Sec. 44201. Addressing waste, fraud, and abuse in the ACA Exchanges

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Section 1311 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18031 ) is amended— in subsection (c)(6)— by striking subparagraph (A); by striking The Secretary and inserting the following: The Secretary ; by redesignating subparagraphs

(B)through

(D)as clauses

(i)through (iii), respectively, and adjusting the margins accordingly; in clause (i), as so redesignated, by striking periods, as determined by the Secretary for calendar years after the initial enrollment period; and inserting the following: periods for plans offered in the individual market— for enrollment for plan years beginning before January 1, 2026, as determined by the Secretary; and for enrollment for plan years beginning on or after January 1, 2026, beginning on November 1 and ending on December 15 of the preceding calendar year; ; in clause (ii), as so redesignated, by inserting subject to subparagraph (B), before special enrollment periods specified ; and by adding at the end the following new subparagraph: With respect to plan years beginning on or after January 1, 2026, the Secretary may not require an Exchange to provide for a special enrollment period for an individual on the basis of the relationship of the income of such individual to the poverty line, other than a special enrollment period based on a change in circumstances or the occurrence of a specific event. ; and in subsection (d), by adding at the end the following new paragraphs: An Exchange may not provide for, with respect to enrollment for plan years beginning on or after January 1, 2026— an annual open enrollment period other than the period described in subparagraph (A)(i) of subsection (c)(6); or a special enrollment period described in subparagraph

(B)of such subsection. With respect to enrollment for plan years beginning on or after January 1, 2026, an Exchange shall verify that each individual seeking to enroll in a qualified health plan offered by the Exchange during a special enrollment period selected under subparagraph

(B)is eligible to enroll during such special enrollment period prior to enrolling such individual in such plan. For purposes of subparagraph (A), an Exchange shall select one or more special enrollment periods for a plan year with respect to which such Exchange shall conduct the verification required under subparagraph

(A)such that the Exchange conducts such verification for not less than 75 percent of all individuals enrolling in a qualified health plan offered by the Exchange during any special enrollment period with respect to such plan year. . Section 1411(e)(4) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18081(e)(4) ) is amended— by redesignating subparagraph

(C)as subparagraph (E); and by inserting after subparagraph

(B)the following new subparagraphs: For plan years beginning on or after January 1, 2026, for purposes of subparagraph (A), in the case that the Exchange requests data from the Secretary of the Treasury regarding an individual’s household income and the Secretary of the Treasury does not return such data, such information may not be verified solely on the basis of the attestation of such individual with respect to such household income, and the Exchange shall take the actions described in subparagraph (A). Subject to clause

(iii), for plan years beginning on or after January 1, 2026, for purposes of subparagraph (A), in the case that a specified income discrepancy described in clause

(ii)of this subparagraph exists with respect to the information provided by an applicant under subsection (b)(3), the household income of such individual shall be treated as inconsistent with information in the records maintained by persons under subsection (c), or as not verified under subsection (d), and the Exchange shall take the actions described in such subparagraph (A). For purposes of clause

(i), a specified income discrepancy exists with respect to the information provided by an applicant under subsection (b)(3) if— the applicant attests to a projected annual household income that would qualify such applicant to be an applicable taxpayer under section 36B(c)(1)(A) of the Internal Revenue Code of 1986 with respect to the taxable year involved; the Exchange receives data from the Secretary of the Treasury or other reliable, third party data, that indicates that the household income of such applicant is less than the household income that would qualify such applicant to be an applicable taxpayer under such section 36B(c)(1)(A) with respect to the taxable year involved; such attested projected annual household income exceeds the income reflected in the data described in subclause

(II)by a reasonable threshold established by the Exchange and approved by the Secretary (which shall be not less than 10 percent, and may also be a dollar amount); and the Exchange has not assessed or determined based on the data described in subclause

(II)that the household income of the applicant meets the applicable income-based eligibility standard for the Medicaid program under title XIX of the Social Security Act or the State children’s health insurance program under title XXI of such Act. This subparagraph shall not apply in the case of an applicant who is an alien lawfully present in the United States, who is not eligible for the Medicaid program under title XIX of the Social Security Act by reason of such alien status. . Section 1412(b) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18082(b) ) is amended by adding at the end the following new paragraph: For plan years beginning on or after January 1, 2026, in the case of an individual with respect to whom any advance payment of the premium tax credit allowable under section 36B of the Internal Revenue Code of 1986 was made under this section to the issuer of a qualified health plan for the relevant prior tax year, an advance determination of eligibility for such premium tax credit may not be made under this subsection with respect to such individual and such plan year if the Exchange determines, based on information provided by the Secretary of the Treasury, that such individual— has not filed an income tax return, as required under sections 6011 and 6012 of such Code (and implementing regulations), for the relevant prior tax year; or as necessary, has not reconciled (in accordance with subsection

(f)of such section 36B) the advance payment of the premium tax credit made with respect to such individual for such relevant prior tax year. For purposes of subparagraph

