Comparison Between HR 1628 as Passed by House of Representatives and Amendment by Senators Graham, Cassidy, Heller and Johnson*

Medicaid

Graham-Cassidy Bill

House-passed Bill

Enhanced Federal Medical Assistance Percentages (FMAP) Ends enhanced FMAP after 2020 and transitions FMAP to 80 percent in 2018–2019. Repeals the Medicaid expansion and allows states to use funding under the Market-based Health Care Grant Program for this population. Ends enhanced FMAP after 2020 except for grandfathered Medicaid beneficiaries without a lapse in coverage.
Medicaid Funding Converts Medicaid to per-capita funding based on five different groups of elderly, blind or disabled adults, children, expansion adults and other adults. The per-capita amount in each group is based on state-selected data for eight consecutive quarters from FY2014- FY2017. Base year amounts are then inflated by CPI-Medical (CPI-Medical +1 for aged and disabled) through 2024 and CPI-U starting in 2025. This also includes $5 billion in public health emergencies from 2020–2024 that is excluded from per-capita cap and block grant amounts. Converts Medicaid to per-capita funding based on CPI-Medical (CPI- Medical +1 for aged and disabled populations). Allocations are assessed based on eligibility group. Same provision exists on New York.
Medicaid Block Grant Funding Allows states to go to block grant funding for nonelderly, nondisabled adults and/or expansion adults beginning in 2020. States may require cost sharing up to 5 percent of family income. Allows states to go to block grant funding for children and non-expansion adults or only for non-expansion adults.
Work Requirements Allowed for nondisabled, nonelderly, nonpregnant individuals to be eligible for Medicaid. States that implement these requirements would receive 5 percent extra federal funding. Allowed for nondisabled, nonelderly, nonpregnant individuals to be eligible for Medicaid. States that implement these requirements would receive 5 percent extra federal funding.
Eligibility Allows states to conduct eligibility redeterminations every six months (or more frequently) for expansion adults. Hospitals can no longer offer presumptive eligibility, and states cannot offer presumptive eligibility to expansion population. This repeals the three-month retroactive coverage requirement.
Same, except no provisions are made on the redeterminations.


Essential Health Benefits (EHBs) in Medicaid States can repeal EHBs in Medicaid for those under the Alternative Benefit Plan (ABP). States can repeal EHBs in Medicaid for expansion populations and ABPs.

Insurance Provisions

Graham-Cassidy Bill

House-passed Bill

Cost-sharing Subsidies Funding through December 31, 2019, and then states could use their block grant funding under the Market-based Health Care Grant Program for this purpose and that funding would end in 2026. Funding through December 31, 2019.
Premium Subsidies (currently available for those at 100 to 400 percent the Federal Poverty Level [FPL]) Remain the same from 2018–2019, except that no funds can be used to purchase a plan that covers abortion. Repealed in 2020. After 2020, it would be subject to block grant funding under the Market-based Health Care Grant Program and that funding would end in 2026. Modified tax credits in 2018–2019. Then, in 2020, it is replaced with a new tax credit that is a flat rate based on age and is reduced $100 per every $1,000 that an individual makes over $75,000, or over $150,000 for joint filers, and the credits can be combined for families up to $14,000. The same prohibition exists on abortion coverage.
Small Business Tax Credit Ends December 31, 2019. Cannot use tax credit from passage—expiration for any plan that includes abortion coverage (except in cases of rape, incest or to save the life of the mother). Same
Parental Coverage of Children to age 26 No change Same
Age Rating Starting in 2019, default age rating goes from 3:1 to 5:1 unless states adopt a new standard. Starting in 2018, default age rating goes from 3:1 to 5:1 unless states adopt a new standard.
Essential Health Benefits (EHBs) States can modify under a waiver. Allows state waivers to modify or eliminate EHBs as well as the actuarial value of the benefits (consumers can be required to pay more).
Pre-Existing Conditions States can modify under a waiver. Would let states opt out of community rating and charge those with pre-existing conditions more if: the state waiver is approved, the state limits the increased premium to one year, the individual went without insurance for more than 63 days and the state does not charge the 30 percent fee for lapse of insurance.
Annual and Lifetime Limits on EHBs States can modify under a waiver. Same

Cost Sharing Limits

on EHBs
States can modify under a waiver. Same
Medical Loss Ratio (MLR) States can modify under a waiver. No change from current law.
1332 Waivers Allows states that participate in the Market-based Health Care Grant Program to waive several provisions including EHB requirements and pre-existing condition limitations. States can modify age rating, modify EHB requirements and allow states to charge those without insurance who have a pre-existing condition more for one year (without the 30 percent fee).
Health Savings Accounts (HSAs) Can be used to pay premiums for a qualified high-deductible health plan that does not include abortion coverage. Does not include allowing HSAs to be used to purchase an insurance plan.
Small Business Health Plans Creates small business health plans to allow employers and self-employed individuals to group together to purchase insurance coverage. Not included
State Stability Funding Provides $35 billion over two years in a federal short-term reinsurance program for insurers. Also includes the Market-based Health Care Grant Program to fund high-risk individuals purchasing non-group coverage, cost-sharing subsidies, premium subsidies, Medicaid funding (both for the current law Medicaid expansion adult population and up to 20 percent for traditional Medicaid population) and other purposes. Funding is more than $1.176 trillion from 2020-2026. Provides a $138 billion Patient and State Stability Fund.
Catastrophic Insurance Plans Available to anyone on the Exchanges (not just young and certain other individuals), but the premiums may be higher because risk pool rating requirements will apply to these plans starting in 2019. None
Individual Mandate Repealed There is a 30 percent premium penalty for one year if a lapse of 63 days occurs in coverage.
Employer Mandate Repealed Repealed
ACA Taxes Repeals the tax on over-the-counter medications, tax on HSAs, medical device tax and the prior elimination of the deduction for retiree drug plans. Repeals most ACA taxes and delays the tax on high-cost employer insurance plans (Cadillac Tax) until 2025.

Miscellaneous Provisions

Graham-Cassidy Bill

House-passed Bill

Planned Parenthood
Funding
No funding for one year. No funding for one year.
Opioid Crisis
Funding
No funding provided. Provided $15 billion in funding over 10 years.
Home- and Community-
based Services
Provided $8 billion in funding for demonstration program from 2020–2023. Not included
Community Health Centers Provided $422 million in funding in 2017. Provided $422 million in funding in 2017.

Congressional Budget Office (CBO) Cost Estimate

Graham-Cassidy Bill

House-passed Bill

Deficit Reduction No CBO estimate currently available, but according to the
Kaiser Family Foundation, it would reduce federal funding
to states by $160 billion from 2020-2026 and $240 billion in 2027 if funding is not renewed.
$119 billion
Number of Additional Uninsured Individuals versus Current Law No CBO estimate currently available, but according to the
Brookings Institute, it would reduce the number of insured Americans by at least 21 million by 2026.

14 million additional uninsured Americans in 2018

19 million additional uninsured Americans in 2020

23 million additional uninsured Americans in 2026

Market Stability versus Current Law Not provided More non-group market instability starting in 2020 due to waivers
Premium Costs versus Current Law Not provided

20 percent higher in 2018

5 percent higher in 2019

2020 and later would depend on state waivers

*As of September 22, 2017

For additional information, please contact the AANP Government Affairs Office at 703-740-2529 or governmentaffairs@aanp.org.

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