Build Back Better Act (BBBA) Health Coverage Provisions: House-Passed and Senate-Released Language

Build Back Better Act (BBBA) Health Coverage Provisions: House-Passed and Senate-Released Language

Build Back Better Act (BBBA) Health Coverage
March 30, 2022
Provisions: House-Passed and Senate-Released Vanessa C. Forsberg,
Language
Coordinator
Analyst in Health Care
This report provides information about House-passed and Senate-released Build Back Better Act
Financing
(BBBA) provisions related to private health insurance, Medicaid, the State Children’s Health

Insurance Program (CHIP), and Medicare. The BBBA, considered under the congressional
Ryan J. Rosso,
reconciliation process, addresses numerous issues, such as taxes, child care, health care,
Coordinator
education, the environment, and immigration, among others.
Analyst in Health Care
Financing
Per the reconciliation instructions in the budget resolution for fiscal year (FY) 2022 (S.Con.Res.

14), the House passed its reconciliation bill, H.R. 5376—the BBBA—with amendments on
November 19, 2021. Since then, two Senate committees, the Senate Finance Committee and the

Senate Committee on Health, Education, Labor, and Pensions (HELP), have released draft bill
language described as being intended for the BBBA. These releases, referred to as Senate-released BBBA provisions or
language for purposes of this report, include provisions affecting the topics covered in this report.
Many of the private health insurance, Medicaid, CHIP, and Medicare provisions are identical or similar in the House-passed
bill and in the Senate-released BBBA language. For example, provisions in both would provide subsidies for private health
insurance offered through the health insurance exchanges for individuals with incomes below the poverty level in certain
states; would create a new program requiring price negotiation of certain Medicare drugs, mandatory rebates on Medicare
drugs, and a redesign of the Medicare Part D outpatient drug benefit; and would implement a Medicaid home and
community-based services (HCBS) improvement program.
There are some variations in the language of the House-passed and Senate-released versions. Examples of such variations
include technical edits; shifts in funding amounts and/or duration; and policy changes, including to the scope and/or timing of
a provision.
Some provisions are included in only the House-passed language or only the Senate-released language. The House-passed
language that would reduce Medicaid disproportionate share hospital (DSH) allotments by 12.5% for states that have not
implemented the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) Medicaid expansion was not
included in the Senate-released language. The Senate-released language includes provisions that were not included in the
House-passed language related to federally certified nursing facilities regarding improvements to the Special Focus Facility
Program and grants to improve staffing and infection control in long-term care institutional settings.
This report contains seven tables that together provide high-level comparisons of relevant House-passed and Senate-released
provisions. The summary of the House-passed language is baselined against current law, and the summary of the Senate-
released language is compared with the House-passed language. Table 1 includes provisions related to private health
insurance. Table 2 includes provisions related to tax credits associated with private health insurance. Table 3 includes
provisions related to prescription drugs. Table 4 includes provisions related to Medicaid. Table 5 includes provisions related
to CHIP. Table 6 includes provisions related to Medicare. Table 7 includes additional provisions that affect the Medicaid
and Medicare programs with respect to HCBS and long-term care facilities (LTCFs).

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Contents
Introduction ..................................................................................................................................... 1
Budget Reconciliation Process ........................................................................................................ 2
Comparison Tables .......................................................................................................................... 4

Tables
Table 1. Private Health Insurance Provisions in the Build Back Better Act (BBBA) ..................... 6
Table 2. Private Health Insurance-Related Tax Credit Provisions in the Build Back Better
Act .............................................................................................................................................. 15
Table 3. Prescription Drug Provisions in the Build Back Better Act ............................................. 19
Table 4. Medicaid Provisions in the Build Back Better Act .......................................................... 46
Table 5. The State Children’s Health Insurance Program (CHIP) Provisions in the Build
Back Better Act .......................................................................................................................... 56
Table 6. Medicare Provisions in the Build Back Better Act .......................................................... 62
Table 7. Home and Community-Based Services (HCBS) and Long-Term Care Facility
(LCTF) Provisions in the Build Back Better Act ....................................................................... 71

Table A-1. Abbreviations Used in This Report .............................................................................. 81
Table B-1. Build Back Better Act Health Coverage Provisions: CRS Experts ............................. 84

Appendixes
Appendix A. Abbreviations Used in This Report .......................................................................... 81
Appendix B. Build Back Better Act Health Coverage Provisions: CRS Experts .......................... 84

Contacts
Author Information ........................................................................................................................ 91

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Introduction
The Build Back Better Act (BBBA) includes provisions addressing numerous issues, such as
taxes, child care, health care, education, the environment, and immigration, among others. This
report provides information about the House-passed and Senate-released BBBA provisions
related to private health insurance, Medicaid, the State Children’s Health Insurance Program
(CHIP), and Medicare.
Per the reconciliation instructions in the budget resolution for fiscal year (FY) 2022 (S.Con.Res.
14), the House passed its reconciliation bill, H.R. 5376—the BBBA—with amendments on
November 19, 2021.1 Since then, two Senate committees, the Senate Finance Committee and the
Senate Committee on Health, Education, Labor, and Pensions (HELP), have released draft bill
language described as being intended for the BBBA. These releases, referred to as Senate-
released BBBA provisions or language for purposes of this report, include provisions that would
affect the topics covered in this report.2
The Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT)
released a summary cost estimate for the text of H.R. 5376, as amended by H.Res. 774 on
November 18, 2021.3 (After release of the CBO score and prior to House passage, the text of H.R.
5376, as amended by H.Res. 774, was further modified upon adoption of H.Res. 803 by the text
of the amendment printed in H.Rept. 117-175.) According to the CBO estimate, H.R. 5376, as
amended by H.Res. 774, would increase federal deficits by $367 billion over the FY2022-
FY2031 period.4 As of this report’s publication date, CBO and JCT had not released a cost
estimate for the Senate-released BBBA language.
The report begins with a summary of the reconciliation process for the BBBA. The report
includes seven tables that together provide high-level comparisons of relevant House-passed and
Senate-released BBBA provisions. The summary of the House-passed language is baselined
against current law, and the summary of the Senate-released language is compared with the
House-passed language. Table 1 includes provisions related to private health insurance. Table 2
includes provisions related to tax credits associated with private health insurance. Table 3
includes provisions related to prescription drugs. Table 4 includes provisions related to Medicaid.
Table 5 includes provisions related to CHIP. Table 6 includes provisions related to Medicare.
Table 7 includes additional provisions that affect the Medicaid and Medicare programs with
respect to home and community-based services (HCBS) and long-term care facilities (LTCFs).
Appendix A includes a table with a list of the abbreviations used in this report, and Appendix B
contains a list of relevant CRS experts.

1 “Build Back Better Act,” Text of the Bill, Congressional Record, daily edition, vol. 167, no. 201 (November 18,
2021), pp. H6375-H6576.
2 Senate Finance Committee-released Build Back Better Act (BBBA) language can be found at U.S. Senate Committee
on Finance, “Finance Committee Releases Updated Build Back Better Text,” press release, December 11, 2021, at
https://www.finance.senate.gov/chairmans-news/finance-committee-releases-updated-build-back-better-text. Senate
Health, Education, Labor, and Pensions (HELP) Committee-released BBBA language can be found at U.S. Senate
HELP Committee, “HELP Committee Posts Updated Build Back Better Text Ahead of Bipartisan Parliamentary
Discussions,” press release, December 11, 2021, at https://www.help.senate.gov/chair/newsroom/press/help-committee-
posts-updated-build-back-better-text-ahead-of-bipartisan-parliamentary-discussions.
3 Congressional Budget Office (CBO), Summary of Cost Estimate for H.R. 5376, the Build Back Better Act, November
18, 2021, at https://www.cbo.gov/publication/57627.
4 This estimate does not account for any revenue that may be generated by additional funding for tax enforcement.
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BBBA Health Coverage Provisions: House-Passed and Senate-Released Language

Budget Reconciliation Process
In August 2021, the House and the Senate adopted S.Con.Res. 14, a budget resolution for
FY2022.5 The budget resolution generally represents an agreement between the House and the
Senate on a budgetary plan for the upcoming fiscal year and allows Congress to employ the
budget reconciliation process.
S.Con.Res. 14 triggered the reconciliation process by including reconciliation directives to 13
House committees and 12 Senate committees, instructing each committee to develop and report
legislation within its jurisdiction that would increase or decrease the deficit by a specified
amount.6 Committees were directed to transmit such legislation to their respective Budget
Committees by September 15, 2021. Under reconciliation procedures, once instructed committees
transmit such legislation to their respective Budget Committees, the appropriate Budget
Committee must package the responses together into an omnibus budget-reconciliation bill and
report the bill without “any substantive revision.”7 The resulting reconciliation bill is then eligible
to be considered under special expedited procedures. These procedures are especially important in
the Senate, as they exempt the reconciliation bill from the general requirement that legislation
garner the support of at least three-fifths of Senators to bring debate to a close.8
In responding to reconciliation instructions, three House committees developed legislation
affecting private health insurance, Medicaid, CHIP, and Medicare, as described in later sections
of this report:
 In response to a reconciliation instruction to increase the deficit by no more than
$779.5 billion over the period FY2022-FY2031, the House Committee on
Education and Labor held a markup on September 9 -10, 2021,9 and voted to
transmit the legislation to the House Budget Committee.10
 In response to a reconciliation instruction to increase the deficit by no more than
$486.5 billion over the period FY2022-FY2031, the House Committee on Energy

5 For more information on S.Con.Res. 14, see CRS Report R46893, S.Con.Res. 14: The Budget Resolution for FY2022.
6 Compliance with reconciliation instructions is measured on a net basis. This means that a committee’s response might
include both deficit increases and deficit decreases so long as, taken as a whole, the legislative text complies with the
instruction.
7 Pursuant to §310(b)(2) of the Congressional Budget Act of 1974, as amended (P.L. 93-344). In fulfilling this
requirement, the Budget Committee typically will hold a business meeting before voting to report to the chamber.
Although amendments are not in order during the markup, members of the Budget Committee still may communicate
support or concern related to the underlying legislation.
8 For more information on the reconciliation process, see CRS Report R44058, The Budget Reconciliation Process:
Stages of Consideration.
9 U.S. Congress, House Committee on Education and Labor, Committee Print to Comply with the Reconciliation
Directive Included in Section 2002 of the Concurrent Resolution on the Budget for Fiscal Year 2022, S.Con.Res. 14,
117th Cong.,2nd sess., September 9, 2021, at https://edlabor.house.gov/hearings/committee-print-to-comply-with-the-
reconciliation-directive-included-in-section-2002-of-the-concurrent-resolution-on-the-budget-for-fiscal-year-2022-s-
con-res-14.
10 U.S. Congress, House Committee on the Budget, Build Back Better Act, report to accompany H.R. 5376, 117th
Cong., 1st sess., H.Rept. 117-130, September 27, 2021, p. 54 (hereinafter, H.Rept. 117-130). The letter of transmission
to the Budget Committee is dated September 14, 2021.
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and Commerce held a markup on September 13-15, 2021,11 and voted to transmit
the legislation to the House Budget Committee.12
 In response to a reconciliation instruction to reduce the deficit by at least
$1 billion over the period FY2022-FY2031, the House Committee on Ways and
Means held a markup on September 9-10 and September 14-15, 2021,13 and
voted to transmit the legislation to the House Budget Committee.14
As required, the House Budget Committee packaged together the reconciliation responses
transmitted by each of the 13 instructed House committees. On September, 25, 2021, the House
Budget Committee voted to report the resulting reconciliation bill, titled the Build Back Better
Act (H.R. 5376).15
On November 6, 2021, the House adopted H.Res. 774, a special rule reported from the House
Committee on Rules that brought H.R. 5376 to the House floor for consideration.16 Upon
adoption of H.Res. 774, the text of H.R. 5376 as reported from the House Budget Committee was
automatically replaced with the text of Rules Committee Print 117-18, modified by Rules
Committee Print 117-19.17
On November 18, 2021, after CBO released a summary cost estimate for the text of H.R. 5376, as
amended by H.Res. 774,18 the House adopted H.Res. 803, a special rule reported from the House
Committee on Rules that provided for further consideration of H.R. 5376. Upon adoption of
H.Res. 803, the text of H.R. 5376 was further modified by the text of the amendment printed in
H.Rept. 117-175. On November 19, the House passed H.R. 5376, as amended.19
The Senate committees that were instructed to submit reconciliation legislation to the Senate
Budget Committee did not formally respond to their instruction; however, many of the
committees released legislative text described as being intended for the BBBA.20 Two Senate
committees released legislation affecting private health insurance, Medicaid, CHIP, and
Medicare, as described in later sections of this report:

11 U.S. Congress, House Committee on Energy and Commerce, Markup of the Build Back Better Act, 117th Cong., 1st
sess., at https://energycommerce.house.gov/committee-activity/markups/markup-of-the-build-back-better-act-full-
committee-september-13-2021.
12 H.Rept. 117-130, p. 151. The letter of transmission to the Budget Committee is dated September 12, 2021.
13 U.S. Congress, House Committee on Ways and Means, Markup of the Build Back Better Act, 117th Cong., 1st sess., at
https://waysandmeans.house.gov/legislation/markups/markup-build-back-better-act.
14 H.Rept. 117-130, p. 785. The letter of transmission to the Budget Committee is dated September 17, 2021.
15 H.Rept. 117-130, p. 1493.
16 H.Res. 744 was considered by the House on November 5, 2021, and was adopted in the early morning hours of
November 6, 2021, by a vote of 221-213. During consideration of H.Res. 744, a point of order was raised against the
resolution under Section 426(a) of the Congressional Budget Act of 1974, which prohibits the consideration of a special
rule that waives the application of requirements included in the Unfunded Mandates Reform Act of 1995. Because such
a point of order is required to be disposed of by the question of consideration, the House proceeded with 20 minutes of
debate, after which the House voted to consider the resolution (in light of the point of order), by a vote of 215-212.
17 Rules Committee Prints 117-18 and 117-19 are available at U.S. Congress, House Committee on Rules, “H.R.
5376—Build Back Better Act,” at https://rules.house.gov/bill/117/hr-5376.
18 CBO, Summary of Cost Estimate for H.R. 5376, the Build Back Better Act, November 18, 2021, at
https://www.cbo.gov/publication/57627.
19 H.R. 5376 was considered by the House on November 18-19, 2021, and passed by a vote of 220-213.
20 See, for example, committees’ legislative text and associated CBO estimates at Senate Democrats, “Senate
Committee CBO Scores for Build Back Better,” January 7, 2022, at https://www.democrats.senate.gov/senate-
committee-cbo-scores-for-build-back-better.
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 The Senate Committee on Finance, which received a reconciliation instruction to
reduce the deficit by at least $1 billion over the period FY2022-FY2031, released
legislative text on its website on December 11, 2021.21
 The Senate HELP Committee, which received a reconciliation instruction to
increase the deficit by no more than $726.38 billion, released legislative text on
its website on December 11, 2021.22
As of the date of this report, no further formal congressional action had occurred on H.R. 5376.
Comparison Tables
Following are seven tables that together provide high-level summaries of the BBBA provisions as
passed by the House and the Senate provisions described as being intended for the BBBA. The
summary of the House-passed language is baselined against current law, and the summary of the
Senate-released language is compared with the House-passed language. Four of the tables focus
on provisions generally related to private health insurance, Medicaid, CHIP, and Medicare,
respectively. Three of the tables address additional and/or crosscutting topics: private health
insurance-related tax credits, prescription drugs, and provisions that affect the Medicaid and
Medicare programs with respect to HCBS and LTCFs.
The tables are organized in this way to facilitate readers’ review of provisions that address a
common topic. Each table does not necessarily align with a single title of the House-passed
BBBA or with one of the Senate committee versions. However, within a table, the provisions are
generally listed in the order in which they appear in H.R. 5376 as passed, with each row generally
representing one section of the House-passed bill and its corresponding section of the language
released by either the Senate Finance Committee or the Senate HELP Committee. There are two
exceptions:
 A few provisions appeared in more than one place in the House and/or Senate
legislation (e.g., a provision related to cost sharing for insulin, which would
amend three existing statutes). In such cases, the several sections are discussed in
the same row, which appears in the table according to the earliest such
appearance in the House bill.
 Where necessary due to complexity or for other reasons, a few provisions are
broken out into multiple rows (e.g., with each subsection in a row).
Many of the private health insurance, Medicaid, CHIP, and Medicare provisions are identical or
similar in the House-passed bill and the Senate-released BBBA language. For example, both the
House bill and the Senate language contain provisions that would provide subsidies for private
health insurance offered through the health insurance exchanges for individuals with incomes
below the poverty level in certain states; would create a new program requiring price negotiation
of certain Medicare drugs, mandatory rebates on Medicare drugs, and a redesign of the Medicare
Part D outpatient drug benefit; and would implement a Medicaid HCBS improvement program.

21 U.S. Congress, Senate Committee on Finance, Finance Committee Build Back Better Text, 117th Cong., 1st sess.,
December 11, 2021, at https://www.finance.senate.gov/download/finance-committee-build-back-better-text-.
22 U.S. Congress, Senate Committee on Health, Education, Labor, and Pensions, “HELP Committee Posts Updated
Build Back Better Text Ahead of Bipartisan Parliamentary Discussions,” press release, December 11, 2021, at
https://www.help.senate.gov/chair/newsroom/press/help-committee-posts-updated-build-back-better-text-ahead-of-
bipartisan-parliamentary-discussions.
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There are some variations in the language of the House-passed and Senate-released versions.
Examples of such variations include technical edits; shifts in funding amount and/or duration; and
policy changes, including to the scope and/or timing of the provision.
Some provisions are included in only the House-passed language or only the Senate-released
language. The House-passed language includes a provision that would reduce Medicaid
disproportionate share hospital (DSH) allotments by 12.5% for states that have not implemented
the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) Medicaid
expansion. This provision was not included in the Senate-released language. The Senate-released
language includes provisions that were not included in the House-passed language related to
federally certified nursing facilities regarding improvements to the Special Focus Facility
Program and grants to improve staffing and infection control in long-term care institutional
settings.
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Table 1. Private Health Insurance Provisions in the Build Back Better Act (BBBA)
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Civil Monetary
Federal mental health parity (MHP) requirements
Section 21005 would extend the Secretary of
Section 21005 is nearly identical
Penalties for Parity
prohibit group health plans and group (and individual)
Labor’s authority to impose CMPs against any group to the House provision, except for
Violations
health insurance issuers that provide coverage for
health plan (including plan sponsors or plan
one technical change: the Senate-
mental health/substance use disorder (MH/SUD)
administrators) or any group health insurance issuer released language would amend
benefits from imposing terms for such coverage that
for violations of MHP requirements. This authority
ERISA at 29 U.S.C. §1132(c)(10),
are more restrictive than terms for the coverage of
would apply with respect to group plans or group
whereas House-passed Section
medical and surgical benefits.
health insurance issuers for plan years (PYs)
21005 would amend ERISA at 29
Under the Employee Retirement Income Security Act
beginning one year after the enactment of the act.
U.S.C. §1132(c)(10)(A).
of 1974 (ERISA; P.L. 93-406), group plan participants
The provision also would allow the Secretary of
and other persons may bring civil actions relating to
Labor to bring civil actions against group health
alleged MHP violations. These persons may file an
insurance issuers to enforce MHP requirements.
action against a group health plan or a group health

insurance issuer to recover benefits under the plan’s
terms or to enforce or clarify the plaintiff’s rights
under the plan’s terms.
The Secretary of Labor also has limited authority to
bring civil actions against group health plan
sponsors—but not against group health insurance
issuers—to enforce MHP requirements.
Although the Secretary of Labor has authority to
impose civil monetary penalties (CMPs) on group
health plan sponsors and group health insurance
issuers to enforce certain other requirements (e.g.,
regarding the use of genetic information), CMPs are
not authorized for enforcement of MHP
requirements.
Ensuring
The Patient Protection and Affordable Care Act
Section 30601 would provide for access to
Section 27001 is similar to the
Affordability of
(ACA; P.L. 111-148, as amended) required
coverage through the health insurance exchanges
House provision, except for
Coverage for
government-run health insurance exchanges to be
for certain low-income individuals. It would address
changes related to retroactive
Certain Low-
established in every state. Through exchanges,
cost sharing, benefits, enrol ment periods, and
cost-sharing reductions in
Income Populations
consumers can purchase qualified health plans (QHPs;
consumer outreach. See discussions of subsections
subsection (a) and new language in
private health insurance plans certified to be sold in
(a)–(e) in sub-rows below for more information.
subsections (d) and (e) that
the exchanges), and can receive financial subsidies for
Note that terminology regarding eligible low-
references these changes. See sub-
coverage, if eligible (based on income and other
income individuals varies slightly across the
rows below.
factors).
subsections.
CRS-6

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Reducing Cost
Individuals may receive cost-sharing reductions (CSRs) Section 30601(a) would temporarily change the
Section 27001(a) is similar to the
Sharing Under
that decrease cost-sharing requirements for certain
CSR income eligibility criteria and would provide
House provision, except it would
Qualified Health QHPs. To be eligible for CSRs, individuals must qualify special access for a limited time to individuals with
require the exchange QHPs in
Plans
for the premium tax credit, be enrol ed in a silver
incomes not exceeding 138% of FPL.
which specified enrol ees are
QHP, and have annual household incomes between
Over the period PY2023-PY2025, this provision
enrol ed during PY2025 to provide
100% and 250% of the federal poverty level (FPL). A
would require only that incomes do not exceed
payments to health care providers
silver QHP is a plan with an actuarial value (AV) of
400% of FPL to be income eligible for CSRs.
or specified enrol ees to cover
70%; AV measures a plan’s generosity, expressed as
items or services provided to the
the percentage of estimated medical expenses paid by
For PY2022, individuals with incomes not exceeding
enrol ees during the retroactive
a health insurance issuer for a standard population
138% of FPL would be treated as having income at
coverage period, as specified in the
and set of allowed charges. CSR-eligible individuals
100% of FPL. This provision would deem such
provision.
receive two types of CSRs: one reduces the annual
individuals to have met the CSR income eligibility
The provision would require plans
cost-sharing limit, and the other directly reduces cost-
criteria and would allow them to receive the highest providing retroactive payments to
sharing requirements (e.g., co-payments). Greater
level of cost-sharing assistance currently available
notify the HHS Secretary of any
cost-sharing assistance is provided to individuals with
(as long as they also met CSR non-income-eligibility
retroactive payments. It also
lower incomes. For example, CSR-eligible individuals
criteria).
would require the Secretary to
with incomes between 100% and 150% of FPL receive
Over the period PY2023-PY2025, the provision
make periodic and timely
cost-sharing assistance that increases the AV of their
would temporarily provide greater cost-sharing
payments to the plans. The
coverage to 94%; by contrast, eligible individuals with
assistance to individuals with incomes not exceeding provision would provide
incomes between 200% and 250% of FPL receive
138% of FPL who would be eligible for CSRs (i.e.,
appropriations of such funds as
assistance that increases their coverage’s AV to 73%.
“specified enrol ees”). The provision would reduce
may be necessary to finance these
cost-sharing requirements to increase the AV of the payments.
exchange QHP in which a specified enrol ee is
enrol ed to 99%.
To effect this provision, the Secretary of Health and
Human Services (HHS) would establish procedures
under which applicable QHPs would reduce cost-
sharing requirements. The provision would require
such plans to notify the HHS Secretary of the cost-
sharing assistance provided to specified enrol ees,
and it would require the Secretary to make periodic
and timely payments to the plans. The provision
would provide appropriations of such sums as may
be necessary to finance these payments.
CRS-7

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Open
Outside of annual open enrol ment periods (OEPs),
Section 30601(b) would create a new federal SEP
Section 27001(b) is identical to
Enrollments
consumers may enrol in a QHP in an individual
to allow “individuals described” to enrol in a silver
the House provision.
Applicable to
exchange only if they qualify for a special enrol ment
QHP for which CSRs are applicable, through their

