,,ii #aafth ,,congress #b;d ,session ,s4 #deba ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,august #aa1 #bjbj,mr4 ,warner introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend the ,patient ,protection and ,affordable ,care ,act to reduce health care costs and expand health care coverage to more ,americans4 #a4 ,short title ,this ,act may be cited as the ,health ,care ,improvement ,act of #bjbj4 #b4 ,table of contents ,the table of contents for this ,act is as follows3 ,sec4 #a4 ,short title4,sec4 #b4 ,table of contents4,,title ,i--,reducing health care costs and protecting people with preexisting conditions,sec4 #aja4 ,improving affordability by expanding premium assistance for consumers4,sec4 #ajb4 ,expanding affordability for working families to fix the family glitch4,sec4 #ajc4 ,establishing a ,state ,health ,insurance ,affordability and ,innovation fund4,sec4 #ajd4 ,rescinding the short-term limited duration insurance regulation4,sec4 #aje4 ,revoking section #accb guidance4,sec4 #ajf4 ,promoting consumer outreach and education4,,title ,,ii--,encouraging ,medicaid ,expansion and ,strengthening the ,medicaid ,program,sec4 #bja4 ,incentivizing ,medicaid expansion4,sec4 #bjb4 ,reducing the administrative ,,fmap for nonexpansion ,states4,sec4 #bjc4 ,state option to provide #ab months of postpartum ,medicaid eligibility4,sec4 #bjd4 ,supporting ,state ,medicaid programs through economic downturns4,sec4 #bje4 ,state flexibility to use administrative simplification policies for enrollment4,,title ,,iii--,establishment of a ,public ,health ,care ,option,sec4 #cja4 ,establishment of health plan4,sec4 #cjb4 ,availability of plan4,sec4 #cjc4 ,affordability4,sec4 #cjd4 ,participating providers4,sec4 #cje4 ,provider payment rates4,sec4 #cjf4 ,no effect on ,medicare benefits or ,medicare trust funds4,,title ,,iv--,fair ,medicare ,payments to ,rural ,providers,sec4 #dja4 ,ensuring fairness in ,medicare hospital payments4,,title ,v--,commonsense ,competition and ,access to ,health ,insurance,sec4 #eja4 ,providing small business health insurance across ,state lines4,sec4 #ejb4 ,report and models4,,title ,,vi--,empowering ,medicare ,seniors to ,negotiate ,prescription ,drug ,prices,sec4 #fja4 ,authority to negotiate fair prices for ,medicare prescription drugs4,,title ,,vii--,commonsense reporting for employers,sec4 #gja4 ,voluntary prospective reporting system4,sec4 #gjb4 ,protection of dependent privacy4,sec4 #gjc4 ,electronic statements4,sec4 #gjd4 ,,gao studies4,sec4 #gje4 ,tax ,compliance4,,title ,,viii--,federal ,ban on ,surprise ,medical ,billing,sec4 #hja4 ,protection against surprise bills4 ,i ,reducing health care costs and protecting people with preexisting conditions #aja4 ,improving affordability by expanding premium assistance for consumers 7a7 ,in general ,section #cf;,b7b77#c77;,a7 of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7,a7 ,applicable percentage ,the applicable percentage for any taxable year shall be the percentage such that the applicable percentage for any taxpayer whose household income is within an income tier specified in the following table shall increase1 on a sliding scale in a linear manner1 from the initial premium percentage to the final premium percentage specified in such table for such income tier3 ,in the case of household income 7expressed as a percent of poverty line7 within the following income tier3,the initial premiumpercentage is--,the final premium percentage is--,up to #aej4j percent#j4jj4jaej4j percent up to #bjj4j percent#j4jc4jbjj4j percent up to #bej4j percent#c4jd4jbej4j percent up to #cjj4j percent#d4jf4jcjj4j percent up to #djj4j percent#f4jh4edjj4j percent and higher#h4eh4e 4 7b7 ,conforming amendment ,section #cf;,b7c77#a77;,a7 of the ,internal ,revenue ,code of #aihf is amended by striking but does not exceed #djj percent4 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjai4 #ajb4 ,expanding affordability for working families to fix the family glitch 7a7 ,in general ,clause 7i7 of section #cf;,b7c77#b77;,c7 of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7i7 ,coverage must be affordable 7,i7 ,employees ,an employee shall not be treated as eligible for minimum essential coverage if such coverage consists of an eligible employer-sponsored plan 7as defined in section #ejjj;,a7f77#b77 and the employee's required contribution 7within the meaning of section #ejjj;,a7e77#a77;,b77 with respect to the plan exceeds #i4e percent of the employee's household income4 7,,ii7 ,family members ,an individual who is eligible to enroll in an eligible employer-sponsored plan 7as defined in section #ejjj;,a7f77#b77 by reason of a relationship the individual bears to the employee shall not be treated as eligible for minimum essential coverage by reason of such eligibility to enroll if the employee's required contribution 7within the meaning of section #ejjj;,a7e77#a77;,b71 determined by substituting family for self-only7 with respect to the plan exceeds #i4e percent of the employee's household income4 4 7b7 ,conforming amendments 7#a7 ,clause 7ii7 of section #cf;,b7c77#b77;,c7 of the ,internal ,revenue ,code of #aihf is amended by striking ,except as provided in clause 7iii71 an employee and inserting ,an individual4 7#b7 ,clause 7iii7 of section #cf;,b7c77#b77;,c7 of such ,code is amended by striking the last sentence of clause 7i7 and inserting clause 7i77,,ii74 7#c7 ,clause 7iv7 of section #cf;,b7c77#b77;,c7 of such ,code is amended by striking the #i4e percent under clause 7i77,,ii7 and inserting the #i4e percent under clauses 7i77,i7 and 7i77,,ii74 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjba4 #ajc4 ,establishing a ,state ,health ,insurance ,affordability and ,innovation fund ,subtitle ,d of title ,i of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjba et seq47 is amended by adding at the end the following3 #f ,state ,health ,insurance ,affordability and ,innovation ,fund #acea4 ,establishment of program ,there is hereby established the ,state ,health ,insurance ,affordability and ,innovation ,fund to be administered by the ,secretary of ,health and ,human ,services1 acting through the ,administrator of the ,centers for ,medicare ,medicaid ,services 7referred to in this section as the ,administrator71 to provide funding1 in accordance with this part1 to each of the #ej ,states and the ,district of ,columbia 7each referred to in this section as a ,state7 beginning on ,january #a1 #bjbb1 for the purposes described in section #aceb4 #aceb4 ,use of funds 7a7 ,in general ,a ,state shall use the funds allocated to the ,state under this part for one of the following purposes3 7#a7 ,to provide reinsurance payments to health insurance issuers with respect to individuals enrolled under individual health insurance coverage 7other than through a plan described in subsection 7b77 offered by such issuers4 7#b7 ,to provide assistance 7other than through payments described in paragraph 7#a77 to reduce out-of-pocket costs1 such as copayments1 coinsurance1 premiums1 and deductibles1 of individuals enrolled under qualified health plans offered on the individual market through an ,exchange4 7#c7 ,state efforts to streamline health insurance enrollment procedures in order to reduce burdens on consumers and facilitate greater enrollment in health insurance coverage in the individual and small group markets1 including automatic enrollment and reenrollment of1 or pre-populated applications for1 individuals without health insurance who are eligible for tax credits under section #cf;,b of the ,internal ,revenue ,code of #aihf1 with the ability to opt out of such enrollment4 7#d7 ,state investment in technology to improve data sharing and collection for the purposes of facilitating greater enrollment in health insurance coverage in such markets4 7#e7 ,feasibility studies to develop comprehensive and coherent ,state plan for increasing enrollment in the individual and small group market4 7b7 ,exclusion of certain grandfathered and transitional plans ,for purposes of subsection 7a71 a plan described in this subsection is the following3 7#a7 ,a grandfathered health plan 7as defined in section #abea74 7#b7 ,a plan 7commonly referred to as a transitional plan7 continued under the letter issued by the ,centers for ,medicare ,medicaid ,services on ,november #ad1 #bjac1 to the ,state ,insurance ,commissioners outlining a transitional policy for coverage in the individual and small group markets to which section #abea does not apply1 and under the extension of the transitional policy for such coverage set forth in the ,insurance ,standards ,bulletin ,series guidance issued by the ,centers for ,medicare ,medicaid ,services on ,march #e1 #bjad1 ,february #bi1 #bjaf1 ,february #ac1 #bjag1 ,april #i1 #bjah1 ,march #be1 #bjai1 and ,january #ca1 #bjbj1 or under any subsequent extensions thereof4 7#c7 ,student health insurance coverage 7as defined in section #adg4ade of title #de1 ,code of ,federal ,regulations74 #acec4 ,state eligibility and approval2 default safeguard 7a7 ,encouraging ,state options for allocations 7#a7 ,in general ,to be eligible for an allocation of funds under this part for a year 7beginning with #bjbb71 a ,state shall submit to the ,administrator an application at such time 7but1 in the case of allocations for #bjbb1 not later than #ij days after the date of the enactment of this part and1 in the case of allocations for a subsequent year1 not later than ,march #a of the previous year7 and in such form and manner as specified by the ,administrator containing-- 7,a7 a description of how the funds will be used2 and 7,b7 such other information as the ,administrator may require4 7#b7 ,automatic approval ,an application so submitted is approved unless the ,administrator notifies the ,state submitting the application1 not later than #fj days after the date of the submission of such application1 that the application has been denied for not being in compliance with any requirement of this part and of the reason for such denial4 7#c7 #e-year application approval ,if an application of a ,state is approved for a purpose described in section #aceb for a year1 such application shall be treated as approved for such purpose for each of the subsequent #d years4 7#d7 ,revocation of approval ,the approval of an application of a ,state1 with respect to a purpose described in section #aceb1 may be revoked if the ,state fails to use funds provided to the ,state under this section for such purpose or otherwise fails to comply with the requirements of this section4 7b7 ,default ,federal safeguard 7#a7 #bjbb ,for #bjbb1 in the case of a ,state that does not submit an application under subsection 7a7 by the #ij-;day submission date applicable to such year under subsection 7a77#a7 and in the case of a ,state that does submit such an application by such date that is not approved1 the ,administrator1 in consultation with the ,state insurance commissioner1 shall1 from the amount calculated under paragraph 7#d7 for such year1 carry out the purpose described in paragraph 7#c7 in such ,state for such year4 7#b7 #bjbc and subsequent years ,for #bjbc or a subsequent year1 in the case of a ,state that does not have in effect an approved application under this section for such year1 the ,administrator1 in consultation with the ,state insurance commissioner1 shall1 from the amount calculated under paragraph 7#d7 for such year1 carry