[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1425 Placed on Calendar Senate (PCS)]
<DOC>
Calendar No. 523
116th CONGRESS
2d Session
H. R. 1425
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
June 30, 2020
Received
August 13, 2020
Read the first time
September 8, 2020
Read the second time and placed on the calendar
_______________________________________________________________________
AN ACT
To amend the Patient Protection and Affordable Care Act to provide for
a Improve Health Insurance Affordability Fund to provide for certain
reinsurance payments to lower premiums in the individual health
insurance market.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Patient Protection and Affordable
Care Enhancement Act''.
SEC. 2. TABLE OF CONTENTS.
The table of contents for this Act is as follows:
Sec. 1. Short title.
Sec. 2. Table of contents.
TITLE I--LOWERING HEALTH CARE COSTS AND PROTECTING PEOPLE WITH
PREEXISTING CONDITIONS
Sec. 101. Improving affordability by expanding premium assistance for
consumers.
Sec. 102. Improving affordability by reducing out-of-pocket and premium
costs for consumers.
Sec. 103. Expanding affordability for working families to fix the
family glitch.
Sec. 104. Tax credit reconciliation protections for individuals
receiving social security lump-sum
payments.
Sec. 105. Preserving State option to implement health care
Marketplaces.
Sec. 106. Establishing a Health Insurance Affordability Fund.
Sec. 107. Rescinding the short-term limited duration insurance
regulation.
Sec. 108. Revoking section 1332 guidance.
Sec. 109. Requiring Marketplace outreach, educational activities, and
annual enrollment targets.
Sec. 110. Report on effects of website maintenance during open
enrollment.
Sec. 111. Promoting consumer outreach and education.
Sec. 112. Improving transparency and accountability in the Marketplace.
Sec. 113. Improving awareness of health coverage options.
Sec. 114. Promoting State innovations to expand coverage.
Sec. 115. Strengthening network adequacy.
Sec. 116. Protecting consumers from unreasonable rate hikes.
Sec. 117. Eligibility of DACA recipients for qualified health plans
offered through Exchanges.
TITLE II--ENCOURAGING MEDICAID EXPANSION AND STRENGTHENING THE MEDICAID
PROGRAM
Sec. 201. Incentivizing Medicaid expansion.
Sec. 202. Providing 12-months of continuous eligibility for Medicaid
and CHIP.
Sec. 203. Mandatory 12-months of postpartum Medicaid eligibility.
Sec. 204. Reducing the administrative FMAP for nonexpansion States.
Sec. 205. Enhanced reporting requirements for nonexpansion states.
Sec. 206. Primary care pay increase.
Sec. 207. Permanent funding for CHIP.
Sec. 208. Permanent extension of CHIP enrollment and quality measures.
Sec. 209. State option to increase children's eligibility for Medicaid
and CHIP.
Sec. 210. Medicaid coverage for citizens of Freely Associated States.
Sec. 211. Extension of full Federal medical assistance percentage to
Indian health care providers.
TITLE III--LOWERING PRICES THROUGH FAIR DRUG PRICE NEGOTIATION
Sec. 301. Establishing a Fair Drug Pricing Program.
Sec. 302. Drug manufacturer excise tax for noncompliance.
Sec. 303. Fair Price Negotiation Implementation Fund.
TITLE IV--PUBLIC HEALTH INVESTMENTS
Sec. 401. Supporting increased innovation.
TITLE I--LOWERING HEALTH CARE COSTS AND PROTECTING PEOPLE WITH
PREEXISTING CONDITIONS
SEC. 101. IMPROVING AFFORDABILITY BY EXPANDING PREMIUM ASSISTANCE FOR
CONSUMERS.
(a) In General.--Section 36B(b)(3)(A) of the Internal Revenue Code
of 1986 is amended to read as follows:
``(A) Applicable percentage.--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
premium percentage to the final premium percentage
specified in such table for such income tier:
------------------------------------------------------------------------
``In the case of household income
(expressed as a percent of poverty The initial The final
line) within the following income premium premium
tier: percentage is-- percentage is--
------------------------------------------------------------------------
Up to 150.0 percent.................. 0.0 0.0
150.0 percent up to 200.0 percent.... 0.0 3.0
200.0 percent up to 250.0 percent.... 3.0 4.0
250.0 percent up to 300.0 percent.... 4.0 6.0
300.0 percent up to 400.0 percent.... 6.0 8.5
400.0 percent and higher............. 8.5 8.5''.
------------------------------------------------------------------------
(b) Conforming Amendment.--Section 36B(c)(1)(A) of the Internal
Revenue Code of 1986 is amended by striking ``but does not exceed 400
percent''.
(c) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2019.
SEC. 102. IMPROVING AFFORDABILITY BY REDUCING OUT-OF-POCKET AND PREMIUM
COSTS FOR CONSUMERS.
Section 1302(c)(4) of the Patient Protection and Affordable Care
Act (42 U.S.C. 18022(c)(4)) is amended by striking ``calendar year)''
and inserting ``calendar year, based on estimates and projections for
the applicable calendar year of the percentage (if any) by which the
average per enrollee premium for eligible employer-sponsored health
plans (as defined in section 5000A(f)(2) of the Internal Revenue Code
of 1986) exceeds such average per enrollee premium for the preceding
calendar year, as published in the National Health Expenditure
Accounts)''.
SEC. 103. EXPANDING AFFORDABILITY FOR WORKING FAMILIES TO FIX THE
FAMILY GLITCH.
(a) In General.--Clause (i) of section 36B(c)(2)(C) of the Internal
Revenue Code of 1986 is amended to read as follows:
``(i) Coverage must be affordable.--
``(I) Employees.--An employee shall
not be treated as eligible for minimum
essential coverage if such coverage
consists of an eligible employer-
sponsored plan (as defined in section
5000A(f)(2)) and the employee's
required contribution (within the
meaning of section 5000A(e)(1)(B)) with
respect to the plan exceeds 9.5 percent
of the employee's household income.
``(II) Family members.--An
individual who is eligible to enroll in
an eligible employer-sponsored plan (as
defined in section 5000A(f)(2)) by
reason of a relationship the individual
bears to the employee shall not be
treated as eligible for minimum
essential coverage by reason of such
eligibility to enroll if the employee's
required contribution (within the
meaning of section 5000A(e)(1)(B),
determined by substituting `family' for
`self-only') with respect to the plan
exceeds 9.5 percent of the employee's
household income.''.
(b) Conforming Amendments.--
(1) Clause (ii) of section 36B(c)(2)(C) of the Internal
Revenue Code of 1986 is amended by striking ``Except as
provided in clause (iii), an employee'' and inserting ``An
individual''.
(2) Clause (iii) of section 36B(c)(2)(C) of such Code is
amended by striking ``the last sentence of clause (i)'' and
inserting ``clause (i)(II)''.
(3) Clause (iv) of section 36B(c)(2)(C) of such Code is
amended by striking ``the 9.5 percent under clause (i)(II)''
and inserting ``the 9.5 percent under clauses (i)(I) and
(i)(II)''.
(c) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2021.
SEC. 104. TAX CREDIT RECONCILIATION PROTECTIONS FOR INDIVIDUALS
RECEIVING SOCIAL SECURITY LUMP-SUM PAYMENTS.
(a) In General.--Section 36B(d)(2) of the Internal Revenue Code of
1986 is amended by adding at the end the following new subparagraph:
``(C) Exclusion of portion of lump-sum social
security benefits.--
``(i) In general.--The term `modified
adjusted gross income' shall not include so
much of any lump-sum social security benefit
payment as is attributable to months ending
before the beginning of the taxable year.
``(ii) Lump-sum social security benefit
payment.--For purposes of this subparagraph,
the term `lump-sum social security benefit
payment' means any payment of social security
benefits (as defined in section 86(d)(1)) which
constitutes more than 1 month of such benefits.
``(iii) Election to include excludable
amount.--A taxpayer may elect (at such time and
in such manner as the Secretary may provide) to
have this subparagraph not apply for any
taxable year.''.
(b) Effective Date.--The amendment made by this section shall apply
to taxable years beginning after December 31, 2019.
SEC. 105. PRESERVING STATE OPTION TO IMPLEMENT HEALTH CARE
MARKETPLACES.
(a) In General.--Section 1311 of the Patient Protection and
Affordable Care Act (42 U.S.C. 18031) is amended--
(1) in subsection (a)--
(A) in paragraph (4)(B), by striking ``under this
subsection'' and inserting ``under this paragraph or
paragraph (1)''; and
(B) by adding at the end the following new
paragraph:
``(6) Additional planning and establishment grants.--
``(A) In general.--There shall be appropriated to
the Secretary, out of any moneys in the Treasury not
otherwise appropriated, $200 million to award grants to
eligible States for the uses described in paragraph
(3).
``(B) Duration and renewability.--A grant awarded
under subparagraph (A) shall be for a period of 2 years
and may not be renewed.
``(C) Limitation.--A grant may not be awarded under
subparagraph (A) after December 31, 2023.
``(D) Eligible state defined.--For purposes of this
paragraph, the term `eligible State' means a State
that, as of the date of the enactment of this
paragraph, is not operating an Exchange (other than an
Exchange described in section 155.200(f) of title 45,
Code of Federal Regulations).''; and
(2) in subsection (d)(5)(A)--
(A) by striking ``operations.--In establishing an
Exchange under this section'' and inserting
``operations.--
``(i) In general.--In establishing an
Exchange under this section (other than in
establishing an Exchange pursuant to a grant
awarded under subsection (a)(6))''; and
(B) by adding at the end the following:
``(ii) Additional planning and
establishment grants.--In establishing an
Exchange pursuant to a grant awarded under
subsection (a)(6), the State shall ensure that
such Exchange is self-sustaining beginning on
January 1, 2025, including allowing the
Exchange to charge assessments or user fees to
participating health insurance issuers, or to
otherwise generate funding, to support its
operations.''.
(b) Clarification Regarding Failure to Establish Exchange or
Implement Requirements.--Section 1321(c) of the Patient Protection and
Affordable Care Act (42 U.S.C. 18041(c)) is amended--
(1) in paragraph (1), by striking ``If'' and inserting
``Subject to paragraph (3), if''; and
(2) by adding at the end the following new paragraph:
``(3) Clarification.--This subsection shall not apply in
the case of a State that elects to apply the requirements
described in subsection (a) and satisfies the requirement
described in subsection (b) on or after January 1, 2014.''.
SEC. 106. ESTABLISHING A HEALTH INSURANCE AFFORDABILITY FUND.
Subtitle D of title I of the Patient Protection and Affordable Care
Act is amended by inserting after part 5 (42 U.S.C. 18061 et seq.) the
following new part:
``PART 6--IMPROVE HEALTH INSURANCE AFFORDABILITY FUND
``SEC. 1351. ESTABLISHMENT OF PROGRAM.
``There is hereby established the `Improve Health Insurance
Affordability 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 part, to
the 50 States and the District of Columbia (each referred to in this
section as a `State') beginning on January 1, 2022, for the purposes
described in section 1352.
``SEC. 1352. USE OF FUNDS.
``(a) In General.--A State shall use the funds allocated to the
State under this part for one of the following purposes:
``(1) To provide reinsurance payments to health insurance
issuers with respect to individuals enrolled under individual
health insurance coverage (other than through a plan described
in subsection (b)) offered by such issuers.
``(2) To provide assistance (other than through payments
described in paragraph (1)) to reduce out-of-pocket costs, such
as copayments, coinsurance, premiums, and deductibles, of
individuals enrolled under qualified health plans offered on
the individual market through an Exchange.
``(b) Exclusion of Certain Grandfathered and Transitional Plans.--
For purposes of subsection (a), a plan described in this subsection is
the following:
``(1) A grandfathered health plan (as defined in section
1251).
``(2) A plan (commonly referred to as a `transitional
plan') continued under the letter issued by the Centers for
Medicare & Medicaid Services on November 14, 2013, to the State
Insurance Commissioners outlining a transitional policy for
coverage in the individual and small group markets to which
section 1251 does not apply, and under the extension of the
transitional policy for such coverage set forth in the
Insurance Standards Bulletin Series guidance issued by the
Centers for Medicare & Medicaid Services on March 5, 2014,
February 29, 2016, February 13, 2017, April 9, 2018, March 25,
2019, and January 31, 2020, or under any subsequent extensions
thereof.
``(3) Student health insurance coverage (as defined in
section 147.145 of title 45, Code of Federal Regulations).
``SEC. 1353. 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 part for a year (beginning with 2022), a State
shall submit to the Administrator an application at such time
(but, in the case of allocations for 2022, not later than 90
days after the date of the enactment of this part and, in the
case of allocations for a subsequent year, not later than March
1 of the previous year) and in such form and manner as
specified by the Administrator containing--
``(A) a description of how the funds will be used;
and
``(B) 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
part and of the reason for such denial.
``(3) 5-year application approval.--If an application of a
State is approved for a purpose described in section 1352 for a
year, such application shall be treated as approved for such
purpose for each of the subsequent 4 years.
``(4) Revocation of approval.--The approval of an
application of a State, with respect to a purpose described in
section 1352, may be revoked if the State fails to use funds
provided to the State under this section for such purpose or
otherwise fails to comply with the requirements of this
section.
``(b) Default Federal Safeguard.--
``(1) 2022.--For 2022, in the case of a State that does not
submit an application under subsection (a) by the 90-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, the Administrator, in
consultation with the State insurance commissioner, shall, from
the amount calculated under paragraph (4) for such year, carry
out the purpose described in paragraph (3) in such State for
such year.
``(2) 2023 and subsequent years.--For 2023 or a subsequent
year, in the case of a State that does not have in effect an
approved application under this section for such year, the
Administrator, in consultation with the State insurance
commissioner, shall, from the amount calculated under paragraph
(4) for such year, carry out the purpose described in paragraph
(3) in such State for such year.
``(3) Specified use.--The amount described in paragraph
(4), with respect to 2022 or a subsequent year, shall be used
to carry out the purpose described in section 1352(a)(1) in
each State described in paragraph (1) or (2) for such year, as
applicable, by providing reinsurance payments to health
insurance issuers with respect to attachment range claims (as
defined in section 1354(b)(2)), using the dollar amounts
specified in subparagraph (B) of such section for such year) in
an amount equal to, subject to paragraph (5), the percentage
(specified for such year by the Secretary under such
subparagraph) of the amount of such claims.
``(4) Amount described.--The amount described in this
paragraph, with respect to 2022 or a subsequent year, is the
amount equal to the total sum of amounts that the Secretary
would otherwise estimate under section 1354(b)(2)(A)(i) for
such year for each State described in paragraph (1) or (2) for
such year, as applicable, if each such State were not so
described for such year.
``(5) Adjustment.--For purposes of this subsection, the
Secretary may apply a percentage under paragraph (3) with
respect to a year that is less than the percentage otherwise
specified in section 1354(b)(2)(B) for such year, if the cost
of paying the total eligible attachment range claims for States
described in this subsection for such year at such percentage
otherwise specified would exceed the amount calculated under
paragraph (4) for such year.
``SEC. 1354. ALLOCATIONS.
``(a) Appropriation.--For the purpose of providing allocations for
States under subsection (b) and payments under section 1353(b) there is
appropriated, out of any money in the Treasury not otherwise
appropriated, $10,000,000,000 for 2022 and each subsequent year.
``(b) Allocations.--
``(1) Payment.--
``(A) In general.--From amounts appropriated under
subsection (a) for a year, the Secretary shall, with
respect to a State not described in section 1353(b) for
such year and not later than the date specified under
subparagraph (B) for such year, allocate for such State
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 2022, the date that is 45 days
after the date of the enactment of this part;
and
``(ii) for 2023 or a subsequent year,
January 1 of the respective year.
``(C) Notifications of allocation amounts.--For
2023 and each subsequent year, the Secretary shall
notify each State of the amount determined for such
State under paragraph (2) for such year by not later
than January 1 of the previous year.
``(2) Allocation amount determinations.--
``(A) In general.--For purposes of paragraph (1),
the amount determined under this paragraph for a year
for a State described in paragraph (1)(A) for such year
is the amount equal to--
``(i) the amount that the Secretary
estimates would be expended under this part for
such year on attachment range claims of
individuals residing in such State if such
State used such funds only for the purpose
described in paragraph (1) of section 1352(a)
at the dollar amounts and percentage specified
under subparagraph (B) for such year; minus
``(ii) the amount, if any, by which the
Secretary determines--
``(I) the estimated amount of
premium tax credits under section 36B
of the Internal Revenue Code of 1986
that would be attributable to
individuals residing in such State for
such year without application of this
part; exceeds
``(II) the estimated amount of
premium tax credits under section 36B
of the Internal Revenue Code of 1986
that would be attributable to
individuals residing in such State for
such year if such State were a State
described in section 1353(b) for such
year.
For purposes of the previous sentence and section
1353(b)(3), the term `attachment range claims' means,
with respect to an individual, the claims for such
individual that exceed a dollar amount specified by the
Secretary for a year, but do not exceed a ceiling
dollar amount specified by the Secretary for such year,
under subparagraph (B).
``(B) Specifications.--For purposes of subparagraph
(A) and section 1353(b)(3), the Secretary shall
determine the dollar amounts and the percentage to be
specified under this subparagraph for a year in a
manner to ensure that the total amount of expenditures
under this part for such year is estimated to equal the
total amount appropriated for such year under
subsection (a) if such expenditures were used solely
for the purpose described in paragraph (1) of section
1352(a) for attachment range claims at the dollar
amounts and percentage so specified for such year.
``(3) Availability.--Funds allocated to a State under this
subsection for a year shall remain available through the end of
the subsequent year.''.
SEC. 107. RESCINDING THE SHORT-TERM LIMITED DURATION INSURANCE
REGULATION.
(a) Findings.--Congress finds the following:
(1) On August 3, 2018, the Administration issued a final
rule entitled ``Short-Term, Limited-Duration Insurance'' (83
Fed. Reg. 38212).