Certain Lower-
period (SEP). An SEP is generally a certain amount of
state’s individual exchange.
Income
time (e.g., 60 days) after a triggering event, such as a
The individuals eligible for this SEP would be those
Populations
change in marital status or a loss of qualifying coverage,
with household income that does not exceed 138%
which generally means the types of coverage
of FPL who are not otherwise eligible for certain
considered to be minimum essential coverage (MEC).
types of government sponsored program MEC
Most types of comprehensive coverage are
(other than the types exempt from the definition of
considered MEC, including government sponsored
MEC, such as certain types of limited-benefit
programs (e.g., ful -benefit Medicaid coverage,
Medicaid coverage). In general, these would be
Medicare), private health insurance, and other types
individuals who otherwise would be eligible for
of coverage as recognized by the HHS Secretary in
coverage through the ACA Medicaid expansion but
coordination with the Secretary of the Treasury. Per
are in states that have not taken up the ACA
regulation, certain types of limited-benefit Medicaid
Medicaid expansion (currently, 12 states).
coverage options (e.g., family planning, tuberculosis
Overall, the SEP would be “for months occurring
services, COVID-19 testing) are not included in the
during” calendar years 2022-2025 (CY2022-
definition of government sponsored program MEC.
CY2025). For an individual described, the SEP

would be for “the continuous period beginning on
the first day that such individual is so described.”
CRS-8

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Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Additional
The ACA requires certain plans, including those sold
Section 30601(c) would require QHP issuers to
Section 27001(c) is identical to
Benefits for
on the exchanges (i.e., QHPs), to cover 10 broad
provide certain benefits to eligible individuals, via
the House provision.
Certain Low-
categories of essential health benefits (EHB). The
silver QHPs for which CSRs are applicable, in
Income
specific benefits that comprise the EHB are not
PY2024-PY2025.
Individuals for
defined in federal law but rather are generally defined
The individuals eligible for the additional benefits
Plan Years
by states. Cost-sharing requirements may apply to
would be those with household income that does
2024 and 2025 services covered as EHB, and coverage details may
not exceed 138% of FPL and who are eligible for
vary for EHB services furnished by out-of-network
CSRs. In general, these would be individuals who
providers, subject to applicable federal and state
otherwise would be eligible for coverage through
requirements.
the ACA Medicaid expansion but are in states that
The ACA also requires most plans, including those
have not taken up the ACA Medicaid expansion.
sold on the exchanges, to cover specified preventive
For such individuals and plans, the provision would
services without cost sharing. These services include
require coverage of the fol owing, where not
contraceptive services and supplies (for women but
already provided as EHB: (1) non-emergency
not for men), as recommended by the Health
medical transportation services and (2) family
Resources and Services Administration. By regulation,
planning services and supplies.a The provision would
plans generally are not required to cover the specified require such coverage without consumer cost
preventive services furnished out of network. Also by
sharing and “without any restriction on the choice
regulation, the requirement to cover specified
of a qualified provider from whom an individual may
preventive services without cost sharing is
receive such benefits.”
incorporated into EHB requirements.
The provision would require applicable QHP issuers
There is no federal requirement regarding QHP or
to notify the HHS Secretary of covering the
other private health insurance coverage of non-
additional benefits as specified, and it would require
emergency medical transportation.
the Secretary to make “periodic and timely

payments to the issuer equal to payments for such
services so furnished.” The provision would
appropriate such sums as may be necessary to the
Secretary to make these payments to issuers.
CRS-9

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Education and
Federal statute and regulations require exchanges to
Section 30601(d)(1) would require the HHS
Section 27001(d) is largely
Outreach
carry out certain consumer outreach and assistance
Secretary to conduct consumer outreach and
identical to the House provision,
Activities
functions.
education activities focused on informing specified
except it would further specify
Requirements include having Navigator programs, for
individuals, in states with FFEs, about the availability
that the provision’s funded
which grants are provided to entities to perform
of QHPs and of financial assistance for such
activities must include informing
consumer outreach and assistance functions.
coverage in each applicable state’s exchange. The
individuals “on the availability of
Exchanges also provide consumer information and
specified individuals would be those who otherwise
payment and reimbursement for
outreach via mail, radio, or television advertisements,
would be eligible for coverage through the ACA
services during the retroactive
and/or other methods.
Medicaid expansion but are in states that have not
coverage period, as defined in
taken up the ACA Medicaid expansion.
section 1402(c)(6)(D)(vii)” (see
Navigator grants and other exchange consumer
discussion of Section 27001(a),
education and outreach activities are federally funded
No funds appropriated for these activities could be
above). This provision would apply
for federally facilitated exchanges (FFEs). There is no
used to promote “non-ACA compliant health
to the outreach and education
specific appropriation or statutorily required program
insurance coverage,” including, as specified, an
activities and to the Navigator
spending level for such activities. To raise funds for
association health plan or short-term, limited-
grants.
these and certain other exchange functions, HHS
duration insurance.
assesses a monthly fee on each health insurance issuer For purposes of conducting these outreach
that offers plans through an FFE.
activities, $105 mil ion would be appropriated for
States with state-based exchanges and state-based
FY2022 and would remain available until expended.
exchanges on the federal platform fund their own
Of that amount, $15 mil ion would be specified for
Navigator grants and other consumer outreach and
use in FY2022 and $30 mil ion would be specified
education activities. These states may assess their
for use in each of FY2023-FY2025.
own user fees on issuers participating in their
Section 30601(d)(2) would require the HHS
exchanges.
Secretary to obligate not less than $10 mil ion for
FY2022 and not less than $20 mil ion for each of
FY2023-FY2025 for the purpose of awarding grants
to Navigator entities in FFEs. These funds would be
obligated from exchange issuer user fee amounts
col ected and would remain available until
expended.
CRS-10

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Funding
Not applicable.
Section 30601(e) would appropriate $65 mil ion to
Section 27001(e) is largely
the HHS Secretary for FY2022, to remain available
identical to the House provision in
until expended, for purposes of “carrying out the
reference to funding for the
provisions of, and the amendments made by”
corresponding provisions in the
Sections 30601-30603.
Senate language, other than the
fol owing difference:
Section 27001(e) would
appropriate an additional
$5 mil ion for FY2022, to remain
available until expended, “for
purposes of carrying out section
1402(c)(6)(D) of the [ACA] (as
added by this section).”
Establishing a
There is currently no federal reinsurance program,
Section 30602 would establish a fund to provide
Section 27002(a) is similar to
Health Insurance
but 15 states have established state-based reinsurance
reinsurance payments to individual health insurance
the House provision, with
Affordability Fund
programs using the Section 1332 waiver process.
issuers with high-cost enrol ees or to provide other
differences highlighted in sub-rows
types of assistance to reduce specified out-of-
below.
pocket costs. (See sub-rows below.)
CRS-11

In General
The ACA established the Transitional Reinsurance
Section 30602(a) would establish the Improve
Section 27002(a) would establish
Program, which was a temporary federal reinsurance
Health Insurance Affordability Fund to allocate
the Improve Health Insurance
program that operated from PY2014 through PY2016
funding to states to either (1) provide reinsurance
Affordability Fund, similar to the
and provided reimbursement to most individual health payments to issuers with respect to their individual
House provision. However,
insurance issuers that enrol ed high-cost enrol ees.
health insurance coverage enrol ees or (2) provide
Section 27002(a) also would apply
Section 1332 of the ACA provides states with the
other types of assistance to reduce out-of-pocket
rules to non-expansion Medicaid
option to waive specified requirements of the ACA in
costs for individuals enrol ed in QHPs offered
states in 2022 that are different
order to implement their own plans to provide health
through an individual market health insurance
from, and in addition to, the rules
insurance coverage to state residents, as long as the
exchange and individuals enrol ed in plans offered
applicable to non-expansion states
plan meets the ACA’s terms. Currently, 15 of the 16
through a BHP. The fund would provide funding
in 2023-2025. Additionally, Section
approved waivers include a variant of a statewide
beginning January 1, 2023.
27002(a) would appropriate
individual market reinsurance program.
To be eligible for a fund allocation, Section
$1 bil ion for FY2022 for the CMS
Administrator to provide
The ACA Medicaid expansion provides Medicaid
30602(a) would require states to submit to the
reinsurance payments to issuers in
eligibility to most non-elderly adults up to 133% of
Administrator of the Centers for Medicare &
non-expansion states in 2022.
FPL. Currently, 12 states are non-expansion states (i.e.,
Medicaid Services (CMS) an application that
These funds would remain
have not implemented the Medicaid expansion).
describes how the funds would be used. Any
application submitted would be approved, unless
available until expended.
The Basic Health Program (BHP) is an optional
the CMS Administrator notified the applying state
Instead of appropriating $10 bil ion
program for states to make affordable health benefits
that its application had been denied for not
for 2023 and each subsequent year
coverage available to a specific group of individuals in
complying with specified requirements.
through 2025 for the HHS
lieu of offering coverage through an exchange.
Secretary to allocate funding to
Through the BHP, states can make coverage available
The HHS Secretary would determine state
states and to make payments for
to individuals under the age of 65 with household
allocation amounts using a formula based on an
non-expansion states, Section
incomes between 133% and 200% of FPL who are not
assumption that all funding would go to reinsurance
27002(a) would appropriate
otherwise eligible for Medicaid or other minimum
payments. Total state allocations would equal the
$30 bil ion in FY2022. Of this
essential coverage specified in the ACA. Minnesota
amount of appropriated funds for a given year.
amount, $10 bil ion would be used
and New York are the only states that have
For 2023, the provision would require the HHS
for each of FY2023-FY2025 to
implemented the BHP.
Secretary to allocate funding to states not later than allocate funding to states and to
90 days after enactment of this section. For 2024-
make payments for non-expansion
2025, the provision would require the HHS
states. Each year’s allocation
Secretary to allocate funding to states not later than would remain available until
January 1 of the respective year. Any funds allocated September 30, 2026.
to a state in a given year would be available to the
state through the end of the subsequent year.

Section 30602(a) would apply different fund rules
to non-expansion states in 2023-2025. Instead of
these states applying and managing their own
allocations, the CMS Administrator, in consultation
with applicable state authorities, would provide
reinsurance payments to issuers in such states with
CRS-12

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
respect to their individual health insurance coverage
enrol ees. The total amount available for these
reinsurance payments would be based on the
summation of all non-expansion-state allocations.
Non-expansion-state allocations would be based on
a formula that is similar, but not identical, to the
formula used to determine expansion states’
allocations.
Section 30602(a) would appropriate $10 bil ion for
2023 and each subsequent year through 2025 for
the HHS Secretary to allocate funding to states and
to make payments for non-expansion states.
Basic Health
States with an optional BHP receive federal payments
Section 30602(b) would require states, as a
Section 27002(b) is identical to
Program
that equal 95% of the value of premium tax credits
condition of establishing a BHP, to report to the
the House provision.
Funding
(PTCs) and CSRs that BHP enrol ees would have been HHS Secretary the premium that would have
Adjustments
provided, had they enrol ed in QHPs through an
applied to each QHP that receives reinsurance
exchange. The HHS Secretary determines this amount payments from the Improve Health Insurance
on a per enrol ee basis, taking into account all relevant Affordability Fund, had the reinsurance payments
factors necessary to determine the value of the PTCs
not applied. This requirement would apply for plan
and CSRs. Minnesota and New York are the only
years beginning on or after January 1, 2023.
states that have implemented the BHP.
The HHS Secretary would use this information from
states to calculate the BHP payments to states.
Implementation
Not applicable.
Section 30602(c) would allow the HHS Secretary
Section 27002(c) is identical to
Authority
to implement the provisions and amendments made
the House provision.
by Section 30602 by sub-regulatory guidance or
otherwise.
Funding for the
The ACA required the Secretary to award grants to
Section 30603 would provide for new funding for
Section 27003 is identical to the
Provision of Health
states to provide for offices of health insurance
these grants. It would appropriate $100 mil ion for
House provision.
Insurance
consumer assistance or health insurance ombudsman
2022, which would remain available until expended.
Consumer
programs.
Of that amount, it would specify $25 mil ion for use
Information
Per that requirement, $30 mil ion were appropriated
in each of 2022-2025.
“for the first fiscal year for which this section applies
to carry out this section” (i.e., FY2010). Such sums as
necessary were authorized to be appropriated for
subsequent FYs.
CRS-13

link to page 18 link to page 22 link to page 84
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Cost-Sharing
The ACA established CSRs and the applicable income
Section 30605 would extend the ARPA’s CSR
Section 27005 is identical to the
Reductions for
and other eligibility criteria. The American Rescue
provision one more year, through PY2022. The
House provision.
Individuals
Plan Act of 2021 (ARPA; P.L. 117-2) provided special
provision would deem individuals who receive UC
Receiving
access to individuals who received unemployment
for any week during a given year to have met the
Unemployment
compensation (UC). The ARPA deemed individuals
CSR income eligibility criteria. It also would change
Compensation
who received UC for any week in CY2021 to have
the income disregard to income in excess of 150%
met the CSR income eligibility criteria for PY2021.
of FPL.
The ARPA also disregarded any household income

above 133% of FPL in 2021, which provided UC
beneficiaries with the greatest level of cost-sharing
assistance.
Funding to Support
Section 1332 of the ACA allows states to apply for
Section 30607 would require the HHS Secretary
Section 127308 is identical to
State Applications
waivers of specified ACA provisions for up to five
to award grants to states for purposes of
the House provision.
for Section 1332
years. Under a state innovation waiver (or Section
developing a new waiver application, preparing an
Waivers and
1332 wavier), a state is expected to implement a plan
application for a waiver extension or amendment,
Administration
(in place of the waived provisions) that meets certain
or implementing a state plan.
minimum requirements. The HHS Secretary and the
Section 30607 would appropriate $50 mil ion to
Secretary of the Treasury review and approve state
the HHS Secretary for FY2022 for purposes of
innovation waiver applications pertaining to provisions implementing the grant program and awarding
under their respective jurisdictions.
grants. These funds would remain available until
expended. The grant amount to a state would not
exceed $5 mil ion and would remain available to the
state until expended.
Sources: CRS analysis of the BBBA as passed by the House and included in the Congressional Record, the language released by the Senate Committee on Health,
Education, Labor, and Pensions (HELP) and the Senate Finance Committee described as being intended for the BBBA, and relevant current law. See report introduction
for links to legislative language.
Notes: This table includes provisions generally relevant to private health insurance. Also see Table 2 and Table 3 for additional provisions related to private health
insurance and tax credits and to private health insurance and prescription drugs, respectively. See Appendix A for all abbreviations used in table.
a. The provision points to the Medicaid statute as a baseline for defining this coverage requirement. The non-emergency medical transportation services benefits
would include coverage “as described in section 1902(a)(4) of the Social Security Act (SSA) for which Federal payments would have been available under title XIX of
the SSA had such services been furnished to an individual under a State plan (or waiver of such plan) under such title.” The family planning services benefits would
include those “described in subsection (a)(4)(C) of section 1905 of [the SSA] for which Federal payments would have been so available.”
CRS-14

Table 2. Private Health Insurance-Related Tax Credit Provisions in the Build Back Better Act
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Improve Affordability
Individuals who meet income eligibility criteria, are
Section 137301 would extend the ARPA PTC
Section 127301 is nearly identical
and Reduce Premium
not eligible for subsidized health coverage (e.g.,
provisions through TY2025 by continuing to
to the House provision, except it
Costs of Health
Medicaid), and meet other requirements may receive
eliminate the eligibility phaseout for households
would permanently disallow the
Insurance for
a PTC, which reduces the cost of QHPs offered
with annual incomes above 400% of FPL and
annual adjustment to applicable
Consumers
through exchanges. As authorized under the ACA,
would use the ARPA-specified percentages
income percentages used in the
the PTC was available to individuals whose annual
(0.0% to 8.5% of income) to calculate the credit
PTC formula.
household incomes were between 100% and 400% of amount. Similar to the ARPA, this provision
FPL. The ARPA made temporary changes to the
would continue ful subsidies to cover standard
PTC. For tax year (TY) 2021 and TY2022, the ARPA
QHP premiums for PTC-eligible individuals with
eliminated the income eligibility phaseout at 400% of
incomes at or below 150% of the FPL.
FPL, requiring individuals to meet only the minimum
In addition, the provision would disallow the
threshold to be income eligible for the PTC (such
annual adjustment to applicable income
individuals must stil meet the applicable non-income
percentages used in the PTC formula through
eligibility criteria to receive the credit).
TY2026.
PTC-eligible individuals stil may be required to pay
an amount toward the premium. Under the ACA,
the required premium contribution is capped at a
dol ar amount that is equivalent to a percentage of
annual household income, with income measured
relative to the FPL. The cap requires lower-income
individuals to contribute a smaller share of income
toward the premium compared with the
contribution requirement for higher-income
individuals, with applicable percentages adjusted on
an annual basis. Prior to enactment of the ARPA, the
2021 percentages varied from 2.07% to 9.83% for
incomes within the original range of 100%-400% of
FPL. The ARPA temporarily reduced the percentage
of income used in the credit formula. For TY2021-
TY2022, applicable percentages range from 0.0% to
8.5% of income, effectively reducing the amounts
eligible individuals pay to enrol in exchange QHPs.
CRS-15

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Modification of
Individuals who are offered health benefits through
Section 137302 would temporarily lower the
Section 127302 is nearly identical
Employer-Sponsored
an employer generally are not eligible for the PTC.
percentage of household income used to
to the House provision, except it
Coverage Affordability
An exception exists for individuals whose employer-
determine affordability of employer coverage
would permanently disallow the
Test in Health
provided health benefits are unaffordable or
for PTC-eligibility purposes. For the period
annual adjustment to the
Insurance Premium Tax inadequate. An applicable employer plan is
TY2022-TY2025, the affordability test applied to affordability test percentage.
Credit
considered unaffordable if the premium for self-only
applicable employer plans would be set at 8.5%
coverage exceeds a certain percentage of household
of household income, allowing more households
income, with such percentage adjusted on an annual
to be eligible for the PTC compared with those
basis. In 2022, employer coverage is considered
eligible under current law.
unaffordable if the premium for self-only coverage
In addition, the provision would disallow the
exceeds 9.83% of household income; the ACA
annual adjustment to the affordability test
initially established the percentage at 9.5%.
percentage from TY2022 through TY2026.
Treatment of Lump-
Social Security provides monthly cash benefits to
Section 137303 would exclude certain income Section 127303 is identical to the
Sum Social Security
qualified workers and certain family members in the
from the determination of PTC eligibility and
House provision.
Benefits In Determining event of a worker’s retirement, disability, or death.
calculation of the credit amount. Beginning in
Household Income
Each year, many Americans become newly entitled to TY2022, the provision would exclude from
Social Security benefits. Whereas applications for
household income any lump-sum Social Security
retirement or survivor benefits are processed
benefit payment attributable to a prior year.
relatively quickly, applications and appeals for
Beginning in TY2026, this provision would allow
disability benefits may take many months or years.
taxpayers to elect to include the excludable
Sometimes, a claimant may be determined to have
amount as part of their income.
been entitled to benefits for months before the
benefit determination is made. In such cases, the
individual receives a lump-sum payment for months
of past-due benefit entitlement, which may include
months in past taxable years. Because calculation of
the PTC is based on household income for a given
year, a multiyear award added to income in one year
may affect an individual’s eligibility for the PTC or
may substantively reduce the credit amount.
CRS-16

Temporary Expansion
Individuals with household incomes less than 100% of Section 137304 would expand PTC eligibility
Section 127304 is identical to the
of Health Insurance
FPL generally are ineligible for the PTC. Likewise,
to certain lower-income households and would
House provision.
Premium Tax Credits
individuals who are eligible for subsidized health
make other changes for the period TY2022-
for Certain Low-
coverage (e.g., Medicaid, employer-provided health
TY2025.
Income Populations
benefits) generally are ineligible for the PTC.
The provision would expand PTC eligibility by
However, current law provides exceptions applicable disregarding income criteria and disallowing the
to certain subsidized coverage.
affordability test applicable to employer health
Eligible individuals may receive the PTC in advance to coverage for households with incomes not
coincide with payment of monthly premiums or wait
exceeding 138% of FPL.
to claim the credit when filing income taxes.
The provision would reduce household tax
Calculation of the advance premium tax credit
liability by decreasing the amount households
(APTC) is based on an estimate of household income with excess APTC would have to pay back, for
for the year in which subsidized exchange coverage is households with incomes less than 200% of FPL,
sought. Individuals who receive the APTC are
and by disallowing the requirement to pay back
required to reconcile that estimated amount with
excess APTC if an exchange projected a
the credit amount they should have received (based
household’s income would not exceed 138% of
on actual income as determined on the tax return). If FPL, for households that would not be required
an individual’s income increased during the year and
to file a tax return except to reconcile APTC
he or she received excess APTC, the excess amount
payments.
general y wil be recaptured as a tax payment. The
amount subject to recapture is capped for individuals
The provision would prevent employees with
with annual household incomes less than 400% of
household incomes projected to not (or that do
FPL, with greater tax relief provided to individuals
not) exceed 138% of FPL from triggering the
with lower incomes.
ESRP penalty or from being factored into any
penalty amount calculations (where applicable).
The employer shared responsibility provisions (ESRP)
generally incentivize large employers to offer
adequate and affordable health insurance coverage to
their ful -time employees (and their employees’
dependents). If an applicable large employer fails to
offer health insurance or offers substandard
coverage, the employer may be subject to a penalty if
at least one ful -time employee enrol s in an
exchange plan and is eligible for a PTC or a CSR. For
applicable large employers subject to an ESRP
penalty, the penalty amount is determined according
to a formula that varies depending on whether the
employer offered health benefits to at least 95% of
its ful -time employees. In situations where an
employer does meet this threshold, the formula for
calculating the penalty incorporates the number of
CRS-17

link to page 9 link to page 84
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
ful -time employees (of such an employer) who
received a PTC or a CSR.
Special Rule for
Under the ARPA, individuals who received UC for
Section 137305 would extend the UC PTC
Section 127305 is identical to the
Individuals Receiving
any week in CY2021 were deemed to have met the
provision one more year, through TY2022. The
House provision.
Unemployment
PTC income eligibility criteria for TY2021. In
provision would deem individuals who receive
Compensation
addition, the calculation of the credit for such
UC for any week during a given year to have
individuals disregarded any household income above
met the PTC income eligibility criteria. The
133% of FPL.
provision also would disregard any household
income above 150% of FPL for credit calculation
purposes in TY2022.
Permanent Credit for
Certain workers who have experienced job loss and
Section 137306 would authorize the HCTC
Section 127306 is identical to the
Health Insurance Costs
retirees whose private pension plans were taken
on a permanent basis by striking the sunset
House provision.
over by the Pension Benefit Guaranty Corporation
date. The provision also would increase the
may have been eligible for the Health Coverage Tax
HCTC’s subsidy rate to 80% of the premium for
Credit (HCTC). The HCTC covered 72.5% of the
qualified health insurance for coverage months
premium for qualified health insurance, as specified in beginning after December 31, 2021.
statute. It had a sunset date of January 1, 2022.
Exclusion of Certain
For purposes of determining eligibility for and the
Section 137307 would temporarily exclude
Section 127307 is identical to the
Dependent Income for
amount of the PTC and CSRs, household income
dependent income for specified purposes. For
House provision.
Purposes of Premium
consists of a given taxpayer’s modified adjusted gross
the period TY2023-TY2026, the provision
Tax Credit
income (MAGI) and the aggregate MAGI of all
would exclude income of a dependent younger
persons for whom the taxpayer claims a deduction
than 24 years of age from the calculation of the
for a personal exemption. Given this definition, the
PTC and determination of eligibility for CSRs.
household may include the taxpayer, the taxpayer’s
An exception to this exclusion would apply to
spouse, and other tax dependents.
aggregate income from all dependents younger
than the age of 24 in a given household that
exceeds $3,500; the dol ar level would be
adjusted annually beginning in TY2024.
Beginning in TY2026, this provision would allow
taxpayers to elect to include the excludable
amount as part of their income.
Sources: CRS analysis of the BBBA as passed by the House and included in the Congressional Record, language released by the Senate Finance Committee described as
being intended for the BBBA, and relevant current law. (The Senate HELP Committee language did not include provisions relevant to this table.) See report introduction
for links to legislative language.
Notes: This table includes provisions relevant to private health insurance and tax credits. Also see Table 1 for provisions related to private health insurance general y.
See Appendix A for all abbreviations used in table.
CRS-18

