TAM18386 S.L.C.

AMENDMENT NO.llll Calendar No.lll

Purpose: To stabilize individual market premiums and pro-
vide meaningful State flexibility.

IN THE SENATE OF THE UNITED STATES—115th Cong., 2d Sess.

H.R. 1625

To amend the State Department Basic Authorities Act of

1956 to include severe forms of trafficking in persons
within the definition of transnational organized crime
for purposes of the rewards program of the Department
of State, and for other purposes.
Referred to the Committee on llllllllll and
ordered to be printed
Ordered to lie on the table and to be printed
AMENDMENT intended to be proposed by lllllll
Viz:
1 At the end, add the following:
2 DIVISION W—BIPARTISAN
3 HEALTH CARE STABILIZATION
4 SECTION 1. SHORT TITLE.

5 This division may be cited as the ‘‘Bipartisan Health

6 Care Stabilization Act of 2018’’.
7 SEC. 2. WAIVERS FOR STATE INNOVATION; COST-SHARING

8 PAYMENTS.

9 (a) WAIVERS FOR STATE INNOVATION.—

TAM18386 S.L.C.

2
1 (1) STREAMLINING THE STATE APPLICATION

2 PROCESS.—Section 1332 of the Patient Protection

3 and Affordable Care Act (42 U.S.C. 18052) is
4 amended—
5 (A) in subsection (a)(1)(C), by striking
6 ‘‘the law’’ and inserting ‘‘a law or has in effect
7 a certification’’; and
8 (B) in subsection (b)(2)—
9 (i) in the paragraph heading, by in-
10 serting ‘‘OR CERTIFY’’ after ‘‘LAW’’;
11 (ii) in subparagraph (A)—
12 (I) by striking ‘‘A law’’ and in-
13 serting the following:
14 ‘‘(i) LAWS.—A law’’; and
15 (II) by adding at the end the fol-
16 lowing:
17 ‘‘(ii) CERTIFICATIONS.—A certifi-
18 cation described in this paragraph is a doc-
19 ument, signed by the Governor of the
20 State, that certifies that such Governor
21 has the authority under existing Federal
22 and State law to take action under this
23 section, including implementation of the
24 State plan under subsection (a)(1)(B).’’;
25 and
TAM18386 S.L.C.

3
1 (iii) in subparagraph (B)—
2 (I) in the subparagraph heading,
3 by striking ‘‘OF OPT OUT’’; and
4 (II) by striking ‘‘may repeal a
5 law’’ and all that follows through the
6 period at the end and inserting the
7 following: ‘‘may terminate the author-
8 ity provided under the waiver with re-
9 spect to the State by—
10 ‘‘(i) repealing a law described in sub-
11 paragraph (A)(i); or
12 ‘‘(ii) terminating a certification de-
13 scribed in subparagraph (A)(ii), through a
14 certification for such termination signed by
15 the Governor of the State.’’.
16 (2) GIVING STATES MORE FUNDING FLEXI-

17 BILITY, TO ESTABLISH REINSURANCE, HIGH RISK

18 POOLS, INVISIBLE HIGH RISK POOLS, INSURANCE

19 STABILITY FUNDS AND OTHER PROGRAMS.—

20 (A) STATE GRANTS UNDER WAIVERS.—

21 Section 1332(a) of the Patient Protection and

22 Affordable Care Act (42 U.S.C. 18052(a)) is
23 amended—
24 (i) in paragraph (3)—
25 (I) in the first sentence—
TAM18386 S.L.C.

4
1 (aa) by inserting ‘‘or would
2 qualify for a reduced portion of’’
3 after ‘‘would not qualify for’’;
4 (bb) by inserting ‘‘, or the
5 State would not qualify for or
6 would qualify for a reduced por-
7 tion of basic health program
8 funds under section 1331,’’ after
9 ‘‘subtitle E’’;
10 (cc) by inserting ‘‘, or basic
11 health program funds the State
12 would have received,’’ after ‘‘this
13 title’’; and
14 (dd) by inserting ‘‘or for im-
15 plementing the basic health pro-
16 gram established under section
17 1331’’ before the period;
18 (II) in the second sentence, by
19 inserting before the period ‘‘, and with
20 respect to participation in the basic
21 health program and funds provided to
22 such other States under section
23 1331’’; and
24 (III) by adding after the second
25 sentence the following: ‘‘A State may
TAM18386 S.L.C.

5
1 request that all of, or any portion of,
2 such aggregate amount of such cred-
3 its, reductions, or funds be paid to the
4 State as described in the first sen-
5 tence.’’;
6 (ii) by redesignating paragraphs (4),
7 (5), and (6) as paragraphs (5), (6), and
8 (7), respectively; and
9 (iii) by inserting after paragraph (3)
10 the following:
11 ‘‘(4) FEDERAL FUNDING FOR INVISIBLE HIGH-

12 RISK POOL AND REINSURANCE PROGRAMS.—

13 ‘‘(A) ALLOCATIONS.—Not later than 45

14 days after the date of enactment of the Bipar-
15 tisan Health Care Stabilization Act of 2018,
16 the Secretary, in consultation with the National
17 Association of Insurance Commissioners, shall
18 specify an allocation methodology for deter-
19 mining the amount of funds appropriated under
20 section 2(a)(2)(B) of the Bipartisan Health
21 Care Stabilization Act of 2018 for a fiscal year
22 to be allocated for each State for purposes of
23 subparagraph (B). Such methodology shall allo-
24 cate funds in a manner that would yield a simi-
25 lar level of premium reduction in all States if
TAM18386 S.L.C.

