[House Report 116-50]
[From the U.S. Government Publishing Office]
116th Congress } { Report
HOUSE OF REPRESENTATIVES
1st Session } { 116-50
======================================================================
EXPAND NAVIGATORS' RESOURCES FOR OUTREACH, LEARNING, AND LONGEVITY ACT
OF 2019
_______
May 3, 2019.--Committed to the Committee of the Whole House on the
State of the Union and ordered to be printed
_______
Mr. Pallone, from the Committee on Energy and Commerce, submitted the
following
R E P O R T
together with
DISSENTING VIEWS
[To accompany H.R. 1386]
The Committee on Energy and Commerce, to whom was referred
the bill (H.R. 1386) to amend the Patient Protection and
Affordable Care Act to provide for additional requirements with
respect to the navigator program, and for other purposes,
having considered the same, report favorably thereon with an
amendment and recommend that the bill as amended do pass.
CONTENTS
Page
Purpose and Summary.............................................. 3
Background and Need for the Legislation.......................... 3
Committee Hearings............................................... 4
Committee Consideration.......................................... 4
Committee Votes.................................................. 4
Oversight Findings...............................................
New Budget Authority, Entitlement Authority, and Tax Expenditures
Congressional Budget Office Estimate............................
Federal Mandates Statement......................................
Statement of General Performance Goals and Objectives............
Duplication of Federal Programs.................................. 8
Committee Cost Estimate.......................................... 8
Earmarks, Limited Tax Benefits, and Limited Tariff Benefits...... 8
Advisory Committee Statement..................................... 8
Applicability to Legislative Branch.............................. 8
Section-by-Section Analysis of the Legislation................... 8
Changes in Existing Law Made by the Bill, as Reported............ 9
Dissenting Views................................................. 21
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Expand Navigators' Resources for
Outreach, Learning, and Longevity Act of 2019'' or the ``ENROLL Act of
2019''.
SEC. 2. PROVIDING FOR ADDITIONAL REQUIREMENTS WITH RESPECT TO THE
NAVIGATOR PROGRAM.
(a) In General.--Section 1311(i) of the Patient Protection and
Affordable Care Act (42 U.S.C. 18031(i)) is amended--
(1) in paragraph (2), by adding at the end the following new
subparagraph:
``(C) Selection of recipients.--In the case of an
Exchange established and operated by the Secretary
within a State pursuant to section 1321(c), in awarding
grants under paragraph (1), the Exchange shall--
``(i) select entities to receive such grants
based on an entity's demonstrated capacity to
carry out each of the duties specified in
paragraph (3);
``(ii) not take into account whether or not
the entity has demonstrated how the entity will
provide information to individuals relating to
group health plans offered by a group or
association of employers described in section
2510.3-5(b) of title 29, Code of Federal
Regulations (or any successor regulation), or
short-term limited duration insurance (as
defined by the Secretary for purposes of
section 2791(b)(5) of the Public Health Service
Act); and
``(iii) ensure that, each year, the Exchange
awards such a grant to--
``(I) at least one entity described
in this paragraph that is a community
and consumer-focused nonprofit group;
and
``(II) at least one entity described
in subparagraph (B), which may include
another community and consumer-focused
nonprofit group in addition to any such
group awarded a grant pursuant to
subclause (I).
In awarding such grants, an Exchange may
consider an entity's record with respect to
waste, fraud, and abuse for purposes of
maintaining the integrity of such Exchange.'';
(2) in paragraph (3)--
(A) in subparagraph (C), by inserting after
``qualified health plans'' the following: ``, State
medicaid plans under title XIX of the Social Security
Act, and State children's health insurance programs
under title XXI of such Act''; and
(B) by adding at the end the following flush left
sentence:
``The duties specified in the preceding sentence may be carried
out by such a navigator at any time during a year.'';
(3) in paragraph (4)(A)--
(A) in the matter preceding clause (i), by striking
``not'';
(B) in clause (i)--
(i) by inserting ``not'' before ``be''; and
(ii) by striking ``; or'' and inserting
``;'';
(C) in clause (ii)--
(i) by inserting ``not'' before ``receive'';
and
(ii) by striking the period and inserting
``;''; and
(D) by adding at the end the following new clause:
``(iii) maintain physical presence in the
State of the Exchange so as to allow in-person
assistance to consumers.''; and
(4) in paragraph (6)--
(A) by striking ``Funding.--Grants under'' and
inserting ``Funding.--
``(A) State exchanges.--Grants under''; and
(B) by adding at the end the following new
subparagraph:
``(B) Federal exchanges.--For purposes of carrying
out this subsection, with respect to an Exchange
established and operated by the Secretary within a
State pursuant to section 1321(c), the Secretary shall
obligate $100,000,000 out of amounts collected through
the user fees on participating health insurance issuers
pursuant to section 156.50 of title 45, Code of Federal
Regulations (or any successor regulations) for fiscal
year 2020 and each subsequent fiscal year. Such amount
for a fiscal year shall remain available until
expended.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply with respect to plan years beginning on or after January 1, 2020.
