S3264-119

1. Short title This Act may be cited as the More Affordable Care Act.

2. Health freedom waiver program Part 4 of subtitle D of title I of the Patient Protection and Affordable Care Act (42 U.S.C. 18051 et seq.) is amended by adding at the end the following: The Secretary shall waive all or any requirements described in paragraph (4), as determined by the applicable State, for plan years beginning on or after January 1, 2026, with respect to health insurance coverage within any State that submits a notification under paragraph (2), provided that the State maintains an invisible high-risk insurance pool or another program designed to mitigate risk to insurance premium costs. A State entity described in paragraph (3) desiring a waiver under this section for any plan year beginning on or after January 1, 2026, shall notify the Secretary of its intent to participate in the waiver program with respect to all or any requirements described in paragraph (4). Such notification shall be filed at such time, not later than 90 days before the State intends to begin participation in the waiver program, and in such manner as the Secretary may require, and contain such information as the Secretary may require, including the requirements under paragraph (4) that the State intends to waive and evidence that the State maintains a high-risk insurance pool. A notification with respect to a State may be submitted by— the governor of the State; or the legislature of the State, upon a majority vote by the State legislature. The requirements described in this paragraph with respect to health insurance coverage within the State are as follows: Part 1 of subtitle D. Part 2 of subtitle D. Section 1402. Sections 36B and 5000A of the Internal Revenue Code of 1986. With respect to a State waiver under paragraph (1), under which, due to the structure of the State plan, individuals and small employers in the State would not qualify for the premium tax credits, cost-sharing reductions, or small business credits under sections 36B of the Internal Revenue Code of 1986 or under part I of subtitle E for which they would otherwise be eligible, 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 waiver, shall be paid into the Trump Health Freedom Accounts established under section 223(i) of the Internal Revenue Code of 1986 of eligible residents of the State. 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 36B of the Internal Revenue Code of 1986 and cost-sharing reduction amounts under section 1402 for the year, had the State not had such waiver in effect. In determining the appropriate payment amount under this subparagraph, 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 year. The Secretary shall make payments into the Trump Health Freedom Accounts of eligible residents on a monthly basis, quarterly basis, or in one lump sum at the beginning of the year, at the option of each eligible resident. The Secretary shall develop a process for coordinating and consolidating the State waiver processes applicable under the provisions of this section, and the existing waiver processes applicable under section 1332 and titles XVIII, XIX, and XXI of the Social Security Act, and any other Federal law relating to the provision of health care items or services. Such process shall permit a State to submit a single application for a waiver under any or all of such provisions. In the case of a State in which a waiver is in effect under this section for a plan year— the State may— operate an Exchange established as described in section 1311(b); or allow one or more private entities to run commercial platforms that sell health plans approved by the State insurance commissioner; or if the State does not operate an Exchange as described in clause (i)(I) or allow for one or more commercial platforms described in clause (i)(II), the Secretary shall operate a Federal Exchange, as described in section 1321(c), provided that any State laws regarding the availability of health plans on, and the operation of, such Exchange shall apply in lieu of any provision under part 1 or part 2 that such State has waived. The Secretary shall make available to any State that allows for commercial platforms described in subparagraph (A)(i)(II), the application program interface used for operating Federal and State Exchanges, for use by any private entity running such a platform under State authority. In this section: The term eligible resident means, with respect to a State for which a waiver is in effect under this section, a resident who— in the absence of such a waiver in the State, would be eligible for a premium tax credit under section 36B of the Internal Revenue Code of 1986 or a cost-sharing reduction under section 1402, if the resident enrolled in a qualified health plan offered on the Exchange of such State; and enrolls in a plan offered on the Exchange described in paragraph (7) for the applicable plan year. Term Secretary means— the Secretary of Health and Human Services with respect to waivers relating to the provisions described in subparagraph (A) through (C) of paragraph (4); and the Secretary of the Treasury with respect