6
1 all States applied for and received funding, tak-
2 ing into account market stability and competi-
3 tion in the various States. If not all States
4 apply for and receive funding under subpara-
5 graph (B), remaining funds shall be used to
6 carry out section 2(a)(2)(C) of the Bipartisan
7 Health Care Stabilization Act of 2018.
8 ‘‘(B) STATE GRANTS.—From amounts ap-
9 propriated under section 2(a)(2)(B) of the Bi-
10 partisan Health Care Stabilization Act of 2018
11 for a fiscal year, the Secretary shall award
12 grants to States for each of fiscal years 2018
13 through 2021, in amounts determined in ac-
14 cordance with the allocation methodology under
15 subparagraph (A), for the following purposes:
16 ‘‘(i) For fiscal year 2018, for adminis-
17 trative costs of the State associated with
18 preparing and submitting information de-
19 scribed in subsection (a)(1)(B) that in-
20 cludes an invisible high-risk pool or rein-
21 surance program that meets the require-
22 ments of subsection (g)(2), or costs associ-
23 ated with the establishment of such invis-
24 ible high-risk pool or reinsurance program.
TAM18386 S.L.C.

7
1 ‘‘(ii) For each of fiscal years 2019,
2 2020, and 2021, for the establishment or
3 maintenance of invisible high-risk pools
4 and reinsurance programs that meet the
5 requirements of subsection (g)(2) and for
6 which the State has received a waiver
7 under this section.
8 ‘‘(C) BUDGET NEUTRALITY.—Funds

9 awarded to a State under a grant awarded

10 under subparagraph (B) shall not be taken into
11 account for purposes of determining under
12 paragraph (1) whether the State waiver is
13 budget neutral, or determining under subsection
14 (b)(1) whether the State waiver increases the
15 Federal deficit.’’.
16 (B) APPROPRIATIONS.—
17 (i) IN GENERAL.—There are author-
18 ized to be appropriated, and there are ap-
19 propriated, to the Secretary of Health and
20 Human Services, for the purposes de-
21 scribed in section 1332(a)(4)(B) of the Pa-
22 tient Protection and Affordable Care Act
23 and subparagraph (C), out of any funds in
24 the Treasury not otherwise appropriated—
TAM18386 S.L.C.

8
1 (I) $500,000,000 for fiscal year
2 2018; and
3 (II) $10,000,000,000 for each of
4 fiscal years 2019, 2020, and 2021.
5 (ii) AVAILABLE UNTIL EXPENDED.—

6 Amounts appropriated under this para-

7 graph shall remain available until ex-
8 pended.
9 (C) DEFAULT FEDERAL SAFEGUARD.—

10 (i) IN GENERAL.—For purposes of

11 plan years 2019 through 2021, in the case
12 of a State that does not, by a date speci-
13 fied by the Secretary of Health and
14 Human Services (referred to in this sub-
15 paragraph as the ‘‘Secretary’’), in con-
16 sultation with the National Association of
17 Insurance Commissioners, have in effect a
18 waiver under section 1332 of the Patient
19 Protection and Affordable Care Act (42
20 U.S.C. 18052) that includes an invisible
21 high-risk pool or reinsurance program that
22 meets the requirements of subsection
23 (g)(2) of such section 1332, the Secretary
24 shall, from amounts appropriated under
25 subparagraph (B), use the allocation deter-
TAM18386 S.L.C.

9
1 mined for the State under subsection
2 (a)(4)(B) of such section 1332 for plan
3 years 2019 through 2021 for the purpose
4 described in clause (ii) for such State.
5 (ii) REQUIRED USE FOR MARKET STA-

6 BILIZATION PAYMENTS TO ISSUERS.—The

7 Secretary shall enter into arrangements

8 with the State or appropriate non-profit
9 entities to help stabilize premiums for
10 health insurance coverage in the individual
11 market, by providing payments to insurers
12 with respect to enrollees whose claims ex-
13 ceed a dollar amount established by the
14 Secretary, in an amount equal to 80 per-
15 cent of the amount of such claims.
16 (3) ENSURING PATIENT ACCESS TO MORE

17 FLEXIBLE HEALTH PLANS.—Section 1332 of the Pa-

18 tient Protection and Affordable Care Act (42 U.S.C.
19 18052) is amended—
20 (A) in subsection (b)—
21 (i) in paragraph (1)—
22 (I) in subparagraph (B), by
23 striking ‘‘at least as affordable’’ and
24 inserting ‘‘of comparable affordability,
25 including for low-income individuals,
TAM18386 S.L.C.

10
1 individuals with serious health needs,
2 and other vulnerable populations,’’;
3 and
4 (II) by amending subparagraph
5 (D) to read as follows:
6 ‘‘(D)(i) will not increase the Federal deficit
7 over the term of the waiver; and
8 ‘‘(ii) will not increase the Federal deficit
9 over the term of the 10-year budget plan sub-
10 mitted under subsection (a)(1)(B)(ii).’’;
11 (ii) by redesignating paragraph (2)
12 (as amended by paragraph (1)) as para-
13 graph (3); and
14 (iii) by inserting after paragraph (1)
15 the following:
16 ‘‘(2) BUDGETARY EFFECT.—

17 ‘‘(A) IN GENERAL.—In determining wheth-

18 er a State plan submitted under subsection (a)
19 meets the deficit neutrality requirements of
20 paragraph (1)(D), the Secretary may take into
21 consideration the direct budgetary effect of the
22 provisions of such plan on sources of Federal
23 funding other than the funding described in
24 subsection (a)(3).
TAM18386 S.L.C.

