Stocks in the airline space are having a good time and are certainly back in favor.
The Dow experienced a turbulent week, even as the broader market was guided by the fortunes of tech stocks.
ERN17282 Discussion Draft S.L.C.AMENDMENT NO.llll Calendar No.lllPurpose: In the nature of a substitute.IN THE SENATE OF THE UNITED STATES—115th Cong., 1st Sess.H. R. 1628To provide for reconciliation pursuant to title II of theconcurrent resolution on the budget for fiscal year 2017.Referred to the Committee on llllllllll andordered to be printedOrdered to lie on the table and to be printedAMENDMENT IN THE NATURE OF A SUBSTITUTE intendedto be proposed by lllllllViz:1 Strike all after the enacting clause and insert the fol-2 lowing:3 SECTION 1. SHORT TITLE.4 This Act may be cited as the ‘‘Better Care Reconcili-5 ation Act of 2017’’.6 TITLE I7 SEC. 101. ELIMINATION OF LIMITATION ON RECAPTURE OF8 EXCESS ADVANCE PAYMENTS OF PREMIUM9 TAX CREDITS.10 Subparagraph (B) of section 36B(f)(2) of the Inter-11 nal Revenue Code of 1986 is amended by adding at the12 end the following new clause: 2ERN17282 Discussion Draft S.L.C.1 ‘‘(iii) NONAPPLICABILITY OF LIMITA-2 TION.—This subparagraph shall not apply3 to taxable years ending after December 31,4 2017.’’.5 SEC. 102. RESTRICTIONS FOR THE PREMIUM TAX CREDIT.6 (a) ELIGIBILITY FOR CREDIT.—7 (1) IN GENERAL.—Section 36B(c)(1) of the In-8 ternal Revenue Code of 1986 is amended—9 (A) by striking ‘‘equals or exceeds 100 per-10 cent but does not exceed 400 percent’’ in sub-11 paragraph (A) and inserting ‘‘does not exceed12 350 percent’’, and13 (B) by striking subparagraph (B) and re-14 designating subparagraphs (C) and (D) as sub-15 paragraphs (B) and (C), respectively.16 (2) TREATMENT OF CERTAIN ALIENS.—17 (A) IN GENERAL.—Paragraph (2) of sec-18 tion 36B(e) of the Internal Revenue Code of19 1986 is amended by striking ‘‘an alien lawfully20 present in the United States’’ and inserting ‘‘a21 qualified alien (within the meaning of section22 431 of the Personal Responsibility and Work23 Opportunity Reconciliation Act of 1996)’’.24 (B) AMENDMENTS TO PATIENT PROTEC-25 TION AND AFFORDABLE CARE ACT.— 3ERN17282 Discussion Draft S.L.C.1 (i) Section 1411(a)(1) of the Patient2 Protection and Affordable Care Act is3 amended by striking ‘‘or an alien lawfully4 present in the United States’’ and insert-5 ing ‘‘or a qualified alien (within the mean-6 ing of section 431 of the Personal Respon-7 sibility and Work Opportunity Reconcili-8 ation Act of 1996)’’.9 (ii) Section 1411(c)(2)(B) of such Act10 is amended by striking ‘‘an alien lawfully11 present in the United States’’ each place it12 appears in clauses (i)(I) and (ii)(II) and13 inserting ‘‘a qualified alien (within the14 meaning of section 431 of the Personal Re-15 sponsibility and Work Opportunity Rec-16 onciliation Act of 1996)’’.17 (iii) Section 1412(d) of such Act is18 amended—19 (I) by striking ‘‘not lawfully20 present in the United States’’ and in-21 serting ‘‘not citizens or nationals of22 the United States or qualified aliens23 (within the meaning of section 431 of24 the Personal Responsibility and Work 4ERN17282 Discussion Draft S.L.C.1 Opportunity Reconciliation Act of2 1996)’’, and3 (II) by striking ‘‘INDIVIDUALS4 NOT LAWFULLY PRESENT’’ in the5 heading and inserting ‘‘CERTAIN6 ALIENS’’.7 (b) MODIFICATION OF LIMITATION ON PREMIUM AS-8 SISTANCE AMOUNT.—9 (1) USE OF BENCHMARK PLAN.—Section10 36B(b) of the Internal Revenue Code of 1986 is11 amended—12 (A) by striking ‘‘applicable second lowest13 cost silver plan’’ each place it appears in para-14 graph (2)(B)(i) and (3)(C) and inserting ‘‘ap-15 plicable median cost benchmark plan’’,16 (B) by striking ‘‘such silver plan’’ in para-17 graph (3)(C) and inserting ‘‘such benchmark18 plan’’, and19 (C) in paragraph (3)(B)—20 (i) by redesignating clauses (i) and21 (ii) as clauses (iii) and (iv), respectively,22 and by striking all that precedes clause23 (iii) (as so redesignated) and inserting the24 following: 5ERN17282 Discussion Draft S.L.C.1 ‘‘(B) APPLICABLE MEDIAN COST BENCH-2 MARK PLAN.—The applicable median cost3 benchmark plan with respect to any applicable4 taxpayer is the qualified health plan offered in5 the individual market in the rating area in6 which the taxpayer resides which—7 ‘‘(i) provides a level of coverage that8 is designed to provide benefits that are ac-9 tuarially equivalent to 58 percent of the10 full actuarial value of the benefits (as de-11 termined under rules similar to the rules of12 paragraphs (2) and (3) of section 1302(d)13 of the Patient Protection and Affordable14 Care Act) provided under the plan,15 ‘‘(ii) has a premium which is the me-16 dian premium of all qualified health plans17 described in clause (i) which are offered in18 the individual market in such rating area19 (or, in any case in which no such plan has20 such median premium, has a premium21 nearest (but not in excess of) such median22 premium),’’, and23 (ii) by striking ‘‘clause (ii)(I)’’ in the24 flush text at the end and inserting ‘‘clause25 (iv)(I)’’. 6ERN17282 Discussion Draft S.L.C.1 (2) MODIFICATION OF APPLICABLE PERCENT-2 AGE.—Section 36B(b)(3)(A) of the Internal Revenue3 Code of 1986 is amended—4 (A) in clause (i), by striking ‘‘from the ini-5 tial premium percentage’’ and all that follows6 and inserting ‘‘from the initial percentage to7 the final percentage specified in such table for8 such income tier with respect to a taxpayer of9 the age involved:‘‘In the case ofhousehold income(expressed as apercent of thepoverty line)within the followingincometier:Up to Age 29 Age 30-39 Age 40-49 Age 50-59 Over Age 59Initial%Final%Initial%Final%Initial%Final%Initial%Final%Initial%Final%Up to 100% 2 2 2 2 2 2 2 2 2 2100%-133% 2 2.5 2 2.5 2 2.5 2 2.5 2 2.5133%-150% 2.5 4 2.5 4 2.5 4 2.5 4 2.5 4150%-200% 4 4.3 4 5.3 4 6.3 4 7.3 4 8.3200%-250% 4.3 4.3 5.3 5.9 6.3 8.05 7.3 9 8.3 10250%-300% 4.3 4.3 5.9 5.9 8.05 8.35 9 10.5 10 11.5300%-350% 4.3 6.4 5.9 8.9 8.35 12.5 10.5 15.8 11.5 16.2’’,10 (B) by striking ‘‘0.504’’ in clause (ii)(III)11 and inserting ‘‘0.4’’, and12 (C) by adding at the end the following new13 clause:14 ‘‘(iii) AGE DETERMINATIONS.—For15 purposes of clause (i), the age of the tax-16 payer taken into account under clause (i)17 with respect to any taxable year is the age18 attained before the close of the taxable19 year by the oldest individual taken into ac-7ERN17282 Discussion Draft S.L.C.1 count on such taxpayer’s return who is2 covered by a qualified health plan taken3 into account under paragraph (2)(A).’’.4 (c) ELIMINATION OF ELIGIBILITY EXCEPTIONS FOR5 EMPLOYER-SPONSORED COVERAGE.—6 (1) IN GENERAL.—Section 36B(c)(2) of the In-7 ternal Revenue Code of 1986 is amended by striking8 subparagraph (C).9 (2) AMENDMENTS RELATED TO QUALIFIED10 SMALL EMPLOYER HEALTH REIMBURSEMENT AR-11 RANGEMENTS.—Section 36B(c)(4) of such Code is12 amended—13 (A) by striking ‘‘which constitutes afford-14 able coverage’’ in subparagraph (A),15 (B) by striking ‘‘the amount described in16 subparagraph (C)(i)(II) for such month’’ in17 subparagraph (B) and inserting ‘‘1/12 of the18 employee’s permitted benefit (as defined in sec-19 tion 9831(d)(3)(C)) under such arrangement’’,20 (C) by striking subparagraphs (C) and (F)21 and redesignating subparagraphs (D) and (E)22 as subparagraphs (C) and (D), respectively, and23 (D) in subparagraph (D), as so redesig-24 nated, by striking ‘‘subparagraph (C)(i)(II)’’25 and inserting ‘‘subparagraph (B)’’. 8ERN17282 Discussion Draft S.L.C.1 (d) MODIFICATION OF DEFINITION OF QUALIFIED2 HEALTH PLAN.—3 (1) IN GENERAL.—Section 36B(c)(3)(A) of the4 Internal Revenue Code of 1986 is amended by in-5 serting before the period at the end the following:6 ‘‘or a plan that includes coverage for abortions7 (other than any abortion necessary to save the life8 of the mother or any abortion with respect to a9 pregnancy that is the result of an act of rape or in-10 cest)’’.11 (2) EFFECTIVE DATE.—The amendment made12 by this subsection shall apply to taxable years begin-13 ning after December 31, 2017.14 (e) INCREASED PENALTY ON ERRONEOUS CLAIMS OF15 CREDIT.—Section 6676(a) of the Internal Revenue Code16 of 1986 is amended by inserting ‘‘(25 percent in the case17 of a claim for refund or credit relating to the health insur-18 ance coverage credit under section 36B)’’ after ‘‘20 per-19 cent’’.20 (f) EFFECTIVE DATE.—Except as otherwise provided21 in this section, the amendments made by this section shall22 apply to taxable years beginning after December 31, 2019.23 SEC. 103. MODIFICATIONS TO SMALL BUSINESS TAX CRED-24 IT.25 (a) SUNSET.— 9ERN17282 Discussion Draft S.L.C.1 (1) IN GENERAL.—Section 45R of the Internal2 Revenue Code of 1986 is amended by adding at the3 end the following new subsection:4 ‘‘(j) SHALL NOT APPLY.—This section shall not5 apply with respect to amounts paid or incurred in taxable6 years beginning after December 31, 2019.’’.7 (2) EFFECTIVE DATE.—The amendment made8 by this subsection shall apply to taxable years begin-9 ning after December 31, 2019.10 (b) DISALLOWANCE OF SMALL EMPLOYER HEALTH11 INSURANCE EXPENSE CREDIT FOR PLAN WHICH IN-12 CLUDES COVERAGE FOR ABORTION.—13 (1) IN GENERAL.—Subsection (h) of section14 45R of the Internal Revenue Code of 1986 is15 amended—16 (A) by striking ‘‘Any term’’ and inserting17 the following:18 ‘‘(1) IN GENERAL.—Any term’’, and19 (B) by adding at the end the following new20 paragraph:21 ‘‘(2) EXCLUSION OF HEALTH PLANS INCLUDING22 COVERAGE FOR ABORTION.—The term ‘qualified23 health plan’ does not include any health plan that24 includes coverage for abortions (other than any25 abortion necessary to save the life of the mother or 10ERN17282 Discussion Draft S.L.C.1 any abortion with respect to a pregnancy that is the2 result of an act of rape or incest).’’.3 (2) EFFECTIVE DATE.—The amendments made4 by this subsection shall apply to taxable years begin-5 ning after December 31, 2017.6 SEC. 104. INDIVIDUAL MANDATE.7 (a) IN GENERAL.—Section 5000A(c) of the Internal8 Revenue Code of 1986 is amended—9 (1) in paragraph (2)(B)(iii), by striking ‘‘2.510 percent’’ and inserting ‘‘Zero percent’’, and11 (2) in paragraph (3)—12 (A) by striking ‘‘$695’’ in subparagraph13 (A) and inserting ‘‘$0’’, and14 (B) by striking subparagraph (D).15 (b) EFFECTIVE DATE.—The amendments made by16 this section shall apply to months beginning after Decem-17 ber 31, 2015.18 SEC. 105. EMPLOYER MANDATE.19 (a) IN GENERAL.—20 (1) Paragraph (1) of section 4980H(c) of the21 Internal Revenue Code of 1986 is amended by in-22 serting ‘‘($0 in the case of months beginning after23 December 31, 2015)’’ after ‘‘$2,000’’.24 (2) Paragraph (1) of section 4980H(b) of the25 Internal Revenue Code of 1986 is amended by in-11ERN17282 Discussion Draft S.L.C.1 serting ‘‘($0 in the case of months beginning after2 December 31, 2015)’’ after ‘‘$3,000’’.3 (b) EFFECTIVE DATE.—The amendments made by4 this section shall apply to months beginning after Decem-5 ber 31, 2015.6 SEC. 106. STATE STABILITY AND INNOVATION PROGRAM.7 (a) IN GENERAL.—Section 2105 of the Social Secu-8 rity Act (42 U.S.C. 1397ee) is amended by adding at the9 end the following new subsections:10 ‘‘(h) SHORT-TERM ASSISTANCE TO ADDRESS COV-11 ERAGE AND ACCESS DISRUPTION AND PROVIDE SUPPORT12 FOR STATES.—13 ‘‘(1) APPROPRIATION.—There are authorized to14 be appropriated, and are appropriated, out of monies15 in the Treasury not otherwise obligated,16 $15,000,000,000 for each of calendar years 201817 and 2019, and $10,000,000,000 for each of calendar18 years 2020 and 2021, to the Administrator of the19 Centers for Medicare & Medicaid Services (in this20 subsection and subsection (i) referred to as the ‘Ad-21 ministrator’) to fund arrangements with health in-22 surance issuers to address coverage and access dis-23 ruption and respond to urgent health care needs24 within States. Funds appropriated under this para-25 graph shall remain available until expended. 12ERN17282 Discussion Draft S.L.C.1 ‘‘(2) PARTICIPATION REQUIREMENTS.—2 ‘‘(A) GUIDANCE.—Not later than 30 days3 after the date of enactment of this subsection,4 the Administrator shall issue guidance to health5 insurance issuers regarding how to submit a no-6 tice of intent to participate in the program es-7 tablished under this subsection.8 ‘‘(B) NOTICE OF INTENT TO PARTICI-9 PATE.—To be eligible for funding under this10 subsection, a health insurance issuer shall sub-11 mit to the Administrator a notice of intent to12 participate at such time (but, in the case of13 funding for calendar year 2018, not later than14 35 days after the date of enactment of this sub-15 section and, in the case of funding for calendar16 year 2019, 2020, or 2021, not later than March17 31 of the previous year) and in such form and18 manner as specified by the Administrator and19 containing—20 ‘‘(i) a certification that the health in-21 surance issuer will use the funds in accord-22 ance with the requirements of paragraph23 (5); and 13ERN17282 Discussion Draft S.L.C.1 ‘‘(ii) such information as the Adminis-2 trator may require to carry out this sub-3 section.4 ‘‘(3) PROCEDURE FOR DISTRIBUTION OF5 FUNDS.