out the purpose described in paragraph 7#c7 in such ,state for such year4 7#c7 ,specified use ,the amount described in paragraph 7#d71 with respect to #bjbb or a subsequent year1 shall be used to carry out the purpose described in section #aceb7;a77#a7 in each ,state described in paragraph 7#a7 or 7#b7 for such year1 as applicable1 by providing reinsurance payments to health insurance issuers with respect to attachment range claims 7as defined in section #aced7;b77#b771 using the dollar amounts specified in subparagraph 7,b7 of such section for such year in an amount equal to1 subject to paragraph 7#e71 the percentage 7specified for such year by the ,secretary under such subparagraph7 of the amount of such claims4 7#d7 ,amount described ,the amount described in this paragraph1 with respect to #bjbb or a subsequent year1 is the amount equal to the total sum of amounts that the ,secretary would otherwise estimate under section #aced7;b77#b77;,a77i7 for such year for each ,state described in paragraph 7#a7 or 7#b7 for such year1 as applicable1 if each such ,state were not so described for such year4 7#e7 ,adjustment ,for purposes of this subsection1 the ,secretary may apply a percentage under paragraph 7#c7 with respect to a year that is less than the percentage otherwise specified in section #aced7;b77#b77;,b7 for such year1 if the cost of paying the total eligible attachment range claims for ,states described in this subsection for such year at such percentage otherwise specified would exceed the amount calculated under paragraph 7#d7 for such year4 #aced4 ,allocations 7a7 ,appropriation ,for the purpose of providing allocations for ,states under subsection 7b7 and payments under section #acec7;b7 there is appropriated1 out of any money in the ,treasury not otherwise appropriated1 #aj1jjj1jjj1jjj for #bjbb and each subsequent year4 7b7 ,allocations 7#a7 ,payment 7,a7 ,in general ,from amounts appropriated under subsection 7a7 for a year1 the ,secretary shall1 with respect to a ,state not described in section #acec7;b7 for such year and not later than the date specified under subparagraph 7,b7 for such year1 allocate for such ,state the amount determined for such ,state and year under paragraph 7#b74 7,b7 ,specified date ,for purposes of subparagraph 7,a71 the date specified in this subparagraph is-- 7i7 for #bjbb1 the date that is #de days after the date of the enactment of this part2 and 7ii7 for #bjbc or a subsequent year1 ,january #a of the respective year4 7,c7 ,notifications of allocation amounts ,for #bjbc and each subsequent year1 the ,secretary shall notify each ,state of the amount determined for such ,state under paragraph 7#b7 for such year by not later than ,january #a of the previous year4 7#b7 ,allocation amount determinations 7,a7 ,in general ,for purposes of paragraph 7#a71 the amount determined under this paragraph for a year for a ,state described in paragraph 7#a77;,a7 for such year is the amount equal to-- 7i7 the amount that the ,secretary estimates would be expended under this part for such year on attachment range claims of individuals residing in such ,state if such ,state used such funds only for the purpose described in paragraph 7#a7 of section #aceb7;a7 at the dollar amounts and percentage specified under subparagraph 7,b7 for such year2 minus 7ii7 the amount1 if any1 by which the ,secretary determines-- 7,i7 the estimated amount of premium tax credits under section #cf;,b of the ,internal ,revenue ,code of #aihf that would be attributable to individuals residing in such ,state for such year without application of this part2 exceeds 7,,ii7 the estimated amount of premium tax credits under section #cf;,b of the ,internal ,revenue ,code of #aihf that would be attributable to individuals residing in such ,state for such year if such ,state were a ,state described in section #acec7;b7 for such year4 ,for purposes of the previous sentence and section #acec7;b77#c71 the term attachment range claims means1 with respect to an individual1 the claims for such individual that exceed a dollar amount specified by the ,secretary for a year1 but do not exceed a ceiling dollar amount specified by the ,secretary for such year1 under subparagraph 7,b74 7,b7 ,specifications ,for purposes of subparagraph 7,a7 and section #acec7;b77#c71 the ,secretary shall determine the dollar amounts and the percentage to be specified under this subparagraph for a year in a manner to ensure that the total amount of expenditures under this part for such year is estimated to equal the total amount appropriated for such year under subsection 7a7 if such expenditures were used solely for the purpose described in paragraph 7#a7 of section #aceb7;a7 for attachment range claims at the dollar amounts and percentage so specified for such year4 7#c7 ,availability ,funds allocated to a ,state under this subsection for a year shall remain available through the end of the subsequent year4 4 #ajd4 ,rescinding the short-term limited duration insurance regulation 7a7 ,prohibition ,the ,secretary of ,health and ,human ,services1 the ,secretary of the ,treasury1 and the ,secretary of ,labor-- 7#a7 may not take any action to implement1 enforce1 or otherwise give effect to the rule entitled ,short-,term1 ,limited ,duration ,insurance 7#hc ,fed4 ,reg4 #chbab 7,august #c1 #bjah772 7#b7 shall apply any regulation revised by such rule as if such rule had not been issued2 and 7#c7 may not promulgate any substantially similar rule4 #aje4 ,revoking section #accb guidance 7a7 ,providing that certain guidance related to waivers for ,state innovation under the ,patient ,protection and ,affordable ,care ,act shall have no force or effect ,beginning ,july #a1 #bjbj1 the ,secretary of ,health and ,human ,services and the ,secretary of the ,treasury may not take any action to implement1 enforce1 or otherwise give effect to the guidance entitled ,state ,relief and ,empowerment ,waivers 7#hc ,fed4 ,reg4 #ecege 7,october #bd1 #bjah771 including any such action that would-- 7#a7 result in individuals losing health insurance coverage that includes the essential health benefits package 7as defined in subsection 7a7 of section #acjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7;a77 without regard to any waiver of any provision of such package under a waiver under such section #accb71 including the maternity and newborn care essential health benefit described in subsection 7b77#a77;,d7 of such section2 7#b7 result in a decrease in the number of such individuals enrolled in coverage that is at least as comprehensive as the coverage defined in section #acjb7;a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7;a77 compared to the number of such individuals who would have been so enrolled in such coverage had such action not been taken2 7#c7 with respect to individuals with substance use disorders1 including opioid use disorders1 reduce the availability or affordability of coverage that is at least as comprehensive as the coverage defined in section #acjb7;a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7;a77 compared to the availability or affordability1 respectively1 of such coverage had such action not been taken2 7#d7 result1 with respect to vulnerable populations 7including low-income individuals1 elderly individuals1 and individuals with serious health issues or who have a greater risk of developing serious health issues71 in a decrease in the availability of coverage that is at least as comprehensive as the coverage defined in section #acjb7;a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7;a77 with coverage and cost-sharing protections required under section #accb7;b77#a77;,b7 of such ,act 7#db ,u4,s4,c4 #ahjeb7;b77#a77;,b772 7#e7 with respect to individuals with preexisting conditions1 reduce the affordability of coverage that is at least as comprehensive as the coverage defined in section #acjb7;a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7;a77 compared to the affordability of such coverage had such action not been taken2 or 7#f7 result in higher health insurance premiums for individuals enrolled in health insurance coverage that is at least as comprehensive as the coverage defined in section #acjb7;b7 of such ,act 7#db ,u4,s4,c4 #ahjbb7;b771 and the ,secretaries may not promulgate any substantially similar guidance or rule4 7b7 ,rule of construction ,nothing in subsection 7a7 shall be construed to affect the approval of waivers under section #accb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjeb7 that establish reinsurance programs that are consistent with the requirements under subsection 7b77#a7 of such section 7#db ,u4,s4,c4 #ahjeb7;b77#a771 lower health insurance premiums1 and protect health insurance coverage for people with preexisting conditions4 #ajf4 ,promoting consumer outreach and education 7a7 ,in general ,section #acaa7;i7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjca7;i77 is amended-- 7#a7 in paragraph 7#b71 by adding at the end the following new subparagraph3 7,c7 ,selection of recipients ,in the case of an ,exchange established and operated by the ,secretary within a ,state pursuant to section #acba7;c71 in awarding grants under paragraph 7#a71 the ,exchange shall-- 7i7 select entities to receive such grants based on an entity's demonstrated capacity to carry out each of the duties specified in paragraph 7#c72 7ii7 not take into account whether or not the entity has demonstrated how the entity will provide information to individuals relating to group health plans offered by a group or association of employers described in section #beaj4c-e7;b7 of title #bi1 ,code of ,federal ,regulations 7or any successor regulation71 or short-term limited duration insurance 7as defined by the ,secretary for purposes of section #bgia7;b77#e7 of the ,public ,health ,service ,act72 and 7iii7 ensure that1 each year1 the ,exchange awards such a grant to-- 7,i7 at least one entity described in this paragraph that is a community and consumer-focused nonprofit group2 and 7,,ii7 at least one entity described in subparagraph 7,b71 which may include another community and consumer-focused nonprofit group in addition to any such group awarded a grant pursuant to subclause 7,i74 ,in awarding such grants1 an ,exchange may consider an entity's record with respect to waste1 fraud1 and abuse for purposes of maintaining the integrity of such ,exchange4 2 7#b7 in paragraph 7#c7-- 7,a7 by amending subparagraph 7,c7 to read as follows3 7,c7 facilitate enrollment1 including with respect to individuals with limited ,english proficiency and individuals with chronic illnesses1 in qualified health plans1 ,state ,medicaid plans under title ,,xix of the ,social ,security ,act1 and ,state child health plans under title ,,xxi of such ,act2 2 7,b7 in subparagraph 7,d71 by striking and at the end2 7,c7 in subparagraph 7,e71 by striking the period at the end and inserting 2 and2 7,d7 by inserting after subparagraph 7,e7 the following new subparagraph3 7,f7 provide referrals to community-based organizations that address social needs related to health outcomes4 2 and 7,e7 by adding at the end the following flush text3 ,the duties specified in the preceding sentence may be carried out by such a navigator at any time during a year4 2 7#c7 in paragraph 7#d77;,a7-- 7,a7 in the matter preceding clause 7i71 by striking not2 7,b7 in clause 7i7-- 7i7 by inserting not before be2 and 7ii7 by