,i #aaith ,,congress #ast ,session ,h4 ,r4 #feab ,,in ,,the ,,house ,,of ,,representatives ,december #i1 #bjbe,mr4 ,biggs of ,arizona 7for himself1 ,mr4 ,ogles1 and ,mr4 ,clyde7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committees on ,ways and ,means1 ,education and ,workforce1 and the ,judiciary1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to ,empower ,american ,families with ,direct ,control ,over ,healthcare ,dollars1 ,codify ,president ,trump's ,proven ,reforms for ,flexibility and ,choice1 ,prohibit ,taxpayer ,funding for ,abortion and ,gender ,transition ,procedures1 ,eliminate ,waste and ,fraud in the ,affordable ,care ,act1 and ,reject ,extensions of ,enhanced ,subsidies to ,insurance ,companies4 #a4 ,short title ,this ,act may be cited as the ,putting ,patients ,first ,healthcare ,freedom ,act #b4 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title4,sec4 #b4 ,table of contents4,title ,i--,putting patients over health insurance companies,subtitle ,a--,more ,affordable ,care ,act,sec4 #ajja4 ,short title4,sec4 #ajjb4 ,health freedom waiver program4,sec4 #ajjc4 ,trump health freedom accounts4,subtitle ,b--,improving ,,hsa access1 utility1 and flexibility,sec4 #ajaa4 ,individuals entitled to part ,a of medicare by reason of age allowed to contribute to health savings account4,sec4 #ajab4 ,allow both spouses to make catch-up contributions to the same health savings account4,sec4 #ajac4 ,,fsa and ,,hra terminations or conversions to fund ,h,s,as4,sec4 #ajad4 ,special rule for certain medical expenses incurred before establishment of health savings account4,sec4 #ajae4 ,contributions permitted if spouse has health flexible spending arrangement4,sec4 #ajaf4 ,increase in health savings account contribution limitation for certain individuals4,sec4 #ajag4 ,health savings accounts used to purchase insurance4,subtitle ,c--,health care sharing ministries ,sec4 #ajah4 ,treatment of health care sharing ministries4,sec4 #ajai4 ,health care sharing ministry fees treated as medical care4,sec4 #ajbj4 ,health care sharing ministries not treated as health insurance4,title ,,ii--,codifying ,trump healthcare freedom agenda,subtitle ,a--,association ,health ,plans ,act,sec4 #bjja4 ,short title4,sec4 #bjjb4 ,treatment of group or association of employers4,sec4 #bjjc4 ,rules applicable to employee welfare benefit plans established and maintained by a group or association of employers4,sec4 #bjjd4 ,rule of construction4,subtitle ,b--,,choice ,arrangement ,act,sec4 #bjaa4 ,short title4,sec4 #bjab4 ,treatment of health reimbursement arrangements integrated with individual market coverage4,sec4 #bjac4 ,participants in choice arrangement eligible for purchase of exchange insurance for purchase of cafeteria plan4,sec4 #bjad4 ,employer credit for choice arrangement4,subtitle ,c--,self-,insurance ,protection ,act,sec4 #bjba4 ,short title4,sec4 #bjbb4 ,findings4,sec4 #bjbc4 ,certain medical stop-loss insurance obtained by certain plan sponsors of group health plans not included under the definition of health insurance coverage4,sec4 #bjbd4 ,effect on other laws4,subtitle ,d--,small ,business ,flexibility ,act,sec4 #bjca4 ,short title4,sec4 #bjcb4 ,notification of flexible health insurance benefits4,subtitle ,e--,health ,coverage ,choice ,act,sec4 #bjda4 ,short title4,sec4 #bjdb4 ,definition of short-term limited duration insurance4,subtitle ,f--,,impact ,act of #bjbe,sec4 #bjea4 ,short title4,sec4 #bjeb4 ,expanding eligibility for catastrophic plans4,subtitle ,g--,new ,health ,options ,act,sec4 #bjfa4 ,short title4,sec4 #bjfb4 ,creation of a reinsurance program for a new health insurance risk pool4,sec4 #bjfb4 ,promotion of high-value care4,sec4 #bjfd4 ,disclosure of lower prices4,subtitle ,h--,fighting waste fraud and abuse in the unaffordable care act,sec4 #bjga4 ,short title4,sec4 #bjgb4 ,addressing waste1 fraud1 and abuse in the ,,aca exchanges4,sec4 #bjgc4 ,funding cost-sharing reduction payments4,title ,,iii--,ending taxpayer funding for abortion and gender transition procedures,subtitle ,a--,no taxpayer funding for abortion and abortion insurance full disclosure act of #bjbe,sec4 #cjjj4 ,applicability to entire act4,sec4 #cjja4 ,short title4,sec4 #cjjb4 ,prohibiting taxpayer funded abortions4,sec4 #cjjc4 ,amendment to table of chapters4,sec4 #cjjd4 ,clarifying application of prohibition to premium credits and cost-sharing reductions under aca4,sec4 #cjje4 ,revision to notice requirements regarding disclosure of extent of health plan coverage of abortion and abortion premium surcharges4,subtitle ,b--,prohibiting ,federal funding for gender transition procedures,sec4 #cjjf4 ,short title4,sec4 #cjjg4 ,prohibiting ,federal funding for gender transition procedures4 ,i ,putting patients over health insurance companies ,a ,more ,affordable ,care ,act #ajja4 ,short title ,this ,act may be cited as the ,more ,affordable ,care ,act4 #ajjb4 ,health freedom waiver program ,part #d of subtitle ,d of title ,i of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjea et seq47 is amended by adding the following3 #acce4 ,health freedom waiver program 7a7 ,in general 7#a7 ,waiver program ,the ,secretary shall waive all or any requirements described in paragraph 7#d71 as determined by the applicable ,state1 for plan years beginning on or after ,january #a1 #bjbf1 with respect to health insurance coverage within any ,state that submits a notification under paragraph 7#b71 provided that the ,state maintains an invisible high-risk insurance pool or another program designed to mitigate risk to insurance premium costs4 7#b7 ,notification ,a ,state entity described in paragraph 7#c7 desiring a waiver under this section for any plan year beginning on or after ,january #a1 #bjbf1 shall notify the ,secretary of its intent to participate in the waiver program with respect to all or any requirements described in paragraph 7#d74 ,such notification shall be filed at such time1 not later than #ij days before the ,state intends to begin participation in the waiver program1 and in such manner as the ,secretary may require1 and contain such information as the ,secretary may require1 including the requirements under paragraph 7#d7 that the ,state intends to waiver and evidence that the ,state maintains a high-risk insurance pool4 7#c7 ,state submission ,a notification with respect to a ,state may be submitted by-- 7,a7 the governor of the ,state2 or 7,b7 the legislature of the ,state1 upon a majority vote by the ,state legislature4 7#d7 ,requirements ,the requirements described in this paragraph with respect to health insurance coverage within the ,state are as follows3 7,a7 ,part #a of subtitle ,d4 7,b7 ,part #b of subtitle ,d4 7,c7 ,section #adjb4 7,d7 ,sections #cf;,b and #ejjj;,a of the ,internal ,revenue ,code of #aihf4 7#e7 ,money follows the person 7,a7 ,in general ,with respect to a ,state waiver under paragraph 7#a71 under which1 due to the structure of the ,state plan1 individuals and small employers in the ,state would not qualify for the premium tax credits1 cost-sharing reductions1 or small business credits under sec4 #cf;,b of the ,internal ,revenue ,code of #aihf or under part ,i of subtitle ,e for which they would otherwise be eligible1 the ,secretary shall provide for an alternative means by which the aggregate amount of such credits or reductions that would have been paid on behalf of participants in the ,exchanges established under this title had the ,state not received such waiver1 shall be paid into the ,trump ,health ,freedom ,accounts established under section #bbc7;i7 of the ,internal ,revenue ,code of #aihf of eligible residents of the ,state4 7,b7 ,payments to trump health freedom accounts ,the ,secretary shall pay into the ,trump ,health ,freedom ,accounts of each eligible resident of a ,state for which a waiver is in effect for a play year the amount equal to the total amount for which the resident would have been eligible in premium tax credit amounts under section #cf;,b of the ,internal ,revenue ,code of #aihf and cost-sharing reduction amounts under section #adjb for the year1 had the ,state not had such waiver in effect4 ,in determining the appropriate payment amount under this subparagraph1 the ,secretary shall calculate premium tax credit amounts and cost-sharing reduction amounts based on the national average annual premium amount for a silver tier benchmark plan among ,states that do not have such waivers in effect for the applicable year4 ,the ,secretary shall make payments into the ,trump ,health ,freedom ,accounts of eligible residents on a monthly basis1 quarterly basis1 or in one lump sum at the beginning of the year1 at the option of each eligible resident4 7#f7 ,coordinated waiver process ,the ,secretary shall develop a process for coordinating and consolidating the ,state waiver processes applicable under the provisions of this section1 and the existing waiver processes applicable under section #accb1 and titles ,,xviii1 ,,xix1 and ,,xxi of the ,social ,security ,act1 and any other ,federal law relating to the provision of health care items or services4 ,such processes shall permit a ,state to submit a single application for a waiver under any or all of such provisions4 7#g7 ,exchanges 7,a7 ,in general ,in the case of a ,state in which a waiver is in effect under this section for a plan year-- 7i7 the ,state may-- 7,i7 operate an ,exchange established as described in section #acaa7;b72 or 7,,ii7 allow one or more private entities to run commercial platforms that sell health plans approved by the ,state insurance commissioner2 or 7ii7 if the ,state does not operate an ,exchange as described in clause 7i77,i7 or allow for one or more commercial platforms described in clause 7i77,,ii71 the ,secretary shall operate a ,federal ,exchange1 as described in section #acba7;c71 provided that any ,state laws regarding the availability of health plans on1 and the operation of1 such ,exchange shall apply in lieu of any provision under part #a or part #b that such ,state has waived4 7,b7 ,application program interface ,the ,secretary shall make available to any ,state that allows for commercial platforms described in subparagraph 7,a77i77,,ii71 the application program interface used for operating ,federal and ,state ,exchanges1 for use by any private entity running such a platform under ,state authority4 7#h7 ,definitions ,in this section3 7,a7 ,eligible resident ,the term eligible resident means1 with respect to a ,state for which a waiver is in effect under this section1 a resident who-- 7i7 in the absence of such a waiver in the ,state1 would be eligible for a premium tax credit under section #cf;,b of the ,internal ,revenue ,code of #aihf or a cost-sharing reduction under section #adjb1 if the resident enrolled in a qualified health plan offered on the ,exchange of such ,state2 and 7ii7 enrolls in a plan offered on the ,exchange described in paragraph 7#g7 for the applicable plan year4 7,b7 ,secretary ,the term ,secretary means-- 7i7 the ,secretary of ,health and ,human ,services with respect to waivers relating to the provisions described in subparagraph 7,a7 through 7,c7 of paragraph 7#d72 and 7ii7 the ,secretary of the ,treasury with respect to waivers relating to the provisions described in paragraph 7#d77;,d74 7b7 ,waiver period ,each waiver under this section shall be in effect beginning on ,january #a of the plan year for which a timely notice is submitted by the ,state under subsection 7a77#b71 and continuing until the entity of the ,state described in subparagraph 7,a7 or 7,b7 of subsection 7a77#c7 that submitted the notification under subsection 7a77#b7 submits to the ,secretary a notification of intent to discontinue participation in the waiver program under this section4 7c7 ,limitation ,the ,secretary may not permit a waiver under this section of any ,federal law or requirement that is not within the authority of the ,secretary4 7d7 ,availability of plans 7#a7 ,in general ,any health insurance coverage offered in a ,state for which a waiver under this section is in effect1 and authorized by the insurance commissioner of the ,state1 shall be made available on1 as applicable1 the ,federal or ,state ,exchange or commercial platforms described in subsection 7a77#g71 of all ,states for which such a waiver is in effect1 subject to the laws of each such ,state4 7#b7 ,child-only plans ,in any ,state for which a waiver under this section is in effect1 a health insurance issuer may offer a plan in which the only individuals eligible to enroll are individuals who1 as of the beginning of a plan year1 have not attained the age of #ba4 7e7 ,regulations ,not later than #a year after the date of enactment of the ,more ,affordable ,care ,act1 the ,secretary of ,health and ,human ,services1 in coordination with the ,secretary of the ,treasury1 shall promulgate regulations to carry out this section4 7f7 ,rule of construction regarding consumer protections1 including the pre-,existing condition protection ,nothing in this section shall be construed to allow a ,state to waive the requirements of title ,,xxvii of the ,public ,health ,service ,act1 including sections #bgja1 #bgjb1 #bgjc1 #bgjd1 #bgje1 #bgjf1 #bgaa1 #bgab1 and #bgah of such ,act4 4 #ajjc4 ,trump health freedom accounts 7a7 ,in general ,section #bbc of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subsection3 7i7 ,trump health freedom accounts ,for purposes of this section-- 7#a7 ,in general ,in the case of a ,trump ,health ,freedom ,account1 this section shall be applied as provided in