(A), the term relevant prior tax year means, with respect to the advance determination of eligibility made under this subsection with respect to an individual, the taxable year for which tax return data would be used for purposes of verifying the household income and family size of such individual (as described in section 1411(b)(3)(A)). If an individual subject to subparagraph

(A)attests that such individual has fulfilled the requirements to file an income tax return for the relevant prior tax year and, as necessary, to reconcile the advance payment of the premium tax credit made with respect to such individual for such relevant prior tax year (as described in clauses

(i)and

(ii)of such subparagraph), the Secretary may make an initial advance determination of eligibility with respect to such individual and may delay for a reasonable period (as determined by the Secretary) any determination based on information provided by the Secretary of the Treasury that such individual has not fulfilled such requirements. If the Secretary determines that an individual did not meet the requirements described in subparagraph

(A)with respect to the relevant prior tax year and notifies the Exchange of such determination, the Exchange shall comply with the notification requirement described in section 155.305(f)(4)(i) of title 45, Code of Federal Regulations (as in effect with respect to plan year 2025). . The Secretary of Health and Human Services shall revise section 155.315(f) of title 45, Code of Federal Regulations, to remove paragraph

(7)of such section such that, with respect to enrollment for plan years beginning on or after January 1, 2026, in the case that an Exchange established under subtitle D of title I of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18021 et seq. ) provides an individual applying for enrollment in a qualified health plan with a 90-day period to resolve an inconsistency in the application of such individual pursuant to section 1411(e)(4)(A)(ii)(II) of such Act, the Exchange may not provide for an automatic extension to such 90-day period on the basis that such individual is required to present satisfactory documentary evidence to verify household income. The Secretary of Health and Human Services shall— revise section 156.140(c) of title 45, Code of Federal Regulations, to provide that, for plan years beginning on or after January 1, 2026, the allowable variation in the actuarial value of a health plan applicable under such section shall be the allowable variation for such plan applicable under such section for plan year 2022; revise section 156.200(b)(3) of title 45, Code of Federal Regulations, to provide that, for plan years beginning on or after January 1, 2026, the requirement for a qualified health plan issuer described in such section is that the issuer ensures that each qualified health plan complies with benefit design standards, as defined in section 156.20 of such title; and revise section 156.400 of title 45, Code of Federal Regulations, to provide that, for plan years beginning on or after January 1, 2026, the term de minimis variation for a silver plan variation means a minus 1 percentage point and plus 1 percentage point allowable actuarial value variation. Section 1302(c)(4) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18022(c)(4) ) is amended— by striking For purposes and inserting: For purposes ; and by adding at the end the following new subparagraph: For calendar years beginning with 2026, the premium adjustment percentage under this paragraph for such calendar year shall be determined consistent with the methodology published in the Federal Register on April 25, 2019 (84 Fed. Reg. 17537 through 17541). . The Secretary of Health and Human Services shall revise section 155.400(g) of title 45, Code of Federal Regulations to eliminate, for plan years beginning on or after January 1, 2026, the gross premium percentage-based premium payment threshold policy described in paragraph

(2)of such section and the fixed-dollar premium payment threshold policy described in paragraph

(3)of such section. The Secretary of Health and Human Services shall revise section 155.335(j) of title 45, Code of Federal Regulations to remove paragraph

(4)of such section such that, with respect to reenrollments for plan years beginning on or after January 1, 2026, an Exchange established under subtitle D of title I of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18021 et seq. ) may not reenroll an individual who was enrolled in a bronze level qualified health plan in a silver level qualified health plan (as such terms are defined in section 1301(a) and described in 1302(d) of such Act) unless otherwise permitted under section 155.335(j) of title 45, Code of Federal Regulations, as in effect on the day before the date of the enactment of this section. Section 1412 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18082 ) is amended— in subsection (a)(3), by inserting , subject to subsection (c)(2)(C), after qualified health plans ; and in subsection (c)(2)— in subparagraph (A), by striking The and inserting Subject to subparagraph (C), the ; and by adding at the end the following new subparagraph: The amount of an advance payment made under subparagraph

(A)to reduce the premium payable for a qualified health plan that provides coverage to a specified reenrolled individual for an applicable month shall be an amount equal to the amount that would otherwise be made under such subparagraph reduced by $5 (or such higher amount as the Secretary determines appropriate). In this subparagraph: The term applicable month means, with respect to a specified reenrolled individual, any month during a plan year beginning on or after January 1, 2027 (or, in the case of an individual reenrolled in a qualified health plan by an Exchange established pursuant to section 1321(c), January 1, 2026) if, prior to the first day of such month, such individual has failed to confirm or update such information as is necessary to redetermine the eligibility of such individual for such plan year pursuant to section 1411(f). The term specified reenrolled individual means an individual who is reenrolled in a qualified health plan and with respect to whom the advance payment made under subparagraph