striking 2 or and inserting a semicolon2 7,c7 in clause 7ii7-- 7i7 by inserting not before receive2 and 7ii7 by striking the period and inserting a semicolon2 and 7,d7 by adding at the end the following new clauses3 7iii7 maintain physical presence in the ,state of the ,exchange so as to allow in-person assistance to consumers2 and 7iv7 receive opioid specific education and training that ensures the navigator can best educate individuals on qualified health plans offered through an ,exchange1 specifically coverage under such plans for opioid health care treatment4 2 and 7#d7 in paragraph 7#f7-- 7,a7 by striking ,grants under and inserting the following3 7,a7 ,state exchanges ,grants under 2 and 7,b7 by adding at the end the following new subparagraph3 7,b7 ,federal exchanges ,for purposes of carrying out this subsection1 with respect to an ,exchange established and operated by the ,secretary within a ,state pursuant to section #acba7;c71 the ,secretary shall obligate #ajj1jjj1jjj out of amounts collected through the user fees on participating health insurance issuers pursuant to section #aef4ej of title #de1 ,code of ,federal ,regulations 7or any successor regulations71 for fiscal year #bjbb and each subsequent fiscal year4 ,such amount for a fiscal year shall remain available until expended4 4 7b7 ,effective date ,the amendments made by this section shall apply with respect to plan years beginning on or after ,january #a1 #bjba4 ,,ii ,encouraging ,medicaid ,expansion and ,strengthening the ,medicaid ,program #bja4 ,incentivizing ,medicaid expansion 7a7 ,in general ,section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7y77#a77 is amended-- 7#a7 in subsection 7y77#a7-- 7,a7 in subparagraph 7,a71 by striking #bjad1 #bjae1 and #bjaf and inserting each of the first #c consecutive #ab-month periods in which the ,state provides medical assistance to newly eligible individuals2 7,b7 in subparagraph 7,b71 by striking #bjag and inserting the fourth consecutive #ab-month period in which the ,state provides medical assistance to newly eligible individuals2 7,c7 in subparagraph 7,c71 by striking #bjah and inserting the fifth consecutive #ab-month period in which the ,state provides medical assistance to newly eligible individuals2 7,d7 in subparagraph 7,d71 by striking #bjai and inserting the sixth consecutive #ab-month period in which the ,state provides medical assistance to newly eligible individuals2 and 7,e7 in subparagraph 7,e71 by striking #bjbj and each year thereafter and inserting the seventh consecutive #ab-month period in which the ,state provides medical assistance to newly eligible individuals and each such period thereafter2 and 7#b7 in subsection 7z77#b77;,b77i77,,ii71 by inserting 7as in effect on the day before the date of enactment of the ,health ,care ,improvement ,act of #bjbj7 after subsection 7y77#a74 7b7 ,effective date ,beginning on ,january #a1 #bjbb1 the amendments made by subsection 7a7 shall take effect as if included in the enactment of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh74 #bjb4 ,reducing the administrative ,,fmap for nonexpansion ,states ,section #aijc of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7 is amended-- 7#a7 in subsection 7a77#g71 by inserting subsection 7bb7 and before section #aiai7;g77#c77;,b72 and 7#b7 by adding at the end the following new subsection3 7bb7 ,reduction of ,federal payments for certain administrative costs of nonexpansion ,states 7#a7 ,in general ,in the case of a ,state that does not provide under the ,state plan of such ,state 7or waiver of such plan7 for making medical assistance available in accordance with section #aijb7k77#a7 to all individuals described in section #aijb7;a77#aj77;i77,,viii7 for a calendar quarter beginning on or after ,october #a1 #bjbb1 the ,secretary may reduce the percentage specified in subsection 7a77#g7 for amounts described in such subsection expended during such quarter by such ,state by the number of percentage points specified in paragraph 7#b7 for such quarter4 7#b7 ,amount of reduction ,for purposes of paragraph 7#a71 the number of percentage points specified in this paragraph for a calendar quarter is the following3 7,a7 ,for the calendar quarter beginning on ,october #a1 #bjbb1 #j4e4 7,b7 ,for a calendar quarter beginning on or after ,january #a1 #bjbc1 and ending before ,july #a1 #bjbg1 the number of percentage points specified under this paragraph for the previous quarter1 plus #j4e4 7,c7 ,for a calendar quarter beginning on or after ,july #a1 #bjbg1 #aj4 7#c7 ,definition ,for purposes of this subsection1 the term ,state means a ,state that is one of the #ej ,states or the ,district of ,columbia4 4 #bjc4 ,state option to provide #ab months of postpartum ,medicaid eligibility 7a7 ,option ,to provide continuous ,medicaid and ,,chip coverage for pregnant and postpartum women 7#a7 ,medicaid ,title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 is amended-- 7,a7 in section #aijb7l77#a77;,a71 by inserting 7or1 at the option of the ,state1 #cfe-;day period7 after #fj-;day period2 7,b7 in section #aijb7;e77#f71 by inserting 7or1 at the option of the ,state1 #cfe-;day period7 after #fj-;day period2 7,c7 in section #aijc7v77#d77;,a77i71 by inserting 7or1 at the option of the ,state1 #cfe-;day period7 after #fj-;day period2 and 7,d7 in section #aije7;a71 in the #dth sentence in the matter following paragraph 7#cj71 by inserting 7or1 at the option of the ,state1 #cfe-;day period7 after #fj-;day period4 7#b7 ,,chip ,section #baab of the ,social ,security ,act 7#db ,u4,s4,c4 #acigll7 is amended by inserting 7or1 at the option of the ,state1 #cfe-;day period7 after #fj-;day period each place it appears4 7b7 ,requiring full benefits for pregnant and postpartum women 7#a7 ,medicaid 7,a7 ,in general ,paragraph 7#e7 of section #aijb7;e7 of the ,social ,security ,act 7#bd ,u4,s4,c4 #acif;a7e77 is amended to read as follows3 7#e7 ,any woman who is eligible for medical assistance under the ,state plan or a waiver of such plan and who is1 or who while so eligible becomes1 pregnant1 shall continue to be eligible under the plan or waiver for medical assistance through the end of the month in which the #fj-;day period 7or1 at the option of the ,state1 #cfe-;day period7 7beginning on the last day of her pregnancy7 ends1 regardless of the basis for the woman's eligibility for medical assistance1 including if the woman's eligibility for medical assistance is on the basis of being pregnant4 4 7,b7 ,conforming amendment ,section #aijb7;a77#aj7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#aj77 is amended in the matter following subparagraph 7,g7 by striking 7,,vii7 the medical assistance and all that follows through complicate pregnancy14 7#b7 ,,chip ,section #bajg7;e77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;gg7e77#a77 is amended-- 7,a7 by redesignating subparagraphs 7,h7 through 7,s7 as subparagraphs 7,i7 through 7,t71 respectively2 and 7,b7 by inserting after subparagraph 7,g71 the following3 7,h7 ,section #aijb7;e77#e7 7requiring #fj-;day 7or1 at the option of the ,state1 #cfe-;day7 continuous coverage for pregnant and postpartum women74 4 7c7 ,maintenance of effort 7#a7 ,medicaid ,section #aijb of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7 is amended-- 7,a7 in paragraph 7#gd71 by striking subsection 7gg72 and and inserting subsections 7gg7 and 7qq722 and 7,b7 by adding at the end the following new subsection3 7qq7 ,maintenance of effort related to low-,income pregnant women ,for calendar quarters beginning on or after the effective date described in section #bjd7;d7 of the ,health ,care ,improvement ,act of #bjbj1 and before ,january #a1 #bjbc1 no ,federal payment shall be made to a ,state under section #aijc7;a7 for amounts expended under a ,state plan under this title or a waiver of such plan if the ,state-- 7#a7 has in effect under such plan eligibility standards1 methodologies1 or procedures for individuals described in subsection 7l77#a7 who are eligible for medical assistance under the ,state plan or waiver under subsection 7a77#aj77;,a77ii77,,ix7 that are more restrictive than the eligibility standards1 methodologies1 or procedures1 respectively1 for such individuals under such plan or waiver that are in effect on the date of the enactment of this subsection2 or 7#b7 provides medical assistance to individuals described in subsection 7l77#a7 who are eligible for medical assistance under such plan or waiver under subsection 7a77#aj77;,a77ii77,,ix7 at a level that is less than the level at which the ,state provides such assistance to such individuals under such plan or waiver on the date of the enactment of this subsection4 4 7#b7 ,,chip ,section #baab of the ,social ,security ,act 7#db ,u4,s4,c4 #acigll71 as amended by subsection 7b71 is further amended by adding at the end the following subsection3 7g7 ,maintenance of effort ,for calendar quarters beginning on or after the effective date described in section #bjd7;d7 of the ,health ,care ,improvement ,act of #bjbj1 and before ,january #a1 #bjbc1 no payment may be made under section #baje7;a7 with respect to a ,state child health plan if the ,state-- 7#a7 has in effect under such plan eligibility standards1 methodologies1 or procedures for targeted low-income pregnant women that are more restrictive than the eligibility standards1 methodologies1 or procedures1 respectively1 under such plan that are in effect on the date of the enactment of this subsection2 or 7#b7 provides pregnancy-related assistance to targeted low-income pregnant women under such plan at a level that is less than the level at which the ,state provides such assistance to such women under such plan on the date of the enactment of this subsection4 4 7d7 ,effective date 7#a7 ,in general ,except as provided under paragraph 7#b71 the amendments made by subsections 7a7 and 7b7 shall take effect on 7and the effective date described in this subsection shall be7 the first day of the calendar quarter during which the last day of the emergency period described in section #aace7;g77#a77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;b-#e7;g77#a77;,b77 occurs4 7#b7 ,extension of effective date for ,state law amendment ,in the case of a ,state plan under title ,,xix or ,state child health plan under title ,,xxi of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq42 #db ,u4,s4,c4 #acig;aa et seq47 which the ,secretary of ,health and ,human ,services determines requires ,state legislation 7other than legislation appropriating funds7 in order for the respective plan to meet the additional requirement imposed by the amendments made by subsection 7a7 or 7b71 respectively1 the respective plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such applicable additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the ,state legislature that begins after the date of enactment of this ,act4 ,for purposes of the previous sentence1 in the case of a ,state that has a #b-year legislative session1 each year of the session is considered to be a separate regular session of the ,state legislature4 #bjd4 ,supporting ,state ,medicaid programs through economic downturns 7a7 ,in general ,section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7 is amended-- 7#a7 in subsection 7b71 by striking and 7ff7 and inserting 7ff71 and 7gg72 and 7#b7 by adding at the end the following new subsection3 7gg7 ,increased ,,fmap during