11
1 ‘‘(B) LIMITATION.—A determination made
2 by the Secretary under subparagraph (A)—
3 ‘‘(i) shall not be construed to affect
4 any waiver process or standards or terms
5 and conditions in effect on the date of en-
6 actment of the Bipartisan Health Care
7 Stabilization Act of 2018 under title XI,
8 XVIII, XIX, or XXI of the Social Security
9 Act, or any other Federal law relating to
10 the provision of health care items or serv-
11 ices; and
12 ‘‘(ii) shall be made without regard to
13 any changes in policy with respect to any
14 waiver process or provision of health care
15 items or services described in clause (i).’’;
16 and
17 (B) in subsection (a)(1)(C), by striking
18 ‘‘subsection (b)(2)’’ and inserting ‘‘subsection
19 (b)(3)’’.
20 (4) PROVIDING EXPEDITED APPROVAL OF

21 STATE WAIVERS.—Section 1332(d) of the Patient

22 Protection and Affordable Care Act (42 U.S.C.
23 18052(d)) is amended—
24 (A) in paragraph (1) by striking ‘‘180’’
25 and inserting ‘‘120’’; and
TAM18386 S.L.C.

12
1 (B) by adding at the end the following:
2 ‘‘(3) EXPEDITED DETERMINATION.—

3 ‘‘(A) IN GENERAL.—With respect to any

4 application under subsection (a)(1) submitted
5 on or after the date of enactment of the Bipar-
6 tisan Health Care Stabilization Act of 2018 or
7 any such application submitted prior to such
8 date of enactment and under review by the Sec-
9 retary on such date of enactment, the Secretary
10 shall make a determination on such application,
11 using the criteria for approval otherwise appli-
12 cable under this section, not later than 45 days
13 after the receipt of such application, and shall
14 allow the public notice and comment at the
15 State and Federal levels described under sub-
16 section (a)(5) to occur concurrently if such
17 State application—
18 ‘‘(i) is submitted in response to an ur-
19 gent situation, with respect to areas in the
20 State that the Secretary determines are at
21 risk for excessive premium increases or
22 having no health plans offered in the appli-
23 cable health insurance market for the cur-
24 rent or following plan year; or
TAM18386 S.L.C.

13
1 ‘‘(ii) is for a waiver that is the same
2 or substantially similar to a waiver that
3 the Secretary already has approved for an-
4 other State.
5 ‘‘(B) APPROVAL.—
6 ‘‘(i) URGENT SITUATIONS.—

7 ‘‘(I) PROVISIONAL APPROVAL.—A

8 waiver approved under the expedited

9 determination process under subpara-
10 graph (A)(i) shall be in effect for a
11 period of 3 years, unless the State re-
12 quests a shorter duration.
13 ‘‘(II) FULL APPROVAL.—Subject

14 to the requirements for approval oth-

15 erwise applicable under this section,
16 not later than 1 year before the expi-
17 ration of a provisional waiver period
18 described in subclause (I) with respect
19 to an application described in sub-
20 paragraph (A)(i), the Secretary shall
21 make a determination on whether to
22 extend the approval of such waiver for
23 the full term of the waiver requested
24 by the State, for a total approval pe-
25 riod not to exceed 6 years. The Sec-
TAM18386 S.L.C.

14
1 retary may request additional infor-
2 mation as the Secretary determines
3 appropriate to make such determina-
4 tion.
5 ‘‘(ii) APPROVAL OF SAME OR SIMILAR

6 APPLICATIONS.—An approval of a waiver

7 under subparagraph (A)(ii) shall be subject
8 to the terms of subsection (e).
9 ‘‘(C) GAO STUDY.—Not later than 5 years
10 after the date of enactment of the Bipartisan
11 Health Care Stabilization Act of 2018, the
12 Comptroller General of the United States shall
13 conduct a review of all waivers approved pursu-
14 ant to subparagraph (A)(ii) to evaluate whether
15 such waivers met the requirements of sub-
16 section (b)(1) and whether the applications
17 should have qualified for such expedited proc-
18 ess.’’.
19 (5) PROVIDING CERTAINTY FOR STATE-BASED

20 REFORMS.—Section 1332(e) of the Patient Protec-

21 tion and Affordable Care Act (42 U.S.C. 18052(e))
22 is amended by striking ‘‘No waiver’’ and all that fol-
23 lows through the period at the end and inserting the
24 following: ‘‘A waiver under this section—
TAM18386 S.L.C.