—The Administrator shall determine an ap-6 propriate procedure for providing and distributing7 funds under this subsection.8 ‘‘(4) NO MATCH.—Neither the State percentage9 applicable to payments to States under subsection10 (i)(5)(B) nor any other matching requirement shall11 apply to funds provided to health insurance issuers12 under this subsection.13 ‘‘(5) USE OF FUNDS.—Funds provided to a14 health insurance issuer under paragraph (1) shall be15 subject to the requirements of paragraphs (1)(D)16 and (7) of subsection (i) in the same manner as17 such requirements apply to States receiving pay-18 ments under subsection (i) and shall be used for the19 activities specified in paragraph (1)(A)(ii) of sub-20 section (i).21 ‘‘(i) LONG-TERM STATE STABILITY AND INNOVATION22 PROGRAM.—23 ‘‘(1) APPLICATION AND CERTIFICATION RE-24 QUIREMENTS.—To be eligible for an allotment of25 funds under this subsection, a State shall submit to 14ERN17282 Discussion Draft S.L.C.1 the Administrator an application, not later than2 March 31, 2018, in the case of allotments for cal-3 endar year 2019, and not later than March 31 of4 the previous year, in the case of allotments for any5 subsequent calendar year) and in such form and6 manner as specified by the Administrator, that con-7 tains the following:8 ‘‘(A) A description of how the funds will be9 used to do 1 or more of the following:10 ‘‘(i) To establish or maintain a pro-11 gram or mechanism to provide financial as-12 sistance to help high-risk individuals, in-13 cluding by reducing premium costs for14 such individuals, who have or are projected15 to have a high rate of utilization of health16 services, as measured by cost, and who do17 not have access to health insurance cov-18 erage offered through an employer, enroll19 in health insurance coverage under a plan20 offered in the individual market (within21 the meaning of section 5000A(f)(1)(C) of22 the Internal Revenue Code of 1986).23 ‘‘(ii) To establish or maintain a pro-24 gram to enter into arrangements with25 health insurance issuers to help stabilize 15ERN17282 Discussion Draft S.L.C.1 premiums and promote State health insur-2 ance market participation and choice in3 plans offered in the individual market4 (within the meaning of section5 5000A(f)(1)(C) of the Internal Revenue6 Code of 1986).7 ‘‘(iii) To provide payments for health8 care providers for the provision of health9 care services, as specified by the Adminis-10 trator.11 ‘‘(iv) To provide assistance to reduce12 out-of-pocket costs, such as copayments,13 coinsurance, and deductibles, of individuals14 enrolled in plans offered in the individual15 market (within the meaning of section16 5000A(f)(1)(C) of the Internal Revenue17 Code of 1986).18 ‘‘(B) A certification that the State shall19 make, from non-Federal funds, expenditures for20 1 or more of the activities specified in subpara-21 graph (A) in an amount that is not less than22 the State percentage required for the year23 under paragraph (5)(B)(ii). 16ERN17282 Discussion Draft S.L.C.1 ‘‘(C) A certification that the funds pro-2 vided under this subsection shall only be used3 for the activities specified in subparagraph (A).4 ‘‘(D) A certification that none of the funds5 provided under this subsection shall be used by6 the State for an expenditure that is attributable7 to an intergovernmental transfer, certified pub-8 lic expenditure, or any other expenditure to fi-9 nance the non-Federal share of expenditures re-10 quired under any provision of law, including11 under the State plans established under this12 title and title XIX or under a waiver of such13 plans.14 ‘‘(E) Such other information as necessary15 for the Administrator to carry out this sub-16 section.17 ‘‘(2) ELIGIBILITY.—Only the 50 States and the18 District of Columbia shall be eligible for an allot-19 ment and payments under this subsection and all20 references in this subsection to a State shall be21 treated as only referring to the 50 States and the22 District of Columbia.23 ‘‘(3) ONE-TIME APPLICATION.—If an applica-24 tion of a State submitted under this subsection is25 approved by the Administrator for a year, the appli-17ERN17282 Discussion Draft S.L.C.1 cation shall be deemed to be approved by the Admin-2 istrator for that year and each subsequent year3 through December 31, 2026.4 ‘‘(4) LONG-TERM STATE STABILITY AND INNO-5 VATION ALLOTMENTS.—6 ‘‘(A) APPROPRIATION; TOTAL ALLOT-7 MENT.—For the purpose of providing allot-8 ments to States under this subsection, there is9 appropriated, out of any money in the Treasury10 not otherwise appropriated—11 ‘‘(i) for calendar year 2019,12 $8,000,000,000;13 ‘‘(ii) for calendar year 2020,14 $14,000,000,000;15 ‘‘(iii) for calendar year 2021,16 $14,000,000,000;17 ‘‘(iv) for calendar year 2022,18 $6,000,000,000;19 ‘‘(v) for calendar year 2023,20 $6,000,000,000;21 ‘‘(vi) for calendar year 2024,22 $5,000,000,000;23 ‘‘(vii) for calendar year 2025,24 $5,000,000,000; and 18ERN17282 Discussion Draft S.L.C.1 ‘‘(viii) for calendar year 2026,2 $4,000,000,000.3 ‘‘(B) ALLOTMENTS.—4 ‘‘(i) IN GENERAL.—In the case of a5 State with an application approved under6 this subsection with respect to a year, the7 Administrator shall allot to the State, in8 accordance with an allotment methodology9 specified by the Administrator that ensures10 that the spending requirement in para-11 graph (6) is met for the year, from12 amounts appropriated for such year under13 subparagraph (A), such amount as speci-14 fied by the Administrator with respect to15 the State and application and year.16 ‘‘(ii) ANNUAL REDISTRIBUTION OF17 PREVIOUS YEAR’S UNUSED FUNDS.—18 ‘‘(I) IN GENERAL.— In carrying19 out clause (i), with respect to a year20 (beginning with 2021), the Adminis-21 trator shall, not later than March 3122 of such year—23 ‘‘(aa) determine the amount24 of funds, if any, remaining un-19ERN17282 Discussion Draft S.L.C.1 used under subparagraph (A)2 from the previous year; and3 ‘‘(bb) if the Administrator4 determines that any funds so re-5 main from the previous year, re-6 distribute such remaining funds7 in accordance with an allotment8 methodology specified by the Ad-9 ministrator to States that have10 submitted an application ap-11 proved under this subsection for12 the year.13 ‘‘(II) APPLICABLE STATE PER-14 CENTAGE.—The State percentage15 specified for a year in paragraph16 (5)(B)(ii) shall apply to funds redis-17 tributed under subclause (I) in that18 year.19 ‘‘(C) AVAILABILITY OF ALLOTTED STATE20 FUNDS.—21 ‘‘(i) IN GENERAL.—Amounts allotted22 to a State pursuant to subparagraph (B)(i)23 for a year shall remain available for ex-24 penditure by the State through the end of25 the second succeeding year. 20ERN17282 Discussion Draft S.L.C.1 ‘‘(ii) AVAILABILITY OF AMOUNTS RE-2 DISTRIBUTED.—Amounts redistributed to3 a State under subparagraph (B)(ii) in a4 year shall be available for expenditure by5 the State through the end of the second6 succeeding year.7 ‘‘(5) PAYMENTS.—8 ‘‘(A) ANNUAL PAYMENT OF ALLOT-9 MENTS.—Subject to subparagraph (B), the Ad-10 ministrator shall pay to each State that has an11 application approved under this subsection for a12 year, the allotment determined under paragraph13 (4)(B) for the State for the year.14 ‘‘(B) MATCH REQUIRED.—15 ‘‘(i) IN GENERAL.—The Administrator16 shall pay each State that has an applica-17 tion approved under this subsection for a18 year, the Federal percentage of the allot-19 ment determined for the State under para-20 graph (4)(B) for the year.21 ‘‘(ii) FEDERAL AND STATE PERCENT-22 AGES DEFINED.—For purposes of clause23 (i), the Federal percentage is equal to 10024 percent reduced by the State percentage 21ERN17282 Discussion Draft S.L.C.1 for that year, and the State percentage is2 equal to—3 ‘‘(I) in the case of calendar year4 2019, 0 percent;5 ‘‘(II) in the case of calendar year6 2020, 0 percent;7 ‘‘(III) in the case of calendar8 year 2021, 0 percent;9 ‘‘(IV) in the case of calendar10 year 2022, 7 percent;11 ‘‘(V) in the case of calendar year12 2023, 14 percent;13 ‘‘(VI) in the case of calendar14 year 2024, 21 percent;15 ‘‘(VII) in the case of calendar16 year 2025, 28 percent; and17 ‘‘(VIII) in the case of calendar18 year 2026, 35 percent.19 ‘‘(C) ADVANCE PAYMENT; RETROSPECTIVE20 ADJUSTMENT.—21 ‘‘(i) IN GENERAL.—If the Adminis-22 trator deems it appropriate, the Adminis-23 trator shall make payments under this sub-24 section for each year on the basis of ad-25 vance estimates of expenditures submitted 22ERN17282 Discussion Draft S.L.C.1 by the State and such other investigation2 as the Administrator shall find necessary,3 and shall reduce or increase the payments4 as necessary to adjust for any overpayment5 or underpayment for prior years.6 ‘‘(ii) MISUSE OF FUNDS.—If the Ad-7 ministrator determines that a State is not8 using funds paid to the State under this9 subsection in a manner consistent with the10 description provided by the State in its ap-11 plication approved under paragraph (1),12 the Administrator may withhold payments,13 reduce payments, or recover previous pay-14 ments to the State under this subsection15 as the Administrator deems appropriate.16 ‘‘(D) FLEXIBILITY IN SUBMITTAL OF17 CLAIMS.—Nothing in this subsection shall be18 construed as preventing a State from claiming19 as expenditures in the year expenditures that20 were incurred in a previous year.21 ‘‘(6) REQUIRED USE FOR PREMIUM STABILIZA-22 TION AND INCENTIVES FOR INDIVIDUAL MARKET23 PARTICIPATION.—In determining allotments for24 States under this subsection for each of calendar25 years 2019, 2020, and 2021, the Administrator shall 23ERN17282 Discussion Draft S.L.C.1 ensure that at least $5,000,000,000 of the amounts2 appropriated for each such year under paragraph3 (4)(A) are used by States for the purposes described4 in paragraph (1)(A)(ii) and in accordance with guid-5 ance issued by the Administrator not later than 306 days after the date of enactment of this subsection7 that specifies the parameters for the use of funds for8 such purposes.9 ‘‘(7) EXEMPTIONS.—Paragraphs (2), (3), (5),10 (6), (8), (10), and (11) of subsection (c) do not11 apply to payments under this subsection.’’.12 (b) OTHER TITLE XXI AMENDMENTS.—13 (1) Section 2101 of such Act (42 U.S.C.14 1397aa) is amended—15 (A) in subsection (a), in the matter pre-16 ceding paragraph (1), by striking ‘‘The pur-17 pose’’ and inserting ‘‘Except with respect to18 short-term assistance activities under section19 2105(h) and the Long-Term State Stability and20 Innovation Program established in section21 2105(i), the purpose’’; and22 (B) in subsection (b), in the matter pre-23 ceding paragraph (1), by inserting ‘‘subsection24 (a) or (g) of’’ before ‘‘section 2105’’. 24ERN17282 Discussion Draft S.L.C.1 (2) Section 2105(c)(1) of such Act (42 U.S.C.2 1397ee(c)(1)) is amended by striking ‘‘and may not3 include’’ and inserting ‘‘or to carry out short-term4 assistance activities under subsection (h) or the5 Long-Term State Stability and Innovation Program6 established in subsection (i) and, except in the case7 of funds made available under subsection (h) or (i),8 may not include’’.9 (3) Section 2106(a)(1) of such Act (42 U.S.C.10 1397ff(a)(1)) is amended by inserting ‘‘subsection11 (a) or (g) of’’ before ‘‘section 2105’’.12 SEC. 107. BETTER CARE RECONCILIATION IMPLEMENTA-13 TION FUND.14 (a) IN GENERAL.—There is hereby established a Bet-15 ter Care Reconciliation Implementation Fund (referred to16 in this section as the ‘‘Fund’’) within the Department of17 Health and Human Services to provide for Federal admin-18 istrative expenses in carrying out this Act.19 (b) FUNDING.—There is appropriated to the Fund,20 out of any funds in the Treasury not otherwise appro-21 priated, $500,000,000. 25ERN17282 Discussion Draft S.L.C.1 SEC. 108. REPEAL OF THE TAX ON EMPLOYEE HEALTH IN-2 SURANCE PREMIUMS AND HEALTH PLAN3 BENEFITS.4 (a) IN GENERAL.—Chapter 43 of the Internal Rev-5 enue Code of 1986 is amended by striking section 4980I.6 (b) EFFECTIVE DATE.—The amendment made by7 subsection (a) shall apply to taxable years beginning after8 December 31, 2019.9 (c) SUBSEQUENT EFFECTIVE DATE.—The amend-10 ment made by subsection (a) shall not apply to taxable11 years beginning after December 31, 2025, and chapter 4312 of the Internal Revenue Code of 1986 is amended to read13 as such chapter would read if such subsection had never14 been enacted.15 SEC. 109. REPEAL OF TAX ON OVER-THE-COUNTER MEDICA-16 TIONS.17 (a) HSAS.—Subparagraph (A) of section 223(d)(2)18 of the Internal Revenue Code of 1986 is amended by strik-19 ing ‘‘Such term’’ and all that follows through the period.20 (b) ARCHER MSAS.—Subparagraph (A) of section21 220(d)(2) of the Internal Revenue Code of 1986 is amend-22 ed by striking ‘‘Such term’’ and all that follows through23 the period.24 (c) HEALTH FLEXIBLE SPENDING ARRANGEMENTS25 AND HEALTH REIMBURSEMENT ARRANGEMENTS.—Sec-26ERN17282 Discussion Draft S.L.C.1 tion 106 of the Internal Revenue Code of 1986 is amended2 by striking subsection (f).3 (d) EFFECTIVE DATES.—4 (1) DISTRIBUTIONS FROM SAVINGS AC-5 COUNTS.