Keeping Health Insurance Affordable Act of 2019

II 116TH CONGRESS 1ST SESSION S. 3 To bring stability to the individual insurance market, make insurance coverage more affordable, lower prescription drug prices, and improve Medicaid. IN THE SENATE OF THE UNITED STATES JANUARY 3, 2019 Mr. CARDIN introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To bring stability to the individual insurance market, make insurance coverage more affordable, lower prescription drug prices, and improve Medicaid. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 3 (a) SHORT TITLE.—This Act may be cited as the 4 ‘‘Keeping Health Insurance Affordable Act of 2019’’. 5 (b) TABLE OF CONTENTS.—The table of contents for 6 this Act is as follows: 7 Sec. 1. Short title; table of contents. TITLE I—MARKETPLACE STABILITY AND SECURITY Sec. 101. Public health insurance option. VerDate Sep 11 2014 01:22 Jan 04, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6211 E:\BILLS\S3.IS S3 kjohnson on DSK79L0C42 with BILLS 2 •S 3 IS TITLE II—HEALTH CARE FINANCIAL ASSISTANCE Sec. 201. Increase in eligibility for premium assistance tax credits. TITLE III—DRUG PRICING Sec. 301. Requiring drug manufacturers to provide drug rebates for drugs dis- pensed to low-income individuals. Sec. 302. Negotiation of prices for Medicare prescription drugs. Sec. 303. Guaranteed prescription drug benefits. Sec. 304. Full reimbursement for qualified retiree prescription drug plans. TITLE I—MARKETPLACE 1 STABILITY AND SECURITY 2 SEC. 101. PUBLIC HEALTH INSURANCE OPTION. 3 (a) IN GENERAL.—Part 3 of subtitle D of title I of 4 the Patient Protection and Affordable Care Act (Public 5 Law 111–148) is amended by adding at the end the fol- 6 lowing new section: 7 ‘‘SEC. 1325. PUBLIC HEALTH INSURANCE OPTION. 8 ‘‘(a) ESTABLISHMENT AND ADMINISTRATION OF A 9 PUBLIC HEALTH INSURANCE OPTION.— 10 ‘‘(1) ESTABLISHMENT.—For years beginning 11 with 2020, the Secretary of Health and Human 12 Services (in this section referred to as the ‘Sec- 13 retary’) shall provide for the offering through Ex- 14 changes established under this title of a health bene- 15 fits plan (in this Act referred to as the ‘public health 16 insurance option’) that ensures choice, competition, 17 and stability of affordable, high-quality coverage 18 throughout the United States in accordance with 19 this section. In designing the option, the Secretary’s 20 VerDate Sep 11 2014 01:22 Jan 04, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S3.IS S3 kjohnson on DSK79L0C42 with BILLS 3 •S 3 IS primary responsibility is to create a low-cost plan 1 without compromising quality or access to care. 2 ‘‘(2) OFFERING THROUGH EXCHANGES.— 3 ‘‘(A) EXCLUSIVE TO EXCHANGES.—The 4 public health insurance option shall be made 5 available only through Exchanges established 6 under this title. 7 ‘‘(B) ENSURING A LEVEL PLAYING 8 FIELD.—Consistent with this section, the public 9 health insurance option shall comply with re- 10 quirements that are applicable under this title 11 to health benefits plans offered through such 12 Exchanges, including requirements related to 13 benefits, benefit levels, provider networks, no- 14 tices, consumer protections, and cost sharing. 15 ‘‘(C) PROVISION OF BENEFIT LEVELS.— 16 The public health insurance option— 17 ‘‘(i) shall offer bronze, silver, and gold 18 plans; and 19 ‘‘(ii) may offer platinum plans. 20 ‘‘(3) ADMINISTRATIVE CONTRACTING.—The 21 Secretary may enter into contracts for the purpose 22 of performing administrative functions (including 23 functions described in subsection (a)(4) of section 24 1874A of the Social Security Act) with respect to 25 VerDate Sep 11 2014 01:22 Jan 04, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S3.IS S3 kjohnson on DSK79L0C42 with BILLS 4 •S 3 IS the public health insurance option in the same man- 1 ner as the Secretary may enter into contracts under 2 subsection (a)(1) of such section. The Secretary has 3 the same authority with respect to the public health 4 insurance option as the Secretary has under sub- 5 sections (a)(1) and (b) of section 1874A of the So- 6 cial Security Act with respect to title XVIII of such 7 Act. Contracts under this subsection shall not in- 8 volve the transfer of insurance risk to such entity. 9 ‘‘(4) OMBUDSMAN.—The Secretary shall estab- 10 lish an office of the ombudsman for the public 11 health insurance option which shall have duties with 12 respect to the public health insurance option similar 13 to the duties of the Medicare Beneficiary Ombuds- 14 man under section 1808(c)(2) of the Social Security 15 Act. In addition, such office shall work with States 16 to ensure that information and notice is provided 17 that the public health insurance option is one of the 18 health plans available through an Exchange. 19 ‘‘(5) DATA COLLECTION.