Table 3. Prescription Drug Provisions in the Build Back Better Act
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Requirements
Private health insurance prescription drug
Section 27001 would amend ERISA, Section
Section 26001 would amend ERISA and
with Respect to
coverage for insulin products can vary by plan,
30604 would amend the Public Health Service Act
the IRC, and Section 27004 would
Cost Sharing for
subject to federal and state requirements.
(PHSA; P.L. 78-410), and Section 137308 would
amend the PHSA, with language identical
Certain Insulin
Differences in coverage include which insulin
amend the Internal Revenue Code (IRC) to establish
to the House provisions in H.R. 5376
Products
products are included in a plan’s formulary and
standards for coverage and cost sharing for certain
Sections 27001, 137308, and 30604,
the associated cost-sharing requirements.
insulin products. These requirements would apply
respectively.
Non-grandfathered plans in the individual and
for PYs beginning on or after January 1, 2023.
small-group markets (on and off the exchanges)
The provisions would require individual market,
must cover 10 categories of EHBs. One category small- and large-group market, and self-insured
is prescription drugs. Although states, rather
group plans to select and provide coverage for at
than the federal government, generally specify
least one type of each dosage form (e.g., vial, pump,
the coverage to be provided within these 10
inhaler) of each different type of insulin (e.g., rapid
categories, certain HHS regulations effectively
to ultra-long acting, premixed), when available. The
require EHB insulin coverage. Cost sharing is
insulin products would need to be licensed, or
possible for EHB, and there are no specific limits
deemed to be licensed, and would continue to be
on consumer cost sharing for insulin products.
marketed pursuant to the license.
There are no federal requirements mandating
The provisions would cap cost sharing for 30-day
the coverage of insulin by large-group market
supplies at the lesser of a $35 co-payment or 25%
and self-insured group plans.
of the negotiated price of the selected insulin
Catastrophic plans cover the EHB but generally
product net of all price concessions received by or
may not provide benefits for any plan year until
on behalf of the plan, including payments to third
after the annual limitation on cost sharing has
parties such as pharmacy benefit managers (PBMs).
been reached. One exception is that
This coverage would be required pre-deductible,
catastrophic plans must cover at least three
and other cost-sharing limits would apply. This cost-
primary care visits per year pre-deductible.
sharing cap requirement would not apply to insulin
Enrol ment eligibility requirements apply.
products delivered by out-of-network providers.
The PHSA provision would require catastrophic
plans to provide coverage for the selected insulin
products for a PY before an enrol ed individual has
incurred cost-sharing expenses in an amount equal
to the annual limitation on cost sharing.
CRS-19

Oversight of
Group health plans and health insurance issuers
Section 27002 would amend ERISA, Section
Section 26002 would amend ERISA and
Pharmacy Benefit
offering group and individual health insurance
30606 would amend PHSA, and Section 137309
the IRC, and Section 27006 would
Manager Services
coverage commonly contract with third-party
would amend the IRC to require the fol owing
amend PHSA, with language identical to
entities referred to as pharmacy benefit
entities to report specified drug pricing data to
the House provisions in H.R. 5376
managers (PBMs) to manage the prescription
group health plan sponsors: (1) a health insurance
Sections 27002, 137309, and 30606,
drug benefits offered under a plan, including
issuer offering group health insurance coverage and
respectively, other than the fol owing
developing prescription drug formularies and
(2) an entity providing PBM services on behalf of a
differences.
contracting with networks of pharmacies that
group health plan or a group health insurance
The Senate and House versions differ in
agree to dispense drugs for set reimbursement.
issuer. The provisions would require reports at
the language regarding the “limited form”
On behalf of the health plan or issuer, the PBM
least once every six months for PYs beginning on or reports. In the House versions of the
also negotiates with pharmaceutical
after January 1, 2023, and would require that
provisions, the Secretaries of Labor, HHS,
manufacturers to obtain discounts, rebates, and
certain reports also be submitted to the
and the Treasury would issue rules
other concessions.
Comptrol er General, as specified.
defining a limited form of the report
Group health plans or health insurance issuers
The provisions would require reports to include
required “of” plan sponsors who are “drug
offering group or individual health insurance
specified information, such as co-payment assistance manufacturers, drug wholesalers, or other
coverage are required to report certain
amounts paid or funded by manufacturers; details
direct participants in the drug supply chain,
information on pharmacy benefits and drug costs
on drugs dispensed, such as number of
in order to prevent anti-competitive
to the Secretaries of Labor, HHS, and the
prescriptions fil ed (as specified); wholesale
behavior.” In the Senate versions of this
Treasury. The information includes total
acquisition cost, consumer out-of-pocket spending,
language, the Secretaries would issue rules
spending on prescription drugs; the 50 most
and additional data by drug category and class; total
defining a limited form of the report
costly prescription drugs and the 50 drugs with
gross spending, price reductions, and net spending
required “to be submitted to” such plan
the greatest increase in expenditures; any impact on prescription drugs by the plan; and
sponsors, for the same reasons.
on premiums by rebates, fees, and other
remuneration for third-party referrals. Existing
In addition, Section 26002(c) would
remuneration paid by drug manufacturers to the
Health Insurance Portability and Accountability Act
appropriate $43.75 mil ion for the
plan; and any premium and out-of-pocket cost
of 1996 (P.L. 104-191) and other requirements
Department of Labor for FY2022, for
reductions associated with such rebates, fees, or
would apply to plans’ use and disclosure of the
purposes of carrying out the amendments
other remuneration paid by manufacturers.
reports.
made by the section.
Currently, there are no federal requirements on
The provisions would bar group health plans, group

PBMs to share certain information, such as drug
health insurance issuers, and entities or subsidiaries
pricing data, with group health plan sponsors
providing PBM services on behalf of such plans or
(e.g., employers) with whom they are contracted issuers from entering into drug manufacturer or
to manage prescription drug coverage. There are other specified contracts that would limit the
requirements on PBMs to share such
disclosure of information in a way that would
information, as specified, with QHP issuers with
prevent the making of the required reports. These
whom they are contracted.
provisions would apply for PYs beginning on or
Currently, there are no federal prohibitions on
after January 1, 2023.
PBMs entering into contracts with drug
The Secretaries of Labor, HHS, and the Treasury
manufacturers or other entities in the
would enforce the reporting requirements and the
prescription drug supply chain, nor are there
specified ban on contracting. Reporting entities
prohibitions on PBMs sharing certain information would be subject to a CMP of $10,000 for each day
CRS-20

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
with group health plans or health insurance
they violated the ban or failed to report the
issuers.
required information, or up to $100,000 per item of
false information knowingly provided, in addition to
other penalties prescribed by law. The Secretaries
could waive penalties or extend the compliance
period for entities that are in violation of the
provisions but made a good-faith effort to comply.
The procedures for enforcing CMPs under SSA
Section 1128A would apply to the enforcement of
these CMPs.
Section 30603 also would require the
Comptrol er General to issue a report to Congress
that would include information on pharmacy
network topics as specified, no later than three
years after enactment of this provision.
CRS-21

Providing for
Medicare Part A covers inpatient hospital
Section 139001 would establish a Drug Price
Section 129001 contains most of the
Lower Prices for
services, skil ed nursing care, hospice care, and
Negotiation Program covering selected qualifying
House Drug Price Negotiation Program
Certain High-
some home health services. Part A typically pays
single-source drugs dispensed to certain Medicare
provisions but would make a number of
Priced Single-
providers for drugs as part of a predetermined
enrol ees, including drugs and biological products
changes to the House bil , including in the
Source Drugs
per episode payment, and hospitals can receive
with the highest expenditures in Medicare Parts B
fol owing areas: (1) definition of a
add-on payments for certain new innovator
and D, as well as insulin products. The negotiated
negotiation-eligible drug, (2) criteria for
drugs.
prices would take effect in 2025.
excepted drugs, (3) calculation of an MFP
Medicare Part B covers physician services,
Identification of selected drugs and negotiation and
ceiling price, and (4) certain timelines.
outpatient services, and some home health and
application of drug maximum fair prices (MFPs) for

preventive services. Providers that administer
the drugs would occur annually. In general,
prescription drugs under Part B are paid based
negotiations would take place yearly for newly
on a list price formula defined in statute (the
identified selected drugs. However, an MFP
average sales price [ASP]), plus a specified add-
resulting from a negotiation would apply during
on payment. Part B beneficiaries pay 20%
price applicability periods that would begin with the
coinsurance.
initial price applicability year for that selected
The voluntary Medicare Part D prescription drug drug—the first year for which the negotiated MFP
benefit provides coverage of outpatient
would become effective—and would end with the
prescription drugs through stand-alone
last year during which the drug was a selected drug.
prescription drug plans or Medicare Part C
Drugs included on the list of selected drugs for a
managed care plans with a Part D component
price applicability year would be considered
(Medicare Advantage prescription drug plans, or
selected drugs until the HHS Secretary determined
MA-PDs). The Part D noninterference provision
there was at least one Food and Drug
bars the HHS Secretary from negotiating Part D
Administration (FDA)-approved drug (generic) or
drug prices and from requiring a set formulary
biological product (biosimilar).
or pricing structure. Part D plan sponsors
The provision would require the HHS Secretary
(insurers), working with PBMs, negotiate
and manufacturers to renegotiate the MFP for a
prescription drug price discounts and rebates
selected drug if a specified change in circumstances
with drug manufacturers and dispensing
occurred.
pharmacies. Sponsors must offer enrol ees their
“negotiated price,” as defined in regulations, for
Although qualifying drugs would be eligible for
covered drugs. Under the HHS definition of
negotiation at 7 and 11 years, the HHS Secretary
negotiated prices, sponsors have latitude to
could not apply an MFP until 9 years had elapsed
decide whether to pass on rebates and certain
since FDA approval (for drugs) or 13 years had
other price concessions at the pharmacy at the
elapsed since licensure (for biological products).
point of sale or to use the rebates to reduce
There would be a ceiling on the MFP, based on a
overall plan premiums.
specified applicable percentage of the nonfederal

average manufacturer price (AMP) for a selected
drug. There also would be a temporary floor for
MFP for drugs manufactured by small biotech firms.
CRS-22

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
MFPs would be adjusted annually to account for
inflation.
Manufacturers would be subject to an excise tax for
noncompliance, including failure to enter into an
agreement to negotiate an MFP.

Negotiation-Eligible Drugs
Negotiation-Eligible Drugs
Under Section 139001, for each initial price
Section 129001 would not change the
applicability year, the HHS Secretary would create a number of drugs selected as negotiation
list of negotiation-eligible drugs ranked in order of
eligible but would change the criteria used
total expenditures under Medicare Parts B and D
to select the highest spending drugs in Part
for the most recent 12-month period prior to the
D. It would base selection on a broader
selected drug publication date for which
definition of Part D total gross covered
expenditure data were available. The combined list
prescription drug costs, as defined in SSA
would include the 50 qualifying single-source drugs
1860D–15(b)(3)), rather than Part D total
with the highest total expenditures under Medicare
expenditures, as in the House provision.
Part D and the 50 qualifying single-source drugs
(The SSA 1860D–15(b)(3) definition of
with the highest total expenditures under Medicare
total gross prescription drug costs is yearly
Part B (with the exception of initial price
costs for an enrol ee incurred under a Part
applicability years 2025 and 2026, when only
D plan, not including administrative costs
Medicare Part D drugs would be on the list).
but including costs directly related to the
Part D total expenditures would be defined as
dispensing of covered Part D drugs and
“ingredient costs, dispensing fees, sales tax, and if
costs relating to the deductible. Costs
applicable, vaccine administration fees.”
count whether paid by the individual or
paid under the plan and regardless of
From the list of selected drugs, the HHS Secretary
whether the plan coverage exceeds basic
would select no more than 10 non-insulin,
Part D drug coverage.)
negotiation-eligible drugs for PY2025. The number
of non-insulin, negotiation-eligible single-source
drugs would increase in subsequent years. For 2026
and 2027, the HHS Secretary would select and
publish a list of not more than 15 non-insulin
qualifying single-source drugs. For 2028 and
subsequent years, the HHS Secretary would select
not more than 20 non-insulin qualifying single-
source drugs. All insulin products that were
considered qualifying single-source drugs would be
considered negotiation-eligible drugs.
CRS-23

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language

Exempt Low-Spend Drugs
Exempt Low-Spend Drugs
Section 139001 would exempt certain drugs from
Under Section 129001, the $200 mil ion
the Drug Price Negotiation Program, including
cap for 2021 would be increased in
certain orphan drugs and low-spend Medicare drugs,
subsequent years by the annual increase in
defined as drugs or biological products (other than
the CPI-U for the 12-month period ending
insulin products) that had total Medicare Parts B
with September of a previous year.
and D expenditures during the most recent period
The section would exempt plasma-derived
for which data were available for at least 12 months
products from the definition of negotiation-
prior to the selected drug publication date of less
eligible drugs.
than $200 mil ion in 2021. For subsequent years,
the expenditure cap would be $200 mil ion,

increased by the annual increase in Consumer Price
Index For All Urban Consumers (CPI-U) as of
December of the previous year.
Termination of Selected Drug Status
Termination of Selected Drug Status
Under Section 139001, negotiation-eligible drugs
Under Section 129001, a drug would
included on the published list of selected drugs for a cease being a selected drug in the first
price applicability year would be considered
year that begins at least 9 months after the
selected drugs for that year. They would continue
date on which the HHS Secretary
to be considered selected drugs for each
determines there is a generic or biosimilar
subsequent plan year until the first plan year
drug for the selected drug on the market.
beginning after the date the HHS Secretary
determined there was at least one drug (generic) or
biological product (biosimilar) that was FDA-
approved or licensed using the selected drug as the
list drug or reference product and was marketed
pursuant to the approval or licensure.
Judicial Review
Judicial Review
Section 139001 would deem certain actions in
Section 129001 also would bar
regard to the Drug Price Negotiation Program as
administrative and judicial review of the
not subject to administrative or judicial review,
determination of qualifying single-source
including the selection of drugs for publication as
drugs.
selected drugs, the determination of whether a drug
is a negotiation-eligible drug, the determination of
the MFP for a selected drug, and the determination
of units of a drug or biological.
CRS-24

MFP Ceiling
MFP Ceiling
Section 139001 would make negotiated MFPs
Section 129001 would differ from the
subject to price ceilings for the first year of a price
House bil because it would set the MFP
applicability period. The MFP ceilings would be set
ceiling by (1) basing the ceiling price on the
as a percentage of an inflation-adjusted nonfederal
lower of a modified nonfederal inflation-
AMP for each drug and would vary depending on
adjusted AMP or changes in Part D and
drug type.
Part B prices and (2) applying a ceiling to
Under the section, the MFP ceiling would be
low-cost insulin. It also would differ from
calculated as fol ows.
House-provision definitions relating to the
different MFP ceilings that are based on
For a drug with an initial price applicability
the time a drug has been on the market.
year of 2025: The MFP ceiling would be based on
the average of the nonfederal AMP for the selected
For a drug with an initial price
drug for the first three calendar quarters of 2021,
applicability year of 2025: The MFP
increased by the percentage increase in the CPI-U
ceiling calculation would be based on the
from September 2021 to the year prior to the
average of the nonfederal AMP for the
drug’s publication as a selected drug. If a selected
selected drug for the first three calendar
drug did not have a nonfederal AMP for any of the
quarters of 2021, increased by the
first three calendar quarters of 2021, then the
percentage increase in the CPI-U from
applicable measure would be the nonfederal AMP
September 2021 (or December of such first
for the first ful year fol owing the drug’s market
full year following the market entry), as
entry, increased by the percentage increase in the
applicable, to September of the year prior
CPI-U for the first ful year fol owing market entry.
to the drug’s publication as a selected
drug. If no nonfederal AMP were available
For initial price applicability in 2026 and
for such drug for any of such first three
subsequent years: The MFP ceiling would be
calendar quarters of 2021, then for the
based on the lower of
first ful year fol owing the drug’s market

the average of the nonfederal AMP for a
entry.
selected drug for the first three calendar
The December and September timeline
quarters of 2021 (or, if no nonfederal AMP
changes also would apply to the MFP
were available for such drug for any of the first
ceiling for 2026 and subsequent years, as
three calendar quarters of 2021, then for the
well as to an MFP price floor for small
first ful year fol owing the drug’s market
biotech firms.
entry), increased by the percentage increase in
the CPI-U from September 2021 (or the first
For a drug other than a low-cost insulin
ful year fol owing market entry), as applicable,
product, with respect to the first year of
to the year prior to the selected drug
the price applicability period, the MFP
publication date for the applicability year; or
ceiling could not exceed the lower of the
annual AMP formula or

the nonfederal AMP for the selected drug for
the year prior to the drug’s publication as a

For a covered Part D drug, the
average net price (defined as the
CRS-25

selected drug, with respect to an initial price
negotiated price under Part D plans
applicability year.
net of all price concessions received
Section 139001 would set different MFP ceilings
by such plans or PBMs on behalf of
for drugs based on how long the drugs had been on
such plans) for the drug under part D
the market.
for the most recent year for which
data are available; and
The allowable ceiling for a short-monopoly drug (i.e.,
any drug that was not a post-exclusivity or long-

For a Part B drug, the ASP for the
monopoly drug, as defined in the bil ) would be 75%
year prior to the year of the selected
of the inflation-adjusted nonfederal AMP.
drug publication date with respect to
the initial price applicability year for
The ceiling for a post-exclusivity drug would be 65%
the drug or biological.
of the inflation-adjusted nonfederal AMP. A selected
drug would be considered a post-exclusivity drug if
MFP Ceiling for Insulin
it were a drug or biological product that had been
Section 129001 would set an MFP ceiling
FDA-approved or licensed for at least 12 years but
for certain low-cost insulin products.
less than 16 years prior to the initial price-
Under the provision, the MFP for a
applicability year.
selected insulin product for the first year
The MFP ceiling for a long-monopoly drug would be
of its price applicability period could not
40%. Long-monopoly drugs would be defined as
exceed the average of the nonfederal AMP
selected drugs or biological products that had been
for the drug for the first three calendar
FDA-approved or licensed for at least 16 years.
quarters of 2021 (or, if there were not an
available nonfederal average AMP for any
of such first three calendar quarters of
2021, for the first ful year fol owing the
market entry for such drug), increased by
the percentage increase in the CPI-U from
September 2021 (or December of such
first ful year fol owing the market entry),
as applicable, to the year prior to the
selected drug publication date with respect
to such initial price applicability year.
An insulin product subject to negotiation
would be considered a low-cost product if
its nonfederal AMP did not exceed 110%
of the sum of (1) the costs and expenses
per unit of the drug and (2) the sales,
general, and administration expenses per
unit of the drug.
Section 129001 refers to short-
monopoly drugs and vaccines.
CRS-26

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
A drug defined as a post-exclusivity drug in
Section 139001 of the House bil would be
defined as an extended monopoly drug in
Section 12900l. A drug would be
considered an extended monopoly drug if
it were a drug or biological product that,
as of the selected drug publication date, had
been FDA-approved or licensed for at
least 12 years but less than 16 years prior
to the initial price applicability year.
Section 129001 would change the
House-passed legislation’s definition of a
long-monopoly drug to specify that long-
monopoly drugs would be selected drugs
for which, as of the selected drug publication
date with respect to an initial price
applicability year, at least 16 years had
elapsed since approval or licensure.
MFP Annual Inflation Update
MFP Annual Inflation Update
Section 139001 would provide an annual inflation-
Section 129001 would provide an annual
based price increase for drugs with a negotiated
inflation-based price update based on the
MFP. For a year after the first initial price
percentage increase in the CPI-U, as of the
applicability year, the updated MFP for selected
12-month period ending with September of
drugs would be the MFP for the selected drug for
the previous year.
the previous year, increased by the annual
percentage increase in the CPI-U, as of September
of the previous year.
MFP Factors in Negotiation
MFP Factors in Negotiation
Section 139001 states that for purposes of
Section 129001 would expand criteria
negotiating the MFP of a selected drug with the
for purposes of negotiating an MFP so that
manufacturer, the HHS Secretary would have to
the HHS Secretary would consider certain
consider a list of factors.
factors about specific drugs and therapeutic
alternatives of such drugs.
CRS-27

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language

340B MFP Prohibition
Section 129001 would add a new
provision to prohibit 340B-covered
entities from purchasing covered
outpatient drugs at the negotiated MFP if
the drugs were subject to a Medicaid
rebate. (Under the 340B program,
manufacturers participating in Medicaid
provide outpatient drugs to covered
entities at reduced prices. Covered
entities include certain health centers,
Ryan White clinics and state AIDS Drug
Assistance programs, children’s hospitals,
Medicare/Medicaid disproportionate share
hospitals [DSHs], and other safety net
providers.)
CRS-28

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language

Part D Noninterference
Part D Noninterference
Under current law, the noninterference provision at Section 129001 differs from the House
SSA §1860D-11(i) states,
bil because it would eliminate the period
“(i) Noninterference.—In order to promote
at the end of (2) of the noninterference
competition under this part and in carrying out provision and adding “except as provided
this part, the Secretary—
under section 1860D–4(b)(3)(l),” which is
a new section created by this provision
(1) may not interfere with the negotiations
pertaining to the required inclusion of Part
between drug manufacturers and pharmacies
D drugs as selected drugs.
and prescription drug plan sponsors; and
(2) may not require a particular formulary or
institute a price structure for the
reimbursement of covered part D drugs.”
Section 139001 would amend the noninterference
provision by striking in (2) “or institute a price
structure for the reimbursement of covered part D
drugs” and instead inserting “for covered part D
drugs.” The section also would add a new (3): “may
not institute a price structure for the
reimbursement of covered part D drugs, except as
provided under part E of title XI.” (Part E is the
new section created by this provision.)
Part D Formulary Placement
Part D Formulary Placement
Section 139001 contains a provision stating that
Section 129001 differs from the House
covered Part D drugs that are selected drugs with
bil because it would alter the formulary
MFPs are to be carried on Part D plan formularies.
requirement to clarify that a Part D plan
sponsor could remove a selected drug
from a plan formulary if an equivalent
generic came to the market.
CRS-29

Selected Drug
Chapter 32 of the IRC imposes excise taxes on
Section 139002 would amend Chapter 32 of the
Section 129002 is identical to the House
Manufacturer
manufacturers of automobiles and related items,
IRC to add new Section 4192, which would impose
bil except for a technical correction to a
Excise Tax
coal, certain vaccines, recreational equipment,
an excise tax on selected drug sales by
citation for the definition of a selected
Imposed During
and medical devices. The taxable event is
manufacturers, producers, or importers during the
drug.
Noncompliance
typically the sale of a covered item. Depending
fol owing noncompliance periods with the Drug
Periods
upon the provision, the amount of the tax may
Price Negotiation Program in Section 139001:
be a fixed amount per sale or per quantity of the

The period beginning on the March 1
item sold, or a percentage of the price for which
immediately fol owing the selected drug
the item is sold. When an excise tax is based on
publication date and ending on the first date
the sale price, it may be charged separately by
during which the selected drug manufacturer
the seller; otherwise, the tax is assumed to be
enters into an agreement with the HHS
included in the total amount paid by the
Secretary to negotiate a drug’s MFP.
purchaser.

