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Discussion Draft
ERN17282
AMENDMENT NO.llll
S.L.C.
Calendar No.lll
Purpose: In the nature of a substitute.
IN THE SENATE OF THE UNITED STATESa115th Cong., 1st Sess.
H. R. 1628
To provide for reconciliation pursuant to title II of the
concurrent resolution on the budget for fiscal year 2017.
Referred to the Committee on llllllllll and
ordered to be printed
Ordered to lie on the table and to be printed
AMENDMENT IN THE NATURE OF A SUBSTITUTE intended
to be proposed by lllllll
Viz:
1
Strike all after the enacting clause and insert the fol-
2 lowing:
3
4
SECTION 1. SHORT TITLE.
This Act may be cited as the aaBetter Care Reconcili-
5 ation Act of 2017aa.
6
TITLE I
7
SEC. 101. ELIMINATION OF LIMITATION ON RECAPTURE OF
8
EXCESS ADVANCE PAYMENTS OF PREMIUM
9
TAX CREDITS.
10
Subparagraph (B) of section 36B(f)(2) of the Inter-
11 nal Revenue Code of 1986 is amended by adding at the
12 end the following new clause:
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2
1
aa(iii) NONAPPLICABILITY
OF LIMITA-
2
TION.aThis
3
to taxable years ending after December 31,
4
2017.aa.
5
6
7
8
subparagraph shall not apply
SEC. 102. RESTRICTIONS FOR THE PREMIUM TAX CREDIT.
(a) ELIGIBILITY FOR CREDIT.a
(1) IN
GENERAL.aSection
36B(c)(1) of the In-
ternal Revenue Code of 1986 is amendeda
9
(A) by striking aaequals or exceeds 100 per-
10
cent but does not exceed 400 percentaa in sub-
11
paragraph (A) and inserting aadoes not exceed
12
350 percentaa, and
13
(B) by striking subparagraph (B) and re-
14
designating subparagraphs (C) and (D) as sub-
15
paragraphs (B) and (C), respectively.
16
(2) TREATMENT
17
(A) IN
OF CERTAIN ALIENS.a
GENERAL.aParagraph
(2) of sec-
18
tion 36B(e) of the Internal Revenue Code of
19
1986 is amended by striking aaan alien lawfully
20
present in the United Statesaa and inserting aaa
21
qualified alien (within the meaning of section
22
431 of the Personal Responsibility and Work
23
Opportunity Reconciliation Act of 1996)aa.
24
25
(B) AMENDMENTS
TO PATIENT PROTEC-
TION AND AFFORDABLE CARE ACT.a
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3
1
(i) Section 1411(a)(1) of the Patient
2
Protection and Affordable Care Act is
3
amended by striking aaor an alien lawfully
4
present in the United Statesaa and insert-
5
ing aaor a qualified alien (within the mean-
6
ing of section 431 of the Personal Respon-
7
sibility and Work Opportunity Reconcili-
8
ation Act of 1996)aa.
9
(ii) Section 1411(c)(2)(B) of such Act
10
is amended by striking aaan alien lawfully
11
present in the United Statesaa each place it
12
appears in clauses (i)(I) and (ii)(II) and
13
inserting aaa qualified alien (within the
14
meaning of section 431 of the Personal Re-
15
sponsibility and Work Opportunity Rec-
16
onciliation Act of 1996)aa.
17
18
(iii) Section 1412(d) of such Act is
amendeda
19
(I) by striking aanot lawfully
20
present in the United Statesaa and in-
21
serting aanot citizens or nationals of
22
the United States or qualified aliens
23
(within the meaning of section 431 of
24
the Personal Responsibility and Work
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ERN17282
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4
1
Opportunity
2
1996)aa, and
Reconciliation
Act
of
3
(II) by striking aaINDIVIDUALS
4
NOT LAWFULLY PRESENTaa in the
5
heading
6
ALIENSaa.
7
8
9
(b) MODIFICATION
SISTANCE
OF
and
inserting
LIMITATION
ON
aaCERTAIN
PREMIUM AS-
AMOUNT.a
(1)
USE
OF
BENCHMARK
PLAN.aSection
10
36B(b) of the Internal Revenue Code of 1986 is
11
amendeda
12
(A) by striking aaapplicable second lowest
13
cost silver planaa each place it appears in para-
14
graph (2)(B)(i) and (3)(C) and inserting aaap-
15
plicable median cost benchmark planaa,
16
(B) by striking aasuch silver planaa in para-
17
graph (3)(C) and inserting aasuch benchmark
18
planaa, and
19
(C) in paragraph (3)(B)a
20
(i) by redesignating clauses (i) and
21
(ii) as clauses (iii) and (iv), respectively,
22
and by striking all that precedes clause
23
(iii) (as so redesignated) and inserting the
24
following:
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5
1
aa(B) APPLICABLE
MEDIAN COST BENCH-
2
MARK
3
benchmark plan with respect to any applicable
4
taxpayer is the qualified health plan offered in
5
the individual market in the rating area in
6
which the taxpayer resides whicha
PLAN.aThe
applicable
median
cost
7
aa(i) provides a level of coverage that
8
is designed to provide benefits that are ac-
9
tuarially equivalent to 58 percent of the
10
full actuarial value of the benefits (as de-
11
termined under rules similar to the rules of
12
paragraphs (2) and (3) of section 1302(d)
13
of the Patient Protection and Affordable
14
Care Act) provided under the plan,
15
aa(ii) has a premium which is the me-
16
dian premium of all qualified health plans
17
described in clause (i) which are offered in
18
the individual market in such rating area
19
(or, in any case in which no such plan has
20
such median premium, has a premium
21
nearest (but not in excess of) such median
22
premium),aa, and
23
(ii) by striking aaclause (ii)(I)aa in the
24
flush text at the end and inserting aaclause
25
(iv)(I)aa.
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6
1
(2) MODIFICATION
OF APPLICABLE PERCENT-
2
AGE.aSection
3
Code of 1986 is amendeda
36B(b)(3)(A) of the Internal Revenue
4
(A) in clause (i), by striking aafrom the ini-
5
tial premium percentageaa and all that follows
6
and inserting aafrom the initial percentage to
7
the final percentage specified in such table for
8
such income tier with respect to a taxpayer of
9
the age involved:
aaIn the case of
household income
(expressed as a
percent of the
poverty line)
within the following income
tier:
Up to 100%
100%-133%
133%-150%
150%-200%
200%-250%
250%-300%
300%-350%
10
11
12
13
14
Up to Age 29
Age 30-39
Age 40-49
Age 50-59
Over Age 59
Initial
%
Final
%
Initial
%
Final
%
Initial
%
Final
%
Initial
%
Final
%
Initial
%
Final
%
2
2
2.5
4
4.3
4.3
4.3
2
2.5
4
4.3
4.3
4.3
6.4
2
2
2.5
4
5.3
5.9
5.9
2
2.5
4
5.3
5.9
5.9
8.9
2
2
2.5
4
6.3
8.05
8.35
2
2.5
4
6.3
8.05
8.35
12.5
2
2
2.5
4
7.3
9
10.5
2
2.5
4
7.3
9
10.5
15.8
2
2
2.5
4
8.3
10
11.5
2
2.5
4
8.3
10
11.5
16.2aa,
(B) by striking aa0.504aa in clause (ii)(III)
and inserting aa0.4aa, and
(C) by adding at the end the following new
clause:
aa(iii)
AGE
DETERMINATIONS.aFor
15
purposes of clause (i), the age of the tax-
16
payer taken into account under clause (i)
17
with respect to any taxable year is the age
18
attained before the close of the taxable
19
year by the oldest individual taken into ac-
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7
1
count on such taxpayeras return who is
2
covered by a qualified health plan taken
3
into account under paragraph (2)(A).aa.
4
(c) ELIMINATION
OF
ELIGIBILITY EXCEPTIONS
FOR
5 EMPLOYER-SPONSORED COVERAGE.a
6
(1) IN
GENERAL.aSection
36B(c)(2) of the In-
7
ternal Revenue Code of 1986 is amended by striking
8
subparagraph (C).
9
(2) AMENDMENTS
RELATED
TO
QUALIFIED
10
SMALL EMPLOYER HEALTH REIMBURSEMENT AR-
11
RANGEMENTS.aSection
12
amendeda
13
14
36B(c)(4) of such Code is
(A) by striking aawhich constitutes affordable coverageaa in subparagraph (A),
15
(B) by striking aathe amount described in
16
subparagraph (C)(i)(II) for such monthaa in
17
subparagraph (B) and inserting aa1/12 of the
18
employeeas permitted benefit (as defined in sec-
19
tion 9831(d)(3)(C)) under such arrangementaa,
20
(C) by striking subparagraphs (C) and (F)
21
and redesignating subparagraphs (D) and (E)
22
as subparagraphs (C) and (D), respectively, and
23
(D) in subparagraph (D), as so redesig-
24
nated, by striking aasubparagraph (C)(i)(II)aa
25
and inserting aasubparagraph (B)aa.
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ERN17282
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8
1
(d) MODIFICATION
OF
DEFINITION
OF
QUALIFIED
2 HEALTH PLAN.a
3
(1) IN
GENERAL.aSection
36B(c)(3)(A) of the
4
Internal Revenue Code of 1986 is amended by in-
5
serting before the period at the end the following:
6
aaor a plan that includes coverage for abortions
7
(other than any abortion necessary to save the life
8
of the mother or any abortion with respect to a
9
pregnancy that is the result of an act of rape or in-
10
cest)aa.
11
(2) EFFECTIVE
DATE.aThe
amendment made
12
by this subsection shall apply to taxable years begin-
13
ning after December 31, 2017.
14
(e) INCREASED PENALTY ON ERRONEOUS CLAIMS OF
15 CREDIT.aSection 6676(a) of the Internal Revenue Code
16 of 1986 is amended by inserting aa(25 percent in the case
17 of a claim for refund or credit relating to the health insur18 ance coverage credit under section 36B)aa after aa20 per19 centaa.
20
(f) EFFECTIVE DATE.aExcept as otherwise provided
21 in this section, the amendments made by this section shall
22 apply to taxable years beginning after December 31, 2019.
23
24
25
SEC. 103. MODIFICATIONS TO SMALL BUSINESS TAX CREDIT.
(a) SUNSET.a
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9
1
(1) IN
GENERAL.aSection
45R of the Internal
2
Revenue Code of 1986 is amended by adding at the
3
end the following new subsection:
4
aa(j) SHALL NOT APPLY.aThis section shall not
5 apply with respect to amounts paid or incurred in taxable
6 years beginning after December 31, 2019.aa.
7
(2) EFFECTIVE
DATE.aThe
amendment made
8
by this subsection shall apply to taxable years begin-
9
ning after December 31, 2019.
10
(b) DISALLOWANCE
OF
SMALL EMPLOYER HEALTH
11 INSURANCE EXPENSE CREDIT
12
13
CLUDES
FOR
PLAN WHICH IN-
COVERAGE FOR ABORTION.a
(1) IN
GENERAL.aSubsection
(h) of section
14
45R of the Internal Revenue Code of 1986 is
15
amendeda
16
(A) by striking aaAny termaa and inserting
17
the following:
18
aa(1) IN
19
GENERAL.aAny
termaa, and
(B) by adding at the end the following new
20
paragraph:
21
aa(2) EXCLUSION
OF HEALTH PLANS INCLUDING
22
COVERAGE
23
health plana does not include any health plan that
24
includes coverage for abortions (other than any
25
abortion necessary to save the life of the mother or
FOR
ABORTION.aThe
term aqualified
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S.L.C.
10
1
any abortion with respect to a pregnancy that is the
2
result of an act of rape or incest).aa.
3
(2) EFFECTIVE
DATE.aThe
amendments made
4
by this subsection shall apply to taxable years begin-
5
ning after December 31, 2017.
6
7
SEC. 104. INDIVIDUAL MANDATE.
(a) IN GENERAL.aSection 5000A(c) of the Internal
8 Revenue Code of 1986 is amendeda
9
10
11
(1) in paragraph (2)(B)(iii), by striking aa2.5
percentaa and inserting aaZero percentaa, and
(2) in paragraph (3)a
12
13
(A) by striking aa$695aa in subparagraph
(A) and inserting aa$0aa, and
14
(B) by striking subparagraph (D).
15
(b) EFFECTIVE DATE.aThe amendments made by
16 this section shall apply to months beginning after Decem17 ber 31, 2015.
18
19
SEC. 105. EMPLOYER MANDATE.
(a) IN GENERAL.a
20
(1) Paragraph (1) of section 4980H(c) of the
21
Internal Revenue Code of 1986 is amended by in-
22
serting aa($0 in the case of months beginning after
23
December 31, 2015)aa after aa$2,000aa.
24
(2) Paragraph (1) of section 4980H(b) of the
25
Internal Revenue Code of 1986 is amended by in-
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11
1
serting aa($0 in the case of months beginning after
2
December 31, 2015)aa after aa$3,000aa.
3
(b) EFFECTIVE DATE.aThe amendments made by
4 this section shall apply to months beginning after Decem5 ber 31, 2015.
6
SEC. 106. STATE STABILITY AND INNOVATION PROGRAM.
7
(a) IN GENERAL.aSection 2105 of the Social Secu-
8 rity Act (42 U.S.C. 1397ee) is amended by adding at the
9 end the following new subsections:
10
aa(h) SHORT-TERM ASSISTANCE
11
ERAGE AND
12
FOR
ACCESS DISRUPTION
AND
TO
ADDRESS COV-
PROVIDE SUPPORT
STATES.a
13
aa(1) APPROPRIATION.aThere are authorized to
14
be appropriated, and are appropriated, out of monies
15
in
16
$15,000,000,000 for each of calendar years 2018
17
and 2019, and $10,000,000,000 for each of calendar
18
years 2020 and 2021, to the Administrator of the
19
Centers for Medicare & Medicaid Services (in this
20
subsection and subsection (i) referred to as the aAd-
21
ministratora) to fund arrangements with health in-
22
surance issuers to address coverage and access dis-
23
ruption and respond to urgent health care needs
24
within States. Funds appropriated under this para-
25
graph shall remain available until expended.
the
Treasury
not
otherwise
obligated,
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12
1
aa(2) PARTICIPATION
REQUIREMENTS.a
2
aa(A) GUIDANCE.aNot later than 30 days
3
after the date of enactment of this subsection,
4
the Administrator shall issue guidance to health
5
insurance issuers regarding how to submit a no-
6
tice of intent to participate in the program es-
7
tablished under this subsection.
8
9
aa(B) NOTICE
PATE.aTo
OF
INTENT
TO
PARTICI-
be eligible for funding under this
10
subsection, a health insurance issuer shall sub-
11
mit to the Administrator a notice of intent to
12
participate at such time (but, in the case of
13
funding for calendar year 2018, not later than
14
35 days after the date of enactment of this sub-
15
section and, in the case of funding for calendar
16
year 2019, 2020, or 2021, not later than March
17
31 of the previous year) and in such form and
18
manner as specified by the Administrator and
19
containinga
20
aa(i) a certification that the health in-
21
surance issuer will use the funds in accord-
22
ance with the requirements of paragraph
23
(5); and
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13
1
aa(ii) such information as the Adminis-
2
trator may require to carry out this sub-
3
section.
4
aa(3)
5
FUNDS.aThe
6
propriate procedure for providing and distributing
7
funds under this subsection.
8
PROCEDURE
aa(4) NO
FOR
DISTRIBUTION
OF
Administrator shall determine an ap-
MATCH.aNeither
the State percentage
9
applicable to payments to States under subsection
10
(i)(5)(B) nor any other matching requirement shall
11
apply to funds provided to health insurance issuers
12
under this subsection.
13
aa(5) USE
OF FUNDS.aFunds
provided to a
14
health insurance issuer under paragraph (1) shall be
15
subject to the requirements of paragraphs (1)(D)
16
and (7) of subsection (i) in the same manner as
17
such requirements apply to States receiving pay-
18
ments under subsection (i) and shall be used for the
19
activities specified in paragraph (1)(A)(ii) of sub-
20
section (i).
21
aa(i) LONG-TERM STATE STABILITY AND INNOVATION
22 PROGRAM.a
23
aa(1) APPLICATION
AND
CERTIFICATION
RE-
24
QUIREMENTS.aTo
25
funds under this subsection, a State shall submit to
be eligible for an allotment of
ERN17282
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S.L.C.
14
1
the Administrator an application, not later than
2
March 31, 2018, in the case of allotments for cal-
3
endar year 2019, and not later than March 31 of
4
the previous year, in the case of allotments for any
5
subsequent calendar year) and in such form and
6
manner as specified by the Administrator, that con-
7
tains the following:
8
9
aa(A) A description of how the funds will be
used to do 1 or more of the following:
10
aa(i) To establish or maintain a pro-
11
gram or mechanism to provide financial as-
12
sistance to help high-risk individuals, in-
13
cluding by reducing premium costs for
14
such individuals, who have or are projected
15
to have a high rate of utilization of health
16
services, as measured by cost, and who do
17
not have access to health insurance cov-
18
erage offered through an employer, enroll
19
in health insurance coverage under a plan
20
offered in the individual market (within
21
the meaning of section 5000A(f)(1)(C) of
22
the Internal Revenue Code of 1986).
23
aa(ii) To establish or maintain a pro-
24
gram to enter into arrangements with
25
health insurance issuers to help stabilize
ERN17282
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S.L.C.
15
1
premiums and promote State health insur-
2
ance market participation and choice in
3
plans offered in the individual market
4
(within
5
5000A(f)(1)(C) of the Internal Revenue
6
Code of 1986).
the
meaning
of
section
7
aa(iii) To provide payments for health
8
care providers for the provision of health
9
care services, as specified by the Adminis-
10
trator.
11
aa(iv) To provide assistance to reduce
12
out-of-pocket costs, such as copayments,
13
coinsurance, and deductibles, of individuals
14
enrolled in plans offered in the individual
15
market (within the meaning of section
16
5000A(f)(1)(C) of the Internal Revenue
17
Code of 1986).
18
aa(B) A certification that the State shall
19
make, from non-Federal funds, expenditures for
20
1 or more of the activities specified in subpara-
21
graph (A) in an amount that is not less than
22
the State percentage required for the year
23
under paragraph (5)(B)(ii).
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16
1
aa(C) A certification that the funds pro-
2
vided under this subsection shall only be used
3
for the activities specified in subparagraph (A).
4
aa(D) A certification that none of the funds
5
provided under this subsection shall be used by
6
the State for an expenditure that is attributable
7
to an intergovernmental transfer, certified pub-
8
lic expenditure, or any other expenditure to fi-
9
nance the non-Federal share of expenditures re-
10
quired under any provision of law, including
11
under the State plans established under this
12
title and title XIX or under a waiver of such
13
plans.
14
aa(E) Such other information as necessary
15
for the Administrator to carry out this sub-
16
section.
17
aa(2) ELIGIBILITY.aOnly the 50 States and the
18
District of Columbia shall be eligible for an allot-
19
ment and payments under this subsection and all
20
references in this subsection to a State shall be
21
treated as only referring to the 50 States and the
22
District of Columbia.
23
aa(3) ONE-TIME
APPLICATION.aIf
an applica-
24
tion of a State submitted under this subsection is
25
approved by the Administrator for a year, the appli-
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17
1
cation shall be deemed to be approved by the Admin-
2
istrator for that year and each subsequent year
3
through December 31, 2026.
4
aa(4) LONG-TERM
STATE STABILITY AND INNO-
5
VATION ALLOTMENTS.a
6
aa(A)
APPROPRIATION;
TOTAL
ALLOT-
7
MENT.aFor
8
ments to States under this subsection, there is
9
appropriated, out of any money in the Treasury
10
11
12
13
14
15
16
17
18
19
20
21
the purpose of providing allot-
not otherwise appropriateda
aa(i)
for
year
2019,
calendar
year
2020,
calendar
year
2021,
calendar
year
2022,
calendar
year
2023,
calendar
year
2024,
calendar
year
2025,
$8,000,000,000;
aa(ii)
for
$14,000,000,000;
aa(iii)
for
$14,000,000,000;
aa(iv)
for
$6,000,000,000;
aa(v)
for
$6,000,000,000;
aa(vi)
for
22
$5,000,000,000;
23
aa(vii)
24
calendar
for
$5,000,000,000; and
ERN17282
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18
1
aa(viii)
2
$4,000,000,000.
