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II
117TH CONGRESS
1ST SESSION
S. 352
To amend the Patient Protection and Affordable Care Act to reduce health
care costs and expand health care coverage to more Americans.
IN THE SENATE OF THE UNITED STATES
FEBRUARY 22, 2021
Mr. WARNER introduced the following bill; which was read twice and referred
to the Committee on Finance
A BILL
To amend the Patient Protection and Affordable Care Act
to reduce health care costs and expand health care cov-
erage to more Americans.
Be it enacted by the Senate and House of Representa-
1
tives of the United States of America in Congress assembled,
2
SECTION 1. SHORT TITLE.
3
This Act may be cited as the ‘‘Health Care Improve-
4
ment Act of 2021’’.
5
SEC. 2. TABLE OF CONTENTS.
6
The table of contents for this Act is as follows:
7
Sec. 1. Short title.
Sec. 2. Table of contents.
TITLE I—REDUCING HEALTH CARE COSTS AND PROTECTING
PEOPLE WITH PREEXISTING CONDITIONS
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Sec. 101. Improving affordability by expanding premium assistance for con-
sumers.
Sec. 102. Expanding affordability for working families to fix the family glitch.
Sec. 103. Establishing a State Health Insurance Affordability and Innovation
Fund.
Sec. 104. Rescinding the short-term limited duration insurance regulation.
Sec. 105. Revoking section 1332 guidance and rules.
Sec. 106. Promoting consumer outreach and education.
TITLE II—ENCOURAGING MEDICAID EXPANSION AND
STRENGTHENING THE MEDICAID PROGRAM
Sec. 201. Incentivizing Medicaid expansion.
Sec. 202. Reducing the administrative FMAP for nonexpansion States.
Sec. 203. State option to provide 12 months of postpartum Medicaid eligibility.
Sec. 204. Supporting State Medicaid programs through economic downturns.
Sec. 205. State flexibility to use administrative simplification policies for enroll-
ment.
TITLE III—ESTABLISHMENT OF A PUBLIC HEALTH CARE OPTION
Sec. 301. Establishment of health plan.
Sec. 302. Availability of plan.
Sec. 303. Affordability.
Sec. 304. Participating providers.
Sec. 305. Provider payment rates.
Sec. 306. No effect on Medicare benefits or Medicare trust funds.
TITLE IV—FAIR MEDICARE PAYMENTS TO RURAL PROVIDERS
Sec. 401. Ensuring fairness in Medicare hospital payments.
TITLE V—COMMONSENSE COMPETITION AND ACCESS TO
HEALTH INSURANCE
Sec. 501. Providing small business health insurance across State lines.
Sec. 502. Report and models.
TITLE VI—EMPOWERING MEDICARE SENIORS TO NEGOTIATE
PRESCRIPTION DRUG PRICES
Sec. 601. Authority to negotiate fair prices for Medicare prescription drugs.
TITLE VII—COMMONSENSE REPORTING FOR EMPLOYERS
Sec. 701. Voluntary prospective reporting system.
Sec. 702. Protection of dependent privacy.
Sec. 703. Electronic statements.
Sec. 704. GAO studies.
Sec. 705. Tax compliance.
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TITLE
I—REDUCING
HEALTH
1
CARE
COSTS
AND
PRO-
2
TECTING PEOPLE WITH PRE-
3
EXISTING CONDITIONS
4
SEC. 101. IMPROVING AFFORDABILITY BY EXPANDING PRE-
5
MIUM ASSISTANCE FOR CONSUMERS.
6
(a) IN GENERAL.—Section 36B(b)(3)(A) of the In-
7
ternal Revenue Code of 1986 is amended to read as fol-
8
lows:
9
‘‘(A) APPLICABLE PERCENTAGE.—The ap-
10
plicable percentage for any taxable year shall be
11
the percentage such that the applicable percent-
12
age for any taxpayer whose household income is
13
within an income tier specified in the following
14
table shall increase, on a sliding scale in a lin-
15
ear manner, from the initial premium percent-
16
age to the final premium percentage specified in
17
such table for such income tier:
18
‘‘In the case of household
income (expressed as
a percent of poverty line)
within the following income tier:
The initial
premium
percentage is—
The final
premium
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’’.
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(b)
CONFORMING
AMENDMENT.—Section
1
36B(c)(1)(A) of the Internal Revenue Code of 1986 is
2
amended by striking ‘‘but does not exceed 400 percent’’.
3
(c) EFFECTIVE DATE.—The amendments made by
4
this section shall apply to taxable years beginning after
5
December 31, 2021.
6
SEC. 102. EXPANDING AFFORDABILITY FOR WORKING FAM-
7
ILIES TO FIX THE FAMILY GLITCH.