—The amendments made by subsections (a)6 and (b) shall apply to amounts paid with respect to7 taxable years beginning after December 31, 2016.8 (2) REIMBURSEMENTS.—The amendment made9 by subsection (c) shall apply to expenses incurred10 with respect to taxable years beginning after Decem-11 ber 31, 2016.12 SEC. 110. REPEAL OF TAX ON HEALTH SAVINGS ACCOUNTS.13 (a) HSAS.—Section 223(f)(4)(A) of the Internal14 Revenue Code of 1986 is amended by striking ‘‘20 per-15 cent’’ and inserting ‘‘10 percent’’.16 (b) ARCHER MSAS.—Section 220(f)(4)(A) of the In-17 ternal Revenue Code of 1986 is amended by striking ‘‘2018 percent’’ and inserting ‘‘15 percent’’.19 (c) EFFECTIVE DATE.—The amendments made by20 this section shall apply to distributions made after Decem-21 ber 31, 2016.22 SEC. 111. REPEAL OF LIMITATIONS ON CONTRIBUTIONS TO23 FLEXIBLE SPENDING ACCOUNTS.24 (a) IN GENERAL.—Section 125 of the Internal Rev-25 enue Code of 1986 is amended by striking subsection (i). 27ERN17282 Discussion Draft S.L.C.1 (b) EFFECTIVE DATE.—The amendment made by2 this section shall apply to plan years beginning after De-3 cember 31, 2017.4 SEC. 112. REPEAL OF TAX ON PRESCRIPTION MEDICA-5 TIONS.6 Subsection (j) of section 9008 of the Patient Protec-7 tion and Affordable Care Act is amended to read as fol-8 lows:9 ‘‘(j) REPEAL.—This section shall apply to calendar10 years beginning after December 31, 2010, and ending be-11 fore January 1, 2018.’’.12 SEC. 113. REPEAL OF MEDICAL DEVICE EXCISE TAX.13 Section 4191 of the Internal Revenue Code of 198614 is amended by adding at the end the following new sub-15 section:16 ‘‘(d) APPLICABILITY.—The tax imposed under sub-17 section (a) shall not apply to sales after December 31,18 2017.’’.19 SEC. 114. REPEAL OF HEALTH INSURANCE TAX.20 Subsection (j) of section 9010 of the Patient Protec-21 tion and Affordable Care Act is amended by striking ‘‘,22 and’’ at the end of paragraph (1) and all that follows23 through ‘‘2017’’. 28ERN17282 Discussion Draft S.L.C.1 SEC. 115. REPEAL OF ELIMINATION OF DEDUCTION FOR2 EXPENSES ALLOCABLE TO MEDICARE PART D3 SUBSIDY.4 (a) IN GENERAL.—Section 139A of the Internal Rev-5 enue Code of 1986 is amended by adding at the end the6 following new sentence: ‘‘This section shall not be taken7 into account for purposes of determining whether any de-8 duction is allowable with respect to any cost taken into9 account in determining such payment.’’.10 (b) EFFECTIVE DATE.—The amendment made by11 this section shall apply to taxable years beginning after12 December 31, 2016.13 SEC. 116. REPEAL OF CHRONIC CARE TAX.14 (a) IN GENERAL.—Subsection (a) of section 213 of15 the Internal Revenue Code of 1986 is amended by striking16 ‘‘10 percent’’ and inserting ‘‘7.5 percent’’.17 (b) EFFECTIVE DATE.—The amendment made by18 this section shall apply to taxable years beginning after19 December 31, 2016.20 SEC. 117. REPEAL OF MEDICARE TAX INCREASE.21 (a) IN GENERAL.—Subsection (b) of section 3101 of22 the Internal Revenue Code of 1986 is amended to read23 as follows:24 ‘‘(b) HOSPITAL INSURANCE.—In addition to the tax25 imposed by the preceding subsection, there is hereby im-26 posed on the income of every individual a tax equal to 1.45 29ERN17282 Discussion Draft S.L.C.1 percent of the wages (as defined in section 3121(a)) re-2 ceived by such individual with respect to employment (as3 defined in section 3121(b).’’.4 (b) SECA.—Subsection (b) of section 1401 of the In-5 ternal Revenue Code of 1986 is amended to read as fol-6 lows:7 ‘‘(b) HOSPITAL INSURANCE.—In addition to the tax8 imposed by the preceding subsection, there shall be im-9 posed for each taxable year, on the self-employment in-10 come of every individual, a tax equal to 2.9 percent of the11 amount of the self-employment income for such taxable12 year.’’.13 (c) EFFECTIVE DATE.—The amendments made by14 this section shall apply with respect to remuneration re-15 ceived after, and taxable years beginning after, December16 31, 2022.17 SEC. 118. REPEAL OF TANNING TAX.18 (a) IN GENERAL.—The Internal Revenue Code of19 1986 is amended by striking chapter 49.20 (b) EFFECTIVE DATE.—The amendment made by21 this section shall apply to services performed after Sep-22 tember 30, 2017.23 SEC. 119. REPEAL OF NET INVESTMENT TAX.24 (a) IN GENERAL.—Subtitle A of the Internal Rev-25 enue Code of 1986 is amended by striking chapter 2A. 30ERN17282 Discussion Draft S.L.C.1 (b) EFFECTIVE DATE.—The amendment made by2 this section shall apply to taxable years beginning after3 December 31, 2016.4 SEC. 120. REMUNERATION.5 Paragraph (6) of section 162(m) of the Internal Rev-6 enue Code of 1986 is amended by adding at the end the7 following new subparagraph:8 ‘‘(I) TERMINATION.—This paragraph shall9 not apply to taxable years beginning after De-10 cember 31, 2016.’’.11 SEC. 121. MAXIMUM CONTRIBUTION LIMIT TO HEALTH SAV-12 INGS ACCOUNT INCREASED TO AMOUNT OF13 DEDUCTIBLE AND OUT-OF-POCKET LIMITA-14 TION.15 (a) SELF-ONLY COVERAGE.—Section 223(b)(2)(A)16 of the Internal Revenue Code of 1986 is amended by strik-17 ing ‘‘$2,250’’ and inserting ‘‘the amount in effect under18 subsection (c)(2)(A)(ii)(I)’’.19 (b) FAMILY COVERAGE.—Section 223(b)(2)(B) of20 such Code is amended by striking ‘‘$4,500’’ and inserting21 ‘‘the amount in effect under subsection (c)(2)(A)(ii)(II)’’.22 (c) COST-OF-LIVING ADJUSTMENT.—Section23 223(g)(1) of such Code is amended—24 (1) by striking ‘‘subsections (b)(2) and’’ both25 places it appears and inserting ‘‘subsection’’, and 31ERN17282 Discussion Draft S.L.C.1 (2) in subparagraph (B), by striking ‘‘deter-2 mined by’’ and all that follows through ‘‘ ‘calendar3 year 2003’.’’ and inserting ‘‘determined by sub-4 stituting ‘calendar year 2003’ for ‘calendar year5 1992’ in subparagraph (B) thereof.’’.6 (d) EFFECTIVE DATE.—The amendments made by7 this section shall apply to taxable years beginning after8 December 31, 2017.9 SEC. 122. ALLOW BOTH SPOUSES TO MAKE CATCH-UP CON-10 TRIBUTIONS TO THE SAME HEALTH SAVINGS11 ACCOUNT.12 (a) IN GENERAL.—Section 223(b)(5) of the Internal13 Revenue Code of 1986 is amended to read as follows:14 ‘‘(5) SPECIAL RULE FOR MARRIED INDIVIDUALS15 WITH FAMILY COVERAGE.—16 ‘‘(A) IN GENERAL.—In the case of individ-17 uals who are married to each other, if both18 spouses are eligible individuals and either19 spouse has family coverage under a high de-20 ductible health plan as of the first day of any21 month—22 ‘‘(i) the limitation under paragraph23 (1) shall be applied by not taking into ac-24 count any other high deductible health25 plan coverage of either spouse (and if such 32ERN17282 Discussion Draft S.L.C.1 spouses both have family coverage under2 separate high deductible health plans, only3 one such coverage shall be taken into ac-4 count),5 ‘‘(ii) such limitation (after application6 of clause (i)) shall be reduced by the ag-7 gregate amount paid to Archer MSAs of8 such spouses for the taxable year, and9 ‘‘(iii) such limitation (after application10 of clauses (i) and (ii)) shall be divided11 equally between such spouses unless they12 agree on a different division.13 ‘‘(B) TREATMENT OF ADDITIONAL CON-14 TRIBUTION AMOUNTS.—If both spouses referred15 to in subparagraph (A) have attained age 5516 before the close of the taxable year, the limita-17 tion referred to in subparagraph (A)(iii) which18 is subject to division between the spouses shall19 include the additional contribution amounts de-20 termined under paragraph (3) for both spouses.21 In any other case, any additional contribution22 amount determined under paragraph (3) shall23 not be taken into account under subparagraph24 (A)(iii) and shall not be subject to division be-25 tween the spouses.’’. 33ERN17282 Discussion Draft S.L.C.1 (b) EFFECTIVE DATE.—The amendment made by2 this section shall apply to taxable years beginning after3 December 31, 2017.4 SEC. 123. SPECIAL RULE FOR CERTAIN MEDICAL EXPENSES5 INCURRED BEFORE ESTABLISHMENT OF6 HEALTH SAVINGS ACCOUNT.7 (a) IN GENERAL.—Section 223(d)(2) of the Internal8 Revenue Code of 1986 is amended by adding at the end9 the following new subparagraph:10 ‘‘(D) TREATMENT OF CERTAIN MEDICAL11 EXPENSES INCURRED BEFORE ESTABLISHMENT12 OF ACCOUNT.—If a health savings account is13 established during the 60-day period beginning14 on the date that coverage of the account bene-15 ficiary under a high deductible health plan be-16 gins, then, solely for purposes of determining17 whether an amount paid is used for a qualified18 medical expense, such account shall be treated19 as having been established on the date that20 such coverage begins.’’.21 (b) EFFECTIVE DATE.—The amendment made by22 this subsection shall apply with respect to coverage under23 a high deductible health plan beginning after December24 31, 2017. 34ERN17282 Discussion Draft S.L.C.1 SEC. 124. FEDERAL PAYMENTS TO STATES.2 (a) IN GENERAL.—Notwithstanding section 504(a),3 1902(a)(23), 1903(a), 2002, 2005(a)(4), 2102(a)(7), or4 2105(a)(1) of the Social Security Act (42 U.S.C. 704(a),5 1396a(a)(23), 1396b(a), 1397a, 1397d(a)(4),6 1397bb(a)(7), 1397ee(a)(1)), or the terms of any Med-7 icaid waiver in effect on the date of enactment of this Act8 that is approved under section 1115 or 1915 of the Social9 Security Act (42 U.S.C. 1315, 1396n), for the 1-year pe-10 riod beginning on the date of enactment of this Act, no11 Federal funds provided from a program referred to in this12 subsection that is considered direct spending for any year13 may be made available to a State for payments to a pro-14 hibited entity, whether made directly to the prohibited en-15 tity or through a managed care organization under con-16 tract with the State.17 (b) DEFINITIONS.—In this section:18 (1) PROHIBITED ENTITY.—The term ‘‘prohib-19 ited entity’’ means an entity, including its affiliates,20 subsidiaries, successors, and clinics—21 (A) that, as of the date of enactment of22 this Act—23 (i) is an organization described in sec-24 tion 501(c)(3) of the Internal Revenue25 Code of 1986 and exempt from tax under26 section 501(a) of such Code; 35ERN17282 Discussion Draft S.L.C.1 (ii) is an essential community provider2 described in section 156.235 of title 45,3 Code of Federal Regulations (as in effect4 on the date of enactment of this Act), that5 is primarily engaged in family planning6 services, reproductive health, and related7 medical care; and8 (iii) provides for abortions, other than9 an abortion—10 (I) if the pregnancy is the result11 of an act of rape or incest; or12 (II) in the case where a woman13 suffers from a physical disorder, phys-14 ical injury, or physical illness that15 would, as certified by a physician,16 place the woman in danger of death17 unless an abortion is performed, in-18 cluding a life-endangering physical19 condition caused by or arising from20 the pregnancy itself; and21 (B) for which the total amount of Federal22 and State expenditures under the Medicaid pro-23 gram under title XIX of the Social Security Act24 in fiscal year 2014 made directly to the entity25 and to any affiliates, subsidiaries, successors, or 36ERN17282 Discussion Draft S.L.C.1 clinics of the entity, or made to the entity and2 to any affiliates, subsidiaries, successors, or3 clinics of the entity as part of a nationwide4 health care provider network, exceeded5 $350,000,000.6 (2) DIRECT SPENDING.—The term ‘‘direct7 spending’’ has the meaning given that term under8 section 250(c) of the Balanced Budget and Emer-9 gency Deficit Control Act of 1985 (2 U.S.C. 900(c)).10 SEC. 125. MEDICAID PROVISIONS.11 The Social Security Act is amended—12 (1) in section 1902 (42 U.S.C. 1396a)—13 (A) in subsection (a)(47)(B), by inserting14 ‘‘and provided that any such election shall cease15 to be effective on January 1, 2020, and no such16 election shall be made after that date’’ before17 the semicolon at the end; and18 (B) in subsection (l)(2)(C), by inserting19 ‘‘and ending December 31, 2019,’’ after ‘‘Janu-20 ary 1, 2014,’’;21 (2) in section 1915(k)(2) (42 U.S.C.22 1396n(k)(2)), by striking ‘‘during the period de-23 scribed in paragraph (1)’’ and inserting ‘‘on or after24 the date referred to in paragraph (1) and before25 January 1, 2020’’; and 37ERN17282 Discussion Draft S.L.C.1 (3) in section 1920(e) (42 U.S.C. 1396r–1(e)),2 by striking ‘‘under clause (i)(VIII), clause (i)(IX), or3 clause (ii)(XX) of subsection (a)(10)(A)’’ and insert-4 ing ‘‘under clause (i)(VIII) or clause (ii)(XX) of sec-5 tion 1902(a)(10)(A) before January 1, 2020, section6 1902(a)(10)(A)(i)(IX),’’.7 SEC. 126. MEDICAID EXPANSION.8 (a) IN GENERAL.—Title XIX of the Social Security9 Act (42 U.S.C. 1396 et seq.) is amended—10 (1) in section 1902 (42 U.S.C. 1396a)—11 (A) in subsection (a)(10)(A)—12 (i) in clause (i)(VIII), by inserting13 ‘‘and ending December 31, 2019,’’ after14 ‘‘2014,’’; and15 (ii) in clause (ii), in subclause (XX),16 by inserting ‘‘and ending December 31,17 2017,’’ after ‘‘2014,’’, and by adding at18 the end the following new subclause:19 ‘‘(XXIII) beginning January 1, 2020,20 who are expansion enrollees (as defined in21 subsection (nn)(1));’’; and22 (B) by adding at the end the following new23 subsection:24 ‘‘(nn) EXPANSION ENROLLEES.