15
1 ‘‘(1) shall be in effect for a period of 6 years
2 unless the State requests a shorter duration;
3 ‘‘(2) may be renewed, subject to the State meet-
4 ing the criteria for approval otherwise applicable
5 under this section, for unlimited additional 6-year
6 periods upon application by the State; and
7 ‘‘(3) may not be suspended or terminated, in
8 whole or in part, by the Secretary at any time before
9 the date of expiration of the waiver period (including
10 any renewal period under paragraph (2)), unless the
11 Secretary determines that the State materially failed
12 to comply with the terms and conditions of the waiv-
13 er.’’.
14 (6) GUIDANCE AND REGULATIONS.—Section

15 1332 of the Patient Protection and Affordable Care

16 Act (42 U.S.C. 18052) is amended—
17 (A) by adding at the end the following:
18 ‘‘(f) GUIDANCE AND REGULATIONS.—
19 ‘‘(1) IN GENERAL.—With respect to carrying
20 out this section, the Secretary shall—
21 ‘‘(A) issue guidance, not later than 60
22 days after the date of enactment of the Bipar-
23 tisan Health Care Stabilization Act of 2018,
24 that includes initial examples of model State
TAM18386 S.L.C.

16
1 plans that meet the requirements for approval
2 under this section; and
3 ‘‘(B) periodically review the guidance
4 issued under subparagraph (A) and when ap-
5 propriate, issue additional examples of model
6 State plans that meet the requirements for ap-
7 proval under this section, which may include—
8 ‘‘(i) State plans establishing reinsur-
9 ance or invisible high-risk pool arrange-
10 ments for purposes of covering the cost of
11 high-risk individuals;
12 ‘‘(ii) State plans expanding insurer
13 participation, access to affordable health
14 plans, network adequacy, and health plan
15 options over the entire applicable health in-
16 surance market in the State;
17 ‘‘(iii) waivers encouraging or requiring
18 health plans in such State to deploy value-
19 based insurance designs which structure
20 enrollee cost-sharing and other health plan
21 design elements to encourage enrollees to
22 consume high-value clinical services;
23 ‘‘(iv) State plans allowing for signifi-
24 cant variation in health plan benefit de-
25 sign; or
TAM18386 S.L.C.

17
1 ‘‘(v) any other State plan as the Sec-
2 retary determines appropriate.
3 ‘‘(2) RESCISSION OF PREVIOUS REGULATIONS

4 AND GUIDANCE.—Beginning on the date of enact-

5 ment of the Bipartisan Health Care Stabilization
6 Act of 2018, the regulations promulgated, and the
7 guidance issued, under this section prior to the date
8 of enactment of the Bipartisan Health Care Sta-
9 bilization Act of 2018 shall have no force or effect.’’;
10 and
11 (B) in subsection (a)(5) (as redesignated
12 by paragraph (2)(A)(ii))—
13 (i) in subparagraph (A), by inserting
14 ‘‘, as applicable’’ before the period; and
15 (ii) in subparagraph (B), by striking
16 ‘‘Not later than 180 days after the date of
17 enactment of this Act, the Secretary shall’’
18 and inserting ‘‘The Secretary may’’.
19 (7) INVISIBLE HIGH RISK POOLS AND REINSUR-

20 ANCE PROGRAMS.—Section 1332 of the Patient Pro-

21 tection and Affordable Care Act (42 U.S.C. 18052),
22 as amended by paragraph (6), is further amended by
23 adding at the end the following:
24 ‘‘(g) INVISIBLE HIGH RISK POOLS AND REINSUR-
25 ANCE PROGRAMS.—
TAM18386 S.L.C.

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1 ‘‘(1) FUNDING.—With respect to a State that
2 has received a waiver under this section to establish
3 an invisible high-risk pool or reinsurance program
4 described in paragraph (2), the State may fund such
5 program, in whole or in part, using one or both of
6 the following:
7 ‘‘(A) Amounts received through a grant de-
8 scribed in subsection (a)(4)(B).
9 ‘‘(B) All of, or a portion of, the payments
10 made to the State as described in subsection
11 (a)(3), consistent with the information the
12 State provides under subsection (a)(1)(B).
13 ‘‘(2) PROGRAM DESIGN.—An invisible high-risk
14 pool or reinsurance program described in this para-
15 graph is a program that meets any of the following:
16 ‘‘(A) An invisible high-risk pool, as defined
17 by the State, under which health insurance
18 issuers, with respect to designated individuals
19 who experience higher than average health costs
20 as determined by the State, and are enrolled in
21 health insurance coverage offered in the indi-
22 vidual market, cede risk to the pool, without af-
23 fecting the premium paid by the designated in-
24 dividuals or their terms of coverage. With re-
25 spect to such pool, the State, or an entity oper-
TAM18386 S.L.C.

19
1 ating the pool on behalf of the State, shall es-
2 tablish—
3 ‘‘(i) the premium amount the ceding
4 issuer shall pay to the reinsurance pool;
5 ‘‘(ii) the applicable attachment points
6 or coinsurance percentages if the ceding
7 issuer retains any portion of the risk under
8 ceded policies; and
9 ‘‘(iii) the mechanism by which high-
10 risk individuals are designated for cession
11 to the pool, which may include a list of
12 designated high-cost health conditions.
13 ‘‘(B) A reinsurance program, as defined by
14 the State, that assumes a portion of the risk for
15 individuals who experience higher than average
16 health costs as determined by the State, in a
17 manner substantially similar to the reinsurance
18 program that operated in the State in accord-
19 ance with section 1341.
20 ‘‘(C) A reinsurance program established by
21 the State not otherwise described in this para-
22 graph.
23 ‘‘(D) A program based on another State’s
24 reinsurance program—
TAM18386 S.L.C.