The period beginning on the November 2
Certain transactions may be exempted from
immediately fol owing the March 1 referenced
these excise taxes. For example, excise taxes
in the first noncompliance period above and
under Chapter 32 are not general y applied to
ending on the first date during which the
items purchased for use by the purchaser in
manufacturer and the HHS Secretary agree on
further manufacturing or purchased for export.
an MFP.

In the case of a selected drug for which the
HHS Secretary had specified a renegotiation
period under an agreement, the period
beginning on the first date after the last date of
the renegotiation period and ending on the
first date during which the manufacturer
agreed to a renegotiated MFP.

With respect to information that was required
to be submitted to the HHS Secretary, the
period beginning on the date on which the
HHS Secretary certified the required
information was overdue and ending when the
information was submitted.
The amount of the excise tax imposed on the sale
of a selected drug would be a percentage of the
sum of the sales price and the tax imposed under
this section (this differs from some other excise
taxes in which the amount of the tax is a
percentage of the sales price alone).
The House Budget Committee report
accompanying H.R. 5376 provides the fol owing
CRS-30

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
il ustration of how this new excise would operate:
“Assume that, prior to imposition of the excise tax,
Manufacturer A charged $100 for drug A. If, after
imposition of the excise tax, Manufacturer A
charges $100 and does not separately state a tax,
the price is deemed to be $35, and Manufacturer A
owes $65 in tax. Alternatively, manufacturer A
could separately state a price of $100 and a tax of
$186, in which case it would owe $186 in tax.” H.
Rept. 117-130 at 441 (internal citations omitted).
The applicable percentage for the excise tax would
increase the longer noncompliance continues, with
an applicable percentage of 65% during the first 90
days, 75% during the 91st day through the 180th day,
85% during the 181st day through the 270th day, and
95% for sales subsequent to the 270th day of the
noncompliance period. For sales that were timed to
avoid the excise tax, the Secretary of the Treasury
would treat the sale as occurring during a day in a
noncompliance period.
Manufacturers would be prohibited from deducting
excise tax payments from their federal income
taxes.
Funding
Not applicable.
Section 139003 would appropriate for FY2022, to Section 129003 would provide to CMS
remain available until expended, $300 mil ion,
$3 bil ion for FY2022, to remain available
available each FY between FY2022 and FY2031 to
until expended, to carry out Sections
carry out Sections 139001 and 139002.
129001 and 129002.
CRS-31

Medicare Part B
Medicare Part B covers selected outpatient
Section 139101 would require drug
Section 129101 is similar to the House
Rebate by
drugs and biologic products (hereinafter for
manufacturers, beginning July 1, 2023, to pay a
provision but includes the fol owing
Manufacturers
Section 139101, drugs), which generally are
quarterly rebate to Medicare when the price of
differences.
administered by health professionals. Biological
most single-source Medicare Part B drugs (rebatable
Section 129101 would require drug
products are medical products derived from
drugs) exceeded the product’s quarterly inflation-
manufacturers to begin paying a quarterly
living organisms, whereas conventional drugs are
adjusted price. Drugs with annual average total Part
inflation rebate on Medicare Part B
manufactured from chemicals.
B allowed charges per individual of less than $100
rebateable drugs on January 1, 2023,
Health providers purchase Part B drugs and bil
and Part B-covered vaccines would not be
rather than July 1, 2023. The Section
Medicare for the cost of the drug and the
considered rebateable drugs.
129101 benchmark period CPI-U would
administration of the product, although payment
The inflation rebate would be waived for drugs that
be January 2021 rather than September
for some Part B drugs can be included in the
were listed on the Federal Food, Drug, and
2021. Section 129101 would change the
payment for a procedure or treatment.
Cosmetic Act (P.L. 75-717) shortage list, as well as
definition for a subsequently approved drug
For most Part B services, after meeting an annual for biosimilar products if the HHS Secretary
to apply to a Part B rebatable drug first
deductible, Medicare beneficiaries are
determines there were severe supply chain
approved or licensed by the FDA after
responsible for coinsurance of 20% of the cost of disruptions. There would be special provisions for
December 1, 2020 (in contrast to March
the item or service. For Part B drugs, the 20%
drugs approved or licensed by the FDA after March
1, 2021, in the House version).
coinsurance is based on a drug’s ASP plus a 6%
1, 2021.
Section 129101 would add a transition
add-on payment.
Drug manufacturers’ Part B rebateable drug
provision allowing the HHS Secretary to
Drug manufacturers are not required to pay
quarterly inflation rebate would be the difference
delay the timeframe for providing drug
rebates to Medicare as a condition for having
between the Part B drug’s price and the drug’s
manufacturers with rebate information for
their drugs covered under Part B.
inflation-adjusted price. The rebate would apply to
calendar quarters beginning in 2023 and
all units of the drug sold, except Medicaid sales, for
2024 until not later than September 30,
each quarter. The Part B rebateable drug rebate
2025.
paid by drug manufacturers would be deposited into Section 129101 would authorize CMS to
the Medicare Supplementary Insurance Trust Fund.
receive the same appropriation as the
The Part B rebateable drug inflation-adjusted price
House version to carry out this section,
would be based on the greater of either the
but the FY2022 appropriation would be
benchmark period CPI-U (September 2021) or the
for $80 mil ion, with $12.5 mil ion
CPI-U for the first month of the calendar quarter
designated for FY2022 and $7.5 mil ion for
that is two calendar quarters prior to the rebate
each of FY2023-FY2031.
period calendar quarter.
Medicare beneficiary coinsurance for Part B
rebatable drugs would be 20% of the inflation-
adjusted Part B drug payment amount. Part B
inflation determinations made by the HHS Secretary
would not be subject to administrative and judicial
review.
The HHS Secretary would be required by the
provision to provide information to drug
CRS-32

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
manufacturers within six months after the end of
the calendar quarter; this information would include
the amount of the Part B inflation rebate owed for
the period. Drug manufacturers would have 30 days
after receiving the information to pay the inflation
rebate. If drug manufacturers failed to pay the Part
B inflation rebate on time, they would be subject to
a CMP of at least 125% of the rebate amount for
that calendar quarter, in addition to other CMP
procedural enforcement provisions.
CMS would receive an appropriation that would
remain available until expended of $12.5 mil ion for
FY2022 and $7.5 mil ion for each of FY2023-
FY2031.
CRS-33

Medicare Part D
No current provision. Manufacturers that
Section 139102 would create a mandatory rebate
Section 129102 would create a
Rebate by
choose to participate in Part D must pay a 70%
program, effective in 2023, for manufacturers of
mandatory rebate program fol owing most
Manufacturers
discount on the negotiated price of certain drugs most Medicare Part D-covered drugs that had price
of the provisions in the House bil .
sold to enrol ees in the benefit coverage gap, or
increases above the rate of consumer inflation (CPI-
However, the Senate language has
doughnut hole. However, discounts at the point
U) since September 2021.
numerous differences from the House bil ,
of sale are different than after-sale rebates.
HHS would calculate an annual price for Part D-
including changes in the timeframes used
Further, the current manufacturer discounts are
covered drugs, based on the AMP, which reflects
to implement the provision and to
not tied to inflation.
drug sales to retail community pharmacies, directly
calculate and report rebates.
or via wholesalers.
In general, the House bil would base
The inflation-adjusted payment amount would be
rebate calculation and payment on annual
defined as the AMP for each dosage form and
changes in inflation and prices. The Senate
strength of the drug in the payment amount
language instead would use defined time
benchmark year (the year ending in the month
periods to calculate inflation and prices.
immediately prior to October 1, 2021), increased
Section 129102 would create an
by the percentage by which the applicable year CPI-
applicable period, which would be the 12-
U (CPI-U in January of an applicable year) exceeded
month period beginning with July 1 of a
the benchmark period CPI-U (CPI-U for the month
year (beginning with July 1, 2022).
immediately prior to October 2021).
Section 129102 would create a payment
Section 139102 would define an applicable year as
benchmark period that would begin on
a calendar year beginning with 2023.
January 1, 2021, and would end in the
If the price of a Part D-covered drug grew faster
month immediately prior to October 1,
than allowable inflation for a year, the manufacturer
2021.
would pay HHS a rebate amount equal to the
Section 129102 would define a
excess price times the total bil ing units of the drug
benchmark period CPI–U, which would be
to all payers (excluding units with rebates paid
the CPI-U for January 2021.
under Medicaid or Medicare Part B).
Applicable period CPI-U would be defined
No later than nine months after the end of an
as the CPI-U for the first month of such an
applicable year, the HHS Secretary would be
applicable period.
required to report the fol owing to the
In Section 129102, no later than nine
manufacturer of a Part D rebatable drug: (1)
months after the end of an applicable
information on the amount, if any, of the excess
period, the HHS Secretary would be
annual manufacturer price increase for each dosage
required to report to the manufacturer (1)
form and strength for such drug and such year and
information on the amount, if any, of the
(2) the rebate amount for each dosage form and
excess manufacturer price increase for
strength of such drug for the year.
each dosage form and strength for such
Should a manufacturer not pay the mandated
drug and such period and (2) the rebate
rebate, the manufacturer would be subject to a
amount for each dosage form and strength
CMP of at least 125% of the rebate amount for such of such drug for the period.
year.
CRS-34

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
There would be some exceptions to the Part D
Section 129102 would expand the list of
rebate requirements, including for a Part D drug
possible exemptions from the rebate
that was on an FDA shortage list or, in the case of a requirement compared with the House
generic drug, when the Secretary determined there
bil . The section would allow an exemption
were severe supply chain disruptions.
for generics and biosimilars that met the
The bil would appropriate to CMS $12.5 mil ion for definition of Part D rebatable drugs, in
FY2022 and $7.5 mil ion for each of FY2023-
situations where the HHS Secretary
FY2031, to remain available until expended, to carry determined there were severe supply
out the provisions of the section.
chain disruptions. The section also would
allow an additional exemption for a

generic in a case where the HHS Secretary
determined that access to the drug could
be severely reduced if a rebate were
imposed. The HHS Secretary would be
required to review the possible exemption
annually.
Section 129102 includes definitions of
drugs or biologicals that could be subject
to a rebate. In general, the definitions refer
to new chemical drugs approved under
Federal Food, Drug, and Cosmetic Act
(P.L. 75-717) 505(c); generic drugs that
lack competition (i.e., the brand-name
drug that the generic is a copy of is not
being marketed, and there are no other
generic versions being marketed) and that
are not covered by the specified 180-day
generic drug-exclusivity periods; and
biologic drugs licensed under Section 351
of the PHSA.
The Senate bil would provide to CMS
$80 mil ion for FY2022, including
$12.5 mil ion for FY2022 and $7.5 mil ion
for each of FY2023-FY2031, to carry out
provisions of the section. The funds would
remain available until expended.

CRS-35

Medicare Part D
Medicare Part D provides a voluntary, outpatient Section 139201 would change the Part D
Section 129201 largely tracks the House
Benefit Redesign
prescription drug benefit for Medicare
standard benefit, beginning in 2024, by
bil but differs from H.R. 5376 throughout.
beneficiaries and is the primary source of drug

Capping annual enrol ee out-of-pocket
Supplemental Coverage
coverage for dual-eligible individuals (low-income
spending at the catastrophic threshold, which
subsidy, or LIS) covered by both Medicare and
Section 129201 adds language that
would be set at $2,000 in out-of-pocket
the state-federal Medicaid program. Part D
would allow enrol ees to count
spending in 2024 and adjusted in subsequent
coverage is provided by private insurers, or plan
supplemental coverage through a group
years based on Part D drug inflation (current
sponsors. At a minimum, Part D sponsors must
health plan or certain other third-party
law formula).
offer plans with standard benefits, as defined in
payment arrangements as their own out-
law. Plan sponsors also may offer alternative or

Reducing the 80% reinsurance subsidy to Part
of-pocket spending.
enhanced coverage that is at least actuarially
D sponsors to the sum of two amounts: an
Reinsurance
equivalent to a standard plan.
amount equal to 20% of the cost of applicable
Section 129201 refines the House
drugs (biologics and brand-name drugs) above
Under the Part D standard benefit, an enrol ee
language on reinsurance to specify that
the catastrophic threshold, plus an amount
pays a deductible. After the deductible has been
reinsurance payments would apply to
equal to 40% of the cost of non-applicable
met, the enrol ee is responsible for 25% of the
covered Part D drug costs, not just Part D
drugs (generics) above the catastrophic
cost of prescription drugs up to the initial
drug costs.
threshold.
coverage limit. After the initial coverage
Premium Stabilization
threshold has been reached, a beneficiary enters

Reducing cost sharing for non-LIS enrol ees to
Section 129201 would add a premium
the coverage gap, or doughnut hole.
23% coinsurance from the current 25%. (There stabilization program for 2023-2027. (The
Manufacturers that choose to sell their drugs
would be no initial coverage limit or coverage
premium stabilization program would be in
through the Part D program are required to
gap in the redesigned benefit. LIS beneficiaries
addition to provisions of the House bil
participate in the coverage gap discount
would continue to have low, set cost sharing.)
that would change the formula for
program, which provides a 70% discount for

Reducing the Part D base premium to 23.5% of calculating the base premium from the
brand-name, biologic, and biosimilar drugs
the average bid of plan sponsors, down from
current 25.5% of the average bid to 23.5%
purchased by non-LIS enrol ees in the doughnut
the current 25.5% level, starting in 2024.
of the average bid starting in 2024.)
hole. Enrol ees exit the doughnut hole if they

have sufficient spending to reach the

Raising the Medicare subsidy to plans for
Under the premium stabilization program,
standard coverage to 76.5% of the average of
catastrophic threshold. Enrol ees above the
the base beneficiary premium for 2023-
plan bids, an increase from the current 74.5%.
catastrophic threshold have a maximum 5%
2025 would be equal to the lesser of (1)
coinsurance, and CMS provides sponsors with

Creating a new manufacturer discount
the base premium for the previous year
80% reinsurance payments for these high-cost
program, effective in PY2024. The existing
(i.e., 2022 for 2023), increased by 4%, or
enrol ees.
coverage gap discount program would sunset
(2) the base beneficiary premium for the
applicable year (in this case, 2023) as
The dol ar levels of the deductible, initial
after 2023.
computed under the underlying statutory
coverage, and catastrophic thresholds are
In the new program, manufacturers would provide a language that otherwise would have
adjusted annually for the standard benefit based
10% discount from a Part D plan’s negotiated price
applied.
on changes in average per capita spending for
for applicable drugs purchased by enrol ees who
covered Part D drugs during the 12-month
had exceeded the annual Part D deductible but had
For 2026, the base premium would be
period ending in July of the previous year.
not reached the catastrophic threshold.
equal to the lesser of (1) the base
premium computed for 2025 increased by
In addition, Part D enrol ees pay monthly
Manufacturers would provide a 20% discount off
4% plus 25% of the difference between (a)
premiums, which are based on a rate equal to
the negotiated price on applicable drugs purchased
CRS-36

25.5% of the annual nationwide average of plan
by enrol ees who had reached the catastrophic
the base premium for 2025 (as increased
bids for standard benefits; however, actual
threshold. The discounted prices would be
by 4%) and (b) the base premium
premiums vary widely by the plan selected.
provided to enrol ees at the pharmacy or through
calculated under statute that otherwise
mail order at the point of sale, and enrol ees would
would have applied for 2026; or (2) the
not be allowed to count the manufacturer discount
base premium calculated for 2026 under
as their own out-of-pocket spending. There would
the statutory formula (23.5% of the
be special provisions for smaller manufacturers and
average bid) that otherwise would have
for drugs primarily sold to LIS enrol ees.
applied.
The legislation would appropriate to CMS
For 2027, the base premium would be
$44 mil ion for FY2022, $38 mil ion for FY2023, and equal to the lesser of (1) the base
$32 mil ion for each of FY2024-FY2031 to carry out premium computed for 2026 increased by
the provisions on this section.
4% plus 50% of the difference between (a)

the base premium for 2026 (as increased
by 4%) and (b) the base premium that
would have applied for 2027 or (2) the
base beneficiary premium calculated for
2027 under the permanent statutory
formula (23.5% of the average bid) that
otherwise would have applied.
For 2028 and fol owing years, the base
premium calculation would revert back to
the underlying formula (23.5% of the
average bid).
Manufacturer Discount Program
Section 129201 would specify that a
manufacturer would have to sign an
agreement by March 1, 2023, to
participate in 2024. The Senate provision
does not include language in the House bil
that specified the HHS Secretary would
have to develop a model agreement by
January 1, 2023, and the manufacturer
would have to sign 30 days after the model
agreement had been established. The
Senate provision also would specify that a
manufacturer discount agreement would
take effect at the start of a calendar
quarter or another date specified by the
HHS Secretary.
CRS-37

Section 129201 does not include
language in the House bil requiring the
HHS Secretary to enter into third-party
contracts to administer the manufacturer
discount program. The House bil , among
other things, would require the third
parties to receive and transmit
information; receive, distribute, or
facilitate the distribution of funds of
manufacturers to appropriate individuals
or entities to meet manufacturers’
obligations under agreements under this
section; and provide adequate and timely
information to manufacturers, as necessary
for the manufacturers to fulfil their
obligations.
Section 129201 would change the
definition of Part D total expenditures to
total gross covered prescription drug
costs as defined in SSA 1860D–15(b)(3).
Section 129201 would not include
House language requiring Part D plan
sponsors to count the value of
manufacturer discounts in their annual
plan bids. Instead, the bil would amend
SSA 1860D–16(b)(1), governing payments
from the managing trustee into the Federal
Supplementary Medical Insurance Trust
Fund, to include payments pertaining to
the Senate bil ’s new Section 1860D–14D.
Under 1860D–14D, in cases where Part D
applicable enrol ees who had not reached
the catastrophic threshold were
prescribed brand-name or biologic drugs
that would have been applicable drugs, had
they not been covered by an HHS
negotiated price agreement under the new
Price Negotiation Program in Section
129001, the HHS Secretary would provide
a 10% discount to a Part D plan.
CRS-38

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
The bil would appropriate $341 mil ion
for FY2022 to carry out the provisions,
which would remain available until
expended. The total would include
$47 mil ion and $38 mil ion in FY2022 and
FY2023, respectively, and $32 mil ion in
each of FY2024-FY2031.
Maximum
No provision.
Section 139202 would amend Part D prescription
Section 129202 largely tracks the House
Monthly Cap on
cost-sharing requirements to allow any enrol ee in a language but would increase the penalty
Cost-Sharing
Part D plan, including an LIS enrol ee, to elect to
for enrol ees who fail to pay the amount
Payments Under
make prescription cost-sharing payments in
bil ed.
Prescription Drug
monthly, capped installments up to the annual out-
Under the Senate provision, if an enrol ee
Plans and MA-PD
of-pocket threshold, beginning in 2025. An enrol ee
failed to pay the amount bil ed for a
Plans
could opt for capped cost sharing at any time prior
month, the enrol ee would lose the right
to or during a plan year.
to participate in the capped option and
Enrol ees who did not make required monthly
would be required to pay the remaining
payments would lose the right to participate in the
cost sharing. In addition, the Part D
capped payment option and would have to pay the
sponsor would be allowed to preclude the
cost sharing otherwise applicable for any Part D
enrol ee from making an election for
drug up to the annual out-of-pocket threshold.
capped cost sharing in a subsequent year.
The section would appropriate $1 mil ion for each
The section would appropriate $10 mil ion
of FY2022-FY2031 to carry out the provisions.
for each of FY2022-FY2031 to carry out
the provisions.
CRS-39

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Prohibiting
The federal anti-kickback statute makes it a
Section 139301 would bar the HHS Secretary,
Section 129301 is identical to the House
Implementation of felony for a person to knowingly and wil ful y
beginning on January 1, 2026, from implementing,
version.
Rule Relating to
offer, pay, solicit, or receive anything of value in
administering, or enforcing the final anti-kickback
Eliminating the
return for a referral or to induce generation of
rebate rule published by the HHS OIG in
Anti-Kickback
business reimbursable under a federal health
November 2020.
Statute Safe
care program. There are certain statutory
Harbor
exceptions to the anti-kickback statute. In
Protection for
addition, the HHS Office of Inspector General
Prescription Drug
(OIG) has promulgated regulations that contain
Rebates
several safe harbors to prevent common business
arrangements from being considered kickbacks.
In November 2020, the HHS OIG published a
final rule that would alter an anti-kickback
regulatory safe harbor to restrict the use of
manufacturer drug rebates to Part D plans.
Implementation of the rule was delayed until
2026 as part of the Infrastructure Investment
and Jobs Act (P.L. 117-158).
Appropriate Cost
Cost sharing for insulin varies among Part D
Section 139401 would cap insulin cost sharing for
Section 129401 would alter the formula
Sharing for
plans and according to the specific brand of
Part D enrol ees. Starting with 2023, Part D
for setting the insulin co-payment. The
Certain Insulin
insulin prescribed to an enrol ee. Beginning with
deductibles would no longer apply to insulin
provision would set the applicable co-
Products Under
PY2021, CMS offered a pilot program (for non-
products. During PY2023, the provision would
payment amount at $35 for PY2023 and
Medicare Part D
LIS beneficiaries) that reduced cost sharing for
require a Part D plan sponsor to provide insulin at a PY2024.
insulin. Under the pilot, participating Part D plan
co-payment of $35, (referred to as the applicable co-
Starting in 2025, the co-payment amount
sponsors could charge no more than a $35 co-
payment). The applicable co-payment would apply
would be the lesser of (1) $35 or (2) an
payment for a 30-day supply of insulin from the
regardless of whether an enrol ee had reached the
amount equal to 25% of the negotiated
plan deductible through the coverage gap.
initial coverage limit or the out-of-pocket threshold. price of the covered insulin product net of
For PY2024 and subsequent PYs, the provision
all price concessions received or expected
would require Part D plans to provide coverage for
to be received by the plan or a PBM on
insulin products at the applicable co-payment
behalf of the plan for such product.
amount up to the annual catastrophic threshold.
The maximum $35 co-payment would apply to both The language would provide that the co-
LIS and non-LIS enrol ees.
payment could not exceed the co-payment
level set in the bil .
The section would appropriate $12.5 mil ion for
FY2022 and $7.5 mil ion for each of FY2023-
The section would appropriate
FY2031 to carry out the provisions of this section.
$1.5 mil ion for FY2022 to carry out the
provisions of this section.
CRS-40

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Coverage of
The Advisory Committee on Immunization
Section 139402 would specify that, beginning in
Section 129402 largely tracks the House
Adult Vaccines
Practices (ACIP) provides guidance to HHS and
2024, Part D plans could no longer set a deductible,
bil , with some technical differences. It
Recommended by the Centers for Disease Control on the use of
coinsurance, or other cost-sharing requirement for
would give the HHS Secretary authority to
the Advisory
vaccines, including recommending immunization
adult vaccinations recommended by the ACIP.
implement the provision by program
Committee on
schedules for the U.S. population, with certain

instruction and other forms of program
Immunization
vaccine dosages based on age.
guidance (rather than by program
Practices Under
Medicare coverage for vaccines is divided
instruction or otherwise).
Medicare Part D
between Part B and Part D. Part B covers
vaccines for influenza, pneumonia, Hepatitis B,
beneficiaries at increased risk, and COVID-19.
Part B also covers vaccines administered directly
in relation to treatment of an injury or direct
exposure to a disease or condition, such as
tetanus shots.
Medicare Part D covers all commercially
available vaccines, except for vaccines covered
under Part B, or in cases where the vaccine
manufacturer has chosen not to participate in
the Part D coverage gap discount program. For
example, the shingles vaccine, which the ACIP
recommends for adults aged 50 and older, is
covered under Part D.
Medicare Part B beneficiaries have no cost
sharing (co-payment and annual deductible) for
covered vaccines, except when the vaccine is
administered for the treatment of an injury or
direct exposure to a disease or condition, in
which case beneficiaries would be responsible
for 20% of the Medicare-approved amount for
the vaccine and its administration. By
comparison, Medicare Part D enrol ees may face
substantial cost sharing for vaccines, especial y if
beneficiaries are in the deductible phase of the
benefit or if a vaccine has been placed on a
formulary tier with high cost sharing.
CRS-41