to waivers relating to the provisions described in paragraph (4)(D). Each waiver under this section shall be in effect beginning on January 1 of the plan year for which a timely notice is submitted by the State under subsection (a)(2), and continuing until the entity of the State described in subparagraph (A) or (B) of subsection (a)(3) that submitted the notification under subsection (a)(2) submits to the Secretary a notification of intent to discontinue participation in the waiver program under this section. The Secretary may not permit a waiver under this section of any Federal law or requirement this is not within the authority of the Secretary. Any health insurance coverage offered in a State for which a waiver under this section is in effect, and authorized by the insurance commissioner of the State, shall be made available on, as applicable, the Federal or State Exchange or commercial platforms described in subsection (a)(7), of all States for which such a waiver is in effect, subject to the laws of each such State. In any State for which a waiver under this section is in effect, a health insurance issuer may offer a plan in which the only individuals eligible to enroll are individuals who, as of the beginning of a plan year, have not yet attained the age of 21. Not later than 1 year after the date of enactment of the More Affordable Care Act, the Secretary of Health and Human Services, in coordination with the Secretary of the Treasury, shall promulgate regulations to carry out this section. Nothing in this section shall be construed to allow a State to waive the requirements of title XXVII of the Public Health Service Act, including sections 2701, 2702, 2703, 2704, 2705, 2708, 2711, 2712, and 2718 of such Act. 1335.Health freedom waiver program(a)In general(1)Waiver programThe Secretary shall waive all or any requirements described in paragraph (4), as determined by the applicable State, for plan years beginning on or after January 1, 2026, with respect to health insurance coverage within any State that submits a notification under paragraph (2), provided that the State maintains an invisible high-risk insurance pool or another program designed to mitigate risk to insurance premium costs.(2)NotificationA State entity described in paragraph (3) desiring a waiver under this section for any plan year beginning on or after January 1, 2026, shall notify the Secretary of its intent to participate in the waiver program with respect to all or any requirements described in paragraph (4). Such notification shall be filed at such time, not later than 90 days before the State intends to begin participation in the waiver program, and in such manner as the Secretary may require, and contain such information as the Secretary may require, including the requirements under paragraph (4) that the State intends to waive and evidence that the State maintains a high-risk insurance pool.(3)State submissionA notification with respect to a State may be submitted by—(A)the governor of the State; or(B)the legislature of the State, upon a majority vote by the State legislature.(4)RequirementsThe requirements described in this paragraph with respect to health insurance coverage within the State are as follows:(A)Part 1 of subtitle D.(B)Part 2 of subtitle D.(C)Section 1402.(D)Sections 36B and 5000A of the Internal Revenue Code of 1986.(5)Money follows the person(A)In generalWith respect to a State waiver under paragraph (1), under which, due to the structure of the State plan, individuals and small employers in the State would not qualify for the premium tax credits, cost-sharing reductions, or small business credits under sections 36B of the Internal Revenue Code of 1986 or under part I of subtitle E for which they would otherwise be eligible, 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 waiver, shall be paid into the Trump Health Freedom Accounts established under section 223(i) of the Internal Revenue Code of 1986 of eligible residents of the State.(B)Payments to Trump Health Freedom AccountsThe 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 36B of the Internal Revenue Code of 1986 and cost-sharing reduction amounts under section 1402 for the year, had the State not had such waiver in effect. In determining the appropriate payment amount under this subparagraph, 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 year. The Secretary shall make payments into the Trump Health Freedom Accounts of eligible residents on a monthly basis, quarterly basis, or in one lump sum at the beginning of the year, at the option of each eligible resident.(6)Coordinated waiver processThe Secretary shall develop a process for coordinating and consolidating the State waiver processes applicable under the provisions of this section, and the existing waiver processes applicable under section 1332 and titles XVIII, XIX, and XXI of the Social Security Act, and any other Federal law relating to the provision of health care items or services. Such process shall permit a State to submit a single application for a waiver under any or all of such provisions.