20
1 ‘‘(i) described in subparagraph (A),
2 (B), or (C), for which an application has
3 been approved under this subsection; or
4 ‘‘(ii) which was implemented prior to
5 the date of enactment of the Bipartisan
6 Health Care Stabilization Act of 2018, and
7 which the Secretary determines meets the
8 requirements of subparagraph (A).
9 ‘‘(3) SINGLE RISK POOL.—An invisible high-risk
10 pool or reinsurance program established in accord-
11 ance with this subsection shall not be considered a
12 separate risk pool for purposes of section 1312(c).’’.
13 (8) APPLICABILITY.—The amendments made
14 by this Act to section 1332 of the Patient Protection
15 and Affordable Care Act (42 U.S.C. 18052)—
16 (A) with respect to applications for waivers
17 under such section 1332 submitted after the
18 date of enactment of this Act and applications
19 for such waivers submitted prior to such date of
20 enactment and under review by the Secretary
21 on the date of enactment, shall take effect on
22 the date of enactment of this Act; and
23 (B) with respect to applications for waivers
24 approved under such section 1332 before the
25 date of enactment of this Act, shall not require
TAM18386 S.L.C.

21
1 reconsideration of whether such applications
2 meet the requirements of such section 1332, ex-
3 cept that, at the request of a State, the Sec-
4 retary shall recalculate the amount of funding
5 provided under subsection (a)(3) of such sec-
6 tion.
7 (9) CLARIFYING BUDGET NEUTRALITY.—Sec-

8 tion 1332(a)(1)(B) of the Patient Protection and Af-

9 fordable Care Act (42 U.S.C. 18052(a)(1)(B)) is
10 amended—
11 (A) in clause (i), by inserting ‘‘, including,
12 as applicable, a description of the State’s plan
13 to use any amounts awarded to the State under
14 paragraph (4) to support an invisible high-risk
15 pool or reinsurance program consistent with
16 subsection (g) and such information about such
17 program as the Secretary may require’’ before
18 the semicolon; and
19 (B) in clause (ii), by inserting ‘‘over both
20 the term of the proposed waiver and the term
21 of the 10-year budget plan’’ after ‘‘Govern-
22 ment’’.
23 (b) COST-SHARING PAYMENTS.—
24 (1) IN GENERAL.—There is appropriated to the
25 Secretary of Health and Human Services (referred
TAM18386 S.L.C.

22
1 to in this section as the ‘‘Secretary’’), out of any
2 funds in the Treasury not otherwise obligated, such
3 sums as may be necessary for payments for cost-
4 sharing reductions, as authorized by section 1402 of
5 the Patient Protection and Affordable Care Act (42
6 U.S.C. 18071) for plan years 2017, 2019, 2020, and
7 2021.
8 (2) SPECIAL RULES FOR COST-SHARING REDUC-

9 TIONS.—

10 (A) BASIC HEALTH PLAN.—For plan year

11 2018, there is appropriated to the Secretary,
12 out of any funds in the Treasury not otherwise
13 obligated, such sums as may be necessary for,
14 with respect to States that have in effect a
15 basic health plan on January 1, 2018, the por-
16 tion of transfers pursuant to section 1331(d) of
17 the Patient Protection and Affordable Care Act
18 (42 U.S.C. 18051(d)) attributable to the cost-
19 sharing reductions under section 1402 of the
20 Patient Protection and Affordable Care Act (42
21 U.S.C. 18071) that would have been provided
22 for plan year 2018 with respect to eligible indi-
23 viduals enrolled in standard health plans in
24 such States.
25 (B) HOLD HARMLESS.—
TAM18386 S.L.C.

23
1 (i) IN GENERAL.—For plan year
2 2018, there is appropriated to the Sec-
3 retary, out of any funds in the Treasury
4 not otherwise obligated, such sums as may
5 be necessary for payments for cost-sharing
6 reductions authorized by section 1402 of
7 the Patient Protection and Affordable Care
8 Act (42 U.S.C. 18071) with respect to
9 specified qualified health plans described in
10 clause (ii).
11 (ii) SPECIFIED QUALIFIED HEALTH

12 PLANS DESCRIBED.—A specified qualified

13 health plan described in this clause is a
14 qualified health plan—
15 (I) offered in a State that—
16 (aa) prohibited increasing
17 premium rates to account for
18 non-payment of cost-sharing re-
19 ductions under section 1402 of
20 the Patient Protection and Af-
21 fordable Care Act; or
22 (bb) did not provide guid-
23 ance on whether to increase pre-
24 miums to account for non-pay-
TAM18386 S.L.C.

24
1 ment of cost-sharing reduction
2 under such section 1402; and
3 (II) for which the Secretary de-
4 termines, based on a certification and
5 appropriate documentation from the
6 issuer of such plan and a certification
7 from the applicable State regulator,
8 that the health insurance issuer of
9 such plan has not increased premium
10 rates for plan year 2018 on account
11 of the issuer assuming, or being in-
12 structed by applicable State regulators
13 to assume, that the issuer would re-
14 ceive payments under such section
15 1402.
16 (3) PROTECTING CONSUMERS FROM INCREASED

17 OUT-OF-POCKET COSTS.—Section 1402 of the Pa-

18 tient Protection and Affordable Care Act (42 U.S.C.
19 18071) is amended by adding at the end, the fol-
20 lowing:
21 ‘‘(g) ADDITIONAL REDUCTION.—
22 ‘‘(1) REDUCTION FOR LOW INCOME IN-

23 SUREDS.—For plan years 2019 through 2021, in ad-

24 dition to the cost-sharing reductions under sub-
25 section (c), the Secretary shall establish procedures
TAM18386 S.L.C.