(2) The final rule dramatically expands the sale and
marketing of insurance that--
(A) may discriminate against individuals living
with preexisting health conditions, including children
with complex medical needs and disabilities and their
families;
(B) lacks important financial protections provided
by the Patient Protection and Affordable Care Act
(Public Law 111-148), including the prohibition of
annual and lifetime coverage limits and annual out-of-
pocket limits, that may increase the cost of treatment
and cause financial hardship to those requiring medical
care, including children with complex medical needs and
disabilities and their families; and
(C) excludes coverage of essential health benefits
including hospitalization, prescription drugs, and
other lifesaving care.
(3) The implementation and enforcement of the final rule
weakens critical protections for up to 130 million Americans
living with preexisting health conditions and may place a large
financial burden on those who enroll in short-term limited-
duration insurance, which jeopardizes Americans' access to
quality, affordable health insurance.
(b) Prohibition.--The Secretary of Health and Human Services, the
Secretary of the Treasury, and the Secretary of Labor--
(1) may not take any action to implement, enforce, or
otherwise give effect to the rule entitled ``Short-Term,
Limited Duration Insurance'' (83 Fed. Reg. 38212 (August 3,
2018));
(2) shall apply any regulation revised by such rule as if
such rule had not been issued; and
(3) may not promulgate any substantially similar rule.
SEC. 108. REVOKING SECTION 1332 GUIDANCE.
(a) Findings.--Congress finds the following:
(1) On October 24, 2018, the administration published new
guidance to carry out section 1332 of the Patient Protection
and Affordable Care Act (42 U.S.C. 18052) entitled ``State
Relief and Empowerment Waivers'' (83 Fed. Reg. 53575).
(2) The new guidance encourages States to provide health
insurance coverage through insurance plans that may
discriminate against individuals with preexisting health
conditions, including the one in four Americans living with a
disability.
(3) The implementation and enforcement of the new guidance
weakens protections for the millions of Americans living with
preexisting health conditions and jeopardizes Americans' access
to quality, affordable health insurance coverage.
(b) Providing That Certain Guidance Related to Waivers for State
Innovation Under the Patient Protection and Affordable Care Act Shall
Have No Force or Effect.--Beginning July 1, 2020, the Secretary of
Health and Human Services and the Secretary of the Treasury may not
take any action to implement, enforce, or otherwise give effect to the
guidance entitled ``State Relief and Empowerment Waivers'' (83 Fed.
Reg. 53575 (October 24, 2018)), including any such action that would
result in individuals losing health insurance coverage that includes
the essential health benefits package (as defined in subsection (a) of
section 1302 of the Patient Protection and Affordable Care Act (42
U.S.C. 18022(a)) without regard to any waiver of any provision of such
package under a waiver under such section 1332), including the
maternity and newborn care essential health benefit described in
subsection (b)(1)(D) of such section, including any such action that
would result in a decrease in the number of such individuals enrolled
in coverage that is at least as comprehensive as the coverage defined
in section 1302(a) of the Patient Protection and Affordable Care Act
(42 U.S.C. 18022(a)) compared to the number of such individuals who
would have been so enrolled in such coverage had such action not been
taken, including any such action that would, with respect to
individuals with substance use disorders, including opioid use
disorders, reduce the availability or affordability of coverage that is
at least as comprehensive as the coverage defined in section 1302(a) of
the Patient Protection and Affordable Care Act (42 U.S.C. 18022(a))
compared to the availability or affordability, respectively, of such
coverage had such action not been taken, including any such action that
would result, with respect to vulnerable populations (including low-
income individuals, elderly individuals, and individuals with serious
health issues or who have a greater risk of developing serious health
issues), in a decrease in the availability of coverage that is at least
as comprehensive as the coverage defined in section 1302(a) of the
Patient Protection and Affordable Care Act (42 U.S.C. 18022(a)) with
coverage and cost sharing protections required under section
1332(b)(1)(B) of such Act (42 U.S.C. 18052(b)(1)(B)), including any
such action that would, with respect to individuals with preexisting
conditions, reduce the affordability of coverage that is at least as
comprehensive as the coverage defined in section 1302(a) of the Patient
Protection and Affordable Care Act (42 U.S.C. 18022(a)) compared to the
affordability of such coverage had such action not been taken,
including any such action that would result in higher health insurance
premiums for individuals enrolled in health insurance coverage that is
at least as comprehensive as the coverage defined in section 1302(b) of
such Act (42 U.S.C. 18022(b)), and the Secretaries may not promulgate
any substantially similar guidance or rule. Nothing in the previous
sentence shall be construed to affect the approval of waivers under
section 1332 of the Patient Protection and Affordable Care Act (42
U.S.C. 18052) that establish reinsurance programs that are consistent
with the requirements under subsection (b)(1) of such section (42
U.S.C. 18052(b)(1)), lower health insurance premiums, and protect
health insurance coverage for people with preexisting conditions.
(c) GAO Report on Affect of State Innovation Waivers on Coverage of
Individuals and on Mental Health Health Care Treatment.--Not later than
1 year after the date of the enactment of this Act, the Comptroller
General of the United States shall submit to Congress a report on the
number of individuals expected to lose access to health insurance
coverage (as defined in section 2791 of the Public Health Service Act
(42 U.S.C. 300gg-91)) if subsection (b) were not enacted and waivers
under section 1332 of the Patient Protection and Affordable Care Act
(42 U.S.C. 18052) were approved under the guidance described in such
subsection (b). Such report shall include an analysis of the expected
effect such waivers approved under such guidance would have on mental
health care treatment.
SEC. 109. REQUIRING MARKETPLACE OUTREACH, EDUCATIONAL ACTIVITIES, AND
ANNUAL ENROLLMENT TARGETS.
(a) In General.--Section 1321(c) of the Patient Protection and
Affordable Care Act (42 U.S.C. 18041(c)), as amended by section 105(b),
is further amended by adding at the end the following new paragraphs:
``(4) Outreach and educational activities.--
``(A) In general.--In the case of an Exchange
established or operated by the Secretary within a State
pursuant to this subsection, the Secretary shall carry
out outreach and educational activities for purposes of
informing individuals about qualified health plans
offered through the Exchange, including by informing
such individuals of the availability of coverage under
such plans and financial assistance for coverage under
such plans. Such outreach and educational activities
shall be provided in a manner that is culturally and
linguistically appropriate to the needs of the
populations being served by the Exchange (including
hard-to-reach populations, such as racial and sexual
minorities, limited English proficient populations,
individuals in rural areas, veterans, and young adults)
and shall be provided to populations residing in high
health disparity areas (as defined in subparagraph (E))
served by the Exchange, in addition to other
populations served by the Exchange.
``(B) Limitation on use of funds.--No funds
appropriated under this paragraph shall be used for
expenditures for promoting non-ACA compliant health
insurance coverage.
``(C) Non-aca compliant health insurance
coverage.--For purposes of subparagraph (B):
``(i) The term `non-ACA compliant health
insurance coverage' means health insurance
coverage, or a group health plan, that is not a
qualified health plan.
``(ii) Such term includes the following:
``(I) An association health plan.
``(II) Short-term limited duration
insurance.
``(D) Funding.--Out of any funds in the Treasury
not otherwise appropriated, there are hereby
appropriated for fiscal year 2022 and each subsequent
fiscal year, $100,000,000 to carry out this paragraph.
Funds appropriated under this subparagraph shall remain
available until expended.
``(E) High health disparity area defined.--For
purposes of subparagraph (A), the term `high health
disparity area' means a contiguous geographic area
that--
``(i) is located in one census tract or ZIP
code;
``(ii) has measurable and documented
racial, ethnic, or geographic health
disparities;
``(iii) has a low-income population, as
demonstrated by--
``(I) average income below 138
percent of the Federal poverty line; or
``(II) a rate of participation in
the special supplemental nutrition
program under section 17 of the Child
Nutrition Act of 1966 (42 U.S.C. 1786)
that is higher than the national
average rate of participation in such
program;
``(iv) has poor health outcomes, as
demonstrated by--
``(I) lower life expectancy than
the national average; or
``(II) a higher percentage of
instances of low birth weight than the
national average; and
``(v) is part of a Metropolitan Statistical
Area identified by the Office of Management and
Budget.
``(5) Annual enrollment targets.--For plan year 2021 and
each subsequent plan year, in the case of an Exchange
established or operated by the Secretary within a State
pursuant to this subsection, the Secretary shall establish
annual enrollment targets for such Exchange for such year.''.
(b) Study and Report.--Not later than 30 days after the date of the
enactment of this Act, the Secretary of Health and Human Services shall
release to Congress all aggregated documents relating to studies and
data sets that were created on or after January 1, 2014, and related to
marketing and outreach with respect to qualified health plans offered
through Exchanges under title I of the Patient Protection and
Affordable Care Act (42 U.S.C. 18001 et seq.).
SEC. 110. REPORT ON EFFECTS OF WEBSITE MAINTENANCE DURING OPEN
ENROLLMENT.
Not later than 1 year after the date of the enactment of this Act,
the Comptroller General of the United States shall submit to Congress a
report examining whether the Department of Health and Human Services
has been conducting maintenance on the website commonly referred to as
``Healthcare.gov'' during annual open enrollment periods (as described
in section 1311(c)(6)(B) of the Patient Protection and Affordable Care
Act (42 U.S.C. 18031(c)(6)(B)) in such a manner so as to minimize any
disruption to the use of such website resulting from such maintenance.
SEC. 111. PROMOTING CONSUMER OUTREACH AND EDUCATION.
(a) In General.--Section 1311(i) of the Patient Protection and
Affordable Care Act (42 U.S.C. 18031(i)) is amended--
(1) in paragraph (2), by adding at the end the following
new subparagraph:
``(C) Selection of recipients.--In the case of an
Exchange established and operated by the Secretary
within a State pursuant to section 1321(c), in awarding
grants under paragraph (1), the Exchange shall--
``(i) select entities to receive such
grants based on an entity's demonstrated
capacity to carry out each of the duties
specified in paragraph (3);
``(ii) not take into account whether or not
the entity has demonstrated how the entity will
provide information to individuals relating to
group health plans offered by a group or
association of employers described in section
2510.3-5(b) of title 29, Code of Federal
Regulations (or any successor regulation), or
short-term limited duration insurance (as
defined by the Secretary for purposes of
section 2791(b)(5) of the Public Health Service
Act); and
``(iii) ensure that, each year, the
Exchange awards such a grant to--
``(I) at least one entity described
in this paragraph that is a community
and consumer-focused nonprofit group;
and
``(II) at least one entity
described in subparagraph (B), which
may include another community and
consumer-focused nonprofit group in
addition to any such group awarded a
grant pursuant to subclause (I).
In awarding such grants, an Exchange may consider an
entity's record with respect to waste, fraud, and abuse
for purposes of maintaining the integrity of such
Exchange.'';
(2) in paragraph (3)--
(A) by amending subparagraph (C) to read as
follows:
``(C) facilitate enrollment, including with respect
to individuals with limited English proficiency and
individuals with chronic illnesses, in qualified health
plans, State medicaid plans under title XIX of the
Social Security Act, and State child health plans under
title XXI of such Act;'';
(B) in subparagraph (D), by striking ``and'' at the
end;
(C) in subparagraph (E), by striking the period at
the end and inserting ``; and'';
(D) by inserting after subparagraph (E) the
following new subparagraph:
``(F) provide referrals to community-based
organizations that address social needs related to
health outcomes.''; and
(E) by adding at the end the following flush left
sentence:
``The duties specified in the preceding sentence may be carried
out by such a navigator at any time during a year.'';
(3) in paragraph (4)(A)--
(A) in the matter preceding clause (i), by striking
``not'';
(B) in clause (i)--
(i) by inserting ``not'' before ``be''; and
(ii) by striking ``; or'' and inserting a
semicolon;
(C) in clause (ii)--
(i) by inserting ``not'' before
``receive''; and
(ii) by striking the period and inserting a
semicolon; and
(D) by adding at the end the following new clauses:
``(iii) maintain physical presence in the
State of the Exchange so as to allow in-person
assistance to consumers; and
``(iv) receive opioid specific education
and training that ensures the navigator can
best educate individuals on qualified health
plans offered through an Exchange, specifically
coverage under such plans for opioid health
care treatment.''; and
(4) in paragraph (6)--
(A) by striking ``Funding.--Grants under'' and
inserting ``Funding.--
``(A) State exchanges.--Grants under''; and
(B) by adding at the end the following new
subparagraph:
``(B) Federal exchanges.--For purposes of carrying
out this subsection, with respect to an Exchange
established and operated by the Secretary within a
State pursuant to section 1321(c), the Secretary shall
obligate $100,000,000 out of amounts collected through
the user fees on participating health insurance issuers
pursuant to section 156.50 of title 45, Code of Federal
Regulations (or any successor regulations), for fiscal
year 2022 and each subsequent fiscal year. Such amount
for a fiscal year shall remain available until
expended.''.
(b) Effective Date.--The amendments made by this section shall
apply with respect to plan years beginning on or after January 1, 2021.
SEC. 112. IMPROVING TRANSPARENCY AND ACCOUNTABILITY IN THE MARKETPLACE.
(a) Open Enrollment Reports.--For plan year 2021 and each
subsequent year, the Secretary of Health and Human Services (referred
to in this section as the ``Secretary''), in coordination with the
Secretary of the Treasury and the Secretary of Labor, shall issue
biweekly public reports during the annual open enrollment period on the
performance of the federally facilitated Exchange operated pursuant to
section 1321(c) of the Patient Protection and Affordable Care Act (42
U.S.C. 18041(c)). Each such report shall include a summary, including
information on a State-by-State basis where available, of--
(1) the number of unique website visits;
(2) the number of individuals who create an account;
(3) the number of calls to the call center;
(4) the average wait time for callers contacting the call
center;
(5) the number of individuals who enroll in a qualified
health plan; and
(6) the percentage of individuals who enroll in a qualified
health plan through each of--
(A) the website;
(B) the call center;
(C) navigators;
(D) agents and brokers;
(E) the enrollment assistant program;
(F) directly from issuers or web brokers; and
(G) other means.
(b) Open Enrollment After Action Report.--For plan year 2021 and
each subsequent year, the Secretary, in coordination with the Secretary
of the Treasury and the Secretary of Labor, shall publish an after
action report not later than 3 months after the completion of the
annual open enrollment period regarding the performance of the Exchange
described in subsection (a) for the applicable plan year. Each such
report shall include a summary, including information on a State-by-
State basis where available, of--
(1) the open enrollment data reported under subsection (a)
for the entirety of the enrollment period; and
(2) activities related to patient navigators described in
section 1311(i) of the Patient Protection and Affordable Care
Act (42 U.S.C. 18031(i)), including--
(A) the performance objectives established by the
Secretary for such patient navigators;
(B) the number of consumers enrolled by such a
patient navigator;
(C) an assessment of how such patient navigators
have met established performance metrics, including a
detailed list of all patient navigators, funding
received by patient navigators, and whether established
performance objectives of patient navigators were met;
and
(D) with respect to the performance objectives
described in subparagraph (A)--
(i) whether such objectives assess the full
scope of patient navigator responsibilities,
including general education, plan selection,
and determination of eligibility for tax
credits, cost-sharing reductions, or other
coverage;
(ii) how the Secretary worked with patient
navigators to establish such objectives; and
(iii) how the Secretary adjusted such
objectives for case complexity and other
contextual factors.
(c) Report on Advertising and Consumer Outreach.--Not later than 3
months after the completion of the annual open enrollment period for
plan year 2021, the Secretary shall issue a report on advertising and
outreach to consumers for the open enrollment period for plan year
2021. Such report shall include a description of--
(1) the division of spending on individual advertising
platforms, including television and radio advertisements and
digital media, to raise consumer awareness of open enrollment;
(2) the division of spending on individual outreach
platforms, including email and text messages, to raise consumer
awareness of open enrollment; and
(3) whether the Secretary conducted targeted outreach to
specific demographic groups and geographic areas.
(b) Promoting Transparency and Accountability in the
Administration's Expenditures of Exchange User Fees.--For plan year
2021 and each subsequent plan year, not later than the date that is 3
months after the end of such plan year, the Secretary of Health and
Human Services shall submit to the appropriate committees of Congress
and make available to the public an annual report on the expenditures
by the Department of Health and Human Services of user fees collected
pursuant to section 156.50 of title 45, Code of Federal Regulations (or
any successor regulations). Each such report for a plan year shall
include a detailed accounting of the amount of such user fees collected
during such plan year and of the amount of such expenditures used
during such plan year for the federally facilitated Exchange operated
pursuant to section 1321(c) of the Patient Protection and Affordable
Care Act (42 U.S.C. 18041(c)) on outreach and enrollment activities,
navigators, maintenance of Healthcare.gov, and operation of call
centers.
SEC. 113. IMPROVING AWARENESS OF HEALTH COVERAGE OPTIONS.
(a) In General.--Not later than 90 days after the date of the
enactment of this Act, the Secretary of Labor, in consultation with the
Secretary of Health and Human Services, shall update, and make publicly
available in a prominent location on the website of the Department of
Labor, the model Consolidated Omnibus Budget Reconciliation Act of 1985
(referred to in this section as ``COBRA'') continuation coverage
general notice and the model COBRA continuation coverage election
notice developed by the Secretary of Labor for purposes of facilitating
compliance of group health plans with the notification requirements
under section 606 of the Employee Retirement Income Security Act of
1974 (29 U.S.C. 1166). In updating each such notice, the Secretary of
Labor shall include information regarding any Exchange established
under title I of the Patient Protection and Affordable Care Act (42
U.S.C. 18001 et seq.) through which a qualified beneficiary may be
eligible to enroll in a qualified health plan, including--
(1) the publicly accessible Internet website address for
such Exchange;
(2) the publicly accessible Internet website address for
the Find Local Help directory maintained by the Department of
Health and Human Services on the healthcare.gov Internet
website (or a successor website);
(3) a clear explanation that--
(A) an individual who is eligible for continuation
coverage may also be eligible to enroll, with financial
assistance, in a qualified health plan offered through
such Exchange, but, in the case that such individual
elects to enroll in such continuation coverage and
subsequently elects to terminate such continuation
coverage before the period of such continuation
coverage expires, such individual will not be eligible
to enroll in a qualified health plan offered through
such Exchange during a special enrollment period; and
(B) an individual who elects to enroll in
continuation coverage will remain eligible to enroll in
a qualified health plan offered through such Exchange
during an open enrollment period and may be eligible
for financial assistance with respect to enrolling in
such a qualified health plan;
(4) information on consumer protections with respect to
enrolling in a qualified health plan offered through such
Exchange, including the requirement for such a qualified health
plan to provide coverage for essential health benefits (as
defined in section 1302(b) of such Act (42 U.S.C. 18022(b)) and
the requirements applicable to such a qualified health plan
under part A of title XXVII of the Public Health Service Act
(42 U.S.C. 300gg et seq.); and
(5) information on the availability of financial assistance
with respect to enrolling in a qualified health plan, including
the maximum income limit for eligibility for a premium tax
credit under section 36B of the Internal Revenue Code of 1986.