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Payment for
Biological products are medical products derived Section 139403 would establish an initial period
Section 129403 is identical to the House
Biosimilar
from living organisms, whereas conventional
payment rate for Medicare Part B biosimilar
provision.
Biological
drugs are manufactured from chemicals.
products furnished on or after July 1, 2023. The
Products During
Medicare reimburses Part B providers and
biosimilar payment rate during the statutory initial
Initial Period
suppliers for prescription drugs and biologicals
period would be the lesser of the fol owing: (1) the
after the provider has purchased the drug or
biosimilar product’s wholesale acquisition cost plus
biological product and administered it to a
a 3% add-on payment or (2) 100% of the reference
patient.
biological product’s ASP plus a 6% add-on payment
based on the reference biological product’s ASP.
Medicare generally reimburses providers and
suppliers for Part B drugs and biologicals at the
rate of the product’s ASP plus a 6% add-on
payment.
To encourage development of lower-priced
biosimilar biological products, Medicare statute
requires that biosimilar biologics are paid 100%
of their ASP plus an add-on payment equal to 6%
of the reference biological product’s ASP.
Medicare statute does not specify the payment
rate for biosimilar biological products during the
initial product introduction period (first ful
calendar quarter in which the drug is marketed),
when pricing data may be insufficient to calculate
the product’s ASP.
Generally, when prescription drug and biological
sales data are insufficient to calculate a product’s
ASP, such as during the initial period the drug or
biological product is marketed, the HHS
Secretary sets the Part B reimbursement rate at
the wholesale acquisition cost, a published price,
which usually exceeds the ASP, plus a 3% add-on
payment.
CRS-42

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Temporary
Biosimilar biological products are based on an
Section 139404 would increase the Medicare Part
Section 129404 is identical to the House
Increase in
original biological (reference) product, similar to
B add-on payment temporarily (for five years) for
provision.
Medicare Part B
a generic drug being an exact copy of the active
qualifying biosimilar biological products from 6% to
Payment for
ingredients in a brand-name prescription drug.
8% of the reference biological product’s ASP. The
Certain Biosimilar
Medicare reimburses Part B providers and
temporary increase in Medicare Part B payments
Biological
suppliers for prescription drugs and biologicals
for biosimilar products would begin April 1, 2022,
Products
after the provider has purchased the drug or
and end March 31, 2027.
biological product and administered it to the
patient. With exceptions, Medicare generally
reimburses providers and suppliers for most Part
B drugs and biologicals at the rate of the
product’s ASP plus a 6% add-on payment. To
encourage development of lower-priced
biosimilar biological products, Medicare statute
requires that biosimilar biologics are paid 100%
of their ASP plus an add-on payment equal to 6%
of the reference biological product’s ASP.
Improving Access
See sub-rows below.
See sub-rows below regarding Section 139405.
See sub-rows below regarding Section
to Adult Vaccines
129405.
Under Medicaid
and CHIP
CRS-43

Medicaid
Federal law provides two primary benefit
Section 139405(a) would add ACIP-recommended
Section 129405(a) is almost identical to
packages with unique federal requirements for
adult vaccines and vaccine administration, without
the House provision, except it would
state Medicaid programs: traditional and
beneficiary cost sharing, to the list of mandatory
clarify that the 1-percentage-point FMAP
alternative benefit plan coverage. For certain
services under traditional Medicaid. For states that
increase also would apply to vaccine
subgroups, states may offer a targeted benefit
offer services in institutions for mental diseases or
administration.
package.
in intermediate-care facilities for the mentally
Under traditional Medicaid, coverage of ACIP-
retarded (or both) to their medically needy
recommended adult vaccines is generally
subgroups, the provision would require such
available at state option. However, states may
coverage, without beneficiary cost sharing. The
cover vaccines and vaccine administration under
FMAP rate associated with adult vaccine coverage
certain traditional state plan mandatory service
under traditional Medicaid would be increased by 1
categories (e.g., physicians’ services), depending
percentage point during the first eight fiscal
on how the state defines such coverage; such
quarters on or after the date of enactment.
coverage would be required for 19- and 20-year-

olds under Medicaid’s Early and Periodic

Screening Diagnostic and Treatment Program.
Adult vaccines and vaccine administration also
may be covered via an optional state plan benefit
category (e.g., preventive services). In addition,
for medically needy subgroups, states may offer a
more restrictive benefit package than is available
to other enrol ees, which could include such
coverage. States are permitted to impose
enrol ee cost sharing on adult vaccines and
vaccine administration, when otherwise
permitted.
States may receive a 1-percentage-point increase
in the state federal medical assistance percentage
(FMAP) rate for providing coverage of adult
vaccines (and vaccine administration), as well as
other preventive services, if states meet certain
specified requirements (e.g., they must cover,
without enrol ee cost sharing, any clinical
preventive services that are assigned a grade of
A or B by the U.S. Preventive Services Task
Force and all ACIP-recommended vaccines and
their administration for adult beneficiaries).
CRS-44

link to page 9 link to page 49 link to page 59 link to page 65 link to page 84 link to page 74
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Under ABPs, coverage of ACIP-recommended
vaccines and vaccine administration, without
enrol ee cost sharing, is mandatory.
CHIP
The State Children’s Health Insurance Program
Section 139405(b) would mandate coverage of
Section 129405(b) is identical to the
(CHIP) provides health insurance coverage to
ACIP-recommended adult vaccines and vaccine
House provision.
low-income, uninsured children (through the age
administration, without beneficiary cost sharing, for
of 18) in families with incomes above applicable
CHIP enrol ees who are 19 years of age or older.
Medicaid income standards, as well as to certain
pregnant women. There are circumstances in
which CHIP coverage may be available to an
adult aged 19 and older, as when states provide
CHIP coverage to pregnant individuals by
extending coverage to unborn children as
permitted through federal regulation. Vaccines
are not required to be covered for pregnant
individuals covered through a separate CHIP
program, although all states that cover pregnant
individuals through a separate CHIP program
currently cover vaccines and their administration
without cost sharing for this population.
Effective Date
Not applicable.
Section 139405(c) would define the effective date
Section 129405(c) is identical to the
as the first day of the first fiscal quarter on or after
House provision.
one year after enactment.
Sources: CRS analysis of the BBBA as passed by the House and included in the Congressional Record, the language released by the Senate HELP Committee and the
Senate Finance Committee described as being intended for the BBBA, and relevant current law. See report introduction for links to legislative language.
Notes: This table includes provisions relevant to prescription drugs for private health insurance, Medicare, Medicaid, and CHIP. Also see Table 1 for provisions related
to private health insurance generally, Table 4 for provisions related to Medicaid generally, Table 5 for provisions related to CHIP generally, and Table 6 for provisions
related to Medicare generally. See Appendix A for all abbreviations used in table.
a. For purposes of this report, MFP or MFPs refers to maximum fair prices in regard to prescription drug pricing; this is distinct from Medicaid MFP, which refers to the
Money Fol ows the Person Program, in Table 7.
CRS-45

Table 4. Medicaid Provisions in the Build Back Better Act
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Adjustments to
Medicaid statute requires that states make
Section 30608(a) would exclude from the
Section 122232 is almost identical
Uncompensated Care
disproportionate share hospital (DSH) payments
determination of uncompensated care pool
to Section 30608(a) in the House bil
Pools and
to hospitals treating large numbers of low-
payments expenditures for the Medicaid
regarding uncompensated care
Disproportionate Share
income patients. In addition, some states have
expansion population in non-expansion states
pools.
Hospital Payments
uncompensated care pools that make Medicaid
beginning in FY2023.
Section 122232 does not include
payments to providers to defray the cost of
Section 30608(b) would reduce the Medicaid
the language from Section 30608(b)
uncompensated care.
DSH allotment by 12.5% for states that do not
in the House bil regarding DSH.
The ACA Medicaid expansion provides Medicaid
provide Medicaid coverage to the expansion
eligibility to most non-elderly adults up to 133%
population for FY2023 and subsequent years.
of FPL. Currently, 12 states are non-expansion
states (i.e., have not implemented the Medicaid
expansion).
Further Increase in FMAP
States received 100% federal reimbursement
Section 30609 would increase the newly
Section 122233 is identical to the
for Medical Assistance for
rate (i.e., ful federal financing) for the cost of
eligible reimbursement rate to 93% for CY2023-
House provision.
Newly Eligible Mandatory
providing Medicaid coverage to newly eligible
CY2025. For CY2026 and subsequent years, the
Individuals
individuals under the ACA Medicaid expansion,
newly eligible Medicaid reimbursement rate
from CY2014 through CY2016. The rate for
would be 90%.
newly eligible individuals phased down to 95% in
CY2017, 94% in CY2018, 93% in CY2019, and
90% for CY2020 and subsequent years.
Extending Continuous
See sub-rows below.
See sub-rows below regarding Section 30721.
See sub-rows below regarding
Coverage for Pregnant and
Section 122211.
Postpartum Individuals
CRS-46

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Medicaid
Medicaid benefits and duration of coverage for
Section 30721(a) would require states to
Section 122211(a) is almost
pregnant individuals can differ by eligibility
provide 12 months of ful Medicaid benefit
identical to the House provision but
pathway, both across and within states.
coverage to postpartum individuals under
includes technical amendments.
Depending on the individual’s eligibility pathway,
Medicaid and would modify the pregnancy and
coverage may include ful Medicaid benefit
postpartum coverage that is available to lawful y
coverage or states may limit services to those
residing pregnant women and children.
related to pregnancy.
Services provided to individuals enrol ed in the
The ARPA establishes a state plan option to
ACA Medicaid expansion and who become
extend ful Medicaid benefit coverage (in addition pregnant would be reimbursed at the “newly
to any available pregnancy-related services and
eligible” increased federal reimbursement rate
60-day postpartum care that an individual might
for the timeframe beginning at the conclusion of
be entitled to) during pregnancy and throughout
60 days postpartum through 12 months after the
the 12-month postpartum period to any
last day of the individual’s pregnancy.
individual who received Medicaid coverage while
In general, the provision would apply to medical
pregnant, during the five-year period beginning
assistance provided starting the first day of the
April 1, 2022, and ending March 31, 2027.
first FY quarter that begins one year after the

date of enactment of this act, with exceptions
for the ARPA state plan option conforming
amendments and for states that require approval
from the state legislature.
CHIP
Eligibility criteria, benefit coverage, and duration
Section 30721(b) would require states to
Section 122211(b) is almost
of coverage for pregnant individuals under
provide all items or services available to a
identical to the House provision but
separate CHIP plans can differ by eligibility
targeted low-income child or a targeted low-
includes technical corrections (e.g.,
pathway, both across and within states.
income pregnant individual under the CHIP state to clarify the current law sections
The ARPA requires states that elect to provide
plan (or waiver) to individuals during pregnancy
that are being amended).
ful Medicaid coverage during pregnancy and
and throughout the 12-month postpartum
throughout the 12-month postpartum period
period.
under Medicaid during the five-year period
In general, the provision would apply to CHIP
beginning April 1, 2022, and ending March 31,
pregnancy-related assistance provided starting
2027, to provide all items or services available to
with the first FY quarter that begins one year
a targeted low-income child or a targeted low-
after the date of enactment, with exceptions for
income pregnant woman under the CHIP state
the ARPA state plan option conforming
plan (or waiver) to individuals during pregnancy
amendments and for states that require approval
and throughout the 12-month postpartum
from the state legislature.
period under CHIP.
CRS-47

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
State Option to Provide
States may establish a Medicaid health home to
Section 30722 would establish a state option
Section 122212 is similar to the
Coordinated Care Through integrate services and coordinate care for
to provide coordinated care through a maternal
House provision but would
a Maternal Health Home
targeted groups of Medicaid enrol ees with
health home for targeted individuals during
eliminate specified provider and
for Pregnant and
complex or chronic physical or behavioral health
pregnancy through 12 months postpartum,
state data collection and reporting
Postpartum Individuals
needs, beginning January 1, 2011. Target
beginning two years after the date of enactment.
requirements. The provision also
populations may include enrol ees with (1) two
The provision would specify what qualifies as a
would eliminate specified
or more chronic conditions, (2) one chronic
maternal health home, the types of providers
coordination, education, and
condition who are at risk for a second, or (3) a
that may participate on the care team, provider
enrol ee confidentiality
serious and persistent mental health condition.
payment methodologies, care coordination, and
requirements, among other changes.
States receive a 90% federal reimbursement rate
provider and state data col ection and reporting
for health home services that meet certain
requirements, among other criteria.
specified standards for the first eight fiscal
During the first eight fiscal quarters that a
quarters that the health home is in effect (or for
maternal health home is in effect, the federal
a total of 10 fiscal quarters for substance use
reimbursement rate for allowable expenditures
disorder-focused health homes approved after
would be increased by 15 percentage points, not
October 1, 2018). Thereafter, the state’s regular
to exceed 90%.
FMAP rate applies.
For FY2022, the provision would appropriate

$5 mil ion for awarding planning grants that
would remain available until expended. States
would receive their regular federal
reimbursement rate for planning grant
expenditures.
CRS-48

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Increasing Medicaid Cap
The territories operate Medicaid programs
Section 30731(a) would provide increased
Section 122221 is almost identical
Amounts and the FMAP for under rules different from those that apply to
federal annual capped funding for Medicaid to
to the House provision. However, it
the Territories
the states. The permanent source of federal
the territories for FY2022 and subsequent years. would increase the aggregate federal
Medicaid funding for the territories is the annual
For FY2022, the federal annual capped funding
annual capped funding for CNMI
federal capped funding, which was significantly
would be $3.6 bil ion for Puerto Rico,
from $70 mil ion to $73 mil ion.
increased for FY2020 and FY2021. The FMAP
$135 mil ion for USVI, $140 mil ion for Guam,
rate for American Samoa, Commonwealth of the $70 mil ion for CNMI, and $90 mil ion for
Northern Mariana Islands (CNMI), Guam, and
American Samoa. For FY2023 and subsequent
the U.S. Virgin Islands (USVI) was increased from years, the federal annual capped funding for
55% to 83% for FY2020 and FY2021. For Puerto
Medicaid would be the sum of the amount
Rico, the FMAP rate was increased from 55% to
provided in the preceding FY increased by the
76% for FY2020 and FY2021; Puerto Rico also
percentage increase, if any, in Medicaid spending
received $200 mil ion in additional funding for
during the preceding FY.
establishing a physician payment rate that was
Section 30731(b)(1)-(3) would keep the
70% of Medicare’s rates.
FMAP rate at 83% for USVI, Guam, CNMI, and
American Samoa for FY2022 and subsequent
years. It would keep the FMAP rate for Puerto
Rico at 76% in FY2022 and 83% in FY2023 and
subsequent years.
Section 30731(b)(4) would establish a
requirement for Puerto Rico to have physician
payment rates that are 70% of Medicare’s rates.
Failure to meet this requirement would result in
a reduction to the FMAP rate. This provision
would be effective the first fiscal quarter after
the date of enactment.
Investments to Ensure
See sub-rows below.
See sub-rows below regarding Section 30741.
See sub-rows below regarding
Continued Access to
Section 122231.
Health Care for Children
and Other Individuals
CRS-49

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Providing for One Year
Under Medicaid, eligibility for MAGI-based
Section 30741(a) would permit the state plan
Section 122231(a) is identical to
of Continuous Eligibility
eligibility groups must be renewed at least
option to continue through the period that is
the House provision.
for Children
annually. Program regulations generally require
one year after the date of enactment. Beginning
enrol ees to report changes in circumstances
one year after the date of enactment (with an
that may affect eligibility between regularly
exception for state legislation), the provision
scheduled redeterminations. States are
would require states to provide continuous
permitted to extend 12 months of continuous
eligibility to Medicaid and CHIP enrol ees under
eligibility to children under an age specified by
the age of 19 until the earlier of (1) 12 months
the state (not to exceed 19 years of age),
after such individual is determined eligible for
regardless of changes in family income or
Medicaid or CHIP, (2) the time that such
composition that may affect that child’s eligibility. individual reaches 19 years of age, or (3) the
Under CHIP, eligibility redeterminations must
date that such individual is no longer a state
occur at least annually. Although a number of
resident.
states extend 12 months of continuous eligibility

to some subpopulations of CHIP program
enrol ees, statutory authority for this policy does
not exist for separate CHIP programs.
Revisions to Temporary
The Families First Coronavirus Response Act
Section 30741(b) would end the FFCRA FMAP
Section 122231(b) is identical to
Increase of Medicaid
(FFCRA; P.L. 116-127), Section 6008, provided
increase on September 30, 2022, and the
the House provision for the
FMAP Under the
an increase to the regular FMAP rate of 6.2
provision would phase down the 6.2-percentage-
phasedown of the FFCRA FMAP
Families First
percentage points, beginning on the first day of
point FFCRA FMAP increase to 3.0 percentage
increase.
Coronavirus Response
the calendar quarter in which the COVID-19
points from April 1, 2022, until June 30, 2022,
The modifications to the FFCRA
Act
public health emergency period began (i.e.,
and to 1.5 percentage points from July 1, 2022,
FMAP increase continuous coverage
January 1, 2020) and ending on the last day of
through September 30, 2022.
requirement are almost identical to
the calendar quarter in which the COVID-19
The provision also would amend the continuous
those in the House bil , but the
public health emergency period ends. To receive
coverage requirement that is tied to receipt of
Senate provision would prohibit
the FFCRA FMAP increase, states must provide
the FFCRA FMAP increase. For the period April
states from initiating
continuous coverage of Medicaid enrol ees
1, 2022, through September 30, 2022, states
redeterminations for more than
during the COVID-19 public health emergency
would be permitted to terminate Medicaid
one-ninth of program enrol ees
period, among other requirements.
coverage for individuals who were enrol ed for
(instead of one-twelfth of program
12 consecutive months and who are no longer
enrol ees) in any month during the
eligible, when certain conditions are met (e.g.,
specified period, among other
states would be prohibited from initiating
changes.
redeterminations of more than one-twelfth of

program enrol ees in any month during the
specified period).
CRS-50

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Medical Assistance
Under Medicaid, an individual detained in a
Section 30741(c) would change certain
Section 122231(c) is similar to the
Under Medicaid for
setting that is organized for the primary purpose
Medicaid and CHIP coverage criteria for inmates
House provision but includes
Inmates During 30-Day
of involuntary confinement (e.g., local jail, state
of public institutions, including eligible juveniles.
technical corrections to separate a
Period Preceding
or federal prison) is considered an “inmate of a
Specifically, the provision would lift the
grouping within the existing list of
Release
public institution.” Medicaid statute prohibits the
prohibition on Medicaid federal matching
individuals who are excluded from
use of federal funds to pay for the health care of
payments to inmates of a public institution,
the definition of targeted low-income
an “inmate of a public institution,” except when
including eligible juveniles, for the 30-day period
child.
the individual is a “patient in a medical
preceding the date of release from a public
institution.”
institution. For eligible juveniles, the provision
Beginning on or after October 24, 2019, the
would (1) prohibit states from suspending
Substance Use-Disorder Prevention That
Medicaid coverage during the 30-day period
Promotes Opioid Recovery and Treatment for
preceding the date of release and (2) require
Patients and Communities Act (SUPPORT Act;
that eligibility determinations for new Medicaid
P.L. 115-271) prohibits states from terminating
applications be completed 30 days prior to
Medicaid eligibility for eligible juveniles (i.e.,
release.
individuals under the age of 21 and former foster The provision also would allow otherwise
youth up to the age of 26 who become
eligible inmates of a public institution to be
incarcerated while enrol ed in Medicaid or who
eligible for CHIP during the 30-day period
are determined eligible for Medicaid while
preceding the date of release of such a child
incarcerated). The SUPPORT Act also requires
from such public institution.
states to process Medicaid applications and make These modifications would take effect on the
an eligibility determination for such individuals
first day of the first FY quarter that begins two
“upon release” from a public institution.
years after the date of the enactment.
Eligibility may be suspended while the individual
is an inmate.
Different eligibility criteria apply to inmates of a
public institution under CHIP. The CHIP statute
explicitly excludes children who are inmates of a
public institution from the definition of targeted
low-income child.
CRS-51

link to page 58
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
[Extension of] Express
States are permitted to rely on a finding from
Section 30741(d)(1) would strike the
Section 122231(d)(1) is identical to
Lane Eligibility Option
specified Express Lane agencies (e.g., those that
requirement for states to use regular eligibility
the House provision.
administer programs such as Temporary
determination procedures for children who did
Assistance for Needy Families and the
not satisfy a Medicaid or CHIP eligibility
Supplemental Nutrition Assistance Program) to
requirement under an Express Lane eligibility
assess whether a child has met one or more of
determination.
the eligibility requirements necessary for a
Medicaid or CHIP initial eligibility determination,
eligibility redetermination, or renewal of
eligibility coverage through FY2027. For children
who do not satisfy a Medicaid or CHIP eligibility
requirement under an Express Lane eligibility
determination, states must use regular Medicaid
or CHIP eligibility determination procedures.
[Extension of]
The ACA extended and expanded the
Section 30741(d)(2) would make permanent
Section 122231(d)(2) is identical to
Conforming
maintenance of effort (MOE) provisions in the
the Medicaid MOE requirements for children in
the House provision.
Amendments for
American Recovery and Reinvestment Act of
families with annual income up to 300% of FPL.
Assurance of
2009 (P.L. 111-5). Under the ACA MOE
The provision would permit states to rol back
Affordability Standards
provisions, states were required to maintain
Medicaid eligibility for children in families with
for Children and
their Medicaid programs with the same eligibility
annual income that exceeds 300% of FPL
Families
standards, methodologies, and procedures in
without the loss of all federal Medicaid matching

place on the date of the ACA’s enactment of the
funds.a
ACA through September 30, 2019, for children
up to the age of 19. The penalty to states for not
complying with this Medicaid MOE requirement
for children is the loss of all federal Medicaid
matching funds.
Multiple laws have extended and amended this
MOE. Currently, the MOE is in place through
FY2027 and, beginning in FY2020, states are
permitted to rol back Medicaid eligibility for
children in families with annual income that
exceeds 300% of FPL.
CRS-52

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Expansion of
The Protecting Access to Medicare Act of 2014
Section 30741(e) would require the HHS
Section 122231(e) is similar to the
Community Mental
(P.L. 113-93), Section 223, authorized a
Secretary to award planning grants to additional
House provision. However, the
Health Services
demonstration program for eight states to
states. The provision also would require the
Senate language would extend the
Demonstration Program
improve community-based behavioral health
HHS Secretary to select new CCBHC
demonstration period for the two
services through establishing Certified
demonstration states, which may be any states
states added in 2020 and the new
Community Behavioral Health Clinics
that were previously or newly awarded planning
states from two years to four years.
(CCBHCs). Currently, this demonstration
grants and that submit applications meeting
program is authorized through September 30,
certain requirements. These states would have a
2023. Two states were added to the
two-year demonstration period.
demonstration program in 2020.
For FY2022, the provision would appropriate
$40 mil ion for planning grants and $5 mil ion for
updating the criteria, drafting annual reports, and
providing technical assistance.
Making Permanent a
The ARPA Section 9813 added a state option to
Section 30741(f) would make permanent this
Section 122231(f) is identical to
State Option to Provide
provide Medicaid coverage of qualifying
state option.
the House provision.
Qualifying Community-
community-based mobile crisis intervention
Based Mobile Crisis
services during the five-year period beginning
Intervention Services
April 1, 2022, and ending March 27, 2027.
Extension of 100%
States receive 100% federal reimbursement (i.e.,
Section 30741(g) would extend 100% federal
Section 122231(g) is almost
FMAP for Urban Indian
ful y federally funded) for Medicaid services
reimbursement for the UIOs and Native
identical to the House provision.
Health Organizations
provided through an Indian Health Service (IHS)
Hawaiian Health Centers for eight fiscal
and Native Hawaiian
facility. This exception applies to (1) IHS-
quarters. With this extension, the FMAP
Health Care Systems
operated facilities and (2) facilities operated by
exception would be in place for 16 quarters
Indian tribes or tribal organizations.
(four years), until March 31, 2025.
The ARPA provided eight fiscal quarters
beginning April 1, 2021, through March 31, 2023,
of 100% federal reimbursement (i.e., ful federal
funding) for Medicaid services received through
(1) Urban Indian Organizations (UIOs) that have
a grant or contract with IHS and (2) Native
Hawaiian Health Centers or qualified entities
that have a grant or contract with the Papa Ola
Lokahi.
CRS-53

