American Health Care Act of 2017

Bill: 115-hr-1628
Sponsor: full_name: Rep. Black, Diane [R-TN-6]
Introduced: 2017-03-20
Policy area: Health
Subjects: Abortion

Accounting and auditing

Bank accounts, deposits, capital

Employee benefits and pensions

Financial services and investments

Gambling

Government information and archives

Government studies and investigations

Health care costs and insurance

Health care coverage and access

Health facilities and institutions

Health information and medical records

Health programs administration and funding

Health promotion and preventive care

Health technology, devices, supplies

Income tax credits

Income tax deductions

Income tax rates

Inflation and prices

Interest, dividends, interest rates

Medicaid

Medical tests and diagnostic methods

Medicare

Prescription drugs

Sales and excise taxes

Small business

State and local finance

Tax administration and collection, taxpayers
Latest action: action_date: 2017-07-28
text: Returned to the Calendar. Calendar No. 120.

Summaries:
action_date: 2017-03-20
action_desc: Introduced in House
text: <p><b>American Health Care Act of 2017</b></p> <p>This bill amends the Patient Protection and Affordable Care Act (PPACA) to eliminate funding for the Prevention and Public Health Fund and increase funding for community health centers.</p> <p>For one year, certain federal funds may not be made available to states for payments to certain family planning providers (e.g., Planned Parenthood Federation of America).</p> <p>The bill amends title XIX (Medicaid) of the Social Security Act (SSAct) to limit, based on enrollment, federal funding for Medicaid beginning in FY2020.</p> <p>Beginning in 2020, the bill eliminates: (1) the enhanced federal matching rate for new enrollees made eligible for Medicaid by PPACA, and (2) the state option to extend Medicaid coverage to such enrollees. At least every six months, states must redetermine the eligibility of enrollees made eligible for Medicaid by PPACA.</p> <p>The bill repeals other changes made to Medicaid by PPACA and modifies additional Medicaid provisions.</p> <p>Cost sharing reductions for low-income individuals are eliminated after 2019.</p> <p>This bill amends the SSAct to establish the Patient and State Stability Fund to provide funding to states for the stabilization of health insurance premiums and other purposes.</p> <p>Health insurers must increase premiums by 30% for one year for enrollees who have not maintained continuous coverage over the previous year.</p> <p>The bill amends the Internal Revenue Code to modify premium subsidies and eliminate the subsidies after 2019.</p> <p>The bill repeals the small employer tax credit for employee health insurance expenses, the penalties associated with the individual and large employer mandates for minimum essential health coverage, and other PPACA taxes and tax increases.</p> <p>The bill establishes a refundable tax credit in 2020 for certain taxpayers who purchase health insurance on the individual market.</p> The bill revises rules for health savings accounts.

action_date: 2017-03-20
action_desc: Reported to House without amendment
text: <p>(This measure has not been amended since it was introduced. The summary has been expanded because action occurred on the measure.) </p> <p><strong>American Health Care Act of 2017</strong> </p> <p>TITLE I--ENERGY AND COMMERCE</p> <p> Subtitle A--Patient Access to Public Health Programs </p> <p>(Sec. 101) This bill amends the Patient Protection and Affordable Care Act to eliminate funding after FY2018 for the Prevention and Public Health Fund, which provides for investment in prevention and public health programs to improve health and restrain the rate of growth in health care costs. Funds that are unobligated at the end of FY2018 are rescinded. </p> <p>(Sec. 102) The bill amends the Medicare Access and CHIP Reauthorization Act of 2015 to increase funding for community health centers. </p> <p>(Sec. 103) For one year, certain federal funds may not be made available to states for payments to certain family planning providers (e.g., Planned Parenthood Federation of America).</p> <p> Subtitle B--Medicaid Program Enhancement </p> <p>(Sec. 111) The bill amends title XIX (Medicaid) of the Social Security Act (SSAct) to limit the state option for a participating-provider hospital to preliminarily determine an individual's Medicaid eligibility for purposes of providing the individual with medical assistance during a presumptive eligibility period. The bill lowers, from 133% to 100% of the official poverty line, the minimum family-income threshold that a state may use to determine the Medicaid eligibility of children between the ages of 6 and 19. In addition, the bill reduces the Federal Medical Assistance Percentage (FMAP) for Medicaid home- and community-based attendant services and supports. </p> <p>(Sec. 112) Beginning in 2020, the bill eliminates: (1) the enhanced FMAP for Medicaid services furnished to adult enrollees made newly eligible for Medicaid by PPACA; and (2) the expansion of Medicaid, under PPACA, to cover such enrollees. However, a state Medicaid program may continue to provide coverage, with the enhanced FMAP, to such enrollees who were enrolled prior to 2020 and do not subsequently have any break in eligibility exceeding one month. With respect to states that expanded Medicaid under PPACA, current law provides for transitional FMAP increases through 2019. The bill eliminates these increases after 2017, capping the FMAP at the 2017 level. Under current law, any alternative benefit plan offered by a state Medicaid program is required to provide specified essential health benefits. The bill eliminates this requirement beginning in 2020. (&quot;Essential health benefits&quot; include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative services, laboratory services, preventative and wellness services, and pediatric services.) </p> <p>(Sec. 113) The bill eliminates Medicaid Disproportionate Share Hospital (DSH) payment reductions: (1) with respect to states that did not implement Medicaid expansion under PPACA, beginning in FY2018; and (2) with respect to other states, beginning in FY2020. (DSH hospitals receive additional payment under Medicaid for treating a large share of low-income patients.) </p> <p>(Sec. 114) The bill specifies how a state must treat qualified lottery winnings and lump sum income, beginning in 2020, for purposes of determining an individual's income-based eligibility for a state Medicaid program. Specifically, a state shall include such winnings or income as income received: (1) in the month in which it was received, if the amount is less than $80,000; (2) over a period of two months, if the amount is at least $80,000 but less than $90,000; (3) over a period of three months, if the amount is at least $90,000 but less than $100,000; and (4) over an additional one-month period for each increment of $10,000 received, not to exceed 120 months. An individual whose income exceeds the applicable eligibility threshold due to qualified lump sum income may continue to be eligible for medical assistance to the extent that the state determines that denial of eligibility would cause undue medical or financial hardship. Qualified lump sum income includes: (1) monetary winnings from gambling, and (2) income received as liquid assets from the estate of a deceased individual. In addition, the bill eliminates the requirement for up to three months of retroactive coverage under Medicaid. Under current law, a state Medicaid program must provide coverage for up to three months prior to an individual's application for benefits if the individual would have been eligible for benefits during that period. The bill eliminates this requirement and instead specifies that coverage begins in the month during which the individual applies for benefits. The bill allows a state to delay or deny an individual's initial eligibility for Medicaid benefits without providing a reasonable opportunity to submit evidence of a satisfactory immigration status or pending official verification of such status. A state that elects to provide a reasonable period for an individual to provide such evidence may not receive payment for amounts expended on the individual's medical assistance during that period. In addition, the bill disallows a state from using, for purposes of determining Medicaid eligibility for long-term care assistance, a home equity limit that exceeds the statutory minimum. </p> <p>(Sec. 115) With respect to states that did not expand Medicaid coverage under PPACA, the bill: (1) with specified limitations, provides for additional federal funding for certain health care services; and (2) through 2022, increases the applicable FMAP. A non-expansion state that subsequently expands Medicaid coverage under PPACA shall become ineligible for this funding. </p> <p>(Sec. 116) No less frequently than every six months, states must redetermine the eligibility of adult enrollees made newly eligible for Medicaid by PPACA. The bill temporarily increases by 5% the FMAP for expenditures that are attributable to meeting this requirement. In addition, the bill increases the civil penalty for improperly filing certain Medicaid claims related to Medicaid expansion under PPACA. </p> <p>Subtitle C--Per Capita Allotment For Medical Assistance </p> <p>(Sec. 121) Under current law, state Medicaid programs are guaranteed federal matching funds for qualifying expenditures. The bill establishes limits on federal funding for state Medicaid programs beginning in FY2020. Specifically, the bill establishes targeted spending caps for each state, using a formula based on the state's FY2016 medical assistance expenditures in each enrollee category: (1) the elderly, (2) the blind and disabled, (3) children, (4) adults made newly eligible for Medicaid by PPACA, and (5) all other enrollees. With respect to a state that exceeds its targeted spending cap in a given fiscal year, the bill provides for reduced federal funding in the following fiscal year. In addition, the bill: (1) requires additional reporting and auditing of state data on medical assistance expenditures, and (2) temporarily increases the FMAP with respect to certain data reporting expenditures. </p> <p>Subtitle D--Patient Relief and Health Insurance Market Stability</p> <p> (Sec. 131) After 2019, the bill eliminates cost sharing reductions for low-income individuals with certain health insurance. </p> <p>(Sec. 132) The bill amends the SSAct to establish and make appropriations for the Patient and State Stability Fund to provide funding to states through 2026, including to: provide financial assistance to high-risk individuals so they may enroll in health insurance, stabilize health insurance premiums, promote participation and increase options in the health insurance market, pay providers for services, and provide financial assistance to enrollees to reduce out-of-pocket costs. Funding is allocated to states based on each state's share of incurred claims and uninsured individuals below the poverty line. To receive funding, states must provide matching funds at a rate that grows from 7% in 2020 to 50% in 2026.</p> <p>(Sec. 133) Health insurers must increase premiums by 30% for one year for enrollees in the individual or small group market who had a break in coverage of more than 62 days in the previous year. </p> <p>(Sec. 134) Beginning in 2020, health insurance benefits no longer must conform to actuarial tiers (e.g., silver level benefits). </p> <p>(Sec. 135) The bill increases the ratio by which health insurance premiums may vary by age, from a three to one ratio to a five to one ratio. This ratio may be preempted by states. </p> <p>TITLE II--COMMITTEE ON WAYS AND MEANS </p> <p>Subtitle A--Repeal and Replace of Health-Related Tax Policy</p> <p> Sections 201-203 of the bill make several modifications to the premium assistance tax credit for a transition period and repeal the credit after 2019. (The credit is currently provided to eligible individuals and families to subsidize the purchase of health insurance plans on an exchange.) </p> <p>(Sec. 201) This section makes taxpayers liable for the full amount of excess advance payments of the credit. (Under current law, liability for certain low-income households is limited to an applicable dollar amount.)</p> <p> (Sec. 202) This section modifies the premium assistance tax credit to: make the credit available for catastrophic qualified health plans and plans that are not offered through an exchange, but otherwise meet the requirements for qualified health plans; prohibit the credit from being used for grandfathered or grandmothered health plans; prohibit the credit from being used for health plans that cover abortions (other than abortions necessary to save the life of the mother or abortions with respect to a pregnancy that is the result of an act of rape or incest); and revise the formula used to calculate the credit using a schedule that varies with household income and the age of individuals or family members. </p> <p>(Sec. 203) This section repeals the premium assistance tax credit for health coverage that begins after December 31, 2019. </p> <p>(Sec. 204) This section modifies the small employer tax credit for employee health insurance expenses to: (1) prohibit the credit from being used for health plans that include coverage for abortions (other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest) for taxable years beginning after December 31, 2017; and (2) repeal the credit for taxable years beginning after December 31, 2019. </p> <p>(Sec. 205) This section repeals the penalties for individuals who are not covered by a health plan that provides at least minimum essential coverage (commonly referred to as the individual mandate). The repeal is effective for months beginning after December 31, 2015.</p> <p> (Sec. 206) This section repeals the penalties for certain large employers who do not offer full-time employees and their dependents minimum essential health coverage under an employer-sponsored health plan (commonly referred to as the employer mandate). The repeal is effective for months beginning after December 31, 2015.</p> <p> (Sec. 207) This section delays the implementation of the excise tax on high cost employer-sponsored health coverage (commonly referred to as the Cadillac tax) until 2025. (Under current law, the tax goes into effect in 2020.)</p> <p> (Sec. 208) This section permits tax-favored health savings accounts (HSAs), Archer Medical Savings Accounts (MSAs), health flexible spending arrangements (FSAs), and health reimbursement arrangements to be used to purchase over-the-counter medicine that is not prescribed by a physician.</p> <p> (Sec. 209) This section repeals the increase in the tax on distributions from HSAs and Archer MSAs that are not used for qualified medical expenses. The bill reduces the tax on HSA distributions from 20% to 10% and reduces the tax for Archer MSA's from 20% to 15% to return the taxes to the levels that existed prior to the enactment of PPACA.</p> <p> (Sec. 210) This section repeals the limitation on FSA salary reduction contributions.</p> <p> (Sec. 211) This section repeals the medical device excise tax for sales in calendar years beginning after December 31, 2017.</p> <p> (Sec. 212) The provision permits employers who provide Medicare-eligible retirees with qualified prescription drug coverage and receive federal subsidies for prescription drug plans to claim a deduction for the expenses without reducing the deduction by the amount of the subsidy.</p> <p> (Sec. 213) This section repeals the increase in the income threshold used to determine whether an individual may claim an itemized deduction for unreimbursed medical expenses. The bill allows all taxpayers to claim an itemized deduction for unreimbursed expenses medical expenses that exceed 7.5% (10% under current law) of adjusted gross income.</p> <p> (Sec. 214) This section repeals the additional Medicare tax that is imposed on certain employees and self-employed individuals with wages or self-employment income above specified thresholds.</p> <p> (Sec. 215) The section establishes a refundable, advanceable tax credit beginning in 2020 for certain taxpayers who purchase health insurance and who are not eligible for other sources of coverage. The credit applies for health insurance coverage that: is offered in the individual health insurance market within a state or is unsubsidized COBRA continuation coverage; is not a grandfathered or grandmothered plan; substantially all of which is not for excepted benefits providing only limited coverage, such as dental, vision, or long-term care; does not include coverage for abortions (other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest); does not consist of short-term limited duration insurance; and is certified by the state in which the insurance is offered as meeting the requirement of this bill. The bill specifies credit amounts which are based on age and adjusted gross income. It also limits the annual credit amount to $14,000 per family. If the amount paid for the insurance is less than the credit amount, Treasury may deposit the excess into an HSA of the individual or a qualifying family member as designated by the individual. The Department of the Treasury must establish a program not later than January 1, 2020, for making advance payments to providers of eligible health insurance on behalf of individuals eligible for the credit. The bill specifies reporting requirements for health insurance providers who provide eligible health insurance coverage to individuals.</p> <p> (Sec. 216) This section increases the limits on HSA contributions to match the sum of the annual deductible and out-of-pocket expenses permitted under a high deductible health plan.</p> <p> (Sec. 217) This section permits both spouses of a married couple who are eligible for HSA catch-up contributions to make the contributions to the same HSA account.</p> <p> (Sec. 218) This section permits an HSA to be used to pay certain medical expenses that were incurred before the HSA was established. If the HSA is established during the 60-day period beginning on the date that an individual's coverage under a high deductible health plan begins, the HSA is treated as having been established on the date coverage under the high deductible health plan begins to determine whether an amount paid is used for a qualified medical expense. </p> <p>Subtitle B--Repeal of Certain Consumer Taxes </p> <p>(Sec. 221) This section repeals the annual fee on branded prescription pharmaceutical manufacturers and importers. </p> <p>(Sec. 222) This section repeals the annual fee imposed on certain health insurance providers based on market share.</p> <p> Subtitle C--Repeal of Tanning Tax </p> <p>(Sec. 231) This section repeals the 10% excise tax on the price of indoor tanning services.</p> <p> Subtitle D--Remuneration From Certain Insurers </p> <p>(Sec. 241) The section repeals a provision that prohibits certain health insurance providers from deducting remuneration paid to an officer, director, or employee in excess of $500,000.</p> <p> Subtitle E--Repeal of Net Investment Income Tax </p> <p>(Sec. 251) This section repeals the 3.8% tax on the net investment income of individuals, estates, and trusts with incomes above specified amounts. </p>

action_date: 2017-05-04
action_desc: Passed House amended
text: <p><strong>American Health Care Act of 2017</strong></p> <p>TITLE I--ENERGY AND COMMERCE</p> <p>Subtitle A--Patient Access to Public Health Programs </p> <p>(Sec. 101) This bill amends the Patient Protection and Affordable Care Act (PPACA) to eliminate funding after FY2018 for the Prevention and Public Health Fund, which provides for investment in prevention and public health programs to improve health and restrain the rate of growth in health care costs. Funds that are unobligated at the end of FY2018 are rescinded. </p> <p>(Sec. 102) The bill amends the Medicare Access and CHIP Reauthorization Act of 2015 to increase funding for community health centers. </p> <p>(Sec. 103) For one year, certain federal funds may not be made available to states for payments to certain family planning providers (e.g., Planned Parenthood Federation of America). </p> <p>Subtitle B--Medicaid Program Enhancement </p> <p>(Sec. 111) The bill amends title XIX (Medicaid) of the Social Security Act (SSAct) to limit the state option for a participating-provider hospital to preliminarily determine an individual's Medicaid eligibility for purposes of providing the individual with medical assistance during a presumptive eligibility period. The bill lowers, from 133% to 100% of the official poverty line, the minimum family-income threshold that a state may use to determine the Medicaid eligibility of children between the ages of 6 and 19. In addition, the bill reduces the Federal Medical Assistance Percentage (FMAP) for Medicaid home- and community-based attendant services and supports. </p> <p>(Sec. 112) Beginning in 2020, the bill eliminates: (1) the enhanced FMAP for Medicaid services furnished to adult enrollees made newly eligible for Medicaid by PPACA; and (2) the expansion of Medicaid, under PPACA, to cover such enrollees. However, a state Medicaid program may continue to provide coverage, with the enhanced FMAP, to such enrollees who were enrolled prior to 2020 and do not subsequently have any break in eligibility exceeding one month. </p> <p>The bill also eliminates, beginning in 2018, the state option to extend Medicaid coverage to non-elderly adults with incomes above 133% of the official poverty line.</p> <p>With respect to states that expanded Medicaid under PPACA, current law provides for transitional FMAP increases through 2019. The bill eliminates these increases after 2017, capping the FMAP at the 2017 level. </p> <p>Under current law, any alternative benefit plan offered by a state Medicaid program is required to provide specified essential health benefits. The bill eliminates this requirement beginning in 2020. ("Essential health benefits" include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative services, laboratory services, preventative and wellness services, and pediatric services.) </p> <p>(Sec. 113) The bill: (1) exempts from Medicaid Disproportionate Share Hospital (DSH) payment reductions, states that did not implement Medicaid expansion under PPACA; and (2) eliminates DSH reductions after FY2019. (DSH hospitals receive additional payment under Medicaid for treating a large share of low-income patients.) </p> <p>(Sec. 114) The bill specifies how a state must treat qualified lottery winnings and lump sum income, beginning in 2020, for purposes of determining an individual's income-based eligibility for a state Medicaid program. Specifically, a state shall include such winnings or income as income received: (1) in the month in which it was received, if the amount is less than $80,000; (2) over a period of two months, if the amount is at least $80,000 but less than $90,000; (3) over a period of three months, if the amount is at least $90,000 but less than $100,000; and (4) over an additional one-month period for each increment of $10,000 received, not to exceed 120 months. An individual whose income exceeds the applicable eligibility threshold due to qualified lump sum income may continue to be eligible for medical assistance to the extent that the state determines that denial of eligibility would cause undue medical or financial hardship. </p> <p>Qualified lump sum income includes: (1) monetary winnings from gambling, and (2) income received as liquid assets from the estate of a deceased individual. </p> <p>In addition, the bill eliminates the requirement for up to three months of retroactive coverage under Medicaid. Under current law, a state Medicaid program must provide coverage for up to three months prior to an individual's application for benefits if the individual would have been eligible for benefits during that period.</p> <p> In addition, the bill disallows a state from using, for purposes of determining Medicaid eligibility for long-term care assistance, a home equity limit that exceeds the statutory minimum. </p> <p>(Sec. 115) With respect to states that did not expand Medicaid coverage under PPACA, the bill: (1) with specified limitations, provides for additional federal funding for certain health care services; and (2) through FY2022, increases the applicable FMAP. A non-expansion state that subsequently expands Medicaid coverage under PPACA shall become ineligible for this funding. </p> <p>(Sec. 116) No less frequently than every six months, states must redetermine the eligibility of adult enrollees made newly eligible for Medicaid by PPACA. The bill temporarily increases by 5% the FMAP for expenditures that are attributable to meeting this requirement. </p> <p>(Sec. 117) The bill allows a state Medicaid program to impose a work requirement as a condition of eligibility. However, a program may not apply such a requirement to: (1) a pregnant woman, (2) the sole parent or caretaker of either a child younger than age 6 or a child with disabilities, (3) an individual younger than age 19, or (4) an individual younger than age 20 who is married or head of a household and either attends secondary school or participates in employment-related education. The bill increases by 5% the FMAP for certain administrative expenditures that are attributable to implementing a work requirement. </p> <p>Subtitle C--Per Capita Allotment for Medical Assistance</p> <p>(Sec. 121) Under current law, state Medicaid programs are guaranteed federal matching funds for qualifying expenditures. The bill establishes limits on federal funding for state Medicaid programs beginning in FY2020. Specifically, the bill establishes targeted spending caps for each state, using a formula based on the state's FY2016 medical assistance expenditures in each enrollee category: (1) the elderly, (2) the blind and disabled, (3) children, (4) adults made newly eligible for Medicaid by PPACA, and (5) all other enrollees. With respect to a state that exceeds its targeted spending cap in a given fiscal year, the bill provides for reduced federal funding in the following fiscal year. In addition, the bill: (1) requires additional reporting and auditing of state data on medical assistance expenditures, and (2) temporarily increases the FMAP with respect to certain data reporting expenditures.</p> <p>The bill reduces targeted spending for certain states that require political subdivisions to contribute funds towards medical assistance. Specifically, the bill applies to states that received, for FY2016, DSH allotments greater than six times the national average. Specified contributions are excepted.</p> <p>A state Medicaid program may elect to receive, for any 10-year period beginning no earlier than FY2020, federal funding in block grant form. The bill establishes a formula, using targeted spending caps, for determining the amount of block grant funds. A state plan for administering a block grant shall specify: (1) conditions of eligibility for receiving health care assistance under the block grant; (2) the types, amount, duration, and scope of services to be covered; and (3) methods of delivery and cost-sharing with respect to covered services. Such a plan must: (1) provide for eligibility of specified children and pregnant women; and (2) offer assistance for hospital care, surgical care, medical care, obstetrical and prenatal care, prescribed drugs and prosthetic devices, other medical supplies, and pediatric care.</p> <p>Subtitle D--Patient Relief and Health Insurance Market Stability </p> <p>(Sec. 131) After 2019, the bill eliminates cost sharing reductions for low-income individuals with certain health insurance.</p> <p> (Sec. 132) The bill amends the SSAct to establish and make appropriations for the Patient and State Stability Fund. The fund is administered by the Centers for Medicare and Medicaid Services (CMS) and provides funding to states through 2026, including to: provide financial assistance to high-risk individuals so they may enroll in health insurance, enter into arrangements with entities to stabilize health insurance premiums in the individual market, promote participation and increase options in the health insurance market, pay providers for services, and provide financial assistance to enrollees to reduce out-of-pocket costs. </p> <p>Funding is allocated to states based on each state's share of incurred claims and uninsured individuals below the poverty line. To receive funding after 2019, states must provide matching funds at a rate that varies from 7% to 50% based on the year and whether the state applied for funding. </p> <p>The bill increases appropriations for 2020 by $15 billion for maternity coverage, newborn care, and services for individuals with mental health or substance use disorders. </p> <p>The bill establishes the Federal Invisible Risk Sharing Program, administered by the CMS, to pay health insurers for certain individuals' claims in order to lower premiums in the individual market. The bill appropriates $15 billion for this fund for 2019-2026.</p> <p>(Sec. 133) Health insurers must increase premiums by 30% for one year for enrollees in the individual market who had a break in coverage of more than 62 days in the previous year. States with programs under this bill to provide financial assistance to high-risk individuals or stabilize health insurance premiums in the individual market and states participating in the Federal Invisible Risk Sharing Program may apply for a waiver to allow health insurers, for individuals with a break in coverage, to vary premiums based on an individual's health status instead of increasing premiums by 30%. </p> <p>The bill appropriates $8 billion for the Patient and State Stability Fund to be allocated to states with a waiver to allow premiums to vary by health status in order to reduce costs for individuals whose premiums increased due to the waiver. </p> <p>(Sec. 134) Beginning in 2020, health insurance benefits no longer must conform to actuarial tiers (e.g., silver level benefits). </p> <p>(Sec. 135) The bill increases the ratio by which health insurance premiums may vary by age, from a three to one ratio to a five to one ratio. This ratio may be preempted by states. </p> <p>(Sec. 136) States may apply to the Department of Health and Human Services (HHS) for waivers to increase the ratio by which health insurance premiums may vary by age and to waive the requirement for insurance to cover the essential health benefits. </p> <p>These waivers and the waiver to allow premiums to vary by health status do not apply to health plans offered through the CO-OP program, multi-state plans, plans the federal government makes available to members of Congress and their staff, or plans under PPACA provisions that allow state flexibility. </p> <p>Subtitle E--Implementation Funding </p> <p>(Sec. 141) The bill establishes and appropriates $1 billion for the American Health Care Implementation Fund to provide for the implementation of programs in this bill</p> <p>TITLE II--COMMITTEE ON WAYS AND MEANS </p> <p>Subtitle A--Repeal and Replace of Health-Related Tax Policy</p> <p> Sections 201-203 and 214 of the bill make several modifications to the premium assistance tax credit, which is currently provided to eligible individuals and families to subsidize the purchase of health insurance plans on an exchange. </p> <p>(Sec. 201) This section makes taxpayers liable for the full amount of excess advance payments of the credit. (Under current law, liability for certain low-income households is limited to an applicable dollar amount.) </p> <p>(Sec. 202) This section modifies the premium assistance tax credit to: </p> <ul> <li>make the credit available for catastrophic qualified health plans and plans that are not offered through an exchange, but otherwise meet the requirements for qualified health plans; </li> <li>prohibit the credit from being used for grandfathered or grandmothered health plans; </li> <li>prohibit the credit from being used for health plans that cover abortions (other than abortions necessary to save the life of the mother or abortions with respect to a pregnancy that is the result of an act of rape or incest); and </li> <li>revise the formula used to calculate the credit using a schedule that varies with household income and the age of individuals or family members. </li> </ul> <p>Advance payments of the credit may not be made with respect to any health plan that is not enrolled in through an exchange. </p> <p>(Sec. 203) This section modifies the small employer tax credit for employee health insurance expenses to: (1) prohibit the credit from being used for health plans that include coverage for abortions (other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest) for taxable years beginning after December 31, 2017; and (2) repeal the credit for taxable years beginning after December 31, 2019. </p> <p>(Sec. 204) This section repeals the penalties for individuals who are not covered by a health plan that provides at least minimum essential coverage (commonly referred to as the individual mandate). The repeal is effective for months beginning after December 31, 2015.</p> <p>(Sec. 205) This section repeals the penalties for certain large employers who do not offer full-time employees and their dependents minimum essential health coverage under an employer-sponsored health plan (commonly referred to as the employer mandate). The repeal is effective for months beginning after December 31, 2015. </p> <p>(Sec. 206) This section delays the implementation of the excise tax on high cost employer-sponsored health coverage (commonly referred to as the Cadillac tax) until 2026. (Under current law, the tax goes into effect in 2020.) </p> <p>(Sec. 207) This section permits tax-favored health savings accounts (HSAs), Archer Medical Savings Accounts (MSAs), health flexible spending arrangements (FSAs), and health reimbursement arrangements to be used to purchase over-the-counter medicine that is not prescribed by a physician.</p> <p> (Sec. 208) This section repeals the increase in the tax on distributions from HSAs and Archer MSAs that are not used for qualified medical expenses. The bill reduces the tax on HSA distributions from 20% to 10% and reduces the tax for Archer MSA's from 20% to 15% to return the taxes to the levels that existed prior to the enactment of PPACA.</p> <p> (Sec. 209) This section repeals the limitation on FSA salary reduction contributions.</p> <p> (Sec. 210) This section repeals the medical device excise tax for sales after December 31, 2016. </p> <p>(Sec. 211) This section permits employers who provide Medicare-eligible retirees with qualified prescription drug coverage and receive federal subsidies for prescription drug plans to claim a deduction for the expenses without reducing the deduction by the amount of the subsidy. </p> <p>(Sec. 212) This section reduces the income threshold used to determine whether an individual may claim an itemized deduction for unreimbursed medical expenses. The bill allows all taxpayers to claim an itemized deduction for unreimbursed expenses medical expenses that exceed 5.8% (10% under current law) of adjusted gross income. </p> <p>(Sec. 213) This section repeals the additional Medicare tax that is imposed on certain employees and self-employed individuals with wages or self-employment income above specified thresholds. </p> <p>(Sec. 214) The section modifies the premium assistance tax credit to allow a refundable, advanceable tax credit beginning in 2020 for certain individuals who purchase health insurance and who are not eligible for other sources of coverage. </p> <p>To be eligible for the credit, an individual: </p> <ul> <li>must be covered by health insurance that is certified by the state in which the insurance is offered as meeting the requirement of this bill;</li> <li> may not be eligible for other specified sources of coverage;</li> <li> must be either a U.S. citizen or national or a qualified alien; and </li> <li>may not be incarcerated, other than incarceration pending the disposition of charges. </li> </ul> <p>The credit is allowed for health insurance coverage that: </p> <ul> <li>is offered in the individual health insurance market within a state; </li> <li>substantially all of which is not for excepted benefits providing only limited coverage, such as dental, vision, or long-term care; </li> <li>does not consist of short-term limited duration insurance; is not a grandfathered or grandmothered plan; and</li> <li>does not include coverage for abortions (other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest). </li> </ul> <p>The bill specifies credit amounts which are based on age and adjusted gross income. It also limits the annual credit amount to $14,000 per family. </p> <p>The Department of the Treasury and HHS must prescribe regulations to establish and operate the advance payment program, with respect to the credit for individuals covered under qualified health plans (whether enrolled in through an exchange or otherwise), in such a manner that protects taxpayer information, provides robust verification of all information necessary to establish eligibility of taxpayer for advance payments, ensures proper and timely payments to appropriate health providers, and protects program integrity. </p> <p>(Sec. 215) This section increases the limits on HSA contributions to match the sum of the annual deductible and out-of-pocket expenses permitted under a high deductible health plan. </p> <p>(Sec. 216) This section permits both spouses of a married couple who are eligible for HSA catch-up contributions to make the contributions to the same HSA account. </p> <p>(Sec. 217) This section permits an HSA to be used to pay certain medical expenses that were incurred before the HSA was established. If the HSA is established during the 60-day period beginning on the date that an individual's coverage under a high deductible health plan begins, the HSA is treated as having been established on the date coverage under the high deductible health plan begins to determine whether an amount paid is used for a qualified medical expense. </p> <p>Subtitle B--Repeal of Certain Consumer Taxes</p> <p>(Sec. 221) This section repeals the annual fee on branded prescription pharmaceutical manufacturers and importers. </p> <p>(Sec. 222) This section repeals the annual fee imposed on certain health insurance providers based on market share. </p> <p>Subtitle C--Repeal of Tanning Tax </p> <p>(Sec. 231) This section repeals the 10% excise tax on the price of indoor tanning services. </p> <p>Subtitle D--Remuneration From Certain Insurers </p> <p>(Sec. 241) The section repeals a provision that prohibits certain health insurance providers from deducting remuneration paid to an officer, director, or employee in excess of $500,000. </p> <p>Subtitle E--Repeal of Net Investment Income Tax </p> <p>(Sec. 251) This section repeals the 3.8% tax on the net investment income of individuals, estates, and trusts with incomes above specified amounts. </p>

tv_txt: IB Union Calendar No. 30 115th CONGRESS 1st Session H. R. 1628 [Report No. 115–52] IN THE HOUSE OF REPRESENTATIVES March 20, 2017 Mrs. Black from the Committee on the Budget , reported the following bill; which was committed to the Committee of the Whole House on the State of the Union and ordered to be printed A BILL To provide for reconciliation pursuant to title II of the concurrent resolution on the budget for fiscal year 2017.

