S4684-118

2. Ensuring affordability of coverage for certain low-income populations Section 1402 of the Patient Protection and Affordable Care Act (42 U.S.C. 18071) is amended— in subsection (b)— in paragraph (2), by inserting (or, with respect to plan years 2026, 2027, and 2028, whose household income does not exceed 400 percent of the poverty line for a family of the size involved) before the period; and in the matter following paragraph (2), by adding at the end the following new sentence: In the case of an individual who is determined at any point to have a household income for 2025 that does not exceed 138 percent of the poverty line for a family of the size involved, such individual shall, for each month during such year, be treated as having a household income equal to 100 percent for purposes of applying this section.; and in subsection (c)— in paragraph (1)(A), in the matter preceding clause (i), by inserting , with respect to eligible insureds (other than, with respect to plan years 2026, 2027, and 2028, specified enrollees (as defined in paragraph (6)(C))), after first be achieved; in paragraph (2), in the matter preceding subparagraph (A), by inserting with respect to eligible insureds (other than, with respect to plan years 2026, 2027, and 2028, specified enrollees) after under the plan; in paragraph (3)— in subparagraph (A), by striking this subsection and inserting paragraph (1) or (2); and in subparagraph (B), by striking this section and inserting paragraphs (1) and (2); and by adding at the end the following new paragraph: The Secretary shall establish procedures under which the issuer of a qualified health plan to which this section applies shall reduce cost-sharing under the plan with respect to months occurring during plan years 2026, 2027, and 2028 for enrollees who are specified enrollees (as defined in subparagraph (C)) in a manner sufficient to increase the plan’s share of the total allowed costs of benefits provided under the plan to 99 percent of such costs. An issuer of a qualified health plan making reductions under this paragraph shall notify the Secretary of such reductions and the Secretary shall, out of funds made available under clause (ii), make periodic and timely payments to the issuer equal to 12 percent of the total allowed costs of benefits provided under each such plan to specified enrollees during plan years 2026, 2027, and 2028. In addition to amounts otherwise available, there are appropriated, out of any money in the Treasury not otherwise appropriated, such sums as may be necessary to the Secretary to make payments under clause (i). For purposes of this section, the term specified enrollee means, with respect to a plan year, an eligible insured who is determined at any point to have a household income for such plan year that does not exceed 138 percent of the poverty line for a family of the size involved. Such insured shall be deemed to be a specified enrollee for each month in such plan year. Section 1311(c) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)) is amended— in paragraph (6)— in subparagraph (C), by striking at the end and; in subparagraph (D), by striking the period at the end and inserting ; and; and by adding at the end the following new subparagraph: with respect to a qualified health plan with respect to which section 1402 applies, for months occurring during the period beginning on January 1, 2025, and ending on December 31, 2028, enrollment periods described in subparagraph (A) of paragraph (8) for individuals described in subparagraph (B) of such paragraph. by adding at the end the following new paragraph: The enrollment period described in this paragraph is, in the case of an individual described in subparagraph (B), the continuous period beginning on the first day that such individual is so described. For purposes of subparagraph (A), an individual described in this subparagraph is an individual— with a household income that does not exceed 138 percent of the poverty line for a family of the size involved; and who is not eligible for minimum essential coverage (as defined in section 5000A(f) of the Internal Revenue Code of 1986), other than for coverage described in any of subparagraphs (B) through (E) of paragraph (1) of such section. Section 1301(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18021(a)) is amended— in paragraph (1)— in subparagraph (B), by striking and at the end; in subparagraph (C)(iv), by striking the period and inserting ; and; and by adding at the end the following new subparagraph: provides, with respect to a plan offered in the silver level of coverage to which section 1402 applies during plan year 2027 and 2028, for benefits described in paragraph (5) in the case of an individual who has a household income that does not exceed 138 percent of the poverty line for a family of the size involved, and who is eligible to receive cost-sharing reductions under section 1402. by adding at the end the following new paragraph: For purposes of paragraph (1)(D), the benefits described in this paragraph to be provided by a qualified health plan are benefits consisting of— non-emergency medical transportation services (as described in section 1902(a)(4) of the Social Security Act) for which Federal payments would have been available under title XIX of the Social Security Act had such services been furnished to an individual enrolled under a State plan (or waiver of such plan) under such title; and services described in subsection (a)(4)(C) of section 1905 of such Act for which Federal payments would have been so available; Benefits described in this paragraph shall be provided— without any restriction on the choice of a qualified provider from whom an individual may receive such benefits; and without any imposition of cost sharing. An issuer of a qualified health plan making payments for services described in subparagraph (A) furnished to individuals described in paragraph (1)(D) during plan year 2027 or 2028 