,,ii #aaith ,,congress #ast ,session ,s4 #cbfd ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,november #bj1 #bjbe,mr4 ,scott of ,florida introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to establish a health freedom waiver program1 to promote better price reporting and outcomes1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,more ,affordable ,care ,act4 #b4 ,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 at the end 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 waive 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 sections #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 ,account of each eligible resident of a ,state for which a waiver is in effect for a plan 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 #accb 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 process 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 ,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 this 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 yet 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 #bgjh1 #bgaa1 #bgab1 and #bgah of such ,act4 4 #c4 ,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 ,health insurance may be purchased from account ,subsection 7d77#b77;,b7 shall not apply4 7#f7 ,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 rules of subsection 7f77#e74 7#g7 ,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 savings account other than a ,trump ,health ,freedom ,account4 7#h7 ,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 procedures1 or 7ii7 abortion services2 or 7,b7 to pay for any service described in clause 7i7 or 7ii7 of subparagraph 7,a74 7#i7 ,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,gn,r,h7 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 supraphysiologic 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 ambiguous1 such as an individual born with #df ,,xx chromosomes with virilization1 an individual born with #df ,,xy chromosomes with undervirilization1 or an individual born having both ovarian and testicular tissue4 7,,ii7 ,services 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 sex1 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 historical 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 7,f7 ,abortion services 7i7 ,in general ,the term abortion services means-- 7,i7 drugs or procedures used with the primary intent to end the life of the human being in the womb1 7,,ii7 pre-viable delivery not described in clause 7ii71 and 7,,iii7 post-viable delivery with intentional death of the fetus4 7ii7 ,exclusions ,such term does not include-- 7,i7 separation of the mother and her embryo or fetus to prevent the mother's death or immediate irreversible bodily harm1 which cannot be mitigated in any other way1 7,,ii7 treatment of ectopic or molar pregnancy1 7,,iii7 treatment of miscarriage1 or 7,,iv7 any service described in clause 7i7 in the case of a pregnancy which is the result of an act of rape or incest4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjbe4 #d4 ,credit for employee insurance expenses of small employers in waiver ,state 7a7 ,in general ,subsection 7g7 of section #de,r of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7g7 ,credit for small employers in waiver ,state ,for purposes of this section-- 7#a7 ,in general ,in the case of an eligible small employer 7determined with the modifications provided in this subsection7 located in a ,state for which a waiver under section #acce of the ,patient ,protection and ,affordable ,care ,act is in effect1 this section shall be applied as provided in paragraphs 7#b7 through 7#g74 7#b7 ,health insurance credit amount ,subsection 7b7 shall be applied by substituting #ej percent for #ej percent 7#ce percent in the case of a tax-exempt eligible small employer74 7#c7 ,qualified plans ,subsections 7b7 and 7d77#d7 shall be applied by treating any health plan authorized to be made available on an ,exchange in such ,state by section #acce7;d7 of such ,act as a qualified health plan offered through an ,exchange4 7#d7 ,phaseout not to apply ,subsection 7c7 shall not apply4 7#e7 ,eligible small employer ,subsection 7d7 shall be applied-- 7,a7 by substituting #ej for #be in paragraph 7#a77;,a7 thereof1 and 7,b7 without regard to subparagraph 7,b7 of paragraph 7#a7 thereof4 7#f7 ,employee ,subsection 7e77#a77;,a7 shall be applied without regard to clause 7i7 thereof4 7#g7 ,credit period ,subsection 7e77#b7 shall not apply1 and the credit period with respect to any such employer shall be the period consisting of the #ast taxable year in which the employer 7or any predecessor7 offers #a or more qualified health plans to its employees1 and any subsequent taxable year4 7#h7 ,tax-exempt rules not to apply ,subsection 7f7 shall not apply4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjbe4 #e4 ,promoting better price reporting and outcomes data ,not later than #ij days after the date of enactment of this ,act1 the ,secretary of ,health and ,human ,services1 in coordination with the ,secretary of the ,treasury and the ,secretary of ,labor1 shall update all regulations and guidance issued by such secretaries pursuant to ,executive ,order #achgg 7#hd ,fed4 ,reg4 #cjhdi 7,june #bd1 #bjai771 including by-- 7#a7 requiring the disclosure of the actual prices of items and services1 not price estimates2 7#b7 issuing updated guidance or regulations ensuring pricing information is standardized and easily comparable across hospitals and health plans2 7#c7 issuing guidance or proposed regulatory action updating enforcement policies designed to ensure compliance with the transparent reporting of complete1 accurate1 and meaningful data2 and 7#d7 requiring the public reporting of outcomes data by providers4