1. Short title This Act may be cited as the American Health Care Act of 2017 . 2. Table of contents The table of contents of this Act is as follows: Sec. 1. Short title. Sec. 2. Table of contents. Title I—Energy and Commerce Subtitle A—Patient Access to Public Health Programs Sec. 101. The Prevention and Public Health Fund. Sec. 102. Community health center program. Sec. 103. Federal payments to States. Subtitle B—Medicaid Program Enhancement Sec. 111. Repeal of Medicaid provisions. Sec. 112. Repeal of Medicaid expansion. Sec. 113. Elimination of DSH cuts. Sec. 114. Reducing State Medicaid costs. Sec. 115. Safety net funding for non-expansion States. Sec. 116. Providing incentives for increased frequency of eligibility redeterminations. Subtitle C—Per Capita Allotment for Medical Assistance Sec. 121. Per capita allotment for medical assistance. Subtitle D—Patient Relief and Health Insurance Market Stability Sec. 131. Repeal of cost-sharing subsidy. Sec. 132. Patient and State Stability Fund. Sec. 133. Continuous health insurance coverage incentive. Sec. 134. Increasing coverage options. Sec. 135. Change in permissible age variation in health insurance premium rates. Title II—Committee on Ways and Means Subtitle A—Repeal and Replace of Health-Related Tax Policy Sec. 201. Recapture excess advance payments of premium tax credits. Sec. 202. Additional modifications to premium tax credit. Sec. 203. Premium tax credit. Sec. 204. Small business tax credit. Sec. 205. Individual mandate. Sec. 206. Employer mandate. Sec. 207. Repeal of the tax on employee health insurance premiums and health plan benefits. Sec. 208. Repeal of tax on over-the-counter medications. Sec. 209. Repeal of increase of tax on health savings accounts. Sec. 210. Repeal of limitations on contributions to flexible spending accounts. Sec. 211. Repeal of medical device excise tax. Sec. 212. Repeal of elimination of deduction for expenses allocable to medicare part D subsidy. Sec. 213. Repeal of increase in income threshold for determining medical care deduction. Sec. 214. Repeal of Medicare tax increase. Sec. 215. Refundable tax credit for health insurance coverage. Sec. 216. Maximum contribution limit to health savings account increased to amount of deductible and out-of-pocket limitation. Sec. 217. Allow both spouses to make catch-up contributions to the same health savings account. Sec. 218. Special rule for certain medical expenses incurred before establishment of health savings account. Subtitle B—Repeal of certain consumer taxes Sec. 221. Repeal of tax on prescription medications. Sec. 222. Repeal of health insurance tax. Subtitle C—Repeal of Tanning Tax Sec. 231. Repeal of tanning tax. Subtitle D—Remuneration from Certain Insurers Sec. 241. Remuneration from certain insurers. Subtitle E—Repeal of Net Investment Income Tax Sec. 251. Repeal of net investment income tax. I Energy and Commerce A Patient Access to Public Health Programs 101. The Prevention and Public Health Fund (a) In general Subsection (b) of section 4002 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 300u–11 ), as amended by section 5009 of the 21st Century Cures Act, is amended— (1) in paragraph (2), by adding and at the end; (2) in paragraph (3)— (A) by striking each of fiscal years 2018 and 2019 and inserting fiscal year 2018 ; and (B) by striking the semicolon at the end and inserting a period; and (3) by striking paragraphs (4) through (8). (b) Rescission of unobligated funds Of the funds made available by such section 4002, the unobligated balance at the end of fiscal year 2018 is rescinded. 102. Community health center program Effective as if included in the enactment of the Medicare Access and CHIP Reauthorization Act of 2015 ( Public Law 114–10 , 129 Stat. 87), paragraph (1) of section 221(a) of such Act is amended by inserting , and an additional $422,000,000 for fiscal year 2017 after 2017 . 103. Federal payments to States (a) In general Notwithstanding section 504(a), 1902(a)(23), 1903(a), 2002, 2005(a)(4), 2102(a)(7), or 2105(a)(1) of the Social Security Act ( 42 U.S.C. 704(a) , 1396a(a)(23), 1396b(a), 1397a, 1397d(a)(4), 1397bb(a)(7), 1397ee(a)(1)), or the terms of any Medicaid waiver in effect on the date of enactment of this Act that is approved under section 1115 or 1915 of the Social Security Act ( 42 U.S.C. 1315 , 1396n), for the 1-year period beginning on the date of the enactment of this Act, no Federal funds provided from a program referred to in this subsection that is considered direct spending for any year may be made available to a State for payments to a prohibited entity, whether made directly to the prohibited entity or through a managed care organization under contract with the State. (b) Definitions In this section: (1) Prohibited entity The term prohibited entity means an entity, including its affiliates, subsidiaries, successors, and clinics— (A) that, as of the date of enactment of this Act— (i) is an organization described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from tax under section 501(a) of such Code; (ii) is an essential community provider described in section 156.235 of title 45, Code of Federal Regulations (as in effect on the date of enactment of this Act), that is primarily engaged in family planning services, reproductive health, and related medical care; and (iii) provides for abortions, other than an abortion— (I) if the pregnancy is the result of an act of rape or incest; or (II) in the case where a woman suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the woman in danger of death unless an abortion is performed, including a life-endangering physical condition caused by or arising from the pregnancy itself; and (B) for which the total amount of Federal and State expenditures under the Medicaid program under title XIX of the Social Security Act in fiscal year 2014 made directly to the entity and to any affiliates, subsidiaries, successors, or clinics of the entity, or made to the entity and to any affiliates, subsidiaries, successors, or clinics of the entity as part of a nationwide health care provider network, exceeded $350,000,000. (2) Direct spending The term direct spending has the meaning given that term under section 250(c) of the Balanced Budget and Emergency Deficit Control Act of 1985 ( 2 U.S.C. 900(c) ). B Medicaid Program Enhancement 111. Repeal of Medicaid provisions The Social Security Act is amended— (1) in section 1902 ( 42 U.S.C. 1396a )— (A) in subsection (a)(47)(B), by inserting and provided that any such election shall cease to be effective on January 1, 2020, and no such election shall be made after that date before the semicolon at the end; and (B) in subsection (l)(2)(C), by inserting and ending December 31, 2019, after January 1, 2014, ; (2) in section 1915(k)(2) ( 42 U.S.C. 1396n(k)(2) ), by striking during the period described in paragraph (1) and inserting on or after the date referred to in paragraph (1) and before January 1, 2020 ; and (3) in section 1920(e) ( 42 U.S.C. 1396r–1(e) ), by striking under clause (i)(VIII), clause (i)(IX), or clause (ii)(XX) of subsection (a)(10)(A) and inserting under clause (i)(VIII) or clause (ii)(XX) of section 1902(a)(10)(A) before January 1, 2020, section 1902(a)(10)(A)(i)(IX), . 112. Repeal of Medicaid expansion (a) In general Section 1902(a)(10)(A) of the Social Security Act ( 42 U.S.C. 1396a(a)(10)(A) ) is amended— (1) in clause (i)(VIII), by inserting at the option of a State, after January 1, 2014, ; and (2) in clause (ii)(XX), by inserting and ending December 31, 2019, after 2014, . (b) Termination of EFMAP for new ACA expansion enrollees Section 1905 of the Social Security Act ( 42 U.S.C. 1396d ) is amended— (1) in subsection (y)(1), in the matter preceding subparagraph (A), by striking with respect to and all that follows through shall be and inserting with respect to amounts expended before January 1, 2020, by such State for medical assistance for newly eligible individuals described in subclause (VIII) of section 1902(a)(10)(A)(i) who are enrolled under the State plan (or a waiver of the plan) before such date and with respect to amounts expended after such date by such State for medical assistance for individuals described in such subclause who were enrolled under such plan (or waiver of such plan) as of December 31, 2019, and who do not have a break in eligibility for medical assistance under such State plan (or waiver) for more than one month after such date, shall be ; and (2) in subsection (z)(2)— (A) in subparagraph (A), by striking medical assistance for individuals and all that follows through shall be and inserting amounts expended before January 1, 2020, by such State for medical assistance for individuals described in section 1902(a)(10)(A)(i)(VIII) who are nonpregnant childless adults with respect to whom the State may require enrollment in benchmark coverage under section 1937 and who are enrolled under the State plan (or a waiver of the plan) before such date and with respect to amounts expended after such date by such State for medical assistance for individuals described in such section, who are nonpregnant childless adults with respect to whom the State may require enrollment in benchmark coverage under section 1937, who were enrolled under such plan (or waiver of such plan) as of December 31, 2019, and who do not have a break in eligibility for medical assistance under such State plan (or waiver) for more than one month after such date, shall be ; and (B) in subparagraph (B)(ii)— (i) in subclause (III), by adding and at the end; and (ii) by striking subclauses (IV), (V), and (VI) and inserting the following new subclause: (IV) 2017 and each subsequent year is 80 percent. . (c) Sunset of essential health benefits requirement Section 1937(b)(5) of the Social Security Act ( 42 U.S.C. 1396u–7(b)(5) ) is amended by adding at the end the following: This paragraph shall not apply after December 31, 2019. . 113. Elimination of DSH cuts Section 1923(f) of the Social Security Act ( 42 U.S.C. 1396r–4(f) ) is amended— (1) in paragraph (7)— (A) in subparagraph (A)— (i) in clause (i)— (I) in the matter preceding subclause (I), by striking 2025 and inserting 2019 ; and (ii) in clause (ii)— (I) in subclause (I), by adding and at the end; (II) in subclause (II), by striking the semicolon at the end and inserting a period; and (III) by striking subclauses (III) through (VIII); and (B) by adding at the end the following new subparagraph: (C) Exemption from exemption for non-expansion States (i) In general In the case of a State that is a non-expansion State for a fiscal year, subparagraph (A)(i) shall not apply to the DSH allotment for such State and fiscal year. (ii) No change in reduction for expansion States In the case of a State that is an expansion State for a fiscal year, the DSH allotment for such State and fiscal year shall be determined as if clause (i) did not apply. (iii) Non-expansion and expansion State defined (I) The term expansion State means with respect to a fiscal year, a State that, as of July 1 of the preceding fiscal year, provides for eligibility under clause (i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) for medical assistance under this title (or a waiver of the State plan approved under section 1115). (II) The term non-expansion State means, with respect to a fiscal year, a State that is not an expansion State. ; and (2) in paragraph (8), by striking fiscal year 2025 and inserting fiscal year 2019 . 114. Reducing State Medicaid costs (a) Letting States disenroll high dollar lottery winners (1) In general Section 1902 of the Social Security Act ( 42 U.S.C. 1396a ) is amended— (A) in subsection (a)(17), by striking (e)(14), (e)(14) and inserting (e)(14), (e)(15) ; and (B) in subsection (e)— (i) in paragraph (14) (relating to modified adjusted gross income), by adding at the end the following new subparagraph : (J) Treatment of certain lottery winnings and income received as a lump sum (i) In general In the case of an individual who is the recipient of qualified lottery winnings (pursuant to lotteries occurring on or after January 1, 2020) or qualified lump sum income (received on or after such date) and whose eligibility for medical assistance is determined based on the application of modified adjusted gross income under subparagraph (A), a State shall, in determining such eligibility, include such winnings or income (as applicable) as income received— (I) in the month in which such winnings or income (as applicable) is received if the amount of such winnings or income is less than $80,000; (II) over a period of 2 months if the amount of such winnings or income (as applicable) is greater than or equal to $80,000 but less than $90,000; (III) over a period of 3 months if the amount of such winnings or income (as applicable) is greater than or equal to $90,000 but less than $100,000; and (IV) over a period of 3 months plus 1 additional month for each increment of $10,000 of such winnings or income (as applicable) received, not to exceed a period of 120 months (for winnings or income of $1,260,000 or more), if the amount of such winnings or income is greater than or equal to $100,000. (ii) Counting in equal installments For purposes of subclauses (II), (III), and (IV) of clause (i), winnings or income to which such subclause applies shall be counted in equal monthly installments over the period of months specified under such subclause. (iii) Hardship exemption An individual whose income, by application of clause (i), exceeds the applicable eligibility threshold established by the State, may continue to be eligible for medical assistance to the extent that the State determines, under procedures established by the State under the State plan (or in the case of a waiver of the plan under section 1115, incorporated in such waiver), or as otherwise established by such State in accordance with such standards as may be specified by the Secretary, that the denial of eligibility of the individual would cause an undue medical or financial hardship as determined on the basis of criteria established by the Secretary. (iv) Notifications and assistance required in case of loss of eligibility A State shall, with respect to an individual who loses eligibility for medical assistance under the State plan (or a waiver of such plan) by reason of clause (i), before the date on which the individual loses such eligibility, inform the individual of the date on which the individual would no longer be considered ineligible by reason of such clause to receive medical assistance under the State plan or under any waiver of such plan and the date on which the individual would be eligible to reapply to receive such medical assistance. (v) Qualified lottery winnings defined In this subparagraph, the term qualified lottery winnings means winnings from a sweepstakes, lottery, or pool described in paragraph (3) of section 4402 of the Internal Revenue Code of 1986 or a lottery operated by a multistate or multijurisdictional lottery association, including amounts awarded as a lump sum payment. (vi) Qualified lump sum income defined In this subparagraph, the term qualified lump sum income means income that is received as a lump sum from one of the following sources: (I) Monetary winnings from gambling (as defined by the Secretary and including monetary winnings from gambling activities described in section 1955(b)(4) of title 18, United States Code). (II) Income received as liquid assets from the estate (as defined in section 1917(b)(4)) of a deceased individual. ; and (ii) by striking (14) Exclusion and inserting (15) Exclusion . (2) Rules of construction (A) Interception of lottery winnings allowed Nothing in the amendment made by paragraph (1)(B)(i) shall be construed as preventing a State from intercepting the State lottery winnings awarded to an individual in the State to recover amounts paid by the State under the State Medicaid plan under title XIX of the Social Security Act for medical assistance furnished to the individual. (B) Applicability limited to eligibility of recipient of lottery winnings or lump sum income Nothing in the amendment made by paragraph (1)(B)(i) shall be construed, with respect to a determination of household income for purposes of a determination of eligibility for medical assistance under the State plan under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq.) (or a waiver of such plan) made by applying modified adjusted gross income under subparagraph (A) of section 1902(e)(14) of such Act ( 42 U.S.C. 1396a(e)(14) ), as limiting the eligibility for such medical assistance of any individual that is a member of the household other than the individual (or the individual’s spouse) who received qualified lottery winnings or qualified lump-sum income (as defined in subparagraph (J) of such section 1902(e)(14), as added by paragraph (1)(B)(i) of this subsection). (b) Repeal of retroactive eligibility (1) In general (A) State plan requirements Section 1902(a)(34) of the Social Security Act ( 42 U.S.C. 1396a(a)(34) ) is amended by striking in or after the third month before the month in which he made application and inserting in or after the month in which the individual made application . (B) Definition of medical assistance Section 1905(a) of the Social Security Act ( 42 U.S.C. 1396d(a) ) is amended by striking in or after the third month before the month in which the recipient makes application for assistance and inserting in or after the month in which the recipient makes application for assistance . (2) Effective date The amendments made by paragraph (1) shall apply to medical assistance with respect to individuals whose eligibility for such assistance is based on an application for such assistance made (or deemed to be made) on or after October 1, 2017. (c) Ensuring States are not forced to pay for individuals ineligible for the program (1) In general Section 1137(f) of the Social Security Act ( 42 U.S.C. 1320b–7(f) ) is amended— (A) by striking Subsections (a)(1) and (d) and inserting (1) Subsections (a)(1) and (d) ; and (B) by adding at the end the following new paragraph: (2) (A) Subparagraphs (A) and (B)(ii) of subsection (d)(4) shall not apply in the case of an initial determination made on or after the date that is 6 months after the date of the enactment of this paragraph with respect to the eligibility of an alien described in subparagraph (B) for benefits under the program listed in subsection (b)(2). (B) An alien described in this subparagraph is an individual declaring to be a citizen or national of the United States with respect to whom a State, in accordance with section 1902(a)(46)(B), requires— (i) pursuant to 1902(ee), the submission of a social security number; or (ii) pursuant to 1903(x), the presentation of satisfactory documentary evidence of citizenship or nationality. . (2) No payments for medical assistance provided before presentation of evidence Section 1903(i)(22) of the Social Security Act ( 42 U.S.C. 1396b(i)(22) ) is amended— (A) by striking with respect to amounts expended and inserting (A) with respect to amounts expended ; (B) by inserting and at the end; and (C) by adding at the end the following new subparagraph: (B) in the case of a State that elects to provide a reasonable period to present satisfactory documentary evidence of such citizenship or nationality pursuant to paragraph (2)(C) of section 1902(ee) or paragraph (4) of subsection (x) of this section, for amounts expended for medical assistance for such an individual (other than an individual described in paragraph (2) of such subsection (x)) during such period; . (3) Conforming amendments Section 1137(d)(4) of the Social Security Act ( 42 U.S.C. 1320b–7(d)(4) ) is amended— (A) in subparagraph (A), in the matter preceding clause (i), by inserting subject to subsection (f)(2), before the State ; and (B) in subparagraph (B)(ii), by inserting subject to subsection (f)(2), before pending such verification . (d) Updating allowable home equity limits in Medicaid (1) In general Section 1917(f)(1) of the Social Security Act ( 42 U.S.C. 1396p(f)(1) ) is amended— (A) in subparagraph (A), by striking subparagraphs (B) and (C) and inserting subparagraph (B) ; (B) by striking subparagraph (B); (C) by redesignating subparagraph (C) as subparagraph (B); and (D) in subparagraph (B), as so redesignated, by striking dollar amounts specified in this paragraph and inserting dollar amount specified in subparagraph (A) . (2) Effective date (A) In general The amendments made by paragraph (1) shall apply with respect to eligibility determinations made after the date that is 180 days after the date of the enactment of this section. (B) Exception for State legislation In the case of a State plan under title XIX of the Social Security Act that the Secretary of Health and Human Services determines requires State legislation in order for the respective plan to meet any requirement imposed by amendments made by this subsection, 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 an 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 the 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 shall be considered to be a separate regular session of the State legislature. 115. Safety net funding for non-expansion States Title XIX of the Social Security Act is amended by inserting after section 1923 ( 42 U.S.C. 1396r–4 ) the following new section: 1923A. Adjustment in payment for services of safety net providers in non-expansion States (a) In general Subject to the limitations of this section, for each year during the period beginning with 2018 and ending with 2021, each State that is one of the 50 States or the District of Columbia and that, as of July 1 of the preceding year, did not provide for eligibility under clause (i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) for medical assistance under this title (or a waiver of the State plan approved under section 1115) (each such State or District referred to in this section for the year as a non-expansion State ) may adjust the payment amounts otherwise provided under the State plan under this title (or a waiver of such plan) to health care providers that provide health care services to individuals enrolled under this title (in this section referred to as eligible providers ). (b) Increase in applicable FMAP Notwithstanding section 1905(b), the Federal medical assistance percentage applicable with respect to expenditures attributable to a payment adjustment under subsection (a) for which payment is permitted under subsection (c) shall be equal to— (1) 100 percent for calendar quarters in calendar years 2018, 2019, 2020, and 2021; and (2) 95 percent for calendar quarters in calendar year 2022. (c) Limitations; disqualification of States (1) Annual allotment limitation Payment under section 1903(a) shall not be made to a State with respect to any payment adjustment made under this section for all calendar quarters in a year in excess of the $2,000,000,000 multiplied by the ratio of— (A) the population of the State with income below 138 percent of the poverty line in 2015 (as determined based the table entitled Health Insurance Coverage Status and Type by Ratio of Income to Poverty Level in the Past 12 Months by Age for the universe of the civilian noninstitutionalized population for whom poverty status is determined based on the 2015 American Community Survey 1-Year Estimates, as published by the Bureau of the Census), to (B) the sum of the populations under subparagraph (A) for all non-expansion States. (2) Limitation on payment adjustment amount for individual providers The amount of a payment adjustment under subsection (a) for an eligible provider may not exceed the provider’s costs incurred in furnishing health care services (as determined by the Secretary and net of payments under this title, other than under this section, and by uninsured patients) to individuals who either are eligible for medical assistance under the State plan (or under a waiver of such plan) or have no health insurance or health plan coverage for such services. (d) Disqualification in case of State coverage expansion If a State is a non-expansion for a year and provides eligibility for medical assistance described in subsection (a) during the year, the State shall no longer be treated as a non-expansion State under this section for any subsequent years. . 116. Providing incentives for increased frequency of eligibility redeterminations (a) In general Section 1902(e)(14) of the Social Security Act ( 42 U.S.C. 1396a(e)(14) ) (relating to modified adjusted gross income), as amended by section 114(a)(1), is further amended by adding at the end the following: (K) Frequency of eligibility redeterminations Beginning on October 1, 2017, and notwithstanding subparagraph (H), in the case of an individual whose eligibility for medical assistance under the State plan under this title (or a waiver of such plan) is determined based on the application of modified adjusted gross income under subparagraph (A) and who is so eligible on the basis of clause (i)(VIII) or clause (ii)(XX) of subsection (a)(10)(A), a State shall redetermine such individual’s eligibility for such medical assistance no less frequently than once every 6 months. . (b) Civil monetary penalty Section 1128A(a) of the Social Security Act (42 U.S.C. 1320a–7a(a)) is amended, in the matter following paragraph (10), by striking (or, in cases under paragraph (3) and inserting the following: (or, in cases under paragraph (1) in which an individual was knowingly enrolled on or after October 1, 2017, pursuant to section 1902(a)(10)(A)(i)(VIII) for medical assistance under the State plan under title XIX whose income does not meet the income threshold specified in such section or in which a claim was presented on or after October 1, 2017, as a claim for an item or service furnished to an individual described in such section but whose enrollment under such State plan is not made on the basis of such individual’s meeting the income threshold specified in such section, $20,000 for each such individual or claim; in cases under paragraph (3) . (c) Increased administrative matching percentage For each calendar quarter during the period beginning on October 1, 2017, and ending on December 31, 2019, the Federal matching percentage otherwise applicable under section 1903(a) of the Social Security Act ( 42 U.S.C. 1396b(a) ) with respect to State expenditures during such quarter that are attributable to meeting the requirement of section 1902(e)(14) (relating to determinations of eligibility using modified adjusted gross income) of such Act shall be increased by 5 percentage points with respect to State expenditures attributable to activities carried out by the State (and approved by the Secretary) to increase the frequency of eligibility redeterminations required by subparagraph (K) of such section (relating to eligibility redeterminations made on a 6-month basis) (as added by subsection (a)). C Per Capita Allotment for Medical Assistance 121. Per capita allotment for medical assistance Title XIX of the Social Security Act is amended— (1) in section 1903 ( 42 U.S.C. 1396b )— (A) in subsection (a), in the matter before paragraph (1), by inserting and section 1903A(a) after except as otherwise provided in this section ; and (B) in subsection (d)(1), by striking to which and inserting to which, subject to section 1903A(a), ; and (2) by inserting after such section 1903 the following new section: 1903A. Per capita-based cap on payments for medical assistance (a) Application of per capita cap on payments for medical assistance expenditures (1) In general If a State has excess aggregate medical assistance expenditures (as defined in paragraph (2)) for a fiscal year (beginning with fiscal year 2020), the amount of payment to the State under section 1903(a)(1) for each quarter in the following fiscal year shall be reduced by ¼ of the excess aggregate medical assistance payments (as defined in paragraph (3)) for that previous fiscal year. In this section, the term State means only the 50 States and the District of Columbia. (2) Excess aggregate medical assistance expenditures In this subsection, the term excess aggregate medical assistance expenditures means, for a State for a fiscal year, the amount (if any) by which— (A) the amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State and fiscal year; exceeds (B) the amount of the target total medical assistance expenditures (as defined in subsection (c)) for the State and fiscal year. (3) Excess aggregate medical assistance payments In this subsection, the term excess aggregate medical assistance payments means, for a State for a fiscal year, the product of— (A) the excess aggregate medical assistance expenditures (as defined in paragraph (2)) for the State for the fiscal year; and (B) the Federal average medical assistance matching percentage (as defined in paragraph (4)) for the State for the fiscal year. (4) Federal average medical assistance matching percentage In this subsection, the term Federal average medical assistance matching percentage means, for a State for a fiscal year, the ratio (expressed as a percentage) of— (A) the amount of the Federal payments that would be made to the State under section 1903(a)(1) for medical assistance expenditures for calendar quarters in the fiscal year if paragraph (1) did not apply; to (B) the amount of the medical assistance expenditures for the State and fiscal year. (b) Adjusted total medical assistance expenditures Subject to subsection (g), the following shall apply: (1) In general In this section, the term adjusted total medical assistance expenditures means, for a State— (A) for fiscal year 2016, the product of— (i) the amount of the medical assistance expenditures (as defined in paragraph (2)) for the State and fiscal year, reduced by the amount of any excluded expenditures (as defined in paragraph (3)) for the State and fiscal year otherwise included in such medical assistance expenditures; and (ii) the 1903A FY16 population percentage (as defined in paragraph (4)) for the State; or (B) for fiscal year 2019 or a subsequent fiscal year, the amount of the medical assistance expenditures (as defined in paragraph (2)) for the State and fiscal year that is attributable to 1903A enrollees, reduced by the amount of any excluded expenditures (as defined in paragraph (3)) for the State and fiscal year otherwise included in such medical assistance expenditures. (2) Medical assistance expenditures In this section, the term medical assistance expenditures means, for a State and fiscal year, the medical assistance payments as reported by medical service category on the Form CMS-64 quarterly expense report (or successor to such a report form, and including enrollment data and subsequent adjustments to any such report, in this section referred to collectively as a CMS-64 report ) that directly result from providing medical assistance under the State plan (including under a waiver of the plan) for which payment is (or may otherwise be) made pursuant to section 1903(a)(1). (3) Excluded expenditures In this section, the term excluded expenditures means, for a State and fiscal year, expenditures under the State plan (or under a waiver of such plan) that are attributable to any of the following: (A) DSH Payment adjustments made for disproportionate share hospitals under section 1923. (B) Medicare cost-sharing Payments made for medicare cost-sharing (as defined in section 1905(p)(3)). (C) Safety net provider payment adjustments in non-expansion States Payment adjustments under subsection (a) of section 1923A for which payment is permitted under subsection (c) of such section. (4) 1903A FY 16 population percentage In this subsection, the term 1903A FY16 population percentage means, for a State, the Secretary’s calculation of the percentage of the actual medical assistance expenditures, as reported by the State on the CMS–64 reports for calendar quarters in fiscal year 2016, that are attributable to 1903A enrollees (as defined in subsection (e)(1)). (c) Target total medical assistance expenditures (1) Calculation In this section, the term target total medical assistance expenditures means, for a State for a fiscal year, the sum of the products, for each of the 1903A enrollee categories (as defined in subsection (e)(2)), of— (A) the target per capita medical assistance expenditures (as defined in paragraph (2)) for the enrollee category, State, and fiscal year; and (B) the number of 1903A enrollees for such enrollee category, State, and fiscal year, as determined under subsection (e)(4). (2) Target per capita medical assistance expenditures In this subsection, the term target per capita medical assistance expenditures means, for a 1903A enrollee category, State, and a fiscal year, an amount equal to— (A) the provisional FY19 target per capita amount for such enrollee category (as calculated under subsection (d)(5)) for the State; increased by (B) the percentage increase in the medical care component of the consumer price index for all urban consumers (U.S. city average) from September of 2019 to September of the fiscal year involved. (d) Calculation of FY19 provisional target amount for each 1903A enrollee category Subject to subsection (g), the following shall apply: (1) Calculation of base amounts for fiscal year 2016 For each State the Secretary shall calculate (and provide notice to the State not later than April 1, 2018, of) the following: (A) The amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State for fiscal year 2016. (B) The number of 1903A enrollees for the State in fiscal year 2016 (as determined under subsection (e)(4)). (C) The average per capita medical assistance expenditures for the State for fiscal year 2016 equal to— (i) the amount calculated under subparagraph (A); divided by (ii) the number calculated under subparagraph (B). (2) Fiscal year 2019 average per capita amount based on inflating the fiscal year 2016 amount to fiscal year 2019 by CPI-medical The Secretary shall calculate a fiscal year 2019 average per capita amount for each State equal to— (A) the average per capita medical assistance expenditures for the State for fiscal year 2016 (calculated under paragraph (1)(C)); increased by (B) the percentage increase in the medical care component of the consumer price index for all urban consumers (U.S. city average) from September, 2016 to September, 2019. (3) Aggregate and average expenditures per capita for fiscal year 2019 The Secretary shall calculate for each State the following: (A) The amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State for fiscal year 2019. (B) The number of 1903A enrollees for the State in fiscal year 2019 (as determined under subsection (e)(4)). (4) Per capita expenditures for fiscal year 2019 for each 1903A enrollee category The Secretary shall calculate (and provide notice to each State not later than January 1, 2020, of) the following: (A) (i) For each 1903A enrollee category, the amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State for fiscal year 2019 for individuals in the enrollee category, calculated by excluding from medical assistance expenditures those expenditures attributable to expenditures described in clause (iii) or non-DSH supplemental expenditures (as defined in clause (ii)). (ii) In this paragraph, the term non-DSH supplemental expenditure means a payment to a provider under the State plan (or under a waiver of the plan) that— (I) is not made under section 1923; (II) is not made with respect to a specific item or service for an individual; (III) is in addition to any payments made to the provider under the plan (or waiver) for any such item or service; and (IV) complies with the limits for additional payments to providers under the plan (or waiver) imposed pursuant to section 1902(a)(30)(A), including the regulations specifying upper payment limits under the State plan in part 447 of title 42, Code of Federal Regulations (or any successor regulations). (iii) An expenditure described in this clause is an expenditure that meets the criteria specified in subclauses (I), (II), and (III) of clause (ii) and is authorized under section 1115 for the purposes of funding a delivery system reform pool, uncompensated care pool, a designated state health program, or any other similar expenditure (as defined by the Secretary). (B) For each 1903A enrollee category, the number of 1903A enrollees for the State in fiscal year 2019 in the enrollee category (as determined under subsection (e)(4)). (C) For fiscal year 2016, the State’s non-DSH supplemental payment percentage is equal to the ratio (expressed as a percentage) of— (i) the total amount of non-DSH supplemental expenditures (as defined in subparagraph (A)(ii)) for the State for fiscal year 2016; to (ii) the amount described in subsection (b)(1)(A) for the State for fiscal year 2016. (D) For each 1903A enrollee category an average medical assistance expenditures per capita for the State for fiscal year 2019 for the enrollee category equal to— (i) the amount calculated under subparagraph (A) for the State, increased by the non-DSH supplemental payment percentage for the State (as calculated under subparagraph (C)); divided by (ii) the number calculated under subparagraph (B) for the State for the enrollee category. (5) Provisional FY19 per capita target amount for each 1903A enrollee category Subject to subsection (f)(2), the Secretary shall calculate for each State a provisional FY19 per capita target amount for each 1903A enrollee category equal to the average medical assistance expenditures per capita for the State for fiscal year 2019 (as calculated under paragraph (4)(D)) for such enrollee category multiplied by the ratio of— (A) the product of— (i) the fiscal year 2019 average per capita amount for the State, as calculated under paragraph (2); and (ii) the number of 1903A enrollees for the State in fiscal year 2019, as calculated under paragraph (3)(B); to (B) the amount of the adjusted total medical assistance expenditures for the State for fiscal year 2019, as calculated under paragraph (3)(A). (e) 1903A enrollee; 1903A enrollee category Subject to subsection (g), for purposes of this section, the following shall apply: (1) 1903A enrollee The term 1903A enrollee means, with respect to a State and a month, any Medicaid enrollee (as defined in paragraph (3)) for the month, other than such an enrollee who for such month is in any of the following categories of excluded individuals: (A) CHIP An individual who is provided, under this title in the manner described in section 2101(a)(2), child health assistance under title XXI. (B) IHS An individual who receives any medical assistance under this title for services for which payment is made under the third sentence of section 1905(b). (C) Breast and cervical cancer services eligible individual An individual who is entitled to medical assistance under this title only pursuant to section 1902(a)(10)(A)(ii)(XVIII). (D) Partial-benefit enrollees An individual who— (i) is an alien who is entitled to medical assistance under this title only pursuant to section 1903(v)(2); (ii) is entitled to medical assistance under this title only pursuant to subclause (XII) or (XXI) of section 1902(a)(10)(A)(ii) (or pursuant to a waiver that provides only comparable benefits); (iii) is a dual eligible individual (as defined in section 1915(h)(2)(B)) and is entitled to medical assistance under this title (or under a waiver) only for some or all of medicare cost-sharing (as defined in section 1905(p)(3)); or (iv) is entitled to medical assistance under this title and for whom the State is providing a payment or subsidy to an employer for coverage of the individual under a group health plan pursuant to section 1906 or section 1906A (or pursuant to a waiver that provides only comparable benefits). (2) 1903A enrollee category The term 1903A enrollee category means each of the following: (A) Elderly A category of 1903A enrollees who are 65 years of age or older. (B) Blind and disabled A category of 1903A enrollees (not described in the previous subparagraph) who are eligible for medical assistance under this title on the basis of being blind or disabled. (C) Children A category of 1903A enrollees (not described in a previous subparagraph) who are children under 19 years of age. (D) Expansion enrollees A category of 1903A enrollees (not described in a previous subparagraph) for whom the amounts expended for medical assistance are subject to an increase or change in the Federal medical assistance percentage under subsection (y) or (z)(2), respectively, of section 1905. (E) Other nonelderly, nondisabled, non-expansion adults A category of 1903A enrollees who are not described in any previous subparagraph. (3) Medicaid enrollee The term Medicaid enrollee means, with respect to a State for a month, an individual who is eligible for medical assistance for items or services under this title and enrolled under the State plan (or a waiver of such plan) under this title for the month. (4) Determination of number of 1903A enrollees The number of 1903A enrollees for a State and fiscal year, and, if applicable, for a 1903A enrollee category, is the average monthly number of Medicaid enrollees for such State and fiscal year (and, if applicable, in such category) that are reported through the CMS–64 report under (and subject to audit under) subsection (h). (f) Special payment rules (1) Application in case of research and demonstration projects and other waivers In the case of a State with a waiver of the State plan approved under section 1115, section 1915, or another provision of this title, this section shall apply to medical assistance expenditures and medical assistance payments under the waiver, in the same manner as if such expenditures and payments had been made under a State plan under this title and the limitations on expenditures under this section shall supersede any other payment limitations or provisions (including limitations based on a per capita limitation) otherwise applicable under such a waiver. (2) Treatment of States expanding coverage after fiscal year 2016 In the case of a State that did not provide for medical assistance for the 1903A enrollee category described in subsection (e)(2)(D) during fiscal year 2016 but which provides for such assistance for such category in a subsequent year, the provisional FY19 per capita target amount for such enrollee category under subsection (d)(5) shall be equal to the provisional FY19 per capita target amount for the 1903A enrollee category described in subsection (e)(2)(E). (3) In case of State failure to report necessary data If a State for any quarter in a fiscal year (beginning with fiscal year 2019) fails to satisfactorily submit data on expenditures and enrollees in accordance with subsection (h)(1), for such fiscal year and any succeeding fiscal year for which such data are not satisfactorily submitted— (A) the Secretary shall calculate and apply subsections (a) through (e) with respect to the State as if all 1903A enrollee categories for which such expenditure and enrollee data were not satisfactorily submitted were a single 1903A enrollee category; and (B) the growth factor otherwise applied under subsection (c)(2)(B) shall be decreased by 1 percentage point. (g) Recalculation of certain amounts for data errors The amounts and percentage calculated under paragraphs (1) and (4)(C) of subsection (d) for a State for fiscal year 2016, and the amounts of the adjusted total medical assistance expenditures calculated under subsection (b) and the number of Medicaid enrollees and 1903A enrollees determined under subsection (e)(4) for a State for fiscal year 2016, fiscal year 2019, and any subsequent fiscal year, may be adjusted by the Secretary based upon an appeal (filed by the State in such a form, manner, and time, and containing such information relating to data errors that support such appeal, as the Secretary specifies) that the Secretary determines to be valid, except that any adjustment by the Secretary under this subsection for a State may not result in an increase of the target total medical assistance expenditures exceeding 2 percent. (h) Required reporting and auditing of CMS–64 data; transitional increase in Federal matching percentage for certain administrative expenses (1) Reporting In addition to the data required on form Group VIII on the CMS–64 report form as of January 1, 2017, in each CMS-64 report required to be submitted (for each quarter beginning on or after October 1, 2018), the State shall include data on medical assistance expenditures within such categories of services and categories of enrollees (including each 1903A enrollee category and each category of excluded individuals under subsection (e)(1)) and the numbers of enrollees within each of such enrollee categories, as the Secretary determines are necessary (including timely guidance published as soon as possible after the date of the enactment of this section) in order to implement this section and to enable States to comply with the requirement of this paragraph on a timely basis. (2) Auditing The Secretary shall conduct for each State an audit of the number of individuals and expenditures reported through the CMS–64 report for fiscal year 2016, fiscal year 2019, and each subsequent fiscal year, which audit may be conducted on a representative sample (as determined by the Secretary). (3) Temporary increase in federal matching percentage to support improved data reporting systems for fiscal years 2018 and 2019 For amounts expended during calendar quarters beginning on or after October 1, 2017, and before October 1, 2019— (A) the Federal matching percentage applied under section 1903(a)(3)(A)(i) shall be increased by 10 percentage points to 100 percent; (B) the Federal matching percentage applied under section 1903(a)(3)(B) shall be increased by 25 percentage points to 100 percent; and (C) the Federal matching percentage applied under section 1903(a)(7) shall be increased by 10 percentage points to 60 percent but only with respect to amounts expended that are attributable to a State’s additional administrative expenditures to implement the data requirements of paragraph (1). . D Patient Relief and Health Insurance Market Stability 131. Repeal of cost-sharing subsidy (a) In general Section 1402 of the Patient Protection and Affordable Care Act is repealed. (b) Effective date The repeal made by subsection (a) shall apply to cost-sharing reductions (and payments to issuers for such reductions) for plan years beginning after December 31, 2019. 132. Patient and State Stability Fund The Social Security Act ( 42 U.S.C. 301 et seq.) is amended by adding at the end the following new title: XXII Patient and State Stability Fund 2201. Establishment of program There is hereby established the Patient and State Stability Fund to be administered by the Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as the Administrator ), to provide funding, in accordance with this title, to the 50 States and the District of Columbia (each referred to in this section as a State ) during the period, subject to section 2204(c), beginning on January 1, 2018, and ending on December 31, 2026, for the purposes described in section 2202. 2202. Use of funds A State may use the funds allocated to the State under this title for any of the following purposes: (1) Helping, through the provision of financial assistance, high-risk individuals who do not have access to health insurance coverage offered through an employer enroll in health insurance coverage in the individual market in the State, as such market is defined by the State (whether through the establishment of a new mechanism or maintenance of an existing mechanism for such purpose). (2) Providing incentives to appropriate entities to enter into arrangements with the State to help stabilize premiums for health insurance coverage in the individual market, as such markets are defined by the State. (3) Reducing the cost for providing health insurance coverage in the individual market and small group market, as such markets are defined by the State, to individuals who have, or are projected to have, a high rate of utilization of health services (as measured by cost). (4) Promoting participation in the individual market and small group market in the State and increasing health insurance options available through such market. (5) Promoting access to preventive services; dental care services (whether preventive or medically necessary); vision care services (whether preventive or medically necessary); prevention, treatment, or recovery support services for individuals with mental or substance use disorders; or any combination of such services. (6) Providing payments, directly or indirectly, to health care providers for the provision of such health care services as are specified by the Administrator. (7) Providing assistance to reduce out-of-pocket costs, such as copayments, coinsurance, premiums, and deductibles, of individuals enrolled in health insurance coverage in the State. 2203. State eligibility and approval; Default safeguard (a) Encouraging State options for allocations (1) In general To be eligible for an allocation of funds under this title for a year during the period described in section 2201 for use for one or more purposes described in section 2202, a State shall submit to the Administrator an application at such time (but, in the case of allocations for 2018, not later than 45 days after the date of the enactment of this title and, in the case of allocations for a subsequent year, not later than March 31 of the previous year) and in such form and manner as specified by the Administrator and containing— (A) a description of how the funds will be used for such purposes; (B) a certification that the State will make, from non-Federal funds, expenditures for such purposes in an amount that is not less than the State percentage required for the year under section 2204(e)(1); and (C) such other information as the Administrator may require. (2) Automatic approval An application so submitted is approved unless the Administrator notifies the State submitting the application, not later than 60 days after the date of the submission of such application, that the application has been denied for not being in compliance with any requirement of this title and of the reason for such denial. (3) One-time application If an application of a State is approved for a year, with respect to a purpose described in section 2202, such application shall be treated as approved, with respect to such purpose, for each subsequent year through 2026. (4) Treatment as a State Health Care Program Any program receiving funds from an allocation for a State under this title, including pursuant to subsection (b), shall be considered to be a State health care program for purposes of sections 1128, 1128A, and 1128B. (b) Default Federal safeguard (1) In general (A) 2018 For allocations made under this title for 2018, in the case of a State that does not submit an application under subsection (a) by the 45-day submission date applicable to such year under subsection (a)(1) and in the case of a State that does submit such an application by such date that is not approved, subject to section 2204(e), the Administrator, in consultation with the State insurance commissioner, shall use the allocation that would otherwise be provided to the State under this title for such year, in accordance with paragraph (2), for such State. (B) 2019 through 2026 In the case of a State that does not have in effect an approved application under this section for 2019 or a subsequent year beginning during the period described in section 2201, subject to section 2204(e), the Administrator, in consultation with the State insurance commissioner, shall use the allocation that would otherwise be provided to the State under this title for such year, in accordance with paragraph (2), for such State. (2) Required use for market stabilization payments to issuers Subject to section 2204(a), an allocation for a State made pursuant to paragraph (1) for a year shall be used to carry out the purpose described in section 2202(2) in such State by providing payments to appropriate entities described in such section with respect to claims that exceed $50,000 (or, with respect to allocations made under this title for 2020 or a subsequent year during the period specified in section 2201, such dollar amount specified by the Administrator), but do not exceed $350,000 (or, with respect to allocations made under this title for 2020 or a subsequent year during such period, such dollar amount specified by the Administrator), in an amount equal to 75 percent (or, with respect to allocations made under this title for 2020 or a subsequent year during such period, such percentage specified by the Administrator) of the amount of such claims. 2204. Allocations (a) Appropriation For the purpose of providing allocations for States (including pursuant to section 2203(b)) under this title there is appropriated, out of any money in the Treasury not otherwise appropriated— (1) for 2018, $15,000,000,000; (2) for 2019, $15,000,000,000; (3) for 2020, $10,000,000,000; (4) for 2021, $10,000,000,000; (5) for 2022, $10,000,000,000; (6) for 2023, $10,000,000,000; (7) for 2024, $10,000,000,000; (8) for 2025, $10,000,000,000; and (9) for 2026, $10,000,000,000. (b) Allocations (1) Payment (A) In general From amounts appropriated under subsection (a) for a year, the Administrator shall, with respect to a State and not later than the date specified under subparagraph (B) for such year, allocate, subject to subsection (e), for such State (including pursuant to section 2203(b)) the amount determined for such State and year under paragraph (2). (B) Specified date For purposes of subparagraph (A), the date specified in this subparagraph is— (i) for 2018, the date that is 45 days after the date of the enactment of this title; and (ii) for 2019 and subsequent years, January 1 of the respective year. (2) Allocation amount determinations (A) For 2018 and 2019 (i) In general For purposes of paragraph (1), the amount determined under this paragraph for 2018 and 2019 for a State is an amount equal to the sum of— (I) the relative incurred claims amount described in clause (ii) for such State and year; and (II) the relative uninsured and issuer participation amount described in clause (iv) for such State and year. (ii) Relative incurred claims amount For purposes of clause (i), the relative incurred claims amount described in this clause for a State for 2018 and 2019 is the product of— (I) 85 percent of the amount appropriated under subsection (a) for the year; and (II) the relative State incurred claims proportion described in clause (iii) for such State and year. (iii) Relative State incurred claims proportion The relative State incurred claims proportion described in this clause for a State and year is the amount equal to the ratio of— (I) the adjusted incurred claims by the State, as reported through the medical loss ratio annual reporting under section 2718 of the Public Health Service Act for the third previous year; to (II) the sum of such adjusted incurred claims for all States, as so reported, for such third previous year. (iv) Relative uninsured and issuer participation amount For purposes of clause (i), the relative uninsured and issuer participation amount described in this clause for a State for 2018 and 2019 is the product of— (I) 15 percent of the amount appropriated under subsection (a) for the year; and (II) the relative State uninsured and issuer participation proportion described in clause (v) for such State and year. (v) Relative State uninsured and issuer participation proportion The relative State uninsured and issuer participation proportion described in this clause for a State and year is— (I) in the case of a State not described in clause (vi) for such year, 0; and (II) in the case of a State described in clause (vi) for such year, the amount equal to the ratio of— (aa) the number of individuals residing in such State who for the third preceding year were not enrolled in a health plan or otherwise did not have health insurance coverage (including through a Federal or State health program) and whose income is below 100 percent of the poverty line applicable to a family of the size involved; to (bb) the sum of the number of such individuals for all States described in clause (vi) for the third preceding year. (vi) States described For purposes of clause (v), a State is described in this clause, with respect to 2018 and 2019, if the State satisfies either of the following criterion: (I) The number of individuals residing in such State and described in clause (v)(II)(aa) was higher in 2015 than 2013. (II) The State have fewer than three health insurance issuers offering qualified health plans through the Exchange for 2017. (B) For 2020 through 2026 For purposes of paragraph (1), the amount determined under this paragraph for a year (beginning with 2020) during the period described in section 2201 for a State is an amount determined in accordance with an allocation methodology specified by the Administrator which— (i) takes into consideration the adjusted incurred claims of such State, the number of residents of such State who for the previous year were not enrolled in a health plan or otherwise did not have health insurance coverage (including through a Federal or State health program) and whose income is below 100 percent of the poverty line applicable to a family of the size involved, and the number of health insurance issuers participating in the insurance market in such State for such year; (ii) is established after consultation with health care consumers, health insurance issuers, State insurance commissioners, and other stakeholders and after taking into consideration additional cost and risk factors that may inhibit health care consumer and health insurance issuer participation; and (iii) reflects the goals of improving the health insurance risk pool, promoting a more competitive health insurance market, and increasing choice for health care consumers. (c) Annual distribution of previous year’s remaining funds In carrying out subsection (b), the Administrator shall, with respect to a year (beginning with 2020 and ending with 2027), not later than March 31 of such year— (1) determine the amount of funds, if any, from the amounts appropriated under subsection (a) for the previous year but not allocated for such previous year; and (2) if the Administrator determines that any funds were not so allocated for such previous year, allocate such remaining funds, in accordance with the allocation methodology specified pursuant to subsection (b)(2)(B)— (A) to States that have submitted an application approved under section 2203(a) for such previous year for any purpose for which such an application was approved; and (B) for States for which allocations were made pursuant to section 2203(b) for such previous year, to be used by the Administrator for such States, to carry out the purpose described in section 2202(2) in such States by providing payments to appropriate entities described in such section with respect to claims that exceed $1,000,000; with, respect to a year before 2027, any remaining funds being made available for allocations to States for the subsequent year. (d) Availability Amounts appropriated under subsection (a) for a year and allocated to States in accordance with this section shall remain available for expenditure through December 31, 2027. (e) Conditions for and limitations on receipt of funds The Secretary may not make an allocation under this title for a State, with respect to a purpose described in section 2202— (1) in the case of an allocation that would be made to a State pursuant to section 2203(a), if the State does not agree that the State will make available non-Federal contributions towards such purpose in an amount equal to— (A) for 2020, 7 percent of the amount allocated under this subsection to such State for such year and purpose; (B) for 2021, 14 percent of the amount allocated under this subsection to such State for such year and purpose; (C) for 2022, 21 percent of the amount allocated under this subsection to such State for such year and purpose; (D) for 2023, 28 percent of the amount allocated under this subsection to such State for such year and purpose; (E) for 2024, 35 percent of the amount allocated under this subsection to such State for such year and purpose; (F) for 2025, 42 percent of the amount allocated under this subsection to such State for such year and purpose; and (G) for 2026, 50 percent of the amount allocated under this subsection to such State for such year and purpose; (2) in the case of an allocation that would be made for a State pursuant to section 2203(b), if the State does not agree that the State will make available non-Federal contributions towards such purpose in an amount equal to— (A) for 2020, 10 percent of the amount allocated under this subsection to such State for such year and purpose; (B) for 2021, 20 percent of the amount allocated under this subsection to such State for such year and purpose; and (C) for 2022, 30 percent of the amount allocated under this subsection to such State for such year and purpose; (D) for 2023, 40 percent of the amount allocated under this subsection to such State for such year and purpose; (E) for 2024, 50 percent of the amount allocated under this subsection to such State for such year and purpose; (F) for 2025, 50 percent of the amount allocated under this subsection to such State for such year and purpose; and (G) for 2026, 50 percent of the amount allocated under this subsection to such State for such year and purpose; or (3) if such an allocation for such purpose would not be permitted under subsection (c)(7) of section 2105 if such allocation were payment made under such section. . 