(b) Name of Notices.--In addition to updating the model COBRA
continuation coverage general notice and the model COBRA continuation
coverage election notice under paragraph (1), the Secretary of Labor
shall rename each such notice as the ``model COBRA continuation
coverage and Affordable Care Act coverage general notice'' and the
``model COBRA continuation coverage and Affordable Care Act coverage
election notice'', respectively.
(c) Consumer Testing.--Prior to making publicly available the model
COBRA continuation coverage general notice and the model COBRA
continuation coverage election notice updated under paragraph (1), the
Secretary of Labor shall provide an opportunity for consumer testing of
each such notice, as so updated, to ensure that each such notice is
clear and understandable to the average participant or beneficiary of a
group health plan.
(d) Definitions.--In this subsection:
(1) Continuation coverage.--The term ``continuation
coverage'', with respect to a group health plan, has the
meaning given such term in section 602 of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1162).
(2) Group health plan.--The term ``group health plan'' has
the meaning given such term in section 607 of such Act (29
U.S.C. 1167).
(3) Qualified beneficiary.--The term ``qualified
beneficiary'' has the meaning given such term in such section
607.
(4) Qualified health plan.--The term ``qualified health
plan'' has the meaning given such term in section 1301 of the
Patient Protection and Affordable Care Act (42 U.S.C. 18021).
SEC. 114. PROMOTING STATE INNOVATIONS TO EXPAND COVERAGE.
(a) In General.--Subject to subsection (d), the Secretary of Health
and Human Services shall award grants to eligible State agencies to
enable such States to explore innovative solutions to promote greater
enrollment in health insurance coverage in the individual and small
group markets, including activities described in subsection (c).
(b) Eligibility.--For purposes of subsection (a), eligible State
agencies are Exchanges established by a State under title I of the
Patient Protection and Affordable Care Act (42 U.S.C. 18001 et seq.)
and State agencies with primary responsibility over health and human
services for the State involved.
(c) Use of Funds.--For purposes of subsection (a), the activities
described in this subsection are the following:
(1) State efforts to streamline health insurance enrollment
procedures in order to reduce burdens on consumers and
facilitate greater enrollment in health insurance coverage in
the individual and small group markets, including automatic
enrollment and reenrollment of, or pre-populated applications
for, individuals without health insurance who are eligible for
tax credits under section 36B of the Internal Revenue Code of
1986, with the ability to opt out of such enrollment.
(2) State investment in technology to improve data sharing
and collection for the purposes of facilitating greater
enrollment in health insurance coverage in such markets.
(3) Implementation of a State version of an individual
mandate to be enrolled in health insurance coverage.
(4) Feasibility studies to develop comprehensive and
coherent State plan for increasing enrollment in the individual
and small group market.
(d) Funding.--For purposes of carrying out this section, there is
hereby appropriated, out of any funds in the Treasury not otherwise
appropriated, $200,000,000 for each of the fiscal years 2022 through
2024. Such amount shall remain available until expended.
SEC. 115. STRENGTHENING NETWORK ADEQUACY.
(a) In General.--Section 1311(d) of the Patient Protection and
Affordable Care Act (42 U.S.C. 18031(d)) is amended by adding at the
end the following new paragraph:
``(8) Network adequacy standards.--
``(A) Certain exchanges.--In the case of an
Exchange operated by the Secretary pursuant section
1321(c)(1) or an Exchange described in section
155.200(f) of title 42, Code of Federal Regulations (or
a successor regulation), the Exchange shall require
each qualified health plan offered through such
Exchange to meet such quantitative network adequacy
standards as the Secretary may prescribe for purposes
of this subparagraph.
``(B) State exchanges.--In the case of an Exchange
not described in subparagraph (A), the Exchange shall
establish quantitative network adequacy standards with
respect to qualified health plans offered through such
Exchange and require such plans to meet such
standards.''.
(b) Effective Date.--The amendment made by this section shall apply
with respect to plan years beginning on or after January 1, 2022.
SEC. 116. PROTECTING CONSUMERS FROM UNREASONABLE RATE HIKES.
(a) Protection From Excessive, Unjustified, or Unfairly
Discriminatory Rates.--The first section 2794 of the Public Health
Service Act (42 U.S.C. 300gg-94), as added by section 1003 of the
Patient Protection and Affordable Care Act (Public Law 111-148), is
amended by adding at the end the following new subsection:
``(e) Protection From Excessive, Unjustified, or Unfairly
Discriminatory Rates.--
``(1) Authority of states.--Nothing in this section shall
be construed to prohibit a State from imposing requirements
(including requirements relating to rate review standards and
procedures and information reporting) on health insurance
issuers with respect to rates that are in addition to the
requirements of this section and are more protective of
consumers than such requirements.
``(2) Consultation in rate review process.--In carrying out
this section, the Secretary shall consult with the National
Association of Insurance Commissioners and consumer groups.
``(3) Determination of who conducts reviews for each
state.--The Secretary shall determine, after the date of
enactment of this section and periodically thereafter, the
following:
``(A) In which markets in each State the State
insurance commissioner or relevant State regulator
shall undertake the corrective actions under paragraph
(4), based on the Secretary's determination that the
State regulator is adequately undertaking and utilizing
such actions in that market.
``(B) In which markets in each State the Secretary
shall undertake the corrective actions under paragraph
(4), in cooperation with the relevant State insurance
commissioner or State regulator, based on the
Secretary's determination that the State is not
adequately undertaking and utilizing such actions in
that market.
``(4) Corrective action for excessive, unjustified, or
unfairly discriminatory rates.--In accordance with the process
established under this section, the Secretary or the relevant
State insurance commissioner or State regulator shall take
corrective actions to ensure that any excessive, unjustified,
or unfairly discriminatory rates are corrected prior to
implementation, or as soon as possible thereafter, through
mechanisms such as--
``(A) denying rates;
``(B) modifying rates; or
``(C) requiring rebates to consumers.
``(5) Noncompliance.--Failure to comply with any corrective
action taken by the Secretary under this subsection may result
in the application of civil monetary penalties under section
2723 and, if the Secretary determines appropriate, make the
plan involved ineligible for classification as a qualified
health plan.''.
(b) Clarification of Regulatory Authority.--Such section is further
amended--
(1) in subsection (a)--
(A) in the heading, by striking ``Premium'' and
inserting ``Rate'';
(B) in paragraph (1), by striking ``unreasonable
increases in premiums'' and inserting ``potentially
excessive, unjustified, or unfairly discriminatory
rates, including premiums,''; and
(C) in paragraph (2)--
(i) by striking ``an unreasonable premium
increase'' and inserting ``a potentially
excessive, unjustified, or unfairly
discriminatory rate'';
(ii) by striking ``the increase'' and
inserting ``the rate''; and
(iii) by striking ``such increases'' and
inserting ``such rates''; and
(2) in subsection (b)--
(A) by striking ``premium increases'' each place it
appears and inserting ``rates''; and
(B) in paragraph (2)(B), by striking ``premium''
and inserting ``rate''.
(c) Conforming Amendments.--Title XXVII of the Public Health
Service Act (42 U.S.C. 300gg et seq.) is amended--
(1) in section 2723 (42 U.S.C. 300gg-22), as redesignated
by the Patient Protection and Affordable Care Act--
(A) in subsection (a)--
(i) in paragraph (1), by inserting ``and
section 2794'' after ``this part''; and
(ii) in paragraph (2), by inserting ``or
section 2794'' after ``this part''; and
(B) in subsection (b)--
(i) in paragraph (1), by inserting ``and
section 2794'' after ``this part''; and
(ii) in paragraph (2)--
(I) in subparagraph (A), by
inserting ``or section 2794 that is''
after ``this part''; and
(II) in subparagraph (C)(ii), by
inserting ``or section 2794'' after
``this part''; and
(2) in section 2761 (42 U.S.C. 300gg-61)--
(A) in subsection (a)--
(i) in paragraph (1), by inserting ``and
section 2794'' after ``this part''; and
(ii) in paragraph (2)--
(I) by inserting ``or section
2794'' after ``set forth in this
part''; and
(II) by inserting ``and section
2794'' after ``the requirements of this
part''; and
(B) in subsection (b)--
(i) by inserting ``and section 2794'' after
``this part''; and
(ii) by inserting ``and section 2794''
after ``part A''.
(d) Applicability to Grandfathered Plans.--Section 1251(a)(4)(A) of
the Patient Protection and Affordable Care Act (Public Law 111-148), as
added by section 2301 of the Health Care and Education Reconciliation
Act of 2010 (Public Law 111-152), is amended by adding at the end the
following:
``(v) Section 2794 (relating to
reasonableness of rates with respect to health
insurance coverage).''.
(e) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this Act such sums as may be necessary.
(f) Effective Date.--The amendments made by this section shall take
effect on the date of enactment of this Act and shall be implemented
with respect to health plans beginning not later than January 1, 2022.
SEC. 117. ELIGIBILITY OF DACA RECIPIENTS FOR QUALIFIED HEALTH PLANS
OFFERED THROUGH EXCHANGES.
(a) In General.--Section 1312(f)(3) of the Patient Protection and
Affordable Care Act (42 U.S.C. 18032(f)(3)) is amended--
(1) by striking ``or an alien lawfully present in the
United States'' and inserting ``, an alien lawfully present in
the United States, or a DACA recipient''; and
(2) by adding at the end the following: ``For purposes of
the previous sentence, the term `DACA recipient' means an
individual who was granted deferred action pursuant to the
Deferred Action for Childhood Arrivals Program announced in the
memorandum of the Secretary of Homeland Security dated June 15,
2012, and for whom such grant remains valid.''.
(b) Application of Reduced Cost-Sharing.--Section 1402(e)(2) of the
Patient Protection and Affordable Care Act (42 U.S.C. 18071(e)(2)) is
amended by adding at the end the following: ``A DACA recipient (as
defined in section 1312(f)(3)) shall be treated as lawfully present for
purposes of this section.''.
(c) Eligibility for Advance Payments.--Section 1412(d) of the
Patient Protection and Affordable Care Act (42 U.S.C. 18082(d)) is
amended by adding at the end the following: ``For purposes of the
previous sentence, a DACA recipient (as defined in section 1312(f)(3))
shall be treated as lawfully present in the United States.''.
(d) Verification of Eligibility.--Section 1411(c)(2)(B) of the
Patient Protection and Affordable Care Act (42 U.S.C. 18081(c)(2)(B))
is amended--
(1) in clause (i)(I), by inserting ``or a DACA recipient
(as defined in section 1312(f)(3))'' after ``an alien lawfully
present in the United States''; and
(2) in clause (ii), by inserting ``or a DACA recipient (as
defined in section 1312(f)(3))'' after ``an alien lawfully
present in the United States''.
(e) Application of Tax Credit for Coverage Under a Qualified Health
Plan.--Section 36B(e)(2) of the Internal Revenue Code of 1986 is
amended by adding at the end the following: ``A DACA recipient (as
defined in section 1312(f)(3) of the Patient Protection and Affordable
Care Act) shall be treated as lawfully present for purposes of this
section.''.
(f) Effective Date.--The amendments made by this section shall take
effect on January 1, 2021.
TITLE II--ENCOURAGING MEDICAID EXPANSION AND STRENGTHENING THE MEDICAID
PROGRAM
SEC. 201. INCENTIVIZING MEDICAID EXPANSION.
(a) In General.--Section 1905(y)(1) of the Social Security Act (42
U.S.C. 1396d(y)(1)) is amended--
(1) in subparagraph (A), by striking ``2014, 2015, and
2016'' and inserting ``each of the first 3 consecutive 12-month
periods in which the State provides medical assistance to newly
eligible individuals'';
(2) in subparagraph (B), by striking ``2017'' and inserting
``the fourth consecutive 12-month period in which the State
provides medical assistance to newly eligible individuals'';
(3) in subparagraph (C), by striking ``2018'' and inserting
``the fifth consecutive 12-month period in which the State
provides medical assistance to newly eligible individuals'';
(4) in subparagraph (D), by striking ``2019'' and inserting
``the sixth consecutive 12-month period in which the State
provides medical assistance to newly eligible individuals'';
and
(5) in subparagraph (E), by striking ``2020 and each year
thereafter'' and inserting ``the seventh consecutive 12-month
period in which the State provides medical assistance to newly
eligible individuals and each such period thereafter''.
(b) Effective Date.--Beginning on January 1, 2022, the amendments
made by subsection (a) shall take effect as if included in the
enactment of the Patient Protection and Affordable Care Act (Public Law
111-148).
SEC. 202. PROVIDING 12-MONTHS OF CONTINUOUS ELIGIBILITY FOR MEDICAID
AND CHIP.
(a) Requirement of 12-Month Continuous Enrollment Under Medicaid.--
Section 1902(e)(12) of the Social Security Act (42 U.S.C. 1396a(e)(12))
is amended to read as follows:
``(12) 12-month continuous enrollment.--Notwithstanding any
other provision of this title, a State plan approved under this
title (or under any waiver of such plan approved pursuant to
section 1115 or section 1915), shall provide that an individual
who is determined to be eligible for benefits under such plan
(or waiver) shall remain eligible and enrolled for such
benefits through the end of the month in which the 12-month
period (beginning on the date of determination of eligibility)
ends.''.
(b) Requirement of 12-Month Continuous Enrollment Under CHIP.--
(1) In general.--Section 2102(b) of the Social Security Act
(42 U.S.C. 1397bb(b)) is amended by adding at the end the
following new paragraph:
``(6) Requirement for 12-month continuous enrollment.--
Notwithstanding any other provision of this title, a State
child health plan that provides child health assistance under
this title through a means other than described in section
2101(a)(2), shall provide that an individual who is determined
to be eligible for benefits under such plan shall remain
eligible and enrolled for such benefits through the end of the
month in which the 12-month period (beginning on the date of
determination of eligibility) ends.''.
(2) Conforming amendment.--Section 2105(a)(4)(A) of the
Social Security Act (42 U.S.C. 1397ee(a)(4)(A)) is amended--
(A) by striking ``has elected the option of'' and
inserting ``is in compliance with the requirement
for''; and
(B) by striking ``applying such policy under its
State child health plan under this title'' and
inserting ``in compliance with section 2102(b)''.
(c) Effective Date.--
(1) In general.--Except as provided in paragraph (2) or
(3), the amendments made by subsections (a) and (b) shall apply
to determinations (and redeterminations) of eligibility made on
or after the date that is 12 months after the last day of the
emergency period described in section 1135(g)(1)(B) of the
Social Security Act (42 U.S.C. 1320b-5(g)(1)(B)).
(2) Extension of effective date for state law amendment.--
In the case of a State plan under title XIX or State child
health plan under title XXI of the Social Security Act (42
U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.) which the
Secretary of Health and Human Services determines requires
State legislation (other than legislation appropriating funds)
in order for the respective plan to meet the additional
requirement imposed by the amendment made by subsection (a) or
(b), respectively, the respective plan shall not be regarded as
failing to comply with the requirements of such title solely on
the basis of its failure to meet such applicable additional
requirement before the first day of the first calendar quarter
beginning after the close of the first regular session of the
State legislature that begins after the date of enactment of
this Act. For purposes of the previous sentence, in the case of
a State that has a 2-year legislative session, each year of the
session is considered to be a separate regular session of the
State legislature.
(3) Option to implement 12-month continuous eligibility
prior to effective date.--A State may elect through a State
plan amendment under title XIX or XXI of the Social Security
Act (42 U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.) to apply
the amendment made by subsection (a) or (b), respectively, on
any date prior to the date specified in paragraph (1), but not
sooner than the date of the enactment of this Act.
SEC. 203. MANDATORY 12-MONTHS OF POSTPARTUM MEDICAID ELIGIBILITY.
(a) Extending Continuous Medicaid and CHIP Coverage for Pregnant
and Postpartum Women.--
(1) Medicaid.--Title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) is amended--
(A) in section 1902(l)(1)(A), by striking ``60-day
period'' and inserting ``365-day period'';
(B) in section 1902(e)(6), by striking ``60-day
period'' and inserting ``365-day period'';
(C) in section 1903(v)(4)(A)(i), by striking ``60-
day period'' and inserting ``365-day period''; and
(D) in section 1905(a), in the 4th sentence in the
matter following paragraph (30), by striking ``60-day
period'' and inserting ``365-day period''.
(2) CHIP.--Section 2112 of the Social Security Act (42
U.S.C. 1397ll) is amended by striking ``60-day period'' each
place it appears and inserting ``365-day period''.
(b) Requiring Full Benefits for Pregnant and Postpartum Women.--
(1) Medicaid.--
(A) In general.--Paragraph (5) of section 1902(e)
of the Social Security Act (24 U.S.C. 1396a(e)) is
amended to read as follows:
``(5) Any woman who is eligible for medical assistance
under the State plan or a waiver of such plan and who is, or
who while so eligible becomes, pregnant, shall continue to be
eligible under the plan or waiver for medical assistance
through the end of the month in which the 365-day period
(beginning on the last day of her pregnancy) ends, regardless
of the basis for the woman's eligibility for medical
assistance, including if the woman's eligibility for medical
assistance is on the basis of being pregnant.''.