Purpose and Summary
H.R. 1386, the ``Expand Navigators' Resources for Outreach,
Learning, and Longevity Act of 2019'' or the ``ENROLL Act of
2019'', was introduced on February 27, 2019, by Representatives
Castor (D-FL), Blunt Rochester (D-DE), Crist (D-FL), and Wilson
(D-FL), and referred to the Committee on Energy and Commerce.
The goal of H.R. 1386 is to fund the Navigator program for
the Federally-Facilitated Marketplace (FFM) at $100 million per
year. H.R. 1386 would require the Department of Health and
Human Services (HHS) to ensure that Navigator grants are
awarded to organizations with a demonstrated capacity to carry
out the duties specified in the Affordable Care Act (ACA) and
would require that there be at least two Navigator entities in
each state. H.R. 1386 would further provide Navigators new
duties pertaining to enrolling individuals in Medicaid and the
Children's Health Insurance Program and would clarify that
Navigators may carry out their duties at any time during a
year. Lastly, the legislation would prohibit HHS from taking
into account an entity's capacity to provide information
relating to association health plans or short-term limited
duration insurance (STLDI) in awarding grants.
Background and Need for Legislation
The ACA required exchanges to establish a Navigator program
and award grants to Navigator entities. The law tasked
Navigators with several marketplace enrollment
responsibilities, including conducting public education
activities to raise awareness of coverage availability on the
marketplaces, facilitating enrollment in qualified health
plans, and providing fair and impartial information on
enrollment and financial assistance.
On August 31, 2017, HHS reduced funding for the Navigator
program from $63 million to $36.8 million, a 40 percent cut
from the previous year.\1\ The Department further reduced
funding for 2019 to $10 million.\2\ The Department set the
funding allocation based on a narrower goal of marketplace
enrollment. A report by the Government Accountability Office
(GAO) found that HHS described the enrollment goals in an
``unclear manner'' and failed to provide Navigator entities
guidance on the performance measure.\3\ The GAO report also
concluded that HHS's decision to cut Navigator funding was
based on ``incomplete and problematic data.''\4\
---------------------------------------------------------------------------
\1\Centers for Medicare & Medicaid Services, Policies Related to
the Navigator Program and Enrollment Education for the Upcoming
Enrollment Period (Aug. 31, 2017) (https://www.cms.gov/cciio/programs-
and-initiatives/health-insurance-marketplaces/downloads/policies-
related-navigator-program-enrollment-education-8-31-2017pdf.pdf).
\2\Centers for Medicare & Medicaid Services, Cooperative Agreement
to Support Navigators in Federally-Facilitated Exchanges (July 10,
2018) (https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-
Insurance-Marketplaces/Downloads/2018-Navigator-FOA-FAQs.pdf).
\3\Government Accountability Office, Health Insurance Exchanges:
HHS Should Enhance Its Management of Open Enrollment Performance (Aug
23, 2018) (https://www.gao.gov/products/GAO-18-565).
\4\ Id.
---------------------------------------------------------------------------
HHS stipulated that funding applications are to be
evaluated based on a Navigator's ability to establish
relationships with individuals who ``may be unaware of the
range of available options in addition to qualified health
plans, such as association health plans [and] STLDI.''\5\
Lastly, HHS eliminated the requirement that each marketplace
have two Navigator entities and that Navigator entities
maintain a physical presence in the area they are serving.\6\
---------------------------------------------------------------------------
\5\See note 2.
\6\Department of Health and Human Services, HHS Notice of Benefit
and Payment Parameters for 2019, 83 Fed. Reg. 16930 (April 17, 2018).
---------------------------------------------------------------------------
H.R. 1386 would reverse HHS's actions to weaken the
Navigator program and would reinstate navigator funding at $100
million per year. It would further strengthen the Navigator
program by clarifying that Navigators can provide year-round
assistance and enroll individuals in Medicaid and the
Children's Health Insurance Program.
Committee Hearings
For the purposes of section 103(i) of H. Res. 6 of the
116th Congress, the following hearing was used to develop or
consider H.R. 1386:
On March 6, 2019, the Subcommittee on Health held a
legislative hearing entitled, ``Strengthening Our Health Care
System: Legislation to Lower Consumer Costs and Expand
Access.'' The hearing focused on H.R. 1386 and two other bills.
The Subcommittee received testimony from the following
witnesses:
Peter Lee, Executive Director, Covered
California;
Audrey Morse Gasteier, Chief of Policy,
Massachusetts Health Connector; and
J.P. Wieske, Vice President, State Affairs,
Council for Affordable Health Coverage.
Committee Consideration
H.R. 1386, the ``Expand Navigators' Resources for Outreach,
Learning, and Longevity Act of 2019 '' or the ``ENROLL Act of
2019'', was introduced on February 27, 2019, by Rep. Castor (D-
FL), and referred to the Committee on Energy and Commerce. The
bill was subsequently referred to the Subcommittee on Health on
February 28, 2019. Following legislative hearings, on March 26,
2019, the Subcommittee met in open markup session, pursuant to
notice, on H.R. 1386 for consideration of the bill. During
markup, an amendment offered by Mr. Walden (R-OR) was defeated
by a voice vote. Subsequently, the Subcommittee on Health
agreed to a motion by Ms. Eshoo, Chairwoman of the
Subcommittee, to favorably forward H.R. 1386 to the full
Committee on Energy and Commerce, without amendment, by a voice
vote.
