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S5682 CONGRESSIONAL RECORD SENATE September 13, 2017

for defense activities of the Depart- SA 1029. Mr. BROWN submitted an 3901) is amended by inserting after the item
ment of Energy, to prescribe military amendment intended to be proposed by relating to section 208 the following:
personnel strengths for such fiscal him to the bill H.R. 2810, to authorize Sec. 209. Protection of credit information
year, and for other purposes; which was appropriations for fiscal year 2018 for of servicemembers..
ordered to lie on the table; as follows: military activities of the Department
of Defense, for military construction, SA 1030. Mr. GRAHAM (for himself,
At the end of subtitle A of title XVI, add
and for defense activities of the De- Mr. CASSIDY, Mr. HELLER, Mr. JOHNSON,
the following:
partment of Energy, to prescribe mili- and Mr. BLUNT) submitted an amend-
SEC. 1607. ROBOTIC SERVICING OF GEO-
SYNCHRONOUS SATELLITES RE- tary personnel strengths for such fiscal ment intended to be proposed by him
PORTING REQUIREMENTS. year, and for other purposes; which was to the bill H.R. 1628, to provide for rec-
(a) REPORT REQUIRED.Concurrent with ordered to lie on the table; as follows: onciliation pursuant to title II of the
the submission of the budget of the Presi- concurrent resolution on the budget for
At the end of subtitle ll of title ll, add
dent to Congress under section 1105(a) of
the following: fiscal year 2017; which was ordered to
title 31, United States Code, for fiscal year lie on the table; as follows:
SEC. llll. PROTECTION OF CREDIT INFORMA-
2019, the Director of the Defense Advanced
TION OF SERVICEMEMBERS. Strike all after the enacting clause and in-
Research Projects Agency shall submit to
(a) IN GENERAL.Title II of the sert the following:
the congressional defense committees and
Servicemembers Civil Relief Act (50 U.S.C. TITLE I
the Comptroller General of the United States
3931 et seq.) is amended by adding at the end
a report on the Robotic Servicing of Geo- SEC. 101. ELIMINATION OF LIMITATION ON RE-
the following: CAPTURE OF EXCESS ADVANCE PAY-
synchronous Satellites program.
SEC. 209. PROTECTION OF CREDIT INFORMA- MENTS OF PREMIUM TAX CREDITS.
(b) COST ESTIMATES. TION OF SERVICEMEMBERS.
(1) IN GENERAL.The report required by Subparagraph (B) of section 36B(f)(2) of the
(a) DEFINITIONS.In this section Internal Revenue Code of 1986 is amended by
subsection (a) shall include an estimate, in
(1) the terms consumer reporting agency adding at the end the following new clause:
six-month increments, of the total cost for
and file have the meanings given those (iii) NONAPPLICABILITY OF LIMITATION.
the Department of Defense and all relevant
terms in section 603 of the Fair Credit Re- This subparagraph shall not apply to taxable
Federal agencies for the payload, operations
porting Act (15 U.S.C. 1681a); years ending after December 31, 2017..
software, payload integration, launch, and
(2) the term covered consumer reporting SEC. 102. PREMIUM TAX CREDIT.
spacecraft and relevant subsystem comple-
agency means a consumer reporting agency
tion under the Robotic Servicing of Geo- (a) PREMIUM TAX CREDIT.
that maintained a file on a servicemember
synchronous Satellites program. (1) MODIFICATION OF DEFINITION OF QUALI-
whose personally identifiable information
(2) PHASING OF COST ESTIMATE.The cost FIED HEALTH PLAN.
(A) was in the file; and
estimates required by paragraph (1) shall be (A) IN GENERAL.Section 36B(c)(3)(A) of
(B) was accessed in a manner not author-
phased over the entire development period the Internal Revenue Code of 1986 is amended
ized by law; and
and subdivided according to the costs of the by inserting before the period at the end the
(3) covered servicemember means a serv-
following: following: or a plan that includes coverage
icemember whose personally identifiable in-
(A) The program acquisition unit cost for for abortions (other than any abortion nec-
formation
the program. essary to save the life of the mother or any
(A) was in a file maintained by a con-
(B) Any cost variance or schedule variance abortion with respect to a pregnancy that is
sumer reporting agency; and
under the program since the contract was the result of an act of rape or incest).
(B) was accessed in a manner not author-
entered into. (B) EFFECTIVE DATE.The amendment
ized by law.
(C) Any significant changes that are (b) REQUIRED NOTIFICATION. made by this paragraph shall apply to tax-
known, expected, or anticipated by the pro- (1) INITIAL NOTIFICATION.Not later than able years beginning after December 31, 2017.
gram manager in 10 days after the date on which a covered (2) REPEAL.
(i) the total cost for development and pro- consumer reporting agency discovers that (A) IN GENERAL.Subpart C of part IV of
curement of the software component of the the personally identifiable information of a subchapter A of chapter 1 of the Internal
program or subprogram; covered servicemember in a file maintained Revenue Code of 1986 is amended by striking
(ii) schedule milestones for the software by the consumer reporting agency has been section 36B.
component of the program or subprogram; or accessed in a manner not authorized by law, (B) EFFECTIVE DATE.The amendment
(iii) expected performance for the software the covered consumer reporting agency shall made by this paragraph shall apply to tax-
component of the program or subprogram. notify the covered servicemember of the un- able years beginning after December 31, 2019.
(c) ASSESSMENT BY COMPTROLLER GENERAL authorized access, including a detailed de- (b) REPEAL OF ELIGIBILITY DETERMINA-
OF THE UNITED STATES.Not later than the TIONS.
scription of what information was accessed.
date that is 45 days after the date on which (2) ANNUAL NOTIFICATION.A covered con- (1) IN GENERAL.The following sections of
the Comptroller General receives the report sumer reporting agency shall submit to the the Patient Protection and Affordable Care
under subsection (a), the Comptroller Gen- covered servicemember annually the notifi- Act are repealed:
eral shall cation described in that paragraph (1) for a (A) Section 1411 (other than subsection (i),
(1) review the sufficiency of the cost esti- 10-year period beginning on the date on the last sentence of subsection (e)(4)(A)(ii),
mates required by subsection (b); and which the covered consumer reporting agen- and such provisions of such section solely to
(2) submit to the congressional defense cy discovers the unauthorized access. the extent related to the application of the
committees an assessment of those esti- (c) REIMBURSEMENT FOR CREDIT MONI- last sentence of subsection (e)(4)(A)(ii)).
mates, including by identifying cost, sched- TORING.A covered consumer reporting (B) Section 1412.
ule, or performance trends. agency shall reimburse a covered service- (2) EFFECTIVE DATE.The repeals in para-
(d) NOTIFICATION OF COMMERCIAL OPER- member the cost of 10 years of a credit moni- graph (1) shall take effect on January 1, 2020.
ATIONS.Following the demonstration of the toring and identity theft product chosen by SEC. 103. MODIFICATIONS TO SMALL BUSINESS
Robotic Servicing of Geosynchronous Sat- the covered servicemember. TAX CREDIT.
ellites program spacecraft and its transition (d) CONVENIENT, COST-FREE CREDIT (a) SUNSET.
to a commercial partner of the Defense Ad- FREEZE FOR SERVICEMEMBERS.A covered (1) IN GENERAL.Section 45R of the Inter-
vanced Research Projects Agency, the Sec- credit reporting agency shall provide to each nal Revenue Code of 1986 is amended by add-
retary of Defense shall be notified of each covered servicemember a convenient, cost- ing at the end the following new subsection:
commercial operation of the spacecraft. free method to prohibit all consumer report- (j) SHALL NOT APPLY.This section shall
(e) REPORT ON TECHNOLOGY TRANSFER. ing agencies from releasing any information not apply with respect to amounts paid or
Concurrent with the submission of the budg- in the file of the covered servicemember for incurred in taxable years beginning after De-
et of the President to Congress under section the purpose of the marketing or extension of cember 31, 2019..
1105(a) of title 31, United States Code, for fis- credit or opening of any financial account (2) EFFECTIVE DATE.The amendment
cal year 2019, the Secretary of Defense shall without the express authorization of the made by this subsection shall apply to tax-
submit to the congressional defense commit- servicemember. able years beginning after December 31, 2019.
tees a report on the technology transfer of (e) REGULATIONS.Not later than 1 year (b) DISALLOWANCE OF SMALL EMPLOYER
the robotic payload, operations software, and after the date of enactment of this section, HEALTH INSURANCE EXPENSE CREDIT FOR
corresponding systems of the Robotic Serv- the Bureau of Consumer Financial Protec- PLAN WHICH INCLUDES COVERAGE FOR ABOR-
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icing of Geosynchronous Satellites program tion shall promulgate regulations carrying TION.
to qualified satellite manufacturers and sat- out this section, including the method and (1) IN GENERAL.Subsection (h) of section
ellite operators to increase the on-orbit content of the notifications required under 45R of the Internal Revenue Code of 1986 is
highly advanced space robotics capabilities subsection (b).. amended
of entities organized under the laws of the (b) TECHNICAL AND CONFORMING AMEND- (A) by striking Any term and inserting
United States and available to the Depart- MENT.The table of contents of the the following:
ment of Defense. Servicemembers Civil Relief Act (50 U.S.C. (1) IN GENERAL.Any term, and

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September 13, 2017 CONGRESSIONAL RECORD SENATE S5683
(B) by adding at the end the following new an appropriate procedure for providing and (iii) A certification that none of the funds
paragraph: distributing funds under this subsection. provided under this subsection shall be used
(2) EXCLUSION OF HEALTH PLANS INCLUDING (4) USE OF FUNDS.Funds provided to a by the State for an expenditure that is at-
COVERAGE FOR ABORTION.The term quali- health insurance issuer under paragraph (1) tributable to an intergovernmental transfer,
fied health plan does not include any health shall be subject to the requirements of para- certified public expenditure, or any other ex-
plan that includes coverage for abortions graphs (1)(A)(iii) and (7) of subsection (i) in penditure to finance the non-Federal share of
(other than any abortion necessary to save the same manner as such requirements apply expenditures required under any provision of
the life of the mother or any abortion with to States receiving payments under sub- law, including under the State plans estab-
respect to a pregnancy that is the result of section (i) and shall be used only for the ac- lished under this title and title XIX or under
an act of rape or incest).. tivities specified in paragraph (1)(A)(i)(II) of a waiver of such plans.
(2) EFFECTIVE DATE.The amendments subsection (i). (iv) A description of any waiver of the
made by this subsection shall apply to tax- (i) MARKET-BASED HEALTH CARE GRANT provisions described in subparagraph (B)(i)
able years beginning after December 31, 2017. PROGRAM. that the State is requesting, and how the
SEC. 104. INDIVIDUAL MANDATE. (1) APPLICATION AND CERTIFICATION RE- State intends to maintain access to adequate
QUIREMENTS.
(a) IN GENERAL.Section 5000A(c) of the In- and affordable health insurance coverage for
(A) IN GENERAL.To be eligible for an al-
ternal Revenue Code of 1986 is amended individuals with pre-existing conditions if
lotment of funds under this subsection, a
(1) in paragraph (2)(B)(iii), by striking 2.5 such waiver is approved.
State shall submit to the Administrator an
percent and inserting Zero percent, and (v) Such other information as necessary
application, not later than March 31, 2019, in
(2) in paragraph (3) for the Administrator to carry out this sub-
the case of allotments for calendar year 2020,
(A) by striking $695 in subparagraph (A) section.
and not later than March 31 of the previous
and inserting $0, and (B) WAIVERS.
year, in the case of allotments for any subse-
(B) by striking subparagraph (D). (i) IN GENERAL.Subject to clause (ii), the
quent calendar year) and in such form and
(b) EFFECTIVE DATE.The amendments Secretary shall waive the requirements of
manner as specified by the Administrator,
made by this section shall apply to months the following Federal statutory provisions
that contains the following:
beginning after December 31, 2015. with respect to health insurance coverage in
(i) A description of how the funds will be
SEC. 105. EMPLOYER MANDATE. used to do 1 or more of the following: a State for a plan year during which the
(a) IN GENERAL. (I) To establish or maintain a program or State has an application approved under this
(1) Paragraph (1) of section 4980H(c) of the mechanism to help high-risk individuals in subsection and to the extent that such appli-
Internal Revenue Code of 1986 is amended by the purchase of health benefits coverage, in- cation includes a request for such a waiver
inserting ($0 in the case of months begin- cluding by reducing premium costs for such and the information described in subpara-
ning after December 31, 2015) after $2,000. individuals, who have or are projected to graph (A)(iv):
(2) Paragraph (1) of section 4980H(b) of the have a high rate of utilization of health serv- (I) Any provision that restricts the cri-
Internal Revenue Code of 1986 is amended by ices, as measured by cost, and who do not teria which a health insurance issuer may
inserting ($0 in the case of months begin- have access to health insurance coverage of- use to vary premium rates for health insur-
ning after December 31, 2015) after $3,000. fered through an employer, enroll in health ance coverage offered in the individual or
(b) EFFECTIVE DATE.The amendments insurance coverage under a plan offered in small group market, or the degree to which
made by this section shall apply to months the individual market (within the meaning an issuer may vary such rates, except that a
beginning after December 31, 2015. of section 5000A(f)(1)(C) of the Internal Rev- health insurance issuer may not vary pre-
SEC. 106. SHORT TERM ASSISTANCE FOR STATES enue Code of 1986). mium rates based on an individuals sex or
AND MARKET-BASED HEALTH CARE (II) To establish or maintain a program to membership in a protected class under the
GRANT PROGRAM. enter into arrangements with health insur- Constitution of the United States.
(a) IN GENERAL.Section 2105 of the Social ance issuers to assist in the purchase of (II) Any provision that prevents a health
Security Act (42 U.S.C. 1397ee) is amended by health benefits coverage by stabilizing pre- insurance issuer offering a coverage plan in
adding at the end the following new sub- miums and promoting State health insur- the individual or small group market from
sections: ance market participation and choice in requiring an individual to pay a premium or
(h) SHORT-TERM ASSISTANCE TO ADDRESS plans offered in the individual market (with- contribution (as a condition of enrollment or
COVERAGE AND ACCESS DISRUPTION AND PRO- in the meaning of section 5000A(f)(1)(C) of continued enrollment under the plan) which
VIDE SUPPORT FOR STATES. the Internal Revenue Code of 1986). is greater than such premium or contribu-
(1) APPROPRIATION.There are authorized (III) To provide payments for health care tion for a similarly situated individual en-
to be appropriated, and are appropriated, out providers for the provision of health care rolled in the plan on the basis of any health
of monies in the Treasury not otherwise obli- services, as specified by the Administrator. status-related factor in relation to the indi-
gated, $10,000,000,000 for calendar year 2019, (IV) To provide health insurance coverage vidual or to an individual enrolled under the
and $15,000,000,000 for calendar year 2020, to by funding assistance to reduce out-of-pock- plan as a dependent of the individual.
the Administrator of the Centers for Medi- et costs, such as copayments, coinsurance, (III) Any provision that requires a health
care & Medicaid Services (in this subsection and deductibles, of individuals enrolled in insurance issuer offering a coverage plan in
and subsection (i) referred to as the Admin- plans offered in the individual market (with- the individual or small group market to en-
istrator) to fund arrangements with health in the meaning of section 5000A(f)(1)(C) of sure that certain benefits are included in
insurance issuers to assist in the purchase of the Internal Revenue Code of 1986). such coverage.
health benefits coverage by addressing cov- (V) To establish or maintain a program or (IV) Any provision that requires a health
erage and access disruption and responding mechanism to help individuals purchase insurance issuer offering a coverage plan in
to urgent health care needs within States. health benefits coverage, including by reduc- the individual or small group market to pro-
Funds appropriated under this paragraph ing premium costs for plans offered in the in- vide a rebate to each enrollee under such
shall remain available until expended. dividual market (within the meaning of sec- coverage if the ratio of the amount of pre-
(2) PARTICIPATION REQUIREMENTS. tion 5000A(f)(1)(C) of the Internal Revenue mium revenue expended by the issuer on the
(A) GUIDANCE.Not later than 30 days Code of 1986) for individuals who do not have costs of providing such coverage for a plan
after the date of enactment of this sub- access to health insurance coverage offered year to the total amount of premium rev-
section, the Administrator shall issue guid- through an employer. enue for the plan year is less than a certain
ance to health insurance issuers regarding (VI) Subject to paragraph (4)(B)(iii), to percentage.
how to submit a notice of intent to partici- provide health insurance coverage for indi- (ii) SCOPE OF WAIVER.
pate in the program established under this viduals who are eligible for medical assist- (I) RELATIONSHIP TO GRANT PROGRAM.
subsection. ance under a State plan under title XIX by Any provision waived under this subpara-
(B) NOTICE OF INTENT TO PARTICIPATE.To establishing or maintaining relationships graph shall only be waived with respect to
be eligible for funding for a calendar year with health insurance issuers to provide such health insurance coverage that is
under this subsection, a health insurance coverage. (aa) provided by an health insurance
issuer shall submit to the Administrator a (VII) To assist in the purchase of health issuer that is receiving funding under a
notice of intent to participate not later than benefits coverage by establishing or main- State program that is funded by a grant
March 31 of the previous fiscal year, in such taining a program or mechanism, as speci- under this subsection; and
form and manner as specified by the Admin- fied by the State, to establish coverage pro- (bb) provided to an individual who is re-
istrator, and containing grams through arrangements with managed ceiving a direct benefit (including reduced
(i) a certification that the health insur- care organizations for the provision of health premium costs or reduced out-of-pocket
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ance issuer will use the funds in accordance care services to individuals who are not eli- costs) under a State program that is funded
with the requirements of paragraph (4); and gible for medical assistance or child health by a grant under this subsection.
(ii) such information as the Adminis- assistance under the State plans under title (II) LIMITATION.The Secretary shall not
trator may require to carry out this sub- XIX or this title. waive any requirement under a Federal stat-
section. (ii) A certification that the funds pro- ute enacted before January 1, 2009.
(3) PROCEDURE FOR DISTRIBUTION OF vided under this subsection shall only be (2) ELIGIBILITY.Only the 50 States and
FUNDS.The Administrator shall determine used for the activities specified in clause (i). the District of Columbia shall be eligible for