25
1 under which the issuer of a qualified health plan to
2 which this section applies shall further reduce cost-
3 sharing under the plan in a manner sufficient to—
4 ‘‘(A) in the case of an eligible insured
5 whose household income is not less than 150
6 percent but not more than 250 percent of the
7 poverty line for a family of the size involved, in-
8 crease the plan’s share of the total allowed
9 costs of benefits provided under the plan to 87
10 percent of such costs; and
11 ‘‘(B) in the case of an eligible insured
12 whose household income is not less than 250
13 percent but not more than 400 percent of the
14 poverty line for a family of the size involved, in-
15 crease the plan’s share of the total allowed
16 costs of benefits provided under the plan to 80
17 percent of such costs.’’.
18 ‘‘(2) CONFORMING AMENDMENT.—For plan
19 years 2019 through 2021, in addition to the coordi-
20 nation with actuarial value limits under subsection
21 (c)(1)(B),the Secretary shall ensure that the reduc-
22 tions under subsection (c)(1) do not result in an in-
23 crease in the plan’s share of the total allowed costs
24 of benefits provided under the plan above—
TAM18386 S.L.C.

26
1 ‘‘(A) 87 percent, in the case of an eligible
2 insured described in paragraph (1)(A); and
3 ‘‘(B) 80 percent, in the case of an eligible
4 insured described in paragraph (1)(B).’’.
5 SEC. 3. ALLOWING ALL INDIVIDUALS PURCHASING HEALTH

6 INSURANCE IN THE INDIVIDUAL MARKET

7 THE OPTION TO PURCHASE A LOWER PRE-

8 MIUM COPPER PLAN.

9 (a) IN GENERAL.—Section 1302(e) of the Patient

10 Protection and Affordable Care Act (42 U.S.C. 18022(e))
11 is amended—
12 (1) in paragraph (1)—
13 (A) by redesignating clauses (i) and (ii) of
14 subparagraph (B) as subparagraphs (A) and
15 (B), respectively, and adjusting the margins ac-
16 cordingly;
17 (B) by striking ‘‘plan year if—’’ and all
18 that follows through ‘‘the plan provides—’’ and
19 inserting ‘‘plan year if the plan provides—’’;
20 and
21 (C) in subparagraph (A), as redesignated
22 by paragraph (1), by striking ‘‘clause (ii)’’ and
23 inserting ‘‘subparagraph (B)’’;
24 (2) by striking paragraph (2); and
TAM18386 S.L.C.

27
1 (3) by redesignating paragraph (3) as para-
2 graph (2).
3 (b) RISK POOLS.—Section 1312(c)(1) of the Patient
4 Protection and Affordable Care Act (42 U.S.C. 18032(c))
5 is amended by inserting ‘‘and including enrollees in cata-
6 strophic plans described in section 1302(e)’’ after ‘‘Ex-
7 change’’.
8 (c) CONFORMING AMENDMENT.—Section
9 1312(d)(3)(C) of the Patient Protection and Affordable
10 Care Act (42 U.S.C. 18032(d)(3)(C)) is amended by strik-
11 ing ‘‘, except that in the case of a catastrophic plan de-
12 scribed in section 1302(e), a qualified individual may en-
13 roll in the plan only if the individual is eligible to enroll
14 in the plan under section 1302(e)(2)’’.
15 (d) EFFECTIVE DATE.—The amendments made by
16 subsections (a), (b), and (c) shall apply with respect to
17 plan years beginning on or after January 1, 2019.
18 SEC. 4. CONSUMER OUTREACH, EDUCATION, AND ASSIST-

19 ANCE.

20 (a) OPEN ENROLLMENT REPORTS.—For plan years

21 2019 through 2021, the Secretary of Health and Human
22 Services (referred to in this section as the ‘‘Secretary’’),
23 in coordination with the Secretary of the Treasury and
24 the Secretary of Labor, shall issue biweekly public reports
25 during the annual open enrollment period on the perform-
TAM18386 S.L.C.

28
1 ance of the Federal Exchange and the Small Business
2 Health Options Program (SHOP) Marketplace. Each such
3 report shall include a summary, including information on
4 a State-by-State basis where available, of—
5 (1) the number of unique website visits;
6 (2) the number of individuals who create an ac-
7 count;
8 (3) the number of calls to the call center;
9 (4) the average wait time for callers contacting
10 the call center;
11 (5) the number of individuals who enroll in a
12 qualified health plan; and
13 (6) the percentage of individuals who enroll in
14 a qualified health plan through each of—
15 (A) the website;
16 (B) the call center;
17 (C) navigators;
18 (D) agents and brokers;
19 (E) the enrollment assistant program;
20 (F) directly from issuers or web brokers;
21 and
22 (G) other means.
23 (b) OPEN ENROLLMENT AFTER ACTION REPORT.—
24 For plan years 2019 through 2021, the Secretary, in co-
25 ordination with the Secretary of the Treasury and the Sec-
TAM18386 S.L.C.