— 38ERN17282 Discussion Draft S.L.C.1 ‘‘(1) IN GENERAL.—In this title, the term ‘ex-2 pansion enrollee’ means an individual—3 ‘‘(A) who is under 65 years of age;4 ‘‘(B) who is not pregnant;5 ‘‘(C) who is not entitled to, or enrolled for,6 benefits under part A of title XVIII, or enrolled7 for benefits under part B of title XVIII;8 ‘‘(D) who is not described in any of sub-9 clauses (I) through (VII) of subsection10 (a)(10)(A)(i); and11 ‘‘(E) whose income (as determined under12 subsection (e)(14)) does not exceed 133 percent13 of the poverty line (as defined in section14 2110(c)(5)) applicable to a family of the size in-15 volved.16 ‘‘(2) APPLICATION OF RELATED PROVISIONS.—17 Any reference in subsection (a)(10)(G), (k), or (gg)18 of this section or in section 1903, 1905(a), 1920(e),19 or 1937(a)(1)(B) to individuals described in sub-20 clause (VIII) of subsection (a)(10)(A)(i) shall be21 deemed to include a reference to expansion enroll-22 ees.’’; and23 (2) in section 1905 (42 U.S.C. 1396d)—24 (A) in subsection (y)(1)— 39ERN17282 Discussion Draft S.L.C.1 (i) in the matter preceding subpara-2 graph (A), by striking ‘‘, with respect to’’3 and all that follows through ‘‘shall be equal4 to’’ and inserting ‘‘and that has elected to5 cover newly eligible individuals before6 March 1, 2017, with respect to amounts7 expended by such State before January 1,8 2020, for medical assistance for newly eli-9 gible individuals described in subclause10 (VIII) of section 1902(a)(10)(A)(i), and,11 with respect to amounts expended by such12 State after December 31, 2019, and before13 January 1, 2024, for medical assistance14 for expansion enrollees (as defined in sec-15 tion 1902(nn)(1)), shall be equal to the16 higher of the percentage otherwise deter-17 mined for the State and year under sub-18 section (b) (without regard to this sub-19 section) and’’;20 (ii) in subparagraph (D), by striking21 ‘‘and’’ after the semicolon;22 (iii) by striking subparagraph (E) and23 inserting the following new subparagraphs:24 ‘‘(E) 90 percent for calendar quarters in25 2020; 40ERN17282 Discussion Draft S.L.C.1 ‘‘(F) 85 percent for calendar quarters in2 2021;3 ‘‘(G) 80 percent for calendar quarters in4 2022; and5 ‘‘(H) 75 percent for calendar quarters in6 2023.’’; and7 (iv) by adding after and below sub-8 paragraph (H) (as added by clause (iii)),9 the following flush sentence:10 ‘‘The Federal medical assistance percentage deter-11 mined for a State and year under subsection (b)12 shall apply to expenditures for medical assistance to13 newly eligible individuals (as so described) and ex-14 pansion enrollees (as so defined), in the case of a15 State that has elected to cover newly eligible individ-16 uals before March 1, 2017, for calendar quarters17 after 2023, and, in the case of any other State, for18 calendar quarters (or portions of calendar quarters)19 after February 28, 2017.’’; and20 (B) in subsection (z)(2)—21 (i) in subparagraph (A)—22 (I) by inserting ‘‘through 2023’’23 after ‘‘each year thereafter’’; and24 (II) by striking ‘‘shall be equal25 to’’ and inserting ‘‘and, for periods 41ERN17282 Discussion Draft S.L.C.1 after December 31, 2019 and before2 January 1, 2024, who are expansion3 enrollees (as defined in section4 1902(nn)(1)) shall be equal to the5 higher of the percentage otherwise de-6 termined for the State and year under7 subsection (b) (without regard to this8 subsection) and’’; and9 (ii) in subparagraph (B)(ii)—10 (I) in subclause (III), by adding11 ‘‘and’’ at the end; and12 (II) by striking subclauses (IV),13 (V), and (VI) and inserting the fol-14 lowing new subclause:15 ‘‘(IV) 2017 and each subsequent year16 through 2023 is 80 percent.’’.17 (b) SUNSET OF ESSENTIAL HEALTH BENEFITS RE-18 QUIREMENT.—Section 1937(b)(5) of the Social Security19 Act (42 U.S.C. 1396u–7(b)(5)) is amended by adding at20 the end the following: ‘‘This paragraph shall not apply21 after December 31, 2019.’’.22 SEC. 127. RESTORING FAIRNESS IN DSH ALLOTMENTS.23 Section 1923(f)(7) of the Social Security Act (4224 U.S.C. 1396r–4(f)(7)) is amended by adding at the end25 the following new subparagraph: 42ERN17282 Discussion Draft S.L.C.1 ‘‘(C) NON-EXPANSION STATES.—2 ‘‘(i) IN GENERAL.—In the case of a3 State that is a non-expansion State for a4 fiscal year—5 ‘‘(I) subparagraph (A) shall not6 apply to the DSH allotment for such7 State and fiscal year; and8 ‘‘(II) the DSH allotment for the9 State for fiscal year 2020 shall be in-10 creased by the amount calculated ac-11 cording to clause (iii).12 ‘‘(ii) NO CHANGE IN REDUCTION FOR13 EXPANSION STATES.—In the case of a14 State that is an expansion State for a fis-15 cal year, the DSH allotment for such State16 and fiscal year shall be determined as if17 clause (i) did not apply.18 ‘‘(iii) AMOUNT CALCULATED.—For19 purposes of clause (i)(II), the amount cal-20 culated according to this clause for a non-21 expansion State is the following:22 ‘‘(I) For each State, the Sec-23 retary shall calculate a ratio equal to24 the State’s fiscal year 2016 DSH al-25 lotment divided by the number of indi-43ERN17282 Discussion Draft S.L.C.1 viduals enrolled in the State plan2 under this title for such fiscal year.3 ‘‘(II) The Secretary shall identify4 the States whose ratio as so deter-5 mined is below the national average of6 such ratio for all States.7 ‘‘(III) The amount calculated8 pursuant to this clause is an amount9 that, if added to the State’s fiscal10 year 2016 DSH allotment, would in-11 crease the ratio calculated pursuant to12 subclause (I) up to the national aver-13 age for all States.14 ‘‘(iv) DISREGARD OF INCREASE.—The15 DSH allotment for a non-expansion State16 for the second, third, and fourth quarters17 of fiscal year 2024 and fiscal years there-18 after shall be determined as if there had19 been no increase in the State’s DSH allot-20 ment for fiscal year 2020 under clause21 (i)(II).22 ‘‘(v) NON-EXPANSION AND EXPANSION23 STATE DEFINED.—In this subparagraph:24 ‘‘(I) The term ‘expansion State’25 means with respect to a fiscal year, a 44ERN17282 Discussion Draft S.L.C.1 State that, as of the date of enact-2 ment of this subparagraph, provided3 for eligibility under clause (i)(VIII) or4 (ii)(XX) of section 1902(a)(10)(A) for5 medical assistance under this title (or6 a waiver of the State plan approved7 under section 1115).8 ‘‘(II) The term ‘non-expansion9 State’ means, with respect to a fiscal10 year, a State that is not an expansion11 State.’’.12 SEC. 128. REDUCING STATE MEDICAID COSTS.13 (a) IN GENERAL.—14 (1) STATE PLAN REQUIREMENTS.—Section15 1902(a)(34) of the Social Security Act (42 U.S.C.16 1396a(a)(34)) is amended by striking ‘‘in or after17 the third month before the month in which he made18 application’’ and inserting ‘‘in or after the month in19 which the individual made application’’.20 (2) DEFINITION OF MEDICAL ASSISTANCE.—21 Section 1905(a) of the Social Security Act (4222 U.S.C. 1396d(a)) is amended by striking ‘‘in or23 after the third month before the month in which the24 recipient makes application for assistance’’ and in-45ERN17282 Discussion Draft S.L.C.1 serting ‘‘in or after the month in which the recipient2 makes application for assistance’’.3 (b) EFFECTIVE DATE.—The amendments made by4 subsection (a) shall apply to medical assistance with re-5 spect to individuals whose eligibility for such assistance6 is based on an application for such assistance made (or7 deemed to be made) on or after October 1, 2017.8 SEC. 129. PROVIDING SAFETY NET FUNDING FOR NON-EX-9 PANSION STATES.10 Title XIX of the Social Security Act is amended by11 inserting after section 1923 (42 U.S.C. 1396r–4) the fol-12 lowing new section:13 ‘‘ADJUSTMENT IN PAYMENT FOR SERVICES OF SAFETY14 NET PROVIDERS IN NON-EXPANSION STATES15 ‘‘SEC. 1923A. (a) IN GENERAL.—Subject to the limi-16 tations of this section, for each year during the period be-17 ginning with fiscal year 2018 and ending with fiscal year18 2022, each State that is one of the 50 States or the Dis-19 trict of Columbia and that, as of July 1 of the preceding20 fiscal year, did not provide for eligibility under clause21 (i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) for medical22 assistance under this title (or a waiver of the State plan23 approved under section 1115) (each such State or District24 referred to in this section for the fiscal year as a ‘non-25 expansion State’) may adjust the payment amounts other-26 wise provided under the State plan under this title (or a 46ERN17282 Discussion Draft S.L.C.1 waiver of such plan) to health care providers that provide2 health care services to individuals enrolled under this title3 (in this section referred to as ‘eligible providers’) so long4 as the payment adjustment to such an eligible provider5 does not exceed the provider’s costs in furnishing health6 care services (as determined by the Secretary and net of7 payments under this title, other than under this section,8 and by uninsured patients) to individuals who either are9 eligible for medical assistance under the State plan (or10 under a waiver of such plan) or have no health insurance11 or health plan coverage for such services.12 ‘‘(b) INCREASE IN APPLICABLE FMAP.—Notwith-13 standing section 1905(b), the Federal medical assistance14 percentage applicable with respect to expenditures attrib-15 utable to a payment adjustment under subsection (a) for16 which payment is permitted under subsection (c) shall be17 equal to—18 ‘‘(1) 100 percent for calendar quarters in fiscal19 years 2018, 2019, 2020, and 2021; and20 ‘‘(2) 95 percent for calendar quarters in fiscal21 year 2022.22 ‘‘(c) ANNUAL ALLOTMENT LIMITATION.—Payment23 under section 1903(a) shall not be made to a State with24 respect to any payment adjustment made under this sec-47ERN17282 Discussion Draft S.L.C.1 tion for all calendar quarters in a fiscal year in excess2 of the $2,000,000,000 multiplied by the ratio of—3 ‘‘(1) the population of the State with income4 below 138 percent of the poverty line in 2015 (as de-5 termined based the table entitled ‘Health Insurance6 Coverage Status and Type by Ratio of Income to7 Poverty Level in the Past 12 Months by Age’ for the8 universe of the civilian noninstitutionalized popu-9 lation for whom poverty status is determined based10 on the 2015 American Community Survey 1–Year11 Estimates, as published by the Bureau of the Cen-12 sus), to13 ‘‘(2) the sum of the populations under para-14 graph (1) for all non-expansion States.15 ‘‘(d) DISQUALIFICATION IN CASE OF STATE COV-16 ERAGE EXPANSION.—If a State is a non-expansion for a17 fiscal year and provides eligibility for medical assistance18 described in subsection (a) during the fiscal year, the19 State shall no longer be treated as a non-expansion State20 under this section for any subsequent fiscal years.’’.21 SEC. 130. ELIGIBILITY REDETERMINATIONS.22 (a) IN GENERAL.—Section 1902(e)(14) of the Social23 Security Act (42 U.S.C. 1396a(e)(14)) (relating to modi-24 fied adjusted gross income) is amended by adding at the25 end the following: 48ERN17282 Discussion Draft S.L.C.1 ‘‘(J) FREQUENCY OF ELIGIBILITY REDE-2 TERMINATIONS.—Beginning on October 1,3 2017, and notwithstanding subparagraph (H),4 in the case of an individual whose eligibility for5 medical assistance under the State plan under6 this title (or a waiver of such plan) is deter-7 mined based on the application of modified ad-8 justed gross income under subparagraph (A)9 and who is so eligible on the basis of clause10 (i)(VIII), (ii)(XX), or (ii)(XXIII) of subsection11 (a)(10)(A), at the option of the State, the State12 plan may provide that the individual’s eligibility13 shall be redetermined every 6 months (or such14 shorter number of months as the State may15 elect).’’.16 (b) INCREASED ADMINISTRATIVE MATCHING PER-17 CENTAGE.—For each calendar quarter during the period18 beginning on October 1, 2017, and ending on December19 31, 2019, the Federal matching percentage otherwise ap-20 plicable under section 1903(a) of the Social Security Act21 (42 U.S.C. 1396b(a)) with respect to State expenditures22 during such quarter that are attributable to meeting the23 requirement of section 1902(e)(14) (relating to determina-24 tions of eligibility using modified adjusted gross income)25 of such Act shall be increased by 5 percentage points with 49ERN17282 Discussion Draft S.L.C.1 respect to State expenditures attributable to activities car-2 ried out by the State (and approved by the Secretary) to3 exercise the option described in subparagraph (J) of such4 section (relating to eligibility redeterminations made on a5 6-month or shorter basis) (as added by subsection (a)) to6 increase the frequency of eligibility redeterminations.7 SEC. 131. OPTIONAL WORK REQUIREMENT FOR NON-8 DISABLED, NONELDERLY, NONPREGNANT IN-9 DIVIDUALS.10 (a) IN GENERAL.—Section 1902 of the Social Secu-11 rity Act (42 U.S.C. 1396a), as previously amended, is fur-12 ther amended by adding at the end the following new sub-13 section:14 ‘‘(oo) OPTIONAL WORK REQUIREMENT FOR NON-15 DISABLED, NONELDERLY, NONPREGNANT INDIVID-16 UALS.—17 ‘‘(1) IN GENERAL.