On April 3, 2019, the full Committee met in open markup
session, pursuant to notice, to consider H.R. 1386. During the
markup, Mr. Latta (R-OH)) offered an amendment to the bill that
was defeated by a record vote of 22 years and 30 nays. An
amendment was offered by Mr. Burgess that was adopted by a
voice vote. At the conclusion of consideration of the bill, the
Committee on Energy and Commerce agreed to a motion by Mr.
Pallone, Chairman of the Committee, to order H.R. 1386
favorably reported to the House, amended, by a record vote of
30 yeas to 22 nays.
Committee Votes
Clause 3(b) of rule XIII of the Rules of the House of
Representatives requires the Committee to list each record vote
on the motion to report legislation and amendments thereto. The
Committee advises that two record votes were taken during
consideration of H.R. 1386. An amendment offered by Mr. Latta
was defeated by a record vote of 22 years to 30 nays. A motion
by Mr. Pallone to order H.R. 1385 favorably reported to the
House, amended, was agreed to by a record vote of 30 yeas to 22
nays. The following are the record votes taken during Committee
consideration, including the names of those members voting for
and against:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Duplication of Federal Programs
Pursuant to clause 3(c)(5) of rule XIII, no provision of
H.R. 1386 is known to be duplicative of another Federal
program, including any program that was included in a report to
Congress pursuant to section 21 of Public Law 111-139 or the
most recent Catalog of Federal Domestic Assistance.
Committee Cost Estimate
Pursuant to clause 3(d)(1) of rule XIII, the Committee
adopts as its own the cost estimate prepared by the Director of
the Congressional Budget Office pursuant to section 402 of the
Congressional Budget Act of 1974.
Earmarks, Limited Tax Benefits, and Limited Tariff Benefits
Pursuant to clause 9(e), 9(f), and 9(g) of rule XXI, the
Committee finds that H.R. 1386 contains no earmarks, limited
tax benefits, or limited tariff benefits.
Advisory Committee Statement
No advisory committees within the meaning of section 5(b)
of the Federal Advisory Committee Act were created by this
legislation.
Applicability to Legislative Branch
The Committee finds that the legislation does not relate to
the terms and conditions of employment or access to public
services or accommodations within the meaning of section
102(b)(3) of the Congressional Accountability Act.
Section-by-Section Analysis of the Legislation
Section 1. Short title
Section 1 designates that the Act may be cited as the
``Expand Navigators' Resources for Outreach, Learning, and
Longevity Act of 2019'' or the ``ENROLL Act of 2019''.
Section 2. Providing for additional requirements with respect to the
Navigator Program
Section 2 amends Section 1311 of the ACA and requires HHS
to award grants to Navigator entities based on an entity's
demonstrated capacity to carry out the duties specific under
Section 1311 of the ACA. The section prohibits HHS from taking
into account a Navigator entity's capacity to provide
information relating to association health plans or STLDI in
awarding grants. The section requires that grants are awarded
to at least two entities, one of which must be a community and
consumer-focused nonprofit group. The section establishes new
Navigator duties pertaining to enrolling individuals in
Medicaid and the Children's Health Insurance Program and
clarifies that all Navigator duties may be carried out at any
time during a year. The section funds Navigator grants at $100
million per year out of the user fees collected from
participating health issuers on the FFM and establishes that
the funds may remain available until expended.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, and existing law in which no
change is proposed is shown in roman):
PATIENT PROTECTION AND AFFORDABLE CARE ACT
* * * * * * *
TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
* * * * * * *
Subtitle D--Available Coverage Choices for All Americans
* * * * * * *
PART 2--CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH
BENEFIT EXCHANGES
SEC. 1311. AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS.
(a) Assistance to States to Establish American Health Benefit
Exchanges.--
(1) Planning and establishment grants.--There shall
be appropriated to the Secretary, out of any moneys in
the Treasury not otherwise appropriated, an amount
necessary to enable the Secretary to make awards, not
later than 1 year after the date of enactment of this
Act, to States in the amount specified in paragraph (2)
for the uses described in paragraph (3).
(2) Amount specified.--For each fiscal year, the
Secretary shall determine the total amount that the
Secretary will make available to each State for grants
under this subsection.
(3) Use of funds.--A State shall use amounts awarded
under this subsection for activities (including
planning activities) related to establishing an
American Health Benefit Exchange, as described in
subsection (b).
(4) Renewability of grant.--
(A) In general.--Subject to subsection
(d)(4), the Secretary may renew a grant awarded
under paragraph (1) if the State recipient of
such grant--
(i) is making progress, as determined
by the Secretary, toward--
(I) establishing an Exchange;
and
(II) implementing the reforms
described in subtitles A and C
(and the amendments made by
such subtitles); and
(ii) is meeting such other benchmarks
as the Secretary may establish.
(B) Limitation.--No grant shall be awarded
under this subsection after January 1, 2015.
(5) Technical assistance to facilitate participation
in SHOP exchanges.--The Secretary shall provide
technical assistance to States to facilitate the
participation of qualified small businesses in such
States in SHOP Exchanges.