133. Continuous health insurance coverage incentive Subpart I of part A of title XXVII of the Public Health Service Act is amended— (1) in section 2701(a)(1)(B), by striking such rate and inserting subject to section 2710A, such rate ; (2) by redesignating the second section 2709 as section 2710; and (3) by adding at the end the following new section: 2710A. Encouraging continuous health insurance coverage (a) Penalty applied (1) In general Notwithstanding section 2701, subject to the succeeding provisions of this section, a health insurance issuer offering health insurance coverage in the individual or small group market shall, in the case of an individual who is an applicable policyholder of such coverage with respect to an enforcement period applicable to enrollments for a plan year beginning with plan year 2019 (or, in the case of enrollments during a special enrollment period, beginning with plan year 2018), increase the monthly premium rate otherwise applicable to such individual for such coverage during each month of such period, by an amount determined under paragraph (2). (2) Amount of penalty The amount determined under this paragraph for an applicable policyholder enrolling in health insurance coverage described in paragraph (1) for a plan year, with respect to each month during the enforcement period applicable to enrollments for such plan year, is the amount that is equal to 30 percent of the monthly premium rate otherwise applicable to such applicable policyholder for such coverage during such month. (b) Definitions For purposes of this section: (1) Applicable policyholder The term applicable policyholder means, with respect to months of an enforcement period and health insurance coverage, an individual who— (A) is a policyholder of such coverage for such months; (B) cannot demonstrate (through presentation of certifications described in section 2704(e) or in such other manner as may be specified in regulations, such as a return or statement made under section 6055(d) or 36C of the Internal Revenue Code of 1986), during the look-back period that is with respect to such enforcement period, there was not a period of at least 63 continuous days during which the individual did not have creditable coverage (as defined in paragraph (1) of section 2704(c) and credited in accordance with paragraphs (2) and (3) of such section); and (C) in the case of an individual who had been enrolled under dependent coverage under a group health plan or health insurance coverage by reason of section 2714 and such dependent coverage of such individual ceased because of the age of such individual, is not enrolling during the first open enrollment period following the date on which such coverage so ceased. (2) Look-back period The term look-back period means, with respect to an enforcement period applicable to an enrollment of an individual for a plan year beginning with plan year 2019 (or, in the case of an enrollment of an individual during a special enrollment period, beginning with plan year 2018) in health insurance coverage described in subsection (a)(1), the 12-month period ending on the date the individual enrolls in such coverage for such plan year. (3) Enforcement period The term enforcement period means— (A) with respect to enrollments during a special enrollment period for plan year 2018, the period beginning with the first month that is during such plan year and that begins subsequent to such date of enrollment, and ending with the last month of such plan year; and (B) with respect to enrollments for plan year 2019 or a subsequent plan year, the 12-month period beginning on the first day of the respective plan year. . 134. Increasing coverage options Section 1302 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18022 ) is amended— (1) in subsection (a)(3), by inserting and with respect to a plan year before plan year 2020 after subsection (e) ; and (2) in subsection (d), by adding at the end the following: (5) Sunset The provisions of this subsection shall not apply after December 31, 2019, and after such date any reference to this subsection or level of coverage or plan described in this subsection and any requirement under law applying such a level of coverage or plan shall have no force or effect (and such a requirement shall be applied as if this section had been repealed). . 135. Change in permissible age variation in health insurance premium rates Section 2701(a)(1)(A)(iii) of the Public Health Service Act ( 42 U.S.C. 300gg(a)(1)(A)(iii) ), as inserted by section 1201(4) of the Patient Protection and Affordable Care Act, is amended by inserting after (consistent with section 2707(c)) the following: or, for plan years beginning on or after January 1, 2018, as the Secretary may implement through interim final regulation, 5 to 1 for adults (consistent with section 2707(c)) or such other ratio for adults (consistent with section 2707(c)) as the State involved may provide . II Committee on Ways and Means A Repeal and Replace of Health-Related Tax Policy 201. Recapture excess advance payments of premium tax credits Subparagraph (B) of section 36B(f)(2) of the Internal Revenue Code of 1986 is amended by adding at the end the following new clause: (iii) Nonapplicability of limitation This subparagraph shall not apply to taxable years beginning after December 31, 2017, and before January 1, 2020. . 202. Additional modifications to premium tax credit (a) Modification of definition of qualified health plan (1) In general Section 36B(c)(3)(A) of the Internal Revenue Code of 1986 is amended— (A) by inserting (determined without regard to subparagraphs (A), (C)(ii), and (C)(iv) of paragraph (1) thereof and without regard to whether the plan is offered on an Exchange) after 1301(a) of the Patient Protection and Affordable Care Act , and (B) by striking shall not include and all that follows and inserting shall not include any health plan that— (i) is a grandfathered health plan or a grandmothered health plan, or (ii) includes coverage for abortions (other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest). . (2) Definition of grandmothered health plan Section 36B(c)(3) of such Code is amended by adding at the end the following new subparagraph: (C) Grandmothered health plan (i) In general The term grandmothered health plan means health insurance coverage which is offered in the individual health insurance market as of October 1, 2013, and is permitted to be offered in such market after January 1, 2014, as a result of CCIIO guidance. (ii) CCIIO guidance defined The term CCIIO guidance means the letter issued by the Centers for Medicare & Medicaid Services on November 14, 2013, to the State Insurance Commissioners outlining a transitional policy for non-grandfathered coverage in the individual health insurance market, as subsequently extended and modified (including by a communication entitled Insurance Standards Bulletin Series—INFORMATION—Extension of Transitional Policy through Calendar Year 2017 issued on February 29, 2016, by the Director of the Center for Consumer Information & Insurance Oversight of such Centers). (iii) Individual health insurance market The term individual health insurance market means the market for health insurance coverage (as defined in section 9832(b)) offered to individuals other than in connection with a group health plan (within the meaning of section 5000(b)(1)). . (3) Conforming amendment related to abortion coverage Section 36B(c)(3) of such Code, as amended by paragraph (2), is amended by adding at the end the following new subparagraph: (D) Certain rules related to abortion (i) Option to purchase separate coverage or plan Nothing in subparagraph (A) shall be construed as prohibiting any individual from purchasing separate coverage for abortions described in such subparagraph, or a health plan that includes such abortions, so long as no credit is allowed under this section with respect to the premiums for such coverage or plan. (ii) Option to offer coverage or plan Nothing in subparagraph (A) shall restrict any health insurance issuer offering a health plan from offering separate coverage for abortions described in such subparagraph, or a plan that includes such abortions, so long as premiums for such separate coverage or plan are not paid for with any amount attributable to the credit allowed under this section (or the amount of any advance payment of the credit under section 1412 of the Patient Protection and Affordable Care Act). (iii) Other treatments The treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of an abortion shall not be treated as an abortion for purposes of subparagraph (A). . (4) Conforming amendments related to off-Exchange coverage (A) Advance payment not applicable Section 1412 of the Patient Protection and Affordable Care Act is amended by adding at the end the following new subsection: (f) Exclusion of off-Exchange coverage Advance payments under this section, and advance determinations under section 1411, with respect to any credit allowed under section 36B shall not be made with respect to any health plan which is not enrolled in through an Exchange. . (B) Reporting Section 6055(b) of the Internal Revenue Code of 1986 is amended by adding at the end the following new paragraph: (3) Information relating to off-Exchange premium credit eligible coverage If minimum essential coverage provided to an individual under subsection (a) consists of a qualified health plan (as defined in section 36B(c)(3)) which is not enrolled in through an Exchange established under title I of the Patient Protection and Affordable Care Act, a return described in this subsection shall include— (A) a statement that such plan is a qualified health plan (as defined in section 36B(c)(3)), (B) the premiums paid with respect to such coverage, (C) the months during which such coverage is provided to the individual, (D) the adjusted monthly premium for the applicable second lowest cost silver plan (as defined in section 36B(b)(3)) for each such month with respect to such individual, and (E) such other information as the Secretary may prescribe. This paragraph shall not apply with respect to coverage provided for any month beginning after December 31, 2019. . (C) Other conforming amendments (i) Section 36B(b)(2)(A) is amended by striking and which were enrolled and all that follows and inserting , or . (ii) Section 36B(b)(3)(B)(i) is amended by striking the same Exchange and all that follows and inserting the Exchange through which such taxpayer is permitted to obtain coverage, and . (b) Modification of applicable percentage Section 36B(b)(3)(A) of such Code is amended to read as follows: (A) Applicable percentage (i) In general The applicable percentage for any taxable year shall be the percentage such that the applicable percentage for any taxpayer whose household income is within an income tier specified in the following table shall increase, on a sliding scale in a linear manner, from the initial percentage to the final percentage specified in such table for such income tier with respect to a taxpayer of the age involved: In the case of household income (expressed as a percent of the poverty line) within the following income tier: Up to Age 29 Age 30-39 Age 40-49 Age 50-59 Over Age 59 Initial % Final % Initial % Final % Initial % Final % Initial % Final % Initial % Final % Up to 133% 2 2 2 2 2 2 2 2 2 2 133%-150% 3 4 3 4 3 4 3 4 3 4 150%-200% 4 4.3 4 5.3 4 6.3 4 7.3 4 8.3 200%-250% 4.3 4.3 5.3 5.9 6.3 8.05 7.3 9 8.3 10 250%-300% 4.3 4.3 5.9 5.9 8.05 8.35 9 10.5 10 11.5 300%-400% 4.3 4.3 5.9 5.9 8.35 8.35 10.5 10.5 11.5 11.5 (ii) Age determinations (I) In general For purposes of clause (i), the age of the taxpayer taken into account under clause (i) with respect to any taxable year is the age attained by such taxpayer before the close of such taxable year. (II) Joint returns In the case of a joint return, the age of the older spouse shall be taken into account under clause (i). (iii) Indexing In the case of any taxable year beginning in calendar year 2019, the initial and final percentages contained in clause (i) shall be adjusted to reflect— (I) the excess (if any) of the rate of premium growth for the period beginning with calendar year 2013 and ending with calendar year 2018, over the rate of income growth for such period, and (II) in addition to any adjustment under subclause (I), the excess (if any) of the rate of premium growth for calendar year 2018, over the rate of growth in the consumer price index for calendar year 2018. (iv) Failsafe Clause (iii)(II) shall apply only if the aggregate amount of premium tax credits under this section and cost-sharing reductions under section 1402 of the Patient Protection and Affordable Care Act for calendar year 2018 exceeds an amount equal to 0.504 percent of the gross domestic product for such calendar year. . (b) Effective date (1) In general Except as otherwise provided in this subsection, the amendments made by this section shall apply to taxable years beginning after December 31, 2017. (2) Advance payment not applicable to off-Exchange coverage The amendment made by subsection (a)(4)(A) shall take effect on January 1, 2018. (3) Reporting The amendment made by subsection (a)(4)(B) shall apply to coverage provided for months beginning after December 31, 2017. (4) Modification of applicable percentage The amendment made by subsection (b) shall apply to taxable years beginning after December 31, 2018. 203. Premium tax credit (a) Repeal of premium tax credit Section 36B of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: (h) Termination No credit shall be allowed under this section with respect to any coverage month which begins after December 31, 2019. . (b) Repeal of advance payment of, and eligibility determination for, premium tax credit Section 1412 of the Patient Protection and Affordable Care Act, as amended by the preceding provisions of this subtitle, is amended by adding at the end the following new subsection: (g) Termination with respect to premium tax credit Effective January 1, 2020, no provision of this section or section 1411 shall apply to the credit allowed under section 36B of the Internal Revenue Code of 1986 (or to the advance payment of, or determination of eligibility for, such credit or payment). . (c) Effective dates (1) Premium tax credit The amendment made by subsection (a) shall apply to months beginning after December 31, 2019, in taxable years ending after such date. (2) Eligibility determinations The amendment made by subsection (b) shall take effect on January 1, 2020. 204. Small business tax credit (a) In general Section 45R of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: (j) Shall not apply This section shall not apply with respect to amounts paid or incurred in taxable years beginning after December 31, 2019. . (b) Disallowance of small employer health insurance expense credit for plan which includes coverage for abortion Subsection (h) of section 45R of the Internal Revenue Code of 1986 is amended— (1) by striking Any term and inserting the following: (1) In general Any term ; and (2) by adding at the end the following new paragraph: (2) Exclusion of health plans including coverage for abortion (A) In general The term qualified health plan does not include any health plan that includes coverage for abortions (other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest) . (B) Certain rules related to abortion (i) Option to purchase separate coverage or plan Nothing in subparagraph (A) shall be construed as prohibiting any employer from purchasing for its employees separate coverage for abortions described in such subparagraph, or a health plan that includes such abortions, so long as no credit is allowed under this section with respect to the employer contributions for such coverage or plan. (ii) Option to offer coverage or plan Nothing in subparagraph (A) shall restrict any health insurance issuer offering a health plan from offering separate coverage for abortions described in such subparagraph, or a plan that includes such abortions, so long as such separate coverage or plan is not paid for with any employer contribution eligible for the credit allowed under this section. (iii) Other treatments The treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of an abortion shall not be treated as an abortion for purposes of subparagraph (A). . (c) Effective dates (1) In general The amendment made by subsection (a) shall apply to taxable years beginning after December 31, 2019. (2) Disallowance of small employer health insurance expense credit for plan which includes coverage for abortion The amendments made by subsection (b) shall apply to taxable years beginning after December 31, 2017. 205. Individual mandate (a) In general Section 5000A(c) of the Internal Revenue Code of 1986 is amended— (1) in paragraph (2)(B)(iii), by striking 2.5 percent and inserting Zero percent , and (2) in paragraph (3)— (A) by striking $695 in subparagraph (A) and inserting $0 , and (B) by striking subparagraph (D). (b) Effective date The amendments made by this section shall apply to months beginning after December 31, 2015. 206. Employer mandate (a) In general (1) Paragraph (1) of section 4980H(c) of the Internal Revenue Code of 1986 is amended by inserting ($0 in the case of months beginning after December 31, 2015) after $2,000 . (2) Paragraph (1) of section 4980H(b) of the Internal Revenue Code of 1986 is amended by inserting ($0 in the case of months beginning after December 31, 2015) after $3,000 . (b) Effective date The amendments made by this section shall apply to months beginning after December 31, 2015. 207. Repeal of the tax on employee health insurance premiums and health plan benefits Section 4980I of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: (h) Shall not apply No tax shall be imposed under this section with respect to any taxable period beginning after December 31, 2019, and before January 1, 2025. . 208. Repeal of tax on over-the-counter medications (a) HSAs Subparagraph (A) of section 223(d)(2) of the Internal Revenue Code of 1986 is amended by striking Such term and all that follows through the period. (b) Archer MSAs Subparagraph (A) of section 220(d)(2) of the Internal Revenue Code of 1986 is amended by striking Such term and all that follows through the period. (c) Health flexible spending arrangements and health reimbursement arrangements Section 106 of the Internal Revenue Code of 1986 is amended by striking subsection (f) and by redesignating subsection (g) as subsection (f). (d) Effective dates (1) Distributions from savings accounts The amendments made by subsections (a) and (b) shall apply to amounts paid with respect to taxable years beginning after December 31, 2017. (2) Reimbursements The amendment made by subsection (c) shall apply to expenses incurred with respect to taxable years beginning after December 31, 2017. 209. Repeal of increase of tax on health savings accounts (a) HSAs Section 223(f)(4)(A) of the Internal Revenue Code of 1986 is amended by striking 20 percent and inserting 10 percent . (b) Archer MSAs Section 220(f)(4)(A) of the Internal Revenue Code of 1986 is amended by striking 20 percent and inserting 15 percent . (c) Effective date The amendments made by this section shall apply to distributions made after December 31, 2017. 210. Repeal of limitations on contributions to flexible spending accounts (a) In general Section 125 of the Internal Revenue Code of 1986 is amended by striking subsection (i). (b) Effective date The amendment made by this section shall apply to taxable years beginning after December 31, 2017. 211. Repeal of medical device excise tax Section 4191 of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: (d) Applicability The tax imposed under subsection (a) shall not apply to sales after December 31, 2017. . 212. Repeal of elimination of deduction for expenses allocable to medicare part D subsidy (a) In general Section 139A of the Internal Revenue Code of 1986 is amended by adding at the end the following new sentence: This section shall not be taken into account for purposes of determining whether any deduction is allowable with respect to any cost taken into account in determining such payment. . (b) Effective date The amendment made by this section shall apply to taxable years beginning after December 31, 2017. 213. Repeal of increase in income threshold for determining medical care deduction (a) In general Subsection (a) of section 213 of the Internal Revenue Code of 1986 is amended by striking 10 percent and inserting 7.5 percent . (b) Extension of special rule Subsection (f) of section 213 of such Code is amended— (1) by striking 2017 and inserting 2018 , and (2) by striking and 2016 and inserting 2016, and 2017 . (c) Effective date (1) In general The amendment made by subsection (a) shall apply to taxable years beginning after December 31, 2017. (2) Extension of special rule The amendments made by subsection (b) shall apply to taxable years beginning after December 31, 2016. 214. Repeal of Medicare tax increase (a) In general Subsection (b) of section 3101 of the Internal Revenue Code of 1986 is amended to read as follows: (b) Hospital insurance In addition to the tax imposed by the preceding subsection, there is hereby imposed on the income of every individual a tax equal to 1.45 percent of the wages (as defined in section 3121(a)) received by such individual with respect to employment (as defined in section 3121(b)). . (b) SECA Subsection (b) of section 1401 of the Internal Revenue Code of 1986 is amended to read as follows: (b) Hospital insurance In addition to the tax imposed by the preceding subsection, there shall be imposed for each taxable year, on the self-employment income of every individual, a tax equal to 2.9 percent of the amount of the self-employment income for such taxable year. . (c) Effective date The amendments made by this section shall apply with respect to remuneration received after, and taxable years beginning after, December 31, 2017. 215. Refundable tax credit for health insurance coverage (a) In general Subpart C of part IV of subchapter A of chapter 1 of the Internal Revenue Code of 1986 is amended by inserting after section 36B the following new section: 36C. Health insurance coverage (a) In general In the case of an individual, there shall be allowed as a credit against the tax imposed by this subtitle for the taxable year the sum of the monthly credit amounts with respect to such taxpayer for calendar months during such taxable year. (b) Monthly credit amounts (1) In general The monthly credit amount with respect to any taxpayer for any calendar month is the lesser of— (A) the sum of the monthly limitation amounts determined under subsection (c) with respect to the taxpayer and the taxpayer’s qualifying family members for such month, or (B) the amount paid for eligible health insurance for the taxpayer and the taxpayer’s qualifying family members for such month. (2) Eligible coverage month requirement No amount shall be taken into account under subparagraph (A) or (B) of paragraph (1) with respect to any individual for any month unless such month is an eligible coverage month with respect to such individual. (c) Monthly limitation amounts (1) In general The monthly limitation amount with respect to any individual for any eligible coverage month during any taxable year is 1/12 of— (A) $2,000 in the case of an individual who has not attained age 30 as of the beginning of such taxable year, (B) $2,500 in the case of an individual who has attained age 30 but who has not attained age 40 as of such time, (C) $3,000 in the case of an individual who has attained age 40 but who has not attained age 50 as of such time, (D) $3,500 in the case of an individual who has attained age 50 but who has not attained age 60 as of such time, and (E) $4,000 in the case of an individual who has attained age 60 as of such time. (2) Limitation based on modified adjusted gross income (A) In general The amount otherwise determined under subsection (b)(1)(A) (without regard to this subparagraph but after any other adjustment of such amount under this section) for the taxable year shall be reduced (but not below zero) by 10 percent of the excess (if any) of— (i) the taxpayer’s modified adjusted gross income for such taxable year, over (ii) $75,000 (twice such amount in the case of a joint return). (B) Modified adjusted gross income For purposes of this paragraph, the term modified adjusted gross income means adjusted gross income increased by— (i) any amount excluded from gross income under section 911, (ii) any amount of interest received or accrued by the taxpayer during the taxable year which is exempt from tax, and (iii) an amount equal to the portion of the taxpayer’s social security benefits (as defined in section 86(d)) which is not included in gross income under section 86 for the taxable year. (3) Other limitations (A) Aggregate dollar limitation The sum of the monthly limitation amounts taken into account under this section with respect to any taxpayer for any taxable year shall not exceed $14,000. (B) Maximum number of individuals taken into account With respect to any taxpayer for any month, monthly limitation amounts shall be taken into account under this section only with respect to the 5 oldest individuals with respect to whom monthly limitation amounts could (without regard to this subparagraph) otherwise be so taken into account. (d) Eligible coverage month For purposes of this section, the term eligible coverage month means, with respect to any individual, any month if, as of the first day of such month, the individual— (1) is covered by eligible health insurance, (2) is not eligible for other specified coverage, (3) is either— (A) a citizen or national of the United States, or (B) a qualified alien (within the meaning of section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 ( 8 U.S.C. 1641 )), and (4) is not incarcerated, other than incarceration pending the disposition of charges. (e) Qualifying family member For purposes of this section, the term qualifying family member means— (1) in the case of a joint return, the taxpayer’s spouse, (2) any dependent of the taxpayer, and (3) with respect to any eligible coverage month, any child (as defined in section 152(f)(1)) of the taxpayer who as of the end of the taxable year has not attained age 27 if such child is covered for such month under eligible health insurance which also covers the taxpayer (in the case of a joint return, either spouse). (f) Eligible health insurance For purposes of this section— (1) In general The term eligible health insurance means any health insurance coverage (as defined in section 9832(b)) if— (A) such coverage is either— (i) offered in the individual health insurance market within a State, or (ii) is unsubsidized COBRA continuation coverage, (B) such coverage is not a grandfathered health plan (as defined in section 1251 of the Patient Protection and Affordable Care Act) or a grandmothered health plan, (C) substantially all of such coverage is not of excepted benefits described in section 9832(c), (D) such coverage does not include coverage for abortions (other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest), (E) such coverage does not consist of short-term limited duration insurance (as defined by the Secretary), and (F) the State in which such insurance is offered certifies that such coverage meets the requirements of this paragraph. (2) Rules related to State certification (A) Certification made available to public A certification shall not be taken into account under paragraph (1)(E) unless such certification is made available to the public and meets such other requirements as the Secretary may provide. (B) Special rule for unsubsidized COBRA continuation coverage In the case of unsubsidized COBRA continuation coverage— (i) paragraph (1)(E) shall be applied by substituting the plan administrator (as defined in section 414(g)) of the health plan for the State in which such insurance is offered , and (ii) the requirements of subparagraph (A) shall be treated as satisfied if the certification meets such requirements as the Secretary may provide. (3) Grandmothered health plan (A) In general The term grandmothered health plan means health insurance coverage which is offered in the individual health insurance market as of January 1, 2013, and is permitted to be offered in such market after January 1, 2014, as a result of CCIIO guidance. (B) CCIIO guidance defined The term CCIIO guidance means the letter issued by the Centers for Medicare & Medicaid Services on November 14, 2013, to the State Insurance Commissioners outlining a transitional policy for non-grandfathered coverage in the individual health insurance market, as subsequently extended and modified (including by a communication entitled Insurance Standards Bulletin Series—INFORMATION—Extension of Transitional Policy through Calendar Year 2017 issued on February 29, 2016, by the Director of the Center for Consumer Information & Insurance Oversight of such Centers). (4) Individual health insurance market The term individual health insurance market means the market for health insurance coverage (as defined in section 9832(b)) offered to individuals other than in connection with a group health plan (within the meaning of section 5000(b)(1)). (g) Other specified coverage For purposes of this section— (1) In general The term other specified coverage means any of the following: (A) Coverage under a group health plan (within the meaning of section 5000(b)(1)) other than— (i) coverage under a plan substantially all of the coverage of which is of excepted benefits described in section 9832(c), and (ii) COBRA continuation coverage. (B) Coverage under the Medicare program under part A of title XVIII of the Social Security Act. (C) Coverage under the Medicaid program under title XIX of the Social Security Act. (D) Coverage under the CHIP program under title XXI of the Social Security Act. (E) Medical coverage under chapter 55 of title 10, United States Code, including coverage under the TRICARE program. (F) Coverage under a health care program under chapter 17 or 18 of title 38, United States Code, as determined by the Secretary of Veterans Affairs, in coordination with the Secretary of Health and Human Services and the Secretary of the Treasury. (G) Coverage under a health plan under section 2504(e) of title 22, United States Code (relating to Peace Corps volunteers). (H) Coverage under the Nonappropriated Fund Health Benefits Program of the Department of Defense, established under section 349 of the National Defense Authorization Act for Fiscal Year 1995 ( Public Law 103–337 ; 10 U.S.C. 1587 note). (2) Special rule with respect to veterans health programs In the case of other specified coverage described in paragraph (1)(F), an individual shall not be treated as eligible for such coverage unless such individual is enrolled in such coverage. (h) Unsubsidized COBRA continuation coverage For purposes of this section— (1) In general The term unsubsidized COBRA continuation coverage means COBRA continuation coverage no portion of the premiums for which are subsidized by the employer. (2) COBRA continuation coverage The term COBRA continuation coverage means continuation coverage provided pursuant to part 6 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (other than under section 609), title XXII of the Public Health Service Act, section 4980B of the Internal Revenue Code of 1986 (other than subsection (f)(1) of such section insofar as it relates to pediatric vaccines), or section 8905a of title 5, United States Code, or under a State program that provides comparable continuation coverage. Such term shall not include coverage under a health flexible spending arrangement. (i) Special rules (1) Married couples must file joint return If the taxpayer is married (within the meaning of section 7703) at the close of the taxable year, no credit shall be allowed under this section to such taxpayer unless such taxpayer and the taxpayer’s spouse file a joint return for such taxable year. (2) Denial of credit to dependents (A) In general No credit shall be allowed under this section to any individual who is a dependent with respect to another taxpayer for a taxable year beginning in the calendar year in which such individual’s taxable year begins. (B) Coordination with rule for older children In the case of any individual who is a qualifying family member described in subsection (e)(3) with respect to another taxpayer for any month, in determining the amount of any credit allowable to such individual under this section for any taxable year of such individual which includes such month, the monthly limitation amount with respect to such individual for such month shall be zero and no amount paid for eligible health insurance with respect to such individual for such month shall be taken into account. (3) Coordination with medical expense deduction Amounts described in subsection (b)(1)(B) with respect to any month shall not be taken into account in determining the deduction allowed under section 213 except to the extent that such amounts exceed the amount described in subsection (b)(1)(A) with respect to such month. (4) Insurance which covers other individuals For purposes of this section, rules similar to the rules of section 213(d)(6) shall apply with respect to any contract for eligible health insurance under which amounts are payable for coverage of an individual other than the taxpayer and the taxpayer’s qualifying family members. (5) Coordination with advance payments of credit With respect to any taxable year— (A) the amount which would (but for this subsection) be allowed as a credit to the taxpayer under subsection (a) shall be reduced (but not below zero) by the aggregate amount paid on behalf of such taxpayer under section 7529 for months beginning in such taxable year, and (B) the tax imposed by section 1 for such taxable year shall be increased by the excess (if any) of— (i) the aggregate amount paid on behalf of such taxpayer under section 7529 for months beginning in such taxable year, over (ii) the amount which would (but for this subsection) be allowed as a credit to the taxpayer under subsection (a). (6) Special rules for qualified small employer health reimbursement arrangements (A) In general If the taxpayer or any qualifying family member of the taxpayer is provided a qualified small employer health reimbursement arrangement for any eligible coverage month, the sum determined under subsection (b)(1)(A) with respect to the taxpayer for such month shall be reduced (but not below zero) by 1/12 of the permitted benefit (as defined in section 9831(d)(3)(C)) under such arrangement. (B) Qualified small employer health reimbursement arrangement For purposes of this paragraph, the term qualified small employer health reimbursement arrangement has the meaning given such term by section 9831(d)(2). (C) Coverage for less than entire year In the case of an employee who is provided a qualified small employer health reimbursement arrangement for less than an entire year, subparagraph (A) shall be applied by substituting the number of months during the year for which such arrangement was provided for 12 . (7) Certain rules related to abortion (A) Option to purchase separate coverage or plan Nothing in subsection (f)(1)(D) shall be construed as prohibiting any individual from purchasing separate coverage for abortions described in such subparagraph, or a health plan that includes such abortions, so long as no credit is allowed under this section with respect to the premiums for such coverage or plan. (B) Option to offer coverage or plan Nothing in subsection (f)(1)(D) shall restrict any health insurance issuer offering a health plan from offering separate coverage for abortions described in such clause, or a plan that includes such abortions, so long as premiums for such separate coverage or plan are not paid for with any amount attributable to the credit allowed under this section. (C) Other treatments The treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of an abortion shall not be treated as an abortion for purposes of subsection (f)(1)(D). (8) Inflation adjustment (A) In general In the case of any taxable year beginning in a calendar year after 2020, each dollar amount in subsection (c)(1), the $75,000 amount in subsection (c)(2)(A)(ii), and the dollar amount in subsection (c)(3)(A), shall be increased by an amount equal to— (i) such dollar amount, multiplied by (ii) the cost-of-living adjustment determined under section 1(f)(3) for the calendar year in which the taxable year begins, determined— (I) by substituting calendar year 2019 for calendar year 1992 in subparagraph (B) thereof, and (II) by substituting for the CPI referred to section 1(f)(3)(A) the amount that such CPI would have been if the annual percentage increase in CPI with respect to each year after 2019 had been one percentage point greater. (B) Terms related to CPI (i) Annual percentage increase For purposes of subparagraph (A)(ii)(II), the term annual percentage increase means the percentage (if any) by which CPI for any year exceeds CPI for the prior year. (ii) Other terms Terms used in this paragraph which are also used in section 1(f)(3) shall have the same meanings as when used in such section. (C) Rounding Any increase determined under subparagraph (A) shall be rounded to the nearest multiple of $50. (9) Regulations The Secretary may prescribe such regulations and other guidance as may be necessary or appropriate to carry out this section, section 6050X, and section 7529. . (b) Advance payment of credit; excess health insurance coverage credit payable to health savings account Chapter 77 of such Code is amended by adding at the end the following: 7529. Advance payment of health insurance coverage credit (a) General rule Not later than January 1, 2020, the Secretary, in consultation with the Secretary of Health and Human Services, the Secretary of Homeland Security, and the Commissioner of Social Security, shall establish a program (hereafter in this section referred to as the advance payment program ) for making payments to providers of eligible health insurance on behalf of taxpayers eligible for the credit under section 36C. (b) Limitation The aggregate payments made under this section with respect to any taxpayer, determined as of any time during any calendar year, shall not exceed the monthly credit amounts determined with respect to such taxpayer under section 36C for months during such calendar year which have ended as of such time. (c) Administration (1) In general The advance payment program shall, to the greatest extent practicable, use the methods and procedures used to administer the programs created under sections 1411 and 1412 of the Patient Protection and Affordable Care Act (determined without regard to section 1412(f) of such Act) and each entity that is authorized to take any actions under the programs created under such sections (as so determined) shall, at the request of the Secretary, take such actions to the extent necessary to carry out this section. (2) Application to off-Exchange coverage Except as otherwise provided by the Secretary, for purposes of applying this subsection in the case of eligible health insurance which is not enrolled in through an Exchange established under title I of the Patient Protection and Affordable Care Act, the sections referred to in paragraph (1) shall be applied by treating references in such sections to an Exchange as references to the provider of such eligible health insurance (or, as the Secretary determines appropriate, to the licensed agent or broker with respect to such insurance), except that the Secretary of Health and Human Services shall carry out the responsibilities of the Exchange under section 1411(e)(4) of the Patient Protection and Affordable Care Act (determined without regard to section 1412(f) of such Act) in the case of such insurance. (3) Documentation regarding other specified coverage (A) In general The advance payment program shall provide that any individual applying to have payments made on their behalf under such program shall, if such individual (or any qualifying family member of such individual taken into account in determining the amount of the credit allowable under section 36C) is employed, submit a written statement from each employer of such individual or such qualifying family member stating whether such individual or qualifying family member (as the case may be) is eligible for other specified coverage in connection with such employment. (B) Issuance of statements An employer shall, at the request of any employee, provide the statement under subparagraph (A) at such time, and in such form and manner, as the Secretary may provide. (d) Definitions For purposes of this section, terms used in this section which are also used in section 36C shall have the same meaning as when used in section 36C. 7530. Excess health insurance coverage credit payable to health savings account (a) In general At the request of an eligible taxpayer, the Secretary shall make a payment to the trustee of the designated health savings account with respect to such taxpayer in an amount equal to the sum of the excesses (if any) described in subsection (c)(2) with respect to months in the taxable year. (b) Designated health savings account The term designated health savings account means a health savings account of an individual described in subsection (c)(3) which is identified by the eligible taxpayer for purposes of this section. (c) Eligible taxpayer The term eligible taxpayer means, with respect to any taxable year, any taxpayer if— (1) such taxpayer is allowed a credit under section 36C for such taxable year, (2) the amount described in subparagraph (A) of section 36C(b)(1) exceeds the amount described in subparagraph (B) of such section with respect to such taxpayer applied with respect to any month during such taxable year, and (3) the taxpayer or one or more of the taxpayer’s qualifying family members (as defined in section 36C(e)) were eligible individuals (as defined in section 223(c)(1)) for one or more months during such taxable year. (d) Contributions treated as rollovers, etc (1) In general Any amount paid the Secretary to a health savings account under this section shall be treated for purposes of this title in the same manner as a rollover contribution described in section 223(f)(5). (2) Coordination with limitation on rollovers Any amount described in paragraph (1) shall not be taken into account in applying section 223(f)(5)(B) with respect to any other amount and the limitation of section 223(f)(5)(B) shall not apply with respect to the application of paragraph (1). (e) Form and manner of request The request referred to in subsection (a) shall be made at such time and in such form and manner as the Secretary may provide. To the extent that the Secretary determines feasible, such request may identify more than one designated health savings account (and the amount to be paid to each such account) provided that the aggregate of such payments with respect to any taxpayer for any taxable year do not exceed the excess described in subsection (c)(2). (f) Taxpayers with seriously delinquent tax debt In the case of an individual who has a seriously delinquent tax debt (as defined in section 7345(b)) which has not been fully satisfied— (1) if such individual is the eligible taxpayer (or, in the case of a joint return, either spouse), the Secretary shall not make any payment under this section with respect to such taxpayer, and (2) if such individual is the account beneficiary (as defined in section 223(d)(3)) of any health savings account, the Secretary shall not make any payment under this section to such health savings account. (g) Advance payment To the extent that the Secretary determines feasible, payment under this section may be made in advance on a monthly basis under rules similar to the rules of sections 7529 and 36C(i)(5)(B). . (c) Information reporting (1) Reporting by health insurance providers Subpart B of part III of subchapter A of chapter 61 of such Code is amended by adding at the end the following new section: 6050X. Returns by health insurance providers relating to health insurance coverage credit (a) Requirement of reporting Every person who provides eligible health insurance for any month of any calendar year with respect to any individual shall, at such time as the Secretary may prescribe, make the return described in subsection (b) with respect to each such individual. With respect to any individual with respect to whom payments under section 7529 are made by the Secretary, the reporting under subsection (b) shall be made on a monthly basis. (b) Form and manner of returns A return is described in this subsection if such return— (1) is in such form as the Secretary may prescribe, and (2) contains, with respect to each policy of eligible health insurance— (A) the name, address, and TIN of each individual covered under such policy, (B) the premiums paid with respect to such policy, (C) the amount of advance payments made on behalf of the individual under section 7529, (D) the months during which such health insurance is provided to the individual, (E) whether such policy constitutes a high deductible health plan (as defined in section 223(c)(2)), and (F) such other information as the Secretary may prescribe. (c) Statements to be furnished to individuals with respect to whom information is required Every person required to make a return under subsection (a) shall furnish to each individual whose name is required to be set forth in such return a written statement showing— (1) the name and address of the person required to make such return and the phone number of the information contact for such person, and (2) the information required to be shown on the return with respect to such individual. The written statement required under the preceding sentence shall be furnished on or before January 31 of the year following the calendar year to which such statement relates. (d) Definitions For purposes of this section, terms used in this section which are also used in section 36C shall have the same meaning as when used in section 36C. . (2) Reporting by employers Section 6051(a) of such Code is amended by striking and at the end of paragraph (14), by striking the period at the end of paragraph (15) and inserting , and , and by inserting after paragraph (15) the following new paragraph: (16) each month with respect to which the employee is eligible for other specified coverage (as defined in section 36C(g)) in connection with employment with the employer. . (3) Assessable penalties (A) Section 6724(d)(1)(B) of such Code is amended by striking or at the end of clause (xxiv), by inserting or at the end of clause (xxv), and by inserting after clause (xxv) the following new clause: (xxvi) section 6050X (relating to returns relating to health insurance coverage credit), . (B) Section 6724(d)(2) of such Code is amended by striking or at the end of subparagraph (HH), by striking the period at the end of subparagraph (II) and inserting a comma, and by adding after subparagraph (II) the following new subparagraphs: (JJ) section 6050X (relating to returns relating to health insurance coverage credit), or (KK) section 7529(c)(3) (relating to documentation regarding other specified coverage). . (d) Disclosures Paragraph (21) of section 6103(l) of the Internal Revenue Code of 1986 is amended— (1) in subparagraph (A)— (A) by striking any premium tax credit under section 36B or any cost-sharing reduction under section 1402 of the Patient Protection and Affordable Care Act or and inserting any credit under section 36C , (B) by striking , a State’s children’s health insurance program under title XXI of the Social Security Act, or a basic health program under section 1331 of Patient Protection and Affordable Care Act and inserting or a State’s children’s health insurance program under title XXI of the Social Security Act , (C) by striking (as defined in section 36B) in clause (iv) and inserting (as defined in section 36C(c)(2)(B)) , and (D) by striking or reduction in clause (v), (2) in subparagraph (B)— (A) by striking may disclose to an Exchange and inserting may disclose— (i) to an Exchange , and (B) by striking the period at the end and inserting , and , and (C) by adding at the end the following new clause: (ii) in the case of any credit under section 36C with respect to any health insurance, the amount of such credit (or the amount of any advance payment of such credit) to the provider of such insurance (or, as the Secretary determines appropriate, the licensed agent or broker with respect to such insurance). , and (3) in subparagraph (C)(i), by striking amount of, any credit or reduction and inserting amount of any credit . (e) Increased penalty on erroneous claims of credit Section 6676(a) of such Code is amended by inserting (25 percent in the case of a claim for refund or credit relating to the health insurance coverage credit under section 36C) after 20 percent . (f) Conforming amendments (1) Section 35(g) of such Code is amended by adding at the end the following new paragraph: (14) Coordination with health insurance coverage credit (A) In general An eligible coverage month to which the election under paragraph (11) applies shall not be treated as an eligible coverage month (as defined in section 36C(d)) for purposes of section 36C with respect to the taxpayer or any of the taxpayer’s qualifying family members (as defined in section 36C(e)). (B) Coordination with advance payments of health insurance coverage credit In the case of a taxpayer who makes the election under paragraph (11) with respect to any eligible coverage month in a taxable year or on behalf of whom any advance payment is made under section 7527 with respect to any month in such taxable year— (i) the tax imposed by this chapter for the taxable year shall be increased by the excess, if any, of— (I) the sum of any advance payments made on behalf of the taxpayer under sections 7527 and 7529 for months during such taxable year, over (II) the sum of the credits allowed under this section (determined without regard to paragraph (1)) and section 36C (determined without regard to subsection (i)(5)(A) thereof) for such taxable year, and (ii) section 36C(i)(5)(B) shall not apply with respect to such taxpayer for such taxable year. . (2) Section 162(l) of such Code is amended by adding at the end the following new paragraph: (6) Coordination with health insurance coverage credit The deduction otherwise allowable to a taxpayer under paragraph (1) for any taxable year shall be reduced (but not below zero) by the sum of— (A) the amount of the credit allowable to such taxpayer under section 36C (determined without regard to subsection (i)(5)(A) thereof) for such taxable year, plus (B) the aggregate payments made with respect to the taxpayer under section 7530 for months during such taxable year. . (3) Section 1324(b)(2) of title 31, United States Code is amended— (A) by inserting 36C, after 36B, , and (B) by striking or 6431 and inserting 6431, or 7530 . (4) The table of sections for subpart C of part IV of subchapter A of chapter 1 of the Internal Revenue Code of 1986 is amended by inserting after the item relating to section 36B the following new item: Sec. 36C. Health insurance coverage. . (5) The table of sections for subpart B of part III of subchapter A of chapter 61 of such Code is amended by adding at the end the following new item: Sec. 6050X. Returns by health insurance providers relating to health insurance coverage credit. . (6) The table of sections for chapter 77 of such Code is amended by adding at the end the following new items: Sec. 7529. Advance payment of health insurance coverage credit. Sec. 7530. Excess health insurance coverage credit payable to health savings account. . (g) Effective date The amendments made by this section shall apply to months beginning after December 31, 2019, in taxable years ending after such date. 216. Maximum contribution limit to health savings account increased to amount of deductible and out-of-pocket limitation (a) Self-Only coverage Section 223(b)(2)(A) of the Internal Revenue Code of 1986 is amended by striking $2,250 and inserting the amount in effect under subsection (c)(2)(A)(ii)(I) . (b) Family coverage Section 223(b)(2)(B) of such Code is amended by striking $4,500 and inserting the amount in effect under subsection (c)(2)(A)(ii)(II) . (c) Conforming amendments Section 223(g)(1) of such Code is amended— (1) by striking subsections (b)(2) and both places it appears and inserting subsection , and (2) in subparagraph (B), by striking determined by and all that follows through calendar year 2003 . and inserting determined by substituting calendar year 2003 for calendar year 1992 in subparagraph (B) thereof . . (d) Effective date The amendments made by this section shall apply to taxable years beginning after December 31, 2017. 217. Allow both spouses to make catch-up contributions to the same health savings account (a) In general Section 223(b)(5) of the Internal Revenue Code of 1986 is amended to read as follows: (5) Special rule for married individuals with family coverage (A) In general In the case of individuals who are married to each other, if both spouses are eligible individuals and either spouse has family coverage under a high deductible health plan as of the first day of any month— (i) the limitation under paragraph (1) shall be applied by not taking into account any other high deductible health plan coverage of either spouse (and if such spouses both have family coverage under separate high deductible health plans, only one such coverage shall be taken into account), (ii) such limitation (after application of clause (i)) shall be reduced by the aggregate amount paid to Archer MSAs of such spouses for the taxable year, and (iii) such limitation (after application of clauses (i) and (ii)) shall be divided equally between such spouses unless they agree on a different division. (B) Treatment of additional contribution amounts If both spouses referred to in subparagraph (A) have attained age 55 before the close of the taxable year, the limitation referred to in subparagraph (A)(iii) which is subject to division between the spouses shall include the additional contribution amounts determined under paragraph (3) for both spouses. In any other case, any additional contribution amount determined under paragraph (3) shall not be taken into account under subparagraph (A)(iii) and shall not be subject to division between the spouses. . (b) Effective date The amendment made by this section shall apply to taxable years beginning after December 31, 2017. 218. Special rule for certain medical expenses incurred before establishment of health savings account (a) In general Section 223(d)(2) of the Internal Revenue Code of 1986 is amended by adding at the end the following new subparagraph: (D) Treatment of certain medical expenses incurred before establishment of account If a health savings account is established during the 60-day period beginning on the date that coverage of the account beneficiary under a high deductible health plan begins, then, solely for purposes of determining whether an amount paid is used for a qualified medical expense, such account shall be treated as having been established on the date that such coverage begins. . (b) Effective date The amendment made by this section shall apply with respect to coverage beginning after December 31, 2017. B Repeal of certain consumer taxes 221. Repeal of tax on prescription medications Section 9008 of the Patient Protection and Affordable Care Act is amended by adding at the end the following new subsection: (l) Termination No fee shall be imposed under subsection (a)(1) with respect to any calendar year beginning after December 31, 2017. . 222. Repeal of health insurance tax Section 9010 of the Patient Protection and Affordable Care Act is amended by adding at the end the following new subsection: (k) Termination No fee shall be imposed under subsection (a)(1) with respect to any calendar year beginning after December 31, 2017. . C Repeal of Tanning Tax 231. Repeal of tanning tax (a) In general The Internal Revenue Code of 1986 is amended by striking chapter 49. (b) Effective date The amendment made by this section shall apply to services performed after December 31, 2017. D Remuneration from Certain Insurers 241. Remuneration from certain insurers Paragraph (6) of section 162(m) of the Internal Revenue Code of 1986 is amended by adding at the end the following new subparagraph: (I) Termination This paragraph shall not apply to taxable years beginning after December 31, 2017. . E Repeal of Net Investment Income Tax 251. Repeal of net investment income tax (a) In general Subtitle A of the Internal Revenue Code of 1986 is amended by striking chapter 2A. (b) Effective date The amendment made by this section shall apply to taxable years beginning after December 31, 2017.