paragraphs 7#c7 through 7#h74 7#b7 ,trump health freedom account ,the term ,trump ,health ,freedom ,account means a health savings account 7determined as provided in this subsection7 established by or on behalf of an individual residing in a ,state for which a waiver under section #acce of the ,patient ,protection and ,affordable ,care ,act is in effect which receives deposits of amounts transferred to the individual pursuant to section #acce7;a77#e7 of such ,act4 7#c7 ,eligible individual ,any individual covered under a health plan authorized to be made available on an ,exchange by section #acce7;d7 of such ,act shall be treated as an eligible individual4 7#d7 ,treatment of transferred contributions ,amounts transferred to a ,trump ,health ,freedom ,account pursuant to section #acce7;a77#e7 of such ,act shall not be taken into account in determining the deduction allowed by subsection 7a74 7#e7 ,account must be only hsa of individual 7,a7 ,in general ,an individual who has a ,trump ,health ,freedom ,account shall not be treated as an eligible individual with respect to any health savings account other than such ,trump ,health ,freedom ,account4 7,b7 ,rollover of existing account permitted ,an individual on whose behalf a ,trump ,health ,freedom ,account is established may roll over the balance of any other health savings account of the individual to such ,trump ,health ,freedom ,account according to the rule of subsection 7f77#e74 7#f7 ,no rollovers permitted ,except as provided in paragraph 7#f77;,b71 subsection 7f77#e7 shall not apply and no amount shall be contributed from a ,trump ,health ,freedom ,account to any health saving account other than a ,trump ,health ,freedom ,account4 7#g7 ,restriction on use of amounts ,no amounts in a ,trump ,health ,freedom ,account may be used-- 7,a7 to pay premiums for a health plan that covers-- 7i7 gender transition procedures2 or 7ii7 abortion2 or 7,b7 pay for any service described in clause 7i7 or 7ii7 or subparagraph 7,a74 7#h7 ,definitions ,for purposes of paragraph 7#h7-- 7,a7 ,gender transition procedure 7i7 ,in general ,the term gender transition procedure means any hormonal or surgical intervention for the purpose of gender transition1 including-- 7,i7 gonadotropin-releasing hormone 7,,gnrh7 agonists or other puberty-blocking or suppressing drugs to stop or delay normal puberty2 7,,ii7 testosterone1 estrogen1 progesterone1 or other androgens to an individual at doses that are superphysiologic to what would normally be produced endogenously in a healthy individual of the same age and sex2 7,,iii7 castration2 7,,iv7 orchiectomy2 7,v7 scrotoplasty2 7,,vi7 implantation of erection or testicular prostheses2 7,,vii7 vasectomy2 7,,viii7 hysterectomy2 7,,ix7 oophorectomy2 7,x7 ovariectomy2 7,,xi7 reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty2 7,,xii7 metoidioplasty2 7,,xiii7 penectomy2 7,,xiv7 phalloplasty2 7,,xv7 vaginoplasty2 7,,xvi7 clitoroplasty2 7,,xvii7 vaginectomy2 7,,xviii7 vulvoplasty2 7,,xix7 reduction thyrochondroplasty2 7,,xx7 chondrolaryngoplasty2 7,,xxi7 mastectomy2 7,,xxii7 tubal ligation2 7,,xxiii7 sterilization2 7,,xxiv7 any plastic1 cosmetic1 or aesthetic surgery that feminizes or masculinizes the facial or other physiological features of an individual2 7,,xxv7 any placement of chest implants to create feminine breasts2 7,,xxvi7 any placement of fat or artificial implants in the gluteal region2 7,,xxvii7 augmentation mammoplasty2 7,,xxviii7 liposuction2 7,,xxix7 lipofilling2 7,,xxx7 voice surgery2 7,,xxxi7 hair reconstruction2 7,,xxxii7 pectoral implants2 and 7,,xxxiii7 the removal of any otherwise healthy or non-diseased body part or tissue4 7ii7 ,exclusions ,the term gender transition procedure does not include the following when furnished to an individual by a health care provider with the consent of such individual or1 if applicable1 such individual's parents or legal guardian3 7,i7 ,services to individuals born with a medically verifiable disorder of sex development1 including an individual with external sex characteristics that are irresolvably ambiguous such as an individual born with #df ,,xx chromosomes with virilization1 and individual born with #df ,,xy chromosomes with undervirilization1 or an individual born having both ovarian and testicular tissue4 7,,ii7 ,service provided when a physician has otherwise diagnosed a disorder of sexual development in which the physician has determined through genetic or biochemical testing that the individual does not have normal sex chromosome structure1 sex steroid hormone production1 or sex steroid hormone action for a healthy individual of the same sex and age4 7,,iii7 ,the treatment of any infection1 injury1 disease1 or disorder that has been caused by or exacerbated by the performance of gender transition procedures1 whether or not the gender transition procedure was performed in accordance with ,state and ,federal law or whether or not funding for the gender transition procedure is permissible under this section4 7,,iv7 ,any procedure undertaken because the individual suffers from a physical disorder1 physical injury1 or physical illness 7but not mental1 behavioral1 or emotional distress or a mental1 behavioral1 or emotional disorder7 that would1 as certified by a physician1 place the individual in imminent danger of death or impairment of major bodily function1 unless the procedure is performed4 7,v7 ,puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for a minor experiencing precocious puberty4 7,,vi7 ,male circumcision4 7,b7 ,gender transition ,the term gender transition means the process in which an individual goes from identifying with or presenting as his or her sex to identifying with or presenting a self-proclaimed identity that does not correspond with or is different from his or her sex and may be accompanied with social1 legal1 or physical changes4 7,c7 ,sex ,the term sex1 when referring to an individual's sex1 means to refer to either male or female1 as biologically determined4 7,d7 ,female ,the term female1 when used to refer to a natural person1 means an individual who naturally has1 had1 will have1 or would have1 but for a congenital anomaly1 historic accident1 or intentional or unintentional disruption1 the reproductive system that at some point produces1 transports1 and utilizes eggs for fertilization4 7,e7 ,male ,the term male1 when used to refer to a natural person1 means an individual who naturally has1 had1 will have1 or would have1 but for a congenital anomaly1 historical accident1 or intentional or unintentional disruption1 the reproductive system that at some point produces1 transports1 and utilizes sperm for fertilization4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjbe4 4 ,b ,improving ,,hsa access1 utility1 and flexibility #ajaa4 ,individuals entitled to part a of medicare by reason of age allowed to contribute to health savings account 7a7 ,in general ,section #bbc7;c77#a77;,b7 is amended by striking and at the end of clause 7ii71 by striking the period at the end of clause 7iii7 and inserting 1 and1 and by adding at the end the following new clause3 7iv7 entitlement to hospital insurance benefits under part ,a of title ,,xviii of the ,social ,security ,act by reason of section #bbf7;a7 of such ,act4 4 7b7 ,treatment of health insurance purchased from account ,section #bbc7;d77#b77;,c77iv7 is amended by inserting and who is not an eligible individual after who has attained the age specified in section #ahaa of the ,social ,security ,act4 7c7 ,coordination with penalty on distributions not used for qualified medical expenses ,section #bbc7;f77#d77;,c7 is amended by striking ,subparagraph 7,a7 and inserting ,except in the case of an eligible individual1 subparagraph 7,a74 7d7 ,conforming amendment ,section #bbc7;b77#g7 is amended by inserting 7other than an entitlement to benefits described in subsection 7c77#a77;,b77iv77 after ,social ,security ,act4 7e7 ,effective date ,the amendments made by this section shall apply to months beginning after ,december #ca1 #bjbe4 #ajab4 ,allow both spouses to make catch-up contributions to the same health savings account 7a7 ,in general ,section #bbc7;b77#e7 is amended to read as follows3 7#e7 ,special rule for married individuals with family coverage 7,a7 ,in general ,in the case of individuals who are married to each other1 if both spouses are eligible individuals and either spouse has family coverage under a high deductible health plan as of the first day of any month-- 7i7 the limitation under paragraph 7#a7 shall be applied by not taking into account any other high deductible health plan coverage of either spouse 7and if such spouses both have family coverage under separate high deductible health plans1 only one such coverage shall be taken into account71 7ii7 such limitation 7after application of clause 7i77 shall be reduced by the aggregate amount paid to ,archer ,m,s,as of such spouses for the taxable year1 and 7iii7 such limitation 7after application of clauses 7i7 and 7ii77 shall be divided equally between such spouses unless they agree on a different division4 7,b7 ,treatment of additional contribution amounts ,if both spouses referred to in subparagraph 7,a7 have attained age #ee before the close of the taxable year1 the limitation referred to in subparagraph 7,a77iii7 which is subject to division between the spouses shall include the additional contribution amounts determined under paragraph 7#c7 for both spouses4 ,in any other case1 any additional contribution amount determined under paragraph 7#c7 shall not be taken into account under subparagraph 7,a77iii7 and shall not be subject to division between the spouses4 4 7b7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjbe4 #ajac4 ,,fsa and ,,hra terminations or conversions to fund hsas 7a7 ,in general ,section #ajf7;e77#b7 is amended to read as follows3 7#b7 ,qualified hsa distribution ,for purposes of this subsection-- 7,a7 ,in general ,the term qualified ,,hsa distribution means1 with respect to any employee1 a distribution from a health flexible spending arrangement or health reimbursement arrangement of such employee contributed directly to a health savings account of such employee if-- 7i7 such distribution is made in connection with such employee establishing coverage under a high deductible health plan 7as defined in section #bbc7;c77#b77 if during the #d-year period preceding the date the employee so establishes coverage the employee was not covered under such a high deductible health plan1 and 7ii7 such arrangement is described in section #bbc7;c77#a77;,b77v7 with respect to any portion of the plan year remaining after such distribution is made1 if such employee remains enrolled in such arrangement4 7,b7 ,dollar limitation ,the aggregate amount of distributions from health flexible spending arrangements and health reimbursement arrangements of any employee which may be treated as qualified ,,hsa distributions in connection with an establishment of coverage described in subparagraph 7,a77i7 shall not exceed the dollar amount in effect under section #abe7;i77#a7 7twice such amount in the case of coverage which is described in section #bbc7;b77#b77;,b774 4 7b7 ,partial reduction of limitation on deductible ,,hsa contributions ,section #bbc7;b77#d7 is amended by striking and at the end of subparagraph 7,b71 by striking the period at the end of subparagraph 7,c7 and inserting 1 and1 and by inserting after subparagraph 7,c7 the following new subparagraph3 7,d7 so much of any qualified ,,hsa distribution 7as defined in section #ajf7;e77#b77 made to a health savings account of such individual during the taxable year as does not exceed the aggregate increases in the balance of the arrangement from which such distribution is made which occur during the portion of the plan year which precedes such distribution 7other than any balance carried over to such plan year and determined without regard to any decrease in such balance during such portion of the plan year74 4 7c7 ,conversion to ,,hsa-,compatible arrangement for remainder of plan year ,section #bbc7;c77#a77;,b71 as amended by this preceding provisions of this ,act1 is amended by striking and at the end of clause 7iii71 by striking the period at the end of clause 7iv7 and inserting 1 and1 and by adding at the end the following new clause3 7v7 coverage under a health flexible spending arrangement or health reimbursement arrangement for the portion of the plan year after a qualified ,,hsa distribution 7as defined in section #ajf7;e77#b7 determined without regard to subparagraph 7,a77ii7 thereof7 is made1 if the terms of such arrangement which apply for such portion of the plan year are such that1 if such terms applied for the entire plan year1 then such arrangement would not be taken into account under subparagraph 7,a77ii7 of this paragraph for such plan year4 4 7d7 ,inclusion of qualified ,,hsa distributions on ,w-#b 7#a7 ,in general ,section #fjea7;a71 as amended by the preceding provisions of this ,act1 is amended by striking and at the end of paragraph 7#ai71 by striking the period at the end of paragraph 7#bj7 and inserting 1 and1 and by inserting after paragraph 7#bj7 the following new paragraph3 7#ba7 the amount of any qualified ,,hsa distribution 7as defined in section #ajf7;e77#b77 with respect to such employee4 4 7#b7 ,conforming amendment ,section #fjea7;a77#ab7 is amended by inserting 7other than any qualified ,,hsa distribution1 as defined in section #ajf7;e77#b77 before the comma at the end4 7e7 ,effective date ,the amendments