(B) Conforming amendment.--Section 1902(a)(10) of
the Social Security Act (42 U.S.C. 1396a(a)(10)) is
amended in the matter following subparagraph (G) by
striking ``(VII) the medical assistance'' and all that
follows through ``complicate pregnancy,''.
(2) CHIP.--Section 2107(e)(1) of the Social Security Act
(42 U.S.C. 1397gg(e)(1)) is amended--
(A) by redesignating subparagraphs (H) through (S)
as subparagraphs (I) through (T), respectively; and
(B) by inserting after subparagraph (G), the
following:
``(H) Section 1902(e)(5) (requiring 365-day
continuous coverage for pregnant and postpartum
women).''.
(c) Maintenance of Effort.--
(1) Medicaid.--Section 1902 of the Social Security Act (42
U.S.C. 1396a) is amended--
(A) in paragraph (74), by striking ``subsection
(gg); and'' and inserting ``subsections (gg) and
(qq);''; and
(B) by adding at the end the following new
subsection:
``(qq) Maintenance of Effort Related to Low-Income Pregnant
Women.--For calendar quarters beginning on or after the effective date
described in section 203(d) of the Patient Protection and Affordable
Care Enhancement Act, and before January 1, 2023, no Federal payment
shall be made to a State under section 1903(a) for amounts expended
under a State plan under this title or a waiver of such plan if the
State--
``(1) has in effect under such plan eligibility standards,
methodologies, or procedures for individuals described in
subsection (l)(1) who are eligible for medical assistance under
the State plan or waiver under subsection (a)(10)(A)(ii)(IX)
that are more restrictive than the eligibility standards,
methodologies, or procedures, respectively, for such
individuals under such plan or waiver that are in effect on the
date of the enactment of this subsection; or
``(2) provides medical assistance to individuals described
in subsection (l)(1) who are eligible for medical assistance
under such plan or waiver under subsection (a)(10)(A)(ii)(IX)
at a level that is less than the level at which the State
provides such assistance to such individuals under such plan or
waiver on the date of the enactment of this subsection.''.
(2) CHIP.--Section 2112 of the Social Security Act (42
U.S.C. 1397ll), as amended by subsection (b), is further
amended by adding at the end the following subsection:
``(g) Maintenance of Effort.--For calendar quarters beginning on or
after the effective date described in section 203(d) of the Patient
Protection and Affordable Care Enhancement Act, and before January 1,
2023, no payment may be made under section 2105(a) with respect to a
State child health plan if the State--
``(1) has in effect under such plan eligibility standards,
methodologies, or procedures for targeted low-income pregnant
women that are more restrictive than the eligibility standards,
methodologies, or procedures, respectively, under such plan
that are in effect on the date of the enactment of this
subsection; or
``(2) provides pregnancy-related assistance to targeted
low-income pregnant women under such plan at a level that is
less than the level at which the State provides such assistance
to such women under such plan on the date of the enactment of
this subsection.''.
(d) Effective Date.--
(1) In general.--Except as provided under paragraph (2),
the amendments made by subsections (a) and (b) shall take
effect on (and the effective date described in this subsection
shall be) the first day of the calendar quarter during which
the last day of the emergency period described in section
1135(g)(1)(B) of the Social Security Act (42 U.S.C. 1320b-
5(g)(1)(B)) occurs.
(2) Extension of effective date for state law amendment.--
In the case of a State plan under title XIX or State child
health plan under title XXI of the Social Security Act (42
U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.) which the
Secretary of Health and Human Services determines requires
State legislation (other than legislation appropriating funds)
in order for the respective plan to meet the additional
requirement imposed by the amendments made by subsection (a) or
(b), respectively, the respective plan shall not be regarded as
failing to comply with the requirements of such title solely on
the basis of its failure to meet such applicable additional
requirement before the first day of the first calendar quarter
beginning after the close of the first regular session of the
State legislature that begins after the date of enactment of
this Act. For purposes of the previous sentence, in the case of
a State that has a 2-year legislative session, each year of the
session is considered to be a separate regular session of the
State legislature.
SEC. 204. REDUCING THE ADMINISTRATIVE FMAP FOR NONEXPANSION STATES.
Section 1903 of the Social Security Act (42 U.S.C. 1396b) is
amended--
(1) in subsection (a)(7), by inserting ``subsection (bb)
and'' before ``section 1919(g)(3)(B)''; and
(2) by adding at the end the following new subsection:
``(bb) Reduction of Federal Payments for Certain Administrative
Costs of Nonexpansion States.--
``(1) In general.--In the case of a State that does not
provide under the State plan of such State (or waiver of such
plan) for making medical assistance available in accordance
with section 1902(k)(1) to all individuals described in section
1902(a)(10)(i)(VIII) for a calendar quarter beginning on or
after October 1, 2022, the Secretary may reduce the percentage
specified in subsection (a)(7) for amounts described in such
subsection expended during such quarter by such State by the
number of percentage points specified in paragraph (2) for such
quarter.
``(2) Amount of reduction.--For purposes of paragraph (1),
the number of percentage points specified in this paragraph for
a calendar quarter is the following:
``(A) For the calendar quarter beginning on October
1, 2022, 0.5.
``(B) For a calendar quarter beginning on or after
January 1, 2023, and ending before July 1, 2027, the
number of percentage points specified under this
paragraph for the previous quarter, plus 0.5.
``(C) For a calendar quarter beginning on or after
July 1, 2027, 10.
``(3) Definition.--For purposes of this subsection, the
term `State' means a State that is one of the 50 States or the
District of Columbia.''.
SEC. 205. ENHANCED REPORTING REQUIREMENTS FOR NONEXPANSION STATES.
Section 1903 of the Social Security Act (42 U.S.C. 1396b), as
amended by section 204, is further amended--
(1) in subsection (a)(7), by striking ``subsection (bb)''
and inserting ``subsections (bb) and (cc)''; and
(2) by adding at the end the following new subsection:
``(cc) Reduction of Federal Payments for Certain Administrative
Costs of Nonexpansion States That Do Not Satisfy Reporting
Requirements.--
``(1) In general.--
``(A) Reduction.--In the case of a nonexpansion
State, with respect to a fiscal year (beginning with
fiscal year 2023) that does not satisfy the reporting
requirement under paragraph (2) for such fiscal year,
the percentage specified in subsection (a)(7) for
amounts described in such subsection expended by such
State during a calendar quarter described in paragraph
(4) with respect to such fiscal year, subject to
subparagraph (B), shall be reduced by the number of
percentage points specified in paragraph (4) for the
respective calendar quarter.
``(B) Exception.--In the case of a nonexpansion
State that is subject to a reduction under subparagraph
(A) for the calendar quarter described in paragraph
(4)(A) with respect to a fiscal year, if the State
satisfies the criteria described in subparagraphs (A),
(B), and (C) of paragraph (2) (without regard to the
dates specified in such subparagraph (A) and (C))
before the beginning of a subsequent calendar quarter
described in paragraph (4) with respect to such fiscal
year, then such State shall not be subject to a
reduction under subparagraph (A) for such subsequent
calendar quarter.
``(2) Reporting requirement.--For purposes of paragraph
(1), a nonexpansion State satisfies the reporting requirement
under this paragraph for a fiscal year, if the nonexpansion
State--
``(A) by not later than January 1 of such year,
posts on the public website of the State agency
administering the State plan, the information described
in paragraph (3) with respect to such State for the
previous year;
``(B) provides for at least a 30-day period for
notice and comment on such information; and
``(C) by not later than March 1 of such year,
submits to the Secretary a complete report including
such information, comments submitted pursuant to
subparagraph (B), and a response by the State to each
such comment.
``(3) Information described.--The information described in
this paragraph, with respect to a State and year, is the
following:
``(A) The the estimated number of individuals who
were uninsured for at least 6 months, shown by age-
groups of 0 to 18 years of age and of 19 years of age
to 64 years of age, as well as a detailed description
of the basis for the estimates.
``(B) The estimated number of the individuals
estimated under subparagraph (A) in the State who would
be eligible for medical assistance under the State plan
if the State were to make medical assistance under the
State plan available in accordance with section
1902(k)(1) to all individuals described in section
1902(a)(10)(i)(VIII), and a detailed description of the
basis for the estimates.
``(C) A comprehensive listing of State income
eligibility criteria for all mandatory and optional
Medicaid eligibility groups for which the State plan
provides medical assistance (other than with respect to
individuals described in clause (i)(II), (ii)(VI), or
(ii)(XXII) of section 1902(a)(10)(A)).
``(D) The total amount of hospital uncompensated-
care costs and a breakdown of the source of such costs,
as well as a breakdown for rural and non-rural
hospitals.
``(4) Percentage described.--For purposes of paragraph (1),
a calendar quarter described in this paragraph, with respect to
a fiscal year, and the percentage points described in this
paragraph for such quarter, with respect to a State, are--
``(A) for the calendar quarter beginning on the
April 1 occurring during such fiscal year, 0.5
percentage points;
``(B) for the calendar quarter beginning on the
July 1 occurring during such fiscal year, 1.0
percentage point; and
``(C) for the calendar quarter beginning on the
October 1 occurring during the subsequent fiscal year,
1.5 percentage points.
``(5) Payment in case of reporting state.--The expenses
incurred by a non-expansion State, with respect to any calendar
quarter with respect to a fiscal year (beginning with 2021),
for carrying out subparagraphs (A) through (C) of paragraph (2)
shall, for purposes of section 1903(a)(7), be considered to be
expenses necessary for the proper and efficient administration
of the State plan under this title.
``(6) Nonexpanion state defined.--For purposes of this
subsection, the term `nonexpansion State' means, with respect
to a fiscal year, a State that as of the first quarter of such
fiscal year does not provide under the State plan of such State
(or waiver of such plan) for making medical assistance
available in accordance with section 1902(k)(1) to all
individuals described in section 1902(a)(10)(i)(VIII).''.
SEC. 206. PRIMARY CARE PAY INCREASE.
(a) Renewal of Payment Floor; Additional Providers.--
(1) In general.--Section 1902(a)(13) of the Social Security
Act (42 U.S.C. 1396a(a)(13)) is amended by striking
subparagraph (C) and inserting the following:
``(C) payment for primary care services (as defined
in subsection (jj)) at a rate that is not less than 100
percent of the payment rate that applies to such
services and physician under part B of title XVIII (or,
if greater, the payment rate that would be applicable
under such part if the conversion factor under section
1848(d) for the year involved were the conversion
factor under such section for 2009), and that is not
less than the rate that would otherwise apply to such
services under this title if the rate were determined
without regard to this subparagraph, and that are--
``(i) furnished during 2013 and 2014, by a
physician with a primary specialty designation
of family medicine, general internal medicine,
or pediatric medicine; or
``(ii) furnished during the period that
begins on the first day of the first month that
begins one year after the date of enactment of
the Patient Protection and Affordable Care
Enhancement Act and ends September 30, 2024--
``(I) by a physician with a primary
specialty designation of family
medicine, general internal medicine, or
pediatric medicine, but only if the
physician self-attests that the
physician is Board certified in family
medicine, general internal medicine, or
pediatric medicine;
``(II) by a physician with a
primary specialty designation of
obstetrics and gynecology, but only if
the physician self-attests that the
physician is Board certified in
obstetrics and gynecology;
``(III) by an advanced practice
clinician, as defined by the Secretary,
that works under the supervision of--
``(aa) a physician that
satisfies the criteria
specified in subclause (I) or
(II); or
``(bb) a nurse practitioner
or a physician assistant (as
such terms are defined in
section 1861(aa)(5)(A)) who is
working in accordance with
State law, or a certified
nurse-midwife (as defined in
section 1861(gg)) who is
working in accordance with
State law;
``(IV) by a rural health clinic,
Federally-qualified health center, or
other health clinic that receives
reimbursement on a fee schedule
applicable to a physician, a nurse
practitioner or a physician assistant
(as such terms are defined in section
1861(aa)(5)(A)) who is working in
accordance with State law, or a
certified nurse-midwife (as defined in
section 1861(gg)) who is working in
accordance with State law, for services
furnished by a physician, nurse
practitioner, physician assistant, or
certified nurse-midwife, or services
furnished by an advanced practice
clinician supervised by a physician
described in subclause (I)(aa) or
(II)(aa), another advanced practice
clinician, or a certified nurse-
midwife; or
``(V) by a nurse practitioner or a
physician assistant (as such terms are
defined in section 1861(aa)(5)(A)) who
is working in accordance with State
law, or a certified nurse-midwife (as
defined in section 1861(gg)) who is
working in accordance with State law,
in accordance with procedures that
ensure that the portion of the payment
for such services that the nurse
practitioner, physician assistant, or
certified nurse-midwife is paid is not
less than the amount that the nurse
practitioner, physician assistant, or
certified nurse-midwife would be paid
if the services were provided under
part B of title XVIII;''.
(2) Conforming amendments.--Section 1905(dd) of the Social
Security Act (42 U.S.C. 1396d(dd)) is amended--
(A) by striking ``Notwithstanding'' and inserting
the following:
``(1) In general.--Notwithstanding'';
(B) by inserting ``or furnished during the
additional period specified in paragraph (2),'' after
``2015,''; and
(C) by adding at the end the following:
``(2) Additional period.--For purposes of paragraph (1),
the additional period specified in this paragraph is the period
that begins on the first day of the first month that begins one
year after the date of enactment of the Patient Protection and
Affordable Care Enhancement Act.''.
(b) Improved Targeting of Primary Care.--Section 1902(jj) of the
Social Security Act (42 U.S.C. 1396a(jj)) is amended--
(1) by redesignating paragraphs (1) and (2) as
subparagraphs (A) and (B), respectively and realigning the left
margins accordingly;
(2) by striking ``For purposes of'' and inserting the
following:
``(1) In general.--For purposes of''; and
(3) by adding at the end the following:
``(2) Exclusions.--Such term does not include any services
described in subparagraph (A) or (B) of paragraph (1) if such
services are provided in an emergency department of a
hospital.''.
(c) Ensuring Payment by Managed Care Entities.--
(1) In general.--Section 1903(m)(2)(A) of the Social
Security Act (42 U.S.C. 1396b(m)(2)(A)) is amended--
(A) in clause (xii), by striking ``and'' after the
semicolon;
(B) by realigning the left margin of clause (xiii)
so as to align with the left margin of clause (xii) and
by striking the period at the end of clause (xiii) and
inserting ``; and''; and
(C) by inserting after clause (xiii) the following:
``(xiv) such contract provides that (I) payments to
providers specified in section 1902(a)(13)(C) for primary care
services defined in section 1902(jj) that are furnished during
a year or period specified in section 1902(a)(13)(C) and
section 1905(dd) are at least equal to the amounts set forth
and required by the Secretary by regulation, (II) the entity
shall, upon request, provide documentation to the State,
sufficient to enable the State and the Secretary to ensure
compliance with subclause (I), and (III) the Secretary shall
approve payments described in subclause (I) that are furnished
through an agreed upon capitation, partial capitation, or other
value-based payment arrangement if the capitation, partial
capitation, or other value-based payment arrangement is based
on a reasonable methodology and the entity provides
documentation to the State sufficient to enable the State and
the Secretary to ensure compliance with subclause (I).''.
(2) Conforming amendment.--Section 1932(f) of the Social
Security Act (42 U.S.C. 1396u-2(f)) is amended by inserting
``and clause (xiv) of section 1903(m)(2)(A)'' before the
period.
SEC. 207. PERMANENT FUNDING FOR CHIP.
(a) In General.--Section 2104(a) of the Social Security Act (42
U.S.C. 1397dd(a)) is amended--
(1) in paragraph (26), by inserting at the end ``and'';
(2) by amending paragraph (27) to read as follows:
``(27) for each fiscal year beginning with fiscal year
2024, such sums as are necessary to fund allotments to States
under subsections (c) and (m).''; and
(3) by striking paragraph (28).
(b) In General.--Section 2104(a)(28) of the Social Security Act (42
U.S.C. 1397dd(a)(28)) is amended to read as follows:
``(28) for fiscal year 2027 and each subsequent year, such
sums as are necessary to fund allotments to States under
subsections (c) and (m).''.
(c) Allotments.--
(1) In general.--Section 2104(m) of the Social Security Act
(42 U.S.C. 1397dd(m)) is amended--
(A) in paragraph (2)(B)(i), by striking ``,, 2023,
and 2027'' and inserting ``and 2023'';
(B) in paragraph (7)--
(i) in subparagraph (A), by striking ``and
ending with fiscal year 2027,''; and
(ii) in the flush left matter at the end,
by striking ``or fiscal year 2026'' and
inserting ``fiscal year 2026, or a subsequent
even-numbered fiscal year'';
(C) in paragraph (9)--
(i) by striking ``(10), or (11)'' and
inserting ``or (10)''; and
(ii) by striking ``2023, or 2027,'' and
inserting ``or 2023''; and
(D) by striking paragraph (11).
(2) Conforming amendment.--Section 50101(b)(2) of the
Bipartisan Budget Act of 2018 (Public Law 115-123) is repealed.
SEC. 208. PERMANENT EXTENSION OF CHIP ENROLLMENT AND QUALITY MEASURES.
(a) Pediatric Quality Measures Program.--Section 1139A(i)(1) of the
Social Security Act (42 U.S.C. 1320b-9a(i)(1)) is amended--
(1) in subparagraph (C), by striking at the end ``and'';
(2) in subparagraph (D), by striking the period at the end
and insert a semicolon; and
(3) by adding at the end the following new subparagraphs:
``(E) for fiscal year 2028, $15,000,000 for the
purpose of carrying out this section (other than
subsections (e), (f), and (g)); and
``(F) for a subsequent fiscal year, the amount
appropriated under this paragraph for the previous
fiscal year, increased by the percentage increase in
the consumer price index for all urban consumers (all
items; United States city average) over such previous
fiscal year, for the purpose of carrying out this
section (other than subsections (e), (f), and (g)).''.
