State Flexibility and Patient Choice Act of 2019

I 116TH CONGRESS 1ST SESSION H. R. 2183 To amend the Patient Protection and Affordable Care Act to streamline the State innovation waiver process, and for other purposes. IN THE HOUSE OF REPRESENTATIVES APRIL 9, 2019 Mr. MARSHALL introduced the following bill; which was referred to the Com- mittee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend the Patient Protection and Affordable Care Act to streamline the State innovation waiver process, and for other purposes. 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 ‘‘State Flexibility and 4 Patient Choice Act of 2019’’. 5 VerDate Sep 11 2014 22:04 Apr 17, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H2183.IH H2183 pamtmann on DSKBFK8HB2PROD with BILLS 2 •HR 2183 IH SEC. 2. STREAMLINING THE STATE INNOVATION WAIVER 1 PROCESS. 2 Section 1332 of the Patient Protection and Afford- 3 able Care Act (42 U.S.C. 18052) is amended— 4 (1) in subsection (a)— 5 (A) in paragraph (1)— 6 (i) in subparagraph (B)(ii), by insert- 7 ing ‘‘over both the term of the proposed 8 waiver and the 10-year budget plan’’ after 9 ‘‘Government’’; and 10 (ii) in subparagraph (C), by striking 11 ‘‘the law described in subsection (b)(2)’’ 12 and inserting ‘‘a law or has in effect a cer- 13 tification described in subsection (b)(3)’’; 14 and 15 (B) in paragraph (3)— 16 (i) in the first sentence— 17 (I) by inserting ‘‘or would qualify 18 for a lesser amount of’’ after ‘‘would 19 not qualify for’’; 20 (II) by inserting ‘‘, or the State 21 would not qualify for or would qualify 22 for a lesser payment under section 23 1331,’’ after ‘‘subtitle E’’; 24 (III) by inserting ‘‘, or on behalf 25 of participants in a basic health pro- 26 VerDate Sep 11 2014 22:04 Apr 17, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H2183.IH H2183 pamtmann on DSKBFK8HB2PROD with BILLS 3 •HR 2183 IH gram established under section 1331 1 had such participants been enrolled in 2 an Exchange,’’ after ‘‘this title’’; and 3 (IV) by inserting ‘‘or for imple- 4 menting a basic health program estab- 5 lished under section 1331’’ before the 6 period; and 7 (ii) in the second sentence, by insert- 8 ing before the period the following: ‘‘, and 9 with respect to participation in the basic 10 health program and funds provided to such 11 other States under section 1331’’; 12 (2) in subsection (b)— 13 (A) in paragraph (1)— 14 (i) in subparagraph (B), by striking 15 ‘‘at least as affordable’’ and inserting ‘‘of 16 comparable affordability’’; and 17 (ii) in subparagraph (D), by inserting 18 ‘‘over the term of the waiver and over the 19 10-year budget plan with respect to such 20 waiver’’ before the period at the end; 21 (B) by redesignating paragraph (2) as 22 paragraph (3); 23 (C) by inserting after paragraph (1) the 24 following new paragraph: 25 VerDate Sep 11 2014 22:04 Apr 17, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H2183.IH H2183 pamtmann on DSKBFK8HB2PROD with BILLS 4 •HR 2183 IH ‘‘(2) BUDGETARY EFFECT.— 1 ‘‘(A) IN GENERAL.—In determining wheth- 2 er a State plan submitted under subsection (a) 3 meets the deficit neutrality requirements of 4 paragraph (1)(D), the Secretary shall take into 5 consideration the direct budgetary effect of the 6 provisions of such plan on sources of Federal 7 funding other than the funding described in 8 subsection (a)(3).’’; and 9 (D) in paragraph (3) (as so redesig- 10 nated)— 11 (i) in the paragraph heading, by in- 12 serting ‘‘OR HAVE IN EFFECT A CER- 13 TIFICATION’’ after ‘‘LAW’’; 14 (ii) in subparagraph (A)— 15 (I) by striking ‘‘A law’’ and in- 16 serting the following: 17 ‘‘(i) LAWS.—A law’’; and 18 (II) by adding at the end the fol- 19 lowing: 20 ‘‘(ii) CERTIFICATIONS.—A certifi- 21 cation described in this paragraph is a doc- 22 ument, signed by the Governor of the 23 State, that certifies that such Governor 24 has the authority under existing State law 25 VerDate Sep 11 2014 22:04 Apr 17, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H2183.IH H2183 pamtmann on DSKBFK8HB2PROD with BILLS 5 •HR 2183 IH to take action under this section, including 1 implementation of the State plan under 2 subsection (a)(1)(B).’’; and 3 (iii) in subparagraph (B)— 4 (I) in the subparagraph heading, 5 by striking ‘‘OF OPT OUT’’; and 6 (II) by striking ‘‘may repeal a 7 law’’ and all that follows through the 8 period at the end and inserting the 9 following: ‘‘may terminate the author- 10 ity provided under the waiver with re- 11 spect to the State by—’’ 12 ‘‘(i) repealing the law described in 13 subparagraph (A)(i); or 14 ‘‘(ii) terminating the certification de- 15 scribed in subparagraph (A)(ii), through a 16 certification for such termination signed by 17 the Governor of the State.’’; 18 (3) in subsection (d)— 19 (A) in paragraph (1), by striking ‘‘180’’ 20 and inserting ‘‘90’’; and 21 (B) by adding at the end the following new 22 paragraph: 23 ‘‘(3) EXPEDITED DETERMINATION.