,i  #aadth ,,congress  #ast ,session    
,h4 ,r4 #cceb  ,,in ,,the ,,house ,,of  
,,representatives  ,july #bi1 #bjae ,mr4
 ,hultgren introduced the following     
bill2 which was referred to the         
,committee on ,energy and ,commerce1 and
 in addition to the ,committee on ,ways 
and ,means1 for a period to be          
subsequently determined by the ,speaker1
 in each case for consideration of such 
provisions as fall within the           
jurisdiction of the committee concerned 
,a ,,bill  ,to amend the ,patient       
,protection and ,affordable ,care ,act  
and the ,internal ,revenue ,code of     
#aihf to provide greater flexibility    
with respect to waivers granted to      
,states1 and for other purposes4  #a4   
,short title ,this ,act may be cited as 
the ,state ,health ,care ,options ,act  
of #bjae4  #b4 ,increasing ,state       
flexibility through provision of        
health-flex and exchange waivers  7a7   
,state options  7#a7 ,in general ,the   
,patient ,protection and ,affordable    

,care ,act is amended by inserting after
 section #accb 7#db ,u4,s4,c4 #ahjeb7   
the following3  #accb;,a4 ,options for  
,state flexibility  7a7 ,state options  
7#a7 ,in general ,if a ,state provides  
to the ,secretary a notice 7in this     
section referred to as a waiver notice7 
of intent to implement a health-flex    
waiver 7described in subsection         
7b77#a771 an exchange waiver 7described 
in subsection 7b77#b771 or both1 and    
such notice complies with paragraph     
7#b71 the waiver shall be deemed to be  
approved and effective1 except as       
provided in paragraphs 7#e7 and 7#f74   
7#b7 ,contents of a waiver notice ,a    
waiver notice with respect to a ,state  
shall include the following3 7,a7 ,the  
years for which the waiver shall be     
effective 7which may be indefinite74    
7,b7 ,an assurance that the ,state will 
comply with annual reporting            
requirements established by the         
,secretary relating to the activities of
 the ,state under the waiver1 which     

reporting requirements shall include    
information on affordability1 access1   
and transparency4  7,c7 ,in the case of 
a health-flex waiver-- 7i7 the          
requirements to be waived2  7ii7 an     
assurance that there will be available  
throughout the ,state one or more health
 plans that provide the catastrophic    
level of coverage described in          
subsection 7c77#a77;,b77i7 for which an 
enrollee's required contribution 7as    
defined in section #ejjj;,a7e77#a77;,b7 
of the ,internal ,revenue ,code of      
#aihf1 determined on an annual basis7   
does not exceed #f4e percent of the     
median household income 7as defined in  
section #cf;,b7d77#b77;,a7 of such      
,code7 of residents of the ,state for   
the most recent taxable year for which  
information on such median household    
income is available to the ,secretary2  
and  7iii7 an assurance that the        
certifying entity 7as defined in        
subsection 7c77#b77 has a process to    
certify health plans as permissible     

health plans consistent with subsection 
7c74  7,d7 ,in the case of an exchange  
waiver1 assurances that the ,state-- 7i7
 will be responsible for functions that 
are necessary to carry out the waiver   
that would otherwise be performed by an 
,exchange2  7ii7 will comply with       
subsection 7d72  7iii7 has the          
capability to receive from the          
,secretary subsidy eligibility          
information2 and  7iv7 has and is       
applying standards for privacy1         
security1 and data encryption for       
subsidy eligibility information that are
 determined to be satisfactory by the   
,secretary4  7#c7 ,effectiveness ,a     
waiver under this section shall be      
effective for the years described in the
 waiver notice under paragraph          
7#b77;,a71 except that no waiver under  
this section shall be effective for a   
year unless the waiver notice for such  
waiver was submitted before ,november #a
 of the previous year4  7#d7            
,modification or termination ,a ,state  

may modify or terminate a waiver for the
 ,state under this section by submitting
 to the ,secretary a subsequent waiver  
notice with respect to such waiver4     
7#e7 ,disapproval authority ,if the     
,secretary determines that a waiver     
notice fails to comply with paragraph   
7#b7 and notifies the ,state of the     
reason for such determination not later 
than #cj days after the date on which   
the ,state submits the waiver notice1   
such waiver notice shall not be         
effective4  7#f7 ,revocation ,if the    
,secretary determines that a ,state is  
in violation of an assurance submitted  
under paragraph 7#b7 and notifies the   
,state of the reason for such           
determination1 the ,secretary may revoke
 the waiver4 ,such revocation shall be  
effective on the first day of the first 
year that begins after the #fj-;day     
period that begins on the date on which 
notification of the revocation occurs4  
7#g7 ,construction ,nothing in this     
section shall be construed as requiring 

a ,state to enact a law in order to     
carry out the provisions of this        
section4  7b7 ,waivers  7#a7            
,health-flex waiver ,a waiver under this
 paragraph 7in this section referred to 
as a health-flex waiver71 with respect  
to a ,state1 is a waiver of any of the  
requirements in sections #acja through  
#acjc4  7#b7 ,exchange waiver ,a waiver 
under this paragraph 7in this section   
referred to as an exchange waiver7      
permits a ,state to elect to be         
responsible for certain ,exchange       
functions1 including serving as the     
certifying entity for the purposes of   
subsection 7c74  7#c7 ,no waiver of     
adult child coverage and preexisting    
conditions ,nothing in this subsection  
may be construed to permit a ,state to  
waive the following3 7,a7 ,prohibition  
of preexisting condition exclusion      
,section #bgjd of the ,public ,health   
,service ,act 7#db ,u4,s4,c4            
#cjj;gg-#c74  7,b7 ,extension of        
coverage for adult children ,section    

