State Health Care Premium Reduction Act of 2021
This bill establishes and provides funding for the Improve Health Insurance Affordability Fund. States must use allocated funds to (1) issue reinsurance payments to health insurers (i.e., reimbursements to protect insurers against exceedingly high claims) for individual health insurance coverage, or (2) provide other assistance to reduce out-of-pocket costs (e.g., copayments, coinsurance, and deductibles) for qualified health plans offered in the individual market through an exchange.
Reinsurance payments using such funds may not be applied to (1) grandfathered health plans in place on March 23, 2010, (2) non-grandfathered transitional plans meeting specified requirements identified by the Centers for Medicare & Medicaid Services (CMS), or (3) student health insurance plans provided by institutions of higher education.
The bill appropriates $10 billion per year for the fund, which the CMS must distribute to states in accordance with a specified methodology based on the estimated amount of reinsurance payments for individuals in a state during the given year, subject to specified deductions. Additionally, states must submit applications explaining how they will use such funds. In the event that a state does not submit an application, the bill directs the CMS to allocate the calculated funding amount to reinsurance programs in that state.
To amend the Patient Protection and Affordable Care Act to establish a 
      health insurance affordability fund, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``State Health Care Premium Reduction 
Act of 2021''.

SEC. 2. ESTABLISHING A HEALTH INSURANCE AFFORDABILITY FUND.

    (a) In General.--Subtitle D of title I of the Patient Protection 
and Affordable Care Act is amended by inserting after part 5 (42 U.S.C. 
18061 et seq.) the following new part:

         ``PART 6--IMPROVE HEALTH INSURANCE AFFORDABILITY FUND

``SEC. 1351. ESTABLISHMENT OF PROGRAM.

    ``There is hereby established the `Improve Health Insurance 
Affordability Fund' to be administered by the Secretary of Health and 
Human Services, acting through the Administrator of the Centers for 
Medicare & Medicaid Services (in this section referred to as the 
`Administrator'), to provide funding, in accordance with this part, to 
the 50 States and the District of Columbia (each referred to in this 
section as a `State') beginning on January 1, 2023, for the purposes 
described in section 1352.

``SEC. 1352. USE OF FUNDS.

    ``(a) In General.--A State shall use the funds allocated to the 
State under this part for one of the following purposes:
            ``(1) To provide reinsurance payments to health insurance 
        issuers with respect to individuals enrolled under individual 
        health insurance coverage (other than through a plan described 
        in subsection (b)) offered by such issuers.
            ``(2) To provide assistance (other than through payments 
        described in paragraph (1)) to reduce out-of-pocket costs, such 
        as copayments, coinsurance, premiums, and deductibles, of 
        individuals enrolled under qualified health plans offered on 
        the individual market through an Exchange and of individuals 
        enrolled under standard health plans offered through a basic 
        health program established under section 1331.
    ``(b) Exclusion of Certain Grandfathered and Transitional Plans.--
For purposes of subsection (a), a plan described in this subsection is 
the following:
            ``(1) A grandfathered health plan (as defined in section 
        1251).
            ``(2) A plan (commonly referred to as a `transitional 
        plan') continued under the letter issued by the Centers for 
        Medicare & Medicaid Services on November 14, 2013, to the State 
        Insurance Commissioners outlining a transitional policy for 
        coverage in the individual and small group markets to which 
        section 1251 does not apply, and under the extension of the 
        transitional policy for such coverage set forth in the 
        Insurance Standards Bulletin Series guidance issued by the 
        Centers for Medicare & Medicaid Services on March 5, 2014, 
        February 29, 2016, February 13, 2017, April 9, 2018, March 25, 
        2019, and January 31, 2020, or under any subsequent extensions 
        thereof.
            ``(3) Student health insurance coverage (as defined in 
        section 147.145 of title 45, Code of Federal Regulations).

``SEC. 1353. STATE ELIGIBILITY AND APPROVAL; DEFAULT SAFEGUARD.