—Beginning October 1,18 2017, subject to paragraph (3), a State may elect to19 condition medical assistance to a nondisabled, non-20 elderly, nonpregnant individual under this title upon21 such an individual’s satisfaction of a work require-22 ment (as defined in paragraph (2)).23 ‘‘(2) WORK REQUIREMENT DEFINED.—In this24 section, the term ‘work requirement’ means, with re-25 spect to an individual, the individual’s participation 50ERN17282 Discussion Draft S.L.C.1 in work activities (as defined in section 407(d)) for2 such period of time as determined by the State, and3 as directed and administered by the State.4 ‘‘(3) REQUIRED EXCEPTIONS.—States admin-5 istering a work requirement under this subsection6 may not apply such requirement to—7 ‘‘(A) a woman during pregnancy through8 the end of the month in which the 60-day pe-9 riod (beginning on the last day of her preg-10 nancy) ends;11 ‘‘(B) an individual who is under 19 years12 of age;13 ‘‘(C) an individual who is the only parent14 or caretaker relative in the family of a child15 who has not attained 6 years of age or who is16 the only parent or caretaker of a child with dis-17 abilities; or18 ‘‘(D) an individual who is married or a19 head of household and has not attained 2020 years of age and who—21 ‘‘(i) maintains satisfactory attendance22 at secondary school or the equivalent; or23 ‘‘(ii) participates in education directly24 related to employment.’’. 51ERN17282 Discussion Draft S.L.C.1 (b) INCREASE IN MATCHING RATE FOR IMPLEMEN-2 TATION.—Section 1903 of the Social Security Act (423 U.S.C. 1396b) is amended by adding at the end the fol-4 lowing:5 ‘‘(aa) The Federal matching percentage otherwise ap-6 plicable under subsection (a) with respect to State admin-7 istrative expenditures during a calendar quarter for which8 the State receives payment under such subsection shall,9 in addition to any other increase to such Federal matching10 percentage, be increased for such calendar quarter by 511 percentage points with respect to State expenditures at-12 tributable to activities carried out by the State (and ap-13 proved by the Secretary) to implement subsection (oo) of14 section 1902.’’.15 SEC. 132. PROVIDER TAXES.16 Section 1903(w)(4)(C) of the Social Security Act (4217 U.S.C. 1396b(w)(4)(C)) is amended by adding at the end18 the following new clause:19 ‘‘(iii) For purposes of clause (i), a de-20 termination of the existence of an indirect21 guarantee shall be made under paragraph22 (3)(i) of section 433.68(f) of title 42, Code23 of Federal Regulations, as in effect on24 June 1, 2017, except that— 52ERN17282 Discussion Draft S.L.C.1 ‘‘(I) for fiscal year 2021, ‘5.82 percent’ shall be substituted for ‘63 percent’ each place it appears;4 ‘‘(II) for fiscal year 2022, ‘5.65 percent’ shall be substituted for ‘66 percent’ each place it appears;7 ‘‘(III) for fiscal year 2023, ‘5.48 percent’ shall be substituted for ‘69 percent’ each place it appears;10 ‘‘(IV) for fiscal year 2024, ‘5.211 percent’ shall be substituted for ‘612 percent’ each place it appears; and13 ‘‘(V) for fiscal year 2025 and14 each subsequent fiscal year, ‘5 per-15 cent’ shall be substituted for ‘6 per-16 cent’ each place it appears.’’.17 SEC. 133. PER CAPITA ALLOTMENT FOR MEDICAL ASSIST-18 ANCE.19 Title XIX of the Social Security Act is amended—20 (1) in section 1903 (42 U.S.C. 1396b)—21 (A) in subsection (a), in the matter before22 paragraph (1), by inserting ‘‘and section23 1903A(a)’’ after ‘‘except as otherwise provided24 in this section’’; and 53ERN17282 Discussion Draft S.L.C.1 (B) in subsection (d)(1), by striking ‘‘to2 which’’ and inserting ‘‘to which, subject to sec-3 tion 1903A(a),’’; and4 (2) by inserting after such section 1903 the fol-5 lowing new section:6 ‘‘SEC. 1903A. PER CAPITA-BASED CAP ON PAYMENTS FOR7 MEDICAL ASSISTANCE.8 ‘‘(a) APPLICATION OF PER CAPITA CAP ON PAY-9 MENTS FOR MEDICAL ASSISTANCE EXPENDITURES.—10 ‘‘(1) IN GENERAL.—If a State which is one of11 the 50 States or the District of Columbia has excess12 aggregate medical assistance expenditures (as de-13 fined in paragraph (2)) for a fiscal year (beginning14 with fiscal year 2020), the amount of payment to15 the State under section 1903(a)(1) for each quarterin the following fiscal year shall be reduced by 1 16 ⁄4 of17 the excess aggregate medical assistance payments18 (as defined in paragraph (3)) for that previous fiscal19 year. In this section, the term ‘State’ means only the20 50 States and the District of Columbia.21 ‘‘(2) EXCESS AGGREGATE MEDICAL ASSISTANCE22 EXPENDITURES.—In this subsection, the term ‘ex-23 cess aggregate medical assistance expenditures’24 means, for a State for a fiscal year, the amount (if25 any) by which— 54ERN17282 Discussion Draft S.L.C.1 ‘‘(A) the amount of the adjusted total med-2 ical assistance expenditures (as defined in sub-3 section (b)(1)) for the State and fiscal year; ex-4 ceeds5 ‘‘(B) the amount of the target total med-6 ical assistance expenditures (as defined in sub-7 section (c)) for the State and fiscal year.8 ‘‘(3) EXCESS AGGREGATE MEDICAL ASSISTANCE9 PAYMENTS.—In this subsection, the term ‘excess ag-10 gregate medical assistance payments’ means, for a11 State for a fiscal year, the product of—12 ‘‘(A) the excess aggregate medical assist-13 ance expenditures (as defined in paragraph (2))14 for the State for the fiscal year; and15 ‘‘(B) the Federal average medical assist-16 ance matching percentage (as defined in para-17 graph (4)) for the State for the fiscal year.18 ‘‘(4) FEDERAL AVERAGE MEDICAL ASSISTANCE19 MATCHING PERCENTAGE.—In this subsection, the20 term ‘Federal average medical assistance matching21 percentage’ means, for a State for a fiscal year, the22 ratio (expressed as a percentage) of—23 ‘‘(A) the amount of the Federal payments24 that would be made to the State under section25 1903(a)(1) for medical assistance expenditures 55ERN17282 Discussion Draft S.L.C.1 for calendar quarters in the fiscal year if para-2 graph (1) did not apply; to3 ‘‘(B) the amount of the medical assistance4 expenditures for the State and fiscal year.5 ‘‘(5) PER CAPITA BASE PERIOD.—6 ‘‘(A) IN GENERAL.—In this section, the7 term ‘per capita base period’ means, with re-8 spect to a State, a period of 8 consecutive fiscal9 quarters selected by the State.10 ‘‘(B) TIMELINE.—Each State shall submit11 its selection of per capita base period to the12 Secretary not later than January 1, 2018.13 ‘‘(C) PARAMETERS.—In selecting a per14 capita base period under this paragraph, a15 State shall—16 ‘‘(i) only select a period of 8 consecu-17 tive fiscal quarters for which all the data18 necessary to make determinations required19 under this section is available, as deter-20 mined by the Secretary; and21 ‘‘(ii) shall not select any period of 822 consecutive fiscal quarters that begins with23 a fiscal quarter earlier than the first quar-24 ter of fiscal year 2014 or ends with a fiscal 56ERN17282 Discussion Draft S.L.C.1 quarter later than the third fiscal quarter2 of 2017.3 ‘‘(D) ADJUSTMENT BY THE SECRETARY.—4 If the Secretary determines that a State took5 actions after the date of enactment of this sec-6 tion (including making retroactive adjustments7 to supplemental payment data in a manner that8 affects a fiscal quarter in the per capita base9 period) to diminish the quality of the data from10 the per capita base period used to make deter-11 minations under this section, the Secretary may12 adjust the data as the Secretary deems appro-13 priate.14 ‘‘(b) ADJUSTED TOTAL MEDICAL ASSISTANCE EX-15 PENDITURES.—Subject to subsection (g), the following16 shall apply:17 ‘‘(1) IN GENERAL.—In this section, the term18 ‘adjusted total medical assistance expenditures’19 means, for a State—20 ‘‘(A) for the State’s per capita base period21 (as defined in subsection (a)(5)), the product22 of—23 ‘‘(i) the amount of the medical assist-24 ance expenditures (as defined in paragraph25 (2) and adjusted under paragraph (5)) for 57ERN17282 Discussion Draft S.L.C.1 the State and period, reduced by the2 amount of any excluded expenditures (as3 defined in paragraph (3) and adjusted4 under paragraph (5)) for the State and pe-5 riod otherwise included in such medical as-6 sistance expenditures; and7 ‘‘(ii) the 1903A base period popu-8 lation percentage (as defined in paragraph9 (4)) for the State; or10 ‘‘(B) for fiscal year 2019 or a subsequent11 fiscal year, the amount of the medical assist-12 ance expenditures (as defined in paragraph (2))13 for the State and fiscal year that is attributable14 to 1903A enrollees, reduced by the amount of15 any excluded expenditures (as defined in para-16 graph (3)) for the State and fiscal year other-17 wise included in such medical assistance ex-18 penditures and includes non-DSH supplemental19 payments (as defined in subsection20 (d)(4)(A)(ii)) and payments described in sub-21 section (d)(4)(A)(iii) but shall not be construed22 as including any expenditures attributable to23 the program under section 1928 (relating to24 State pediatric vaccine distribution programs).25 In applying subparagraph (B), non-DSH sup-58ERN17282 Discussion Draft S.L.C.1 plemental payments (as defined in subsection2 (d)(4)(A)(ii)) and payments described in sub-3 section (d)(4)(A)(iii) shall be treated as fully at-4 tributable to 1903A enrollees.5 ‘‘(2) MEDICAL ASSISTANCE EXPENDITURES.—6 In this section, the term ‘medical assistance expendi-7 tures’ means, for a State and fiscal year or per cap-8 ita base period, the medical assistance payments as9 reported by medical service category on the Form10 CMS-64 quarterly expense report (or successor to11 such a report form, and including enrollment data12 and subsequent adjustments to any such report, in13 this section referred to collectively as a ‘CMS-64 re-14 port’) for quarters in the year or base period for15 which payment is (or may otherwise be) made pur-16 suant to section 1903(a)(1), adjusted, in the case of17 a per capita base period, under paragraph (5).18 ‘‘(3) EXCLUDED EXPENDITURES.—In this sec-19 tion, the term ‘excluded expenditures’ means, for a20 State and fiscal year or per capita base period, ex-21 penditures under the State plan (or under a waiver22 of such plan) that are attributable to any of the fol-23 lowing: 59ERN17282 Discussion Draft S.L.C.1 ‘‘(A) DSH.—Payment adjustments made2 for disproportionate share hospitals under sec-3 tion 1923.4 ‘‘(B) MEDICARE COST-SHARING.—Pay-5 ments made for medicare cost-sharing (as de-6 fined in section 1905(p)(3)).7 ‘‘(C) SAFETY NET PROVIDER PAYMENT AD-8 JUSTMENTS IN NON-EXPANSION STATES.—Pay-9 ment adjustments under subsection (a) of sec-10 tion 1923A for which payment is permitted11 under subsection (c) of such section.12 ‘‘(4) 1903A BASE PERIOD POPULATION PER-13 CENTAGE.—In this subsection, the term ‘1903A base14 period population percentage’ means, for a State,15 the Secretary’s calculation of the percentage of the16 actual medical assistance expenditures, as reported17 by the State on the CMS–64 reports for calendar18 quarters in the State’s per capita base period, that19 are attributable to 1903A enrollees (as defined in20 subsection (e)(1)).21 ‘‘(5) ADJUSTMENTS FOR PER CAPITA BASE PE-22 RIOD.—In calculating medical assistance expendi-23 tures under paragraph (2) and excluded expendi-24 tures under paragraph (3) for a State for the State’s25 per capita base period, the total amount of each type 60ERN17282 Discussion Draft S.L.C.1 of expenditure for the State and base period shall be2 divided by 2.3 ‘‘(c) TARGET TOTAL MEDICAL ASSISTANCE EXPEND-4 ITURES.—5 ‘‘(1) CALCULATION.—In this section, the term6 ‘target total medical assistance expenditures’ means,7 for a State for a fiscal year and subject to para-8 graph (4), the sum of the products, for each of the9 1903A enrollee categories (as defined in subsection10 (e)(2)), of—11 ‘‘(A) the target per capita medical assist-12 ance expenditures (as defined in paragraph (2))13 for the enrollee category, State, and fiscal year;14 and15 ‘‘(B) the number of 1903A enrollees for16 such enrollee category, State, and fiscal year, as17 determined under subsection (e)(4).18 ‘‘(2) TARGET PER CAPITA MEDICAL ASSISTANCE19 EXPENDITURES.—In this subsection, the term ‘tar-20 get per capita medical assistance expenditures’21 means, for a 1903A enrollee category and State—22 ‘‘(A) for fiscal year 2020, an amount equal23 to—24 ‘‘(i) the provisional FY19 target per25 capita amount for such enrollee category 61ERN17282 Discussion Draft S.L.C.1 (as calculated under subsection (d)(5)) for2 the State; increased by3 ‘‘(ii) the applicable annual inflation4 factor (as defined in paragraph (3)) for5 fiscal year 2020; and6 ‘‘(B) for each succeeding fiscal year, an7 amount equal to—8 ‘‘(i) the target per capita medical as-9 sistance expenditures (under subparagraph10 (A) or this subparagraph) for the 1903A11 enrollee category and State for the pre-12 ceding fiscal year; increased by13 ‘‘(ii) the applicable annual inflation14 factor for that succeeding fiscal year.15 ‘‘(3) APPLICABLE ANNUAL INFLATION FAC-16 TOR.