Sec. 3. 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, 2019, and ending on December 31, 2028, for the purposes described in section 2202.
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. 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 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.
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. 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 (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.
The Administrator shall make a determination as to the approval or disapproval of an application not later than 90 days after the receipt of such application. The Administrator shall make a determination as to the approval or disapproval of an application not later than 45 days after the receipt of such application if such application— is submitted in response to an urgent situation, with respect to areas in the State that the Administrator determines are at risk for excessive premium increases or having no health plans offered in the applicable health insurance market for the current or following plan year; or resembles an application that is the same or substantially similar to an application that the Administrator has already approved for another State.
If an application of a State is approved for a year, with respect to a purpose described in section 2202, such application shall also be treated as approved, with respect to such purpose, for each of the subsequent 4 years, but in no case shall an application be approved for a year after 2028. 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.
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, $11,500,000,000 for each of 2019 through 2028. From amounts appropriated under subsection
(a)for a year, the Administrator shall, with respect to a State and not later than January 1 of 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 paragraph (1), the amount determined under this paragraph for each of 2019 through 2021 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 2019, 2020, and 2021 is the product of— 90 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 2019, 2020, and 2021 is the product of— 10 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 2019, 2020, and 2021, 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 2022) 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 2022 and ending with 2028), 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), with, respect to a year before 2028, 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, 2028. 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, 5 percent of the amount allocated under this subsection to such State for such year and purpose; and for 2021 and each subsequent year through 2028, 10 percent of the amount allocated under this subsection to such State for such year and purpose. .
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Sec. 3
Patient and State Stability Fund
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