    ``(a) Encouraging State Options for Allocations.--
            ``(1) In general.--To be eligible for an allocation of 
        funds under this part for a year (beginning with 2023), a State 
        shall submit to the Administrator an application at such time 
        (but, in the case of allocations for 2023, not later than 90 
        days after the date of the enactment of this part and, in the 
        case of allocations for a subsequent year, not later than March 
        1 of the previous year) and in such form and manner as 
        specified by the Administrator containing--
                    ``(A) a description of how the funds will be used; 
                and
                    ``(B) such other information as the Administrator 
                may require.
            ``(2) Automatic approval.--An application so submitted is 
        approved unless the Administrator notifies the State submitting 
        the application, not later than 60 days after the date of the 
        submission of such application, that the application has been 
        denied for not being in compliance with any requirement of this 
        part and of the reason for such denial.
            ``(3) 5-year application approval.--If an application of a 
        State is approved for a purpose described in section 1352 for a 
        year, such application shall be treated as approved for such 
        purpose for each of the subsequent 4 years.
            ``(4) Revocation of approval.--The approval of an 
        application of a State, with respect to a purpose described in 
        section 1352, may be revoked if the State fails to use funds 
        provided to the State under this section for such purpose or 
        otherwise fails to comply with the requirements of this 
        section.
    ``(b) Default Federal Safeguard.--
            ``(1) 2023.--For 2023, in the case of a State that does not 
        submit an application under subsection (a) by the 90-day 
        submission date applicable to such year under subsection (a)(1) 
        and in the case of a State that does submit such an application 
        by such date that is not approved, the Administrator, in 
        consultation with the State insurance commissioner, shall, from 
        the amount calculated under paragraph (4) for such year, carry 
        out the purpose described in paragraph (3) in such State for 
        such year.
            ``(2) 2024 and subsequent years.--For 2024 or a subsequent 
        year, in the case of a State that does not have in effect an 
        approved application under this section for such year, the 
        Administrator, in consultation with the State insurance 
        commissioner, shall, from the amount calculated under paragraph 
        (4) for such year, carry out the purpose described in paragraph 
        (3) in such State for such year.
            ``(3) Specified use.--The amount described in paragraph 
        (4), with respect to 2023 or a subsequent year, shall be used 
        to carry out the purpose described in section 1352(a)(1) in 
        each State described in paragraph (1) or (2) for such year, as 
        applicable, by providing reinsurance payments to health 
        insurance issuers with respect to attachment range claims (as 
        defined in section 1354(b)(2)), using the dollar amounts 
        specified in subparagraph (B) of such section for such year) in 
        an amount equal to, subject to paragraph (5), the percentage 
        (specified for such year by the Secretary under such 
        subparagraph) of the amount of such claims.
            ``(4) Amount described.--The amount described in this 
        paragraph, with respect to 2023 or a subsequent year, is the 
        amount equal to the total sum of amounts that the Secretary 
        would otherwise estimate under section 1354(b)(2)(A)(i) for 
        such year for each State described in paragraph (1) or (2) for 
        such year, as applicable, if each such State were not so 
        described for such year.
            ``(5) Adjustment.--For purposes of this subsection, the 
        Secretary may apply a percentage under paragraph (3) with 
        respect to a year that is less than the percentage otherwise 
        specified in section 1354(b)(2)(B) for such year, if the cost 
        of paying the total eligible attachment range claims for States 
        described in this subsection for such year at such percentage 
        otherwise specified would exceed the amount calculated under 
        paragraph (4) for such year.

``SEC. 1354. ALLOCATIONS.