(b) American Health Benefit Exchanges.--
(1) In general.--Each State shall, not later than
January 1, 2014, establish an American Health Benefit
Exchange (referred to in this title as an ``Exchange'')
for the State that--
(A) facilitates the purchase of qualified
health plans;
(B) provides for the establishment of a Small
Business Health Options Program (in this title
referred to as a ``SHOP Exchange'') that is
designed to assist qualified employers in the
State who are small employers in facilitating
the enrollment of their employees in qualified
health plans offered in the small group market
in the State; and
(C) meets the requirements of subsection (d).
(2) Merger of individual and SHOP Exchanges.--A State
may elect to provide only one Exchange in the State for
providing both Exchange and SHOP Exchange services to
both qualified individuals and qualified small
employers, but only if the Exchange has adequate
resources to assist such individuals and employers.
(c) Responsibilities of the Secretary.--
(1) In general.--The Secretary shall, by regulation,
establish criteria for the certification of health
plans as qualified health plans. Such criteria shall
require that, to be certified, a plan shall, at a
minimum--
(A) meet marketing requirements, and not
employ marketing practices or benefit designs
that have the effect of discouraging the
enrollment in such plan by individuals with
significant health needs;
(B) ensure a sufficient choice of providers
(in a manner consistent with applicable network
adequacy provisions under section 2702(c) of
the Public Health Service Act), and provide
information to enrollees and prospective
enrollees on the availability of in-network and
out-of-network providers;
(C) include within health insurance plan
networks those essential community providers,
where available, that serve predominately low-
income, medically-underserved individuals, such
as health care providers defined in section
340B(a)(4) of the Public Health Service Act and
providers described in section
1927(c)(1)(D)(i)(IV) of the Social Security Act
as set forth by section 221 of Public Law 111-
8, except that nothing in this subparagraph
shall be construed to require any health plan
to provide coverage for any specific medical
procedure;
(D)(i) be accredited with respect to local
performance on clinical quality measures such
as the Healthcare Effectiveness Data and
Information Set, patient experience ratings on
a standardized Consumer Assessment of
Healthcare Providers and Systems survey, as
well as consumer access, utilization
management, quality assurance, provider
credentialing, complaints and appeals, network
adequacy and access, and patient information
programs by any entity recognized by the
Secretary for the accreditation of health
insurance issuers or plans (so long as any such
entity has transparent and rigorous
methodological and scoring criteria); or
(ii) receive such accreditation within a
period established by an Exchange for such
accreditation that is applicable to all
qualified health plans;
(E) implement a quality improvement strategy
described in subsection (g)(1);
(F) utilize a uniform enrollment form that
qualified individuals and qualified employers
may use (either electronically or on paper) in
enrolling in qualified health plans offered
through such Exchange, and that takes into
account criteria that the National Association
of Insurance Commissioners develops and submits
to the Secretary;
(G) utilize the standard format established
for presenting health benefits plan options;
(H) provide information to enrollees and
prospective enrollees, and to each Exchange in
which the plan is offered, on any quality
measures for health plan performance endorsed
under section 399JJ of the Public Health
Service Act, as applicable; and
(I) report to the Secretary at least annually
and in such manner as the Secretary shall
require, pediatric quality reporting measures
consistent with the pediatric quality reporting
measures established under section 1139A of the
Social Security Act.
(2) Rule of construction.--Nothing in paragraph
(1)(C) shall be construed to require a qualified health
plan to contract with a provider described in such
paragraph if such provider refuses to accept the
generally applicable payment rates of such plan.
(3) Rating system.--The Secretary shall develop a
rating system that would rate qualified health plans
offered through an Exchange in each benefits level on
the basis of the relative quality and price. The
Exchange shall include the quality rating in the
information provided to individuals and employers
through the Internet portal established under paragraph
(4).
(4) Enrollee satisfaction system.--The Secretary
shall develop an enrollee satisfaction survey system
that would evaluate the level of enrollee satisfaction
with qualified health plans offered through an
Exchange, for each such qualified health plan that had
more than 500 enrollees in the previous year. The
Exchange shall include enrollee satisfaction
information in the information provided to individuals
and employers through the Internet portal established
under paragraph (5) in a manner that allows individuals
to easily compare enrollee satisfaction levels between
comparable plans.
(5) Internet portals.--The Secretary shall--
(A) continue to operate, maintain, and update
the Internet portal developed under section
1103(a) and to assist States in developing and
maintaining their own such portal; and
(B) make available for use by Exchanges a
model template for an Internet portal that may
be used to direct qualified individuals and
qualified employers to qualified health plans,
to assist such individuals and employers in
determining whether they are eligible to
participate in an Exchange or eligible for a
premium tax credit or cost-sharing reduction,
and to present standardized information
(including quality ratings) regarding qualified
health plans offered through an Exchange to
assist consumers in making easy health
insurance choices.
Such template shall include, with respect to each
qualified health plan offered through the Exchange in
each rating area, access to the uniform outline of
coverage the plan is required to provide under section
2716 of the Public Health Service Act and to a copy of
the plan's written policy.