8
(a) IN GENERAL.—Clause (i) of section 36B(c)(2)(C)
9
of the Internal Revenue Code of 1986 is amended to read
10
as follows:
11
‘‘(i) COVERAGE
MUST
BE
AFFORD-
12
ABLE.—
13
‘‘(I) EMPLOYEES.—An employee
14
shall not be treated as eligible for
15
minimum essential coverage if such
16
coverage consists of an eligible em-
17
ployer-sponsored plan (as defined in
18
section 5000A(f)(2)) and the employ-
19
ee’s required contribution (within the
20
meaning of section 5000A(e)(1)(B))
21
with respect to the plan exceeds 9.5
22
percent of the employee’s household
23
income.
24
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‘‘(II) FAMILY MEMBERS.—An in-
1
dividual who is eligible to enroll in an
2
eligible employer-sponsored plan (as
3
defined in section 5000A(f)(2)) by
4
reason of a relationship the individual
5
bears to the employee shall not be
6
treated as eligible for minimum essen-
7
tial coverage by reason of such eligi-
8
bility to enroll if the employee’s re-
9
quired contribution (within the mean-
10
ing of section 5000A(e)(1)(B), deter-
11
mined by substituting ‘family’ for
12
‘self-only’) with respect to the plan ex-
13
ceeds 9.5 percent of the employee’s
14
household income.’’.
15
(b) CONFORMING AMENDMENTS.—
16
(1) Clause (ii) of section 36B(c)(2)(C) of the
17
Internal Revenue Code of 1986 is amended by strik-
18
ing ‘‘Except as provided in clause (iii), an employee’’
19
and inserting ‘‘An individual’’.
20
(2) Clause (iii) of section 36B(c)(2)(C) of such
21
Code is amended by striking ‘‘the last sentence of
22
clause (i)’’ and inserting ‘‘clause (i)(II)’’.
23
(3) Clause (iv) of section 36B(c)(2)(C) of such
24
Code is amended by striking ‘‘the 9.5 percent under
25
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clause (i)(II)’’ and inserting ‘‘the 9.5 percent under
1
clauses (i)(I) and (i)(II)’’.
2
(c) EFFECTIVE DATE.—The amendments made by
3
this section shall apply to taxable years beginning after
4
December 31, 2021.
5
SEC. 103. ESTABLISHING A STATE HEALTH INSURANCE AF-
6
FORDABILITY AND INNOVATION FUND.
7
Subtitle D of title I of the Patient Protection and
8
Affordable Care Act (42 U.S.C. 18021 et seq.) is amended
9
by adding at the end the following:
10
‘‘PART 6—STATE HEALTH INSURANCE
11
AFFORDABILITY AND INNOVATION FUND
12
‘‘SEC. 1351. ESTABLISHMENT OF PROGRAM.
13
‘‘There is hereby established the ‘State Health Insur-
14
ance Affordability and Innovation Fund’ to be adminis-
15
tered by the Secretary of Health and Human Services, act-
16
ing through the Administrator of the Centers for Medicare
17
& Medicaid Services (referred to in this section as the ‘Ad-
18
ministrator’), to provide funding, in accordance with this
19
part, to each of the 50 States and the District of Columbia
20
(each referred to in this section as a ‘State’) beginning
21
on January 1, 2022, for the purposes described in section
22
1352.
23
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‘‘SEC. 1352. USE OF FUNDS.
1
‘‘(a) IN GENERAL.—A State shall use the funds allo-
2
cated to the State under this part for one of the following
3
purposes:
4
‘‘(1) To provide reinsurance payments to health
5
insurance issuers with respect to individuals enrolled
6
under individual health insurance coverage (other
7
than through a plan described in subsection (b)) of-
8
fered by such issuers.
9
‘‘(2) To provide assistance (other than through
10
payments described in paragraph (1)) to reduce out-
11
of-pocket costs, such as copayments, coinsurance,
12
premiums, and deductibles, of individuals enrolled
13
under qualified health plans offered on the indi-
14
vidual market through an Exchange.
15
‘‘(3) State efforts to streamline health insur-
16
ance enrollment procedures in order to reduce bur-
17
dens on consumers and facilitate greater enrollment
18
in health insurance coverage in the individual and
19
small group markets, including automatic enrollment
20
and reenrollment of, or pre-populated applications
21
for, individuals without health insurance who are eli-
22
gible for tax credits under section 36B of the Inter-
23
nal Revenue Code of 1986, with the ability to opt
24
out of such enrollment.
25
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‘‘(4) State investment in technology to improve
1
data sharing and collection for the purposes of facili-
2
tating greater enrollment in health insurance cov-
3
erage in such markets.