economic downturns 7#a7 ,in general ,if a fiscal quarter that begins on or after ,january #a1 #bjbj1 is an economic downturn quarter 7as defined in paragraph 7#b77 with respect to a ,state1 then the ,federal medical assistance percentage determined for each ,state for such quarter under subsection 7b7 shall be equal to the percentage determined for the ,state and quarter under paragraph 7#c74 7#b7 ,economic downturn quarter 7,a7 ,in general 7i7 ,in general ,in this subsection1 the term economic downturn quarter means1 with respect to a ,state1 a fiscal quarter during which the ,state's unemployment rate for the quarter exceeds the percentage determined for the ,state and quarter under clause 7ii74 7ii7 ,threshold percentage ,the percentage determined under this clause for a ,state and fiscal quarter is the percentage equal to the lower of-- 7,i7 the ,state unemployment rate at the #bjth percentile of the distribution of the ,state's quarterly unemployment rates for the #fj-quarter period preceding the quarter involved1 increased by #a percentage point2 and 7,,ii7 the ,state's average quarterly unemployment rate for the #ab-quarter period preceding the quarter involved1 increased by #a percentage point4 7,b7 ,unemployment data 7i7 ,in general ,except as provided in clause 7ii71 for purposes of determining unemployment rates for a ,state and a quarter under this paragraph1 the ,secretary shall use data from the ,local ,area ,unemployment ,statistics from the ,bureau of ,labor ,statistics4 7ii7 ,application to certain territories ,in the case of the ,virgin ,islands1 ,guam1 the ,northern ,mariana ,islands1 ,american ,samoa1 or any other jurisdiction for which suitable data from the ,local ,area ,unemployment ,statistics from the ,bureau of ,labor ,statistics are unavailable1 the ,secretary shall use data from the ,u-#c unemployment measure of the ,bureau of ,labor ,statistics to make any necessary determinations under subparagraph 7,a74 7#c7 ,increased ,,fmap during economic downturn quarter 7,a7 ,in general ,during a fiscal quarter that is an economic downturn quarter with respect to a ,state1 the ,federal medical assistance percentage for the ,state and quarter determined under subsection 7b7 shall be equal to-- 7i7 the ,federal medical assistance percentage determined for the ,state and quarter under subsection 7b7 without regard to this subsection 7but including any increase to such percentage for such quarter made pursuant to section #fjjh7;a7 of the ,families ,first ,coronavirus ,response ,act72 increased by 7ii7 the number of percentage points 7rounded to the nearest tenth of a percentage point7 equal to the product of-- 7,i7 the number of percentage points 7rounded to the nearest tenth of a percentage point7 by which the unemployment rate for the ,state and quarter exceeds the percentage determined for the ,state and quarter under paragraph 7#b77;,a77ii72 and 7,,ii7 #d4h4 7,b7 ,rules of application ,the following rules shall apply with respect to the ,federal medical assistance percentage determined for a ,state and an economic downturn quarter under this subsection3 7i7 ,scope of application ,such ,federal medical assistance percentage shall not apply for purposes of-- 7,i7 disproportionate share hospital payments described in section #aibc2 7,,ii7 payments under part ,d of title ,,iv2 or 7,,iii7 any payments under this title that are based on a ,federal medical assistance percentage determined for a ,state under subsection 7aa7 7but only to the extent that such ,federal medical assistance percentage is higher than the economic recovery ,,fmap74 7ii7 ,limitation ,in no case shall-- 7,i7 the ,federal medical assistance percentage determined for a ,state and quarter pursuant to this subsection exceed #ie percent2 or 7,,ii7 any increase to the ,federal medical assistance percentage determined for a ,state and quarter pursuant to this subsection result in the application of a ,federal medical assistance percentage that exceeds #ie percent4 7iii7 ,application to ,,chip ,notwithstanding the first sentence of section #baje7;b71 the application of this subsection may result in the enhanced ,,fmap of a ,state for a fiscal year under such section exceeding #he percent1 but in no case may the application of this subsection before application of the second sentence of such section result in the enhanced ,,fmap of the ,state exceeding #ie percent4 7#d7 ,advance payment2 retrospective adjustment 7,a7 ,in general ,prior to the beginning of each fiscal quarter that begins on or after ,july #a1 #bjbj1 the ,secretary shall1 with respect to each ,state-- 7i7 make an initial determination1 based on the projections made for the ,state and quarter under subparagraph 7,b71 as to-- 7,i7 whether the application of this subsection is expected to result in the application of a higher ,federal medical assistance percentage for the ,state and quarter than the percentage that would otherwise apply without regard to this subsection2 and-- 7,,ii7 if the application of this subsection is expected to result in such a higher ,federal medical assistance percentage for the ,state and quarter1 what such higher percentage is expected to be2 and 7ii7 if the ,secretary determines under clause 7i7 that the application of this subsection is expected to result in the application of a higher ,federal medical assistance percentage for the ,state and quarter than the percentage that would otherwise apply without regard to this subsection-- 7,i7 apply such higher ,federal medical assistance percentage of the ,state for purposes of making payments to the ,state for amounts expended during such quarter as medical assistance under the ,state plan2 and 7,,ii7 take into account such higher ,federal medical assistance percentage of the ,state for purposes of calculating the enhanced ,,fmap for the ,state and quarter under section #baje7;b74 7,b7 ,projection of ,state unemployment rates ,prior to the beginning of each fiscal quarter that begins on or after ,july #a1 #bjbj1 the ,secretary1 acting through the ,chief ,actuary of the ,centers for ,medicare ,medicaid ,services1 shall1 using the most recently available data described in paragraph 7#b77;,b71 make projections with respect to-- 7i7 the unemployment rates for each ,state for such quarter2 7ii7 the threshold percentages described in paragraph 7#b77;,a77ii7 for each ,state for such quarter2 and 7iii7 the national unemployment rate for such quarter4 7,c7 ,retrospective adjustment ,as soon as practicable after final unemployment data becomes available for a fiscal quarter that begins on or after ,july #a1 #bjbj1 the ,secretary shall1 with respect to each ,state-- 7i7 make a final determination with respect to the application of this subsection for purposes of determining the ,federal medical assistance percentage and enhanced ,,fmap of the ,state for the quarter2 and 7ii7 in accordance with section #aijc7;d77#b7 and section #baje7;e71 reduce or increase the amount payable to the ,state under section #aijc7;a7 or section #baje for a subsequent fiscal quarter to the extent of any overpayment or underpayment under either such section which the ,secretary determines was made as a result of an incorrect initial determination under subparagraph 7,a77i7 with respect to the application of this subsection for purposes of determining the ,federal medical assistance percentage and enhanced ,,fmap of the ,state for such prior fiscal quarter4 7#e7 ,retrospective application of over-the-limit ,,fmap increases 7,a7 ,in general ,if a ,state has excess percentage points with respect to an economic downturn quarter and an applicable ,,fmap 7as determined under subparagraph 7,b771 the ,state may elect to apply such excess percentage points to increase such applicable ,,fmap for one or more quarters during the look-back period for the ,state and economic downturn quarter in accordance with this paragraph4 7,b7 ,excess percentage points ,for purposes of this paragraph1 the number of excess percentage points for a ,state1 economic downturn quarter1 and an applicable ,,fmap shall be equal to the number of percentage points by which-- 7i7 the applicable ,,fmap for the ,state and quarter 7after application of paragraph 7#c7 but without regard to subparagraph 7,b77ii7 of such paragraph72 exceeds 7ii7 #ie percent4 7,c7 ,effect of application of excess percentage points ,if a ,state elects to apply excess percentage points to an applicable ,,fmap to a quarter during a look-back period under this paragraph1 the ,secretary shall determine the additional amount of payment under section #aijc7;a7 to which the ,state would have been entitled for such quarter if the applicable ,,fmap 7as so increased7 had been in effect for such quarter1 and shall treat such additional amount as an underpayment for such quarter4 7,d7 ,distribution of excess percentage points ,a ,state that has excess percentage points with respect to an economic downturn quarter and applicable ,,fmap may elect to divide such points among more than #a quarter during the look-back period for such ,state and quarter provided that no excess percentage point 7or fraction of an excess percentage point7 is applied to the applicable ,,fmap of more than #a quarter4 7,e7 ,limitations 7i7 ,no increases over #ajj percent ,a ,state may not increase an applicable ,,fmap for any quarter during a look-back period under this paragraph if such increase would result in the applicable ,,fmap for such quarter exceeding #ajj percent4 7ii7 ,scope of application ,any increase to an applicable ,,fmap of a ,state for a fiscal quarter under this paragraph-- 7,i7 shall only apply with respect to payments for amounts expended by the ,state for medical assistance for services furnished during such quarter to which such applicable ,,fmap is applicable2 and 7,,ii7 shall not apply with respect to payments described in paragraph 7#c77;,b77i74 7,f7 ,definitions ,in this paragraph3 7i7 ,applicable ,,fmap ,the term applicable ,,fmap means1 with respect to a ,state and fiscal quarter-- 7,i7 the ,federal medical assistance percentage determined for the ,state and quarter under subsection 7b72 7,,ii7 the ,federal medical assistance percentage applicable under subsection 7y72 7,,iii7 the ,federal medical assistance percentage applicable under subsection 7z77#b72 7,,iv7 the ,federal medical assistance percentage determined for the ,state and quarter under subsection 7ff72 or 7,v7 the enhanced ,,fmap determined for the ,state and quarter under section #baje7;b74 7ii7 ,look-back period ,the term look-back period means1 with respect to a ,state and a fiscal quarter that is an economic downturn quarter for the ,state1 the period of #d fiscal quarters that ends with the fourth quarter which precedes the most recent fiscal quarters that was not an economic downturn quarter for the ,state4 7#f7 ,requirement for all ,states ,this subsection shall not apply to a ,state with respect to a fiscal quarter1 if-- 7,a7 eligibility standards1 methodologies1 or procedures under the ,state plan or a waiver of such plan are more restrictive during such quarter than the eligibility standards1 methodologies1 or procedures1 respectively1 under such plan 7or waiver7 as in effect on the last day of the most recent fiscal quarter that was not an economic downturn quarter for the ,state2 7,b7 the amount of any premium imposed by the ,state pursuant to section #aiaf or #aiaf;,a during