March 20, 2017 Committed to the Committee of the Whole House on the State of the Union and ordered to be printed

tv_txt: IB 115th CONGRESS 1st Session H. R. 1628 IN THE HOUSE OF REPRESENTATIVES AN ACT To provide for reconciliation pursuant to title II of the concurrent resolution on the budget for fiscal year 2017.

1. Short title This Act may be cited as the American Health Care Act of 2017 . 2. Table of contents The table of contents of this Act is as follows: Sec. 1. Short title. Sec. 2. Table of contents. Title I—Energy and Commerce Subtitle A—Patient Access to Public Health Programs Sec. 101. The Prevention and Public Health Fund. Sec. 102. Community health center program. Sec. 103. Federal payments to States. Subtitle B—Medicaid Program Enhancement Sec. 111. Repeal of Medicaid provisions. Sec. 112. Repeal of Medicaid expansion. Sec. 113. Elimination of DSH cuts. Sec. 114. Reducing State Medicaid costs. Sec. 115. Safety net funding for non-expansion States. Sec. 116. Providing incentives for increased frequency of eligibility redeterminations. Sec. 117. Permitting States to apply a work requirement for nondisabled, nonelderly, nonpregnant adults under Medicaid. Subtitle C—Per Capita Allotment for Medical Assistance Sec. 121. Per capita allotment for medical assistance. Subtitle D—Patient Relief and Health Insurance Market Stability Sec. 131. Repeal of cost-sharing subsidy. Sec. 132. Patient and State Stability Fund. Sec. 133. Continuous health insurance coverage incentive. Sec. 134. Increasing coverage options. Sec. 135. Change in permissible age variation in health insurance premium rates. Subtitle E—Implementation Funding Sec. 141. American Health Care Implementation Fund. Title II—Committee on Ways and Means Subtitle A—Repeal and Replace of Health-Related Tax Policy Sec. 201. Recapture excess advance payments of premium tax credits. Sec. 202. Additional modifications to premium tax credit. Sec. 203. Small business tax credit. Sec. 204. Individual mandate. Sec. 205. Employer mandate. Sec. 206. Repeal of the tax on employee health insurance premiums and health plan benefits. Sec. 207. Repeal of tax on over-the-counter medications. Sec. 208. Repeal of increase of tax on health savings accounts. Sec. 209. Repeal of limitations on contributions to flexible spending accounts. Sec. 210. Repeal of medical device excise tax. Sec. 211. Repeal of elimination of deduction for expenses allocable to medicare part D subsidy. Sec. 212. Reduction of income threshold for determining medical care deduction. Sec. 213. Repeal of Medicare tax increase. Sec. 214. Refundable tax credit for health insurance coverage. Sec. 215. Maximum contribution limit to health savings account increased to amount of deductible and out-of-pocket limitation. Sec. 216. Allow both spouses to make catch-up contributions to the same health savings account. Sec. 217. Special rule for certain medical expenses incurred before establishment of health savings account. Subtitle B—Repeal of certain consumer taxes Sec. 221. Repeal of tax on prescription medications. Sec. 222. Repeal of health insurance tax. Subtitle C—Repeal of Tanning Tax Sec. 231. Repeal of tanning tax. Subtitle D—Remuneration from Certain Insurers Sec. 241. Remuneration from certain insurers. Subtitle E—Repeal of Net Investment Income Tax Sec. 251. Repeal of net investment income tax. I Energy and Commerce A Patient Access to Public Health Programs 101. The Prevention and Public Health Fund (a) In general Subsection (b) of section 4002 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 300u–11 ), as amended by section 5009 of the 21st Century Cures Act, is amended— (1) in paragraph (2), by adding and at the end; (2) in paragraph (3)— (A) by striking each of fiscal years 2018 and 2019 and inserting fiscal year 2018 ; and (B) by striking the semicolon at the end and inserting a period; and (3) by striking paragraphs (4) through (8). (b) Rescission of unobligated funds Of the funds made available by such section 4002, the unobligated balance at the end of fiscal year 2018 is rescinded. 102. Community health center program Effective as if included in the enactment of the Medicare Access and CHIP Reauthorization Act of 2015 ( Public Law 114–10 , 129 Stat. 87), paragraph (1) of section 221(a) of such Act is amended by inserting , and an additional $422,000,000 for fiscal year 2017 after 2017 . 103. Federal payments to States (a) In general Notwithstanding section 504(a), 1902(a)(23), 1903(a), 2002, 2005(a)(4), 2102(a)(7), or 2105(a)(1) of the Social Security Act ( 42 U.S.C. 704(a) , 1396a(a)(23), 1396b(a), 1397a, 1397d(a)(4), 1397bb(a)(7), 1397ee(a)(1)), or the terms of any Medicaid waiver in effect on the date of enactment of this Act that is approved under section 1115 or 1915 of the Social Security Act ( 42 U.S.C. 1315 , 1396n), for the 1-year period beginning on the date of the enactment of this Act, no Federal funds provided from a program referred to in this subsection that is considered direct spending for any year may be made available to a State for payments to a prohibited entity, whether made directly to the prohibited entity or through a managed care organization under contract with the State. (b) Definitions In this section: (1) Prohibited entity The term prohibited entity means an entity, including its affiliates, subsidiaries, successors, and clinics— (A) that, as of the date of enactment of this Act— (i) is an organization described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from tax under section 501(a) of such Code; (ii) is an essential community provider described in section 156.235 of title 45, Code of Federal Regulations (as in effect on the date of enactment of this Act), that is primarily engaged in family planning services, reproductive health, and related medical care; and (iii) provides for abortions, other than an abortion— (I) if the pregnancy is the result of an act of rape or incest; or (II) in the case where a woman suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the woman in danger of death unless an abortion is performed, including a life-endangering physical condition caused by or arising from the pregnancy itself; and (B) for which the total amount of Federal and State expenditures under the Medicaid program under title XIX of the Social Security Act in fiscal year 2014 made directly to the entity and to any affiliates, subsidiaries, successors, or clinics of the entity, or made to the entity and to any affiliates, subsidiaries, successors, or clinics of the entity as part of a nationwide health care provider network, exceeded $350,000,000. (2) Direct spending The term direct spending has the meaning given that term under section 250(c) of the Balanced Budget and Emergency Deficit Control Act of 1985 ( 2 U.S.C. 900(c) ). B Medicaid Program Enhancement 111. Repeal of Medicaid provisions The Social Security Act is amended— (1) in section 1902 ( 42 U.S.C. 1396a )— (A) in subsection (a)(47)(B), by inserting and provided that any such election shall cease to be effective on January 1, 2020, and no such election shall be made after that date before the semicolon at the end; and (B) in subsection (l)(2)(C), by inserting and ending December 31, 2019, after January 1, 2014, ; (2) in section 1915(k)(2) ( 42 U.S.C. 1396n(k)(2) ), by striking during the period described in paragraph (1) and inserting on or after the date referred to in paragraph (1) and before January 1, 2020 ; and (3) in section 1920(e) ( 42 U.S.C. 1396r–1(e) ), by striking under clause (i)(VIII), clause (i)(IX), or clause (ii)(XX) of subsection (a)(10)(A) and inserting under clause (i)(VIII) or clause (ii)(XX) of section 1902(a)(10)(A) before January 1, 2020, section 1902(a)(10)(A)(i)(IX), . 112. Repeal of Medicaid expansion (a) In general Title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq.) is amended— (1) in section 1902 ( 42 U.S.C. 1396a )— (A) in subsection (a)(10)(A)— (i) in clause (i)(VIII), by inserting and ending December 31, 2019, after 2014, ; (ii) in clause (ii)(XX), by inserting and ending December 31, 2017, after 2014, ; and (iii) in clause (ii), by adding at the end the following new subclause: (XXIII) beginning January 1, 2020— (aa) who are expansion enrollees (as defined in subsection (nn)(1)); or (bb) who are grandfathered expansion enrollees (as defined in subsection (nn)(2)); ; and (B) by adding at the end the following new subsection: (nn) Expansion enrollees In this title: (1) In general The term expansion enrollee means an individual— (A) who is under 65 years of age; (B) who is not pregnant; (C) who is not entitled to, or enrolled for, benefits under part A of title XVIII, or enrolled for benefits under part B of title XVIII; (D) who is not described in any of subclauses (I) through (VII) of subsection (a)(10)(A)(i); and (E) whose income (as determined under subsection (e)(14)) does not exceed 133 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved. (2) Grandfathered expansion enrollees The term grandfathered expansion enrollee means an expansion enrollee who— (A) was enrolled under the State plan under this title (or under a waiver of such plan) as of December 31, 2019; and (B) does not have a break in eligibility for medical assistance under such State plan (or waiver) for more than one month after such date. (3) Application of related provisions Any reference in subsection (a)(10)(G), (k), or (gg) of this section or in section 1903, 1905(a), 1920(e), or 1937(a)(1)(B) to individuals described in subclause (VIII) of subsection (a)(10)(A)(i) shall be deemed to include a reference to expansion enrollees (including grandfathered expansion enrollees). ; and (2) in section 1905 ( 42 U.S.C. 1396d )— (A) in subsection (y)(1), in the matter preceding subparagraph (A)— (i) by inserting and that has elected to cover newly eligible individuals before March 1, 2017 after that is one of the 50 States or the District of Columbia ; and (ii) by inserting after subclause (VIII) of section 1902(a)(10)(A)(i) the following: who, for periods after December 31, 2019, are grandfathered expansion enrollees (as defined in section 1902(nn)(2)) ; and (B) in subsection (z)(2)— (i) in subparagraph (A), by inserting after section 1937 the following: and, for periods after December 31, 2019, who are grandfathered expansion enrollees (as defined in section 1902(nn)(2)) ; and (ii) in subparagraph (B)(ii)— (I) in subclause (III), by adding and at the end; and (II) by striking subclauses (IV), (V), and (VI) and inserting the following new subclause: (IV) 2017 and each subsequent year is 80 percent. . (b) Sunset of essential health benefits requirement Section 1937(b)(5) of the Social Security Act ( 42 U.S.C. 1396u–7(b)(5) ) is amended by adding at the end the following: This paragraph shall not apply after December 31, 2019. . 113. Elimination of DSH cuts Section 1923(f) of the Social Security Act ( 42 U.S.C. 1396r–4(f) ) is amended— (1) in paragraph (7)— (A) in subparagraph (A)— (i) in clause (i)— (I) in the matter preceding subclause (I), by striking 2025 and inserting 2019 ; and (ii) in clause (ii)— (I) in subclause (I), by adding and at the end; (II) in subclause (II), by striking the semicolon at the end and inserting a period; and (III) by striking subclauses (III) through (VIII); and (B) by adding at the end the following new subparagraph: (C) Exemption from Reduction for non-expansion States (i) In general In the case of a State that is a non-expansion State for a fiscal year, subparagraph (A)(i) shall not apply to the DSH allotment for such State and fiscal year. (ii) No change in reduction for expansion States In the case of a State that is an expansion State for a fiscal year, the DSH allotment for such State and fiscal year shall be determined as if clause (i) did not apply. (iii) Non-expansion and expansion State defined (I) The term expansion State means with respect to a fiscal year, a State that, as of July 1 of the preceding fiscal year, provides for eligibility under clause (i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) for medical assistance under this title (or a waiver of the State plan approved under section 1115). (II) The term non-expansion State means, with respect to a fiscal year, a State that is not an expansion State. ; and (2) in paragraph (8), by striking fiscal year 2025 and inserting fiscal year 2019 . 114. Reducing State Medicaid costs (a) Letting States disenroll high dollar lottery winners (1) In general Section 1902 of the Social Security Act ( 42 U.S.C. 1396a ) is amended— (A) in subsection (a)(17), by striking (e)(14), (e)(14) and inserting (e)(14), (e)(15) ; and (B) in subsection (e)— (i) in paragraph (14) (relating to modified adjusted gross income), by adding at the end the following new subparagraph : (J) Treatment of certain lottery winnings and income received as a lump sum (i) In general In the case of an individual who is the recipient of qualified lottery winnings (pursuant to lotteries occurring on or after January 1, 2020) or qualified lump sum income (received on or after such date) and whose eligibility for medical assistance is determined based on the application of modified adjusted gross income under subparagraph (A), a State shall, in determining such eligibility, include such winnings or income (as applicable) as income received— (I) in the month in which such winnings or income (as applicable) is received if the amount of such winnings or income is less than $80,000; (II) over a period of 2 months if the amount of such winnings or income (as applicable) is greater than or equal to $80,000 but less than $90,000; (III) over a period of 3 months if the amount of such winnings or income (as applicable) is greater than or equal to $90,000 but less than $100,000; and (IV) over a period of 3 months plus 1 additional month for each increment of $10,000 of such winnings or income (as applicable) received, not to exceed a period of 120 months (for winnings or income of $1,260,000 or more), if the amount of such winnings or income is greater than or equal to $100,000. (ii) Counting in equal installments For purposes of subclauses (II), (III), and (IV) of clause (i), winnings or income to which such subclause applies shall be counted in equal monthly installments over the period of months specified under such subclause. (iii) Hardship exemption An individual whose income, by application of clause (i), exceeds the applicable eligibility threshold established by the State, may continue to be eligible for medical assistance to the extent that the State determines, under procedures established by the State under the State plan (or in the case of a waiver of the plan under section 1115, incorporated in such waiver), or as otherwise established by such State in accordance with such standards as may be specified by the Secretary, that the denial of eligibility of the individual would cause an undue medical or financial hardship as determined on the basis of criteria established by the Secretary. (iv) Notifications and assistance required in case of loss of eligibility A State shall, with respect to an individual who loses eligibility for medical assistance under the State plan (or a waiver of such plan) by reason of clause (i), before the date on which the individual loses such eligibility, inform the individual of the date on which the individual would no longer be considered ineligible by reason of such clause to receive medical assistance under the State plan or under any waiver of such plan and the date on which the individual would be eligible to reapply to receive such medical assistance. (v) Qualified lottery winnings defined In this subparagraph, the term qualified lottery winnings means winnings from a sweepstakes, lottery, or pool described in paragraph (3) of section 4402 of the Internal Revenue Code of 1986 or a lottery operated by a multistate or multijurisdictional lottery association, including amounts awarded as a lump sum payment. (vi) Qualified lump sum income defined In this subparagraph, the term qualified lump sum income means income that is received as a lump sum from one of the following sources: (I) Monetary winnings from gambling (as defined by the Secretary and including monetary winnings from gambling activities described in section 1955(b)(4) of title 18, United States Code). (II) Income received as liquid assets from the estate (as defined in section 1917(b)(4)) of a deceased individual. ; and (ii) by striking (14) Exclusion and inserting (15) Exclusion . (2) Rules of construction (A) Interception of lottery winnings allowed Nothing in the amendment made by paragraph (1)(B)(i) shall be construed as preventing a State from intercepting the State lottery winnings awarded to an individual in the State to recover amounts paid by the State under the State Medicaid plan under title XIX of the Social Security Act for medical assistance furnished to the individual. (B) Applicability limited to eligibility of recipient of lottery winnings or lump sum income Nothing in the amendment made by paragraph (1)(B)(i) shall be construed, with respect to a determination of household income for purposes of a determination of eligibility for medical assistance under the State plan under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq.) (or a waiver of such plan) made by applying modified adjusted gross income under subparagraph (A) of section 1902(e)(14) of such Act ( 42 U.S.C. 1396a(e)(14) ), as limiting the eligibility for such medical assistance of any individual that is a member of the household other than the individual (or the individual’s spouse) who received qualified lottery winnings or qualified lump-sum income (as defined in subparagraph (J) of such section 1902(e)(14), as added by paragraph (1)(B)(i) of this subsection). (b) Repeal of retroactive eligibility (1) In general (A) State plan requirements Section 1902(a)(34) of the Social Security Act ( 42 U.S.C. 1396a(a)(34) ) is amended by striking in or after the third month before the month in which he made application and inserting in or after the month in which the individual made application . (B) Definition of medical assistance Section 1905(a) of the Social Security Act ( 42 U.S.C. 1396d(a) ) is amended by striking in or after the third month before the month in which the recipient makes application for assistance and inserting in or after the month in which the recipient makes application for assistance . (2) Effective date The amendments made by paragraph (1) shall apply to medical assistance with respect to individuals whose eligibility for such assistance is based on an application for such assistance made (or deemed to be made) on or after October 1, 2017. (c) Updating allowable home equity limits in Medicaid (1) In general Section 1917(f)(1) of the Social Security Act ( 42 U.S.C. 1396p(f)(1) ) is amended— (A) in subparagraph (A), by striking subparagraphs (B) and (C) and inserting subparagraph (B) ; (B) by striking subparagraph (B); (C) by redesignating subparagraph (C) as subparagraph (B); and (D) in subparagraph (B), as so redesignated, by striking dollar amounts specified in this paragraph and inserting dollar amount specified in subparagraph (A) . (2) Effective date (A) In general The amendments made by paragraph (1) shall apply with respect to eligibility determinations made after the date that is 180 days after the date of the enactment of this section. (B) Exception for State legislation In the case of a State plan under title XIX of the Social Security Act that the Secretary of Health and Human Services determines requires State legislation in order for the respective plan to meet any requirement imposed by amendments made by this subsection, 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 an 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 the 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 shall be considered to be a separate regular session of the State legislature. 115. Safety net funding for non-expansion States Title XIX of the Social Security Act is amended by inserting after section 1923 ( 42 U.S.C. 1396r–4 ) the following new section: 1923A. Adjustment in payment for services of safety net providers in non-expansion States (a) In general Subject to the limitations of this section, for each year during the period beginning with fiscal year 2018 and ending with fiscal year 2022, each State that is one of the 50 States or the District of Columbia and that, as of July 1 of the preceding fiscal year, did not provide for eligibility under clause (i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) for medical assistance under this title (or a waiver of the State plan approved under section 1115) (each such State or District referred to in this section for the fiscal year as a non-expansion State ) may adjust the payment amounts otherwise provided under the State plan under this title (or a waiver of such plan) to health care providers that provide health care services to individuals enrolled under this title (in this section referred to as eligible providers ) so long as the payment adjustment to such an eligible provider does not exceed the provider’s costs in furnishing health care services (as determined by the Secretary and net of payments under this title, other than under this section, and by uninsured patients) to individuals who either are eligible for medical assistance under the State plan (or under a waiver of such plan) or have no health insurance or health plan coverage for such services. (b) Increase in applicable FMAP Notwithstanding section 1905(b), the Federal medical assistance percentage applicable with respect to expenditures attributable to a payment adjustment under subsection (a) for which payment is permitted under subsection (c) shall be equal to— (1) 100 percent for calendar quarters in fiscal years 2018, 2019, 2020, and 2021; and (2) 95 percent for calendar quarters in fiscal year 2022. (c) Annual allotment limitation Payment under section 1903(a) shall not be made to a State with respect to any payment adjustment made under this section for all calendar quarters in a fiscal year in excess of the $2,000,000,000 multiplied by the ratio of— (1) the population of the State with income below 138 percent of the poverty line in 2015 (as determined based the table entitled Health Insurance Coverage Status and Type by Ratio of Income to Poverty Level in the Past 12 Months by Age for the universe of the civilian noninstitutionalized population for whom poverty status is determined based on the 2015 American Community Survey 1–Year Estimates, as published by the Bureau of the Census), to (2) the sum of the populations under paragraph (1) for all non-expansion States. (d) Disqualification in case of State coverage expansion If a State is a non-expansion for a fiscal year and provides eligibility for medical assistance described in subsection (a) during the fiscal year, the State shall no longer be treated as a non-expansion State under this section for any subsequent fiscal years. . 116. Providing incentives for increased frequency of eligibility redeterminations (a) In general Section 1902(e)(14) of the Social Security Act ( 42 U.S.C. 1396a(e)(14) ) (relating to modified adjusted gross income), as amended by section 114(a)(1), is further amended by adding at the end the following: (K) Frequency of eligibility redeterminations Beginning on October 1, 2017, and notwithstanding subparagraph (H), in the case of an individual whose eligibility for medical assistance under the State plan under this title (or a waiver of such plan) is determined based on the application of modified adjusted gross income under subparagraph (A) and who is so eligible on the basis of clause (i)(VIII) or clause (ii)(XX) of subsection (a)(10)(A), a State shall redetermine such individual’s eligibility for such medical assistance no less frequently than once every 6 months. . (b) Increased administrative matching percentage For each calendar quarter during the period beginning on October 1, 2017, and ending on December 31, 2019, the Federal matching percentage otherwise applicable under section 1903(a) of the Social Security Act ( 42 U.S.C. 1396b(a) ) with respect to State expenditures during such quarter that are attributable to meeting the requirement of section 1902(e)(14) (relating to determinations of eligibility using modified adjusted gross income) of such Act shall be increased by 5 percentage points with respect to State expenditures attributable to activities carried out by the State (and approved by the Secretary) to increase the frequency of eligibility redeterminations required by subparagraph (K) of such section (relating to eligibility redeterminations made on a 6-month basis) (as added by subsection (a)). 117. Permitting States to apply a work requirement for nondisabled, nonelderly, nonpregnant adults under Medicaid (a) In general Section 1902 of the Social Security Act ( 42 U.S.C. 1396a ), as previously amended, is further amended by adding at the end the following new subsection: (oo) Work requirement option for nondisabled, nonelderly, nonpregnant adults (1) In general Beginning October 1, 2017, subject to paragraph (3), a State may elect to condition medical assistance to a nondisabled, nonelderly, nonpregnant individual under this title upon such an individual’s satisfaction of a work requirement (as defined in paragraph (2)). (2) Work requirement defined In this section, the term work requirement means, with respect to an individual, the individual’s participation in work activities (as defined in section 407(d)) for such period of time as determined by the State, and as directed and administered by the State. (3) Required exceptions States administering a work requirement under this subsection may not apply such requirement to— (A) a woman during pregnancy through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends; (B) an individual who is under 19 years of age; (C) an individual who is the only parent or caretaker relative in the family of a child who has not attained 6 years of age or who is the only parent or caretaker of a child with disabilities; or (D) an individual who is married or a head of household and has not attained 20 years of age and who— (i) maintains satisfactory attendance at secondary school or the equivalent; or (ii) participates in education directly related to employment. . (b) Increase in matching rate for implementation Section 1903 of the Social Security Act ( 42 U.S.C. 1396b ) is amended by adding at the end the following: (aa) The Federal matching percentage otherwise applicable under subsection (a) with respect to State administrative expenditures during a calendar quarter for which the State receives payment under such subsection shall, in addition to any other increase to such Federal matching percentage, be increased for such calendar quarter by 5 percentage points with respect to State expenditures attributable to activities carried out by the State (and approved by the Secretary) to implement subsection (oo) of section 1902. . C Per Capita Allotment for Medical Assistance 121. Per capita allotment for medical assistance Title XIX of the Social Security Act is amended— (1) in section 1903 ( 42 U.S.C. 1396b )— (A) in subsection (a), in the matter before paragraph (1), by inserting and section 1903A(a) after except as otherwise provided in this section ; and (B) in subsection (d)(1), by striking to which and inserting to which, subject to section 1903A(a), ; and (2) by inserting after such section 1903 the following new section: 1903A. Per capita-based cap on payments for medical assistance (a) Application of per capita cap on payments for medical assistance expenditures (1) In general If a State has excess aggregate medical assistance expenditures (as defined in paragraph (2)) for a fiscal year (beginning with fiscal year 2020), the amount of payment to the State under section 1903(a)(1) for each quarter in the following fiscal year shall be reduced by ¼ of the excess aggregate medical assistance payments (as defined in paragraph (3)) for that previous fiscal year. In this section, the term State means only the 50 States and the District of Columbia. (2) Excess aggregate medical assistance expenditures In this subsection, the term excess aggregate medical assistance expenditures means, for a State for a fiscal year, the amount (if any) by which— (A) the amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State and fiscal year; exceeds (B) the amount of the target total medical assistance expenditures (as defined in subsection (c)) for the State and fiscal year. (3) Excess aggregate medical assistance payments In this subsection, the term excess aggregate medical assistance payments means, for a State for a fiscal year, the product of— (A) the excess aggregate medical assistance expenditures (as defined in paragraph (2)) for the State for the fiscal year; and (B) the Federal average medical assistance matching percentage (as defined in paragraph (4)) for the State for the fiscal year. (4) Federal average medical assistance matching percentage In this subsection, the term Federal average medical assistance matching percentage means, for a State for a fiscal year, the ratio (expressed as a percentage) of— (A) the amount of the Federal payments that would be made to the State under section 1903(a)(1) for medical assistance expenditures for calendar quarters in the fiscal year if paragraph (1) did not apply; to (B) the amount of the medical assistance expenditures for the State and fiscal year. (b) Adjusted total medical assistance expenditures Subject to subsection (g), the following shall apply: (1) In general In this section, the term adjusted total medical assistance expenditures means, for a State— (A) for fiscal year 2016, the product of— (i) the amount of the medical assistance expenditures (as defined in paragraph (2)) for the State and fiscal year, reduced by the amount of any excluded expenditures (as defined in paragraph (3)) for the State and fiscal year otherwise included in such medical assistance expenditures; and (ii) the 1903A FY16 population percentage (as defined in paragraph (4)) for the State; or (B) for fiscal year 2019 or a subsequent fiscal year, the amount of the medical assistance expenditures (as defined in paragraph (2)) for the State and fiscal year that is attributable to 1903A enrollees, reduced by the amount of any excluded expenditures (as defined in paragraph (3)) for the State and fiscal year otherwise included in such medical assistance expenditures and includes non-DSH supplemental payments (as defined in subsection (d)(4)(A)(ii)) and payments described in subsection (d)(4)(A)(iii) but shall not be construed as including any expenditures attributable to the program under section 1928. In applying subparagraph (B), non-DSH supplemental payments (as defined in subsection (d)(4)(A)(ii)) and payments described in subsection (d)(4)(A)(iii) shall be treated as fully attributable to 1903A enrollees. (2) Medical assistance expenditures In this section, the term medical assistance expenditures means, for a State and fiscal year, the medical assistance payments as reported by medical service category on the Form CMS-64 quarterly expense report (or successor to such a report form, and including enrollment data and subsequent adjustments to any such report, in this section referred to collectively as a CMS-64 report ) for which payment is (or may otherwise be) made pursuant to section 1903(a)(1). (3) Excluded expenditures In this section, the term excluded expenditures means, for a State and fiscal year, expenditures under the State plan (or under a waiver of such plan) that are attributable to any of the following: (A) DSH Payment adjustments made for disproportionate share hospitals under section 1923. (B) Medicare cost-sharing Payments made for medicare cost-sharing (as defined in section 1905(p)(3)). (C) Safety net provider payment adjustments in non-expansion States Payment adjustments under subsection (a) of section 1923A for which payment is permitted under subsection (c) of such section. (4) 1903A FY 16 population percentage In this subsection, the term 1903A FY16 population percentage means, for a State, the Secretary’s calculation of the percentage of the actual medical assistance expenditures, as reported by the State on the CMS–64 reports for calendar quarters in fiscal year 2016, that are attributable to 1903A enrollees (as defined in subsection (e)(1)). (c) Target total medical assistance expenditures (1) Calculation In this section, the term target total medical assistance expenditures means, for a State for a fiscal year and subject to paragraph (4), the sum of the products, for each of the 1903A enrollee categories (as defined in subsection (e)(2)), of— (A) the target per capita medical assistance expenditures (as defined in paragraph (2)) for the enrollee category, State, and fiscal year; and (B) the number of 1903A enrollees for such enrollee category, State, and fiscal year, as determined under subsection (e)(4). (2) Target per capita medical assistance expenditures In this subsection, the term ‘target per capita medical assistance expenditures’ means, for a 1903A enrollee category and State— (A) for fiscal year 2020, an amount equal to— (i) the provisional FY19 target per capita amount for such enrollee category (as calculated under subsection (d)(5)) for the State; increased by (ii) the applicable annual inflation factor (as defined in paragraph (3)) for fiscal year 2020; and (B) for each succeeding fiscal year, an amount equal to— (i) the target per capita medical assistance expenditures (under subparagraph (A) or this subparagraph) for the 1903A enrollee category and State for the preceding fiscal year, increased by (ii) the applicable annual inflation factor for that succeeding fiscal year. (3) Applicable annual inflation factor In paragraph (2), the term applicable annual inflation factor means, for a fiscal year— (A) for each of the 1903A enrollee categories described in subparagraphs (C), (D), and (E) of subsection (e)(2), the percentage increase in the medical care component of the consumer price index for all urban consumers (U.S. city average) from September of the previous fiscal year to September of the fiscal year involved; and (B) for each of the 1903A enrollee categories described in subparagraphs (A) and (B) of subsection (e)(2), the percentage increase described in subparagraph (A) plus 1 percentage point. (4) Decrease in target expenditures for required expenditures by certain political subdivisions (A) In general In the case of a State that had a DSH allotment under section 1923(f) for fiscal year 2016 that was more than 6 times the national average of such allotments for all the States for such fiscal year and that requires political subdivisions within the State to contribute funds towards medical assistance or other expenditures under the State plan under this title (or under a waiver of such plan) for a fiscal year (beginning with fiscal year 2020), the target total medical assistance expenditures for such State and fiscal year shall be decreased by the amount that political subdivisions in the State are required to contribute under the plan (or waiver) without reimbursement from the State for such fiscal year, other than contributions described in subparagraph (B). (B) Exceptions The contributions described in this subparagraph are the following: (i) Contributions required by a State from a political subdivision that, as of the first day of the calendar year in which the fiscal year involved begins— (I) has a population of more than 5,000,000, as estimated by the Bureau of the Census; and (II) imposes a local income tax upon its residents. (ii) Contributions required by a State from a political subdivision for administrative expenses if the State required such contributions from such subdivision without reimbursement from the State as of January 1, 2017. (d) Calculation of FY19 provisional target amount for each 1903A enrollee category Subject to subsection (g), the following shall apply: (1) Calculation of base amounts for fiscal year 2016 For each State the Secretary shall calculate (and provide notice to the State not later than April 1, 2018, of) the following: (A) The amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State for fiscal year 2016. (B) The number of 1903A enrollees for the State in fiscal year 2016 (as determined under subsection (e)(4)). (C) The average per capita medical assistance expenditures for the State for fiscal year 2016 equal to— (i) the amount calculated under subparagraph (A); divided by (ii) the number calculated under subparagraph (B). (2) Fiscal year 2019 average per capita amount based on inflating the fiscal year 2016 amount to fiscal year 2019 by CPI-medical The Secretary shall calculate a fiscal year 2019 average per capita amount for each State equal to— (A) the average per capita medical assistance expenditures for the State for fiscal year 2016 (calculated under paragraph (1)(C)); increased by (B) the percentage increase in the medical care component of the consumer price index for all urban consumers (U.S. city average) from September, 2016 to September, 2019. (3) Aggregate and average expenditures per capita for fiscal year 2019 The Secretary shall calculate for each State the following: (A) The amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State for fiscal year 2019. (B) The number of 1903A enrollees for the State in fiscal year 2019 (as determined under subsection (e)(4)). (4) Per capita expenditures for fiscal year 2019 for each 1903A enrollee category The Secretary shall calculate (and provide notice to each State not later than January 1, 2020, of) the following: (A) (i) For each 1903A enrollee category, the amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State for fiscal year 2019 for individuals in the enrollee category, calculated by excluding from medical assistance expenditures those expenditures attributable to expenditures described in clause (iii) or non-DSH supplemental expenditures (as defined in clause (ii)). (ii) In this paragraph, the term non-DSH supplemental expenditure means a payment to a provider under the State plan (or under a waiver of the plan) that— (I) is not made under section 1923; (II) is not made with respect to a specific item or service for an individual; (III) is in addition to any payments made to the provider under the plan (or waiver) for any such item or service; and (IV) complies with the limits for additional payments to providers under the plan (or waiver) imposed pursuant to section 1902(a)(30)(A), including the regulations specifying upper payment limits under the State plan in part 447 of title 42, Code of Federal Regulations (or any successor regulations). (iii) An expenditure described in this clause is an expenditure that meets the criteria specified in subclauses (I), (II), and (III) of clause (ii) and is authorized under section 1115 for the purposes of funding a delivery system reform pool, uncompensated care pool, a designated state health program, or any other similar expenditure (as defined by the Secretary). (B) For each 1903A enrollee category, the number of 1903A enrollees for the State in fiscal year 2019 in the enrollee category (as determined under subsection (e)(4)). (C) For fiscal year 2016, the State’s non-DSH supplemental and pool payment percentage is equal to the ratio (expressed as a percentage) of— (i) the total amount of non-DSH supplemental expenditures (as defined in subparagraph (A)(ii)) and payments described in subparagraph (A)(iii) for the State for fiscal year 2016; to (ii) the amount described in subsection (b)(1)(A) for the State for fiscal year 2016. (D) For each 1903A enrollee category an average medical assistance expenditures per capita for the State for fiscal year 2019 for the enrollee category equal to— (i) the amount calculated under subparagraph (A) for the State, increased by the non-DSH supplemental and pool payment percentage for the State (as calculated under subparagraph (C)); divided by (ii) the number calculated under subparagraph (B) for the State for the enrollee category. (5) Provisional FY19 per capita target amount for each 1903A enrollee category Subject to subsection (f)(2), the Secretary shall calculate for each State a provisional FY19 per capita target amount for each 1903A enrollee category equal to the average medical assistance expenditures per capita for the State for fiscal year 2019 (as calculated under paragraph (4)(D)) for such enrollee category multiplied by the ratio of— (A) the product of— (i) the fiscal year 2019 average per capita amount for the State, as calculated under paragraph (2); and (ii) the number of 1903A enrollees for the State in fiscal year 2019, as calculated under paragraph (3)(B); to (B) the amount of the adjusted total medical assistance expenditures for the State for fiscal year 2019, as calculated under paragraph (3)(A). (e) 1903A enrollee; 1903A enrollee category Subject to subsection (g), for purposes of this section, the following shall apply: (1) 1903A enrollee The term 1903A enrollee means, with respect to a State and a month and subject to subsection (i)(1)(B), any Medicaid enrollee (as defined in paragraph (3)) for the month, other than such an enrollee who for such month is in any of the following categories of excluded individuals: (A) CHIP An individual who is provided, under this title in the manner described in section 2101(a)(2), child health assistance under title XXI. (B) IHS An individual who receives any medical assistance under this title for services for which payment is made under the third sentence of section 1905(b). (C) Breast and cervical cancer services eligible individual An individual who is entitled to medical assistance under this title only pursuant to section 1902(a)(10)(A)(ii)(XVIII). (D) Partial-benefit enrollees An individual who— (i) is an alien who is entitled to medical assistance under this title only pursuant to section 1903(v)(2); (ii) is entitled to medical assistance under this title only pursuant to subclause (XII) or (XXI) of section 1902(a)(10)(A)(ii) (or pursuant to a waiver that provides only comparable benefits); (iii) is a dual eligible individual (as defined in section 1915(h)(2)(B)) and is entitled to medical assistance under this title (or under a waiver) only for some or all of medicare cost-sharing (as defined in section 1905(p)(3)); or (iv) is entitled to medical assistance under this title and for whom the State is providing a payment or subsidy to an employer for coverage of the individual under a group health plan pursuant to section 1906 or section 1906A (or pursuant to a waiver that provides only comparable benefits). (2) 1903A enrollee category The term 1903A enrollee category means each of the following: (A) Elderly A category of 1903A enrollees who are 65 years of age or older. (B) Blind and disabled A category of 1903A enrollees (not described in the previous subparagraph) who are eligible for medical assistance under this title on the basis of being blind or disabled. (C) Children A category of 1903A enrollees (not described in a previous subparagraph) who are children under 19 years of age. (D) Expansion enrollees A category of 1903A enrollees (not described in a previous subparagraph) for whom the amounts expended for medical assistance are subject to an increase or change in the Federal medical assistance percentage under subsection (y) or (z)(2), respectively, of section 1905. (E) Other nonelderly, nondisabled, non-expansion adults A category of 1903A enrollees who are not described in any previous subparagraph. (3) Medicaid enrollee The term Medicaid enrollee means, with respect to a State for a month, an individual who is eligible for medical assistance for items or services under this title and enrolled under the State plan (or a waiver of such plan) under this title for the month. (4) Determination of number of 1903A enrollees The number of 1903A enrollees for a State and fiscal year, and, if applicable, for a 1903A enrollee category, is the average monthly number of Medicaid enrollees for such State and fiscal year (and, if applicable, in such category) that are reported through the CMS–64 report under (and subject to audit under) subsection (h). (f) Special payment rules (1) Application in case of research and demonstration projects and other waivers In the case of a State with a waiver of the State plan approved under section 1115, section 1915, or another provision of this title, this section shall apply to medical assistance expenditures and medical assistance payments under the waiver, in the same manner as if such expenditures and payments had been made under a State plan under this title and the limitations on expenditures under this section shall supersede any other payment limitations or provisions (including limitations based on a per capita limitation) otherwise applicable under such a waiver. (2) Treatment of States expanding coverage after fiscal year 2016 In the case of a State that did not provide for medical assistance for the 1903A enrollee category described in subsection (e)(2)(D) during fiscal year 2016 but which provides for such assistance for such category in a subsequent year, the provisional FY19 per capita target amount for such enrollee category under subsection (d)(5) shall be equal to the provisional FY19 per capita target amount for the 1903A enrollee category described in subsection (e)(2)(E). (3) In case of State failure to report necessary data If a State for any quarter in a fiscal year (beginning with fiscal year 2019) fails to satisfactorily submit data on expenditures and enrollees in accordance with subsection (h)(1), for such fiscal year and any succeeding fiscal year for which such data are not satisfactorily submitted— (A) the Secretary shall calculate and apply subsections (a) through (e) with respect to the State as if all 1903A enrollee categories for which such expenditure and enrollee data were not satisfactorily submitted were a single 1903A enrollee category; and (B) the growth factor otherwise applied under subsection (c)(2)(B) shall be decreased by 1 percentage point. (g) Recalculation of certain amounts for data errors The amounts and percentage calculated under paragraphs (1) and (4)(C) of subsection (d) for a State for fiscal year 2016, and the amounts of the adjusted total medical assistance expenditures calculated under subsection (b) and the number of Medicaid enrollees and 1903A enrollees determined under subsection (e)(4) for a State for fiscal year 2016, fiscal year 2019, and any subsequent fiscal year, may be adjusted by the Secretary based upon an appeal (filed by the State in such a form, manner, and time, and containing such information relating to data errors that support such appeal, as the Secretary specifies) that the Secretary determines to be valid, except that any adjustment by the Secretary under this subsection for a State may not result in an increase of the target total medical assistance expenditures exceeding 2 percent. (h) Required reporting and auditing of CMS–64 data; transitional increase in Federal matching percentage for certain administrative expenses (1) Reporting In addition to the data required on form Group VIII on the CMS–64 report form as of January 1, 2017, in each CMS-64 report required to be submitted (for each quarter beginning on or after October 1, 2018), the State shall include data on medical assistance expenditures within such categories of services and categories of enrollees (including each 1903A enrollee category and each category of excluded individuals under subsection (e)(1)) and the numbers of enrollees within each of such enrollee categories, as the Secretary determines are necessary (including timely guidance published as soon as possible after the date of the enactment of this section) in order to implement this section and to enable States to comply with the requirement of this paragraph on a timely basis. (2) Auditing The Secretary shall conduct for each State an audit of the number of individuals and expenditures reported through the CMS–64 report for fiscal year 2016, fiscal year 2019, and each subsequent fiscal year, which audit may be conducted on a representative sample (as determined by the Secretary). (3) Temporary increase in federal matching percentage to support improved data reporting systems for fiscal years 2018 and 2019 For amounts expended during calendar quarters beginning on or after October 1, 2017, and before October 1, 2019— (A) the Federal matching percentage applied under section 1903(a)(3)(A)(i) shall be increased by 10 percentage points to 100 percent; (B) the Federal matching percentage applied under section 1903(a)(3)(B) shall be increased by 25 percentage points to 100 percent; and (C) the Federal matching percentage applied under section 1903(a)(7) shall be increased by 10 percentage points to 60 percent but only with respect to amounts expended that are attributable to a State’s additional administrative expenditures to implement the data requirements of paragraph (1). (i) Flexible block grant option for States (1) In general In the case of a State that elects the option of applying this subsection for a 10-fiscal-year period (beginning no earlier than fiscal year 2020 and, at the State option, for any succeeding 10-fiscal-year period) and that has a plan approved by the Secretary under paragraph (2) to carry out the option for such period— (A) the State shall receive, instead of amounts otherwise payable to the State under this title for medical assistance for block grant individuals within the applicable block grant category (as defined in paragraph (6)) for the State during the period in which the election is in effect, the amount specified in paragraph (4); (B) the previous provisions of this section shall be applied as if— (i) block grant individuals within the applicable block grant category for the State and period were not section 1903A enrollees for each 10-fiscal year period for which the State elects to apply this subsection; and (ii) if such option is not extended at the end of a 10-fiscal-year-period, the per capita limitations under such previous provisions shall again apply after such period and such limitations shall be applied as if the election under this subsection had never taken place; (C) the payment under this subsection may only be used consistent with the State plan under paragraph (2) for block grant health care assistance (as defined in paragraph (7)); and (D) with respect to block grant individuals within the applicable block grant category for the State for which block grant health care assistance is made available under this subsection, such assistance shall be instead of medical assistance otherwise provided to the individual under this title. (2) State plan for administering block grant option (A) In general No payment shall be made under this subsection to a State pursuant to an election for a 10-fiscal-year period under paragraph (1) unless the State has a plan, approved under subparagraph (B), for such period that specifies— (i) the applicable block grant category with respect to which the State will apply the option under this subsection for such period; (ii) the conditions for eligibility of block grant individuals within such applicable block grant category for block grant health care assistance under the option, which shall be instead of other conditions for eligibility under this title, except that in the case of a State that has elected the applicable block grant category described in— (I) subparagraph (A) of paragraph (6), the plan must provide for eligibility for pregnant women and children required to be provided medical assistance under subsections (a)(10)(A)(i) and (e)(4) of section 1902; or (II) subparagraph (B) of paragraph (6), the plan must provide for eligibility for pregnant women required to be provided medical assistance under subsection (a)(10)(A)(i); and (iii) the types of items and services, the amount, duration, and scope of such services, the cost-sharing with respect to such services, and the method for delivery of block grant health care assistance under this subsection, which shall be instead of the such types, amount, duration, and scope, cost-sharing, and methods of delivery for medical assistance otherwise required under this title, except that the plan must provide for assistance for— (I) hospital care; (II) surgical care and treatment; (III) medical care and treatment; (IV) obstetrical and prenatal care and treatment; (V) prescribed drugs, medicines, and prosthetic devices; (VI) other medical supplies and services; and (VII) health care for children under 18 years of age. (B) Review and approval A plan described in subparagraph (A) shall be deemed approved by the Secretary unless the Secretary determines, within 30 days after the date of the Secretary’s receipt of the plan, that the plan is incomplete or actuarially unsound and, with respect to such plan and its implementation under this subsection, the requirements of paragraphs (1), (10)(B), (17), and (23) of section 1902(a) shall not apply. (3) Amount of block grant funds (A) For initial fiscal year The block grant amount under this paragraph for a State for the initial fiscal year in the first 10-fiscal-year period is equal to the sum of the products (for each applicable block grant category for such State and period) of— (i) the target per capita medical assistance expenditures for such State for such fiscal year (under subsection (c)(2)); (ii) the number of 1903A enrollees for such category and State for fiscal year 2019, as determined under subsection (e)(4); and (iii) the Federal average medical assistance matching percentage (as defined in subsection (a)(4)) for the State for fiscal year 2019. (B) For any subsequent fiscal year The block grant amount under this paragraph for a State for each succeeding fiscal year (in any 10-fiscal-year period) is equal to the block grant amount under subparagraph (A) (or this subparagraph) for the State for the previous fiscal year increased by the annual increase in the consumer price index for all urban consumers (all items; U.S. city average) for the fiscal year involved. (C) Availability of rollover funds The block grant amount under this paragraph for a State for a fiscal year shall remain available to the State for expenditures under this subsection for the succeeding fiscal year but only if an election is in effect under this subsection for the State in such succeeding fiscal year. (4) Federal payment and State responsibility The Secretary shall pay to each State with an election in effect under this subsection for a fiscal year, from its block grant amount under paragraph (3) available for such fiscal year, an amount for each quarter of such fiscal year equal to the enhanced FMAP described in the first sentence of section 2105(b) of the total amount expended under the State plan under this subsection during such quarter, and the State is responsible for the balance of funds to carry out such plan. (5) Block grant individual defined In this subsection, the term block grant individual means, with respect to a State for a 10-fiscal-year period, an individual who is not disabled (as defined for purposes of the State plan) and who is within an applicable block grant category for the State and such period. (6) Applicable block grant category defined In this subsection, the term applicable block grant category means with respect to a State for a 10-fiscal-year period, either of the following as specified by the State for such period in its plan under paragraph (2)(A)(i): (A) 2 enrollee categories Both of the following 1903A enrollee categories: (i) Children The 1903A enrollee category specified in subparagraph (C) of subsection (e)(2). (ii) Other nonelderly, nondisabled, non-expansion adults The 1903A enrollee category specified in subparagraph (E) of such subsection. (B) Other nonelderly, nondisabled, non-expansion adults Only the 1903A enrollee category specified in subparagraph (E) of subsection (e)(2). (7) Block grant health care assistance In this subsection, the term block grant health care assistance means assistance for health-care-related items and medical services for block grant individuals within the applicable block grant category for the State and 10-fiscal-year period involved who are low-income individuals (as defined by the State). (8) Auditing As a condition of receiving funds under this subsection, a State shall contract with an independent entity to conduct audits of its expenditures made with respect to activities funded under this subsection for each fiscal year for which the State elects to apply this subsection to ensure that such funds are used consistent with this subsection and shall make such audits available to the Secretary upon the request of the Secretary. . D Patient Relief and Health Insurance Market Stability 131. Repeal of cost-sharing subsidy (a) In general Section 1402 of the Patient Protection and Affordable Care Act is repealed. (b) Effective date The repeal made by subsection (a) shall apply to cost-sharing reductions (and payments to issuers for such reductions) for plan years beginning after December 31, 2019. 132. Patient and State Stability Fund The Social Security Act ( 42 U.S.C. 301 et seq.) is amended by adding at the end the following new title: XXII Patient and State Stability Fund 2201. Establishment of program There is hereby established the Patient and State Stability Fund to be administered by the Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as the Administrator ), to provide funding, in accordance with this title, to the 50 States and the District of Columbia (each referred to in this section as a State ) during the period, subject to section 2204(c), beginning on January 1, 2018, and ending on December 31, 2026, for the purposes described in section 2202. 2202. Use of funds (a) In General Subject to subsections (b) and (c), a State may use the funds allocated to the State under this title for any of the following purposes: (1) Helping, through the provision of financial assistance, high-risk individuals who do not have access to health insurance coverage offered through an employer enroll in health insurance coverage in the individual market in the State, as such market is defined by the State (whether through the establishment of a new mechanism or maintenance of an existing mechanism for such purpose). (2) Providing incentives to appropriate entities to enter into arrangements with the State to help stabilize premiums for health insurance coverage in the individual market, as such markets are defined by the State. (3) Reducing the cost for providing health insurance coverage in the individual market and small group market, as such markets are defined by the State, to individuals who have, or are projected to have, a high rate of utilization of health services (as measured by cost) and to individuals who have high costs of health insurance coverage due to the low density population of the State in which they reside. (4) Promoting participation in the individual market and small group market in the State and increasing health insurance options available through such market. (5) Promoting access to preventive services; dental care services (whether preventive or medically necessary); vision care services (whether preventive or medically necessary); or any combination of such services. (6) Maternity coverage and newborn care. (7) Prevention, treatment, or recovery support services for individuals with mental or substance use disorders, focused on either or both of the following: (A) Direct inpatient or outpatient clinical care for treatment of addiction and mental illness. (B) Early identification and intervention for children and young adults with serious mental illness. (8) Providing payments, directly or indirectly, to health care providers for the provision of such health care services as are specified by the Administrator. (9) Providing assistance to reduce out-of-pocket costs, such as copayments, coinsurance, premiums, and deductibles, of individuals enrolled in health insurance coverage in the State. (b) Required use of increase in allotment A State shall use the additional allocation provided to the State from the funds appropriated under the second sentence of section 2204(a) for each year only for the purposes described in paragraphs (6) and (7) of subsection (a). (c) Required use of additional increase to certain waiver States to provide financial hardship assistance A State shall use the additional allocation provided to the State from the funds appropriated under the last sentence of section 2204(a) only in accordance with such last sentence. 2203. State eligibility and approval; Default safeguard (a) Encouraging State options for allocations (1) In general To be eligible for an allocation of funds under this title for a year during the period described in section 2201 for use for one or more purposes described in section 2202, a State shall submit to the Administrator an application at such time (but, in the case of allocations for 2018, not later than 45 days after the date of the enactment of this title and, in the case of allocations for a subsequent year, not later than March 31 of the previous year) and in such form and manner as specified by the Administrator and containing— (A) a description of how the funds will be used for such purposes; (B) a certification that the State will make, from non-Federal funds, expenditures for such purposes in an amount that is not less than the State percentage required for the year under section 2204(e)(1); and (C) such other information as the Administrator may require. (2) Automatic approval An application so submitted is approved unless the Administrator notifies the State submitting the application, not later than 60 days after the date of the submission of such application, that the application has been denied for not being in compliance with any requirement of this title and of the reason for such denial. (3) One-time application If an application of a State is approved for a year, with respect to a purpose described in section 2202, such application shall be treated as approved, with respect to such purpose, for each subsequent year through 2026. (4) Treatment as a State Health Care Program Any program receiving funds from an allocation for a State under this title, including pursuant to subsection (b), shall be considered to be a State health care program for purposes of sections 1128, 1128A, and 1128B. (b) Default Federal safeguard (1) In general (A) 2018 For allocations made under this title for 2018, in the case of a State that does not submit an application under subsection (a) by the 45-day submission date applicable to such year under subsection (a)(1) and in the case of a State that does submit such an application by such date that is not approved, subject to section 2204(e), the Administrator, in consultation with the State insurance commissioner, shall use the allocation that would otherwise be provided to the State under this title for such year, in accordance with paragraph (2), for such State. (B) 2019 through 2026 In the case of a State that does not have in effect an approved application under this section for 2019 or a subsequent year beginning during the period described in section 2201, subject to section 2204(e), the Administrator, in consultation with the State insurance commissioner, shall use the allocation that would otherwise be provided to the State under this title for such year, in accordance with paragraph (2), for such State. (2) Required use for market stabilization payments to issuers Subject to section 2204(a), an allocation for a State made pursuant to paragraph (1) for a year shall be used to carry out the purpose described in section 2202(2) in such State by providing payments to appropriate entities described in such section with respect to claims that exceed $50,000 (or, with respect to allocations made under this title for 2020 or a subsequent year during the period specified in section 2201, such dollar amount specified by the Administrator), but do not exceed $350,000 (or, with respect to allocations made under this title for 2020 or a subsequent year during such period, such dollar amount specified by the Administrator), in an amount equal to 75 percent (or, with respect to allocations made under this title for 2020 or a subsequent year during such period, such percentage specified by the Administrator) of the amount of such claims. 