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Ensuring Accurate
Subject to CMS approval, state Medicaid
Section 30741(h) would require the HHS
Section 122231(h) is identical to
Payments to Pharmacies programs determine the amount to reimburse
Secretary to continue conducting the NADAC
the House provision, except it
Under Medicaid
retail community pharmacies (RCPs) for covered survey of Medicaid-covered outpatient drug
would reduce the CMPs to up to
outpatient drugs dispensed to Medicaid
prices available at RCPs. To receive federal
$750 per day for small business
beneficiaries.
matching funds for prescription drugs, state
pharmacies (as determined by the
The amount state Medicaid programs receive in
Medicaid programs would have to require that
HHS Secretary) for RCPs that
federal matching payments for the ingredient
randomly selected RCPs receiving Medicaid or
knowingly failed to provide timely
costs of multiple-source covered outpatient
CHIP funds participate in the NADAC survey by
NADAC survey data.
drugs is subject to an aggregate federal upper
submitting drug cost and payment information.
In comparison to the House
limit.
RCPs that knowingly failed to provide timely or
provision, funding availability would
accurate NADAC data could be subject to
State Medicaid-covered outpatient drug payment
be addressed in Section 122231(i).
CMPs up to $10,000 for each day such
rates include two components: ingredient cost
information was not provided.
and dispensing fee. Medicaid regulations require
states to base multiple-source drugs’ ingredient
Section 30741(h) would require the HHS
cost on each product’s actual acquisition cost.
Secretary to publicly report NADAC survey
results. The HHS Secretary would receive a
State Medicaid programs have discretion in
$7 mil ion appropriation in FY2023 and each
determining actual acquisition costs for covered
year thereafter to conduct the NADAC survey.
outpatient drugs and may use resources such as
Section 13941(h) would be effective on the first
state-administered pharmacy surveys or the
day of the first quarter beginning 18 months
results of a statutory national RCP survey of
after the enactment date.
prices paid to acquire covered outpatient drugs.
To implement the statutory RCP survey
requirement, CMS established the National
Average Drug Acquisition Cost (NADAC)
survey, a voluntary, monthly survey of RCP
acquisition costs for most covered outpatient
drugs.
Funding for
Not applicable.
Section 30741(i) would appropriate $20 mil ion
Section 122231(i) is almost
Implementation and
to the HHS Secretary for FY2022 (available until
identical to the House provision.
Administration
expended) to provide technical assistance and
guidance and to cover administrative costs
associated with implementing Part 4 (i.e.,
Section 30741(a)-(h)) and Part 2 (Sections
30721 and 30722).
CRS-54

link to page 59 link to page 22 link to page 74 link to page 84
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Encouraging Continued
FFCRA Section 6008 provided an increase to the Section 30751 would encourage states to
Section 122241 is similar to the
Access After the End of
regular FMAP rate of 6.2 percentage points
maintain Medicaid eligibility standards after the
House provision. However, it would
the Public Health
during the COVID-19 public health emergency
end of the public health emergency period.
add that in applying this provision,
Emergency
period. To receive the FFCRA FMAP increase,
Between October 1, 2022, and December 31,
the eligibility standards,
states must provide continuous coverage of
2025, if in any calendar quarter a state puts into
methodologies, or procedures that
Medicaid enrol ees during the COVID-19 public
effect Medicaid “eligibility standards,
were in effect October 1, 2021,
health emergency period, among other
methodologies, and procedures” that are more
should be determined without
requirements.
restrictive than those that were in effect on
regard to those established during
October 1, 2021, the regular FMAP rate for that
the COVID-19 public health
state would be reduced by 3.1 percentage points emergency period under a COVID-
for such calendar quarter, with an exception for
19-related emergency authority.
states that modify eligibility for nonpregnant,
nondisabled adults with annual income greater
than 133% of FPL and certify with the HHS
Secretary the existence of a budget deficit or
projected budget deficit during this period.
Sources: CRS analysis of the BBBA as passed by the House and included in the Congressional Record, the language released by the Senate Finance Committee described
as being intended for the BBBA, and relevant current law. (The Senate HELP Committee language did not include provisions relevant to this table.) See report
introduction for links to legislative language.
Notes: Although this table focuses on Medicaid in general, some rows also are relevant to CHIP and some rows are relevant to prescription drugs (in either case,
especial y where such rows represent subsections of a larger provision). Also see Table 5 for provisions generally relevant to CHIP, Table 3 for additional provisions
relevant to prescription drugs and Medicaid, and Table 7 for additional Medicaid provisions regarding Home and Community-Based Services and Long-Term Care
Facilities. See Appendix A for all abbreviations used in table.
a. Section 30801(b)(2) of H.R. 5376 as passed by the House also would make changes to the CHIP child MOE requirement by removing the end date of the period
during which the CHIP MOE requirements would apply for children in families with annual income less than 300% of FPL. In addition, the provision would eliminate
the two exceptions to the MOE requirement for separate CHIP programs.

CRS-55

Table 5. The State Children’s Health Insurance Program (CHIP) Provisions in the Build Back Better Act
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Investments to Strengthen
See sub-rows below.
See sub-rows below regarding Section 30801. See sub-rows below regarding
CHIP
Section 122301.
Permanent Extension of
Multiple laws have funded CHIP since its
Section 30801(a) would permanently fund
Section 122301(a) is identical to
CHIP
establishment in the Balanced Budget Act of
CHIP by providing such sums as are necessary
the House provision.
1997 (P.L. 105-33). CHIP was funded from
to fund allotments to states for FY2027 and
FY1998 through FY2023 with appropriated
each subsequent year.
amounts specified in statute. Funding amounts
for FY2024-FY2026 were not specified; instead,
the appropriation provides such sums as are
necessary to fund allotments to states. Funding
for FY2027 consists of semiannual appropriations
of equal amounts plus a one-time appropriation.
CRS-56

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Pediatric Quality
SSA Section 1139A authorized various activities
Section 30801(b)(1) would appropriate
Section 122301(b)(1) is identical to
Measures Program
related to pediatric quality measurement for
$15 mil ion for FY2028. It also would
the House provision.
health care provided under Medicaid or CHIP,
appropriate, for each subsequent FY, the
including identifying and publishing an initial core
amount appropriated for the previous FY,
set of pediatric quality measures; establishing a
increased by the percentage increase in the
Pediatric Quality Measures Program; and
CPI-U over such previous FY.
requiring states to submit reports to the HHS
Secretary annually to include information about
state-specific child health quality measures as
applied by the state.
The Children’s Health Insurance Program
Reauthorization Act (CHIPRA; P.L. 111-3)
originally appropriated funding for SSA Section
1139A in the amount of $45 mil ion for each of
FY2009-FY2013. The Medicare Access and CHIP
Reauthorization Act of 2015 (P.L. 114-10)
appropriated $20 mil ion for the period FY2016-
FY2017, and the HEALTHY KIDS Act (Division
C, P.L. 115-120) appropriated funding in the
amount of $90 mil ion for the period FY2018-
FY2023. The Bipartisan Budget Act of 2018 (BBA
2018; P.L. 115-72) appropriated $60 mil ion for
the period FY2024-FY2027. The funds are
available until expended.
CRS-57

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Assurance of Eligibility
Under the ACA MOE provisions, states were
Section 30801(b)(2) would make permanent
Section 122301(b)(2) is identical to
Standards for Children
required to maintain their Medicaid and CHIP
the CHIP MOE by removing the end date of
the House provision.
programs with the same eligibility standards,
the period during which CHIP MOE
methodologies, and procedures in place on the
requirements would apply for children in
date of the ACA’s enactment through September families with annual income less than 300% of
30, 2019, for children up to the age of 19. The
FPL.
penalty to states for not complying with either
The provision also would eliminate the two
the Medicaid or the CHIP child MOE
exceptions to the child MOE requirement for
requirements would have been the loss of all
separate CHIP programs.
federal Medicaid funds.
Multiple laws have extended and amended this
MOE. Currently, the MOE is in place through
FY2027, and states have been permitted to make
Medicaid and/or CHIP eligibility more restrictive
for children in families with annual income that
exceeds 300% of FPL since FY2020.
CHIP provides health coverage to eligible
children (up to the age of 19) without health
insurance who do not qualify for Medicaid. States
can administer their CHIP programs as part of
Medicaid, as a separate program, or as a
combination of Medicaid and one or more
separate CHIP programs. States with separate
CHIP programs receive two exceptions to the
child MOE requirement: (1) states may impose
waiting lists or enrol ment caps to limit CHIP
expenditures and (2) after September 1, 2015,
states may enrol CHIP-eligible children in
qualified health plans in the health insurance
exchanges.
CRS-58

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Qualifying States Option Certain states had significantly expanded
Section 30801(b)(3) would permanently
Section 122301(b)(3) is identical to
Medicaid eligibility for children prior to the 1997
extend the qualifying states option.
the House provision.
enactment of CHIP. These states may use their
CHIP allotment funds to finance the difference
between the Medicaid and CHIP matching rates
(i.e., FMAP and enhanced federal medical
assistance percentage, or E-FMAP, rates,
respectively) for the cost of Medicaid-eligible
children in families with income above 133% of
FPL. This provision is referred to as the qualifying
states option. FY2027 is the last year in which the
qualifying states option is authorized.
Outreach and
CHIPRA Section 201 appropriated (out of funds
Section 30801(b)(4) would appropriate
Section 122301(b)(4) is identical to
Enrollment Program
in the Treasury that were not otherwise
$60 mil ion for CHIP outreach and enrol ment
the House provision.
appropriated) $100 mil ion in outreach and
grants for the period FY2028-FY2030. For each
enrol ment grants for FY2009-FY2013 to be used of three FYs after FY2030, the section specifies
by eligible entities (e.g., states, local
that the appropriation for such grants would be
governments) to conduct outreach and
the amount appropriated under this subsection
enrol ment efforts that increase the participation
for the previous FY, increased by the
of Medicaid- and CHIP-eligible children. The
percentage increase in the CPI-U rounded to
section also provided direction for the use of
the nearest $100,000 over such previous FY.
such funds. Subsequent laws provided additional
The provision also would extend the authority
appropriations and identified set-aside amounts
for such grants, including the requirements that
to be directed at specified activities, among other 10% of the funding be used for a national
changes. Most recently, BBA 2018 provides
campaign to improve the enrol ment of
$48 mil ion for CHIP outreach and enrol ment
underserved child populations and another 10%
grants for the period FY2024-FY2027. Currently,
of the funding be used for evaluations and
the law requires 10% of the funding to be set
technical assistance.
aside to use for a national campaign to improve
the enrol ment of underserved child populations
and another 10% of the funding to be set aside
for evaluations and technical assistance.
CRS-59

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Child Enrollment
For FY2009-FY2027, states with a funding
Section 30801(b)(5) would permanently
Section 122301(b)(5) is identical to
Contingency Fund
shortfall and CHIP enrol ment for children
extend the funding mechanism for the Child
the House provision.
exceeding a state-specific target level receive a
Enrol ment Contingency Fund and payments
payment from the Child Enrol ment Contingency
from the fund.
Fund. This payment is equal to the amount by
which the enrol ment exceeds the target,
multiplied by the product of projected per capita
expenditures and the E-FMAP, which is the
federal share of CHIP expenditures.
CHIP Drug Rebates
CHIP covers uninsured children through age 18.
Section 30801(c) would require drug
Section 122301(c) is identical to
States may include CHIP in Medicaid, have a
manufacturers to pay rebates on drugs
the House provision.
separate program, or combine CHIP and
provided to separate CHIP program
Medicaid.
beneficiaries beginning January 1, 2024. The
States determine their CHIP benefit coverage
HHS Secretary would be required by Section
and cost sharing fol owing federal rules. All state
30801(c) to develop or adapt necessary
CHIP programs cover outpatient prescription
processes and mechanisms, including to report
drugs, regardless of whether the programs are
and col ect data to bil and track prescription
administered as part of Medicaid, separately, or
drug rebates for covered outpatient drugs,
in combination.
including methadone and opioid addiction
treatment biologic products, provided as CHIP
Drug manufacturers that participate in Medicaid
or pregnancy-related assistance under a child
are statutorily required to pay rebates on
health plan.
covered outpatient drugs.
Section 30801(c) would prohibit duplicate
Medicaid covers most FDA-approved outpatient
CHIP rebates and PHSA Section 340B Program
prescription drugs and biological products, as
discounts.
well as insulin.
Federal Medicaid and CHIP statutes do not
specifically require drug manufacturers to pay
rebates on drugs purchased by separate CHIP
programs.
CRS-60

link to page 22 link to page 49 link to page 84
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
State Option to Expand
States have broad discretion in setting their
Section 30801(d)(1) would permit states to
No provision.
Children’s Eligibility for
CHIP income eligibility standards, and eligibility
extend coverage to children in families at
Medicaid and CHIP
varies across states. The ACA required states to
higher income levels by increasing the CHIP
transition to MAGI income counting rules,
upper income eligibility standards beyond those
beginning January 1, 2014. The transition to
established by the state as a part of the
MAGI effectively limited CHIP upper income
transition to the MAGI income counting rules.
eligibility levels for states by eliminating state use
Section 30801(d)(2) would allow the
of income disregards to expand eligibility.
territories to receive an increase to their
State CHIP allotments are the funds allocated to
federal CHIP allotments to account for a
each state and territory for the federal share of
program expansion.
its CHIP expenditures. Federal CHIP allotments
Section 30801(d)(3) would remove the
are distributed to states based on a statutory
expiration date of the provision al owing states
formula that differs across even and odd years. In and DC to increase their federal CHIP
addition, CHIP allotment increases to account
allotments to account for program expansions.
for program eligibility or benefit expansions are
permitted for states and the District of Columbia
(DC) through FY2027.
Funding for
Not applicable.
Section 30801(e) would appropriate $5 mil ion Section 122301(d) is identical to
Implementation and
to the HHS Secretary for FY2022 (available
the House provision.
Administration
until expended) to provide technical assistance
and guidance and to cover administrative costs
associated with implementing Section
30801(a)-(d).
Sources: CRS analysis of the BBBA as passed by the House and included in the Congressional Record, language released by the Senate Finance Committee described as
being intended for the BBBA, and relevant current law. (The Senate HELP Committee language did not include provisions relevant to this table.) See report introduction
for links to legislative language.
Notes: Although this table focuses on CHIP in general, some rows also are relevant to Medicaid and some rows are relevant to prescription drugs (in either case,
especial y where such rows represent subsections of a larger provision). Also see Table 3 for provisions relevant to prescription drugs, including in CHIP, and Table 4
for provisions generally relevant to Medicaid, including some provisions relevant to CHIP. See Appendix A for all abbreviations used in table.

CRS-61

Table 6. Medicare Provisions in the Build Back Better Act
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Providing
Medicare Part B covers certain auditory
Section 30901(a) would expand coverage of
Section 122101 would expand coverage of
Coverage for
services, such as hearing and balance
auditory services starting January 1, 2023, to
auditory services and hearing aids in the same
Hearing Care
assessments when furnished by a qualified
include aural rehabilitation and treatment
way as the House version, with the fol owing
Under the
audiologist.
services and hearing assessments when
exceptions:
Medicare
Part B also covers certain prosthetics when
furnished by a qualified hearing aid professional. Section 122101(a) would clarify that qualified
Program
they replace the functioning of parts of the ear A qualified hearing aid professional would be
audiologists could perform treatment services
anatomy.
defined as one who is licensed or registered by
(including greater specificity about which
Hearing aids and hearing aid examinations are
the state in which services are furnished and
activities would be included under treatment)
excluded from Medicare coverage.
meets other requirements as determined by the related to hearing and balance in addition to
HHS Secretary (including requirements relating
hearing aid examinations; qualified hearing aid
Physicians, nonphysician practitioners, and
to educational certification or accreditation),
professionals could conduct only hearing aid
other Part B suppliers that provide auditory
taking into account any additional requirements
examinations.
services may bil Medicare as either
established by other payers.
participating or nonparticipating providers and
Additionally, the provision would specify that
receive payment according to a fee schedule.
Payment for hearing assessment services
when audiologists provide hearing and balance
Participating providers accept the Medicare
furnished by a qualified hearing aid professional
assessment services and hearing aid examination
payment as payment in ful for all services
would be 80% of either the lesser of the actual
and treatment services, these services would not
provided to beneficiaries, whereas
charge for the service or 85% of the amount for require an order from a physician or practitioner
nonparticipating providers do not accept the
such service determined under the Medicare
to be covered by Medicare. Hearing aid
Medicare payment as payment in ful and can
physician fee schedule.
examinations provided by a qualified hearing aid
balance bil .
Section 30901(b-d) would eliminate the
professional stil would require an order from a
physician or practitioner, as per Section 30901(a)
Medicare payments for certain prosthetics
statutory exclusion for hearing aids furnished
of the House version.
may be based on statutorily specified fee
under the prosthetic benefit starting January 1,
schedules or competitive bidding.
2023. Covered hearing aids would be allowed
Section 122101 (b-d) would modify coverage
for beneficiaries diagnosed with moderately
by deleting the word “diagnosed” with respect to
Medicare covers certain services provided at
severe, severe, or profound hearing loss. The
hearing loss that would qualify a beneficiary for
rural health clinics (RHCs) based on an all-
section would limit coverage to not more than
hearing aid coverage. The Senate version also
inclusive rate (AIR) for each visit and pays
once per ear during any five-year period and
would add a definition section that defines (1) a
federally qualified health centers (FQHCs) on
only with a written order from a physician or
hearing aid as the item and related services and
the basis of a prospective payment system
practitioner.
(2) a qualified hearing aid supplier as a qualified
(PPS).
Hearing aid payments would be made on an
audiologist; physician; physician assistant; nurse
The Ethics in Patient Referrals Act, commonly
assignment-related basis (precluding suppliers
practitioner; or clinical nurse specialist, qualified
referred to as the Stark Law (part of the
from balance bil ing) and would be subject to
hearing aid professional, or other supplier as
Omnibus Budget Reconciliation Act of 1989,
competitive bidding. However, hearing aids and
determined by the HHS Secretary.
P.L. 101-239), prohibits certain physician self-
services furnished by physicians or other
Additionally, the Senate version would require
referrals for designated health services that
practitioners to their own patients as part of
the HHS Secretary to begin a competition for
may be paid for by Medicare.
CRS-62

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
their professional services would be exempt
competitive bidding of hearing aids not later than
from competitive bidding.
January 1, 2028.
Section 30901(e) would define audiology
The Senate version would add an exception to
services as qualified physician services at RHCs
the physician self-referral prohibition in the Stark
and FQHCs and would include qualified
law for hearing aid examination services and
audiologists and hearing aid professionals as
hearing aids.
RHC and FQHC practitioners. Temporary
payment rates for audiology services furnished
at RHCs and FQHCs would be based on the
Medicare physician fee schedule until the HHS
Secretary determined that sufficient data had
been col ected to establish rates under the
RHC AIR or the FQHC PPS or until January 1,
2029, if no such determination had yet been
made in either case. The costs of audiology
services furnished to Medicare beneficiaries
would not be considered in determining other
RHC AIR or FQHC PPS payment rates during
the interim.
Section 30901(f) would appropriate to the
HHS Secretary for FY2022 $370 mil ion to
implement the provision beginning January 1,
2022, and ending September 30, 2031. The HHS
Secretary would be required to implement this
section for 2022 and 2023 by program
instructions.
Registered
Skil ed nursing facilities (SNFs) and nursing
Section 132000 would require SNFs and NFs
Section 122115 is identical to the House
Professional
facilities (NFs) must provide 24-hour licensed
to use the services of an RN for 24 hours a day, provision.
Nurses
nursing services sufficient to meet the nursing
seven days a week
needs of their residents. These services must
include, at a minimum, services of a registered
nurse (RN) at least eight consecutive hours a
day, seven days a week.
CRS-63

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Permanent
The Medicare Independence at Home (IAH)
Section 132001 would make permanent the
Section 122121 would reorder the House
Extension of the
demonstration is a payment-incentive and
IAH demonstration program, remove the limit
provision and would require a transition period
Independence at
service-delivery model that uses home-based
on the number of demonstration participants,
during which the limit for the total number of
Home Medical
primary care teams to reduce expenditures
and open participation to additional qualified
qualified medical practices participating in the
Practice
and improve health outcomes in the care of
IAH medical practices without limit. The
program would increase from 25,000 in CY2022
Demonstration
certain chronically il Medicare beneficiaries.
participating beneficiaries newly added due to
to 200,000 in CY2029. For CY2030 and
Program
Qualifying IAH medical practices are legal
the expansion would be included in determining subsequent years, there would be no limit.
entities comprising an individual physician or
the estimated annual spending target for each
nurse practitioner or a group of physicians and IAH medical practice and its incentive payment
nurse practitioners that provide chronic care
under the demonstration. The sum of
management services as part of a team.
$60 mil ion would be appropriated to the CMS
CMS initially selected 15 individual practices
Program Management Account for FY2022 to
and launched the IAH demonstration in 2012.
administer the IAH demonstration program;
Originally scheduled to end in 2017, the IAH
these funds would be available until September
demonstration has been extended twice
30, 2031.
through legislation and is set to end on
December 31, 2023. These laws also raised
the limit on the number of IAH demonstration
participants (from 10,000 to 20,000) and the
related limit on the number of IAH
participating practices.
Administrative
No current law.
Section 137401 would appropriate $6 mil ion
Section 127401 is identical to the House
Funding of the
in FY2022 to administer the Rural and
provision.
Rural and
Underserved Pathway to Practice Training
Underserved
Program for Post-Baccalaureate and Medical
Pathway to
Students (which would be established by
Practice Training
Section 137402, see below) and the Rural and
Programs for
Underserved Pathway to Practice Training
Post-
Program for Medical Residents (which would be
Baccalaureate
established by Section 137404, see below). The
Students,
amount appropriated would remain available
Medical
until expended.
Students, and
Medical
Residents
CRS-64