such quarter1 with respect to an individual enrolled under such plan 7or waiver71 exceeds the amount of such premium as of the date described in subparagraph 7,a72 or 7,c7 the ,state fails to provide that an individual who is enrolled for benefits under such plan 7or waiver7 as of the date described in subparagraph 7,a7 or enrolls for benefits under such plan 7or waiver7 during the period beginning with such date and ending with the day before the first day of the next quarter that is not an economic downturn quarter for the ,state shall be treated as eligible for such benefits for not less than #ab months after such date or 7if later7 the date that such individual so enrolls unless the individual requests a voluntary termination of eligibility or the individual ceases to be a resident of the ,state4 4 7b7 ,exclusion of economic downturn ,,fmap increases from territorial caps2 special rule for ,,chip allotments 7#a7 ,exclusion from territorial caps ,section #aajh of the ,social ,security ,act 7#db ,u4,s4,c4 #acjh7 is amended-- 7,a7 in subsection 7f71 in the matter preceding paragraph 7#a71 by striking subsection 7g7 and section #aice7;e77#a77;,b7 and inserting subsections 7g7 and 7h7 and section #aice7;e77#a77;,b72 and 7,b7 by adding at the end the following3 7h7 ,exclusion from caps of amounts attributable to economic downturn ,,fmap ,any payment made to a territory for a fiscal year in which the ,federal medical assistance percentage for the territory is determined under section #aije7;gg7 shall not be taken into account for purposes of applying payment limits under subsections 7f7 and 7g7 to the extent that such payment exceeds the amount of the payment that would have been made to the territory for the year if the ,federal medical assistance percentage for the territory had been determined without regard to such section4 4 7#b7 ,,chip allotments ,section #bajd7m7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;dd7m77 is amended-- 7,a7 in paragraph 7#b77;,b71 in the matter preceding clause 7i71 by striking paragraphs 7#e7 and 7#g7 and inserting paragraphs 7#e71 7#g71 and 7#ab72 and 7,b7 by adding at the end the following new paragraph3 7#ab7 ,special rule for adjusting allotments during fiscal years with economic downturn quarters 7,a7 ,in general ,if a fiscal quarter occurring during fiscal year #bjbj or any succeeding fiscal year is determined to be an economic downturn quarter with respect to a ,state 7as determined under section #aije7;gg77 then1 as soon as practicable after such determination1 the ,secretary shall increase the allotment for the ,state and fiscal year in accordance with subparagraph 7,b74 7,b7 ,amount of increase 7i7 ,in general ,the amount of an increase to the allotment of a ,state described in subparagraph 7,a7 for a fiscal year shall be equal to the amount by which ,federal payments made to the ,state for the preceding fiscal year under this title would have been increased 7without regard to whether such payments would exceed the amount of the ,state's allotment for such preceding fiscal year7 if the enhanced ,,fmap determined for the ,state for such preceding fiscal year had been increased to the same extent that the ,state's enhanced ,,fmap for the fiscal year involved is expected to be increased as a result of the application of section #aije7;gg7 relative to the enhanced ,,fmap that would apply to the ,state for the fiscal year involved without the application of such section4 7ii7 ,inclusion of projected increases ,in increasing the allotment of a ,state for a fiscal year under this paragraph1 the ,secretary may base the calculation of such increase on projections made by the ,secretary with respect to-- 7,i7 the number of fiscal quarters during such fiscal year that will be economic downturn quarters2 and 7,,ii7 the effect that the application of section #aije7;gg7 is expected to have on the enhanced ,,fmap of the ,state for such fiscal year4 7,c7 ,disregard of increased payments for purposes of future allotments ,any ,federal payment made to a ,state under this title for a fiscal year in which the ,federal medical assistance percentage for the ,state is determined under section #aije7;gg7 shall be disregarded when determining the allotment of the ,state for any subsequent year1 including for purposes of applying this paragraph1 to the extent that such payment exceeds the amount of the payment that would have been made to the ,state for the year if the ,federal medical assistance percentage for the ,state and year had been determined without regard to such section4 4 #bje4 ,state flexibility to use administrative simplification policies for enrollment 7a7 ,permanent extension of medicaid and ,,chip express lane option ,section #aijb7;e77#ac7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7e77#ac77 is amended by striking subparagraph 7,i74 7b7 ,extending express lane eligibility to adults ,section #aijb7;e77#ac77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7e77#ac77;,a77 is amended by adding at the end the following new clause3 7iii7 ,state option to extend express lane eligibility to adults 7,i7 ,in general ,at the option of the ,state1 the ,state may apply the provisions of this paragraph with respect to determining eligibility under this title for an eligible individual 7as defined in subclause 7,,ii774 ,in applying this paragraph in the case of a ,state making such an option1 any reference in this paragraph to a child with respect to this title 7other than a reference to child health assistance7 shall be deemed to be a reference to an eligible individual4 7,,ii7 ,eligible individual defined ,in this clause1 the term eligible individual means-- 7aa7 any individual 7other than a child7 whose income eligibility under the ,state plan or under a waiver of the plan for medical assistance is determined under paragraph 7#ad72 and 7bb7 an individual included in any other group of individuals the ,secretary determines appropriate4 4 7c7 ,consent by benefit utilization ,section #aijb7;e77#ac77;,d77i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7e77#ac77;,d77i77 is amended by inserting by using medical assistance to access care1 after through electronic signature14 7d7 ,study and report on options for automatic enrollment in ,medicaid and ,,chip 7#a7 ,study ,the ,secretary of ,health and ,human ,services1 by grant1 contract1 or interagency agency1 shall conduct a study to identify options for1 and barriers to1 ,states automatically enrolling individuals who1 on the basis of data and information from income tax returns and other sources1 are likely to be eligible for medical assistance under the ,state ,medicaid plan established under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 7or a waiver of such plan7 or for child health assistance 7or1 if applicable1 pregnancy-related assistance7 under the ,state child health plan established under title ,,xxi of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;aa et seq47 7or a waiver of such plan71 and would not be required to pay a premium for enrollment in such a plan or waiver4 7#b7 ,report ,not later than #a year after the date of enactment of this ,act1 the ,secretary of ,health and ,human ,services shall submit a report to ,congress on the results of the study conducted under subsection 7a74 ,the report shall include the following3 7,a7 ,an analysis of the financial1 regulatory1 and legislative barriers that limit the ability of ,states to implement automatic enrollment for individuals described in subsection 7a74 7,b7 ,an analysis of the extent to which ,state implementation of automatic enrollment for such individuals would reduce the number of uninsured individuals in each ,state4 7,c7 ,recommendations for administrative and legislative actions that1 if taken1 would eliminate the barriers identified under subparagraph 7,a7 and allow ,states to elect to automatically enroll individuals described in subsection 7a7 in the ,state ,medicaid plan established under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 7or a waiver of such plan7 or for child health assistance 7or1 if applicable1 pregnancy-related assistance7 under the ,state child health plan established under title ,,xxi of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;aa et seq47 7or a waiver of such plan74 ,,iii ,establishment of a ,public ,health ,care ,option #cja4 ,establishment of health plan 7a7 ,in general ,the ,secretary shall establish a coordinated and low-cost health plan 7referred to in this section as the health plan7 to provide access to quality health care for enrollees4 7b7 ,individual market availability ,the ,secretary shall make the health plan available in the individual market for plan year #bjbb and each subsequent plan year4 7c7 ,rulemaking ,the ,secretary may promulgate such regulations as may be necessary to carry out this title4 7d7 ,authorization of appropriations ,there are authorized to be appropriated such sums as may be necessary to carry out this title4 #cjb4 ,availability of plan 7a7 ,eligibility ,an individual shall be eligible to enroll in the health plan if such individual1 for the entire period for which enrollment is sought-- 7#a7 is a qualified individual within the meaning of section #acab of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjcb72 7#b7 is not eligible for benefits under the ,medicare program under title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq472 and 7#c7 is not otherwise eligible for1 or has been otherwise offered1 employer-sponsored health care coverage4 7b7 ,exchanges ,the health plan shall be made available through the ,exchanges1 including the ,small ,business ,health ,options ,program ,exchange4 #cjc4 ,affordability ,the ,secretary shall ensure that coverage options for the health plan are not more costly than comparable options offered on the ,exchange in the applicable market4 #cjd4 ,participating providers 7a7 ,requirement ,to participate in order ,to be enrolled under ,medicare ,beginning ,january #a1 #bjba1 the ,secretary may require a health care provider enrolled under the ,medicare program under section #ahff7;j7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7j77 to be a participating provider under the health plan4 7b7 ,requirement ,to participate in order ,to participate in ,medicaid ,beginning ,january #a1 #bjba1 the ,secretary may require a health care provider under a ,state ,medicaid plan under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 to also be a participating provider under the health plan4 #cje4 ,provider payment rates ,the ,secretary shall set competitive provider payment rates under the health plan using the best information publically available and data otherwise accessible to the ,secretary4 ,the ,secretary shall give consideration to existing provider payment rates for commercial health plans and provider costs to deliver care1 giving special consideration to increased costs for providers to deliver care in rural and medically underserved areas4 #cjf4 ,no effect on ,medicare benefits or ,medicare trust funds ,nothing in this title shall-- 7#a7 affect the benefits available under title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq472 or 7#b7 impact the ,federal ,hospital ,insurance ,trust ,fund under section #ahag of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7 or the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda of the ,social ,security ,act 7#db ,u4,s4,c4 #aciet7 7including the ,medicare ,prescription ,drug ,account within such ,trust ,fund74 ,,iv ,fair ,medicare ,payments to ,rural ,providers #dja4 ,ensuring fairness in ,medicare hospital payments 7a7 ,hospital inpatient services 7#a7 ,in general ,section #ahhf7;d77#c77;,e77i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciewww7d77#c77;,e77 is amended-- 7,a7 in clause 7i71 in the first sentence1 by striking or 7iii7 and inserting 1 7iii71 or 7iv72 and 7,b7 by adding at the end the following new clause3 7iv7 ,area wage index floor 7,i7 ,in general ,for discharges occurring on or after ,october #a1 #bjbj1 the area wage index applicable under this subparagraph to any hospital which is not located in a frontier ,state 7as defined in clause 7iii77,,ii77 may not be less than #j4he4 7,,ii7 ,waiving budget neutrality ,pursuant to the fifth sentence of clause 7i71 this clause shall not be applied in a budget neutral manner4 4 7#b7 ,waiving budget neutrality 7,a7 ,technical amendatory correction ,section #ajcbd7;a77#b7 of ,public ,law #aaa-adh is amended by striking third sentence and inserting fifth sentence4 7,b7 ,waiver ,section #ahhf7;d77#c77;,e77i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#c77;,e77i77 is amended1 in the fifth sentence-- 7i7 by striking and the amendments and inserting 1 the amendments2 and 7ii7 by inserting 1 and the amendments made by section #dja7;a77#a7 of the ,health ,care ,improvement ,act of #bjbj after ,care ,act4 7b7 ,hospital outpatient department services ,section #ahcc7t7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t771 is amended-- 7#a7 in paragraph 7#b77;,d71 by striking 7#ai71 the ,secretaryand inserting 7#ai7 and paragraph 7#bc71 the ,secretary2 and 7#b7 by adding at the end the following new paragraph3 7#bc7 ,floor on area wage adjustment factor for hospital outpatient department services ,with respect to covered ,,opd services furnished on or after ,january #a1 #bjba1 the area wage adjustment factor applicable under the payment system established under this subsection to any hospital outpatient department which is not located in a frontier ,state 7as defined in section #ahhf7;d77#c77;,e77iii77,,ii77 may not be less than #j4he4 ,the preceding sentence shall not be implemented in a budget neutral manner4 4 ,v ,commonsense ,competition and ,access to ,health ,insurance #eja4 ,providing small business health insurance across ,state lines ,section #accc7;a77#a77;,a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjec7;a77#a77;,a77 is amended by inserting and small group markets after individual markets4 #ejb4 ,report and models ,section #accc of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjec7 is amended by adding at the end the following3 7b7 ,,naic report and models 7#a7 ,in general ,not later than ,december #ca1 #bjba1 the ,secretary shall request that the ,national ,association of ,insurance ,commissioners submit to the ,secretary a report concerning health plans provided for under this section4 ,such report shall include-- 7,a7 a description of the challenges that ,states would face by permitting issuers of qualified health plans to offer such plans in ,states other than those ,states where such plan was originally written or issued2 7,b7 an assessment of how an out-of-,state insurer would go about building an adequate provider network2 7,c7 a description of how such challenges could be lessened without weakening the enforcement of laws and regulations described in subsection 7a77#a77;,b77i7 in any ,state that is included in a compact under this section2 7,d7 a description of the commonalities that exist in ,state laws and opportunities to allow issuers of qualified health plans to offer such plans in ,states other than those ,states where such plan was originally written or issued2 and 7,e7 models to be used by ,states to establish and enter into interstate health care choice compacts under this section1 which-- 7i7 may include model legislation for use by ,states to enact laws to enter into such compacts2 7ii7 shall identify how ,states would continue to enforce1 and not weaken1 the laws and regulations described in subsection 7a77#a77;,b77i7 in any ,state that is included in such compact2 and 7iii7 shall identify how such models would ensure that there is no violation of the conditions for ,secretarial approval under subsection 7a77#c74 7#b7 ,other organizations and entities ,in making the request under paragraph 7#a71 the ,secretary may also request that the ,national ,association of ,insurance ,commissioners gather concepts for inclusion in the report under such paragraph from organizations and entities that have experience in offering qualified health plans in ,states in which such plans were not originally issued4 4 ,,vi ,empowering ,medicare ,seniors to ,negotiate ,prescription ,drug ,prices #fja4 ,authority to negotiate fair prices for ,medicare prescription drugs 7a7 ,in general ,section #ahfj;,d-#aa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aaa7 is amended by striking subsection 7i74 7b7 ,effective date ,the amendment made by this section shall take effect on the date of the enactment of this ,act4 ,,vii ,commonsense reporting for employers #gja4 ,voluntary prospective reporting system 7a7 ,in general ,not later than #a year after the date of the enactment of this ,act1 the ,secretary of the ,treasury1 in consultation with the ,secretary of ,health and ,human ,services1 the ,secretary of ,labor1 and the ,administrator of the ,small ,business ,administration1 shall develop and implement guidance providing for a prospective reporting system meeting the requirements of subsection 7b74 ,such system shall be available for use by employers on a voluntary basis beginning not later than ,january #a1 #bjba4 7b7 ,requirements ,the system created under subsection 7a7 shall include-- 7#a7 voluntary reporting by each participating employer that offers minimum essential coverage to its full-time employees and their dependents under an eligible employer-sponsored plan1 not later than #de days before the first day of the annual open enrollment period under section #acaa7;c77#f77;,b7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjca7;c77#f77;,b77 for each calendar year1 of-- 7,a7 the name and employer identification number for purposes of section #fjef of the ,internal ,revenue ,code of #aihf of the employer2 7,b7 a certification of-- 7i7 whether coverage meeting the definition of minimum essential coverage in section #ejjj;,a7f7 of the ,internal ,revenue ,code of #aihf is offered to the full-time employees 7within the meaning of section #dihj;,h of such ,code7 of the employer2 7ii7 whether such coverage is offered to part-time employees of the employer2 7iii7 whether such coverage is offered to dependents of employees2 7iv7 whether such coverage is offered to spouses of employees2 7v7 whether such coverage meets the minimum value requirement of section #cf;,b7c77#b77;,c77ii7 of such ,code2 7vi7 whether such coverage satisfies the requirements to qualify for one of the affordability safe harbors promulgated by the ,secretary of the ,treasury for purposes of section #dihj;,h of such ,code2 and 7vii7 whether the employer reasonably expects to be liable for any shared responsibility payment under section #dihj;,h of such ,code for such year2 7,c7 the months during the prospective reporting period that such coverage is available to individuals described in clauses 7i7 through 7iv7 of subparagraph 7,b72 7,d7 what waiting periods1 if any1 apply with respect to such coverage2 and 7,e7 a list of all employer identification numbers of the employer for entities that employ employees within the employers control group under subsection 7b71 7c71 7m71 or 7o7 of section #dad of the ,internal ,revenue ,code for #aihf2 7#b7 processes necessary to ensure that ,exchanges1 the ,federal ,marketplace ,data ,services ,hub1 and the ,internal ,revenue ,service can securely and confidentially access the information described in paragraph 7#a7 as necessary to carry out their respective missions1 and to provide to the ,secretary of ,health and ,human ,services additional information relating to eligibility determinations for advance payment of the premium tax credits under section #cf;,b of such ,code and the cost-sharing subsidies under section #adjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjga72 7#c7 a process to allow ,exchanges to follow up with employers in order to obtain additional reasonably necessary information relating to an employee's eligibility for such advance payment or such cost-sharing subsidies1 and to allow an employee to receive notification of any problem in verifying such eligibility2 and 7#d7 a process to allow employers using the system to provide timely updates to the ,federal ,marketplace ,data ,services ,hub regarding any cancellation of coverage or significant change in coverage for participating employees that would change the information reported under paragraph 7#a74 7c7 ,employer notification of employee enrollment in exchange plans ,subparagraph 7,j7 of section #acaa7;d77#d7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjca7;d77#d77;,j77 is amended by striking to each employer and all that follows through 7and the effective date of such cessation72 and and inserting to each employer-- 7i7 the name of each employee of the employer who enrolls in a qualified health plan for a plan year1 or whose dependents enroll in such a plan1 at the time of such enrollment2 or 7ii7 the name of each employee of the employer described in subparagraph 7,i77ii7 who ceases coverage under a qualified health plan during a plan year 7and the effective date of such cessation72 and 4 7d7 ,exemption from reporting requirement under internal revenue code of #aihf ,section #fjef of the ,internal ,revenue ,code of #aihf is amended by redesignating subsection 7f7 as subsection 7g7 and by inserting after subsection 7e7 the following new subsection3 7f7 ,exemption ,if1 through the system created pursuant to section #gja7;a7 of the ,health ,care ,improvement ,act of #bjbj1 an employer provides prospective reporting for any calendar year that meets the requirements of section #gja7;b77#a7 of such ,act-- 7#a7 such employer shall be treated as satisfying the return requirements of subsections 7a7 and 7b7 for such year2 and 7#b7 such employer shall be treated as satisfying the requirements of subsection 7c7 for such year if the employer-- 7,a7 furnishes the statement described in such section to those employees of the employer whose names have been provided to the employer by an ,exchange under section #acaa7;d77#d77;,j77i7 of the ,patient ,protection and ,affordable ,care ,act regarding enrollment of the employee or a dependent in a qualified health plan 7as defined in section #acja of such ,act7 through the ,exchange2 and 7,b7 furnishes a copy of such statement with respect to such employees to the ,secretary4 4 7e7 ,third-,party filing ,an employer may contract with a third party to make the report under subsection 7b77#a7 without affecting the employer's treatment as having satisfied the return requirements of subsections 7a7 and 7b7 of section #fjef of the ,internal ,revenue ,code of #aihf4 7f7 ,access to the national directory of new hires ,subsection 7i77#c7 of section #dec of the ,social ,security ,act 7#db ,u4,s4,c4 #fec7 is amended by adding at the end the following new