made by this section shall apply to distributions made after ,december #ca1 #bjbe4 #ajad4 ,special rule for certain medical expenses incurred before establishment of health savings account 7a7 ,in general ,section #bbc7;d77#b71 as amended by the preceding provisions of this ,act1 is amended by adding at the end the following new subparagraph3 7,f7 ,treatment of certain medical expenses incurred before establishment of account ,if a health savings account is established during the #fj-;day period beginning on the date that coverage of the account beneficiary under a high deductible health plan begins1 then1 solely for purposes of determining whether an amount paid is used for a qualified medical expense1 such account shall be treated as having been established on the date that such coverage begins4 4 7b7 ,effective date ,the amendment made by this section shall apply with respect to coverage beginning after ,december #ca1 #bjbe4 #ajae4 ,contributions permitted if spouse has health flexible spending arrangement 7a7 ,contributions permitted if spouse has a health flexible spending arrangement ,section #bbc7;c77#a77;,b71 as amended by this preceding provisions of this ,act1 is amended by striking and at the end of clause 7iv71 by striking the period at the end of clause 7v7 and inserting 1 and1 and by adding at the end the following new clause3 7vi7 coverage under a health flexible spending arrangement of the spouse of the individual for any plan year of such arrangement if the aggregate reimbursements under such arrangement for such year do not exceed the aggregate expenses which would be eligible for reimbursement under such arrangement if such expenses were determined without regard to any expenses paid or incurred with respect to such individual4 4 7b7 ,effective date ,the amendment made by this section shall apply to plan years beginning after ,december #ca1 #bjbe4 #ajaf4 ,increase in health savings account contribution limitation for certain individuals 7a7 ,increase 7#a7 ,in general ,section #bbc7;b7 is amended by adding at the end the following new paragraph3 7#i7 ,increase in limitation for certain taxpayers 7,a7 ,in general ,the applicable limitation under subparagraphs 7,a7 and 7,b7 of paragraph 7#b7 shall be increased by #d1cjj and #h1eej1 respectively4 7,b7 ,limitation based on modified adjusted gross income ,the amount of the increase under subparagraph 7,a7 7determined without regard to this subparagraph7 shall be reduced 7but not below zero7 by the amount which bears the same ratio to the amount of such increase 7as so determined7 as-- 7i7 the excess 7if any7 of-- 7,i7 the taxpayer's adjusted gross income for such taxable year1 over 7,,ii7 #ge1jjj 7#aej1jjj in the case of a joint return1 if the eligible individual has family coverage71 bears to 7ii7 #be1jjj 7#ej1jjj in the case of a joint return1 if the eligible individual has family coverage74 ,for purposes of the preceding sentence1 adjusted gross income shall be determined in the same manner as under section #bai7;g77#c77;,a71 except determined without regard to any deduction allowed under this section4 4 7#b7 ,only to apply to employee contributions ,section #ajf7;d77#a7 is amended by inserting and section #bbc7;b77#i7 after determined without regard to this subsection4 7b7 ,inflation adjustment ,section #bbc7;g71 as amended by the preceding provisions of this ,act1 is amended-- 7#a7 by inserting 1 7b77#i77;,a71 7b77#i77;,b77i77,,ii71 before and 7c77#b77;,a7 each place it appears1 7#b7 by striking clauses 7ii7 and 7ii7 in paragraph 7#a77;,b77i7 and inserting clauses 7ii71 7iii71 and 7iv71 7#c7 by striking and at the end of paragraph 7#a77;,b77ii71 7#d7 by striking the period at the end of paragraph 7#a77;,b77iii7 and inserting 1 and1 and 7#e7 by inserting after paragraph 7#a77;,b77iii7 the following new clause3 7iv7 in the case of the dollar amounts in subsections 7b77#i77;,a7 and 7b77#i77;,b77i77,,ii71 calendar year #bjbe 4 7c7 ,effective date 7#a7 ,subsection 7a7 ,the amendments made by subsection 7a7 shall apply to taxable years beginning after ,december #ca1 #bjbe4 7#b7 ,subsection 7b7 ,the amendments made by subsection 7b7 shall apply to taxable years beginning after ,december #ca1 #bjbf4 #ajag4 ,health savings accounts used to purchase insurance 7a7 ,in general ,section #bbc7;d77#b7 of the ,internal ,revenue ,code of #aihf is amended-- 7#a7 by striking subparagraphs 7,b7 and 7,c71 and 7#b7 by redesignating subparagraph 7,d7 as subparagraph 7,c74 7b7 ,effective date ,the amendment made by this section shall apply to plan years beginning after ,december #ca1 #bjbe4 ,c ,health care sharing ministries #ajah4 ,treatment of health care sharing ministries 7a7 ,inclusion as medical expenses ,paragraph 7#b7 of section #bbc7;c7 of the ,internal ,revenue ,code of #aihf1 as redesignated and amended by the preceding provisions of this ,act1 is further amended by adding at the end the following new subparagraph3 7,d7 ,inclusion of health care sharing ministries ,the term qualified medical expenses shall include amounts paid by a member of a health care sharing ministry 7as defined in section #ejjj;,a7d77#b77;,b77ii7 without regard to subclause 7,,iv7 thereof7 for-- 7i7 the sharing of medical expenses among members1 and 7ii7 administrative fees of the ministry4 4 7b7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after the date of enactment of this ,act4 #ajai4 ,health care sharing ministry fees treated as medical care 7a7 ,in general ,section #bac7;d7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new paragraph3 7#ab7 ,health care sharing ministries ,for purposes of this section1 the term medical care shall include amounts paid by a member of a health care sharing ministry 7as defined in section #ejjj;,a7d77#b77;,b77ii7 without regard to subclause 7,,iv7 thereof7 for-- 7,a7 the sharing of medical expenses among members1 and 7,b7 administrative fees of the ministry4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4 #ajbj4 ,health care sharing ministries not treated as health insurance 7a7 ,in general ,section #bbc7;c7 of the ,internal ,revenue ,code of #aihf1 as redesignated and amended by the preceding provisions of this ,act1 is amended by adding at the end the following new paragraph3 7#e7 ,health care sharing ministries not treated as health insurance ,a health care sharing ministry 7as defined in section #ejjj;,a7d77#b77;,b77ii7 without regard to subclause 7,,iv7 thereof7 shall not be treated as health plan or insurance for purposes of this title4 4 7b7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after the date of enactment of this ,act4 ,,ii ,codifying ,trump healthcare freedom agenda ,a ,association ,health ,plan ,act #bjja4 ,short title ,this ,act may be cited the ,association ,health ,plan ,act4 #bjjb4 ,treatment of group or association of employers 7a7 ,in general ,section #c7e7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #ajjb7e77 is amended-- 7#a7 by striking ,the term and inserting 7,a7 ,the term2 and 7#b7 by adding at the end the following3 7,b7 ,for purposes of subparagraph 7,a71 a group or association of employers shall be treated as an employer1 regardless of whether the employers composing such group or association are in the same industry1 trade1 or profession1 if such group or association-- 7i7 7,i7 has established and maintains an employee welfare benefit plan that is a group health plan 7as defined in section #gcc7;a77#a772 7,,ii7 provides coverage under such plan to at least #ea employees after all of the employees employed by all of the employer members of such group or association have been aggregated and counted together as described in subparagraph 7,d72 7,,iii7 has been actively in existence for at least #b years2 7,,iv7 has been formed and maintained in good faith for purposes other than providing medical care 7as defined in section #gcc7;a77#b77 through the purchase of insurance or otherwise2 7,v7 does not condition membership in the group or association on any health status-related factor 7as described in section #gjb7;a77#a77 relating to any individual2 7,,vi7 makes coverage under such plan available to all employer members of such group or association regardless of any health status-related factor 7as described in section #gjb7;a77#a77 relating to such employer members2 7,,vii7 does not provide coverage under such plan to any individual other than an employee of an employer member of such group or association2 7,,viii7 has established a governing board with by-laws or other similar indications of formality to manage and operate such plan in both form and substance1 of which at least #ge percent of the board members shall be made up of employer members of such group or association participating in the plan that are duly elected by each participating employer member casting #a vote during a scheduled election2 7,,ix7 is not a health insurance issuer 7as defined in section #gcc7;b77#b771 and is not owned or controlled by such a health insurance issuer or by a subsidiary or affiliate of such a health insurance issuer1 other than to the extent such a health insurance issuer may participate in the group or association as a member2 7ii7 is structured in good faith with any set of criteria to qualify for such treatment in any advisory opinion issued prior to the date of enactment of the ,association ,health ,plans ,act2 or 7iii7 meets any other set of criteria to qualify for such treatment that the ,secretary by regulation may provide4 7,c7 7i7 ,for purposes of subparagraph 7,b71 a self-employed individual shall be treated as-- 7,i7 an employer who may become a member of a group or association of employers2 7,,ii7 an employee who may participate in an employee welfare benefit plan established and maintained by such group or association2 and 7,,iii7 a participant of such plan subject to the eligibility determination and monitoring requirements set forth in clause 7iii74 7ii7 ,for purposes of this subparagraph1 the term self-employed individual means an individual who-- 7,i7 does not have any common law employees2 7,,ii7 has a bona fide ownership right in a trade or business1 regardless of whether such trade or business is incorporated or unincorporated2 7,,iii7 earns wages 7as defined in section #caba7;a7 of the ,internal ,revenue ,code of #aihf7 or self-employment income 7as defined in section #adjb7;b7 of such ,code7 from such trade or business2 and 7,,iv7 works at least #aj hours a week or #dj hours per month providing personal services to such trade or business4 7iii7 ,the board of a group or association of employers shall-- 7,i7 initially determine whether an individual meets the requirements under clause 7ii7 to be considered to a self-employed individual for the purposes of being treated as an-- 7aa7 employer member of such group or association 7in accordance with clause 7i77,i772 and 7bb7 employee who may participate in the employee welfare benefit plan established and maintained by such group or association 7in accordance with clause 7i77,,ii772 7,,ii7 through reasonable monitoring procedures1 periodically determine whether the individual continues to meet such requirements2 and 7,,iii7 if the board determines that an individual no longer meets such requirements1 not make such plan coverage available to such individual 7or dependents thereof7 for any plan year following the plan year during which the board makes such determination4 ,if1 subsequent to a determination that an individual no longer meets such requirements1 such individual furnishes evidence of satisfying such requirements1 such individual 7and dependents thereof7 shall be eligible to receive plan coverage4 7,d7 ,for purposes of subparagraph 7,b71 all of the employees 7including self-employed individuals7 employed by all of the employer members 7including self-employed individuals7 of a group or association of employers shall be-- 7i7 treated as participants in a single plan multiple employer welfare arrangement2 and 7ii7 aggregated and counted together for purposes of any regulation of an employee welfare benefit plan established and maintained by such group or association4 4 7b7 ,determination of employer or joint employer status ,the provision of employee welfare benefit plan coverage by a group or association of employers shall not be construed as evidence for establishing an employer or joint employer relationship under any ,federal or ,state law4 #bjjc4 ,rules applicable to employee welfare benefit plans established and maintained by a group or association of employers ,part #g of subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aaha1 et seq47 is amended by adding at the end the following3 #gcf4 ,rules applicable to employee welfare benefit plans established and maintained by a group or association of employers 7a7 ,premium rates for a group or association of employers 7#a7 7,a7 ,in the case of an employee welfare benefit plan established and maintained by a group or association of employers described in section #c7e77;,b71 such plan may1 to the extent not prohibited under ,state law-- 7i7 establish base premium rates formed on an actuarially sound1 modified community rating methodology that considers the pooling of all plan participant claims2 and 7ii7 utilize the specific risk profile of each employer member of such group or association to determine contribution rates for each such employer member's share of a premium by actuarially adjusting above or below the established base premium rates4 7,b7 ,for purposes of paragraph 7#a71 the term employer member