4
‘‘(5) Feasibility studies to develop a comprehen-
5
sive and coherent State plan for increasing enroll-
6
ment in the individual and small group market.
7
‘‘(b) EXCLUSION OF CERTAIN GRANDFATHERED AND
8
TRANSITIONAL PLANS.—For purposes of subsection (a),
9
a plan described in this subsection is the following:
10
‘‘(1) A grandfathered health plan (as defined in
11
section 1251).
12
‘‘(2) A plan (commonly referred to as a ‘transi-
13
tional plan’) continued under the letter issued by the
14
Centers for Medicare & Medicaid Services on No-
15
vember 14, 2013, to the State Insurance Commis-
16
sioners outlining a transitional policy for coverage in
17
the individual and small group markets to which sec-
18
tion 1251 does not apply, and under the extension
19
of the transitional policy for such coverage set forth
20
in the Insurance Standards Bulletin Series guidance
21
issued by the Centers for Medicare & Medicaid Serv-
22
ices on March 5, 2014, February 29, 2016, Feb-
23
ruary 13, 2017, April 9, 2018, March 25, 2019, and
24
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January 31, 2020, or under any subsequent exten-
1
sions thereof.
2
‘‘(3) Student health insurance coverage (as de-
3
fined in section 147.145 of title 45, Code of Federal
4
Regulations).
5
‘‘SEC. 1353. STATE ELIGIBILITY AND APPROVAL; DEFAULT
6
SAFEGUARD.
7
‘‘(a) ENCOURAGING STATE OPTIONS FOR ALLOCA-
8
TIONS.—
9
‘‘(1) IN GENERAL.—To be eligible for an alloca-
10
tion of funds under this part for a year (beginning
11
with 2022), a State shall submit to the Adminis-
12
trator an application at such time (but, in the case
13
of allocations for 2022, not later than 90 days after
14
the date of the enactment of this part and, in the
15
case of allocations for a subsequent year, not later
16
than March 1 of the previous year) and in such form
17
and manner as specified by the Administrator con-
18
taining—
19
‘‘(A) a description of how the funds will be
20
used; and
21
‘‘(B) such other information as the Admin-
22
istrator may require.
23
‘‘(2) AUTOMATIC APPROVAL.—An application so
24
submitted is approved unless the Administrator noti-
25
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fies the State submitting the application, not later
1
than 60 days after the date of the submission of
2
such application, that the application has been de-
3
nied for not being in compliance with any require-
4
ment of this part and of the reason for such denial.
5
‘‘(3) 5-YEAR
APPLICATION
APPROVAL.—If an
6
application of a State is approved for a purpose de-
7
scribed in section 1352 for a year, such application
8
shall be treated as approved for such purpose for
9
each of the subsequent 4 years.
10
‘‘(4) REVOCATION
OF
APPROVAL.—The ap-
11
proval of an application of a State, with respect to
12
a purpose described in section 1352, may be revoked
13
if the State fails to use funds provided to the State
14
under this section for such purpose or otherwise fails
15
to comply with the requirements of this section.
16
‘‘(b) DEFAULT FEDERAL SAFEGUARD.—
17
‘‘(1) 2022.—For 2022, in the case of a State
18
that does not submit an application under subsection
19
(a) by the 90-day submission date applicable to such
20
year under subsection (a)(1) and in the case of a
21
State that does submit such an application by such
22
date that is not approved, the Administrator, in con-
23
sultation with the State insurance commissioner,
24
shall, from the amount calculated under paragraph
25
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•S 352 IS
(4) for such year, carry out the purpose described in
1
paragraph (3) in such State for such year.
2
‘‘(2) 2023
AND
SUBSEQUENT
YEARS.—For
3
2023 or a subsequent year, in the case of a State
4
that does not have in effect an approved application
5
under this section for such year, the Administrator,
6
in consultation with the State insurance commis-
7
sioner, shall, from the amount calculated under
8
paragraph (4) for such year, carry out the purpose
9
described in paragraph (3) in such State for such
10
year.
11
‘‘(3) SPECIFIED USE.—The amount described
12
in paragraph (4), with respect to 2022 or a subse-
13
quent year, shall be used to carry out the purpose
14
described in section 1352(a)(1) in each State de-
15
scribed in paragraph (1) or (2) for such year, as ap-
16
plicable, by providing reinsurance payments to
17
health insurance issuers with respect to attachment
18
range claims (as defined in section 1354(b)(2)),
19
using the dollar amounts specified in subparagraph
20
(B) of such section for such year in an amount equal
21
to, subject to paragraph (5), the percentage (speci-
22
fied for such year by the Secretary under such sub-
23
paragraph) of the amount of such claims.
24
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