Medicare Buy-In and Health Care Stabilization Act of 2021
Bill: H.R.2881 | Sponsor: Rep. Higgins, Brian (D-NY)
Policy area: Health

Summary:
Medicare Buy-In and Health Care Stabilization Act of 2021
This bill establishes a Medicare buy-in option for certain qualifying individuals and makes a series of other changes relating to health care costs.
Specifically, the bill allows individuals aged 50 to 64 to enroll in Medicare if such individuals would otherwise qualify for Medicare at the age of 65. The Centers for Medicare & Medicaid Services (CMS) must determine enrollment periods and set premiums for the buy-in option established under the bill, in accordance with specified requirements. The CMS must also award grants to states and nonprofit organizations for outreach and enrollment activities relating to the buy-in option.
The bill also (1) establishes a supplemental option under Medicare to cover cost-sharing for beneficiaries; (2) repeals provisions that prohibit the CMS from negotiating the prices of prescription drugs; (3) establishes an individual market reinsurance program relating to coverage of high-cost individuals, as specified; and (4) makes permanent certain increases and expansions of the premium tax credit.

To amend title XVIII of the Social Security Act to provide for an 
 option for individuals who are ages 50 to 64 to buy into Medicare, to 
   provide for health insurance market stabilization, and for other 
                               purposes.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medicare Buy-In and Health Care 
Stabilization Act of 2021''.

SEC. 2. FINDINGS.

    Congress finds as follows:
            (1) Medicare has coverage gaps and should provide more 
        comprehensive coverage, including increasing coverage for the 
        medical needs of beneficiaries relating to hearing, dental, and 
        vision care.
            (2) Special needs populations face financial challenges to 
        secure coverage for Medicare's out of pocket costs and other 
        hurdles.
            (3) Medicare Buy-In is a step in the right direction as 
        Congress considers additional needed legislation to address 
        these and other coverage issues and beneficiary financial 
        challenges in Medicare and Medicare Buy-In.

SEC. 3. MEDICARE BUY-IN OPTION.