—The Secretary shall 20 collect such data as may be required to establish 21 premiums and payment rates for the public health 22 insurance option and for other purposes under this 23 section, including to improve quality and to reduce 24 VerDate Sep 11 2014 01:22 Jan 04, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S3.IS S3 kjohnson on DSK79L0C42 with BILLS 5 •S 3 IS racial, ethnic, and other disparities in health and 1 health care. 2 ‘‘(6) ACCESS TO FEDERAL COURTS.—The provi- 3 sions of Medicare (and related provisions of title II 4 of the Social Security Act) relating to access of 5 Medicare beneficiaries to Federal courts for the en- 6 forcement of rights under Medicare, including with 7 respect to amounts in controversy, shall apply to the 8 public health insurance option and individuals en- 9 rolled under such option under this title in the same 10 manner as such provisions apply to Medicare and 11 Medicare beneficiaries. 12 ‘‘(b) PREMIUMS AND FINANCING.— 13 ‘‘(1) ESTABLISHMENT OF PREMIUMS.— 14 ‘‘(A) IN GENERAL.—The Secretary shall 15 establish geographically adjusted premium rates 16 for the public health insurance option— 17 ‘‘(i) in a manner that complies with 18 the premium rules under paragraph (3); 19 and 20 ‘‘(ii) at a level sufficient to fully fi- 21 nance the costs of— 22 ‘‘(I) health benefits provided by 23 the public health insurance option; 24 and 25 VerDate Sep 11 2014 01:22 Jan 04, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S3.IS S3 kjohnson on DSK79L0C42 with BILLS 6 •S 3 IS ‘‘(II) administrative costs related 1 to operating the public health insur- 2 ance option. 3 ‘‘(B) CONTINGENCY MARGIN.—In estab- 4 lishing premium rates under subparagraph (A), 5 the Secretary shall include an appropriate 6 amount for a contingency margin. 7 ‘‘(2) ACCOUNT.— 8 ‘‘(A) ESTABLISHMENT.—There is estab- 9 lished in the Treasury of the United States an 10 account for the receipts and disbursements at- 11 tributable to the operation of the public health 12 insurance option, including the start-up funding 13 under subparagraph (B). Section 1854(g) of 14 the Social Security Act shall apply to receipts 15 described in the previous sentence in the same 16 manner as such section applies to payments or 17 premiums described in such section. 18 ‘‘(B) START-UP FUNDING.— 19 ‘‘(i) IN GENERAL.—In order to pro- 20 vide for the establishment of the public 21 health insurance option there is hereby ap- 22 propriated to the Secretary, out of any 23 funds in the Treasury not otherwise appro- 24 priated, $2,000,000,000. In order to pro- 25 VerDate Sep 11 2014 01:22 Jan 04, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S3.IS S3 kjohnson on DSK79L0C42 with BILLS 7 •S 3 IS vide for initial claims reserves before the 1 collection of premiums, there is hereby ap- 2 propriated to the Secretary, out of any 3 funds in the Treasury not otherwise appro- 4 priated, such sums as necessary to cover 5 90 days worth of claims reserves based on 6 projected enrollment. 7 ‘‘(ii) AMORTIZATION OF START-UP 8 FUNDING.—The Secretary shall provide for 9 the repayment of the startup funding pro- 10 vided under clause (i) to the Treasury in 11 an amortized manner over the 10-year pe- 12 riod beginning with 2020. 13 ‘‘(iii) LIMITATION ON FUNDING.— 14 Nothing in this subsection shall be con- 15 strued as authorizing any additional appro- 16 priations to the account, other than such 17 amounts as are otherwise provided with re- 18 spect to other health benefits plans partici- 19 pating under the Exchange involved. 20 ‘‘(3) INSURANCE RATING RULES.—The pre- 21 mium rate charged for the public health insurance 22 option may not vary except as provided under sec- 23 tion 2701 of the Public Health Service Act. 24 ‘‘(c) PAYMENT RATES FOR ITEMS AND SERVICES.— 25 VerDate Sep 11 2014 01:22 Jan 04, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S3.IS S3 kjohnson on DSK79L0C42 with BILLS 8 •S 3 IS ‘‘(1) RATES ESTABLISHED BY SECRETARY.— 1 ‘‘(A) IN GENERAL.—The Secretary shall 2 establish payment rates for the public health in- 3 surance option for services and health care pro- 4 viders consistent with this subsection and may 5 change such payment rates in accordance with 6 subsection (d). 7 ‘‘(B) INITIAL PAYMENT RULES.— 8 ‘‘(i) IN GENERAL.—During 2020, 9 2021, and 2022, the Secretary shall set 10 the payment rates under this subsection 11 for services and providers described in sub- 12 paragraph (A) equal to the payment rates 13 for equivalent services and providers under 14 parts A and B of Medicare, subject to 15 clause (ii), paragraph (4), and subsection 16 (d). 17 ‘‘(ii) EXCEPTIONS.—The Secretary 18 may determine the extent to which Medi- 19 care adjustments applicable to base pay- 20 ment rates under parts A and B of Medi- 21 care for graduate medical education and 22 disproportionate share hospitals shall apply 23 under this section. 