H.R. 3080 — Health Care Fairness for All Act

This section terminates the individual health insurance mandate (i.e., the tax penalty under IRC §5000A for failing to maintain minimum essential health coverage) for months beginning after December 31, 2024. (Thus, individuals face no penalty for lacking such coverage beginning in 2025.)

This section repeals the employer mandate for health insurance (i.e., IRC §4980H), which imposes penalties on applicable large employers (generally those with 50 or more full-time employees) that fail to offer affordable minimum essential coverage to full-time employees or have at least one full-time employee receiving a premium tax credit. It also repeals related employer reporting requirements (IRC §6056), eliminates a required study and report under the Affordable Care Act, and makes conforming amendments, with the repeal generally effective for months beginning more than 30 days after enactment (and the study repeal effective immediately).

This section provides that an employer health care arrangement—such as a health reimbursement arrangement (HRA) or other employment plan—under which an employer reimburses an employee for premiums for individual health insurance coverage does not constitute a group health plan for purposes of the Public Health Service Act (including sections 2711 and 2714), the Affordable Care Act (P.L. 111-148), ERISA, the Internal Revenue Code of 1986 (other than section 36B), HIPAA (including privacy regulations), and COBRA continuation coverage requirements. (Thus, such arrangements are exempt from group health plan requirements under those laws, except for premium tax credit eligibility.)

This section limits the application of title XXVII of the Public Health Service Act (PHSA), as amended by the Patient Protection and Affordable Care Act (ACA, P.L. 111-148), to group health plans and health insurance coverage in the individual and group markets—whether offered through an ACA Exchange or not—by generally reverting to pre-ACA PHSA provisions, except for the following ACA consumer protections that continue to apply: (1) no lifetime or annual limits under PHSA §2711 (except for limited benefit insurance as defined in §122(b)); (2) dependent coverage through age 26 under §2714; (3) modified guaranteed availability under §2702; (4) guaranteed renewability under §2703; (5) prohibition on preexisting condition exclusions under §2704; (6) prohibition on discrimination based on health status under §2705; and (7) nondiscrimination in health care under §2706. The section imposes a late enrollment penalty on individuals lacking at least 12 months of continuous creditable coverage: a 20% increase in monthly premiums per consecutive 12-month coverage gap (ending before enrollment), applied for up to three times the length of the most recent gap (as specified by the Secretary of Health and Human Services). The section directs coordination of pre-ACA PHSA provisions with continuing ACA protections by treating the latter as incorporated into relevant pre-ACA subparts of PHSA, ERISA (29 U.S.C. 1181 et seq.), and the Internal Revenue Code; in conflicts, continuing protections control, with interagency rulemaking required. States may seek waivers of the late enrollment penalty for alternative continuous-coverage incentives deemed similar or stronger by the Secretary.

This section conditions the availability of premium tax credits under IRC §§36B and 36C for a state's residents on state-based Exchanges offering basic health insurance—defined to include state-specified coverage and limited benefit insurance (i.e., individual coverage with Secretary-specified annual benefit limits that may vary by individual or family)—in all areas of the state. This section further protects assets of individuals who exhaust annual limits under limited benefit insurance from liability for costs of subsequent items and services in the plan year, insofar as such liability exceeds the bankruptcy valuation of the individual's property minus the annual limit; such protected property is exempt from attachment or seizure related to the debt. (Thus, after exhaustion, health care providers are not required to furnish further services without payment arrangements, except as required under other laws such as EMTALA (i.e., the Emergency Medical Treatment and Labor Act, which mandates hospitals with emergency departments to screen and stabilize individuals with emergency medical conditions regardless of ability to pay).)

This section defines short-term limited duration insurance, for purposes of its exclusion from the definition of health insurance coverage under PHS Act §2791(b)(5), by reference to the rule entitled “Short-Term, Limited Duration Insurance” (83 Fed. Reg. 38212, Aug. 3, 2018). (As background, such insurance is exempt from Affordable Care Act requirements applicable to individual and small group markets, including guaranteed issue, essential health benefits, and premium rating limits.)

This section makes permanent all Medicare telehealth flexibilities in section 1834(m) of the Social Security Act (i.e., coverage of telehealth services under Medicare Part B, including waivers of geographic restrictions on originating sites, expanded eligible distant sites and practitioner types, and audio-only consultations) that otherwise would expire at the end of the COVID-19 public health emergency under section 1135(g)(1)(B) or on December 1, 2026. (Thus, Medicare continues reimbursing such services indefinitely without those temporary pandemic-era limits.)

This section establishes a new health insurance tax credit (IRC §36C) for qualified residents covered by creditable coverage. The credit equals the sum of monthly amounts of up to 1/12 of $4,000 per qualified resident (twice that amount for a joint return if both spouses qualify and are covered) plus 1/12 of $2,000 per qualifying child (within the meaning of IRC §152) who is a qualified resident, eligible for the dependency exemption under IRC §151, and covered, subject to (1) reduction for limited benefit insurance based on its actuarial value relative to standard coverage, and (2) a monthly cap equal to the taxpayer's HSA contributions plus premiums paid for creditable coverage (with carryforwards allowed for excesses in either direction). The annual credit is further limited to the excess of the maximum credit over the taxpayer's employer-provided health insurance tax subsidy (i.e., the value of federal income and payroll tax exclusions for employer-sponsored coverage), with any excess subsidy included in gross income.