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S5684 CONGRESSIONAL RECORD SENATE September 13, 2017
an allotment and payments under this sub- (II) AVAILABILITY FOR 2026 ALLOTMENTS. (bb) shall not select any period of 4 con-
section and all references in this subsection To the extent that any funds reserved under secutive fiscal quarters that begins with a
to a State shall be treated as only referring clause (i) remain after December 31, 2020, fiscal quarter earlier than the first quarter
to the 50 States and the District of Colum- such funds shall be available for making al- of fiscal year 2014 or ends with a fiscal quar-
bia. lotments to States for calendar year 2026. ter later than the first fiscal quarter of 2018.
(3) ONE-TIME APPLICATION.If an applica- (5) DETERMINATION OF ALLOTMENT (iv) GROWTH FACTORS.The growth factor
tion of a State submitted under this sub- AMOUNTS. described in this clause for a State is
section is approved by the Administrator for (A) CALENDAR YEAR 2020. (I) for the amount described in subclause
a year, the application shall be deemed to be (i) IN GENERAL.Subject to subparagraph (I) of clause (i), the projected percentage in-
approved by the Administrator for that year (H), the amount determined under this para- crease in Medicaid expenditures from the
and each subsequent year through December graph for a State for calendar year 2020 shall last month of the States premium assist-
31, 2026. be equal to the States base period amount, ance base period to November of 2019, as de-
(4) MARKET-BASED HEALTH CARE GRANT AL- as defined in clause (ii). termined by the Medicaid and CHIP Pay-
LOTMENTS. (ii) BASE PERIOD AMOUNT.In this para- ment and Access Commission; and
(A) APPROPRIATION.For the purpose of graph, the term base period amount means, (II) for the amounts described in sub-
providing allotments to States under this with respect to a State, the sum of the fol- clauses (II), (III), and (IV) of clause (i), the
subsection, there is appropriated, out of any lowing amounts: percentage increase in the medical care com-
money in the Treasury not otherwise appro- (I) The amount, increased by the State ponent of the consumer price index for all
growth factor described in clause (iv)(I), of urban consumers (U.S. city average) from
priated
Federal payments the last month of the States premium as-
(i) for calendar year 2020, $146,000,000,000;
(aa) that were made to the State during sistance base period to November of 2019.
(ii) for calendar year 2021, $146,000,000,000;
the States premium assistance base period (B) CALENDAR YEARS 2021 THROUGH 2025.
(iii) for calendar year 2022, $157,000,000,000;
(as defined in clause (iii)) for medical assist- Subject to subparagraphs (D), (E), (F), (G),
(iv) for calendar year 2023, $168,000,000,000;
ance provided to individuals under clause and (H), for each of calendar years 2021
(v) for calendar year 2024, $179,000,000,000;
(i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) through 2025, the amount determined under
(vi) for calendar year 2025, $190,000,000,000;
(including medical assistance provided to in- this paragraph for a State and calendar year
and dividuals who are not newly eligible (as de- shall be equal to
(vii) for calendar year 2026, fined in section 1905(y)(2)) individuals de- (i) the amount determined for the State
$190,000,000,000. scribed in subclause (VIII) of section under this paragraph (including any applica-
(B) ALLOTMENTS; AVAILABILITY OF ALLOT- 1902(a)(10)(A)(i)); or ble adjustments) for the previous calendar
MENTS.
(bb) that would have been made to a year; plus
(i) IN GENERAL.In the case of a State State during the States premium assistance (ii) an amount equal to 16 of the dif-
with an application approved under this sub- base period for medical assistance provided ference between
section with respect to a year, the Adminis- to individuals who would have been described (I) the projected 2026 amount for the
trator shall allot to the State for the year, in section 1902(a)(10)(A)(i)(VIII) (without re- State and year (as defined in subparagraph
from amounts appropriated for such year gard to the first sunset date in such section) (J)); minus
under subparagraph (A), the amount deter- but who were provided such assistance under (II) the amount allotted to the State for
mined for the State and year under para- a title XIX State plan waiver that made calendar year 2020.
graph (5). medical assistance available to all individ- (C) CALENDAR YEAR 2026.Subject to sub-
(ii) AVAILABILITY OF ALLOTMENTS; UNUSED uals described in such subsection whose in- paragraphs (D), (E), (F), (G), and (H), for cal-
AMOUNTS. come did not exceed 100 percent of the pov- endar year 2026, the amount determined
(I) IN GENERAL.Amounts allotted to a erty line and that was in effect on September under this paragraph for a State shall be
State for a calendar year under this subpara- 1, 2017, if such assistance was treated as as- equal to the product of the amount appro-
graph shall remain available for obligation sistance under such section. priated for the year under paragraph
by the State through December 31 of the sec- (II) The amount, increased by the State (4)(A)(vii) (increased by any available
ond calendar year following the year for growth factor described in clause (iv)(II), of amounts described in paragraph (4)(C)(ii)(II))
which the allotment is made, except that in Federal payments made to the State during and the ratio of
no case shall amounts appropriated for any the States premium assistance base period (i) the number of low-income individuals
year before calendar year 2027 remain avail- for operating a Basic Health Program under (as defined in subparagraph (I)) in the State
able for obligation by a State after Decem- section 1331 of the Patient Protection and for calendar year 2025; to
ber 31, 2026. Affordable Care Act during such period. (ii) the number of low-income individuals
(II) UNUSED AMOUNTS TO BE USED FOR DEF- (III) The amount, increased by the State in all States for calendar year 2025.
ICIT REDUCTION.Amounts allotted to a growth factor described in clause (iv)(II), of (D) POPULATION RISK ADJUSTMENT.
State for a calendar year that remain unobli- advance payments of premium assistance (i) IN GENERAL.Subject to clauses (ii)
gated on April 1 of the following year shall credits allowable under section 36B of the In- and (iii), for each calendar year after 2020,
be deposited into the general fund of the ternal Revenue Code of 1986 made under sec- the Secretary shall adjust the amount deter-
Treasury and shall be used for deficit reduc- tion 1412(a) of the Patient Protection and Af- mined for each State for the year under sub-
tion fordable Care Act during the States pre- paragraph (B) or (C) so that the amount is
(iii) LIMITATION. mium assistance base period on behalf of in- equal to the product of
(I) IN GENERAL.Subject to subclause (II), dividuals who purchased insurance through (I) the amount so determined for the
in no case may a State use more than 15 per- the Exchange established for or by the State State and year; and
cent of the amount allotted to the State for pursuant to title I of such Act. (II) the population risk index (as defined
a year under this subparagraph for the pur- (IV) The amount, increased by the State in subparagraph (K)) for the State and year.
pose described in subclause (VI) of paragraph growth factor described in clause (iv)(II), of (ii) PHASE-IN OF POPULATION RISK ADJUST-
(1)(A)(i). Federal payments for cost-sharing reduc- MENT.For each of calendar years 2021
(II) EXCEPTION.The Secretary may per- tions provided during the States premium through 2023, the amount of the adjustment
mit a State to use not more than 20 percent assistance base period under section 1402 of determined for a State for a year under
of the amount allotted to the State for a such Act to individuals who purchased insur- clause (i) shall be reduced
year under this subparagraph for the purpose ance through the Exchange established for or (I) in calendar year 2021, by 75 percent;
described in subclause (VI) of paragraph by the State pursuant to title I of such Act. (II) in calendar year 2022, by 50 percent;
(1)(A)(i) if the State submits an application (iii) PREMIUM ASSISTANCE BASE PERIOD. and
to waive the restriction in subclause (I) and (I) IN GENERAL.In this paragraph, the (III) in calendar year 2023, by 25 percent.
the Secretary determines that the State is term premium assistance base period (iii) CAP ON RISK ADJUSTMENT.In no case
using such amounts allotted to the State to means, with respect to a State, a period of 4 shall the Secretary increase or reduce the
supplement, and not supplant, State expendi- consecutive fiscal quarters selected by the amount determined for a State and year
tures on the State plan under title XIX. State. under subparagraph (B) or (C) by an amount
(C) RESERVATION OF FUNDS FOR ADVANCED (II) TIMELINE.Each State shall submit that is greater than 10 percent of the amount
PAYMENTS TO STATES IN 2020. its selection of a premium assistance base so determined.
(i) IN GENERAL.From the amount appro- period to the Secretary not later than July (E) COVERAGE VALUE ADJUSTMENT.
priated for calendar year 2020, $10,000,000,000 1, 2018. (i) IN GENERAL.Subject to clause (iii),
shall be reserved for the purpose of increas- (III) PARAMETERS.In selecting a pre- for each calendar year after 2023, the amount
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ing State allotments for calendar year 2020 mium assistance base period under this determined for a State under subparagraph
under paragraph (9). clause, a State shall (B) or (C) and adjusted under subparagraph
(ii) AVAILABILITY OF RESERVED FUNDS. (aa) only select a period of 4 consecutive (D) shall be reduced by the coverage value
(I) IN GENERAL.Funds reserved under fiscal quarters for which all the data nec- adjustment amount determined for the State
clause (i) shall be available for the purpose essary to make determinations required and year under clause (ii).
described in such clause until December 31, under this paragraph is available, as deter- (ii) COVERAGE VALUE ADJUSTMENT
2020. mined by the Secretary; and AMOUNT.The coverage value adjustment

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September 13, 2017 CONGRESSIONAL RECORD SENATE S5685
amount determined under this clause for a justed gross income)) is greater than 45 per- (II) ANNUAL UPDATES.Not later than 15
State and year shall be equal to the amount, cent but less than 133 percent of the poverty days prior to the beginning of each calendar
if any, by which the amount determined for line (as defined in section 2110(c)(5), subject year, the Secretary shall make publicly
the State and year under subparagraph (B) to subparagraph (O)(ii)) applicable to a fam- available updates to the methodology se-
or (C) and adjusted under subparagraph (D) ily of the size involved. lected under subclause (I).
exceeds the product of (J) PROJECTED 2026 AMOUNT.The term (M) CLINICAL RISK FACTOR.The term
(I) the amount so determined and ad- projected 2026 amount means, with respect clinical risk factor means, with respect to
justed for the State and year; and to a State and calendar year, the product of each clinical risk category and calendar
(II) the ratio of the amount appropriated for calendar year year, the ratio of
(aa) the average actuarial value of health 2026 under paragraph (4)(A)(vii) and the ratio (i) the average per capita amount of ex-
care coverage for low-income individuals in of penditures for all States for the previous cal-
the State for the previous calendar year, as (i) the number of low-income individuals endar year for low-income individuals in the
determined under subparagraph (N); and (as defined in subparagraph (I)) in the State category; to
(bb) the lowest possible actuarial value of for the calendar year preceding the calendar (ii) the average per capita amount of ex-
health benefits coverage that would satisfy year involved; to penditures for all States for the previous cal-
the requirements of section 2103(a) (or, if ap- (ii) the number of low-income individuals endar year for all low-income individuals.
plicable, any waiver of such requirements in all States for such preceding year. (N) DETERMINATION OF ACTUARIAL VALUE
that is effective in such State for such year) (K) POPULATION RISK INDEX.The term OF COVERAGE.In determining the average
if such coverage were provided as child
population risk index means, for a State for actuarial value of coverage for low-income
health assistance to a targeted low-income
a calendar year, the ratio of individuals for a State and calendar year
child under the State child health plan.
(i) the sum of the products, for each of (i) any plan offered on the health insur-
(iii) PHASE-IN OF COVERAGE VALUE ADJUST-
the clinical risk categories (as defined in ance marketplace established for or by the
MENT.For each of calendar years 2024
subparagraph (L)(i)), of State that does not offer a benefits package
through 2026, the amount of any reduction
(I) the clinical risk factor for the cat- that is at least equivalent to one of the
determined for a State for a year under
egory (as defined in subparagraph (M)); and benchmark benefits packages described in
clause (ii) shall be reduced
(I) in calendar year 2024, by 75 percent; (II) the number of low-income individuals section 2103(b) shall be deemed to have an ac-
(II) in calendar year 2025, by 50 percent; for the State, year, and category; to tuarial value of 40 percent; and
and (ii) the number of enrollees in the State. (ii) any low-income individual who is not
(III) in calendar year 2026, by 25 percent. (L) CLINICAL RISK CATEGORY. enrolled in any plan for health benefits cov-
(F) STATE SPECIFIC POPULATION ADJUST- (i) IN GENERAL.The term clinical risk erage for more than 3 months during such
MENT FACTOR.
category means a grouping of low-income year shall be deemed to have been enrolled
(i) IN GENERAL.For calendar years after individuals based on their clinical character- in a plan for health benefits coverage with
2020, the Secretary may adjust the amount istics that is established by the Secretary an actuarial value of 0 percent.
determined for a State for a year under sub- under this subparagraph. (O) POPULATION AND POVERTY DATA.
paragraph (B) or (C) and adjusted under sub- (ii) METHODOLOGY FOR ESTABLISHING CAT- (i) IN GENERAL.In making the deter-
paragraphs (D) and (E) according to a popu- EGORIES AND ASSIGNING INDIVIDUALS TO A CAT- minations required under this paragraph, the
lation adjustment factor developed by the EGORY.The Secretary shall select a meth- Secretary shall, where appropriate, use data
Secretary. odology for establishing clinical risk cat- from the most recently available Current
(ii) DEVELOPMENT OF POPULATION ADJUST- egories and for assigning low-income individ- Population Survey of the Bureau of the Cen-
MENT FACTOR.Not later than July 31, 2019, uals to such categories, except that any sus.
the Secretary shall develop a State specific methodology selected by the Secretary shall (ii) USE OF SEPARATE POVERTY LINES.In
population adjustment factor that accounts meet the following requirements: the case of a State for which the Secretary
for legitimate factors that impact the health (I) The methodology shall be composed of has issued under the authority of section
care expenditures in a State beyond the clin- exhaustive and mutually exclusive risk cat- 673(2) of the Omnibus Budget Reconciliation
ical characteristics of the low-income indi- egories such that every low-income indi- Act of 1981 a separate poverty guideline for
viduals in the State. Such factors may in- vidual is assigned to a risk category and 2017 that is higher than the poverty line (as
clude State demographics, wage rates, in- each individual may be assigned to only one defined in section 2110(c)(5)) that is applica-
come levels, and other factors as determined risk category. ble to the majority of States, the Secretary
by the Secretary. (II) The methodology shall account for shall determine the number of low-income
(G) 2026 REDUCTION FOR STATES RECEIVING clinical characteristics of individuals that individuals in such State using such separate
ADVANCED PAYMENTS IN 2020.For calendar impact per capita health care expenditures. poverty guideline instead of such poverty
year 2026, the amount determined for a State (III) The methodology shall account for line.
for such year under subparagraph (C) and ad- the chronic illness burden associated with (6) PAYMENTS.
justed under subparagraphs (D), (E), and (F), multiple comorbid chronic diseases and be (A) IN GENERAL.The Administrator shall
shall be reduced by the amount of any in- composed of risk categories that explicitly pay to each State that has an application ap-
crease to the States allotment for calendar differentiate individuals based on their se- proved under this subsection for a year, from
year 2020 under paragraph (9). verity of illness. the amount allotted to the State under para-
(H) PRORATION RULE. (IV) The methodology shall include risk graph (4)(B) for the year, an amount equal to
(i) IN GENERAL.In no case shall the total categories that account for complex pedi- the States expenditures for the year on the
amount of State allotments (including any atric enrollees. activities described by the State in its appli-
adjustments under subparagraphs (D), (E), (V) The methodology for assigning indi- cation approved under paragraph (1).
(F), and (G)) determined for a calendar year viduals to such clinical risk categories shall (B) ADVANCE PAYMENT; RETROSPECTIVE AD-
under this paragraph exceed the amount ap- be based on characteristics of individuals JUSTMENT.
propriated for a calendar year under para- contained in data routinely collected in ad- (i) IN GENERAL.If the Administrator
graph (4)(A) (increased, in the case of cal- ministrative claims data and shall be capa- deems it appropriate, the Administrator
endar year 2026, by any available amounts ble of utilizing pharmacy data and func- shall make payments under this subsection
described in paragraph (4)(C)(ii)(II)). tional health status data when such data be- for each 6 month period in a year on the
(ii) PRORATION.If the amount so appro- comes routinely available. basis of advance estimates of expenditures
priated (VI) To the extent possible, the method- submitted by the State and such other inves-
(I) is less than the total amount of State ology shall be a methodology that has been tigation as the Administrator shall find nec-
allotments determined for such year under implemented for the purpose of determining essary, and shall reduce or increase the pay-
this paragraph (after any adjustments under per capita payments by a State plan under ments as necessary to adjust for any over-
subparagraphs (D), (E), (F), and (G)), the title XIX to a managed care entity respon- payment or underpayment for prior periods.
amount allotted to each State for such year sible for providing or arranging for services (ii) MISUSE OF FUNDS.If the Adminis-
shall be reduced proportionally; and for a population of enrollees that includes trator determines that a State is not using
(II) is greater than the total amount of enrollees with complex pediatric conditions funds paid to the State under this subsection
State allotments determined for such year and enrollees who are eligible for benefits in a manner consistent with the description
under this paragraph (after any adjustments under both titles XVIII and XIX. provided by the State in its application ap-
under subparagraphs (D), (E), (F), and (G)), (VII) The methodology shall be open, proved under paragraph (1) or is inappropri-
the amount allotted to each State for such transparent, and available for review and ately withholding payments owed to pro-
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year shall be increased proportionally. comment by the public. viders of services or health insurance issuers,
(I) LOW-INCOME INDIVIDUAL.In this para- (iii) TIMELINE. the Administrator may withhold payments,
graph, the term low-income individual (I) IN GENERAL.The Secretary shall se- reduce payments, or recover previous pay-
means an individual lect the methodology for establishing clin- ments to the State under this subsection as
(i) who is a citizen or legal resident; and ical risk categories and assigning low-in- the Administrator deems appropriate.
(ii) whose income (as determined under come individuals to such categories not later (C) FLEXIBILITY IN SUBMITTAL OF CLAIMS.
section 1902(e)(14) (relating to modified ad- than January 1, 2020. Nothing in this subsection shall be construed