—In paragraph (2), the term ‘applicable annual17 inflation factor’ means—18 ‘‘(A) for fiscal years before 2025—19 ‘‘(i) for each of the 1903A enrollee20 categories described in subparagraphs (C),21 (D), and (E) of subsection (e)(2), the per-22 centage increase in the medical care com-23 ponent of the consumer price index for all24 urban consumers (U.S. city average) from 62ERN17282 Discussion Draft S.L.C.1 September of the previous fiscal year to2 September of the fiscal year involved; and3 ‘‘(ii) for each of the 1903A enrollee4 categories described in subparagraphs (A)5 and (B) of subsection (e)(2), the percent-6 age increase described in clause (i) plus 17 percentage point; and8 ‘‘(B) for fiscal years after 2024, for all9 1903A enrollee categories, the percentage in-10 crease in the consumer price index for all urban11 consumers (U.S. city average) from September12 of the previous fiscal year to September of the13 fiscal year involved.14 ‘‘(4) DECREASE IN TARGET EXPENDITURES15 FOR REQUIRED EXPENDITURES BY CERTAIN POLIT-16 ICAL SUBDIVISIONS.—17 ‘‘(A) IN GENERAL.—In the case of a State18 that had a DSH allotment under section19 1923(f) for fiscal year 2016 that was more than20 6 times the national average of such allotments21 for all the States for such fiscal year and that22 requires political subdivisions within the State23 to contribute funds towards medical assistance24 or other expenditures under the State plan25 under this title (or under a waiver of such plan) 63ERN17282 Discussion Draft S.L.C.1 for a fiscal year (beginning with fiscal year2 2020), the target total medical assistance ex-3 penditures for such State and fiscal year shall4 be decreased by the amount that political sub-5 divisions in the State are required to contribute6 under the plan (or waiver) without reimburse-7 ment from the State for such fiscal year, other8 than contributions described in subparagraph9 (B).10 ‘‘(B) EXCEPTIONS.—The contributions de-11 scribed in this subparagraph are the following:12 ‘‘(i) Contributions required by a State13 from a political subdivision that, as of the14 first day of the calendar year in which the15 fiscal year involved begins—16 ‘‘(I) has a population of more17 than 5,000,000, as estimated by the18 Bureau of the Census; and19 ‘‘(II) imposes a local income tax20 upon its residents.21 ‘‘(ii) Contributions required by a22 State from a political subdivision for ad-23 ministrative expenses if the State required24 such contributions from such subdivision 64ERN17282 Discussion Draft S.L.C.1 without reimbursement from the State as2 of January 1, 2017.3 ‘‘(5) ADJUSTMENTS TO STATE EXPENDITURES4 TARGETS TO PROMOTE PROGRAM EQUITY ACROSS5 STATES.—6 ‘‘(A) IN GENERAL.—Beginning with fiscal7 year 2020, the target per capita medical assist-8 ance expenditures for a 1903A enrollee cat-9 egory, State, and fiscal year, as determined10 under paragraph (2), shall be adjusted (subject11 to subparagraph (C)(i)) in accordance with this12 paragraph.13 ‘‘(B) ADJUSTMENT BASED ON LEVEL OF14 PER CAPITA SPENDING FOR 1903A ENROLLEE15 CATEGORIES.—Subject to subparagraph (C),16 with respect to a State, fiscal year, and 1903A17 enrollee category, if the State’s per capita cat-18 egorical medical assistance expenditures (as de-19 fined in subparagraph (D)) for the State and20 category in the preceding fiscal year—21 ‘‘(i) exceed the mean per capita cat-22 egorical medical assistance expenditures23 for the category for all States for such pre-24 ceding year by not less than 25 percent,25 the State’s target per capita medical as-65ERN17282 Discussion Draft S.L.C.1 sistance expenditures for such category for2 the fiscal year involved shall be reduced by3 a percentage that shall be determined by4 the Secretary but which shall not be less5 than 0.5 percent or greater than 2 percent;6 or7 ‘‘(ii) are less than the mean per capita8 categorical medical assistance expenditures9 for the category for all States for such pre-10 ceding year by not less than 25 percent,11 the State’s target per capita medical as-12 sistance expenditures for such category for13 the fiscal year involved shall be increased14 by a percentage that shall be determined15 by the Secretary but which shall not be16 less than 0.5 percent or greater than 217 percent.18 ‘‘(C) RULES OF APPLICATION.—19 ‘‘(i) BUDGET NEUTRALITY REQUIRE-20 MENT.—In determining the appropriate21 percentages by which to adjust States’ tar-22 get per capita medical assistance expendi-23 tures for a category and fiscal year under24 this paragraph, the Secretary shall make25 such adjustments in a manner that does 66ERN17282 Discussion Draft S.L.C.1 not result in a net increase in Federal pay-2 ments under this section for such fiscal3 year, and if the Secretary cannot adjust4 such expenditures in such a manner there5 shall be no adjustment under this para-6 graph for such fiscal year.7 ‘‘(ii) ASSUMPTION REGARDING STATE8 EXPENDITURES.—For purposes of clause9 (i), in the case of a State that has its tar-10 get per capita medical assistance expendi-11 tures for a 1903A enrollee category and12 fiscal year increased under this paragraph,13 the Secretary shall assume that the cat-14 egorical medical assistance expenditures15 (as defined in subparagraph (D)(ii)) for16 such State, category, and fiscal year will17 equal such increased target medical assist-18 ance expenditures.19 ‘‘(iii) NONAPPLICATION TO LOW-DEN-20 SITY STATES.—This paragraph shall not21 apply to any State that has a population22 density of less than 15 individuals per23 square mile, based on the most recent data24 available from the Bureau of the Census. 67ERN17282 Discussion Draft S.L.C.1 ‘‘(iv) DISREGARD OF ADJUSTMENT.—2 Any adjustment under this paragraph to3 target medical assistance expenditures for4 a State, 1903A enrollee category, and fis-5 cal year shall be disregarded when deter-6 mining the target medical assistance ex-7 penditures for such State and category for8 a succeeding year under paragraph (2).9 ‘‘(v) APPLICATION FOR FISCAL YEARS10 2020 AND 2021.—In fiscal years 2020 and11 2021, the Secretary shall apply this para-12 graph by deeming all categories of 1903A13 enrollees to be a single category.14 ‘‘(D) PER CAPITA CATEGORICAL MEDICAL15 ASSISTANCE EXPENDITURES.—16 ‘‘(i) IN GENERAL.—In this paragraph,17 the term ‘per capita categorical medical as-18 sistance expenditures’ means, with respect19 to a State, 1903A enrollee category, and20 fiscal year, an amount equal to—21 ‘‘(I) the categorical medical ex-22 penditures (as defined in clause (ii))23 for the State, category, and year; di-24 vided by 68ERN17282 Discussion Draft S.L.C.1 ‘‘(II) the number of 1903A en-2 rollees for the State, category, and3 year.4 ‘‘(ii) CATEGORICAL MEDICAL ASSIST-5 ANCE EXPENDITURES.—The term ‘categor-6 ical medical assistance expenditures’7 means, with respect to a State, 1903A en-8 rollee category, and fiscal year, an amount9 equal to the total medical assistance ex-10 penditures (as defined in paragraph (2))11 for the State and fiscal year that are at-12 tributable to 1903A enrollees in the cat-13 egory, excluding any excluded expenditures14 (as defined in paragraph (3)) for the State15 and fiscal year that are attributable to16 1903A enrollees in the category.17 ‘‘(d) CALCULATION OF FY19 PROVISIONAL TARGET18 AMOUNT FOR EACH 1903A ENROLLEE CATEGORY.—Sub-19 ject to subsection (g), the following shall apply:20 ‘‘(1) CALCULATION OF BASE AMOUNTS FOR PER21 CAPITA BASE PERIOD.—For each State the Sec-22 retary shall calculate (and provide notice to the23 State not later than April 1, 2018, of) the following:24 ‘‘(A) The amount of the adjusted total25 medical assistance expenditures (as defined in 69ERN17282 Discussion Draft S.L.C.1 subsection (b)(1)) for the State for the State’s2 per capita base period.3 ‘‘(B) The number of 1903A enrollees for4 the State in the State’s per capita base period5 (as determined under subsection (e)(4)).6 ‘‘(C) The average per capita medical as-7 sistance expenditures for the State for the8 State’s per capita base period equal to—9 ‘‘(i) the amount calculated under sub-10 paragraph (A); divided by11 ‘‘(ii) the number calculated under sub-12 paragraph (B).13 ‘‘(2) FISCAL YEAR 2019 AVERAGE PER CAPITA14 AMOUNT BASED ON INFLATING THE PER CAPITA15 BASE PERIOD AMOUNT TO FISCAL YEAR 2019 BY CPI-16 MEDICAL.—The Secretary shall calculate a fiscal17 year 2019 average per capita amount for each State18 equal to—19 ‘‘(A) the average per capita medical assist-20 ance expenditures for the State for the State’s21 per capita base period (calculated under para-22 graph (1)(C)); increased by23 ‘‘(B) the percentage increase in the med-24 ical care component of the consumer price index25 for all urban consumers (U.S. city average) 70ERN17282 Discussion Draft S.L.C.1 from the last month of the State’s per capita2 base period to September of fiscal year 2019.3 ‘‘(3) AGGREGATE AND AVERAGE EXPENDI-4 TURES PER CAPITA FOR FISCAL YEAR 2019.—The5 Secretary shall calculate for each State the fol-6 lowing:7 ‘‘(A) The amount of the adjusted total8 medical assistance expenditures (as defined in9 subsection (b)(1)) for the State for fiscal year10 2019.11 ‘‘(B) The number of 1903A enrollees for12 the State in fiscal year 2019 (as determined13 under subsection (e)(4)).14 ‘‘(4) PER CAPITA EXPENDITURES FOR FISCAL15 YEAR 2019 FOR EACH 1903A ENROLLEE CATEGORY.—16 The Secretary shall calculate (and provide notice to17 each State not later than January 1, 2020, of) the18 following:19 ‘‘(A)(i) For each 1903A enrollee category,20 the amount of the adjusted total medical assist-21 ance expenditures (as defined in subsection22 (b)(1)) for the State for fiscal year 2019 for in-23 dividuals in the enrollee category, calculated by24 excluding from medical assistance expenditures25 those expenditures attributable to expenditures 71ERN17282 Discussion Draft S.L.C.1 described in clause (iii) or non-DSH supple-2 mental expenditures (as defined in clause (ii)).3 ‘‘(ii) In this paragraph, the term ‘non-4 DSH supplemental expenditure’ means a pay-5 ment to a provider under the State plan (or6 under a waiver of the plan) that—7 ‘‘(I) is not made under section 1923;8 ‘‘(II) is not made with respect to a9 specific item or service for an individual;10 ‘‘(III) is in addition to any payments11 made to the provider under the plan (or12 waiver) for any such item or service; and13 ‘‘(IV) complies with the limits for ad-14 ditional payments to providers under the15 plan (or waiver) imposed pursuant to sec-16 tion 1902(a)(30)(A), including the regula-17 tions specifying upper payment limits18 under the State plan in part 447 of title19 42, Code of Federal Regulations (or any20 successor regulations).21 ‘‘(iii) An expenditure described in this22 clause is an expenditure that meets the criteria23 specified in subclauses (I), (II), and (III) of24 clause (ii) and is authorized under section 111525 for the purposes of funding a delivery system 72ERN17282 Discussion Draft S.L.C.1 reform pool, uncompensated care pool, a des-2 ignated State health program, or any other3 similar expenditure (as defined by the Sec-4 retary).5 ‘‘(B) For each 1903A enrollee category,6 the number of 1903A enrollees for the State in7 fiscal year 2019 in the enrollee category (as de-8 termined under subsection (e)(4)).9 ‘‘(C) For the State’s per capita base pe-10 riod, the State’s non-DSH supplemental and11 pool payment percentage is equal to the ratio12 (expressed as a percentage) of—13 ‘‘(i) the total amount of non-DSH14 supplemental expenditures (as defined in15 subparagraph (A)(ii) and adjusted under16 subparagraph (E)) and payments described17 in subparagraph (A)(iii) (and adjusted18 under subparagraph (E)) for the State for19 the period; to20 ‘‘(ii) the amount described in sub-21 section (b)(1)(A) for the State for the22 State’s per capita base period.23 ‘‘(D) For each 1903A enrollee category an24 average medical assistance expenditures per 73ERN17282 Discussion Draft S.L.C.1 capita for the State for fiscal year 2019 for the2 enrollee category equal to—3 ‘‘(i) the amount calculated under sub-4 paragraph (A) for the State, increased by5 the non-DSH supplemental and pool pay-6 ment percentage for the State (as cal-7 culated under subparagraph (C)); divided8 by9 ‘‘(ii) the number calculated under sub-10 paragraph (B) for the State for the en-11 rollee category.12 ‘‘(E) For purposes of subparagraph (C)(i),13 in calculating the total amount of non-DSH14 supplemental expenditures and payments de-15 scribed in subparagraph (A)(iii) for a State for16 the per capita base period, the total amount of17 such expenditures and the total amount of such18 payments for the State and base period shall19 each be divided by 2.20 ‘‘(5) PROVISIONAL FY19 PER CAPITA TARGET21 AMOUNT FOR EACH 1903A ENROLLEE CATEGORY.