Sec. 132. Patient and State Stability Fund
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The Social Security Act ( 42 U.S.C. 301 et seq.) is amended by adding at the end the following new title: There is hereby established the Patient and State Stability Fund to be administered by the Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as the Administrator ), to provide funding, in accordance with this title, to the 50 States and the District of Columbia (each referred to in this section as a State ) during the period, subject to section 2204(c), beginning on January 1, 2018, and ending on December 31, 2026, for the purposes described in section 2202. Subject to subsections
(b)and (c), a State may use the funds allocated to the State under this title for any of the following purposes: Helping, through the provision of financial assistance, high-risk individuals who do not have access to health insurance coverage offered through an employer enroll in health insurance coverage in the individual market in the State, as such market is defined by the State (whether through the establishment of a new mechanism or maintenance of an existing mechanism for such purpose). Providing incentives to appropriate entities to enter into arrangements with the State to help stabilize premiums for health insurance coverage in the individual market, as such markets are defined by the State. Reducing the cost for providing health insurance coverage in the individual market and small group market, as such markets are defined by the State, to individuals who have, or are projected to have, a high rate of utilization of health services (as measured by cost) and to individuals who have high costs of health insurance coverage due to the low density population of the State in which they reside. Promoting participation in the individual market and small group market in the State and increasing health insurance options available through such market. Promoting access to preventive services; dental care services (whether preventive or medically necessary); vision care services (whether preventive or medically necessary); or any combination of such services. Maternity coverage and newborn care. Prevention, treatment, or recovery support services for individuals with mental or substance use disorders, focused on either or both of the following: Direct inpatient or outpatient clinical care for treatment of addiction and mental illness. Early identification and intervention for children and young adults with serious mental illness. Providing payments, directly or indirectly, to health care providers for the provision of such health care services as are specified by the Administrator. Providing assistance to reduce out-of-pocket costs, such as copayments, coinsurance, premiums, and deductibles, of individuals enrolled in health insurance coverage in the State. A State shall use the additional allocation provided to the State from the funds appropriated under the second sentence of section 2204(a) for each year only for the purposes described in paragraphs
(6)and
(7)of subsection (a). A State shall use the additional allocation provided to the State from the funds appropriated under the last sentence of section 2204(a) only in accordance with such last sentence. To be eligible for an allocation of funds under this title for a year during the period described in section 2201 for use for one or more purposes described in section 2202, a State shall submit to the Administrator an application at such time (but, in the case of allocations for 2018, not later than 45 days after the date of the enactment of this title and, in the case of allocations for a subsequent year, not later than March 31 of the previous year) and in such form and manner as specified by the Administrator and containing— a description of how the funds will be used for such purposes; a certification that the State will make, from non-Federal funds, expenditures for such purposes in an amount that is not less than the State percentage required for the year under section 2204(e)(1); and such other information as the Administrator may require. An application so submitted is approved unless the Administrator notifies the State submitting the application, not later than 60 days after the date of the submission of such application, that the application has been denied for not being in compliance with any requirement of this title and of the reason for such denial. If an application of a State is approved for a year, with respect to a purpose described in section 2202, such application shall be treated as approved, with respect to such purpose, for each subsequent year through 2026. Any program receiving funds from an allocation for a State under this title, including pursuant to subsection (b), shall be considered to be a State health care program for purposes of sections 1128, 1128A, and 1128B. For allocations made under this title for 2018, in the case of a State that does not submit an application under subsection
(a)by the 45-day submission date applicable to such year under subsection (a)(1) and in the case of a State that does submit such an application by such date that is not approved, subject to section 2204(e), the Administrator, in consultation with the State insurance commissioner, shall use the allocation that would otherwise be provided to the State under this title for such year, in accordance with paragraph (2), for such State. In the case of a State that does not have in effect an approved application under this section for 2019 or a subsequent year beginning during the period described in section 2201, subject to section 2204(e), the Administrator, in consultation with the State insurance commissioner, shall use the allocation that would otherwise be provided to the State under this title for such year, in accordance with paragraph (2), for such State. Subject to section 2204(a), an allocation for a State made pursuant to paragraph