shall notify the Secretary of such payments and the Secretary shall, out of funds made available under clause (ii), make periodic and timely payments to the issuer equal to payments for such services so furnished. In addition to amounts otherwise available, there is appropriated, out of any money in the Treasury not otherwise appropriated, such sums as may be necessary to the Secretary to make payments under clause (i). Section 1321(c) of the Patient Protection and Affordable Care Act (42 U.S.C. 18041(c)) is amended by adding at the end the following new paragraph: In the case of an Exchange established or operated by the Secretary within a State pursuant to this subsection, the Secretary shall carry out outreach and educational activities for purposes of informing individuals described in section 1902(a)(10)(A)(i)(VIII) of the Social Security Act who reside in States that have not expended amounts under a State plan (or waiver of such plan) under title XIX of such Act for all such individuals about qualified health plans offered through the Exchange, including by informing such individuals of the availability of coverage under such plans and financial assistance for coverage under such plans. Such outreach and educational activities shall be provided in a manner that is culturally and linguistically appropriate to the needs of the populations being served by the Exchange (including hard-to-reach populations, such as racial and sexual minorities, limited English proficient populations, individuals residing in areas where the unemployment rates exceeds the national average unemployment rate, individuals in rural areas, veterans, and young adults). Funds appropriated under this paragraph shall not be used to promote any health insurance coverage other than qualified health plans. In addition to amounts otherwise available, there is appropriated, out of any money in the Treasury not otherwise appropriated, to remain available until expended, $105,000,000 for fiscal year 2025 to carry out this paragraph, of which— $15,000,000 shall be used to carry out this paragraph in fiscal year 2025; and $30,000,000 shall be used to carry out this paragraph for each of fiscal years 2026 through 2028. Section 1311(i) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(i)) is amended— in paragraph (1)— by striking An Exchange and inserting the following: An Exchange by adding at the end the following: The Secretary shall establish a program to award grants to entities described in paragraph (2) to carry out the duties described in paragraph (3) in one or more States that do not provide under the State plan under title XIX of the Social Security Act (or a waiver of such plan) benchmark coverage described in section 1937(b)(1) of such Act or benchmark equivalent coverage described in section 1937(b)(2) of such Act to all individuals described in section 1902(a)(10)(A)(i)(VIII) of such Act. in paragraph (6)— by striking Grants under and inserting the following: Except as provided in subparagraph (B), grants under by adding at the end the following new subparagraph: For purposes of carrying out this subsection, with respect to an Exchange established and operated by the Secretary within a State pursuant to section 1321(c) and with respect to grants under paragraph (1)(B), the Secretary shall obligate not less than $10,000,000 out of amounts collected through the user fees on participating health insurance issuers pursuant to section 156.50 of title 45, Code of Federal Regulations (or any successor regulations) for fiscal year 2026, and not less than $20,000,000 for each of fiscal years 2027 and 2028. Such amount so obligated for a fiscal year shall remain available until expended. In addition to amounts otherwise available, there is appropriated to the Secretary of Health and Human Services for fiscal year 2025, out of any money in the Treasury not otherwise appropriated, $65,000,000, to remain available until expended, for purposes of carrying out the provisions of, and the amendments made by, this section. (6)Special rule for specified enrollees (A)In generalThe Secretary shall establish procedures under which the issuer of a qualified health plan to which this section applies shall reduce cost-sharing under the plan with respect to months occurring during plan years 2026, 2027, and 2028 for enrollees who are specified enrollees (as defined in subparagraph (C)) in a manner sufficient to increase the plan’s share of the total allowed costs of benefits provided under the plan to 99 percent of such costs. (B)Methods for reducing cost sharing (i)In generalAn issuer of a qualified health plan making reductions under this paragraph shall notify the Secretary of such reductions and the Secretary shall, out of funds made available under clause (ii), make periodic and timely payments to the issuer equal to 12 percent of the total allowed costs of benefits provided under each such plan to specified enrollees during plan years 2026, 2027, and 2028. (ii)AppropriationIn addition to amounts otherwise available, there are appropriated, out of any money in the Treasury not otherwise appropriated, such sums as may be necessary to the Secretary to make payments under clause (i). (C)Specified enrollee definedFor purposes of this section, the term specified enrollee means, with respect to a plan year, an eligible insured who is determined at any point to have a household income for such plan year that does not exceed 138 percent of the poverty line for a family of the size involved. Such insured shall be deemed to be a specified enrollee for each month in such plan year.. (E)with respect to a qualified health plan with respect to which section 1402 applies, for months occurring during the period beginning on January 1, 2025, and ending on December 31, 2028, enrollment periods described in subparagraph (A) of paragraph (8) for individuals described in subparagraph (B) of such paragraph.; and (8)Special enrollment period for certain low-income