This section establishes a grant program under which the Secretary of HHS, using 25% of aggregate unused tax credits under IRC §36C(d)(3) for qualified residents of each state (calculated annually beginning in 2026 as the excess of maximum allowable credits over credits actually allowed), appropriates funds (beginning in FY2025) for states to assist in furnishing health services to uninsured individuals or to increase disproportionate share hospital (DSH) payment adjustments under Medicare (§1886(d)(5)(F)) and Medicaid (§1923). (As background, DSH adjustments provide additional payments to hospitals serving disproportionate numbers of low-income patients.) States apply for grants up to their unused credit amount, with payments based on initial estimates reconciled after year-end.

This section authorizes a state Medicaid plan to permit eligible individuals—those entitled to a full range of acute care services—to opt, in lieu of standard medical assistance, for coverage under a private health plan qualifying for a tax credit under IRC §36C (26 U.S.C. 36C), with the state depositing into the individual's health savings account (HSA) an amount equal to such tax credit minus the coverage cost. For federal financial participation (FFP) purposes under Medicaid (42 U.S.C. 1396b), such state payments for plan coverage and HSA deposits are treated as medical assistance, subject to the federal medical assistance percentage (FMAP) and state matching requirements, but reduced by any §36C tax credits provided.

This section repeals the requirement under IRC §6051(a)(14) for employers to report the aggregate cost of employer-sponsored health coverage (i.e., premiums and benefits) on employees' Forms W-2, effective for calendar years beginning after December 31, 2018. (Thus, employers are relieved of this reporting obligation for tax years 2019 and later.)

This section directs the Secretary of Health and Human Services to submit to Congress, for each year beginning on or after the date of enactment, a report evaluating whether health insurance tax credits under new IRC §36C (as added by this Act) sufficiently cover the cost of health insurance for individuals electing such coverage.

This section prohibits the Secretary of Health and Human Services, when designating services as hospital outpatient department services eligible for payment under the Medicare outpatient prospective payment system (OPPS), from refusing such designation solely on the basis that the service may only be safely furnished in an inpatient setting. (Thus, Medicare's inpatient-only list—which excludes certain procedures (e.g., certain surgeries) from OPPS payment—may no longer serve as the sole basis for exclusion.)

This section promotes Medicare site-neutral payments (i.e., applying lower physician fee schedule rates instead of higher hospital outpatient prospective payment system rates) for services furnished at off-campus outpatient departments (OPDs) of providers (generally, hospitals). (As background, off-campus OPDs established on or after November 2, 2015, generally receive site-neutral payments except for dedicated emergency departments and certain other excepted locations.) Specifically, the section (1) redefines an off-campus OPD under SSA section 1833(t)(21)(B) as a hospital department not located on the hospital campus or within the specified distance from a remote hospital location (per 42 CFR 413.65(a)(2), as of the Bipartisan Budget Act of 2015 enactment), effective for services furnished on or after January 1, 2026; (2) limits the site-neutral payment exception for off-campus emergency departments to services furnished before January 1, 2026; (3) authorizes the Secretary to implement site-neutral policies under SSA section 1833(t)(2)(F), including preventing hospitals from billing off-campus OPD services as on-campus; (4) requires HIPAA unique identifier standards under SSA section 1173(b) to assign separate National Provider Identifiers (NPIs) to off-campus OPDs by January 1, 2026; and (5) directs the Secretary to revise 45 CFR 162.408 and 162.410 by January 1, 2026, to treat off-campus OPDs as subparts assigned unique NPIs. (Thus, these changes narrow exceptions to site-neutral payments and enable distinct billing for off-campus OPDs to enforce lower rates.)

This section authorizes Medicare Advantage plans to make deposits to a Roth HSA (as described in section 530A of the Internal Revenue Code of 1986) for chronically ill enrollees as a supplemental benefit. (Medicare Advantage plans must cover all Medicare Parts A and B benefits and may use rebate payments to provide supplemental benefits beyond those required benefits.)

This section expands Medicare Part A coverage of inpatient hospital services and inpatient critical access hospital services to include those (including telehealth services) furnished through an Acute Hospital Care at Home Program (as defined by the Secretary), beginning on the date of enactment. (As background, such programs enable hospitals to provide acute-level inpatient care in beneficiaries' homes as an alternative to facility-based hospitalization.) Specifically, it (1) waives geographic restrictions on telehealth under section 1834(m)(4)(C)(i) and permits services at a beneficiary's home or temporary residence; (2) satisfies 24-hour nursing conditions of participation through virtual access to nurses, advanced practice providers, or physicians; (3) deems life safety code requirements met for homes or temporary residences the program determines safe and appropriate; and (4) requires the Secretary to issue health and safety regulations for such programs within 12 months of enactment.