(6) Enrollment periods.--The Secretary shall require
an Exchange to provide for--
(A) an initial open enrollment, as determined
by the Secretary (such determination to be made
not later than July 1, 2012);
(B) annual open enrollment periods, as
determined by the Secretary for calendar years
after the initial enrollment period;
(C) special enrollment periods specified in
section 9801 of the Internal Revenue Code of
1986 and other special enrollment periods under
circumstances similar to such periods under
part D of title XVIII of the Social Security
Act; and
(D) special monthly enrollment periods for
Indians (as defined in section 4 of the Indian
Health Care Improvement Act).
(d) Requirements.--
(1) In general.--An Exchange shall be a governmental
agency or nonprofit entity that is established by a
State.
(2) Offering of coverage.--
(A) In general.--An Exchange shall make
available qualified health plans to qualified
individuals and qualified employers.
(B) Limitation.--
(i) In general.--An Exchange may not
make available any health plan that is
not a qualified health plan.
(ii) Offering of stand-alone dental
benefits.--Each Exchange within a State
shall allow an issuer of a plan that
only provides limited scope dental
benefits meeting the requirements of
section 9832(c)(2)(A) of the Internal
Revenue Code of 1986 to offer the plan
through the Exchange (either separately
or in conjunction with a qualified
health plan) if the plan provides
pediatric dental benefits meeting the
requirements of section 1302(b)(1)(J)).
(3) Rules relating to additional required benefits.--
(A) In general.--Except as provided in
subparagraph (B), an Exchange may make
available a qualified health plan
notwithstanding any provision of law that may
require benefits other than the essential
health benefits specified under section
1302(b).
(B) States may require additional benefits.--
(i) In general.--Subject to the
requirements of clause (ii), a State
may require that a qualified health
plan offered in such State offer
benefits in addition to the essential
health benefits specified under section
1302(b).
(ii) State must assume cost.--A State
shall make payments--
(I) to an individual enrolled
in a qualified health plan
offered in such State; or
(II) on behalf of an
individual described in
subclause (I) directly to the
qualified health plan in which
such individual is enrolled;
to defray the cost of any additional
benefits described in clause (i).
(4) Functions.--An Exchange shall, at a minimum--
(A) implement procedures for the
certification, recertification, and
decertification, consistent with guidelines
developed by the Secretary under subsection
(c), of health plans as qualified health plans;
(B) provide for the operation of a toll-free
telephone hotline to respond to requests for
assistance;
(C) maintain an Internet website through
which enrollees and prospective enrollees of
qualified health plans may obtain standardized
comparative information on such plans;
(D) assign a rating to each qualified health
plan offered through such Exchange in
accordance with the criteria developed by the
Secretary under subsection (c)(3);
(E) utilize a standardized format for
presenting health benefits plan options in the
Exchange, including the use of the uniform
outline of coverage established under section
2715 of the Public Health Service Act;
(F) in accordance with section 1413, inform
individuals of eligibility requirements for the
medicaid program under title XIX of the Social
Security Act, the CHIP program under title XXI
of such Act, or any applicable State or local
public program and if through screening of the
application by the Exchange, the Exchange
determines that such individuals are eligible
for any such program, enroll such individuals
in such program;
(G) establish and make available by
electronic means a calculator to determine the
actual cost of coverage after the application
of any premium tax credit under section 36B of
the Internal Revenue Code of 1986 and any cost-
sharing reduction under section 1402;
(H) subject to section 1411, grant a
certification attesting that, for purposes of
the individual responsibility penalty under
section 5000A of the Internal Revenue Code of
1986, an individual is exempt from the
individual requirement or from the penalty
imposed by such section because--
(i) there is no affordable qualified
health plan available through the
Exchange, or the individual's employer,
covering the individual; or
(ii) the individual meets the
requirements for any other such
exemption from the individual
responsibility requirement or penalty;
(I) transfer to the Secretary of the
Treasury--
(i) a list of the individuals who are
issued a certification under
subparagraph (H), including the name
and taxpayer identification number of
each individual;
(ii) the name and taxpayer
identification number of each
individual who was an employee of an
employer but who was determined to be
eligible for the premium tax credit
under section 36B of the Internal
Revenue Code of 1986 because--
(I) the employer did not
provide minimum essential
coverage; or
(II) the employer provided
such minimum essential coverage
but it was determined under
section 36B(c)(2)(C) of such
Code to either be unaffordable
to the employee or not provide
the required minimum actuarial
value; and
(iii) the name and taxpayer
identification number of each
individual who notifies the Exchange
under section 1411(b)(4) that they have
changed employers and of each
individual who ceases coverage under a
qualified health plan during a plan
year (and the effective date of such
cessation);
(J) provide to each employer the name of each
employee of the employer described in
subparagraph (I)(ii) who ceases coverage under
a qualified health plan during a plan year (and
the effective date of such cessation); and
(K) establish the Navigator program described
in subsection (i).
(5) Funding limitations.--
(A) No Federal funds for continued
operations.--In establishing an Exchange under
this section, the State shall ensure that such
Exchange is self-sustaining beginning on
January 1, 2015, including allowing the
Exchange to charge assessments or user fees to
participating health insurance issuers, or to
otherwise generate funding, to support its
operations.
(B) Prohibiting wasteful use of funds.--In
carrying out activities under this subsection,
an Exchange shall not utilize any funds
intended for the administrative and operational
expenses of the Exchange for staff retreats,
promotional giveaways, excessive executive
compensation, or promotion of Federal or State
legislative and regulatory modifications.