—22 Subject to subsection (f)(2), the Secretary shall cal-23 culate for each State a provisional FY19 per capita24 target amount for each 1903A enrollee category25 equal to the average medical assistance expenditures 74ERN17282 Discussion Draft S.L.C.1 per capita for the State for fiscal year 2019 (as cal-2 culated under paragraph (4)(D)) for such enrollee3 category multiplied by the ratio of—4 ‘‘(A) the product of—5 ‘‘(i) the fiscal year 2019 average per6 capita amount for the State, as calculated7 under paragraph (2); and8 ‘‘(ii) the number of 1903A enrollees9 for the State in fiscal year 2019, as cal-10 culated under paragraph (3)(B); to11 ‘‘(B) the amount of the adjusted total12 medical assistance expenditures for the State13 for fiscal year 2019, as calculated under para-14 graph (3)(A).15 ‘‘(e) 1903A ENROLLEE; 1903A ENROLLEE CAT-16 EGORY.—Subject to subsection (g), for purposes of this17 section, the following shall apply:18 ‘‘(1) 1903A ENROLLEE.—The term ‘1903A en-19 rollee’ means, with respect to a State and a month20 and subject to subsection (i)(1)(B), any Medicaid21 enrollee (as defined in paragraph (3)) for the month,22 other than such an enrollee who for such month is23 in any of the following categories of excluded indi-24 viduals: 75ERN17282 Discussion Draft S.L.C.1 ‘‘(A) CHIP.—An individual who is pro-2 vided, under this title in the manner described3 in section 2101(a)(2), child health assistance4 under title XXI.5 ‘‘(B) IHS.—An individual who receives6 any medical assistance under this title for serv-7 ices for which payment is made under the third8 sentence of section 1905(b).9 ‘‘(C) BREAST AND CERVICAL CANCER10 SERVICES ELIGIBLE INDIVIDUAL.—An indi-11 vidual who is eligible for medical assistance12 under this title only on the basis of section13 1902(a)(10)(A)(ii)(XVIII).14 ‘‘(D) PARTIAL-BENEFIT ENROLLEES.—An15 individual who—16 ‘‘(i) is an alien who is eligible for17 medical assistance under this title only on18 the basis of section 1903(v)(2);19 ‘‘(ii) is eligible for medical assistance20 under this title only on the basis of sub-21 clause (XII) or (XXI) of section22 1902(a)(10)(A)(ii) (or on the basis of a23 waiver that provides only comparable bene-24 fits); 76ERN17282 Discussion Draft S.L.C.1 ‘‘(iii) is a dual eligible individual (as2 defined in section 1915(h)(2)(B)) and is3 eligible for medical assistance under this4 title (or under a waiver) only for some or5 all of medicare cost-sharing (as defined in6 section 1905(p)(3)); or7 ‘‘(iv) is eligible for medical assistance8 under this title and for whom the State is9 providing a payment or subsidy to an em-10 ployer for coverage of the individual under11 a group health plan pursuant to section12 1906 or section 1906A (or pursuant to a13 waiver that provides only comparable bene-14 fits).15 ‘‘(E) BLIND AND DISABLED CHILDREN.—16 An individual who—17 ‘‘(i) is a child under 19 years of age;18 and19 ‘‘(ii) is eligible for medical assistance20 under this title on the basis of being blind21 or disabled.22 ‘‘(2) 1903A ENROLLEE CATEGORY.—The term23 ‘1903A enrollee category’ means each of the fol-24 lowing: 77ERN17282 Discussion Draft S.L.C.1 ‘‘(A) ELDERLY.—A category of 1903A en-2 rollees who are 65 years of age or older.3 ‘‘(B) BLIND AND DISABLED.—A category4 of 1903A enrollees (not described in the pre-5 vious subparagraph) who—6 ‘‘(i) are 19 years of age or older; and7 ‘‘(ii) are eligible for medical assistance8 under this title on the basis of being blind9 or disabled.10 ‘‘(C) CHILDREN.—A category of 1903A11 enrollees (not described in a previous subpara-12 graph) who are children under 19 years of age.13 ‘‘(D) EXPANSION ENROLLEES.—A cat-14 egory of 1903A enrollees (not described in a15 previous subparagraph) who are eligible for16 medical assistance under this title only on the17 basis of clause (i)(VIII), (ii)(XX), or18 (ii)(XXIII) of section 1902(a)(10)(A).19 ‘‘(E) OTHER NONELDERLY, NONDISABLED,20 NON-EXPANSION ADULTS.—A category of21 1903A enrollees who are not described in any22 previous subparagraph.23 ‘‘(3) MEDICAID ENROLLEE.—The term ‘Med-24 icaid enrollee’ means, with respect to a State for a25 month, an individual who is eligible for medical as-78ERN17282 Discussion Draft S.L.C.1 sistance for items or services under this title and en-2 rolled under the State plan (or a waiver of such3 plan) under this title for the month.4 ‘‘(4) DETERMINATION OF NUMBER OF 1903A5 ENROLLEES.—The number of 1903A enrollees for a6 State and fiscal year or the State’s per capita base7 period, and, if applicable, for a 1903A enrollee cat-8 egory, is the average monthly number of Medicaid9 enrollees for such State and fiscal year or base pe-10 riod (and, if applicable, in such category) that are11 reported through the CMS–64 report under (and12 subject to audit under) subsection (h).13 ‘‘(f) SPECIAL PAYMENT RULES.—14 ‘‘(1) APPLICATION IN CASE OF RESEARCH AND15 DEMONSTRATION PROJECTS AND OTHER WAIVERS.—16 In the case of a State with a waiver of the State17 plan approved under section 1115, section 1915, or18 another provision of this title, this section shall19 apply to medical assistance expenditures and medical20 assistance payments under the waiver, in the same21 manner as if such expenditures and payments had22 been made under a State plan under this title and23 the limitations on expenditures under this section24 shall supersede any other payment limitations or25 provisions (including limitations based on a per cap-79ERN17282 Discussion Draft S.L.C.1 ita limitation) otherwise applicable under such a2 waiver.3 ‘‘(2) TREATMENT OF STATES EXPANDING COV-4 ERAGE AFTER FISCAL YEAR 2016.—In the case of a5 State that did not provide for medical assistance for6 the 1903A enrollee category described in subsection7 (e)(2)(D) during fiscal year 2016 but which provides8 for such assistance for such category in a subse-9 quent year, the provisional FY19 per capita target10 amount for such enrollee category under subsection11 (d)(5) shall be equal to the provisional FY19 per12 capita target amount for the 1903A enrollee cat-13 egory described in subsection (e)(2)(E).14 ‘‘(3) IN CASE OF STATE FAILURE TO REPORT15 NECESSARY DATA.—If a State for any quarter in a16 fiscal year (beginning with fiscal year 2019) fails to17 satisfactorily submit data on expenditures and en-18 rollees in accordance with subsection (h)(1), for such19 fiscal year and any succeeding fiscal year for which20 such data are not satisfactorily submitted—21 ‘‘(A) the Secretary shall calculate and22 apply subsections (a) through (e) with respect23 to the State as if all 1903A enrollee categories24 for which such expenditure and enrollee data 80ERN17282 Discussion Draft S.L.C.1 were not satisfactorily submitted were a single2 1903A enrollee category; and3 ‘‘(B) the growth factor otherwise applied4 under subsection (c)(2)(B) shall be decreased5 by 1 percentage point.6 ‘‘(g) RECALCULATION OF CERTAIN AMOUNTS FOR7 DATA ERRORS.—The amounts and percentage calculated8 under paragraphs (1) and (4)(C) of subsection (d) for a9 State for the State’s per capita base period, and the10 amounts of the adjusted total medical assistance expendi-11 tures calculated under subsection (b) and the number of12 Medicaid enrollees and 1903A enrollees determined under13 subsection (e)(4) for a State for the State’s per capita14 base period, fiscal year 2019, and any subsequent fiscal15 year, may be adjusted by the Secretary based upon an ap-16 peal (filed by the State in such a form, manner, and time,17 and containing such information relating to data errors18 that support such appeal, as the Secretary specifies) that19 the Secretary determines to be valid, except that any ad-20 justment by the Secretary under this subsection for a21 State may not result in an increase of the target total22 medical assistance expenditures exceeding 2 percent.23 ‘‘(h) REQUIRED REPORTING AND AUDITING; TRANSI-24 TIONAL INCREASE IN FEDERAL MATCHING PERCENTAGE25 FOR CERTAIN ADMINISTRATIVE EXPENSES.— 81ERN17282 Discussion Draft S.L.C.1 ‘‘(1) REPORTING OF CMS–64 DATA.—2 ‘‘(A) IN GENERAL.—In addition to the3 data required on form Group VIII on the CMS–4 64 report form as of January 1, 2017, in each5 CMS-64 report required to be submitted (for6 each quarter beginning on or after October 1,7 2018), the State shall include data on medical8 assistance expenditures within such categories9 of services and categories of enrollees (including10 each 1903A enrollee category and each category11 of excluded individuals under subsection (e)(1))12 and the numbers of enrollees within each of13 such enrollee categories, as the Secretary deter-14 mines are necessary (including timely guidance15 published as soon as possible after the date of16 the enactment of this section) in order to imple-17 ment this section and to enable States to com-18 ply with the requirement of this paragraph on19 a timely basis.20 ‘‘(B) REPORTING ON QUALIFIED INPA-21 TIENT PSYCHIATRIC HOSPITAL SERVICES.—Not22 later than 60 days after the date of the enact-23 ment of this section, the Secretary shall modify24 the CMS–64 report form to require that States25 submit data with respect to medical assistance 82ERN17282 Discussion Draft S.L.C.1 expenditures for qualified inpatient psychiatric2 hospital services (as defined in section3 1905(h)(3)).4 ‘‘(C) REPORTING ON CHILDREN WITH5 COMPLEX MEDICAL CONDITIONS.—Not later6 than January 1, 2020, the Secretary shall mod-7 ify the CMS–64 report form to require that8 States submit data with respect to individuals9 who—10 ‘‘(i) are enrolled in a State plan under11 this title or title XXI or under a waiver of12 such plan;13 ‘‘(ii) are under 21 years of age; and14 ‘‘(iii) have a chronic medical condition15 or serious injury that—16 ‘‘(I) affects two or more body17 systems;18 ‘‘(II) affects cognitive or physical19 functioning (such as reducing the abil-20 ity to perform the activities of daily21 living, including the ability to engage22 in movement or mobility, eat, drink,23 communicate, or breathe independ-24 ently); and25 ‘‘(III) either— 83ERN17282 Discussion Draft S.L.C.1 ‘‘(aa) requires intensive2 healthcare interventions (such as3 multiple medications, therapies,4 or durable medical equipment)5 and intensive care coordination to6 optimize health and avoid hos-7 pitalizations or emergency de-8 partment visits; or9 ‘‘(bb) meets the criteria for10 medical complexity under existing11 risk adjustment methodologies12 using a recognized, publicly avail-13 able pediatric grouping system14 (such as the pediatric complex15 conditions classification system16 or the Pediatric Medical Com-17 plexity Algorithm) selected by the18 Secretary in close collaboration19 with the State agencies respon-20 sible for administering State21 plans under this title and a na-22 tional panel of pediatric, pedi-23 atric specialty, and pediatric sub-24 specialty experts. 84ERN17282 Discussion Draft S.L.C.1 ‘‘(2) AUDITING OF CMS–64 DATA.—The Sec-2 retary shall conduct for each State an audit of the3 number of individuals and expenditures reported4 through the CMS–64 report for the State’s per cap-5 ita base period, fiscal year 2019, and each subse-6 quent fiscal year, which audit may be conducted on7 a representative sample (as determined by the Sec-8 retary).9 ‘‘(3) AUDITING OF STATE SPENDING.—The In-10 spector General of the Department of Health and11 Human Services shall conduct an audit (which shall12 be conducted using random sampling, as determined13 by the Inspector General) of each State’s spending14 under this section not less than once every 3 years.15 ‘‘(4) TEMPORARY INCREASE IN FEDERAL16 MATCHING PERCENTAGE TO SUPPORT IMPROVED17 DATA REPORTING SYSTEMS FOR FISCAL YEARS 201818 AND 2019.—In the case of any State that selects as19 its per capita base period the most recent 8 consecu-20 tive quarter period for which the data necessary to21 make the determinations required under this section22 is available, for amounts expended during calendar23 quarters beginning on or after October 1, 2017, and24 before October 1, 2019— 85ERN17282 Discussion Draft S.L.C.1 ‘‘(A) the Federal matching percentage ap-2 plied under section 1903(a)(3)(A)(i) shall be in-3 creased by 10 percentage points to 100 percent;4 ‘‘(B) the Federal matching percentage ap-5 plied under section 1903(a)(3)(B) shall be in-6 creased by 25 percentage points to 100 percent;7 and8 ‘‘(C) the Federal matching percentage ap-9 plied under section 1903(a)(7) shall be in-10 creased by 10 percentage points to 60 percent11 but only with respect to amounts expended that12 are attributable to a State’s additional adminis-13 trative expenditures to implement the data re-14 quirements of paragraph (1).15 ‘‘(5) HHS REPORT ON ADOPTION OF T–MSIS16 DATA.—Not later than January 1, 2025, the Sec-17 retary shall submit to Congress a report making rec-18 ommendations as to whether data from the Trans-19 formed Medicaid Statistical Information System20 would be preferable to CMS–64 report data for pur-21 poses of making the determinations necessary under22 this section.’’. 86ERN17282 Discussion Draft S.L.C.1 SEC. 134. FLEXIBLE BLOCK GRANT OPTION FOR STATES.2 Title XIX of the Social Security Act, as amended by3 section 133, is further amended by inserting after section4 1903A the following new section:5 ‘‘SEC. 1903B. MEDICAID FLEXIBILITY PROGRAM.6 ‘‘(a) IN GENERAL.