#bgad of the ,public ,health ,service   
,act 7#db ,u4,s4,c4 #cjj;gg-#ad74  7c7  
,certifying permissible health plans    
7#a7 ,permissible health plan defined   
,for the purposes of this section1 the  
term permissible health plan means1 with
 respect to a ,state1 a health plan that
 is offered for sale in the individual  
or small group market in the ,state and 
that is certified by a certifying entity
 to meet the following requirements3    
7,a7 ,benefits ,the plan provides       
benefits for items and services within  
each of the following categories3 7i7   
,ambulatory patient services4  7ii7     
,emergency services4  7iii7             
,hospitalization4  7iv7 ,physician      
services4  7,b7 ,levels of coverage ,the
 plan provides a level of coverage that 
complies with one of the following      
levels of coverage 7as established by   
the ,state73  7i7 ,catastrophic4  7ii7  
,standard4  7iii7 ,high4  7,c7          
,transparency justifying premiums ,the  
issuer of the plan makes available to   

the public information about the        
demographics of the population enrolled 
under the plan1 the utilization of      
health care items and services by such  
population under the plan1 and other    
factors that serve as a justification   
for the premium levels 7including any   
premium increases7 under the plan4  7,d7
 ,information requirement ,the issuer of
 the plan submits information as        
required under section                  
#cf;,b7g77#c77;,c7 of the ,internal     
,revenue ,code of #aihf4  7#b7          
,certifying entity defined ,in this     
section1 the term certifying entity     
means-- 7,a7 in the case of a health    
plan that is offered through an         
,exchange established by a ,state1 such 
,exchange2 and  7,b7 in the case of a   
health plan that is not so offered1 the 
,state in which such plan is offered4   
7#c7 ,effect of certifying permissible  
health plans ,with respect to           
eligibility for premium assistance tax  
credits and reduced cost-sharing for    

individuals enrolled in permissible     
health plans1 see section #cf;,b7g7 of  
the ,internal ,revenue ,code of #aihf   
and section #adjb7;f77#d7 of the        
,patient ,protection and ,affordable    
,care ,act 7#db ,u4,s4,c4 #ahjga71      
respectively4  7d7 ,determining subsidy 
eligibility  7#a7 ,in general ,in the   
case of a ,state that has in effect an  
exchange waiver1 the ,state shall       
determine the eligibility of individuals
 residing in the ,state for the         
assistance described in subparagraphs   
7,a7 and 7,b7 of paragraph 7#c74  7#b7  
,disclosure of ,federal information ,in 
the case of a ,state that has in effect 
an exchange waiver1 the ,secretary or   
the ,secretary of the ,treasury1 as     
appropriate1 shall make subsidy         
eligibility information available to the
 ,state1 but only the minimum amount of 
information necessary to enable the     
,state to determine the amount of the   
assistance described in subparagraphs   
7,a7 and 7,b7 of paragraph 7#c7 for     

which the individual enrolled in a      
permissible health plan is eligible4    
7#c7 ,subsidy eligibility information   
defined ,in this subsection1 the term   
subsidy eligibility information means   
information concerning the eligibility  
of an enrollee or a prospective enrollee
 in a health plan for--  7,a7 a premium 
assistance credit under section         
#cf;,b7a7 of the ,internal ,revenue     
,code of #aihf2 and  7,b7 reduced       
cost-sharing under section #adjb4  4    
7#b7 ,reporting requirements ,the       
,secretary shall establish annual       
reporting requirements under            
#accb;,a7a77#b77;,b7 of the ,patient    
,protection and ,affordable ,care ,act  
that include information on             
affordability1 access1 and transparency4
  7#c7 ,conforming amendment ,the table 
of contents of the ,patient ,protection 
and ,affordable ,care ,act is amended by
 inserting after the item relating to   
section #accb the following3  ,sec4     
#accb;,a4 ,options for ,state           

flexibility4  4  7b7 ,subsidies for     
individuals enrolled in permissible     
health plans  7#a7 ,premium assistance  
tax credits ,section #cf;,b of the      
,internal ,revenue ,code of #aihf is    
amended-- 7,a7 by redesignating         
subsection 7g7 as subsection 7h72 and   
7,b7 by inserting after subsection 7f7  
the following3  7g7 ,special rules in   
case of waivers under section #accb;,a  
of ,,ppaca  7#a7 ,limiting eligibility  
to taxpayers with income at or below    
#cjj percent of ,,fpl ,in the case of a 
section #accb;,a ,state1 subsection     
7c77#a77;,a7 shall be applied by        
substituting #cjj percent for #djj      
percent for a taxpayer who obtains      
coverage through a plan issued under the
 law of such ,state for a year4  7#b7   
,permissible health plans ,in the case  
of a taxpayer who obtains coverage with 
respect to a section #accb;,a ,state1   
for a coverage month1 a permissible     
health plan1 as defined in section      
#accb;,a7c77#a7 of the ,patient         