3
aa(B) ALLOTMENTS.a
4
aa(i) IN
for
calendar
GENERAL.aIn
year
2026,
the case of a
5
State with an application approved under
6
this subsection with respect to a year, the
7
Administrator shall allot to the State, in
8
accordance with an allotment methodology
9
specified by the Administrator that ensures
10
that the spending requirement in para-
11
graph (6) is met for the year, from
12
amounts appropriated for such year under
13
subparagraph (A), such amount as speci-
14
fied by the Administrator with respect to
15
the State and application and year.
16
17
18
aa(ii) ANNUAL
REDISTRIBUTION
OF
PREVIOUS YEARaS UNUSED FUNDS.a
aa(I) IN
GENERAL.a
In carrying
19
out clause (i), with respect to a year
20
(beginning with 2021), the Adminis-
21
trator shall, not later than March 31
22
of such yeara
23
aa(aa) determine the amount
24
of funds, if any, remaining un-
ERN17282
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19
1
used under subparagraph (A)
2
from the previous year; and
3
aa(bb) if the Administrator
4
determines that any funds so re-
5
main from the previous year, re-
6
distribute such remaining funds
7
in accordance with an allotment
8
methodology specified by the Ad-
9
ministrator to States that have
10
submitted
11
proved under this subsection for
12
the year.
13
aa(II) APPLICABLE
an
application
ap-
STATE PER-
14
CENTAGE.aThe
15
specified for a year in paragraph
16
(5)(B)(ii) shall apply to funds redis-
17
tributed under subclause (I) in that
18
year.
19
20
21
aa(C) AVAILABILITY
State
percentage
OF ALLOTTED STATE
FUNDS.a
aa(i) IN
GENERAL.aAmounts
allotted
22
to a State pursuant to subparagraph (B)(i)
23
for a year shall remain available for ex-
24
penditure by the State through the end of
25
the second succeeding year.
Discussion Draft
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20
1
aa(ii) AVAILABILITY
OF AMOUNTS RE-
2
DISTRIBUTED.aAmounts
3
a State under subparagraph (B)(ii) in a
4
year shall be available for expenditure by
5
the State through the end of the second
6
succeeding year.
7
8
9
redistributed to
aa(5) PAYMENTS.a
aa(A)
ANNUAL
MENTS.aSubject
PAYMENT
OF
ALLOT-
to subparagraph (B), the Ad-
10
ministrator shall pay to each State that has an
11
application approved under this subsection for a
12
year, the allotment determined under paragraph
13
(4)(B) for the State for the year.
14
15
aa(B) MATCH
aa(i) IN
REQUIRED.a
GENERAL.aThe
Administrator
16
shall pay each State that has an applica-
17
tion approved under this subsection for a
18
year, the Federal percentage of the allot-
19
ment determined for the State under para-
20
graph (4)(B) for the year.
21
aa(ii) FEDERAL
AND STATE PERCENT-
22
AGES DEFINED.aFor
23
(i), the Federal percentage is equal to 100
24
percent reduced by the State percentage
purposes of clause
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1
for that year, and the State percentage is
2
equal toa
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
aa(I) in the case of calendar year
2019, 0 percent;
aa(II) in the case of calendar year
2020, 0 percent;
aa(III) in the case of calendar
year 2021, 0 percent;
aa(IV) in the case of calendar
year 2022, 7 percent;
aa(V) in the case of calendar year
2023, 14 percent;
aa(VI) in the case of calendar
year 2024, 21 percent;
aa(VII) in the case of calendar
year 2025, 28 percent; and
aa(VIII) in the case of calendar
year 2026, 35 percent.
aa(C) ADVANCE
PAYMENT; RETROSPECTIVE
ADJUSTMENT.a
aa(i) IN
GENERAL.aIf
the Adminis-
22
trator deems it appropriate, the Adminis-
23
trator shall make payments under this sub-
24
section for each year on the basis of ad-
25
vance estimates of expenditures submitted
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1
by the State and such other investigation
2
as the Administrator shall find necessary,
3
and shall reduce or increase the payments
4
as necessary to adjust for any overpayment
5
or underpayment for prior years.
6
aa(ii) MISUSE
OF FUNDS.aIf
the Ad-
7
ministrator determines that a State is not
8
using funds paid to the State under this
9
subsection in a manner consistent with the
10
description provided by the State in its ap-
11
plication approved under paragraph (1),
12
the Administrator may withhold payments,
13
reduce payments, or recover previous pay-
14
ments to the State under this subsection
15
as the Administrator deems appropriate.
16
aa(D) FLEXIBILITY
IN
SUBMITTAL
OF
17
CLAIMS.aNothing
18
construed as preventing a State from claiming
19
as expenditures in the year expenditures that
20
were incurred in a previous year.
21
aa(6) REQUIRED
in this subsection shall be
USE FOR PREMIUM STABILIZA-
22
TION AND INCENTIVES FOR INDIVIDUAL MARKET
23
PARTICIPATION.aIn
24
States under this subsection for each of calendar
25
years 2019, 2020, and 2021, the Administrator shall
determining
allotments
for
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1
ensure that at least $5,000,000,000 of the amounts
2
appropriated for each such year under paragraph
3
(4)(A) are used by States for the purposes described
4
in paragraph (1)(A)(ii) and in accordance with guid-
5
ance issued by the Administrator not later than 30
6
days after the date of enactment of this subsection
7
that specifies the parameters for the use of funds for
8
such purposes.
9
aa(7) EXEMPTIONS.aParagraphs (2), (3), (5),
10
(6), (8), (10), and (11) of subsection (c) do not
11
apply to payments under this subsection.aa.
12
(b) OTHER TITLE XXI AMENDMENTS.a
13
14
(1) Section 2101 of such Act (42 U.S.C.
1397aa) is amendeda
15
(A) in subsection (a), in the matter pre-
16
ceding paragraph (1), by striking aaThe pur-
17
poseaa and inserting aaExcept with respect to
18
short-term assistance activities under section
19
2105(h) and the Long-Term State Stability and
20
Innovation Program established in section
21
2105(i), the purposeaa; and
22
(B) in subsection (b), in the matter pre-
23
ceding paragraph (1), by inserting aasubsection
24
(a) or (g) ofaa before aasection 2105aa.
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1
(2) Section 2105(c)(1) of such Act (42 U.S.C.
2
1397ee(c)(1)) is amended by striking aaand may not
3
includeaa and inserting aaor to carry out short-term
4
assistance activities under subsection (h) or the
5
Long-Term State Stability and Innovation Program
6
established in subsection (i) and, except in the case
7
of funds made available under subsection (h) or (i),
8
may not includeaa.
9
(3) Section 2106(a)(1) of such Act (42 U.S.C.
10
1397ff(a)(1)) is amended by inserting aasubsection
11
(a) or (g) ofaa before aasection 2105aa.
12
13
14
SEC. 107. BETTER CARE RECONCILIATION IMPLEMENTATION FUND.
(a) IN GENERAL.aThere is hereby established a Bet-
15 ter Care Reconciliation Implementation Fund (referred to
16 in this section as the aaFundaa) within the Department of
17 Health and Human Services to provide for Federal admin18 istrative expenses in carrying out this Act.
19
(b) FUNDING.aThere is appropriated to the Fund,
20 out of any funds in the Treasury not otherwise appro21 priated, $500,000,000.
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1
SEC. 108. REPEAL OF THE TAX ON EMPLOYEE HEALTH IN-
2
SURANCE
3
BENEFITS.
4
PREMIUMS
AND
HEALTH
PLAN
(a) IN GENERAL.aChapter 43 of the Internal Rev-
5 enue Code of 1986 is amended by striking section 4980I.
6
(b) EFFECTIVE DATE.aThe amendment made by
7 subsection (a) shall apply to taxable years beginning after
8 December 31, 2019.
9
(c) SUBSEQUENT EFFECTIVE DATE.aThe amend-
10 ment made by subsection (a) shall not apply to taxable
11 years beginning after December 31, 2025, and chapter 43
12 of the Internal Revenue Code of 1986 is amended to read
13 as such chapter would read if such subsection had never
14 been enacted.
15
SEC. 109. REPEAL OF TAX ON OVER-THE-COUNTER MEDICA-
16
TIONS.
17
(a) HSAS.aSubparagraph (A) of section 223(d)(2)
18 of the Internal Revenue Code of 1986 is amended by strik19 ing aaSuch termaa and all that follows through the period.
20
(b) ARCHER MSAS.aSubparagraph (A) of section
21 220(d)(2) of the Internal Revenue Code of 1986 is amend22 ed by striking aaSuch termaa and all that follows through
23 the period.
24
25
(c) HEALTH FLEXIBLE SPENDING ARRANGEMENTS
AND
HEALTH REIMBURSEMENT ARRANGEMENTS.aSec-
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1 tion 106 of the Internal Revenue Code of 1986 is amended
2 by striking subsection (f).
3
4
(d) EFFECTIVE DATES.a
(1)
DISTRIBUTIONS
FROM
SAVINGS
AC-
5
COUNTS.aThe
6
and (b) shall apply to amounts paid with respect to
7
taxable years beginning after December 31, 2016.
amendments made by subsections (a)
8
(2) REIMBURSEMENTS.aThe amendment made
9
by subsection (c) shall apply to expenses incurred
10
with respect to taxable years beginning after Decem-
11
ber 31, 2016.
12
SEC. 110. REPEAL OF TAX ON HEALTH SAVINGS ACCOUNTS.
13
(a) HSAS.aSection 223(f)(4)(A) of the Internal
14 Revenue Code of 1986 is amended by striking aa20 per15 centaa and inserting aa10 percentaa.
16
(b) ARCHER MSAS.aSection 220(f)(4)(A) of the In-
17 ternal Revenue Code of 1986 is amended by striking aa20
18 percentaa and inserting aa15 percentaa.
19
(c) EFFECTIVE DATE.aThe amendments made by
20 this section shall apply to distributions made after Decem21 ber 31, 2016.
22
SEC. 111. REPEAL OF LIMITATIONS ON CONTRIBUTIONS TO
23
FLEXIBLE SPENDING ACCOUNTS.
24
(a) IN GENERAL.aSection 125 of the Internal Rev-
25 enue Code of 1986 is amended by striking subsection (i).
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1
(b) EFFECTIVE DATE.aThe amendment made by
2 this section shall apply to plan years beginning after De3 cember 31, 2017.
4
SEC. 112. REPEAL OF TAX ON PRESCRIPTION MEDICA-
5
6
TIONS.
Subsection (j) of section 9008 of the Patient Protec-
7 tion and Affordable Care Act is amended to read as fol8 lows:
9
aa(j) REPEAL.aThis section shall apply to calendar
10 years beginning after December 31, 2010, and ending be11 fore January 1, 2018.aa.
12
13
SEC. 113. REPEAL OF MEDICAL DEVICE EXCISE TAX.
Section 4191 of the Internal Revenue Code of 1986
14 is amended by adding at the end the following new sub15 section:
16
aa(d) APPLICABILITY.aThe tax imposed under sub-
17 section (a) shall not apply to sales after December 31,
18 2017.aa.
19
20
SEC. 114. REPEAL OF HEALTH INSURANCE TAX.
Subsection (j) of section 9010 of the Patient Protec-
21 tion and Affordable Care Act is amended by striking aa,
22 andaa at the end of paragraph (1) and all that follows
23 through aa2017aa.
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1
SEC. 115. REPEAL OF ELIMINATION OF DEDUCTION FOR
2
EXPENSES ALLOCABLE TO MEDICARE PART D
3
SUBSIDY.
4
(a) IN GENERAL.aSection 139A of the Internal Rev-
5 enue Code of 1986 is amended by adding at the end the
6 following new sentence: aaThis section shall not be taken
7 into account for purposes of determining whether any de8 duction is allowable with respect to any cost taken into
9 account in determining such payment.aa.
10
(b) EFFECTIVE DATE.aThe amendment made by
11 this section shall apply to taxable years beginning after
12 December 31, 2016.
13
14
SEC. 116. REPEAL OF CHRONIC CARE TAX.
(a) IN GENERAL.aSubsection (a) of section 213 of
15 the Internal Revenue Code of 1986 is amended by striking
16 aa10 percentaa and inserting aa7.5 percentaa.
17
(b) EFFECTIVE DATE.aThe amendment made by
18 this section shall apply to taxable years beginning after
19 December 31, 2016.
20
21
SEC. 117. REPEAL OF MEDICARE TAX INCREASE.
(a) IN GENERAL.aSubsection (b) of section 3101 of
22 the Internal Revenue Code of 1986 is amended to read
23 as follows:
24
aa(b) HOSPITAL INSURANCE.aIn addition to the tax
25 imposed by the preceding subsection, there is hereby im26 posed on the income of every individual a tax equal to 1.45
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29
1 percent of the wages (as defined in section 3121(a)) re2 ceived by such individual with respect to employment (as
3 defined in section 3121(b).aa.
4
(b) SECA.aSubsection (b) of section 1401 of the In-
5 ternal Revenue Code of 1986 is amended to read as fol6 lows:
7
aa(b) HOSPITAL INSURANCE.aIn addition to the tax
8 imposed by the preceding subsection, there shall be im9 posed for each taxable year, on the self-employment in10 come of every individual, a tax equal to 2.9 percent of the
11 amount of the self-employment income for such taxable
12 year.aa.
13
(c) EFFECTIVE DATE.aThe amendments made by
14 this section shall apply with respect to remuneration re15 ceived after, and taxable years beginning after, December
16 31, 2022.
17
18
SEC. 118. REPEAL OF TANNING TAX.
(a) IN GENERAL.aThe Internal Revenue Code of
19 1986 is amended by striking chapter 49.
20
(b) EFFECTIVE DATE.aThe amendment made by
21 this section shall apply to services performed after Sep22 tember 30, 2017.
23
24
SEC. 119. REPEAL OF NET INVESTMENT TAX.
(a) IN GENERAL.aSubtitle A of the Internal Rev-
25 enue Code of 1986 is amended by striking chapter 2A.
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1
(b) EFFECTIVE DATE.aThe amendment made by
2 this section shall apply to taxable years beginning after
3 December 31, 2016.
4
5
SEC. 120. REMUNERATION.
Paragraph (6) of section 162(m) of the Internal Rev-
6 enue Code of 1986 is amended by adding at the end the
7 following new subparagraph:
8
aa(I) TERMINATION.aThis paragraph shall
9
not apply to taxable years beginning after De-
10
cember 31, 2016.aa.
11
SEC. 121. MAXIMUM CONTRIBUTION LIMIT TO HEALTH SAV-
12
INGS ACCOUNT INCREASED TO AMOUNT OF
13
DEDUCTIBLE AND OUT-OF-POCKET LIMITA-
14
TION.
15
(a) SELF-ONLY COVERAGE.aSection 223(b)(2)(A)
16 of the Internal Revenue Code of 1986 is amended by strik17 ing aa$2,250aa and inserting aathe amount in effect under
18 subsection (c)(2)(A)(ii)(I)aa.
19
(b) FAMILY COVERAGE.aSection 223(b)(2)(B) of
20 such Code is amended by striking aa$4,500aa and inserting
21 aathe amount in effect under subsection (c)(2)(A)(ii)(II)aa.
22
(c)
COST-OF-LIVING
ADJUSTMENT.aSection
23 223(g)(1) of such Code is amendeda
24
25
(1) by striking aasubsections (b)(2) andaa both
places it appears and inserting aasubsectionaa, and
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31
1
(2) in subparagraph (B), by striking aadeter-
2
mined byaa and all that follows through aa acalendar
3
year 2003a.aa and inserting aadetermined by sub-
4
stituting acalendar year 2003a for acalendar year
5
1992a in subparagraph (B) thereof.aa.
6
(d) EFFECTIVE DATE.aThe amendments made by
7 this section shall apply to taxable years beginning after
8 December 31, 2017.
9
SEC. 122. ALLOW BOTH SPOUSES TO MAKE CATCH-UP CON-
10
TRIBUTIONS TO THE SAME HEALTH SAVINGS
11
ACCOUNT.
12
(a) IN GENERAL.aSection 223(b)(5) of the Internal
13 Revenue Code of 1986 is amended to read as follows:
14
aa(5) SPECIAL
RULE FOR MARRIED INDIVIDUALS
15
WITH FAMILY COVERAGE.a
16
aa(A) IN
GENERAL.aIn
the case of individ-
17
uals who are married to each other, if both
18
spouses are eligible individuals and either
19
spouse has family coverage under a high de-
20
ductible health plan as of the first day of any
21
montha
22
aa(i) the limitation under paragraph
23
(1) shall be applied by not taking into ac-
24
count any other high deductible health
25
plan coverage of either spouse (and if such
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32
1
spouses both have family coverage under
2
separate high deductible health plans, only
3
one such coverage shall be taken into ac-
4
count),
5
aa(ii) such limitation (after application
6
of clause (i)) shall be reduced by the ag-
7
gregate amount paid to Archer MSAs of
8
such spouses for the taxable year, and
9
aa(iii) such limitation (after application
10
of clauses (i) and (ii)) shall be divided
11
equally between such spouses unless they
12
agree on a different division.
13
aa(B) TREATMENT
OF ADDITIONAL CON-
14
TRIBUTION AMOUNTS.aIf
15
to in subparagraph (A) have attained age 55
16
before the close of the taxable year, the limita-
17
tion referred to in subparagraph (A)(iii) which
18
is subject to division between the spouses shall
19
include the additional contribution amounts de-
20
termined under paragraph (3) for both spouses.
21
In any other case, any additional contribution
22
amount determined under paragraph (3) shall
23
not be taken into account under subparagraph
24
(A)(iii) and shall not be subject to division be-
25
tween the spouses.aa.
both spouses referred
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1
(b) EFFECTIVE DATE.aThe amendment made by
2 this section shall apply to taxable years beginning after
3 December 31, 2017.
4
SEC. 123. SPECIAL RULE FOR CERTAIN MEDICAL EXPENSES
5
INCURRED
6
HEALTH SAVINGS ACCOUNT.
7
BEFORE
ESTABLISHMENT
OF
(a) IN GENERAL.aSection 223(d)(2) of the Internal
8 Revenue Code of 1986 is amended by adding at the end
9 the following new subparagraph:
10
aa(D) TREATMENT
OF CERTAIN MEDICAL
11
EXPENSES INCURRED BEFORE ESTABLISHMENT
12
OF ACCOUNT.aIf
13
established during the 60-day period beginning
14
on the date that coverage of the account bene-
15
ficiary under a high deductible health plan be-
16
gins, then, solely for purposes of determining
17
whether an amount paid is used for a qualified
18
medical expense, such account shall be treated
19
as having been established on the date that
20
such coverage begins.aa.
21
a health savings account is
(b) EFFECTIVE DATE.aThe amendment made by
22 this subsection shall apply with respect to coverage under
23 a high deductible health plan beginning after December
24 31, 2017.
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1
2
SEC. 124. FEDERAL PAYMENTS TO STATES.
(a) IN GENERAL.aNotwithstanding section 504(a),
3 1902(a)(23), 1903(a), 2002, 2005(a)(4), 2102(a)(7), or
4 2105(a)(1) of the Social Security Act (42 U.S.C. 704(a),
5 1396a(a)(23),
1396b(a),
1397a,
1397d(a)(4),
6 1397bb(a)(7), 1397ee(a)(1)), or the terms of any Med7 icaid waiver in effect on the date of enactment of this Act
8 that is approved under section 1115 or 1915 of the Social
9 Security Act (42 U.S.C. 1315, 1396n), for the 1-year pe10 riod beginning on the date of enactment of this Act, no
11 Federal funds provided from a program referred to in this
12 subsection that is considered direct spending for any year
13 may be made available to a State for payments to a pro14 hibited entity, whether made directly to the prohibited en15 tity or through a managed care organization under con16 tract with the State.
