H.R. 1776 — New Health Options Act of 2025

This section establishes a Reinsurance Program, administered by the Secretary of Health and Human Services, to make payments to health insurance issuers for claims above an attachment point of $110,000 (90% payment proportion, up to a $300,000 cap per eligible individual) for individuals enrolled in certain off-Exchange individual market plans for 2026-2030, funded by an annual appropriation of $50 per member month (capped at $6 billion per year). (Covered plans are those for which the issuer elects under amended ACA §1312(c)(1)(A) to opt out of the single individual market risk pool and that exclude coverage of abortions; the Secretary may adjust parameters to stay within funding limits, and unexpended funds carry forward. Thus, the program aims to lower premiums in this new risk pool segment by reinsuring high-cost claims.) This section further (1) permits issuers to elect to exclude non-grandfathered, non-qualified health plans (QHPs) from the single risk pool under ACA §1312(c)(1)—with opted-out plans forming their own risk pool—effective for plan years beginning on or after January 1, 2026; (2) prohibits QHPs (under ACA §1301(a)(1)) from making that election and requires QHPs to maintain a 3-to-1 age rating ratio (consistent with PHS Act §2707(c)); and (3) removes the 3-to-1 age rating limit under PHS Act §2701(a)(1)(A)(iii) for opted-out plans, allowing actuarially justified variation, effective for plan years beginning on or after January 1, 2026. (As background, ACA single risk pool rules require issuers to combine enrollees across all individual market plans for premium rating purposes; QHPs are certified plans offered on state or federal Exchanges that must cover essential health benefits and meet other standards.)

This section establishes a new requirement under the Public Health Service Act for group health plans and health insurance issuers offering group or individual health insurance coverage to apply an enrollee's out-of-pocket costs for certain out-of-network items and services—at the enrollee's option—to the deductible or out-of-pocket maximum applicable to in-network providers and facilities, provided (1) benefits are available under the plan or coverage for the item or service and (2) the out-of-network charge does not exceed the lowest in-network payment rate for that service in the same rating area or the 25th percentile of statewide charges for that service. Plans and issuers must disclose these benchmark amounts to enrollees for each covered item or service. (Thus, enrollees may satisfy in-network cost-sharing using low-cost out-of-network services.) The requirement applies to plan years beginning on or after January 1, 2026.

This section requires each health care provider and health care facility, beginning January 1, 2026, to disclose to patients and prospective patients enrolled in a group health plan, group or individual health insurance coverage, or Federal health care program (as defined in section 1128B(f) of the Social Security Act, 42 U.S.C. 1320a-7b(f), including the Federal Employees Health Benefits program under 5 U.S.C. ch. 89) whether the patient's cost-sharing amount (i.e., deductibles, copayments, and coinsurance) for an item or service exceeds the cash price charged to an uninsured individual for the same item or service. It further authorizes an individual harmed by a violation to bring a civil action in federal district court against the provider or facility for injunctive relief and damages equal to the amount available under the law of the state where the provider or facility is located.