2204. Allocations (a) Appropriation For the purpose of providing allocations for States (including pursuant to section 2203(b)) under this title there is appropriated, out of any money in the Treasury not otherwise appropriated— (1) for 2018, $15,000,000,000; (2) for 2019, $15,000,000,000; (3) for 2020, $10,000,000,000; (4) for 2021, $10,000,000,000; (5) for 2022, $10,000,000,000; (6) for 2023, $10,000,000,000; (7) for 2024, $10,000,000,000; (8) for 2025, $10,000,000,000; and (9) for 2026, $10,000,000,000. The amount otherwise appropriated under the previous sentence for 2020 shall be increased by $15,000,000,000, to be used and available under subsection (d) only for the purposes described in paragraphs (6) and (7) of section 2202(a). The amount otherwise appropriated under this subsection shall be increased by $8,000,000,000 for the period beginning with 2018 and ending with 2023, to be allocated to States with a waiver in effect under section 2701(b) of the Public Health Service Act with respect to the purpose described in paragraph (1)(C) of such section, in accordance with an allocation methodology specified by the Secretary that takes into account the relative allocation of other amounts appropriated under this subsection among such States, and to be used by (and made available under subsection (d), for any year during such period that such waiver is in effect, to) such States for the purpose of providing assistance to reduce premiums or other out-of-pocket costs of individuals who are subject to an increase in the monthly premium rate for health insurance coverage as a result of such waiver. (b) Allocations (1) Payment (A) In general From amounts appropriated under subsection (a) for a year, the Administrator shall, with respect to a State and not later than the date specified under subparagraph (B) for such year, allocate, subject to subsection (e), for such State (including pursuant to section 2203(b)) the amount determined for such State and year under paragraph (2). (B) Specified date For purposes of subparagraph (A), the date specified in this subparagraph is— (i) for 2018, the date that is 45 days after the date of the enactment of this title; and (ii) for 2019 and subsequent years, January 1 of the respective year. (2) Allocation amount determinations (A) For 2018 and 2019 (i) In general For purposes of paragraph (1), the amount determined under this paragraph for 2018 and 2019 for a State is an amount equal to the sum of— (I) the relative incurred claims amount described in clause (ii) for such State and year; and (II) the relative uninsured and issuer participation amount described in clause (iv) for such State and year. (ii) Relative incurred claims amount For purposes of clause (i), the relative incurred claims amount described in this clause for a State for 2018 and 2019 is the product of— (I) 85 percent of the amount appropriated under subsection (a) for the year; and (II) the relative State incurred claims proportion described in clause (iii) for such State and year. (iii) Relative State incurred claims proportion The relative State incurred claims proportion described in this clause for a State and year is the amount equal to the ratio of— (I) the adjusted incurred claims by the State, as reported through the medical loss ratio annual reporting under section 2718 of the Public Health Service Act for the third previous year; to (II) the sum of such adjusted incurred claims for all States, as so reported, for such third previous year. (iv) Relative uninsured and issuer participation amount For purposes of clause (i), the relative uninsured and issuer participation amount described in this clause for a State for 2018 and 2019 is the product of— (I) 15 percent of the amount appropriated under subsection (a) for the year; and (II) the relative State uninsured and issuer participation proportion described in clause (v) for such State and year. (v) Relative State uninsured and issuer participation proportion The relative State uninsured and issuer participation proportion described in this clause for a State and year is— (I) in the case of a State not described in clause (vi) for such year, 0; and (II) in the case of a State described in clause (vi) for such year, the amount equal to the ratio of— (aa) the number of individuals residing in such State who for the third preceding year were not enrolled in a health plan or otherwise did not have health insurance coverage (including through a Federal or State health program) and whose income is below 100 percent of the poverty line applicable to a family of the size involved; to (bb) the sum of the number of such individuals for all States described in clause (vi) for the third preceding year. (vi) States described For purposes of clause (v), a State is described in this clause, with respect to 2018 and 2019, if the State satisfies either of the following criterion: (I) The ratio described in subclause (II) of clause (v) that would be determined for such State by substituting 2015 for each reference in such subclause to the third preceding year and by substituting all such States for the reference in item (bb) of such subclause to all States described in clause (vi) is greater than the ratio described in such subclause that would be determined for such State by substituting 2013 for each reference in such subclause to the third preceding year and by substituting all such States for the reference in item (bb) of such subclause to all States described in clause (vi) . (II) The State has fewer than three health insurance issuers offering qualified health plans through the Exchange for 2017. (B) For 2020 through 2026 For purposes of paragraph (1), the amount determined under this paragraph for a year (beginning with 2020) during the period described in section 2201 for a State is an amount determined in accordance with an allocation methodology specified by the Administrator which— (i) takes into consideration the adjusted incurred claims of such State, the number of residents of such State who for the previous year were not enrolled in a health plan or otherwise did not have health insurance coverage (including through a Federal or State health program) and whose income is below 100 percent of the poverty line applicable to a family of the size involved, and the number of health insurance issuers participating in the insurance market in such State for such year; (ii) is established after consultation with health care consumers, health insurance issuers, State insurance commissioners, and other stakeholders and after taking into consideration additional cost and risk factors that may inhibit health care consumer and health insurance issuer participation; and (iii) reflects the goals of improving the health insurance risk pool, promoting a more competitive health insurance market, and increasing choice for health care consumers. (c) Annual distribution of previous year’s remaining funds In carrying out subsection (b), the Administrator shall, with respect to a year (beginning with 2020 and ending with 2027), not later than March 31 of such year— (1) determine the amount of funds, if any, from the amounts appropriated under subsection (a) for the previous year but not allocated for such previous year; and (2) if the Administrator determines that any funds were not so allocated for such previous year, allocate such remaining funds, in accordance with the allocation methodology specified pursuant to subsection (b)(2)(B)— (A) to States that have submitted an application approved under section 2203(a) for such previous year for any purpose for which such an application was approved; and (B) for States for which allocations were made pursuant to section 2203(b) for such previous year, to be used by the Administrator for such States, to carry out the Federal Invisible Risk Sharing Program in such States under section 2205; with, respect to a year before 2027, any remaining funds being made available for allocations to States for the subsequent year. (d) Availability Amounts appropriated under subsection (a) for a year and allocated to States in accordance with this section shall remain available for expenditure through December 31, 2027. (e) Conditions for and limitations on receipt of funds The Secretary may not make an allocation under this title for a State, with respect to a purpose described in section 2202— (1) in the case of an allocation that would be made to a State pursuant to section 2203(a), if the State does not agree that the State will make available non-Federal contributions towards such purpose in an amount equal to— (A) for 2020, 7 percent of the amount allocated under this subsection to such State for such year and purpose; (B) for 2021, 14 percent of the amount allocated under this subsection to such State for such year and purpose; (C) for 2022, 21 percent of the amount allocated under this subsection to such State for such year and purpose; (D) for 2023, 28 percent of the amount allocated under this subsection to such State for such year and purpose; (E) for 2024, 35 percent of the amount allocated under this subsection to such State for such year and purpose; (F) for 2025, 42 percent of the amount allocated under this subsection to such State for such year and purpose; and (G) for 2026, 50 percent of the amount allocated under this subsection to such State for such year and purpose; (2) in the case of an allocation that would be made for a State pursuant to section 2203(b), if the State does not agree that the State will make available non-Federal contributions towards such purpose in an amount equal to— (A) for 2020, 10 percent of the amount allocated under this subsection to such State for such year and purpose; (B) for 2021, 20 percent of the amount allocated under this subsection to such State for such year and purpose; and (C) for 2022, 30 percent of the amount allocated under this subsection to such State for such year and purpose; (D) for 2023, 40 percent of the amount allocated under this subsection to such State for such year and purpose; (E) for 2024, 50 percent of the amount allocated under this subsection to such State for such year and purpose; (F) for 2025, 50 percent of the amount allocated under this subsection to such State for such year and purpose; and (G) for 2026, 50 percent of the amount allocated under this subsection to such State for such year and purpose; or (3) if such an allocation for such purpose would not be permitted under subsection (c)(7) of section 2105 if such allocation were payment made under such section. 2205. Federal Invisible Risk Sharing Program (a) In general There is established within the Patient and State Stability Fund a Federal Invisible Risk Sharing Program (in this section referred to as the Program ), to be administered by the Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as the Administrator ), to provide payments to health insurance issuers with respect to claims for eligible individuals for the purpose of lowering premiums for health insurance coverage offered in the individual market. (b) Funding (1) Appropriation For the purpose of providing funding for the Program there is appropriated, out of any money in the Treasury not otherwise appropriated, $15,000,000,000 for the period beginning on January 1, 2018, and ending on December 31, 2026. (2) Use of unallocated funds Funds provided under section 2204(c)(2)(B) to carry out this section are in addition to the amount appropriated under paragraph (1). (c) Operation of program (1) In general The Administrator shall establish, after consultation with health care consumers, health insurance issuers, State insurance commissioners, and other stakeholders and after taking into consideration high cost health conditions and other health trends that generate high cost, parameters for the operation of the Program consistent with this section and consistent with the same limitation on payment with respect to health insurance coverage that applies to payment with respect health benefits coverage under section 2105(c)(7). (2) Deadline for initial operation Not later than 60 days after the date of the enactment of this title, the Administrator shall establish sufficient parameters to specify how the Program will operate for plan year 2018. (3) State operation of program The Administrator shall establish a process for a State to operate the Program in such State beginning with plan year 2020. (d) Details of program The parameters for the Program shall include the following: (1) Eligible individuals A definition for eligible individuals. (2) Health status statements The development and use of health status statements with respect to such individuals. (3) Standards for qualification (A) Automatic qualification The identification of health conditions that automatically qualify individuals as eligible individuals at the time of application for health insurance coverage. (B) Voluntary qualification A process under which health insurance issuers may voluntarily qualify individuals, who do not automatically qualify under subparagraph (A), as eligible individuals at the time of application for such coverage. (4) Percentage of insurance premiums to be applied The percentage of the premiums paid, to health insurance issuers for health insurance coverage by eligible individuals, that shall be collected and deposited to the credit (and available for the use) of the Program. (5) Attachment dollar amount and payment proportion The dollar amount of claims for eligible individuals after which the Program will provide payments to health insurance issuers and the proportion of such claims above such dollar amount that the Program will pay. . 133. Continuous health insurance coverage incentive Subpart I of part A of title XXVII of the Public Health Service Act is amended— (1) in section 2701(a)(1)(B), by striking such rate and inserting subject to section 2710A, such rate ; (2) by redesignating the second section 2709 as section 2710; and (3) by adding at the end the following new section: 2710A. Encouraging continuous health insurance coverage (a) Penalty applied (1) In general Subject to the succeeding provisions of this section, a health insurance issuer offering health insurance coverage in the individual market shall, in the case of an individual who is an applicable policyholder of such coverage with respect to an enforcement period applicable to enrollments for a plan year beginning with plan year 2019 (or, in the case of enrollments during a special enrollment period, beginning with plan year 2018), increase the monthly premium rate otherwise applicable to such individual for such coverage during each month of such period, by an amount determined under paragraph (2). (2) Amount of penalty The amount determined under this paragraph for an applicable policyholder enrolling in health insurance coverage described in paragraph (1) for a plan year, with respect to each month during the enforcement period applicable to enrollments for such plan year, is the amount that is equal to 30 percent of the monthly premium rate otherwise applicable to such applicable policyholder for such coverage during such month. (b) Definitions For purposes of this section: (1) Applicable policyholder The term applicable policyholder means, with respect to months of an enforcement period and health insurance coverage, an individual who— (A) is a policyholder of such coverage for such months; (B) cannot demonstrate that (through presentation of certifications described in section 2704(e) or in such other manner as may be specified in regulations, such as a return or statement made under section 6055(d) or 36B of the Internal Revenue Code of 1986), during the look-back period that is with respect to such enforcement period, there was not a period of at least 63 continuous days during which the individual did not have creditable coverage (as defined in paragraph (1) of section 2704(c) and credited in accordance with paragraphs (2) and (3) of such section); and (C) in the case of an individual who had been enrolled under dependent coverage under a group health plan or health insurance coverage by reason of section 2714 and such dependent coverage of such individual ceased because of the age of such individual, is not enrolling during the first open enrollment period following the date on which such coverage so ceased. (2) Look-back period The term look-back period means, with respect to an enforcement period applicable to an enrollment of an individual for a plan year beginning with plan year 2019 (or, in the case of an enrollment of an individual during a special enrollment period, beginning with plan year 2018) in health insurance coverage described in subsection (a)(1), the 12-month period ending on the date the individual enrolls in such coverage for such plan year. (3) Enforcement period The term enforcement period means— (A) with respect to enrollments during a special enrollment period for plan year 2018, the period beginning with the first month that is during such plan year and that begins subsequent to such date of enrollment, and ending with the last month of such plan year; and (B) with respect to enrollments for plan year 2019 or a subsequent plan year, the 12-month period beginning on the first day of the respective plan year. . 134. Increasing coverage options Section 1302 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18022 ) is amended— (1) in subsection (a)(3), by inserting and with respect to a plan year before plan year 2020 after subsection (e) ; and (2) in subsection (d), by adding at the end the following: (5) Sunset The provisions of this subsection shall not apply after December 31, 2019, and after such date any reference to this subsection or level of coverage or plan described in this subsection and any requirement under law applying such a level of coverage or plan shall have no force or effect (and such a requirement shall be applied as if this section had been repealed). . 135. Change in permissible age variation in health insurance premium rates Section 2701(a)(1)(A)(iii) of the Public Health Service Act ( 42 U.S.C. 300gg(a)(1)(A)(iii) ), as inserted by section 1201(4) of the Patient Protection and Affordable Care Act, is amended by inserting after (consistent with section 2707(c)) the following: or, for plan years beginning on or after January 1, 2018, as the Secretary may implement through interim final regulation, 5 to 1 for adults (consistent with section 2707(c)) or such other ratio for adults (consistent with section 2707(c)) as the State involved may provide (or, in the case of a State with a waiver under subsection (b) in effect for such a plan year, the ratio applied for such plan year in accordance with such waiver) . 136. Permitting States to waive certain ACA requirements to encourage fair health insurance premiums (a) In general Section 2701 of the Public Health Service Act ( 42 U.S.C. 300gg ) is amended by adding at the end the following new subsection: (b) Permissible State waiver to encourage fair health insurance premiums (1) In general A State may submit an application to the Secretary for one or more of the following purposes: (A) In the case of plan years beginning on or after January 1, 2018, to apply, subject to paragraph (5), under subsection (a)(1)(A)(iii), instead of the ratio specified in such subsection, a higher ratio specified by the State (consistent with section 2707(c)). (B) In the case of plan years beginning on or after January 1, 2020, for health insurance coverage offered in the individual or small group market in such State, to apply, subject to paragraph (5), instead of the essential health benefits specified under subsection (b) of section 1302 of the Patient Protection and Affordable Care Act, essential health benefits as specified by the State. (C) In the case of a State that has in place a program that carries out the purpose described in paragraph (1) or (2) of section 2202(a) of the Social Security Act or participates in the program established under section 2205 of such Act, for health insurance offered in the individual market in such State, with respect to an individual who is an applicable policyholder of such coverage with respect to an enforcement period (as defined in section 2710A(b)) applicable to enrollments for a plan year beginning with plan year 2019 (or, in the case of enrollments during a special enrollment period, beginning with plan year 2018), to— (i) subject to paragraph (5), not apply any increase to the monthly premium rate that would otherwise apply under section 2710A to such individual for such coverage; and (ii) instead, subject to paragraph (5)— (I) apply subsection (a)(1) as if health status were included as a factor described in subparagraph (A) of such subsection; and (II) not apply section 2705(b). (2) Default approval An application submitted under paragraph (1) is approved unless the Secretary notifies the State submitting the application, not later than 60 days after the date of the submission of such application, that the application has been denied for not being in compliance with any requirement of paragraph (3) and of the reason for such denial. (3) Requirements The requirements of this paragraph, with respect to an application submitted under paragraph (1), are the following: (A) The application is submitted at such time, and in such manner, as the Secretary may require. (B) The application specifies how the approval of such application will provide for one or more of the following: (i) Reducing average premiums for health insurance coverage in the State. (ii) Increasing enrollment in health insurance coverage in the State. (iii) Stabilizing the market for health insurance coverage in the State. (iv) Stabilizing premiums for individuals with pre-existing conditions. (v) Increasing the choice of health plans in the State. (C) The application specifies the period for which the waiver is to be effective, consistent with paragraph (4). (D) In the case of an application for purposes of paragraph (1)(A), the application specifies the higher ratio to be applied pursuant to such paragraph. (E) In the case of an application for purposes of paragraph (1)(B), the application specifies the essential health benefits to be applied pursuant to such paragraph. (F) In the case of an application for purposes of paragraph (1)(C), the application demonstrates that the State has in place a program that carries out the purpose described in paragraph (1) or (2) of section 2202(a) of the Social Security Act or participates in the program established under section 2205 of such Act. (4) Term of waiver (A) In general No waiver for a State under this subsection may extend over a period of longer than 10 years unless the State requests continuation of such waiver, and such request shall be deemed granted unless the Secretary, within 90 days after the date of its submission to the Secretary, either denies such request in writing or informs the State in writing with respect to any additional information which is needed in order to make a final determination with respect to the request. (B) Special rule A waiver applied for by a State under paragraph (1)(C) may only be effective for a period during which the State— (i) has in place a program that carries out the purpose described in paragraph (1) or (2) of section 2202(a) of the Social Security Act; or (ii) participates in the program established under section 2205 of such Act. (5) Non-application rules (A) Specified non-application provisions In no case may a waiver for purposes of paragraph (1) apply with respect to any of the following provisions: (i) Section 1301 of the Patient Protection and Affordable Care Act, to the extent that such section applies to qualified health plans offered through the CO-OP program under section 1322 of such Act or multi-State plans under section 1334 of such Act. (ii) Sections 1312(d)(3)(D), 1331, 1332, 1333, and 1334 of such Act. (B) Hold harmless Any standard or requirement adopted by a State pursuant to the terms of a waiver approved under this subsection shall be deemed to comply with section 1252 of the Patient Protection and Affordable Care Act and subsection (a) of section 1324 of such Act, insofar as such standard or requirement relates to a Federal or State law described in subsection (b)(2) of such section (relating to rating). . (b) Application to essential health benefits Section 1302(a)(1) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18022(a)(1) ) is amended by inserting (or, in the case of health insurance coverage offered in the individual or small group market in a State for which there is an applicable waiver in effect under section 2701(b) of the Public Health Service Act for a plan year, the essential health benefits applicable under such waiver) after subsection (b) . 137. Constructions (a) No gender rating Nothing in this Act shall be construed as permitting health insurance issuers to discriminate in rates for health insurance coverage by gender. (b) No limiting access to coverage for individuals with preexisting conditions Nothing in this Act shall be construed as permitting health insurance issuers to limit access to health coverage for individuals with preexisting conditions. E Implementation Funding 141. American Health Care Implementation Fund (a) In general There is hereby established an American Health Care Implementation Fund (referred to in this section as the Fund ) within the Department of Health and Human Services to carry out sections 121, 132, 202, and 214 (including the amendments made by such sections). (b) Funding There is appropriated to the Fund, out of any funds in the Treasury not otherwise appropriated, $1,000,000,000 for Federal administrative expenses to carry out the sections described in subsection (a) (including the amendments made by such sections). II Committee on Ways and Means A Repeal and Replace of Health-Related Tax Policy 201. Recapture excess advance payments of premium tax credits Subparagraph (B) of section 36B(f)(2) of the Internal Revenue Code of 1986 is amended by adding at the end the following new clause: (iii) Nonapplicability of limitation This subparagraph shall not apply to taxable years beginning after December 31, 2017, and before January 1, 2020. . 202. Additional modifications to premium tax credit (a) Modification of definition of qualified health plan (1) In general Section 36B(c)(3)(A) of the Internal Revenue Code of 1986 is amended— (A) by inserting (determined without regard to subparagraphs (A), (C)(ii), and (C)(iv) of paragraph (1) thereof and without regard to whether the plan is offered on an Exchange) after 1301(a) of the Patient Protection and Affordable Care Act , and (B) by striking shall not include and all that follows and inserting shall not include any health plan that— (i) is a grandfathered health plan or a grandmothered health plan, or (ii) includes coverage for abortions (other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest). . (2) Definition of grandmothered health plan Section 36B(c)(3) of such Code is amended by adding at the end the following new subparagraph: (C) Grandmothered health plan (i) In general The term grandmothered health plan means health insurance coverage which is offered in the individual health insurance market as of October 1, 2013, and is permitted to be offered in such market after January 1, 2014, as a result of CCIIO guidance. (ii) CCIIO guidance defined The term CCIIO guidance means the letter issued by the Centers for Medicare & Medicaid Services on November 14, 2013, to the State Insurance Commissioners outlining a transitional policy for non-grandfathered coverage in the individual health insurance market, as subsequently extended and modified (including by a communication entitled Insurance Standards Bulletin Series—INFORMATION—Extension of Transitional Policy through Calendar Year 2017 issued on February 29, 2016, by the Director of the Center for Consumer Information & Insurance Oversight of such Centers). (iii) Individual health insurance market The term individual health insurance market means the market for health insurance coverage (as defined in section 9832(b)) offered to individuals other than in connection with a group health plan (within the meaning of section 5000(b)(1)). . (3) Conforming amendment related to abortion coverage Section 36B(c)(3) of such Code, as amended by paragraph (2), is amended by adding at the end the following new subparagraph: (D) Certain rules related to abortion (i) Option to purchase separate coverage or plan Nothing in subparagraph (A) shall be construed as prohibiting any individual from purchasing separate coverage for abortions described in such subparagraph, or a health plan that includes such abortions, so long as no credit is allowed under this section with respect to the premiums for such coverage or plan. (ii) Option to offer coverage or plan Nothing in subparagraph (A) shall restrict any health insurance issuer offering a health plan from offering separate coverage for abortions described in such subparagraph, or a plan that includes such abortions, so long as premiums for such separate coverage or plan are not paid for with any amount attributable to the credit allowed under this section (or the amount of any advance payment of the credit under section 1412 of the Patient Protection and Affordable Care Act). (iii) Other treatments The treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of an abortion shall not be treated as an abortion for purposes of subparagraph (A). . (4) Conforming amendments related to off-Exchange coverage (A) Advance payment not applicable Section 1412 of the Patient Protection and Affordable Care Act is amended by adding at the end the following new subsection: (f) Exclusion of off-Exchange coverage Advance payments under this section, and advance determinations under section 1411, with respect to any credit allowed under section 36B shall not be made with respect to any health plan which is not enrolled in through an Exchange. . (B) Reporting Section 6055(b) of the Internal Revenue Code of 1986 is amended by adding at the end the following new paragraph: (3) Information relating to off-Exchange premium credit eligible coverage If minimum essential coverage provided to an individual under subsection (a) consists of a qualified health plan (as defined in section 36B(c)(3)) which is not enrolled in through an Exchange established under title I of the Patient Protection and Affordable Care Act, a return described in this subsection shall include— (A) a statement that such plan is a qualified health plan (as defined in section 36B(c)(3)), (B) the premiums paid with respect to such coverage, (C) the months during which such coverage is provided to the individual, (D) the adjusted monthly premium for the applicable second lowest cost silver plan (as defined in section 36B(b)(3)) for each such month with respect to such individual, and (E) such other information as the Secretary may prescribe. . (C) Other conforming amendments (i) Section 36B(b)(2)(A) of such Code is amended by striking and which were enrolled and all that follows and inserting , or . (ii) Section 36B(b)(3)(B)(i) of such Code is amended by striking the same Exchange and all that follows and inserting the Exchange through which such taxpayer is permitted to obtain coverage, and . (iii) Section 36B(c)(2)(A)(i) of such Code is amended by striking that was enrolled in through an Exchange established by the State under section 1311 of the Patient Protection and Affordable Care Act . (b) Modification of applicable percentage Section 36B(b)(3)(A) of such Code is amended to read as follows: (A) Applicable percentage (i) In general The applicable percentage for any taxable year shall be the percentage such that the applicable percentage for any taxpayer whose household income is within an income tier specified in the following table shall increase, on a sliding scale in a linear manner, from the initial percentage to the final percentage specified in such table for such income tier with respect to a taxpayer of the age involved: In the case of household income (expressed as a percent of the poverty line) within the following income tier: Up to Age 29 Age 30-39 Age 40-49 Age 50-59 Over Age 59 Initial % Final % Initial % Final % Initial % Final % Initial % Final % Initial % Final % Up to 133% 2 2 2 2 2 2 2 2 2 2 133%-150% 3 4 3 4 3 4 3 4 3 4 150%-200% 4 4.3 4 5.3 4 6.3 4 7.3 4 8.3 200%-250% 4.3 4.3 5.3 5.9 6.3 8.05 7.3 9 8.3 10 250%-300% 4.3 4.3 5.9 5.9 8.05 8.35 9 10.5 10 11.5 300%-400% 4.3 4.3 5.9 5.9 8.35 8.35 10.5 10.5 11.5 11.5 (ii) Age determinations (I) In general For purposes of clause (i), the age of the taxpayer taken into account under clause (i) with respect to any taxable year is the age attained by such taxpayer before the close of such taxable year. (II) Joint returns In the case of a joint return, the age of the older spouse shall be taken into account under clause (i). (iii) Indexing In the case of any taxable year beginning in calendar year 2019, the initial and final percentages contained in clause (i) shall be adjusted to reflect— (I) the excess (if any) of the rate of premium growth for the period beginning with calendar year 2013 and ending with calendar year 2018, over the rate of income growth for such period, and (II) in addition to any adjustment under subclause (I), the excess (if any) of the rate of premium growth for calendar year 2018, over the rate of growth in the consumer price index for calendar year 2018. (iv) Failsafe Clause (iii)(II) shall apply only if the aggregate amount of premium tax credits under this section and cost-sharing reductions under section 1402 of the Patient Protection and Affordable Care Act for calendar year 2018 exceeds an amount equal to 0.504 percent of the gross domestic product for such calendar year. . (c) Effective date (1) In general Except as otherwise provided in this subsection, the amendments made by this section shall apply to taxable years beginning after December 31, 2017. (2) Advance payment not applicable to off-Exchange coverage The amendment made by subsection (a)(4)(A) shall take effect on January 1, 2018. (3) Reporting The amendment made by subsection (a)(4)(B) shall apply to coverage provided for months beginning after December 31, 2017. (4) Modification of applicable percentage The amendment made by subsection (b) shall apply to taxable years beginning after December 31, 2018. 203. Small business tax credit (a) In general Section 45R of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: (j) Shall not apply This section shall not apply with respect to amounts paid or incurred in taxable years beginning after December 31, 2019. . (b) Disallowance of small employer health insurance expense credit for plan which includes coverage for abortion Subsection (h) of section 45R of the Internal Revenue Code of 1986 is amended— (1) by striking Any term and inserting the following: (1) In general Any term ; and (2) by adding at the end the following new paragraph: (2) Exclusion of health plans including coverage for abortion (A) In general The term qualified health plan does not include any health plan that includes coverage for abortions (other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest). (B) Certain rules related to abortion (i) Option to purchase separate coverage or plan Nothing in subparagraph (A) shall be construed as prohibiting any employer from purchasing for its employees separate coverage for abortions described in such subparagraph, or a health plan that includes such abortions, so long as no credit is allowed under this section with respect to the employer contributions for such coverage or plan. (ii) Option to offer coverage or plan Nothing in subparagraph (A) shall restrict any health insurance issuer offering a health plan from offering separate coverage for abortions described in such subparagraph, or a plan that includes such abortions, so long as such separate coverage or plan is not paid for with any employer contribution eligible for the credit allowed under this section. (iii) Other treatments The treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of an abortion shall not be treated as an abortion for purposes of subparagraph (A). . (c) Effective dates (1) In general The amendment made by subsection (a) shall apply to taxable years beginning after December 31, 2019. (2) Disallowance of small employer health insurance expense credit for plan which includes coverage for abortion The amendments made by subsection (b) shall apply to taxable years beginning after December 31, 2017. 204. Individual mandate (a) In general Section 5000A(c) of the Internal Revenue Code of 1986 is amended— (1) in paragraph (2)(B)(iii), by striking 2.5 percent and inserting Zero percent , and (2) in paragraph (3)— (A) by striking $695 in subparagraph (A) and inserting $0 , and (B) by striking subparagraph (D). (b) Effective date The amendments made by this section shall apply to months beginning after December 31, 2015. 205. Employer mandate (a) In general (1) Paragraph (1) of section 4980H(c) of the Internal Revenue Code of 1986 is amended by inserting ($0 in the case of months beginning after December 31, 2015) after $2,000 . (2) Paragraph (1) of section 4980H(b) of the Internal Revenue Code of 1986 is amended by inserting ($0 in the case of months beginning after December 31, 2015) after $3,000 . (b) Effective date The amendments made by this section shall apply to months beginning after December 31, 2015. 206. Repeal of the tax on employee health insurance premiums and health plan benefits Section 4980I of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: (h) Shall not apply No tax shall be imposed under this section with respect to any taxable period beginning after December 31, 2019, and before January 1, 2026. . 207. Repeal of tax on over-the-counter medications (a) HSAs Subparagraph (A) of section 223(d)(2) of the Internal Revenue Code of 1986 is amended by striking Such term and all that follows through the period. (b) Archer MSAs Subparagraph (A) of section 220(d)(2) of the Internal Revenue Code of 1986 is amended by striking Such term and all that follows through the period. (c) Health flexible spending arrangements and health reimbursement arrangements Section 106 of the Internal Revenue Code of 1986 is amended by striking subsection (f) and by redesignating subsection (g) as subsection (f). (d) Effective dates (1) Distributions from savings accounts The amendments made by subsections (a) and (b) shall apply to amounts paid with respect to taxable years beginning after December 31, 2016. (2) Reimbursements The amendment made by subsection (c) shall apply to expenses incurred with respect to taxable years beginning after December 31, 2016. 208. Repeal of increase of tax on health savings accounts (a) HSAs Section 223(f)(4)(A) of the Internal Revenue Code of 1986 is amended by striking 20 percent and inserting 10 percent . (b) Archer MSAs Section 220(f)(4)(A) of the Internal Revenue Code of 1986 is amended by striking 20 percent and inserting 15 percent . (c) Effective date The amendments made by this section shall apply to distributions made after December 31, 2016. 209. Repeal of limitations on contributions to flexible spending accounts (a) In general Section 125 of the Internal Revenue Code of 1986 is amended by striking subsection (i). (b) Effective date The amendment made by this section shall apply to taxable years beginning after December 31, 2016. 210. Repeal of medical device excise tax Section 4191 of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: (d) Applicability The tax imposed under subsection (a) shall not apply to sales after December 31, 2016. . 211. Repeal of elimination of deduction for expenses allocable to medicare part D subsidy (a) In general Section 139A of the Internal Revenue Code of 1986 is amended by adding at the end the following new sentence: This section shall not be taken into account for purposes of determining whether any deduction is allowable with respect to any cost taken into account in determining such payment. . (b) Effective date The amendment made by this section shall apply to taxable years beginning after December 31, 2016. 212. Reduction of income threshold for determining medical care deduction (a) In general Subsection (a) of section 213 of the Internal Revenue Code of 1986 is amended by striking 10 percent and inserting 5.8 percent . (b) Effective date The amendment made by this section shall apply to taxable years beginning after December 31, 2016. 213. Repeal of Medicare tax increase (a) In general Subsection (b) of section 3101 of the Internal Revenue Code of 1986 is amended to read as follows: (b) Hospital insurance In addition to the tax imposed by the preceding subsection, there is hereby imposed on the income of every individual a tax equal to 1.45 percent of the wages (as defined in section 3121(a)) received by such individual with respect to employment (as defined in section 3121(b)). . (b) SECA Subsection (b) of section 1401 of the Internal Revenue Code of 1986 is amended to read as follows: (b) Hospital insurance In addition to the tax imposed by the preceding subsection, there shall be imposed for each taxable year, on the self-employment income of every individual, a tax equal to 2.9 percent of the amount of the self-employment income for such taxable year. . (c) Effective date The amendments made by this section shall apply with respect to remuneration received after, and taxable years beginning after, December 31, 2022. 214. Refundable tax credit for health insurance coverage (a) In general Section 36B of the Internal Revenue Code of 1986 is amended to read as follows: 36B. Refundable credit for coverage under a qualified health plan (a) Allowance of premium tax credit In the case of an individual, there shall be allowed as a credit against the tax imposed by this subtitle for the taxable year the sum of the monthly credit amounts with respect to such taxpayer for calendar months during such taxable year which are eligible coverage months appropriately taken into account under subsection (b)(2) with respect to the taxpayer or any qualifying family member of the taxpayer. (b) Monthly credit amounts (1) In general The monthly credit amount with respect to any taxpayer for any calendar month is the lesser of— (A) the sum of the monthly limitation amounts determined under subsection (c) with respect to the taxpayer and the taxpayer’s qualifying family members for such month, or (B) the amount paid for a qualified health plan for the taxpayer and the taxpayer’s qualifying family members for such month. (2) Eligible coverage month requirement No amount shall be taken into account under subparagraph (A) or (B) of paragraph (1) with respect to any individual for any month unless such month is an eligible coverage month with respect to such individual. (c) Monthly limitation amounts (1) In general The monthly limitation amount with respect to any individual for any eligible coverage month during any taxable year is 1/12 of— (A) $2,000 in the case of an individual who has not attained age 30 as of the beginning of such taxable year, (B) $2,500 in the case of an individual who has attained age 30 but who has not attained age 40 as of such time, (C) $3,000 in the case of an individual who has attained age 40 but who has not attained age 50 as of such time, (D) $3,500 in the case of an individual who has attained age 50 but who has not attained age 60 as of such time, and (E) $4,000 in the case of an individual who has attained age 60 as of such time. (2) Limitation based on modified adjusted gross income The credit allowed under subsection (a) with respect to any taxpayer for any taxable year shall be reduced (but not below zero) by 10 percent of the excess (if any) of— (A) the taxpayer’s modified adjusted gross income (as defined in section 36B(d)(2)(B), as in effect for taxable years beginning before January 1, 2020) for such taxable year, over (B) $75,000 (twice such amount in the case of a joint return). (3) Other limitations (A) Aggregate dollar limitation The sum of the monthly limitation amounts taken into account under this section with respect to any taxpayer for any taxable year shall not exceed $14,000. (B) Maximum number of individuals taken into account With respect to any taxpayer for any month, monthly limitation amounts shall be taken into account under this section only with respect to the 5 oldest individuals with respect to whom monthly limitation amounts could (without regard to this subparagraph) otherwise be so taken into account. (d) Eligible coverage month For purposes of this section, the term eligible coverage month means, with respect to any individual, any month if, as of the first day of such month, the individual meets the following requirements: (1) The individual is covered by a health insurance coverage which is certified by the State in which such insurance is offered as coverage that meets the requirements for qualified health plans under subsection (f). (2) The individual is not eligible for— (A) coverage under a group health plan (within the meaning of section 5000(b)(1)) other than coverage under a plan substantially all of the coverage of which is of excepted benefits described in section 9832(c), or (B) coverage described in section 5000A(f)(1)(A). (3) The individual is either— (A) a citizen or national of the United States, or (B) a qualified alien (within the meaning of section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 ( 8 U.S.C. 1641 )). (4) The individual is not incarcerated, other than incarceration pending the disposition of charges. (e) Qualifying family member For purposes of this section, the term qualifying family member means— (1) in the case of a joint return, the taxpayer’s spouse, (2) any dependent of the taxpayer, and (3) with respect to any eligible coverage month, any child (as defined in section 152(f)(1)) of the taxpayer who as of the end of the taxable year has not attained age 27 if such child is covered for such month under a qualified health plan which also covers the taxpayer (in the case of a joint return, either spouse). (f) Qualified health plan For purposes of this section, the term qualified health plan means any health insurance coverage (as defined in section 9832(b)) if— (1) such coverage is offered in the individual health insurance market within a State (within the meaning of section 5000A(f)(1)(C)), (2) substantially all of such coverage is not of excepted benefits described in section 9832(c), (3) such coverage does not consist of short-term limited duration insurance (within the meaning of section 2791(b)(5) of the Public Health Service Act), (4) such coverage is not a grandfathered health plan (as defined in section 1251 of the Patient Protection and Affordable Care Act) or a grandmothered health plan (as defined in section 36B(c)(3)(C) as in effect for taxable years beginning before January 1, 2020), and (5) such coverage does not include coverage for abortions (other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest). (g) Special rules (1) Married couples must file joint return (A) In general Except as provided in subparagraph (B), if the taxpayer is married (within the meaning of section 7703) at the close of the taxable year, no credit shall be allowed under this section to such taxpayer unless such taxpayer and the taxpayer’s spouse file a joint return for such taxable year. (B) Exception for certain taxpayers Subparagraph (A) shall not apply to any married taxpayer who— (i) is living apart from the taxpayer's spouse at the time the taxpayer files the tax return, (ii) is unable to file a joint return because such taxpayer is a victim of domestic abuse or spousal abandonment, (iii) certifies on the tax return that such taxpayer meets the requirements of clauses (i) and (ii), and (iv) has not met the requirements of clauses (i), (ii), and (iii) for each of the 3 preceding taxable years. (2) Denial of credit to dependents (A) In general No credit shall be allowed under this section to any individual who is a dependent with respect to another taxpayer for a taxable year beginning in the calendar year in which such individual’s taxable year begins. (B) Coordination with rule for older children In the case of any individual who is a qualifying family member described in subsection (e)(3) with respect to another taxpayer for any month, in determining the amount of any credit allowable to such individual under this section for any taxable year of such individual which includes such month, the monthly limitation amount with respect to such individual for such month shall be zero and no amount paid for any qualified health plan with respect to such individual for such month shall be taken into account. (3) Coordination with medical expense deduction Amounts described in subsection (b)(1)(B) with respect to any month shall not be taken into account in determining the deduction allowed under section 213 except to the extent that such amounts exceed the amount described in subsection (b)(1)(A) with respect to such month. (4) Coordination with advance payments of credit With respect to any taxable year— (A) the amount which would (but for this subsection) be allowed as a credit to the taxpayer under subsection (a) shall be reduced (but not below zero) by the aggregate amount paid on behalf of such taxpayer under section 1412 of the Patient Protection and Affordable Care Act for months beginning in such taxable year, and (B) the tax imposed by section 1 for such taxable year shall be increased by the excess (if any) of— (i) the aggregate amount paid on behalf of such taxpayer under such section 1412 for months beginning in such taxable year, over (ii) the amount which would (but for this subsection) be allowed as a credit to the taxpayer under subsection (a). (5) Special rules for qualified small employer health reimbursement arrangements (A) In general If the taxpayer or any qualifying family member of the taxpayer is provided a qualified small employer health reimbursement arrangement for an eligible coverage month, the sum determined under subsection (b)(1)(A) with respect to the taxpayer shall be reduced (but not below zero) by 1/12 of the permitted benefit (as defined in section 9831(d)(3)(C)) under such arrangement for each such month such arrangement is provided to such taxpayer. (B) Qualified small employer health reimbursement arrangement For purposes of this paragraph, the term qualified small employer health reimbursement arrangement has the meaning given such term by section 9831(d)(2). (C) Coverage for less than entire year In the case of an employee who is provided a qualified small employer health reimbursement arrangement for less than an entire year, subparagraph (A) shall be applied by substituting the number of months during the year for which such arrangement was provided for 12 . (6) Certain rules related to nonqualified health plans The rules of section 36B(c)(3)(D), as in effect for taxable years beginning before January 1, 2020, shall apply with respect to subsection (f)(5). (7) Inflation adjustment (A) In general In the case of any taxable year beginning in a calendar year after 2020, each dollar amount in subsection (c)(1), the $75,000 amount in subsection (c)(2)(B), and the dollar amount in subsection (c)(3)(A), shall be increased by an amount equal to— (i) such dollar amount, multiplied by (ii) the cost-of-living adjustment determined under section 1(f)(3) for the calendar year in which the taxable year begins, determined— (I) by substituting calendar year 2019 for calendar year 1992 in subparagraph (B) thereof, and (II) by substituting for the CPI referred to section 1(f)(3)(A) the amount that such CPI would have been if the annual percentage increase in CPI with respect to each year after 2019 had been one percentage point greater. (B) Terms related to CPI (i) Annual percentage increase For purposes of subparagraph (A)(ii)(II), the term annual percentage increase means the percentage (if any) by which CPI for any year exceeds CPI for the prior year. (ii) Other terms Terms used in this paragraph which are also used in section 1(f)(3) shall have the same meanings as when used in such section. (C) Rounding Any increase determined under subparagraph (A) shall be rounded to the nearest multiple of $50. (8) Rules related to State certification of qualified health plans A certification shall not be taken into account under subsection (d)(1) unless such certification is made available to the public and meets such other requirements as the Secretary may provide. (9) Regulations The Secretary may prescribe such regulations and other guidance as may be necessary or appropriate to carry out this section and section 1412 of the Patient Protection and Affordable Care Act. . (b) Advance payment of credit Section 1412(f) of the Patient Protection and Affordable Care Act, as added by section 202, is amended to read as follows: (f) Application to certain plans The Secretary and the Secretary of the Treasury shall prescribe such regulations as each respective Secretary may deem necessary in order to establish and operate the advance payment program established under this section for individuals covered under qualified health plans (whether enrolled in through an Exchange or otherwise) in such a manner that protects taxpayer information (including names, taxpayer identification numbers, and other confidential information), provides robust verification of all information necessary to establish eligibility of taxpayer for advance payments under this section, ensures proper and timely payments to appropriate health providers, and protects program integrity to the maximum extent feasible. . (c) Increased penalty on erroneous claims of credit Section 6676(a) of the Internal Revenue Code of 1986 is amended by inserting (25 percent in the case of a claim for refund or credit relating to the health insurance coverage credit under section 36B) . (d) Reporting by employers Section 6051(a) of such Code is amended by striking and at the end of paragraph (14), by striking the period at the end of paragraph (15) and inserting , and , and by inserting after paragraph (15) the following new paragraph: (16) each month with respect to which the employee is eligible for coverage described in section 36B(d)(2) in connection with employment with the employer. . (e) Coordination with other tax benefits (1) Credit for health insurance costs of eligible individuals Section 35(g) of such Code is amended by adding at the end the following new paragraph: (14) Coordination with health insurance coverage credit (A) In general An eligible coverage month to which the election under paragraph (11) applies shall not be treated as an eligible coverage month (as defined in section 36B(d)) for purposes of section 36B with respect to the taxpayer or any of the taxpayer’s qualifying family members (as defined in section 36B(e)). (B) Coordination with advance payments of health insurance coverage credit In the case of a taxpayer who makes the election under paragraph (11) with respect to any eligible coverage month in a taxable year or on behalf of whom any advance payment is made under section 7527 with respect to any month in such taxable year— (i) the tax imposed by this chapter for the taxable year shall be increased by the excess, if any, of— (I) the sum of any advance payments made on behalf of the taxpayer under section 7527 and section 1412 of the Patient Protection and Affordable Care Act, over (II) the sum of the credits allowed under this section (determined without regard to paragraph (1)) and section 36B (determined without regard to subsection (g)(4)(A) thereof) for such taxable year, and (ii) section 36B(g)(4)(B) shall not apply with respect to such taxpayer for such taxable year. . (2) Trade or business deduction Section 162(l) of such Code is amended by adding at the end the following new paragraph: (6) Coordination with health insurance coverage credit The deduction otherwise allowable to a taxpayer under paragraph (1) for any taxable year shall be reduced (but not below zero) by the amount of the credit allowable to such taxpayer under section 36B (determined without regard to subsection (g)(4)(A) thereof) for such taxable year. . (f) Effective date The amendments made by this section shall apply to months beginning after December 31, 2019, in taxable years ending after such date. 215. Maximum contribution limit to health savings account increased to amount of deductible and out-of-pocket limitation (a) Self-Only coverage Section 223(b)(2)(A) of the Internal Revenue Code of 1986 is amended by striking $2,250 and inserting the amount in effect under subsection (c)(2)(A)(ii)(I) . (b) Family coverage Section 223(b)(2)(B) of such Code is amended by striking $4,500 and inserting the amount in effect under subsection (c)(2)(A)(ii)(II) . (c) Conforming amendments Section 223(g)(1) of such Code is amended— (1) by striking subsections (b)(2) and both places it appears and inserting subsection , and (2) in subparagraph (B), by striking determined by and all that follows through calendar year 2003 . and inserting determined by substituting calendar year 2003 for calendar year 1992 in subparagraph (B) thereof. . (d) Effective date The amendments made by this section shall apply to taxable years beginning after December 31, 2017. 216. Allow both spouses to make catch-up contributions to the same health savings account (a) In general Section 223(b)(5) of the Internal Revenue Code of 1986 is amended to read as follows: (5) Special rule for married individuals with family coverage (A) In general In the case of individuals who are married to each other, if both spouses are eligible individuals and either spouse has family coverage under a high deductible health plan as of the first day of any month— (i) the limitation under paragraph (1) shall be applied by not taking into account any other high deductible health plan coverage of either spouse (and if such spouses both have family coverage under separate high deductible health plans, only one such coverage shall be taken into account), (ii) such limitation (after application of clause (i)) shall be reduced by the aggregate amount paid to Archer MSAs of such spouses for the taxable year, and (iii) such limitation (after application of clauses (i) and (ii)) shall be divided equally between such spouses unless they agree on a different division. (B) Treatment of additional contribution amounts If both spouses referred to in subparagraph (A) have attained age 55 before the close of the taxable year, the limitation referred to in subparagraph (A)(iii) which is subject to division between the spouses shall include the additional contribution amounts determined under paragraph (3) for both spouses. In any other case, any additional contribution amount determined under paragraph (3) shall not be taken into account under subparagraph (A)(iii) and shall not be subject to division between the spouses. . (b) Effective date The amendment made by this section shall apply to taxable years beginning after December 31, 2017. 217. Special rule for certain medical expenses incurred before establishment of health savings account (a) In general Section 223(d)(2) of the Internal Revenue Code of 1986 is amended by adding at the end the following new subparagraph: (D) Treatment of certain medical expenses incurred before establishment of account If a health savings account is established during the 60-day period beginning on the date that coverage of the account beneficiary under a high deductible health plan begins, then, solely for purposes of determining whether an amount paid is used for a qualified medical expense, such account shall be treated as having been established on the date that such coverage begins. . (b) Effective date The amendment made by this section shall apply with respect to coverage beginning after December 31, 2017. B Repeal of certain consumer taxes 221. Repeal of tax on prescription medications Subsection (j) of section 9008 of the Patient Protection and Affordable Care Act is amended to read as follows: (j) Repeal This section shall apply to calendar years beginning after December 31, 2010, and ending before January 1, 2017. . 222. Repeal of health insurance tax Subsection (j) of section 9010 of the Patient Protection and Affordable Care Act is amended to read as follows: (j) Repeal This section shall apply to calendar years beginning after December 31, 2013, and ending before January 1, 2017. . C Repeal of Tanning Tax 231. Repeal of tanning tax (a) In general The Internal Revenue Code of 1986 is amended by striking chapter 49. (b) Effective date The amendment made by this section shall apply to services performed after June 30, 2017. D Remuneration from Certain Insurers 241. Remuneration from certain insurers Paragraph (6) of section 162(m) of the Internal Revenue Code of 1986 is amended by adding at the end the following new subparagraph: (I) Termination This paragraph shall not apply to taxable years beginning after December 31, 2016. . E Repeal of Net Investment Income Tax 251. Repeal of net investment income tax (a) In general Subtitle A of the Internal Revenue Code of 1986 is amended by striking chapter 2A. (b) Effective date The amendment made by this section shall apply to taxable years beginning after December 31, 2016.