17
18
(b) DEFINITIONS.aIn this section:
(1) PROHIBITED
ENTITY.aThe
term aaprohib-
19
ited entityaa means an entity, including its affiliates,
20
subsidiaries, successors, and clinicsa
21
22
(A) that, as of the date of enactment of
this Acta
23
(i) is an organization described in sec-
24
tion 501(c)(3) of the Internal Revenue
25
Code of 1986 and exempt from tax under
26
section 501(a) of such Code;
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1
(ii) is an essential community provider
2
described in section 156.235 of title 45,
3
Code of Federal Regulations (as in effect
4
on the date of enactment of this Act), that
5
is primarily engaged in family planning
6
services, reproductive health, and related
7
medical care; and
8
9
10
11
(iii) provides for abortions, other than
an abortiona
(I) if the pregnancy is the result
of an act of rape or incest; or
12
(II) in the case where a woman
13
suffers from a physical disorder, phys-
14
ical injury, or physical illness that
15
would, as certified by a physician,
16
place the woman in danger of death
17
unless an abortion is performed, in-
18
cluding a life-endangering physical
19
condition caused by or arising from
20
the pregnancy itself; and
21
(B) for which the total amount of Federal
22
and State expenditures under the Medicaid pro-
23
gram under title XIX of the Social Security Act
24
in fiscal year 2014 made directly to the entity
25
and to any affiliates, subsidiaries, successors, or
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1
clinics of the entity, or made to the entity and
2
to any affiliates, subsidiaries, successors, or
3
clinics of the entity as part of a nationwide
4
health
5
$350,000,000.
6
(2) DIRECT
care
provider
network,
SPENDING.aThe
exceeded
term aadirect
7
spendingaa has the meaning given that term under
8
section 250(c) of the Balanced Budget and Emer-
9
gency Deficit Control Act of 1985 (2 U.S.C. 900(c)).
10
11
12
SEC. 125. MEDICAID PROVISIONS.
The Social Security Act is amendeda
(1) in section 1902 (42 U.S.C. 1396a)a
13
(A) in subsection (a)(47)(B), by inserting
14
aaand provided that any such election shall cease
15
to be effective on January 1, 2020, and no such
16
election shall be made after that dateaa before
17
the semicolon at the end; and
18
(B) in subsection (l)(2)(C), by inserting
19
aaand ending December 31, 2019,aa after aaJanu-
20
ary 1, 2014,aa;
21
(2)
in
section
1915(k)(2)
(42
U.S.C.
22
1396n(k)(2)), by striking aaduring the period de-
23
scribed in paragraph (1)aa and inserting aaon or after
24
the date referred to in paragraph (1) and before
25
January 1, 2020aa; and
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1
(3) in section 1920(e) (42 U.S.C. 1396ra1(e)),
2
by striking aaunder clause (i)(VIII), clause (i)(IX), or
3
clause (ii)(XX) of subsection (a)(10)(A)aa and insert-
4
ing aaunder clause (i)(VIII) or clause (ii)(XX) of sec-
5
tion 1902(a)(10)(A) before January 1, 2020, section
6
1902(a)(10)(A)(i)(IX),aa.
7
8
SEC. 126. MEDICAID EXPANSION.
(a) IN GENERAL.aTitle XIX of the Social Security
9 Act (42 U.S.C. 1396 et seq.) is amendeda
10
(1) in section 1902 (42 U.S.C. 1396a)a
11
(A) in subsection (a)(10)(A)a
12
(i) in clause (i)(VIII), by inserting
13
aaand ending December 31, 2019,aa after
14
aa2014,aa; and
15
(ii) in clause (ii), in subclause (XX),
16
by inserting aaand ending December 31,
17
2017,aa after aa2014,aa, and by adding at
18
the end the following new subclause:
19
aa(XXIII) beginning January 1, 2020,
20
who are expansion enrollees (as defined in
21
subsection (nn)(1));aa; and
22
(B) by adding at the end the following new
23
24
subsection:
aa(nn) EXPANSION ENROLLEES.a
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1
2
aa(1) IN
GENERAL.aIn
this title, the term aex-
pansion enrolleea means an individuala
3
aa(A) who is under 65 years of age;
4
aa(B) who is not pregnant;
5
aa(C) who is not entitled to, or enrolled for,
6
benefits under part A of title XVIII, or enrolled
7
for benefits under part B of title XVIII;
8
9
10
aa(D) who is not described in any of subclauses
(I)
through
(VII)
of
subsection
(a)(10)(A)(i); and
11
aa(E) whose income (as determined under
12
subsection (e)(14)) does not exceed 133 percent
13
of the poverty line (as defined in section
14
2110(c)(5)) applicable to a family of the size in-
15
volved.
16
aa(2) APPLICATION
OF RELATED PROVISIONS.a
17
Any reference in subsection (a)(10)(G), (k), or (gg)
18
of this section or in section 1903, 1905(a), 1920(e),
19
or 1937(a)(1)(B) to individuals described in sub-
20
clause (VIII) of subsection (a)(10)(A)(i) shall be
21
deemed to include a reference to expansion enroll-
22
ees.aa; and
23
24
(2) in section 1905 (42 U.S.C. 1396d)a
(A) in subsection (y)(1)a
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1
(i) in the matter preceding subpara-
2
graph (A), by striking aa, with respect toaa
3
and all that follows through aashall be equal
4
toaa and inserting aaand that has elected to
5
cover newly eligible individuals before
6
March 1, 2017, with respect to amounts
7
expended by such State before January 1,
8
2020, for medical assistance for newly eli-
9
gible individuals described in subclause
10
(VIII) of section 1902(a)(10)(A)(i), and,
11
with respect to amounts expended by such
12
State after December 31, 2019, and before
13
January 1, 2024, for medical assistance
14
for expansion enrollees (as defined in sec-
15
tion 1902(nn)(1)), shall be equal to the
16
higher of the percentage otherwise deter-
17
mined for the State and year under sub-
18
section (b) (without regard to this sub-
19
section) andaa;
20
21
(ii) in subparagraph (D), by striking
aaandaa after the semicolon;
22
(iii) by striking subparagraph (E) and
23
inserting the following new subparagraphs:
24
aa(E) 90 percent for calendar quarters in
25
2020;
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1
2
3
4
5
6
aa(F) 85 percent for calendar quarters in
2021;
aa(G) 80 percent for calendar quarters in
2022; and
aa(H) 75 percent for calendar quarters in
2023.aa; and
7
(iv) by adding after and below sub-
8
paragraph (H) (as added by clause (iii)),
9
the following flush sentence:
10
aaThe Federal medical assistance percentage deter-
11
mined for a State and year under subsection (b)
12
shall apply to expenditures for medical assistance to
13
newly eligible individuals (as so described) and ex-
14
pansion enrollees (as so defined), in the case of a
15
State that has elected to cover newly eligible individ-
16
uals before March 1, 2017, for calendar quarters
17
after 2023, and, in the case of any other State, for
18
calendar quarters (or portions of calendar quarters)
19
after February 28, 2017.aa; and
20
21
22
23
(B) in subsection (z)(2)a
(i) in subparagraph (A)a
(I) by inserting aathrough 2023aa
after aaeach year thereafteraa; and
24
(II) by striking aashall be equal
25
toaa and inserting aaand, for periods
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1
after December 31, 2019 and before
2
January 1, 2024, who are expansion
3
enrollees
4
1902(nn)(1)) shall be equal to the
5
higher of the percentage otherwise de-
6
termined for the State and year under
7
subsection (b) (without regard to this
8
subsection) andaa; and
9
(ii) in subparagraph (B)(ii)a
10
(as
defined
in
section
(I) in subclause (III), by adding
11
aaandaa at the end; and
12
(II) by striking subclauses (IV),
13
(V), and (VI) and inserting the fol-
14
lowing new subclause:
15
16
aa(IV) 2017 and each subsequent year
through 2023 is 80 percent.aa.
17
(b) SUNSET
18
QUIREMENT.aSection
OF
ESSENTIAL HEALTH BENEFITS RE1937(b)(5) of the Social Security
19 Act (42 U.S.C. 1396ua7(b)(5)) is amended by adding at
20 the end the following: aaThis paragraph shall not apply
21 after December 31, 2019.aa.
22
23
SEC. 127. RESTORING FAIRNESS IN DSH ALLOTMENTS.
Section 1923(f)(7) of the Social Security Act (42
24 U.S.C. 1396ra4(f)(7)) is amended by adding at the end
25 the following new subparagraph:
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42
1
2
aa(C) NON-EXPANSION
aa(i) IN
STATES.a
GENERAL.aIn
the case of a
3
State that is a non-expansion State for a
4
fiscal yeara
5
aa(I) subparagraph (A) shall not
6
apply to the DSH allotment for such
7
State and fiscal year; and
8
aa(II) the DSH allotment for the
9
State for fiscal year 2020 shall be in-
10
creased by the amount calculated ac-
11
cording to clause (iii).
12
aa(ii) NO
CHANGE IN REDUCTION FOR
13
EXPANSION
14
State that is an expansion State for a fis-
15
cal year, the DSH allotment for such State
16
and fiscal year shall be determined as if
17
clause (i) did not apply.
18
aa(iii)
STATES.aIn
AMOUNT
the case of a
CALCULATED.aFor
19
purposes of clause (i)(II), the amount cal-
20
culated according to this clause for a non-
21
expansion State is the following:
22
aa(I) For each State, the Sec-
23
retary shall calculate a ratio equal to
24
the Stateas fiscal year 2016 DSH al-
25
lotment divided by the number of indi-
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43
1
viduals enrolled in the State plan
2
under this title for such fiscal year.
3
aa(II) The Secretary shall identify
4
the States whose ratio as so deter-
5
mined is below the national average of
6
such ratio for all States.
7
aa(III) The amount calculated
8
pursuant to this clause is an amount
9
that, if added to the Stateas fiscal
10
year 2016 DSH allotment, would in-
11
crease the ratio calculated pursuant to
12
subclause (I) up to the national aver-
13
age for all States.
14
aa(iv) DISREGARD
OF INCREASE.aThe
15
DSH allotment for a non-expansion State
16
for the second, third, and fourth quarters
17
of fiscal year 2024 and fiscal years there-
18
after shall be determined as if there had
19
been no increase in the Stateas DSH allot-
20
ment for fiscal year 2020 under clause
21
(i)(II).
22
23
aa(v) NON-EXPANSION
STATE DEFINED.aIn
AND EXPANSION
this subparagraph:
24
aa(I) The term aexpansion Statea
25
means with respect to a fiscal year, a
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1
State that, as of the date of enact-
2
ment of this subparagraph, provided
3
for eligibility under clause (i)(VIII) or
4
(ii)(XX) of section 1902(a)(10)(A) for
5
medical assistance under this title (or
6
a waiver of the State plan approved
7
under section 1115).
8
aa(II) The term anon-expansion
9
Statea means, with respect to a fiscal
10
year, a State that is not an expansion
11
State.aa.
12
13
14
SEC. 128. REDUCING STATE MEDICAID COSTS.
(a) IN GENERAL.a
(1)
STATE
PLAN
REQUIREMENTS.aSection
15
1902(a)(34) of the Social Security Act (42 U.S.C.
16
1396a(a)(34)) is amended by striking aain or after
17
the third month before the month in which he made
18
applicationaa and inserting aain or after the month in
19
which the individual made applicationaa.
20
(2) DEFINITION
OF MEDICAL ASSISTANCE.a
21
Section 1905(a) of the Social Security Act (42
22
U.S.C. 1396d(a)) is amended by striking aain or
23
after the third month before the month in which the
24
recipient makes application for assistanceaa and in-
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1
serting aain or after the month in which the recipient
2
makes application for assistanceaa.
3
(b) EFFECTIVE DATE.aThe amendments made by
4 subsection (a) shall apply to medical assistance with re5 spect to individuals whose eligibility for such assistance
6 is based on an application for such assistance made (or
7 deemed to be made) on or after October 1, 2017.
8
9
10
SEC. 129. PROVIDING SAFETY NET FUNDING FOR NON-EXPANSION STATES.
Title XIX of the Social Security Act is amended by
11 inserting after section 1923 (42 U.S.C. 1396ra4) the fol12 lowing new section:
13
14
15
aaADJUSTMENT
IN PAYMENT FOR SERVICES OF SAFETY
NET PROVIDERS IN NON-EXPANSION STATES
aaSEC. 1923A. (a) IN GENERAL.aSubject to the limi-
16 tations of this section, for each year during the period be17 ginning with fiscal year 2018 and ending with fiscal year
18 2022, each State that is one of the 50 States or the Dis19 trict of Columbia and that, as of July 1 of the preceding
20 fiscal year, did not provide for eligibility under clause
21 (i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) for medical
22 assistance under this title (or a waiver of the State plan
23 approved under section 1115) (each such State or District
24 referred to in this section for the fiscal year as a anon25 expansion Statea) may adjust the payment amounts other26 wise provided under the State plan under this title (or a
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46
1 waiver of such plan) to health care providers that provide
2 health care services to individuals enrolled under this title
3 (in this section referred to as aeligible providersa) so long
4 as the payment adjustment to such an eligible provider
5 does not exceed the provideras costs in furnishing health
6 care services (as determined by the Secretary and net of
7 payments under this title, other than under this section,
8 and by uninsured patients) to individuals who either are
9 eligible for medical assistance under the State plan (or
10 under a waiver of such plan) or have no health insurance
11 or health plan coverage for such services.
12
aa(b) INCREASE
IN
APPLICABLE FMAP.aNotwith-
13 standing section 1905(b), the Federal medical assistance
14 percentage applicable with respect to expenditures attrib15 utable to a payment adjustment under subsection (a) for
16 which payment is permitted under subsection (c) shall be
17 equal toa
18
19
20
aa(1) 100 percent for calendar quarters in fiscal
years 2018, 2019, 2020, and 2021; and
aa(2) 95 percent for calendar quarters in fiscal
21
year 2022.
22
aa(c) ANNUAL ALLOTMENT LIMITATION.aPayment
23 under section 1903(a) shall not be made to a State with
24 respect to any payment adjustment made under this sec-
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1 tion for all calendar quarters in a fiscal year in excess
2 of the $2,000,000,000 multiplied by the ratio ofa
3
aa(1) the population of the State with income
4
below 138 percent of the poverty line in 2015 (as de-
5
termined based the table entitled aHealth Insurance
6
Coverage Status and Type by Ratio of Income to
7
Poverty Level in the Past 12 Months by Agea for the
8
universe of the civilian noninstitutionalized popu-
9
lation for whom poverty status is determined based
10
on the 2015 American Community Survey 1aYear
11
Estimates, as published by the Bureau of the Cen-
12
sus), to
13
aa(2) the sum of the populations under para-
14
graph (1) for all non-expansion States.
15
aa(d) DISQUALIFICATION
16
ERAGE
IN
CASE
OF
STATE COV-
EXPANSION.aIf a State is a non-expansion for a
17 fiscal year and provides eligibility for medical assistance
18 described in subsection (a) during the fiscal year, the
19 State shall no longer be treated as a non-expansion State
20 under this section for any subsequent fiscal years.aa.
21
22
SEC. 130. ELIGIBILITY REDETERMINATIONS.
(a) IN GENERAL.aSection 1902(e)(14) of the Social
23 Security Act (42 U.S.C. 1396a(e)(14)) (relating to modi24 fied adjusted gross income) is amended by adding at the
25 end the following:
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1
aa(J) FREQUENCY
2
TERMINATIONS.aBeginning
3
2017, and notwithstanding subparagraph (H),
4
in the case of an individual whose eligibility for
5
medical assistance under the State plan under
6
this title (or a waiver of such plan) is deter-
7
mined based on the application of modified ad-
8
justed gross income under subparagraph (A)
9
and who is so eligible on the basis of clause
10
(i)(VIII), (ii)(XX), or (ii)(XXIII) of subsection
11
(a)(10)(A), at the option of the State, the State
12
plan may provide that the individualas eligibility
13
shall be redetermined every 6 months (or such
14
shorter number of months as the State may
15
elect).aa.
16
17
OF ELIGIBILITY REDE-
on
October
1,
(b) INCREASED ADMINISTRATIVE MATCHING PERCENTAGE.aFor
each calendar quarter during the period
18 beginning on October 1, 2017, and ending on December
19 31, 2019, the Federal matching percentage otherwise ap20 plicable under section 1903(a) of the Social Security Act
21 (42 U.S.C. 1396b(a)) with respect to State expenditures
22 during such quarter that are attributable to meeting the
23 requirement of section 1902(e)(14) (relating to determina24 tions of eligibility using modified adjusted gross income)
25 of such Act shall be increased by 5 percentage points with
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49
1 respect to State expenditures attributable to activities car2 ried out by the State (and approved by the Secretary) to
3 exercise the option described in subparagraph (J) of such
4 section (relating to eligibility redeterminations made on a
5 6-month or shorter basis) (as added by subsection (a)) to
6 increase the frequency of eligibility redeterminations.
7
SEC.
131.
OPTIONAL
WORK
REQUIREMENT
FOR
NON-
8
DISABLED, NONELDERLY, NONPREGNANT IN-
9
DIVIDUALS.
10
(a) IN GENERAL.aSection 1902 of the Social Secu-
11 rity Act (42 U.S.C. 1396a), as previously amended, is fur12 ther amended by adding at the end the following new sub13 section:
14
aa(oo) OPTIONAL WORK REQUIREMENT
15
DISABLED,
16
UALS.a
17
NONELDERLY,
aa(1) IN
FOR
NONPREGNANT
GENERAL.aBeginning
NON-
INDIVID-
October 1,
18
2017, subject to paragraph (3), a State may elect to
19
condition medical assistance to a nondisabled, non-
20
elderly, nonpregnant individual under this title upon
21
such an individualas satisfaction of a work require-
22
ment (as defined in paragraph (2)).
23
aa(2) WORK
REQUIREMENT DEFINED.aIn
this
24
section, the term awork requirementa means, with re-
25
spect to an individual, the individualas participation
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50
1
in work activities (as defined in section 407(d)) for
2
such period of time as determined by the State, and
3
as directed and administered by the State.
4
aa(3) REQUIRED
EXCEPTIONS.aStates
admin-
5
istering a work requirement under this subsection
6
may not apply such requirement toa
7
aa(A) a woman during pregnancy through
8
the end of the month in which the 60-day pe-
9
riod (beginning on the last day of her preg-
10
11
12
nancy) ends;
aa(B) an individual who is under 19 years
of age;
13
aa(C) an individual who is the only parent
14
or caretaker relative in the family of a child
15
who has not attained 6 years of age or who is
16
the only parent or caretaker of a child with dis-
17
abilities; or
18
aa(D) an individual who is married or a
19
head of household and has not attained 20
20
years of age and whoa
21
22
23
24
aa(i) maintains satisfactory attendance
at secondary school or the equivalent; or
aa(ii) participates in education directly
related to employment.aa.
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1
2
(b) INCREASE
TATION.aSection
IN
MATCHING RATE
FOR
IMPLEMEN-
1903 of the Social Security Act (42
3 U.S.C. 1396b) is amended by adding at the end the fol4 lowing:
5
aa(aa) The Federal matching percentage otherwise ap-
6 plicable under subsection (a) with respect to State admin7 istrative expenditures during a calendar quarter for which
8 the State receives payment under such subsection shall,
9 in addition to any other increase to such Federal matching
10 percentage, be increased for such calendar quarter by 5
11 percentage points with respect to State expenditures at12 tributable to activities carried out by the State (and ap13 proved by the Secretary) to implement subsection (oo) of
14 section 1902.aa.