— 24 VerDate Sep 11 2014 22:04 Apr 17, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H2183.IH H2183 pamtmann on DSKBFK8HB2PROD with BILLS 6 •HR 2183 IH ‘‘(A) IN GENERAL.—With respect to any 1 application under subsection (a)(1) submitted 2 on or after the date of the enactment of this 3 paragraph, the Secretary shall make a deter- 4 mination on such application, using the criteria 5 for approval otherwise applicable under this sec- 6 tion, not later than 60 days after the receipt of 7 such application and shall allow the public no- 8 tice and comment at the State and Federal lev- 9 els described under subsection (a)(4) to occur 10 concurrently if such State application— 11 ‘‘(i) is submitted in response to an ur- 12 gent situation, with respect to areas in the 13 State that the Secretary determines are at 14 risk for substantial increases in premium 15 rates or having no health plans offered in 16 the applicable health insurance market for 17 the current or following plan year; or 18 ‘‘(ii) is for a waiver that is the same 19 or substantially similar to a waiver that 20 the Secretary already has approved for an- 21 other State. 22 ‘‘(B) APPROVAL LIMITATIONS FOR URGENT 23 SITUATIONS.— 24 VerDate Sep 11 2014 22:04 Apr 17, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H2183.IH H2183 pamtmann on DSKBFK8HB2PROD with BILLS 7 •HR 2183 IH ‘‘(i) PROVISIONAL APPROVAL.—A 1 waiver approved under the expedited deter- 2 mination process under subparagraph 3 (A)(i) may extend over a period of not 4 longer than 3 years. 5 ‘‘(ii) FULL APPROVAL.—Subject to 6 the requirements for approval otherwise 7 applicable under this section, not later 8 than 1 year before the expiration of a pro- 9 visional waiver period described in clause 10 (i) with respect to an application described 11 in subparagraph (A)(i), the Secretary shall 12 make a determination on whether to ex- 13 tend the term of such waiver for longer 14 than the period described in clause (i), for 15 a total waiver term not to exceed 6 years. 16 The Secretary may request additional in- 17 formation as the Secretary determines ap- 18 propriate to make such determination. 19 ‘‘(C) GAO STUDY.—Not later than 5 years 20 after the date of enactment of the State Flexi- 21 bility and Patient Choice Act of 2019, the 22 Comptroller General of the United States shall 23 conduct a review of all waivers approved pursu- 24 ant to an application under subparagraph 25 VerDate Sep 11 2014 20:52 Apr 26, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H2183.IH H2183 pamtmann on DSKBFK8HB2PROD with BILLS 8 •HR 2183 IH (A)(ii) to evaluate whether such waivers met 1 the requirements of subsection (b)(1) and 2 whether the applications should have qualified 3 for such an expedited determination.’’; 4 (4) in subsection (e), by inserting ‘‘(or, in the 5 case of an application under subsection (a)(1) sub- 6 mitted on or after the date of the enactment of the 7 State Flexibility and Patient Choice Act of 2019, 6 8 years)’’ after ‘‘5 years’’; and 9 (5) by adding at the end the following new sub- 10 section: 11 ‘‘(f) ADDITIONAL PROVISIONS.—In carrying out this 12 section, the Secretary shall— 13 ‘‘(1) issue guidance, not later than 30 days 14 after the date of the enactment of this subsection, 15 that includes initial examples of model State plans 16 that may meet the requirements for approval under 17 this section; and 18 ‘‘(2) periodically review the guidance issued 19 under paragraph (1) and, when appropriate, issue 20 additional examples of model State plans that may 21 meet the requirements for approval under this sec- 22 tion, which may include— 23 ‘‘(A) model plans establishing reinsurance 24 or invisible high-risk pool arrangements for pur- 25 VerDate Sep 11 2014 20:52 Apr 26, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H2183.IH H2183 pamtmann on DSKBFK8HB2PROD with BILLS 9 •HR 2183 IH poses of covering the cost of high-risk individ- 1 uals; 2 ‘‘(B) model plans expanding insurer par- 3 ticipation, access to affordable health plans, 4 network adequacy, and health plan options over 5 the entire applicable health insurance market in 6 the State; 7 ‘‘(C) model plans that encourage or require 8 health plans in a State to deploy value-based in- 9 surance designs which structure enrollee cost- 10 sharing and other health plan design elements 11 to encourage enrollees to consume high-value 12 clinical services; 13 ‘‘(D) model plans allowing for significant 14 variation in health plan benefit design; or 15 ‘‘(E) any other model plan determined ap- 16 propriate by the Secretary.’’. 17 Æ VerDate Sep 11 2014 20:52 Apr 26, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6301 E:\BILLS\H2183.IH H2183 pamtmann on DSKBFK8HB2PROD with BILLS