(7)Exchanges(A)In generalIn the case of a State in which a waiver is in effect under this section for a plan year—(i)the State may—(I)operate an Exchange established as described in section 1311(b); or(II)allow one or more private entities to run commercial platforms that sell health plans approved by the State insurance commissioner; or(ii)if the State does not operate an Exchange as described in clause (i)(I) or allow for one or more commercial platforms described in clause (i)(II), the Secretary shall operate a Federal Exchange, as described in section 1321(c), provided that any State laws regarding the availability of health plans on, and the operation of, such Exchange shall apply in lieu of any provision under part 1 or part 2 that such State has waived.(B)Application program interfaceThe Secretary shall make available to any State that allows for commercial platforms described in subparagraph (A)(i)(II), the application program interface used for operating Federal and State Exchanges, for use by any private entity running such a platform under State authority.(8)DefinitionsIn this section:(A)Eligible residentThe term eligible resident means, with respect to a State for which a waiver is in effect under this section, a resident who—(i)in the absence of such a waiver in the State, would be eligible for a premium tax credit under section 36B of the Internal Revenue Code of 1986 or a cost-sharing reduction under section 1402, if the resident enrolled in a qualified health plan offered on the Exchange of such State; and(ii)enrolls in a plan offered on the Exchange described in paragraph (7) for the applicable plan year.(B)SecretaryTerm Secretary means—(i)the Secretary of Health and Human Services with respect to waivers relating to the provisions described in subparagraph (A) through (C) of paragraph (4); and(ii)the Secretary of the Treasury with respect to waivers relating to the provisions described in paragraph (4)(D).(b)Waiver periodEach waiver under this section shall be in effect beginning on January 1 of the plan year for which a timely notice is submitted by the State under subsection (a)(2), and continuing until the entity of the State described in subparagraph (A) or (B) of subsection (a)(3) that submitted the notification under subsection (a)(2) submits to the Secretary a notification of intent to discontinue participation in the waiver program under this section.(c)LimitationThe Secretary may not permit a waiver under this section of any Federal law or requirement this is not within the authority of the Secretary.(d)Availability of plans(1)In generalAny health insurance coverage offered in a State for which a waiver under this section is in effect, and authorized by the insurance commissioner of the State, shall be made available on, as applicable, the Federal or State Exchange or commercial platforms described in subsection (a)(7), of all States for which such a waiver is in effect, subject to the laws of each such State.(2)Child-only plansIn any State for which a waiver under this section is in effect, a health insurance issuer may offer a plan in which the only individuals eligible to enroll are individuals who, as of the beginning of a plan year, have not yet attained the age of 21.(e)RegulationsNot later than 1 year after the date of enactment of the More Affordable Care Act, the Secretary of Health and Human Services, in coordination with the Secretary of the Treasury, shall promulgate regulations to carry out this section. (f) Rule of construction regarding consumer protections, 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 Act, including sections 2701, 2702, 2703, 2704, 2705, 2708, 2711, 2712, and 2718 of such Act. .

1335. Health freedom waiver program The Secretary shall waive all or any requirements described in paragraph (4), as determined by the applicable State, for plan years beginning on or after January 1, 2026, with respect to health insurance coverage within any State that submits a notification under paragraph (2), provided that the State maintains an invisible high-risk insurance pool or another program designed to mitigate risk to insurance premium costs. A State entity described in paragraph (3) desiring a waiver under this section for any plan year beginning on or after January 1, 2026, shall notify the Secretary of its intent to participate in the waiver program with respect to all or any requirements described in paragraph (4). Such notification shall be filed at such time, not later than 90 days before the State intends to begin participation in the waiver program, and in such manner as the Secretary may require, and contain such information as the Secretary may require, including the requirements under paragraph (4) that the State intends to waive and evidence that the State maintains a high-risk insurance pool. A notification with respect to a State may be submitted by— the governor of the State; or the legislature of the State, upon a majority vote by the State legislature. The requirements described in this paragraph with respect to health insurance coverage within the State are as follows: Part 1 of subtitle D. Part 2 of subtitle D. Section 1402. Sections 36B and 5000A of the Internal Revenue Code of 1986. With respect to a State waiver under paragraph (1), under which, due to the structure of the State plan, individuals and small employers in the State would not qualify for the premium tax credits, cost-sharing reductions, or small business credits under sections 36B of the Internal Revenue Code of 1986 or under part I of subtitle E for which they would otherwise be eligible, 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 waiver, shall be paid into the Trump Health Freedom Accounts established under section 223(i) of the Internal Revenue Code of 1986 of eligible residents of the State. 