15
16
SEC. 132. PROVIDER TAXES.
Section 1903(w)(4)(C) of the Social Security Act (42
17 U.S.C. 1396b(w)(4)(C)) is amended by adding at the end
18 the following new clause:
19
aa(iii) For purposes of clause (i), a de-
20
termination of the existence of an indirect
21
guarantee shall be made under paragraph
22
(3)(i) of section 433.68(f) of title 42, Code
23
of Federal Regulations, as in effect on
24
June 1, 2017, except thata
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1
aa(I) for fiscal year 2021, a5.8
2
percenta shall be substituted for a6
3
percenta each place it appears;
4
aa(II) for fiscal year 2022, a5.6
5
percenta shall be substituted for a6
6
percenta each place it appears;
7
aa(III) for fiscal year 2023, a5.4
8
percenta shall be substituted for a6
9
percenta each place it appears;
10
aa(IV) for fiscal year 2024, a5.2
11
percenta shall be substituted for a6
12
percenta each place it appears; and
13
aa(V) for fiscal year 2025 and
14
each subsequent fiscal year, a5 per-
15
centa shall be substituted for a6 per-
16
centa each place it appears.aa.
17
18
19
20
SEC. 133. PER CAPITA ALLOTMENT FOR MEDICAL ASSISTANCE.
Title XIX of the Social Security Act is amendeda
(1) in section 1903 (42 U.S.C. 1396b)a
21
(A) in subsection (a), in the matter before
22
paragraph (1), by inserting aaand section
23
1903A(a)aa after aaexcept as otherwise provided
24
in this sectionaa; and
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1
(B) in subsection (d)(1), by striking aato
2
whichaa and inserting aato which, subject to sec-
3
tion 1903A(a),aa; and
4
(2) by inserting after such section 1903 the fol-
5
6
lowing new section:
aaSEC. 1903A. PER CAPITA-BASED CAP ON PAYMENTS FOR
7
8
9
10
MEDICAL ASSISTANCE.
aa(a) APPLICATION
MENTS FOR
OF
PER CAPITA CAP
ON
PAY-
MEDICAL ASSISTANCE EXPENDITURES.a
aa(1) IN
GENERAL.aIf
a State which is one of
11
the 50 States or the District of Columbia has excess
12
aggregate medical assistance expenditures (as de-
13
fined in paragraph (2)) for a fiscal year (beginning
14
with fiscal year 2020), the amount of payment to
15
the State under section 1903(a)(1) for each quarter
16
in the following fiscal year shall be reduced by 1a4 of
17
the excess aggregate medical assistance payments
18
(as defined in paragraph (3)) for that previous fiscal
19
year. In this section, the term aStatea means only the
20
50 States and the District of Columbia.
21
aa(2) EXCESS
AGGREGATE MEDICAL ASSISTANCE
22
EXPENDITURES.aIn
23
cess aggregate medical assistance expendituresa
24
means, for a State for a fiscal year, the amount (if
25
any) by whicha
this subsection, the term aex-
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1
aa(A) the amount of the adjusted total med-
2
ical assistance expenditures (as defined in sub-
3
section (b)(1)) for the State and fiscal year; ex-
4
ceeds
5
aa(B) the amount of the target total med-
6
ical assistance expenditures (as defined in sub-
7
section (c)) for the State and fiscal year.
8
aa(3) EXCESS
9
PAYMENTS.aIn
AGGREGATE MEDICAL ASSISTANCE
this subsection, the term aexcess ag-
10
gregate medical assistance paymentsa means, for a
11
State for a fiscal year, the product ofa
12
aa(A) the excess aggregate medical assist-
13
ance expenditures (as defined in paragraph (2))
14
for the State for the fiscal year; and
15
aa(B) the Federal average medical assist-
16
ance matching percentage (as defined in para-
17
graph (4)) for the State for the fiscal year.
18
aa(4) FEDERAL
AVERAGE MEDICAL ASSISTANCE
19
MATCHING PERCENTAGE.aIn
20
term aFederal average medical assistance matching
21
percentagea means, for a State for a fiscal year, the
22
ratio (expressed as a percentage) ofa
this subsection, the
23
aa(A) the amount of the Federal payments
24
that would be made to the State under section
25
1903(a)(1) for medical assistance expenditures
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55
1
for calendar quarters in the fiscal year if para-
2
graph (1) did not apply; to
3
aa(B) the amount of the medical assistance
4
expenditures for the State and fiscal year.
5
aa(5) PER
6
CAPITA BASE PERIOD.a
aa(A) IN
GENERAL.aIn
this section, the
7
term aper capita base perioda means, with re-
8
spect to a State, a period of 8 consecutive fiscal
9
quarters selected by the State.
10
aa(B) TIMELINE.aEach State shall submit
11
its selection of per capita base period to the
12
Secretary not later than January 1, 2018.
13
aa(C) PARAMETERS.aIn selecting a per
14
capita base period under this paragraph, a
15
State shalla
16
aa(i) only select a period of 8 consecu-
17
tive fiscal quarters for which all the data
18
necessary to make determinations required
19
under this section is available, as deter-
20
mined by the Secretary; and
21
aa(ii) shall not select any period of 8
22
consecutive fiscal quarters that begins with
23
a fiscal quarter earlier than the first quar-
24
ter of fiscal year 2014 or ends with a fiscal
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1
quarter later than the third fiscal quarter
2
of 2017.
3
aa(D) ADJUSTMENT
BY THE SECRETARY.a
4
If the Secretary determines that a State took
5
actions after the date of enactment of this sec-
6
tion (including making retroactive adjustments
7
to supplemental payment data in a manner that
8
affects a fiscal quarter in the per capita base
9
period) to diminish the quality of the data from
10
the per capita base period used to make deter-
11
minations under this section, the Secretary may
12
adjust the data as the Secretary deems appro-
13
priate.
14
15
aa(b) ADJUSTED TOTAL MEDICAL ASSISTANCE EXPENDITURES.aSubject
to subsection (g), the following
16 shall apply:
17
aa(1) IN
GENERAL.aIn
this section, the term
18
aadjusted total medical assistance expendituresa
19
means, for a Statea
20
aa(A) for the Stateas per capita base period
21
(as defined in subsection (a)(5)), the product
22
ofa
23
aa(i) the amount of the medical assist-
24
ance expenditures (as defined in paragraph
25
(2) and adjusted under paragraph (5)) for
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57
1
the State and period, reduced by the
2
amount of any excluded expenditures (as
3
defined in paragraph (3) and adjusted
4
under paragraph (5)) for the State and pe-
5
riod otherwise included in such medical as-
6
sistance expenditures; and
7
aa(ii) the 1903A base period popu-
8
lation percentage (as defined in paragraph
9
(4)) for the State; or
10
aa(B) for fiscal year 2019 or a subsequent
11
fiscal year, the amount of the medical assist-
12
ance expenditures (as defined in paragraph (2))
13
for the State and fiscal year that is attributable
14
to 1903A enrollees, reduced by the amount of
15
any excluded expenditures (as defined in para-
16
graph (3)) for the State and fiscal year other-
17
wise included in such medical assistance ex-
18
penditures and includes non-DSH supplemental
19
payments
20
(d)(4)(A)(ii)) and payments described in sub-
21
section (d)(4)(A)(iii) but shall not be construed
22
as including any expenditures attributable to
23
the program under section 1928 (relating to
24
State pediatric vaccine distribution programs).
25
In applying subparagraph (B), non-DSH sup-
(as
defined
in
subsection
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1
plemental payments (as defined in subsection
2
(d)(4)(A)(ii)) and payments described in sub-
3
section (d)(4)(A)(iii) shall be treated as fully at-
4
tributable to 1903A enrollees.
5
aa(2) MEDICAL
ASSISTANCE EXPENDITURES.a
6
In this section, the term amedical assistance expendi-
7
turesa means, for a State and fiscal year or per cap-
8
ita base period, the medical assistance payments as
9
reported by medical service category on the Form
10
CMS-64 quarterly expense report (or successor to
11
such a report form, and including enrollment data
12
and subsequent adjustments to any such report, in
13
this section referred to collectively as a aCMS-64 re-
14
porta) for quarters in the year or base period for
15
which payment is (or may otherwise be) made pur-
16
suant to section 1903(a)(1), adjusted, in the case of
17
a per capita base period, under paragraph (5).
18
aa(3) EXCLUDED
EXPENDITURES.aIn
this sec-
19
tion, the term aexcluded expendituresa means, for a
20
State and fiscal year or per capita base period, ex-
21
penditures under the State plan (or under a waiver
22
of such plan) that are attributable to any of the fol-
23
lowing:
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1
aa(A) DSH.aPayment adjustments made
2
for disproportionate share hospitals under sec-
3
tion 1923.
4
aa(B)
MEDICARE
COST-SHARING.aPay-
5
ments made for medicare cost-sharing (as de-
6
fined in section 1905(p)(3)).
7
aa(C) SAFETY
NET PROVIDER PAYMENT AD-
8
JUSTMENTS IN NON-EXPANSION STATES.aPay-
9
ment adjustments under subsection (a) of sec-
10
tion 1923A for which payment is permitted
11
under subsection (c) of such section.
12
aa(4) 1903A
BASE PERIOD POPULATION PER-
13
CENTAGE.aIn
14
period population percentagea means, for a State,
15
the Secretaryas calculation of the percentage of the
16
actual medical assistance expenditures, as reported
17
by the State on the CMSa64 reports for calendar
18
quarters in the Stateas per capita base period, that
19
are attributable to 1903A enrollees (as defined in
20
subsection (e)(1)).
21
this subsection, the term a1903A base
aa(5) ADJUSTMENTS
FOR PER CAPITA BASE PE-
22
RIOD.aIn
23
tures under paragraph (2) and excluded expendi-
24
tures under paragraph (3) for a State for the Stateas
25
per capita base period, the total amount of each type
calculating medical assistance expendi-
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1
of expenditure for the State and base period shall be
2
divided by 2.
3
aa(c) TARGET TOTAL MEDICAL ASSISTANCE EXPEND-
4
ITURES.a
5
aa(1) CALCULATION.aIn this section, the term
6
atarget total medical assistance expendituresa means,
7
for a State for a fiscal year and subject to para-
8
graph (4), the sum of the products, for each of the
9
1903A enrollee categories (as defined in subsection
10
(e)(2)), ofa
11
aa(A) the target per capita medical assist-
12
ance expenditures (as defined in paragraph (2))
13
for the enrollee category, State, and fiscal year;
14
and
15
aa(B) the number of 1903A enrollees for
16
such enrollee category, State, and fiscal year, as
17
determined under subsection (e)(4).
18
aa(2) TARGET
PER CAPITA MEDICAL ASSISTANCE
19
EXPENDITURES.aIn
20
get per capita medical assistance expendituresa
21
means, for a 1903A enrollee category and Statea
22
23
this subsection, the term atar-
aa(A) for fiscal year 2020, an amount equal
toa
24
aa(i) the provisional FY19 target per
25
capita amount for such enrollee category
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1
(as calculated under subsection (d)(5)) for
2
the State; increased by
3
aa(ii) the applicable annual inflation
4
factor (as defined in paragraph (3)) for
5
fiscal year 2020; and
6
aa(B) for each succeeding fiscal year, an
7
amount equal toa
8
aa(i) the target per capita medical as-
9
sistance expenditures (under subparagraph
10
(A) or this subparagraph) for the 1903A
11
enrollee category and State for the pre-
12
ceding fiscal year; increased by
13
aa(ii) the applicable annual inflation
14
15
factor for that succeeding fiscal year.
aa(3) APPLICABLE
16
TOR.aIn
17
inflation factora meansa
18
ANNUAL
INFLATION
FAC-
paragraph (2), the term aapplicable annual
aa(A) for fiscal years before 2025a
19
aa(i) for each of the 1903A enrollee
20
categories described in subparagraphs (C),
21
(D), and (E) of subsection (e)(2), the per-
22
centage increase in the medical care com-
23
ponent of the consumer price index for all
24
urban consumers (U.S. city average) from
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1
September of the previous fiscal year to
2
September of the fiscal year involved; and
3
aa(ii) for each of the 1903A enrollee
4
categories described in subparagraphs (A)
5
and (B) of subsection (e)(2), the percent-
6
age increase described in clause (i) plus 1
7
percentage point; and
8
aa(B) for fiscal years after 2024, for all
9
1903A enrollee categories, the percentage in-
10
crease in the consumer price index for all urban
11
consumers (U.S. city average) from September
12
of the previous fiscal year to September of the
13
fiscal year involved.
14
aa(4) DECREASE
IN
TARGET
EXPENDITURES
15
FOR REQUIRED EXPENDITURES BY CERTAIN POLIT-
16
ICAL SUBDIVISIONS.a
17
aa(A) IN
GENERAL.aIn
the case of a State
18
that had a DSH allotment under section
19
1923(f) for fiscal year 2016 that was more than
20
6 times the national average of such allotments
21
for all the States for such fiscal year and that
22
requires political subdivisions within the State
23
to contribute funds towards medical assistance
24
or other expenditures under the State plan
25
under this title (or under a waiver of such plan)
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1
for a fiscal year (beginning with fiscal year
2
2020), the target total medical assistance ex-
3
penditures for such State and fiscal year shall
4
be decreased by the amount that political sub-
5
divisions in the State are required to contribute
6
under the plan (or waiver) without reimburse-
7
ment from the State for such fiscal year, other
8
than contributions described in subparagraph
9
(B).
10
aa(B) EXCEPTIONS.aThe contributions de-
11
scribed in this subparagraph are the following:
12
aa(i) Contributions required by a State
13
from a political subdivision that, as of the
14
first day of the calendar year in which the
15
fiscal year involved beginsa
16
aa(I) has a population of more
17
than 5,000,000, as estimated by the
18
Bureau of the Census; and
19
aa(II) imposes a local income tax
20
upon its residents.
21
aa(ii) Contributions required by a
22
State from a political subdivision for ad-
23
ministrative expenses if the State required
24
such contributions from such subdivision
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1
without reimbursement from the State as
2
of January 1, 2017.
3
aa(5) ADJUSTMENTS
TO STATE EXPENDITURES
4
TARGETS TO PROMOTE PROGRAM EQUITY ACROSS
5
STATES.a
6
aa(A) IN
GENERAL.aBeginning
with fiscal
7
year 2020, the target per capita medical assist-
8
ance expenditures for a 1903A enrollee cat-
9
egory, State, and fiscal year, as determined
10
under paragraph (2), shall be adjusted (subject
11
to subparagraph (C)(i)) in accordance with this
12
paragraph.
13
aa(B) ADJUSTMENT
BASED ON LEVEL OF
14
PER CAPITA SPENDING FOR 1903A ENROLLEE
15
CATEGORIES.aSubject
16
with respect to a State, fiscal year, and 1903A
17
enrollee category, if the Stateas per capita cat-
18
egorical medical assistance expenditures (as de-
19
fined in subparagraph (D)) for the State and
20
category in the preceding fiscal yeara
to subparagraph (C),
21
aa(i) exceed the mean per capita cat-
22
egorical medical assistance expenditures
23
for the category for all States for such pre-
24
ceding year by not less than 25 percent,
25
the Stateas target per capita medical as-
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1
sistance expenditures for such category for
2
the fiscal year involved shall be reduced by
3
a percentage that shall be determined by
4
the Secretary but which shall not be less
5
than 0.5 percent or greater than 2 percent;
6
or
7
aa(ii) are less than the mean per capita
8
categorical medical assistance expenditures
9
for the category for all States for such pre-
10
ceding year by not less than 25 percent,
11
the Stateas target per capita medical as-
12
sistance expenditures for such category for
13
the fiscal year involved shall be increased
14
by a percentage that shall be determined
15
by the Secretary but which shall not be
16
less than 0.5 percent or greater than 2
17
percent.
18
aa(C) RULES
19
OF APPLICATION.a
aa(i) BUDGET
NEUTRALITY REQUIRE-
20
MENT.aIn
21
percentages by which to adjust Statesa tar-
22
get per capita medical assistance expendi-
23
tures for a category and fiscal year under
24
this paragraph, the Secretary shall make
25
such adjustments in a manner that does
determining the appropriate
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1
not result in a net increase in Federal pay-
2
ments under this section for such fiscal
3
year, and if the Secretary cannot adjust
4
such expenditures in such a manner there
5
shall be no adjustment under this para-
6
graph for such fiscal year.
7
aa(ii) ASSUMPTION
REGARDING STATE
8
EXPENDITURES.aFor
9
(i), in the case of a State that has its tar-
10
get per capita medical assistance expendi-
11
tures for a 1903A enrollee category and
12
fiscal year increased under this paragraph,
13
the Secretary shall assume that the cat-
14
egorical medical assistance expenditures
15
(as defined in subparagraph (D)(ii)) for
16
such State, category, and fiscal year will
17
equal such increased target medical assist-
18
ance expenditures.
19
purposes of clause
aa(iii) NONAPPLICATION
TO LOW-DEN-
20
SITY STATES.aThis
21
apply to any State that has a population
22
density of less than 15 individuals per
23
square mile, based on the most recent data
24
available from the Bureau of the Census.
paragraph shall not
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1
aa(iv) DISREGARD
OF ADJUSTMENT.a
2
Any adjustment under this paragraph to
3
target medical assistance expenditures for
4
a State, 1903A enrollee category, and fis-
5
cal year shall be disregarded when deter-
6
mining the target medical assistance ex-
7
penditures for such State and category for
8
a succeeding year under paragraph (2).
9
aa(v) APPLICATION
FOR FISCAL YEARS
10
2020 AND 2021.aIn
11
2021, the Secretary shall apply this para-
12
graph by deeming all categories of 1903A
13
enrollees to be a single category.
14
aa(D) PER
15
16
fiscal years 2020 and
CAPITA CATEGORICAL MEDICAL
ASSISTANCE EXPENDITURES.a
aa(i) IN
GENERAL.aIn
this paragraph,
17
the term aper capita categorical medical as-
18
sistance expendituresa means, with respect
19
to a State, 1903A enrollee category, and
20
fiscal year, an amount equal toa
21
aa(I) the categorical medical ex-
22
penditures (as defined in clause (ii))
23
for the State, category, and year; di-
24
vided by
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1
aa(II) the number of 1903A en-
2
rollees for the State, category, and
3
year.
4
aa(ii) CATEGORICAL
5
ANCE EXPENDITURES.aThe
6
ical
7
means, with respect to a State, 1903A en-
8
rollee category, and fiscal year, an amount
9
equal to the total medical assistance ex-
10
penditures (as defined in paragraph (2))
11
for the State and fiscal year that are at-
12
tributable to 1903A enrollees in the cat-
13
egory, excluding any excluded expenditures
14
(as defined in paragraph (3)) for the State
15
and fiscal year that are attributable to
16
1903A enrollees in the category.
17
medical
aa(d) CALCULATION
OF
MEDICAL ASSIST-
assistance
term acategorexpendituresa
FY19 PROVISIONAL TARGET
18 AMOUNT FOR EACH 1903A ENROLLEE CATEGORY.aSub19 ject to subsection (g), the following shall apply:
20
aa(1) CALCULATION
21
CAPITA BASE PERIOD.aFor
22
retary shall calculate (and provide notice to the
23
State not later than April 1, 2018, of) the following:
24
aa(A) The amount of the adjusted total
25
medical assistance expenditures (as defined in
OF BASE AMOUNTS FOR PER
each State the Sec-
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1
subsection (b)(1)) for the State for the Stateas
2
per capita base period.
3
aa(B) The number of 1903A enrollees for
4
the State in the Stateas per capita base period
5
(as determined under subsection (e)(4)).