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

                        ``medicare buy-in option

    ``Sec. 1899C.  (a) Option.--
            ``(1) In general.--Every individual who meets the 
        requirements described in paragraph (2) shall be eligible to 
        enroll under this section.
            ``(2) Eligibility.--An individual who meets the following 
        requirements is eligible to enroll under this section:
                    ``(A) Age.--The individual has attained 50 years of 
                age, but has not attained 65 years of age.
                    ``(B) Medicare eligibility (but for age).--The 
                individual is not otherwise entitled to benefits under 
                part A or eligible to enroll under part A or part B but 
                would be eligible for benefits under part A or part B 
                if the individual were 65 years of age.
            ``(3) Part a, b, and d benefits and protections.--An 
        individual enrolled under this section is entitled to the same 
        benefits (and shall receive the same protections) under this 
        title as an individual who is entitled to benefits under part A 
        and enrolled under parts B and D, including the ability to 
        enroll in a Medicare Advantage plan that provides qualified 
        prescription drug coverage (an MA-PD plan) and including access 
        to the Medicare Beneficiary Ombudsman under section 1808(c).
    ``(b) Enrollment and Coverage Periods.--The Secretary shall 
establish enrollment and coverage periods for individuals who enroll 
under this section. Such periods shall be established in coordination 
with the enrollment and coverage periods for plans offered under an 
Exchange established under title I of the Patient Protection and 
Affordable Care Act. The Secretary shall establish such periods so that 
coverage under this section shall first begin on January 1 of the first 
year beginning at least one year after the date of the enactment of 
this section and shall include special enrollment periods, in 
accordance with section 155.420 of title 45 of the Code of Federal 
Regulations, that are applicable to qualified health plans offered 
through an Exchange.
    ``(c) Buy-In Premium.--
            ``(1) Amount of monthly premiums.--The Secretary shall 
        (beginning for the first year that begins more than 1 year 
        after the date of the enactment of this section), during 
        September of the preceding year, determine a monthly premium 
        for individuals enrolled under this section. Such monthly 
        premium shall be equal to \1/12\ of the annual premium computed 
        under paragraph (2)(B), which shall apply with respect to 
        coverage provided under this section for any month in such 
        year.
            ``(2) Annual premium.--
                    ``(A) Combined national, per capita average for 
                parts a, b, and d benefits.--The Secretary shall 
                estimate the average, annual per capita amount for 
                benefits and administrative expenses that will be 
                payable under parts A, B, and D in the year for all 
                individuals enrolled under this section.
                    ``(B) Annual premium.--Subject to subparagraphs (C) 
                and (D), the annual premium under this subsection for 
                months in a year is equal to the average, annual per 
                capita amount estimated under subparagraph (A) for the 
                year.
                    ``(C) Adjustments.--The Secretary shall adjust the 
                annual premium under this subsection as necessary--
                            ``(i) to ensure that expenditures under 
                        this title for any year are not increased by 
                        reason of this section; and
                            ``(ii) by a geographic adjustment factor to 
                        address regional affordability concerns.
                    ``(D) Authority to calculate amounts of monthly 
                premiums separately for different ages.--In determining 
                the annual premium amount under this paragraph for 
                months in a year, the Secretary may make separate 
                determinations of such amount for individuals by age, 
                if the Secretary determines that making such separate 
                determinations would increase enrollment under this 
                section and reduce the risk of adverse selection.
            ``(3) Additional premium for certain part d plans.--Nothing 
        in this section shall preclude an individual from choosing a 
        prescription drug plan which requires the individual to pay an 
        additional amount (because of the inclusion of supplemental 
        prescription drug benefits or because the plan is a more 
        expensive plan, pursuant to section 1860D-13(a)(1)). In such 
        case, the monthly premium under paragraph (1) shall be 
        increased with respect to such individual.
    ``(d) Payment of Premiums.--
            ``(1) Payment.--Premiums for enrollment under this section 
        shall be paid to the Secretary at such times, and in such 
        manner, as the Secretary determines appropriate.
            ``(2) Deposit.--Amounts collected by the Secretary under 
        this section shall be deposited in the Medicare Buy-In Trust 
        Fund established under subsection (e).
    ``(e) Medicare Buy-In Trust Fund.--
            ``(1) In general.--There is hereby created on the books of 
        the Treasury of the United States a trust fund to be known as 
        the `Medicare Buy-In Trust Fund' (in this subsection referred 
        to as the `Trust Fund'). The Trust Fund shall consist of such 
        gifts and bequests as may be made as provided in section 
        201(i)(1) and such amounts as may be deposited in, or 
        appropriated to, such fund as provided in this title.
            ``(2) Premiums.--Premiums collected under subsection (d) 
        shall be transferred to the Trust Fund.
            ``(3) Incorporation of provisions.--Subsections (b) through 
        (i) of section 1841 shall apply with respect to the Trust Fund 
        and this title in the same manner as they apply with respect to 
        the Federal Supplementary Medical Insurance Trust Fund and part 
        B, respectively, except that in applying such section 1841, any 
        reference in such section to `this part' shall be construed to 
        be a reference to this section and any reference in section 
        1841(h) to section 1840(d) and in section 1841(i) to sections 
        1840(b)(1) and 1842(g) are deemed to be references to 
        comparable authority exercised under this section.
    ``(f) Clarification.--Nothing in this section shall affect the 
benefits or eligibility under this title of individuals who would 
otherwise be entitled to or eligible for benefits under this title or 
