S. 3368 — Restoring Patient Protections and Affordability Act of 2025

This section extends the temporary enhanced premium tax credits for Affordable Care Act marketplace coverage—including increased subsidy amounts and eligibility for households with income above 400% of the federal poverty line—through taxable years beginning before January 1, 2029 (from January 1, 2026). (As background, these enhancements, originally enacted in the American Rescue Plan Act and extended by the Inflation Reduction Act, subsidize qualified health insurance premiums for eligible individuals and families.)

This section extends the annual open enrollment period for American Health Benefit Exchanges for plan year 2026 through May 1, 2026 (from January 15, 2026).

This section provides $100 million for FY2026, available until expended, for navigator grants (i.e., consumer assistance for enrolling in qualified health plans through Affordable Care Act Exchanges) with respect to federally-facilitated Exchanges (operated by HHS in states without state-based Exchanges), to be obligated from user fees on participating health insurance issuers; and (2) prohibits navigators from charging fees to applicants or enrollees or requesting any remuneration from or on behalf of applicants or enrollees.

This section repeals the disallowance of the premium tax credit under the Affordable Care Act for certain health insurance coverage enrolled in during a special enrollment period (i.e., enrollment outside the annual open enrollment period due to qualifying life events). The repeal applies to plan years beginning after December 31, 2025.

This section directs the Secretary of Health and Human Services to require each health insurance issuer offering a qualified health plan through a Federal or State Exchange for plan year 2025 to notify all individuals enrolled in such plan for any month of 2025, not later than 15 days after enactment, of (1) changes to eligibility for premium tax credits and to such credit amounts under IRC §36B effective for plan year 2026, (2) the extended open enrollment period for plan year 2026 under section 101, and (3) additional information relating to eligibility and enrollment as determined appropriate by the Secretary, including the website and phone number for the applicable Exchange.

This section requires the Secretary of Health and Human Services to direct each health insurance issuer offering a qualified health plan through a Federal or State Exchange for plan year 2026 to notify enrollees of (1) changes to eligibility for premium tax credits under IRC §36B and to such credit amounts that first take effect for plan year 2026, (2) the extended open enrollment period for plan year 2026 under section 101 of this Act, and (3) additional information as determined appropriate by the Secretary (e.g., the Exchange website and phone number). Issuers must provide the notice not later than 15 days after the date of enactment for individuals enrolled as of enactment and not later than 15 days after enrollment for individuals enrolling thereafter during the plan year 2026 open enrollment period.

This section requires each health insurance issuer subject to the requirements of sections 201 and 202 to submit to the Secretary of Health and Human Services, not later than 90 days after the date of enactment of this Act, a report attesting to compliance with those requirements. The section further directs the Secretary to submit to the Senate Committees on Finance and Health, Education, Labor, and Pensions and the House Committees on Ways and Means, Energy and Commerce, and Education and the Workforce, not later than 120 days after such date of enactment, a report consolidating the issuer reports.

This section authorizes the Secretary of Health and Human Services to impose civil monetary penalties, consistent with the process in 45 C.F.R. §156.805(d) and (e) (or successor regulations), on health insurance issuers that fail to comply with enrollee notification requirements under §§201 or 202 or reporting requirements under §203. Penalty amounts are (1) $1,000 for each individual enrolled in a plan for plan year 2025 or 2026 who did not receive a required notice under §201 or §202, for each day from the due date until the notice is provided; and (2) $1,000 per day for each individual enrolled in health insurance coverage requiring a report under §203, from the report due date until submission.

This section eliminates the requirement under the premium tax credit eligibility rules (IRC §36B(c)(5)(A)) for applicants to provide or verify applicable enrollment information during reenrollment. The amendment applies to taxable years beginning after December 31, 2027.

This section requires American Health Benefit Exchanges to provide special enrollment periods for individuals denied advance payments of the premium tax credit pending eligibility verification under IRC §36B(c)(5)(A), permitting such individuals to enroll in coverage following verification. The requirement applies to plan years beginning on or after January 1, 2028. (As background, Exchanges are state-based or federally facilitated health insurance marketplaces under the Patient Protection and Affordable Care Act that facilitate enrollment in qualified health plans, including through special enrollment periods outside annual open enrollment for qualifying life events.)

This section directs the Secretary of Health and Human Services to revise regulations to authorize Federal and State Affordable Care Act (ACA) Exchanges to reenroll individuals from bronze-level qualified health plans (QHPs) (i.e., covering 60% of average costs for a standard population) into silver-level QHPs (i.e., covering 70% of average costs) for plan years beginning on or after January 1, 2026. (As background, silver-level QHPs are eligible for enhanced federal cost-sharing reductions that reduce enrollee out-of-pocket costs for lower-income individuals.)

This section requires state-based and federally facilitated health insurance Exchanges to provide a special enrollment period once per month for individuals eligible for advance payments of the premium tax credit whose household income is not expected to exceed 150% of the federal poverty line, effective for plan years beginning on or after January 1, 2026. (Thus, these low-income individuals may enroll in or change qualified health plans outside the annual open enrollment period.)

This section directs the Secretary of Health and Human Services to revise regulations governing Affordable Care Act (ACA) Marketplace health plans to (1) freeze the allowable actuarial value variation—i.e., the permitted deviation from a plan's standard percentage of covered healthcare costs—at the plan year 2025 level for plan years beginning on or after January 1, 2026; and (2) limit the de minimis actuarial value variation for silver plan variations (i.e., plans providing cost-sharing reductions to low-income enrollees) to minus 0 percentage points to plus 2 percentage points for such plan years.

This section directs the Secretary of Health and Human Services to revise Exchange regulations (45 C.F.R. § 155.305(f)(4)) to permit determination of ineligibility for advance premium tax credits (APTCs) under IRC § 36B only after a taxpayer (or spouse, if married) fails to file a federal income tax return and reconcile prior APTC for two consecutive years used to verify household income and family size (previously allowable after one such year or data mismatch). The revision applies to plan years beginning on or after January 1, 2026. (Thus, it delays potential APTC termination for Marketplace enrollees who fail to file taxes for one year.)

This section revises the repayment limitation for excess advance payments of the premium tax credit (PTC) under IRC §36B(f)(2) for taxable years beginning after December 31, 2025, by capping such repayment for household income less than 400% of the poverty line at (1) $600 if less than 200%, (2) $1,500 if at least 200% but less than 300%, or (3) $2,500 if at least 300% but less than 400% of the poverty line (one-half those amounts for taxpayers whose tax is determined under §1(c)). Those dollar amounts are indexed for calendar years beginning after 2014 by the cost-of-living adjustment under §1(f)(3) determined using calendar year 2013 as the base year (rounded to the next lowest multiple of $50). It also makes a conforming amendment to the coordination provision in §35(g)(12)(B)(ii).

This section sets, for calendar year 2026 and subsequent years, the lower bound of the allowable premium adjustment percentage under ACA Section 1302(c)(4)—used for purposes of subsection (c)(1)(B)(i) to adjust actuarial value levels of essential health benefits coverage based on differences between individual-market and employer-sponsored insurance premiums—to the lower bound that applied for plan year 2022 using National Health Expenditure Accounts projections of average per enrollee employer-sponsored insurance premiums. (As background, ACA cost-sharing requirements specify actuarial value levels for bronze (60%), silver (70%), gold (80%), and platinum (90%) plans in individual and small-group markets, with premium adjustments applied when nongroup premiums exceed employer-sponsored premiums to maintain benefit equivalence.)