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S5686 CONGRESSIONAL RECORD SENATE September 13, 2017
as preventing a State from claiming as ex- out short-term assistance activities under (1) by striking and any dependent (as de-
penditures in the year expenditures that subsection (h) or the Market-Based Health fined in section 152, determined without re-
were incurred in a previous year. Care Grant Program established in sub- gard to subsections (b)(1), (b)(2), and (d)(1)(B)
(7) EXEMPTIONS.Paragraphs (2), (3), (5), section (i) and, except in the case of funds thereof) of such individual in subparagraph
(6), (8), (10), and (11) of subsection (c) do not made available under subsection (h) or (i), (A) and inserting any dependent (as defined
apply to payments under this subsection. may not include. in section 152, determined without regard to
(8) CONTINGENCY FUND. (3) Section 2106(a)(1) of such Act (42 U.S.C. subsections (b)(1), (b)(2), and (d)(1)(B) there-
(A) IN GENERAL.From the amount appro- 1397ff(a)(1)) is amended by inserting sub- of) of such individual, and any child (as de-
priated under subparagraph (C), the Sec- section (a) or (g) of before section 2105. fined in section 152(f)(1)) of such individual
retary may increase the allotment amount SEC. 107. BETTER CARE RECONCILIATION IMPLE- who has not attained the age of 27 before the
determined under paragraph (5) for each of MENTATION FUND. end of such individuals taxable year,
calendar years 2020 and 2021 for any State (a) IN GENERAL.There is hereby estab- (2) by striking subparagraph (B) and insert-
that is a low-density State or a non-expan- lished a Better Care Reconciliation Imple- ing the following:
sion State for the year. mentation Fund (referred to in this section (B) HEALTH INSURANCE MAY NOT BE PUR-
(B) DEFINITIONS.In this paragraph: as the Fund) within the Department of CHASED FROM ACCOUNT.Except as provided
(i) LOW-DENSITY STATE DEFINED.The Health and Human Services to provide for in subparagraph (C), subparagraph (A) shall
term low-density State means, with respect Federal administrative expenses in carrying not apply to any payment for insurance.,
to a calendar year, a State that has a popu- out this Act. and
lation density of less than 15 individuals per (b) FUNDING.There is appropriated to the (3) by striking or at the end of subpara-
square mile, based on the most recent data Fund, out of any funds in the Treasury not graph (C)(iii), by striking the period at the
available from the Bureau of the Census. otherwise appropriated, $2,000,000,000. end of subparagraph (C)(iv) and inserting ,
(ii) NON-EXPANSION STATE.The term SEC. 108.
REPEAL OF TAX ON OVER-THE- or, and by adding at the end the following:
non-expansion State means a State that COUNTER MEDICATIONS. (v) a high deductible health plan but only
(I) is not a low-density State; and (a) HSAS.Subparagraph (A) of section to the extent of the portion of such expense
(II) did not provide eligibility under sec- 223(d)(2) of the Internal Revenue Code of 1986 in excess of
tion 1902(a)(10)(A)(i)(VIII) for medical assist- is amended by striking Such term and all (I) any amount allowable as a credit
ance under the State plan under title XIX on under section 36B for the taxable year with
that follows through the period.
September 1, 2017 (or provided eligibility for (b) ARCHER MSAS.Subparagraph (A) of respect to such coverage,
individuals described in such section under a (II) any amount allowable as a deduction
section 220(d)(2) of the Internal Revenue
waiver of the State plan approved under sec- under section 162(l) with respect to such cov-
Code of 1986 is amended by striking Such
tion 1115). erage, or
term and all that follows through the pe-
(C) FUNDING. (III) any amount excludable from gross
riod.
(i) IN GENERAL.There is appropriated, income with respect to such coverage under
(c) HEALTH FLEXIBLE SPENDING ARRANGE-
out of any money in the Treasury not other- section 106 (including by reason of section
MENTS AND HEALTH REIMBURSEMENT AR-
wise appropriated, $6,000,000,000 for calendar 125) or 402(l)..
RANGEMENTS.Section 106 of the Internal
year 2020, and $5,000,000,00 for calendar year (b) EFFECTIVE DATE.The amendments
Revenue Code of 1986 is amended by striking
2021, for the purpose of carrying out this made by this section shall apply with respect
subsection (f).
paragraph. to amounts paid for expenses incurred for,
(d) EFFECTIVE DATES.
(ii) RESERVATION OF FUNDS.The Sec- and distributions made for, coverage under a
(1) DISTRIBUTIONS FROM SAVINGS AC-
retary shall reserve, for each of calendar high deductible health plan beginning after
COUNTS.The amendments made by sub-
years 2020 and 2021, from the funds appro- December 31, 2017.
sections (a) and (b) shall apply to amounts
priated for each such year under clause (i)
paid with respect to taxable years beginning SEC. 113. PRIMARY CARE ENHANCEMENT.
(I) 25 percent of such funds for the pur-
after December 31, 2016. (a) TREATMENT OF DIRECT PRIMARY CARE
pose of increasing the grant amounts for
(2) REIMBURSEMENTS.The amendment SERVICE ARRANGEMENTS.Section 223(c) of
States that are low-density States; and
made by subsection (c) shall apply to ex- the Internal Revenue Code of 1986 is amended
(II) 75 percent of such funds for the pur-
penses incurred with respect to taxable years by adding at the end the following new para-
pose of increasing the grant amounts for
States that are non-expansion States. beginning after December 31, 2016. graph:
(9) ADVANCE PAYMENT FUND. SEC. 109. REPEAL OF TAX ON HEALTH SAVINGS (6) TREATMENT OF DIRECT PRIMARY CARE
ACCOUNTS. SERVICE ARRANGEMENTS.An arrangement
(A) IN GENERAL.From the amount re-
served under paragraph (4)(C), the Secretary (a) HSAS.Section 223(f)(4)(A) of the Inter- under which an individual is provided cov-
may increase the allotment amount deter- nal Revenue Code of 1986 is amended by erage restricted to primary care services in
mined under paragraph (5) for calendar year striking 20 percent and inserting 10 per- exchange for a fixed periodic fee or payment
2020 for any State that applies for an in- cent. for such services
crease under this paragraph by the amount (b) ARCHER MSAS.Section 220(f)(4)(A) of (A) shall not be treated as a health plan
determined for the State under subparagraph the Internal Revenue Code of 1986 is amended for purposes of paragraph (1)(A)(ii), and
(B). by striking 20 percent and inserting 15 (B) shall not be treated as insurance for
(B) AMOUNT OF INCREASE.Subject to sub- percent. purposes of subsection (d)(2)(B)..
(c) EFFECTIVE DATE.The amendments (b) CERTAIN PROVIDER FEES TO BE TREATED
paragraph (C), the Secretary shall increase
made by this section shall apply to distribu- AS MEDICAL CARE.Section 213(d) of the In-
the allotment amount determined under
tions made after December 31, 2016. ternal Revenue Code of 1986 is amended by
paragraph (5) for a State for calendar year
SEC. 110. REPEAL OF MEDICAL DEVICE EXCISE adding at the end the following new para-
2020 by the amount requested by the State,
TAX. graph:
except that in no case shall the Secretary in-
Section 4191 of the Internal Revenue Code (12) PERIODIC PROVIDER FEES.The term
crease a States allotment amount by an
of 1986 is amended by adding at the end the medical care shall include periodic fees paid
amount that exceeds 5 percent of the amount
following new subsection: for a defined set of primary care medical
so determined.
(d) APPLICABILITY.The tax imposed services provided on an as-needed basis..
(C) PRORATION RULE.If the amount re-
under subsection (a) shall not apply to sales (c) EFFECTIVE DATE.The amendments
served under paragraph (4)(C) is less than the
after December 31, 2017.. made by this section shall apply to taxable
total amount of increases requested by
years beginning after December 31, 2016.
States under this paragraph, the amount of SEC. 111. REPEAL OF ELIMINATION OF DEDUC-
TION FOR EXPENSES ALLOCABLE TO SEC. 114. MAXIMUM CONTRIBUTION LIMIT TO
the increase for each State shall be reduced HEALTH SAVINGS ACCOUNT IN-
proportionally.. MEDICARE PART D SUBSIDY.
CREASED TO AMOUNT OF DEDUCT-
(b) OTHER TITLE XXI AMENDMENTS. (a) IN GENERAL.Section 139A of the Inter- IBLE AND OUT-OF-POCKET LIMITA-
(1) Section 2101 of such Act (42 U.S.C. nal Revenue Code of 1986 is amended by add- TION.
1397aa) is amended ing at the end the following new sentence: (a) SELF-ONLY COVERAGE.Section
(A) in subsection (a), in the matter pre- This section shall not be taken into ac- 223(b)(2)(A) of the Internal Revenue Code of
ceding paragraph (1), by striking The pur- count for purposes of determining whether 1986 is amended by striking $2,250 and in-
pose and inserting Except with respect to any deduction is allowable with respect to serting the amount in effect under sub-
short-term assistance activities under sec- any cost taken into account in determining section (c)(2)(A)(ii)(I).
tion 2105(h) and the Market-Based Health such payment.. (b) FAMILY COVERAGE.Section 223(b)(2)(B)
Care Grant Program established in section (b) EFFECTIVE DATE.The amendment of such Code is amended by striking $4,500
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2105(i), the purpose; and made by this section shall apply to taxable and inserting the amount in effect under
(B) in subsection (b), in the matter pre- years beginning after December 31, 2016. subsection (c)(2)(A)(ii)(II).
ceding paragraph (1), by inserting sub- SEC. 112. PURCHASE OF INSURANCE FROM (c) COST-OF-LIVING ADJUSTMENT.Section
section (a) or (g) of before section 2105. HEALTH SAVINGS ACCOUNT. 223(g)(1) of such Code is amended
(2) Section 2105(c)(1) of such Act (42 U.S.C. (a) IN GENERAL.Paragraph (2) of section (1) by striking subsections (b)(2) and
1397ee(c)(1)) is amended by striking and 223(d) of the Internal Revenue Code of 1986 is both places it appears and inserting sub-
may not include and inserting or to carry amended section, and