title XIX, or both.
    ``(g) Eligibility for Financial Assistance.--
            ``(1) In general.--Individuals enrolled in coverage under 
        this section shall, from amounts transferred under paragraph 
        (2), receive financial assistance for such coverage that is 
        substantially similar to the assistance the individual would 
        have received if the individual were enrolled in a qualified 
        health plan through an Exchange.
            ``(2) Transfer of funds to medicare buy-in trust fund.--
                    ``(A) In general.--The Secretary shall transfer to 
                the Medicare Buy-In Trust Fund under subsection (d) for 
                each plan year the amount determined under paragraph 
                (C) for such year.
                    ``(B) Use of funds.--The amounts transferred to the 
                Medicare Buy-In Trust Fund under subparagraph (A) shall 
                only be used to reduce the premiums and cost-sharing 
                for coverage under this section of individuals enrolled 
                under such coverage who would be eligible for cost-
                sharing reductions under section 1402 of the Patient 
                Protection and Affordable Care Act and premium 
                assistance under section 36B of the Internal Revenue 
                Code of 1986 if such individual were enrolled in a 
                qualified health plan.
                    ``(C) Amount of transfer.--
                            ``(i) In general.--The amount determined 
                        under this subparagraph for any plan year is 
                        the aggregate amount the Secretary determines 
                        is equal to 100 percent of the premium tax 
                        credits under section 36B of the Internal 
                        Revenue Code of 1986, and 100 percent of the 
                        cost-sharing reductions under section 1402 of 
                        the Patient Protection and Affordable Care Act, 
                        that would have been provided for the plan year 
                        to eligible individuals who meet specified 
                        income criteria and are enrolled for such plan 
                        year in coverage provided through enrollment 
                        under this section if such individuals were 
                        enrolled for such year in a qualified health 
                        plan through an Exchange.
                            ``(ii) Specific requirements.--The 
                        Secretary shall make the determination under 
                        clause (i) on a per enrollee basis and shall 
                        take into account all relevant factors 
                        necessary to determine the value of the premium 
                        tax credits and cost-sharing reductions that 
                        would have been provided to eligible 
                        individuals described in section 1331 of the 
                        Patient Protection and Affordable Care Act, 
                        including the age and income of the enrollee, 
                        geographic differences in average spending for 
                        health care across rating areas, the health 
                        status of the enrollee for purposes of 
                        determining risk adjustment payments and 
                        reinsurance payments that would have been made 
                        if the enrollee had enrolled in a qualified 
                        health plan through an Exchange, and whether 
                        any reconciliation of the credit or cost-
                        sharing reductions would have occurred if the 
                        enrollee had been so enrolled. This 
                        determination shall take into consideration the 
                        experience of other States with respect to 
                        participation in an Exchange and such credits 
                        and reductions provided to residents of the 
                        other States, with a special focus on enrollees 
                        with income below 200 percent of poverty.
                    ``(D) Certification.--
                            ``(i) In general.--The Chief Actuary of the 
                        Centers for Medicare & Medicaid Services, in 
                        consultation with the Office of Tax Analysis of 
                        the Department of the Treasury, shall certify 
                        whether the methodology used to make 
                        determinations under subparagraph (C), and such 
                        determinations, meet the requirements of this 
                        paragraph. Such certifications shall be based 
                        on sufficient data from the federal exchange 
                        and from comparable States about their 
                        experience with programs created by the Basic 
                        Health Plan.
                            ``(ii) Corrections.--The Secretary shall 
                        adjust the payment to the Trust Fund for any 
                        plan year to reflect any error in the 
                        determinations under subparagraph (C) for any 
                        preceding plan year.
                            ``(iii) Application.--Coverage provided 
                        through enrollment under this part and parts B 
                        and D pursuant to this section shall be treated 
                        as coverage under a qualified health plan in 
                        the silver level of coverage in the individual 
                        market offered through an Exchange and the 
                        Secretary shall be treated as the issuer of 
                        such plan.
    ``(h) Treatment in Relation to the Affordable Care Act.--
            ``(1) Treatment as minimum essential coverage.--For 
        purposes of applying section 5000A of the Internal Revenue Code 
        of 1986, the coverage provided through enrollment under this 
        section constitutes minimum essential coverage under subsection 
        (f)(1)(A)(i) of such section.
            ``(2) Use of exchanges.--Coverage provided through 
        enrollment under this section shall be deemed to be coverage 
        under a qualified health plan for purposes of section 
        1311(d)(4)(C) of the Patient Protection and Affordable Care Act 
        and shall be made available for enrollment, information 
        comparison, and otherwise as such a plan through any internet 
        website maintained by an Exchange established under title I of 
        such Act (as described in such section).
            ``(3) Medicaid managed care.--States are prohibited from 
        buying their Medicaid beneficiaries ages 50 to 64 into Medicare 