means-- 7i7 an employer who is a member of such group or association of employers and employs at least #a common law employee2 or 7ii7 a group made up solely of self-employed individuals1 within which all of the self-employed individual members of such group or association are aggregated together as a single employer member group1 provided the group includes at least #bj self-employed individual members4 7#b7 ,in the event a group or association is made up solely of self-employed individuals 7and no employers with at least #a common law employee are members of such group or association71 the employee welfare benefit plan established by such group or association shall-- 7,a7 treat all self-employed individuals who are members of such group or association as a single risk pool2 7,b7 pool all plan participant claims2 and 7,c7 charge each plan participant the same premium rate4 7b7 ,discrimination and pre-,existing condition protections ,an employee welfare benefit plan established and maintained by a group or association of employers described in section #c7e77;,b7 shall be prohibited from-- 7#a7 establishing any rule for eligibility 7including continued eligibility7 of any individual 7including an employee of an employer member or a self-employed individual1 or a dependent of such employee or self-employed individual7 to enroll for benefits under the terms of the plan that discriminates based on any health status-related factor that relates to such individual 7consistent with the rules under section #gjb7;a77#a772 7#b7 requiring an individual 7including an employee of an employer member or a self-employed individual1 or a dependent of such employee or self-employed individual71 as a condition of enrollment or continued enrollment under the plan1 to pay a premium or contribution that is greater than the premium or contribution for a similarly situated individual enrolled in the plan based on any health status-related factor that relates to such individual 7consistent with the rules under section #gjb7;b77#a772 and 7#c7 denying coverage under such plan on the basis of a pre-existing condition 7consistent with the rules under section #bgjd of the ,public ,health ,service ,act74 4 #bjjd4 ,rule of construction ,nothing in this ,act shall be construed to exempt a group health plan which is an employee welfare benefit plan offered through a group or association of employers from the requirements of part #g of subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aaha et4 seq471 including the provisions of part ,a of title ,,xxvii of the ,public ,health ,service ,act as incorporated by reference into this ,act through section #gae4 ,b ,,choice ,arrangement ,act #bjaa4 ,short title ,this ,act may be cited as the ,,choice ,arrangement ,act4 #bjab4 ,treatment of health reimbursement arrangements integrated with individual market coverage 7a7 ,in general ,section #ihae7;b7 is amended-- 7#a7 ,by striking 8exception ,notwithstanding subsection 7a70 and inserting the following3 ,exceptions4-- 7#a7 ,self-insured group health plans ,notwithstanding subsection 7a7 7#b7 by adding at the end the following new paragraph3 7#b7 ,custom health option and individual care expense arrangements 7,a7 ,in general ,for purposes of this subchapter1 a custom health option and individual care expense arrangement shall be treated as meeting the requirements of section #ihjb and sections #bgje1 #bgaa1 #bgac1 and #bgae of title ,,xxvii of the ,public ,health ,service ,act4 7,b7 ,custom health option and individual care expense arrangements defined ,for purposes of this section1 the term custom health option and individual care expense arrangement means a health reimbursement arrangement-- 7i7 which is an employer-provided group health plan funded solely by employer contributions to provide payments or reimbursements for medical care subject to a maximum fixed dollar amount for a period1 7ii7 under which such payments or reimbursements may only be made for medical care provided during periods during which the individual is covered-- 7,i7 under individual health insurance coverage 7other than coverage that consists solely of excepted benefits71 or 7,,ii7 under part ,a and ,b of title ,,xviii of the ,social ,security ,act or part ,c of such title1 7iii7 which meets the nondiscrimination requirements of subparagraph 7,c71 7iv7 which meets the substantiation requirements of subparagraph 7,d71 and 7v7 which meets the notice requirements of subparagraph 7,e74 7,c7 ,nondiscrimination 7i7 ,in general ,an arrangement meets the requirements of this subparagraph if an employer offering such arrangement to an employee within a specified class of employee-- 7,i7 offers such arrangement to all employees within such specified class on the same terms1 and 7,,ii7 does not offer any other group health plan 7other than an account-based group health plan or a group health plan that consists solely of excepted benefits7 to any employees within such specified class4 ,in the case of an employer who offers a group health plan provided through health insurance coverage in the small group market 7that is subject to section #bgja of the ,public ,health ,service ,act7 to all employees within such specified class1 subclause 7,,ii7 shall not apply to such group health plan4 7ii7 ,specified class of employee ,for purposes of this subparagraph1 any of the following may be designated as a specified class of employee3 7,i7 ,full-time employees4 7,,ii7 ,part-time employees4 7,,iii7 ,salaried employees4 7,,iv7 ,non-salaried employees4 7,v7 ,employees whose primary site of employment is in the same rating area4 7,,vi7 ,employees who are included in a unit of employees covered under a collective bargaining agreement to which the employer is subject 7determined under rules similar to the rules of section #aje7;h774 7,,vii7 ,employees who have not met a group health plan1 or health insurance issuer offering group health insurance coverage1 waiting period requirement that satisfies section #bgjh of the ,public ,health ,service ,act4 7,,viii7 ,seasonal employees4 7,,ix7 ,employees who are nonresident aliens and who receive no earned income 7within the meaning of section #iaa7;d77#b77 from the employer which constitutes income from sources within the ,united ,states 7within the meaning of section #hfa7;a77#c774 7,x7 ,such other classes of employees as the ,secretary may designate4 ,an employer may designate 7in such manner as is prescribed by the ,secretary7 two or more of the classes described in the preceding subclauses as the specified class of employees to which the arrangement is offered for purposes of applying this subparagraph4 7iii7 ,special rule for new hires ,an employer may designate prospectively so much of a specified class of employees as are hired after a date set by the employer4 ,such subclass of employees shall be treated as the specified class for purposes of applying clause 7i74 7iv7 ,rules for determining type of employee ,for purposes for clause 7ii71 any determination of full-time1 part-time1 or seasonal employment status shall be made under rules similar to the rules of section #aje7;h7 or #dihj;,h1 whichever the employer elects for the plan year4 ,such election shall apply with respect to all employees of the employer for the plan year4 7v7 ,permitted variation ,for purposes of clause 7i77,i71 an arrangement shall not fail to be treated as provided on the same terms within a specified class merely because the maximum dollar amount of payments and reimbursements which may be made under the terms of the arrangement for the year with respect to each employee within such class-- 7,i7 increases as additional dependents of the employee are covered under the arrangement1 and 7,,ii7 increases with respect to a participant as the age of the participant increases1 but not in excess of an amount equal to #cjj percent of the lowest maximum dollar amount with respect to such a participant determined without regard to age4 7,d7 ,substantiation requirements ,an arrangement meets the requirements of this subparagraph if the arrangement has reasonable procedures to substantiate-- 7i7 that the participant and any dependents are1 or will be1 enrolled in coverage described in subparagraph 7,b77ii7 as of the beginning of the plan year of the arrangement 7or as of the beginning of coverage under the arrangement in the case of an employee who first becomes eligible to participate in the arrangement after the date notice is given with respect to the plan under subparagraph 7,e7 7determined without regard to clause 7iii7 thereof771 and 7ii7 any requests made for payment or reimbursement of medical care under the arrangement and that the participant and any dependents remain so enrolled4 7,e7 ,notice 7i7 ,in general ,except as provided in clause 7iii71 an arrangement meets the requirements of this subparagraph if1 under the arrangement1 each employee eligible to participate is1 not later than #fj days before the beginning of the plan year1 given written notice of the employee's rights and obligations under the arrangement which-- 7,i7 is sufficiently accurate and comprehensive to apprise the employee of such rights and obligations1 and 7,,ii7 is written in a manner calculated to be understood by the average employee eligible to participate4 7ii7 ,notice requirements ,such notice shall include such information as the ,secretary may by regulation prescribe4 7iii7 ,notice deadline for certain employees ,in the case of an employee-- 7,i7 who first becomes eligible to participate in the arrangement after the date notice is given with respect to the plan under clause 7i7 7determined without regard to this clause71 or 7,,ii7 whose employer is first established fewer than #abj days before the beginning of the first plan year of the arrangement1 the requirements of this subparagraph shall be treated as met if the notice required under clause 7i7 is provided not later than the date the arrangement may take effect with respect to such employee4 4 7b7 ,inclusion of ,,choice arrangement permitted benefits on ,w-#b 7#a7 ,in general ,section #fjea7;a71 as amended by the preceding provisions of this ,act1 is amended by striking and at the end of paragraph 7#ah71 by striking the period at the end of paragraph 7#ai7 and inserting 1 and1 and by inserting after paragraph 7#ai7 the following new paragraph3 7#bj7 the total amount of permitted benefits for enrolled individuals under a custom health option and individual care expense arrangement 7as defined in section #ihae7;b77#b77 with respect to such employee4 4 7c7 ,treatment of current rules relating to certain arrangements 7#a7 ,no inference ,to the extent not inconsistent with the amendments made by this section-- 7,a7 no inference shall be made from such amendments with respect to the rules prescribed in the ,federal ,register on ,june #bj1 #bjai 7#hd ,fed4 ,reg4 #bhhhh71 relating to health reimbursement arrangements and other account-based group health plans1 and 7,b7 any reference to custom health option and individual care expense arrangements shall for purposes of such rules be treated as including a reference to individual coverage health reimbursement arrangements4 7#b7 ,other conforming of rules ,the ,secretary of the ,treasury1 the ,secretary of ,health and ,human ,services1 and the ,secretary of ,labor shall modify such rules as may be necessary to conform to the amendments made by this section4 7d7 ,effective date ,the amendments made by this section shall apply to plan years beginning after ,december #ca1 #bjbe4 #bjac4 ,participants in choice arrangement eligible for purchase of exchange insurance for purchase of cafeteria plan 7a7 ,in general ,section #abe7;f77#c7 is amended by adding at the end the following new subparagraph3 7,c7 ,exception for participants in choice arrangement ,subparagraph 7,a7 shall not apply in the case of an employee participating in a custom health option and individual care expense arrangement 7within the meaning of section #ihae7;b77#b77 offered by the employee's employer4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjbe4 #bjad4 ,employer credit for choice arrangement 7a7 ,in general ,subpart ,d of part ,,iv of subchapter ,a of chapter #a is amended by adding at the end the following new section3 #de;,,bb4 ,employer credit for choice arrangement 7a7 ,in general ,for purposes of section #ch1 in the case of an eligible employer1 the ,,choice arrangement credit determined under this section for any taxable year is an amount1 with respect to each employee enrolled during the credit period in a ,,choice arrangement maintained by the employer1 equal to-- 7#a7 #ajj multiplied by the number of months for which the employee is so enrolled during the first year in the credit period1 and 7#b7 one-half of the dollar amount in effect under paragraph 7#a7 for the taxable year1 multiplied by the number of months for which the employee is so enrolled during the second year of the credit period4 7b7 ,arrangement must constitute minimum essential coverage ,an employee shall not be taken into account under subsection 7a7 unless such employee's eligibility for the ,,choice arrangement 7determined without regard to the employee being enrolled7 would cause the employee to be treated under section #cf;,b7c77#b7 as being eligible for minimum essential coverage consisting of an eligible employer-sponsored plan 7as defined in section #ejjj;,a7f77#b774 7c7 ,definitions ,for purposes of this section-- 7#a7 ,,choice arrangement ,the term ,,choice arrangement means a custom health