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 36B of the Internal Revenue Code of 1986 and cost-sharing reduction amounts under section 1402 for the year, had the State not had such waiver in effect. In determining the appropriate payment amount under this subparagraph, 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 year. The Secretary shall make payments into the Trump Health Freedom Accounts of eligible residents on a monthly basis, quarterly basis, or in one lump sum at the beginning of the year, at the option of each eligible resident. The Secretary shall develop a process for coordinating and consolidating the State waiver processes applicable under the provisions of this section, and the existing waiver processes applicable under section 1332 and titles XVIII, XIX, and XXI of the Social Security Act, and any other Federal law relating to the provision of health care items or services. Such process shall permit a State to submit a single application for a waiver under any or all of such provisions. In the case of a State in which a waiver is in effect under this section for a plan year— the State may— operate an Exchange established as described in section 1311(b); or allow one or more private entities to run commercial platforms that sell health plans approved by the State insurance commissioner; or if the State does not operate an Exchange as described in clause (i)(I) or allow for one or more commercial platforms described in clause (i)(II), the Secretary shall operate a Federal Exchange, as described in section 1321(c), provided that any State laws regarding the availability of health plans on, and the operation of, such Exchange shall apply in lieu of any provision under part 1 or part 2 that such State has waived. The Secretary shall make available to any State that allows for commercial platforms described in subparagraph (A)(i)(II), the application program interface used for operating Federal and State Exchanges, for use by any private entity running such a platform under State authority. In this section: The term eligible resident means, with respect to a State for which a waiver is in effect under this section, a resident who— in the absence of such a waiver in the State, would be eligible for a premium tax credit under section 36B of the Internal Revenue Code of 1986 or a cost-sharing reduction under section 1402, if the resident enrolled in a qualified health plan offered on the Exchange of such State; and enrolls in a plan offered on the Exchange described in paragraph (7) for the applicable plan year. Term Secretary means— the Secretary of Health and Human Services with respect to waivers relating to the provisions described in subparagraph (A) through (C) of paragraph (4); and the Secretary of the Treasury with respect to waivers relating to the provisions described in paragraph (4)(D). Each waiver under this section shall be in effect beginning on January 1 of the plan year for which a timely notice is submitted by the State under subsection (a)(2), and continuing until the entity of the State described in subparagraph (A) or (B) of subsection (a)(3) that submitted the notification under subsection (a)(2) submits to the Secretary a notification of intent to discontinue participation in the waiver program under this section. The Secretary may not permit a waiver under this section of any Federal law or requirement this is not within the authority of the Secretary. Any health insurance coverage offered in a State for which a waiver under this section is in effect, and authorized by the insurance commissioner of the State, shall be made available on, as applicable, the Federal or State Exchange or commercial platforms described in subsection (a)(7), of all States for which such a waiver is in effect, subject to the laws of each such State. In any State for which a waiver under this section is in effect, a health insurance issuer may offer a plan in which the only individuals eligible to enroll are individuals who, as of the beginning of a plan year, have not yet attained the age of 21. Not later than 1 year after the date of enactment of the More Affordable Care Act, the Secretary of Health and Human Services, in coordination with the Secretary of the Treasury, shall promulgate regulations to carry out this section. Nothing in this section shall be construed to allow a State to waive the requirements of title XXVII of the Public Health Service Act, including sections 2701, 2702, 2703, 2704, 2705, 2708, 2711, 2712, and 2718 of such Act.