        under this section, and individuals otherwise eligible for 
        enrollment under a State plan under title XIX are prohibited 
        from coverage under this title pursuant to enrollment under 
        this section. The preceding sentence shall not apply to 
        Medicaid beneficiaries whose Medicaid coverage or eligibility 
        does not meet the definition of minimum essential coverage 
        under a government-sponsored program under section 1.5000A-2 of 
        title 26, Code of Federal Regulations (or any successor 
        regulation).
            ``(4) Access to medigap.--Coverage provided through 
        medicare supplemental policies certified under section 1882 
        shall be made available to individuals eligible for enrollment 
        pursuant to this section for enrollment, information, 
        comparison, and otherwise as such a policy through any internet 
        website described in paragraph (2).
    ``(i) Oversight.--There is established an advisory committee to be 
known as the `Medicare Buy In Oversight Board' to monitor and oversee 
the implementation of this section, including the experience of the 
individuals enrolling under this section. The Medicare Buy In Oversight 
Board shall make periodic recommendations for the continual improvement 
of the implementation of this section as well as the relationship of 
enrollment under this section to other health care programs.
    ``(j) Outreach and Enrollment.--
            ``(1) In general.--During the period that begins on January 
        1, 2021, and ends on December 31, 2023, the Secretary shall 
        award grants to eligible entities for the following purposes:
                    ``(A) Outreach and enrollment.--To carry out 
                outreach, public education activities, and enrollment 
                activities to raise awareness of the availability of, 
                and encourage, enrollment under this section.
                    ``(B) Assisting individuals transition under this 
                section.--To provide assistance to individuals to 
                enroll under this section.
                    ``(C) Raising awareness of premium assistance and 
                cost-sharing reductions.--To distribute fair and 
                impartial information concerning enrollment under this 
                section and the availability of premium assistance tax 
                credits under section 36B of the Internal Revenue Code 
                of 1986 and cost-sharing reductions under section 1402 
                of the Patient Protection and Affordable Care Act, and 
                to assist eligible individuals in applying for such tax 
                credits and cost-sharing reductions.
            ``(2) Eligible entities.--
                    ``(A) In general.--In this subsection, the term 
                `eligible entity' means--
                            ``(i) a State; or
                            ``(ii) a nonprofit community-based 
                        organization.
                    ``(B) Enrollment agents.--Such term includes a 
                licensed independent insurance agent or broker that has 
                an arrangement with a State or nonprofit community-
                based organization to enroll eligible individuals under 
                this section.
                    ``(C) Exclusions.--Such term does not include an 
                entity that--
                            ``(i) is a health insurance issuer; or
                            ``(ii) receives any consideration, either 
                        directly or indirectly, from any health 
                        insurance issuer in connection with the 
                        enrollment of any individuals under this 
                        section.
            ``(3) Priority.--In awarding grants under this subsection, 
        the Secretary shall give priority to awarding grants to States 
        or eligible entities in States that have geographic rating 
        areas at risk of having no qualified health plans in the 
        individual market.
            ``(4) Funding.--Out of any moneys in the Treasury not 
        otherwise appropriated, $500,000,000 is appropriated to the 
        Secretary for each of calendar years 2021 through 2023, to 
        carry out this subsection.
    ``(k) Implementation.--
            ``(1) Consultation.--In carrying out this section, the 
        Secretary shall--
                    ``(A) consult with other Federal agencies, 
                including the Department of the Treasury, the 
                Department of Labor, the Department of Veterans 
                Affairs, the Department of Defense, and the Office of 
                Personnel Management; and
                    ``(B) incorporate significant public consultation 
                and feedback, through public forums, notice and comment 
                rulemaking, and any other appropriate mediums.
            ``(2) Report.--No later than one year after the date of the 
        enactment of this section, the Secretary shall submit to 
        Congress a report establishing the administrative parameters 
        for the implementation of this section.
    ``(l) Feasibility Study.--The Secretary shall conduct a study on 
the feasibility of applying this section with respect to individuals 
residing in States that are not within the 50 States or the District of 
Columbia.''.
    (b) Medigap.--Section 1882 of the Social Security Act is amended by 
adding at the end the following new subsection:
    ``(aa) Development of New Standards for Certain Medicare 
Supplemental Policies Relating to Buy-In Option.--The Secretary shall 
request the National Association of Insurance Commissioners to review 
and revise the standards for benefit packages described in subsection 
(p)(1), to otherwise update standards to include requirements for each 
medicare supplemental policy that offers such a policy in a State, with 
respect to each year, to accept every individual in the State who is 
eligible for enrollment pursuant to section 1899C and who applies for 
such coverage for such year if the individual applies for enrollment in 
such policy during the 30-day period following the date of enrollment 
pursuant to section 1899C and to accept every such individual during a 
period of transition from enrollment pursuant to such section to 
enrollment under this title pursuant to eligibility other than under 
such section. Such revisions shall be made consistent with the rules 
applicable under subsection (p)(1)(E) with the reference to the `1991 
NAIC Model Regulation' deemed a reference to the NAIC Model Regulation 
as published in the Federal Register on December 4, 1998, and as 
subsequently updated by the National Association of Insurance 
Commissioners to reflect previous changes in law and the reference to 
`date of enactment of this subsection' deemed a reference to the date 
of enactment of this subsection (aa).''.