(1)for a year shall be used to carry out the purpose described in section 2202(2) in such State by providing payments to appropriate entities described in such section with respect to claims that exceed $50,000 (or, with respect to allocations made under this title for 2020 or a subsequent year during the period specified in section 2201, such dollar amount specified by the Administrator), but do not exceed $350,000 (or, with respect to allocations made under this title for 2020 or a subsequent year during such period, such dollar amount specified by the Administrator), in an amount equal to 75 percent (or, with respect to allocations made under this title for 2020 or a subsequent year during such period, such percentage specified by the Administrator) of the amount of such claims. For the purpose of providing allocations for States (including pursuant to section 2203(b)) under this title there is appropriated, out of any money in the Treasury not otherwise appropriated— for 2018, $15,000,000,000; for 2019, $15,000,000,000; for 2020, $10,000,000,000; for 2021, $10,000,000,000; for 2022, $10,000,000,000; for 2023, $10,000,000,000; for 2024, $10,000,000,000; for 2025, $10,000,000,000; and for 2026, $10,000,000,000. The amount otherwise appropriated under the previous sentence for 2020 shall be increased by $15,000,000,000, to be used and available under subsection
(d)only for the purposes described in paragraphs
(6)and
(7)of section 2202(a). The amount otherwise appropriated under this subsection shall be increased by $8,000,000,000 for the period beginning with 2018 and ending with 2023, to be allocated to States with a waiver in effect under section 2701(b) of the Public Health Service Act with respect to the purpose described in paragraph (1)(C) of such section, in accordance with an allocation methodology specified by the Secretary that takes into account the relative allocation of other amounts appropriated under this subsection among such States, and to be used by (and made available under subsection (d), for any year during such period that such waiver is in effect, to) such States for the purpose of providing assistance to reduce premiums or other out-of-pocket costs of individuals who are subject to an increase in the monthly premium rate for health insurance coverage as a result of such waiver. From amounts appropriated under subsection
(a)for a year, the Administrator shall, with respect to a State and not later than the date specified under subparagraph
(B)for such year, allocate, subject to subsection (e), for such State (including pursuant to section 2203(b)) the amount determined for such State and year under paragraph (2). For purposes of subparagraph (A), the date specified in this subparagraph is— for 2018, the date that is 45 days after the date of the enactment of this title; and for 2019 and subsequent years, January 1 of the respective year. For purposes of paragraph (1), the amount determined under this paragraph for 2018 and 2019 for a State is an amount equal to the sum of— the relative incurred claims amount described in clause
(ii)for such State and year; and the relative uninsured and issuer participation amount described in clause
(iv)for such State and year. For purposes of clause (i), the relative incurred claims amount described in this clause for a State for 2018 and 2019 is the product of— 85 percent of the amount appropriated under subsection
(a)for the year; and the relative State incurred claims proportion described in clause
(iii)for such State and year. The relative State incurred claims proportion described in this clause for a State and year is the amount equal to the ratio of— the adjusted incurred claims by the State, as reported through the medical loss ratio annual reporting under section 2718 of the Public Health Service Act for the third previous year; to the sum of such adjusted incurred claims for all States, as so reported, for such third previous year. For purposes of clause (i), the relative uninsured and issuer participation amount described in this clause for a State for 2018 and 2019 is the product of— 15 percent of the amount appropriated under subsection
(a)for the year; and the relative State uninsured and issuer participation proportion described in clause
(v)for such State and year. The relative State uninsured and issuer participation proportion described in this clause for a State and year is— in the case of a State not described in clause
(vi)for such year, 0; and in the case of a State described in clause
(vi)for such year, the amount equal to the ratio of— the number of individuals residing in such State who for the third preceding year were not enrolled in a health plan or otherwise did not have health insurance coverage (including through a Federal or State health program) and whose income is below 100 percent of the poverty line applicable to a family of the size involved; to the sum of the number of such individuals for all States described in clause
(vi)for the third preceding year. For purposes of clause (v), a State is described in this clause, with respect to 2018 and 2019, if the State satisfies either of the following criterion: The ratio described in subclause
(II)of clause
(v)that would be determined for such State by substituting 2015 for each reference in such subclause to the third preceding year and by substituting all such States for the reference in item
(bb)of such subclause to all States described in clause
(vi)is greater than the ratio described in such subclause that would be determined for such State by substituting 2013 for each reference in such subclause to the third preceding year and by substituting all such States for the reference in item
(bb)of such subclause to all States described in clause
(vi). The State has fewer than three health insurance issuers offering qualified health plans through the Exchange for 2017. For purposes of paragraph (1), the amount determined under this paragraph for a year (beginning with 2020) during the period described in section 2201 for a State is an amount determined in accordance with an allocation methodology specified by the Administrator which— takes into consideration the adjusted incurred claims of such State, the number of residents of such State who for the previous year were not enrolled in a health plan or otherwise did not have health insurance coverage (including through a Federal or State health program) and whose income is below 100 percent of the poverty line applicable to a family of the size involved, and the number of health insurance issuers participating in the insurance market in such State for such year; is established after consultation with health care consumers, health insurance issuers, State insurance commissioners, and other stakeholders and after taking into consideration additional cost and risk factors that may inhibit health care consumer and health insurance issuer participation; and reflects the goals of improving the health insurance risk pool, promoting a more competitive health insurance market, and increasing choice for health care consumers. In carrying out subsection (b), the Administrator shall, with respect to a year (beginning with 2020 and ending with 2027), not later than March 31 of such year— determine the amount of funds, if any, from the amounts appropriated under subsection