    ``(a) Appropriation.--For the purpose of providing allocations for 
States under subsection (b) and payments under section 1353(b) there is 
appropriated, out of any money in the Treasury not otherwise 
appropriated, $10,000,000,000 for 2023 and each subsequent year.
    ``(b) Allocations.--
            ``(1) Payment.--
                    ``(A) In general.--From amounts appropriated under 
                subsection (a) for a year, the Secretary shall, with 
                respect to a State not described in section 1353(b) for 
                such year and not later than the date specified under 
                subparagraph (B) for such year, allocate for such State 
                the amount determined for such State and year under 
                paragraph (2).
                    ``(B) Specified date.--For purposes of subparagraph 
                (A), the date specified in this subparagraph is--
                            ``(i) for 2023, the date that is 45 days 
                        after the date of the enactment of this part; 
                        and
                            ``(ii) for 2024 or a subsequent year, 
                        January 1 of the respective year.
                    ``(C) Notifications of allocation amounts.--For 
                2024 and each subsequent year, the Secretary shall 
                notify each State of the amount determined for such 
                State under paragraph (2) for such year by not later 
                than January 1 of the previous year.
            ``(2) Allocation amount determinations.--
                    ``(A) In general.--For purposes of paragraph (1), 
                the amount determined under this paragraph for a year 
                for a State described in paragraph (1)(A) for such year 
                is the amount equal to--
                            ``(i) the amount that the Secretary 
                        estimates would be expended under this part for 
                        such year on attachment range claims of 
                        individuals residing in such State if such 
                        State used such funds only for the purpose 
                        described in paragraph (1) of section 1352(a) 
                        at the dollar amounts and percentage specified 
                        under subparagraph (B) for such year; minus
                            ``(ii) the amount, if any, by which the 
                        Secretary determines--
                                    ``(I) the estimated amount of 
                                premium tax credits under section 36B 
                                of the Internal Revenue Code of 1986 
                                that would be attributable to 
                                individuals residing in such State for 
                                such year without application of this 
                                part; exceeds
                                    ``(II) the estimated amount of 
                                premium tax credits under section 36B 
                                of the Internal Revenue Code of 1986 
                                that would be attributable to 
                                individuals residing in such State for 
                                such year if such State were a State 
                                described in section 1353(b) for such 
                                year.
                For purposes of the previous sentence and section 
                1353(b)(3), the term `attachment range claims' means, 
                with respect to an individual, the claims for such 
                individual that exceed a dollar amount specified by the 
                Secretary for a year, but do not exceed a ceiling 
                dollar amount specified by the Secretary for such year, 
                under subparagraph (B).
                    ``(B) Specifications.--For purposes of subparagraph 
                (A) and section 1353(b)(3), the Secretary shall 
                determine the dollar amounts and the percentage to be 
                specified under this subparagraph for a year in a 
                manner to ensure that the total amount of expenditures 
                under this part for such year is estimated to equal the 
                total amount appropriated for such year under 
                subsection (a) if such expenditures were used solely 
                for the purpose described in paragraph (1) of section 
                1352(a) for attachment range claims at the dollar 
                amounts and percentage so specified for such year.
            ``(3) Availability.--Funds allocated to a State under this 
        subsection for a year shall remain available through the end of 
        the subsequent year.''.
    (b) Basic Health Program Funding Adjustments.--Section 1331 of the 
Patient Protection and Affordable Care Act (42 U.S.C. 18051) is 
amended--
            (1) in subsection (a), by adding at the end the following 
        new paragraph:
            ``(3) Provision of information on qualified health plan 
        premiums.--
                    ``(A) In general.--The program described in 
                paragraph (1) shall provide that a State may not 
                establish a basic health program unless such State 
                furnishes to the Secretary, with respect to each 
                qualified health plan offered in such State during a 
                year that receives any reinsurance payment from funds 
                made available under part 6 for such year, the adjusted 
                premium amount (as defined in subparagraph (B)) for 
                each such plan and year.
                    ``(B) Adjusted premium amount defined.--For 
                purposes of subparagraph (A), the term `adjusted 
                premium amount' means, with respect to a qualified 
                health plan and a year, the monthly premium for such 
                plan and year that would have applied had such plan not 
                received any payments described in subparagraph (A) for 
                such year.''; and
            (2) in subsection (d)(3)(A)(ii), by adding at the end the 
        following new sentence: ``In making such determination, the 
        Secretary shall calculate the value of such premium tax credits 
        that would have been provided to such individuals enrolled 
        through a basic health program established by a State during a 
        year using the adjusted premium amounts (as defined in 
        subsection (a)(3)(B)) for qualified health plans offered in 
        such State during such year.''.
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State Health Care Premium Reduction Act of 2021
To amend the Patient Protection and Affordable Care Act to establish a health insurance affordability fund, and for other purposes.
State Health Care Premium Reduction Act of 2021
Rep. Craig, Angie