24 VerDate Sep 11 2014 01:22 Jan 04, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S3.IS S3 kjohnson on DSK79L0C42 with BILLS 9 •S 3 IS ‘‘(C) FOR NEW SERVICES.—The Secretary 1 shall modify payment rates described in sub- 2 paragraph (B) in order to accommodate pay- 3 ments for services, such as well-child visits, that 4 are not otherwise covered under Medicare. 5 ‘‘(D) PRESCRIPTION DRUGS.—Payment 6 rates under this subsection for prescription 7 drugs that are not paid for under part A or 8 part B of Medicare shall be at rates negotiated 9 by the Secretary. 10 ‘‘(2) SUBSEQUENT PERIODS; PROVIDER NET- 11 WORK.— 12 ‘‘(A) SUBSEQUENT PERIODS.—Beginning 13 with 2023 and for subsequent years, the Sec- 14 retary shall continue to use an administrative 15 process to set such rates in order to promote 16 payment accuracy, to ensure adequate bene- 17 ficiary access to providers, and to promote af- 18 fordability and the efficient delivery of medical 19 care consistent with subsection (a)(1). Such 20 rates shall not be set at levels expected to in- 21 crease average medical costs per enrollee cov- 22 ered under the public health insurance option 23 beyond what would be expected if the process 24 under paragraph (1)(B) were continued, as cer- 25 VerDate Sep 11 2014 01:22 Jan 04, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S3.IS S3 kjohnson on DSK79L0C42 with BILLS 10 •S 3 IS tified by the Office of the Actuary of the Cen- 1 ters for Medicare & Medicaid Services. 2 ‘‘(B) ESTABLISHMENT OF A PROVIDER 3 NETWORK.—Health care providers participating 4 under Medicare are participating providers in 5 the public health insurance option unless they 6 opt out in a process established by the Sec- 7 retary. 8 ‘‘(3) ADMINISTRATIVE PROCESS FOR SETTING 9 RATES.—Chapter 5 of title 5, United States Code 10 shall apply to the process for the initial establish- 11 ment of payment rates under this subsection but not 12 to the specific methodology for establishing such 13 rates or the calculation of such rates. 14 ‘‘(4) CONSTRUCTION.—Nothing in this section 15 shall be construed as limiting the Secretary’s author- 16 ity to correct for payments that are excessive or defi- 17 cient, taking into account the provisions of sub- 18 section (a)(1) and any appropriate adjustments 19 based on the demographic characteristics of enrollees 20 covered under the public health insurance option, 21 but in no case shall the correction of payments 22 under this paragraph result in a level of expendi- 23 tures per enrollee that exceeds the level of expendi- 24 tures that would have occurred under paragraph 25 VerDate Sep 11 2014 01:22 Jan 04, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S3.IS S3 kjohnson on DSK79L0C42 with BILLS 11 •S 3 IS (1)(B), as certified by the Office of the Actuary of 1 the Centers for Medicare & Medicaid Services. 2 ‘‘(5) CONSTRUCTION.—Nothing in this section 3 shall be construed as affecting the authority of the 4 Secretary to establish payment rates, including pay- 5 ments to provide for the more efficient delivery of 6 services, such as the initiatives provided for under 7 subsection (d). 8 ‘‘(6) LIMITATIONS ON REVIEW.—There shall be 9 no administrative or judicial review of a payment 10 rate or methodology established under this sub- 11 section or under subsection (d). 12 ‘‘(d) MODERNIZED PAYMENT INITIATIVES AND DE- 13 LIVERY SYSTEM REFORM.— 14 ‘‘(1) IN GENERAL.—For plan years beginning 15 with 2020, the Secretary may utilize innovative pay- 16 ment mechanisms and policies to determine pay- 17 ments for items and services under the public health 18 insurance option. The payment mechanisms and 19 policies under this subsection may include patient- 20 centered medical home and other care management 21 payments, accountable care organizations, value- 22 based purchasing, bundling of services, differential 23 payment rates, performance or utilization based pay- 24 ments, partial capitation, and direct contracting with 25 VerDate Sep 11 2014 01:22 Jan 04, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S3.IS S3 kjohnson on DSK79L0C42 with BILLS 12 •S 3 IS providers. Payment rates under such payment mech- 1 anisms and policies shall not be set at levels ex- 2 pected to increase average medical costs per enrollee 3 covered under the public health insurance option be- 4 yond what would be expected if the process under 5 subsection (c)(1)(B) were continued, as certified by 6 the Office of the Actuary of the Centers for Medi- 7 care & Medicaid Services. 8 ‘‘(2) REQUIREMENTS FOR INNOVATIVE PAY- 9 MENTS.—The Secretary shall design and implement 10 the payment mechanisms and policies under this 11 subsection in a manner that— 12 ‘‘(A) seeks to— 13 ‘‘(i) improve health outcomes; 14 ‘‘(ii) reduce health disparities (includ- 15 ing racial, ethnic, and o [Text truncated for display. Full text available on Congress.gov.]