populations (A)In generalThe enrollment period described in this paragraph is, in the case of an individual described in subparagraph (B), the continuous period beginning on the first day that such individual is so described. (B)Individual describedFor purposes of subparagraph (A), an individual described in this subparagraph is an individual— (i)with a household income that does not exceed 138 percent of the poverty line for a family of the size involved; and (ii)who is not eligible for minimum essential coverage (as defined in section 5000A(f) of the Internal Revenue Code of 1986), other than for coverage described in any of subparagraphs (B) through (E) of paragraph (1) of such section.. (D)provides, with respect to a plan offered in the silver level of coverage to which section 1402 applies during plan year 2027 and 2028, for benefits described in paragraph (5) in the case of an individual who has a household income that does not exceed 138 percent of the poverty line for a family of the size involved, and who is eligible to receive cost-sharing reductions under section 1402.; and (5)Additional benefits for certain low-income individuals for plan year 2027 and 2028 (A)In general (i)BenefitsFor purposes of paragraph (1)(D), the benefits described in this paragraph to be provided by a qualified health plan are benefits consisting of— (I)non-emergency medical transportation services (as described in section 1902(a)(4) of the Social Security Act) for which Federal payments would have been available under title XIX of the Social Security Act had such services been furnished to an individual enrolled under a State plan (or waiver of such plan) under such title; and (II)services described in subsection (a)(4)(C) of section 1905 of such Act for which Federal payments would have been so available;which are not otherwise provided under such plan as part of the essential health benefits package described in section 1302(a). (ii)Condition on provision of benefitsBenefits described in this paragraph shall be provided— (I)without any restriction on the choice of a qualified provider from whom an individual may receive such benefits; and (II)without any imposition of cost sharing. (B)Payments for additional benefits (i)In generalAn issuer of a qualified health plan making payments for services described in subparagraph (A) furnished to individuals described in paragraph (1)(D) during plan year 2027 or 2028 shall notify the Secretary of such payments and the Secretary shall, out of funds made available under clause (ii), make periodic and timely payments to the issuer equal to payments for such services so furnished. (ii)AppropriationIn addition to amounts otherwise available, there is appropriated, out of any money in the Treasury not otherwise appropriated, such sums as may be necessary to the Secretary to make payments under clause (i).. (3)Outreach and educational activities (A)In generalIn the case of an Exchange established or operated by the Secretary within a State pursuant to this subsection, the Secretary shall carry out outreach and educational activities for purposes of informing individuals described in section 1902(a)(10)(A)(i)(VIII) of the Social Security Act who reside in States that have not expended amounts under a State plan (or waiver of such plan) under title XIX of such Act for all such individuals about qualified health plans offered through the Exchange, including by informing such individuals of the availability of coverage under such plans and financial assistance for coverage under such plans. Such outreach and educational activities shall be provided in a manner that is culturally and linguistically appropriate to the needs of the populations being served by the Exchange (including hard-to-reach populations, such as racial and sexual minorities, limited English proficient populations, individuals residing in areas where the unemployment rates exceeds the national average unemployment rate, individuals in rural areas, veterans, and young adults). (B)Limitation on use of fundsFunds appropriated under this paragraph shall not be used to promote any health insurance coverage other than qualified health plans. (C)FundingIn addition to amounts otherwise available, there is appropriated, out of any money in the Treasury not otherwise appropriated, to remain available until expended, $105,000,000 for fiscal year 2025 to carry out this paragraph, of which— (i)$15,000,000 shall be used to carry out this paragraph in fiscal year 2025; and (ii)$30,000,000 shall be used to carry out this paragraph for each of fiscal years 2026 through 2028.. (A)In generalAn Exchange; and (B)Grants for eligible entities with respect to certain StatesThe Secretary shall establish a program to award grants to entities described in paragraph (2) to carry out the duties described in paragraph (3) in one or more States that do not provide under the State plan under title XIX of the Social Security Act (or a waiver of such plan) benchmark coverage described in section 1937(b)(1) of such Act or benchmark equivalent coverage described in section 1937(b)(2) of such Act to all individuals described in section 1902(a)(10)(A)(i)(VIII) of such Act.; and (A)State ExchangesExcept as provided in subparagraph (B), grants under; and (B)Federal Exchanges; grants to eligible entities with respect to certain StatesFor purposes of carrying out this subsection, with respect to an Exchange established and operated by the Secretary within a State pursuant to section 1321(c) and with respect to grants under paragraph (1)(B), the Secretary shall obligate not less than $10,000,000 out of amounts collected through the user fees on participating health insurance issuers pursuant to section 156.50 of title 45, Code of Federal Regulations (or any successor regulations) for fiscal year 2026, and not less than $20,000,000 for each of fiscal years 2027 and 2028. Such amount so obligated for a fiscal year shall remain available until expended..