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September 13, 2017 CONGRESSIONAL RECORD SENATE S5687
(2) in subparagraph (B), by striking deter- any abortion necessary to save the life of the (cc) reside in a State that provided for
mined by and all that follows through mother or any abortion with respect to a medical assistance under such subclause on
calendar year 2003. and inserting deter- pregnancy that is the result of an act of rape December 31, 2019;
mined by substituting calendar year 2003 or incest).. (dd) were enrolled under the State plan
for calendar year 1992 in subparagraph (B) (b) EFFECTIVE DATE.The amendment under this title (or a waiver of such plan) on
thereof.. made by this section shall apply with respect December 31, 2019; and
(d) EFFECTIVE DATE.The amendments to coverage under a high deductible health (ee) after December 31, 2019, do not have a
made by this section shall apply to taxable plan beginning after December 31, 2017. break in eligibility for medical assistance
years beginning after December 31, 2017. SEC. 118. FEDERAL PAYMENTS TO STATES. under the State plan under this title for such
SEC. 115.ALLOW BOTH SPOUSES TO MAKE (a) IN GENERAL.Notwithstanding section a period of time as the State may specify
CATCH-UP CONTRIBUTIONS TO THE 504(a), 1902(a)(23), 1903(a), 2002, 2005(a)(4), (but which in no case shall be less than 6
SAME HEALTH SAVINGS ACCOUNT. 2102(a)(7), or 2105(a)(1) of the Social Security months); and
(a) IN GENERAL.Section 223(b)(5) of the In- Act (42 U.S.C. 704(a), 1396a(a)(23), 1396b(a), (B) in subsection (a)(47)(B), by inserting
ternal Revenue Code of 1986 is amended to 1397a, 1397d(a)(4), 1397bb(a)(7), 1397ee(a)(1)), or and provided that any such election shall
read as follows: the terms of any Medicaid waiver in effect on cease to be effective on January 1, 2020, and
(5) SPECIAL RULE FOR MARRIED INDIVID- the date of enactment of this Act that is ap- no such election shall be made after that
UALS WITH FAMILY COVERAGE. proved under section 1115 or 1915 of the So- date before the semicolon at the end;
(A) IN GENERAL.In the case of individ- cial Security Act (42 U.S.C. 1315, 1396n), for (2) in section 1905
uals who are married to each other, if both the 1-year period beginning on the date of (A) in the first sentence of subsection (b),
spouses are eligible individuals and either enactment of this Act, no Federal funds pro- by inserting (50 percent on or after January
spouse has family coverage under a high de- vided from a program referred to in this sub- 1, 2020) after 55 percent;
ductible health plan as of the first day of any section that is considered direct spending for (B) in subsection (y)(1), by striking the
month any year may be made available to a State semicolon at the end of subparagraph (D) and
(i) the limitation under paragraph (1) for payments to a prohibited entity, whether all that follows through thereafter; and
shall be applied by not taking into account made directly to the prohibited entity or (C) in subsection (z)(2)
any other high deductible health plan cov- through a managed care organization under (i) in subparagraph (A), by inserting
erage of either spouse (and if such spouses contract with the State. through 2019 after each year thereafter;
both have family coverage under separate (b) DEFINITIONS.In this section: and
high deductible health plans, only one such (1) PROHIBITED ENTITY.The term prohib- (ii) in subparagraph (B)(ii):
coverage shall be taken into account), ited entity means an entity, including its (I) in subclause (V), by striking 2018 is 90
(ii) such limitation (after application of affiliates, subsidiaries, successors, and clin- inserting 2018 and 2019 is 90 percent; and
ics (II) in subclause (VI) by striking 2019 and
clause (i)) shall be reduced by the aggregate
(A) that, as of the date of enactment of each subsequent year is 90 percent and in-
amount paid to Archer MSAs of such spouses
this Act serting 2020 and each subsequent year is 0
for the taxable year, and
(i) is an organization described in section percent;
(iii) such limitation (after application of
501(c)(3) of the Internal Revenue Code of 1986 (3) in section 1915(k)(2), by striking during
clauses (i) and (ii)) shall be divided equally
and exempt from tax under section 501(a) of the period described in paragraph (1) and in-
between such spouses unless they agree on a
such Code; serting on or after the date referred to in
different division.
(ii) is an essential community provider de- paragraph (1) and before January 1, 2020;
(B) TREATMENT OF ADDITIONAL CONTRIBU-
scribed in section 156.235 of title 45, Code of (4) in section 1920(e), by adding at the end
TION AMOUNTS.If both spouses referred to in
Federal Regulations (as in effect on the date the following: This subsection shall not
subparagraph (A) have attained age 55 before
of enactment of this Act), that is primarily apply after December 31, 2019.;
the close of the taxable year, the limitation
engaged in family planning services, repro- (5) in section 1937(b)(5), by adding at the
referred to in subparagraph (A)(iii) which is
ductive health, and related medical care; and end the following: This paragraph shall not
subject to division between the spouses shall
(iii) provides for abortions, other than an apply after December 31, 2019.; and
include the additional contribution amounts
abortion (6) in section 1943(a), by inserting and be-
determined under paragraph (3) for both
(I) if the pregnancy is the result of an act fore January 1, 2020, after January 1,
spouses. In any other case, any additional
of rape or incest; or 2014,.
contribution amount determined under para-
(II) in the case where a woman suffers from SEC. 120. REDUCING STATE MEDICAID COSTS.
graph (3) shall not be taken into account
a physical disorder, physical injury, or phys- (a) IN GENERAL.
under subparagraph (A)(iii) and shall not be
ical illness that would, as certified by a phy- (1) STATE PLAN REQUIREMENTS.Section
subject to division between the spouses..
(b) EFFECTIVE DATE.The amendment sician, place the woman in danger of death 1902(a)(34) of the Social Security Act (42
made by this section shall apply to taxable unless an abortion is performed, including a U.S.C. 1396a(a)(34)) is amended by striking
years beginning after December 31, 2017. life-endangering physical condition caused in or after the third month and all that
SEC. 116. SPECIAL RULE FOR CERTAIN MEDICAL
by or arising from the pregnancy itself; and follows through individual) and inserting
EXPENSES INCURRED BEFORE ES- (B) for which the total amount of Federal in or after the second month before the
TABLISHMENT OF HEALTH SAVINGS and State expenditures under the Medicaid month in which the individual (or, in the
ACCOUNT. program under title XIX of the Social Secu- case of a deceased individual, another indi-
(a) IN GENERAL.Section 223(d)(2) of the In- rity Act in fiscal year 2014 made directly to vidual acting on the individuals behalf)
ternal Revenue Code of 1986 is amended by the entity and to any affiliates, subsidiaries, made application (or, in the case of an indi-
adding at the end the following new subpara- successors, or clinics of the entity, or made vidual who is 65 years of age or older or who
graph: to the entity and to any affiliates, subsidi- is eligible for medical assistance under the
(D) TREATMENT OF CERTAIN MEDICAL EX- aries, successors, or clinics of the entity as plan on the basis of being blind or disabled,
PENSES INCURRED BEFORE ESTABLISHMENT OF part of a nationwide health care provider in or after the month before such second
ACCOUNT.If a health savings account is es- network, exceeded $1,000,000. month).
tablished during the 60-day period beginning (2) DIRECT SPENDING.The term direct (2) DEFINITION OF MEDICAL ASSISTANCE.
on the date that coverage of the account spending has the meaning given that term Section 1905(a) of the Social Security Act (42
beneficiary under a high deductible health under section 250(c) of the Balanced Budget U.S.C. 1396d(a)) is amended by striking in or
plan begins, then, solely for purposes of de- and Emergency Deficit Control Act of 1985 (2 after the third month before the month in
termining whether an amount paid is used U.S.C. 900(c)). which the recipient makes application for
for a qualified medical expense, such account SEC. 119. MEDICAID. assistance and inserting in or after the
shall be treated as having been established The Social Security Act (42 U.S.C. 301 et second month before the month in which the
on the date that such coverage begins.. seq.) is amended recipient makes application for assistance,
(b) EFFECTIVE DATE.The amendment (1) in section 1902 or, in the case of a recipient who is 65 years
made by this subsection shall apply with re- (A) in subsection (a)(10)(A) of age or older or who is eligible for medical
spect to coverage under a high deductible (i) in each of clauses (i)(VIII) and (ii)(XX), assistance on the basis of being blind or dis-
health plan beginning after December 31, by inserting and ending September 1, 2017 abled at the time application is made, in or
2017. (or, in the case of a State that provided for after the month before such second month,.
SEC. 117. EXCLUSION FROM HSAS OF HIGH DE- medical assistance under this subclause on (b) EFFECTIVE DATE.The amendments
DUCTIBLE HEALTH PLANS INCLUD- July 1, 2016, December 31, 2019), after Jan- made by subsection (a) shall apply to med-
ING COVERAGE FOR ABORTION. uary 1, 2014,; and ical assistance with respect to individuals
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(a) IN GENERAL.Subparagraph (C) of sec- (ii) in clause (ii), by adding at the end the whose eligibility for such assistance is based
tion 223(d)(2) of the Internal Revenue Code of following new subclause: on an application for such assistance made
1986 is amended by adding at the end the fol- (XXIII) beginning January 1, 2020, who (or deemed to be made) on or after October 1,
lowing flush sentence: (aa) are members of an Indian tribe; 2017.
A high deductible health plan shall not be (bb) are described in subclause (VIII) of SEC. 121. ELIGIBILITY REDETERMINATIONS.
treated as described in clause (v) if such plan clause (i) (without regard to the sunset dates (a) IN GENERAL.Section 1902(e)(14) of the
includes coverage for abortions (other than in such subclause); Social Security Act (42 U.S.C. 1396a(e)(14))

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S5688 CONGRESSIONAL RECORD SENATE September 13, 2017
(relating to modified adjusted gross income) (F) an individual who is a full-time stu- (B) the amount of the target total med-
is amended by adding at the end the fol- dent at an institution of higher education as ical assistance expenditures (as defined in
lowing: defined in sections 101 and 102 of the Higher subsection (c)) for the State and fiscal year.
(J) FREQUENCY OF ELIGIBILITY REDETER- Education Act of 1965.. (3) EXCESS AGGREGATE MEDICAL ASSIST-
MINATIONS.Beginning on October 1, 2017, (b) INCREASE IN MATCHING RATE FOR IMPLE- ANCE PAYMENTS.In this subsection, the
and notwithstanding subparagraph (H), in MENTATION.Section 1903 of the Social Secu- term excess aggregate medical assistance
the case of an individual whose eligibility for rity Act (42 U.S.C. 1396b) is amended by add- payments means, for a State for a fiscal
medical assistance under the State plan ing at the end the following: year, the product of
under this title (or a waiver of such plan) is (aa) The Federal matching percentage (A) the excess aggregate medical assist-
determined based on the application of modi- otherwise applicable under subsection (a) ance expenditures (as defined in paragraph
fied adjusted gross income under subpara- with respect to State administrative expend- (2)) for the State for the fiscal year; and
graph (A) and who is so eligible on the basis itures during a calendar quarter for which (B) the Federal average medical assist-
of clause (i)(VIII) or (ii)(XX) of subsection the State receives payment under such sub- ance matching percentage (as defined in
(a)(10)(A), at the option of the State, the section shall, in addition to any other in- paragraph (4)) for the State for the fiscal
State plan may provide that the individuals crease to such Federal matching percentage, year.
eligibility shall be redetermined every 6 be increased for such calendar quarter by 5 (4) FEDERAL AVERAGE MEDICAL ASSISTANCE
months (or such shorter number of months percentage points with respect to State ex- MATCHING PERCENTAGE.In this subsection,
as the State may elect).. penditures attributable to activities carried the term Federal average medical assistance
(b) INCREASED ADMINISTRATIVE MATCHING out by the State (and approved by the Sec- matching percentage means, for a State for
PERCENTAGE.For each calendar quarter retary) to implement subsection (oo) of sec- a fiscal year, the ratio (expressed as a per-
during the period beginning on October 1, tion 1902.. centage) of
2017, and ending on December 31, 2019, the SEC. 123. PROVIDER TAXES. (A) the amount of the Federal payments
Federal matching percentage otherwise ap- Section 1903(w)(4)(C) of the Social Security that would be made to the State under sec-
plicable under section 1903(a) of the Social Act (42 U.S.C. 1396b(w)(4)(C)) is amended by tion 1903(a)(1) for medical assistance expend-
Security Act (42 U.S.C. 1396b(a)) with respect adding at the end the following new clause: itures for calendar quarters in the fiscal year
to State expenditures during such quarter (iii) For purposes of clause (i), a deter- if paragraph (1) did not apply; to
that are attributable to meeting the require- mination of the existence of an indirect (B) the amount of the medical assistance
ment of section 1902(e)(14) (relating to deter- guarantee shall be made under paragraph expenditures for the State and fiscal year.
minations of eligibility using modified ad- (3)(i) of section 433.68(f) of title 42, Code of (5) PER CAPITA BASE PERIOD.
justed gross income) of such Act shall be in- Federal Regulations, as in effect on June 1, (A) IN GENERAL.In this section, the term
creased by 5 percentage points with respect 2017, except that per capita base period means, with respect
to State expenditures attributable to activi- (I) for fiscal year 2021, 5.6 percent shall to a State, a period of 8 consecutive fiscal
ties carried out by the State (and approved be substituted for 6 percent each place it quarters selected by the State.
by the Secretary) to exercise the option de- appears; (B) TIMELINE.Each State shall submit
scribed in subparagraph (J) of such section (II) for fiscal year 2022, 5.2 percent shall its selection of a per capita base period to
(relating to eligibility redeterminations be substituted for 6 percent each place it the Secretary not later than January 1, 2018.
made on a 6-month or shorter basis) (as appears; (C) PARAMETERS.In selecting a per cap-
added by subsection (a)) to increase the fre- (III) for fiscal year 2023, 4.8 percent shall ita base period under this paragraph, a State
quency of eligibility redeterminations. be substituted for 6 percent each place it shall
SEC. 122. OPTIONAL WORK REQUIREMENT FOR appears; (i) only select a period of 8 consecutive
NONDISABLED, NONELDERLY, NON-
(IV) for fiscal year 2024, 4.4 percent shall fiscal quarters for which all the data nec-
PREGNANT INDIVIDUALS.
be substituted for 6 percent each place it essary to make determinations required
(a) IN GENERAL.Section 1902 of the Social
appears; and under this section is available, as deter-
Security Act (42 U.S.C. 1396a), as previously
(V) for fiscal year 2025 and each subse- mined by the Secretary; and
amended, is further amended by adding at
the end the following new subsection: quent fiscal year, 4 percent shall be sub- (ii) shall not select any period of 8 con-
(oo) OPTIONAL WORK REQUIREMENT FOR stituted for 6 percent each place it ap- secutive fiscal quarters that begins with a
NONDISABLED, NONELDERLY, NONPREGNANT pears.. fiscal quarter earlier than the first quarter
INDIVIDUALS. SEC. 124. PER CAPITA ALLOTMENT FOR MEDICAL of fiscal year 2014 or ends with a fiscal quar-
(1) IN GENERAL.Beginning October 1, ASSISTANCE. ter later than the third fiscal quarter of 2017.
2017, subject to paragraph (3), a State may (a) IN GENERAL.Title XIX of the Social (b) ADJUSTED TOTAL MEDICAL ASSISTANCE
elect to condition medical assistance to a Security Act is amended EXPENDITURES.Subject to subsection (g),
nondisabled, nonelderly, nonpregnant indi- (1) in section 1903 (42 U.S.C. 1396b) the following shall apply:
vidual under this title upon such an individ- (A) in subsection (a), in the matter before (1) IN GENERAL.In this section, the term
uals satisfaction of a work requirement (as paragraph (1), by inserting and section adjusted total medical assistance expendi-
defined in paragraph (2)). 1903A(a) after except as otherwise provided tures means, for a State
(2) WORK REQUIREMENT DEFINED.In this in this section; and (A) for the States per capita base period
section, the term work requirement means, (B) in subsection (d)(1), by striking to (as defined in subsection (a)(5)), the product
with respect to an individual, the individ- which and inserting to which, subject to of
uals participation in work activities (as de- section 1903A(a),; and (i) the amount of the medical assistance
fined in section 407(d)) for such period of (2) by inserting after such section 1903 the expenditures (as defined in paragraph (2) and
time as determined by the State, and as di- following new section: adjusted under paragraph (5)) for the State
rected and administered by the State. SEC. 1903A. PER CAPITA-BASED CAP ON PAY- and period, reduced by the amount of any ex-
(3) REQUIRED EXCEPTIONS.States admin- MENTS FOR MEDICAL ASSISTANCE. cluded expenditures (as defined in paragraph
istering a work requirement under this sub- (a) APPLICATION OF PER CAPITA CAP ON (3) and adjusted under paragraph (5)) for the
section may not apply such requirement to PAYMENTS FOR MEDICAL ASSISTANCE EXPEND- State and period otherwise included in such
(A) a woman during pregnancy through ITURES. medical assistance expenditures; and
the end of the month in which the 60-day pe- (1) IN GENERAL.Subject to subsection (i), (ii) the 1903A base period population per-
riod (beginning on the last day of her preg- if a State which is one of the 50 States or the centage (as defined in paragraph (4)) for the
nancy) ends; District of Columbia has excess aggregate State; or
(B) an individual who is under 19 years of medical assistance expenditures (as defined (B) for fiscal year 2019 or a subsequent fis-
age; in paragraph (2)) for a fiscal year (beginning cal year, the amount of the medical assist-
(C) an individual who is the only parent with fiscal year 2020), the amount of pay- ance expenditures (as defined in paragraph
or caretaker relative in the family of a child ment to the State under section 1903(a)(1) for (2)) for the State and fiscal year that is at-
who has not attained 6 years of age or who is each quarter in the following fiscal year tributable to 1903A enrollees, reduced by the
the only parent or caretaker of a child with shall be reduced by 14 of the excess aggregate amount of any excluded expenditures (as de-
disabilities; medical assistance payments (as defined in fined in paragraph (3)) for the State and fis-
(D) an individual who is married or a head paragraph (3)) for that previous fiscal year. cal year otherwise included in such medical
of household and has not attained 20 years of In this section, the term State means only assistance expenditures and includes non-
age and who the 50 States and the District of Columbia. DSH supplemental payments (as defined in
(i) maintains satisfactory attendance at (2) EXCESS AGGREGATE MEDICAL ASSIST- subsection (d)(4)(A)(ii)) and payments de-
secondary school or the equivalent; or ANCE EXPENDITURES.In this subsection, the scribed in subsection (d)(4)(A)(iii) but shall
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(ii) participates in education directly re- term excess aggregate medical assistance not be construed as including any expendi-
lated to employment; expenditures means, for a State for a fiscal tures attributable to the program under sec-
(E) an individual who is a regular partici- year, the amount (if any) by which tion 1928 (relating to State pediatric vaccine
pant in an inpatient or intensive outpatient (A) the amount of the adjusted total med- distribution programs). In applying subpara-
drug addiction or alcoholic treatment and ical assistance expenditures (as defined in graph (B), non-DSH supplemental payments
rehabilitation program that satisfies such subsection (b)(1)) for the State and fiscal (as defined in subsection (d)(4)(A)(ii)) and
criteria as the State shall require; or year; exceeds payments described in subsection