SEC. 4. MEDICARE DIRECT SUPPLEMENTAL INSURANCE OPTION.

    (a) In General.--Title XVIII of the Social Security Act is amended 
by inserting after section 1882 (42 U.S.C. 1395ss) the following new 
section:

``SEC. 1882A. MEDICARE DIRECT SUPPLEMENTAL INSURANCE OPTION.

    ``(a) In General.--The Secretary shall provide for the offering 
under this section of a voluntary program to supplement the benefits 
provided to individuals under parts A and B of this title.
    ``(b) Eligibility; Enrollment.--The Secretary shall provide 
procedures for the enrollment under the program under this section of 
individuals who are entitled to benefits under part A and enrolled 
under part B, but who are not enrolled in a Medicare Advantage plan (or 
in a plan under section 1876). Such procedures shall be consistent with 
the following:
            ``(1) There shall be an initial enrollment period during 
        the last calendar quarter of 2022 that permits all individuals 
        who are eligible to enroll at that time under this subsection 
        to enroll and obtain benefits effective on January 1, 2023.
            ``(2) For individuals who are not eligible to enroll at 
        such time but who subsequently become eligible, there shall be 
        an individual enrollment period which is the 6-month period 
        described in section 1882(s)(2)(A).
            ``(3) The Secretary shall permit eligible individuals to 
        enroll at other times (and not less frequently than annually) 
        in a uniform manner, but such enrollment shall be subject to a 
        late enrollment penalty under subsection (d)(2)(B).
    ``(c) Benefits.--
            ``(1) In general.--The benefits provided under the program 
        under this section shall consist of payment of the cost of 
        deductibles, copayments, and other cost-sharing amounts 
        (including amounts attributable to and permitted as balance 
        billing) otherwise imposed or permitted under this title, 
        subject to an annual deductible of $100.
            ``(2) Administration.--The Secretary shall coordinate 
        payment of benefits under this part with those under parts A 
        and B and may, for such purpose, enter into appropriate 
        arrangements with qualified entities (which may include fiscal 
        intermediaries and carriers).
            ``(3) No pre-existing condition limitations.--The benefits 
        under this section shall not be subject to any pre-existing 
        condition or similar underwriting limitation.
    ``(d) Premiums.--
            ``(1) Actuarial cost.--The Secretary shall, during 
        September of each year beginning with 2022, determine a monthly 
        actuarial rate for all enrollees under this section, which rate 
        shall be applicable for months in the succeeding calendar year. 
        Such actuarial rate shall be the amount the Secretary estimates 
        to be necessary so that the aggregate amount for such calendar 
        year with respect to those enrollees will equal the total 
        amount which the Secretary estimates will be payable under this 
        section for benefits accrued (including services performed and 
        related administrative costs incurred) in such calendar year 
        under the program under this section. In calculating the 
        monthly actuarial rate, the Secretary shall make adjustments to 
        take into account errors in estimations under this paragraph 
        for previous years and shall include an appropriate amount for 
        a contingency margin.
            ``(2) Premium.--
                    ``(A) In general.--The monthly premium of each 
                individual enrolled under this section for a month in a 
                year shall be the monthly actuarial rate determined 
                under paragraph (1) for months in such year. Such 
                premium shall be community-rated and shall not vary 
                among enrollees based upon the age, place of residence, 
                or any other factors, except as provided under 
                subparagraph (B).
                    ``(B) Penalty for late enrollment.--In the case of 
                an individual who does not enroll under this section in 
                a period provided under paragraph (1) or (2) of 
                subsection (b), the Secretary shall increase the 
                monthly premium (in a manner similar to that applied 
                under part B pursuant to section 1839(b)) of 10 percent 
                for each full 12 months in which the individual could 
                have been but was not so enrolled. In applying such an 
                increase--
                            ``(i) the aggregate percentage increase may 
                        not exceed 100 percent; and
                            ``(ii) periods of time in which an 
                        individual is enrolled under an employee 
                        welfare benefit plan described in section 
                        1882(s)(3)(B)(i), under a Medicare Advantage 
                        plan, with an organization described in section 
                        1882(s)(3)(B)(iii), or under a PACE program 
                        under section 1894 shall not be taken into 
                        account.
            ``(3) Collection.--The Secretary shall provide for the 
        collection of premiums for enrollees under this part in the 
        same manner as premiums under part B are collected under 
        section 1840, except that any reference in such section to the 
        Federal Supplementary Medical Insurance Trust Fund shall be 
        deemed a reference to an account (to be known as the `Direct 
        Medicare Supplemental Insurance Account') to be established in 
        the Treasury by the Secretary to carry out the program under 
        this section. Amounts in such account may be invested and draw 
        interest in the same manner as such Trust Fund under section 
        1840(c).
            ``(4) Use of funds.--Premium amounts deposited into the 
        account established under paragraph (3) shall be available 
        without regard to appropriations to the Secretary to make 
        payment for benefits and administrative costs incurred in 
        carrying out this section.
    ``(e) Nonduplication of Coverage.--For purposes of applying section 
1882(d)(3)(A), coverage under this section shall be treated as coverage 
under a Medicare supplemental policy.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
take effect on the date of the enactment of this Act and shall apply to 
benefits for months beginning with January 2022.