,protection and ,affordable ,care ,act1 
shall be treated as a qualified health  
plan with respect to such taxpayer4     
7#c7 ,adjusted monthly premium ,in the  
case of a ,state that has in effect a   
health-flex waiver described in section 
#accb;,a7b77#a7 of such ,act1 subsection
 7b77#c77;,c7 shall be applied as if the
 adjusted monthly premium calculated    
under such subsection were multiplied by
 the ratio of the full actuarial value  
of the benefits provided under the plan 
being offered to the full actuarial     
value of essential health benefits4     
7#d7 ,eliminating certain requirements  
in the case of an exchange waiver ,in   
the case of a ,state that has in effect 
an exchange waiver described in section 
#accb;,a7b77#b7 of such ,act for a      
coverage month1 the following shall     
apply3  7,a7 ,eliminating exchange      
references ,subsections 7b77#b77;,a71   
7c77#b77;,a77i71 7d77#c77;,b71 and      
7e77#c7 shall be applied by treating the
 permissible health plan as if it were  

offered through an ,exchange4  7,b7     
,applicable second lowest cost silver   
plan ,subsection 7b77#c77;,b7 shall be  
applied by substituting-- 7i7 qualified 
health plan for which1 if the adjusted  
monthly premium1 taking into account    
subsection 7g77#c71 were multiplied by  
the ratio of #gj percent to the level of
 coverage expressed as a percent of the 
full actuarial value of the benefits    
provided under the plan1 the product of 
such multiplication would be the second 
lowest such product for any plan offered
 in for second lowest cost silver plan  
of1 and  7ii7 is offered in such rating 
area for is offered through the same    
,exchange through which the qualified   
health plans taken into account under   
paragraph 7#b77;,a7 were offered4  7,c7 
,information requirement ,in the case of
 a permissible health plan which is not 
offered through an ,exchange1 such plan 
shall provide to the ,secretary and to  
the individual enrolled in the plan the 
information described in subsection     

7f77#c7 with respect to such plan and   
such individual4  7#e7 ,special rule for
 part-time resident taxpayers with      
income above #cjj percent of ,,fpl ,in  
the case of a taxpayer who1 during a    
taxable year1 obtains coverage with     
respect to a #accb;,a ,state and with   
respect to a ,state which is not a      
#accb;,a ,state1 paragraph 7#a7 shall   
not apply and the premium assistance    
amount 7otherwise determined under      
subsection 7b77#b77 for such taxpayer   
for a coverage month shall be #j if--   
7,a7 the household income of the        
taxpayer for the taxable year equals or 
exceeds #cjj percent of an amount equal 
to the poverty line for a family of the 
size involved1 and  7,b7 the taxpayer   
receives coverage with respect to a     
section #accb;,a ,state for such        
coverage month4  7#f7 ,section #accb;,a 
,state defined ,for purposes of this    
subsection1 the term section #accb;,a   
,state means a ,state has in effect a   
waiver under section #accb;,a of the    

,patient ,protection and ,affordable    
,care ,act4  4  7#b7 ,reduced           
cost-sharing ,section #adjb7;f7 of the  
,patient ,protection and ,affordable    
,care ,act 7#db ,u4,s4,c4 #ahjga7;f77 is
 amended by adding at the end the       
following3  7#d7 #accb;,a waivers ,if a 
,state has in effect a waiver under     
#accb;,a1 the following shall apply with
 respect to a coverage month with       
respect to individuals residing in the  
,state on the first of the month3  7,a7 
,eliminating reduced cost-sharing for   
individuals with income above #cjj      
percent of ,,fpl ,no individual whose   
household income exceeds #cjj percent of
 the poverty line for a family of the   
size involved may be considered an      
eligible insured under this section4    
7,b7 ,permissible health plans ,for the 
purposes of this section1 a permissible 
health plan1 as defined in section      
#accb;,a7c77,a71 shall be treated as a  
qualified health plan4  7,c7 ,exchange  
waiver ,if a ,state has in effect an    

exchange waiver described in section    
#accb;,a7b77#b71 subsections 7b77#a71   
7d77#a71 and 7e77#c7 shall apply as if  
there were no references to an          
,exchange4  4  7c7 ,acceleration of     
innovation waivers ,section             
#accb7;a77#a7 of the ,patient           
,protection and ,affordable ,care ,act  
7#db ,u4,s4,c4 #ahjeb7 is amended1 in   
the matter preceding subparagraph 7,a71 
by striking ,january #a1 #bjag and      
inserting the date of the enactment of  
the ,state ,health ,care ,options ,act  
of #bjae4