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September 13, 2017 CONGRESSIONAL RECORD SENATE S5689
(d)(4)(A)(iii) shall be treated as fully attrib- (C) AGGREGATE LIMITATION ON EXCLUSIONS consumer price index for all urban con-
utable to 1903A enrollees. AND ADDITIONAL BLOCK GRANT PAYMENTS. sumers (U.S. city average) from September
(2) MEDICAL ASSISTANCE EXPENDITURES. The aggregate amount of expenditures ex- of the previous fiscal year to September of
In this section, the term medical assistance cluded under this paragraph and additional the fiscal year involved.
expenditures means, for a State and fiscal payments made under section 1903B(c)(3)(E) (4) ADJUSTMENTS TO STATE EXPENDITURES
year or per capita base period, the medical for the period described in subparagraph (A) TARGETS TO PROMOTE PROGRAM EQUITY ACROSS
assistance payments as reported by medical shall not exceed $5,000,000,000. STATES.
service category on the Form CMS-64 quar- (D) REVIEW.If the Secretary exercises (A) IN GENERAL.Beginning with fiscal
terly expense report (or successor to such a the authority under this paragraph with re- year 2020, the target per capita medical as-
report form, and including enrollment data spect to a State for a fiscal year or portion sistance expenditures for a 1903A enrollee
and subsequent adjustments to any such re- of a fiscal year, the Secretary shall, not later category, State, and fiscal year, as deter-
port, in this section referred to collectively than 6 months after the declaration de- mined under paragraph (2), shall be adjusted
as a CMS-64 report) for quarters in the year scribed in subparagraph (A)(i) ceases to be in (subject to subparagraph (C)(i)) in accord-
or base period for which payment is (or may effect, conduct an audit of the States med- ance with this paragraph.
otherwise be) made pursuant to section ical assistance expenditures for 1903A enroll- (B) ADJUSTMENT BASED ON LEVEL OF PER
1903(a)(1), adjusted, in the case of a per cap- ees during the year or portion of a year to CAPITA SPENDING FOR 1903A ENROLLEE CAT-
ita base period, under paragraph (5). ensure that all of the expenditures so ex- EGORIES.Subject to subparagraph (C), with
(3) EXCLUDED EXPENDITURES.In this sec- cluded were made for the purpose of ensuring respect to a State, fiscal year, and 1903A en-
that the health care needs of 1903A enrollees
tion, the term excluded expenditures rollee category, if the States per capita cat-
in areas affected by a public health emer-
means, for a State and fiscal year or per cap- egorical medical assistance expenditures (as
gency are met.
ita base period, expenditures under the State (c) TARGET TOTAL MEDICAL ASSISTANCE defined in subparagraph (D)) for the State
plan (or under a waiver of such plan) that are EXPENDITURES. and category in the preceding fiscal year
attributable to any of the following: (1) CALCULATION.In this section, the (i) exceed the mean per capita categorical
(A) DSH.Payment adjustments made for term target total medical assistance ex- medical assistance expenditures for the cat-
disproportionate share hospitals under sec- penditures means, for a State for a fiscal egory for all States for such preceding year
tion 1923. year, the sum of the products, for each of the by not less than 25 percent, the States tar-
(B) MEDICARE COST-SHARING.Payments 1903A enrollee categories (as defined in sub- get per capita medical assistance expendi-
made for medicare cost-sharing (as defined section (e)(2)), of tures for such category for the fiscal year in-
in section 1905(p)(3)). (A) the target per capita medical assist- volved shall be reduced by a percentage that
(C) EXPENDITURES FOR PUBLIC HEALTH ance expenditures (as defined in paragraph shall be determined by the Secretary but
EMERGENCIES.Any expenditures that are (2)) for the enrollee category, State, and fis- which shall not be less than 0.5 percent or
subject to a public health emergency exclu- cal year; and greater than 2 percent; or
sion under paragraph (6). (B) the number of 1903A enrollees for such (ii) are less than the mean per capita cat-
(4) 1903A BASE PERIOD POPULATION PER- enrollee category, State, and fiscal year, as egorical medical assistance expenditures for
CENTAGE.In this subsection, the term 1903A determined under subsection (e)(4). the category for all States for such preceding
base period population percentage means, (2) TARGET PER CAPITA MEDICAL ASSIST- year by not less than 25 percent, the States
for a State, the Secretarys calculation of ANCE EXPENDITURES.In this subsection, the target per capita medical assistance expendi-
the percentage of the actual medical assist- term target per capita medical assistance tures for such category for the fiscal year in-
ance expenditures, as reported by the State expenditures means, for a 1903A enrollee volved shall be increased by a percentage
on the CMS64 reports for calendar quarters category and State that shall be determined by the Secretary
in the States per capita base period, that (A) for fiscal year 2020, an amount equal but which shall not be less than 0.5 percent
are attributable to 1903A enrollees (as de- to or greater than 3 percent.
fined in subsection (e)(1)). (i) the provisional FY19 target per capita (C) RULES OF APPLICATION.
(5) ADJUSTMENTS FOR PER CAPITA BASE PE- amount for such enrollee category (as cal- (i) BUDGET NEUTRALITY REQUIREMENT.In
RIOD.In calculating medical assistance ex- culated under subsection (d)(5)) for the determining the appropriate percentages by
penditures under paragraph (2) and excluded State; increased by which to adjust States target per capita
expenditures under paragraph (3) for a State (ii) the applicable annual inflation factor medical assistance expenditures for a cat-
for the States per capita base period, the (as defined in paragraph (3)) for fiscal year egory and fiscal year under this paragraph,
total amount of each type of expenditure for 2020; and the Secretary shall make such adjustments
the State and base period shall be divided by (B) for each succeeding fiscal year, an in a manner that does not result in a net in-
2. amount equal to crease in Federal payments under this sec-
(6) AUTHORITY TO EXCLUDE STATE EXPENDI- (i) the target per capita medical assist- tion for such fiscal year, and if the Secretary
TURES FROM CAPS DURING PUBLIC HEALTH ance expenditures (under subparagraph (A) cannot adjust such expenditures in such a
EMERGENCY. or this subparagraph) for the 1903A enrollee manner there shall be no adjustment under
(A) IN GENERAL.During the period that category and State for the preceding fiscal this paragraph for such fiscal year.
begins on January 1, 2020, and ends on De- year; increased by (ii) ASSUMPTION REGARDING STATE EXPEND-
cember 31, 2024, the Secretary may exclude, (ii) the applicable annual inflation factor ITURES.For purposes of clause (i), in the
from a States medical assistance expendi- for that succeeding fiscal year. case of a State that has its target per capita
tures for a fiscal year or portion of a fiscal (3) APPLICABLE ANNUAL INFLATION FAC- medical assistance expenditures for a 1903A
year that occurs during such period, an TOR.In paragraph (2), the term applicable enrollee category and fiscal year increased
amount that shall not exceed the amount de- annual inflation factor means under this paragraph, the Secretary shall as-
termined under subparagraph (B) for the (A) for fiscal years before 2025 sume that the categorical medical assistance
State and year or portion of a year if (i) for each of the 1903A enrollee cat- expenditures (as defined in subparagraph
(i) a public health emergency declared by egories described in subparagraphs (C) and (D)(ii)) for such State, category, and fiscal
the Secretary pursuant to section 319 of the (D) of subsection (e)(2), the percentage in- year will equal such increased target med-
Public Health Service Act existed within the crease in the medical care component of the ical assistance expenditures.
State during such year or portion of a year; consumer price index for all urban con- (iii) NONAPPLICATION TO LOW-DENSITY
and sumers (U.S. city average) from September STATES.This paragraph shall not apply to
(ii) the Secretary determines that such an of the previous fiscal year to September of any State that has a population density of
exemption would be appropriate. the fiscal year involved; and less than 15 individuals per square mile,
(B) MAXIMUM AMOUNT OF ADJUSTMENT. (ii) for each of the 1903A enrollee cat- based on the most recent data available from
The amount excluded for a State and fiscal egories described in subparagraphs (A) and the Bureau of the Census.
year or portion of a fiscal year under this (B) of subsection (e)(2), the percentage in- (iv) APPLICATION FOR FISCAL YEARS 2020
paragraph shall not exceed the amount by crease described in clause (i) plus 1 percent- AND 2021.In fiscal years 2020 and 2021, the
which age point; and Secretary shall apply this paragraph by
(i) the amount of State expenditures for (B) for fiscal years after 2024 deeming all categories of 1903A enrollees to
medical assistance for 1903A enrollees in (i) for each of the 1903A enrollee cat- be a single category.
areas of the State which are subject to a dec- egories described in subparagraphs (C) and (D) PER CAPITA CATEGORICAL MEDICAL AS-
laration described in subparagraph (A)(i) for (D) of subsection (e)(2), the percentage in- SISTANCE EXPENDITURES.
the fiscal year or portion of a fiscal year; ex- crease in the consumer price index for all (i) IN GENERAL.In this paragraph, the
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ceeds urban consumers (U.S. city average) from term per capita categorical medical assist-
(ii) the amount of such expenditures for September of the previous fiscal year to Sep- ance expenditures means, with respect to a
such enrollees in such areas during the most tember of the fiscal year involved; and State, 1903A enrollee category, and fiscal
recent fiscal year or portion of a fiscal year (ii) for each of the 1903A enrollee cat- year, an amount equal to
of equal length to the portion of a fiscal year egories described in subparagraphs (A) and (I) the categorical medical expenditures
involved during which no such declaration (B) of subsection (e)(2), the percentage in- (as defined in clause (ii)) for the State, cat-
was in effect. crease in the medical care component of the egory, and year; divided by

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S5690 CONGRESSIONAL RECORD SENATE September 13, 2017
(II) the number of 1903A enrollees for the (III) is in addition to any payments made enrollee who for such month is in any of the
State, category, and year. to the provider under the plan (or waiver) for following categories of excluded individuals:
(ii) CATEGORICAL MEDICAL ASSISTANCE EX- any such item or service; and (A) CHIP.An individual who is provided,
PENDITURES.The term categorical medical (IV) complies with the limits for addi- under this title in the manner described in
assistance expenditures means, with respect tional payments to providers under the plan section 2101(a)(2), child health assistance
to a State, 1903A enrollee category, and fis- (or waiver) imposed pursuant to section under title XXI.
cal year, an amount equal to the total med- 1902(a)(30)(A), including the regulations (B) IHS.An individual who receives any
ical assistance expenditures (as defined in specifying upper payment limits under the medical assistance under this title for serv-
paragraph (2)) for the State and fiscal year State plan in part 447 of title 42, Code of Fed- ices for which payment is made under the
that are attributable to 1903A enrollees in eral Regulations (or any successor regula- third sentence of section 1905(b).
the category, excluding any excluded ex- tions). (C) BREAST AND CERVICAL CANCER SERV-
penditures (as defined in paragraph (3)) for (iii) An expenditure described in this ICES ELIGIBLE INDIVIDUAL.An individual who
the State and fiscal year that are attrib- clause is an expenditure that meets the cri- is eligible for medical assistance under this
utable to 1903A enrollees in the category. teria specified in subclauses (I), (II), and (III) title only on the basis of section
of clause (ii) and is authorized under section 1902(a)(10)(A)(ii)(XVIII).
(d) CALCULATION OF FY19 PROVISIONAL 1115 for the purposes of funding a delivery (D) PARTIAL-BENEFIT ENROLLEES.An in-
TARGET AMOUNT FOR EACH 1903A ENROLLEE system reform pool, uncompensated care dividual who
CATEGORY.Subject to subsection (g), the pool, a designated State health program, or (i) is an alien who is eligible for medical
following shall apply: any other similar expenditure (as defined by assistance under this title only on the basis
(1) CALCULATION OF BASE AMOUNTS FOR PER the Secretary). of section 1903(v)(2);
CAPITA BASE PERIOD.For each State the (B) For each 1903A enrollee category, the (ii) is eligible for medical assistance
Secretary shall calculate (and provide notice number of 1903A enrollees for the State in under this title only on the basis of sub-
to the State not later than April 1, 2018, of) fiscal year 2019 in the enrollee category (as clause (XII) or (XXI) of section
the following: determined under subsection (e)(4)). 1902(a)(10)(A)(ii) (or on the basis of a waiver
(A) The amount of the adjusted total (C) For the States per capita base period, that provides only comparable benefits);
medical assistance expenditures (as defined the States non-DSH supplemental and pool (iii) is a dual eligible individual (as de-
in subsection (b)(1)) for the State for the payment percentage is equal to the ratio (ex- fined in section 1915(h)(2)(B)) and is eligible
States per capita base period. pressed as a percentage) of for medical assistance under this title (or
(B) The number of 1903A enrollees for the (i) the total amount of non-DSH supple- under a waiver) only for some or all of medi-
State in the States per capita base period mental expenditures (as defined in subpara- care cost-sharing (as defined in section
(as determined under subsection (e)(4)). graph (A)(ii) and adjusted under subpara- 1905(p)(3)); or
(C) The average per capita medical assist- graph (E)) and payments described in sub- (iv) is eligible for medical assistance
ance expenditures for the State for the paragraph (A)(iii) (and adjusted under sub- under this title and for whom the State is
paragraph (E)) for the State for the period; providing a payment or subsidy to an em-
States per capita base period equal to
to ployer for coverage of the individual under a
(i) the amount calculated under subpara-
(ii) the amount described in subsection group health plan pursuant to section 1906 or
graph (A); divided by
(b)(1)(A) for the State for the States per cap-
(ii) the number calculated under subpara- section 1906A (or pursuant to a waiver that
ita base period.
graph (B). provides only comparable benefits).
(D) For each 1903A enrollee category an
(2) FISCAL YEAR 2019 AVERAGE PER CAPITA (E) BLIND AND DISABLED CHILDREN.An in-
average medical assistance expenditures per
AMOUNT BASED ON INFLATING THE PER CAPITA dividual who
capita for the State for fiscal year 2019 for
BASE PERIOD AMOUNT TO FISCAL YEAR 2019 BY (i) is a child under 19 years of age; and
the enrollee category equal to
CPI-MEDICAL.The Secretary shall calculate (ii) is eligible for medical assistance
(i) the amount calculated under subpara-
a fiscal year 2019 average per capita amount under this title on the basis of being blind or
graph (A) for the State, increased by the
for each State equal to disabled.
non-DSH supplemental and pool payment
(A) the average per capita medical assist- (2) 1903A ENROLLEE CATEGORY.The term
percentage for the State (as calculated under
ance expenditures for the State for the subparagraph (C)); divided by 1903A enrollee category means each of the
States per capita base period (calculated (ii) the number calculated under subpara- following:
under paragraph (1)(C)); increased by graph (B) for the State for the enrollee cat- (A) ELDERLY.A category of 1903A enroll-
(B) the percentage increase in the med- egory. ees who are 65 years of age or older.
ical care component of the consumer price (E) For purposes of subparagraph (C)(i), in (B) BLIND AND DISABLED.A category of
index for all urban consumers (U.S. city av- calculating the total amount of non-DSH 1903A enrollees (not described in the previous
erage) from the last month of the States per supplemental expenditures and payments de- subparagraph) who
capita base period to September of fiscal scribed in subparagraph (A)(iii) for a State (i) are 19 years of age or older; and
year 2019. for the per capita base period, the total (ii) are eligible for medical assistance
(3) AGGREGATE AND AVERAGE EXPENDI- amount of such expenditures and the total under this title on the basis of being blind or
TURES PER CAPITA FOR FISCAL YEAR 2019.The amount of such payments for the State and disabled.
Secretary shall calculate for each State the base period shall each be divided by 2. (C) CHILDREN.A category of 1903A enroll-
following: (5) PROVISIONAL FY19 PER CAPITA TARGET ees (not described in a previous subpara-
(A) The amount of the adjusted total AMOUNT FOR EACH 1903A ENROLLEE CATEGORY.
graph) who are children under 19 years of
medical assistance expenditures (as defined Subject to subsection (f)(2), the Secretary age.
in subsection (b)(1)) for the State for fiscal shall calculate for each State a provisional (D) OTHER NONELDERLY, NONDISABLED,
year 2019. NON-EXPANSION ADULTS.A category of 1903A
FY19 per capita target amount for each 1903A
(B) The number of 1903A enrollees for the enrollee category equal to the average med- enrollees who are not described in any pre-
State in fiscal year 2019 (as determined under ical assistance expenditures per capita for vious subparagraph.
subsection (e)(4)). the State for fiscal year 2019 (as calculated (3) MEDICAID ENROLLEE.The term Med-
(4) PER CAPITA EXPENDITURES FOR FISCAL under paragraph (4)(D)) for such enrollee cat- icaid enrollee means, with respect to a State
YEAR 2019 FOR EACH 1903A ENROLLEE CAT- egory multiplied by the ratio of for a month, an individual who is eligible for
EGORY.The Secretary shall calculate (and (A) the product of medical assistance for items or services
provide notice to each State not later than (i) the fiscal year 2019 average per capita under this title and enrolled under the State
January 1, 2020, of) the following: amount for the State, as calculated under plan (or a waiver of such plan) under this
(A)(i) For each 1903A enrollee category, paragraph (2); and title for the month.
the amount of the adjusted total medical as- (ii) the number of 1903A enrollees for the (4) DETERMINATION OF NUMBER OF 1903A EN-
sistance expenditures (as defined in sub- ROLLEES.The number of 1903A enrollees for
State in fiscal year 2019, as calculated under
section (b)(1)) for the State for fiscal year paragraph (3)(B); to a State and fiscal year or the States per
2019 for individuals in the enrollee category, (B) the amount of the adjusted total med- capita base period, and, if applicable, for a
calculated by excluding from medical assist- ical assistance expenditures for the State for 1903A enrollee category, is the average
ance expenditures those expenditures attrib- fiscal year 2019, as calculated under para- monthly number of Medicaid enrollees for
utable to expenditures described in clause graph (3)(A). such State and fiscal year or base period
(iii) or non-DSH supplemental expenditures (e) 1903A ENROLLEE; 1903A ENROLLEE CAT- (and, if applicable, in such category) that are
(as defined in clause (ii)). EGORY.Subject to subsection (g), for pur- reported through the CMS64 report under
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(ii) In this paragraph, the term non-DSH poses of this section, the following shall (and subject to audit under) subsection (h).
supplemental expenditure means a payment apply: (f) SPECIAL PAYMENT RULES.
to a provider under the State plan (or under (1) 1903A ENROLLEE.The term 1903A en- (1) APPLICATION IN CASE OF RESEARCH AND
a waiver of the plan) that rollee means, with respect to a State and a DEMONSTRATION PROJECTS AND OTHER WAIV-
(I) is not made under section 1923; month and subject to subsection (i)(1)(B), ERS.In the case of a State with a waiver of
(II) is not made with respect to a specific any Medicaid enrollee (as defined in para- the State plan approved under section 1115,
item or service for an individual; graph (3)) for the month, other than such an section 1915, or another provision of this