option and individual care expense arrangement 7as defined in section #ihae7;b77#b77;,b774 7#b7 ,credit period ,the credit period with respect to an eligible employer is the first #b one-year periods beginning with the month during which the employer first establishes a ,,choice arrangement on behalf of employees of the employer4 7#c7 ,eligible employer ,the term eligible employer means1 with respect to any taxable year beginning in a calendar year1 an employer who is not an applicable large employer for the calendar year under section #dihj;,h4 7d7 ,inflation adjustment 7#a7 ,in general ,in the case of any taxable year beginning in a calendar year after #bjbf1 the dollar amount in subsection 7a7 shall be increased by an amount equal to-- 7,a7 such dollar amount1 multiplied by 7,b7 the cost-of-living adjustment determined under section #a7;f77#c7 for the calendar year in which such taxable year begins by substituting calendar year #bjbe for calendar year #bjaf in subparagraph 7,a77ii7 thereof4 7#b7 ,rounding ,if any amount after adjustment under paragraph 7#a7 is not a multiple of #aj1 such amount shall be rounded to the next lower multiple of #aj4 4 7b7 ,credit made part of general business credit ,section #ch7;b7 is amended by striking plus at the end of paragraph 7#dj71 by striking the period at the end of paragraph 7#da7 and inserting 1 plus1 and by adding at the end the following new paragraph3 7#db7 the ,,choice arrangement credit determined under section #de;,,bb7a74 4 7c7 ,credit allowed against alternative minimum tax ,section #ch7;c77#d77;,b7 is amended-- 7#a7 by redesignating clauses 7x71 7xi71 and 7xii7 as clauses 7xi71 7xii71 and 7xiii71 respectively1 and 7#b7 by inserting after clause 7ix7 the following new clause3 7x7 the credit determined under section #de;,,bb1 4 7d7 ,clerical amendment ,the table of sections for subpart ,d of part ,,iv of subchapter ,a of chapter #a is amended by adding at the end the following new item3 7e7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjbe4 ,c ,self-,insurance ,protection ,act #bjba4 ,short title ,this ,act may be cited as the ,self-,insurance ,protection ,act4 #bjbb4 ,findings ,congress finds the following3 7#a7 ,small and large employers offer health benefit plan coverage to employees in self-funded arrangements using company assets or a fund1 or by paying premiums to purchase fully-insured coverage from a health insurance company4 7#b7 ,employers that self-fund health benefit plans will often purchase stop-loss insurance as a financial risk management tool to protect against excess or unexpected catastrophic health plan claims losses that arise above projected costs paid out of company assets4 7#c7 ,stop-loss coverage insures the employer sponsoring the health benefit plan against unforeseen health plan claims1 does not insure the employee health benefit plan itself1 and does not pay health care providers for medical services provided to the employees4 7#d7 ,employer-sponsored health benefit plans are regulated under the ,employee ,retirement ,income ,security ,act of #aigd1 however1 ,states regulate the availability and the coverage terms of stop-loss insurance coverage that employers purchase to protect company assets and to protect a fund against excess or unexpected claims losses4 7#e7 ,both large and small employers that choose to self-fund must also be able to protect company assets or a fund against excess or unexpected claims losses and ,states must reasonably regulate stop-loss insurance to assure its availability to both large and small employers4 #bjbc4 ,certain medical stop-loss insurance obtained by certain plan sponsors of group health plans not included under the definition of health insurance coverage ,section #gcc7;b77#a7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aaia;b7b77#a77 is amended by adding at the end the following sentence3 ,such term shall not include a stop-loss policy obtained by a self-insured group health plan or a plan sponsor of a group health plan that self-insures the health risks of its plan participants to reimburse the plan or sponsor for losses that the plan or sponsor incurs in providing health or medical benefits to such plan participants in excess of a predetermined level set forth in the stop-loss policy obtained by such plan or sponsor44 #bjbd4 ,effect on other laws ,section #ead7;b7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aadd7;b77 is amended by adding at the end the following3 7#aj7 ,the provisions of this title 7including part #g relating to group health plans7 shall preempt ,state laws insofar as they may now or hereafter prevent an employee benefit plan that is a group health plan from insuring against the risk of excess or unexpected health plan claims losses4 4 ,d ,small ,business ,flexibility ,act #bjca4 ,short title ,this ,act may be cited as the ,small ,business ,flexibility ,act4 #bjcb4 ,notification of flexible health insurance benefits 7a7 ,in general ,subchapter ,c of chapter #ajj of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new section3 #ihce4 ,notification of flexible health insurance benefits 7a7 ,in general ,not later than #a year after the date of enactment of this section1 the ,secretary shall notify employers of the availability of tax-advantaged flexible health insurance benefits1 with an initial focus on small businesses1 particularly in rural areas 7as defined in section #acic7;a77#b774 7b7 ,definitions ,in this section3 7#a7 ,employer ,the term employer has the meaning given such term in section #c7e7 of the ,employee ,retirement ,income ,security ,act 7#bi ,u4,s4,c4 #ajjb7e774 7#b7 ,flexible health insurance benefits ,the term flexible health insurance benefits means-- 7,a7 an individual contribution health reimbursement arrangement 7as described in the rule entitled ,health ,reimbursement ,arrangements and ,other ,account-,based ,group ,health ,plans 7#hd ,fed4 ,reg4 #bhhhh 7,june #bj1 #bjai7772 7,b7 a qualified small employer health reimbursement arrangement 7as defined in section #ihca7;d77#b772 and 7,c7 the small employer health insurance credit determined under section #de,r4 4 7b7 ,clerical amendment ,the table of sections for subchapter ,c of chapter #ajj of such ,code is amended by adding at the end the following new item3 ,sec4 #ihce4 ,notification of flexible health insurance benefits 4 ,e ,health ,coverage ,choice ,act #bjda4 ,short title ,this ,act may be cited as the ,health ,coverage ,choice ,act4 #bjdb4 ,definition of short-term limited duration insurance ,section #bgia7;b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ia7;b77 is amended by adding at the end the following new paragraph3 7#f7 ,short-term limited duration insurance ,the term short-term limited duration insurance means health insurance coverage provided under a contract with a health insurance issuer that-- 7,a7 has an expiration date specified in the contract that is less than #ab months after the original effective date of the contract2 and 7,b7 has a duration of not more than #aj years 7taking into account renewals or extensions7 after the original effective date of the contract4 4 ,f ,,impact ,act of #bjbe #bjea4 ,short title ,this ,act may be cited as the ,improved ,medical ,patients ,affordable ,care ,today ,act of #bjbe or the ,,impact ,act of #bjbe4 #bjeb4 ,expanding eligibility for catastrophic plans 7a7 ,in general ,section #acjb7;e77#b7 of the ,patient ,protection and ,affordable ,care ,act 7#db4 ,u4,s4,c4 #ahjbb7;e77#b7 is amended-- 7#a7 in subparagraph 7,b77ii71 by striking the period at the end and inserting 2 or2 and 7#b7 by adding at the end the following new subparagraph3 7,c7 with respect to the plan year involved1 is determined to be ineligible 7or reasonably expects to be ineligible7 for the premium tax credit under section #cf;,b of the ,internal ,revenue ,code of #aihf or for reduced cost-sharing under section #adjb on the basis of the individual's household income for such year4 4 7b7 ,effective date ,the amendments made by this section shall apply with respect to plan years beginning on or after ,january #a1 #bjbf4 ,g ,new ,health ,options ,act #bjfa4 ,short title ,this ,act may be cited as the ,new ,health ,options ,act4 #bjfb4 ,creation of a reinsurance program for a new health insurance risk pool 7a7 ,in general ,part ,v of subtitle ,b of title ,i of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjfa et seq47 is amended by adding at the end the following new section3 #acdd4 ,reinsurance program for certain off-exchange plans 7a7 ,in general ,there is established a ,reinsurance ,program1 to be administered by the ,secretary of ,health and ,human ,services1 to provide payments to health insurance issuers with respect to claims for eligible individuals for the purpose of lowering premiums for such individuals4 7b7 ,funding 7#a7 ,appropriation ,for the purpose of providing funding for the ,reinsurance ,program1 for each year during the period beginning on ,january #a1 #bjbf1 and ending on ,december #ca1 #bjcj1 there is appropriated out of any monies in the ,treasury not otherwise obligated an amount equal to the product of #ej and the aggregate number of member months for all eligible individuals enrolled in a covered plan during such year4 7#b7 ,limitation on appropriation ,in no year shall the appropriation for the ,reinsurance ,program authorized in paragraph 7#a7 exceed #f1jjj1jjj1jjj4 7#c7 ,use of unexpended funds ,appropriated amounts remaining unexpended at the end of any year may be used to make payments under the ,reinsurance ,program in any future year4 7#d7 ,limitation on use of funds ,no funds received under the ,reinsurance ,program may be used to pay for services described in section #acjc7;b77#a77;,b77i7 7as in effect on the date of the enactment of this section74 7c7 ,operation of program 7#a7 ,in general ,the ,secretary shall establish parameters for the operation of the ,reinsurance ,program consistent with this section4 7#b7 ,deadline for initial operation ,not later than #abj days after the date of the enactment1 the ,secretary shall establish sufficient parameters to specify how the ,program will operate for #bjbf4 7#c7 ,definitions ,in this section3 7,a7 ,covered plan ,the term covered plan means individual health insurance coverage 7as such term is defined in section #bgia of the ,public ,health ,service ,act7-- 7i7 with respect to which the issuer of such coverage has made the election described in section #acab7;c77#a77;,a72 and 7ii7 that does not provide coverage for services described in section #acjc7;b77#a77;,b77i7 7as in effect on the date of the enactment of this section74 7,b7 ,eligible individual ,the term eligible individual means an individual enrolled in a covered plan4 7d7 ,attachment dollar amount and payment proportion 7#a7 ,in general ,the ,secretary shall annually establish an attachment point1 payment proportion1 and reinsurance cap with respect to claims for eligible individuals for payments under the ,reinsurance ,program1 consistent with the following3 7,a7 ,the attachment point for the period beginning ,january #a1 #bjbf1 and ending ,december #ca1 #bjbf1 shall be #aaj1jjj4 7,b7 ,the payment proportion for the period beginning ,january #a1 #bjbf1 and ending ,december #ca1 #bjbf1 shall be #ij percent4 7,c7 ,the reinsurance cap for the period beginning ,january #a1 #bjbf and ending ,december #ca1 #bjbf1 shall be #cjj1jjj4 7#b7 ,adjustment authority ,the ,secretary may adjust any amounts described in paragraph 7#a7 as necessary to ensure the ,reinsurance ,program does not make payment for a year in excess of the amount available for such year under subsection 7b74 4 7b7 ,election ,to opt out of single risk pool 7#a7 ,in general ,section #acab7;c77#a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjcb7;c77#a77 is amended-- 7,a7 by striking ,a health insurance issuer and inserting the following3 7,a7 ,in general ,a health insurance issuer 2 7,b7 in subparagraph 7,a71 as inserted by paragraph 7#a71 by inserting and other than any health plan with respect to which such issuer has elected for this subparagraph not to apply after grandfathered health plans2 and 7,c7 by adding at the end the following new subparagraph3 7,b7 ,treatment of plans opting out of single risk pool ,a health insurance issuer shall consider all enrollees in all health plans offered by such issuer in the individual market with respect to which such issuer has made the election described in subparagraph 7,a7 to be members of a single risk pool4 4 7#b7 ,prohibiting single risk pool opt out for qualified health plans ,section #acja7;a77#a77;,c7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjba7;a77#a77 is amended-- 7,a7 in clause 7iii71 by striking and at the end2 7,b7 in clause 7iv71 by striking the period and inserting 2 and2 and 7,c7 by adding at the end the following new clause3 7v7 has not made the election described in section #acab7;c77#a77;,a7 with respect to such plan4 4 7#c7 ,effective date ,the amendments made by this subsection shall apply with respect to plan years beginning on or after ,january #a1 #bjbf4 7c7 ,removing age premium variation limitation for certain plans 7#a7 ,in general 7,a7 ,removal of limitation for certain plans ,section #bgja7;a77#a77;,a77iii7 of the ,public ,health ,service ,act 7#db ,u4,s4,c #cjj;gg7a77#a77;,a77iii77 is amended by inserting or1 in the case of such coverage with respect to which the issuer of such coverage has made the election described in section #acab7;c77#a77;,a7 of the ,patient ,protection and ,affordable ,care ,act1 by more than an actuarially justified amount for adults before 2 and4 7,b7 ,effective date ,the amendment made by subparagraph 7,a7 shall apply with respect to plan years beginning on or after ,january #a1 #bjbf4 7#b7 ,maintaining age premium variation limitation for qualified health plans ,section #acja7;a77#a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjba7;a77#a771 as amended by subsection 7b71 is further amended-- 7,a7 in subparagraph 7,b71 by striking and at the end2 7,b7 in subparagraph 7,c77v71 by striking the period and inserting 2 and2 and 7,c7 by adding at the end the following new subparagraph3 7,d7 with respect to the premium rate charged by such plan1 if such plan varies such rate by age1 does not vary such rate by more than #c to #a for adults 7consistent with section #bgjg7;c7 of the ,public ,health ,service ,act74 4 7d7 ,treatment of opt out plans in relation to individual health coverage reimbursement arrangements ,the ,secretaries of ,health and ,human ,services1 ,labor1 and the ,treasury shall not fail to treat any individual health insurance coverage 7as defined in section #bgia of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ia77 as eligible for integration with an individual health care reimbursement arrangement on the basis that the health insurance issuer 7as so defined7 of such coverage has made the election described in section #acab7;c77#a77;,a7 of the ,patient ,protection and ,affordable ,care ,act 7as inserted by subsection 7b774 #bjfb4 ,promotion of high-value care 7a7 ,in general ,subpart ,,ii of part ,a of title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#aa et seq47 is amended by adding at the end the following new section3 #bgcj4 ,application of certain out-of-network costs to deductibles and out-of-pocket maximums 7a7 ,in general ,a group health plan1 and a health insurance issuer offering group or individual health insurance coverage1 shall1 in the case that an individual enrolled under such plan or coverage is furnished items or services by a health care provider or health care facility that does not have in effect a contractual relationship with such plan or issuer for the furnishing of such items or services and such individual incurs any out-of-pockets costs with respect to such items and services1 at the option of such individual1 apply such costs to any deductible or out-of-pocket maximum applicable to items and services furnished by health care providers or health care facilities with contracts in effect with such plan or issuer for the furnishing of such items or services1 but only if the following requirements are met3 7#a7 ,the item or service furnished by such provider or facility without a contract in effect with such plan or issuer is an item or service for which benefits are available under such plan or coverage4 7#b7 ,the amount charged by such provider or facility for such item or service is equal to or less than-- 7,a7 the lowest amount recognized by the plan or coverage as payment for such item or service out of all health care providers and health care facilities with a contract in effect with such plan or issuer to furnish such item or service in the same rating area 7as defined for purposes of section #bgja7 in which the item or service described in paragraph 7#a7 was furnished2 or 7,b7 the #beth percentile of charges for such item or service furnished in the same ,state in which the item or service described in paragraph 7#a7 was furnished4 7b7 ,disclosure of information ,a group health plan1 and a health insurance issuer offering group or individual health insurance coverage1 shall1 with respect to each item or service for which benefits are available under such plan or coverage1 make available the lowest amount described in subsection 7a77#b77;,a7 and the #beth percentile described in subsection 7a77#b77;,b7 to all individuals enrolled under such plan or coverage4 4 7b7 ,effective date ,the amendment made by subsection 7a7 shall apply to plan years beginning on or after ,january #a1 #bjbf4 #bjfd4 ,disclosure of lower prices ,part ,e of title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#aca7 is amended by adding at the end the following new section3 #bgii;,b-#aj4 ,disclosure of lower prices 7a7 ,in general ,beginning ,january #a1 #bjbf1 each health care provider and health care facility shall disclose to patients and prospective patients enrolled in a group health plan1 group or individual health insurance coverage1 or a ,federal health care program 7as defined in section #aabh;,b but including the program established under chapter #hi of title #e1 ,united ,states ,code7 being furnished or seeking to be furnished an item or service by such provider or facility for which benefits are available under such plan1 coverage1 or program1 as applicable1 whether the amount of cost sharing 7including deductibles1 copayments1 and coinsurance7 that would be incurred by such individual for such item or service under such plan1 coverage1 or program1 as applicable1 exceeds the charge that would apply for such item or service for an individual without benefits under any such plan1 coverage1 or program for such item or service4 7b7 ,additional enforcement ,in addition to any other penalty applicable with respect to a violation of subsection 7a71 an individual who is harmed by a violation of this section by a health care provider or health care facility may bring an action against such provider or facility in an appropriate district court of the ,united ,states for-- 7#a7 appropriate injunctive relief2 and 7#b7 damages in an amount that is equal to the amount provided for such harm in a civil action under the law of the ,state in which the provider or facility is located4 4 ,h ,fighting waste fraud and abuse in the unaffordable care act #bjga4 ,short title ,this ,act may be cited as the ,fighting ,waste ,fraud and ,abuse in the ,unaffordable ,care ,exchanges ,act of #bjbe4 #bjgb4 ,addressing waste1 fraud1 and abuse in the ,,aca exchanges 7a7 ,changes to enrollment periods for enrolling in exchanges ,section #acaa of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjca7 is amended-- 7#a7 in subsection 7c77#f7-- 7,a7 by striking subparagraph 7,a72 7,b7 by striking ,the ,secretary and inserting the following3 7,a7 ,in general ,the ,secretary 2 7,c7 by redesignating subparagraphs 7,b7 through 7,d7 as clauses 7i7 through 7iii7 respectively1 and adjusting the margins accordingly2 7,d7 in clause 7i71 as so redesignated1 by striking periods1 as determined by the ,secretary for calendar years after the initial enrollment period2 and inserting the following3 periods for plans offered in the individual market-- 7,i7 for enrollment for plan years beginning before ,january #a1 #bjbg1 as determined by the ,secretary2 and 7,,ii7 for enrollment for plan years beginning on or after ,january #a1 #bjbg1 beginning on ,november #a1 and ending on ,december #ae of the preceding calendar year2 4 7,e7 in clause 7ii71 as so redesignated1 by inserting subject to subparagraph 7,b71 before special enrollment period specified2 and 7,f7 by adding at the end the following new subparagraph2 7,b7 ,prohibited special enrollment period ,with respect to plans years beginning on or after ,january #a1 #bjbg1 the ,secretary may not require an ,exchange to provide for a special enrollment period for an individual on the basis of the relationship of the income of such individual to the poverty line1 other than a special enrollment period based on a change in circumstances or the occurrence of a specific event4 2 7#b7 in subsection 7d71 by adding at the end the following new paragraphs3 7#h7 ,prohibited enrollment periods ,an exchange may not provide for1 with respect to enrollment for plan years beginning on or after ,january #a1 #bjbg-- 7,a7 an annual open enrollment period other than the period described in subparagraph 7,a77i7 of subsection 7c77#f72 or 7,b7 a special enrollment period described in subparagraph 7,b7 of such subsection4 7#i7 ,verification of eligibility for special enrollment periods 7,a7 ,in general ,with respect to enrollment for plan years beginning on or after ,january #a1 #bjbg1 an ,exchange shall verify that each individual seeking to enroll in a qualified health plan offered by the ,exchange during a special enrollment period selected under paragraph 7,b7 is eligible to enroll during such special enrollment period prior to enrolling such individual in such plan4 7,b7 ,selected special enrollment periods ,for purposes of subparagraph 7,a71 an ,exchange shall select one or more special enrollment periods for a plan year with respect to which such ,exchange shall conduct the verification required under subparagraph 7,a7 such that the ,exchange conducts such verification for not less than #ge percent of all individuals enrolling in a qualified health plan offered by the ,exchange during any special enrollment period with respect to such plan year4 4 7b7 ,verifying income for individuals enrolled in a qualified health plan through an exchange 7#a7 ,in general ,section #adaa7;e77#d7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjha7;e77#d77 is amended-- 7,a7 by redesignating subparagraph 7,c7 as subparagraph 7,e72 and 7,b7 by inserting after subparagraph 7,b7 the following new subparagraphs3 7,c7 ,requiring verification of income and family size when tax data is unavailable ,for plan years beginning on or after ,january #a1 #bjbg1 for purposes of subparagraph 7,a71 in the case that the ,exchange requests data from the ,secretary of the ,treasury regarding an individual's household income and the ,secretary of the ,treasury does not return such data1 such information may not be verified solely on the basis of the attestation of such individual with respect to such household income1 and the ,exchange shall take the actions described in subparagraph 7,a74 7,d7 ,requiring verification of income in the case of certain income discrepancies 7i7 ,in general ,subject to clause 7iii71 for plan years beginning on or after ,january #a1 #bjbg1 for purposes of subparagraph 7,a71 in the case that a specified income discrepancy described in clause 7ii7 of this subparagraph exists with respect to the information provided by an applicant under subsection 7b77#c71 the household income of such individual shall be treated as inconsistent with information in the records maintained by persons under subsection 7c71 or as not verified under subsection 7d71 and the ,exchange shall take the actions described in such subparagraph 7,a74 7ii7 ,specified income discrepancy ,for purposes of clause 7i71 a specified income discrepancy exists with respect to the information provided by an applicant under subsection 7b77#c7 if-- 7,i7 the applicant attests to a projected annual household income that would qualify such applicant to be an applicable taxpayer under section #cf;,b7c77#a77;,a7 of the ,internal ,revenue ,code of #aihf with respect to the taxable year involved2 7,,ii7 the ,exchange receives data from the ,secretary of the ,treasury or other reliable1 third party data1 that indicates that the household income of such applicant is less than the household income that would qualify such applicant to be an applicable taxpayer under such section #cf;,b7c77#a77;,a7 with respect to the taxable year involved2 7,,iii7 such attested projected annual household income exceeds the income reflected in the data described in subclause 7,,ii7 by a reasonable threshold established by the ,exchange and approved by the ,secretary 7which shall be not less than #aj percent1 and may also be a dollar amount72 and 7,,iv7 the ,exchange has not assessed or determined based on the data described in subclause 7,,ii7 that the household income of the applicant meets the applicable income-based eligibility standard for the ,medicaid program under title ,,xix of the ,social ,security ,act or the ,state children's health insurance program under title ,,xxi of such ,act4 7iii7 ,exclusion of certain individuals ineligible for medicaid ,the subparagraph shall not apply in the case of an applicant who is an alien lawfully present in the ,united ,states1 who is not eligible for the ,medicaid program under title ,,xix of the ,social ,security ,act by reason of such alien status4 4 7#b7 ,requiring individuals on whose behalf advance payments of the premium tax credit are made to file and reconcile on an annual basis ,section #adab7;b7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjhb7;b77 is amended by adding at the end the following new paragraph3 7#c7 ,annual requirement to file and reconcile 7,a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbg1 in the case of an individual with respect to whom any advance payment of the premium tax credit allowable under section #cf;,b of the ,internal ,revenue ,code of #aihf was made under this section to the issuers of a qualified health plan for the relevant prior tax year1 an advance determination of eligibility for such premium tax credit may not be made under this subsection with respect to such individual and such plan year if the ,exchange determines1 based on information provided by the ,secretary of the ,treasury1 that such individual-- 7i7 has not filed an income tax return1 as required under section #fjaa and #fjab of such code 7and implementing regulations71 for the relevant prior tax year2 or 7ii7 as necessarily1 has not been reconciled 7in accordance with subsection 7f7 of such section #cf;,b7 the advance payment of the premium tax credit made with respect to such individual for such relevant