6
aa(C) The average per capita medical as-
7
sistance expenditures for the State for the
8
Stateas per capita base period equal toa
9
10
aa(i) the amount calculated under subparagraph (A); divided by
11
12
13
aa(ii) the number calculated under subparagraph (B).
aa(2) FISCAL
YEAR 2019 AVERAGE PER CAPITA
14
AMOUNT BASED ON INFLATING THE PER CAPITA
15
BASE PERIOD AMOUNT TO FISCAL YEAR 2019 BY CPI-
16
MEDICAL.aThe
17
year 2019 average per capita amount for each State
18
equal toa
Secretary shall calculate a fiscal
19
aa(A) the average per capita medical assist-
20
ance expenditures for the State for the Stateas
21
per capita base period (calculated under para-
22
graph (1)(C)); increased by
23
aa(B) the percentage increase in the med-
24
ical care component of the consumer price index
25
for all urban consumers (U.S. city average)
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1
from the last month of the Stateas per capita
2
base period to September of fiscal year 2019.
3
aa(3) AGGREGATE
AND
AVERAGE
EXPENDI-
4
TURES PER CAPITA FOR FISCAL YEAR 2019.aThe
5
Secretary shall calculate for each State the fol-
6
lowing:
7
aa(A) The amount of the adjusted total
8
medical assistance expenditures (as defined in
9
subsection (b)(1)) for the State for fiscal year
10
2019.
11
aa(B) The number of 1903A enrollees for
12
the State in fiscal year 2019 (as determined
13
under subsection (e)(4)).
14
aa(4) PER
CAPITA EXPENDITURES FOR FISCAL
15
YEAR 2019 FOR EACH 1903A ENROLLEE CATEGORY.a
16
The Secretary shall calculate (and provide notice to
17
each State not later than January 1, 2020, of) the
18
following:
19
aa(A)(i) For each 1903A enrollee category,
20
the amount of the adjusted total medical assist-
21
ance expenditures (as defined in subsection
22
(b)(1)) for the State for fiscal year 2019 for in-
23
dividuals in the enrollee category, calculated by
24
excluding from medical assistance expenditures
25
those expenditures attributable to expenditures
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1
described in clause (iii) or non-DSH supple-
2
mental expenditures (as defined in clause (ii)).
3
aa(ii) In this paragraph, the term anon-
4
DSH supplemental expenditurea means a pay-
5
ment to a provider under the State plan (or
6
under a waiver of the plan) thata
7
aa(I) is not made under section 1923;
8
aa(II) is not made with respect to a
9
specific item or service for an individual;
10
aa(III) is in addition to any payments
11
made to the provider under the plan (or
12
waiver) for any such item or service; and
13
aa(IV) complies with the limits for ad-
14
ditional payments to providers under the
15
plan (or waiver) imposed pursuant to sec-
16
tion 1902(a)(30)(A), including the regula-
17
tions specifying upper payment limits
18
under the State plan in part 447 of title
19
42, Code of Federal Regulations (or any
20
successor regulations).
21
aa(iii) An expenditure described in this
22
clause is an expenditure that meets the criteria
23
specified in subclauses (I), (II), and (III) of
24
clause (ii) and is authorized under section 1115
25
for the purposes of funding a delivery system
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1
reform pool, uncompensated care pool, a des-
2
ignated State health program, or any other
3
similar expenditure (as defined by the Sec-
4
retary).
5
aa(B) For each 1903A enrollee category,
6
the number of 1903A enrollees for the State in
7
fiscal year 2019 in the enrollee category (as de-
8
termined under subsection (e)(4)).
9
aa(C) For the Stateas per capita base pe-
10
riod, the Stateas non-DSH supplemental and
11
pool payment percentage is equal to the ratio
12
(expressed as a percentage) ofa
13
aa(i) the total amount of non-DSH
14
supplemental expenditures (as defined in
15
subparagraph (A)(ii) and adjusted under
16
subparagraph (E)) and payments described
17
in subparagraph (A)(iii) (and adjusted
18
under subparagraph (E)) for the State for
19
the period; to
20
aa(ii) the amount described in sub-
21
section (b)(1)(A) for the State for the
22
Stateas per capita base period.
23
aa(D) For each 1903A enrollee category an
24
average medical assistance expenditures per
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1
capita for the State for fiscal year 2019 for the
2
enrollee category equal toa
3
aa(i) the amount calculated under sub-
4
paragraph (A) for the State, increased by
5
the non-DSH supplemental and pool pay-
6
ment percentage for the State (as cal-
7
culated under subparagraph (C)); divided
8
by
9
aa(ii) the number calculated under sub-
10
paragraph (B) for the State for the en-
11
rollee category.
12
aa(E) For purposes of subparagraph (C)(i),
13
in calculating the total amount of non-DSH
14
supplemental expenditures and payments de-
15
scribed in subparagraph (A)(iii) for a State for
16
the per capita base period, the total amount of
17
such expenditures and the total amount of such
18
payments for the State and base period shall
19
each be divided by 2.
20
aa(5) PROVISIONAL
FY19 PER CAPITA TARGET
21
AMOUNT FOR EACH 1903A ENROLLEE CATEGORY.a
22
Subject to subsection (f)(2), the Secretary shall cal-
23
culate for each State a provisional FY19 per capita
24
target amount for each 1903A enrollee category
25
equal to the average medical assistance expenditures
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1
per capita for the State for fiscal year 2019 (as cal-
2
culated under paragraph (4)(D)) for such enrollee
3
category multiplied by the ratio ofa
4
aa(A) the product ofa
5
aa(i) the fiscal year 2019 average per
6
capita amount for the State, as calculated
7
under paragraph (2); and
8
aa(ii) the number of 1903A enrollees
9
for the State in fiscal year 2019, as cal-
10
culated under paragraph (3)(B); to
11
aa(B) the amount of the adjusted total
12
medical assistance expenditures for the State
13
for fiscal year 2019, as calculated under para-
14
graph (3)(A).
15
16
aa(e) 1903A ENROLLEE; 1903A ENROLLEE CATEGORY.aSubject
to subsection (g), for purposes of this
17 section, the following shall apply:
18
aa(1) 1903A
ENROLLEE.aThe
term a1903A en-
19
rolleea means, with respect to a State and a month
20
and subject to subsection (i)(1)(B), any Medicaid
21
enrollee (as defined in paragraph (3)) for the month,
22
other than such an enrollee who for such month is
23
in any of the following categories of excluded indi-
24
viduals:
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1
aa(A) CHIP.aAn individual who is pro-
2
vided, under this title in the manner described
3
in section 2101(a)(2), child health assistance
4
under title XXI.
5
aa(B) IHS.aAn individual who receives
6
any medical assistance under this title for serv-
7
ices for which payment is made under the third
8
sentence of section 1905(b).
9
aa(C) BREAST
AND
CERVICAL
CANCER
10
SERVICES
11
vidual who is eligible for medical assistance
12
under this title only on the basis of section
13
1902(a)(10)(A)(ii)(XVIII).
14
15
ELIGIBLE
INDIVIDUAL.aAn
aa(D) PARTIAL-BENEFIT
indi-
ENROLLEES.aAn
individual whoa
16
aa(i) is an alien who is eligible for
17
medical assistance under this title only on
18
the basis of section 1903(v)(2);
19
aa(ii) is eligible for medical assistance
20
under this title only on the basis of sub-
21
clause
22
1902(a)(10)(A)(ii) (or on the basis of a
23
waiver that provides only comparable bene-
24
fits);
(XII)
or
(XXI)
of
section
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1
aa(iii) is a dual eligible individual (as
2
defined in section 1915(h)(2)(B)) and is
3
eligible for medical assistance under this
4
title (or under a waiver) only for some or
5
all of medicare cost-sharing (as defined in
6
section 1905(p)(3)); or
7
aa(iv) is eligible for medical assistance
8
under this title and for whom the State is
9
providing a payment or subsidy to an em-
10
ployer for coverage of the individual under
11
a group health plan pursuant to section
12
1906 or section 1906A (or pursuant to a
13
waiver that provides only comparable bene-
14
fits).
15
aa(E) BLIND
16
AND DISABLED CHILDREN.a
An individual whoa
17
aa(i) is a child under 19 years of age;
18
and
19
aa(ii) is eligible for medical assistance
20
under this title on the basis of being blind
21
or disabled.
22
aa(2) 1903A
ENROLLEE CATEGORY.aThe
term
23
a1903A enrollee categorya means each of the fol-
24
lowing:
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1
2
3
aa(A) ELDERLY.aA category of 1903A enrollees who are 65 years of age or older.
aa(B) BLIND
AND DISABLED.aA
category
4
of 1903A enrollees (not described in the pre-
5
vious subparagraph) whoa
6
aa(i) are 19 years of age or older; and
7
aa(ii) are eligible for medical assistance
8
under this title on the basis of being blind
9
or disabled.
10
aa(C) CHILDREN.aA category of 1903A
11
enrollees (not described in a previous subpara-
12
graph) who are children under 19 years of age.
13
aa(D) EXPANSION
ENROLLEES.aA
cat-
14
egory of 1903A enrollees (not described in a
15
previous subparagraph) who are eligible for
16
medical assistance under this title only on the
17
basis
18
(ii)(XXIII) of section 1902(a)(10)(A).
19
of
clause
aa(E) OTHER
(i)(VIII),
(ii)(XX),
or
NONELDERLY, NONDISABLED,
20
NON-EXPANSION
21
1903A enrollees who are not described in any
22
previous subparagraph.
23
aa(3) MEDICAID
ADULTS.aA
category
ENROLLEE.aThe
of
term aMed-
24
icaid enrolleea means, with respect to a State for a
25
month, an individual who is eligible for medical as-
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1
sistance for items or services under this title and en-
2
rolled under the State plan (or a waiver of such
3
plan) under this title for the month.
4
aa(4) DETERMINATION
OF NUMBER OF 1903A
5
ENROLLEES.aThe
6
State and fiscal year or the Stateas per capita base
7
period, and, if applicable, for a 1903A enrollee cat-
8
egory, is the average monthly number of Medicaid
9
enrollees for such State and fiscal year or base pe-
10
riod (and, if applicable, in such category) that are
11
reported through the CMSa64 report under (and
12
subject to audit under) subsection (h).
13
aa(f) SPECIAL PAYMENT RULES.a
14
number of 1903A enrollees for a
aa(1) APPLICATION
IN CASE OF RESEARCH AND
15
DEMONSTRATION PROJECTS AND OTHER WAIVERS.a
16
In the case of a State with a waiver of the State
17
plan approved under section 1115, section 1915, or
18
another provision of this title, this section shall
19
apply to medical assistance expenditures and medical
20
assistance payments under the waiver, in the same
21
manner as if such expenditures and payments had
22
been made under a State plan under this title and
23
the limitations on expenditures under this section
24
shall supersede any other payment limitations or
25
provisions (including limitations based on a per cap-
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1
ita limitation) otherwise applicable under such a
2
waiver.
3
aa(2) TREATMENT
OF STATES EXPANDING COV-
4
ERAGE AFTER FISCAL YEAR 2016.aIn
5
State that did not provide for medical assistance for
6
the 1903A enrollee category described in subsection
7
(e)(2)(D) during fiscal year 2016 but which provides
8
for such assistance for such category in a subse-
9
quent year, the provisional FY19 per capita target
10
amount for such enrollee category under subsection
11
(d)(5) shall be equal to the provisional FY19 per
12
capita target amount for the 1903A enrollee cat-
13
egory described in subsection (e)(2)(E).
14
aa(3) IN
the case of a
CASE OF STATE FAILURE TO REPORT
15
NECESSARY DATA.aIf
16
fiscal year (beginning with fiscal year 2019) fails to
17
satisfactorily submit data on expenditures and en-
18
rollees in accordance with subsection (h)(1), for such
19
fiscal year and any succeeding fiscal year for which
20
such data are not satisfactorily submitteda
a State for any quarter in a
21
aa(A) the Secretary shall calculate and
22
apply subsections (a) through (e) with respect
23
to the State as if all 1903A enrollee categories
24
for which such expenditure and enrollee data
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1
were not satisfactorily submitted were a single
2
1903A enrollee category; and
3
aa(B) the growth factor otherwise applied
4
under subsection (c)(2)(B) shall be decreased
5
by 1 percentage point.
6
aa(g) RECALCULATION
OF
CERTAIN AMOUNTS
FOR
7 DATA ERRORS.aThe amounts and percentage calculated
8 under paragraphs (1) and (4)(C) of subsection (d) for a
9 State for the Stateas per capita base period, and the
10 amounts of the adjusted total medical assistance expendi11 tures calculated under subsection (b) and the number of
12 Medicaid enrollees and 1903A enrollees determined under
13 subsection (e)(4) for a State for the Stateas per capita
14 base period, fiscal year 2019, and any subsequent fiscal
15 year, may be adjusted by the Secretary based upon an ap16 peal (filed by the State in such a form, manner, and time,
17 and containing such information relating to data errors
18 that support such appeal, as the Secretary specifies) that
19 the Secretary determines to be valid, except that any ad20 justment by the Secretary under this subsection for a
21 State may not result in an increase of the target total
22 medical assistance expenditures exceeding 2 percent.
23
aa(h) REQUIRED REPORTING AND AUDITING; TRANSI-
24
TIONAL INCREASE IN
25
FOR
FEDERAL MATCHING PERCENTAGE
CERTAIN ADMINISTRATIVE EXPENSES.a
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1
2
aa(1) REPORTING
aa(A) IN
OF CMSa64 DATA.a
GENERAL.aIn
addition to the
3
data required on form Group VIII on the CMSa
4
64 report form as of January 1, 2017, in each
5
CMS-64 report required to be submitted (for
6
each quarter beginning on or after October 1,
7
2018), the State shall include data on medical
8
assistance expenditures within such categories
9
of services and categories of enrollees (including
10
each 1903A enrollee category and each category
11
of excluded individuals under subsection (e)(1))
12
and the numbers of enrollees within each of
13
such enrollee categories, as the Secretary deter-
14
mines are necessary (including timely guidance
15
published as soon as possible after the date of
16
the enactment of this section) in order to imple-
17
ment this section and to enable States to com-
18
ply with the requirement of this paragraph on
19
a timely basis.
20
aa(B) REPORTING
ON
QUALIFIED
INPA-
21
TIENT PSYCHIATRIC HOSPITAL SERVICES.aNot
22
later than 60 days after the date of the enact-
23
ment of this section, the Secretary shall modify
24
the CMSa64 report form to require that States
25
submit data with respect to medical assistance
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1
expenditures for qualified inpatient psychiatric
2
hospital
3
1905(h)(3)).
4
services
(as
aa(C) REPORTING
defined
ON
in
section
CHILDREN
WITH
5
COMPLEX
6
than January 1, 2020, the Secretary shall mod-
7
ify the CMSa64 report form to require that
8
States submit data with respect to individuals
9
whoa
MEDICAL
CONDITIONS.aNot
later
10
aa(i) are enrolled in a State plan under
11
this title or title XXI or under a waiver of
12
such plan;
13
aa(ii) are under 21 years of age; and
14
aa(iii) have a chronic medical condition
15
16
17
or serious injury thata
aa(I) affects two or more body
systems;
18
aa(II) affects cognitive or physical
19
functioning (such as reducing the abil-
20
ity to perform the activities of daily
21
living, including the ability to engage
22
in movement or mobility, eat, drink,
23
communicate, or breathe independ-
24
ently); and
25
aa(III) eithera
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1
aa(aa)
requires
intensive
2
healthcare interventions (such as
3
multiple medications, therapies,
4
or durable medical equipment)
5
and intensive care coordination to
6
optimize health and avoid hos-
7
pitalizations or emergency de-
8
partment visits; or
9
aa(bb) meets the criteria for
10
medical complexity under existing
11
risk
12
using a recognized, publicly avail-
13
able pediatric grouping system
14
(such as the pediatric complex
15
conditions classification system
16
or the Pediatric Medical Com-
17
plexity Algorithm) selected by the
18
Secretary in close collaboration
19
with the State agencies respon-
20
sible
21
plans under this title and a na-
22
tional panel of pediatric, pedi-
23
atric specialty, and pediatric sub-
24
specialty experts.
adjustment
for
methodologies
administering
State
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1
aa(2) AUDITING
OF CMSa64 DATA.aThe
Sec-
2
retary shall conduct for each State an audit of the
3
number of individuals and expenditures reported
4
through the CMSa64 report for the Stateas per cap-
5
ita base period, fiscal year 2019, and each subse-
6
quent fiscal year, which audit may be conducted on
7
a representative sample (as determined by the Sec-
8
retary).
9
aa(3) AUDITING
OF STATE SPENDING.aThe
In-
10
spector General of the Department of Health and
11
Human Services shall conduct an audit (which shall
12
be conducted using random sampling, as determined
13
by the Inspector General) of each Stateas spending
14
under this section not less than once every 3 years.
15
aa(4)
TEMPORARY
INCREASE
IN
FEDERAL
SUPPORT
IMPROVED
16
MATCHING
17
DATA REPORTING SYSTEMS FOR FISCAL YEARS 2018
18
AND 2019.aIn
19
its per capita base period the most recent 8 consecu-
20
tive quarter period for which the data necessary to
21
make the determinations required under this section
22
is available, for amounts expended during calendar
23
quarters beginning on or after October 1, 2017, and
24
before October 1, 2019a
PERCENTAGE
TO
the case of any State that selects as
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1
aa(A) the Federal matching percentage ap-
2
plied under section 1903(a)(3)(A)(i) shall be in-
3
creased by 10 percentage points to 100 percent;
4
aa(B) the Federal matching percentage ap-
5
plied under section 1903(a)(3)(B) shall be in-
6
creased by 25 percentage points to 100 percent;
7
and
8
aa(C) the Federal matching percentage ap-
9
plied under section 1903(a)(7) shall be in-
10
creased by 10 percentage points to 60 percent
11
but only with respect to amounts expended that
12
are attributable to a Stateas additional adminis-
13
trative expenditures to implement the data re-
14
quirements of paragraph (1).
15
aa(5) HHS
REPORT ON ADOPTION OF TaMSIS
16
DATA.aNot
17
retary shall submit to Congress a report making rec-
18
ommendations as to whether data from the Trans-
19
formed Medicaid Statistical Information System
20
would be preferable to CMSa64 report data for pur-
21
poses of making the determinations necessary under
22
this section.aa.
later than January 1, 2025, the Sec-
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1
2
SEC. 134. FLEXIBLE BLOCK GRANT OPTION FOR STATES.
Title XIX of the Social Security Act, as amended by
3 section 133, is further amended by inserting after section
4 1903A the following new section:
5
6
aaSEC. 1903B. MEDICAID FLEXIBILITY PROGRAM.
aa(a) IN GENERAL.aBeginning with fiscal year 2020,
7 any State (as defined in subsection (e)) that has an appli8 cation approved by the Secretary under subsection (b)
9 may conduct a Medicaid Flexibility Program to provide
10 targeted health assistance to program enrollees.
11
12
aa(b) STATE APPLICATION.a
aa(1) IN
GENERAL.aTo
be eligible to conduct a
13
Medicaid Flexibility Program, a State shall submit
14
an application to the Secretary that meets the re-
15
quirements of this subsection.
16
aa(2) CONTENTS
OF APPLICATION.aAn
applica-
17
tion under this subsection shall include the fol-
18
lowing:
19
aa(A) A description of the proposed Med-
20
icaid Flexibility Program and how the State will
21
satisfy the requirements described in subsection
22
(d).
23
24
aa(B) The proposed conditions for eligibility
of program enrollees.
25
aa(C) A description of the types, amount,
26
duration, and scope of services which will be of-
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1
fered as targeted health assistance under the
2
program, including a description of the pro-
3
posed package of services which will be provided
4
to program enrollees to whom the State would
5
otherwise be required to make medical assist-
6
ance available under section 1902(a)(10)(A)(i).