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September 13, 2017 CONGRESSIONAL RECORD SENATE S5691
title, this section shall apply to medical as- (i) DELAY OF PER CAPITA CAP FOR CERTAIN any State that is one of the 15 States in the
sistance expenditures and medical assistance LOW-DENSITY STATES. United States with the lowest population
payments under the waiver, in the same (1) IN GENERAL.Subsection (a) shall not density, as determined by the Secretary
manner as if such expenditures and pay- to apply for a fiscal year with respect to any based on data from the Bureau of the Census.
ments had been made under a State plan State (3) TERM OF DEMONSTRATION PROJECT.
under this title and the limitations on ex- (A) that has a population density of less The demonstration project shall be con-
penditures under this section shall supersede than 15 individuals per square mile, based on ducted for the 4-year period beginning on
any other payment limitations or provisions the most recent data available from the Bu- January 1, 2020, and ending on December 31,
(including limitations based on a per capita reau of the Census; 2023.
limitation) otherwise applicable under such (B) that is allotted an amount under sec-
(4) STATE ALLOTMENTS AND INCREASED
a waiver. tion 2105(i) for the calendar year that begins
FMAP FOR PAYMENT ADJUSTMENTS.
(2) IN CASE OF STATE FAILURE TO REPORT on January 1 of such fiscal year that
(i) is less than (A) IN GENERAL.
NECESSARY DATA.If a State for any quarter
(I) the amount allotted to such State (i) ANNUAL ALLOTMENT.Subject to clause
in a fiscal year (beginning with fiscal year
under such section for calendar year 2020; in- (ii), for each year of the demonstration
2019) fails to satisfactorily submit data on
creased by project, the Secretary shall allot an amount
expenditures and enrollees in accordance
(II) the percentage increase in the med- to each State that is an eligible State for the
with subsection (h)(1), for such fiscal year
ical care component of the consumer price year.
and any succeeding fiscal year for which
such data are not satisfactorily submitted index for all urban consumers (U.S. city av- (ii) LIMITATION ON FEDERAL SPENDING.
(A) the Secretary shall calculate and erage) from September of 2020 to September The aggregate amount that may be allotted
apply subsections (a) through (e) with re- of the last calendar year that ended before to eligible States under clause (i) for all
spect to the State as if all 1903A enrollee cat- the fiscal year involved; or years of the demonstration project shall not
egories for which such expenditure and en- (ii) is insufficient, as determined by the exceed $8,000,000,000.
rollee data were not satisfactorily submitted Secretary (after taking into consideration (B) FMAP APPLICABLE TO HCBS PAYMENT
were a single 1903A enrollee category; and the unique circumstances of such State), to ADJUSTMENTS.For each year of the dem-
(B) the growth factor otherwise applied provide comprehensive and adequate assist- onstration project, notwithstanding section
under subsection (c)(2)(B) shall be decreased ance to individuals in the State under a mar- 1905(b) but subject to the limitations de-
by 1 percentage point. ket-based health care grant program under scribed in subparagraph (C), the Federal
(g) RECALCULATION OF CERTAIN AMOUNTS such section; and medical assistance percentage applicable
FOR DATA ERRORS.The amounts and per- (C) for each fiscal year after fiscal year with respect to expenditures by an eligible
centage calculated under paragraphs (1) and 2020, to which subsection (a) did not apply State that are attributable to HCBS pay-
(4)(C) of subsection (d) for a State for the for the previous fiscal year as a result of the ment adjustments shall be equal to (and
States per capita base period, and the application of this subsection. shall in no case exceed) 100 percent.
amounts of the adjusted total medical assist- If a State elects to terminate a Medicaid (C) INDIVIDUAL PROVIDER AND ALLOTMENT
ance expenditures calculated under sub- Flexibility Program, the per capita cap limi- LIMITATIONS.Payment under section 1903(a)
section (b) and the number of Medicaid en- tations under section 1903A shall apply effec- shall not be made to an eligible State for ex-
rollees and 1903A enrollees determined under tive with the day described in clause (i), and
penditures for a year that are attributable to
subsection (e)(4) for a State for the States such limitations shall be applied as if the
an HCBS payment adjustment
per capita base period, fiscal year 2019, and State had never conducted a Medicaid Flexi-
(i) that is paid to a single provider and ex-
any subsequent fiscal year, may be adjusted bility Program.
ceeds a percentage which shall be established
by the Secretary based upon an appeal (filed (2) APPLICATION OF PER CAPITA CAP AFTER
by the Secretary of the payment otherwise
by the State in such a form, manner, and DELAY.If a State to which subsection (a)
time, and containing such information relat- does not apply for a fiscal year as a result of made to the provider; or
ing to data errors that support such appeal, the application of this subsection is not de- (ii) to the extent that the aggregate
as the Secretary specifies) that the Sec- scribed in paragraph (1) in any subsequent amount of HCBS payment adjustments made
retary determines to be valid, except that fiscal year, subsection (a) by the State in the year exceeds the amount
any adjustment by the Secretary under this (A) shall apply to such State effective allotted to the State for the year under
subsection for a State may not result in an with the first day of such subsequent fiscal clause (i).
increase of the target total medical assist- year; and (5) REPORTING AND EVALUATION.
ance expenditures exceeding 2 percent. (B) shall be applied as if it had applied to (A) IN GENERAL.As a condition of receiv-
(h) REQUIRED REPORTING AND AUDITING; the State from the first day of fiscal year ing the increased Federal medical assistance
TRANSITIONAL INCREASE IN FEDERAL MATCH- 2020.. percentage described in paragraph (4)(B),
ING PERCENTAGE FOR CERTAIN ADMINISTRA- (b) ENSURING ACCESS TO HOME AND COMMU- each eligible State shall collect and report
TIVE EXPENSES. NITY BASED SERVICES.Section 1915 of the information, as determined necessary by the
(1) AUDITING OF CMS64 DATA.The Sec- Social Security Act (42 U.S.C. 1396n) is Secretary, for the purposes of providing Fed-
retary shall conduct for each State an audit amended by adding at the end the following eral oversight and evaluating the States
of the number of individuals and expendi- new subsection: compliance with the health and welfare and
tures reported through the CMS64 report for (l) INCENTIVE PAYMENTS FOR HOME AND financial accountability safeguards taken by
the States per capita base period, fiscal year COMMUNITY-BASED SERVICES. the State under subsection (c)(2)(A).
2019, and each subsequent fiscal year, which (1) IN GENERAL.The Secretary shall es- (B) FORMS.Expenditures by eligible
audit may be conducted on a representative tablish a demonstration project (referred to States on HCBS payment adjustments shall
sample (as determined by the Secretary). in this subsection as the demonstration be separately reported on the CMS-64 Form
(2) AUDITING OF STATE SPENDING.The In- project) under which eligible States may and in T-MSIS.
spector General of the Department of Health make HCBS payment adjustments for the (6) DEFINITIONS.In this subsection:
and Human Services shall conduct an audit purpose of continuing to provide and improv-
(A) ELIGIBLE STATE.The term eligible
(which shall be conducted using random sam- ing the quality of home and community-
State means a State that
pling, as determined by the Inspector Gen- based services provided under a waiver under
(i) is one of the 50 States or the District
eral) of each States spending under this sec- subsection (c) or (d) or a State plan amend-
of Columbia;
tion not less than once every 3 years. ment under subsection (i).
(ii) has in effect
(3) TEMPORARY INCREASE IN FEDERAL (2) SELECTION OF ELIGIBLE STATES.
MATCHING PERCENTAGE TO SUPPORT IMPROVED (A) APPLICATION.A State seeking to par- (I) a waiver under subsection (c) or (d); or
DATA REPORTING SYSTEMS FOR FISCAL YEARS ticipate in the demonstration project shall (II) a State plan amendment under sub-
2018 AND 2019.In the case of any State that submit to the Secretary, at such time and in section (i);
selects as its per capita base period the most such manner as the Secretary shall require, (iii) submits an application under para-
recent 8 consecutive quarter period for which an application that includes graph (2)(A); and
the data necessary to make the determina- (i) an assurance that any HCBS payment (iv) is selected by the Secretary to par-
tions required under this section is available, adjustment made by the State under this ticipate in the demonstration project.
for amounts expended during calendar quar- subsection will comply with the health and (B) HCBS PAYMENT ADJUSTMENT.The
ters beginning on or after October 1, 2017, welfare and financial accountability safe- term HCBS payment adjustment means a
and before October 1, 2019 guards taken by the State under subsection payment adjustment made by an eligible
(A) the Federal matching percentage ap- (c)(2)(A); and State to the amount of payment otherwise
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plied under section 1903(a)(3)(A)(i) shall be (ii) such other information and assur- provided under a waiver under subsection (c)
increased by 10 percentage points to 100 per- ances as the Secretary shall require. or (d) or a State plan amendment under sub-
cent; and (B) SELECTION.The Secretary shall se- section (i) for a home and community-based
(B) the Federal matching percentage ap- lect States to participate in the demonstra- service which is provided to a 1903A enrollee
plied under section 1903(a)(3)(B) shall be in- tion project on a competitive basis except (as defined in section 1903A(e)(1)) who is in
creased by 25 percentage points to 100 per- that, in making selections under this para- the enrollee category described in subpara-
cent. graph, the Secretary shall give priority to graph (A) or (B) of section 1903A(e)(2)..