Passed the House of Representatives May 4, 2017. Karen L. Haas, Clerk.

tv_txt: II Calendar No. 120 115th CONGRESS 1st Session H. R. 1628 IN THE SENATE OF THE UNITED STATES June 7, 2017 Received; read the first time June 8, 2017 Read twice and placed on the calendar AN ACT To provide for reconciliation pursuant to title II of the concurrent resolution on the budget for fiscal year 2017.

1. Short title This Act may be cited as the American Health Care Act of 2017 . 2. Table of contents The table of contents of this Act is as follows: Sec. 1. Short title. Sec. 2. Table of contents. Title I—Energy and Commerce Subtitle A—Patient Access to Public Health Programs Sec. 101. The Prevention and Public Health Fund. Sec. 102. Community health center program. Sec. 103. Federal payments to States. Subtitle B—Medicaid Program Enhancement Sec. 111. Repeal of Medicaid provisions. Sec. 112. Repeal of Medicaid expansion. Sec. 113. Elimination of DSH cuts. Sec. 114. Reducing State Medicaid costs. Sec. 115. Safety net funding for non-expansion States. Sec. 116. Providing incentives for increased frequency of eligibility redeterminations. Sec. 117. Permitting States to apply a work requirement for nondisabled, nonelderly, nonpregnant adults under Medicaid. Subtitle C—Per Capita Allotment for Medical Assistance Sec. 121. Per capita allotment for medical assistance. Subtitle D—Patient Relief and Health Insurance Market Stability Sec. 131. Repeal of cost-sharing subsidy. Sec. 132. Patient and State Stability Fund. Sec. 133. Continuous health insurance coverage incentive. Sec. 134. Increasing coverage options. Sec. 135. Change in permissible age variation in health insurance premium rates. Subtitle E—Implementation Funding Sec. 141. American Health Care Implementation Fund. Title II—Committee on Ways and Means Subtitle A—Repeal and Replace of Health-Related Tax Policy Sec. 201. Recapture excess advance payments of premium tax credits. Sec. 202. Additional modifications to premium tax credit. Sec. 203. Small business tax credit. Sec. 204. Individual mandate. Sec. 205. Employer mandate. Sec. 206. Repeal of the tax on employee health insurance premiums and health plan benefits. Sec. 207. Repeal of tax on over-the-counter medications. Sec. 208. Repeal of increase of tax on health savings accounts. Sec. 209. Repeal of limitations on contributions to flexible spending accounts. Sec. 210. Repeal of medical device excise tax. Sec. 211. Repeal of elimination of deduction for expenses allocable to medicare part D subsidy. Sec. 212. Reduction of income threshold for determining medical care deduction. Sec. 213. Repeal of Medicare tax increase. Sec. 214. Refundable tax credit for health insurance coverage. Sec. 215. Maximum contribution limit to health savings account increased to amount of deductible and out-of-pocket limitation. Sec. 216. Allow both spouses to make catch-up contributions to the same health savings account. Sec. 217. Special rule for certain medical expenses incurred before establishment of health savings account. Subtitle B—Repeal of certain consumer taxes Sec. 221. Repeal of tax on prescription medications. Sec. 222. Repeal of health insurance tax. Subtitle C—Repeal of Tanning Tax Sec. 231. Repeal of tanning tax. Subtitle D—Remuneration from Certain Insurers Sec. 241. Remuneration from certain insurers. Subtitle E—Repeal of Net Investment Income Tax Sec. 251. Repeal of net investment income tax. I Energy and Commerce A Patient Access to Public Health Programs 101. The Prevention and Public Health Fund (a) In general Subsection (b) of section 4002 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 300u–11 ), as amended by section 5009 of the 21st Century Cures Act, is amended— (1) in paragraph (2), by adding and at the end; (2) in paragraph (3)— (A) by striking each of fiscal years 2018 and 2019 and inserting fiscal year 2018 ; and (B) by striking the semicolon at the end and inserting a period; and (3) by striking paragraphs (4) through (8). (b) Rescission of unobligated funds Of the funds made available by such section 4002, the unobligated balance at the end of fiscal year 2018 is rescinded. 102. Community health center program Effective as if included in the enactment of the Medicare Access and CHIP Reauthorization Act of 2015 ( Public Law 114–10 , 129 Stat. 87), paragraph (1) of section 221(a) of such Act is amended by inserting , and an additional $422,000,000 for fiscal year 2017 after 2017 . 103. Federal payments to States (a) In general Notwithstanding section 504(a), 1902(a)(23), 1903(a), 2002, 2005(a)(4), 2102(a)(7), or 2105(a)(1) of the Social Security Act ( 42 U.S.C. 704(a) , 1396a(a)(23), 1396b(a), 1397a, 1397d(a)(4), 1397bb(a)(7), 1397ee(a)(1)), or the terms of any Medicaid waiver in effect on the date of enactment of this Act that is approved under section 1115 or 1915 of the Social Security Act ( 42 U.S.C. 1315 , 1396n), for the 1-year period beginning on the date of the enactment of this Act, no Federal funds provided from a program referred to in this subsection that is considered direct spending for any year may be made available to a State for payments to a prohibited entity, whether made directly to the prohibited entity or through a managed care organization under contract with the State. (b) Definitions In this section: (1) Prohibited entity The term prohibited entity means an entity, including its affiliates, subsidiaries, successors, and clinics— (A) that, as of the date of enactment of this Act— (i) is an organization described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from tax under section 501(a) of such Code; (ii) is an essential community provider described in section 156.235 of title 45, Code of Federal Regulations (as in effect on the date of enactment of this Act), that is primarily engaged in family planning services, reproductive health, and related medical care; and (iii) provides for abortions, other than an abortion— (I) if the pregnancy is the result of an act of rape or incest; or (II) in the case where a woman suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the woman in danger of death unless an abortion is performed, including a life-endangering physical condition caused by or arising from the pregnancy itself; and (B) for which the total amount of Federal and State expenditures under the Medicaid program under title XIX of the Social Security Act in fiscal year 2014 made directly to the entity and to any affiliates, subsidiaries, successors, or clinics of the entity, or made to the entity and to any affiliates, subsidiaries, successors, or clinics of the entity as part of a nationwide health care provider network, exceeded $350,000,000. (2) Direct spending The term direct spending has the meaning given that term under section 250(c) of the Balanced Budget and Emergency Deficit Control Act of 1985 ( 2 U.S.C. 900(c) ). B Medicaid Program Enhancement 111. Repeal of Medicaid provisions The Social Security Act is amended— (1) in section 1902 ( 42 U.S.C. 1396a )— (A) in subsection (a)(47)(B), by inserting and provided that any such election shall cease to be effective on January 1, 2020, and no such election shall be made after that date before the semicolon at the end; and (B) in subsection (l)(2)(C), by inserting and ending December 31, 2019, after January 1, 2014, ; (2) in section 1915(k)(2) ( 42 U.S.C. 1396n(k)(2) ), by striking during the period described in paragraph (1) and inserting on or after the date referred to in paragraph (1) and before January 1, 2020 ; and (3) in section 1920(e) ( 42 U.S.C. 1396r–1(e) ), by striking under clause (i)(VIII), clause (i)(IX), or clause (ii)(XX) of subsection (a)(10)(A) and inserting under clause (i)(VIII) or clause (ii)(XX) of section 1902(a)(10)(A) before January 1, 2020, section 1902(a)(10)(A)(i)(IX), . 112. Repeal of Medicaid expansion (a) In general Title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq.) is amended— (1) in section 1902 ( 42 U.S.C. 1396a )— (A) in subsection (a)(10)(A)— (i) in clause (i)(VIII), by inserting and ending December 31, 2019, after 2014, ; (ii) in clause (ii)(XX), by inserting and ending December 31, 2017, after 2014, ; and (iii) in clause (ii), by adding at the end the following new subclause: (XXIII) beginning January 1, 2020— (aa) who are expansion enrollees (as defined in subsection (nn)(1)); or (bb) who are grandfathered expansion enrollees (as defined in subsection (nn)(2)); ; and (B) by adding at the end the following new subsection: (nn) Expansion enrollees In this title: (1) In general The term expansion enrollee means an individual— (A) who is under 65 years of age; (B) who is not pregnant; (C) who is not entitled to, or enrolled for, benefits under part A of title XVIII, or enrolled for benefits under part B of title XVIII; (D) who is not described in any of subclauses (I) through (VII) of subsection (a)(10)(A)(i); and (E) whose income (as determined under subsection (e)(14)) does not exceed 133 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved. (2) Grandfathered expansion enrollees The term grandfathered expansion enrollee means an expansion enrollee who— (A) was enrolled under the State plan under this title (or under a waiver of such plan) as of December 31, 2019; and (B) does not have a break in eligibility for medical assistance under such State plan (or waiver) for more than one month after such date. (3) Application of related provisions Any reference in subsection (a)(10)(G), (k), or (gg) of this section or in section 1903, 1905(a), 1920(e), or 1937(a)(1)(B) to individuals described in subclause (VIII) of subsection (a)(10)(A)(i) shall be deemed to include a reference to expansion enrollees (including grandfathered expansion enrollees). ; and (2) in section 1905 ( 42 U.S.C. 1396d )— (A) in subsection (y)(1), in the matter preceding subparagraph (A)— (i) by inserting and that has elected to cover newly eligible individuals before March 1, 2017 after that is one of the 50 States or the District of Columbia ; and (ii) by inserting after subclause (VIII) of section 1902(a)(10)(A)(i) the following: who, for periods after December 31, 2019, are grandfathered expansion enrollees (as defined in section 1902(nn)(2)) ; and (B) in subsection (z)(2)— (i) in subparagraph (A), by inserting after section 1937 the following: and, for periods after December 31, 2019, who are grandfathered expansion enrollees (as defined in section 1902(nn)(2)) ; and (ii) in subparagraph (B)(ii)— (I) in subclause (III), by adding and at the end; and (II) by striking subclauses (IV), (V), and (VI) and inserting the following new subclause: (IV) 2017 and each subsequent year is 80 percent. . (b) Sunset of essential health benefits requirement Section 1937(b)(5) of the Social Security Act ( 42 U.S.C. 1396u–7(b)(5) ) is amended by adding at the end the following: This paragraph shall not apply after December 31, 2019. . 113. Elimination of DSH cuts Section 1923(f) of the Social Security Act ( 42 U.S.C. 1396r–4(f) ) is amended— (1) in paragraph (7)— (A) in subparagraph (A)— (i) in clause (i)— (I) in the matter preceding subclause (I), by striking 2025 and inserting 2019 ; and (ii) in clause (ii)— (I) in subclause (I), by adding and at the end; (II) in subclause (II), by striking the semicolon at the end and inserting a period; and (III) by striking subclauses (III) through (VIII); and (B) by adding at the end the following new subparagraph: (C) Exemption from Reduction for non-expansion States (i) In general In the case of a State that is a non-expansion State for a fiscal year, subparagraph (A)(i) shall not apply to the DSH allotment for such State and fiscal year. (ii) No change in reduction for expansion States In the case of a State that is an expansion State for a fiscal year, the DSH allotment for such State and fiscal year shall be determined as if clause (i) did not apply. (iii) Non-expansion and expansion State defined (I) The term expansion State means with respect to a fiscal year, a State that, as of July 1 of the preceding fiscal year, provides for eligibility under clause (i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) for medical assistance under this title (or a waiver of the State plan approved under section 1115). (II) The term non-expansion State means, with respect to a fiscal year, a State that is not an expansion State. ; and (2) in paragraph (8), by striking fiscal year 2025 and inserting fiscal year 2019 . 114. Reducing State Medicaid costs (a) Letting States disenroll high dollar lottery winners (1) In general Section 1902 of the Social Security Act ( 42 U.S.C. 1396a ) is amended— (A) in subsection (a)(17), by striking (e)(14), (e)(14) and inserting (e)(14), (e)(15) ; and (B) in subsection (e)— (i) in paragraph (14) (relating to modified adjusted gross income), by adding at the end the following new subparagraph : (J) Treatment of certain lottery winnings and income received as a lump sum (i) In general In the case of an individual who is the recipient of qualified lottery winnings (pursuant to lotteries occurring on or after January 1, 2020) or qualified lump sum income (received on or after such date) and whose eligibility for medical assistance is determined based on the application of modified adjusted gross income under subparagraph (A), a State shall, in determining such eligibility, include such winnings or income (as applicable) as income received— (I) in the month in which such winnings or income (as applicable) is received if the amount of such winnings or income is less than $80,000; (II) over a period of 2 months if the amount of such winnings or income (as applicable) is greater than or equal to $80,000 but less than $90,000; (III) over a period of 3 months if the amount of such winnings or income (as applicable) is greater than or equal to $90,000 but less than $100,000; and (IV) over a period of 3 months plus 1 additional month for each increment of $10,000 of such winnings or income (as applicable) received, not to exceed a period of 120 months (for winnings or income of $1,260,000 or more), if the amount of such winnings or income is greater than or equal to $100,000. (ii) Counting in equal installments For purposes of subclauses (II), (III), and (IV) of clause (i), winnings or income to which such subclause applies shall be counted in equal monthly installments over the period of months specified under such subclause. (iii) Hardship exemption An individual whose income, by application of clause (i), exceeds the applicable eligibility threshold established by the State, may continue to be eligible for medical assistance to the extent that the State determines, under procedures established by the State under the State plan (or in the case of a waiver of the plan under section 1115, incorporated in such waiver), or as otherwise established by such State in accordance with such standards as may be specified by the Secretary, that the denial of eligibility of the individual would cause an undue medical or financial hardship as determined on the basis of criteria established by the Secretary. (iv) Notifications and assistance required in case of loss of eligibility A State shall, with respect to an individual who loses eligibility for medical assistance under the State plan (or a waiver of such plan) by reason of clause (i), before the date on which the individual loses such eligibility, inform the individual of the date on which the individual would no longer be considered ineligible by reason of such clause to receive medical assistance under the State plan or under any waiver of such plan and the date on which the individual would be eligible to reapply to receive such medical assistance. (v) Qualified lottery winnings defined In this subparagraph, the term qualified lottery winnings means winnings from a sweepstakes, lottery, or pool described in paragraph (3) of section 4402 of the Internal Revenue Code of 1986 or a lottery operated by a multistate or multijurisdictional lottery association, including amounts awarded as a lump sum payment. (vi) Qualified lump sum income defined In this subparagraph, the term qualified lump sum income means income that is received as a lump sum from one of the following sources: (I) Monetary winnings from gambling (as defined by the Secretary and including monetary winnings from gambling activities described in section 1955(b)(4) of title 18, United States Code). (II) Income received as liquid assets from the estate (as defined in section 1917(b)(4)) of a deceased individual. ; and (ii) by striking (14) Exclusion and inserting (15) Exclusion . (2) Rules of construction (A) Interception of lottery winnings allowed Nothing in the amendment made by paragraph (1)(B)(i) shall be construed as preventing a State from intercepting the State lottery winnings awarded to an individual in the State to recover amounts paid by the State under the State Medicaid plan under title XIX of the Social Security Act for medical assistance furnished to the individual. (B) Applicability limited to eligibility of recipient of lottery winnings or lump sum income Nothing in the amendment made by paragraph (1)(B)(i) shall be construed, with respect to a determination of household income for purposes of a determination of eligibility for medical assistance under the State plan under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq.) (or a waiver of such plan) made by applying modified adjusted gross income under subparagraph (A) of section 1902(e)(14) of such Act ( 42 U.S.C. 1396a(e)(14) ), as limiting the eligibility for such medical assistance of any individual that is a member of the household other than the individual (or the individual’s spouse) who received qualified lottery winnings or qualified lump-sum income (as defined in subparagraph (J) of such section 1902(e)(14), as added by paragraph (1)(B)(i) of this subsection). (b) Repeal of retroactive eligibility (1) In general (A) State plan requirements Section 1902(a)(34) of the Social Security Act ( 42 U.S.C. 1396a(a)(34) ) is amended by striking in or after the third month before the month in which he made application and inserting in or after the month in which the individual made application . (B) Definition of medical assistance Section 1905(a) of the Social Security Act ( 42 U.S.C. 1396d(a) ) is amended by striking in or after the third month before the month in which the recipient makes application for assistance and inserting in or after the month in which the recipient makes application for assistance . (2) Effective date The amendments made by paragraph (1) shall apply to medical assistance with respect to individuals whose eligibility for such assistance is based on an application for such assistance made (or deemed to be made) on or after October 1, 2017. (c) Updating allowable home equity limits in Medicaid (1) In general Section 1917(f)(1) of the Social Security Act ( 42 U.S.C. 1396p(f)(1) ) is amended— (A) in subparagraph (A), by striking subparagraphs (B) and (C) and inserting subparagraph (B) ; (B) by striking subparagraph (B); (C) by redesignating subparagraph (C) as subparagraph (B); and (D) in subparagraph (B), as so redesignated, by striking dollar amounts specified in this paragraph and inserting dollar amount specified in subparagraph (A) . (2) Effective date (A) In general The amendments made by paragraph (1) shall apply with respect to eligibility determinations made after the date that is 180 days after the date of the enactment of this section. (B) Exception for State legislation In the case of a State plan under title XIX of the Social Security Act that the Secretary of Health and Human Services determines requires State legislation in order for the respective plan to meet any requirement imposed by amendments made by this subsection, 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 an 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 the 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 shall be considered to be a separate regular session of the State legislature. 115. Safety net funding for non-expansion States Title XIX of the Social Security Act is amended by inserting after section 1923 ( 42 U.S.C. 1396r–4 ) the following new section: 1923A. Adjustment in payment for services of safety net providers in non-expansion States (a) In general Subject to the limitations of this section, for each year during the period beginning with fiscal year 2018 and ending with fiscal year 2022, each State that is one of the 50 States or the District of Columbia and that, as of July 1 of the preceding fiscal year, did not provide for eligibility under clause (i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) for medical assistance under this title (or a waiver of the State plan approved under section 1115) (each such State or District referred to in this section for the fiscal year as a non-expansion State ) may adjust the payment amounts otherwise provided under the State plan under this title (or a waiver of such plan) to health care providers that provide health care services to individuals enrolled under this title (in this section referred to as eligible providers ) so long as the payment adjustment to such an eligible provider does not exceed the provider’s costs in furnishing health care services (as determined by the Secretary and net of payments under this title, other than under this section, and by uninsured patients) to individuals who either are eligible for medical assistance under the State plan (or under a waiver of such plan) or have no health insurance or health plan coverage for such services. (b) Increase in applicable FMAP Notwithstanding section 1905(b), the Federal medical assistance percentage applicable with respect to expenditures attributable to a payment adjustment under subsection (a) for which payment is permitted under subsection (c) shall be equal to— (1) 100 percent for calendar quarters in fiscal years 2018, 2019, 2020, and 2021; and (2) 95 percent for calendar quarters in fiscal year 2022. (c) Annual allotment limitation Payment under section 1903(a) shall not be made to a State with respect to any payment adjustment made under this section for all calendar quarters in a fiscal year in excess of the $2,000,000,000 multiplied by the ratio of— (1) the population of the State with income below 138 percent of the poverty line in 2015 (as determined based the table entitled Health Insurance Coverage Status and Type by Ratio of Income to Poverty Level in the Past 12 Months by Age for the universe of the civilian noninstitutionalized population for whom poverty status is determined based on the 2015 American Community Survey 1–Year Estimates, as published by the Bureau of the Census), to (2) the sum of the populations under paragraph (1) for all non-expansion States. (d) Disqualification in case of State coverage expansion If a State is a non-expansion for a fiscal year and provides eligibility for medical assistance described in subsection (a) during the fiscal year, the State shall no longer be treated as a non-expansion State under this section for any subsequent fiscal years. . 116. Providing incentives for increased frequency of eligibility redeterminations (a) In general Section 1902(e)(14) of the Social Security Act ( 42 U.S.C. 1396a(e)(14) ) (relating to modified adjusted gross income), as amended by section 114(a)(1), is further amended by adding at the end the following: (K) Frequency of eligibility redeterminations Beginning on October 1, 2017, and notwithstanding subparagraph (H), in the case of an individual whose eligibility for medical assistance under the State plan under this title (or a waiver of such plan) is determined based on the application of modified adjusted gross income under subparagraph (A) and who is so eligible on the basis of clause (i)(VIII) or clause (ii)(XX) of subsection (a)(10)(A), a State shall redetermine such individual’s eligibility for such medical assistance no less frequently than once every 6 months. . (b) Increased administrative matching percentage For each calendar quarter during the period beginning on October 1, 2017, and ending on December 31, 2019, the Federal matching percentage otherwise applicable under section 1903(a) of the Social Security Act ( 42 U.S.C. 1396b(a) ) with respect to State expenditures during such quarter that are attributable to meeting the requirement of section 1902(e)(14) (relating to determinations of eligibility using modified adjusted gross income) of such Act shall be increased by 5 percentage points with respect to State expenditures attributable to activities carried out by the State (and approved by the Secretary) to increase the frequency of eligibility redeterminations required by subparagraph (K) of such section (relating to eligibility redeterminations made on a 6-month basis) (as added by subsection (a)). 117. Permitting States to apply a work requirement for nondisabled, nonelderly, nonpregnant adults under Medicaid (a) In general Section 1902 of the Social Security Act ( 42 U.S.C. 1396a ), as previously amended, is further amended by adding at the end the following new subsection: (oo) Work requirement option for nondisabled, nonelderly, nonpregnant adults (1) In general Beginning October 1, 2017, subject to paragraph (3), a State may elect to condition medical assistance to a nondisabled, nonelderly, nonpregnant individual under this title upon such an individual’s satisfaction of a work requirement (as defined in paragraph (2)). (2) Work requirement defined In this section, the term work requirement means, with respect to an individual, the individual’s participation in work activities (as defined in section 407(d)) for such period of time as determined by the State, and as directed and administered by the State. (3) Required exceptions States administering a work requirement under this subsection may not apply such requirement to— (A) a woman during pregnancy through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends; (B) an individual who is under 19 years of age; (C) an individual who is the only parent or caretaker relative in the family of a child who has not attained 6 years of age or who is the only parent or caretaker of a child with disabilities; or (D) an individual who is married or a head of household and has not attained 20 years of age and who— (i) maintains satisfactory attendance at secondary school or the equivalent; or (ii) participates in education directly related to employment. . (b) Increase in matching rate for implementation Section 1903 of the Social Security Act ( 42 U.S.C. 1396b ) is amended by adding at the end the following: (aa) The Federal matching percentage otherwise applicable under subsection (a) with respect to State administrative expenditures during a calendar quarter for which the State receives payment under such subsection shall, in addition to any other increase to such Federal matching percentage, be increased for such calendar quarter by 5 percentage points with respect to State expenditures attributable to activities carried out by the State (and approved by the Secretary) to implement subsection (oo) of section 1902. . C Per Capita Allotment for Medical Assistance 121. Per capita allotment for medical assistance Title XIX of the Social Security Act is amended— (1) in section 1903 ( 42 U.S.C. 1396b )— (A) in subsection (a), in the matter before paragraph (1), by inserting and section 1903A(a) after except as otherwise provided in this section ; and (B) in subsection (d)(1), by striking to which and inserting to which, subject to section 1903A(a), ; and (2) by inserting after such section 1903 the following new section: 1903A. Per capita-based cap on payments for medical assistance (a) Application of per capita cap on payments for medical assistance expenditures (1) In general If a State has excess aggregate medical assistance expenditures (as defined in paragraph (2)) for a fiscal year (beginning with fiscal year 2020), the amount of payment to the State under section 1903(a)(1) for each quarter in the following fiscal year shall be reduced by ¼ of the excess aggregate medical assistance payments (as defined in paragraph (3)) for that previous fiscal year. In this section, the term State means only the 50 States and the District of Columbia. (2) Excess aggregate medical assistance expenditures In this subsection, the term excess aggregate medical assistance expenditures means, for a State for a fiscal year, the amount (if any) by which— (A) the amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State and fiscal year; exceeds (B) the amount of the target total medical assistance expenditures (as defined in subsection (c)) for the State and fiscal year. (3) Excess aggregate medical assistance payments In this subsection, the term excess aggregate medical assistance payments means, for a State for a fiscal year, the product of— (A) the excess aggregate medical assistance expenditures (as defined in paragraph (2)) for the State for the fiscal year; and (B) the Federal average medical assistance matching percentage (as defined in paragraph (4)) for the State for the fiscal year. (4) Federal average medical assistance matching percentage In this subsection, the term Federal average medical assistance matching percentage means, for a State for a fiscal year, the ratio (expressed as a percentage) of— (A) the amount of the Federal payments that would be made to the State under section 1903(a)(1) for medical assistance expenditures for calendar quarters in the fiscal year if paragraph (1) did not apply; to (B) the amount of the medical assistance expenditures for the State and fiscal year. (b) Adjusted total medical assistance expenditures Subject to subsection (g), the following shall apply: (1) In general In this section, the term adjusted total medical assistance expenditures means, for a State— (A) for fiscal year 2016, the product of— (i) the amount of the medical assistance expenditures (as defined in paragraph (2)) for the State and fiscal year, reduced by the amount of any excluded expenditures (as defined in paragraph (3)) for the State and fiscal year otherwise included in such medical assistance expenditures; and (ii) the 1903A FY16 population percentage (as defined in paragraph (4)) for the State; or (B) for fiscal year 2019 or a subsequent fiscal year, the amount of the medical assistance expenditures (as defined in paragraph (2)) for the State and fiscal year that is attributable to 1903A enrollees, reduced by the amount of any excluded expenditures (as defined in paragraph (3)) for the State and fiscal year otherwise included in such medical assistance expenditures and includes non-DSH supplemental payments (as defined in subsection (d)(4)(A)(ii)) and payments described in subsection (d)(4)(A)(iii) but shall not be construed as including any expenditures attributable to the program under section 1928. In applying subparagraph (B), non-DSH supplemental payments (as defined in subsection (d)(4)(A)(ii)) and payments described in subsection (d)(4)(A)(iii) shall be treated as fully attributable to 1903A enrollees. (2) Medical assistance expenditures In this section, the term medical assistance expenditures means, for a State and fiscal year, the medical assistance payments as reported by medical service category on the Form CMS-64 quarterly expense report (or successor to such a report form, and including enrollment data and subsequent adjustments to any such report, in this section referred to collectively as a CMS-64 report ) for which payment is (or may otherwise be) made pursuant to section 1903(a)(1). (3) Excluded expenditures In this section, the term excluded expenditures means, for a State and fiscal year, expenditures under the State plan (or under a waiver of such plan) that are attributable to any of the following: (A) DSH Payment adjustments made for disproportionate share hospitals under section 1923. (B) Medicare cost-sharing Payments made for medicare cost-sharing (as defined in section 1905(p)(3)). (C) Safety net provider payment adjustments in non-expansion States Payment adjustments under subsection (a) of section 1923A for which payment is permitted under subsection (c) of such section. (4) 1903A FY 16 population percentage In this subsection, the term 1903A FY16 population percentage means, for a State, the Secretary’s calculation of the percentage of the actual medical assistance expenditures, as reported by the State on the CMS–64 reports for calendar quarters in fiscal year 2016, that are attributable to 1903A enrollees (as defined in subsection (e)(1)). (c) Target total medical assistance expenditures (1) Calculation In this section, the term target total medical assistance expenditures means, for a State for a fiscal year and subject to paragraph (4), the sum of the products, for each of the 1903A enrollee categories (as defined in subsection (e)(2)), of— (A) the target per capita medical assistance expenditures (as defined in paragraph (2)) for the enrollee category, State, and fiscal year; and (B) the number of 1903A enrollees for such enrollee category, State, and fiscal year, as determined under subsection (e)(4). (2) Target per capita medical assistance expenditures In this subsection, the term ‘target per capita medical assistance expenditures’ means, for a 1903A enrollee category and State— (A) for fiscal year 2020, an amount equal to— (i) the provisional FY19 target per capita amount for such enrollee category (as calculated under subsection (d)(5)) for the State; increased by (ii) the applicable annual inflation factor (as defined in paragraph (3)) for fiscal year 2020; and (B) for each succeeding fiscal year, an amount equal to— (i) the target per capita medical assistance expenditures (under subparagraph (A) or this subparagraph) for the 1903A enrollee category and State for the preceding fiscal year, increased by (ii) the applicable annual inflation factor for that succeeding fiscal year. (3) Applicable annual inflation factor In paragraph (2), the term applicable annual inflation factor means, for a fiscal year— (A) for each of the 1903A enrollee categories described in subparagraphs (C), (D), and (E) of subsection (e)(2), the percentage increase in the medical care component of the consumer price index for all urban consumers (U.S. city average) from September of the previous fiscal year to September of the fiscal year involved; and (B) for each of the 1903A enrollee categories described in subparagraphs (A) and (B) of subsection (e)(2), the percentage increase described in subparagraph (A) plus 1 percentage point. (4) Decrease in target expenditures for required expenditures by certain political subdivisions (A) In general In the case of a State that had a DSH allotment under section 1923(f) for fiscal year 2016 that was more than 6 times the national average of such allotments for all the States for such fiscal year and that requires political subdivisions within the State to contribute funds towards medical assistance or other expenditures under the State plan under this title (or under a waiver of such plan) for a fiscal year (beginning with fiscal year 2020), the target total medical assistance expenditures for such State and fiscal year shall be decreased by the amount that political subdivisions in the State are required to contribute under the plan (or waiver) without reimbursement from the State for such fiscal year, other than contributions described in subparagraph (B). (B) Exceptions The contributions described in this subparagraph are the following: (i) Contributions required by a State from a political subdivision that, as of the first day of the calendar year in which the fiscal year involved begins— (I) has a population of more than 5,000,000, as estimated by the Bureau of the Census; and (II) imposes a local income tax upon its residents. (ii) Contributions required by a State from a political subdivision for administrative expenses if the State required such contributions from such subdivision without reimbursement from the State as of January 1, 2017. (d) Calculation of FY19 provisional target amount for each 1903A enrollee category Subject to subsection (g), the following shall apply: (1) Calculation of base amounts for fiscal year 2016 For each State the Secretary shall calculate (and provide notice to the State not later than April 1, 2018, of) the following: (A) The amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State for fiscal year 2016. (B) The number of 1903A enrollees for the State in fiscal year 2016 (as determined under subsection (e)(4)). (C) The average per capita medical assistance expenditures for the State for fiscal year 2016 equal to— (i) the amount calculated under subparagraph (A); divided by (ii) the number calculated under subparagraph (B). (2) Fiscal year 2019 average per capita amount based on inflating the fiscal year 2016 amount to fiscal year 2019 by CPI-medical The Secretary shall calculate a fiscal year 2019 average per capita amount for each State equal to— (A) the average per capita medical assistance expenditures for the State for fiscal year 2016 (calculated under paragraph (1)(C)); increased by (B) the percentage increase in the medical care component of the consumer price index for all urban consumers (U.S. city average) from September, 2016 to September, 2019. (3) Aggregate and average expenditures per capita for fiscal year 2019 The Secretary shall calculate for each State the following: (A) The amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State for fiscal year 2019. (B) The number of 1903A enrollees for the State in fiscal year 2019 (as determined under subsection (e)(4)). (4) Per capita expenditures for fiscal year 2019 for each 1903A enrollee category The Secretary shall calculate (and provide notice to each State not later than January 1, 2020, of) the following: (A) (i) For each 1903A enrollee category, the amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State for fiscal year 2019 for individuals in the enrollee category, calculated by excluding from medical assistance expenditures those expenditures attributable to expenditures described in clause (iii) or non-DSH supplemental expenditures (as defined in clause (ii)). (ii) In this paragraph, the term non-DSH supplemental expenditure means a payment to a provider under the State plan (or under a waiver of the plan) that— (I) is not made under section 1923; (II) is not made with respect to a specific item or service for an individual; (III) is in addition to any payments made to the provider under the plan (or waiver) for any such item or service; and (IV) complies with the limits for additional payments to providers under the plan (or waiver) imposed pursuant to section 1902(a)(30)(A), including the regulations specifying upper payment limits under the State plan in part 447 of title 42, Code of Federal Regulations (or any successor regulations). (iii) An expenditure described in this clause is an expenditure that meets the criteria specified in subclauses (I), (II), and (III) of clause (ii) and is authorized under section 1115 for the purposes of funding a delivery system reform pool, uncompensated care pool, a designated state health program, or any other similar expenditure (as defined by the Secretary). (B) For each 1903A enrollee category, the number of 1903A enrollees for the State in fiscal year 2019 in the enrollee category (as determined under subsection (e)(4)). (C) For fiscal year 2016, the State’s non-DSH supplemental and pool payment percentage is equal to the ratio (expressed as a percentage) of— (i) the total amount of non-DSH supplemental expenditures (as defined in subparagraph (A)(ii)) and payments described in subparagraph (A)(iii) for the State for fiscal year 2016; to (ii) the amount described in subsection (b)(1)(A) for the State for fiscal year 2016. (D) For each 1903A enrollee category an average medical assistance expenditures per capita for the State for fiscal year 2019 for the enrollee category equal to— (i) the amount calculated under subparagraph (A) for the State, increased by the non-DSH supplemental and pool payment percentage for the State (as calculated under subparagraph (C)); divided by (ii) the number calculated under subparagraph (B) for the State for the enrollee category. (5) Provisional FY19 per capita target amount for each 1903A enrollee category Subject to subsection (f)(2), the Secretary shall calculate for each State a provisional FY19 per capita target amount for each 1903A enrollee category equal to the average medical assistance expenditures per capita for the State for fiscal year 2019 (as calculated under paragraph (4)(D)) for such enrollee category multiplied by the ratio of— (A) the product of— (i) the fiscal year 2019 average per capita amount for the State, as calculated under paragraph (2); and (ii) the number of 1903A enrollees for the State in fiscal year 2019, as calculated under paragraph (3)(B); to (B) the amount of the adjusted total medical assistance expenditures for the State for fiscal year 2019, as calculated under paragraph (3)(A). (e) 1903A enrollee; 1903A enrollee category Subject to subsection (g), for purposes of this section, the following shall apply: (1) 1903A enrollee The term 1903A enrollee means, with respect to a State and a month and subject to subsection (i)(1)(B), any Medicaid enrollee (as defined in paragraph (3)) for the month, other than such an enrollee who for such month is in any of the following categories of excluded individuals: (A) CHIP An individual who is provided, under this title in the manner described in section 2101(a)(2), child health assistance under title XXI. (B) IHS An individual who receives any medical assistance under this title for services for which payment is made under the third sentence of section 1905(b). (C) Breast and cervical cancer services eligible individual An individual who is entitled to medical assistance under this title only pursuant to section 1902(a)(10)(A)(ii)(XVIII). (D) Partial-benefit enrollees An individual who— (i) is an alien who is entitled to medical assistance under this title only pursuant to section 