29
1 retary of Labor, shall publish an after action report not
2 later than 3 months after the completion of the annual
3 open enrollment period regarding the performance of the
4 Federal Exchange and the Small Business Health Options
5 Program (SHOP) Marketplace for the applicable plan
6 year. Each such report shall include a summary, including
7 information on a State-by-State basis where available,
8 of—
9 (1) the open enrollment data reported under
10 subsection (a) for the entirety of the enrollment pe-
11 riod; and
12 (2) activities related to patient navigators de-
13 scribed in section 1311(i) of the Patient Protection
14 and Affordable Care Act (42 U.S.C. 18031(i)), in-
15 cluding—
16 (A) the performance objectives established
17 by the Secretary for such patient navigators;
18 (B) the number of consumers enrolled by
19 such a patient navigator;
20 (C) an assessment of how such patient
21 navigators have met established performance
22 metrics, including a detailed list of all patient
23 navigators, funding received by patient naviga-
24 tors, and whether established performance ob-
25 jectives of patient navigators were met; and
TAM18386 S.L.C.

30
1 (D) with respect to the performance objec-
2 tives described in subparagraph (A)—
3 (i) whether such objectives assess the
4 full scope of patient navigator responsibil-
5 ities, including general education, plan se-
6 lection, and determination of eligibility for
7 tax credits, cost-sharing reductions, or
8 other coverage;
9 (ii) how the Secretary worked with pa-
10 tient navigators to establish such objec-
11 tives; and
12 (iii) how the Secretary adjusted such
13 objectives for case complexity and other
14 contextual factors.
15 (c) REPORT ON ADVERTISING AND CONSUMER OUT-
16 REACH.—Not later than 3 months after the completion of
17 the annual open enrollment period for the 2019 plan year,
18 the Secretary shall issue a report on advertising and out-
19 reach to consumers for the open enrollment period for the
20 2019 plan year. Such report shall include a description
21 of—
22 (1) the division of spending on individual adver-
23 tising platforms, including television and radio ad-
24 vertisements and digital media, to raise consumer
25 awareness of open enrollment;
TAM18386 S.L.C.

31
1 (2) the division of spending on individual out-
2 reach platforms, including email and text messages,
3 to raise consumer awareness of open enrollment; and
4 (3) whether the Secretary conducted targeted
5 outreach to specific demographic groups and geo-
6 graphic areas.
7 (d) OUTREACH AND ENROLLMENT ACTIVITIES.—
8 (1) OPEN ENROLLMENT.—Of the amounts col-
9 lected through the user fees on participating health
10 insurance issuers pursuant to section 156.50 of title
11 45, Code of Federal Regulations (or any successor
12 regulations), the Secretary shall obligate
13 $105,800,000 for outreach and enrollment activities
14 for each of the open enrollment periods for plan
15 years 2019 through 2021.
16 (2) OUTREACH AND ENROLLMENT ACTIVI-

17 TIES.—

18 (A) IN GENERAL.—For purposes of this

19 subsection, the term ‘‘outreach and enrollment
20 activities’’ means—
21 (i) activities to educate consumers
22 about coverage options or to encourage
23 consumers to enroll in or maintain health
24 insurance coverage (excluding allocations
TAM18386 S.L.C.

32
1 to the call center for the Federal Ex-
2 change); and
3 (ii) activities conducted by an in-per-
4 son consumer assistance program that does
5 not have a conflict of interest and that,
6 among other activities, facilitates enroll-
7 ment of individuals through the Federal
8 Exchange, and distributes fair and impar-
9 tial information concerning enrollment
10 through such Exchange and the availability
11 of tax credits and cost-sharing reductions.
12 (B) CONNECTION WITH FEDERAL EX-

13 CHANGE.—Activities conducted under this sub-

14 section shall be in connection with the operation
15 of the Federal Exchange, to provide special
16 benefits to health insurance issuers partici-
17 pating in the Federal Exchange.
18 (3) CONTRACT AUTHORITY.—The Secretary
19 may contract with a State to conduct outreach and
20 enrollment activities for plan years 2019 through
21 2021. Any outreach and enrollment activities con-
22 ducted by a State or other entity at the direction of
23 the State, in accordance with such a contract, shall
24 be treated as Federal activities to provide special
TAM18386 S.L.C.

33
1 benefits to participating health insurance issuers
2 consistent with OMB Circular No. A–25R.
3 (4) CLARIFICATIONS.—
4 (A) PRIOR FUNDING.—Nothing in this
5 subsection should be construed as rescinding or
6 cancelling any funds already obligated on the
7 date of enactment of this Act for outreach and
8 enrollment activities for plan year 2019.
9 (B) AVAILABILITY OF FUNDING.—The

10 Secretary shall ensure that outreach and enroll-

11 ment activities are conducted in all applicable
12 States, including, as necessary, by providing for
13 such activities through contracts described in
14 paragraph (3).
15 SEC. 5. OFFERING HEALTH PLANS IN MORE THAN ONE

16 STATE.

17 Not later than 1 year after the date of enactment

18 of this Act, the Secretary of Health and Human Services,
19 in consultation with the National Association of Insurance
20 Commissioners, shall issue regulations for the implemen-
21 tation of health care choice compacts established under
22 section 1333 of the Patient Protection and Affordable
23 Care Act (42 U.S.C. 18053) to allow for the offering of
24 health plans in more than one State.
TAM18386 S.L.C.