7
aa(D) A description of how the State will
8
notify individuals currently enrolled in the State
9
plan for medical assistance under this title of
10
11
12
the transition to such program.
aa(E) Statements certifying that the State
agrees toa
13
aa(i) submit regular enrollment data
14
with respect to the program to the Centers
15
for Medicare & Medicaid Services at such
16
time and in such manner as the Secretary
17
may require;
18
aa(ii) submit timely and accurate data
19
to the Transformed Medicaid Statistical
20
Information System (TaMSIS);
21
aa(iii) report annually to the Secretary
22
on adult health quality measures imple-
23
mented under the program and informa-
24
tion on the quality of health care furnished
25
to program enrollees under the program as
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1
part of the annual report required under
2
section 1139B(d)(1);
3
aa(iv) submit such additional informa-
4
tion not described in any of the preceding
5
clauses of this subparagraph but which the
6
Secretary determines is necessary for mon-
7
itoring, evaluation, or program integrity
8
purposes, includinga
9
aa(I) survey data, such as the
10
data from Consumer Assessment of
11
Healthcare Providers and Systems
12
(CAHPS) surveys;
13
aa(II) birth certificate data; and
14
aa(III) clinical patient data for
15
quality measurements which may not
16
be present in a claim, such as labora-
17
tory data, body mass index, and blood
18
pressure; and
19
aa(v) on an annual basis, conduct a re-
20
port evaluating the program and make
21
such report available to the public.
22
aa(F) An information technology systems
23
plan demonstrating that the State has the capa-
24
bility to support the technological administra-
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1
tion of the program and comply with reporting
2
requirements under this section.
3
4
aa(G) A statement of the goals of the proposed program, which shall includea
5
aa(i) goals related to quality, access,
6
rate of growth targets, consumer satisfac-
7
tion, and outcomes;
8
aa(ii) a plan for monitoring and evalu-
9
ating the program to determine whether
10
such goals are being met; and
11
aa(iii) a proposed process for the State,
12
in consultation with the Centers for Medi-
13
care & Medicaid Services, to take remedial
14
action to make progress on unmet goals.
15
aa(H) Such other information as the Sec-
16
retary may require.
17
aa(3) STATE
18
aa(A) IN
NOTICE AND COMMENT PERIOD.a
GENERAL.aBefore
submitting an
19
application under this subsection, a State shall
20
make the application publicly available for a 30
21
day notice and comment period.
22
aa(B) NOTICE
AND COMMENT PROCESS.a
23
During the notice and comment period de-
24
scribed in subparagraph (A), the State shall
25
provide opportunities for a meaningful level of
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1
public input, which shall include public hearings
2
on the proposed Medicaid Flexibility Program.
3
aa(4) FEDERAL
NOTICE
AND
COMMENT
PE-
4
RIOD.aThe
5
plication to conduct a Medicaid Flexibility Program
6
without making such application publicly available
7
for a 30 day notice and comment period.
8
9
Secretary shall not approve of any ap-
aa(5) TIMELINE
aa(A) IN
FOR SUBMISSION.a
GENERAL.aA
State may submit
10
an application under this subsection to conduct
11
a Medicaid Flexibility Program that would
12
begin in the next fiscal year at any time, sub-
13
ject to subparagraph (B).
14
aa(B) DEADLINES.aEach year beginning
15
with 2019, the Secretary shall specify a dead-
16
line for submitting an application under this
17
subsection to conduct a Medicaid Flexibility
18
Program that would begin in the next fiscal
19
year, but such deadline shall not be earlier than
20
60 days after the date that the Secretary pub-
21
lishes the amounts of State block grants as re-
22
quired under subsection (c)(4).
23
24
25
aa(c) FINANCING.a
aa(1) IN
GENERAL.aFor
each fiscal year during
which a State is conducting a Medicaid Flexibility
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1
Program, the State shall receive, instead of amounts
2
otherwise payable to the State under this title for
3
medical
4
amount specified in paragraph (3)(A).
5
assistance
aa(2) AMOUNT
6
for
program
enrollees,
the
OF BLOCK GRANT FUNDS.a
aa(A) FOR
INITIAL YEAR.aSubject
to sub-
7
paragraph (C), for the first fiscal year in which
8
a State conducts a Medicaid Flexibility Pro-
9
gram, the block grant amount under this para-
10
graph for the State and year shall be equal to
11
the Federal average medical assistance match-
12
ing
13
1903A(a)(4)) for the State and year multiplied
14
by the product ofa
percentage
(as
defined
in
section
15
aa(i) the target per capita medical as-
16
sistance expenditures (as defined in section
17
1903A(c)(2)) for the State and year for
18
the enrollee category described in section
19
1903A(e)(2)(E); and
20
aa(ii) the number of 1903A enrollees in
21
such category for the State for the second
22
fiscal year preceding such first fiscal year,
23
increased by the percentage increase in
24
State population from such second pre-
25
ceding fiscal year to such first fiscal year,
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1
based on the best available estimates of the
2
Bureau of the Census.
3
aa(B) FOR
ANY SUBSEQUENT YEAR.aFor
4
any fiscal year that is not the first fiscal year
5
in which a State conducts a Medicaid Flexibility
6
Program, the block grant amount under this
7
paragraph for the State and year shall be equal
8
to the block grant amount determined for the
9
State for the most recent previous fiscal year in
10
which the State conducted a Medicaid Flexi-
11
bility Program, except that such amount shall
12
be increased by the percentage increase in the
13
consumer price index for all urban consumers
14
(U.S. city average) from April of the second fis-
15
cal year preceding the fiscal year involved to
16
April of the fiscal year preceding the fiscal year
17
involved.
18
aa(C) CAP
ON TOTAL POPULATION OF 1903A
19
ENROLLEES FOR PURPOSES OF BLOCK GRANT
20
CALCULATION.a
21
aa(i) IN
GENERAL.aIn
calculating the
22
amount of a block grant for the first year
23
in which a State conducts a Medicaid
24
Flexibility Program under subparagraph
25
(A), the total number of 1903A enrollees
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1
in the 1903A enrollee category described in
2
section 1903A(e)(2)(E) for the State and
3
year shall not exceed the adjusted number
4
of base period non-expansion enrollees for
5
the State (as defined in clause (ii)).
6
aa(ii) ADJUSTED
NUMBER
OF
2016
ENROLLEES.aThe
term
7
NON-EXPANSION
8
aadjusted number of base period non-ex-
9
pansion enrolleesa means, with respect to a
10
State, the number of 1903A enrollees in
11
the enrollee category described in section
12
1903A(e)(2)(E) for the State for the
13
Stateas per capita base period (as deter-
14
mined under section 1903A(e)(4)), in-
15
creased by the percentage increase, if any,
16
in the total State population from the last
17
April in the Stateas per capita base period
18
to April of the fiscal year preceding the fis-
19
cal year involved (determined using the
20
best available data from the Bureau of the
21
Census) plus 3 percentage points.
22
aa(D)
23
FUNDS.a
24
25
AVAILABILITY
aa(i) IN
OF
GENERAL.aTo
ROLLOVER
the extent that
the block grant amount available to a
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1
State for a fiscal year under this para-
2
graph exceeds the amount of Federal pay-
3
ments made to the State for such fiscal
4
year under paragraph (3)(A), the Sec-
5
retary shall make such funds available to
6
the State for the succeeding fiscal year if
7
the Statea
8
aa(I) satisfies the State mainte-
9
nance of effort requirement under
10
paragraph (3)(B); and
11
aa(II) is conducting a Medicaid
12
Flexibility Program in such suc-
13
ceeding fiscal year.
14
aa(ii)
USE
OF
FUNDS.aSection
15
1903(i)(17) shall not apply to funds made
16
available to a State under this subpara-
17
graph and a State may use such funds for
18
other State health programs (as defined or
19
approved by the Secretary) or for any
20
other purpose which is consistent with the
21
quality standards established by the Sec-
22
retary under clause (iii).
23
aa(iii) QUALITY
24
25
aa(I) IN
STANDARDS.a
GENERAL.aNot
later
than January 1, 2020, the Secretary
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1
shall establish quality standards appli-
2
cable to a Stateas use of funds made
3
available to the State under this sub-
4
paragraph.
5
aa(II) ALLOWABLE
USES.aIn
es-
6
tablishing quality standards under
7
this clause, the Secretary shall not
8
prohibit a State from using such
9
funds fora
10
aa(aa) a program that is not
11
related to health care, provided
12
that using the funds for such
13
program is otherwise consistent
14
with the standards; or
15
aa(bb) the State maintenance
16
of effort expenditures required
17
under paragraph (3)(B).
18
19
20
aa(3) FEDERAL
PAYMENT AND STATE MAINTE-
NANCE OF EFFORT.a
aa(A) FEDERAL
PAYMENT.aSubject
to sub-
21
paragraph (D), the Secretary shall pay to each
22
State conducting a Medicaid Flexibility Pro-
23
gram under this section for a fiscal year, from
24
its block grant amount under paragraph (2) for
25
such year, an amount for each quarter of such
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1
year equal to the Federal average medical as-
2
sistance percentage (as defined in section
3
1903A(a)(4)) of the total amount expended
4
under the program during such quarter, and
5
the State is responsible for the balance of the
6
funds to carry out such program.
7
aa(B) STATE
8
EXPENDITURES.aFor
9
State is conducting a Medicaid Flexibility Pro-
10
gram, the State shall make expenditures for
11
targeted health assistance under the program in
12
an amount equal to the product ofa
MAINTENANCE OF EFFORT
each year during which a
13
aa(i) the block grant amount deter-
14
mined for the State and year under para-
15
graph (2); and
16
aa(ii) the enhanced FMAP described in
17
the first sentence of section 2105(b) for
18
the State and year.
19
aa(C)
REDUCTION
IN
BLOCK
GRANT
20
AMOUNT FOR STATES FAILING TO MEET MOE
21
REQUIREMENT.a
22
aa(i) IN
GENERAL.aIn
the case of a
23
State conducting a Medicaid Flexibility
24
Program that makes expenditures for tar-
25
geted health assistance under the program
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1
for a fiscal year in an amount that is less
2
than the required amount for the fiscal
3
year under subparagraph (B), the amount
4
of the block grant determined for the State
5
under paragraph (2) for the succeeding fis-
6
cal year shall be reduced by the amount by
7
which such expenditures are less than such
8
required amount.
9
aa(ii) DISREGARD
OF REDUCTION.a
10
For purposes of determining the amount of
11
a State block grant under paragraph (2),
12
any reduction made under this subpara-
13
graph to a Stateas block grant amount in
14
a previous fiscal year shall be disregarded.
15
aa(iii) APPLICATION
TO STATES THAT
16
TERMINATE PROGRAM.aIn
17
State described in clause (i) that termi-
18
nates the State Medicaid Flexibility Pro-
19
gram under subsection (d)(2)(B) and such
20
termination is effective with the end of the
21
fiscal year in which the State fails to make
22
the required amount of expenditures under
23
subparagraph (B), the reduction amount
24
determined for the State and succeeding
the case of a
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1
fiscal year under clause (i) shall be treated
2
as an overpayment under this title.
3
aa(D) REDUCTION
FOR NONCOMPLIANCE.a
4
If the Secretary determines that a State con-
5
ducting a Medicaid Flexibility Program is not
6
complying with the requirements of this section,
7
the Secretary may withhold payments, reduce
8
payments, or recover previous payments to the
9
State under this section as the Secretary deems
10
appropriate.
11
aa(4) DETERMINATION
AND PUBLICATION OF
12
BLOCK GRANT AMOUNT.aBeginning
13
each year thereafter, the Secretary shall determine
14
for each State, regardless of whether the State is
15
conducting a Medicaid Flexibility Program or has
16
submitted an application to conduct such a program,
17
the amount of the block grant for the State under
18
paragraph (2) which would apply for the upcoming
19
fiscal year if the State were to conduct such a pro-
20
gram in such fiscal year, and shall publish such de-
21
terminations not later than June 1 of each year.
22
aa(d) PROGRAM REQUIREMENTS.a
23
24
aa(1) IN
GENERAL.aNo
in 2019 and
payment shall be made
under this section to a State conducting a Medicaid
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1
Flexibility Program unless such program meets the
2
requirements of this subsection.
3
4
aa(2) TERM
OF PROGRAM.a
aa(A) IN
GENERAL.aA
State Medicaid
5
Flexibility Program approved under subsection
6
(b)a
7
8
aa(i) shall be conducted for not less
than 1 program period;
9
aa(ii) at the option of the State, may
10
be continued for succeeding program peri-
11
ods without resubmitting an application
12
under subsection (b), provided thata
13
aa(I) the State provides notice to
14
the Secretary of its decision to con-
15
tinue the program; and
16
aa(II) no significant changes are
17
made to the program; and
18
aa(iii) shall be subject to termination
19
only by the State, which may terminate the
20
program by making an election under sub-
21
paragraph (B).
22
aa(B) ELECTION
23
24
25
TO
TERMINATE
PRO-
GRAM.a
aa(i) IN
GENERAL.aSubject
to clause
(ii), a State conducting a Medicaid Flexi-
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1
bility Program may elect to terminate the
2
program effective with the first day after
3
the end of the program period in which the
4
State makes the election.
5
aa(ii) TRANSITION
PLAN
REQUIRE-
6
MENT.aA
7
nate a Medicaid Flexibility Program unless
8
the State has in place an appropriate tran-
9
sition plan approved by the Secretary.
10
State may not elect to termi-
aa(iii) EFFECT
OF TERMINATION.aIf
a
11
State elects to terminate a Medicaid Flexi-
12
bility Program, the per capita cap limita-
13
tions under section 1903A shall apply ef-
14
fective with the day described in clause (i),
15
and such limitations shall be applied as if
16
the State had never conducted a Medicaid
17
Flexibility Program.
18
19
20
aa(3) PROVISION
OF TARGETED HEALTH ASSIST-
ANCE.a
aa(A) IN
GENERAL.aA
State Medicaid
21
Flexibility Program shall provide targeted
22
health assistance to program enrollees and such
23
assistance shall be instead of medical assistance
24
which would otherwise be provided to the enroll-
25
ees under this title.
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1
aa(B) CONDITIONS
2
aa(i) IN
FOR ELIGIBILITY.a
GENERAL.aA
State con-
3
ducting a Medicaid Flexibility Program
4
shall establish conditions for eligibility of
5
program enrollees, which shall be instead
6
of other conditions for eligibility under this
7
title, except that the program must provide
8
for eligibility for program enrollees to
9
whom the State would otherwise be re-
10
quired to make medical assistance available
11
under section 1902(a)(10)(A)(i).
12
aa(ii) MAGI.aAny determination of
13
income necessary to establish the eligibility
14
of a program enrollee for purposes of a
15
State Medicaid Flexibility Program shall
16
be made using modified adjusted gross in-
17
come
18
1902(e)(14).
19
20
in
aa(4) BENEFITS
accordance
with
section
AND SERVICES.a
aa(A) REQUIRED
SERVICES.aIn
the case of
21
program enrollees to whom the State would oth-
22
erwise be required to make medical assistance
23
available under section 1902(a)(10)(A)(i), a
24
State conducting a Medicaid Flexibility Pro-
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1
gram shall provide as targeted health assistance
2
the following types of services:
3
4
aa(i) Inpatient and outpatient hospital
services.
5
aa(ii) Laboratory and X-ray services.
6
aa(iii) Nursing facility services for indi-
7
viduals aged 21 and older.
8
aa(iv) Physician services.
9
aa(v) Home health care services (in-
10
cluding home nursing services, medical
11
supplies, equipment, and appliances).
12
13
aa(vi) Rural health clinic services (as
defined in section 1905(l)(1)).
14
aa(vii) Federally-qualified health center
15
services (as defined in section 1905(l)(2)).
16
aa(viii) Family planning services and
17
supplies.
18
aa(ix) Nurse midwife services.
19
aa(x) Certified pediatric and family
20
21
22
23
24
25
nurse practitioner services.
aa(xi) Freestanding birth center services (as defined in section 1905(l)(3)).
aa(xii) Emergency medical transportation.
aa(xiii) Non-cosmetic dental services.
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1
aa(xiv) Pregnancy-related services, in-
2
cluding postpartum services for the 12-
3
week period beginning on the last day of a
4
pregnancy.
5
aa(B) OPTIONAL
BENEFITS.aA
State may,
6
at its option, provide services in addition to the
7
services described in subparagraph (A) as tar-
8
geted health assistance under a Medicaid Flexi-
9
bility Program.
10
aa(C) BENEFIT
11
aa(i)
IN
PACKAGES.a
GENERAL.aThe
targeted
12
health assistance provided by a State to
13
any group of program enrollees under a
14
Medicaid Flexibility Program shall have an
15
aggregate actuarial value that is equal to
16
at least 95 percent of the aggregate actu-
17
arial value of the benchmark coverage de-
18
scribed in subsection (b)(1) of section 1937
19
or
20
scribed in subsection (b)(2) of such sec-
21
tion, as such subsections were in effect
22
prior to the enactment of the Patient Pro-
23
tection and Affordable Care Act.
benchmark-equivalent
24
aa(ii) AMOUNT,
25
OF BENEFITS.aSubject
coverage
de-
DURATION, AND SCOPE
to clause (i), the
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1
State shall determine the amount, dura-
2
tion, and scope with respect to services
3
provided as targeted health assistance
4
under a Medicaid Flexibility Program, in-
5
cluding with respect to services that are re-
6
quired to be provided to certain program
7
enrollees under subparagraph (A) except
8
as otherwise provided under such subpara-
9
graph.
10
aa(iii) MENTAL
HEALTH
AND
SUB-
11
STANCE USE DISORDER COVERAGE AND
12
PARITY.aThe
13
provided by a State to program enrollees
14
under a Medicaid Flexibility Program shall
15
include mental health services and sub-
16
stance use disorder services and the finan-
17
cial requirements and treatment limitations
18
applicable to such services under the pro-
19
gram shall comply with the requirements
20
of section 2726 of the Public Health Serv-
21
ice Act in the same manner as such re-
22
quirements apply to a group health plan.
23
targeted health assistance
aa(iv) PRESCRIPTION
DRUGS.aIf
the
24
targeted health assistance provided by a
25
State to program enrollees under a Med-
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1
icaid Flexibility Program includes assist-
2
ance for covered outpatient drugs, such
3
drugs shall be subject to a rebate agree-
4
ment that complies with the requirements
5
of section 1927, and any requirements ap-
6
plicable to medical assistance for covered
7
outpatient drugs under a State plan (in-
8
cluding the requirement that the State pro-
9
vide information to a manufacturer) shall
10
apply in the same manner to targeted
11
health assistance for covered outpatient
12
drugs under a Medicaid Flexibility Pro-
13
gram.
14
aa(D) COST
SHARING.aA
State conducting
15
a Medicaid Flexibility Program may impose
16
premiums, deductibles, cost-sharing, or other
17
similar charges, except that the total annual ag-
18
gregate amount of all such charges imposed
19
with respect to all program enrollees in a family
20
shall not exceed 5 percent of the familyas in-
21
come for the year involved.
22
aa(5) ADMINISTRATION
OF
PROGRAM.aEach
23
State conducting a Medicaid Flexibility Program
24
shall do the following:
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1
aa(A) SINGLE
AGENCY.aDesignate
a single
2
State agency responsible for administering the
3
program.
4
aa(B) ENROLLMENT
SIMPLIFICATION AND
5
COORDINATION WITH STATE HEALTH INSUR-
6
ANCE EXCHANGES.aProvide
7
rollment processes (such as online enrollment
8
and reenrollment and electronic verification)
9
and coordination with State health insurance
10
11
for simplified en-
exchanges.
aa(C) BENEFICIARY
PROTECTIONS.aEstab-
12
lish a fair process (which the State shall de-
13
scribe in the application required under sub-
14
section (b)) for individuals to appeal adverse
15
eligibility determinations with respect to the
16
program.
17
aa(6) APPLICATION
18
aa(A) IN
OF REST OF TITLE XIX.a
GENERAL.aTo
the extent that a
19
provision of this section is inconsistent with an-
20
other provision of this title, the provision of this
21
section shall apply.
22
aa(B) APPLICATION
OF SECTION 1903A.a
23
With respect to a State that is conducting a
24
Medicaid Flexibility Program, section 1903A
25
shall be applied as if program enrollees were
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1
not 1903A enrollees for each program period
2
during which the State conducts the program.