SEC. 5. NEGOTIATION OF LOWER COVERED PART D DRUG PRICES ON BEHALF OF 
              MEDICARE BENEFICIARIES.

    (a) Negotiation by Secretary.--Section 1860D-11 of the Social 
Security Act (42 U.S.C. 1395w-111) is amended by striking subsection 
(i) (relating to noninterference) and inserting the following:
    ``(i) Negotiation of Lower Drug Prices.--
            ``(1) In general.--Notwithstanding any other provision of 
        law, the Secretary shall negotiate with pharmaceutical 
        manufacturers the prices (including discounts, rebates, and 
        other price concessions) that may be charged to PDP sponsors 
        and MA organizations for covered part D drugs for part D 
        eligible individuals who are enrolled under a prescription drug 
        plan or under an MA-PD plan.
            ``(2) No change in rules for formularies.--
                    ``(A) In general.--Nothing in paragraph (1) shall 
                be construed to authorize the Secretary to establish or 
                require a particular formulary.
                    ``(B) Construction.--Subparagraph (A) shall not be 
                construed as affecting the Secretary's authority to 
                ensure appropriate and adequate access to covered part 
                D drugs under prescription drug plans and under MA-PD 
                plans, including compliance of such plans with 
                formulary requirements under section 1860D-4(b)(3).
            ``(3) Construction.--Nothing in this subsection shall be 
        construed as preventing the sponsor of a prescription drug 
        plan, or an organization offering an MA-PD plan, from obtaining 
        a discount or reduction of the price for a covered part D drug 
        below the price negotiated under paragraph (1).
            ``(4) Semi-annual reports to congress.--Not later than June 
        1, 2024, and every 6 months thereafter, the Secretary shall 
        submit to the Committees on Ways and Means, Energy and 
        Commerce, and Oversight and Reform of the House of 
        Representatives and the Committee on Finance of the Senate a 
        report on negotiations conducted by the Secretary to achieve 
        lower prices for Medicare beneficiaries, and the prices and 
        price discounts achieved by the Secretary as a result of such 
        negotiations.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
take effect on the date of the enactment of this Act and shall first 
apply to negotiations and prices for plan years beginning on January 1, 
2024.

SEC. 6. INDIVIDUAL MARKET REINSURANCE FUND.