1903(v)(2); (ii) is entitled to medical assistance under this title only pursuant to subclause (XII) or (XXI) of section 1902(a)(10)(A)(ii) (or pursuant to a waiver that provides only comparable benefits); (iii) is a dual eligible individual (as defined in section 1915(h)(2)(B)) and is entitled to medical assistance under this title (or under a waiver) only for some or all of medicare cost-sharing (as defined in section 1905(p)(3)); or (iv) is entitled to medical assistance under this title and for whom the State is providing a payment or subsidy to an employer for coverage of the individual under a group health plan pursuant to section 1906 or section 1906A (or pursuant to a waiver that provides only comparable benefits). (2) 1903A enrollee category The term 1903A enrollee category means each of the following: (A) Elderly A category of 1903A enrollees who are 65 years of age or older. (B) Blind and disabled A category of 1903A enrollees (not described in the previous subparagraph) who are eligible for medical assistance under this title on the basis of being blind or disabled. (C) Children A category of 1903A enrollees (not described in a previous subparagraph) who are children under 19 years of age. (D) Expansion enrollees A category of 1903A enrollees (not described in a previous subparagraph) for whom the amounts expended for medical assistance are subject to an increase or change in the Federal medical assistance percentage under subsection (y) or (z)(2), respectively, of section 1905. (E) Other nonelderly, nondisabled, non-expansion adults A category of 1903A enrollees who are not described in any previous subparagraph. (3) Medicaid enrollee The term Medicaid enrollee means, with respect to a State for a month, an individual who is eligible for medical assistance for items or services under this title and enrolled under the State plan (or a waiver of such plan) under this title for the month. (4) Determination of number of 1903A enrollees The number of 1903A enrollees for a State and fiscal year, and, if applicable, for a 1903A enrollee category, is the average monthly number of Medicaid enrollees for such State and fiscal year (and, if applicable, in such category) that are reported through the CMS–64 report under (and subject to audit under) subsection (h). (f) Special payment rules (1) Application in case of research and demonstration projects and other waivers In the case of a State with a waiver of the State plan approved under section 1115, section 1915, or another provision of this title, this section shall apply to medical assistance expenditures and medical assistance payments under the waiver, in the same manner as if such expenditures and payments had been made under a State plan under this title and the limitations on expenditures under this section shall supersede any other payment limitations or provisions (including limitations based on a per capita limitation) otherwise applicable under such a waiver. (2) Treatment of States expanding coverage after fiscal year 2016 In the case of a State that did not provide for medical assistance for the 1903A enrollee category described in subsection (e)(2)(D) during fiscal year 2016 but which provides for such assistance for such category in a subsequent year, the provisional FY19 per capita target amount for such enrollee category under subsection (d)(5) shall be equal to the provisional FY19 per capita target amount for the 1903A enrollee category described in subsection (e)(2)(E). (3) In case of State failure to report necessary data If a State for any quarter in a fiscal year (beginning with fiscal year 2019) fails to satisfactorily submit data on expenditures and enrollees in accordance with subsection (h)(1), for such fiscal year and any succeeding fiscal year for which such data are not satisfactorily submitted— (A) the Secretary shall calculate and apply subsections (a) through (e) with respect to the State as if all 1903A enrollee categories for which such expenditure and enrollee data were not satisfactorily submitted were a single 1903A enrollee category; and (B) the growth factor otherwise applied under subsection (c)(2)(B) shall be decreased by 1 percentage point. (g) Recalculation of certain amounts for data errors The amounts and percentage calculated under paragraphs (1) and (4)(C) of subsection (d) for a State for fiscal year 2016, and the amounts of the adjusted total medical assistance expenditures calculated under subsection (b) and the number of Medicaid enrollees and 1903A enrollees determined under subsection (e)(4) for a State for fiscal year 2016, fiscal year 2019, and any subsequent fiscal year, may be adjusted by the Secretary based upon an appeal (filed by the State in such a form, manner, and time, and containing such information relating to data errors that support such appeal, as the Secretary specifies) that the Secretary determines to be valid, except that any adjustment by the Secretary under this subsection for a State may not result in an increase of the target total medical assistance expenditures exceeding 2 percent. (h) Required reporting and auditing of CMS–64 data; transitional increase in Federal matching percentage for certain administrative expenses (1) Reporting In addition to the data required on form Group VIII on the CMS–64 report form as of January 1, 2017, in each CMS-64 report required to be submitted (for each quarter beginning on or after October 1, 2018), the State shall include data on medical assistance expenditures within such categories of services and categories of enrollees (including each 1903A enrollee category and each category of excluded individuals under subsection (e)(1)) and the numbers of enrollees within each of such enrollee categories, as the Secretary determines are necessary (including timely guidance published as soon as possible after the date of the enactment of this section) in order to implement this section and to enable States to comply with the requirement of this paragraph on a timely basis. (2) Auditing The Secretary shall conduct for each State an audit of the number of individuals and expenditures reported through the CMS–64 report for fiscal year 2016, fiscal year 2019, and each subsequent fiscal year, which audit may be conducted on a representative sample (as determined by the Secretary). (3) Temporary increase in federal matching percentage to support improved data reporting systems for fiscal years 2018 and 2019 For amounts expended during calendar quarters beginning on or after October 1, 2017, and before October 1, 2019— (A) the Federal matching percentage applied under section 1903(a)(3)(A)(i) shall be increased by 10 percentage points to 100 percent; (B) the Federal matching percentage applied under section 1903(a)(3)(B) shall be increased by 25 percentage points to 100 percent; and (C) the Federal matching percentage applied under section 1903(a)(7) shall be increased by 10 percentage points to 60 percent but only with respect to amounts expended that are attributable to a State’s additional administrative expenditures to implement the data requirements of paragraph (1). (i) Flexible block grant option for States (1) In general In the case of a State that elects the option of applying this subsection for a 10-fiscal-year period (beginning no earlier than fiscal year 2020 and, at the State option, for any succeeding 10-fiscal-year period) and that has a plan approved by the Secretary under paragraph (2) to carry out the option for such period— (A) the State shall receive, instead of amounts otherwise payable to the State under this title for medical assistance for block grant individuals within the applicable block grant category (as defined in paragraph (6)) for the State during the period in which the election is in effect, the amount specified in paragraph (4); (B) the previous provisions of this section shall be applied as if— (i) block grant individuals within the applicable block grant category for the State and period were not section 1903A enrollees for each 10-fiscal year period for which the State elects to apply this subsection; and (ii) if such option is not extended at the end of a 10-fiscal-year-period, the per capita limitations under such previous provisions shall again apply after such period and such limitations shall be applied as if the election under this subsection had never taken place; (C) the payment under this subsection may only be used consistent with the State plan under paragraph (2) for block grant health care assistance (as defined in paragraph (7)); and (D) with respect to block grant individuals within the applicable block grant category for the State for which block grant health care assistance is made available under this subsection, such assistance shall be instead of medical assistance otherwise provided to the individual under this title. (2) State plan for administering block grant option (A) In general No payment shall be made under this subsection to a State pursuant to an election for a 10-fiscal-year period under paragraph (1) unless the State has a plan, approved under subparagraph (B), for such period that specifies— (i) the applicable block grant category with respect to which the State will apply the option under this subsection for such period; (ii) the conditions for eligibility of block grant individuals within such applicable block grant category for block grant health care assistance under the option, which shall be instead of other conditions for eligibility under this title, except that in the case of a State that has elected the applicable block grant category described in— (I) subparagraph (A) of paragraph (6), the plan must provide for eligibility for pregnant women and children required to be provided medical assistance under subsections (a)(10)(A)(i) and (e)(4) of section 1902; or (II) subparagraph (B) of paragraph (6), the plan must provide for eligibility for pregnant women required to be provided medical assistance under subsection (a)(10)(A)(i); and (iii) the types of items and services, the amount, duration, and scope of such services, the cost-sharing with respect to such services, and the method for delivery of block grant health care assistance under this subsection, which shall be instead of the such types, amount, duration, and scope, cost-sharing, and methods of delivery for medical assistance otherwise required under this title, except that the plan must provide for assistance for— (I) hospital care; (II) surgical care and treatment; (III) medical care and treatment; (IV) obstetrical and prenatal care and treatment; (V) prescribed drugs, medicines, and prosthetic devices; (VI) other medical supplies and services; and (VII) health care for children under 18 years of age. (B) Review and approval A plan described in subparagraph (A) shall be deemed approved by the Secretary unless the Secretary determines, within 30 days after the date of the Secretary’s receipt of the plan, that the plan is incomplete or actuarially unsound and, with respect to such plan and its implementation under this subsection, the requirements of paragraphs (1), (10)(B), (17), and (23) of section 1902(a) shall not apply. (3) Amount of block grant funds (A) For initial fiscal year The block grant amount under this paragraph for a State for the initial fiscal year in the first 10-fiscal-year period is equal to the sum of the products (for each applicable block grant category for such State and period) of— (i) the target per capita medical assistance expenditures for such State for such fiscal year (under subsection (c)(2)); (ii) the number of 1903A enrollees for such category and State for fiscal year 2019, as determined under subsection (e)(4); and (iii) the Federal average medical assistance matching percentage (as defined in subsection (a)(4)) for the State for fiscal year 2019. (B) For any subsequent fiscal year The block grant amount under this paragraph for a State for each succeeding fiscal year (in any 10-fiscal-year period) is equal to the block grant amount under subparagraph (A) (or this subparagraph) for the State for the previous fiscal year increased by the annual increase in the consumer price index for all urban consumers (all items; U.S. city average) for the fiscal year involved. (C) Availability of rollover funds The block grant amount under this paragraph for a State for a fiscal year shall remain available to the State for expenditures under this subsection for the succeeding fiscal year but only if an election is in effect under this subsection for the State in such succeeding fiscal year. (4) Federal payment and State responsibility The Secretary shall pay to each State with an election in effect under this subsection for a fiscal year, from its block grant amount under paragraph (3) available for such fiscal year, an amount for each quarter of such fiscal year equal to the enhanced FMAP described in the first sentence of section 2105(b) of the total amount expended under the State plan under this subsection during such quarter, and the State is responsible for the balance of funds to carry out such plan. (5) Block grant individual defined In this subsection, the term block grant individual means, with respect to a State for a 10-fiscal-year period, an individual who is not disabled (as defined for purposes of the State plan) and who is within an applicable block grant category for the State and such period. (6) Applicable block grant category defined In this subsection, the term applicable block grant category means with respect to a State for a 10-fiscal-year period, either of the following as specified by the State for such period in its plan under paragraph (2)(A)(i): (A) 2 enrollee categories Both of the following 1903A enrollee categories: (i) Children The 1903A enrollee category specified in subparagraph (C) of subsection (e)(2). (ii) Other nonelderly, nondisabled, non-expansion adults The 1903A enrollee category specified in subparagraph (E) of such subsection. (B) Other nonelderly, nondisabled, non-expansion adults Only the 1903A enrollee category specified in subparagraph (E) of subsection (e)(2). (7) Block grant health care assistance In this subsection, the term block grant health care assistance means assistance for health-care-related items and medical services for block grant individuals within the applicable block grant category for the State and 10-fiscal-year period involved who are low-income individuals (as defined by the State). (8) Auditing As a condition of receiving funds under this subsection, a State shall contract with an independent entity to conduct audits of its expenditures made with respect to activities funded under this subsection for each fiscal year for which the State elects to apply this subsection to ensure that such funds are used consistent with this subsection and shall make such audits available to the Secretary upon the request of the Secretary. . D Patient Relief and Health Insurance Market Stability 131. Repeal of cost-sharing subsidy (a) In general Section 1402 of the Patient Protection and Affordable Care Act is repealed. (b) Effective date The repeal made by subsection (a) shall apply to cost-sharing reductions (and payments to issuers for such reductions) for plan years beginning after December 31, 2019. 132. Patient and State Stability Fund The Social Security Act ( 42 U.S.C. 301 et seq.) is amended by adding at the end the following new title: XXII Patient and State Stability Fund 2201. Establishment of program There is hereby established the Patient and State Stability Fund to be administered by the Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as the Administrator ), to provide funding, in accordance with this title, to the 50 States and the District of Columbia (each referred to in this section as a State ) during the period, subject to section 2204(c), beginning on January 1, 2018, and ending on December 31, 2026, for the purposes described in section 2202. 2202. Use of funds (a) In General Subject to subsections (b) and (c), a State may use the funds allocated to the State under this title for any of the following purposes: (1) Helping, through the provision of financial assistance, high-risk individuals who do not have access to health insurance coverage offered through an employer enroll in health insurance coverage in the individual market in the State, as such market is defined by the State (whether through the establishment of a new mechanism or maintenance of an existing mechanism for such purpose). (2) Providing incentives to appropriate entities to enter into arrangements with the State to help stabilize premiums for health insurance coverage in the individual market, as such markets are defined by the State. (3) Reducing the cost for providing health insurance coverage in the individual market and small group market, as such markets are defined by the State, to individuals who have, or are projected to have, a high rate of utilization of health services (as measured by cost) and to individuals who have high costs of health insurance coverage due to the low density population of the State in which they reside. (4) Promoting participation in the individual market and small group market in the State and increasing health insurance options available through such market. (5) Promoting access to preventive services; dental care services (whether preventive or medically necessary); vision care services (whether preventive or medically necessary); or any combination of such services. (6) Maternity coverage and newborn care. (7) Prevention, treatment, or recovery support services for individuals with mental or substance use disorders, focused on either or both of the following: (A) Direct inpatient or outpatient clinical care for treatment of addiction and mental illness. (B) Early identification and intervention for children and young adults with serious mental illness. (8) Providing payments, directly or indirectly, to health care providers for the provision of such health care services as are specified by the Administrator. (9) Providing assistance to reduce out-of-pocket costs, such as copayments, coinsurance, premiums, and deductibles, of individuals enrolled in health insurance coverage in the State. (b) Required use of increase in allotment A State shall use the additional allocation provided to the State from the funds appropriated under the second sentence of section 2204(a) for each year only for the purposes described in paragraphs (6) and (7) of subsection (a). (c) Required use of additional increase to certain waiver States to provide financial hardship assistance A State shall use the additional allocation provided to the State from the funds appropriated under the last sentence of section 2204(a) only in accordance with such last sentence. 2203. State eligibility and approval; Default safeguard (a) Encouraging State options for allocations (1) In general To be eligible for an allocation of funds under this title for a year during the period described in section 2201 for use for one or more purposes described in section 2202, a State shall submit to the Administrator an application at such time (but, in the case of allocations for 2018, not later than 45 days after the date of the enactment of this title and, in the case of allocations for a subsequent year, not later than March 31 of the previous year) and in such form and manner as specified by the Administrator and containing— (A) a description of how the funds will be used for such purposes; (B) a certification that the State will make, from non-Federal funds, expenditures for such purposes in an amount that is not less than the State percentage required for the year under section 2204(e)(1); and (C) such other information as the Administrator may require. (2) Automatic approval An application so submitted is approved unless the Administrator notifies the State submitting the application, not later than 60 days after the date of the submission of such application, that the application has been denied for not being in compliance with any requirement of this title and of the reason for such denial. (3) One-time application If an application of a State is approved for a year, with respect to a purpose described in section 2202, such application shall be treated as approved, with respect to such purpose, for each subsequent year through 2026. (4) Treatment as a State Health Care Program Any program receiving funds from an allocation for a State under this title, including pursuant to subsection (b), shall be considered to be a State health care program for purposes of sections 1128, 1128A, and 1128B. (b) Default Federal safeguard (1) In general (A) 2018 For allocations made under this title for 2018, in the case of a State that does not submit an application under subsection (a) by the 45-day submission date applicable to such year under subsection (a)(1) and in the case of a State that does submit such an application by such date that is not approved, subject to section 2204(e), the Administrator, in consultation with the State insurance commissioner, shall use the allocation that would otherwise be provided to the State under this title for such year, in accordance with paragraph (2), for such State. (B) 2019 through 2026 In the case of a State that does not have in effect an approved application under this section for 2019 or a subsequent year beginning during the period described in section 2201, subject to section 2204(e), the Administrator, in consultation with the State insurance commissioner, shall use the allocation that would otherwise be provided to the State under this title for such year, in accordance with paragraph (2), for such State. (2) Required use for market stabilization payments to issuers Subject to section 2204(a), an allocation for a State made pursuant to paragraph (1) for a year shall be used to carry out the purpose described in section 2202(2) in such State by providing payments to appropriate entities described in such section with respect to claims that exceed $50,000 (or, with respect to allocations made under this title for 2020 or a subsequent year during the period specified in section 2201, such dollar amount specified by the Administrator), but do not exceed $350,000 (or, with respect to allocations made under this title for 2020 or a subsequent year during such period, such dollar amount specified by the Administrator), in an amount equal to 75 percent (or, with respect to allocations made under this title for 2020 or a subsequent year during such period, such percentage specified by the Administrator) of the amount of such claims. 2204. Allocations (a) Appropriation For the purpose of providing allocations for States (including pursuant to section 2203(b)) under this title there is appropriated, out of any money in the Treasury not otherwise appropriated— (1) for 2018, $15,000,000,000; (2) for 2019, $15,000,000,000; (3) for 2020, $10,000,000,000; (4) for 2021, $10,000,000,000; (5) for 2022, $10,000,000,000; (6) for 2023, $10,000,000,000; (7) for 2024, $10,000,000,000; (8) for 2025, $10,000,000,000; and (9) for 2026, $10,000,000,000. The amount otherwise appropriated under the previous sentence for 2020 shall be increased by $15,000,000,000, to be used and available under subsection (d) only for the purposes described in paragraphs (6) and (7) of section 2202(a). The amount otherwise appropriated under this subsection shall be increased by $8,000,000,000 for the period beginning with 2018 and ending with 2023, to be allocated to States with a waiver in effect under section 2701(b) of the Public Health Service Act with respect to the purpose described in paragraph (1)(C) of such section, in accordance with an allocation methodology specified by the Secretary that takes into account the relative allocation of other amounts appropriated under this subsection among such States, and to be used by (and made available under subsection (d), for any year during such period that such waiver is in effect, to) such States for the purpose of providing assistance to reduce premiums or other out-of-pocket costs of individuals who are subject to an increase in the monthly premium rate for health insurance coverage as a result of such waiver. (b) Allocations (1) Payment (A) In general From amounts appropriated under subsection (a) for a year, the Administrator shall, with respect to a State and not later than the date specified under subparagraph (B) for such year, allocate, subject to subsection (e), for such State (including pursuant to section 2203(b)) the amount determined for such State and year under paragraph (2). (B) Specified date For purposes of subparagraph (A), the date specified in this subparagraph is— (i) for 2018, the date that is 45 days after the date of the enactment of this title; and (ii) for 2019 and subsequent years, January 1 of the respective year. (2) Allocation amount determinations (A) For 2018 and 2019 (i) In general For purposes of paragraph (1), the amount determined under this paragraph for 2018 and 2019 for a State is an amount equal to the sum of— (I) the relative incurred claims amount described in clause (ii) for such State and year; and (II) the relative uninsured and issuer participation amount described in clause (iv) for such State and year. (ii) Relative incurred claims amount For purposes of clause (i), the relative incurred claims amount described in this clause for a State for 2018 and 2019 is the product of— (I) 85 percent of the amount appropriated under subsection (a) for the year; and (II) the relative State incurred claims proportion described in clause (iii) for such State and year. (iii) Relative State incurred claims proportion The relative State incurred claims proportion described in this clause for a State and year is the amount equal to the ratio of— (I) the adjusted incurred claims by the State, as reported through the medical loss ratio annual reporting under section 2718 of the Public Health Service Act for the third previous year; to (II) the sum of such adjusted incurred claims for all States, as so reported, for such third previous year. (iv) Relative uninsured and issuer participation amount For purposes of clause (i), the relative uninsured and issuer participation amount described in this clause for a State for 2018 and 2019 is the product of— (I) 15 percent of the amount appropriated under subsection (a) for the year; and (II) the relative State uninsured and issuer participation proportion described in clause (v) for such State and year. (v) Relative State uninsured and issuer participation proportion The relative State uninsured and issuer participation proportion described in this clause for a State and year is— (I) in the case of a State not described in clause (vi) for such year, 0; and (II) in the case of a State described in clause (vi) for such year, the amount equal to the ratio of— (aa) the number of individuals residing in such State who for the third preceding year were not enrolled in a health plan or otherwise did not have health insurance coverage (including through a Federal or State health program) and whose income is below 100 percent of the poverty line applicable to a family of the size involved; to (bb) the sum of the number of such individuals for all States described in clause (vi) for the third preceding year. (vi) States described For purposes of clause (v), a State is described in this clause, with respect to 2018 and 2019, if the State satisfies either of the following criterion: (I) The ratio described in subclause (II) of clause (v) that would be determined for such State by substituting 2015 for each reference in such subclause to the third preceding year and by substituting all such States for the reference in item (bb) of such subclause to all States described in clause (vi) is greater than the ratio described in such subclause that would be determined for such State by substituting 2013 for each reference in such subclause to the third preceding year and by substituting all such States for the reference in item (bb) of such subclause to all States described in clause (vi) . (II) The State has fewer than three health insurance issuers offering qualified health plans through the Exchange for 2017. (B) For 2020 through 2026 For purposes of paragraph (1), the amount determined under this paragraph for a year (beginning with 2020) during the period described in section 2201 for a State is an amount determined in accordance with an allocation methodology specified by the Administrator which— (i) takes into consideration the adjusted incurred claims of such State, the number of residents of such State who for the previous year were not enrolled in a health plan or otherwise did not have health insurance coverage (including through a Federal or State health program) and whose income is below 100 percent of the poverty line applicable to a family of the size involved, and the number of health insurance issuers participating in the insurance market in such State for such year; (ii) is established after consultation with health care consumers, health insurance issuers, State insurance commissioners, and other stakeholders and after taking into consideration additional cost and risk factors that may inhibit health care consumer and health insurance issuer participation; and (iii) reflects the goals of improving the health insurance risk pool, promoting a more competitive health insurance market, and increasing choice for health care consumers. (c) Annual distribution of previous year’s remaining funds In carrying out subsection (b), the Administrator shall, with respect to a year (beginning with 2020 and ending with 2027), not later than March 31 of such year— (1) determine the amount of funds, if any, from the amounts appropriated under subsection (a) for the previous year but not allocated for such previous year; and (2) if the Administrator determines that any funds were not so allocated for such previous year, allocate such remaining funds, in accordance with the allocation methodology specified pursuant to subsection (b)(2)(B)— (A) to States that have submitted an application approved under section 2203(a) for such previous year for any purpose for which such an application was approved; and (B) for States for which allocations were made pursuant to section 2203(b) for such previous year, to be used by the Administrator for such States, to carry out the Federal Invisible Risk Sharing Program in such States under section 2205; with, respect to a year before 2027, any remaining funds being made available for allocations to States for the subsequent year. (d) Availability Amounts appropriated under subsection (a) for a year and allocated to States in accordance with this section shall remain available for expenditure through December 31, 2027. (e) Conditions for and limitations on receipt of funds The Secretary may not make an allocation under this title for a State, with respect to a purpose described in section 2202— (1) in the case of an allocation that would be made to a State pursuant to section 2203(a), if the State does not agree that the State will make available non-Federal contributions towards such purpose in an amount equal to— (A) for 2020, 7 percent of the amount allocated under this subsection to such State for such year and purpose; (B) for 2021, 14 percent of the amount allocated under this subsection to such State for such year and purpose; (C) for 2022, 21 percent of the amount allocated under this subsection to such State for such year and purpose; (D) for 2023, 28 percent of the amount allocated under this subsection to such State for such year and purpose; (E) for 2024, 35 percent of the amount allocated under this subsection to such State for such year and purpose; (F) for 2025, 42 percent of the amount allocated under this subsection to such State for such year and purpose; and (G) for 2026, 50 percent of the amount allocated under this subsection to such State for such year and purpose; (2) in the case of an allocation that would be made for a State pursuant to section 2203(b), if the State does not agree that the State will make available non-Federal contributions towards such purpose in an amount equal to— (A) for 2020, 10 percent of the amount allocated under this subsection to such State for such year and purpose; (B) for 2021, 20 percent of the amount allocated under this subsection to such State for such year and purpose; and (C) for 2022, 30 percent of the amount allocated under this subsection to such State for such year and purpose; (D) for 2023, 40 percent of the amount allocated under this subsection to such State for such year and purpose; (E) for 2024, 50 percent of the amount allocated under this subsection to such State for such year and purpose; (F) for 2025, 50 percent of the amount allocated under this subsection to such State for such year and purpose; and (G) for 2026, 50 percent of the amount allocated under this subsection to such State for such year and purpose; or (3) if such an allocation for such purpose would not be permitted under subsection (c)(7) of section 2105 if such allocation were payment made under such section. 2205. Federal Invisible Risk Sharing Program (a) In general There is established within the Patient and State Stability Fund a Federal Invisible Risk Sharing Program (in this section referred to as the Program ), to be administered by the Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as the Administrator ), to provide payments to health insurance issuers with respect to claims for eligible individuals for the purpose of lowering premiums for health insurance coverage offered in the individual market. (b) Funding (1) Appropriation For the purpose of providing funding for the Program there is appropriated, out of any money in the Treasury not otherwise appropriated, $15,000,000,000 for the period beginning on January 1, 2018, and ending on December 31, 2026. (2) Use of unallocated funds Funds provided under section 2204(c)(2)(B) to carry out this section are in addition to the amount appropriated under paragraph (1). (c) Operation of program (1) In general The Administrator shall establish, after consultation with health care consumers, health insurance issuers, State insurance commissioners, and other stakeholders and after taking into consideration high cost health conditions and other health trends that generate high cost, parameters for the operation of the Program consistent with this section and consistent with the same limitation on payment with respect to health insurance coverage that applies to payment with respect health benefits coverage under section 2105(c)(7). (2) Deadline for initial operation Not later than 60 days after the date of the enactment of this title, the Administrator shall establish sufficient parameters to specify how the Program will operate for plan year 2018. (3) State operation of program The Administrator shall establish a process for a State to operate the Program in such State beginning with plan year 2020. (d) Details of program The parameters for the Program shall include the following: (1) Eligible individuals A definition for eligible individuals. (2) Health status statements The development and use of health status statements with respect to such individuals. (3) Standards for qualification (A) Automatic qualification The identification of health conditions that automatically qualify individuals as eligible individuals at the time of application for health insurance coverage. (B) Voluntary qualification A process under which health insurance issuers may voluntarily qualify individuals, who do not automatically qualify under subparagraph (A), as eligible individuals at the time of application for such coverage. (4) Percentage of insurance premiums to be applied The percentage of the premiums paid, to health insurance issuers for health insurance coverage by eligible individuals, that shall be collected and deposited to the credit (and available for the use) of the Program. (5) Attachment dollar amount and payment proportion The dollar amount of claims for eligible individuals after which the Program will provide payments to health insurance issuers and the proportion of such claims above such dollar amount that the Program will pay. . 133. Continuous health insurance coverage incentive Subpart I of part A of title XXVII of the Public Health Service Act is amended— (1) in section 2701(a)(1)(B), by striking such rate and inserting subject to section 2710A, such rate ; (2) by redesignating the second section 2709 as section 2710; and (3) by adding at the end the following new section: 2710A. Encouraging continuous health insurance coverage (a) Penalty applied (1) In general Subject to the succeeding provisions of this section, a health insurance issuer offering health insurance coverage in the individual market shall, in the case of an individual who is an applicable policyholder of such coverage with respect to an enforcement period applicable to enrollments for a plan year beginning with plan year 2019 (or, in the case of enrollments during a special enrollment period, beginning with plan year 2018), increase the monthly premium rate otherwise applicable to such individual for such coverage during each month of such period, by an amount determined under paragraph (2). (2) Amount of penalty The amount determined under this paragraph for an applicable policyholder enrolling in health insurance coverage described in paragraph (1) for a plan year, with respect to each month during the enforcement period applicable to enrollments for such plan year, is the amount that is equal to 30 percent of the monthly premium rate otherwise applicable to such applicable policyholder for such coverage during such month. (b) Definitions For purposes of this section: (1) Applicable policyholder The term applicable policyholder means, with respect to months of an enforcement period and health insurance coverage, an individual who— (A) is a policyholder of such coverage for such months; (B) cannot demonstrate that (through presentation of certifications described in section 2704(e) or in such other manner as may be specified in regulations, such as a return or statement made under section 6055(d) or 36B of the Internal Revenue Code of 1986), during the look-back period that is with respect to such enforcement period, there was not a period of at least 63 continuous days during which the individual did not have creditable coverage (as defined in paragraph (1) of section 2704(c) and credited in accordance with paragraphs (2) and (3) of such section); and (C) in the case of an individual who had been enrolled under dependent coverage under a group health plan or health insurance coverage by reason of section 2714 and such dependent coverage of such individual ceased because of the age of such individual, is not enrolling during the first open enrollment period following the date on which such coverage so ceased. (2) Look-back period The term look-back period means, with respect to an enforcement period applicable to an enrollment of an individual for a plan year beginning with plan year 2019 (or, in the case of an enrollment of an individual during a special enrollment period, beginning with plan year 2018) in health insurance coverage described in subsection (a)(1), the 12-month period ending on the date the individual enrolls in such coverage for such plan year. (3) Enforcement period The term enforcement period means— (A) with respect to enrollments during a special enrollment period for plan year 2018, the period beginning with the first month that is during such plan year and that begins subsequent to such date of enrollment, and ending with the last month of such plan year; and (B) with respect to enrollments for plan year 2019 or a subsequent plan year, the 12-month period beginning on the first day of the respective plan year. . 134. Increasing coverage options Section 1302 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18022 ) is amended— (1) in subsection (a)(3), by inserting and with respect to a plan year before plan year 2020 after subsection (e) ; and (2) in subsection (d), by adding at the end the following: (5) Sunset The provisions of this subsection shall not apply after December 31, 2019, and after such date any reference to this subsection or level of coverage or plan described in this subsection and any requirement under law applying such a level of coverage or plan shall have no force or effect (and such a requirement shall be applied as if this section had been repealed). . 135. Change in permissible age variation in health insurance premium rates Section 2701(a)(1)(A)(iii) of the Public Health Service Act ( 42 U.S.C. 300gg(a)(1)(A)(iii) ), as inserted by section 1201(4) of the Patient Protection and Affordable Care Act, is amended by inserting after (consistent with section 2707(c)) the following: or, for plan years beginning on or after January 1, 2018, as the Secretary may implement through interim final regulation, 5 to 1 for adults (consistent with section 2707(c)) or such other ratio for adults (consistent with section 2707(c)) as the State involved may provide (or, in the case of a State with a waiver under subsection (b) in effect for such a plan year, the ratio applied for such plan year in accordance with such waiver) . 