H.R. 6501 — Bipartisan Health Insurance Affordability Act

This section extends and modifies the enhanced premium tax credit (PTC) under IRC §36B—available to eligible individuals and families to subsidize premiums for qualified health plans purchased through Affordable Care Act marketplaces—for taxable years 2026 and 2027 (from 2021-2025). Specifically, it (1) sets the PTC amount for households at or below 150% of the federal poverty line (FPL) as the excess of the lesser of the benchmark plan or second-lowest-cost silver plan premium over $5; (2) provides a linear sliding scale reduction in the PTC for households between 150% and 200% FPL, from the amount under (1) to an amount reflecting a 2% required contribution; (3) applies a new table of initial and final premium percentages for households above 200% FPL (previously reverting to pre-2021 table above 400% FPL), as follows— | Household income (% of FPL) | Initial premium % | Final premium % | |-----------------------------|-------------------|-----------------| | 200-250 | 2.0 | 4.0 | | 250-300 | 4.0 | 6.0 | | 300-400 | 6.0 | 8.5 | | 400-600 | 8.5 | 8.5 | | 600-700 | 8.5 | 9.25 | —and (4) extends PTC eligibility to households up to 700% FPL (from 400%). (Thus, under prior law after 2025, households above 400% FPL would receive no PTC, and required contributions would revert to the original scale of 2.0-9.5% of income up to 400% FPL.)

This section imposes new civil and criminal penalties on agents and brokers who negligently, knowingly, or willfully provide incorrect or fraudulent information in applications for enrollment in qualified health plans through an Exchange and requires the Secretary to establish a verification process for agent- or broker-assisted enrollments and coverage changes in federally-facilitated Exchanges (i.e., those operated by the Secretary under section 1321(c)(1)) for plan years beginning no later than January 1, 2029. Specifically, it (1) subjects negligent agents or brokers to civil penalties of $10,000-$50,000 per affected individual; (2) subjects those committing knowing violations to civil penalties of up to $200,000 per individual (with procedures mirroring those under Social Security Act section 1128A); and (3) subjects those acting knowingly and willfully to criminal penalties including fines under 18 U.S.C. and imprisonment for up to 10 years. The verification process requires, among other elements, proof of enrollee consent (e.g., standardized form), withholding of commissions until inconsistencies are resolved, notifications of changes to individuals, and online or hotline access to account information including agent of record. (Thus, these measures aim to reduce fraudulent enrollments in Affordable Care Act Exchanges, which facilitate qualified individuals' and small employers' purchase of health coverage.)

This section directs the Secretary of Health and Human Services to revise regulations to extend the annual open enrollment period for American Health Benefit Exchanges for plan year 2026 to end on March 1, 2026 (from January 15, 2026), beginning on November 1, 2025. (Thus, consumers have an additional 45 days to enroll in or change qualified health plans through Exchanges.)

This section establishes requirements for pharmacy benefit managers (PBMs) under contracts with prescription drug plan (PDP) sponsors in Medicare Part D (i.e., the voluntary outpatient prescription drug benefit program), for plan years beginning on or after January 1, 2029. Such requirements include (1) prohibiting PBMs and affiliates from deriving remuneration other than bona fide service fees for services related to covered Part D drugs (with exceptions for qualifying incentive payments and manufacturer rebates or discounts fully passed through to PDP sponsors), subjecting remuneration arrangements to Secretary review for fair market value, and requiring disgorgement of improper remuneration; (2) mandating PBM transparency in defining terms (e.g., generic drug, brand name drug), identifying exclusions, and calculating pricing guarantees or cost performance measures using wholesale acquisition cost equivalents where applicable; and (3) requiring PBMs to submit annual reports to PDP sponsors and the Secretary by July 1, beginning in 2029.

This section amends ERISA §408(b)(2), which exempts reasonable contracts or arrangements for necessary services with parties in interest (including covered service providers) from prohibited transaction restrictions under §406, by (1) adding an exception from §406(a)(1)(C) and (D) for a responsible plan fiduciary who reasonably was unaware of a covered service provider's failure to remit required amounts under §408(b)(2)(C)(i) (typically, participant contributions), provided the fiduciary promptly requests written remission and notifies the Secretary of Labor if not received within 90 days; and (2) establishing, for plan years beginning on or after 30 months after enactment of this provision, a new reasonableness condition for pharmacy benefit management (PBM) service contracts (or renewals/extensions) provided to group health plans through health insurance issuers, third-party administrators, or PBM entities, requiring 100% pass-through of drug-related rebates, fees, alternative discounts, and other remuneration from applicable entities (e.g., drug manufacturers, rebate aggregators) to the plan or issuer on a quarterly basis not later than 90 days after quarter-end (or sooner for underpayments), with full disclosure, annual audit availability, return of over-remitted amounts, upstream quarterly remittance by aggregators or group purchasing organizations within 45 days, and audit access to underlying rebate contracts (subject to confidentiality limits). (Thus, PBMs may not retain any such remuneration, enhancing plan recovery of drug cost savings.)

This section establishes eligibility for Health Savings Accounts (HSAs) for "qualified Exchange enrollees" (i.e., individuals enrolled, as of the first day of a month, in the lowest-cost bronze qualified health plan available through an Affordable Care Act (ACA) Exchange or in an Exchange plan with a lower monthly premium than their prior year's Exchange plan), treating them as HSA-eligible individuals for the full taxable year and all subsequent years (effective for taxable years beginning after December 31, 2025). It excludes from eligibility any such individual electing advance premium assistance payments under ACA section 1412(c)(2)(C) for any month in the year; modifies HSA contribution limits to disregard the high-deductible health plan requirement for these plans, with reductions (but not below zero) for any contributions under ACA section 1412(f); and permits HSA funds to be used to purchase insurance without regard to existing restrictions on non-high-deductible plans or Medicare supplemental policies. (As background, HSAs provide tax-advantaged savings for qualified medical expenses but are currently available only to those with high-deductible health plans; most ACA Exchange plans do not qualify.)

This section amends the advance payment program for Affordable Care Act premium tax credits (PTCs) and cost-sharing reductions (42 U.S.C. 18082(c)) to allow, for plan years beginning in 2026, certain PTC-eligible individuals whose premium assistance amount is determined under IRC §36B(b)(3)(A)(iii)(II) to elect to prepay up to $60 ($5 multiplied by 12 months, or prorated for later enrollments) directly to their qualified health plan issuer, which further reduces their monthly premium by $5. The section further amends the program to allow other PTC-eligible individuals who are qualified Exchange enrollees (per IRC §223(i)) and do not elect the prepayment option to direct 50% of their monthly advance PTC to their health savings account (HSA, as defined in IRC §223(d))—up to the annual HSA contribution limit under IRC §223(b)—with the remaining 50% paid to the issuer. (As background, the program enables health insurance Exchanges to request advance eligibility determinations under ACA §1411, after which the Treasury pays issuers to reduce eligible enrollees' premiums; these options provide enrollees added flexibility for premium discounts or tax-advantaged savings.)

This section directs the Secretary of the Treasury and the Secretary of Health and Human Services, not later than one year after enactment, to jointly submit to Congress a report on the implementation of sections 7 and 8 and any recommendations for expanding accessibility of health savings accounts (HSAs).