(b) Express Lane Eligibility Option.--Section 1902(e)(13) of the
Social Security Act (42 U.S.C. 1396a(e)(13)) is amended by striking
subparagraph (I).
(c) Assurance of Affordability Standard for Children and
Families.--
(1) In general.--Section 2105(d)(3) of the Social Security
Act (42 U.S.C. 1397ee(d)(3)) is amended--
(A) in the paragraph heading, by striking ``through
september 30, 2027''; and
(B) in subparagraph (A), in the matter preceding
clause (i)--
(i) by striking ``During the period that
begins on the date of enactment of the Patient
Protection and Affordable Care Act and ends on
September 30, 2027'' and inserting ``Beginning
on the date of the enactment of the Patient
Protection and Affordable Care Act'';
(ii) by striking ``During the period that
begins on October 1, 2019, and ends on
September 30, 2027'' and inserting ``Beginning
on October 1, 2019''; and
(iii) by striking ``The preceding sentences
shall not be construed as preventing a State
during any such periods from'' and inserting
``The preceding sentences shall not be
construed as preventing a State from''.
(2) Conforming amendments.--Section 1902(gg)(2) of the
Social Security Act (42 U.S.C. 1396a(gg)(2)) is amended--
(A) in the paragraph heading, by striking ``through
september 30, 2027''; and
(B) by striking ``through September 30'' and all
that follows through ``ends on September 30, 2027'' and
inserting ``(but beginning on October 1, 2019,''.
(d) Qualifying States Option.--Section 2105(g)(4) of the Social
Security Act (42 U.S.C. 1397ee(g)(4)) is amended--
(1) in the paragraph heading, by striking ``for fiscal
years 2009 through 2027'' and inserting ``after fiscal year
2008''; and
(2) in subparagraph (A), by striking ``for any of fiscal
years 2009 through 2027'' and inserting ``for any fiscal year
after fiscal year 2008''.
(e) Outreach and Enrollment Program.--Section 2113 of the Social
Security Act (42 U.S.C. 1397mm) is amended--
(1) in subsection (a)--
(A) in paragraph (1), by striking ``during the
period of fiscal years 2009 through 2027'' and
inserting ``, beginning with fiscal year 2009,'';
(B) in paragraph (2)--
(i) by striking ``10 percent of such
amounts'' and inserting ``10 percent of such
amounts for the period or the fiscal year for
which such amounts are appropriated''; and
(ii) by striking ``during such period'' and
inserting ``, during such period or such fiscal
year,''; and
(C) in paragraph (3), by striking ``For the period
of fiscal years 2024 through 2027, an amount equal to
10 percent of such amounts'' and inserting ``Beginning
with fiscal year 2024, an amount equal to 10 percent of
such amounts for the period or the fiscal year for
which such amounts are appropriated''; and
(2) in subsection (g)--
(A) by striking ``2017,,'' and inserting ``2017,'';
(B) by striking ``and $48,000,000'' and inserting
``$48,000,000''; and
(C) by inserting after ``through 2027'' the
following: ``, $12,000,000 for fiscal year 2028, and,
for each fiscal year after fiscal year 2028, the amount
appropriated under this subsection for the previous
fiscal year, increased by the percentage increase in
the consumer price index for all urban consumers (all
items; United States city average) over such previous
fiscal year''.
(f) Child Enrollment Contingency Fund.--Section 2104(n) of the
Social Security Act (42 U.S.C. 1397dd(n)) is amended--
(1) in paragraph (2)--
(A) in subparagraph (A)(ii)--
(i) by striking ``and 2024 through 2026''
and inserting ``beginning with fiscal year
2024''; and
(ii) by striking ``2023, and 2027'' and
inserting ``, and 2023''; and
(B) in subparagraph (B)--
(i) by striking ``2024 through 2026'' and
inserting ``beginning with fiscal year 2024'';
and
(ii) by striking ``2023, and 2027'' and
inserting ``, and 2023''; and
(2) in paragraph (3)(A)--
(A) by striking ``fiscal years 2024 through 2026''
and inserting ``beginning with fiscal year 2024''; and
(B) by striking ``2023, or 2027'' and inserting ``,
or 2023''.
SEC. 209. STATE OPTION TO INCREASE CHILDREN'S ELIGIBILITY FOR MEDICAID
AND CHIP.
Section 2110(b)(1)(B)(ii) of the Social Security Act (42 U.S.C.
1397jj(b)(1)(B)(ii)) is amended--
(1) in subclause (II), by striking ``or'' at the end;
(2) in subclause (III), by striking ``and'' at the end and
inserting ``or''; and
(3) by inserting after subclause (III) the following new
subclause:
``(IV) at the option of the State,
whose family income exceeds the maximum
income level otherwise established for
children under the State child health
plan as of the date of the enactment of
this subclause; and''.
SEC. 210. MEDICAID COVERAGE FOR CITIZENS OF FREELY ASSOCIATED STATES.
(a) In General.--Section 402(b)(2) of the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1612(b)(2))
is amended by adding at the end the following new subparagraph:
``(G) Medicaid exception for citizens of freely
associated states.--With respect to eligibility for
benefits for the designated Federal program defined in
paragraph (3)(C) (relating to the Medicaid program),
section 401(a) and paragraph (1) shall not apply to any
individual who lawfully resides in 1 of the 50 States
or the District of Columbia in accordance with the
Compacts of Free Association between the Government of
the United States and the Governments of the Federated
States of Micronesia, the Republic of the Marshall
Islands, and the Republic of Palau and shall not apply,
at the option of the Governor of Puerto Rico, the
Virgin Islands, Guam, the Northern Mariana Islands, or
American Samoa as communicated to the Secretary of
Health and Human Services in writing, to any individual
who lawfully resides in the respective territory in
accordance with such Compacts.''.
(b) Exception to 5-Year Limited Eligibility.--Section 403(d) of
such Act (8 U.S.C. 1613(d)) is amended--
(1) in paragraph (1), by striking ``or'' at the end;
(2) in paragraph (2), by striking the period at the end and
inserting ``; or''; and
(3) by adding at the end the following new paragraph:
``(3) an individual described in section 402(b)(2)(G), but
only with respect to the designated Federal program defined in
section 402(b)(3)(C).''.
(c) Definition of Qualified Alien.--Section 431(b) of such Act (8
U.S.C. 1641(b)) is amended--
(1) in paragraph (6), by striking ``; or'' at the end and
inserting a comma;
(2) in paragraph (7), by striking the period at the end and
inserting ``, or''; and
(3) by adding at the end the following new paragraph:
``(8) an individual who lawfully resides in the United
States in accordance with a Compact of Free Association
referred to in section 402(b)(2)(G), but only with respect to
the designated Federal program defined in section 402(b)(3)(C)
(relating to the Medicaid program).''.
(d) Application to State Plans.--Section 1902(a)(10)(A)(i) of the
Social Security Act (42 U.S.C. 1396a(a)(10)(A)(i)) is amended by
inserting after subclause (IX) the following:
``(X) who are described in section
402(b)(2)(G) of the Personal
Responsibility and Work Opportunity
Reconciliation Act of 1996 and eligible
for benefits under this title by reason
of application of such section;''.
(e) Conforming Amendments.--Section 1108 of the Social Security Act
(42 U.S.C. 1308) is amended--
(1) in subsection (f), in the matter preceding paragraph
(1), by striking ``subsections (g) and (h) and section
1935(e)(1)(B)'' and inserting ``subsections (g), (h), and (i)
and section 1935(e)(1)(B)''; and
(2) by adding at the end the following:
``(i) Exclusion of Medical Assistance Expenditures for Citizens of
Freely Associated States.--Expenditures for medical assistance provided
to an individual described in section 431(b)(8) of the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 (8
U.S.C. 1641(b)(8)) shall not be taken into account for purposes of
applying payment limits under subsections (f) and (g).''.
(f) Effective Date.--The amendments made by this section shall
apply to benefits for items and services furnished on or after the date
of the enactment of this Act.
SEC. 211. EXTENSION OF FULL FEDERAL MEDICAL ASSISTANCE PERCENTAGE TO
INDIAN HEALTH CARE PROVIDERS.
(a) In General.--Section 1905 of the Social Security Act (42 U.S.C.
1396d) is amended--
(1) in subsection (a), by amending paragraph (9) to read as
follows:
``(9) clinic services furnished by or under the direction
of a physician, without regard to whether the clinic itself is
administered by a physician, including--
``(A) such services furnished outside the clinic by
clinic personnel to an eligible individual who does not
reside in a permanent dwelling or does not have a fixed
home or mailing address; and
``(B) such services provided outside the clinic on
the basis of a referral from a clinic administered by
an Indian Health Program (as defined in paragraph (12)
of section 4 of the Indian Health Care Improvement Act,
or an Urban Indian Organization as defined in paragraph
(29) of section 4 of such Act that has a grant or
contract with the Indian Health Service under title V
of such Act;''.
(2) in subsection (b), by inserting after ``(as defined in
section 4 of the Indian Health Care Improvement Act)'' the
following: ``; the Federal medical assistance percentage shall
also be 100 per centum with respect to amounts expended as
medical assistance for services which are received through an
Urban Indian organization (as defined in section 4 of the
Indian Health Care Improvement Act) that has a grant or
contract with the Indian Health Service under title V of such
Act''.
(b) Extension of Full Federal Medical Assistance Percentage to
Services Furnished by Native Hawaiian Health Care Systems.--
(1) In general.--Beginning on the date of enactment of this
Act--
(A) for purposes of section 1905(a)(9) of the
Social Security Act (42 U.S.C. 1396d(a)(9)), services
described in subsection (b) that are furnished in any
location shall be deemed to be clinic services; and
(B) notwithstanding section 1905(b) of the Social
Security Act (42 U.S.C. 1396d(b)), the Federal medical
assistance percentage with respect to amounts expended
as medical assistance for such services shall be 100
percent.
(2) Services described.--The services described in this
subsection are services for which payment is available under
the State plan under title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) of Hawaii (or any waiver of such plan)
that--
(A) are furnished on or after the date of enactment
of this Act;
(B) are furnished to an individual who--
(i) is a Native Hawaiian; and
(ii) is eligible for medical assistance
under such plan; and
(C) are furnished by an Indian health care provider
(as such term is defined in section 1932(h)(4)(A) of
the Social Security Act (42 U.S.C. 1396u-2(h)(4)(A)) or
a Native Hawaiian health care system (without regard to
whether such services are furnished through an Indian
Health Service facility).
TITLE III--LOWERING PRICES THROUGH FAIR DRUG PRICE NEGOTIATION
SEC. 301. ESTABLISHING A FAIR DRUG PRICING PROGRAM.
(a) Program To Lower Prices for Certain High-Priced Single Source
Drugs.--Title XI of the Social Security Act (42 U.S.C. 1301 et seq.) is
amended by adding at the end the following new part:
``PART E--FAIR PRICE NEGOTIATION PROGRAM TO LOWER PRICES FOR CERTAIN
HIGH-PRICED SINGLE SOURCE DRUGS
``SEC. 1191. ESTABLISHMENT OF PROGRAM.
``(a) In General.--The Secretary shall establish a Fair Price
Negotiation Program (in this part referred to as the `program'). Under
the program, with respect to each price applicability period, the
Secretary shall--
``(1) publish a list of selected drugs in accordance with
section 1192;
``(2) enter into agreements with manufacturers of selected
drugs with respect to such period, in accordance with section
1193;
``(3) negotiate and, if applicable, renegotiate maximum
fair prices for such selected drugs, in accordance with section
1194; and
``(4) carry out the administrative duties described in
section 1196.
``(b) Definitions Relating to Timing.--For purposes of this part:
``(1) Initial price applicability year.--The term `initial
price applicability year' means a plan year (beginning with
plan year 2023) or, if agreed to in an agreement under section
1193 by the Secretary and manufacturer involved, a period of
more than one plan year (beginning on or after January 1,
2023).
``(2) Price applicability period.--The term `price
applicability period' means, with respect to a drug, the period
beginning with the initial price applicability year with
respect to which such drug is a selected drug and ending with
the last plan year during which the drug is a selected drug.
``(3) Selected drug publication date.--The term `selected
drug publication date' means, with respect to each initial
price applicability year, April 15 of the plan year that begins
2 years prior to such year.
``(4) Voluntary negotiation period.--The term `voluntary
negotiation period' means, with respect to an initial price
applicability year with respect to a selected drug, the
period--
``(A) beginning on the sooner of--
``(i) the date on which the manufacturer of
the drug and the Secretary enter into an
agreement under section 1193 with respect to
such drug; or
``(ii) June 15 following the selected drug
publication date with respect to such selected
drug; and
``(B) ending on March 31 of the year that begins
one year prior to the initial price applicability year.
``(c) Other Definitions.--For purposes of this part:
``(1) Fair price eligible individual.--The term `fair price
eligible individual' means, with respect to a selected drug--
``(A) in the case such drug is furnished or
dispensed to the individual at a pharmacy or by a mail
order service--
``(i) an individual who is enrolled under a
prescription drug plan under part D of title
XVIII or an MA-PD plan under part C of such
title if coverage is provided under such plan
for such selected drug; and
``(ii) an individual who is enrolled under
a group health plan or health insurance
coverage offered in the group or individual
market (as such terms are defined in section
2791 of the Public Health Service Act) with
respect to which there is in effect an
agreement with the Secretary under section 1197
with respect to such selected drug as so
furnished or dispensed; and
``(B) in the case such drug is furnished or
administered to the individual by a hospital,
physician, or other provider of services or supplier--
``(i) an individual who is entitled to
benefits under part A of title XVIII or
enrolled under part B of such title if such
selected drug is covered under the respective
part; and
``(ii) an individual who is enrolled under
a group health plan or health insurance
coverage offered in the group or individual
market (as such terms are defined in section
2791 of the Public Health Service Act) with
respect to which there is in effect an
agreement with the Secretary under section 1197
with respect to such selected drug as so
furnished or administered.
``(2) Maximum fair price.--The term `maximum fair price'
means, with respect to a plan year during a price applicability
period and with respect to a selected drug (as defined in
section 1192(c)) with respect to such period, the price
published pursuant to section 1195 in the Federal Register for
such drug and year.
``(3) Average international market price defined.--
``(A) In general.--The terms `average international
market price' and `AIM price' mean, with respect to a
drug, the average price (which shall be the net average
price, if practicable, and volume-weighted, if
practicable) for a unit (as defined in paragraph (4))
of the drug for sales of such drug (calculated across
different dosage forms and strengths of the drug and
not based on the specific formulation or package size
or package type), as computed (as of the date of
publication of such drug as a selected drug under
section 1192(a)) in all countries described in clause
(ii) of subparagraph (B) that are applicable countries
(as described in clause (i) of such subparagraph) with
respect to such drug.
``(B) Applicable countries.--
``(i) In general.--For purposes of
subparagraph (A), a country described in clause
(ii) is an applicable country described in this
clause with respect to a drug if there is
available an average price for any unit for the
drug for sales of such drug in such country.
``(ii) Countries described.--For purposes
of this paragraph, the following are countries
described in this clause:
``(I) Australia.
``(II) Canada.
``(III) France.
``(IV) Germany.
``(V) Japan.
``(VI) The United Kingdom.
``(4) Unit.--The term `unit' means, with respect to a drug,
the lowest identifiable quantity (such as a capsule or tablet,
milligram of molecules, or grams) of the drug that is
dispensed.
``SEC. 1192. SELECTION OF NEGOTIATION-ELIGIBLE DRUGS AS SELECTED DRUGS.
``(a) In General.--Not later than the selected drug publication
date with respect to an initial price applicability year, subject to
subsection (h), the Secretary shall select and publish in the Federal
Register a list of--
``(1)(A) with respect to an initial price applicability
year during 2023, at least 25 negotiation-eligible drugs
described in subparagraphs (A) and (B), but not subparagraph
(C), of subsection (d)(1) (or, with respect to an initial price
applicability year during such period beginning after 2023, the
maximum number (if such number is less than 25) of such
negotiation-eligible drugs for the year) with respect to such
year; and
``(B) with respect to an initial price applicability year
during 2024 or a subsequent year, at least 50 negotiation-
eligible drugs described in subparagraphs (A) and (B), but not
subparagraph (C), of subsection (d)(1) (or, with respect to an
initial price applicability year during such period, the
maximum number (if such number is less than 50) of such
negotiation-eligible drugs for the year) with respect to such
year;
``(2) all negotiation-eligible drugs described in
subparagraph (C) of such subsection with respect to such year;
and
``(3) all new-entrant negotiation-eligible drugs (as
defined in subsection (g)(1)) with respect to such year.
Each drug published on the list pursuant to the previous sentence shall
be subject to the negotiation process under section 1194 for the
voluntary negotiation period with respect to such initial price
applicability year (and the renegotiation process under such section as
applicable for any subsequent year during the applicable price
applicability period). In applying this subsection, any negotiation-
eligible drug that is selected under this subsection for an initial
price applicability year shall not count toward the required minimum
amount of drugs to be selected under paragraph (1) for any subsequent
year, including such a drug so selected that is subject to
renegotiation under section 1194.
``(b) Selection of Drugs.--In carrying out subsection (a)(1) the
Secretary shall select for inclusion on the published list described in
subsection (a) with respect to a price applicability period, the
negotiation-eligible drugs that the Secretary projects will result in
the greatest savings to the Federal Government or fair price eligible
individuals during the price applicability period. In making this
projection of savings for drugs for which there is an AIM price for a
price applicability period, the savings shall be projected across
different dosage forms and strengths of the drugs and not based on the
specific formulation or package size or package type of the drugs,
taking into consideration both the volume of drugs for which payment is
made, to the extent such data is available, and the amount by which the
net price for the drugs exceeds the AIM price for the drugs.