3
4
5
aa(C) WAIVERS
AND STATE PLAN AMEND-
MENTS.a
aa(i) IN
GENERAL.aIn
the case of a
6
State conducting a Medicaid Flexibility
7
Program that has in effect a waiver or
8
State plan amendment, such waiver or
9
amendment shall not apply with respect to
10
the program, targeted health assistance
11
provided under the program, or program
12
enrollees.
13
aa(ii) REPLICATION
OF
WAIVER
OR
14
AMENDMENT.aIn
15
Flexibility Program, a State may mirror
16
provisions of a waiver or State plan
17
amendment described in clause (i) in the
18
program to the extent that such provisions
19
are otherwise consistent with the require-
20
ments of this section.
21
aa(iii) EFFECT
designing a Medicaid
OF TERMINATION.aIn
22
the case of a State described in clause (i)
23
that terminates its program under sub-
24
section (d)(2)(B), any waiver or amend-
25
ment which was limited pursuant to sub-
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1
paragraph (A) shall cease to be so limited
2
effective with the effective date of such ter-
3
mination.
4
aa(D) NONAPPLICATION
OF PROVISIONS.a
5
With respect to the design and implementation
6
of Medicaid Flexibility Programs conducted
7
under this section, paragraphs (1), (10)(B),
8
(17), and (23) of section 1902(a), as well as
9
any other provision of this title (except for this
10
section and as otherwise provided by this sec-
11
tion) that the Secretary deems appropriate,
12
shall not apply.
13
14
aa(e) DEFINITIONS.aFor purposes of this section:
aa(1) MEDICAID
FLEXIBILITY PROGRAM.aThe
15
term aMedicaid Flexibility Programa means a State
16
program for providing targeted health assistance to
17
program enrollees funded by a block grant under
18
this section.
19
20
aa(2) PROGRAM
aa(A) IN
ENROLLEE.a
GENERAL.aThe
term aprogram
21
enrolleea means, with respect to a State that is
22
conducting a Medicaid Flexibility Program, an
23
individual who is a 1903A enrollee (as defined
24
in section 1903A(e)(1)) who is in the 1903A
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1
enrollee
2
1903A(e)(2)(E).
3
aa(B) RULE
category
described
in
section
OF CONSTRUCTION.aFor
pur-
4
poses of section 1903A(e)(3), eligibility and en-
5
rollment of an individual under a Medicaid
6
Flexibility Program shall be deemed to be eligi-
7
bility and enrollment under a State plan (or
8
waiver of such plan) under this title.
9
aa(3) PROGRAM
PERIOD.aThe
term aprogram
10
perioda means, with respect to a State Medicaid
11
Flexibility Program, a period of 5 consecutive fiscal
12
years that begins with eithera
13
14
aa(A) the first fiscal year in which the State
conducts the program; or
15
aa(B) the next fiscal year in which the
16
State conducts such a program that begins
17
after the end of a previous program period.
18
aa(4) STATE.aThe term aStatea means one of
19
20
the 50 States or the District of Columbia.
aa(5) TARGETED
HEALTH
ASSISTANCE.aThe
21
term atargeted health assistancea means assistance
22
for health-care-related items and medical services for
23
program enrollees.aa.
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1
SEC. 135. MEDICAID AND CHIP QUALITY PERFORMANCE
2
3
BONUS PAYMENTS.
Section 1903 of the Social Security Act (42 U.S.C.
4 1396b) is amended by adding at the end the following new
5 subsection:
6
7
aa(aa) QUALITY PERFORMANCE BONUS PAYMENTS.a
aa(1) INCREASED
FEDERAL SHARE.aWith
re-
8
spect to each of fiscal years 2023 through 2026, in
9
the case of one of the 50 States or the District of
10
Columbia (each referred to in this subsection as a
11
aStatea) thata
12
aa(A) equals or exceeds the qualifying
13
amount (as established by the Secretary) of
14
lower than expected aggregate medical assist-
15
ance expenditures (as defined in paragraph (4))
16
for that fiscal year; and
17
aa(B) submits to the Secretary, in accord-
18
ance with such manner and format as specified
19
by the Secretary and for the performance pe-
20
riod (as defined by the Secretary) for such fis-
21
cal yeara
22
aa(i) information on the applicable
23
quality measures identified under para-
24
graph (3) with respect to each category of
25
Medicaid eligible individuals under the
26
State plan or a waiver of such plan; and
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1
aa(ii) a plan for spending a portion of
2
additional funds resulting from application
3
of this subsection on quality improvement
4
within the State plan under this title or
5
under a waiver of such plan,
6
the Federal matching percentage otherwise ap-
7
plied under subsection (a)(7) for such fiscal
8
year shall be increased by such percentage (as
9
determined by the Secretary) so that the aggre-
10
gate amount of the resulting increase pursuant
11
to this subsection for the State and fiscal year
12
does not exceed the State allotment established
13
under paragraph (2) for the State and fiscal
14
year.
15
aa(2) ALLOTMENT
DETERMINATION.aThe
Sec-
16
retary shall establish a formula for computing State
17
allotments under this paragraph for each fiscal year
18
described in paragraph (1) such thata
19
aa(A) such an allotment to a State is deter-
20
mined based on the performance, including im-
21
provement, of such State under this title and
22
title XXI with respect to the quality measures
23
submitted under paragraph (3) by such State
24
for the performance period (as defined by the
25
Secretary) for such fiscal year; and
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1
aa(B) the total of the allotments under this
2
paragraph for all States for the period of the
3
fiscal years described in paragraph (1) is equal
4
to $8,000,000,000.
5
aa(3)
QUALITY
MEASURES
REQUIRED
FOR
6
BONUS PAYMENTS.aFor
7
the Secretary shall, pursuant to rulemaking and
8
after consultation with State agencies administering
9
State plans under this title, identify and publish
10
(and update as necessary) peer-reviewed quality
11
measures (which shall include health care and long-
12
term care outcome measures and may include the
13
quality measures that are overseen or developed by
14
the National Committee for Quality Assurance or
15
the Agency for Healthcare Research and Quality or
16
that are identified under section 1139A or 1139B)
17
that are quantifiable, objective measures that take
18
into account the clinically appropriate measures of
19
quality for different types of patient populations re-
20
ceiving benefits or services under this title or title
21
XXI.
22
aa(4) LOWER
purposes of this subsection,
THAN
EXPECTED
AGGREGATE
23
MEDICAL ASSISTANCE EXPENDITURES.aIn
24
section, the term alower than expected aggregate
this sub-
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1
medical assistance expendituresa means, with respect
2
to a State the amount (if any) by whicha
3
aa(A) the amount of the adjusted total med-
4
ical assistance expenditures for the State and
5
fiscal year determined in section 1903A(b)(1)
6
without regard to the 1903A enrollee category
7
described in section 1903A(e)(2)(E); is less
8
than
9
aa(B) the amount of the target total med-
10
ical assistance expenditures for the State and
11
fiscal year determined in section 1903A(c) with-
12
out regard to the 1903A enrollee category de-
13
scribed in section 1903A(e)(2)(E).aa.
14
15
16
17
SEC. 136. GRANDFATHERING CERTAIN MEDICAID WAIVERS;
PRIORITIZATION OF HCBS WAIVERS.
(a) MANAGED CARE WAIVERS.a
(1) IN
GENERAL.aIn
the case of a State with
18
a grandfathered managed care waiver, the State
19
may, at its option through a State plan amendment,
20
continue to implement the managed care delivery
21
system that is the subject of such waiver in per-
22
petuity under the State plan under title XIX of the
23
Social Security Act (or a waiver of such plan) with-
24
out submitting an application to the Secretary for a
25
new waiver to implement such managed care delivery
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1
system, so long as the terms and conditions of the
2
waiver involved (other than such terms and condi-
3
tions that relate to budget neutrality as modified
4
pursuant to section 1903A(f)(1) of the Social Secu-
5
rity Act) are not modified.
6
7
(2) MODIFICATIONS.a
(A) IN
GENERAL.aIf
a State with a
8
grandfathered managed care waiver seeks to
9
modify the terms or conditions of such a waiv-
10
er, the State shall submit to the Secretary an
11
application for approval of a new waiver under
12
such modified terms and conditions.
13
(B) APPROVAL
14
(i) IN
OF MODIFICATION.a
GENERAL.aAn
application de-
15
scribed in subparagraph (A) is deemed ap-
16
proved unless the Secretary, not later than
17
90 days after the date on which the appli-
18
cation is submitted, submits to the Statea
19
(I) a denial; or
20
(II) a request for more informa-
21
tion regarding the application.
22
(ii) ADDITIONAL
INFORMATION.aIf
23
the Secretary requests additional informa-
24
tion, the Secretary has 30 days after a
25
State submission in response to the Sec-
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1
retaryas request to deny the application or
2
request more information.
3
(3) GRANDFATHERED
MANAGED CARE WAIVER
4
DEFINED.aIn
5
fathered managed care waiveraa means the provisions
6
of a waiver or an experimental, pilot, or demonstra-
7
tion project that relate to the authority of a State
8
to implement a managed care delivery system under
9
the State plan under title XIX of such Act (or under
10
a waiver of such plan under section 1115 of such
11
Act) thata
this subsection, the term aagrand-
12
(A) is approved by the Secretary of Health
13
and Human Services under section 1915(b),
14
1932, or 1115(a)(1) of the Social Security Act
15
(42 U.S.C. 1396n(b), 1396ua2, 1315(a)(1)) as
16
of January 1, 2017; and
17
18
19
(B) has been renewed by the Secretary not
less than 1 time.
(b) HCBS WAIVERS.aThe Secretary of Health and
20 Human Services shall implement procedures encouraging
21 States to adopt or extend waivers related to the authority
22 of a State to make medical assistance available for home
23 and community-based services under the State plan under
24 title XIX of the Social Security Act if the State determines
25 that such waivers would improve patient access to services.
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1
2
SEC. 137. COORDINATION WITH STATES.
Title XIX of the Social Security Act is amended by
3 inserting after section 1904 (42 U.S.C. 1396d) the fol4 lowing:
5
6
aaCOORDINATION
WITH STATES
aaSEC. 1904A. No proposed rule (as defined in section
7 551(4) of title 5, United States Code) implementing or
8 interpreting any provision of this title shall be finalized
9 on or after January 1, 2018, unless the Secretarya
10
aa(1) provides for a process under which the
11
Secretary or the Secretaryas designee solicits advice
12
from each Stateas State agency responsible for ad-
13
ministering the State plan under this title (or a
14
waiver of such plan) and State Medicaid Directora
15
aa(A) on a regular, ongoing basis on mat-
16
ters relating to the application of this title that
17
are likely to have a direct effect on the oper-
18
ation or financing of State plans under this title
19
(or waivers of such plans); and
20
aa(B) prior to submission of any final pro-
21
posed rule, plan amendment, waiver request, or
22
proposal for a project that is likely to have a di-
23
rect effect on the operation or financing of
24
State plans under this title (or waivers of such
25
plans);
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1
aa(2) accepts and considers written and oral
2
comments from a bipartisan, nonprofit, professional
3
organization that represents State Medicaid Direc-
4
tors, and from any State agency administering the
5
plan under this title, regarding such proposed rule;
6
and
7
aa(3) incorporates in the preamble to the pro-
8
posed rule a summary of comments referred to in
9
paragraph (2) and the Secretaryas response to such
10
11
12
13
comments.aa.
SEC. 138. OPTIONAL ASSISTANCE FOR CERTAIN INPATIENT
PSYCHIATRIC SERVICES.
(a) STATE OPTION.aSection 1905 of the Social Se-
14 curity Act (42 U.S.C. 1396d) is amendeda
15
16
17
18
(1) in subsection (a)a
(A) in paragraph (16)a
(i) by striking aaand, (B)aa and inserting aa(B)aa; and
19
(ii) by inserting before the semicolon
20
at the end the following: aa, and (C) subject
21
to subsection (h)(4), qualified inpatient
22
psychiatric hospital services (as defined in
23
subsection (h)(3)) for individuals who are
24
over 21 years of age and under 65 years
25
of ageaa; and
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1
(B) in the subdivision (B) that follows
2
paragraph (29), by inserting aa(other than serv-
3
ices described in subparagraph (C) of para-
4
graph (16) for individuals described in such
5
subparagraph)aa after aapatient in an institution
6
for mental diseasesaa; and
7
(2) in subsection (h), by adding at the end the
8
following new paragraphs:
9
aa(3) For purposes of subsection (a)(16)(C), the term
10 aqualified inpatient psychiatric hospital servicesa means,
11 with respect to individuals described in such subsection,
12 services described in subparagraph (B) of paragraph (1)
13 that
are
not
otherwise
covered
under
subsection
14 (a)(16)(A) and are furnisheda
15
aa(A) in an institution (or distinct part thereof)
16
which is a psychiatric hospital (as defined in section
17
1861(f)); and
18
aa(B) with respect to such an individual, for a
19
period not to exceed 30 consecutive days in any
20
month and not to exceed 90 days in any calendar
21
year.
22
aa(4) As a condition for a State including qualified
23 inpatient psychiatric hospital services as medical assist24 ance under subsection (a)(16)(C), the State must (during
25 the period in which it furnishes medical assistance under
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1 this title for services and individuals described in such
2 subsection)a
3
aa(A) maintain at least the number of licensed
4
beds at psychiatric hospitals owned, operated, or
5
contracted for by the State that were being main-
6
tained as of the date of the enactment of this para-
7
graph or, if higher, as of the date the State applies
8
to the Secretary to include medical assistance under
9
such subsection; and
10
aa(B) maintain on an annual basis a level of
11
funding expended by the State (and political subdivi-
12
sions thereof) other than under this title from non-
13
Federal funds for inpatient services in an institution
14
described in paragraph (3)(A), and for active psy-
15
chiatric care and treatment provided on an out-
16
patient basis, that is not less than the level of such
17
funding for such services and care as of the date of
18
the enactment of this paragraph or, if higher, as of
19
the date the State applies to the Secretary to include
20
medical assistance under such subsection.aa.
21
(b) SPECIAL MATCHING RATE.aSection 1905(b) of
22 the Social Security Act (42 U.S.C. 1395d(b)) is amended
23 by adding at the end the following: aaNotwithstanding the
24 previous provisions of this subsection, the Federal medical
25 assistance percentage shall be 50 percent with respect to
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1 medical assistance for services and individuals described
2 in subsection (a)(16)(C).aa.
3
(c) EFFECTIVE DATE.aThe amendments made by
4 this section shall apply to qualified inpatient psychiatric
5 hospital services furnished on or after October 1, 2018.
6
7
SEC. 139. SMALL BUSINESS HEALTH PLANS.
(a) TAX TREATMENT
OF
SMALL BUSINESS HEALTH
8 PLANS.aFor purposes of applying subchapter B of chap9 ter 100 of the Internal Revenue Code of 1986, title XXVII
10 of the Public Health Service Act (42 U.S.C. 300gg et
11 seq.), and part 7 of title I of the Employee Retirement
12 Income Security Act of 1974 (29 U.S.C. 1181 et seq.),
13 a small business health plan as defined in section 801(a)
14 of the Employee Retirement Income Security Act of 1974
15 that is offered to employees shall be treated as a group
16 health plan, as defined in section 2791 of the Public
17 Health Service Act (42 U.S.C. 300gga91).
18
(b) IN GENERAL.aSubtitle B of title I of the Em-
19 ployee Retirement Income Security Act of 1974 (29
20 U.S.C. 1021 et seq.) is amended by adding at the end
21 the following new part:
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1
aaPART 8aRULES GOVERNING SMALL BUSINESS
2
RISK SHARING POOLS
3
4
aaSEC. 801. SMALL BUSINESS HEALTH PLANS.
aa(a) IN GENERAL.aFor purposes of this part, the
5 term asmall business health plana means a fully insured
6 group health plan, offered by a health insurance issuer in
7 the large group market, whose sponsor is described in sub8 section (b).
9
aa(b) SPONSOR.aThe sponsor of a group health plan
10 is described in this subsection ifa
11
12
aa(1) such sponsor is a qualified sponsor and receives certification by the Secretary;
13
aa(2) is organized and maintained in good faith,
14
with a constitution and bylaws specifically stating its
15
purpose and providing for periodic meetings on at
16
least an annual basis;
17
aa(3) is established as a permanent entity;
18
aa(4) is established for a purpose other than
19
providing health benefits to its members, such as an
20
organization established as a bona fide trade asso-
21
ciation; and
22
23
aa(5) does not condition membership on the
basis of a minimum group size.
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1
aaSEC. 802. FILING FEE AND CERTIFICATION OF SMALL
2
3
BUSINESS HEALTH PLANS.
aa(a) FILING FEE.aA small business health plan
4 shall pay to the Secretary at the time of filing an applica5 tion for certification under subsection (b) a filing fee in
6 the amount of $5,000, which shall be available to the Sec7 retary for the sole purpose of administering the certifi8 cation procedures applicable with respect to small business
9 health plans.
10
11
aa(b) CERTIFICATION.a
aa(1) IN
GENERAL.aNot
later than 6 months
12
after the date of enactment of this part, the Sec-
13
retary shall prescribe by interim final rule a proce-
14
dure under which the Secretarya
15
aa(A) will certify a qualified sponsor of a
16
small business health plan, upon receipt of an
17
application that includes the information de-
18
scribed in paragraph (2);
19
aa(B) may provide for continued certifi-
20
cation of small business health plans under this
21
part; and
22
aa(C) shall provide for the revocation of a
23
certification if the applicable authority finds
24
that the small business health plan involved
25
fails to comply with the requirements of this
26
part.
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1
aa(2) INFORMATION
TO BE INCLUDED IN APPLI-
2
CATION FOR CERTIFICATION.aAn
3
certification under this part meets the requirements
4
of this section only if it includes, in a manner and
5
form which shall be prescribed by the applicable au-
6
thority by regulation, at least the following informa-
7
tion:
application for
8
aa(A) Identifying information.
9
aa(B) States in which the plan intends to
10
do business.
11
aa(C) Bonding requirements.
12
aa(D) Plan documents.
13
aa(E) Agreements with service providers.
14
aa(c) FILING NOTICE
OF
CERTIFICATION WITH
15 STATES.aA certification granted under this part to a
16 small business health plan shall not be effective unless
17 written notice of such certification is filed with the appli18 cable State authority of each State in which the small
19 business health plans operate.
20
aa(d) NOTICE
OF
MATERIAL CHANGES.aIn the case
21 of any small business health plan certified under this part,
22 descriptions of material changes in any information which
23 was required to be submitted with the application for the
24 certification under this part shall be filed in such form
25 and manner as shall be prescribed by the applicable au-
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1 thority by regulation. The applicable authority may re2 quire by regulation prior notice of material changes with
3 respect to specified matters which might serve as the basis
4 for suspension or revocation of the certification.
5
6
aa(e) NOTICE REQUIREMENTS
MINATION.aA
FOR
VOLUNTARY TER-
small business health plan which is or has
7 been certified under this part may terminate (upon or at
8 any time after cessation of accruals in benefit liabilities)
9 only if the board of trustees, not less than 60 days before
10 the proposed termination datea
11
aa(1) provides to the participants and bene-
12
ficiaries a written notice of intent to terminate stat-
13
ing that such termination is intended and the pro-
14
posed termination date;
15
aa(2) develops a plan for winding up the affairs
16
of the plan in connection with such termination in
17
a manner which will result in timely payment of all
18
benefits for which the plan is obligated; and
19
aa(3) submits such plan in writing to the appli-
20
cable authority.
21
aa(f) OVERSIGHT
OF
CERTIFIED PLAN SPONSORS.a
22 The Secretary has the discretion to determine whether any
23 person has violated or is about to violate any provision
24 of this part, and may conduct periodic review of certified
25 small business health plan sponsors, consistent with sec-
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1 tion 504, and apply the requirements of sections 518, 519,
2 and 520.