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Establishing the
Multiple federal programs aim to increase the
Section 137402 would establish a new
Section 127402 would create a new program
Rural and
number of physicians from diverse
program to award scholarship vouchers to
that would be substantively similar to the
Underserved
backgrounds and to increase the number of
individuals from disadvantaged backgrounds, as
program included in the House provision, except
Pathway to
physicians who practice in rural and
specified, for post-baccalaureate and medical
that this program would specify “selection
Practice Training
underserved communities. Generally, these
school tuition and education expenses.
criteria” that the HHS Secretary would be
Program for
programs provide scholarships or loan
Scholarship recipients would be required to
required to consider when selecting qualifying
Post-
repayment in exchange for practicing in health
practice medicine in a health professional
students to receive medical scholarship vouchers
Baccalaureate
professional shortage areas or medically
shortage area, in a medically underserved area,
(as opposed to the “prioritization criteria”
Students and
underserved areas, generally at outpatient
at a public hospital, or in a rural area for the
contained in the House provision).
Medical Students
facilities. These programs generally target
number of years of scholarship support
This section also defines a number of terms,
primary care and behavioral health providers
received.
including qualifying medical school, for purposes of
and support health professional education
The section specifies the criteria to be
the program. Specifically, the Senate provision
(e.g., medical school). Programs also may
prioritized when selecting participating students
would require a qualifying medical school to
target individuals from underserved
and the requirements for schools receiving
provide certain coursework and training focused
communities or provide training exposure in
tuition vouchers. It also specifies the penalties
on “effectively providing care for populations
such communities. Programs that incur service that scholarship recipients would incur if they
belonging to diverse cultural, social and economic
commitments generally specify repayment
failed to complete their scholarship
backgrounds,” whereas the House provision
penalties for individuals who fail to complete
requirements. The provision also would add
would focus on medical issues prevalent in
their service requirements. In some cases,
this new program to the list of programs for
“cultural or structural competency.”
health providers may have their Medicare
which the HHS Secretary is required to enter
payments withheld for failing to fulfil their
into agreements with the physicians who have
service commitments.
breached their contracts to deduct the amount
owed from the Medicare payments that the
individuals otherwise would receive.
The section defines a number of terms,
including qualifying medical school, for purposes
of the program. Among the elements of the
definition, qualifying medical schools would be
those that are required to provide coursework
and training experiences focused on medical
issues prevalent in health professional shortage
areas, medically underserved areas, and rural
areas and in coursework and training in cultural
or structural competency.
CRS-65

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Funding for the
Scholarships received by an educational
Section 137403 would create a new
Section 127403 includes punctuation and minor
Rural and
institution on behalf of a student for
refundable tax credit for qualifying educational
language changes but is otherwise substantively
Underserved
educational expenses are included in the
institutions—certain medical schools or
the same as the House provision.
Pathway to
institution’s revenue and are not tax
providers of a post-baccalaureate medical

Practice Training
deductible to the institution under current
education and training—to offset amounts “paid
Programs for
law.
or incurred” by the institution for each eligible
Post-
Students, in contrast, may receive a tax benefit student who receives a Rural and Underserved
Baccalaureate
from a scholarship. Specifically, students
Pathway to Practice medical scholarship
Students and
generally do not have to pay tax on a
voucher. This credit would effectively be a
Medical Students
scholarship, as long as the scholarship is not
financing mechanism to fund these
considered compensation for services (e.g.,
scholarships—qualifying educational institutions
research, student teaching). Scholarship or
would provide these scholarships to students,
fellowship income that is considered
and the federal government would reimburse
compensation for services is generally taxable,
these institutions with a tax credit. (Educational
unless specifically excluded by law—statutory
institutions with little to no income tax liability,
exceptions include amounts received under
including those that are federally tax exempt,
the National Health Service Corps Scholarship would be able to benefit from this provision
Program and the Armed Forces Health
because it is a refundable credit.) Under current
Professions Scholarship and Financial
law, no comparable tax benefit to the one
Assistance Program.
proposed here exists.
CRS-66

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Establishing the
Medicare pays hospitals with an approved
Section 137404 would exclude the Medicare
Section 127404 is identical to the House
Rural and
medical residency program for the direct and
GME FTE medical residents that an applicable
provision, except it would define an applicable
Underserved
indirect costs of a medical residency training
hospital trains under the Rural and
hospital differently. Specifically, the Senate
Pathway to
program. Medicare’s graduate medical
Underserved Pathway to Practice Medical
provision would include the requirement that the
Practice Training
education (GME) payments to a hospital in a
Residency Training Program during a Medicare
hospital have a residency program that includes
Program for
given year are subject to a hospital-specific
cost-reporting year beginning on or after
“training for residents on how to effectively
Medical
ful -time equivalent (FTE) limit, or cap, for
October 1, 2026, from counting toward a
provide care for populations belonging to diverse
Residents
allopathic and osteopathic residents. In some
hospital’s Medicare GME FTE cap. Thus, this
cultural, social, and economic backgrounds.” By
cases, the FTE cap is not absolute—Medicare
section would increase both the aggregate
contrast, the House bil would include the
provides GME funding for new medical
number of FTEs and the number of an
requirement that the hospital have a residency
residency programs sponsored either by a
applicable hospital’s FTEs that are supported by
program that “includes cultural or structural
new hospital or by an existing hospital that
Medicare only for the period during which a
competency as part of the training of residents.”
develops a new residency program and for
hospital or hospitals are training residents
certain GME programs that train residents in
under the Rural and Underserved Pathway to
rural areas.
Practice Medical Residency Training Program.
Medicare requires limited tracking of
(The provision would not limit the number of
residents’ medical specialties and does not
medical residents that a hospital may train
require hospitals to report information about
under the Rural and Underserved Pathway to
former residents’ post-residency practice
Practice Medical Residency Training Program.)
patterns.
The provision would require applicable
hospitals to provide information to the HHS
Secretary about where qualifying residents
practice medicine or participate in fellowships
immediately after their residency.
It also defines key terms, such as qualifying
resident, applicable hospital, health professional
shortage area, medically underserved area,
qualifying medical school, qualifying medical
student, and rural area.
CRS-67

Distribution of
Medicare’s GME payments to a hospital in a
Section 137405 would add a total of 4,000
Section 127405 is identical to the House
Additional
given year are subject to a hospital-specific
Medicare-supported GME resident FTE
provision.
Residency
FTE cap for allopathic and osteopathic
positions to be distributed to qualifying
Positions
residents. Generally, the FTE cap is
hospitals in FY2025, FY2026, and any
determined at the hospital level. However,
succeeding FYs until all FTEs are distributed.
under Medicare GME rules, groups of
The provision would require a hospital to apply
hospitals may enter into formal affiliation
for increases, and it would require the HHS
agreements that permit these hospitals to
Secretary to initiate a separate round of
pool their FTEs. This pooling allows some
applications for each FY. A hospital that
hospitals within the affiliated group to reduce
received FTE residency positions through this
their FTE caps and others to increase their
provision would have its FTE cap increased by
FTE caps for purposes of Medicare GME
such number of FTEs. The aggregate number of
payments, as long as the aggregate number of
FTE residency positions distributed in any FY
FTEs among the affiliated group remains the
would not exceed 2,000. No hospital would be
same.
eligible to receive more than an additional 25
The FTE cap is not absolute—Medicare wil
FTEs under this provision.
recognize and pay for FTEs of a new medical
With regard to medical specialty, not less than
residency program sponsored by either a new
25% of the aggregate FTEs would be for
hospital or an existing hospital that develops a
primary care (as defined) or obstetrics and
new residency program, or certain GME
gynecology residents; 15% would be for
programs that train residents in rural areas.
psychiatry residents (as defined). Any FTEs that
However, a hospital that already has an FTE
remain to be distributed after July 1, 2027,
cap and wishes to grow its medical residency
would be distributed without regard to
training program to correspond with the
specialty. Hospitals would be permitted to
growth of the hospital, its service area, or the
receive additional residents under this provision
population served cannot receive additional
and under the CAA 2021 during a given FY.
Medicare GME funding to support additional
With regard to hospital types, 30% of the
residents.
aggregate FTEs would be distributed to
Since the FTE cap was established, Congress
hospitals that are training more residents than
has enacted exceptions to the FTE caps. For
the Medicare FTE limit; 20% to hospitals that
example, the Consolidated Appropriations
are located in rural areas or are treated as such
Act, 2021 (CAA 2021; P.L. 116-260),
under certain Medicare hospital wage index
increased the aggregate number of Medicare
reclassifications, are located in a census tract
GME FTEs by 1,000; the HHS Secretary must
assigned a rural-urban commuting area code of
begin distributing these FTE positions in
4 or greater, or are Medicare sole community
FY2023. A hospital that receives additional
hospitals; 20% to hospitals in states with new
FTEs under the CAA 2021 wil have its
medical schools or campuses (as defined); 20%
hospital-specific cap increased by the number
to hospitals located in or that serve an area or
of additional FTEs the hospital receives under
population designated as a health professional
this law.
shortage area (HPSA); and 10% to hospitals
CRS-68

Medicare does not require that hospitals
located in states in the lowest quartile for
report data about the practice patterns or
medical resident-to-population ratios. Any FTEs
other information about former residents as a
remaining to be distributed after July 1, 2027,
condition of receiving Medicare GME
would be distributed first based on the
payments or additional FTEs. However,
aforementioned hospital types that
hospitals must distinguish between primary
demonstrate a likelihood of fil ing the residency
care and non-primary care FTEs, because
positions within five years of the effective date
Medicare GME payments differ based on
of the FTE cap increase made under this
whether the residents are training in a primary provision and that would use a portion of such
care specialty or a non-primary care specialty.
FTEs for residencies in primary care, obstetrics
Medicare defines primary care as family
and gynecology, and psychiatry.
medicine, general internal medicine, general
During the five-year period beginning after the
pediatrics, preventive medicine, geriatric
effective date of the increase, a hospital
medicine, or osteopathic general practice.
receiving an FTE increase under this provision
would not be allowed to reduce its number of
primary care or psychiatry FTE residents to
below the number it was otherwise training in
those specialties during the three most recent
Medicare cost-reporting periods preceding
enactment.
Hospitals receiving an FTE increase under this
provision would be required to make a good-
faith effort to report to the HHS Secretary
information about former residents, including
their race and ethnicity, medical specialty of
practice, and whether former residents practice
in HPSAs or rural areas.
The FTEs distributed to a rural hospital under
this provision must be used to expand existing
programs, not to establish new programs. This
provision also would require the HHS Secretary
to reduce the FTE cap of a hospital that
received an FTE increase under this provision if
the hospital no longer met the requirements for
such increase; in that case, the provision would
require the HHS Secretary to redistribute
those FTEs to other hospitals based on the
distribution requirements under this provision.
Hospitals receiving an FTE increase under this
provision would be permitted, after five years,
CRS-69

link to page 22 link to page 74 link to page 74 link to page 84
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
to include such FTEs in the pool of FTEs as part
of an affiliation agreement among a group of
hospitals. The per resident amount for FTEs
distributed under this provision would be
calculated in the same manner as under current
law for primary care and non-primary care
Medicare GME residents. Finally, the provision
would make conforming amendments to the
Medicare Indirect Medical Education (IME)
statute so that Medicare could calculate the IME
portion of the Medicare GME payment for
hospitals with added FTE residency positions
allowed by this provision.
The section would appropriate $10 mil ion to
carry out this provision. The funds would
remain available until expended.
Sources: CRS analysis of the BBBA as passed by the House and included in the Congressional Record, the language released by the Senate Finance Committee described
as being intended for the BBBA, and relevant current law. (The Senate HELP Committee language did not include provisions relevant to this table.) See report
introduction for links to legislative language.
Notes: This table includes provisions generally relevant to Medicare. Also see Table 3 for additional provisions relevant to prescription drugs and Medicare and Table
7 for additional Medicare provisions regarding Home and Community-Based Services and Long-Term Care Facilities. See Appendix A for all abbreviations used in table.
CRS-70

Table 7. Home and Community-Based Services (HCBS) and Long-Term Care Facility (LCTF) Provisions
in the Build Back Better Act
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Medicaid HCBS
States are required to cover certain Medicaid-
Section 30711 would appropriate
Section 122201 is similar to the House
Improvement Planning
covered long-term services and supports (LTSS)
$130 mil ion for FY2022 (available until
provision. It would make certain changes
Grants
for eligible beneficiaries, such as NF care and
expended) to carry out grants to states and
to the use of grant funds, HCBS
home health care. States have a range of options territories no later than 12 months after
improvement planning grant requirements,
that allow LTSS coverage of HCBS, such as case
enactment. Grants would be awarded for the
and definitions.
management, personal care, homemaker, respite purposes of developing and implementing
care, and adult day health care, among other
states’ HCBS improvement plans in order to
services.
expand Medicaid-eligible individuals’ access to
and use of HCBS and to expand the HCBS
direct care workforce.
The provision would appropriate an
additional $5 mil ion for FY2022 (available
until expended) for technical assistance and
guidance to states intending to apply for, or
that are awarded, HCBS improvement
planning grants and for other related
administrative expenses.
CRS-71

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Medicaid HCBS
The ARPA Section 9817 increases the FMAP
Section 30712 would provide a few FMAP
Section 122202 is similar to the House
Improvement Program
rate of Medicaid expenditures by 10 percentage
increases for certain HCBS program
provision. However, the Senate provision
points for certain HCBS for states that meet the improvement states.
would change some requirements for a
ARPA-specified HCBS program requirements
These states could receive a 6-percentage-
state to be eligible for the FMAP increases.
during the program improvement period (i.e.,
point increase to the regular FMAP rate for
April 1, 2021, through March 31, 2022).
Medicaid HCBS for each fiscal quarter
beginning on or after the date on which the
state becomes an HCBS program
improvement state, if the state meets the
specified requirements. An HCBS program
improvement state could receive an
additional 2-percentage-point increase (but
not to exceed 95%) during the first six fiscal
quarters the state has a program to support
self-directed models for the delivery of
services.
HCBS program improvement states also
would receive an increase to an 80% federal
reimbursement rate before October 1, 2031,
for certain administrative costs for expanding
and enhancing HCBS.
Funding for Federal
No current law.
Section 30713 would appropriate
Section 122203 is similar to the House
Activities Related to
$40 mil ion for FY2022 (available until
provision but excludes preparing and
Medicaid HCBS
expended) to carry out the HCBS
submitting reports to Congress.
improvement program, including issuing
guidance and technical assistance to states;
conducting program integrity and oversight
efforts; and preparing and submitting reports
to Congress.
CRS-72

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Funding for HCBS Quality
Quality measurement activities in the Medicaid
Section 30714(a) would provide 80%
Section 122204 would appropriate
Measurement and
and CHIP programs currently are carried out
federal reimbursement for the reporting of
$25 mil ion to the HHS Secretary for
Improvement
under the authority of two provisions: SSA
information regarding the quality of HCBS, in
FY2022 (available until expended) to
Section 1139A for pediatric quality
accordance with the child health quality
develop, in consultation with
measurement and SSA Section 1139B for quality measures and the adult health quality
nongovernmental stakeholders, a
measurement for the adult Medicaid population.
measures.
recommended set of HCBS quality
These authorities do not encompass HCBS
Section 30714(b) would appropriate
measures that reflect the ful range of
measure-specific activity.
$22 mil ion to the HHS Secretary for FY2022, HCBS and the recipients of such services.
Broadly, these sections required the
to remain available until expended, to carry
development, updating, and maintenance of core out the inclusion of HCBS quality measures in
pediatric and adult health quality measure sets;
the core set of adult health quality measures
the establishment of quality measurement
maintained under Section 1139B. Generally,
programs (both pediatric and adult health);
the provision would amend SSA Sections
support for the development of quality
1139A and 1139B to include HCBS quality
measures to fil identified gaps in these areas;
measurement and improvement in some of
and requirements around state reporting to
the activities under these sections, specifically
HHS on quality and quality measures, among
the development of new HCBS quality
other things.
measures, their incorporation into the
Funding for Section 1139B expired in FY2014.
existing pediatric and Medicaid adult core
quality measure sets, and state reporting of
these new measures.
Permanent Extension of
When determining financial eligibility for
Section 30715 would permanently apply
Section 122205 is identical to the House
Medicaid Protections
Medicaid-covered LTSS, there are specific rules
spousal impoverishment protections to all
provision.
Against Spousal
for the treatment of a married couple’s assets
married individuals who are eligible for
Impoverishment for
when one spouse needs long-term care
Medicaid HCBS under specified authorities.
Recipients of Home and
provided in an institution, such as a nursing
Community-Based
home. Commonly referred to as spousal
Services
impoverishment rules, these rules attempt to
allocate income and assets equitably to each
spouse when determining Medicaid financial
eligibility and are intended to prevent the
impoverishment of the non-Medicaid spouse.
These rules have been temporarily extended to
HCBS participants over time and were most
recently extended through September 30, 2023.
CRS-73

link to page 83
Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Permanent Extension of
The Medicaid Money Fol ows the Person
Section 30716 would make permanent the
Section 122206 is identical to the House
Medicaid Money Fol ows
(Medicaid MFP) Rebalancing Demonstration
Medicaid MFP program by removing the
provision, except it would appropriate
the Person Rebalancing
Program authorized CMS to award competitive
specific amounts provided for FY2022 and
$450 mil ion “for each fiscal year after fiscal
Demonstration
grants to states to transition Medicaid
FY2023, respectively, and would appropriate
year 2021” for competitive grants to states.
participants who reside in institutional settings
$450 mil ion “for each fiscal year after fiscal
that provide LTSS, such as NFs, into
year 2022” for competitive grants to states. It
community-based settings.a Medicaid MFP has
would appropriate $5 mil ion to states for
been extended over time. Most recently,
FY2022 and for each subsequent three-year
Medicaid MFP was appropriated $450 mil ion in
period for carrying out quality assurance and
federal funding for each of FY2021-FY2023, for
improvement, technical assistance, oversight,
a total of $1.35 bil ion.
research and evaluation, and specified reports
on best practices.
Funding to Improve the
Most SNFs are paid by the Medicare program
Section 30717 would provide $50 mil ion
Section 122111 is identical to the House
Accuracy and Reliability of under a PPS. The HHS Secretary has established
from the Treasury to support VBP validation
provision.
Certain Skil ed Nursing
an SNF Value-Based Purchasing (VBP) program
activities for the period of FY2022-FY2031.
Facility Data
that adjusts PPS payments to SNFs based on the
During the period of FY2024-FY2031, the
SNFs’ performance related to hospital
section would expand validation activities to
readmissions.
include submissions of MDS data and PBJ
SNFs are required to perform assessments of
information.
each resident’s functional capacity at specified
Further, during the period beginning with
times during the resident’s stay and to report
FY2026 and ending with FY2031, if the HHS
the information to the HHS Secretary and
Secretary determined through the validation
relevant state agencies. CMS refers to the
activities that, with respect to each FY, data
submitted resident assessment data as the
related to the VBP measures, MDS data, or
minimum data set (MDS).
PBJ information submitted by an SNF was
In addition to the MDS, SNFs are required to
inaccurate, the Medicare SNF PPS payments
submit direct-care staffing information based on
made to the SNF would be reduced by 2% for
payrol and other auditable data. The CMS
the FY.
system for electronic submission of staffing
information is referred to as the Payrol -Based
Journal (PBJ).
CRS-74

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Ensuring Accurate
SNFs, as well as other Medicare providers, are
Section 30718 would provide to the HHS
Section 122112 is identical to the House
Information on Cost
required to submit an annual cost report to
Secretary, out of what is already
provision.
Reports
CMS. The cost report contains provider
appropriated, $250 mil ion from the Treasury
information, such as service cost and charges (in for purposes of conducting annual audits of
total and for Medicare), and financial statement
cost reports submitted by SNFs, beginning
data.
with cost reports submitted for 2023 and
ending with 2031. The funds would be
available for FY2022 and would remain
available through FY2031.
CRS-75

Survey Improvements
To participate in Medicare and/or Medicaid,
Section 30719 would require the HHS
Section 122113 differs from the House
SNFs and/or NFs, respectively, must adhere to a Secretary to conduct reviews of
version in a number of ways. Most
set of federal requirements, known as the

significantly, the Senate language would

the extent to which current surveys and
Conditions of Participation (CoPs).
enforcement actions result in compliance include of Medicaid facilities (NFs) and
To determine whether SNFs and/or NFs comply
with the SNF CoPs;
would authorize the HHS Secretary to use
with the CoPs, federal law requires the HHS
appropriated funds for general surveying.

the timeliness and thoroughness of SA
Secretary to work in col aboration with state
verification of compliance after a
Section 122113 would require the HHS
survey agencies (SAs) to inspect (survey) SNFs
deficiency has been identified in an SNF;
Secretary to provide training, tools,
and/or NFs.
technical assistance, and funding to state

The HHS Secretary may impose enforcement

the appropriateness of the scoping and
agencies that perform surveys of SNFs
substantiation of cited deficiencies at
remedies against noncompliant providers. If,
and/or NFs for the purpose of improving
SNFs;
after the SA completes a survey, an SNF and/or

the extent to which the current
NF is found to be deficient in one or more

the accuracy of the identification and
surveys and enforcement actions
standards, the nursing home is provided with a
appropriateness of the scope and
result in compliance with the SNF and
statement that cites these CoP deficiencies. The
severity of life safety, infection control,
NF CoPs;
remedies imposed upon an SNF and/or NF
and emergency preparedness CoP

the timeliness and thoroughness of SA
depend on how “serious” the deficient behavior
deficiencies in SNFs;
verification of compliance after a
is determined to be.

the timeliness of SA investigations of
deficiency has been identified in an
complaints; facility-reported incidents;
SNF and/or NF;
and allegations of abuse, neglect, and
exploitation in SNFs;

the identification of the scope and
severity of CoP deficiencies at SNFs

the consistency of SNF reporting of
and/or NFs, particularly with respect
substantiated complaints to law
to identified life safety, infection
enforcement;
control, and emergency preparedness

SAs’ ability to sufficiently hire, train, and
CoP deficiencies in SNFs and/or NFs;
retain individuals who conduct surveys

the timeliness of SA investigations of
of SNFs; and
complaints and allegations of abuse,

any other area related to surveys of
neglect, and exploitation in SNFs
SNFs that the HHS Secretary determines
and/or NFs;
to be appropriate.

the identification of SNFs and/or NFs
The provision would require the HHS
that consistently fail to report
Secretary, based on the required reviews, to
substantiated complaints to
identify plans (as appropriate) for improving
appropriate state and local authorities
the areas reviewed and to provide training,
in accordance with state law;
tools, technical assistance, and financial

the hiring, training, and retention of
support to SAs for the purpose of improving
individuals who conduct surveys of
the surveying of SNFs and the related
SNFs and/or NFs; and
enforcement processes.
CRS-76

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Section 30719 would appropriate

any other area related to surveys of
$325 mil ion from the Treasury for FY2022,
SNFs and/or NFs that the HHS
to remain available through FY2031, for the
Secretary determines to be
HHS Secretary to implement the activities
appropriate.
required by the provision.
Section 122113 would appropriate
$325 mil ion from the Treasury for
FY2022, to remain available until
September 30, 2031, for general surveying
of SNFs and/or NFs and for the HHS
Secretary to implement the activities
required by the provision.
Nurse Staffing
There are no required staffing ratios (i.e.,
Section 30720 would require the HHS
Section 122114 is identical to the House
Requirements
number of staff to residents) for SNFs.
Secretary to conduct a study on the
provision with two exceptions:
appropriateness of establishing minimum staff-

The HHS Secretary would not be
to-resident ratios for SNFs and to submit a
required to specify minimum staffing
report to Congress no later than three years
ratios through regulation.
after the date of enactment and no less
frequently than every five years thereafter.