sentence3 ,the ,secretary of the ,treasury and the ,secretary of ,health and ,human ,services shall have access to the information in the ,national ,directory of ,new ,hires for purposes of administering section #cf;,b and #dihj;,h of the ,internal ,revenue ,code of #aihf and section #adjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjga74 ,subsection 7k77#c7 shall not apply to information received for purposes of the administration of such sections #cf;,b and #dihj;,h of such ,code and section #adjb of such ,act44 7g7 ,improving employee access to accurate ,e,i,ns ,not later than #a year after the date of the enactment of this ,act1 the ,secretary of the ,treasury shall develop and implement guidance for allowing any employee of an employer to receive1 on request1 the employer's employer identification number for purposes of section #fjef of the ,internal ,revenue ,code of #aihf4 ,employers shall provide the employer's employer identification number for purposes of section #fjef of the ,internal ,revenue ,code of #aihf on one of the following documents of the employer's election3 7#a7 ,health ,insurance ,marketplace ,coverage ,options ,notice required under section #ah;,b of the ,fair ,labor ,standards ,act4 7#b7 ,summary of ,benefits and ,coverage described in section #bgae of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjga74 7#c7 ,marketplace ,employer ,coverage tool4 7#d7 ,annual benefits enrollment materials distributed to employees1 including through an intranet or an online portal accessible by employees4 7#e7 ,employee pay statements or ,form ,w-#b4 7h7 ,funding for voluntary prospective reporting system ,it is the sense of ,congress that building and maintaining the voluntary prospective reporting system described in this section will require appropriations to the ,secretary of the ,treasury1 the ,secretary of ,health and ,human ,services1 the ,secretary of ,labor1 and the ,administrator of the ,small ,business ,administration1 and that necessary sums to carry out the requirements of this section should be appropriated for such purpose4 #gjb4 ,protection of dependent privacy 7a7 ,in general ,paragraph 7#a7 of section #fjee7;b7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following flush sentence3 ,for purposes of subparagraph 7,b77i71 in the case of an individual other than the primary insured1 if the health insurance issuer or the employer is unable to collect or maintain information on the ,t,i,ns of such individuals 7other than for purposes of this section71 the ,secretary may allow the individual's full name and date of birth to be substituted for the name and ,,tin4 ,in the event the ,secretary allows the use of the individual's full name and date of birth in lieu of the ,,tin1 the ,social ,security ,administration shall assist the ,internal ,revenue ,service in providing data matches to determine the ,,tin associated with the name and date of birth provided by the ,internal ,revenue ,service with respect to such individual4 4 7b7 ,effective date ,the amendment made by this section shall apply to returns the due date for which is after the date that is #fj days after the date of the enactment of this ,act4 #gjc4 ,electronic statements 7a7 ,in general ,subsection 7c7 of section #fjef of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new paragraph3 7#c7 ,electronic delivery ,an individual shall be deemed to have consented to receive the statement under this subsection in electronic form if such individual has affirmatively consented at any prior time1 to the person who is the employer of the individual during the calendar year to which the statement relates1 to receive such statement in electronic form4 ,the preceding sentence shall not apply if the individual revokes consent in writing with respect to the statement under this subsection4 4 7b7 ,statements relating to health insurance coverage ,subsection 7c7 of section #fjee of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new paragraph3 7#c7 ,electronic delivery ,an individual shall be deemed to have consented to receive the statement under this subsection in electronic form if such individual has affirmatively consented at any prior time1 to the person required to make such statement 7such as the provider of the individual's health coverage71 to receive in electronic form any private health information 7such as electronic health records71 unless the individual revokes such consent in writing4 4 7c7 ,effective date ,the amendments made by this section shall apply to statements the due date for which is after ,december #ca1 #bjai4 #gjd4 ,,gao studies 7a7 ,study of first years of employer reporting 7#a7 ,in general ,the ,comptroller ,general of the ,united ,states shall conduct a study that evaluates1 with respect to the period beginning on ,january #a1 #bjae1 and ending on ,december #ca1 #bjah-- 7,a7 the notification of employers by ,exchanges established under title ,i of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh7 that a full-time employee of the employer has been determined eligible for advance payment of premium tax credits under section #cf;,b of the ,internal ,revenue ,code of #aihf or cost-sharing subsidies under section #adjb of such ,act 7#db ,u4,s4,c4 #ahjga71 including information regarding-- 7i7 the data elements included in the employer notification2 7ii7 the process by which the notification forms were developed and sent to employers1 including whether the process provided for a formal notice and comment period2 7iii7 whether employers report that such notifications provided sufficient and relevant information for them to make appropriate decisions about whether to utilize the appeals process2 7iv7 the total number of notifications sent to employers and the timeline of when such notifications were sent2 7v7 differences in the notification process between the marketplace facilitated by the ,federal ,government and the ,state-,based ,marketplaces2 and 7vi7 challenges that have arisen in the notification process1 and recommendations to address these challenges2 and 7,b7 the extent to which the ,secretary of ,health and ,human ,services has established a separate appeals process for employers who received such a notification to challenge the eligibility determination1 as required by section #adaa7;f77#b7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjha7;f77#b774 7#b7 ,report ,not later than #a year after the date of the enactment of this ,act1 the ,comptroller ,general shall submit to the ,committees on ,finance and ,health1 ,education1 ,labor1 and ,pensions of the ,senate and the ,committees on ,ways and ,means1 ,energy and ,commerce1 and ,education and ,labor of the ,house of ,representatives a report on the results of the study conducted under paragraph 7#a74 7b7 ,study of prospective reporting system 7#a7 ,in general ,the ,comptroller ,general of the ,united ,states shall conduct a study that evaluates1 with respect to the period beginning on ,january #a1 #bjbj1 and ending on ,december #ca1 #bjbj1 the functionality of the prospective reporting system established pursuant to section #gja1 including the accuracy of information collected1 the number of employers electing to report under such system1 and any challenges that have arisen in implementing such system4 7#b7 ,report ,not later than ,july #a1 #bjba1 the ,comptroller ,general shall submit to the ,committees on ,finance and ,health1 ,education1 ,labor1 and ,pensions of the ,senate and the ,committees on ,ways and ,means1 ,energy and ,commerce1 and ,education and ,labor of the ,house of ,representatives a report on the results of the study conducted under paragraph 7#a74 #gje4 ,tax ,compliance 7a7 ,in general ,section #fgbd7;d77#a77;,b77xxv7 of the ,internal ,revenue ,code of #aihf is amended by inserting or1 in the case of an employer to which section #fjef7;f7 applies1 section #gja7;b77#a7 of the ,health ,care ,improvement ,act of #bjbj before 1 or4 7b7 ,effective date ,the amendment made by this section shall apply to returns required to be filed after the date of the enactment of this ,act4 ,,viii ,federal ,ban on ,surprise ,medical ,billing #hja4 ,protection against surprise bills 7a7 ,,phsa ,section #bgai;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 is amended by adding at the end the following3 7e7 ,out-of-,network ancillary services 7#a7 ,coverage of services ,subject to subsection 7h71 in the case of an enrollee in a group health plan or group or individual health insurance coverage who receives out-of-network ancillary services at an in-network facility1 including any referrals for diagnostic services1 and such services would be covered under such plan or coverage if provided in-network-- 7,a7 the cost-sharing requirement 7expressed as a copayment amount1 coinsurance rate1 or deductible7 with respect to such services shall be the same requirement that would apply if such services were provided by an in-network practitioner1 and any coinsurance or deductible shall be based on in-network rates2 and 7,b7 amounts paid toward such cost-sharing shall be counted towards the in-network deductible and in-network out-of-pocket maximum amount1 as applicable1 under the plan or coverage for the plan year4 7#b7 ,notice before providing non-emergency services ,subject to subsection 7h71 in the case of an enrollee in a group health plan or group or individual health insurance coverage who receives out-of-network1 non-emergency services that are not ancillary services1 from an out-of-network provider at an in-network facility1 and such services would be covered under such plan or coverage if provided in-network1 the cost-sharing requirement 7expressed as a copayment amount1 coinsurance rate1 or deductible7 with respect to such services shall be the same requirement that would apply if such services were provided by an in-network practitioner1 and any coinsurance or deductible shall be based on in-network rates1 unless1 as soon as practicable1 and in no case later than #dh hours prior to providing non-emergency services that are not ancillary services-- 7,a7 the in-network facility provides to the enrollee who is scheduled to receive such services notice that-- 7i7 is provided in paper or electronic form 7and including electronic notification whenever practicable72 7ii7 states that such service will be provided out-of-network2 7iii7 includes the estimated amount that such practitioner or facility may charge the enrollee for such services2 and 7iv7 provides the option to affirmatively consent to receiving such services from such practitioner or facility2 7,b7 such enrollee signs such notice consenting to receive such services from an out-of-network provider at an in-network facility1 and acknowledging that the out-of-network services may be covered at an out-of-network cost-sharing amount1 requiring higher cost-sharing obligations of the enrollee than if the service were provided by an in-network practitioner or facility2 and 7,c7 such facility maintains documentation of the enrollee's signature or confirmation of receipt of such information under subparagraph 7,b7 in the enrollee's patient record for #b years after the date of services4 7f7 ,coverage of out-of-,network services for enrollees admitted after emergency services 7#a7 ,protection for enrollees admitted to the hospital for emergency services prior to stabilization ,in the case of an enrollee in a group health plan