``(c) Selected Drug.--For purposes of this part, each drug included
on the list published under subsection (a) with respect to an initial
price applicability year shall be referred to as a `selected drug' with
respect to such year and each subsequent plan year beginning before the
first plan year beginning after the date on which the Secretary
determines two or more drug products--
``(1) are approved or licensed (as applicable)--
``(A) under section 505(j) of the Federal Food,
Drug, and Cosmetic Act using such drug as the listed
drug; or
``(B) under section 351(k) of the Public Health
Service Act using such drug as the reference product;
and
``(2) continue to be marketed.
``(d) Negotiation-Eligible Drug.--
``(1) In general.--For purposes of this part, the term
`negotiation-eligible drug' means, with respect to the selected
drug publication date with respect to an initial price
applicability year, a qualifying single source drug, as defined
in subsection (e), that meets any of the following criteria:
``(A) Covered part d drugs.--The drug is among the
125 covered part D drugs (as defined in section 1860D-
2(e)) for which there was an estimated greatest net
spending under parts C and D of title XVIII, as
determined by the Secretary, during the most recent
plan year prior to such drug publication date for which
data are available.
``(B) Other drugs.--The drug is among the 125 drugs
for which there was an estimated greatest net spending
in the United States (including the 50 States, the
District of Columbia, and the territories of the United
States), as determined by the Secretary, during the
most recent plan year prior to such drug publication
date for which data are available.
``(C) Insulin.--The drug is a qualifying single
source drug described in subsection (e)(3).
``(2) Clarification.--In determining whether a qualifying
single source drug satisfies any of the criteria described in
paragraph (1), the Secretary shall, to the extent practicable,
use data that is aggregated across dosage forms and strengths
of the drug and not based on the specific formulation or
package size or package type of the drug.
``(3) Publication.--Not later than the selected drug
publication date with respect to an initial price applicability
year, the Secretary shall publish in the Federal Register a
list of negotiation-eligible drugs with respect to such
selected drug publication date.
``(e) Qualifying Single Source Drug.--For purposes of this part,
the term `qualifying single source drug' means any of the following:
``(1) Drug products.--A drug that--
``(A) is approved under section 505(c) of the
Federal Food, Drug, and Cosmetic Act and continues to
be marketed pursuant to such approval; and
``(B) is not the listed drug for any drug that is
approved and continues to be marketed under section
505(j) of such Act.
``(2) Biological products.--A biological product that--
``(A) is licensed under section 351(a) of the
Public Health Service Act, including any product that
has been deemed to be licensed under section 351 of
such Act pursuant to section 7002(e)(4) of the
Biologics Price Competition and Innovation Act of 2009,
and continues to be marketed under section 351 of such
Act; and
``(B) is not the reference product for any
biological product that is licensed and continues to be
marketed under section 351(k) of such Act.
``(3) Insulin product.--Notwithstanding paragraphs (1) and
(2), any insulin product that is approved under subsection (c)
or (j) of section 505 of the Federal Food, Drug, and Cosmetic
Act or licensed under subsection (a) or (k) of section 351 of
the Public Health Service Act and continues to be marketed
under such section 505 or 351, including any insulin product
that has been deemed to be licensed under section 351(a) of the
Public Health Service Act pursuant to section 7002(e)(4) of the
Biologics Price Competition and Innovation Act of 2009 and
continues to be marketed pursuant to such licensure.
For purposes of applying paragraphs (1) and (2), a drug or biological
product that is marketed by the same sponsor or manufacturer (or an
affiliate thereof or a cross-licensed producer or distributor) as the
listed drug or reference product described in such respective paragraph
shall not be taken into consideration.
``(f) Information on International Drug Prices.--For purposes of
determining which negotiation-eligible drugs to select under subsection
(a) and, in the case of such drugs that are selected drugs, to
determine the maximum fair price for such a drug and whether such
maximum fair price should be renegotiated under section 1194, the
Secretary shall use data relating to the AIM price with respect to such
drug as available or provided to the Secretary and shall on an ongoing
basis request from manufacturers of selected drugs information on the
AIM price of such a drug.
``(g) New-Entrant Negotiation-Eligible Drugs.--
``(1) In general.--For purposes of this part, the term
`new-entrant negotiation-eligible drug' means, with respect to
the selected drug publication date with respect to an initial
price applicability year, a qualifying single source drug--
``(A) that is first approved or licensed, as
described in paragraph (1), (2), or (3) of subsection
(e), as applicable, during the year preceding such
selected drug publication date; and
``(B) that the Secretary determines under paragraph
(2) is likely to be included as a negotiation-eligible
drug with respect to the subsequent selected drug
publication date.
``(2) Determination.--In the case of a qualifying single
source drug that meets the criteria described in subparagraph
(A) of paragraph (1), with respect to an initial price
applicability year, if the wholesale acquisition cost at which
such drug is first marketed in the United States is equal to or
greater than the median household income (as determined
according to the most recent data collected by the United
States Census Bureau), the Secretary shall determine before the
selected drug publication date with respect to the initial
price applicability year, if the drug is likely to be included
as a negotiation-eligible drug with respect to the subsequent
selected drug publication date, based on the projected spending
under title XVIII or in the United States on such drug. For
purposes of this paragraph the term `United States' includes
the 50 States, the District of Columbia, and the territories of
the United States.
``(h) Conflict of Interest.--
``(1) In general.--In the case the Inspector General of the
Department of Health and Human Services determines the
Secretary has a conflict, with respect to a matter described in
paragraph (2), the individual described in paragraph (3) shall
carry out the duties of the Secretary under this part, with
respect to a negotiation-eligible drug, that would otherwise be
such a conflict.
``(2) Matter described.--A matter described in this
paragraph is--
``(A) a financial interest (as described in section
2635.402 of title 5, Code of Federal Regulations
(except for an interest described in subsection
(b)(2)(iv) of such section)) on the date of the
selected drug publication date, with respect the price
applicability year (as applicable);
``(B) a personal or business relationship (as
described in section 2635.502 of such title) on the
date of the selected drug publication date, with
respect the price applicability year;
``(C) employment by a manufacturer of a
negotiation-eligible drug during the preceding 10-year
period beginning on the date of the selected drug
publication date, with respect to each price
applicability year; and
``(D) any other matter the General Counsel
determines appropriate.
``(3) Individual described.--An individual described in
this paragraph is--
``(A) the highest-ranking officer or employee of
the Department of Health and Human Services (as
determined by the organizational chart of the
Department) that does not have a conflict under this
subsection; and
``(B) is nominated by the President and confirmed
by the Senate with respect to the position.
``SEC. 1193. MANUFACTURER AGREEMENTS.
``(a) In General.--For purposes of section 1191(a)(2), the
Secretary shall enter into agreements with manufacturers of selected
drugs with respect to a price applicability period, by not later than
June 15 following the selected drug publication date with respect to
such selected drug, under which--
``(1) during the voluntary negotiation period for the
initial price applicability year for the selected drug, the
Secretary and manufacturer, in accordance with section 1194,
negotiate to determine (and, by not later than the last date of
such period and in accordance with subsection (c), agree to) a
maximum fair price for such selected drug of the manufacturer
in order to provide access to such price--
``(A) to fair price eligible individuals who with
respect to such drug are described in subparagraph (A)
of section 1191(c)(1) and are furnished or dispensed
such drug during, subject to subparagraph (2), the
price applicability period; and
``(B) to hospitals, physicians, and other providers
of services and suppliers with respect to fair price
eligible individuals who with respect to such drug are
described in subparagraph (B) of such section and are
furnished or administered such drug during, subject to
subparagraph (2), the price applicability period;
``(2) the Secretary and the manufacturer shall, in
accordance with a process and during a period specified by the
Secretary pursuant to rulemaking, renegotiate (and, by not
later than the last date of such period and in accordance with
subsection (c), agree to) the maximum fair price for such drug
if the Secretary determines that there is a material change in
any of the factors described in section 1194(d) relating to the
drug, including changes in the AIM price for such drug, in
order to provide access to such maximum fair price (as so
renegotiated)--
``(A) to fair price eligible individuals who with
respect to such drug are described in subparagraph (A)
of section 1191(c)(1) and are furnished or dispensed
such drug during any year during the price
applicability period (beginning after such
renegotiation) with respect to such selected drug; and
``(B) to hospitals, physicians, and other providers
of services and suppliers with respect to fair price
eligible individuals who with respect to such drug are
described in subparagraph (B) of such section and are
furnished or administered such drug during any year
described in subparagraph (A);
``(3) the maximum fair price (including as renegotiated
pursuant to paragraph (2)), with respect to such a selected
drug, shall be provided to fair price eligible individuals, who
with respect to such drug are described in subparagraph (A) of
section 1191(c)(1), at the pharmacy or by a mail order service
at the point-of-sale of such drug;
``(4) the manufacturer, subject to subsection (d), submits
to the Secretary, in a form and manner specified by the
Secretary--
``(A) for the voluntary negotiation period for the
price applicability period (and, if applicable, before
any period of renegotiation specified pursuant to
paragraph (2)) with respect to such drug all
information that the Secretary requires to carry out
the negotiation (or renegotiation process) under this
part, including information described in section
1192(f) and section 1194(d)(1); and
``(B) on an ongoing basis, information on changes
in prices for such drug that would affect the AIM price
for such drug or otherwise provide a basis for
renegotiation of the maximum fair price for such drug
pursuant to paragraph (2);
``(5) the manufacturer agrees that in the case the selected
drug of a manufacturer is a drug described in subsection (c),
the manufacturer will, in accordance with such subsection, make
any payment required under such subsection with respect to such
drug; and
``(6) the manufacturer complies with requirements imposed
by the Secretary for purposes of administering the program,
including with respect to the duties described in section 1196.
``(b) Agreement in Effect Until Drug Is No Longer a Selected
Drug.--An agreement entered into under this section shall be effective,
with respect to a drug, until such drug is no longer considered a
selected drug under section 1192(c).
``(c) Special Rule for Certain Selected Drugs Without AIM Price.--
``(1) In general.--In the case of a selected drug for which
there is no AIM price available with respect to the initial
price applicability year for such drug and for which an AIM
price becomes available beginning with respect to a subsequent
plan year during the price applicability period for such drug,
if the Secretary determines that the amount described in
paragraph (2)(A) for a unit of such drug is greater than the
amount described in paragraph (2)(B) for a unit of such drug,
then by not later than one year after the date of such
determination, the manufacturer of such selected drug shall pay
to the Treasury an amount equal to the product of--
``(A) the difference between such amount described
in paragraph (2)(A) for a unit of such drug and such
amount described in paragraph (2)(B) for a unit of such
drug; and
``(B) the number of units of such drug sold in the
United States, including the 50 States, the District of
Columbia, and the territories of the United States,
during the period described in paragraph (2)(B).
``(2) Amounts described.--
``(A) Weighted average price before aim price
available.--For purposes of paragraph (1), the amount
described in this subparagraph for a selected drug
described in such paragraph, is the amount equal to the
weighted average manufacturer price (as defined in
section 1927(k)(1)) for such dosage strength and form
for the drug during the period beginning with the first
plan year for which the drug is included on the list of
negotiation-eligible drugs published under section
1192(d) and ending with the last plan year during the
price applicability period for such drug with respect
to which there is no AIM price available for such drug.
``(B) Amount multiplier after aim price
available.--For purposes of paragraph (1), the amount
described in this subparagraph for a selected drug
described in such paragraph, is the amount equal to 200
percent of the AIM price for such drug with respect to
the first plan year during the price applicability
period for such drug with respect to which there is an
AIM price available for such drug.
``(d) Confidentiality of Information.--Information submitted to the
Secretary under this part by a manufacturer of a selected drug that is
proprietary information of such manufacturer (as determined by the
Secretary) may be used only by the Secretary or disclosed to and used
by the Comptroller General of the United States or the Medicare Payment
Advisory Commission for purposes of carrying out this part.
``(e) Regulations.--
``(1) In general.--The Secretary shall, pursuant to
rulemaking, specify, in accordance with paragraph (2), the
information that must be submitted under subsection (a)(4).
``(2) Information specified.--Information described in
paragraph (1), with respect to a selected drug, shall include
information on sales of the drug (by the manufacturer of the
drug or by another entity under license or other agreement with
the manufacturer, with respect to the sales of such drug,
regardless of the name under which the drug is sold) in any
foreign country that is part of the AIM price. The Secretary
shall verify, to the extent practicable, such sales from
appropriate officials of the government of the foreign country
involved.
``(f) Compliance With Requirements for Administration of Program.--
Each manufacturer with an agreement in effect under this section shall
comply with requirements imposed by the Secretary or a third party with
a contract under section 1196(c)(1), as applicable, for purposes of
administering the program.
``SEC. 1194. NEGOTIATION AND RENEGOTIATION PROCESS.
``(a) In General.--For purposes of this part, under an agreement
under section 1193 between the Secretary and a manufacturer of a
selected drug, with respect to the period for which such agreement is
in effect and in accordance with subsections (b) and (c), the Secretary
and the manufacturer--
``(1) shall during the voluntary negotiation period with
respect to the initial price applicability year for such drug,
in accordance with this section, negotiate a maximum fair price
for such drug for the purpose described in section 1193(a)(1);
and
``(2) as applicable pursuant to section 1193(a)(2) and in
accordance with the process specified pursuant to such section,
renegotiate such maximum fair price for such drug for the
purpose described in such section.
``(b) Negotiating Methodology and Objective.--
``(1) In general.--The Secretary shall develop and use a
consistent methodology for negotiations under subsection (a)
that, in accordance with paragraph (2) and subject to paragraph
(3), achieves the lowest maximum fair price for each selected
drug while appropriately rewarding innovation.
``(2) Prioritizing factors.--In considering the factors
described in subsection (d) in negotiating (and, as applicable,
renegotiating) the maximum fair price for a selected drug, the
Secretary shall, to the extent practicable, consider all of the
available factors listed but shall prioritize the following
factors:
``(A) Research and development costs.--The factor
described in paragraph (1)(A) of subsection (d).
``(B) Market data.--The factor described in
paragraph (1)(B) of such subsection.
``(C) Unit costs of production and distribution.--
The factor described in paragraph (1)(C) of such
subsection.
``(D) Comparison to existing therapeutic
alternatives.--The factor described in paragraph (2)(A)
of such subsection.
``(3) Requirement.--
``(A) In general.--In negotiating the maximum fair
price of a selected drug, with respect to an initial
price applicability year for the selected drug, and, as
applicable, in renegotiating the maximum fair price for
such drug, with respect to a subsequent year during the
price applicability period for such drug, in the case
that the manufacturer of the selected drug offers under
the negotiation or renegotiation, as applicable, a
price for such drug that is not more than the target
price described in subparagraph (B) for such drug for
the respective year, the Secretary shall agree under
such negotiation or renegotiation, respectively, to
such offered price as the maximum fair price.
``(B) Target price.--
``(i) In general.--Subject to clause (ii),
the target price described in this subparagraph
for a selected drug with respect to a year, is
the average price (which shall be the net
average price, if practicable, and volume-
weighted, if practicable) for a unit of such
drug for sales of such drug, as computed
(across different dosage forms and strengths of
the drug and not based on the specific
formulation or package size or package type of
the drug) in the applicable country described
in section 1191(c)(3)(B) with respect to such
drug that, with respect to such year, has the
lowest average price for such drug as compared
to the average prices (as so computed) of such
drug with respect to such year in the other
applicable countries described in such section
with respect to such drug.
``(ii) Selected drugs without aim price.--
In applying this paragraph in the case of
negotiating the maximum fair price of a
selected drug for which there is no AIM price
available with respect to the initial price
applicability year for such drug, or, as
applicable, renegotiating the maximum fair
price for such drug with respect to a
subsequent year during the price applicability
period for such drug before the first plan year
for which there is an AIM price available for
such drug, the target price described in this
subparagraph for such drug and respective year
is the amount that is 80 percent of the average
manufacturer price (as defined in section
1927(k)(1)) for such drug and year.
``(4) Annual report.--After the completion of each
voluntary negotiation period, the Secretary shall submit to
Congress a report on the maximum fair prices negotiated (or, as
applicable, renegotiated) for such period. Such report shall
include information on how such prices so negotiated (or
renegotiated) meet the requirements of this part, including the
requirements of this subsection.
``(c) Limitation.--
``(1) In general.--Subject to paragraph (2), the maximum
fair price negotiated (including as renegotiated) under this
section for a selected drug, with respect to each plan year
during a price applicability period for such drug, shall not
exceed 120 percent of the AIM price applicable to such drug
with respect to such year.
``(2) Selected drugs without aim price.--In the case of a
selected drug for which there is no AIM price available with
respect to the initial price applicability year for such drug,
for each plan year during the price applicability period before
the first plan year for which there is an AIM price available
for such drug, the maximum fair price negotiated (including as
renegotiated) under this section for the selected drug shall
not exceed the amount equal to 85 percent of the average
manufacturer price for the drug with respect to such year.
``(d) Considerations.--For purposes of negotiating and, as
applicable, renegotiating (including for purposes of determining
whether to renegotiate) the maximum fair price of a selected drug under
this part with the manufacturer of the drug, the Secretary, consistent
with subsection (b)(2), shall take into consideration the factors
described in paragraphs (1), (2), (3), and (5), and may take into
consideration the factor described in paragraph (4):
``(1) Manufacturer-specific information.--The following
information, including as submitted by the manufacturer:
``(A) Research and development costs of the
manufacturer for the drug and the extent to which the
manufacturer has recouped research and development
costs.
``(B) Market data for the drug, including the
distribution of sales across different programs and
purchasers and projected future revenues for the drug.
``(C) Unit costs of production and distribution of
the drug.
``(D) Prior Federal financial support for novel
therapeutic discovery and development with respect to
the drug.
``(E) Data on patents and on existing and pending
exclusivity for the drug.
``(F) National sales data for the drug.
``(G) Information on clinical trials for the drug
in the United States or in applicable countries
described in section 1191(c)(3)(B).