(6) Consultation.--An Exchange shall consult with
stakeholders relevant to carrying out the activities
under this section, including--
(A) educated health care consumers who are
enrollees in qualified health plans;
(B) individuals and entities with experience
in facilitating enrollment in qualified health
plans;
(C) representatives of small businesses and
self-employed individuals;
(D) State Medicaid offices; and
(E) advocates for enrolling hard to reach
populations.
(7) Publication of costs.--An Exchange shall publish
the average costs of licensing, regulatory fees, and
any other payments required by the Exchange, and the
administrative costs of such Exchange, on an Internet
website to educate consumers on such costs. Such
information shall also include monies lost to waste,
fraud, and abuse.
(e) Certification.--
(1) In general.--An Exchange may certify a health
plan as a qualified health plan if--
(A) such health plan meets the requirements
for certification as promulgated by the
Secretary under subsection (c)(1); and
(B) the Exchange determines that making
available such health plan through such
Exchange is in the interests of qualified
individuals and qualified employers in the
State or States in which such Exchange
operates, except that the Exchange may not
exclude a health plan--
(i) on the basis that such plan is a
fee-for-service plan;
(ii) through the imposition of
premium price controls; or
(iii) on the basis that the plan
provides treatments necessary to
prevent patients' deaths in
circumstances the Exchange determines
are inappropriate or too costly.
(2) Premium considerations.--The Exchange shall
require health plans seeking certification as qualified
health plans to submit a justification for any premium
increase prior to implementation of the increase. Such
plans shall prominently post such information on their
websites. The Exchange shall take this information, and
the information and the recommendations provided to the
Exchange by the State under section 2794(b)(1) of the
Public Health Service Act (relating to patterns or
practices of excessive or unjustified premium
increases), into consideration when determining whether
to make such health plan available through the
Exchange. The Exchange shall take into account any
excess of premium growth outside the Exchange as
compared to the rate of such growth inside the
Exchange, including information reported by the States.
(3) Transparency in coverage.--
(A) In general.--The Exchange shall require
health plans seeking certification as qualified
health plans to submit to the Exchange, the
Secretary, the State insurance commissioner,
and make available to the public, accurate and
timely disclosure of the following information:
(i) Claims payment policies and
practices.
(ii) Periodic financial disclosures.
(iii) Data on enrollment.
(iv) Data on disenrollment.
(v) Data on the number of claims that
are denied.
(vi) Data on rating practices.
(vii) Information on cost-sharing and
payments with respect to any out-of-
network coverage.
(viii) Information on enrollee and
participant rights under this title.
(ix) Other information as determined
appropriate by the Secretary.
(B) Use of plain language.--The information
required to be submitted under subparagraph (A)
shall be provided in plain language. The term
``plain language'' means language that the
intended audience, including individuals with
limited English proficiency, can readily
understand and use because that language is
concise, well-organized, and follows other best
practices of plain language writing. The
Secretary and the Secretary of Labor shall
jointly develop and issue guidance on best
practices of plain language writing.
(C) Cost sharing transparency.--The Exchange
shall require health plans seeking
certification as qualified health plans to
permit individuals to learn the amount of cost-
sharing (including deductibles, copayments, and
coinsurance) under the individual's plan or
coverage that the individual would be
responsible for paying with respect to the
furnishing of a specific item or service by a
participating provider in a timely manner upon
the request of the individual. At a minimum,
such information shall be made available to
such individual through an Internet website and
such other means for individuals without access
to the Internet.
(D) Group health plans.--The Secretary of
Labor shall update and harmonize the
Secretary's rules concerning the accurate and
timely disclosure to participants by group
health plans of plan disclosure, plan terms and
conditions, and periodic financial disclosure
with the standards established by the Secretary
under subparagraph (A).
(f) Flexibility.--
(1) Regional or other interstate Exchanges.--An
Exchange may operate in more than one State if--
(A) each State in which such Exchange
operates permits such operation; and
(B) the Secretary approves such regional or
interstate Exchange.
(2) Subsidiary Exchanges.--A State may establish one
or more subsidiary Exchanges if--
(A) each such Exchange serves a
geographically distinct area; and
(B) the area served by each such Exchange is
at least as large as a rating area described in
section 2701(a) of the Public Health Service
Act.
(3) Authority to contract.--
(A) In general.--A State may elect to
authorize an Exchange established by the State
under this section to enter into an agreement
with an eligible entity to carry out 1 or more
responsibilities of the Exchange.
(B) Eligible entity.--In this paragraph, the
term ``eligible entity'' means--
(i) a person--
(I) incorporated under, and
subject to the laws of, 1 or
more States;
(II) that has demonstrated
experience on a State or
regional basis in the
individual and small group
health insurance markets and in
benefits coverage; and
(III) that is not a health
insurance issuer or that is
treated under subsection (a) or
(b) of section 52 of the
Internal Revenue Code of 1986
as a member of the same
controlled group of
corporations (or under common
control with) as a health
insurance issuer; or
(ii) the State medicaid agency under
title XIX of the Social Security Act.