prior tax year4 7,b7 ,relevant prior tax year ,for purposes of subparagraph 7,a71 the term relevant prior tax year means1 with respect to the advance determination of eligibility made under this subsection with respect to an individual1 the taxable year for which tax return data would be used for purposes of verifying the household income and family size of such individual 7as described in section #adaa7;b77#c77;,a774 7,c7 ,preliminary attestation ,if an individual subject to subparagraph 7,a7 attests that such individual has fulfilled the requirements to file an income tax return for the relevant prior tax year and1 as necessary1 to reconcile the advance payment of the premium tax credit made with respect to such individual for such relevant prior tax year 7as described in clauses 7i7 and 7ii7 of such subparagraph71 the ,secretary may make an initial advance determination of eligibility with respect to such individual and may delay for a reasonable period 7as determined by the ,secretary7 any determination based on information provided by the ,secretary of the ,treasury that such individual has not fulfilled such requirements4 7,d7 ,notice ,if the ,secretary determines that an individual did not meet the requirements described in subparagraph 7,a7 with respect to the relevant prior tax year and notifies the ,exchange of such determination1 the ,exchange shall comply with the notification requirement described in section #aee4cje7;f77#d77;i7 of title #de1 ,code of ,federal ,regulations 7as in effect with respect to plan year #bjbe74 4 7#c7 ,removing automatic extension of period to resolve income inconsistencies ,the ,secretary of ,health and ,human ,services shall revise section #aee4cae7;f7 of title #de1 ,code of ,federal ,regulations1 to remove paragraph 7#g7 of such section1 such that1 with respect to enrollment for plan years beginning on or after ,january #a1 #bjbg1 in the case that an ,exchange established under subtitle ,d of title ,i of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjba et seq47 provides an individual applying for enrollment in a qualified health plan with a #ij-;day period to resolve an inconsistency in the application of such individual pursuant to section #adaa7;e77#d77;,a77ii77,,ii7 of such ,act1 the ,exchange may not provide for an automatic extension to such #ij-;day period on the basis that such individual is required to present satisfactory documentary evidence to verify household income4 7c7 ,revising rules of allowable variation in actuarial value of health plans ,the ,secretary of ,health and ,human ,services shall-- 7#a7 revise section #aef4adj7;c7 of title #de1 ,code of ,federal ,regulations1 to provide that1 for plan years beginning on or after ,january #a1 #bjbg1 the allowable variation in the actuarial value of a health plan applicable under such section shall be the allowable variation for such plan applicable under such section for plan year #bjbb2 7#b7 revise sections #aef4bi7;b77#c7 of title #de1 ,code of ,federal ,regulations1 to provide that1 for plan years beginning on or after ,january #a1 #bjbg1 the requirement for a qualified health plan issuer described in such section is that the issuer ensures that each qualified health plan complies with benefit design standards1 as defined in section #aef4bj of such title2 and 7#c7 revise section #aef4djj of title #de1 ,code of ,federal ,regulations1 to provide that1 for plans years beginning on or after ,january #a1 #bjbg1 the term de minimum variation for a silver plan variation means a minus #a percentage point and plus #a percentage point allowable actuarial value variation4 7d7 ,updating premium adjustment percentage methodology ,section #acjb7;c77#d7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7;c77#d77 is amended-- 7#a7 by striking ,for purposes and inserting3 7,a7 ,in general ,for purposes 2 and 7#b7 by adding at the end the following new subparagraph3 7,b7 ,update to methodology ,for calendar years beginning with #bjbg1 the premium adjustment percentage under this paragraph for such calendar year shall be determined consistent with the methodology published in the ,federal ,register on ,april #be1 #bjai 7#hd ,fed4 ,reg4 #agecg through #ageda74 4 7e7 ,eliminating the fixed-,dollar and gross-,percentage thresholds applicable to exchange enrollments ,the ,secretary of ,health and ,human ,services shall revise section #aee4djj7;g7 of title #de1 ,code of ,federal ,regulations to eliminate1 for plan years beginning on or after ,january #a1 #bjbg1 the gross premium percentage-base premium payment threshold policy described in paragraph 7#b7 of such section and the fixed-dollar premium payment threshold policy described in paragraph 7#c7 of such section4 7f7 ,prohibiting automatic reenrollment from bronze to silver level qualified health plans offered by exchanges ,the ,secretary of ,health and ,human ,services shall revise section #aee4cce7;j7 of title #de1 ,code of ,federal ,regulations1 to remove paragraph 7#d7 of such section that1 with respect to reenrollments for plan years beginning on or after ,january #a1 #bjbg1 an ,exchange established under subtitle ,d of title ,i of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjba et seq47 may not reenroll an individual who was enrolled in a bronze level qualified health plan in a silver level qualified health plan 7as such terms are defined in section #acja7;a7 and described in #acjb7;d7 of such ,act7 unless otherwise permitted under section #aee4cce7;j7 of title #de1 ,code of ,federal ,regulations1 as in effect on the day before the date of the enactment of this section4 7g7 ,reducing advance payments of premium tax credits for certain individuals reenrolled in exchanges ,section #adab of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjhb7 is amended-- 7#a7 in subsection 7a77#c71 by inserting 1 subject to subsection 7c77#b77;,c71 after qualified health plans2 and 7#b7 in subsection 7c77#b7-- 7,a7 in subparagraph 7,a71 by striking ,the and inserting ,subject to subparagraph 7,c71 the2 and 7,b7 by adding at the end the following subparagraph3 7,c7 ,reduction in advance payment for specified reenrolled individuals 7i7 ,in general ,the amount of an advance payment made under subparagraph 7,a7 to reduce the premium payable for a qualified health plan that provides coverage to a specific reenrolled individual for an applicable month shall be an amount equal to the amount that would otherwise be made under such subparagraph reduced by #e 7or such higher amount as the ,secretary determines appropriate74 7ii7 ,definitions ,in this subparagraph3 7,i7 ,applicable month ,the term applicable month means1 with respect to a specified reenrolled individual1 any month during a plan year beginning on or after ,january #a1 #bjbg 7or1 in the case of an individual reenrolled in a qualified health plan by an ,exchange established pursuant to section #acba7;c71 ,january #a1 #bjbg7 if1 prior to the first day of such month1 such individual has failed to confirm or update such information as is necessary to redetermine the eligibility of such individual for such plan year pursuant to section #adaa7;f74 7,,ii7 ,specified reenrolled individual ,the term specified reenrolled individual means an individual who is reenrolled in a qualified health plan and with respect to whom the advance payment made under subparagraph 7,a7 would1 without application of any reduction under this subparagraph1 reduce the premium payable for a qualified health plan that provides coverage to such an individual to #j4 4 7h7 ,prohibiting coverage of gender transition procedures as an essential health benefit under plans offered by exchanges 7#a7 ,in general ,section #acjb7;b77#b7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7;b77#b77 is amended by adding at the end the following new subparagraph3 7,c7 ,gender transition procedures ,for plan years beginning on or after ,january #a1 #bjbg1 the essential health benefits defined pursuant to paragraph 7#a7 may not include items and services furnished for a gender transition procedure4 4 7#b7 ,gender transition procedure defined ,section #acjd of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbd7 is amended by adding at the end the following new subsection3 7f7 ,gender transition procedure 7#a7 ,in general ,in this title1 except as provided in paragraph 7#b71 the term gender transition procedure means1 with respect to an individual1 any of the following when performed for this purpose of intentionally changing the body of such individual 7including by disrupting the body's development1 inhibiting its natural functions1 or modifying its appearance7 to no longer correspond to the individuals sex3 7,a7 ,performing any surgery1 including-- 7i7 castration2 7ii7 sterilization2 7iii7 orchiectomy2 7iv7 scrotoplasty2 7v7 vasectomy2 7vi7 tubal ligation2 7vii7 hysterectomy2 7viii7 oophorectomy2 7ix7 ovariectomy2 7x7 metoidioplasty2 7xi7 clitoroplasty2 7xii7 reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty2 7xiii7 penectomy2 7xiv7 phalloplasty2 7xv7 vaginoplasty2 7xvi7 vaginectomy2 7xvii7 vulvoplasty2 7xviii7 reduction thyrochondroplasty2 7xix7 chrondrolaryngoplasty2 7xx7 mastectomy2 and 7xxi7 any plastic1 cosmetic1 or aesthetic surgery that feminizes or masculinizes the facial or other body features of an individual4 7,b7 ,any placement of chest implants to create feminine breasts or any placement of erection or testicular prostheses4 7,c7 ,any placement of fat or artificial implants in the gluteal region4 7,d7 ,administering1 prescribing1 or dispensing to an individual medications1 including-- 7i7 gonadotropin-releasing hormone 7,gn,r,h7 analogues or other puberty-blocking drugs to stop or delay normal puberty2 and 7ii7 testosterone1 estrogen1 or other androgens to an individual at doses that are superphysiologic than would normally be produced endogenously in a health individual of the same age and sex4 7#b7 ,exception ,paragraph 7#a7 shall not apply to the following3 7,a7 ,puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for an individual experiencing precocious puberty4 7,b7 ,medically necessary procedures or treatments to correct for-- 7i7 a medically verifiable disorder of sex development1 including-- 7,i7 #df1 ,,xx chromosomes with virilization2 7,,ii7 #df1 ,,xy chromosomes with undervirilization2 and 7,,iii7 both ovarian and testicular tissue2 7ii7 sex chromosome structure1 sex steroid hormone production1 or sex hormone action1 if determined to be abnormal by a physician through genetic or biochemical testing2 7iii7 infection1 disease1 injury1 or disorder caused or exacerbated by a previous procedure described in paragraph 7#a71 or a physical disorder1 physical injury1 or physical illness that would1 as certified by a physician1 place the individual in imminent danger of death or impairment of a major bodily function unless the procedure is performed1 not including procedures performed for the alleviation of mental distress2 or 7iv7 procedures to restore or reconstruct the body of the individual in order to correspond to the individual's sex after one or more previous procedures described in paragraph 7#a71 which may include the removal of a pseudo phallus or breast augmentation4 7#c7 ,sex ,for purposes of this subsection1 the term sex means either male or female1 as biologically determined and defined by subparagraph 7,a7 and subparagraph 7,b74 7,a7 ,female ,the term female means an individual who naturally has1 had1 will have1 or would have1 but for a developmental or genetic anomaly or historical accident1 the reproductive systems that at some point produces1 transports1 and utilizes eggs for fertilization4 7,b7 ,male ,the term male means an individual who naturally has1 had1 will have1 or would have1 but for a developmental or genetic anomaly or historical accident1 the reproductive system that at some point produces1 transports1 and utilizes sperm for fertilization4 4 7i7 ,ensuring appropriate application of guaranteed issue requirements in case of non-,payment of past premiums 7#a7 ,in general ,section #bgjb of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#a7 is amended by adding at the end the following new subsection3 7e7 ,nonpayment of past premiums 7#a7 ,in general ,a health insurance issuer offering individual health coverage may1 to the extent allowed under ,state law1 deny such coverage in the case of an individual who owes any amount for premiums for individual health insurance coverage offered by such issuer 7or by a health insurance issuer in the same controlled group 7as defined in paragraph 7#c77 as such issuer7 in which such individual was previously enrolled4 7#b7 ,attribution of initial premium payment owed amount ,a health insurance issued offering individual health insurance coverage may1 in the case of an individual described in paragraph 7#a7 and to the extent allowed under ,state law1 attribute the initial premium payment for such coverage applicable to such individual to the amount owed by such individual for premiums for individual health insurance coverage offered by such issuer 7or by a health insurance issuer in the same controlled group as the issuer7 in which such individual was previously enrolled4 7#c7 ,controlled group defined ,for purposes of this subsection1 the term controlled group means a group of two or more persons that is treated as a single employed under section #eb7;a71 #eb7;b71 #dad7m71 or #dad7o7 of the ,internal ,revenue ,code of #aihf4 4 7#b7 ,effective date ,the amendment made by paragraph 7#a7 shall apply with respect