or group or individual health insurance coverage who receives emergency services1 or maternal care for a woman in labor1 in the emergency department of an out-of-network facility and has not been stabilized 7within the meaning of subsection 7b77#b77;,c771 if the patient is subsequently admitted to the out-of-network facility for care1 the cost-sharing requirement 7expressed as a copayment amount1 coinsurance rate1 or deductible7 with respect to any out-of-network services provided to the enrollee prior to being stable and in a condition to receive information under 7#b71 is the same requirement that would apply as under subsection 7b77#b77;,c77ii77,,ii74 7#b7 ,notice and consent 7,a7 ,in general ,subject to subsection 7h71 in the case of an enrollee in a group health plan or group or individual health insurance coverage who receives emergency services1 or maternal care for a woman in labor1 in the emergency department of an out-of-network facility and has been stabilized 7within the meaning of subsection 7b77#b77;,c771 if the patient is subsequently admitted to the out-of-network facility for care1 the cost-sharing requirement 7expressed as a copayment amount1 coinsurance rate1 or deductible7 with respect to any out-of-network services is the same requirement that would apply if such services were provided by an in-network provider1 unless the enrollee1 once stable and in a condition to receive such information1 including having sufficient mental capacity-- 7i7 has been provided by the facility1 prior to the provision of any post-stabilization1 out-of-network service at such facility1 with-- 7,i7 paper or electronic notification that the practitioner or facility is an out-of-network health care provider and the out-of-network rate of the provider1 as applicable1 and the option to affirmatively consent to receiving services from such practitioner or facility2 and 7,,ii7 the estimated amount that such provider may charge the participant1 beneficiary1 or enrollee for such services involved2 7ii7 has been provided by the plan or coverage1 prior to the provision of any post-stabilization1 out-of-network service at such facility1 with-- 7,i7 paper or electronic notification 7and including electronic notification whenever practicable7 that the practitioner or facility is an out-of-network health care provider1 and the option to affirmatively consent to receiving services from such practitioner or facility2 7,,ii7 a list of in-network practitioners or facilities in the relevant geographic area that could provide the same services1 and an option for a referral to such providers2 and 7,,iii7 information about whether prior authorization or other care management limitations may be required in advance of receiving in-network services at the facility2 and 7iii7 has acknowledged1 in writing1 that the out-of-network services provided after the individual has been stabilized may not be covered or may be covered at an out-of-network cost-sharing amount1 requiring higher cost-sharing obligations of the enrollee than if the service were provided at an in-network facility4 7,b7 ,requirements of notice ,the notice under subparagraph 7,a7 shall be in a format determined by the ,secretary to give a reasonable layperson clear comprehension of the terms of the agreement1 including all possible financial responsibilities1 including the requirements that the notice-- 7i7 does not exceed one page in length2 7ii7 is readily identifiable for its purpose and as a contract of consent2 7iii7 clearly states that consent to potential out-of-network charges is optional and that the enrollee has the choice to transfer to an in-network facility2 7iv7 includes an estimate of the amount that such provider will charge the participant1 beneficiary1 or enrollee for such services involved2 and 7v7 be available in the #ae most common languages in the facility's geographic area1 with the facility making a good faith effort to provide oral notice in the enrollee's primary language if it is not one of such #ae languages4 7,c7 ,maintenance of records ,a facility shall maintain documentation of notice given to an enrollee pursuant to this subsection and the enrollee's confirmation of receipt of such information in the enrollee's patient record for #b years after the date of services4 7#c7 ,rulemaking ,not later than #f months after the date of enactment of this subsection1 the ,secretary shall issue regulations to carry out this subsection1 which shall include clarification on how to determine whether an individual is stabilized and the timing of the notice required under this paragraph4 7g7 ,prohibition on billing more than an in-,network rate under certain circumstances 7#a7 ,in general ,a facility or practitioner furnishing-- 7,a7 emergency services1 as defined in subsection 7b77#b71 regardless of the ,state in which the patient resides2 7,b7 out-of-network services at an in-network facility described in subsection 7e77#a72 7,c7 out-of-network services at an in-network facility described in subsection 7e77#b71 where the notice and consent for receiving such services out-of-network did not meet the requirement of such subsection2 7,d7 services furnished by an out-of-network provider after an enrollee has been admitted to the hospital for emergency services but prior to stabilization1 as described in subsection 7f77#a72 or 7,e7 out-of-network services furnished after the enrollee has been stabilized 7within the meaning of subsection 7b77#b77;,c771 where the notice and option for receiving care at an alternate facility required under subsection 7f77#b7 have not been provided to the enrollee and the enrollee did not give consent under subsection 7f77#c71 may not bill an enrollee in a group health plan or group or individual health insurance coverage for amounts beyond the cost-sharing amount that would apply under subsection 7b77#a77;,c77ii77,,ii71 7e77#a71 7e77#b71 or 7f71 as applicable4 7#b7 ,notice ,a facility furnishing services described in paragraph 7#a7 shall provide enrollees in a group health plan or group or individual health insurance coverage with a one-page notice1 in #af-point font1 upon intake at the emergency room or being admitted at the facility of the prohibition on balance billing under paragraph 7#a7 and who to contact for recourse if they are sent a balance bill in violation of such paragraph4 ,the facility shall be responsible for obtaining the signature from the enrollee on such notice4 ,the ,secretary shall issue regulations within #f months of the date of enactment of this subsection on the requirements for the notice under this paragraph4 7h7 ,maintaining ,state surprise billing protections 7#a7 ,in general ,nothing in this section shall prevent a ,state from establishing or continuing in effect1 with respect to health insurance issuers1 facilities1 or practitioners1 an alternate method under ,state law for determining the appropriate compensation for services described in subsection 7b71 7e71 or 7f74 7#b7 ,additional application ,in the case of group health plans or group or individual health insurance coverage offered in a ,state that has not established an alternate method described in paragraph 7#a71 such as arbitration or a benchmark1 or for services described in subsection 7b71 7e71 or 7f7 that are not covered by such ,state's alternate method described in paragraph 7#a71 the provisions of this section shall apply4 7#c7 ,self-insured plans ,subsections 7b71 7e71 and 7f7 shall apply to a self-insured group health plan that is not subject to ,state insurance regulation4 7i7 ,definitions ,in this section3 7#a7 ,in-network ,the term in-network1 with respect to a group health plan or health insurance coverage means a provider that has a contractual relationship with the plan4 7#b7 ,enrollee ,the term enrollee1 with respect to health insurance coverage or a group health plan1 includes a participant1 dependent1 or beneficiary4 7#c7 ,ancillary services ,the term ancillary services means non-emergency care that is-- 7,a7 provided by anesthesiologists1 pathologists1 emergency medicine providers1 intensivists1 radiologists1 neonatologists1 hospitalists1 and assistant surgeons1 whether the care is provided by a physician or non-physician practitioner2 7,b7 a diagnostic service 7including radiology and lab services72 or 7,c7 provided by such other specialty practitioner not typically selected by the patients receiving the care1 which the ,secretary may add periodically to such definition through rulemaking4 4 7b7 ,enforcement of balance billing prohibitions ,part ,c of title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ia et seq47 is amended by adding at the end the following3 #bgie4 ,enforcement of balance billing prohibitions 7a7 ,in general ,subject to subsection 7b71 a facility or practitioner that violates a requirement under section #bgai;,a7g77#a7 or fails to provide notice or obtain consent as required under subsection 7e77#b7 or 7f77#b7 shall be subject to a civil monetary penalty of not more than #aj1jjj for each act constituting such violation4 7b7 ,procedure ,the provisions of section #aabh;,a of the ,social ,security ,act1 other than subsections 7a7 and 7b7 and the first sentence of subsection 7c77#a7 of such section1 shall apply to civil money penalties under this subsection in the same manner as such provisions apply to a penalty or proceeding under section #aabh;,a of the ,social ,security ,act4 7c7 ,safe harbor 7#a7 ,in general ,the ,secretary shall waive the penalties described under subsection 7a7 with respect to a facility or1 practitioner who does not knowingly violate1 and should not have reasonably known it violated1 section #bgai;,a7g77#a7 with respect to an enrollee1 if such facility or practitioner1 within #cj days of the violation1 withdraws the bill that was in violation of section #bgai;,a7g77#a71 and1 as applicable1 reimburses the group health plan1 health insurance issuer1 or enrollee1 in an amount equal to the difference between the amount billed and the amount allowed to be billed under section #bgai;,a7g77#a71 plus interest1 at an interest rate determined by the ,secretary4 7#b7 ,hardship exemption ,the ,secretary may establish a hardship exemption to the penalties under this section4 7#c7 ,state enforcement ,the ,secretary shall waive penalties under this section with respect to a facility or practitioner that has already been subject to enforcement action under ,state law for a violation described in subsection 7a74 4 7c7 ,application to grandfathered plans ,section #abea7;a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjaa7;a77 is amended by adding at the end the following3 7#e7 ,application of additional provisions ,subsections 7b7 through 7h7 of section #bgai;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 shall apply to grandfathered health plans for plan years beginning with the second plan year that begins after the date of enactment of this paragraph4 4 7d7 ,coverage under ,federal ,employees ,health ,benefits ,program ,section #hijd of title #e1 ,united ,states ,code1 is amended by adding at the end the following3 7c7 ,any health benefits plan offered under this chapter shall be treated as a group health plan or group or individual health insurance coverage for purposes of subsections 7e7 through 7g7 of section #bgai;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 7except for paragraph 7#c7 of such subsection 7g774 4