3. Trump Health Freedom Accounts Section 223 of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: For purposes of this section— In the case of a Trump Health Freedom Account, this section shall be applied as provided in paragraphs (3) through (8). The term Trump Health Freedom Account means a health savings account (determined as provided in this subsection) established by or on behalf of an individual residing in a State for which a waiver under section 1335 of the Patient Protection and Affordable Care Act is in effect which receives deposits of amounts transferred to the individual pursuant to section 1335(a)(5) of such Act. Any individual covered under a health plan authorized to be made available on an Exchange by section 1335(d) of such Act shall be treated as an eligible individual. Amounts transferred to a Trump Health Freedom Account pursuant to section 1335(a)(5) of such Act shall not be taken into account in determining the deduction allowed by subsection (a). Subsection (d)(2)(B) shall not apply. 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 Account. 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 (f)(5). Except as provided in paragraph (6)(B), subsection (f)(5) 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 Account. No amounts in a Trump Health Freedom Account may be used— to pay premiums for a health plan that covers— gender transition procedures, or abortion services; or to pay for any service described in clause (i) or (ii) of subparagraph (A). For purposes of paragraph (8)— The term gender transition procedure means any hormonal or surgical intervention for the purpose of gender transition, including— gonadotropin-releasing hormone (GnRH) agonists or other puberty-blocking or suppressing drugs to stop or delay normal puberty; testosterone, estrogen, progesterone, 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 sex; castration; orchiectomy; scrotoplasty; implantation of erection or testicular prostheses; vasectomy; hysterectomy; oophorectomy; ovariectomy; reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty; metoidioplasty; penectomy; phalloplasty; vaginoplasty; clitoroplasty; vaginectomy; vulvoplasty; reduction thyrochondroplasty; chondrolaryngoplasty; mastectomy; tubal ligation; sterilization; any plastic, cosmetic, or aesthetic surgery that feminizes or masculinizes the facial or other physiological features of an individual; any placement of chest implants to create feminine breasts; any placement of fat or artificial implants in the gluteal region; augmentation mammoplasty; liposuction; lipofilling; voice surgery; hair reconstruction; pectoral implants; and the removal of any otherwise healthy or non-diseased body part or tissue. 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 or, if applicable, such individual’s parents or legal guardian: Services to individuals born with a medically verifiable disorder of sex development, including an individual with external sex characteristics that are irresolvably ambiguous, such as an individual born with 46 XX chromosomes with virilization, an individual born with 46 XY chromosomes with undervirilization, or an individual born having both ovarian and testicular tissue. 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 structure, sex steroid hormone production, or sex steroid hormone action for a healthy individual of the same sex and age. The treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of gender transition procedures, 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 section. Any procedure undertaken because the individual suffers from a physical disorder, physical injury, or physical illness (but not mental, behavioral, or emotional distress or a mental, behavioral, or emotional disorder) that would, as certified by a physician, place the individual in imminent danger of death or impairment of major bodily function, unless the procedure is performed. Puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for a minor experiencing precocious puberty. Male circumcision. 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 social, legal, or physical changes. The term sex, when referring to an individual’s sex, means to refer to either male or female, as biologically determined. The term female, when used to refer to a natural person, means an individual who naturally has, had, will have, or would have, but for a congenital anomaly, historical accident, or intentional or unintentional disruption, the reproductive system that at some point produces, transports, and utilizes eggs for fertilization. The term male, when used to refer to a natural person, means an individual who naturally has, had, will have, or would have, but for a congenital anomaly, historical accident, or intentional or unintentional disruption, the reproductive system that at some point produces, transports, and utilizes sperm for fertilization. The term abortion services means— drugs or procedures used with the primary intent to end the life of the human being in the womb, pre-viable delivery not described in clause (ii), and post-viable delivery with intentional death of the fetus. Such term does not include— separation of the mother and her embryo or fetus to prevent the mother’s death or immediate irreversible bodily harm, which cannot be mitigated in any other way, treatment of ectopic or molar pregnancy, treatment of miscarriage, or any service described in clause (i) in the case of a pregnancy which is the result of an act of rape or incest. The amendment made by this section shall apply to taxable years beginning after December 31, 2025. (i)Trump Health Freedom AccountsFor purposes of this section—(1)In generalIn the case of a Trump Health Freedom Account, this section shall be applied as provided in paragraphs (3) through (8).