, in addition to funds made available 
under paragraph (2) of section 1001(b) of the 21st Cen-
tury Cures Act (Public Law 114–255), there is authorized 
to be appropriated, and there is appropriated to the NIH 
Innovation Account established under such section 
1001(b), out of any moneys in the Treasury not otherwise 
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obligated, $2,000,000,000 for fiscal year 2021, to remain 
available until expended. 
Passed the House of Representatives June 29, 2020. 
Attest: 
CHERYL L. JOHNSON, 
Clerk. 
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Calendar No. 523 
116TH CONGRESS 
2D SESSION 
H. R. 1425 
AN ACT 
To amend the Patient Protection and Affordable 
Care Act to provide for a Improve Health Insur-
ance Affordability Fund to provide for certain re-
insurance payments to lower premiums in the in-
dividual health insurance market. 
SEPTEMBER 8, 2020 
Read the second time and placed on the calendar 
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