—Beginning with fiscal year 2020,7 any State (as defined in subsection (e)) that has an appli-8 cation approved by the Secretary under subsection (b)9 may conduct a Medicaid Flexibility Program to provide10 targeted health assistance to program enrollees.11 ‘‘(b) STATE APPLICATION.—12 ‘‘(1) IN GENERAL.—To be eligible to conduct a13 Medicaid Flexibility Program, a State shall submit14 an application to the Secretary that meets the re-15 quirements of this subsection.16 ‘‘(2) CONTENTS OF APPLICATION.—An applica-17 tion under this subsection shall include the fol-18 lowing:19 ‘‘(A) A description of the proposed Med-20 icaid Flexibility Program and how the State will21 satisfy the requirements described in subsection22 (d).23 ‘‘(B) The proposed conditions for eligibility24 of program enrollees.25 ‘‘(C) A description of the types, amount,26 duration, and scope of services which will be of-87ERN17282 Discussion Draft S.L.C.1 fered as targeted health assistance under the2 program, including a description of the pro-3 posed package of services which will be provided4 to program enrollees to whom the State would5 otherwise be required to make medical assist-6 ance available under section 1902(a)(10)(A)(i).7 ‘‘(D) A description of how the State will8 notify individuals currently enrolled in the State9 plan for medical assistance under this title of10 the transition to such program.11 ‘‘(E) Statements certifying that the State12 agrees to—13 ‘‘(i) submit regular enrollment data14 with respect to the program to the Centers15 for Medicare & Medicaid Services at such16 time and in such manner as the Secretary17 may require;18 ‘‘(ii) submit timely and accurate data19 to the Transformed Medicaid Statistical20 Information System (T–MSIS);21 ‘‘(iii) report annually to the Secretary22 on adult health quality measures imple-23 mented under the program and informa-24 tion on the quality of health care furnished25 to program enrollees under the program as 88ERN17282 Discussion Draft S.L.C.1 part of the annual report required under2 section 1139B(d)(1);3 ‘‘(iv) submit such additional informa-4 tion not described in any of the preceding5 clauses of this subparagraph but which the6 Secretary determines is necessary for mon-7 itoring, evaluation, or program integrity8 purposes, including—9 ‘‘(I) survey data, such as the10 data from Consumer Assessment of11 Healthcare Providers and Systems12 (CAHPS) surveys;13 ‘‘(II) birth certificate data; and14 ‘‘(III) clinical patient data for15 quality measurements which may not16 be present in a claim, such as labora-17 tory data, body mass index, and blood18 pressure; and19 ‘‘(v) on an annual basis, conduct a re-20 port evaluating the program and make21 such report available to the public.22 ‘‘(F) An information technology systems23 plan demonstrating that the State has the capa-24 bility to support the technological administra-89ERN17282 Discussion Draft S.L.C.1 tion of the program and comply with reporting2 requirements under this section.3 ‘‘(G) A statement of the goals of the pro-4 posed program, which shall include—5 ‘‘(i) goals related to quality, access,6 rate of growth targets, consumer satisfac-7 tion, and outcomes;8 ‘‘(ii) a plan for monitoring and evalu-9 ating the program to determine whether10 such goals are being met; and11 ‘‘(iii) a proposed process for the State,12 in consultation with the Centers for Medi-13 care & Medicaid Services, to take remedial14 action to make progress on unmet goals.15 ‘‘(H) Such other information as the Sec-16 retary may require.17 ‘‘(3) STATE NOTICE AND COMMENT PERIOD.—18 ‘‘(A) IN GENERAL.—Before submitting an19 application under this subsection, a State shall20 make the application publicly available for a 3021 day notice and comment period.22 ‘‘(B) NOTICE AND COMMENT PROCESS.—23 During the notice and comment period de-24 scribed in subparagraph (A), the State shall25 provide opportunities for a meaningful level of 90ERN17282 Discussion Draft S.L.C.1 public input, which shall include public hearings2 on the proposed Medicaid Flexibility Program.3 ‘‘(4) FEDERAL NOTICE AND COMMENT PE-4 RIOD.—The Secretary shall not approve of any ap-5 plication to conduct a Medicaid Flexibility Program6 without making such application publicly available7 for a 30 day notice and comment period.8 ‘‘(5) TIMELINE FOR SUBMISSION.—9 ‘‘(A) IN GENERAL.—A State may submit10 an application under this subsection to conduct11 a Medicaid Flexibility Program that would12 begin in the next fiscal year at any time, sub-13 ject to subparagraph (B).14 ‘‘(B) DEADLINES.—Each year beginning15 with 2019, the Secretary shall specify a dead-16 line for submitting an application under this17 subsection to conduct a Medicaid Flexibility18 Program that would begin in the next fiscal19 year, but such deadline shall not be earlier than20 60 days after the date that the Secretary pub-21 lishes the amounts of State block grants as re-22 quired under subsection (c)(4).23 ‘‘(c) FINANCING.—24 ‘‘(1) IN GENERAL.—For each fiscal year during25 which a State is conducting a Medicaid Flexibility 91ERN17282 Discussion Draft S.L.C.1 Program, the State shall receive, instead of amounts2 otherwise payable to the State under this title for3 medical assistance for program enrollees, the4 amount specified in paragraph (3)(A).5 ‘‘(2) AMOUNT OF BLOCK GRANT FUNDS.—6 ‘‘(A) FOR INITIAL YEAR.—Subject to sub-7 paragraph (C), for the first fiscal year in which8 a State conducts a Medicaid Flexibility Pro-9 gram, the block grant amount under this para-10 graph for the State and year shall be equal to11 the Federal average medical assistance match-12 ing percentage (as defined in section13 1903A(a)(4)) for the State and year multiplied14 by the product of—15 ‘‘(i) the target per capita medical as-16 sistance expenditures (as defined in section17 1903A(c)(2)) for the State and year for18 the enrollee category described in section19 1903A(e)(2)(E); and20 ‘‘(ii) the number of 1903A enrollees in21 such category for the State for the second22 fiscal year preceding such first fiscal year,23 increased by the percentage increase in24 State population from such second pre-25 ceding fiscal year to such first fiscal year, 92ERN17282 Discussion Draft S.L.C.1 based on the best available estimates of the2 Bureau of the Census.3 ‘‘(B) FOR ANY SUBSEQUENT YEAR.—For4 any fiscal year that is not the first fiscal year5 in which a State conducts a Medicaid Flexibility6 Program, the block grant amount under this7 paragraph for the State and year shall be equal8 to the block grant amount determined for the9 State for the most recent previous fiscal year in10 which the State conducted a Medicaid Flexi-11 bility Program, except that such amount shall12 be increased by the percentage increase in the13 consumer price index for all urban consumers14 (U.S. city average) from April of the second fis-15 cal year preceding the fiscal year involved to16 April of the fiscal year preceding the fiscal year17 involved.18 ‘‘(C) CAP ON TOTAL POPULATION OF 1903A19 ENROLLEES FOR PURPOSES OF BLOCK GRANT20 CALCULATION.—21 ‘‘(i) IN GENERAL.—In calculating the22 amount of a block grant for the first year23 in which a State conducts a Medicaid24 Flexibility Program under subparagraph25 (A), the total number of 1903A enrollees 93ERN17282 Discussion Draft S.L.C.1 in the 1903A enrollee category described in2 section 1903A(e)(2)(E) for the State and3 year shall not exceed the adjusted number4 of base period non-expansion enrollees for5 the State (as defined in clause (ii)).6 ‘‘(ii) ADJUSTED NUMBER OF 20167 NON-EXPANSION ENROLLEES.—The term8 ‘adjusted number of base period non-ex-9 pansion enrollees’ means, with respect to a10 State, the number of 1903A enrollees in11 the enrollee category described in section12 1903A(e)(2)(E) for the State for the13 State’s per capita base period (as deter-14 mined under section 1903A(e)(4)), in-15 creased by the percentage increase, if any,16 in the total State population from the last17 April in the State’s per capita base period18 to April of the fiscal year preceding the fis-19 cal year involved (determined using the20 best available data from the Bureau of the21 Census) plus 3 percentage points.22 ‘‘(D) AVAILABILITY OF ROLLOVER23 FUNDS.—24 ‘‘(i) IN GENERAL.—To the extent that25 the block grant amount available to a 94ERN17282 Discussion Draft S.L.C.1 State for a fiscal year under this para-2 graph exceeds the amount of Federal pay-3 ments made to the State for such fiscal4 year under paragraph (3)(A), the Sec-5 retary shall make such funds available to6 the State for the succeeding fiscal year if7 the State—8 ‘‘(I) satisfies the State mainte-9 nance of effort requirement under10 paragraph (3)(B); and11 ‘‘(II) is conducting a Medicaid12 Flexibility Program in such suc-13 ceeding fiscal year.14 ‘‘(ii) USE OF FUNDS.—Section15 1903(i)(17) shall not apply to funds made16 available to a State under this subpara-17 graph and a State may use such funds for18 other State health programs (as defined or19 approved by the Secretary) or for any20 other purpose which is consistent with the21 quality standards established by the Sec-22 retary under clause (iii).23 ‘‘(iii) QUALITY STANDARDS.—24 ‘‘(I) IN GENERAL.—Not later25 than January 1, 2020, the Secretary 95ERN17282 Discussion Draft S.L.C.1 shall establish quality standards appli-2 cable to a State’s use of funds made3 available to the State under this sub-4 paragraph.5 ‘‘(II) ALLOWABLE USES.—In es-6 tablishing quality standards under7 this clause, the Secretary shall not8 prohibit a State from using such9 funds for—10 ‘‘(aa) a program that is not11 related to health care, provided12 that using the funds for such13 program is otherwise consistent14 with the standards; or15 ‘‘(bb) the State maintenance16 of effort expenditures required17 under paragraph (3)(B).18 ‘‘(3) FEDERAL PAYMENT AND STATE MAINTE-19 NANCE OF EFFORT.—20 ‘‘(A) FEDERAL PAYMENT.—Subject to sub-21 paragraph (D), the Secretary shall pay to each22 State conducting a Medicaid Flexibility Pro-23 gram under this section for a fiscal year, from24 its block grant amount under paragraph (2) for25 such year, an amount for each quarter of such 96ERN17282 Discussion Draft S.L.C.1 year equal to the Federal average medical as-2 sistance percentage (as defined in section3 1903A(a)(4)) of the total amount expended4 under the program during such quarter, and5 the State is responsible for the balance of the6 funds to carry out such program.7 ‘‘(B) STATE MAINTENANCE OF EFFORT8 EXPENDITURES.—For each year during which a9 State is conducting a Medicaid Flexibility Pro-10 gram, the State shall make expenditures for11 targeted health assistance under the program in12 an amount equal to the product of—13 ‘‘(i) the block grant amount deter-14 mined fo
The Boeing Company (BA) has received an order to transform 100 of its existing orders of 737 MAX jets to that of 737 Max 10 jets.
All the day’s economic and financial news, as the CBI reports that UK manufacturing picked up in JuneLatest: Eurozone consumer confidence highest since 2001UK manufacturing orders jump,says CBIExperts are still cautious, thoughProtests in GreeceEarlier:Brent crude has hit a seven-month low, below $45/barrelMarkets ‘lose faith’ in OpecSugar, wheat, cocoa and coffee also falling 4.23pm BST Hold onto your hats, folks. Japanese bank Nomura have predicted that the Bank of England will raise interest rates at its next meeting, in August.That’s a gutsy move, as BoE governor Mark Carney argued forcibly on Tuesday that it’s too early for a rate hike.It has been a rollercoaster of a week when it comes to central bank commentary, with Governor Carney’s Mansion House address justifying no change in interest rates but Chief Economist Haldane highlighting the need for a possible imminent reversal of last year’s loosening.On balance,we have decided to change our view and now expect the MPC to raise interest rates by 25bp on 3 August. With the Bank growing increasingly intolerant of above-target inflation, it has begun to feel that weaker data would now be needed to prove the case for keeping policy on hold, rather than stronger data being required to justify higher rates.Now this is a bold call. The Bank of England will raise rates at its next meeting in August, say Nomura's UK analysts. 4.00pm BST Back to Greece where today’s protests and the electric atmosphere that prevailed may well be a shocking wake up call for the leftist-led government.Municipal workers are warning of a “very hot summer” if short-term contracts aren’t replaced with permanent positions.“From now on there will be huge and dynamic mobilisations with decisions being taken in the coming hours.” Continue reading...
Alaska Air's (ALK) increased CASM view might hurt its bottom line.
The Zacks Analyst Blog Highlights: Southwest Airlines, Air France-KLM SA, United Continental Holdings, International Consolidated Airlines Group SA and Deutsche Lufthansa AG
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Why Airline Stocks Should Still Grace Your Portfolio
Shares of Hawaiian Holdings, Inc. (HA) open more than 7% lower on Wednesday, and continued to fall, down about 11% in morning-trading after the release of an analyst note.