H.R. 3911 — Choose Medicare Act

This section establishes Medicare part E public health plans (public option plans) available in the individual, small group, and large group health insurance markets. These plans are qualified health plans under the Affordable Care Act (ACA) that (1) provide essential health benefits under ACA section 1302(b) (42 U.S.C. 18022(b)), all Medicare part A and B benefits, gold-level coverage under ACA section 1302(d)(1)(C), and abortion and reproductive services (preempting state prohibitions); (2) are offered through ACA Exchanges (including SHOPs) in the individual and small group markets; (3) are available to U.S. residents not entitled to Medicare, Medicaid, or CHIP; and (4) include employer-sponsored options in small and large group markets with portability for individuals losing employer coverage. The Secretary sets premiums sufficient to cover benefits and administrative costs (compliant with ACA rating rules), reimburses providers at negotiated rates between Medicare fee-for-service levels and average Exchange insurer rates to ensure network adequacy, deems existing Medicare providers as participating, and applies Medicare balance-billing limits.

This section amends Section 18B of the Fair Labor Standards Act of 1938 (29 U.S.C. 218b), which requires employers to provide employees written notice about state health insurance Exchanges (i.e., ACA Marketplaces). Specifically, it (1) requires employers that do not offer minimum essential coverage or offer a plan that is unaffordable or fails to provide minimum value (per IRC §§5000A(f)(2) and 36B(c)(2)(C)) to refer full-time employees (per IRC §4980H(c)) to a state Exchange navigator (per ACA §1311(i)) or equivalent at hiring (or two years after enactment of the Choose Medicare Act for current employees); (2) directs the Comptroller General to study the impact of these requirements on uninsured rates (per IRC §5000A(f)) by January 1, 2030; and (3) authorizes appropriations for ACA navigator grants (42 U.S.C. 18031(i)(6)) to address capacity limitations. (Navigator referrals take effect two years after enactment, while notices remain effective from March 1, 2013.)

This section establishes an annual out-of-pocket limit on cost-sharing for Medicare Parts A and B fee-for-service enrollees (i.e., traditional Medicare beneficiaries), beginning in 2027 at $6,700 and adjusted annually thereafter by the percentage change in the medical care component of the Consumer Price Index for All Urban Consumers (rounded to the nearest $5). Once the limit is reached in a year, the beneficiary incurs no further cost-sharing for covered Parts A or B deductibles, coinsurance, copayments, or exhausted benefits (excluding non-covered services and excess charges above assignment-related amounts for non-participating providers); the Secretary must announce each year's limit beginning in 2026. (Thus, Medicare fee-for-service—unlike Medicare Advantage, which already caps out-of-pocket costs—imposes no overall annual limit under current law.)

This section modifies the premium tax credit for Affordable Care Act (ACA) Marketplace health insurance—i.e., refundable tax credits that help eligible individuals and families cover premiums based on a benchmark plan premium minus a required contribution determined by household income as a percentage of the federal poverty level (FPL)—effective for taxable years beginning after December 31, 2025, by (1) replacing references to the second lowest cost silver plan (70% actuarial value) with the second lowest cost gold plan (80% actuarial value) as the benchmark for credit calculations and affordability tests (thus increasing credit amounts), and (2) eliminating the 400% FPL eligibility cap and related provisions while revising the applicable percentage table to extend enhanced contribution rates on a sliding scale to all income levels.

This section revises the cost-sharing reduction (CSR) program under the ACA, which reduces enrollees' deductibles, copays, and other cost-sharing in qualified health plans (QHPs) offered through an Exchange for eligible individuals with household incomes between 100% and 400% of the federal poverty level (FPL), by (1) expanding eligibility from silver level QHPs (standard 70% actuarial value, or AV) to gold level QHPs (standard 80% AV); and (2) replacing the prior reduction methodology—primarily fractional reductions in out-of-pocket limits with AV caps of 94% (100-150% FPL), 87% (150-200% FPL), 73% (200-250% FPL), and 70% (250-400% FPL)—with required increases in the QHP's AV to 94% (100-133% FPL), 92% (133-150% FPL), 90% (150-200% FPL), 85% (200-300% FPL), and 80% (300-400% FPL), including conforming updates to the AV caps. The amendments apply to plan years beginning after December 31, 2025. (Thus, the changes enhance subsidies with higher AVs across more granular income bands and shift them to gold plans, potentially lowering enrollee costs further relative to silver plans.)

This section establishes a program, administered by the Secretary in consultation with the National Association of Insurance Commissioners, to enable each state for plan years beginning in the 3-year period starting January 1, 2026, to either (1) provide reinsurance payments to health insurance issuers with respect to individuals enrolled in individual market coverage or (2) provide assistance—other than reinsurance—to reduce out-of-pocket costs (such as copayments, coinsurance, premiums, and deductibles) for individuals enrolled in qualified health plans offered through an Exchange. The program is funded by a $30 billion appropriation for FY2026 through FY2028, to remain available until expended.

This section expands the prohibition on discriminatory premium rates to health insurance coverage offered in the individual or group market (previously limited to the individual or small group market only) by striking the special rule for the large group market. (Thus, premium rates for all such coverage may vary only by individual or family enrollment, rating area, age (maximum 3-to-1 ratio for adults), and tobacco use (maximum 1.5-to-1 ratio) and by no other factors.) The amendments apply to plans offered in the first plan year beginning after the date of enactment.

This section revises health insurance rate review requirements under Section 2794 of the Public Health Service Act (i.e., the program requiring review of potentially unreasonable rate increases) by expanding the scope to excessive, unjustified, or unfairly discriminatory rates, including premiums (previously, unreasonable premium increases); authorizing states to impose more protective requirements; directing the Secretary to consult with the National Association of Insurance Commissioners and consumer groups, determine whether states or the Secretary conducts reviews in each market, and take corrective actions such as denying rates, modifying rates, or requiring consumer rebates; and imposing civil monetary penalties for noncompliance, with potential ineligibility for qualified health plan status. The section makes conforming terminology changes throughout Section 2794 and in other ACA provisions. It further applies these rate review requirements to grandfathered health plans (i.e., plans enrolled on March 23, 2010, exempt from many ACA reforms) for plan years beginning on or after January 1, 2026 (previously inapplicable). Amendments take effect on enactment and apply to plans beginning not later than January 1, 2026.

This section expresses the sense of Congress that (1) the federal government, acting as an insurer, employer, or health care provider, should serve as a model by ensuring coverage of all reproductive services; and (2) all restrictions on coverage of reproductive services in the private insurance market should end.