(g) Rewarding Quality Through Market-Based Incentives.--
(1) Strategy described.--A strategy described in this
paragraph is a payment structure that provides
increased reimbursement or other incentives for--
(A) improving health outcomes through the
implementation of activities that shall include
quality reporting, effective case management,
care coordination, chronic disease management,
medication and care compliance initiatives,
including through the use of the medical home
model, for treatment or services under the plan
or coverage;
(B) the implementation of activities to
prevent hospital readmissions through a
comprehensive program for hospital discharge
that includes patient-centered education and
counseling, comprehensive discharge planning,
and post discharge reinforcement by an
appropriate health care professional;
(C) the implementation of activities to
improve patient safety and reduce medical
errors through the appropriate use of best
clinical practices, evidence based medicine,
and health information technology under the
plan or coverage;
(D) the implementation of wellness and health
promotion activities; and
(E) the implementation of activities to
reduce health and health care disparities,
including through the use of language services,
community outreach, and cultural competency
trainings.
(2) Guidelines.--The Secretary, in consultation with
experts in health care quality and stakeholders, shall
develop guidelines concerning the matters described in
paragraph (1).
(3) Requirements.--The guidelines developed under
paragraph (2) shall require the periodic reporting to
the applicable Exchange of the activities that a
qualified health plan has conducted to implement a
strategy described in paragraph (1).
(h) Quality Improvement.--
(1) Enhancing patient safety.--Beginning on January
1, 2015, a qualified health plan may contract with--
(A) a hospital with greater than 50 beds only
if such hospital--
(i) utilizes a patient safety
evaluation system as described in part
C of title IX of the Public Health
Service Act; and
(ii) implements a mechanism to ensure
that each patient receives a
comprehensive program for hospital
discharge that includes patient-
centered education and counseling,
comprehensive discharge planning, and
post discharge reinforcement by an
appropriate health care professional;
or
(B) a health care provider only if such
provider implements such mechanisms to improve
health care quality as the Secretary may by
regulation require.
(2) Exceptions.--The Secretary may establish
reasonable exceptions to the requirements described in
paragraph (1).
(3) Adjustment.--The Secretary may by regulation
adjust the number of beds described in paragraph
(1)(A).
(i) Navigators.--
(1) In general.--An Exchange shall establish a
program under which it awards grants to entities
described in paragraph (2) to carry out the duties
described in paragraph (3).
(2) Eligibility.--
(A) In general.--To be eligible to receive a
grant under paragraph (1), an entity shall
demonstrate to the Exchange involved that the
entity has existing relationships, or could
readily establish relationships, with employers
and employees, consumers (including uninsured
and underinsured consumers), or self-employed
individuals likely to be qualified to enroll in
a qualified health plan.
(B) Types.--Entities described in
subparagraph (A) may include trade, industry,
and professional associations, commercial
fishing industry organizations, ranching and
farming organizations, community and consumer-
focused nonprofit groups, chambers of commerce,
unions, resource partners of the Small Business
Administration, other licensed insurance agents
and brokers, and other entities that--
(i) are capable of carrying out the
duties described in paragraph (3);
(ii) meet the standards described in
paragraph (4); and
(iii) provide information consistent
with the standards developed under
paragraph (5).
(C) Selection of recipients.--In the case of
an Exchange established and operated by the
Secretary within a State pursuant to section
1321(c), in awarding grants under paragraph
(1), the Exchange shall--
(i) select entities to receive such
grants based on an entity's
demonstrated capacity to carry out each
of the duties specified in paragraph
(3);
(ii) not take into account whether or
not the entity has demonstrated how the
entity will provide information to
individuals relating to group health
plans offered by a group or association
of employers described in section
2510.3-5(b) of title 29, Code of
Federal Regulations (or any successor
regulation), or short-term limited
duration insurance (as defined by the
Secretary for purposes of section
2791(b)(5) of the Public Health Service
Act); and
(iii) ensure that, each year, the
Exchange awards such a grant to--
(I) at least one entity
described in this paragraph
that is a community and
consumer-focused nonprofit
group; and
(II) at least one entity
described in subparagraph (B),
which may include another
community and consumer-focused
nonprofit group in addition to
any such group awarded a grant
pursuant to subclause (I).
In awarding such grants, an Exchange
may consider an entity's record with
respect to waste, fraud, and abuse for
purposes of maintaining the integrity
of such Exchange.
(3) Duties.--An entity that serves as a navigator
under a grant under this subsection shall--
(A) conduct public education activities to
raise awareness of the availability of
qualified health plans;
(B) distribute fair and impartial information
concerning enrollment in qualified health
plans, and the availability of premium tax
credits under section 36B of the Internal
Revenue Code of 1986 and cost-sharing
reductions under section 1402;
(C) facilitate enrollment in qualified health
plans, State medicaid plans under title XIX of
the Social Security Act, and State children's
health insurance programs under title XXI of
such Act;
(D) provide referrals to any applicable
office of health insurance consumer assistance
or health insurance ombudsman established under
section 2793 of the Public Health Service Act,
or any other appropriate State agency or
agencies, for any enrollee with a grievance,
complaint, or question regarding their health
plan, coverage, or a determination under such
plan or coverage; and
(E) provide information in a manner that is
culturally and linguistically appropriate to
the needs of the population being served by the
Exchange or Exchanges.