(a)for the previous year but not allocated for such previous year; and if the Administrator determines that any funds were not so allocated for such previous year, allocate such remaining funds, in accordance with the allocation methodology specified pursuant to subsection (b)(2)(B)— to States that have submitted an application approved under section 2203(a) for such previous year for any purpose for which such an application was approved; and for States for which allocations were made pursuant to section 2203(b) for such previous year, to be used by the Administrator for such States, to carry out the Federal Invisible Risk Sharing Program in such States under section 2205; with, respect to a year before 2027, any remaining funds being made available for allocations to States for the subsequent year. Amounts appropriated under subsection
(a)for a year and allocated to States in accordance with this section shall remain available for expenditure through December 31, 2027. The Secretary may not make an allocation under this title for a State, with respect to a purpose described in section 2202— in the case of an allocation that would be made to a State pursuant to section 2203(a), if the State does not agree that the State will make available non-Federal contributions towards such purpose in an amount equal to— for 2020, 7 percent of the amount allocated under this subsection to such State for such year and purpose; for 2021, 14 percent of the amount allocated under this subsection to such State for such year and purpose; for 2022, 21 percent of the amount allocated under this subsection to such State for such year and purpose; for 2023, 28 percent of the amount allocated under this subsection to such State for such year and purpose; for 2024, 35 percent of the amount allocated under this subsection to such State for such year and purpose; for 2025, 42 percent of the amount allocated under this subsection to such State for such year and purpose; and for 2026, 50 percent of the amount allocated under this subsection to such State for such year and purpose; in the case of an allocation that would be made for a State pursuant to section 2203(b), if the State does not agree that the State will make available non-Federal contributions towards such purpose in an amount equal to— for 2020, 10 percent of the amount allocated under this subsection to such State for such year and purpose; for 2021, 20 percent of the amount allocated under this subsection to such State for such year and purpose; and for 2022, 30 percent of the amount allocated under this subsection to such State for such year and purpose; for 2023, 40 percent of the amount allocated under this subsection to such State for such year and purpose; for 2024, 50 percent of the amount allocated under this subsection to such State for such year and purpose; for 2025, 50 percent of the amount allocated under this subsection to such State for such year and purpose; and for 2026, 50 percent of the amount allocated under this subsection to such State for such year and purpose; or if such an allocation for such purpose would not be permitted under subsection (c)(7) of section 2105 if such allocation were payment made under such section. There is established within the Patient and State Stability Fund a Federal Invisible Risk Sharing Program (in this section referred to as the Program ), to be administered by the Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as the Administrator ), to provide payments to health insurance issuers with respect to claims for eligible individuals for the purpose of lowering premiums for health insurance coverage offered in the individual market. For the purpose of providing funding for the Program there is appropriated, out of any money in the Treasury not otherwise appropriated, $15,000,000,000 for the period beginning on January 1, 2018, and ending on December 31, 2026. Funds provided under section 2204(c)(2)(B) to carry out this section are in addition to the amount appropriated under paragraph (1). The Administrator shall establish, after consultation with health care consumers, health insurance issuers, State insurance commissioners, and other stakeholders and after taking into consideration high cost health conditions and other health trends that generate high cost, parameters for the operation of the Program consistent with this section and consistent with the same limitation on payment with respect to health insurance coverage that applies to payment with respect health benefits coverage under section 2105(c)(7). Not later than 60 days after the date of the enactment of this title, the Administrator shall establish sufficient parameters to specify how the Program will operate for plan year 2018. The Administrator shall establish a process for a State to operate the Program in such State beginning with plan year 2020. The parameters for the Program shall include the following: A definition for eligible individuals. The development and use of health status statements with respect to such individuals. The identification of health conditions that automatically qualify individuals as eligible individuals at the time of application for health insurance coverage. A process under which health insurance issuers may voluntarily qualify individuals, who do not automatically qualify under subparagraph (A), as eligible individuals at the time of application for such coverage. The percentage of the premiums paid, to health insurance issuers for health insurance coverage by eligible individuals, that shall be collected and deposited to the credit (and available for the use) of the Program. The dollar amount of claims for eligible individuals after which the Program will provide payments to health insurance issuers and the proportion of such claims above such dollar amount that the Program will pay. .
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Sec. 132
Patient and State Stability Fund
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