136. Permitting States to waive certain ACA requirements to encourage fair health insurance premiums (a) In general Section 2701 of the Public Health Service Act ( 42 U.S.C. 300gg ) is amended by adding at the end the following new subsection: (b) Permissible State waiver to encourage fair health insurance premiums (1) In general A State may submit an application to the Secretary for one or more of the following purposes: (A) In the case of plan years beginning on or after January 1, 2018, to apply, subject to paragraph (5), under subsection (a)(1)(A)(iii), instead of the ratio specified in such subsection, a higher ratio specified by the State (consistent with section 2707(c)). (B) In the case of plan years beginning on or after January 1, 2020, for health insurance coverage offered in the individual or small group market in such State, to apply, subject to paragraph (5), instead of the essential health benefits specified under subsection (b) of section 1302 of the Patient Protection and Affordable Care Act, essential health benefits as specified by the State. (C) In the case of a State that has in place a program that carries out the purpose described in paragraph (1) or (2) of section 2202(a) of the Social Security Act or participates in the program established under section 2205 of such Act, for health insurance offered in the individual market in such State, with respect to an individual who is an applicable policyholder of such coverage with respect to an enforcement period (as defined in section 2710A(b)) applicable to enrollments for a plan year beginning with plan year 2019 (or, in the case of enrollments during a special enrollment period, beginning with plan year 2018), to— (i) subject to paragraph (5), not apply any increase to the monthly premium rate that would otherwise apply under section 2710A to such individual for such coverage; and (ii) instead, subject to paragraph (5)— (I) apply subsection (a)(1) as if health status were included as a factor described in subparagraph (A) of such subsection; and (II) not apply section 2705(b). (2) Default approval An application submitted under paragraph (1) is approved unless the Secretary notifies the State submitting the application, not later than 60 days after the date of the submission of such application, that the application has been denied for not being in compliance with any requirement of paragraph (3) and of the reason for such denial. (3) Requirements The requirements of this paragraph, with respect to an application submitted under paragraph (1), are the following: (A) The application is submitted at such time, and in such manner, as the Secretary may require. (B) The application specifies how the approval of such application will provide for one or more of the following: (i) Reducing average premiums for health insurance coverage in the State. (ii) Increasing enrollment in health insurance coverage in the State. (iii) Stabilizing the market for health insurance coverage in the State. (iv) Stabilizing premiums for individuals with pre-existing conditions. (v) Increasing the choice of health plans in the State. (C) The application specifies the period for which the waiver is to be effective, consistent with paragraph (4). (D) In the case of an application for purposes of paragraph (1)(A), the application specifies the higher ratio to be applied pursuant to such paragraph. (E) In the case of an application for purposes of paragraph (1)(B), the application specifies the essential health benefits to be applied pursuant to such paragraph. (F) In the case of an application for purposes of paragraph (1)(C), the application demonstrates that the State has in place a program that carries out the purpose described in paragraph (1) or (2) of section 2202(a) of the Social Security Act or participates in the program established under section 2205 of such Act. (4) Term of waiver (A) In general No waiver for a State under this subsection may extend over a period of longer than 10 years unless the State requests continuation of such waiver, and such request shall be deemed granted unless the Secretary, within 90 days after the date of its submission to the Secretary, either denies such request in writing or informs the State in writing with respect to any additional information which is needed in order to make a final determination with respect to the request. (B) Special rule A waiver applied for by a State under paragraph (1)(C) may only be effective for a period during which the State— (i) has in place a program that carries out the purpose described in paragraph (1) or (2) of section 2202(a) of the Social Security Act; or (ii) participates in the program established under section 2205 of such Act. (5) Non-application rules (A) Specified non-application provisions In no case may a waiver for purposes of paragraph (1) apply with respect to any of the following provisions: (i) Section 1301 of the Patient Protection and Affordable Care Act, to the extent that such section applies to qualified health plans offered through the CO-OP program under section 1322 of such Act or multi-State plans under section 1334 of such Act. (ii) Sections 1312(d)(3)(D), 1331, 1332, 1333, and 1334 of such Act. (B) Hold harmless Any standard or requirement adopted by a State pursuant to the terms of a waiver approved under this subsection shall be deemed to comply with section 1252 of the Patient Protection and Affordable Care Act and subsection (a) of section 1324 of such Act, insofar as such standard or requirement relates to a Federal or State law described in subsection (b)(2) of such section (relating to rating). . (b) Application to essential health benefits Section 1302(a)(1) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18022(a)(1) ) is amended by inserting (or, in the case of health insurance coverage offered in the individual or small group market in a State for which there is an applicable waiver in effect under section 2701(b) of the Public Health Service Act for a plan year, the essential health benefits applicable under such waiver) after subsection (b) . 137. Constructions (a) No gender rating Nothing in this Act shall be construed as permitting health insurance issuers to discriminate in rates for health insurance coverage by gender. (b) No limiting access to coverage for individuals with preexisting conditions Nothing in this Act shall be construed as permitting health insurance issuers to limit access to health coverage for individuals with preexisting conditions. E Implementation Funding 141. American Health Care Implementation Fund (a) In general There is hereby established an American Health Care Implementation Fund (referred to in this section as the Fund ) within the Department of Health and Human Services to carry out sections 121, 132, 202, and 214 (including the amendments made by such sections). (b) Funding There is appropriated to the Fund, out of any funds in the Treasury not otherwise appropriated, $1,000,000,000 for Federal administrative expenses to carry out the sections described in subsection (a) (including the amendments made by such sections). II Committee on Ways and Means A Repeal and Replace of Health-Related Tax Policy 201. Recapture excess advance payments of premium tax credits Subparagraph (B) of section 36B(f)(2) of the Internal Revenue Code of 1986 is amended by adding at the end the following new clause: (iii) Nonapplicability of limitation This subparagraph shall not apply to taxable years beginning after December 31, 2017, and before January 1, 2020. . 202. Additional modifications to premium tax credit (a) Modification of definition of qualified health plan (1) In general Section 36B(c)(3)(A) of the Internal Revenue Code of 1986 is amended— (A) by inserting (determined without regard to subparagraphs (A), (C)(ii), and (C)(iv) of paragraph (1) thereof and without regard to whether the plan is offered on an Exchange) after 1301(a) of the Patient Protection and Affordable Care Act , and (B) by striking shall not include and all that follows and inserting shall not include any health plan that— (i) is a grandfathered health plan or a grandmothered health plan, or (ii) includes coverage for abortions (other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest). . (2) Definition of grandmothered health plan Section 36B(c)(3) of such Code is amended by adding at the end the following new subparagraph: (C) Grandmothered health plan (i) In general The term grandmothered health plan means health insurance coverage which is offered in the individual health insurance market as of October 1, 2013, and is permitted to be offered in such market after January 1, 2014, as a result of CCIIO guidance. (ii) CCIIO guidance defined The term CCIIO guidance means the letter issued by the Centers for Medicare & Medicaid Services on November 14, 2013, to the State Insurance Commissioners outlining a transitional policy for non-grandfathered coverage in the individual health insurance market, as subsequently extended and modified (including by a communication entitled Insurance Standards Bulletin Series—INFORMATION—Extension of Transitional Policy through Calendar Year 2017 issued on February 29, 2016, by the Director of the Center for Consumer Information & Insurance Oversight of such Centers). (iii) Individual health insurance market The term individual health insurance market means the market for health insurance coverage (as defined in section 9832(b)) offered to individuals other than in connection with a group health plan (within the meaning of section 5000(b)(1)). . (3) Conforming amendment related to abortion coverage Section 36B(c)(3) of such Code, as amended by paragraph (2), is amended by adding at the end the following new subparagraph: (D) Certain rules related to abortion (i) Option to purchase separate coverage or plan Nothing in subparagraph (A) shall be construed as prohibiting any individual from purchasing separate coverage for abortions described in such subparagraph, or a health plan that includes such abortions, so long as no credit is allowed under this section with respect to the premiums for such coverage or plan. (ii) Option to offer coverage or plan Nothing in subparagraph (A) shall restrict any health insurance issuer offering a health plan from offering separate coverage for abortions described in such subparagraph, or a plan that includes such abortions, so long as premiums for such separate coverage or plan are not paid for with any amount attributable to the credit allowed under this section (or the amount of any advance payment of the credit under section 1412 of the Patient Protection and Affordable Care Act). (iii) Other treatments The treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of an abortion shall not be treated as an abortion for purposes of subparagraph (A). . (4) Conforming amendments related to off-Exchange coverage (A) Advance payment not applicable Section 1412 of the Patient Protection and Affordable Care Act is amended by adding at the end the following new subsection: (f) Exclusion of off-Exchange coverage Advance payments under this section, and advance determinations under section 1411, with respect to any credit allowed under section 36B shall not be made with respect to any health plan which is not enrolled in through an Exchange. . (B) Reporting Section 6055(b) of the Internal Revenue Code of 1986 is amended by adding at the end the following new paragraph: (3) Information relating to off-Exchange premium credit eligible coverage If minimum essential coverage provided to an individual under subsection (a) consists of a qualified health plan (as defined in section 36B(c)(3)) which is not enrolled in through an Exchange established under title I of the Patient Protection and Affordable Care Act, a return described in this subsection shall include— (A) a statement that such plan is a qualified health plan (as defined in section 36B(c)(3)), (B) the premiums paid with respect to such coverage, (C) the months during which such coverage is provided to the individual, (D) the adjusted monthly premium for the applicable second lowest cost silver plan (as defined in section 36B(b)(3)) for each such month with respect to such individual, and (E) such other information as the Secretary may prescribe. . (C) Other conforming amendments (i) Section 36B(b)(2)(A) of such Code is amended by striking and which were enrolled and all that follows and inserting , or . (ii) Section 36B(b)(3)(B)(i) of such Code is amended by striking the same Exchange and all that follows and inserting the Exchange through which such taxpayer is permitted to obtain coverage, and . (iii) Section 36B(c)(2)(A)(i) of such Code is amended by striking that was enrolled in through an Exchange established by the State under section 1311 of the Patient Protection and Affordable Care Act . (b) Modification of applicable percentage Section 36B(b)(3)(A) of such Code is amended to read as follows: (A) Applicable percentage (i) In general The applicable percentage for any taxable year shall be the percentage such that the applicable percentage for any taxpayer whose household income is within an income tier specified in the following table shall increase, on a sliding scale in a linear manner, from the initial percentage to the final percentage specified in such table for such income tier with respect to a taxpayer of the age involved: In the case of household income (expressed as a percent of the poverty line) within the following income tier: Up to Age 29 Age 30-39 Age 40-49 Age 50-59 Over Age 59 Initial % Final % Initial % Final % Initial % Final % Initial % Final % Initial % Final % Up to 133% 2 2 2 2 2 2 2 2 2 2 133%-150% 3 4 3 4 3 4 3 4 3 4 150%-200% 4 4.3 4 5.3 4 6.3 4 7.3 4 8.3 200%-250% 4.3 4.3 5.3 5.9 6.3 8.05 7.3 9 8.3 10 250%-300% 4.3 4.3 5.9 5.9 8.05 8.35 9 10.5 10 11.5 300%-400% 4.3 4.3 5.9 5.9 8.35 8.35 10.5 10.5 11.5 11.5 (ii) Age determinations (I) In general For purposes of clause (i), the age of the taxpayer taken into account under clause (i) with respect to any taxable year is the age attained by such taxpayer before the close of such taxable year. (II) Joint returns In the case of a joint return, the age of the older spouse shall be taken into account under clause (i). (iii) Indexing In the case of any taxable year beginning in calendar year 2019, the initial and final percentages contained in clause (i) shall be adjusted to reflect— (I) the excess (if any) of the rate of premium growth for the period beginning with calendar year 2013 and ending with calendar year 2018, over the rate of income growth for such period, and (II) in addition to any adjustment under subclause (I), the excess (if any) of the rate of premium growth for calendar year 2018, over the rate of growth in the consumer price index for calendar year 2018. (iv) Failsafe Clause (iii)(II) shall apply only if the aggregate amount of premium tax credits under this section and cost-sharing reductions under section 1402 of the Patient Protection and Affordable Care Act for calendar year 2018 exceeds an amount equal to 0.504 percent of the gross domestic product for such calendar year. . (c) Effective date (1) In general Except as otherwise provided in this subsection, the amendments made by this section shall apply to taxable years beginning after December 31, 2017. (2) Advance payment not applicable to off-Exchange coverage The amendment made by subsection (a)(4)(A) shall take effect on January 1, 2018. (3) Reporting The amendment made by subsection (a)(4)(B) shall apply to coverage provided for months beginning after December 31, 2017. (4) Modification of applicable percentage The amendment made by subsection (b) shall apply to taxable years beginning after December 31, 2018. 203. Small business tax credit (a) In general Section 45R of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: (j) Shall not apply This section shall not apply with respect to amounts paid or incurred in taxable years beginning after December 31, 2019. . (b) Disallowance of small employer health insurance expense credit for plan which includes coverage for abortion Subsection (h) of section 45R of the Internal Revenue Code of 1986 is amended— (1) by striking Any term and inserting the following: (1) In general Any term ; and (2) by adding at the end the following new paragraph: (2) Exclusion of health plans including coverage for abortion (A) In general The term qualified health plan does not include any health plan that includes coverage for abortions (other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest). (B) Certain rules related to abortion (i) Option to purchase separate coverage or plan Nothing in subparagraph (A) shall be construed as prohibiting any employer from purchasing for its employees separate coverage for abortions described in such subparagraph, or a health plan that includes such abortions, so long as no credit is allowed under this section with respect to the employer contributions for such coverage or plan. (ii) Option to offer coverage or plan Nothing in subparagraph (A) shall restrict any health insurance issuer offering a health plan from offering separate coverage for abortions described in such subparagraph, or a plan that includes such abortions, so long as such separate coverage or plan is not paid for with any employer contribution eligible for the credit allowed under this section. (iii) Other treatments The treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of an abortion shall not be treated as an abortion for purposes of subparagraph (A). . (c) Effective dates (1) In general The amendment made by subsection (a) shall apply to taxable years beginning after December 31, 2019. (2) Disallowance of small employer health insurance expense credit for plan which includes coverage for abortion The amendments made by subsection (b) shall apply to taxable years beginning after December 31, 2017. 204. Individual mandate (a) In general Section 5000A(c) of the Internal Revenue Code of 1986 is amended— (1) in paragraph (2)(B)(iii), by striking 2.5 percent and inserting Zero percent , and (2) in paragraph (3)— (A) by striking $695 in subparagraph (A) and inserting $0 , and (B) by striking subparagraph (D). (b) Effective date The amendments made by this section shall apply to months beginning after December 31, 2015. 205. Employer mandate (a) In general (1) Paragraph (1) of section 4980H(c) of the Internal Revenue Code of 1986 is amended by inserting ($0 in the case of months beginning after December 31, 2015) after $2,000 . (2) Paragraph (1) of section 4980H(b) of the Internal Revenue Code of 1986 is amended by inserting ($0 in the case of months beginning after December 31, 2015) after $3,000 . (b) Effective date The amendments made by this section shall apply to months beginning after December 31, 2015. 206. Repeal of the tax on employee health insurance premiums and health plan benefits Section 4980I of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: (h) Shall not apply No tax shall be imposed under this section with respect to any taxable period beginning after December 31, 2019, and before January 1, 2026. . 207. Repeal of tax on over-the-counter medications (a) HSAs Subparagraph (A) of section 223(d)(2) of the Internal Revenue Code of 1986 is amended by striking Such term and all that follows through the period. (b) Archer MSAs Subparagraph (A) of section 220(d)(2) of the Internal Revenue Code of 1986 is amended by striking Such term and all that follows through the period. (c) Health flexible spending arrangements and health reimbursement arrangements Section 106 of the Internal Revenue Code of 1986 is amended by striking subsection (f) and by redesignating subsection (g) as subsection (f). (d) Effective dates (1) Distributions from savings accounts The amendments made by subsections (a) and (b) shall apply to amounts paid with respect to taxable years beginning after December 31, 2016. (2) Reimbursements The amendment made by subsection (c) shall apply to expenses incurred with respect to taxable years beginning after December 31, 2016. 208. Repeal of increase of tax on health savings accounts (a) HSAs Section 223(f)(4)(A) of the Internal Revenue Code of 1986 is amended by striking 20 percent and inserting 10 percent . (b) Archer MSAs Section 220(f)(4)(A) of the Internal Revenue Code of 1986 is amended by striking 20 percent and inserting 15 percent . (c) Effective date The amendments made by this section shall apply to distributions made after December 31, 2016. 209. Repeal of limitations on contributions to flexible spending accounts (a) In general Section 125 of the Internal Revenue Code of 1986 is amended by striking subsection (i). (b) Effective date The amendment made by this section shall apply to taxable years beginning after December 31, 2016. 210. Repeal of medical device excise tax Section 4191 of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: (d) Applicability The tax imposed under subsection (a) shall not apply to sales after December 31, 2016. . 211. Repeal of elimination of deduction for expenses allocable to medicare part D subsidy (a) In general Section 139A of the Internal Revenue Code of 1986 is amended by adding at the end the following new sentence: This section shall not be taken into account for purposes of determining whether any deduction is allowable with respect to any cost taken into account in determining such payment. . (b) Effective date The amendment made by this section shall apply to taxable years beginning after December 31, 2016. 212. Reduction of income threshold for determining medical care deduction (a) In general Subsection (a) of section 213 of the Internal Revenue Code of 1986 is amended by striking 10 percent and inserting 5.8 percent . (b) Effective date The amendment made by this section shall apply to taxable years beginning after December 31, 2016. 213. Repeal of Medicare tax increase (a) In general Subsection (b) of section 3101 of the Internal Revenue Code of 1986 is amended to read as follows: (b) Hospital insurance In addition to the tax imposed by the preceding subsection, there is hereby imposed on the income of every individual a tax equal to 1.45 percent of the wages (as defined in section 3121(a)) received by such individual with respect to employment (as defined in section 3121(b)). . (b) SECA Subsection (b) of section 1401 of the Internal Revenue Code of 1986 is amended to read as follows: (b) Hospital insurance In addition to the tax imposed by the preceding subsection, there shall be imposed for each taxable year, on the self-employment income of every individual, a tax equal to 2.9 percent of the amount of the self-employment income for such taxable year. . (c) Effective date The amendments made by this section shall apply with respect to remuneration received after, and taxable years beginning after, December 31, 2022. 214. Refundable tax credit for health insurance coverage (a) In general Section 36B of the Internal Revenue Code of 1986 is amended to read as follows: 36B. Refundable credit for coverage under a qualified health plan (a) Allowance of premium tax credit In the case of an individual, there shall be allowed as a credit against the tax imposed by this subtitle for the taxable year the sum of the monthly credit amounts with respect to such taxpayer for calendar months during such taxable year which are eligible coverage months appropriately taken into account under subsection (b)(2) with respect to the taxpayer or any qualifying family member of the taxpayer. (b) Monthly credit amounts (1) In general The monthly credit amount with respect to any taxpayer for any calendar month is the lesser of— (A) the sum of the monthly limitation amounts determined under subsection (c) with respect to the taxpayer and the taxpayer’s qualifying family members for such month, or (B) the amount paid for a qualified health plan for the taxpayer and the taxpayer’s qualifying family members for such month. (2) Eligible coverage month requirement No amount shall be taken into account under subparagraph (A) or (B) of paragraph (1) with respect to any individual for any month unless such month is an eligible coverage month with respect to such individual. (c) Monthly limitation amounts (1) In general The monthly limitation amount with respect to any individual for any eligible coverage month during any taxable year is 1/12 of— (A) $2,000 in the case of an individual who has not attained age 30 as of the beginning of such taxable year, (B) $2,500 in the case of an individual who has attained age 30 but who has not attained age 40 as of such time, (C) $3,000 in the case of an individual who has attained age 40 but who has not attained age 50 as of such time, (D) $3,500 in the case of an individual who has attained age 50 but who has not attained age 60 as of such time, and (E) $4,000 in the case of an individual who has attained age 60 as of such time. (2) Limitation based on modified adjusted gross income The credit allowed under subsection (a) with respect to any taxpayer for any taxable year shall be reduced (but not below zero) by 10 percent of the excess (if any) of— (A) the taxpayer’s modified adjusted gross income (as defined in section 36B(d)(2)(B), as in effect for taxable years beginning before January 1, 2020) for such taxable year, over (B) $75,000 (twice such amount in the case of a joint return). (3) Other limitations (A) Aggregate dollar limitation The sum of the monthly limitation amounts taken into account under this section with respect to any taxpayer for any taxable year shall not exceed $14,000. (B) Maximum number of individuals taken into account With respect to any taxpayer for any month, monthly limitation amounts shall be taken into account under this section only with respect to the 5 oldest individuals with respect to whom monthly limitation amounts could (without regard to this subparagraph) otherwise be so taken into account. (d) Eligible coverage month For purposes of this section, the term eligible coverage month means, with respect to any individual, any month if, as of the first day of such month, the individual meets the following requirements: (1) The individual is covered by a health insurance coverage which is certified by the State in which such insurance is offered as coverage that meets the requirements for qualified health plans under subsection (f). (2) The individual is not eligible for— (A) coverage under a group health plan (within the meaning of section 5000(b)(1)) other than coverage under a plan substantially all of the coverage of which is of excepted benefits described in section 9832(c), or (B) coverage described in section 5000A(f)(1)(A). (3) The individual is either— (A) a citizen or national of the United States, or (B) a qualified alien (within the meaning of section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 ( 8 U.S.C. 1641 )). (4) The individual is not incarcerated, other than incarceration pending the disposition of charges. (e) Qualifying family member For purposes of this section, the term qualifying family member means— (1) in the case of a joint return, the taxpayer’s spouse, (2) any dependent of the taxpayer, and (3) with respect to any eligible coverage month, any child (as defined in section 152(f)(1)) of the taxpayer who as of the end of the taxable year has not attained age 27 if such child is covered for such month under a qualified health plan which also covers the taxpayer (in the case of a joint return, either spouse). (f) Qualified health plan For purposes of this section, the term qualified health plan means any health insurance coverage (as defined in section 9832(b)) if— (1) such coverage is offered in the individual health insurance market within a State (within the meaning of section 5000A(f)(1)(C)), (2) substantially all of such coverage is not of excepted benefits described in section 9832(c), (3) such coverage does not consist of short-term limited duration insurance (within the meaning of section 2791(b)(5) of the Public Health Service Act), (4) such coverage is not a grandfathered health plan (as defined in section 1251 of the Patient Protection and Affordable Care Act) or a grandmothered health plan (as defined in section 36B(c)(3)(C) as in effect for taxable years beginning before January 1, 2020), and (5) such coverage does not include coverage for abortions (other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest). (g) Special rules (1) Married couples must file joint return (A) In general Except as provided in subparagraph (B), if the taxpayer is married (within the meaning of section 7703) at the close of the taxable year, no credit shall be allowed under this section to such taxpayer unless such taxpayer and the taxpayer’s spouse file a joint return for such taxable year. (B) Exception for certain taxpayers Subparagraph (A) shall not apply to any married taxpayer who— (i) is living apart from the taxpayer's spouse at the time the taxpayer files the tax return, (ii) is unable to file a joint return because such taxpayer is a victim of domestic abuse or spousal abandonment, (iii) certifies on the tax return that such taxpayer meets the requirements of clauses (i) and (ii), and (iv) has not met the requirements of clauses (i), (ii), and (iii) for each of the 3 preceding taxable years. (2) Denial of credit to dependents (A) In general No credit shall be allowed under this section to any individual who is a dependent with respect to another taxpayer for a taxable year beginning in the calendar year in which such individual’s taxable year begins. (B) Coordination with rule for older children In the case of any individual who is a qualifying family member described in subsection (e)(3) with respect to another taxpayer for any month, in determining the amount of any credit allowable to such individual under this section for any taxable year of such individual which includes such month, the monthly limitation amount with respect to such individual for such month shall be zero and no amount paid for any qualified health plan with respect to such individual for such month shall be taken into account. (3) Coordination with medical expense deduction Amounts described in subsection (b)(1)(B) with respect to any month shall not be taken into account in determining the deduction allowed under section 213 except to the extent that such amounts exceed the amount described in subsection (b)(1)(A) with respect to such month. (4) Coordination with advance payments of credit With respect to any taxable year— (A) the amount which would (but for this subsection) be allowed as a credit to the taxpayer under subsection (a) shall be reduced (but not below zero) by the aggregate amount paid on behalf of such taxpayer under section 1412 of the Patient Protection and Affordable Care Act for months beginning in such taxable year, and (B) the tax imposed by section 1 for such taxable year shall be increased by the excess (if any) of— (i) the aggregate amount paid on behalf of such taxpayer under such section 1412 for months beginning in such taxable year, over (ii) the amount which would (but for this subsection) be allowed as a credit to the taxpayer under subsection (a). (5) Special rules for qualified small employer health reimbursement arrangements (A) In general If the taxpayer or any qualifying family member of the taxpayer is provided a qualified small employer health reimbursement arrangement for an eligible coverage month, the sum determined under subsection (b)(1)(A) with respect to the taxpayer shall be reduced (but not below zero) by 1/12 of the permitted benefit (as defined in section 9831(d)(3)(C)) under such arrangement for each such month such arrangement is provided to such taxpayer. (B) Qualified small employer health reimbursement arrangement For purposes of this paragraph, the term qualified small employer health reimbursement arrangement has the meaning given such term by section 9831(d)(2). (C) Coverage for less than entire year In the case of an employee who is provided a qualified small employer health reimbursement arrangement for less than an entire year, subparagraph (A) shall be applied by substituting the number of months during the year for which such arrangement was provided for 12 . (6) Certain rules related to nonqualified health plans The rules of section 36B(c)(3)(D), as in effect for taxable years beginning before January 1, 2020, shall apply with respect to subsection (f)(5). (7) Inflation adjustment (A) In general In the case of any taxable year beginning in a calendar year after 2020, each dollar amount in subsection (c)(1), the $75,000 amount in subsection (c)(2)(B), and the dollar amount in subsection (c)(3)(A), shall be increased by an amount equal to— (i) such dollar amount, multiplied by (ii) the cost-of-living adjustment determined under section 1(f)(3) for the calendar year in which the taxable year begins, determined— (I) by substituting calendar year 2019 for calendar year 1992 in subparagraph (B) thereof, and (II) by substituting for the CPI referred to section 1(f)(3)(A) the amount that such CPI would have been if the annual percentage increase in CPI with respect to each year after 2019 had been one percentage point greater. (B) Terms related to CPI (i) Annual percentage increase For purposes of subparagraph (A)(ii)(II), the term annual percentage increase means the percentage (if any) by which CPI for any year exceeds CPI for the prior year. (ii) Other terms Terms used in this paragraph which are also used in section 1(f)(3) shall have the same meanings as when used in such section. (C) Rounding Any increase determined under subparagraph (A) shall be rounded to the nearest multiple of $50. (8) Rules related to State certification of qualified health plans A certification shall not be taken into account under subsection (d)(1) unless such certification is made available to the public and meets such other requirements as the Secretary may provide. (9) Regulations The Secretary may prescribe such regulations and other guidance as may be necessary or appropriate to carry out this section and section 1412 of the Patient Protection and Affordable Care Act. . (b) Advance payment of credit Section 1412(f) of the Patient Protection and Affordable Care Act, as added by section 202, is amended to read as follows: (f) Application to certain plans The Secretary and the Secretary of the Treasury shall prescribe such regulations as each respective Secretary may deem necessary in order to establish and operate the advance payment program established under this section for individuals covered under qualified health plans (whether enrolled in through an Exchange or otherwise) in such a manner that protects taxpayer information (including names, taxpayer identification numbers, and other confidential information), provides robust verification of all information necessary to establish eligibility of taxpayer for advance payments under this section, ensures proper and timely payments to appropriate health providers, and protects program integrity to the maximum extent feasible. . (c) Increased penalty on erroneous claims of credit Section 6676(a) of the Internal Revenue Code of 1986 is amended by inserting (25 percent in the case of a claim for refund or credit relating to the health insurance coverage credit under section 36B) . (d) Reporting by employers Section 6051(a) of such Code is amended by striking and at the end of paragraph (14), by striking the period at the end of paragraph (15) and inserting , and , and by inserting after paragraph (15) the following new paragraph: (16) each month with respect to which the employee is eligible for coverage described in section 36B(d)(2) in connection with employment with the employer. . (e) Coordination with other tax benefits (1) Credit for health insurance costs of eligible individuals Section 35(g) of such Code is amended by adding at the end the following new paragraph: (14) Coordination with health insurance coverage credit (A) In general An eligible coverage month to which the election under paragraph (11) applies shall not be treated as an eligible coverage month (as defined in section 36B(d)) for purposes of section 36B with respect to the taxpayer or any of the taxpayer’s qualifying family members (as defined in section 36B(e)). (B) Coordination with advance payments of health insurance coverage credit In the case of a taxpayer who makes the election under paragraph (11) with respect to any eligible coverage month in a taxable year or on behalf of whom any advance payment is made under section 7527 with respect to any month in such taxable year— (i) the tax imposed by this chapter for the taxable year shall be increased by the excess, if any, of— (I) the sum of any advance payments made on behalf of the taxpayer under section 7527 and section 1412 of the Patient Protection and Affordable Care Act, over (II) the sum of the credits allowed under this section (determined without regard to paragraph (1)) and section 36B (determined without regard to subsection (g)(4)(A) thereof) for such taxable year, and (ii) section 36B(g)(4)(B) shall not apply with respect to such taxpayer for such taxable year. . (2) Trade or business deduction Section 162(l) of such Code is amended by adding at the end the following new paragraph: (6) Coordination with health insurance coverage credit The deduction otherwise allowable to a taxpayer under paragraph (1) for any taxable year shall be reduced (but not below zero) by the amount of the credit allowable to such taxpayer under section 36B (determined without regard to subsection (g)(4)(A) thereof) for such taxable year. . (f) Effective date The amendments made by this section shall apply to months beginning after December 31, 2019, in taxable years ending after such date. 215. Maximum contribution limit to health savings account increased to amount of deductible and out-of-pocket limitation (a) Self-Only coverage Section 223(b)(2)(A) of the Internal Revenue Code of 1986 is amended by striking $2,250 and inserting the amount in effect under subsection (c)(2)(A)(ii)(I) . (b) Family coverage Section 223(b)(2)(B) of such Code is amended by striking $4,500 and inserting the amount in effect under subsection (c)(2)(A)(ii)(II) . (c) Conforming amendments Section 223(g)(1) of such Code is amended— (1) by striking subsections (b)(2) and both places it appears and inserting subsection , and (2) in subparagraph (B), by striking determined by and all that follows through calendar year 2003 . and inserting determined by substituting calendar year 2003 for calendar year 1992 in subparagraph (B) thereof. . (d) Effective date The amendments made by this section shall apply to taxable years beginning after December 31, 2017. 216. Allow both spouses to make catch-up contributions to the same health savings account (a) In general Section 223(b)(5) of the Internal Revenue Code of 1986 is amended to read as follows: (5) Special rule for married individuals with family coverage (A) In general In the case of individuals who are married to each other, if both spouses are eligible individuals and either spouse has family coverage under a high deductible health plan as of the first day of any month— (i) the limitation under paragraph (1) shall be applied by not taking into account any other high deductible health plan coverage of either spouse (and if such spouses both have family coverage under separate high deductible health plans, only one such coverage shall be taken into account), (ii) such limitation (after application of clause (i)) shall be reduced by the aggregate amount paid to Archer MSAs of such spouses for the taxable year, and (iii) such limitation (after application of clauses (i) and (ii)) shall be divided equally between such spouses unless they agree on a different division. (B) Treatment of additional contribution amounts If both spouses referred to in subparagraph (A) have attained age 55 before the close of the taxable year, the limitation referred to in subparagraph (A)(iii) which is subject to division between the spouses shall include the additional contribution amounts determined under paragraph (3) for both spouses. In any other case, any additional contribution amount determined under paragraph (3) shall not be taken into account under subparagraph (A)(iii) and shall not be subject to division between the spouses. . (b) Effective date The amendment made by this section shall apply to taxable years beginning after December 31, 2017. 217. Special rule for certain medical expenses incurred before establishment of health savings account (a) In general Section 223(d)(2) of the Internal Revenue Code of 1986 is amended by adding at the end the following new subparagraph: (D) Treatment of certain medical expenses incurred before establishment of account If a health savings account is established during the 60-day period beginning on the date that coverage of the account beneficiary under a high deductible health plan begins, then, solely for purposes of determining whether an amount paid is used for a qualified medical expense, such account shall be treated as having been established on the date that such coverage begins. . (b) Effective date The amendment made by this section shall apply with respect to coverage beginning after December 31, 2017. B Repeal of certain consumer taxes 221. Repeal of tax on prescription medications Subsection (j) of section 9008 of the Patient Protection and Affordable Care Act is amended to read as follows: (j) Repeal This section shall apply to calendar years beginning after December 31, 2010, and ending before January 1, 2017. . 222. Repeal of health insurance tax Subsection (j) of section 9010 of the Patient Protection and Affordable Care Act is amended to read as follows: (j) Repeal This section shall apply to calendar years beginning after December 31, 2013, and ending before January 1, 2017. . C Repeal of Tanning Tax 231. Repeal of tanning tax (a) In general The Internal Revenue Code of 1986 is amended by striking chapter 49. (b) Effective date The amendment made by this section shall apply to services performed after June 30, 2017. D Remuneration from Certain Insurers 241. Remuneration from certain insurers Paragraph (6) of section 162(m) of the Internal Revenue Code of 1986 is amended by adding at the end the following new subparagraph: (I) Termination This paragraph shall not apply to taxable years beginning after December 31, 2016. . E Repeal of Net Investment Income Tax 251. Repeal of net investment income tax (a) In general Subtitle A of the Internal Revenue Code of 1986 is amended by striking chapter 2A. (b) Effective date The amendment made by this section shall apply to taxable years beginning after December 31, 2016.

Passed the House of Representatives May 4, 2017. Karen L. Haas, Clerk

June 8, 2017 Read twice and placed on the calendar