    (a) Establishment of Fund.--
            (1) In general.--There is established the ``Individual 
        Market Reinsurance Fund'' (in this section referred to as the 
        ``Fund'') to be administered by the Secretary to provide 
        funding for an individual market stabilization reinsurance 
        program in each State that complies with the requirements of 
        this section.
            (2) Funding.--Amounts made available to the Fund shall 
        consist of the funds deposited into the Fund under paragraph 
        (3) and shall be used to carry out this section (other than 
        subsection (c)) for each calendar year beginning with 2023. 
        Amounts made available to the Fund shall remain available 
        without fiscal or calendar year limitation to carry out this 
        section.
            (3) Cost-sharing in costs of program.--
                    (A) In general.--A qualified health plan that 
                participates in the reinsurance program established 
                under subsection (b) shall pay the fee established 
                under subparagraph (B).
                    (B) Authorization.--The Secretary is authorized to 
                charge a fee to each qualified health plan that 
                participates in the reinsurance program established 
                under subsection (b). Any amounts collected pursuant to 
                this paragraph shall be deposited into the Fund for 
                purposes of payments under subsection (b).
                    (C) Requirements.--In establishing the fee under 
                subparagraph (B)--
                            (i) the Secretary shall consult with 
                        interested parties; and
                            (ii) shall ensure that the amount of such 
                        fee is not excessive so as to unduly discourage 
                        qualified health plans from participating in 
                        the reinsurance program.
    (b) Individual Market Reinsurance Program.--
            (1) Use of funds.--The Secretary shall use amounts in the 
        Fund to establish a reinsurance program under which the 
        Secretary shall make reinsurance payments, subject to 
        subsection (a)(3), to health insurance issuers with respect to 
        high-cost individuals enrolled in qualified health plans 
        offered by such issuers that are not grandfathered health plans 
        or transitional health plans for any plan year beginning with 
        the 2020 plan year. This subsection constitutes budget 
        authority in advance of appropriations Acts and represents the 
        obligation of the Secretary to provide payments from the Fund 
        in accordance with this subsection.
            (2) Amount of payment.--The payment made to a health 
        insurance issuer under paragraph (1) with respect to each high-
        cost individual enrolled in a qualified health plan issued by 
        the issuer that is not a grandfathered health plan or a 
        transitional health plan shall equal 80 percent of the lesser 
        of--
                    (A) the amount (if any) by which the individual's 
                claims incurred during the plan year exceeds--
                            (i) in the case of the 2021, 2022, or 2023 
                        plan year, $50,000; and
                            (ii) in the case of any other plan year, 
                        $100,000; or
                    (B) for plan years described in--
                            (i) subparagraph (A)(i), $450,000; and
                            (ii) subparagraph (A)(ii), $400,000.
            (3) Indexing.--In the case of plan years beginning after 
        2021, the dollar amounts that appear in subparagraphs (A) and 
        (B) of paragraph (2) shall each be increased by an amount equal 
        to--
                    (A) such amount; multiplied by
                    (B) the premium adjustment percentage specified 
                under section 1302(c)(4) of the Affordable Care Act, 
                but determined by substituting ``2019'' for ``2013''.
            (4) Payment methods.--
                    (A) In general.--Payments under this subsection 
                shall be based on such a method as the Secretary 
                determines. The Secretary may establish a payment 
                method by which interim payments of amounts under this 
                subsection are made during a plan year based on the 
                Secretary's best estimate of amounts that will be 
                payable after obtaining all of the information.
                    (B) Requirement for provision of information.--
                            (i) Requirement.--Payments under this 
                        subsection to a health insurance issuer are 
                        conditioned upon the furnishing to the 
                        Secretary, in a form and manner specified by 
                        the Secretary, of such information as may be 
                        required to carry out this subsection.
                            (ii) Restriction on use of information.--
                        Information disclosed or obtained pursuant to 
                        clause (i) is subject to the HIPAA privacy and 
                        security law, as defined in section 3009(a) of 
                        the Public Health Service Act (42 U.S.C. 300jj-
                        19(a)).
            (5) Secretary flexibility for budget neutral revisions to 
        reinsurance payment specifications.--If the Secretary 
        determines appropriate, the Secretary may substitute higher 
        dollar amounts for the dollar amounts specified under 
        subparagraphs (A) and (B) of paragraph (2) (and adjusted under 
        paragraph (3), if applicable) if the Secretary certifies that 
        such substitutions, considered together, neither increase nor 
        decease the total projected payments under this subsection.
    (c) Reports to Congress.--
            (1) Annual report.--The Secretary shall submit a report to 
        Congress, not later than January 21, 2021, and each year 
        thereafter, that contains the following information for the 
        most recently ended year:
                    (A) The number and types of plans in each State's 
                individual market, specifying the number that are 
                qualified health plans, grandfathered health plans, or 
                health insurance coverage that is not a qualified 
                health plan.
                    (B) The impact of the reinsurance payments provided 
                under this section on the availability of coverage, 
                cost of coverage, and coverage options in each State.
                    (C) The amount of premiums paid by individuals in 
                each State by age, family size, geographic area in the 
                State's individual market, and category of health plan 
                (as described in subparagraph (A)).
                    (D) The process used to award funds for outreach 
                and enrollment activities awarded to eligible entities 
                under subsection (c), the amount of such funds awarded, 
                and the activities carried out with such funds.
                    (E) Such other information as the Secretary deems 
                relevant.
            (2) Evaluation report.--Not later than January 31, 2024, 
        the Secretary shall submit to Congress a report that--
                    (A) analyzes the impact of the funds provided under 
                this section on premiums and enrollment in the 
                individual market in all States; and
                    (B) contains a State-by-State comparison of the 
                design of the programs carried out by States with funds 
                provided under this section.
    (d) Definitions.--In this section:
            (1) Secretary.--The term ``Secretary'' means the Secretary 
        of the Department of Health and Human Services.
            (2) Fund.--The term ``Fund'' means the Individual Market 
        Reinsurance Fund established under subsection (a).
            (3) Grandfathered health plan.--The term ``grandfathered 
        health plan'' has the meaning given that term in section 
        1251(e) of the Patient Protection and Affordable Care Act.
            (4) High-cost individual.--The term ``high-cost 
        individual'' means an individual enrolled in a qualified health 
        plan (other than a grandfathered health plan or a transitional 
        health plan) who incurs claims in excess of $50,000 during a 
        plan year.
            (5) State.--The term ``State'' means each of the 50 States 
        and the District of Columbia.
            (6) Transitional health plan.--The term ``transitional 
        health plan'' means a plan continued under the letter issued by 
        the Centers for Medicare & Medicaid Services on November 14, 
        2013, to the State Insurance Commissioners outlining a 
        transitional policy for coverage in the individual and small 
        group markets to which section 1251 of the Patient Protection 
        and Affordable Care Act 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 Services on March 5, 2014, 
        February 29, 2016, and February 13, 2017.