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S5692 CONGRESSIONAL RECORD SENATE September 13, 2017
SEC. 125. FLEXIBLE BLOCK GRANT OPTION FOR (ii) a plan for monitoring and evaluating urban consumers (U.S. city average) from
STATES. the program to determine whether such April of the second fiscal year preceding the
Title XIX of the Social Security Act, as goals are being met; and fiscal year involved to April of the fiscal
previously amended, is further amended by (iii) a proposed process for the State, in year preceding the fiscal year involved.
inserting after section 1903A the following consultation with the Centers for Medicare & (C) CAP ON TOTAL POPULATION OF 1903A EN-
new section: Medicaid Services, to take remedial action ROLLEES FOR PURPOSES OF BLOCK GRANT CAL-
SEC. 1903B. MEDICAID FLEXIBILITY PROGRAM. to make progress on unmet goals. CULATION.
(a) IN GENERAL.Beginning with fiscal (H) Such other information as the Sec- (i) IN GENERAL.In calculating the
year 2020, any State (as defined in subsection retary may require. amount of a block grant for the first year in
(e)) that has an application approved by the (3) STATE NOTICE AND COMMENT PERIOD. which a Medicaid Flexibility Program is con-
Secretary under subsection (b) may conduct (A) IN GENERAL.Before submitting an ducted by the State under subparagraph
a Medicaid Flexibility Program to provide application under this subsection, a State (B)(i), the total number of 1903A enrollees in
targeted health assistance to program en- shall make the application publicly available the category described in section
rollees. for a 30 day notice and comment period. 1903A(e)(2)(D) for the State and year shall
(b) STATE APPLICATION. (B) NOTICE AND COMMENT PROCESS.Dur- not exceed the adjusted number of base pe-
(1) IN GENERAL.To be eligible to conduct ing the notice and comment period described riod enrollees for the State (as defined in
in subparagraph (A), the State shall provide clause (ii)).
a Medicaid Flexibility Program, a State
opportunities for a meaningful level of pub- (ii) ADJUSTED NUMBER OF BASE PERIOD EN-
shall submit an application to the Secretary
lic input, which shall include public hearings ROLLEES.The term adjusted number of
that meets the requirements of this sub-
on the proposed Medicaid Flexibility Pro- base period enrollees means, with respect to
section.
gram. a State, the number of 1903A enrollees in the
(2) CONTENTS OF APPLICATION.An appli-
(4) FEDERAL NOTICE AND COMMENT PE- enrollee category described in section
cation under this subsection shall include
RIOD.The Secretary shall not approve of 1903A(e)(2)(D) for the State for the States
the following:
any application to conduct a Medicaid Flexi- per capita base period (as determined under
(A) A description of the proposed Med-
bility Program without making such appli- section 1903A(e)(4)), increased by the per-
icaid Flexibility Program and how the State cation publicly available for a 30 day notice centage increase, if any, in the total State
will satisfy the requirements described in and comment period. population from the last April in the States
subsection (d). (5) TIMELINE FOR SUBMISSION. per capita base period to April of the fiscal
(B) The proposed conditions for eligibility (A) IN GENERAL.A State may submit an year preceding the fiscal year involved (de-
of program enrollees. application under this subsection to conduct termined using the best available data from
(C) A description of the types, amount, a Medicaid Flexibility Program that would the Bureau of the Census) plus 3 percentage
duration, and scope of services which will be begin in the next fiscal year at any time, points.
offered as targeted health assistance under subject to subparagraph (B). (3) FEDERAL PAYMENT AND STATE MAINTE-
the program, including a description of the (B) DEADLINES.Each year beginning NANCE OF EFFORT.
proposed package of services which will be with 2019, the Secretary shall specify a dead- (A) FEDERAL PAYMENT.Subject to sub-
provided to program enrollees to whom the line for submitting an application under this paragraphs (D) and (E), the Secretary shall
State would otherwise be required to make subsection to conduct a Medicaid Flexibility pay to each State conducting a Medicaid
medical assistance available under section Program that would begin in the next fiscal Flexibility Program under this section for a
1902(a)(10)(A)(i). year, but such deadline shall not be earlier fiscal year, from its block grant amount
(D) A description of how the State will than 60 days after the date that the Sec- under paragraph (2) for such year, an amount
notify individuals currently enrolled in the retary publishes the amounts of State block for each quarter of such year equal to the
State plan for medical assistance under this grants as required under subsection (c)(4). Federal average medical assistance percent-
title of the transition to such program. (c) FINANCING. age (as defined in section 1903A(a)(4)) of the
(E) Statements certifying that the State (1) IN GENERAL.For each fiscal year dur- total amount expended under the program
agrees to ing which a State is conducting a Medicaid during such quarter as targeted health as-
(i) submit regular enrollment data with Flexibility Program, the State shall receive, sistance, and the State is responsible for the
respect to the program to the Centers for instead of amounts otherwise payable to the balance of the funds to carry out such pro-
Medicare & Medicaid Services at such time State under this title for medical assistance gram.
and in such manner as the Secretary may re- for program enrollees, the amount specified (B) STATE MAINTENANCE OF EFFORT EX-
quire; in paragraph (3)(A). PENDITURES.For each year during which a
(ii) submit timely and accurate data to (2) AMOUNT OF BLOCK GRANT FUNDS. State is conducting a Medicaid Flexibility
the Transformed Medicaid Statistical Infor- (A) IN GENERAL.The block grant amount Program, the State shall make expenditures
mation System (TMSIS); under this paragraph for a State and year for targeted health assistance under the pro-
(iii) report annually to the Secretary on shall be equal to the amount determined gram in an amount equal to the product of
adult health quality measures implemented under subparagraph (B) for the State and (i) the block grant amount determined for
under the program and information on the year. the State and year under paragraph (2); and
quality of health care furnished to program (B) ENROLLEE CATEGORY AMOUNTS. (ii) the enhanced FMAP described in the
enrollees under the program as part of the (i) FOR INITIAL YEAR.Subject to subpara- first sentence of section 2105(b) for the State
annual report required under section graph (C), for the first fiscal year in which a and year.
1139B(d)(1); Medicaid Flexibility Program is conducted (C) REDUCTION IN BLOCK GRANT AMOUNT
(iv) submit such additional data and in- by a State, the amount determined under FOR STATES FAILING TO MEET MOE REQUIRE-
formation not described in any of the pre- this subparagraph for the State and year MENT.
ceding clauses of this subparagraph but shall be equal to the Federal average med- (i) IN GENERAL.In the case of a State
which the Secretary determines is necessary ical assistance matching percentage (as de- conducting a Medicaid Flexibility Program
for monitoring, evaluation, or program in- fined in section 1903A(a)(4)) for the State and that makes expenditures for targeted health
tegrity purposes, including year multiplied by the product of assistance under the program for a fiscal
(I) survey data, such as the data from (I) the target per capita medical assist- year in an amount that is less than the re-
Consumer Assessment of Healthcare Pro- ance expenditures (as defined in section quired amount for the fiscal year under sub-
viders and Systems (CAHPS) surveys; 1903A(c)(2)) for the State and year; and paragraph (B), the amount of the block grant
(II) birth certificate data; and (II) the number of 1903A enrollees in the determined for the State under paragraph (2)
(III) clinical patient data for quality category described in section 1903A(e)(2)(D) for the succeeding fiscal year shall be re-
measurements which may not be present in a for the State for the second fiscal year pre- duced by the amount by which such expendi-
claim, such as laboratory data, body mass ceding such first fiscal year, increased by the tures are less than such required amount.
index, and blood pressure; and percentage increase in State population from (ii) DISREGARD OF REDUCTION.For pur-
(v) on an annual basis, conduct a report such second preceding fiscal year to such poses of determining the amount of a State
evaluating the program and make such re- first fiscal year, based on the best available block grant under paragraph (2), any reduc-
port available to the public. estimates of the Bureau of the Census. tion made under this subparagraph to a
(F) An information technology systems (ii) FOR ANY SUBSEQUENT YEAR.For any States block grant amount in a previous fis-
plan demonstrating that the State has the fiscal year that is not the first fiscal year in cal year shall be disregarded.
capability to support the technological ad- which a Medicaid Flexibility Program is con- (iii) APPLICATION TO STATES THAT TERMI-
ministration of the program and comply ducted by the State, the block grant amount NATE PROGRAM.In the case of a State de-
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with reporting requirements under this sec- under this paragraph for the State and year scribed in clause (i) that terminates the
tion. shall be equal to the amount determined for State Medicaid Flexibility Program under
(G) A statement of the goals of the pro- the State for the most recent previous fiscal subsection (d)(2)(B) and such termination is
posed program, which shall include year in which the State conducted a Med- effective with the end of the fiscal year in
(i) goals related to quality, access, rate of icaid Flexibility Program, except that such which the State fails to make the required
growth targets, consumer satisfaction, and amount shall be increased by the percentage amount of expenditures under subparagraph
outcomes; increase in the consumer price index for all (B), the reduction amount determined for the

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September 13, 2017 CONGRESSIONAL RECORD SENATE S5693
State and succeeding fiscal year under of the block grant for the State under para- (iii) Nursing facility services for individ-
clause (i) shall be treated as an overpayment graph (2) which would apply for the upcom- uals aged 21 and older.
under this title. ing fiscal year if the State were to conduct (iv) Physician services.
(D) REDUCTION FOR NONCOMPLIANCE.If such a program in such fiscal year, and shall (v) Home health care services (including
the Secretary determines that a State con- publish such determinations not later than home nursing services, medical supplies,
ducting a Medicaid Flexibility Program is June 1 of each year. equipment, and appliances).
not complying with the requirements of this (d) PROGRAM REQUIREMENTS. (vi) Rural health clinic services (as de-
section, the Secretary may withhold pay- (1) IN GENERAL.No payment shall be fined in section 1905(l)(1)).
ments, reduce payments, or recover previous made under this section to a State con- (vii) Federally-qualified health center
payments to the State under this section as ducting a Medicaid Flexibility Program un- services (as defined in section 1905(l)(2)).
the Secretary deems appropriate. less such program meets the requirements of (viii) Family planning services and sup-
(E) ADDITIONAL FEDERAL PAYMENTS DUR- this subsection. plies.
ING PUBLIC HEALTH EMERGENCY. (2) TERM OF PROGRAM. (ix) Nurse midwife services.
(i) IN GENERAL.In the case of a State and (A) IN GENERAL.A State Medicaid Flexi- (x) Certified pediatric and family nurse
fiscal year or portion of a fiscal year for bility Program approved under subsection
practitioner services.
which the Secretary has excluded expendi- (b)
(xi) Freestanding birth center services (as
tures under section 1903A(b)(6), if the State (i) shall be conducted for not less than 1
defined in section 1905(l)(3)).
has uncompensated targeted health assist- program period;
(xii) Emergency medical transportation.
ance expenditures for the year or portion of (ii) at the option of the State, may be
(xiii) Non-cosmetic dental services.
a year, the Secretary may make an addi- continued for succeeding program periods
without resubmitting an application under (xiv) Pregnancy-related services, includ-
tional payment to such State equal to the
subsection (b), provided that ing postpartum services for the 12-week pe-
Federal average medical assistance percent-
(I) the State provides notice to the Sec- riod beginning on the last day of a preg-
age (as defined in section 1903A(a)(4)) for the
retary of its decision to continue the pro- nancy.
year or portion of a year of the amount of
gram; and (B) OPTIONAL BENEFITS.A State may, at
such uncompensated targeted health assist-
(II) no significant changes are made to its option, provide services in addition to the
ance expenditures, except that the amount of
such payment shall not exceed the amount the program; and services described in subparagraph (A) as
determined for the State and year or portion (iii) shall be subject to termination only targeted health assistance under a Medicaid
of a year under clause (ii). by the State, which may terminate the pro- Flexibility Program.
(ii) MAXIMUM AMOUNT OF ADDITIONAL PAY- gram by making an election under subpara- (C) BENEFIT PACKAGES.
MENT.The amount determined for a State graph (B). (i) IN GENERAL.The targeted health as-
and fiscal year or portion of a fiscal year (B) ELECTION TO TERMINATE PROGRAM. sistance provided by a State to any group of
under this subparagraph shall not exceed the (i) IN GENERAL.Subject to clause (ii), a program enrollees under a Medicaid Flexi-
Federal average medical assistance percent- State conducting a Medicaid Flexibility Pro- bility Program shall have an aggregate actu-
age (as defined in section 1903A(a)(4)) for gram may elect to terminate the program ef- arial value that is equal to at least 95 per-
such year or portion of a year of the amount fective with the first day after the end of the cent of the aggregate actuarial value of the
by which program period in which the State makes benchmark coverage described in subsection
(I) the amount of State expenditures for the election. (b)(1) of section 1937 or benchmark-equiva-
targeted health assistance for program en- (ii) TRANSITION PLAN REQUIREMENT.A lent coverage described in subsection (b)(2)
rollees in areas of the State which are sub- State may not elect to terminate a Medicaid of such section, as such subsections were in
ject to a declaration described in section Flexibility Program unless the State has in effect prior to the enactment of the Patient
1903A(b)(6)(A)(i) for the year or portion of a place an appropriate transition plan ap- Protection and Affordable Care Act.
year; exceeds proved by the Secretary. (ii) AMOUNT, DURATION, AND SCOPE OF BEN-
(II) the amount of such expenditures for (iii) EFFECT OF TERMINATION.If a State EFITS.Subject to clause (i), the State shall
such enrollees in such areas during the most elects to terminate a Medicaid Flexibility determine the amount, duration, and scope
recent fiscal year involved (or portion of a Program, the per capita cap limitations with respect to services provided as targeted
fiscal year of equal length to the portion of under section 1903A shall apply effective health assistance under a Medicaid Flexi-
a fiscal year involved) during which no such with the day described in clause (i), and such bility Program, including with respect to
declaration was in effect. limitations shall be applied as if the State services that are required to be provided to
(iii) UNCOMPENSATED TARGETED HEALTH had never conducted a Medicaid Flexibility certain program enrollees under subpara-
ASSISTANCE.In this subparagraph, the term Program. graph (A) except as otherwise provided under
uncompensated targeted health assistance (3) PROVISION OF TARGETED HEALTH ASSIST- such subparagraph.
expenditures means, with respect to a State ANCE. (iii) MENTAL HEALTH AND SUBSTANCE USE
and fiscal year or portion of a fiscal year, an (A) IN GENERAL.A State Medicaid Flexi- DISORDER COVERAGE AND PARITY.The tar-
amount equal to the amount (if any) by bility Program shall provide targeted health geted health assistance provided by a State
which assistance to program enrollees and such as- to program enrollees under a Medicaid Flexi-
(I) the total amount expended by the sistance shall be instead of medical assist- bility Program shall include mental health
State under the program for targeted health ance which would otherwise be provided to services and substance use disorder services
assistance for the year or portion of a year; the enrollees under this title. and the financial requirements and treat-
exceeds (B) CONDITIONS FOR ELIGIBILITY. ment limitations applicable to such services
(II) the amount equal to the amount of (i) IN GENERAL.A State conducting a under the program shall comply with the re-
the block grant (reduced, in the case of a Medicaid Flexibility Program shall establish quirements of section 2726 of the Public
portion of a year, to the same proportion of conditions for eligibility of program enroll- Health Service Act in the same manner as
the full block grant amount that the portion ees, which shall be instead of other condi- such requirements apply to a group health
of the year bears to the whole year) divided tions for eligibility under this title, except plan.
by the Federal average medical assistance that the program must provide for eligibility (iv) PRESCRIPTION DRUGS.If the targeted
percentage for the year or portion of a year. for program enrollees to whom the State health assistance provided by a State to pro-
(iv) REVIEW.If the Secretary makes a would otherwise be required to make med- gram enrollees under a Medicaid Flexibility
payment to a State for a fiscal year or por- ical assistance available under section Program includes assistance for covered out-
tion of a fiscal year, the Secretary shall, not 1902(a)(10)(A)(i). patient drugs, such drugs shall be subject to
later than 6 months after the declaration de- (ii) MAGI.Any determination of income a rebate agreement that complies with the
scribed in section 1903A(b)(6)(A)(i) ceases to necessary to establish the eligibility of a requirements of section 1927, and any re-
be in effect, conduct an audit of the States program enrollee for purposes of a State quirements applicable to medical assistance
targeted health assistance expenditures for Medicaid Flexibility Program shall be made for covered outpatient drugs under a State
program enrollees during the year or portion using modified adjusted gross income in ac- plan (including the requirement that the
of a year to ensure that all of the expendi- cordance with section 1902(e)(14). State provide information to a manufac-
tures for which the additional payment was (4) BENEFITS AND SERVICES. turer) shall apply in the same manner to tar-
made were made for the purpose of ensuring (A) REQUIRED SERVICES.In the case of geted health assistance for covered out-
that the health care needs of program enroll- program enrollees to whom the State would patient drugs under a Medicaid Flexibility
ees in areas affected by a public health emer- otherwise be required to make medical as- Program.
gency are met. sistance available under section (D) COST SHARING.A State conducting a
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(4) DETERMINATION AND PUBLICATION OF 1902(a)(10)(A)(i), a State conducting a Med- Medicaid Flexibility Program may impose
BLOCK GRANT AMOUNT.Beginning in 2019 and icaid Flexibility Program shall provide as premiums, deductibles, cost-sharing, or
each year thereafter, the Secretary shall de- targeted health assistance the following other similar charges, except that the total
termine for each State, regardless of whether types of services: annual aggregate amount of all such charges
the State is conducting a Medicaid Flexi- (i) Inpatient and outpatient hospital serv- imposed with respect to all program enroll-
bility Program or has submitted an applica- ices. ees in a family shall not exceed 5 percent of
tion to conduct such a program, the amount (ii) Laboratory and X-ray services. the familys income for the year involved.

