I 116th CONGRESS 1st Session H. R. 2183 IN THE HOUSE OF REPRESENTATIVES April 9, 2019 Mr. Marshall introduced the following bill; which was referred to the Committee on Energy and Commerce , and in addition to the Committee on Ways and Means , for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend the Patient Protection and Affordable Care Act to streamline the State innovation waiver process, and for other purposes.

1. Short title This Act may be cited as the State Flexibility and Patient Choice Act of 2019 . 2. Streamlining the State innovation waiver process Section 1332 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18052 ) is amended— (1) in subsection (a)— (A) in paragraph (1)— (i) in subparagraph (B)(ii), by inserting over both the term of the proposed waiver and the 10-year budget plan after Government ; and (ii) in subparagraph (C), by striking the law described in subsection (b)(2) and inserting a law or has in effect a certification described in subsection (b)(3) ; and (B) in paragraph (3)— (i) in the first sentence— (I) by inserting or would qualify for a lesser amount of after would not qualify for ; (II) by inserting , or the State would not qualify for or would qualify for a lesser payment under section 1331, after subtitle E ; (III) by inserting , or on behalf of participants in a basic health program established under section 1331 had such participants been enrolled in an Exchange, after this title ; and (IV) by inserting or for implementing a basic health program established under section 1331 before the period; and (ii) in the second sentence, by inserting before the period the following: , and with respect to participation in the basic health program and funds provided to such other States under section 1331 ; (2) in subsection (b)— (A) in paragraph (1)— (i) in subparagraph (B), by striking at least as affordable and inserting of comparable affordability ; and (ii) in subparagraph (D), by inserting over the term of the waiver and over the 10-year budget plan with respect to such waiver before the period at the end; (B) by redesignating paragraph (2) as paragraph (3); (C) by inserting after paragraph (1) the following new paragraph: (2) Budgetary effect (A) In general In determining whether a State plan submitted under subsection (a) meets the deficit neutrality requirements of paragraph (1)(D), the Secretary shall take into consideration the direct budgetary effect of the provisions of such plan on sources of Federal funding other than the funding described in subsection (a)(3). ; and (D) in paragraph (3) (as so redesignated)— (i) in the paragraph heading, by inserting OR HAVE IN EFFECT A CERTIFICATION after LAW ; (ii) in subparagraph (A)— (I) by striking A law and inserting the following: (i) Laws A law ; and (II) by adding at the end the following: (ii) Certifications A certification described in this paragraph is a document, signed by the Governor of the State, that certifies that such Governor has the authority under existing State law to take action under this section, including implementation of the State plan under subsection (a)(1)(B). ; and (iii) in subparagraph (B)— (I) in the subparagraph heading, by striking OF OPT OUT ; and (II) by striking may repeal a law and all that follows through the period at the end and inserting the following: may terminate the authority provided under the waiver with respect to the State by— (i) repealing the law described in subparagraph (A)(i); or (ii) terminating the certification described in subparagraph (A)(ii), through a certification for such termination signed by the Governor of the State. ; (3) in subsection (d)— (A) in paragraph (1), by striking 180 and inserting 90 ; and (B) by adding at the end the following new paragraph: (3) Expedited determination (A) In general With respect to any application under subsection (a)(1) submitted on or after the date of the enactment of this paragraph, the Secretary shall make a determination on such application, using the criteria for approval otherwise applicable under this section, not later than 60 days after the receipt of such application and shall allow the public notice and comment at the State and Federal levels described under subsection (a)(4) to occur concurrently if such State application— (i) is submitted in response to an urgent situation, with respect to areas in the State that the Secretary determines are at risk for substantial increases in premium rates or having no health plans offered in the applicable health insurance market for the current or following plan year; or (ii) is for a waiver that is the same or substantially similar to a waiver that the Secretary already has approved for another State. (B) Approval limitations for urgent situations (i) Provisional approval A waiver approved under the expedited determination process under subparagraph (A)(i) may extend over a period of not longer than 3 years. (ii) Full approval Subject to the requirements for approval otherwise applicable under this section, not later than 1 year before the expiration of a provisional waiver period described in clause (i) with respect to an application described in subparagraph (A)(i), the Secretary shall make a determination on whether to extend the term of such waiver for longer than the period described in clause (i), for a total waiver term not to exceed 6 years. The Secretary may request additional information as the Secretary determines appropriate to make such determination. (C) GAO study Not later than 5 years after the date of enactment of the State Flexibility and Patient Choice Act of 2019, the Comptroller General of the United States shall conduct a review of all waivers approved pursuant to an application under subparagraph (A)(ii) to evaluate whether such waivers met the requirements of subsection (b)(1) and whether the applications should have qualified for such an expedited determination. ; (4) in subsection (e), by inserting (or, in the case of an application under subsection (a)(1) submitted on or after the date of the enactment of the State Flexibility and Patient Choice Act of 2019, 6 years) after 5 years ; and (5) by adding at the end the following new subsection: (f) Additional provisions In carrying out this section, the Secretary shall— (1) issue guidance, not later than 30 days after the date of the enactment of this subsection, that includes initial examples of model State plans that may meet the requirements for approval under this section; and (2) periodically review the guidance issued under paragraph (1) and, when appropriate, issue additional examples of model State plans that may meet the requirements for approval under this section, which may include— (A) model plans establishing reinsurance or invisible high-risk pool arrangements for purposes of covering the cost of high-risk individuals; (B) model plans expanding insurer participation, access to affordable health plans, network adequacy, and health plan options over the entire applicable health insurance market in the State; (C) model plans that encourage or require health plans in a State to deploy value-based insurance designs which structure enrollee cost-sharing and other health plan design elements to encourage enrollees to consume high-value clinical services; (D) model plans allowing for significant variation in health plan benefit design; or (E) any other model plan determined appropriate by the Secretary. .