The duties specified in the preceding sentence may be
carried out by such a navigator at any time during a
year.
(4) Standards.--
(A) In general.--The Secretary shall
establish standards for navigators under this
subsection, including provisions to ensure that
any private or public entity that is selected
as a navigator is qualified, and licensed if
appropriate, to engage in the navigator
activities described in this subsection and to
avoid conflicts of interest. Under such
standards, a navigator shall [not]--
(i) not be a health insurance
issuer[; or];
(ii) not receive any consideration
directly or indirectly from any health
insurance issuer in connection with the
enrollment of any qualified individuals
or employees of a qualified employer in
a qualified health plan[.];
(iii) maintain physical presence in
the State of the Exchange so as to
allow in-person assistance to
consumers.
(5) Fair and impartial information and services.--The
Secretary, in collaboration with States, shall develop
standards to ensure that information made available by
navigators is fair, accurate, and impartial.
(6) [Funding.--] [Grants under] Funding._
(A) State exchanges._Grants under this
subsection shall be made from the operational
funds of the Exchange and not Federal funds
received by the State to establish the
Exchange.
(B) Federal exchanges.--For purposes of
carrying out this subsection, with respect to
an Exchange established and operated by the
Secretary within a State pursuant to section
1321(c), the Secretary shall obligate
$100,000,000 out of amounts collected through
the user fees on participating health insurance
issuers pursuant to section 156.50 of title 45,
Code of Federal Regulations (or any successor
regulations) for fiscal year 2020 and each
subsequent fiscal year. Such amount for a
fiscal year shall remain available until
expended.
(j) Applicability of Mental Health Parity.--Section 2726 of
the Public Health Service Act shall apply to qualified health
plans in the same manner and to the same extent as such section
applies to health insurance issuers and group health plans.
(k) Conflict.--An Exchange may not establish rules that
conflict with or prevent the application of regulations
promulgated by the Secretary under this subtitle.
* * * * * * *
DISSENTING VIEWS
This legislation redirects $100 million annually from the
exchange user fee program to the Navigator program. The Centers
for Medicare and Medicaid Services (CMS) recently proposed
reducing the Federally-facilitated marketplace (FFM) exchange
user fee from 3.5 to 3.0 percent, prior to the introduction of
H.R. 1386.\1\ This user fee reduction was maintained in the
final rule published in the Federal Register April 25, 2019.\2\
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\1\Patient Protection and Affordable Care Act; HHS Notice of
Benefit and Payment Parameters for 2020, 84 Fed. Reg. 227 (2019),
Centers for Medicare and Medicaid Services, Proposed rule: Patient
Protection and Affordable Care Act; HHS Notice of Benefit and Payment
Parameters for 2020, (Jan. 17, 2019), available at https://
s3.amazonaws.com/public-inspection.federalregister.gov/2019-00077.pdf.
\2\Patient Protection and Affordable Care Act; HHS Notice of
Benefit and Payment Parameters for 2020, 84 Fed. Reg. 17454 (2019);
Centers for Medicare and Medicaid Services, Final rule: Patient
Protection and Affordable Care Act; HHS Notice of Benefit and Payment
Parameters for 2020, (April 25, 2019), available at https://
www.federalregister.gov/documents/2019/04/25/2019-08017/patient-
protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-
parameters-for-2020.
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The Patient Protection and Affordable Care Act (PPACA)
established the Navigator program and enrollment education to
provide guidance to enrollees, inform consumers of Open
Enrollment Periods, and notify potential enrollees about ways
to sign up for coverage.\3\ For plan year 2017, Navigators
received a total of $62.5 million in grants and enrolled 81,426
individuals,\4\ which accounted for less than one percent of
total enrollees. Meanwhile, according to CMS, ``[b]y contrast,
agents and brokers assisted with 42 percent of [Federally
Facilitated Exchange (FFE)] enrollment for plan year 2018,
which cost the FFE only $2.40 per enrollee to provide training
and technical assistance.''\5\ For this reason, Navigator
grantees received funding for plan year 2018 based on their
ability to reach enrollment goals for the previous year.
Therefore, the Navigator program should not be provided
additional funding, particularly because the program has failed
to reach enrollment goals and have
been proven highly inefficient and susceptible to waste. The
program should not be granted further taxpayer dollars that are
likely to be inefficiently used.
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\3\Patient Protection and Affordable Care Act, Pub. L. No. 111-148,
124 Stat. 119, (2010) (as amended by Health Care and Education
Reconciliation Act of 2010, Pub L. No. 111-152, 124 Stat. 1029 (2010)).
\4\Centers for Medicare and Medicaid Services, CMS Announcement on
ACA Navigator Program and Promotion for Upcoming Open Enrollment, (Aug.
31, 2017), available at https.//www.cms.gov/newsroom/press-releases/
cms-announcement-aca-navigator-program-and-promotion-upcoming-open-
enrollment.
\5\Id.
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Greg Walden,
Republican Leader, Committee
on Energy and Commerce.
Michael C. Burgess, M.D.,
Rublican Leader,
Subcommittee on Health,
Committee on Energy and
Commerce.
[all]