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S5694 CONGRESSIONAL RECORD SENATE September 13, 2017
(5) ADMINISTRATION OF PROGRAM.Each secutive fiscal years that begins with ei- that take into account the clinically appro-
State conducting a Medicaid Flexibility Pro- ther priate measures of quality for different types
gram shall do the following: (A) the first fiscal year in which the State of patient populations receiving benefits or
(A) SINGLE AGENCY.Designate a single conducts the program; or services under this title or title XXI.
State agency responsible for administering (B) the next fiscal year in which the State (4) LOWER THAN EXPECTED AGGREGATE
the program. conducts such a program that begins after MEDICAL ASSISTANCE EXPENDITURES.In this
(B) ENROLLMENT SIMPLIFICATION AND CO- the end of a previous program period. subsection, the term lower than expected
ORDINATION WITH STATE HEALTH INSURANCE (4) STATE.The term State means one of aggregate medical assistance expenditures
EXCHANGES.Provide for simplified enroll- the 50 States or the District of Columbia. means, with respect to a State the amount
ment processes (such as online enrollment (5) TARGETED HEALTH ASSISTANCE.The (if any) by which
and reenrollment and electronic verification) term targeted health assistance means as- (A) the amount of the adjusted total med-
and coordination with State health insur- sistance for health-care-related items and ical assistance expenditures for the State
ance exchanges. medical services for program enrollees.. and fiscal year determined in section
(C) BENEFICIARY PROTECTIONS.Establish SEC. 126. MEDICAID AND CHIP QUALITY PER- 1903A(b)(1) without regard to the 1903A en-
a fair process (which the State shall describe FORMANCE BONUS PAYMENTS. rollee category described in section
in the application required under subsection Section 1903 of the Social Security Act (42 1903A(e)(2)(E); is less than
(b)) for individuals to appeal adverse eligi- U.S.C. 1396b), as previously amended, is fur- (B) the amount of the target total med-
bility determinations with respect to the ther amended by adding at the end the fol- ical assistance expenditures for the State
program. lowing new subsection: and fiscal year determined in section
(6) APPLICATION OF REST OF TITLE XIX. (bb) QUALITY PERFORMANCE BONUS PAY- 1903A(c) without regard to the 1903A enrollee
(A) IN GENERAL.To the extent that a MENTS. category described in section
provision of this section is inconsistent with (1) INCREASED FEDERAL SHARE.With re- 1903A(e)(2)(E)..
another provision of this title, the provision spect to each of fiscal years 2023 through SEC. 127. OPTIONAL ASSISTANCE FOR CERTAIN
of this section shall apply. 2026, in the case of one of the 50 States or the INPATIENT PSYCHIATRIC SERVICES.
(B) APPLICATION OF SECTION 1903A.With District of Columbia (each referred to in this (a) STATE OPTION.Section 1905 of the So-
respect to a State that is conducting a Med- subsection as a State) that cial Security Act (42 U.S.C. 1396d) is amend-
icaid Flexibility Program, section 1903A (A) equals or exceeds the qualifying ed
shall be applied as if program enrollees were amount (as established by the Secretary) of (1) in subsection (a)
not 1903A enrollees for each program period lower than expected aggregate medical as- (A) in paragraph (16)
during which the State conducts the pro- sistance expenditures (as defined in para- (i) by striking and, (B) and inserting
gram. graph (4)) for that fiscal year; and (B); and
(C) WAIVERS AND STATE PLAN AMEND- (B) submits to the Secretary, in accord- (ii) by inserting before the semicolon at
MENTS. ance with such manner and format as speci- the end the following: , and (C) subject to
(i) IN GENERAL.In the case of a State fied by the Secretary and for the perform- subsection (h)(4), qualified inpatient psy-
conducting a Medicaid Flexibility Program ance period (as defined by the Secretary) for chiatric hospital services (as defined in sub-
that has in effect a waiver or State plan such fiscal year section (h)(3)) for individuals who are over 21
amendment, such waiver or amendment shall (i) information on the applicable quality years of age and under 65 years of age; and
not apply with respect to the program, tar- measures identified under paragraph (3) with (B) in the subdivision (B) that follows para-
geted health assistance provided under the respect to each category of Medicaid eligible graph (29), by inserting (other than services
program, or program enrollees. individuals under the State plan or a waiver described in subparagraph (C) of paragraph
(ii) REPLICATION OF WAIVER OR AMEND- of such plan; and (16) for individuals described in such sub-
MENT.In designing a Medicaid Flexibility (ii) a plan for spending a portion of addi- paragraph) after patient in an institution
Program, a State may mirror provisions of a tional funds resulting from application of for mental diseases; and
waiver or State plan amendment described this subsection on quality improvement (2) in subsection (h), by adding at the end
in clause (i) in the program to the extent within the State plan under this title or the following new paragraphs:
that such provisions are otherwise con- under a waiver of such plan, (3) For purposes of subsection (a)(16)(C),
sistent with the requirements of this section. the term qualified inpatient psychiatric
the Federal matching percentage otherwise hospital services means, with respect to in-
(iii) EFFECT OF TERMINATION.In the case applied under subsection (a)(7) for such fiscal
of a State described in clause (i) that termi- dividuals described in such subsection, serv-
year shall be increased by such percentage ices described in subparagraph (B) of para-
nates its program under subsection (d)(2)(B), (as determined by the Secretary) so that the graph (1) that are not otherwise covered
any waiver or amendment which was limited aggregate amount of the resulting increase under subsection (a)(16)(A) and are fur-
pursuant to subparagraph (A) shall cease to pursuant to this subsection for the State and nished
be so limited effective with the effective date fiscal year does not exceed the State allot- (A) in an institution (or distinct part
of such termination. ment established under paragraph (2) for the thereof) which is a psychiatric hospital (as
(D) NONAPPLICATION OF PROVISIONS.With State and fiscal year. defined in section 1861(f)); and
respect to the design and implementation of (2) ALLOTMENT DETERMINATION.The Sec- (B) with respect to such an individual, for
Medicaid Flexibility Programs conducted retary shall establish a formula for com- a period not to exceed 30 consecutive days in
under this section, paragraphs (1), (10)(B), puting State allotments under this para- any month and not to exceed 90 days in any
(17), and (23) of section 1902(a), as well as any graph for each fiscal year described in para- calendar year.
other provision of this title (except for this graph (1) such that (4) As a condition for a State including
section and as otherwise provided by this (A) such an allotment to a State is deter- qualified inpatient psychiatric hospital serv-
section) that the Secretary deems appro- mined based on the performance, including ices as medical assistance under subsection
priate, shall not apply. improvement, of such State under this title (a)(16)(C), the State must (during the period
(e) DEFINITIONS.For purposes of this sec- and title XXI with respect to the quality in which it furnishes medical assistance
tion: measures submitted under paragraph (3) by under this title for services and individuals
(1) MEDICAID FLEXIBILITY PROGRAM.The such State for the performance period (as de- described in such subsection)
term Medicaid Flexibility Program means a fined by the Secretary) for such fiscal year; (A) maintain at least the number of li-
State program for providing targeted health and censed beds at psychiatric hospitals owned,
assistance to program enrollees funded by a (B) the total of the allotments under this operated, or contracted for by the State that
block grant under this section. paragraph for all States for the period of the were being maintained as of the date of the
(2) PROGRAM ENROLLEE. fiscal years described in paragraph (1) is enactment of this paragraph or, if higher, as
(A) IN GENERAL.The term program en- equal to $8,000,000,000. of the date the State applies to the Sec-
rollee means, with respect to a State that is (3) QUALITY MEASURES REQUIRED FOR retary to include medical assistance under
conducting a Medicaid Flexibility Program BONUS PAYMENTS.For purposes of this sub- such subsection; and
for a program period, an individual who is a section, the Secretary shall, pursuant to (B) maintain on an annual basis a level of
1903A enrollee (as defined in section rulemaking and after consultation with funding expended by the State (and political
1903A(e)(1)) who is in the 1903A enrollee cat- State agencies administering State plans subdivisions thereof) other than under this
egory described in section 1903A(e)(2)(D). under this title, identify and publish (and up- title from non-Federal funds for inpatient
(B) RULE OF CONSTRUCTION.For purposes date as necessary) peer-reviewed quality services in an institution described in para-
of section 1903A(e)(3), eligibility and enroll- measures (which shall include health care graph (3)(A), and for active psychiatric care
lotter on DSKBCFDHB2PROD with SENATE

ment of an individual under a Medicaid and long-term care outcome measures and and treatment provided on an outpatient
Flexibility Program shall be deemed to be may include the quality measures that are basis, that is not less than the level of such
eligibility and enrollment under a State plan overseen or developed by the National Com- funding for such services and care as of the
(or waiver of such plan) under this title. mittee for Quality Assurance or the Agency date of the enactment of this paragraph or,
(3) PROGRAM PERIOD.The term program for Healthcare Research and Quality or that if higher, as of the date the State applies to
period means, with respect to a State Med- are identified under section 1139A or 1139B) the Secretary to include medical assistance
icaid Flexibility Program, a period of 5 con- that are quantifiable, objective measures under such subsection..

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September 13, 2017 CONGRESSIONAL RECORD SENATE S5695
(b) SPECIAL MATCHING RATE.Section shortfall amount for a State and a fiscal him to the bill H.R. 2810, to authorize
1905(b) of the Social Security Act (42 U.S.C. year exceed the amount of the reduction appropriations for fiscal year 2018 for
1395d(b)) is amended by adding at the end the specified under subparagraph (B) for the military activities of the Department
following: Notwithstanding the previous State and fiscal year..
provisions of this subsection, the Federal
of Defense, for military construction,
TITLE II and for defense activities of the De-
medical assistance percentage shall be 50 SEC. 201. THE PREVENTION AND PUBLIC HEALTH
percent with respect to medical assistance partment of Energy, to prescribe mili-
FUND.
for services and individuals described in sub- Subsection (b) of section 4002 of the Pa-
tary personnel strengths for such fiscal
section (a)(16)(C), except that, in the case of tient Protection and Affordable Care Act (42 year, and for other purposes; which was
a State for which the Federal medical assist- U.S.C. 300u11) is amended ordered to lie on the table; as follows:
ance percentage applicable to such assist- At the end of subtitle C of title I, add the
(1) in paragraph (3), by striking each of
ance for such services and individuals on following:
fiscal years 2018 and 2019 and inserting fis-
September 30, 2018, was greater than 50 per- SEC. lll. CERTIFICATION OF THE ENHANCED
cal year 2018; and
cent, such greater percentage shall continue MULTI MISSION PARACHUTE SYS-
(2) by striking paragraphs (4) through (8).
to apply with respect to medical assistance TEM FOR THE UNITED STATES MA-
SEC. 202. COMMUNITY HEALTH CENTER PRO-
provided by such State for such services and RINE CORPS.
GRAM.
individuals.. (a) CERTIFICATION.Not later than 90 days
(c) EFFECTIVE DATE.The amendments Effective as if included in the enactment of
after the date of the enactment of this Act,
made by this section shall apply to qualified the Medicare Access and CHIP Reauthoriza-
the Secretary of the Navy shall submit to
inpatient psychiatric hospital services fur- tion Act of 2015 (Public Law 11410, 129 Stat.
the congressional defense committees a cer-
nished on or after October 1, 2018. 87), paragraph (1) of section 221(a) of such
tification
SEC. 128. ENHANCED FMAP FOR MEDICAL AS- Act is amended by inserting , and an addi-
(1) whether either the Marine Corps cur-
SISTANCE TO ELIGIBLE INDIANS. tional $422,000,000 for fiscal year 2017 after rently fielded multi mission parachute sys-
Section 1905(b) of the Social Security Act 2017. tem or the Armys RA1 parachute system
(42 U.S.C. 1396d(b)) is amended, in the third SEC. 203. ALLOWING ALL INDIVIDUALS PUR-
meet the Marine Corps requirements;
sentence, by inserting and with respect to CHASING HEALTH INSURANCE IN
THE INDIVIDUAL MARKET THE OP- (2) whether the Marine Corps PARIS, Spe-
amounts expended by a State as medical as- cial Application Parachute meets the Marine
TION TO PURCHASE A LOWER PRE-
sistance for services provided by any other MIUM CATASTROPHIC PLAN. Corps requirement;
provider under the State plan to an indi- (3) whether the testing plan for the en-
(a) IN GENERAL.Section 1302(e) of the Pa-
vidual who is a member of an Indian tribe hanced multi mission parachute system
tient Protection and Affordable Care Act (42
who is eligible for assistance under the State meets all regulatory requirements; and
U.S.C. 18022(e)) is amended by adding at the
plan before the period. (4) whether the Department of the Navy
end the following:
SEC. 129. NON-APPLICATION OF DSH CUTS FOR has determined that a high glide canopy is as
STATES WITH LOW MARKET-BASED (4) CONSUMER FREEDOM.For plan years
HEALTH CARE GRANT ALLOTMENTS; beginning on or after January 1, 2019, para- safe and effective as the currently fielded
ONE-TIME DSH ALLOTMENT IN- graph (1)(A) shall not apply with respect to free fall parachute systems.
CREASE FOR 2026. any plan offered in the State.. (b) REPORT.Not later than 90 days after
Section 1923(f)(7) of the Social Security (b) RISK POOLS.Section 1312(c) of the Pa- the date of the enactment of this Act, the
Act (42 U.S.C. 1396r4(f)(7)) is amended by tient Protection and Affordable Care Act (42 Secretary of the Navy shall submit to the
adding at the end the following new subpara- U.S.C. 18032(c)) is amended congressional defense committees a report
graph: (1) in paragraph (1), by inserting and in- that includes
(C) LOW-GRANT STATES. cluding, with respect to plan years beginning (1) an explanation for using the Parachute
(i) IN GENERAL.For each of fiscal years on or after January 1, 2019, enrollees in cata- Industry Association specification for a mili-
2021 through 2025, the amount of the reduc- strophic plans described in section 1302(e) tary parachute given that sports parachutes
tion specified under subparagraph (B) for a after Exchange; and are employed from relatively slow flying ci-
State and fiscal year shall be reduced by the (2) in paragraph (2), by inserting and in- vilian aircraft at altitudes below 10,000 feet;
grant shortfall amount for the State and cluding, with respect to plan years beginning (2) a cost estimate for any new equipment
year. on or after January 1, 2019, enrollees in cata- and training that the Marine Corps will re-
(ii) ONE-TIME INCREASE FOR FISCAL 2026. strophic plans described in section 1302(e) quire in order to employ a high glide para-
(I) IN GENERAL.Any State that has a after Exchange. chute;
grant shortfall amount for fiscal year 2026 SEC. 204. APPLICATION OF ENFORCEMENT PEN- (3) justification of why the Department of
shall be eligible for a one-time increase in ALTIES. the Navy is not conducting any testing until
the States DSH allotment for fiscal year (a) IN GENERAL.Section 2723 of the Public first article testing; and
2026 in the amount described in subclause Health Service Act (42 U.S.C. 300gg22) is (4) an assessment of the risks associated
(II). amended with high glide canopies with a focus on how
(II) AMOUNT OF INCREASE.Subject to (1) in subsection (a) the Department of the Navy will mitigate
clause (III), the amount described in this (A) in paragraph (1), by inserting and of the risk for malfunctions experienced in
subclause for a State shall be equal to section 1303 of the Patient Protection and other high glide canopy programs.
(aa) the total amount of the reductions Affordable Care Act after this part; and
specified for the State under subparagraph (B) in paragraph (2), by inserting or in SA 1032. Mr. ISAKSON (for himself,
(B) for each of fiscal years 2018 through 2025; such section 1303 after this part; and Mr. PERDUE, Mr. GRAHAM, and Mr. COT-
minus (2) in subsection (b) TON) submitted an amendment in-
(bb) the total amount of any reductions (A) in paragraphs (1) and (2)(A), by insert- tended to be proposed to amendment
for each of fiscal years 2021 through 2025 ing or section 1303 of the Patient Protec- SA 1003 proposed by Mr. MCCAIN (for
under clause (i). tion and Affordable Care Act after this himself and Mr. REED) to the bill H.R.
(III) LIMITATION.The amount of the in- part each place such term appears; 2810, to authorize appropriations for
crease for a State and fiscal year under this (B) in paragraph (2)(C)(ii), by inserting
clause shall not exceed the grant shortfall fiscal year 2018 for military activities
and section 1303 of the Patient Protection of the Department of Defense, for mili-
amount for the State and year. and Affordable Care Act after this part.
(iii) GRANT SHORTFALL AMOUNT DEFINED. (b) EFFECT OF WAIVER.A State waiver tary construction, and for defense ac-
(I) IN GENERAL.In this subparagraph, the pursuant to section 1332 of the Patient Pro- tivities of the Department of Energy,
term grant shortfall amount means, with tection and Affordable Care Act (42 U.S.C. to prescribe military personnel
respect to a State and a fiscal year, the 18052) shall not affect the authority of the strengths for such fiscal year, and for
amount, if any, by which the amount that Secretary to impose penalties under section other purposes; which was ordered to
was allotted to the State under section 2723 of the Public Health Service Act (42 lie on the table; as follows:
2105(i) for the last calendar year that began U.S.C. 300gg22). At the end of subtitle D of title I, add the
before the end of such fiscal year is less SEC. 205. REPEAL OF COST-SHARING SUBSIDY following:
than PROGRAM. SEC. lll. PROHIBITION ON AVAILABILITY OF
(aa) the amount allotted to such State (a) IN GENERAL.Section 1402 of the Pa- FUNDS FOR RETIREMENT OF E8
under such section for calendar year 2020; in- tient Protection and Affordable Care Act is JSTARS AIRCRAFT.
creased by repealed. (a) PROHIBITION ON AVAILABLE OF FUNDS
(bb) the percentage increase in the med- (b) EFFECTIVE DATE.The repeal made by FOR RETIREMENT.Except as provided by
lotter on DSKBCFDHB2PROD with SENATE

ical care component of the consumer price subsection (a) shall apply to cost-sharing re- subsection (b), none of the funds authorized
index for all urban consumers (U.S. city av- ductions (and payments to issuers for such to be appropriated by this Act or otherwise
erage) from September of 2020 to September reductions) for plan years beginning after made available for fiscal year 2018 for the Air
of the last calendar year that ended before December 31, 2019. Force may be obligated or expended to re-
the fiscal year involved. tire, or prepare to retire, any E-8 Joint Sur-
(II) LIMITATION.For fiscal years before SA 1031. Mr. TILLIS submitted an veillance Target Attack Radar System air-
fiscal year 2026, in no case shall the grant amendment intended to be proposed by craft.

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