``(2) Information on alternative products.--The following
information:
``(A) The extent to which the drug represents a
therapeutic advance as compared to existing therapeutic
alternatives and, to the extent such information is
available, the costs of such existing therapeutic
alternatives.
``(B) Information on approval by the Food and Drug
Administration of alternative drug products.
``(C) Information on comparative effectiveness
analysis for such products, taking into consideration
the effects of such products on specific populations,
such as individuals with disabilities, the elderly,
terminally ill, children, and other patient
populations.
In considering information described in subparagraph (C), the
Secretary shall not use evidence or findings from comparative
clinical effectiveness research in a manner that treats
extending the life of an elderly, disabled, or terminally ill
individual as of lower value than extending the life of an
individual who is younger, nondisabled, or not terminally ill.
Nothing in the previous sentence shall affect the application
or consideration of an AIM price for a selected drug.
``(3) Foreign sales information.--To the extent available
on a timely basis, including as provided by a manufacturer of
the selected drug or otherwise, information on sales of the
selected drug in each of the countries described in section
1191(c)(3)(B).
``(4) VA drug pricing information.--Information disclosed
to the Secretary pursuant to subsection (f).
``(5) Additional information.--Information submitted to the
Secretary, in accordance with a process specified by the
Secretary, by other parties that are affected by the
establishment of a maximum fair price for the selected drug.
``(e) Request for Information.--For purposes of negotiating and, as
applicable, renegotiating (including for purposes of determining
whether to renegotiate) the maximum fair price of a selected drug under
this part with the manufacturer of the drug, with respect to a price
applicability period, and other relevant data for purposes of this
section--
``(1) the Secretary shall, not later than the selected drug
publication date with respect to the initial price
applicability year of such period, request drug pricing
information from the manufacturer of such selected drug,
including information described in subsection (d)(1); and
``(2) by not later than October 1 following the selected
drug publication date, the manufacturer of such selected drug
shall submit to the Secretary such requested information in
such form and manner as the Secretary may require.
The Secretary shall request, from the manufacturer or others, such
additional information as may be needed to carry out the negotiation
and renegotiation process under this section.
``(f) Disclosure of Information.--For purposes of this part, the
Secretary of Veterans Affairs may disclose to the Secretary of Health
and Human Services the price of any negotiation-eligible drug that is
purchased pursuant to section 8126 of title 38, United States Code.
``SEC. 1195. PUBLICATION OF MAXIMUM FAIR PRICES.
``(a) In General.--With respect to an initial price applicability
year and selected drug with respect to such year, not later than April
1 of the plan year prior to such initial price applicability year, the
Secretary shall publish in the Federal Register the maximum fair price
for such drug negotiated under this part with the manufacturer of such
drug.
``(b) Updates.--
``(1) Subsequent year maximum fair prices.--For a selected
drug, for each plan year subsequent to the initial price
applicability year for such drug with respect to which an
agreement for such drug is in effect under section 1193, the
Secretary shall publish in the Federal Register--
``(A) subject to subparagraph (B), the amount equal
to the maximum fair price published for such drug for
the previous year, increased by the annual percentage
increase in the consumer price index for all urban
consumers (all items; U.S. city average) as of
September of such previous year; or
``(B) in the case the maximum fair price for such
drug was renegotiated, for the first year for which
such price as so renegotiated applies, such
renegotiated maximum fair price.
``(2) Prices negotiated after deadline.--In the case of a
selected drug with respect to an initial price applicability
year for which the maximum fair price is determined under this
part after the date of publication under this section, the
Secretary shall publish such maximum fair price in the Federal
Register by not later than 30 days after the date such maximum
price is so determined.
``SEC. 1196. ADMINISTRATIVE DUTIES; COORDINATION PROVISIONS.
``(a) Administrative Duties.--
``(1) In general.--For purposes of section 1191, the
administrative duties described in this section are the
following:
``(A) The establishment of procedures (including
through agreements with manufacturers under this part,
contracts with prescription drug plans under part D of
title XVIII and MA-PD plans under part C of such title,
and agreements under section 1197 with group health
plans and health insurance issuers of health insurance
coverage offered in the individual or group market)
under which the maximum fair price for a selected drug
is provided to fair price eligible individuals, who
with respect to such drug are described in subparagraph
(A) of section 1191(c)(1), at pharmacies or by mail
order service at the point-of-sale of the drug for the
applicable price period for such drug and providing
that such maximum fair price is used for determining
cost-sharing under such plans or coverage for the
selected drug.
``(B) The establishment of procedures (including
through agreements with manufacturers under this part
and contracts with hospitals, physicians, and other
providers of services and suppliers and agreements
under section 1197 with group health plans and health
insurance issuers of health insurance coverage offered
in the individual or group market) under which, in the
case of a selected drug furnished or administered by
such a hospital, physician, or other provider of
services or supplier to fair price eligible individuals
(who with respect to such drug are described in
subparagraph (B) of section 1191(c)(1)), the maximum
fair price for the selected drug is provided to such
hospitals, physicians, and other providers of services
and suppliers (as applicable) with respect to such
individuals and providing that such maximum fair price
is used for determining cost-sharing under the
respective part, plan, or coverage for the selected
drug.
``(C) The establishment of procedures (including
through agreements and contracts described in
subparagraphs (A) and (B)) to ensure that, not later
than 90 days after the dispensing of a selected drug to
a fair price eligible individual by a pharmacy or mail
order service, the pharmacy or mail order service is
reimbursed for an amount equal to the difference
between--
``(i) the lesser of--
``(I) the wholesale acquisition
cost of the drug;
``(II) the national average drug
acquisition cost of the drug; and
``(III) any other similar
determination of pharmacy acquisition
costs of the drug, as determined by the
Secretary; and
``(ii) the maximum fair price for the drug.
``(D) The establishment of procedures to ensure
that the maximum fair price for a selected drug is
applied before--
``(i) any coverage or financial assistance
under other health benefit plans or programs
that provide coverage or financial assistance
for the purchase or provision of prescription
drug coverage on behalf of fair price eligible
individuals as the Secretary may specify; and
``(ii) any other discounts.
``(E) The establishment of procedures to enter into
appropriate agreements and protocols for the ongoing
computation of AIM prices for selected drugs,
including, to the extent possible, to compute the AIM
price for selected drugs and including by providing
that the manufacturer of such a selected drug should
provide information for such computation not later than
3 months after the first date of the voluntary
negotiation period for such selected drug.
``(F) The establishment of procedures to compute
and apply the maximum fair price across different
strengths and dosage forms of a selected drug and not
based on the specific formulation or package size or
package type of the drug.
``(G) The establishment of procedures to negotiate
and apply the maximum fair price in a manner that does
not include any dispensing or similar fee.
``(H) The establishment of procedures to carry out
the provisions of this part, as applicable, with
respect to--
``(i) fair price eligible individuals who
are enrolled under a prescription drug plan
under part D of title XVIII or an MA-PD plan
under part C of such title;
``(ii) fair price eligible individuals who
are enrolled under a group health plan or
health insurance coverage offered by a health
insurance issuer in the individual or group
market with respect to which there is an
agreement in effect under section 1197; and
``(iii) fair price eligible individuals who
are entitled to benefits under part A of title
XVIII or enrolled under part B of such title.
``(I) The establishment of a negotiation process
and renegotiation process in accordance with section
1194, including a process for acquiring information
described in subsection (d) of such section and
determining amounts described in subsection (b) of such
section.
``(J) The provision of a reasonable dispute
resolution mechanism to resolve disagreements between
manufacturers, fair price eligible individuals, and the
third party with a contract under subsection (c)(1).
``(2) Monitoring compliance.--
``(A) In general.--The Secretary shall monitor
compliance by a manufacturer with the terms of an
agreement under section 1193, including by establishing
a mechanism through which violations of such terms may
be reported.
``(B) Notification.--If a third party with a
contract under subsection (c)(1) determines that the
manufacturer is not in compliance with such agreement,
the third party shall notify the Secretary of such
noncompliance for appropriate enforcement under section
4192 of the Internal Revenue Code of 1986 or section
1198, as applicable.
``(b) Collection of Data.--
``(1) From prescription drug plans and ma-pd plans.--The
Secretary may collect appropriate data from prescription drug
plans under part D of title XVIII and MA-PD plans under part C
of such title in a timeframe that allows for maximum fair
prices to be provided under this part for selected drugs.
``(2) From health plans.--The Secretary may collect
appropriate data from group health plans or health insurance
issuers offering group or individual health insurance coverage
in a timeframe that allows for maximum fair prices to be
provided under this part for selected drugs.
``(3) Coordination of data collection.--To the extent
feasible, as determined by the Secretary, the Secretary shall
ensure that data collected pursuant to this subsection is
coordinated with, and not duplicative of, other Federal data
collection efforts.
``(c) Contract With Third Parties.--
``(1) In general.--The Secretary may enter into a contract
with 1 or more third parties to administer the requirements
established by the Secretary in order to carry out this part.
At a minimum, the contract with a third party under the
preceding sentence shall require that the third party--
``(A) receive and transmit information between the
Secretary, manufacturers, and other individuals or
entities the Secretary determines appropriate;
``(B) receive, distribute, or facilitate the
distribution of funds of manufacturers to appropriate
individuals or entities in order to meet the
obligations of manufacturers under agreements under
this part;
``(C) provide adequate and timely information to
manufacturers, consistent with the agreement with the
manufacturer under this part, as necessary for the
manufacturer to fulfill its obligations under this
part; and
``(D) permit manufacturers to conduct periodic
audits, directly or through contracts, of the data and
information used by the third party to determine
discounts for applicable drugs of the manufacturer
under the program.
``(2) Performance requirements.--The Secretary shall
establish performance requirements for a third party with a
contract under paragraph (1) and safeguards to protect the
independence and integrity of the activities carried out by the
third party under the program under this part.
``SEC. 1197. VOLUNTARY PARTICIPATION BY OTHER HEALTH PLANS.
``(a) Agreement to Participate Under Program.--
``(1) In general.--Subject to paragraph (2), under the
program under this part the Secretary shall be treated as
having in effect an agreement with a group health plan or
health insurance issuer offering group or individual health
insurance coverage (as such terms are defined in section 2791
of the Public Health Service Act), with respect to a price
applicability period and a selected drug with respect to such
period--
``(A) with respect to such selected drug furnished
or dispensed at a pharmacy or by mail order service if
coverage is provided under such plan or coverage during
such period for such selected drug as so furnished or
dispensed; and
``(B) with respect to such selected drug furnished
or administered by a hospital, physician, or other
provider of services or supplier if coverage is
provided under such plan or coverage during such period
for such selected drug as so furnished or administered.
``(2) Opting out of agreement.--The Secretary shall not be
treated as having in effect an agreement under the program
under this part with a group health plan or health insurance
issuer offering group or individual health insurance coverage
with respect to a price applicability period and a selected
drug with respect to such period if such a plan or issuer
affirmatively elects, through a process specified by the
Secretary, not to participate under the program with respect to
such period and drug.
``(b) Publication of Election.--With respect to each price
applicability period and each selected drug with respect to such
period, the Secretary and the Secretary of Labor and the Secretary of
the Treasury, as applicable, shall make public a list of each group
health plan and each health insurance issuer offering group or
individual health insurance coverage, with respect to which coverage is
provided under such plan or coverage for such drug, that has elected
under subsection (a) not to participate under the program with respect
to such period and drug.
``SEC. 1198. CIVIL MONETARY PENALTY.
``(a) Violations Relating To Offering of Maximum Fair Price.--Any
manufacturer of a selected drug that has entered into an agreement
under section 1193, with respect to a plan year during the price
applicability period for such drug, that does not provide access to a
price that is not more than the maximum fair price (or a lesser price)
for such drug for such year--
``(1) to a fair price eligible individual who with respect
to such drug is described in subparagraph (A) of section
1191(c)(1) and who is furnished or dispensed such drug during
such year; or
``(2) to a hospital, physician, or other provider of
services or supplier with respect to fair price eligible
individuals who with respect to such drug is described in
subparagraph (B) of such section and is furnished or
administered such drug by such hospital, physician, or provider
or supplier during such year;
shall be subject to a civil monetary penalty equal to ten times the
amount equal to the difference between the price for such drug made
available for such year by such manufacturer with respect to such
individual or hospital, physician, provider, or supplier and the
maximum fair price for such drug for such year.
``(b) Violations of Certain Terms of Agreement.--Any manufacturer
of a selected drug that has entered into an agreement under section
1193, with respect to a plan year during the price applicability period
for such drug, that is in violation of a requirement imposed pursuant
to section 1193(a)(6) shall be subject to a civil monetary penalty of
not more than $1,000,000 for each such violation.
``(c) Application.--The provisions of section 1128A (other than
subsections (a) and (b)) shall apply to a civil monetary penalty under
this section in the same manner as such provisions apply to a penalty
or proceeding under section 1128A(a).
``SEC. 1199. MISCELLANEOUS PROVISIONS.
``(a) Paperwork Reduction Act.--Chapter 35 of title 44, United
States Code, shall not apply to data collected under this part.
``(b) National Academy of Medicine Study.--Not later than December
31, 2025, the National Academy of Medicine shall conduct a study, and
submit to Congress a report, on recommendations for improvements to the
program under this part, including the determination of the limits
applied under section 1194(c).
``(c) MedPAC Study.--Not later than December 31, 2025, the Medicare
Payment Advisory Commission shall conduct a study, and submit to
Congress a report, on the program under this part with respect to the
Medicare program under title XVIII, including with respect to the
effect of the program on individuals entitled to benefits or enrolled
under such title.
``(d) Limitation on Judicial Review.--The following shall not be
subject to judicial review:
``(1) The selection of drugs for publication under section
1192(a).
``(2) The determination of whether a drug is a negotiation-
eligible drug under section 1192(d).
``(3) The determination of the maximum fair price of a
selected drug under section 1194.
``(4) The determination of units of a drug for purposes of
section 1191(c)(3).
``(e) Coordination.--In carrying out this part with respect to
group health plans or health insurance coverage offered in the group
market that are subject to oversight by the Secretary of Labor or the
Secretary of the Treasury, the Secretary of Health and Human Services
shall coordinate with such respective Secretary.
``(f) Data Sharing.--The Secretary shall share with the Secretary
of the Treasury such information as is necessary to determine the tax
imposed by section 4192 of the Internal Revenue Code of 1986.
``(g) GAO Study.--Not later than December 31, 2025, the Comptroller
General of the United States shall conduct a study of, and submit to
Congress a report on, the implementation of the Fair Price Negotiation
Program under this part.''.
(b) Application of Maximum Fair Prices and Conforming Amendments.--
(1) Under medicare.--
(A) Application to payments under part b.--Section
1847A(b)(1)(B) of the Social Security Act (42 U.S.C.
1395w-3a(b)(1)(B)) is amended by inserting ``or in the
case of such a drug or biological that is a selected
drug (as defined in section 1192(c)), with respect to a
price applicability period (as defined in section
1191(b)(2)), 106 percent of the maximum fair price (as
defined in section 1191(c)(2) applicable for such drug
and a plan year during such period'' after ``paragraph
(4)''.
(B) Exception to part d non-interference.--Section
1860D-11(i) of the Social Security Act (42 U.S.C.
1395w-111(i)) is amended by inserting ``, except as
provided under part E of title XI'' after ``the
Secretary''.
(C) Application as negotiated price under part d.--
Section 1860D-2(d)(1) of the Social Security Act (42
U.S.C. 1395w-102(d)(1)) is amended--
(i) in subparagraph (B), by inserting ``,
subject to subparagraph (D),'' after
``negotiated prices''; and
(ii) by adding at the end the following new
subparagraph:
``(D) Application of maximum fair price for
selected drugs.--In applying this section, in the case
of a covered part D drug that is a selected drug (as
defined in section 1192(c)), with respect to a price
applicability period (as defined in section
1191(b)(2)), the negotiated prices used for payment (as
described in this subsection) shall be the maximum fair
price (as defined in section 1191(c)(2)) for such drug
and for each plan year during such period.''.
(D) Information from prescription drug plans and
ma-pd plans required.--
(i) Prescription drug plans.--Section
1860D-12(b) of the Social Security Act (42
U.S.C. 1395w-112(b)) is amended by adding at
the end the following new paragraph:
``(8) Provision of information related to maximum fair
prices.--Each contract entered into with a PDP sponsor under
this part with respect to a prescription drug plan offered by
such sponsor shall require the sponsor to provide information
to the Secretary as requested by the Secretary in accordance
with section 1196(b).''.
(ii) MA-PD plans.--Section 1857(f)(3) of
the Social Security Act (42 U.S.C. 1395w-
27(f)(3)) is amended by adding at the end the
following new subparagraph:
``(E) Provision of information related to maximum
fair prices.--Section 1860D-12(b)(8).''.
(2) Under group health plans and health insurance
coverage.--
(A) PHSA.--Part A of title XXVII of the Public
Health Service Act is amended by inserting after
section 2729 the following new section:
``SEC. 2729A. FAIR PRICE NEGOTIATION PROGRAM AND APPLICATION OF MAXIMUM
FAIR PRICES.