SEC. 7. REAUTHORIZATION OF RISK CORRIDORS.

    Section 1342(a) of the Patient Protection and Affordable Care Act 
(42 U.S.C. 18062(a)) is amended by inserting ``and calendar years 2023 
through 2026'' after ``2016''.

SEC. 8. INTEGRATION OF INDIVIDUALS AGED 50 TO 64 INTO HEALTH 
              DEMONSTRATIONS.

    The Center for Medicare and Medicaid Innovation under section 1115A 
of the Social Security Act (42 U.S.C. 1315a) is authorized to include 
the individuals enrolled under title XVIII of the Social Security Act 
pursuant to section 1899C of such Act, as added by section 3, into 
existing and future demonstrations conducted by such Center.

SEC. 9. QUALIFIED HEALTH PLAN TAX CREDIT EXPANSION MADE PERMANENT.

    (a) In General.--Section 36B of the Internal Revenue Code of 1986 
is amended--
            (1) in subsection (b)(3)(A)(iii)--
                    (A) by striking the header and inserting 
                ``Percentages for taxable years beginning after 2020'', 
                and
                    (B) by striking ``beginning in 2021 or 2022'' and 
                inserting ``beginning after 2020'', and
            (2) in subsection (c)(1)(E)--
                    (A) by striking the header and inserting ``Rule for 
                taxable years after 2020'', and
                    (B) by striking ``beginning in 2021 or 2022'' and 
                inserting ``beginning after 2020''.
    (b) Effective Date.--The amendments made by this section shall 
apply to taxable years beginning after December 31, 2020.
                                 <all>