34
1 SEC. 6. SHORT-TERM LIMITED DURATION HEALTH INSUR-

2 ANCE POLICIES.

3 (a) PROHIBITION ON PROPOSED RULE.—Notwith-

4 standing any other provision of law, the Secretary of
5 Health and Human Services, the Secretary of the Treas-
6 ury, and the Secretary of Labor may not take any action
7 to implement, enforce, or otherwise give effect to the pro-
8 posed rule relating to the definition of short-term limited-
9 duration insurance (83 Fed. Reg. 7437–7447, February
10 21, 2018), insofar as such proposed rule relates to a re-
11 vised definition of the term ‘‘short-term limited duration
12 insurance’’ and the Secretaries shall implement, enforce,
13 and otherwise give effect to the definition of such term
14 as applied by the Secretaries under the regulations in ef-
15 fect on the date of enactment of this Act (81 Fed. Reg.
16 75316), and such regulations shall continue in effect with
17 respect to policies until the effective date described in sub-
18 section (b)(2).
19 (b) STANDARDS.—
20 (1) IN GENERAL.—Section 2791(b) of the Pub-
21 lic Health Service Act (42 U.S.C. 300gg–91) is
22 amended by adding at the end the following:
23 ‘‘(6) SHORT-TERM LIMITED DURATION INSUR-

24 ANCE.—The term ‘short-term limited duration insur-

25 ance’ means health insurance coverage provided pur-
TAM18386 S.L.C.

35
1 suant to a contract with a health insurance issuer
2 that—
3 ‘‘(A) has a specified, limited duration not
4 to exceed 93 days after the original effective
5 date of the contract, except that the health plan
6 may permit coverage to continue until the end
7 of the period of hospitalization for a condition
8 for which the covered person was hospitalized
9 on the day that coverage would otherwise have
10 ended;
11 ‘‘(B) is non-renewable and issued only to
12 individuals who have not been covered under a
13 short-term limited duration insurance policy
14 from any health insurance issuer within the
15 prior 12 months;
16 ‘‘(C) displays prominently in marketing
17 materials, the contract, and in any application
18 materials provided in connection with enroll-
19 ment in such insurance a notice to consumers
20 that includes such information which the State
21 insurance commissioner deems sufficient to in-
22 form the individual that coverage and benefits
23 are limited;
TAM18386 S.L.C.

36
1 ‘‘(D) covers essential health benefits as set
2 forth in section 1302 of the Patient Protection
3 and Affordable Care Act;
4 ‘‘(E) meets the following requirements for
5 individual health insurance coverage as set
6 forth in this title—
7 ‘‘(i) section 2701 (relating to fair
8 health insurance premiums);
9 ‘‘(ii) section 2702 (relating to guaran-
10 teed availability of coverage), except as
11 provided in paragraph (1) consistent with
12 the limitations of subsection (c);
13 ‘‘(iii) section 2704 (relating to the
14 prohibition of pre-existing condition exclu-
15 sions or other discrimination based on
16 health status);
17 ‘‘(iv) section 2705 (relating to the
18 prohibition of discrimination against indi-
19 vidual participants and beneficiaries based
20 on health status);
21 ‘‘(v) section 2706 (relating to non-
22 discrimination in health care);
23 ‘‘(vi) section 2707 (relating to com-
24 prehensive health insurance coverage);
TAM18386 S.L.C.

37
1 ‘‘(vii) section 2711 (prohibiting life-
2 time and annual limits);
3 ‘‘(viii) section 2712 (prohibiting re-
4 scissions);
5 ‘‘(ix) section 2713 (coverage of pre-
6 ventive health services);
7 ‘‘(x) section 2714 (relating to cov-
8 erage of dependents); and
9 ‘‘(xi) section 2719 (relating to ap-
10 peals); and
11 ‘‘(F) upon the issuance of a health insur-
12 ance plan that an issuer asserts to be short-
13 term limited duration insurance, the issuer of
14 such plan shall provide documentation to the
15 Secretary and the State insurance commis-
16 sioner, in a form determined by the Secretary,
17 regarding the individuals covered by the plan
18 and the duration of the plan which shall be re-
19 viewed by the entity responsible for enforcement
20 under section 2722, together with documenta-
21 tion submitted by other issuers, to determine
22 whether the plan satisfies the requirement
23 under subparagraph (B) and, if not, such entity
24 shall take appropriate enforcement action.’’.
TAM18386 S.L.C.

38
1 (2) EFFECTIVE DATE.—The amendment made
2 by paragraph (1) shall apply to plan years beginning
3 on or after January 1, 2019.
4 SEC. 7. FUNDING.

5 Notwithstanding any other provision of law related

6 to the services described in subsection (b)(1)(B) of section
7 1303 of Public Law 111–148, amounts appropriated
8 under this division are subject to no requirements or limi-
9 tations related to such services other than the require-
10 ments or limitations established under such section 1303,
11 and, in the case of amounts appropriated under section
12 2(a)(2)(B), such section 1303 shall apply to such amounts
13 in the same manner and to the same extent as if the pur-
14 poses for which such amounts are appropriated under sec-
15 tion 2(a)(2)(B) were purposes specified in subsection
16 (b)(2)(A) of such section 1303.