``(a) In General.--In the case of a group health plan or health
insurance issuer offering group or individual health insurance coverage
that is treated under section 1197 of the Social Security Act as having
in effect an agreement with the Secretary under the Fair Price
Negotiation Program under part E of title XI of such Act, with respect
to a price applicability period (as defined in section 1191(b) of such
Act) and a selected drug (as defined in section 1192(c) of such Act)
with respect to such period with respect to which coverage is provided
under such plan or coverage--
``(1) the provisions of such part shall apply--
``(A) if coverage of such selected drug is provided
under such plan or coverage if the drug is furnished or
dispensed at a pharmacy or by a mail order service, to
the plans or coverage offered by such plan or issuer,
and to the individuals enrolled under such plans or
coverage, during such period, with respect to such
selected drug, in the same manner as such provisions
apply to prescription drug plans and MA-PD plans, and
to individuals enrolled under such prescription drug
plans and MA-PD plans during such period; and
``(B) if coverage of such selected drug is provided
under such plan or coverage if the drug is furnished or
administered by a hospital, physician, or other
provider of services or supplier, to the plans or
coverage offered by such plan or issuers, to the
individuals enrolled under such plans or coverage, and
to hospitals, physicians, and other providers of
services and suppliers during such period, with respect
to such drug in the same manner as such provisions
apply to the Secretary, to individuals entitled to
benefits under part A of title XVIII or enrolled under
part B of such title, and to hospitals, physicians, and
other providers and suppliers participating under title
XVIII during such period;
``(2) the plan or issuer shall apply any cost-sharing
responsibilities under such plan or coverage, with respect to
such selected drug, by substituting an amount not more than the
maximum fair price negotiated under such part E of title XI for
such drug in lieu of the drug price upon which the cost-sharing
would have otherwise applied, and such cost-sharing
responsibilities with respect to such selected drug may not
exceed such maximum fair price; and
``(3) the Secretary shall apply the provisions of such part
E to such plan, issuer, and coverage, such individuals so
enrolled in such plans and coverage, and such hospitals,
physicians, and other providers and suppliers participating in
such plans and coverage.
``(b) Notification Regarding Nonparticipation in Fair Price
Negotiation Program.--A group health plan or a health insurance issuer
offering group or individual health insurance coverage shall publicly
disclose in a manner and in accordance with a process specified by the
Secretary any election made under section 1197 of the Social Security
Act by the plan or issuer to not participate in the Fair Price
Negotiation Program under part E of title XI of such Act with respect
to a selected drug (as defined in section 1192(c) of such Act) for
which coverage is provided under such plan or coverage before the
beginning of the plan year for which such election was made.''.
(B) ERISA.--
(i) In general.--Subpart B of part 7 of
subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29
U.S.C. 1181 et seq.) is amended by adding at
the end the following new section:
``SEC. 716. FAIR PRICE NEGOTIATION PROGRAM AND APPLICATION OF MAXIMUM
FAIR PRICES.
``(a) In General.--In the case of a group health plan or health
insurance issuer offering group health insurance coverage that is
treated under section 1197 of the Social Security Act as having in
effect an agreement with the Secretary under the Fair Price Negotiation
Program under part E of title XI of such Act, with respect to a price
applicability period (as defined in section 1191(b) of such Act) and a
selected drug (as defined in section 1192(c) of such Act) with respect
to such period with respect to which coverage is provided under such
plan or coverage--
``(1) the provisions of such part shall apply, as
applicable--
``(A) if coverage of such selected drug is provided
under such plan or coverage if the drug is furnished or
dispensed at a pharmacy or by a mail order service, to
the plans or coverage offered by such plan or issuer,
and to the individuals enrolled under such plans or
coverage, during such period, with respect to such
selected drug, in the same manner as such provisions
apply to prescription drug plans and MA-PD plans, and
to individuals enrolled under such prescription drug
plans and MA-PD plans during such period; and
``(B) if coverage of such selected drug is provided
under such plan or coverage if the drug is furnished or
administered by a hospital, physician, or other
provider of services or supplier, to the plans or
coverage offered by such plan or issuers, to the
individuals enrolled under such plans or coverage, and
to hospitals, physicians, and other providers of
services and suppliers during such period, with respect
to such drug in the same manner as such provisions
apply to the Secretary, to individuals entitled to
benefits under part A of title XVIII or enrolled under
part B of such title, and to hospitals, physicians, and
other providers and suppliers participating under title
XVIII during such period;
``(2) the plan or issuer shall apply any cost-sharing
responsibilities under such plan or coverage, with respect to
such selected drug, by substituting an amount not more than the
maximum fair price negotiated under such part E of title XI for
such drug in lieu of the drug price upon which the cost-sharing
would have otherwise applied, and such cost-sharing
responsibilities with respect to such selected drug may not
exceed such maximum fair price; and
``(3) the Secretary shall apply the provisions of such part
E to such plan, issuer, and coverage, and such individuals so
enrolled in such plans.
``(b) Notification Regarding Nonparticipation in Fair Price
Negotiation Program.--A group health plan or a health insurance issuer
offering group health insurance coverage shall publicly disclose in a
manner and in accordance with a process specified by the Secretary any
election made under section 1197 of the Social Security Act by the plan
or issuer to not participate in the Fair Price Negotiation Program
under part E of title XI of such Act with respect to a selected drug
(as defined in section 1192(c) of such Act) for which coverage is
provided under such plan or coverage before the beginning of the plan
year for which such election was made.''.
(ii) Application to retiree and certain
small group health plans.--Section 732(a) of
the Employee Retirement Income Security Act of
1974 (29 U.S.C. 1191a(a)) is amended by
striking ``section 711'' and inserting
``sections 711 and 716''.
(iii) Clerical amendment.--The table of
sections for subpart B of part 7 of subtitle B
of title I of the Employee Retirement Income
Security Act of 1974 is amended by adding at
the end the following:
``Sec. 716. Fair Price Negotiation Program and application of maximum
fair prices.''.
(C) IRC.--
(i) In general.--Subchapter B of chapter
100 of the Internal Revenue Code of 1986 is
amended by adding at the end the following new
section:
``SEC. 9816. FAIR PRICE NEGOTIATION PROGRAM AND APPLICATION OF MAXIMUM
FAIR PRICES.
``(a) In General.--In the case of a group health plan that is
treated under section 1197 of the Social Security Act as having in
effect an agreement with the Secretary under the Fair Price Negotiation
Program under part E of title XI of such Act, with respect to a price
applicability period (as defined in section 1191(b) of such Act) and a
selected drug (as defined in section 1192(c) of such Act) with respect
to such period with respect to which coverage is provided under such
plan--
``(1) the provisions of such part shall apply, as
applicable--
``(A) if coverage of such selected drug is provided
under such plan if the drug is furnished or dispensed
at a pharmacy or by a mail order service, to the plan,
and to the individuals enrolled under such plan during
such period, with respect to such selected drug, in the
same manner as such provisions apply to prescription
drug plans and MA-PD plans, and to individuals enrolled
under such prescription drug plans and MA-PD plans
during such period; and
``(B) if coverage of such selected drug is provided
under such plan if the drug is furnished or
administered by a hospital, physician, or other
provider of services or supplier, to the plan, to the
individuals enrolled under such plan, and to hospitals,
physicians, and other providers of services and
suppliers during such period, with respect to such drug
in the same manner as such provisions apply to the
Secretary, to individuals entitled to benefits under
part A of title XVIII or enrolled under part B of such
title, and to hospitals, physicians, and other
providers and suppliers participating under title XVIII
during such period;
``(2) the plan shall apply any cost-sharing
responsibilities under such plan, with respect to such selected
drug, by substituting an amount not more than the maximum fair
price negotiated under such part E of title XI for such drug in
lieu of the drug price upon which the cost-sharing would have
otherwise applied, and such cost-sharing responsibilities with
respect to such selected drug may not exceed such maximum fair
price; and
``(3) the Secretary shall apply the provisions of such part
E to such plan and such individuals so enrolled in such plan.
``(b) Notification Regarding Nonparticipation in Fair Price
Negotiation Program.--A group health plan shall publicly disclose in a
manner and in accordance with a process specified by the Secretary any
election made under section 1197 of the Social Security Act by the plan
to not participate in the Fair Price Negotiation Program under part E
of title XI of such Act with respect to a selected drug (as defined in
section 1192(c) of such Act) for which coverage is provided under such
plan before the beginning of the plan year for which such election was
made.''.
(ii) Application to retiree and certain
small group health plans.--Section 9831(a)(2)
of the Internal Revenue Code of 1986 is amended
by inserting ``other than with respect to
section 9816,'' before ``any group health
plan''.
(iii) Clerical amendment.--The table of
sections for subchapter B of chapter 100 of
such Code is amended by adding at the end the
following new item:
``Sec. 9816. Fair Price Negotiation Program and application of maximum
fair prices.''.
(3) Fair price negotiation program prices included in best
price and amp.--Section 1927 of the Social Security Act (42
U.S.C. 1396r-8) is amended--
(A) in subsection (c)(1)(C)(ii)--
(i) in subclause (III), by striking at the
end ``; and'';
(ii) in subclause (IV), by striking at the
end the period and inserting ``; and''; and
(iii) by adding at the end the following
new subclause:
``(V) in the case of a rebate
period and a covered outpatient drug
that is a selected drug (as defined in
section 1192(c)) during such rebate
period, shall be inclusive of the price
for such drug made available from the
manufacturer during the rebate period
by reason of application of part E of
title XI to any wholesaler, retailer,
provider, health maintenance
organization, nonprofit entity, or
governmental entity within the United
States.''; and
(B) in subsection (k)(1)(B), by adding at the end
the following new clause:
``(iii) Clarification.--Notwithstanding
clause (i), in the case of a rebate period and
a covered outpatient drug that is a selected
drug (as defined in section 1192(c)) during
such rebate period, any reduction in price paid
during the rebate period to the manufacturer
for the drug by a wholesaler or retail
community pharmacy described in subparagraph
(A) by reason of application of part E of title
XI shall be included in the average
manufacturer price for the covered outpatient
drug.''.
(4) FEHBP.--Section 8902 of title 5, United States Code, is
amended by adding at the end the following:
``(p) A contract may not be made or a plan approved under this
chapter with any carrier that has affirmatively elected, pursuant to
section 1197 of the Social Security Act, not to participate in the Fair
Price Negotiation Program established under section 1191 of such Act
for any selected drug (as that term is defined in section 1192(c) of
such Act).''.
(5) Option of secretary of veterans affairs to purchase
covered drugs at maximum fair prices.--Section 8126 of title
38, United States Code, is amended--
(A) in subsection (a)(2), by inserting ``, subject
to subsection (j),'' after ``may not exceed'';
(B) in subsection (d), in the matter preceding
paragraph (1), by inserting ``, subject to subsection
(j)'' after ``for the procurement of the drug''; and
(C) by adding at the end the following new
subsection:
``(j)(1) In the case of a covered drug that is a selected drug, for
any year during the price applicability period for such drug, if the
Secretary determines that the maximum fair price of such drug for such
year is less than the price for such drug otherwise in effect pursuant
to this section (including after application of any reduction under
subsection (a)(2) and any discount under subsection (c)), at the option
of the Secretary, in lieu of the maximum price (determined after
application of the reduction under subsection (a)(2) and any discount
under subsection (c), as applicable) that would be permitted to be
charged during such year for such drug pursuant to this section without
application of this subsection, the maximum price permitted to be
charged during such year for such drug pursuant to this section shall
be such maximum fair price for such drug and year.
``(2) For purposes of this subsection:
``(A) The term `maximum fair price' means, with respect to
a selected drug and year during the price applicability period
for such drug, the maximum fair price (as defined in section
1191(c)(2) of the Social Security Act) for such drug and year.
``(B) The term `negotiation eligible drug' has the meaning
given such term in section 1192(d)(1) of the Social Security
Act.
``(C) The term `price applicability period' has, with
respect to a selected drug, the meaning given such term in
section 1191(b)(2) of such Act.
``(D) The term `selected drug' means, with respect to a
year, a drug that is a selected drug under section 1192(c) of
such Act for such year.''.
SEC. 302. DRUG MANUFACTURER EXCISE TAX FOR NONCOMPLIANCE.
(a) In General.--Subchapter E of chapter 32 of the Internal Revenue
Code of 1986 is amended by adding at the end the following new section:
``SEC. 4192. SELECTED DRUGS DURING NONCOMPLIANCE PERIODS.
``(a) In General.--There is hereby imposed on the sale by the
manufacturer, producer, or importer of any selected drug during a day
described in subsection (b) a tax in an amount such that the applicable
percentage is equal to the ratio of--
``(1) such tax, divided by
``(2) the sum of such tax and the price for which so sold.
``(b) Noncompliance Periods.--A day is described in this subsection
with respect to a selected drug if it is a day during one of the
following periods:
``(1) The period beginning on the June 16th immediately
following the selected drug publication date and ending on the
first date during which the manufacturer of the drug has in
place an agreement described in subsection (a) of section 1193
of the Social Security Act with respect to such drug.
``(2) The period beginning on the April 1st immediately
following the June 16th described in paragraph (1) and ending
on the first date during which the manufacturer of the drug has
agreed to a maximum fair price under such agreement.
``(3) In the case of a selected drug with respect to which
the Secretary of Health and Human Services has specified a
renegotiation period under such agreement, the period beginning
on the first date after the last date of such renegotiation
period and ending on the first date during which the
manufacturer of the drug has agreed to a renegotiated maximum
fair price under such agreement.
``(4) With respect to information that is required to be
submitted to the Secretary of Health and Human Services under
such agreement, the period beginning on the date on which such
Secretary certifies that such information is overdue and ending
on the date that such information is so submitted.
``(5) In the case of a selected drug with respect to which
a payment is due under subsection (c) of such section 1193, the
period beginning on the date on which the Secretary of Health
and Human Services certifies that such payment is overdue and
ending on the date that such payment is made in full.
``(c) Applicable Percentage.--For purposes of this section, the
term `applicable percentage' means--
``(1) in the case of sales of a selected drug during the
first 90 days described in subsection (b) with respect to such
drug, 65 percent,
``(2) in the case of sales of such drug during the 91st day
through the 180th day described in subsection (b) with respect
to such drug, 75 percent,
``(3) in the case of sales of such drug during the 181st
day through the 270th day described in subsection (b) with
respect to such drug, 85 percent, and
``(4) in the case of sales of such drug during any
subsequent day, 95 percent.
``(d) Selected Drug.--For purposes of this section--
``(1) In general.--The term `selected drug' means any
selected drug (within the meaning of section 1192 of the Social
Security Act) which is manufactured or produced in the United
States or entered into the United States for consumption, use,
or warehousing.
``(2) United states.--The term `United States' has the
meaning given such term by section 4612(a)(4).
``(3) Coordination with rules for possessions of the united
states.--Rules similar to the rules of paragraphs (2) and (4)
of section 4132(c) shall apply for purposes of this section.
``(e) Other Definitions.--For purposes of this section, the terms
`selected drug publication date' and `maximum fair price' have the
meaning given such terms in section 1191 of the Social Security Act.
``(f) Anti-Abuse Rule.--In the case of a sale which was timed for
the purpose of avoiding the tax imposed by this section, the Secretary
may treat such sale as occurring during a day described in subsection
(b).''.
(b) No Deduction for Excise Tax Payments.--Section 275 of the
Internal Revenue Code of 1986 is amended by adding ``or by section
4192'' before the period at the end of subsection (a)(6).
(c) Conforming Amendments.--
(1) Section 4221(a) of the Internal Revenue Code of 1986 is
amended by inserting ``or 4192'' after ``section 4191''.
(2) Section 6416(b)(2) of such Code is amended by inserting
``or 4192'' after ``section 4191''.
(d) Clerical Amendments.--
(1) The heading of subchapter E of chapter 32 of the
Internal Revenue Code of 1986 is amended by striking ``Medical
Devices'' and inserting ``Other Medical Products''.
(2) The table of subchapters for chapter 32 of such Code is
amended by striking the item relating to subchapter E and
inserting the following new item:
``subchapter e. other medical products''.
(3) The table of sections for subchapter E of chapter 32 of
such Code is amended by adding at the end the following new
item:
``Sec. 4192. Selected drugs during noncompliance periods.''.
(e) Effective Date.--The amendments made by this section shall
apply to sales after the date of the enactment of this Act.
SEC. 303. FAIR PRICE NEGOTIATION IMPLEMENTATION FUND.
(a) In General.--There is hereby established a Fair Price
Negotiation Implementation Fund (referred to in this section as the
``Fund''). The Secretary of Health and Human Services may obligate and
expend amounts in the Fund to carry out this title (and the amendments
made by such title).
(b) Funding.--There is authorized to be appropriated, and there is
hereby appropriated, out of any monies in the Treasury not otherwise
appropriated, to the Fund $3,000,000,000, to remain available until
expended, of which--
(1) $600,000,000 shall become available on the date of the
enactment of this Act;
(2) $600,000,000 shall become available on October 1, 2020;
(3) $600,000,000 shall become available on October 1, 2021;
(4) $600,000,000 shall become available on October 1, 2022;
and
(5) $600,000,000 shall become available on October 1, 2023.
(c) Supplement Not Supplant.--Any amounts appropriated pursuant to
this section shall be in addition to any other amounts otherwise
appropriated pursuant to any other provision of law.
TITLE IV--PUBLIC HEALTH INVESTMENTS
SEC. 401. SUPPORTING INCREASED INNOVATION.
(a) In General.--The Secretary of Health and Human Services, acting
through the Director of the National Institutes of Health, shall
continue to support and to expand, as applicable, biomedical research
carried out through the National Institutes of Health innovation
projects described in section 1001(b)(4) of the 21st Century Cures Act
(Public Law 114-255). The Secretary shall ensure that any such research
(and related activities) is conducted in compliance with section 492B
of the Public Health Service Act (42 U.S.C. 289a-2) (relating to the
inclusion of women and members of minority groups in research).
(b) Authorization of Appropriations.--To carry out this subsection,
in addition to funds made available under paragraph (2) of section
1001(b) of the 21st Century Cures Act (Public Law 114-255), there is
authorized to be appropriated, and there is appropriated to the NIH
Innovation Account established under such section 1001(b), out of any
moneys in the Treasury not otherwise obligated, $2,000,000,000 for
fiscal year 2021, to remain available until expended.
Passed the House of Representatives June 29, 2020.
Attest:
CHERYL L. JOHNSON,
Clerk.
Calendar No. 523
116th CONGRESS
2d Session
H. R. 1425
_______________________________________________________________________
AN ACT
To amend the Patient Protection and Affordable Care Act to provide for
a Improve Health Insurance Affordability Fund to provide for certain
reinsurance payments to lower premiums in the individual health
insurance market.
_______________________________________________________________________
September 8, 2020
Read the second time and placed on the calendar