(A)would, without application of any reduction under this subparagraph, reduce the premium payable for a qualified health plan that provides coverage to such an individual to $0. . Section 1302(b)(2) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18022(b)(2) ) is amended by adding at the end the following new subparagraph: For plan years beginning on or after January 1, 2027, the essential health benefits defined pursuant to paragraph

(1)may not include items and services furnished for a gender transition procedure. . Section 1304 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18024 ) is amended by adding at the end the following new subsection: In this title, except as provided in paragraph

(2), the term gender transition procedure means, with respect to an individual, any of the following when performed for the purpose of intentionally changing the body of such individual (including by disrupting the body’s development, inhibiting its natural functions, or modifying its appearance) to no longer correspond to the individual’s sex: Performing any surgery, including— castration; sterilization; orchiectomy; scrotoplasty; vasectomy; tubal ligation; hysterectomy; oophorectomy; ovariectomy; metoidioplasty; clitoroplasty; reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty; penectomy; phalloplasty; vaginoplasty; vaginectomy; vulvoplasty; reduction thyrochondroplasty; chondrolaryngoplasty; mastectomy; and any plastic, cosmetic, or aesthetic surgery that feminizes or masculinizes the facial or other body features of an individual. Any placement of chest implants to create feminine breasts or any placement of erection or testicular prosetheses. Any placement of fat or artificial implants in the gluteal region. Administering, prescribing, or dispensing to an individual medications, including— gonadotropin-releasing hormone

(GnRH)analogues or other puberty-blocking drugs to stop or delay normal puberty; and testosterone, estrogen, or other androgens to an individual at doses that are supraphysiologic than would normally be produced endogenously in a healthy individual of the same age and sex. Paragraph

(1)shall not apply to the following: Puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for an individual experiencing precocious puberty. Medically necessary procedures or treatments to correct for— a medically verifiable disorder of sex development, including— 46,XX chromosomes with virilization; 46,XY chromosomes with undervirilization; and both ovarian and testicular tissue; sex chromosome structure, sex steroid hormone production, or sex hormone action, if determined to be abnormal by a physician through genetic or biochemical testing; infection, disease, injury, or disorder caused or exacerbated by a previous procedure described in paragraph (1), or a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the individual in imminent danger of death or impairment of a major bodily function unless the procedure is performed, not including procedures performed for the alleviation of mental distress; or procedures to restore or reconstruct the body of the individual in order to correspond to the individual’s sex after one or more previous procedures described in paragraph

(1), which may include the removal of a pseudo phallus or breast augmentation. For purposes of this subsection, the term sex means either male or female, as biologically determined and defined by subparagraph

(A)and subparagraph

(B). The term female means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes eggs for fertilization. The term male means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes sperm for fertilization. . Section 1312(f) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18032(f) ) is amended by adding at the end the following new paragraph: In this title, the term alien lawfully present in the United States does not include an alien granted deferred action under the Deferred Action for Childhood Arrivals process pursuant to the memorandum of the Department of Homeland Security entitled Exercising Prosecutorial Discretion with Respect to Individuals Who Came to the United States as Children issued on June 15, 2012. . Section 1402(e)(2) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18071(e)(2) ) is amended by adding at the end the following new sentence: For purposes of this section, an individual shall not be treated as lawfully present if the individual is an alien granted deferred action under the Deferred Action for Childhood Arrivals process pursuant to the memorandum of the Department of Homeland Security entitled . Exercising Prosecutorial Discretion with Respect to Individuals Who Came to the United States as Children issued on June 15, 2012. Section 1412(d) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18082(d) ) is amended by adding at the end the following new sentence: For purposes of the previous sentence, an individual shall not be treated as lawfully present if the individual is an alien granted deferred action under the Deferred Action for Childhood Arrivals process pursuant to the memorandum of the Department of Homeland Security entitled . Exercising Prosecutorial Discretion with Respect to Individuals Who Came to the United States as Children issued on June 15, 2012. The amendments made by this section shall apply with respect to plan years beginning on or after January 1, 2026. Section 2702 of the Public Health Service Act ( 42 U.S.C. 300gg–1 ) is amended by adding at the end the following new subsection: A health insurance issuer offering individual health insurance coverage may, to the extent allowed under State law, deny such coverage in the case of an individual who owes any amount for premiums for individual health insurance coverage offered by such issuer (or by a health insurance issuer in the same controlled group (as defined in paragraph (3)) as such issuer) in which such individual was previously enrolled. A health insurance issuer offering individual health insurance coverage may, in the case of an individual described in paragraph

(1)and to the extent allowed under State law, attribute the initial premium payment for such coverage applicable to such individual to the amount owed by such individual for premiums for individual health insurance coverage offered by such issuer (or by a health insurance issuer in the same controlled group as such issuer) in which such individual was previously enrolled. For purposes of this subsection, the term controlled group means a group of of two or more persons that is treated as a single employer under section 52(a), 52(b), 414(m), or 414(o) of the Internal Revenue Code of 1986. . The amendment made by paragraph

(1)shall apply with respect to plan years beginning on or after January 1, 2026.

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