For purposes of carrying out the
activities required by Section
For the first report and subsequent reports,
122114, $50 mil ion would be
the section would require the HHS Secretary
appropriated from the Treasury for
to include recommendations on minimum
FY2022, to remain available until
staffing levels for specified professionals. It
September 30, 2031.
would require the HHS Secretary to specify
through regulation, no later than one year
after each report is submitted to Congress,
the appropriate minimum staffing ratios that
are consistent with the recommendations
made in each submitted report.
Section 30720 would set criteria that would
allow the Secretary to waive staffing ratio
requirements for certain SNFs located in
rural areas.
For purposes of carrying out the activities
required by Section 30720, $50 mil ion
would be appropriated from the Treasury for
FY2022, to remain available through FY2031.
CRS-77

Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
Improvements to the
The HHS Secretary is required to conduct a
No provision.
Section 122116 would appropriate
Special Focus Facility
special focus facility (SFF) Program, which
$100 mil ion from the Treasury for
Program
provides additional oversight to the SNFs
FY2022, to remain available until
and/or NFs that the HHS Secretary has
September 30, 2026, to expand the SFF
identified as having “substantially failed” to meet
Program and conduct on-site consultation
the requirements for participating in the
and educational programming for SNFs
Medicare and/or Medicaid program.
and/or NFs in the SFF Program.
As currently conducted, the SFF Program has 88
Section 122116 would require, for a
“slots” for SNFs and/or NFs, out of the over
period of not less than three years
15,000 facilities.
beginning no later than October 1, 2023,
that the number of SFF Program
participants equal at least 3.5% of all
federally certified nursing homes.
Section 122116 would establish, for a
period of not less than two years beginning
no later than October 1, 2024, mandatory
on-site consultation and educational
programming for SFF Program participants
that would be carried out by quality-
improvement organizations or other
independent organizations of similar type
that are deemed appropriate by the HHS
Secretary and have no conflicts of interest.
CRS-78

Grants to Improve
No current law.
No provision.
Section 122117 would establish grants
Staffing and Infection
for states to carry out at least two of the
Control In Long-Term
fol owing three activities in eligible LTCFs:
Care Institutional Settings

Provide wage or benefit
enhancements for one or more types
of eligible workers who care for
individuals in LTCFs

Improve and develop training and
career development opportunities,
including opportunities for training for
infection control, for eligible workers
who care for individuals in LTCFs;

Expand staffing of one or more types
of eligible workers who care for
individuals in LTCFs to increase the
staffing ratio of workers to individuals.
For the aforementioned activities: SNFs,
NFs, and Intermediate Care Facility for
Individuals with Intellectual Disabilities
(ICF/IIDs) would be considered eligible
LTCFs; Medicaid recipients and all
residents of LTCFs would be considered
eligible individuals; RNs, licensed practical
nurses, licensed nursing assistants, certified
nursing assistants, nursing assistants,
infection preventionists, and any other
relevant staffers (as determined by the
CMS Administrator) who furnish services
to individuals in LTCFs, for which payment
is available under the state Medicaid
program, would be considered eligible
workers.
Beginning with FY2024, the provision
would require the HHS Secretary, acting
through the CMS Administrator, to solicit
and make four-FY-term grants to each
state (including DC and U.S. territories)
that submits an application that meets
specified requirements. To use grant funds,
CRS-79

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Provision
Current Law
H.R. 5376 as Passed by the House
Senate-Released Language
states would be required to carry out
grant-funded activities in ICF/IIDs and in
SNFs or NFs. Additionally, states would be
prohibited from using grant funds for the
nonfederal share of state expenditures
under the state Medicaid program. Each
state also must agree to continue state
spending using nonfederal funds on grant-
supported activities at amounts no less
than the state previously spent on such
activities during a specified four-quarter
period that occurred before the enactment
of the section.
Section 122117 would appropriate
$800 mil ion to the HHS Secretary for
FY2022, to remain available through
September 30, 2031, for making staffing
and infection control improvement grants.
The provision would require the CMS
Administrator, in determining the amounts
awarded to states, to consider the number
of individuals in the state and the proposed
improvements to staffing and infection
control.
Section 122117 would appropriate
$3 mil ion to the HHS Secretary for
FY2022, to remain available through
September 30, 2031, for administrative and
technical assistance costs in carrying out
this section.
Sources: CRS analysis of the BBBA as passed by the House and included in the Congressional Record, the language released by the Senate Finance Committee described
as being intended for the BBBA, and relevant current law. (The Senate HELP Committee language did not include provisions relevant to this table.) See report
introduction for links to legislative language.
Notes: This table includes provisions that affect the Medicaid and Medicare programs with respect to HCBS and LCTFs. Also see Table 4 and Table 6 for provisions
generally relevant to Medicaid and Medicare, respectively. See Appendix A for all abbreviations used in table.
a. For purposes of this report, Medicaid MFP refers to the Money Fol ows the Person Program, which is distinct from references to MFP or MFPs (maximum fair
prices), in regard to prescription drug pricing, in Table 3.
CRS-80

BBBA Health Coverage Provisions: House-Passed and Senate-Released Language

Appendix A. Abbreviations Used in This Report
Table A-1. Abbreviations Used in This Report
Abbreviation
Definition
ABP
Alternative Benefit Plan
ACA
Patient Protection and Affordable Care Act (P.L. 111-148, as amended)
ACIP
Advisory Committee on Immunization Practices
AIR
All-Inclusive Rate
AMP
Average Manufacturer Price
APTC
Advance Premium Tax Credit
ARPA
American Rescue Plan Act of 2021 (P.L. 117-2)
ASP
Average Sales Price
AV
Actuarial Value
BBA 2018
Bipartisan Budget Act of 2018 (P.L. 115-72)
BHP
Basic Health Program
CAA 2021
Consolidated Appropriations Act, 2021 (P.L. 116-260)
CCBHC
Certified Community Behavioral Health Clinic
CHIP
State Children’s Health Insurance Program
CHIPRA
Children’s Health Insurance Program Reauthorization Act (P.L. 111-3)
CMP
Civil Monetary Penalty
CMS
Centers for Medicare & Medicaid Services
CNMI
Commonwealth of the Northern Mariana Islands
CoPs
Conditions of Participation
COVID-19
Coronavirus Disease 2019
CPI-U
Consumer Price Index For All Urban Consumers
CSR
Cost-Sharing Reduction
CY
Calendar Year
DC
District of Columbia
DSH
Disproportionate Share Hospital
E-FMAP
Enhanced Federal Medical Assistance Percentage
EHB
Essential Health Benefits
ERISA
Employee Retirement Income Security Act of 1974 (P.L. 93-406)
ESRP
Employer Shared Responsibility Provisions
FDA
Food and Drug Administration
FFCRA
Families First Coronavirus Response Act (P.L. 116-127)
FFE
Federally Facilitated Exchange
FMAP
Federal Medical Assistance Percentage
FPL
Federal Poverty Level
Congressional Research Service

81

BBBA Health Coverage Provisions: House-Passed and Senate-Released Language

Abbreviation
Definition
FQHC
Federally Qualified Health Center
FTE
Ful -Time Equivalent
FY
Fiscal Year
GME
Graduate Medical Education
HCBS
Home and Community-Based Services
HCTC
Health Coverage Tax Credit
HELP
Health, Education, Labor, and Pensions
HHS
Department of Health and Human Services
HPSA
Health Professional Shortage Area
IAH
Independence at Home Program
ICF/IID
Intermediate Care Facility for Individuals with Intellectual Disabilities
IHS
Indian Health Service
IME
Indirect Medical Education
IRC
Internal Revenue Code
LIS
Low-Income Subsidy (for individuals who meet set income and asset tests)
LTCF
Long-Term Care Facility
LTSS
Long Term Services and Supports
MAGI
Modified Adjusted Gross Income
MA-PD
Medicare Advantage Prescription Drug Plan
MDS
Minimum Data Set
MEC
Minimum Essential Coverage
Medicaid MFP
Money Fol ows the Person
MFP
Maximum Fair Price
MH
Mental Health
MHP
Mental Health Parity
MOE
Maintenance of Effort
NADAC
National Average Drug Acquisition Cost
NF
Nursing Facility
OEP
Open Enrol ment Period
OIG
Office of Inspector General
PBJ
Payrol -Based Journal
PBM
Pharmacy Benefit Manager
PHSA
Public Health Service Act (P.L. 78-410)
PPS
Prospective Payment System
PTC
Premium Tax Credit
PY
Plan Year
QHP
Qualified Health Plan
Congressional Research Service

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BBBA Health Coverage Provisions: House-Passed and Senate-Released Language

Abbreviation
Definition
RCP
Retail Community Pharmacy
RHC
Rural Health Clinic
RN
Registered Nurse
SA
State Survey Agency
SEP
Special Enrol ment Period
SFF
Special Focus Facility
SNF
Skil ed Nursing Facility
SSA
Social Security Act
SUD
Substance Use Disorder
SUPPORT Act
Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment
for Patients and Communities Act (P.L. 115-271)
TY
Tax Year
U.S.C.
U.S. Code
UC
Unemployment Compensation
UIO
Urban Indian Organization
USVI
U.S. Virgin Islands
VBP
Value-Based Purchasing
Source: CRS analysis.
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Appendix B. Build Back Better Act Health Coverage
Provisions: CRS Experts
See author contact information at the end of this report.
Table B-1. Build Back Better Act Health Coverage Provisions: CRS Experts
H.R. 5376 Section
H.R. 5376 Section
Number
Title
Table in this Report
CRS Contact(s)
Title II, Subtitle B, Section
Civil Monetary Penalties
Table 1
Vanessa Forsberg
21005
for Parity Violations
Title II, Subtitle H, Section Requirements with
Table 3
Katherine Kehres
27001
Respect to Cost Sharing
for Certain Insulin
Products
Title II, Subtitle H, Section Oversight of Pharmacy
Table 3
Vanessa Forsberg
27002
Benefit Manager Services
Title III, Subtitle E, Section Ensuring Affordability of
Table 1
See sub-rows below.
30601
Coverage for Certain
Low-Income Populations
Title III, Subtitle E,
Reducing Cost Sharing
Table 1
Bernadette Fernandez
Section 30601(a)
Under Qualified Health
Plans
Title III, Subtitle E,
Open Enrol ments
Table 1
Vanessa Forsberg
Section 30601(b)
Applicable to Certain
Lower-Income
Populations
Title III, Subtitle E,
Additional Benefits for
Table 1
Vanessa Forsberg
Section 30601(c)
Certain Low-Income
Individuals for Plan Years
2024 and 2025
Title III, Subtitle E,
Education and Outreach
Table 1
Vanessa Forsberg
Section 30601(d)
Activities
Title III, Subtitle E,
Funding
Table 1
Vanessa Forsberg
Section 30601(e)
Title III, Subtitle E, Section Establishing a Health
Table 1
See sub-rows below.
30602
Insurance Affordability
Fund
Title III, Subtitle E,
In General
Table 1
Ryan Rosso
Section 30602(a)
Title III, Subtitle E,
Basic Health Program
Table 1
Ryan Rosso and Alison
Section 30602(b)
Funding Adjustments
Mitchell
Title III, Subtitle E,
Implementation Authority
Table 1
Ryan Rosso
Section 30602(c)
Title III, Subtitle E, Section Funding for the Provision
Table 1
Vanessa Forsberg
30603
of Health Insurance
Consumer Information
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H.R. 5376 Section
H.R. 5376 Section
Number
Title
Table in this Report
CRS Contact(s)
Title III, Subtitle E, Section Requirements with
Table 3
Katherine Kehres
30604
Respect to Cost Sharing
for Insulin Products
Title III, Subtitle E, Section Cost-Sharing Reductions
Table 1
Bernadette Fernandez
30605
for Individuals Receiving
Unemployment
Compensation
Title III, Subtitle E, Section Oversight of Pharmacy
Table 3
Katherine Kehres
30606
Benefit Manager Services
Title III, Subtitle E, Section Funding to Support State
Table 1
Ryan Rosso
30607
Applications for Section
1332 Waivers and
Administration
Title III, Subtitle E, Section Adjustments to
Table 4
Alison Mitchell
30608
Uncompensated Care
Pools and
Disproportionate Share
Hospital Payments
Title III, Subtitle E, Section Further Increase in FMAP
Table 4
Alison Mitchell
30609
for Medical Assistance for
Newly Eligible Mandatory
Individuals
Title III, Subtitle F, Section Medicaid HCBS
Table 7
Kirsten Colello
30711
Improvement Planning
Grants
Title III, Subtitle F, Section Medicaid HCBS
Table 7
Kirsten Colello and
30712
Improvement Program
Alison Mitchell
Title III, Subtitle F, Section Funding for Federal
Table 7
Kirsten Colello
30713
Activities Related to
Medicaid HCBS
Title III, Subtitle F, Section Funding for HCBS Quality
Table 7
Amanda Sarata and Alison
30714
Measurement and
Mitchell
Improvement
Title III, Subtitle F, Section Permanent Extension of
Table 7
Kirsten Colello
30715
Medicaid Protections
Against Spousal
Impoverishment for
Recipients of Home and
Community-Based
Services
Title III, Subtitle F, Section Permanent Extension of
Table 7
Kirsten Colello
30716
Medicaid Money Fol ows
the Person Rebalancing
Demonstration
Title III, Subtitle F, Section Funding to Improve the
Table 7
Phoenix Voorhies
30717
Accuracy and Reliability of
Certain Skil ed Nursing
Facility Data
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H.R. 5376 Section
H.R. 5376 Section
Number
Title
Table in this Report
CRS Contact(s)
Title III, Subtitle F, Section Ensuring Accurate
Table 7
Phoenix Voorhies
30718
Information on Cost
Reports
Title III, Subtitle F, Section Survey Improvements
Table 7
Phoenix Voorhies
30719
Title III, Subtitle F, Section Nurse Staffing
Table 7
Phoenix Voorhies
30720
Requirements
Title III, Subtitle F, Section Extending Continuous
Table 4
Evelyne Baumrucker
30721
Coverage for Pregnant
and Postpartum
Individuals
Title III, Subtitle F, Section State Option to Provide
Table 4
Evelyne Baumrucker
30722
Coordinated Care
Through a Maternal
Health Home for
Pregnant and Postpartum
Individuals
Title III, Subtitle F, Section Increasing Medicaid Cap
Table 4
Alison Mitchell
30731
Amounts and the FMAP
for the Territories
Title III, Subtitle F, Section Investments to Ensure
Table 4
See sub-rows below.
30741
Continued Access to
Health Care for Children
and Other Individuals
Title III, Subtitle F,
Providing for One Year of Table 4
Evelyne Baumrucker
Section 30741(a)
Continuous Eligibility for
Children
Title III, Subtitle F,
Revisions to Temporary
Table 4
Alison Mitchell and
Section 30741(b)
Increase of Medicaid
Evelyne Baumrucker
FMAP Under the Families
First Coronavirus
Response Act
Title III, Subtitle F,
Medical Assistance Under
Table 4
Evelyne Baumrucker
Section 30741(c)
Medicaid for Inmates
During 30-Day Period
Preceding Release
Title III, Subtitle F,
Extension of Certain
Table 4
Evelyne Baumrucker
Section 30741(d)
Provisions
Title III, Subtitle F,
Expansion of Community
Table 4
Alison Mitchell
Section 30741(e)
Mental Health Services
Demonstration Program
Title III, Subtitle F,
Making Permanent a State
Table 4
Alison Mitchell
Section 30741(f)
Option to Provide
Qualifying Community-
Based Mobile Crisis
Intervention Services
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H.R. 5376 Section
H.R. 5376 Section
Number
Title
Table in this Report
CRS Contact(s)
Title III, Subtitle F,
Extension of 100% FMAP
Table 4
Alison Mitchell and Elayne
Section 30741(g)
for Urban Indian Health
Heisler
Organizations and Native
Hawaiian Health Care
Systems
Title III, Subtitle F,
Ensuring Accurate
Table 4
Cliff Binder
Section 30741(h)
Payments to Pharmacies
Under Medicaid
Title III, Subtitle F,
Funding for
Table 4
Alison Mitchell
Section 30741(i)
Implementation And
Administration
Title III, Subtitle F, Section Encouraging Continued
Table 4
Evelyne Baumrucker and
30751
Access After the End of
Alison Mitchell
the Public Health
Emergency
Title III, Subtitle G,
Investments to Strengthen Table 5
See sub-rows below.
Section 30801
CHIP
Title III, Subtitle G,
Permanent Extension of
Table 5
Alison Mitchell
Section 30801(a)
Children’s Health
Insurance Program
Title III, Subtitle G,
Pediatric Quality
Table 5
Amanda Sarata
Section 30801(b)(1)
Measures Program
Title III, Subtitle G,
Assurance of Eligibility
Table 5
Evelyne Baumrucker
Section 30801(b)(2)
Standards for Children
Title III, Subtitle G,
Qualifying States Option
Table 5
Alison Mitchell
Section 30801(b)(3)
Title III, Subtitle G,
Outreach and Enrol ment
Table 5
Evelyne Baumrucker
Section 30801(b)(4)
Program
Title III, Subtitle G,
Child Enrol ment
Table 5
Alison Mitchell
Section 30801(b)(5)
Contingency Fund
Title III, Subtitle G,
CHIP Drug Rebates
Table 5
Cliff Binder
Section 30801(c)
Title III, Subtitle G,
State Option to Expand
Table 5
Evelyne Baumrucker
Section 30801(d)
Children’s Eligibility for
Medicaid and CHIP
Title III, Subtitle G,
Funding for
Table 5
Alison Mitchell
Section 30801(e)
Implementation and
Administration
Title III, Subtitle H,
Providing Coverage for
Table 6
Paulette Morgan and Jim
Section 30901
Hearing Care Under the
Hahn
Medicare Program
Title XIII, Subtitle B,
Registered Professional
Table 6
Phoenix Voorhies
Section 132000
Nurses
Title XIII, Subtitle B,
Permanent Extension of
Table 6
Jim Hahn
Section 132001
the Independence at
Home Medical Practice
Demonstration Program
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H.R. 5376 Section
H.R. 5376 Section
Number
Title
Table in this Report
CRS Contact(s)
Title XIII, Subtitle G,
Improve Affordability and
Table 2
Bernadette Fernandez
Section 137301
Reduce Premium Costs of
Health Insurance for
Consumers
Title XIII, Subtitle G,
Modification of Employer-
Table 2
Bernadette Fernandez
Section 137302
Sponsored Coverage
Affordability Test in
Health Insurance
Premium Tax Credit
Title XIII, Subtitle G,
Treatment of Lump-Sum
Table 2
Bernadette Fernandez
Section 137303
Social Security Benefits in
Determining Household
Income
Title XIII, Subtitle G,
Temporary Expansion of
Table 2
Bernadette Fernandez and
Section 137304
Health Insurance
Ryan Rosso
Premium Tax Credits for
Certain Low-Income
Populations
Title XIII, Subtitle G,
Special Rule for
Table 2
Bernadette Fernandez
Section 137305
Individuals Receiving
Unemployment
Compensation
Title XIII, Subtitle G,
Permanent Credit for
Table 2
Bernadette Fernandez
Section 137306
Health Insurance Costs
Title XIII, Subtitle G,
Exclusion of Certain
Table 2
Bernadette Fernandez
Section 137307
Dependent Income for
Purposes of Premium Tax
Credit
Title XIII, Subtitle G,
Requirements with
Table 3
Katherine Kehres
Section 137308
Respect to Cost Sharing
for Certain Insulin
Products
Title XIII, Subtitle G,
Oversight of Pharmacy
Table 3
Katherine Kehres
Section 137309
Benefit Manager Services
Title XIII, Subtitle G,
Administrative Funding of
Table 6
Marco Vil agrana
Section 137401
the Rural and
Underserved Pathway to
Practice Training
Programs for Post-
Baccalaureate Students,
Medical Students, and
Medical Residents
Title XIII, Subtitle G,
Establishing Rural and
Table 6
Elayne Heisler
Section 137402
Underserved Pathway to
Practice Training Program
for Post-Baccalaureate
Students and Medical
Students
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H.R. 5376 Section
H.R. 5376 Section
Number
Title
Table in this Report
CRS Contact(s)
Title XIII, Subtitle G,
Funding for the Rural and
Table 6
Margot Crandall-Hol ick
Section 137403
Underserved Pathway to
Practice Training Program
for Post-Baccalaureate
Students and Medical
Students
Title XIII, Subtitle G,
Establishing Rural and
Table 6
Marco Vil agrana
Section 137404
Underserved Pathway to
Practice Training Program
for Medical Residents
Title XIII, Subtitle G,
Distribution of Additional
Table 6
Marco Vil agrana
Section 137405
Residency Positions
Title XIII, Subtitle I,
Providing for Lower
Table 3
Suzanne Kirchhoff
Section 139001
Prices for Certain High-
Priced Single-Source
Drugs
Title XIII, Subtitle I,
Selected Drug
Table 3
Suzanne Kirchhoff and
Section 139002
Manufacturer Excise Tax
Edward Liu
Imposed During
Noncompliance Periods
Title XIII, Subtitle I,
Funding
Table 3
Suzanne Kirchhoff
Section 139003
Title XIII, Subtitle I,
Medicare Part B Rebate
Table 3
Cliff Binder
Section 139101
by Manufacturers
Title XIII, Subtitle I,
Medicare Part D Rebate
Table 3
Suzanne Kirchhoff
Section 139102
by Manufacturers
Title XIII, Subtitle I,
Medicare Part D Benefit
Table 3
Suzanne Kirchhoff
Section 139201
Redesign
Title XIII, Subtitle I,
Maximum Monthly Cap
Table 3
Suzanne Kirchhoff
Section 139202
on Cost-Sharing Payments
Under Prescription Drug
Plans and MA-PD Plans
Title XIII, Subtitle I,
Prohibiting
Table 3
Suzanne Kirchhoff
Section 139301
Implementation of Rule
Relating to Eliminating the
Anti-Kickback Statute Safe
Harbor Protection for
Prescription Drug
Rebates
Title XIII, Subtitle I,
Appropriate Cost Sharing
Table 3
Suzanne Kirchhoff
Section 139401
for Certain Insulin
Products Under Medicare
Part D
Title XIII, Subtitle I,
Coverage of Adult
Table 3
Suzanne Kirchhoff
Section 139402
Vaccines Recommended
by the Advisory
Committee on
Immunization Practices
Under Medicare Part D
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H.R. 5376 Section
H.R. 5376 Section
Number
Title
Table in this Report
CRS Contact(s)
Title XIII, Subtitle I,
Payment for Biosimilar
Table 3
Cliff Binder
Section 139403
Biological Products
During Initial Period
Title XIII, Subtitle I,
Temporary Increase in
Table 3
Cliff Binder
Section 139404
Medicare Part B Payment
for Certain Biosimilar
Biological Products
Title XIII, Subtitle I,
Improving Access to
Table 3
Evelyne Baumrucker
Section 139405
Adult Vaccines Under
Medicaid and CHIP
Senate-Released BBBA Provisions Not Included in H.R. 5376
Title XII, Subtitle B,
Improvements to the
Table 7
Phoenix Voorhies
Section 122116
Special Focus Facility
Program
Title XII, Subtitle B,
Grants to Improve
Table 7
Phoenix Voorhies
Section 122117
Staffing and Infection
Control in Long-Term
Care Institutional Settings
Source: Created by CRS.
Notes: For purposes of this table, the Build Back Better Act (BBBA) refers to the H.R. 5376, as passed by the
House, and the language released by the Senate Finance Committee and the Senate Committee on Health,
Education, Labor, and Pensions described as being intended for the BBBA.

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BBBA Health Coverage Provisions: House-Passed and Senate-Released Language

Author Information

Vanessa C. Forsberg, Coordinator
Suzanne M. Kirchhoff
Analyst in Health Care Financing
Analyst in Health Care Financing

Ryan J. Rosso, Coordinator
Megan S. Lynch
Analyst in Health Care Financing
Specialist on Congress and the Legislative Process

Evelyne P. Baumrucker
Alison Mitchell
Specialist in Health Care Financing
Specialist in Health Care Financing

Cliff Binder
Paulette C. Morgan
Analyst in Health Care Financing
Specialist in Health Care Financing

Kirsten J. Colello
Isaac A. Nicchitta
Specialist in Health and Aging Policy
Research Assistant

Margot L. Crandall-Hollick
Amanda K. Sarata
Specialist in Public Finance
Specialist in Health Policy

Bernadette Fernandez
Marco A. Villagrana
Specialist in Health Care Financing
Analyst in Health Care Financing

Jim Hahn
Phoenix Voorhies
Specialist in Health Care Financing
Analyst in Health Care Financing

Elayne J. Heisler

Specialist in Health Services

Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan
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under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other
than public understanding of information that has been provided by CRS to Members of Congress in
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not
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