to plan years beginning on or after ,january #a1 #bjbg4 #bjgc4 ,funding cost-sharing reduction payments ,section #adjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjga7 is amended by adding at the end the following new subsection3 7h7 ,funding 7#a7 ,in general ,there are appropriated out of any monies in the ,treasury not otherwise appropriated such sums as may be necessary for purposes of making payments under this section for plan years beginning on or after ,january #a1 #bjbg4 7#b7 ,limitation 7,a7 ,in general ,the amounts appropriated under paragraph 7#a7 may not be used for purposes of making payments under this section for a qualified health plan that provides health benefit coverage that includes coverage of abortion4 7,b7 ,exception ,subparagraph 7,a7 shall not apply to payments for a qualified health plan that provides coverage of abortion only if necessary to save the life of the mother or if the pregnancy is a result of an act of rape or incest4 4 ,,iii ,ending taxpayer funding for abortion and gender transition procedures ,a ,no taxpayer funding for abortion and abortion insurance full disclosure act of #bjbe #cjjj4 ,applicability to entire act 7a7 ,notwithstanding any other provision of law1 the prohibitions and limitations set forth in this title1 including the amendments made by this title1 shall apply to all funds authorized or appropriated under this ,act1 including under title ,i1 title ,,ii1 and every subtitle thereof1 and to any trust fund to which such funds are contributed4 7b7 ,effective date ,this section shall take effect on the date of the enactment of this ,act4 #cjja4 ,short title ,this ,act may be cited as the ,no ,taxpayer ,funding for ,abortion and ,abortion ,insurance ,full ,disclosure ,act of #bjbe4 #cjjb4 ,prohibiting taxpayer funded abortions ,title #a1 ,united ,states ,code1 is amended by adding at the end the following new chapter3 #d ,prohibiting taxpayer funded abortions #cja4 ,prohibition on funding for abortions ,no funds authorized or appropriated by ,federal law1 and none of the funds in any trust fund to which funds are authorized or appropriated by ,federal law1 shall be expended for any abortion4 #cjb4 ,prohibition on funding for health benefits plans that cover abortion ,none of the funds authorized or appropriated by ,federal law1 and none of the funds in any trust fund to which funds are authorized or appropriated by ,federal law1 shall be expended for health benefits coverage that includes coverage of abortion4 #cjc4 ,limitation on federal facilities and employees ,no health care service furnished-- 7#a7 by or in a health care facility owned or operated by the ,federal ,government2 or 7#b7 by any physician or other individual employed by the ,federal ,government to provide health care services within the scope of the physician's or individual's employment1 may include abortion4 #cjd4 ,construction relating to separate coverage ,nothing in this chapter shall be construed as prohibiting any individual1 entity1 or ,state or locality from purchasing separate abortion coverage or health benefits coverage that includes abortion so long as such coverage is paid for entirely using only funds not authorized or appropriated by ,federal law and such coverage shall not be purchased using matching funds required for a federally subsidized program1 including a ,state's or locality's contribution of ,medicaid matching funds4 #cje4 ,construction relating to the use of non-federal funds for health coverage ,nothing in this chapter shall be construed as restricting the ability of any non-,federal health benefits coverage provider from offering abortion coverage1 or the ability of a ,state or locality to contract separately with such a provider for such coverage1 so long as only funds not authorized or appropriated by ,federal law are used and such coverage shall not be purchased using matching funds required for a federally subsidized program1 including a ,state's or locality's contribution of ,medicaid matching funds4 #cjf4 ,non-preemption of other federal laws ,nothing in this chapter shall repeal1 amend1 or have any effect on any other ,federal law to the extent such law imposes any limitation on the use of funds for abortion or for health benefits coverage that includes coverage of abortion1 beyond the limitations set forth in this chapter4 #cjg4 ,construction relating to complications arising from abortion ,nothing in this chapter shall be construed to apply to the treatment of any infection1 injury1 disease1 or disorder that has been caused by or exacerbated by the performance of an abortion4 ,this rule of construction shall be applicable without regard to whether the abortion was performed in accord with ,federal or ,state law1 and without regard to whether funding for the abortion is permissible under section #cjh4 #cjh4 ,treatment of abortions related to rape1 incest1 or preserving the life of the mother ,the limitations established in sections #cja1 #cjb1 and #cjc shall not apply to an abortion-- 7#a7 if the pregnancy is the result of an act of rape or incest2 or 7#b7 in the case where a woman suffers from a physical disorder1 physical injury1 or physical illness that would1 as certified by a physician1 place the woman in danger of death unless an abortion is performed1 including a life-endangering physical condition caused by or arising from the pregnancy itself4 #cji4 ,application to district of columbia ,in this chapter3 7#a7 ,any reference to funds appropriated by ,federal law shall be treated as including any amounts within the budget of the ,district of ,columbia that have been approved by an ,act of ,congress pursuant to section #ddf of the ,district of ,columbia ,home ,rule ,act 7or any applicable successor ,federal law74 7#b7 ,the term ,federal ,government includes the ,government of the ,district of ,columbia4 4 #cjjc4 ,amendment to table of chapters ,the table of chapters for title #a1 ,united ,states ,code1 is amended by adding at the end the following new item3 #d,prohibiting taxpayer funded abortions #cja 4 #cjjd4 ,clarifying application of prohibition to premium credits and cost-sharing reductions under aca 7a7 ,in general 7#a7 ,disallowance of refundable credit and cost-sharing reductions for coverage under qualified health plan which provides coverage for abortion 7,a7 ,in general ,subparagraph 7,a7 of section #cf;,b7c77#c7 of the ,internal ,revenue ,code of #aihf is amended by inserting before the period at the end the following3 or any health plan that includes coverage for abortions 7other than any abortion or treatment described in section #cjg or #cjh of title #a1 ,united ,states ,code74 7,b7 ,option to purchase or offer separate coverage or plan ,paragraph 7#c7 of section #cf;,b7c7 of such ,code is amended by adding at the end the following new subparagraph3 7,c7 ,separate abortion coverage or plan allowed 7i7 ,option to purchase separate coverage or plan ,nothing in subparagraph 7,a7 shall be construed as prohibiting any individual from purchasing separate coverage for abortions described in such subparagraph1 or a health plan that includes such abortions1 so long as no credit is allowed under this section with respect to the premiums for such coverage or plan4 7ii7 ,option to offer coverage or plan ,nothing in subparagraph 7,a7 shall restrict any non-,federal health insurance issuer offering a health plan from offering separate coverage for abortions described in such subparagraph1 or a plan that includes such abortions1 so long as premiums for such separate coverage or plan are not paid for with any amount attributable to the credit allowed under this section 7or the amount of any advance payment of the credit under section #adab of the ,patient ,protection and ,affordable ,care ,act74 4 7#b7 ,disallowance of small employer health insurance expense credit for plan which includes coverage for abortion ,subsection 7h7 of section #de,r of the ,internal ,revenue ,code of #aihf is amended-- 7,a7 by striking ,any term and inserting the following3 7#a7 ,in general ,any term 2 and 7,b7 by adding at the end the following new paragraph3 7#b7 ,exclusion of health plans including coverage for abortion 7,a7 ,in general ,the term qualified health plan does not include any health plan that includes coverage for abortions 7other than any abortion or treatment described in section #cjg or #cjh of title #a1 ,united ,states ,code74 7,b7 ,separate abortion coverage or plan allowed 7i7 ,option to purchase separate coverage or plan ,nothing in subparagraph 7,a7 shall be construed as prohibiting any employer from purchasing for its employees separate coverage for abortions described in such subparagraph1 or a health plan that includes such abortions1 so long as no credit is allowed under this section with respect to the employer contributions for such coverage or plan4 7ii7 ,option to offer coverage or plan ,nothing in subparagraph 7,a7 shall restrict any non-,federal health insurance issuer offering a health plan from offering separate coverage for abortions described in such subparagraph1 or a plan that includes such abortions1 so long as such separate coverage or plan is not paid for with any employer contribution eligible for the credit allowed under this section4 4 7#c7 ,conforming aca amendments ,section #acjc7;b7 of ,public ,law #aaa-adh 7#db ,u4,s4,c4 #ahjbc7;b77 is amended-- 7,a7 by striking paragraph 7#b72 7,b7 by striking paragraph 7#c71 as amended by section #bjb7;a72 and 7,c7 by redesignating paragraph 7#d7 as paragraph 7#b74 7b7 ,application to multi-,state plans ,paragraph 7#f7 of section #accd7;a7 of ,public ,law #aaa-adh 7#db ,u4,s4,c4 #ahjed7;a77 is amended to read as follows3 7#f7 ,coverage consistent with federal abortion policy ,in entering into contracts under this subsection1 the ,director shall ensure that no multi-,state qualified health plan offered in an ,exchange provides health benefits coverage for which the expenditure of ,federal funds is prohibited under chapter #d of title #a1 ,united ,states ,code4 4 7c7 ,effective date ,the amendments made by subsection 7a7 shall apply to taxable years ending after ,december #ca1 #bjbe1 but only with respect to plan years beginning after such date1 and the amendment made by subsection 7b7 shall apply to plan years beginning after such date4 #cjje4 ,revision to notice requirements regarding disclosure of extent of health plan coverage of abortion and abortion premium surcharges 7a7 ,in general ,paragraph 7#c7 of section #acjc7;b7 of ,public ,law #aaa-adh 7#db ,u4,s4,c4 #ahjbc7;b77 is amended to read as follows3 7#c7 ,rules relating to notice 7,a7 ,in general ,the extent of coverage 7if any7 of services described in paragraph 7#a77;,b77i7 or 7#a77;,b77ii7 by a qualified health plan shall be disclosed to enrollees at the time of enrollment in the plan and shall be prominently displayed in any marketing or advertising materials1 comparison tools1 or summary of benefits and coverage explanation made available with respect to such plan by the issuer of the plan1 by an ,exchange1 or by the ,secretary1 including information made available through an internet portal or ,exchange under sections #acaa7;c77#e7 and #acaa7;d77#d77;,c74 7,b7 ,separate disclosure of abortion surcharges ,in the case of a qualified health plan that includes the services described in paragraph 7#a77;,b77i7 and where the premium for the plan is disclosed1 including in any marketing or advertising materials or any other information referred to in subparagraph 7,a71 the surcharge described in paragraph 7#b77;,b77i77,,ii7 that is attributable to such services shall also be disclosed and identified separately4 4 7b7 ,effective date ,the amendment made by subsection 7a7 shall apply to materials1 tools1 or other information made available more than #cj days after the date of the enactment of this ,act4 ,b ,prohibiting ,federal funding for gender transition procedures #cjjf4 ,short title ,this ,act may be cited as the ,end ,taxpayer ,funding of ,gender ,experimentation ,act of #bjbe #cjjg4 ,prohibiting federal funding for gender transition procedures 7a7 ,definition ,in this section1 the term ,specified sex-trait modification procedure means any pharmaceutical or surgical intervention that is provided for the purpose of attempting to align an individual's physical appearance or body with an asserted identity that differs from the individual's sex either by3 7#a7 ,intentionally disrupting or suppressing the normal development of natural biological functions1 including primary or secondary sex-based traits2 or 7#b7 ,intentionally altering an individual's physical appearance or body1 including amputating1 minimizing or destroying primary or secondary sex-based traits such as the sexual and reproductive organs4 7#c7 ,this term does not include procedures undertaken3 7,a7 ,to treat a person with a medically verifiable disorder of sexual development2 or 7,b7 ,for purposes other than attempting to align an individual's physical appearance or body with an asserted identity that differs from the individual's sex4 7b7 ,general prohibition ,notwithstanding any other provision of law1 no ,federal funds 7including funds provided through grants1 contracts1 insurance1 or any other means7 may be used to pay for1 reimburse1 or otherwise support any specified sex-trait modification procedure4 7c7 ,effective date ,the amendments made by this section shall take effect on the date of the enactment of this ,act and shall apply to payments1 reimbursements1 and services provided on or after such date4