(2)Trump Health Freedom AccountThe term Trump Health Freedom Account means a health savings account (determined as provided in this subsection) established by or on behalf of an individual residing in a State for which a waiver under section 1335 of the Patient Protection and Affordable Care Act is in effect which receives deposits of amounts transferred to the individual pursuant to section 1335(a)(5) of such Act.(3)Eligible individualAny individual covered under a health plan authorized to be made available on an Exchange by section 1335(d) of such Act shall be treated as an eligible individual.(4)Treatment of transferred contributionsAmounts transferred to a Trump Health Freedom Account pursuant to section 1335(a)(5) of such Act shall not be taken into account in determining the deduction allowed by subsection (a).(5)Health insurance may be purchased from accountSubsection (d)(2)(B) shall not apply.(6)Account must be only HSA of individual(A)In generalAn 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 Account.(B)Rollover of existing account permittedAn 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 (f)(5).(7)No rollovers permittedExcept as provided in paragraph (6)(B), subsection (f)(5) 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 Account.(8)Restriction on use of amountsNo amounts in a Trump Health Freedom Account may be used—(A)to pay premiums for a health plan that covers—(i)gender transition procedures, or(ii)abortion services; or(B)to pay for any service described in clause (i) or (ii) of subparagraph (A).(9)DefinitionsFor purposes of paragraph (8)—(A)Gender transition procedure(i)In generalThe term gender transition procedure means any hormonal or surgical intervention for the purpose of gender transition, including—(I)gonadotropin-releasing hormone (GnRH) agonists or other puberty-blocking or suppressing drugs to stop or delay normal puberty;(II)testosterone, estrogen, progesterone, 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 sex;(III)castration;(IV)orchiectomy;(V)scrotoplasty;(VI)implantation of erection or testicular prostheses;(VII)vasectomy;(VIII)hysterectomy;(IX)oophorectomy;(X)ovariectomy;(XI)reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty;(XII)metoidioplasty;(XIII)penectomy;(XIV)phalloplasty;(XV)vaginoplasty; (XVI) clitoroplasty; (XVII)vaginectomy;(XVIII)vulvoplasty;(XIX)reduction thyrochondroplasty;(XX)chondrolaryngoplasty;(XXI)mastectomy;(XXII)tubal ligation;(XXIII)sterilization;(XXIV)any plastic, cosmetic, or aesthetic surgery that feminizes or masculinizes the facial or other physiological features of an individual;(XXV)any placement of chest implants to create feminine breasts;(XXVI)any placement of fat or artificial implants in the gluteal region;(XXVII)augmentation mammoplasty;(XXVIII)liposuction;(XXIX)lipofilling;(XXX)voice surgery;(XXXI)hair reconstruction;(XXXII)pectoral implants; and(XXXIII)the removal of any otherwise healthy or non-diseased body part or tissue.(ii)ExclusionsThe 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 or, if applicable, such individual’s parents or legal guardian:(I)Services to individuals born with a medically verifiable disorder of sex development, including an individual with external sex characteristics that are irresolvably ambiguous, such as an individual born with 46 XX chromosomes with virilization, an individual born with 46 XY chromosomes with undervirilization, or an individual born having both ovarian and testicular tissue.(II)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 structure, sex steroid hormone production, or sex steroid hormone action for a healthy individual of the same sex and age.(III)The treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of gender transition procedures, 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 section.(IV)Any procedure undertaken because the individual suffers from a physical disorder, physical injury, or physical illness (but not mental, behavioral, or emotional distress or a mental, behavioral, or emotional disorder) that would, as certified by a physician, place the individual in imminent danger of death or impairment of major bodily function, unless the procedure is performed.(V)Puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for a minor experiencing precocious puberty.(VI)Male circumcision.(B)Gender transitionThe 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 social, legal, or physical changes.(C)SexThe term sex, when referring to an individual’s sex, means to refer to either male or female, as biologically determined.(D)FemaleThe term female, when used to refer to a natural person, means an individual who naturally has, had, will have, or would have, but for a congenital anomaly, historical accident, or intentional or unintentional disruption, the reproductive system that at some point produces, transports, and utilizes eggs for fertilization.(E)MaleThe term male, when used to refer to a natural person, means an individual who naturally has, had, will have, or would have, but for a congenital anomaly, historical accident, or intentional or unintentional disruption, the reproductive system that at some point produces, transports, and utilizes sperm for fertilization.(F)Abortion services(i)In generalThe term abortion services means—(I)drugs or procedures used with the primary intent to end the life of the human being in the womb,(II)pre-viable delivery not described in clause (ii), and(III)post-viable delivery with intentional death of the fetus.(ii)ExclusionsSuch term does not include—(I)separation of the mother and her embryo or fetus to prevent the mother’s death or immediate irreversible bodily harm, which cannot be mitigated in any other way,(II)treatment of ectopic or molar pregnancy,(III)treatment of miscarriage, or(IV)any service described in clause (i) in the case of a pregnancy which is the result of an act of rape or incest..