3
4
aa(g) EXPEDITED AND DEEMED CERTIFICATION.a
aa(1) IN
GENERAL.aIf
the Secretary fails to act
5
on a complete application for certification under this
6
section within 90 days of receipt of such complete
7
application, the applying small business health plan
8
sponsor shall be deemed certified until such time as
9
the Secretary may deny for cause the application for
10
certification.
11
aa(2) PENALTY.aThe Secretary may assess a
12
penalty against the board of trustees and plan spon-
13
sor (jointly and severally) of a small business health
14
plan sponsor that is deemed certified under para-
15
graph (1) of up to $500,000 in the event the Sec-
16
retary determines that the application for certifi-
17
cation of such small business health plan sponsor
18
was willfully or with gross negligence incomplete or
19
inaccurate.
20
aa(h) MODIFICATIONS.aThe Secretary shall, through
21 promulgation and implementation of such regulations as
22 the Secretary may reasonably determine necessary or ap23 propriate, and in consultation with a balanced spectrum
24 of effected entities and persons, modify the implementa25 tion and application of this part to accommodate with min-
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1 imum disruption such changes to State or Federal law
2 provided in this part and the (and the amendments made
3 by such Act) or in regulations issued thereto.
4
5
6
aaSEC. 803. REQUIREMENTS RELATING TO SPONSORS AND
BOARDS OF TRUSTEES.
aa(a) BOARD
OF
TRUSTEES.aThe Secretary shall en-
7 sure that Board of Trustees of a small business health
8 plan certified under this part complies with the require9 ments such Secretary sets forth with respect to fiscal con10 trol and rules of operation and financial controls.
11
aa(b) TREATMENT
OF
FRANCHISES.aIn the case of
12 a group health plan that is established and maintained
13 by a franchisor for a franchisor or for its franchiseesa
14
aa(1) the requirements of subsection (a) and sec-
15
tion 801(a) shall be deemed met if such require-
16
ments would otherwise be met if the franchisor were
17
deemed to be the sponsor referred to in section
18
801(b) and each franchisee were deemed to be a
19
member (of the sponsor) referred to in section
20
801(b); and
21
22
aa(2) the requirements of section 804(a)(1) shall
be deemed met.
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1
aaSEC.
804.
2
3
PARTICIPATION
AND
COVERAGE
REQUIRE-
MENTS.
aa(a) COVERED EMPLOYERS
AND INDIVIDUALS.aThe
4 requirements of this subsection are met with respect to
5 a small business health plan if, under the terms of the
6 plana
7
aa(1) each participating employer must bea
8
aa(A) a member of the sponsor;
9
aa(B) the sponsor; or
10
aa(C) an affiliated member of the sponsor,
11
except that, in the case of a sponsor which is
12
a professional association or other individual-
13
based association, if at least one of the officers,
14
directors, or employees of an employer, or at
15
least one of the individuals who are partners in
16
an employer and who actively participates in
17
the business, is a member or such an affiliated
18
member of the sponsor, participating employers
19
may also include such employer; and
20
aa(2) all individuals commencing coverage under
21
the plan after certification under this part must
22
bea
23
aa(A) active or retired owners (including
24
self-employed individuals), officers, directors, or
25
employees of, or partners in, participating em-
26
ployers; or
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1
2
3
aa(B) the dependents of individuals described in subparagraph (A).
aa(b) INDIVIDUAL MARKET UNAFFECTED.aThe re-
4 quirements of this subsection are met with respect to a
5 small business health plan if, under the terms of the plan,
6 no participating employer may provide health insurance
7 coverage in the individual market for any employee not
8 covered under the plan, if such exclusion of the employee
9 from coverage under the plan is based on a health status10 related factor with respect to the employee and such em11 ployee would, but for such exclusion on such basis, be eligi12 ble for coverage under the plan.
13
14
aa(c) PROHIBITION OF DISCRIMINATION AGAINST EMPLOYERS AND
EMPLOYEES ELIGIBLE
TO
PARTICIPATE.a
15 The requirements of this subsection are met with respect
16 to a small business health plan if information regarding
17 all coverage options available under the plan is made read18 ily available to any employer eligible to participate.
19
20
21
aaSEC. 805. DEFINITIONS; RENEWAL.
aa(a) DEFINITIONS.aFor purposes of this part:
aa(1) AFFILIATED
MEMBER.aThe
term aaffili-
22
ated membera means, in connection with a sponsora
23
aa(A) a person who is otherwise eligible to
24
be a member of the sponsor but who elects an
25
affiliated status with the sponsor, or
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1
aa(B) in the case of a sponsor with mem-
2
bers which consist of associations, a person who
3
is a member or employee of any such associa-
4
tion and elects an affiliated status with the
5
sponsor.
6
aa(2) APPLICABLE
STATE
AUTHORITY.aThe
7
term aapplicable State authoritya means, with respect
8
to a health insurance issuer in a State, the State in-
9
surance commissioner or official or officials des-
10
ignated by the State to enforce the requirements of
11
title XXVII of the Public Health Service Act for the
12
State involved with respect to such issuer.
13
aa(3) FRANCHISOR;
FRANCHISEE.aThe
terms
14
afranchisora and afranchiseea have the meanings given
15
such terms for purposes of sections 436.2(a)
16
through 436.2(c) of title 16, Code of Federal Regu-
17
lations (including any such amendments to such reg-
18
ulation after the date of enactment of this part).
19
aa(4) HEALTH
PLAN TERMS.aThe
terms agroup
20
health plana, ahealth insurance coveragea, and ahealth
21
insurance issuera have the meanings provided in sec-
22
tion 733.
23
aa(5) INDIVIDUAL
24
aa(A) IN
25
MARKET.a
GENERAL.aThe
term aindividual
marketa means the market for health insurance
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1
coverage offered to individuals other than in
2
connection with a group health plan.
3
4
5
aa(B)
TREATMENT
OF
VERY
SMALL
GROUPS.a
aa(i) IN
GENERAL.aSubject
to clause
6
(ii), such term includes coverage offered in
7
connection with a group health plan that
8
has fewer than 2 participants as current
9
employees or participants described in sec-
10
tion 732(d)(3) on the first day of the plan
11
year.
12
aa(ii) STATE
EXCEPTION.aClause
(i)
13
shall not apply in the case of health insur-
14
ance coverage offered in a State if such
15
State regulates the coverage described in
16
such clause in the same manner and to the
17
same extent as coverage in the small group
18
market (as defined in section 2791(e)(5) of
19
the Public Health Service Act) is regulated
20
by such State.
21
aa(6) PARTICIPATING
EMPLOYER.aThe
term
22
aparticipating employera means, in connection with a
23
small business health plan, any employer, if any in-
24
dividual who is an employee of such employer, a
25
partner in such employer, or a self-employed indi-
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1
vidual who is such employer (or any dependent, as
2
defined under the terms of the plan, of such indi-
3
vidual) is or was covered under such plan in connec-
4
tion with the status of such individual as such an
5
employee, partner, or self-employed individual in re-
6
lation to the plan.
7
aa(b) RENEWAL.aA participating employer in a small
8 business health plan shall not be deemed to be a plan
9 sponsor in applying requirements relating to coverage re10 newal.aa.
11
(c) PREEMPTION RULES.aSection 514 of the Em-
12 ployee Retirement Income Security Act of 1974 (29
13 U.S.C. 1144) is amended by adding at the end the fol14 lowing:
15
aa(e) Except as provided in subsection (b)(4), the pro-
16 visions of this title shall supersede any and all State laws
17 insofar as they may now or hereafter preclude a health
18 insurance issuer from offering health insurance coverage
19 in connection with a small business health plan which is
20 certified under part 8.aa.
21
(d) PLAN SPONSOR.aSection 3(16)(B) of such Act
22 (29 U.S.C. 102(16)(B)) is amended by adding at the end
23 the following new sentence: aaSuch term also includes a
24 person serving as the sponsor of a small business health
25 plan under part 8.aa.
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1
(e) SAVINGS CLAUSE.aSection 731(c) of such Act is
2 amended by inserting aaor part 8aa after aathis partaa.
3
(f) COOPERATION BETWEEN FEDERAL
AND
STATE
4 AUTHORITIES.aSection 506 of the Employee Retirement
5 Income Security Act of 1974 (29 U.S.C. 1136) is amended
6 by adding at the end the following new subsection:
7
8
9
aa(d) CONSULTATION WITH STATES WITH RESPECT
TO
SMALL BUSINESS HEALTH PLANS.a
aa(1) AGREEMENTS
WITH STATES.aThe
Sec-
10
retary shall consult with the State recognized under
11
paragraph (2) with respect to a small business
12
health plan regarding the exercise ofa
13
aa(A) the Secretaryas authority under sec-
14
tions 502 and 504 to enforce the requirements
15
for certification under part 8; and
16
aa(B) the Secretaryas authority to certify
17
small business health plans under part 8 in ac-
18
cordance with regulations of the Secretary ap-
19
plicable to certification under part 8.
20
aa(2) RECOGNITION
OF DOMICILE STATE.aIn
21
carrying out paragraph (1), the Secretary shall en-
22
sure that only one State will be recognized, with re-
23
spect to any particular small business health plan,
24
as the State with which consultation is required.aa.
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1
(g) EFFECTIVE DATE.aThe amendments made by
2 this section shall take effect 1 year after the date of the
3 enactment of this Act. The Secretary of Labor shall first
4 issue all regulations necessary to carry out the amend5 ments made by this section within 6 months after the date
6 of the enactment of this Act.
TITLE II
7
8
9
SEC. 201. THE PREVENTION AND PUBLIC HEALTH FUND.
Subsection (b) of section 4002 of the Patient Protec-
10 tion and Affordable Care Act (42 U.S.C. 300ua11) is
11 amended by striking paragraphs (3) through (8).
12
13
14
SEC. 202. SUPPORT FOR STATE RESPONSE TO OPIOID CRISIS.
There is authorized to be appropriated, and is appro-
15 priated, out of monies in the Treasury not otherwise obli16 gated, $2,000,000,000 for fiscal year 2018, to the Sec17 retary of Health and Human Services to provide grants
18 to States to support substance use disorder treatment and
19 recovery support services for individuals with mental or
20 substance use disorders. Funds appropriated under this
21 section shall remain available until expended.
22
23
SEC. 203. COMMUNITY HEALTH CENTER PROGRAM.
Effective as if included in the enactment of the Medi-
24 care Access and CHIP Reauthorization Act of 2015 (Pub25 lic Law 114a10, 129 Stat. 87), paragraph (1) of section
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134
1 221(a) of such Act is amended by inserting aa, and an ad2 ditional $422,000,000 for fiscal year 2017aa after aa2017aa.
3
SEC. 204. CHANGE IN PERMISSIBLE AGE VARIATION IN
4
5
HEALTH INSURANCE PREMIUM RATES.
Section 2701(a)(1)(A)(iii) of the Public Health Serv-
6 ice Act (42 U.S.C. 300gg(a)(1)(A)(iii)) is amended by in7 serting after aa(consistent with section 2707(c))aa the fol8 lowing: aaor, for plan years beginning on or after January
9 1, 2019, 5 to 1 for adults (consistent with section 2707(c))
10 or such other ratio for adults (consistent with section
11 2707(c)) as the State may determineaa.
12
SEC. 205. MEDICAL LOSS RATIO DETERMINED BY THE
13
14
STATE.
Section 2718(b) of the Public Health Service Act (42
15 U.S.C. 300gga18(b)) is amended by adding at the end the
16 following:
17
aa(4) SUNSET.aParagraphs (1) through (3)
18
shall not apply for plan years beginning on or after
19
January 1, 2019, and after such date any reference
20
in law to such paragraphs shall have no force or ef-
21
fect.
22
aa(5) MEDICAL
LOSS RATIO DETERMINED BY
23
THE STATE.aFor
24
January 1, 2019, each State shalla
plan years beginning on or after
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1
aa(A) set the ratio of the amount of pre-
2
mium revenue a health insurance issuer offering
3
group or individual health insurance coverage
4
may expend on non-claims costs to the total
5
amount of premium revenue; and
6
aa(B) determine the amount of any annual
7
rebate required to be paid to enrollees under
8
such coverage if the ratio of the amount of pre-
9
mium revenue expended by the issuer on non-
10
claims costs to the total amount of premium
11
revenue exceeds the ratio set by the State under
12
subparagraph (A).aa.
13
14
SEC. 206. WAIVERS FOR STATE INNOVATION.
(a) IN GENERAL.aSection 1332 of the Patient Pro-
15 tection and Affordable Care Act (42 U.S.C. 18052) is
16 amendeda
17
18
19
20
(1) in subsection (a)a
(A) in paragraph (1)a
(i) in subparagraph (B)a
(I) by amending clause (i) to
21
read as follows:
22
aa(i) a description of how the State
23
plan meeting the requirements of a waiver
24
under this section would, with respect to
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136
1
health
2
Statea
insurance
coverage
within
the
3
aa(I) take the place of the require-
4
ments described in paragraph (2) that
5
are waived; and
6
aa(II)
provide
for
alternative
7
means of, and requirements for, in-
8
creasing access to comprehensive cov-
9
erage, reducing average premiums,
10
and increasing enrollment; andaa; and
11
(II) in clause (ii), by striking
12
aathat is budget neutral for the Fed-
13
eral Governmentaa and inserting aa,
14
demonstrating that the State plan
15
does not increase the Federal deficitaa;
16
and
17
(ii) in subparagraph (C), by striking
18
aathe lawaa and inserting aaa law or has in
19
effect a certificationaa;
20
(B) in paragraph (3)a
21
(i) by adding after the second sen-
22
tence the following: aaA State may request
23
that all of, or any portion of, such aggre-
24
gate amount of such credits or reductions
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1
be paid to the State as described in the
2
first sentence.aa;
3
(ii) in the paragraph heading, by
4
striking aaPASS
5
and inserting aaFUNDINGaa;
6
THROUGH OF FUNDINGaa
(iii) by striking aaWith respectaa and
7
inserting the following:
8
aa(A) PASS
9
THROUGH OF FUNDING.aWith
respectaa; and
10
(iv) by adding at the end the fol-
11
lowing:
12
aa(B) ADDITIONAL
FUNDING.aThere
is au-
13
thorized to be appropriated, and is appro-
14
priated, to the Secretary of Health and Human
15
Services, out of monies in the Treasury not oth-
16
erwise obligated, $2,000,000,000 for fiscal year
17
2017, to remain available until the end of fiscal
18
year 2019, to provide grants to States for pur-
19
poses of submitting an application for a waiver
20
granted under this section and implementing
21
the State plan under such waiver.
22
aa(C) AUTHORITY
TO
USE
LONG-TERM
23
STATE
24
MENT.aIf
25
allotment under section 2105(i) of the Social
INNOVATION
AND
STABILITY
ALLOT-
the State has an application for an
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1
Security Act for the plan year, the State may
2
use the funds available under the Stateas allot-
3
ment for the plan year to carry out the State
4
plan under this section, so long as such use is
5
consistent with the requirements of paragraphs
6
(1) and (7) of section 2105(i) of such Act
7
(other than paragraph (1)(B) of such section).
8
Any funds used to carry out a State plan under
9
this subparagraph shall not be considered in de-
10
termining whether the State plan increases the
11
Federal deficit.aa; and
12
13
14
(C) in paragraph (4), by adding at the end
the following:
aa(D) EXPEDITED
PROCESS.aThe
Sec-
15
retary shall establish an expedited application
16
and approval process that may be used if the
17
Secretary determines that such expedited proc-
18
ess is necessary to respond to an urgent or
19
emergency situation with respect to health in-
20
surance coverage within a State.aa;
21
(2) in subsection (b)a
22
23
24
(A) in paragraph (1)a
(i) in the matter preceding subparagraph (A)a
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1
2
3
(I) by striking aamayaa and inserting aashallaa; and
(II) by striking aaonly ifaa and in-
4
serting aaunlessaa; and
5
(ii) by striking aaplanaaa and all that
6
follows through the period at the end of
7
subparagraph (D) and inserting aaplan will
8
increase the Federal deficit, not taking
9
into account any amounts received through
10
a grant under subsection (a)(3)(B).aa;
11
(B) in paragraph (2)a
12
13
(i) in the paragraph heading, by inserting aaOR
CERTIFYaa
after aaLAWaa;
14
(ii) in subparagraph (A), by inserting
15
before the period aa, and a certification de-
16
scribed in this paragraph is a document,
17
signed by the Governor, and the State in-
18
surance commissioner, of the State, that
19
provides authority for State actions under
20
a waiver under this section, including the
21
implementation of the State plan under
22
subsection (a)(1)(B)aa; and
23
24
25
(iii) in subparagraph (B)a
(I) in the subparagraph heading,
by striking aaOF
OPT OUTaa;
and
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1
(II) by striking aa may repeal a
2
lawaa and all that follows through the
3
period at the end and inserting the
4
following: aamay terminate the author-
5
ity provided under the waiver with re-
6
spect to the State bya
7
aa(i) repealing a law described in sub-
8
paragraph (A); or
9
aa(ii) terminating a certification de-
10
scribed in subparagraph (A), through a
11
certification for such termination signed by
12
the Governor, and the State insurance
13
commissioner, of the State.aa;
14
(3) in subsection (d)(2)(B), by striking aaand
15
the reasons thereforeaa and inserting aaand the rea-
16
sons therefore, and provide the data on which such
17
determination was madeaa; and
18
(4) in subsection (e), by striking aaNo waiveraa
19
and all that follows through the period at the end
20
and inserting the following: aaA waiver under this
21
sectiona
22
23
24
25
aa(1) shall be in effect for a period of 8 years
unless the State requests a shorter duration;
aa(2) may be renewed for unlimited additional 8year periods upon application by the State; and
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1
aa(3) may not be cancelled by the Secretary be-
2
fore the expiration of the 8-year period (including
3
any renewal period under paragraph (2)).aa.
4
(b) APPLICABILITY.aSection 1332 of the Patient
5 Protection and Affordable Care Act (42 U.S.C. 18052)
6 shall apply as follows:
7
(1) In the case of a State for which a waiver
8
under such section was granted prior to the date of
9
enactment of this Act, such section 1332, as in ef-
10
fect on the day before the date of enactment of this
11
Act shall apply to the waiver and State plan.
12
(2) In the case of a State that submitted an ap-
13
plication for a waiver under such section prior to the
14
date of enactment of this Act, and which application
15
the Secretary of Health and Human Services has
16
not approved prior to such date, the State may elect
17
to have such section 1332, as in effect on the day
18
before the date of enactment of this Act, or such
19
section 1332, as amended by subsection (a), apply to
20
such application and State plan.
21
(3) In the case of a State that submits an ap-
22
plication for a waiver under such section on or after
23
the date of enactment of this Act, such section 1332,
24
as amended by subsection (a), shall apply to such
25
application and State plan.
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1
2
SEC. 207. FUNDING FOR COST-SHARING PAYMENTS.
There is appropriated to the Secretary of Health and
3 Human Services, out of any money in the Treasury not
4 otherwise appropriated, such sums as may be necessary
5 for payments for cost-sharing reductions authorized by the
6 Patient Protection and Affordable Care Act (including ad7 justments to any prior obligations for such payments) for
8 the period beginning on the date of enactment of this Act
9 and ending on December 31, 2019. Notwithstanding any
10 other provision of this Act, payments and other actions
11 for adjustments to any obligations incurred for plan years
12 2018 and 2019 may be made through December 31, 2020.
13
14
SEC. 208. REPEAL OF COST-SHARING SUBSIDY PROGRAM.
(a) IN GENERAL.aSection 1402 of the Patient Pro-
15 tection and Affordable Care Act is repealed.
16
(b) EFFECTIVE DATE.aThe repeal made by sub-
17 section (a) shall apply to cost-sharing reductions (and pay18 ments to issuers for such reductions) for plan years begin19 ning after December 31, 2019.