4. Credit for employee insurance expenses of small employers in waiver State Subsection (g) of section 45R of the Internal Revenue Code of 1986 is amended to read as follows: For purposes of this section— In the case of an eligible small employer (determined with the modifications provided in this subsection) located in a State for which a waiver under section 1335 of the Patient Protection and Affordable Care Act is in effect, this section shall be applied as provided in paragraphs (2) through (7). Subsection (b) shall be applied by substituting 50 percent for 50 percent (35 percent in the case of a tax-exempt eligible small employer). Subsections (b) and (d)(4) shall be applied by treating any health plan authorized to be made available on an Exchange in such State by section 1335(d) of such Act as a qualified health plan offered through an Exchange. Subsection (c) shall not apply. Subsection (d) shall be applied— by substituting 50 for 25 in paragraph (1)(A) thereof, and without regard to subparagraph (B) of paragraph (1) thereof. Subsection (e)(1)(A) shall be applied without regard to clause (i) thereof. Subsection (e)(2) shall not apply, and the credit period with respect to any such employer shall be the period consisting of the 1st taxable year in which the employer (or any predecessor) offers 1 or more qualified health plans to its employees, and any subsequent taxable year. Subsection (f) shall not apply. The amendment made by this section shall apply to taxable years beginning after December 31, 2025. (g)Credit for small employers in waiver StateFor purposes of this section—(1)In generalIn the case of an eligible small employer (determined with the modifications provided in this subsection) located in a State for which a waiver under section 1335 of the Patient Protection and Affordable Care Act is in effect, this section shall be applied as provided in paragraphs (2) through (7).(2)Health insurance credit amountSubsection (b) shall be applied by substituting 50 percent for 50 percent (35 percent in the case of a tax-exempt eligible small employer).(3)Qualified plansSubsections (b) and (d)(4) shall be applied by treating any health plan authorized to be made available on an Exchange in such State by section 1335(d) of such Act as a qualified health plan offered through an Exchange.(4)Phaseout not to applySubsection (c) shall not apply.(5)Eligible small employerSubsection (d) shall be applied—(A)by substituting 50 for 25 in paragraph (1)(A) thereof, and(B)without regard to subparagraph (B) of paragraph (1) thereof.(6)EmployeeSubsection (e)(1)(A) shall be applied without regard to clause (i) thereof.(7)Credit periodSubsection (e)(2) shall not apply, and the credit period with respect to any such employer shall be the period consisting of the 1st taxable year in which the employer (or any predecessor) offers 1 or more qualified health plans to its employees, and any subsequent taxable year.(8)Tax-exempt rules not to applySubsection (f) shall not apply..

5. Promoting better price reporting and outcomes data Not later than 90 days after the date of enactment of this Act, the Secretary of Health and Human Services, in coordination with the Secretary of the Treasury and the Secretary of Labor, shall update all regulations and guidance issued by such secretaries pursuant to Executive Order 13877 (84 Fed. Reg. 30849 (June 24, 2019)), including by— requiring the disclosure of the actual prices of items and services, not price estimates; issuing updated guidance or regulations ensuring pricing information is standardized and easily comparable across hospitals and health plans; issuing guidance or proposed regulatory action updating enforcement policies designed to ensure compliance with the transparent reporting of complete, accurate, and meaningful data; and requiring the public reporting of outcomes data by providers.